History of Nursing in Pacific Canada

The Vancouver Medical Association Bulletin: December, 1930 Vancouver Medical Association 1930

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 Bullet
■!gv; m |     of the   H^^^H
Vancouver Medical Association
Contents
Laboratory Bulletin
Gastric Symptoms
Clinical Section
Meetings
General—Dec. 2nd
Clinical—Dec.  16th
ANNUAL MEETING
CANADIAN MEDICAL ASSOCIATION
JUNE 22—26, 1931
VANCOUVER, B. C.
Vol.   VII.
DECEMBER,  1930
No. 3  THE  VANCOUVER   MEDICAL  ASSOCIATION
BULLETI N
Published Monthly By McBeath-Campbell Ltd., 326 West Pender St. under the Auspices
of the Vancouver Medical Association in the Interests of the Medical Profession.
Offices:
203 Medical and Dental Building, Georgia Street, Vancouver, B. C.
Editorial Board:
Dr. J. M. Pearson
Dr. J. H. MacDermot Dr. D. E. H. Cleveland
All communications to be addressed to the Editor at -the abovs address.
Vol. VII.
DECEMBER, 1930
No. 3
OFFICERS 1929-30
Dr. G. F. Strong Dr. C. Wesley Prowd Dr. T. H. Lennie
President Vice-President Past President
Dr. E. M. Blair Dr. W. T. Lockhart
Hon. Secretary Hon. Treasurer
Additional Members of Executive:—Dr. A. C. Frost; Dr. W. L. Pedlow
Trustees
Dr. W. B. Burnett Dr. W. F. Coy Dr. J. M. Pearson
Auditors:  Messrs. Shaw, Salter & Plommer
SECTIONS
Clinical Section
Dr. S. Sievenpiper Chairman
Dr. J. E. Harrison Secretary
Eye, Ear, Nose and Throat
Dr. N. E. MacDougall  Chairman
Dr. J. A. Smith Secretary
Pediatric Section
Dr. H.  A. Spohn Chairman
Dr. R. P. Kinsman Secretary
STANDING COMMITTEES
Library Orchestra Summer School
__—_ -^ttwtn Dr.  R. P.  Kinsman
Dr. D. F  Busteed Dr. J  R. Davies Dr  w   | Graham
Dr. D. M. Meekison Dr. J. H MacDermot Dr   C   E   Brown
Dr. W. H. Hatfield Dr. F. N. Robertson Dr; £ l."Buttars
Dr. C. H. Bastin Dr. J. A. Smith Dr  q r Vrooman
Dr. C. H Vrooman Dr. j. w. Arbuckle
Dr. C. E. Brown                                    Publications
Hospitals
Dr. J. M. Pearson Dr. j. w. Arbuckle
Dinner Dr. j. H. MacDermot Dr. J. A. Gillespie
Dr. L. H.Webster Dr- d- e- h- Cleveland Dr. W. C. Walsh
Dr. J. E. Harrison Dr- i W. Lees
Dr. E. E. Day                                           Credentials V.O.N. Advisory Board
t, .   ,,   r.  ^  ur j   a        Dr. W: S. Turnbull Dr. Isabel Day
Rep. to B. C. Med. Assn.   .-.     .   T ,,    T .„ „ .„ r>„   w  i-r  r^ivm
e Dr. A. J. MacLachlan JJr. ri. Jto. caple
Dr. H. H. Milburn Dr. P. W. Barker Dr. G. O. Matthews
Sickness and Benevolent Fund — The President — The Trustees VANCOUVER HEALTH DEPARTMENT
1930
STATISTICS, OCTOBER
Total Population   (estimated)	
Asiatic   Population    (estimated)    	
Total   Deaths   	
Asiatic   Deaths	
Deaths—Residents   only   	
Birth Registrations     Male      197 / .	
Female 183  (
  240,421
9,335
1,000 of Population
8.5
21.4
7.9
18.6
INFANTILE MORTALITY—
Deaths under one year of age  9
Death Rate—per  1,000 Births ;  23.7
Stillbirths   (not  included in above)  9
Cases of Contagious Diseases Reported in City
September, 1930
Cases    Deaths
October, 1930
Cases  • Deaths
Smallpox  |
Scarlet Fever  21
Diphtheria  20
Chicken-pox  3
' Measles  0
Mumps  3
Whooping-cough  7
Typhoid Fever  0
Paratyphoid  0
Tuberculosis  19
Poliomyelitis  7
Meningococcus   Meningitis     1
Erysipelas        4
November 1st
to 15th, 1930
Cases    Deaths
in cystitis and pyelitis
TRADE
PYRIDIUM
Phenyl-azo-alpha-alpha-diamino-pyridine hydrochloride
(Manufactured by The Pyridium Corp.)
MARK
For oral administration in the specific treatment
of genitO'urinary and gynecological affections.
Sole distributors in Canada
MERCK & CO. Limited  1 Montreal
412 St. Sulpice-St.
Page 49 Dependable Always
You can always depend upon the purity and
strength of medicinals used in Georgia
Pharmacy prescriptions.
'       ©fl® 1
Seymour
1050
Georgia
Pharmacy
Grsmville at QeortCifc^
Open
All Night
f I II I I I I I I I I I I I I I I I I I I I I II I I I I I I I I I I I I I I I ! I I I I I I I 1
•   Say It etsMi Shivers
and
For SERVICE, QUALITY and SELECTION
Phone us at Seymour 1484
or
Drop into any of our five convenient shops.
665 Granville St.      691 Broadway W.    (At Heather)
189 Hastings St. W.   3205 13th Ave. E.
48 Hastings St. E. (On the Grandview Highway)
BROWN BROS. & Co. Ltd. M
Vancouver's Master Florists
Private Exchange, Sey. 1484 connects all Departments.
71 I I t t t t t I I I l l l t t t t t t t t T t l l l l l I 1 I l I 1 1 t t I I l i I l t l l x~2 EDITOR'S PAGE
"It's the last straw that breaks the camel's back."
About two weeks ago, in a press account of a committee of the
City Council dealing with the indigent, an alderman was reported to
have suggested that the medical profession be asked to help by treating
the indigent free. We understand that such a request may be made for
consideration by the Vancouver Medical Association. The latter will,
of course, decide to do what seems to it best, but there are some things
that need to be said about this matter.
One hardly knows how to take such a suggestion—whether to be
amused or indignant at the remarkable ignorance shown by the speaker.
"How," one may ask, "have the sick indigent been looked after all this
time, and how much have doctors made out of it?" We may assure
him that, what with the work done by hospital staffs and private practitioners, this work has always been done free, and we hardly see how it
can be done any more cheaply than this. Truly, the philosopher who
defined gratitude as "a lively sense of favours to come" was not far
astray.
Btit there is a deeper, more serious aspect to this question. For
many generations the question of the medical care of indigents has remained undefined, and we have accepted it as such. Without any definite
understanding on the subject, we have gone on our way, treating the
sick poor free. For, and mark this, we did it of our own free will, as
an act, if you will, of generosity, or of good citizenship or perhaps with
some measure of selfishness as a reason. But now comes the City, and
wants us to go officially on record as willing to treat the indigent sick
free. We feel that this brings us face to face with a situation of the
gravest importance.    A number of principles are here involved.
Every doctor has his own private list of patients whom he treats
free—not as charity cases necessarily, be it said. Some were once paying
patients and from personal loyalty to them, or friendship or interest, he
carries them on. Others, while never able to pay themselves, do loyal
service to the doctor by sending him their friends as patients, and so
repay him as best they can. Others he carries for various reasons. But
all this is the doctor's own private business. He, presumably, receives
a reward in one way or other that suits him. He has his own personal
relationships with these patients, and they are important to him.
But it by no means follows that he is in any way bound to treat all
indigent people free. Nor has the City or the State any right to ask him
to do so. If the City is going to assume, as it has assumed, the burden
of caring for the indigent, then it has no right to ask free service of
the doctor, any more than of the grocer, or baker or butcher. These unfortunates are given food, clothing, and shelter, with care in time of
sickness. The only one of these that is not fully paid for, is the care in
time of sickness, and the only part of this that is not paid for at all
is the doctor's fee. Yet the doctor pays taxes for this very thing, the
care of the indigent. He pays exactly the same taxes as everyone else,
even more than some, he receives no consideration of any kind, and has
Page 50 nver asked for any, nor does he want any.   But he does want and is going
to insist on fair treatment.
We would suggest to the City that if it wants a definition of our
attitude it would be thus: If the City is going to pay for all the other
costs of the care of the indigent, it must, in fairness, pay also for medical
care—either by the appointment of medical officers, or through private
practitioners, who shall be paid on a scale of fees to be decided upon by
agreement.
We sincerely trust that every medical man will give this matter
most serious consideration. It is vital—it involves a serious principle.
Our answer to any such request should be clear-cut and final. It should
take into consideration the economic side of the matter, and if the City
wants the situation defined, we should see to it that the definition is
clear.
NOTICE
A special meeting of the Vancouver Medical Association will be
held in the Auditorium, Medical Dental Building, at 8 p.m. on Wednesday, December 3rd, to hear an address by Dr. Emil Ries of Chicago,
a well known surgeon and a recognized authority on surgical pathology.
NEWS AND NOTES
Dr. A. M. Menzies has severed his connection with the Laboratories
of the Vancouver General Hospital and has gone East for post-graduate
work in public health.
The B. C. Medical Association has arranged with the Provincial Department of Police at Victoria that the 19000 series of motor license
plates shall again be reserved for medical men. This year, however, all
communications for these plates should be sent direct to the Commissioner, Provincial Police, Motor Branch, Victoria, and NOT TO THE
B. C. MEDICAL ASSOCIATION OFFICES. Full instructions have
been sent to each member of the profession in the Province.
«• * =:-
Dr. A. R. Stevenson, who looked after Dr. Colin Graham's practice
while the latter was in Vienna, is now associated with Drs. McCaig,
Duncan and Wiley at the Sault St. Marie Clinic, Ontario.
Dr. Sheffield (formerly of Coalmont, B. C.) has accepted an appointment in the Department of Pensions and National Health, at
Shaughnessy Military Hospital.
Drs. J. H. MacDermot and D. E. H. Cleveland have been appointed
President and Secretary respectively of the Greater Vancouver Health
League. The League has an office in the Medical Dental Building, under
the care of Mr. Court.
Page 51 MEETINGS
The Vancouver Medical Association held a Luncheon at the Hotel
Vancouver on Friday, November 7th, to welcome Dr. A. K. Haywood,
superintendent of the Vancouver General Hospital, who took up his
duties on the first of the month. The luncheon was attended by more
than a hundred members and was a very pleasant function.
The November General meeting of the Association was held on the
4th. The speaker of the evening was Dr. J. G. McKay, who addressed
the members on the "Early Recognition and Treatment of the Psychoses."
Dr. A. L. Crease was to have spoken on the same subject but was unavoidably prevented from attending the meeting. Dr. McKay's paper
was discussed by Drs. Irlma Kennedy, R. E. Coleman and F. J. Buller.
Fifty members were present.
Drs. H. R. L. Davis, C. A. Eggert, S. G. Elliott, A. T. Henry, J. W.
Shier, R. Miller-Tait and T. R. Whaley were elected to membership.
Dr. Busteed, Chairman of the Library Committee, moved a resolution that a portion of the Summer School surplus be placed at the disposal of the Treasurer for Library purposes. The resolution carried
unanimously.
The first meeting of the Clinical Section was held on October 21st.
Sixty-three members were present. The first case was one of paresis of
the hand following an injury in the region of the elbow shown by Dr.
T. H. Lennie. The point in discussion of the case was whether the
paresis was of organic or functional origin. Dr. Greaves was able to
demonstrate very clearly, by means of electrical stimulation and a short
history of progress of the condition under this treatment, that the paresis
was functional rather than organic.
Dr. G. F. Strong next presented a case of lung abscess, with treatment and autopsy report given by Dr. H. H. Pitts. Dr. Strong first
gave a short resume of the aetiology of lung abscess in general, as follows:
(a) Post-operative; (b) Post-pneumonic; (c) Bronchiectatic; (d) Foreign body.
The case was one of suppurative pneumonitis following a bronchopneumonia localized to a single patch in the lower lobe of the right lung. The patient, a logger, age
21, had spent several days on the beach in a bathing suit, sunning himself, prior to
illness. On August 12 th, while at the beach, he developed a pain in the right lower
chest on inspiration. He went home to bed but pain continued and he was admitted to
the hospital on August 13, 1930.
Physical examination showed a well nourished and developed young male whose
respirations were shallow. Left chest negative. Right chest showed physical signs which
led to diagnosis (provisional) of pleurisy with effusion. Two weeks later X-ray showed
area of consolidation in central portion of right lower lobe. Diagnosis was then considered possibly a central pneumonia. A day or so thereafter, however, he began to
have a foul sputum which increased rapidly in amount until he was bringing up three
cupfuls daily. Temperature was sustained at 101°. It was decided to follow the
method of treatment of Dr. Rich of Detroit who says that if early collapse of the lung
in these cases is done then the period of illness may be greatly shortened. Artificial
pneumothorax was induced September 18th, five weeks after onset of illness and
three weeks after pus appeared. Air was introduced four times at two or three day
intervals, but it was found by X-ray that an adhesion at the base of the lung was
holding it out. However, the patient felt better and his sputum decreased. Bronchoscopy was considered but he appeared  to be  draining well so it was  deemed  advisable
Page 52 not to interfere. Ten days after collapse there was a sudden increase in pain, a sharp
rise in temperature and patient became very toxic. He developed signs of an empyema
in the right chest and died in three days.
In discussion of this case, Dr. Strong said that Rich, of Detroit, had
treated eight cases in this manner with six cures. Other literature on
the subject shows the mortality to be high.
At autopsy a large quantity of pus was found in the pleural cavity
and also a tremendously increased air pressure. A communication with
the abscess cavity was found to be probably due to tearing of the
lung by the restraining adhesion at the base during artificial pneumothorax. Subsequently air was pumped into the pleural cavity by the valvelike action of the tear during inspiration and expiration, thus accounting for the greatly increased pressure in the pleural cavity.
Dr. C. H. Vrooman presented three cases:
Case 1—F. E. C, age 53, leather" worker, no serious illness all his working life
until last February. Taken, acutely ill in February with acute pain in side and fever.
In bed about ten days. Slight cough after going back to work—gradually became
worse. Some pinkish sputum—had to go back to bed for a few days. This happened
again about May 1st, when cough left for a time, again June 1st and 24th. Rather
thin man weighing 110 lbs. P. 84, Temp, normal. Chest showed right slight dullness
and definite basal rales. X-ray showed at base of right lung a definite opacity the size
of a small pea extending from hilus into parenchyma of lung. Examination of other
systems negative.    Sputum repeatedly negative to T.B.
Diagnosis—Lung abscess or lung tumour.
Treatment Pot. Iod. gr. t. i. d. and postural drainage. The man continued at
light work and reported at intervals for examination. September 24th—reported cough
had disappeared for four weeks. Examination of lungs negative. X-Ray shows almost
complete disappearance of tumour mass shown in first plate. There were some fibrous
strands and a definite pleural line between lower and mid lobe.
Case 2—E. J. W., male, age 27, farmer.
First seen August, 1928 with a history of having aspirated a chicken bone one
month previously. About a week ago started to raise very foul pus. Felt sick and
miserable. Examination showed dullness and many moist rales upper left lung. X-ray
showed very definite mottling almost suggestive of T.B. over upper part of left lung.
Repeated sputum tests negative for T.B.
August 20, 1928,—Dr. H. M. Cunningham examined patient with bronchoscope—
failed to find any foreign body.
September 12, 1928—Patient discharged from Vancouver General Hospital feeling good, very little cough or sputum, good condition. Showing marked improvement,
continued to improve until February, 1929, when he coughed quite suddenly a half
pint of blood and had some recurrence of foul sputum for a time. Spent summer of
1929 at Field and was able to work, though coughing some foul and pinkish sputum
occasionally.
August 19, 1929—Coughed about a pint of blood. In St. Paul's Hospital about
two months—returned home still coughing foul sputum but general condition somewhat improved. Sputum so foul that his friends could not have him in the house.
Admitted to Vancouver General Hospital February 21, 1930. Temperature 100° to
101° daily until about May when he coughed about another pint of blood. Consultation with Dr. Schinbein in May re thoracoplasty, decided to try pneumothorax first.
Pneumothorax induced in May, followed by some improvement, lower half of left lung
was collapsed—unable to collapse upper half on account of adhesions. Showed some
improvement but still had some temperature and coughed, considerable pus. Transferred
in August to service of Dr. Robertson who tried vaccine treatment. Patient continued
to show improvement, cough has now become much less,  general  condition much  im-
Page 53
—^ provide. X-ray showed definite lesion in left apex with small cavities. The case was
presented as one now suitable for thoracoplasty as giving the best hope of permanent
result.
Case 3—A. McD., age 48, quartz miner for 15 years.
No history of any previous serious illness. Seen first July 14, 1930. Worked until
two months previously when he caught cold and had to go to hospital at Anyox.
Coughed a good deal of foul sputum, lost weight and strength. Average weight 165 lbs.
weight in July 145 lbs. Physical examination shows extensive dullness over whole
right side with many moist rales. X-ray showed uniform mottling of whole of right
lung, no definite abscess cavity. From clinical findings and X-ray, diagnosis made of
probable multiple abscesses of  lung  following pneumonia.
In September, pneumothorax induced with collapse of lower half of lung. After this
patient's condition improved steadily—sputum decreased from five ounces to about one
ounce daily. Foul- odour disappeared to some extent. Temperature normal for six
weeks—patient steadily gaining weight. The question of course remains whether
there will ultimately be healing of abscess cavities or will a thoracoplasty have to be
done eventually.
Discussion
Dr. Whitelaw spoke of the difficulty of X-ray diagnosis in these
cases. He believed that Dr. Strong's case was an aspiration of contaminated water followed by abscess. This type usually occurs in lung hilum
and extends outward to periphery where the pus may break through into
pleural cavity. A second type is the pneumonic type which by reason of
the mode of entry is nearly always peripheral. Dr. Whitelaw felt that an
abscess which would not yield to treatment in three months would
never heal without surgical intervention.
Dr. Vrooman's case, he said, was the pneumonic type, with multiple
abscesses and adhesions over upper lobe.
Dr. Schinbein stated that dogmatism in lung conditions was to be
condemned and no matter what the treatment, the mortality is high.
He believes that lung abscess, as well as brain abscess, frequently follows
surgical procedures. Abscesses which evacuate themselves and do not
bleed, should be treated conservatively with rest and forced feeding and
postural drainage. Most of these recover readily, but if no improvement,
or bleeding takes place, other measures must be tried such as artificial
collapse of lung. Some of these will recover, those that do not may have
extra-pleural thoracoplasty. In abscesses of the base phrenicotomy may
be tried first and some of these are successful. Occassionally an abscess
may have to be drained from without (a peripheral abscess). Dr. Schinbein mentioned experiments which have been carried out at Mayo's to
determine whether cases of suppuration in chest post-operatively are
embolic in origin or due to inspiration. Dogs were anaesthetized and
dye placed in mouths, some lying flat, some with head up, and others
head down. Those in Trendelenberg position showed no dye in bronchi
while those in other positions did. Incisions in abdomens of other dogs
were covered with dye and dye was recovered in the lung. Therefore
two aetiological factors are possible, emboli and aspiration.
Dr. Schinbein also spoke of lobectomy by the cautery method of
Graham and lobectomy with tying off of the pedicle.
Page 54 Dr. E. E. Day mentioned a patient of Dr. Archibald's, of Montreal,
who had a button in lung three years. Button removed, abscess continued in spite of bronchoscopic treatment, and after five years lobectomy
was done. In Dr. Ballon's Clinic, Montreal, cases were treated by bronchoscopic drainage and instillation of lipiodol every two weeks. Most
of these cleared up slowly, but might have done as well on other treatment.
Many cases of lateral sinus thrombosis develop lung abscess. This
was mentioned in support of the embolic theory. Dr. Day thinks some
cases of lung abscess can be kept much more comfortable by bronchoscopic treatment.
Dr. Keith remembered many cases which were called gangrene of the
lung (really abscessed), which were left alone and got well. He believed that no treatment is possibly good treatment. Any case in which
is is difficult to introduce the bronchoscope is beter treated conservatively.
Dr. Vrooman, in closing, stated that the pleural cavity absorbs air
with varying rapidity in different individuals. Usually 50 cc. are absorbed daily. Therefore 500 cc. of air introduced into cavity every nineteen
days replaces the quantity absorbed. The amount introduced at a time
is judged by manometer pressure. It is better not to give a positive
pressure. If pain is complained of during introduction of air it is dangerous to continue. Usually this means adhesions and the manometer
wlil show the pressure.
Dr. A. W. Hunter presented a rare and interesting case of rhabdomyoma of the scrotum, and Dr. H. H. Pitts showed the specimen and
micro-photograph slides of it.
INTERPRETATION OF GASTRIC SYMPTOMS
A clinical and roentgenological study of three thousand cases.
By Maurice F. Dwyer, M.D.
Seattle, Wash.
It is a well-known truth, that the majority of patients consulting
a physician on account of gastric symptoms, do not have organic gastric
disease. Four years ago we presented a statistical study of 1,650 patients
complaining of chronic dyspepsia. We have continued this investigation
and believe that it may be of interest to present briefly the conclusions
drawn from a routine examination of 3,000 consecutive patients, requiring a gastro-intestinal examination before a final diagnosis could be reached. Such an examination included the taking of the clinical history,
physical examination, roentgen gastro-intestinal study, the usual routine
laboratory tests, and other roentgen and laboratory examinations when
indicated. The final diagnoses have been made only after careful correlation of all clinical, laboratory, and roentgen evidence.
Errors in diagnosis undoubtedly exist; yet we feel that the same
percentage of errors in the various diagnoses are fairly constant, hence the
figures are relatively correct. It is now very probable that after a careful
Page 55 routine examination less than 10 per cent of patients' major complaints
are wrongly diagnosed.
In the study of 3,000 consecutive histories of patients having a
gastro-intestinal examination, 450 (or 15 per cent) received a diagnosis
of organic gastric lesions. These 450 diagnoses comprise 295 duodenal
ulcers, 57 gastric ulcers, 92 gastric cancers, 2 cases of gastric syphilis, 3
cases of benign gastric tumors, and 1 gastric hair-ball. Extra-gastric conditions are by far the chief causes of stomach trouble. In 85 per cent
of the series the stomach was found not to be the primary cause of the
dyspepsia.
Duodenal ulcer is the most frequent lesion of the stomach or the
duodenum causing gastric symptoms and comprised 65.7 per cent of the
organic gastroduodenal lesions and 8.1 per cent of the number of patients
complaining of gastric symptoms. In this series the average age of patients
suffering with duodenal ulcer was forty-one years. Fifty-six per cent
stated that the onset of their present gastric complaint began before
the age of twenty-five, and 25 per cent before the age of twenty. The
diagnosis of duodenal ulcer depends upon two salient factors: carefully
obtained clinical history and proper interpretation of x-ray findings.
It is relatively rare for the roentgenologist to demonstrate an ulcer
without at least a suggestive clinical history, and, conversely, the roentgen
report, when returned to the clinician, seldom disappoints him if he has
sufficient clinical evidence to cause him to suspect strongly the presence
of an ulcer. When frequent differences affecting the final diagnosis arise
betweeen these two departments, they are generally due to an unbalanced
ratio of proficiency or to a lack of confidence in one another's judgment.
A study of 100 consecutive clinical histories of duodenal ulcers
showed that 82 per cent gave the so-styled "typical duodenal ulcer
history,' and 14 per cent a suggestive history, which may or may not
have meant ulcer. The so-called typical history of duodenal ulcer is of
great importance, and we wish in no way to detract from its high value
in the diagnosis of such a lesion, but if one depends solely on the history
many ulcers will remain undiagnosed or confused with other abdominal
conditions, causing gastric symptoms, as 18 per cent of the cases studied
gave anything but a classical history. In those cases with definite ulcer
symptoms the roentgenologist is of great value in confirming the diagnosis. In the group presenting suggestive and indefinite histories the
roentgenological examination will determine or exclude more ulcers than
the combination of all other diagnostic methods.
Gastric ulcer was diagnosed 57 times in this series and comprised
12.6 per cent of the organic gastroduodenal conditions—one fifth as
common as duodenal ulcer. The average age at the time diagnosis was
made was forty-eight years. In comparing the histories of gastric and
duodenal ulcer patients, it was interesting to note that only 36 per cent
sought relief before forty-five years of age, 25 per cent before the age of
twenty-five years, and only 3.5 per cent stated that their stomach bothered them before the age of twenty.  Gastric ulcer, in comparison with
Page 5 6 duodenal ulcer, is essentially a disease of older persons. Seventy-five per
cent dated the beginning of their trouble after the age of twenty-five.
The clinical differentiation between gastric and duodenal ulcer is
frequently difficult, as many gastric ulcers are atypical and present an
indefinite history. Here the roentgenologist localizes the lesion and
occasionally is able to establish the presence of an ulcer when the clinical
signs and symptoms are highly inconclusive.
The largest percentage of gastric ulcers occur along the lesser
curvature, extending slightly on to the posterior wall. If these ulcerations
are more than mucosal erosions, their direct presence will generally be
recognized. It must be remembered, however, that approximately 16 per
cent of gastric ulcers are located on the posterior wall, a considerable
distance from the curvature, and unless the roentgenologist is constantly
on his guard and employs as a routine the method advocated by Carman
for examining the posterior gastric wall, many posterior ulcers will be
overlooked.
Next to duodenal ulcer, cancer is the most frequent lesion of the
stomach and duodenum. Ninety-two patients in this series suffered from
cancer of the stomach. Twenty per cent of gastroduodenal conditions and
3.5 per cent of general gastric symptoms were found to be due to cancer
of the stomach.
The problem of cancer becomes of more interest daily, both to the
profession and to the public at large. The stomach has the distinction
of being affected more frequently with carcinoma than any other organ
of the body. Cancer of the stomach is not often cured. The disease can be
removed and recurrence prevented only by surgical treatment. The
problem here is the same as cancer eleswhere, to discover the earliest signs
and syptoms whereby the patient may be afforded the only possible chance
for a cure, an early resection. This fact is well known, yet how seldom
does one see an early gastric carcinoma?
Recently we carefully reviewed one hundred cases of gastric cancer,
and although nothing particularly new was brought out we felt justified
in re-emphazing some important facts concerning such a relatively common condition, the incidence of which is apparently on the increase.
The most common lesions of the stomach and duodenum bear
approximately the following ratio: gastric ulcer 1, gastric cancer 2, and
duodenal ulcer 5.
The symptomatology of gastric carcinoma has been described too
often to need more than brief mention. The constant discomfort, food
distress, distaste for food,, loss of weight, nausea and vomiting, haem-
atemesis and anaemia are all relatively late symptoms of the disease. They
are clinically important but do not often bring the patient in for examination early enough to allow successful palliative or curative surgery.
We have reviewed in detail our clinical histories to determine the
earliest syptoms of the disease noted by the patients. Localized gastric
symptoms described as distress, pain, soreness, or pressure have been the
first symptoms noted in two thirds of all our cases. Vomiting (8 per cent)
Page 57 or loss of appetite (7 per cent) were the initial symptoms in 15 per cent
more. In one fifth of all cases the early symptoms were not referred by
the patient to his stomach. Loss of weight and strength were noted as the
earliest symptoms in five instances. Dysphagia was the first symptom
noted in two cases, and diarrhoea in one case. A few patients were unable
to recall their first symptoms, or we failed to note them.
Loss of weight is not often considered by the patient as of serious
significance. Three fourths of our patients had lost more than 20 pounds
(9 Kg.) before coming for examination, and many had lost enormously.
The weight loss of seventy-nine patients about whom we have accurate
figures totalled considerably more than a ton, or nearly 30 pounds
(14 Kg.) per patient. Only two patients remembered weight loss as
the first symptom, and only twenty considered it a prominent symptom.
Nausea and vomiting was a prominent symptom in more than half
of all patients. Haematemesis was considered of major importance by only
two patients, and recorded in only eleven histories. Nausea, vomiting, and
haematemesis are not common early symptoms, but are noteworthy symptoms in more than half of all patients by the time they come in for
examination.
Loss of strength and loss of appetite are not common early symptoms
but have been prominent symptoms in about one-third of the patients
by the time the history was written.
A gastric mass was complained of by the patient in only six instances,
yet forty-one had a palpable mass present.
Any detailed study of the histories of patients suffering from gastric
cancer rapidly brings out two distinct groups. The larger group does
not give any history of stomach disturbances prior to the onset of the
symptoms of cancer or the present complaint; while each case of the
smaller group gives a history of long-continued gastric disturbances prior
to the onset of the present symptoms.
The larger group of cases gives a history of an onset of symptoms
so insidious that it is difficult to recognize the exact beginning. Yet the
beginning is not remote, and the progress of the disease has been rapid.
Such patients usually state that there has not been any trouble with their
digestion and that they have enjoyed vigorous health. Their present
increasing gastric symptoms have averaged only eight months. Examination
of these patients shows with a remarkable uniformity a total lack of free
hydrochloric acid and a large filling defect. It is interesting to note that
the filling defect is less often in the pyloric region (44 per cent) than
in the upper portions of the stomach (56 per cent). Such cases include
two thirds of all patients suffering from gastric carcinoma. In our series,
62 per cent of all cases come into this group; they had not had any
gastric symptoms preceeding the beginning of their complaints; and in
only two instances was even a trace of free hydrochloric acid discovered.
Thirty-seven patients in this group who had gastric analyses recorded
and in whom the original site of the growth could be located with reasonable certainty presented sixteen pyloric lesions, fifteen body lesions, and
six cardiac lesions.
Page 58 The smaller, group of cases give a striking contrast in having a
longer early history of gastric disturbances. The history of dyspepsia runs
bask over an average of ten years before the onset of the symptoms of
cancer. The old history may suggest chronic cholecystitis, a functional type
of hyperacidity, or other gastric disturbance, or a more or less typical
syndrome of gastric ulcer. Approximately one-third of all cases presented
such a history, and these have been carefully reviewed. Gastric analyses
(thirty-one cases) have shown that 70 per cent of these show free gastric
acid, and occasionally even high gastric acidity. In thirteen instances the
histories have been classified as either a story of cholecystitis or an irregular gastric history; five of these presented free hydrochloric acid,
averaging free hydrochloric acid 10, while free acid was absent in nine.
In twelve instances the history has been classified as probable old ulcer,
and in every instance analysis has shown free hydrochloric acid averaging
24 degrees. In six cases the history is so typical of gastric ulcer that a
tyro should make the diagnosis; each presented free hydrochloric acid,
averaging a free hydrochloric acidity of 42 degrees. In studying eighteen
patients in this group who had free acid and in whom the original site
of the growth could be reported with reasonable accuracy, we find that
fifteen originated in the pylorus, three in the pars media, and none in the
cardiac end of the stomach. Stated differently, eighteen cases in which
there were long histories of dyspepsia and later development of gastric
cancer with free acid present show 83 per cent pyloric origin and 17 per
cent pars media origin, or 100 per cent below the cardia. By contrasts,
thirty-seven patients with short clinical histories and gastric cancer with
achlorhydria show 44 per cent pyloric origin, 39 per cent body origin, and
17 per cent cardiac origin, more than half originating above the pyloric
region.
The three cases of benign gastric tumors which were found taught us
that one must continuously bear in mind that a benign gastric tumour
although rare, may be the cause of an atypical gastro-intestinal complaint
or an unexplained chronic anaemia. The first case was a leiomyoma; the
second, five very vascular mucous polypi; the third, a large fibromyoma.
In reviewing these three cases of benign tumours of the stomach we were
impressed by the absence of gastric symptoms. All the patients complained of weakness, anaemia, and loss of weight, but none attributed his
ill health to a lesion in the stomach. Diarrhoea was present in two cases.
In the patient having the polypi, diarrhoea was practically the sole complaint. After removal of these polypi the diarrhoea stopped and has remained so to date, eighteen months after the operation. All the tumours
found in these patients were located on the posterior wall of the stomach.
One case in all probability would not have been diagnosed had we not
made it routine to carefully palpate the partially barium-filled stomach
during fluoroscopy.
We believe that gallbladder disease is the most common cause of
stomach symptoms, and have carefully tabulated our findings relative
to this statement for the past ten years. In 1924 we reviewed 1,650
consecutive histories of chronic dyspepsia, and gallbladder disease was
diagnosed in 19.3 per cent of the series. In 1926 the study was increased
to 2,225 patients, and the percentage of biliary tract disease was found
to be 20.4 per cent. In reviewing 3,000 cases the gallbladder and ducts
Page 59 are considered responsible for the symptoms in 21.3 percent. This percentage remains fairly constant throughout the entire series. The incidence
of gallbladder disease is one-third greater than that of all the organic
gastro-duodenal lesions together. Owing to the fact that gallbladder
disease is such a relatively common condition and that, for the past few
years, so much investigation has been done regarding this organ, a review
of some clinical aspects of the disease may be of interest.
Dowling, reviewing the gallbladder diagnoses in our clinic up to
January 1, 1928, noted that 1,004 patients out of a total registration
of 26,500, received a diagnosis of disease involving the gallbladder or bile
ducts. This is an incidence of 3.8 per cent. Only 8 per cent of the total
registration was under the age of fifteen, so that, for practical purposes,
this may be considered a group of adults. The history of gallbladder
disease is the most important single factor in the diagnosis. This review
showed that the early and prominent symptoms were dyspepsia in 64.5 per
cent and pain in 35.5 per cent of cases.
An analysis of the term "dyspepsia," as applied to biliary tract
diseases, showed that the most common complaints were gas, distention
and belching, food selection, sour stomach and heartburn, bilious spells,
acid eructations, headaches, and constipation, Vague abdominal and chest
pains were frequently noted. Soda relief was not uncommon, and abstinence from food generally gave relief.
Al these symptoms may be found in dyspepsia from other causes,
but their association in a group, accompanied in at least one-third of the
cases by occasional severe radiating epigastric pain, in another third by
less severe pain, by occasional jaundice and septic symptoms with acid frequently absent or low, and a negative roentgenologic report of the
organic gastroduodenal conditions, makes the diagnosis correct in over
90 per cent of those checked by operation. To these add the positive aid
of cholecystography and the diagnosis of gallbladder disease becomes as
accurate as of other gastro-intestinal lesions. The operative findings have
agreed with the preoperative diagnosis in over 90 per cent of the cases.
A recent study of 200 consecutive case histories of patients receiving a diagnosis of gallbladder disease to determine the degree of
gastric acidity showed that 70 (or 35.5 per cent) had a normal amount
of acid; 41 per cent low acid; and 47 (or 23.5 per cent) absence of
acid. Thus 64.5 per cent had low or absent acid. No record was found
of any of these 200 patients who had high acid. Since this study was
made we have record of one patient having high acid, on whom a
diagnosis of gallbladder disaese had been made. Low or absent acid in
a patient with chronic gastric disturbances speaks strongly for gallbladder
disease, and the clinician should not be hasty in diagnosing disease of that
organ in the presence of high acid.
Cholecystography has been used for the past five years practically as
a routine method of examination, in all cases suspected of having gallbladder disease. We have studied over 1000 patients by this method and
are convinced that cholecystography far surpasses all previous objective
means of examining the gallbladder. After trying both oral and intraven-
Page 60 ous methods of administering the dye, the intravenous is preferred and
has been used exclusively for three years.
Cholecystography is purely a functional test of the gallbladder.
Positive evidence of gallbladder disease, such as absent or persistently faint
concentration of the dye, speaks more for impaired function and disease
of that organ than any other method of objective examination. On the
other hand, a well visualized gallbladder does not by any means rule out
gallbladder disease, as the organ may be markedly diseased and still retain
the power of concentration.
The clinicians have diagnosed gallbladder disease in 12 per cent of the
cases giving negative cholecystographic findings.
General neuroses and the various functional dyspepsias bring more
patients to the physician than any other type of indigestion; no patients
require more careful diagnosis. The neurotic, fat female of forty, with an
indefinite dyspepsia as part of a long line of complaints, will cause a
great deal of worry for the conscientious physician. Such women often
have gallstones, and these are found by cholecystographic methods, even
when they are responsible for only a small portion, or for no portion,
of the patient's complaint. Such patients do not get symptomatically well
after cholecystectomy.
The thin, gassy, debilitated female of forty may show occasionally
no cholecystographic shadow at a first examination, yet at a second examination we may find a normal gallbladder shadow, or operation may
show an apparently normal gallbladder. This fact has been noted by us
and has been reported by Eusterman, Such failure to visualize the normal
gallbladder must be due to some temporary functional failure of the
normal gallbladder to concentrate the bile.
Functional disturbances have often been diagnosed as due to organic disease, and patients with gastric organic dyspepsia may have an
overshadowing functional disturbance. For this reason we feel that close
cooperation between the roentgenologist and the internist is essential to the
attainment of a high percentage of finally accurate diagnoses.
The combined diagnoses in our clinic of all organic lesions of the
stomach, duodenum, and gallbladder total only one-third of the number
of those who have had digestive symptoms sufficient to warrant a gastrointestinal or cholecystographic examination. Two-thirds of all dyspeptics
have had their stomach symptoms secondary to extra-gastro-cholecystic
.disease or to functional derangement.
SUMMARY
1. Fifteen per cent of patients complaining of chronic gastric disturbances have organic conditions in the stomach or duodenum, accounting
for the symptoms.
2. Duodenal ulcer accounted for the symptoms of 8.1 per cent of
the total series and the most frequent organic finding in the stomach
and duodenum. Fifty-six per cent of the patients stated their gastric disturbances began before the of twenty-five
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Medical-Dental Building Vancouver 3. Gastric ulcer is one-fifth as common as duodenal ulcer and is
comparatively a disease of older individuals. Seventy-five per cent began
to have stomach symptoms after twenty-five years of age.
4. Twenty per cent of organic gastroduodenal conditions and 3 per
cent of general gastric symptoms were due to cancer of the stomach.
Eighty per cent of these cancers apparently originated in a resectable part
of the stomach. Early pyloric obstruction is a fortunate complication, because it brings the patient in early for relief.
5. Sixty-two per cent of the patients with gastric cancer described
their earliest symptoms as pain, soreness, or pressure, and 15 per cent as
vomiting or loss of appetite; 23 per cent did not believe that the stomach
was the cause of their illness.
6. Seventy-five patients lost more than 20 pounds (9Kg.) each before coming for examination, yet only two remembered loss of weight as
an early symptom and only twenty considered it a prominent symptom.
7. A gastric mass was complained of by the patient in only six
instances, though forty-one had a palpable mass present.
8. Sixty-two per cent did not give a history of stomach trouble prior
to the onset of the cancer symptoms, yet this onset is so insidious that it is
difficult to recognize the exact beginning. The average duration of their
complaint was eight months.
9. The examination of the group of gastric cancer patients presenting short histories showed with a remarkable uniformity a total lack of
free hydrochloric acid and definite roentgen evidence of large filling
defects.
10. The smaller group, comprising 38 per cent of the series, gives
a striking contrast in having an early history of much longer duration.
They gave histories of gastric disturbances averaging ten years before the
onset of the symptoms of cancer.
11. Seventy per cent, of the smaller group had free hydrochloric
acid present, some in excess of the normal. Eighty-three per cent of the
patients presenting long histories and the presence of free acid had the
tumor located in the pyloric region, compared with 44 per cent of the
group with short histories and absent free acid.
12. Gallbladder disease is the most frequent organic cause of gastric
symptoms. We believe the gallbladder was responsible for the dyspepsia
in 21.3 per cent of the total series. Positive cholecystographic findings by
the intravenous administration of the dye speak volumes for disease of the
gallbladder. Negative cholecystographic findings in the presence of a good
clinical history of gallbladder disease and a negative roentgen report of the
stomach and duodenum should not prevent the clinician from diagnosing
disease of the gallbladder.
13. In 59 per cent of all cases presenting gastric symptoms the cause
for the dyspepsia was not due to functional or organic conditions in the
stomach, duodenum, or gallbladder.
Page 62 CORRESPONDENCE
To the Editor,
Vancouver Medical Association Bulletin.
Dear Sir:
The following notes are based upon the discussion of an article read
at the June meeting, 1923, of the Canadian Public Health Association held
at Edmonton, Alberta, and published in full in the Public Health Journal
of December 1923 and January 1924. These remarks also bear upon the
correspondence between Drs. H. W. Hill and J. E. Campbell published
in "The Bulletin" last year.
The idea advocated in the article in the Public Health Journal is
that a positive Wassermann means protection, and, of course, the natural
conclusion would be that instead of endeavoring to obtain a negative
result in the treatment of our syphilitic patients we should treat our
patient for his syphilis by building up and keeping up his natural resistance. We all know that our life span is determined by our ability to
protect the body from enemies from within and enemies from without.
Our serological tests, other than in syphilis are to determine the presence
or absence of protective changes against certain pathogenic invaders. We
endeavour to imitate these changes, i.e. to produce protective substances
as in typhoid, scarlet fever, small pox, etc. by the use of vaccines, and
to get quick action by the use of serums—diphtheria, etc. by adding the
protection—on the other hand nature has made one very serious blunder
(or have we made it?) in the case of syphilis:
"A positive reaction, as has been noted, means the presence in the
body of living treponemas, and as long as the reaction remains
positive, just so long is the patient a victim of syphilitic infection,
regardless of the occurrence of other symptoms of the disease."
These are the teachings upon which our present treatment of syphilis
is based. There is no necessity to further point out that the treatment of
spphilis is actually guided by the Wassermann reaction, that a positive
means treatment and a negative Wassermann none. Who is there in
the profession who does not implicity believe that a positive Wassermann
is an absolute indication for further treatment? Statements such as the
following run riot throughout our classics on serology. "Treatment in
syphilis should never be discontinued until the Wassermann test has become negative unless it is found that the case is Wassermann fast, i.e.
that no amount of treatment will cause the reaction to become negative."
That surely means, if it means anything, to treat the Wassermann
and let the rest of the man go. by. That surely is the basis of treatment
as generally followed.
I would suggest we, as a profession, seriously think this matter
over—reverse our idea of the meaning of the Wassermann and Kahn
reactions—work our problems out on the principle of the Wassermann
being a measure of protection—and, although many seeming contradictions may appear, yet by sticking to the principle a new and clearer
Page 63 vision will enter our consciousness, not only in the treatment of syphilis
but all medical problems.
Our legislators are honestly struggling with the health problem,
which is a bewildering one. The heads of our Health Department are
doing all they can and relying on the rank and file of the profession
to give of their best, and the best cannot be attained by prejudice or
the absence of an open mind.
I shall never forget the quandary one of our profession found himself
in after listening to a talk at a neighboring Medical Association meeting
when the speaker stated that:
a. A patient may have a positive Wassermann and still be cured of his
syphilis.
b. That another patient may have a four plus and still be greatly in
need of treatment.
These apparent contradictions are still quite true. Work this problem
out on the principle of a -j-1 positive Wassermann meaning protection
and the result is self evident. As an illustration:
We have two automobiles, A and B, with a difficulty to overcome
or an enemy to vanquish which we call C and which is Shaughnessy Hill
(any hill will do) from 15th to Angus Drive. Both A and B have their
full complement of gasoline, lubricating oil, well greased and machinery
in perfect working order. A starts at scratch and at the top of the hill
is making 50 miles an hour. B starts at scratch, stalls half way up the hill
is forced to back down and get a flying start. Why this difference, in
overcoming their enemy C? Both plus or all the power they can develop,
one requiring no help, the other a flying start. The enemy's resistance was
not sufficient to deter A but did show up the weak spots in B. B required the tonic of a "flying start," so, with our patients, some require
considerable building up, others none.
It is very gratifying to read articles such as appeared on page 289 of
The Canadian Medical Association Journal under date of March 1929,
"Specific Treatment of Syphilis." In this it is to be noted that our present
intensive specific form of treatment is not indulged in. The results are
rather interesting. 0.6% of general paresis cases, compared to 4%, as
generally accepted under usual specifics, or better by almost 7 to 1.
Dr. Bruusgaard remarks: "Evidently in a considerable number of
cases the body is by itself able, not only to arrest the process of syphilis
but even to eradicate the disease." At this point it may be interesting to
recall the disappearance of primaries and secondaries which have come
to our attention in many patients, and to ponder the probable cause of
such disappearance of symptoms and our previous ideas of treatment
must be revised, to understand why others with these symptoms not only
do not improve but actually grow much worse.
The article then goes on. In syphilis, like any other disease, we
must recognize the natural resources of the body as a very material
aid to any specific therapy  we may employ,  and this  idea not new."
Page 64 Then again a very important point is noted, "In both our material
series and our tryparsamide series the relief of symptoms which
took place was subsequent to the physical betterment of the patients.
They first began to gain in strength, to increase in weight and to show
a normal appetite. In watching their recovery, one was strongly reminded
of the way in which the body recovers from wasting diseases. That is to
say, the whole picture during recovery seems to be due to the marshalling
of the resistive forces of the body rather than to a direct spirochaeticidal
action. Had our Victoria friend thought of his plus Wassermann case
badly in need of treatment (Car) climbing the Malahat and again the
case (car) of the plus Wassermann requiring no treatment, gliding adong
the level Duncan road, he would have least have had some peace of mind
and a rather fair explanation of his problem. A few days ago a patient
called at our Government Dispensary suffering from progressive G.P.I.
He had a double plus Wassermann upwards of two years previously, all
negative serological tests since, and regular intensive treatment since his
first visit. Too late then for tonics, etc., for so far as I am aware tonics do
not materially help scar tissue; if they did what a wonderful boon they
would be to our surgeons and then we could hope for a real family pact
with our internists.
It may be well to remember that probably a drug which is bacterio-
tropic is also organotropic, that a drug continued gradually loses its
effect, as a result, no doubt, of the formation of anti-bodies. The French,
some years ago, showed that this actually took place upon the administration of "606" and allied preparations.
Without malice aforethought, with an open mind, clean hands
and a pure heart it might be well for all of us to re-consider our entire
system of treatment of syphilis and at least give some reasonable reason
for the faith that is in us to our public health organizations and our
legislators who are backing our efforts.
This viewpoint necessarily implies that most value must be placed
on clean living. Syphilitic patients are very prone to indulge in alcohol,
while those with V.D.G. are proverbial for their anxiety for early indulgence of their sensual instincts. The one probably, due to depression
reaching for a whip rather than for oats; the latter undoubtedly from
irritation, or shall we say stimulation.
It would seem that our treatment in the great majority of instances
has been weighed in the balance and found wanting if we have neglected
to appreciate our patient's thoughts, his words, his actions and his habits.
For each follows the other as cause and effect and we must emphasize the
importance of cleanliness and self control.
Some controversy of late has existed whether or not the Kahn Test
would not be preferable to the Wassermann in the diagnosis and as a
guide to the treatment of syphilis. With the present mode of treatment
would it not be very dangerous, as it seems the Kahn is much more
sensitive and can actually be carried out in office practise by the physician
administering the treatment. On the other hand we would have a ready
means of judging our patient's pulling power, his power of protection,
through comparatively simple office means and thus check up the rises
Page 65 and falls of resistance. With such a ready means at our disposal combined
with physical symptoms and providing always that the result of our tests
meant to us (serological, physical and mental) a measure of the degree
of protection, we should be in a position to treat and advise our patient
as to his habits of life and avoid the onus of entire responsibility
for a cure when we feel that we are not having the support we should
have in the co-operation of our patient.
It is pitiful the confidence placed in treatment by drugs alone and
the relief of the patient when he asks "is my blood pure yet" and he
sees a negative Wassermann. I feel certain that it is nothing short of a
calamity to doctor, patient and comunity to persist in the present idea
that a "plus Wassermann" means living spirochetes.
In conclusion, allow me to refer those interested in the treatment of
lues to the July issue of "The British Journal of Venereal Diseases."
This issue deals exclusively with the problems of syphilis. Many red
herrings will be found to cross the trail during this perusal
but at least two outstanding points seem to be emphasized viz.
1—Drugs used in the treatment of syphilis do not attack the spirochaeta
pallida directly but rather by stimulating the production of protective substances in the blood stream of the host.
2—Careful supervision of the general health of the patient must be
exercised in order to maintain his resistance at the highest point possible.
J. J. Gibbs.
SIGNIFICANCE AND TREATMENT OF HEMATEMESIS
By Dr. W. F. Cheney, San Francisco.
There are four causes of this condition that stand out prominently.
(1) Ulcer of the Stomach or Duodenum; (2) Cancer of the Stomach;
(3) Cirrhosis of the Liver; and (4) Splenic Anaemia. Compared with
these, all other possibilities are far less frequent.
I. Ulcer is the most common cause of hematemesis, but statistics
show that hematemesis occurs in only 10 to 25 per cent, of all cases of
ulcer. It should be classed, therefore, as a complication and not as a
symptom. The vomited blood comes most often from a gastric ulcer,
but many occur from a duodenal as well. Bleeding undoubtedly is more
common but not in sufficient amount to be vomited.
There are certain rules for guidance in deciding about the significance of hematemesis: (a) When in doubt, assume ulcer as the cause
until some other source has been proven; (b) an ulcer history usually
precedes, but ulcer may be latent until hematemesis occurs; (c) the
quantity is variable and the amount vomited does not always indicate
the seriousness of the situation; (d) one haemorrhage is frequently followed by others, with a day or two interval, and it may start as a
simple oozing or discharge of a small amount of bright blood, or the
Page 66 first one may be so large as to prove fatal; (e) death from a first attack
of hematemesis is rare but does occur from erosion of a large vessel. It
is much wiser, therefore, to regard every hematemesis as serious and to
act promptly in caring for it.
The suspicion that hematemesis is due to ulcer is confirmed by
(1) a previous history of indigestion, with the characteristic features of
chronicity, periodicity, rhythmicity and the nature of the symptoms,
but there may be no such history preceding and bleeding may be the
first sign of the disease.. (2) Observation of the amount and character
of the blood vomited; this may be variable in quantity, simply brown
shreds in the vomitus, or dark brown discolouration of the fluid contents
of the stomach, or a small amount of bright red blood, or an amount so
large it may prove fatal. The common course is for small repeated haemorrhages to occur at short intervals before there is a large one.
At the time of the hematemesis, history only is available for diagnosis, with observation of the patient and of the material vomited. It
is wiser to treat the hematemesis and wait before making further investigation. Such delay should be for at least one week after the last haemorrhage. Then it is proper to employ as further methods of diagnosis
(3) physical examination, which, if ulcer is the cause, shows no tumour
mass and no alteration in the size of the liver or spleen and is otherwise
negative except for epigastric tenderness; (4) gastric analysis, which
tells much about gastric secretion and the differentiation between ulcer
and cancer; and (5) gastro-intestinal X-ray examination. But it must
be remembered that soon after a large haemorrhage there may be a low
acidity because of secondary anaemia, and the X-ray report may be
negative because the ulcer base is concealed by a blood clot.
II. Cancer of the stomach rarely causes profuse bleeding; usually
there is slight oozing mixed with gastric secretion that results in dark
brown or blackish shreds known as "coffee-ground" vomitus. But on
the other hand, the hematemesis produced by cancer may exceptionally
be copious and even fatal. Multiple hematemesis, due to repeated small
haemorrhages, is the rule. In all other forms, one large haemorrhage is
usually followed by a free interval for months or years; but in cancer
the hematemesis is more or less continuous.
The suspicion that the cause of the bleeding in cancer is confirmed
by a preceding history of indigestion and pain, with loss of appetite and
weight and color, vomiting of food, increasing pallor and cachexia,
usually extending over a period of months, but not over years as in ulcer.
It is undoubtedly true, however, that cancer may be latent until bleeding
occurs and hematemesis may afford the first sign. Physical examination
usually but not always reveals a palpable tumour. Gastric analysis
and X-ray films made after a little delay as in ulcer, usually reveal characteristic and diagnostic evidence of the true pathology present.
III. Portal Cirrhosis of the Liver. The hematemesis due
to this cause usually comes with little or no warning of any previous
disease of consequence. There is one large single hematemesis, seldom
repeated soon. If the bleeding is often repeated it is not due to cirrhosis.
The quantity is usually large and may be very large.    The blood most
Page 67 often is poured out from ruptured oesophageal varices, and therefore
darker and more clotted than blood from an ulcer. Collapse is not so
frequent or so marked, and alarming symptoms are more rare when hematemesis is due to ulcer. But here again, rarely, the first haemorrhage
may prove immediately fatal. While the source of the blood, as already
stated, is usually from ruptured veins in the lower oesophagus, in 80 per
cent, of the cases shown at autopsy, it may be from gastritis and small
superficial abrasions of the gastric mucous membrane.
The suspicion thus created that the hematemesis is due to cirrhosis,
is confirmed by (a) a history of previous indigestion, with repeated gastric upsets*, abdominal discomfort, morning nausea and vomiting, poor
appetite, but no pain such as that of ulcer or cancer. Previous painful
dyspepsia is against the hematemesis meaning cirrhosis. (b) Physical
examination may be practically negative, or frequently changes are
found in the size of the liver and spleen. However, even though liver
and spleen are both enlarged before a haemorrhage, they may be practically normal in size after it. There is no palpable tumour found as in
cancer and no localized sharp tenderness as in ulcer; and if there is
tenderness at all, it is diffuse and dull over the gastric area. Hematemesis
is a comparatively early event in cirrhosis, but the most important early
warning that some serious disease exists. Hence there is no such characteristic picture to be expected on physical examination, as is shown
later on when ascites has occurred, (c) Laboratory examinations: gastric analysis shows the typical picture of a chronic gastritis, with abundant mucous, absent or greatly decreased secretion of acid and poor
trituration of food; the blood gives evidence of a secondary anaemia and
may show a positive Wassermann reaction if the cirrhosis has a luetic
origin; liver function tests are not ordinarily of much value in the
early stage at which hematemesis occurs, (d) Gastro-intestinal X-ray
examination eliminates pathology in the stomach and duodenum such as
might account for the hematemesis.
IV. Splenic Anaemia, also known as Banti's Disease, occurs
most often in younger patients, 20 to 40. The characteristic picture
presented is one of periodic large haemorrhages from stomach and bowels
for years, with good health between them, provided they are far enough
apart to allow blood reconstruction. This may go on for ten or more
years, with no gastric symptoms whatever between the attacks of hematemesis. The characteristic features of this disease are therefore; (1) a
history of repeated hematemesis; (2) good health between attacks; (3) a
greatly enlarged spleen and moderately enlarged liver, with the spleen
much larger than in ordinary cirrhosis; (4) a marked secondary anaemia,
with leucopenia.
Other causes of hematemesis are remote and rare as compared with
the four just reviewed. These other possibilities that must be kept in
mind are persistent vomiting and retching from any cause; gastric crises;
swallowed blood; acute gastritis; syphilis of the stomach; aneurism of
the aorta that is leaking into the oesophagus; uraemia; leukaemia; purpura haemorrhagica; the so-called gastro-staxis described by Hale White,
due to oozing from the gastric mucous membrane; and the bleeding described by Dieulafoy, from numerous broad, shallow erosions in the
mucous membrane of the stomach.
Page 68 Treatment of Hematemesis
At the time this emergency arises it should be treated regardless of
cause, leaving the investigation of the meaning until a later occasion.
The physician should have in advance a definite plan to follow so that he
will not lose his equanimity and share in the general perturbation that a
large hematemesis usually causes not only to the patient but to his family
and friends.
The following rules for guidance, based on experience, may be
accepted as trustworthy: (1) Place the patient in a hospital, if possible,
for further observation and investigation, as well as for the better treatment of his condition. Whether there or at home, a nurse to carry out
instructions faithfully is essential. (2) Absolute rest in bed should be
enforced, with no unnecessary change of position, no rising from the
supine posture, no visitors to the bedside. (3) Morphine hypodermic-
ally, to ensure mental and bodily quiet, should be given at once and every
four hours thereafter if necessary. (4) Nothing whatever should be
given by mouth, no food, no water, no drugs. (5) Ice should be kept
continually applied to the abdomen by the ice-coil or the ice-bag.
(6) Avoid immediate saline infusion, or intra-venous glucose solution
or even transfusion; for the cessation of bleeding depends on collapse of
the vessel wall and clot formation. (7) No stimulants are indicated,
such as strychnine, camphor, caffeine or digitalis, even though the pulse
is weak and rapid; for weakness offers the best defense against continuance or resumption of the haemorrhage. (8) After twelve hours, ice
water may be given by mouth first, a half ounce every hour, but even
this stimulates peristalsis. The amount can be gradually increased after
twenty-four hours, if there is no further haemorrhage. (9) Rectal
feeding is not indicated, because food by bowel stimulates reverse peristalsis. (10) If a second haemorrhage follows in a few hours after the
first, judge of the seriousness of this both by the amount vomited or
passed by bowel and by a blood test which will prove by the hemoglobin
percentage and the red cell count how far these have fallen below normal.
(11) It is always better to change too soon than too late from medical
to surgical treatment, and while there can be no absolute rule about this,
when the hemoglobin falls below 40 per cent, and the red count below
two million, it is best not to delay further. Then the patient should be
taken to the operating room, a blood transfusion given at once, the abdomen opened and the bleeding ulcer area excised or cauterized. (12) But
if no further haemorrhage occurs after the first or second and the
anaemia does not exceed the figures mentioned, after 48 hours the feeding
of milk and cream mixture by the Sippy plan may begin, with the usual
alkaline powders half way between feedings, gradually increasing the
amount of food given. (13) If after feeding is resumed another haemorrhage occurs, resort  to surgery is indicated, following a  transfusion.
Such is the immediate emergency treatment for any large hematemesis no matter from what cause. After it has ceased and at least one
week has elapsed, then investigate its meaning. But the most common
cause is ulcer and when in doubt accept that diagnosis pending further
diagnostic tests.
If the further evidence obtained by gastric analysis and by X-ray
examination proves that the patient has cancer of the stomach, as the
Page 69 cause of the hematemesis, this ought to be removed by the surgeon if it
is considered operable. If it is inoperable, then daily lavage with hot
bicarbonate of soda solution will frequently suffice, by keeping the ulcerated area clean, to stop the bleeding. If not, then some mild astringent
may be used for lavage, such as silver nitrate solution, 1 to 2,000.
In cirrhosis of the liver, no method of treatment has yet been devised for getting at the lower end of the oesophagus satisfactorily and
treating the dilated veins. The plan of suitable diet and depletion of
the liver by saline cathartics helps to relieve the venous congestion in the
entire gastro-intestinal tract as well as anything can.
The only treatment for splenic anaemia that offers any permanent
relief is splenectomy; and for years after such operation patients whose
course has been followed have remained free from hematemesis.
CANADIAN MEDICAL ASSOCIATION
Preparations for the meeting of the Canadian Medical Association,
which will be held in Vancouver June 22nd to 26th, 1931, are proceeding actively. The Chairmen of the various committees responsible for
the arrangements, together with their secretaries are meeting weekly
under the Chairmanship of Dr. A. S. Monro. Designs for a special badge,
which will feature the local colour of British Columbia, are being prepared. The Hotel Vancouver has been very generous in its offer of floor
space for exhibits in the lobby and prospective exhibitors are being
"lined up" by Dr. H. H. Milburn with a view to locating them to the
best advantage. Beginning in January, 1931, special articles will appear
monthly in the Canadian Medical Association Journal setting forth the
attractions of the Pacific Coast country and its big advantages for such
a gathering as is projected. Various transportation agencies, national,
provincial and local, are preparing special itineraries and attractive side
trips which visitors from the East may avail themselves of at small additional cost.
As has been said before, it behooves each member of the medical
profession in British Columbia to make the success of this convention
a personal matter, not only by resolving to attend and share in all the
professional and social activities, but to urge upon all of his Eastern
friends the fact that they cannot miss this convention without a very
real loss to themselves.
WARNING
It may be well at this time to renew a warning to doctors against
lending money to strangers. This is occasioned by the fact that at
present a person who introduces himself as a doctor has been calling upon
members of the profession, and on the strength of certain social affiliations, and his business prospects in Vancouver, has borrowed various
sums of money. Up to the moment of writing none of these sums have
been returned.
Page 70 British Columbia Laboratory Bulletin
Published irregularly in co-operation with the Vancouver Medical Association Bulletin
in the interests of the Hospital, Clinical and Public Health Laboratories of B. C.
Edited by
The Vancouver General Hospital Laboratories
Financed by
The British Columbia Provincial Board of Health
COLLABORATORS: The Laboratories of the Jubilee Hospital and St. Joseph's Hospital,
Victoria; St. Paul's Hospital, Vancouver; Royal Columbian Hospital, New Westminster;
Royal Inland Hospital, Kamloops;  Tranquille Sanatorium;  Kelowna General Hospital;
and Vancouver General Hospital.
All communications should be addressed to the Editor as above.   Material for publication
should reach the Editor not later than the seventh day of the month of publication.
Vol. IV.
DECEMBER, 1930
No. 9
CONTENTS
Milk-Borne  Typhoid    Sinclair
Changes in Laboratory Service -- Hill
B. C. MILK-BORNE TYPHOID EPIDEMIC
By Dr. F. D. Sinclair, Mj-H.O, Surrey, B. C.
It is not the purpose of this article to go into minute details of a
typhoid outbreak, but rather to relate some of the problems whcih
frequently confront a rural Medical Officer of Health and the relationship of those problems to adjoining urban centres and the public at
large.
We must admit that the occurrence of typhoid fever in a district
is a direct reflection on the efficiency of the sanitary personnel of the
district concerned. However, on October 18th last, Dr. D. A. Clarke
reported to me a case of typhoid fever in the South Westminster district
of Surrey Municipality which he had seen and diagnosed in his private
practice. Fortunately Dr. Clarke was Medical Officer of Health for the
City of New Westminster, but his private practice extended into the
adjoining Municipality of Surrey. He had two other suspicious cases
under observation. These two cases were living in a house in Surrey
from which milk was being distributed in raw state both locally and in
New Westminster City. There had not been a case of typhoid reported
in Surrey for more than a year. On the following day two other suspicious cases had developed. We began a joint investigation. It was
found that all cases were getting their milk supply from a small dairy
in South Westminster. There was no delivery route, but customers
called to get their supply at the door. The proprietor of the dairy had
died about three weeks before the onset of the first case from bronchopneumonia and myocardial degeneration. He had been ill for about five
weeks, but had remained on his feet until the last few days.    During his
Page 71 illness he had continued to attend to his cattle and do the milking. He
had had no medical attention until the last few days of life when
pneumonia had developed; heart had played out. The history previous to
this was that he had suffered from malaise headaches and gastro-intestinal disturbance. In view of the evidence it seemed conclusive that we
had reached the source of the infection, and had to deal not with a
carrier of typhoid, but with a case.
The water supply for the house and dairy was from two sources.
One supply, a natural spring in the yard, about which a pit had been
dug, showed gross pollution. The other supply, from a natural spring
high up on the hillside but reasonably removed from direct drainage,
on laboratory analyses was found contaminated.
A list of customers was obtained. Thirteen families in all were getting milk regularly from this dairy—eleven locally and two families in
New Westminster City. All families were visited and warned of exposure and advised to have anti-typhoid vaccine administered without
delay. Vaccine was supplied immediately by the Provincial Department
of Public Health, and any necessary laboratory work done by the Provincial Government Laboratories, Vancouver. In all some fifty inoculations were given. We have not heard of any reactions from the vaccine
other than a very transitory malaise. In all fourteen cases developed in
the area, all traceable to the milk supply; no cases have occurred in persons having inoculation, and no cases have developed since November 1.
A further angle to this case of interest to the adjoining urban centres
is the disposal of effluent from the infected premises. The septic tank
drained into bottom land subject to a high water level in wet weather
and thus passing into a road ditch. It was found in tracing this out
that water cress grows profusely in the ditch and that market gardeners
had been taking cress away in quantities for consumption in the adjoining cities. Fortunately as far as could be learned no cress had been
gathered since the outbreak. We were fortunate in this case in having
to deal with a milk borne infection, the source of which was so readily
apparent and the distribution so limited.
One is struck by the necessity of all persons having to do with
the handling of milk reporting illness; of the desirability of early
notification and co-operation between adjoining health bodies, and of the
early use of laboratory facilities in all doubtful illness in purveyors of
food supplies; and again impressed with the inability of part time rural
medical offiicers of health without the advantage of trained saintary
personnel to adequately cope with infections of this nature.
CHANGES IN LABORATORY SERVICE
By H. W. Hill, M.D., Director, V.G.H. Laboratories
Vancouver, B. C.
Beginning October 6th, 1930, these Laboratories, hitherto open until
11 p.m. each night, close at 6 p.m.
Thereafter, to 8 a.m. next morning, only certain emergency examinations, emergency urinalysis, white cell counts, red cell counts, spinal
Page fluid, Vincent's and Gonococcus examinations are made; and these are
made by Internes, refreshed as to technique by special instruction given
during the day by the Laboratories.
Regular laboratory workers are on call, however, from 6 p.m. to
8 a.m., to deal with the more intricate biochemical reactions which may
be needed (Blood sugar, N.P.N., blood groupings, blood cultures, etc.)
Reports on all specimens examined during the evening period by
the Internes or by the regular staff on call are filed next morning in the
Laboratory and become part of the regular records. Reports to jphysi-
cians on these are of course made by the Interne or call-staff as soon as
the examination is complete.
The closing of the Laboratories at 6- p.m. means that reports on
specimens examined during the day up to 6 p.m. cannot be obtained
after 6 p.m. by phone to the Laboratories as heretofore.
Physicians desirous of phone reports on specimens examined late in
the afternoon, should phone the Laboratories before 6 p.m. Such reports
as are then ready can thus be obtained by phone, and are mailed in any
case.
Such reports as are not ready by 6 p.m. cannot of course be ready
until next morning, so that phoning after 6 p.m. can not obtain any
information that is not available before 6 p.m.
These changes we believe will not prove disadvantageous to the
physicians or the Laboratory work, although they may require some
minor readjustments.
They have not been adopted by choice but from pressure of necessity. They constitute a method of meeting the laboratory shortage in
space, which shortage in turn means shortage in staff; both of which
shortage are due to a shortage of funds.
Even had we sufficient available funds at this moment for ideal readjustment of the laboratory services on a plane and scale suitable to the
largest hospital in Canada, months would necessarily elapse before such
ideal changes could be implemented, since increased space would be the
first material addition essential to all others.
Patience and co-operation are asked of the profession, especially
during these inevitable "hard times."
It must be remembered that the above change in closing hours will
not materially reduce the number of specimens to be handled by the
regular laboratory staff.
What it accomplishes is this—that the staff is relieved of covering,
every night, the period from 6 p.m. to 12 p.m., thus releasing one technician and one clerk for the peak load hours of the morning and the
afternoon.
We have lost (by marriage) two technicians. The readjustment
now in effect, practically restores to us one technician. We have lost
also our Administrative Medical Assistant, whose services have been
invaluable; we are attempting to carry on without replacing him. But both Public Health work and Hospital work continue to increase except in the item of urines (routine and diabetic).
Thus the nine months of 1930 (January to September, inclusive)
compare with the same nine months of 1929, thus:
Jan.—Sept.,  1930 Jan.—Sept., 1929
Routine urines .          23,689^1 20,373")
Diabetic urines .                 2,644 t    39,432 1,847 [»    35,916
All other Hospital exams  13,099 J 13,696 J
Public  Health  examinations 39,099 46,228
Total _  .'. 79,064 82,144
We have (in round numbers), as thus shown, a 4% increase in total
work; a 16% increase in Public Health work; a 4% increase in Hospital
work, other than routine and diabetic urines; together with a 16% decrease in those urines themselves.
We congratulate the Hospital, the physicians, and ourselves, on the
reduction in routine urines; and also on the increase shown in the other,
more valuable, items. But, unless provision for increased space, staff
and funds be made, the increases in certain items must cease, or be balanced by decreases in other items; otherwise the unfortunate necessity,
already realized in part, of refusing certain work, will inevitably materialize further.
.jSsljP'
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ajfe.
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5E^j,J$fe&
rv-j
Rest Haven Sanitarium and Hospital
MARINE DRIVE,  SIDNEY, B.  C,   (Near Victoria)
Particularly  convenient  and  desirable  for   Rest—Recuperation  and   Convalescence.
Rates  are  reasonable,   with  meals  and  treatments  included.
Direct patients to Rest Haven from Victoria by the Vancouver Island Coach Lines,  Ltd.,
at the Broughton  Street  Station.    Private car will meet boats if  desired.
FOR   RESERVATIONS  AND   FURTHER  INFORMATION   WRITE  OR
TELEPHONE MEDICAL SUPERINTENDENT OR MANAGER,  SIDNEY 95—61L.
Page 74 [ACCEPTED, COUNCIL ON PHARMACY AND CHEMISTRY, A.M.A.
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accompany
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TEROL
in Oil, 250 D
originally called Acterol
♦ I } EFFECTIVE i. .
OCTOBER 1st, 1930
Mead's Viosterol tn Oil is now
designated 250 D because, in accordance with the provisions of the
Wisconsin Alumni Research Foundation, we are now assaying the
product by the Steenbock method.
Before October 1, 1930, this same
product was assayed by the McCol-
lum-Shipley method and was designated 100 D This was done in the
belief that this method gave results comparable with that prescribed by the Wisconsin Alumni
Research Foundation for its licensees. It was discovered, however,
that when assayed by this method
the potency of the product was virtually 250 D in comparison with
products standardized by the Steenbock method.
Mead's Viosterol in Oil, 250 D
(Steenbock method)—in normal
dosage—is clinically demonstrated
to be potent enough to prevent and
cure rickets in almost every case.
Likeotherspecificsforother diseases,
larger dosage may be required for
extreme cases. It is safe to say—
based upon extensive clinical research by authoritative investigators (reprints on request)—that
when used in the indicated dosage.
Mead's Viosterol in Oil, 250 D is a
specific in almost all cases of human
rickets, regardless of degree and
duration, as demonstrated serologically, roentgenologically and clinically.
The change in Mead's Product
is in designation only—not in actual
potency. Mead's Viosterol in Oil,
250 D—in proper dosage—continues to prevent and cure rickets.
MEAD JOHNSON & CO.
of CANADA, LTD., Belleville, Ont.
—Pioneers in Vitamin /?esearcA—
riitmimitiitliimiiiimr
riiiiiimininiiiiiriin
iiumuin luim un iiii itnnnuiiiiiu i utiiiiui fit
PREVENTS AND CURES RICKETS PROGRAMME OF THE 33rd ANNUAL SESSION
VANCOUVER MEDICAL ASSOCIATION
Founded 1898 Incorporated 1906
GENERAL MEETINGS will  be  held on  the first Tuesday  and
CLINICAL MEETINGS on the third Tuesday of the month at 8 p.m.
Place of meeting will appear on the Agenda.
December   2nd—-General Meeting:
Speakers—Dr.  E.  H.  Saunders;   "Early Recognition
of Acute Mastoiditis"
Dr.   N.  E.  MacDougall;   "The  Common
Cold"
December 16th—Clinical Meeting.
January       6th—General Meeting:
Speaker—Mr. Justice Morrison; Certain Contacts of
Medicine and the Law."
20th—Clinical Meeting.
3rd—General Meeting:
Speakers—Dr. F. N. Robertson; "Some Unusual Uses
of Common Drugs."
Dr. Wallace Wilson; "Stenosis of the Mitral Valve."
17th—Clinical Meeting.
3rd—General Meeting:
THE OSLER LECTURE—
Dr.   R.   E.  McKechnie;   "Reminiscences  of Forty
Years' Practice."
17th—Clinical Meeting.
7th—General Meeting:
Speaker—Dr.   C.   F.   Covernton;   "Problems  of   the
Primipara."
21st—Clinical Meeting.
28 th—Annual Meeting.
January
February
February
March
March
April
April
April
i
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