History of Nursing in Pacific Canada

The Vancouver Medical Association Bulletin: November, 1935 Vancouver Medical Association Nov 30, 1935

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Vol. XII.
In This Issue:
! Ill
Radiation Ointment
Obtainable at:
or any
Western Wholesale Drug Co.
(1928) Limited
'Published ^Monthly under the ^Auspices of the Vancouver ■Zhlcdical ^Association in the
Interests of the ^Medical "Profession.
203 Medical Dental Building, Georgia Street, Vancouver, B. C.
Editorial Board:
Dr. J. H. MacDermot
Dr. M. McC Baird Dr. D. E. H. Cleveland
All communications to be addressed to the Editor at the above address
Vol. Xn.
No. 2
OFFICERS  193 5-193 6
Dr. C. H. Vrooman
Dr. G. H. Clement
Hon. Secretary
Dr. W. T. Ewing Dr. A. C. Frost
Vice-President Past President
Dr. W. T. Lockhart
Hon. Treasurer
Additional Members of Executive—Dr. T. R. B. Nelles, Dr. F. N. Robertson
Dr. F. Brodie
Dr. W. D. Brydone-Jack Dr. J. A. Gillespie
Auditors: Messrs. Shaw, Salter & Plommer
Clinical Section
Dr. J. R. Neelson Chairman
Dr. Roy Huggard .   Secretary
Eye, Ear, Nose and Throat
Dr. H. R.' Mustard.—™: Chairman
Dr. L. Leeson    Secretary
Paediatric Section
Dr. G. A. Lamont — ;   Chairman
Dr. J. R. Davies    jSfHI _      Secretary
Cancer Section
Dr. J. W. Thomson . Chairman
Dr. Roy Huggard       Secretary
Dr. G. E. Kddd
Dr. W. K. Burwell
Dr. C. A. Ryan
Dr. W. D. Keith
Dr. H. A. Rawlings
Dr. A. W. Bagnall
Dr. J. H. MacDermot
Dr. Murray Baird
Dr. D. E. H. Cleveland
Dr. Lavell Leeson
Dr. J. E. Harrison
Dr. A. Lowrie
Summer School
Dr. J. W. Arbuckle
Dr. J. E. Walker
Dr. H. A. DesBrisay
Dr. H. R. Mustard
Dr. A. C. Frost
Dr. J. R. Naden
Dr. H. A. Spohn
Dr. J. W. Thomson
Dr. W. L. Graham
V. O. N. Advisory Board
Dr. I. T. Day
Dr. W. H. Hatfield
Dr. A. B. Schinbein
Sickness and Benevolent Fund — The President — The Trustees
Rep. to B. C. Medical Assn
Dr. Wallace Wilson I iii
Diphtheria Antitoxin
Diphtheria Toxin for Schick Test
Diphtheria Toxoid   (Anatoxine-Ramon)
Scarlet Fever Antitoxin
Scarlet Fever Toxin for Dick Test
Scarlet Fever Toxin
Tetanus Antitoxin
Anti-Meningitis Serum
Anti-Pneumococcic Serum. (Type 1)
Anti-Anthrax Serum
Normal Horse Serum
Smallpox Vaccine
Typhoid Vaccine
Typhoid-Paratyphoid Vaccine
Pertussis Vaccine
Rabies Vaccine   (Semple Method)
Price List Upon Request
University of Toronto
Depot for British Columbia
Macdonald's Prescriptions Limited
Medical-Dental Building, Vancouver, B. C. VANCOUVER HEALTH DEPARTMENT
Total Population (Estimated) .  244,329
Japanese Population  (Estimated).  8,037
Chinese Population (Estimated) _^__!  7,803
Hindu Population (Estimated) :  276
Total   deaths	
Japanese  deaths
Chinese   deaths.
Deaths;:—Residents  only 139
Birth Registrations: Male, 164; Female, 145 309
Rate per 1,000
Deaths under one year of age	
Death rate—per 1,000 births	
Stillbirths  (not included in above).
Sept., 193 5
Sept., 1934
August, 193 5
Cases Deaths
Smallpox  0 0
Scarlet   Fever  20 0
Diphtheria .  0 0
Chicken   Pox .  11 0
Measles   ! .  15 0
Rubella .  0 0
Mumps  2 0
Whooping-cough  '    7 0
Typhoid Fever   2 0
Undulant Fever   3 0
Poliomyelitis j  0 0
Tuberculosis   36 9
Meningitis   (Epimedic)  0 0
Erysipelas : -.—  1 0
Encephalitis   Lethargica  0 0
Paratyphoid  2 0
September, 193 5
Cases     Deaths
October 1st
to 15th, 1935
Cases     Deaths
High Blood Pressure...
"The most effective therapy available."
Formula—Each 1 cc. Ampoule contains:
Pancreas    25 grammes of the fresh hypotensive principle
Anterior Lobe Pituitary 2 grammes of fresh substance
Kmbryonin    i— 2 grammes of fresh substance
Biological and Research
Ponsbourne Manor, Hertford, England.
Rep., S. N. BAYNE
1432 Medical Dental Building       Phone Sey. 4239        Vancouver, B. C.
References: "Ask the Doctor who has used it."
Page 24 in
Obtainable  front B. O. Drug's  Limited,  Vancouver;  Georgia  Pharmacy, Vancouver; McG-ill & Orme, Victoria.
Founded 1898
Incorporated 1906
Programme of the 3 8th Annual Session
GENERAL MEETINGS will be held on the first Tuesday of the month
at 8 p.m.
CLINICAL MEETINGS will be held on the third Tuesday of the month
at 8 p.m.
Place of meeting will appear on Agenda.
General Meetings will conform to the following order:
8:00 p.m.—Business as per Agenda.
9:00 p.m.—Paper of the evening.
Dr. G. F. Strong: "Cardiac Pain."
Discussion opened by Dr. H. A. DesBrisay.
Dr. A. M. Agnew: "Vaginal Plastic Surgery."
Discussion opened by Dr. J. J. Mason.
Dr. J. R. Naden: "Epiphyseal Injuries."
Discussion opened by Dr. F. P. Patterson.
Dr. J. H. MacDermot: "Early Medical History of the B. C. Coast."
Dr. Lyall Hodgins: "Diabetes."
Discussion opened by Dr. Wallace Wilson.
Dr. Frank Turnbull: "The Early Diagnosis of Brain Tumours."
Discussion opened by Dr. F. W. Emmons.
Dr. Walter M. Paton: "Tumours of the Head and Neck."
Discussion opened by Dr. H. H. Pitts.
Dr. B. J. Harrison: "Roentgenology of Cardiac Diseases."
Discussion opened by Dr. G. F. Strong.
Mr. J. W. deB. Farris: "Medico-Legal Problems."
Dr. C. E. Dolman: "Serum Therapy."
Discussion by Dr. Howard Spohn and Dr. A. Y. McNair.
Page 25 11
I 111
An interesting study that might some day be undertaken, preferably by
a hard-headed, mathematically-minded Scotchman of the actuarial type of
mind, would be the matter of "vested interests," as we call them—how
they begin, how they grow, and their effect on society. Somebody plants a
seed in good soil, and we don't know whether it will grow into a cactus or
a banana palm until it has grown and taken firm root and established, so to
speak, a claim for existence.
There are vested interests and vested interests. Some are frankly pernicious, others are beneficial and useful; all have one thing in common: like
Frankenstein's statue, they are quite different from what they started out
to be, and full of all sorts of unsuspected potentialities, some of which are
not quite as innocent as they appeared at first to be.
To "cut the cackle and come to the 'osses," we are indulging in these
flights of fancy, inspired thereto by the reading of a book written by an old
acquaintance of ours, Dr. Malcolm T. McEachern, formerly General Superintendent of the V. G. H. The book is entitled "Hospital Organization and
Management," and is a monumental piece of work. It is in many ways a
unique book. Primarily it is intended as a textbook of the subject which
gives it its name, but is prefaced with a short but quite vivid and interesting
history of hospitals. Dr. McEachern early refers to his King Charles' head,
viz., the standardisation of hospitals, and expatiates on the virtues of this
step. He is no doubt right, and yet an unregenerate corner of our soul refuses
to accept standardisation and the somewhat Fascist attitude adopted by the
American College of Surgeons as the final key to happiness and complete
However, this is heresy. He then plunges in medias res of his subject, and
from then on the book is a masterly summary, and most amply documented
account of hospital organisation. Nothing is forgotten—not even the
patient. For instance, we open the book at "The Minimum Standard."
There are five standards. The first four deal entirely with organization, the
last refers to "the necessity for diagnostic and therapeutic facilities . . .
for the study, diagnosis and treatment of patients."
If one were preaching a sermon, one would need a text. Our opening
remarks referred to vested interests, and their departure in many details
from the original ideals with which, or as a result of which, they came into
being. No better text could we find than the curious fact referred to above,
that in defining the objects of a hospital, the care of the patient is put last.
That this is not Dr. McEachern's ideal is shewn by his own definition of
the first function of hospitals, which is "to care for the sick."
Still, it is interesting to trace the growth and the trends of thought and
development which have made it possible for any organisation to place last
the purpose for which it was first designed, and to put first the educational
and organisational aspects of its work. These aspects are important—very
important—but they should surely be secondary. And it is where they are
put first that the interests of the sick person, who is really the one important
consideration, may suffer somewhat.
The hospital is today a great school—for nurses, for doctors, and, as we
are sometimes reminded in this book, for the public. We are told that it is
a "health centre" whence radiate knowledge of health, and education in
preventive medicine; whence social service emanates; round which cluster
the temples of community medicine. This is all as it should be, if it was so—
Page 26 but is it always so? True, we have clinics, and immunizing depots, and pure
milk stations and chest clinics—and they all do excellent work. But we
cannot help feeling that a hospital is, after all, one of the doctor's main
weapons against disease, and in our earnest desire for prevention, inadequately supplied as it must needs be by the hospital, we may overlook or
impair our real raison d'etre, treatment. Prevention we must have, far more
indeed than we now have, but we question, in our old-fashioned way,
whether the hospital is the place for it. Perhaps some day we shall have the
courage to tell the public that the hospital is the place for the sick, and that
prevention should be carried on in specially designed institutions—where
it can grow to full stature itself, and neither hamper* nor be hampered by,
its sister, therapeusis. In this way, prevention of disease would assume the
importance that we should attach to it; at present it is a sort of Cinderella
of medicine, and gets what is left over after the main business of the hospital
is done.
The book has a remarkable series of pictures, rather of the poster type
of picture, and admirable bibliographies. It should be a very valuable reference book for all hospitals; and we most sincerely congratulate the writer
on the work he has done.
Members of the V. M. A. are reminded that annual dues for the current
year should have been paid on April 1st and are now seven months in arrears.
We publish in this number an open letter from Dr. H. H. Milburn,
president of the B. C. Medical Association. We are heartily in accord with
his suggestions and appeal for endorsement. We feel that the most important
step we can take is to consolidate the Canadian medical profession. As provincial bodies we are almost if not quite helpless; as a national body we could
"speak with our enemy in the gates" in tones that no political Mussolini
could shout down.
We must, as Dr. J. C. Meakins pointed out in his address while here,
organise nationally. Our very bread and butter, not to mention all medical
progress in Canada, depends on our unity and coherence. For a very slight
additional fee, we can obtain inestimable benefits; and no man can lightly
disregard this challenge, for his own sake, if not for those of his colleagues
and profession.
Dr. Murray Meekison is in San Francisco. He expects to be gone about
three weeks, and will take the meeting of the A. C. S. in his stride.
A weeding of much interest took place at Marpole United Church on
October 5th when Dr. E. E. Day was married to Miss Gertrude Douglas of
Vancouver. Dr. R. P. Kinsman was "best man" when the gong sounded but
at the last moment the decision went to Dr. Day. The winner and his bride
then left for a journey to California.
Dr. A. C. Des Brisay and Dr. Taylor Henry1, left for the Mayo Clinic on
October 15tjt After learning what it is all about, they expect to return
home by way of San Francisco about the beginning of November.
Page 27 We note with regret that Dr. W. D. Brydone-Jack is in the General
Hospital as a patient. We wish him a speedy return to health and activity.
As also to Dr. A. Mack Warner, who has been ill for quite a while, but
at the time of writing is feeling a good deal better.
We note the name of Dr. C. F. Covernton as away from the city. His
son has recently entered McGill.
Dr. A. B. Schinbein has left for San Francisco, where he will attend the
meeting of the American College of Surgeons.
Dr. Gordon James, formerly with the Granby Consolidated Mining &
Smelting Co. at Anyox, is now with the Britannia Mining Co.
At the opening meeting of the 193 5-36 session of the Vancouver Medical Association Dr. J. W. Thomson presented a report of a very successful Summer School. An exceptional feature this year was that
although the B. C. Medical Association had offered to make up any deficit
within certain limits, there turned out to be no deficit but a surplus of
funds. In the course of his report Dr. Thomson paid warm tribute to the
very efficient secretaryship of Dr. J. E. Walker. He recommended that the
1936 Summer School be held in September on account of the Canadian
Medical Association meeting in June, and that the B. C. Medical Association
be asked for a regular grant of $500 towards the Summer School. This was
put in the form of a motion and carried.
The election of Dr. F. J. Nicholson to life membership was moved by
Dr. G. F. Strong, seconded by Dr. J. W. Thomson, and passed unanimously.
Dr. Nicholson's generous contributions to the Library are known to all the
The Chairman, Dr. C. H. Vrooman, drew attention of the meeting to
the register now prepared and requested members to call in at the Library
and fill in the data concerning themselves for the edification of future members of the Society. It is hoped that these will be a little more informative
and detailed than that of the Jewish merchant who was asked to fill out a
form for the immigration authorities. After stating his name he put after
the word "born" the simple affirmative "yes" and after the word "business"
the comprehensive statement "rotten."
The announcement was made of the resignation of Miss Firmin, the
Librarian. The members were requested to make themselves known to Miss
A tentative announcement was made of a special meeting to be held
on the last Tuesday in October to pass the new by-laws and possibly to discuss further the matter of Health Insurance.
Dr. A. C. Frost and Dr. J. R. Naden were elected by acclamation to
the Summer School Committee.
Some innovations were announced concerning the presentation of papers
at meetings during the coming session. The time of twenty minutes and
not more is allotted to the reading of the paper and the presentor will be
given three minutes warning of the time when his presentaB&n must terminate. Speakers are requested to appear in evening dres|j|Two papers will
Page 28 be presented at each meeting and one person selected to open the discussion,
with a short time allotted to others who may wish to follow him.
The first paper of the evening was by Dr. G. F. Strong on the subject of
"Cardiac Pain." In view of the number of categories under which this subject might be discussed, Dr. Strong decided to limit himself to the subject
of the pain of angina pectoris. His lecture appears in full in this issue.
The second paper of the evening was given by Dr. A. M. Agnew on
"Vaginal Plastic Surgery, illustrated by an excellent series of diagrams. The
paper was discussed by Drs. Mason and Arbuckle, and several other members.
Dear Doctor:
At the Annual Meeting of the B. C. Medical Association in Vancouver
on September 20th last a resolution was moved by Dr. Hodgins, "That our
Exectffiive be given power to so change our constitution that it be known as
the Canadian Medical Association, B. C. Division, and that in addition our
Executive take such steps as are necessary to finance the undertaking." This
was passed unanimously and is a mandate, I take it, for the present Executive to confer with the Council of the College of Physicians and Surgeons
and consummate the change with the least amount of delay.
Under the "optional plan" as adopted by the Canadian Medical Association at Atlantic City last June, a "Division" is a provincial association
which has merged its identity in that of the Canadian Medical Association
and is known as the Canadian Medical Association (name of province)
Division. All its members are members of the Canadian Medical Association and are entitled to its rights and privileges, including subscription to the Journal. A division sets its own membership fee but includes
for each member a sum to be determined by the General Council for national
administration. Here again this sum could be at least 20 per cent lower than
the $10.00 charged for members of branch associations.
Each Division nominates its own representatives on the General Council, Nominating Committee and Executive Committee of the Canadian
Medical Association, the elections being left in the hands of the General
In order to become a Division all members "of the B. C. Medical Association must become members of the Canadian Medical Association, the
additional fee to be $8.00 instead of the $10.00 Canadian Medical Association fee now in effect—subscription to the Journal is included. This will
make the combined fees of the College of Physicians and Surgeons ($12.00)
and the Canadian Medical Association ($8.00) $20.00. We now have
some 324 members of the Canadian Medical Association in B. C, roughly
half of the members of the B. C. Medical Association. These members will
save 20 per cent of the present Canadian Medical Association fee by the
Naturally one asks how will this change affect our position? I feel sure
that everyone who gives this matter careful thought will reajize that it
will materially strengthen it. Instead of being a provincial organization
affiliated only with the Canadian Medical Association, we will be an integral
part of a national federation still maintaining our own organization, and
should emergencies arise, such as the present pending Health Insurance legis-
Page 29 I,
lation, we would be able to have the full strength of the national association
behind the profession here. This point was very emphatically stressed by Dr.
Routley at our Annual Meeting last month. The increased revenue of the
Canadian Medical Association will allow for more post graduate activities
on the part of that body we are assured, and probably increased secretarial
services, with the possibility of a Western Secretary being appointed. Alberta
has already become a Division, and other provinces are in the process of
doing so. I am sure all must agree that medicine in Canada now more than
ever before is in need of strong effective organization—the larger it is the
more effective it will be.
Your Executive feels that the sooner this change is accomplished the
better, particularly since the proposal has met with such widespread approval
on the part of the profession of the province—so far I have heard from no
objectors. To this end we are earnestly requesting the support and co-operation of all members of our Association in the move which it, at its Annual
Meeting this year, authorized us to make. The Council of the College of
Physicians and Surgeons we trust will lend its full assistance, particularly
in arranging the financial end of the undertaking. Your Executive will do
its utmost to carry out your expressed wishes.
Faithfully yours,
H. H. Milburn.
i ill
Dr. H. H. Milburn
It was imperative that Dr. A. D. Lapp, our President, be in Toronto by
the 17th of the month, making it impossible for him to be present at this
meeting and preside. It must have been a great disappointment to him,
having given, as he did, a great deal of time and thought to the interests of
our Association, particularly during the past two years. He was keenly
interested in the success of this meeting. I very much regret his absence and
only hope in filling his place I have been able to measure up in some degree to
the necessities of the occasion.
In reviewing the work of the B. C. Medical Association during the past
year permit me to comment briefly on the activities of the various committees. First, that of the Cancer Committee under the chairmanship of
Dr. J. J. Mason. Dr. Mason has been particularly interested in this work for
a number of years and was largely instrumental in establishing a cancer
section in our local association in Vancouver. When the impetus for renewed
activity in cancer study was supplied by the drive for funds throughout
Canada by the King George V Jubilee Cancer Fund, he was the right man
in the right place. Taking advantage of the opportunity offered by the
drive, he organized a large representative committee including men from
the various local associations throughout the province, nad began a careful
study of our needs in British Columbia, at the same time supporting the
Jubilee Campaign as much as possible. The B. C. Cancer Foundation was
really initiated by Dr. Mason's committee when it invited two representatives from the Health Bureau of the Vancouver Board of Trade and two
from the Greater Vancouver Health League to meet with two representatives from his own committee to discuss ways and means of meeting the
urgent problem of cancer treatment iin British Columbia. The Cancer
Foundation of B. C. is now an active organization incorporated under the
Societies Act of the province, with prominent laymen from nearly every
Page 30
m section of B. C. on its Board of Governors. They are keenly interested and
are very much alive to the situation. The Foundation is making arrange-
mentSor an active campaign to raise funds in the near future and government support has already been assured. I feel confident that facilities for the
efficient handling of this most dread disease will be very markedly improved in the not far distant future through this organization. The present
objective is the establishment of a Cancer Institute at some central point
with, perhaps, cancer centres elsewhere in the province. A very cursory
examination of our present equipment for treating cancer in B. C. will
show the great need for this. We are pleased to note this activity in our
Association and through our Cancer Committee the profession must continue to sponsor and give leadership in this work. Let me urge all local
associations to have active Cancer Committees keeping in touch with what
is going on elsewhere in the province through their representatives on the
Provincial Committee, so that when any movement like a province-wide
drive for funds takes place they will be able to give it the proper medical
support in their localities.
The work of the Programme and Budget Committee under Dr. Strong
has surely shown its activity and efficiency in arranging this convention.
It speaks for itself and needs no comment from the Chair. All I will say
further is that I have attended conventions which were no better and in
some instances not as good at which registration cost me more than the
$12.00 we have paid for our membership in the College of Physicians and
Surgeons of B. C, which includes our registration at this meeting.
At the Annual Meeting of the B. C. Medical Association at Kamloops
last year we had the opportunity for the first time of meeting as the College
of Physicians and Surgeons of B. C. and hearing directly from the members
of the Council a report of the activities of that body—we were privileged to
discuss with them the problems they were handling for us. At 8 o'clock tonight we shall again have that opportunity, and with Health Insurance the
vital question of the day, it should be a very important meeting, to say the
least. I feel that we are particularly fortunate at this time in having an
organized body, representative of the whole profession of the province,
responsible for our economic interests. The work of the Health Insurance
Committee under Dr. Ainley has made it possible for us to have the proposed Health Insurance Bill carefully studied from the medical man's standpoint, and I hope it will allow us to present a united front in the matter of
Health Insurance. The reorganization of the two provincial bodies, namely,
College of Physicians and Surgeons and B. C. Medical Association, which
was completed two years ago, has already justified tself, I feel. Certainly
every member gets his $12.00 worth this year.
Dr. Amyot, on behalf of the Health Committee, has given us some very
valuable suggestions, and if we are able to take advantage of these some of
the work now done by Public Health bodies should be diverted to the practising physicians to their advantage. Study and co-operation on our part,
through our own committees, both local and provincial, on health matters,
may do a great deal for us. I cannot emphasize too strongly the value of
■committee work.
Dr. Prowd's report as Chairman of the Constitution and By-laws Committee is important. The change in our by-laws made tonight makes provision for a larger executive by the addition of a Second Vice-President and
the Chairmen of Standing Committees: most of these committees are similar
to standing committees of the Canadian Medical Association. The Chairmen
Page 31 of these provincial committees are to be members of the similar Canadian
Medical Association committees. This arrangement was initiated by the
Canadian Medical Association executive this year and should insure better
committee work than formerly, as the Chairman of a provincial committee
naturally will be a keenly interested man and should be able to represent his
province better than one who is chosen by the Canadian Medical Associa-ion.
By this arrangement standing committees of the Canadian Medical Association shoud be very representative of the whole Dominion. This should
harmonize the organization work of the profession throughout Canada a
great deal.
I would like to see this arrangement carried out still further and similar
standing committees to those of the Canadian Medical Association and Provincial Associations appointed by the local societies, the chairmen of the
local association committees to be automatically members of the Provincial
Committee. This would make the Provincial Committee a representative
body also, representing in this instance all the local societies of the province.
It strikes me that this would create much more interest in medical affairs
by the profession generally. We need now, more than ever before, better and
more effective organization in facing our problems. These cannot be solved
by individual action any longer. We simply must see to it that only men
who are interested and are willing to give both time and thought to the work
they undertake are selected to, represent us. If we build from the bottom in
this way we should have a strong organization fully capable of handling our
many and increasingly complex problems. Among other things, medicine
has considerable house-cleaning to do and the sooner we do it the better.
The Publicity and Educational Committee under Dr. Purvis has worked
largely with the Cancer Committee this year and its part has been reflected
in the excellent work of that committee.
Dr. Cleveland through B. C. news in the Canadian Medical Association
Journal and the Bulletin of the Vancouver Medical Association has kept
B. C. medicine in the limelight every month. He is an excellent editor and is
constantly on the lookout for news of interest to the profession.
You can see from this brief summary that your committees have not
been idle during the year. They have accomplished a great deal and have
begun valuable work in several directions which I trust will be carried
forward by their successors. If men will offer themselves more willingly and
whole-heartedly to the study of our medical problems in committee work
I am sure both medicine in general and they themselves will reap abundantly.
There is one matter I must mention before closing which we will have to
deal with shortly, and that is closer union of the Provincial Association with
the Canadian Medical Association. Under the revised constitution of that
body each Provincial Medical Association is recognized as a branch of the
Canadian Medical Association and shall be represented in the general council and the executive of that body. Sholl we become a Division of the Canadian Medical Association and change our name to the Canadian Medical
Association B. C. Division? At the meeting in Atlantic City two plans were
submitted—the "All-or-None Plan" and the "Optional Plan." These are
fully explained in the supplement of the September issue of the Canadian
Medical Association Journal, which I hope you have all read. The Optional
Plan was adopted, as follows:
A Provincial Association may, by resolution of its governing body, become
either a Branch or a Division of the Canadian Medical Association.
Members of a Branch Association are entitled to membership in the Canadian
Page 32 Medical Association and to all its rights and privileges, including subscription to
the Journal, on payment of the annual fee.
A Division is a Provincial Association which has merged its identity in that of
the Canadian Medical Association and is known as the Canadian Medical Association (name of Province) Division. All its members are members of the Canadian
Medical Association and are entitled to all its rights and privileges, including subscription to the Journal. A Division sets its own membership fee, but includes for
each member a sum to be determined by the General Council for National administration. Here again it has been shown that this sum could be at least 20 per cent
lower than the $10.00 fee of members of Branch Associations.
Each Branch or Division has representation on the General Council ana on
the Executive Committee irrespective of its official status, but a Division, as in the
"All-or-None" plan) nominates its own representatives on the General Council,
the Nominating Committee and the Executive Committee, the elections being left
in the hands of the General Council.
You are aware that two years ago we adopted a plan in British Columbia
similar to that which had been operating in Alberta for a number of years,
where the Alberta Medical Association joined with the College of Physicians
and Surgeons of that province in a combined scheme, the Council of the
College of Physicians and Surgeons undertaking to look after the economic
part of the work and the Alberta Medical Association the educational and
scientific part. A single compulsory fee was set to finance the operation of
the two bodies. It has worked very) satisfactorily in Alberta and so far has
done so here. (When the Council appoints a full-time Executive Secretary
it will perhaps operate even better.) How does this affect our becoming a
Division of the Canadian Medical Association? If the Council of the College of Physicians and Surgeons could legally make grants to us as Canadian
Medical Association (B. C. Division) we may be able to become such. There
is a legal point to settle in this and at our request the Council is having it
investigated. If it finds it can legally do this, then the whole matter
will have to be submitted to the medical men of the province for their
approval, as there would have to be an extra fee of $8.00 per member
charged to take care of the membership in the Canadian Medical Association including the Journal. The Alberta Medical Association has recently
revised its by-laws with this object in view apparently. Dr. Prowd in his
report has made brief reference to it. I personally am in favor of it as it
would make for a much stronger organization and certainly would have
greater influence in any part of Canada where influence was required—for
instance, Health Insurance in British Columbia. A government would respect
the opinions of an organization representing the whole profession of the Dominion more than that of a single province. As the Canadian Medical Association (B. C. Division) we could draw on the resources of the whole Canadian Medical Association, as what would affect any part of the Canadian
Medical Association would consequently affect the whole. However, this is a
matter for the new Executive and new Constitution and By-laws Committee to undertake. This is where a representative Committee would operate
to advantage. The federation of committee work as I have suggested earlier
in this report seems to be to be an ideal working arrangement .
p|me does not permit me to deal more with this matter at this time but
I trust the opportunity will present itself in the near future for so doing.
I take this opportunity of expressing the sincere thanks of both Dr.
Lapp and myself to the members of the Executive and the Committees of
this Association for their excellent work and generous support during the
year. I cannot imagine anything more interesting and instructive than the
discussions that took place in many of our Executive meetings. All expressed
Page 33 ApmL
themselves freely and very fairly, and in nearly all matters under discussion
definite agreement was reached.
We particularly wish to express our sincere thanks to our retiring Secretary, Dr. Ethlyn Trapp, for her excellent services during the past two years.
She has given very generously of her time and talents in the interests of our
Association, especially this year in our Cancer activities. We trust that her
contemplated trip to Europe will be fruitful and pleasant.
I also wish to thank this Association for the high honour it has done me
in electing me President and hope and trust that I may be able in some way
to merit your confidence. I shall do my best.
In closing I wish to remind you that the Canadian Medical Association
Convention will be in Victoria next June and the generous support of this
Association must be behind Victoria medical men in the task that lies
before them.
G. F. Strong, M.D.
Ten years ago I read a paper to this Association on Cardiac Pain, and
it occurred to me that it might be of interest and some value to bring that
subject down to date. In the previous paper heart pain was classified as:
(1) simple fatigue pain such as occurs in some cases of long standing
valvular disease, vascular hypertension, and in certain of the arrhythmias
such as paroxysmal tachycardia or fibrillation; (2) the pain of nervous
irritable heart, the so-called effort syndrome or neurocirculatory asthenia;
(3) the pain of angina pectoris, and (4) most severe of all, the pain of
coronary thrombosis. Tonight I am going to discuss angina pectoris, choosing this type of heart pain because of the apparent increase in this interesting and important cardiac condition.
Ten years ago we were witnessing the long argument between the
so-called "aortic" and "coronary" schools of thought regarding the origin
of anginal pain. Allbutt had maintained that angina occurred as a result
of irritation of sensory nerves in the wall of a diseased aorta. McKenzie
and others had expressed the idea that the pain of angina arose from the
heart muscle as a result of disturbance in the circulation through the
coronaries. At the present time the trend of medical opinion is toward
this myocardial-coronary idea. The only way that aortic disease can produce angina is through narrowing or puckering of the orifices of the
coronary arteries in the aorta with a resulting diminution in blood flow to
the heart muscle. The best argument in favor of the coronary theory of
angina is the fact that the pain in coronary thrombosis is so similar to the
pain of angina, in character, in location and in radiation, differing only
in severity. The reduction in coronary circulation is brought about in different ways, as by coronary spasm, by actual coronary narrowing (coronary sclerosis), or by relative coronary narrowing as when the stiffened
coronaries are unable to dilate to meet the increased demands made on the
heart during exertion or excitement. The .coronary circulation that may
be adequate when the patient is at rest may be entirely insufficient when
the heart rate is suddenly increased. Pain probably develops when the
reduced blood supply leads to an anoxaemia and permits the accumulation
of the end products of muscular activity. Just how this pain is produced
and just which of the metabolites proves irritating to the sensory nerves
Read at meeting of the Vancouver Medical Association, October 1, 193 5.
Page 34 ending is still obscure. The nerve pathways by which the sensation reaches
the level of consciousness are now fairly well determined, and this knowledge has enabled surgeons to give some of these cases relied.
The sensation described by angina patients varies from a severe pain to
a mild distress or oppression. The adjectives are aching, burning, gnawing,
boring, gripping, tearing, twisting. In the milder forms there is a sensation of weight, pressure, or discomfort. The commonest site of the pain
is under the middle of the sternum and it is generally true that while in
rare cases the pain of angina may occur elsewhere, in the great majority
the sensation is localized to the centre of the chest. So true is this that the
diagnosis must be regarded with suspicion where the only pain or distress
occurs elsewhere and in such cases there must be confirmatory evidence
such as the existence of organic heart disease, coronary sclerosis or hypertension, or the distress must be definitely and constantly associated with a
given amount of exertion. There is often an association with flatulence, a
fact which leads to a diagnosis of indigestion. A distended stomach may
easily precipitate an attack of angina by the upward pressure causing
torsion of the heart with consequent angulation of one or both coronary
arteries. Invariably angina is brought on at first by exertion or excitement
and is induced more readily by exercise immediately after a meal, and in
cold weather. The duration of the pain is important, for in angina the
typical attack is transient, lasting from a few seconds to 15 or 20 minutes.
Pain that lasts over half an hour and certainly that persisting for more
than one hour is most unlikely to be the result of uncomplicated angina.
These longer attacks suggest mild coronary thromboses, of which there
are probably a great many more than we realize. Aortitis may also give
rise to more lasting pain, as may other non-cardiac causes to be mentioned
later. The text book description of angina is apt to stress radiation of the
pain down the left arm. While it is possible to have radiation to either
arm, more commonly the left, it is by no means an essential feature of
the attack. In rare cases the attack may start with pain or discomfort in
the wrist or elbow which then spreads to the substernal region. Other non-
cardiac conditions may cause distress down the arms. There are certain
other manifestations that occur in these patients which might be designated as anginal equivalents. The commonest of these is cardiac asthma
and the more serious pulmonary oedema, both of which probably arise as
evidence of weakness of the left ventricle consequent upon coronary
sclerosis. Many patients with angina develop cardiac asthma as a terminal
event and these patients invariably exhibit evidence or coronary sclerosis.
The diagnosis of angina pectoris must rest on the patient's own story.
No doubt an intelligent and informed malingerer could deceive the most
astute diagnostician. The story told by a neurotic patient full of aches
and pains must be distinguished from the definite effort distress as detailed
by the stoic. Often we can judge the patient fairly accurately in the course
of our first examination and gain an idea as to his interpretation of pain.
It is well known that a given stimulus may produce pain in one patient,
a mild distress or discomfort in another, and absolutely no sensation in a
third: Where there is difficulty in deciding the type of patient we are
dealing with there are several methods of gaining insight on this point
and we must attempt to classify our patients into the hypersensitive, the
normal or the hyposensitive group. One simple procedure that I have found
helpful in this regard is to observe their reaction to the taking of their
blood pressures.  Some few hypersensitives complain bitterly during the
Page 3 J i!
time the pressure is elevated in the cuff. Another useful observation is
their reaction to dental work—some hypersensitive individuals cannot
stand any sort of work requiring a drill without the use of a local anaesthetic, whereas, at the other end of the scale, the hyposensitive individual
submits to anything, even extraction, without any anaesthetic and without much discomfort. Libman many years ago suggested the ffinple procedure of cousing pressure on the styloid process and studying the patient's
reaction. Osier suggested steady pressure on the sternum just above the
attachment of the iphoid which causes a disagreeable gnawing ache that
is disturbing even to a normal person. By the application of one or more of
these tests we can classify our patient and this will go a long way to help
us to evaluate the significance of his symptoms.
Angina is more common in men than women, a fact which should
make us regard with suspicion the extremely atypical case in a woman.
It is not necessarily a disease of old age but may occur in the thirties,
though the commonest age is the late forties or early fifties. It is essential
to take a careful record of the patient's own sensations in his own words.
In the great majority of cases this simple record will establish the diagnosis.
Physical examination and an x-ray and an electrocardiogram merely confirm and the latter methods furnish a graphic record of the condition. In
most of these patients there is a hypertension, evidence of generalized
arteriosclerosis, or organic heart disease. Some few will present entirely
normal physical findings. It is possible for a patient suffering from angina
to successfully pass an insurance examination. For this reason most companies now require an x-ray and a cardiogram on applicants for large
policies who are over 5 0 years of age. The electrocardiogram has its greatest value in this group of patients. A normal cardiogram is a finding of
some importance particularly regarding prognosis. The cardiogram is the
best method we have of detecting the presence and the extent of coronary
sclerosis and most patients with angina show evidence of some deviation
from normal. Coronary sclerosis is suggested when the cardiogram shows:
(1) block, particularly of the intraventricular type; (2) T wave changes
—either the so-called coronary T wave or definitely abnormal inversion;
(3) disturbance, either depression or elevation of the R-T segment, the so-
called low or high take off, and (4) development of Q wave in lead III. Most
important of all are the serial changes, as by repeated observations minor
deviations from the normal may be detected. Of interest but not much clinical importance are the changes in the cardiogram that occur during an
attack. It has long been recognized that there are often certain definite and
constant changes that occur when these patients develop an attack of
angina1, 2. Interestingly enough these changes are very similar to some of
those observed as a result of coronary thrombosis—agaifc confirming the coronary basis of angina. These changes are also seen in individuals subject to
rebreathing sufficient to produce an anoxaemia3, 4. There is a depression of the
R-T segment in one or more leads and a sharp inversion of the T wave in
leads I and II, or II and III. Widening of the initial ventricular deflections
also occurs of the type formerly designated as aborization block or the more
common forms of branch block. In certain cases a fourth or chest lead is
desirable, as it may bring out evidence of coronary sclerosis that is not
detected by the three ordinary leads. This fourth lead is secured by applying
electrodes to the anterior and posterior chest walls.
Differential Diagnosis.—Many patients complain of pain in their chest,
many believe this pain arises from the heart and in many there is a fear of
Page 36 the dread angina. The pain or discomfort of angina pectoris must arise as
a result of exertion or excitement, must be of short duration, and must be
relieved by rest and the nitrites. If we adhere rigidly to this simple rule
much of the difficulty of differential diagnosis will be overcome. There
are, however, many borderline cases, the most difficult, in my opinion,
being in the group with nervous irritable hearts. Practically all of these
patients complain of pain in their heart but this pain is usually apical, is
constant, is not definitely related to exertion, and is not relieved by nitrites.
Certain mild cases of coronary thrombosis will present a picture very
similar to angina and the importance of making a differential diagnosis
lies in the extreme importance of instituting proper treatment. As already
pointed out, the pain in coronary thrombosis is similar in location, character and radiation to the pain in angina. The former is usually much
more severe, persists for hours and is associated with shock, a rapid pulse
and a low blood pressure. In cases of coronary thrombosis where the vessel
that is plugged is small the pain may be very mild, may not persist, and
the symptoms of shock may be wanting. It is there that confusion may
arise. The pain of coronary thrombosis is not relieved by nitrites but
requires morphine. The doubtful cases should be watched and invariably
in coronary thrombosis they will show slight temperature, a fleeting pericardial rub, or a leucocytosis within the first 72 hours of the onset. These
patients must be kept in bed for 4 to 6 weeks, a precaution not necessary
for every case of angina. In certain instances of severe anaemia anginal
pain may occur even with perfectly normal coronary arteries. This pain
disappears when the anaemia is adequately treated. Hyperthyroidism may
produce an angina because of the excessive demands made on the heart by
the elevated metabolism, and in these an accurate diagnosis is important
because the angina can be relieved by curing the hyperthyroidism.
Of the non-cardiac causes of chest pain that may lead to confusion
the commonest is the pain occurring in cases suffering from arthritis of
the dorsal spine. Here we are more apt to find pain related to rectain postures or certain movements as, for instance, turning over in bed or in
reaching or twisting, and there is no nitrite relief. Another confusion arises
in intercostal neuralgia in which the pain is more constant and not affected
by exertion or excitement. Again in all these instances it is important to
determine the type of patient with whom we are dealing. Peptic ulcer may
occasionally cause some confusion but a more common gastro-intestinal
source of difficulty is the gall-bladder. A diseased gall bladder can produce
a certain amount of distress under the lower sternum and a biliary colic
may suggest angina, but again there is no relation to exertion and no
nitrite relief. A cholecystitis may aggravate a latent angina.
Prognosis.—In the course of an uncompleted study of my own private
cases of angina pectoris seen prior to the end of 1934 I have thus far
reviewed 186 records. The figures on these patients are of some interest.
No. %
Recovered    ___        11 5.9 j.
Improved  =     50 26.8 j    -/
Unchanged   _      15 8.0
Dead      74 39.7
Not    traced _  36 19.3
In spite of a general attitude on the part of the medical profession that
angina is hopeless, a third of these patients were benefited by medical
Those that recovered were invariably those that were able to readjust
Page 37 i ' -: a
their lives to a much restricted level of physical activity. Many of those
classed as improved considered that they had recovered, in that their pains
were much less severe and less frequent. Where any recurrences occurred,
however, they have not been listed as recovered. Many of those that were
unchanged were victims of circumstances over which they or their doctors had no control—improvement could hardly be expected in this group.
Many of those that died were improved for a matter of months or several
years before their deaths. Most of those not traced were from out of town
and were seen only once. The commonest cause of death was coronary
thrombosis though some died of progressive congestive heart failure. Ten
patients suffering from angina survived an attack of coronary thrombosis.
There was a high incidence of cerebral vascular accidents in this group
of patients, an indication of the accompanying hypertensive cardiovascular
In view of these figures I think our attitude regarding angina should
be revised. While it is a serious malady, much can be done by adequate
medical management to relieve or improve these patients. Many will live
for years to die of some other condition. There is no relation between the
severity of the pain and the prognosis. The most serious aspect of angina
is its uncertainty—at any time coronary thrombosis may occur, and if
this involves a large branch death may be instantaneous. The occurrence
of angina while at rest, or cardiac asthma, or pulmonary cedema, adds to
the gravity of the prognosis.
Treatment.—Rest is our most important therapeutic agent and rest
must be a part of any treatment that we outline. Invariably these patients
are of the keen, over-active type that throw themselves into their work
wihout stint. Ofen, moderation or slowing up will lessen the frequency
and severity of their attacks. Occasionally a month or six weeks of absolute bed rest is necessary to secure relief. The diet should be simple full
diet in small amounts, and rest after meals is often beneficial. These
patients should discontinue the use of tobacco. I think that there can be
no doubt that tobacco is capable of producing a certain amount of heart
pain. For the relief of the attack nitroglycerine grains l/lOO in hypo
tablet under the tongue usually produces prompt results, though a few
patients find the inhalation of amyl nitrite more effective. As to activity
the rule should be to avoid that amount of exertion that will produce pain.
Treatment between attacks must be given to the patient as well as to the
angina. Theobromine grain 5, three times a day, after meals, has seemed
to me of definite benefit—often combined with l/z grain of phenobarbital
where hypertension or nervousness exists. My practice is to give this remedy for three weeks each month over long periods. The other xanthine
derivatives have not been of any greater value to the patient and are all
more expensive. Euphyllin can occasionally be substituted for theobromine. Occasionally I have used it intramuscularly in severe cases but
without much success. The time-honored iodides are always worth using
in small doses of 5 to 10 grains, three times a day after meals, over long
periods, at least three months at a time. Digitalis in so-called tonic doses
of grains 1 l/z once a day is often beneficial. The great majority of angina
patients will benefit by a combination of rest, nitrites, theobromine and
iodides. In fact, I think 90 per cent will be eanbled to carry on sedentary
or very light work. The remainder represent the intractable cases that
show no improvement and that require further treatment. Tissue extracts,
such as the French preparation Angioxyl, or the American No. 568, given
Page 38 intramuscularly are worth a trial in these cases and occasionally give some
relief. I have recently secured a tissue extract for oral use that I am trying
out in a controlled series of patients at the Out-Patient clinic. X-ray of
the dorsal nerve roots has been suggested and has met with some approval.
My experience is too limited (2 cases) to pass any judgment, but the
rationale is not very clear. Alcohol injection of the dorsal nerve roots, on
the other hand, may be a most helpful procedure in the severest types of
angina as by this method in competent hands relief can certainly be obtained. It is obviously a last resort and should only be considered after all
these other measures have failed. The injection of the dorsal nerve roots
has almost entirely superseded the various types of cervical sympathectomy. Another surgical procedure recently advocated for these patients is
the complete removal of the thyroid in an effort to produce hypothyroidism and so lessen the demands on the heart, and some excellent results have
been reported.
Again let me emphasize that all these surgical procedures are only to
be considered when more conservative methods have failed after adequate
trial. In my series of 18 6 cases of angina only 3 suffered severely enough
to suggest the need for surgery. One of these patients became worse so
rapidly that there was no opportunity for surgical treatment, and the
other two absolutely refused to even consider any operative intervention.
1. Angina pectoris seems to be on the increase.
2. The diagnosis should rest on the development of transient attacks
of substernal distress or pain due to exertion or excitement and
relieved by the nitrites.
3. The prognosis while grave, is not as serious as has been supposed.
4. Much can be done for these patients by adequate medical treatment; for the intractable case surgery may be required.
5. The keynote of treatment is rest.
1. Feu., H., and Siegel, M. L.—American Journal Medical Science, 175:255, 1928.
2. Wood, F. C, Wolferth, C. C, and Livezey, M. M.—Archives Internal Medicina,
47:339,  1931.
3. Kountz, W. B., and Hammonda, M.—American Heart Journal, 8:259, 1932.
4. Katz, T. N., Hamburger, W. W., Schutz, W. J.—American Heart Journal, 9:771,
Verne C. Hunt, M.D.
Los Angeles, California
Even though one may be entirely familiar with the various procedures
that are necessarily employed in the diagnosis of surgical renal lesions, it
should be constantly borne in mind that often surgical lesions of the
kidney have been allowed to progress irreparably through failure to recognize indications for investigation of the urinary tract. Cliincal manifestations often are entirely misleading, and too frequently incomplete examination has led to improper interpretation of signs and symptoms. The urinary
tract must always receive due consideration in the differential diagnosis of
An abridgment of lecture presented at the Vancouver Medical Association Summer
School, Vancouver, June 20, 193 5.
Page 39 i hi
:s t
obscure symptoms referable to the abdomen. While it is not my desire to
discuss the various diagnostic procedures, it nevertheless seems appropriate
to the discussion to at least recall to your attention that under certain conditions accurate interpretation of clinical manifestations is impossible or
may be undertaken only with considerable opportunity for error in the
absence of careful, competent investigation of the urinary tract.
Renal lithiasis, the most common surgical lesion of the kidney, should
at least be thought of in many instances of abdominal pain, and particularly in most instances when the pain is in the right abdomen, suggesting
pathology in the appendix or gallbladder. It is worthy of emphasis that the
absence of microscopic cellular elements in the urine provides insufficient
evidence to conclude that the kidneys are normal and do not harbour
pathology which may be responsible for all symptoms or exist as coincident
or associated pathology to that responsible for the symptoms. The presence
of microscopic cellular elements in the urine, unless readily accounted for,
should usually direct attention to the necessity, in the absence of acute
emergency situations, for investigations of the urinary tract. In the vast
majority of cases a roentgenogram that encompasses the kidney, ureter and
bladder area on each side usually verifies or excludes a suspected urinary
A history of haematuria or an active haematuria most urgently suggests
investigation of the urinary tract, for one or the other kidney is not an
infrequent source of bleeding. Some years ago, in reporting fifteen cases
of papillary epithelioma of the renal pelvis, I stated that gross haematuria
was a predominant symptom in every case as an intermittent haematuria
for a period of from two weeks to as long as four years. In two-thirds of
the cases the gross haematuria had existed for more than six months, and
the average duration of intermittent bleeding was one year before careful
urological examination was instituted, leading to the diagnosis of a tumour
of the kidney. Inasmuch as prognosis is so dependent upon the duration
of symptoms, the onset of gross haematuria, often the earliest symptom,
should lead to immediate investigation of the urinary tract.
Likewise the presence of a tumour in either quadrant of the abdomen,
unless its nature is readily determined by other means, should suggest the
possibility of an enlarged kidney, which often proves to be a tumour of
the kidney. In a large series of malignant tumours of the kidney reviewed
some time ago by Hager and me, a tumour was palpable in 66 per cent of
the cases.
We are well aware of the painstaking effort so necessary on the part
of the urologist to establish a diagnosis of a surgical lesion of the urinary
tract and the necessity for care in the selection of procedures incident to
urologic diagnosis and competent interpretation of data. The symptoms of
intra-abdominal disease and those of disturbances of the urinary tract are
often sufficiently atypical not only to be confusing in diagnosis but to be
entirely misleading. The frequency with which the gallbladder or the
appendix or both have been removed for symptoms that have been produced by primary disease of the urinary tract emphasizes the necessity of
urologic investigation if there is doubt regarding the accuracy of the
Lithiasis.—Approximately 50 per cent of the operations upon the
kidney are for renal stone, and fortunately the diagnosis is not difficult,
for the mineral content of kidney stones is such that shadows are usually
readily depicted in the roentgenograms of the urinary tract area. As yet no
Page 40 clear and uniform conception of the aetiology of lithiasis has been presented, but clinical and experimental investigation has resulted in the exposition of certain significant factors. The theory that remote foci of infection are instrumental in the development of kidney stones has received
much support. Considerable evidence has accumulated, tending to indicate
that perhaps chemical changes incident to the advent of bacterial invasion
of the kidney and the urine may be instrumental in the precipitation and
agglutination of the normal mineral content of the urine, i.e., the oxalates,
urates and phosphates, the most common constituents of calculi. Rosenow
has shown that certain strains of bacteria possess definite specificity, and
clinical observation has shown that the elimination of active foci of infection has usually resulted in the cessation of the process of recurrent formation of stones in patients who possess a so-called stone forming kidney.
At any rate, experience has proved that the treatment of patients with
renal lithiasis is incomplete without the investigation and elimination of
all remote foci of infection.
The disturbance that occurs in the metabolism incident to hyperparathyroidism, in which the alteration in the blood calcium and phosphorus
are particularly prominent, has in recent years been shown to bear more
than an incidental relationship to renal lithiasis. Hyperparathyroidism is
always unique in giving a combination of a high serum calcium and a low
serum phosphorus. There is also an increased excretion of calcium in the
urine as well as an increased urinary excretion of phosphorus in spite of a
decreased serum phosphorus. It is of interest that in a series of seventeen
cases of hyperparathyroidism reported by Albright, Aub and Bauer, urinary calculous disease co-existed in thirteen cases, and in ten of these the
stones were situated in the kidney. It seems not unreasonable to assume
that metabolic disturbances, particularly as the serum calcium and serum
phosphorus become altered quantitatively, must receive due consideration
as aetiological factors in renal lithiasis, not only as these metabolic disturbances occur in hyperparathyroidism but in other conditions in which
a higher than normal serum calcium is encountered.
Once the diagnosis of renal lithiasis has been made, the question of
treatment is immediately presented. Many factors influence the decisions
that may be made, and most important of these are: (1) the number of
stones, as to whether there is a single stone or whether stones are multiple;
(2) obstruction at the uretero-pelvic juncture by stone; (3) unilateral or
bilateral lithiasis; (4) associated ureteral stones; and (5) the status of
renal function. In terms of generalities it may be stated that in the absence
of distinct contraindications, a stone in the kidney one half centimetre or
more in diameter should be surgically removed whether or not it is producing symptoms. Stones as they are depicted in the roentgenogram less
than 5 m.m. in diameter may usually, in the absence of the acute manifestations of obstruction, be given the opportunity to pass spontaneously,
and frequently will do so. Stones of larger diameter are not likely to pass
spontaneously, and even though they may be entirely silent so far as
symptoms are concerned, experience has proved that stone in the kidney
is seldom silent so far as its effect upon the kidney is concerned. I have
previously stated elsewhere on a number of occasions that in a large personal experience in the surgery of renal lithiasis it has been necessary to
perform nephrectomy in thirty-five per cent of the cases of renal lithiasis
on account of the extensive damage that has occurred to the kidney.
Multiplicity of stones in the kidney often contributes much to the
Page 41 i ill
difficulty of completely removing all stones and fragments, which usually
is most successfully accomplished under fluoroscopic control. Obstruction
at the uretero-pelvic juncture by stone often is manifested by acute symptoms characterized by pains, chills and high fever, and not infrequently
rapid damage to kidney structure occurs in the presence of infection with
the development of multiple cortical abscesses requiring nephrectomy.
When bilateral renal lithiasis is encountered, the general principle, notwithstanding recent statements to the contrary, of operating first, in the
absence of acute symptoms, upon the kidney with the better function in
order to take advantage of the function of the poorer kidney, has proved
highly successful.
Renal lithiasis complicated by ureteral lithiasis provides problems which
are not always easy of solution. In general, effort should be directed
toward removal of a ureteral calculus, particularly when it is situated in
the lower third of the ureter, by one method or another previous to surgical removal of kidney stones. When a ureteral stone is present in the
upper third of the ureter on the same side as the renal calculus, it usually
can be readily moved simultaneously with the removal of the kidney stone.
Excluding the cases of renal lithiasis in which damage to the kidney
has been so great as to require nephrectomy, conservative procedures for
the removal of renal stones are usually readily instituted without damage
to kidney tissue. Stones have been removed by pelviolithotomy in 86 per
cent of my cases, in which the conservative operation could be done; only
13.7 per cent of the cases required removal through the cortex or by combined procedures through the cortex and the renal pelvis.
It is possible for renal stones to re-form through the persistence of preexisting foci of infection and other indeterminate factors entering into the
formation of stone. There are so-called stone forming kidneys in which
calculi continue to develop even though all demonstrable foci of infection
have been eliminated. However, true re-formation of stones occurs rather
infrequently and experience has shown that the relatively high incidence
of so-called re-formation of stones has in reality been the continued development of stones overlooked at the time of operation, or of particles incompletely removed, which serve as nuclei for subsequent stones. Surgeons
of wide experience in operating for renal lithiasis have all suffered the
humiliation of being unable to find enough stones at operation to account
for all the shadows in the roentgenogram and of having shadows persist
after operation. Likewise, shadows have been found immediately after
operation when the surgeon was certain he had removed single or multiple
stones completely. In other words, overlooking one or more stones at
operation is a significant factor in the so-called re-formation of stones.
Roentgen-ray examination as a routine a few days after operation is the
only means of distinguishing between the oversight of stones and their
subsequent formation.
Renal tuberculosis.—The upper part of the urinary tract seldom is
alone the site of tuberculosis, and primary tuberculosis of the urinary tract
seldom, if ever, occurs. It is generally accepted that tuberculosis of the
kidney is hematogenous in origin. The high incidence of pulmonary tuberculosis in general necropsy records would seem to indicate that the lungs
serve as the primary focus for secondary dissemination through the blood
stream. In fully 80 per cent of the cases of renal tuberculosis there is
associated tuberculosis elsewhere; however, in the absence of contraindications or of activity of a major tuberculous lesion elsewhere, associated lesions
Page 42 should not necessarily deprive the patient of the benefit to be obtaind
from removal of the major tuberculous process if it is in one kidney.
Although heliotherapy and non-surgical methods of treatment have been
advocated and unquestionably possess some merit, the cure of unilateral
renal tuberculosis is usually not accomplished except by nephrectomy.
There is considerable divergence of opinion regarding the frequency
with which renal tuberculosis is encountered as bilateral disease. Medlar,
Thomas and others are of the opinion that bacilluria is evidence of tuberculous disease of the kidney and that bilaterality of the disease is common.
Wildbolz has stated that the demonstration of bacilli of tuberculosis in the
renal secretion by no means signifies that the corresponding kidney is the
seat of specific tuberculous tissue changes and that the presence of bacilli
in the renal secretion may be due to so-called bacilluria, especially in
patients with advanced pulmonary lesions, without there being any tuberculous tissue changes in the kidney. It is worthy of emphasis that autopsy
records of patients dying from pulmonary tuberculosis are not suitable for
determining the incidence of bilaterality of surgical renal tubercul
Only those cases may be studied for this purpose in which the genitourinary tuberculosis is the major lesion. The question of nephrectomy seldom if ever arises in the patient with an active, cavitating, debilitating
pulmonary tuberculosis in which bilaterality of the disease in the kidney
not infrequently exists. It is the patient in whom the major clinical manifestations are those related to the genito-urinary tract and in whom other
pre-existing or coexisting tuberculous lesions are healed or quiescent that
the question of bilaterality is most important. Some years ago, for the
purpose of determining the incidence of bilaterality of renal tuberculosis
in patients whose major clinical manifestations were those of the genitourinary tract, I reviewed a series of 838 cases of renal tuberculosis that
had been under observation during a ten-year period. Without enterin
into the analytical details of the review, which has been published else
where, it was found, after making liberal allowance in favor of bilatera
involvement when any question existed, that the incidence of bilaterality
of renal tuberculosis was 13 per cent.
As to whether or not nephrectomy should be considered in the presence
of tuberculous lesions elsewhere depends largely upon the degree of activity of the various tuberculous lesions. Certainly in the absence of general contraindications where the tuberculous kidney is the most important
tuberculous lesion its removal is justly indicated. The low primary mortality rate of approximately 2.5 per cent following nephrectomy for unilateral renal tuberculosis justifies the operation even if there is moderate
pulmonary involvement.
Renal Malignancy.—Neoplastic disease comprises about 9 per cent of the surgical
lesions of the kidney and about 13 per cent of the indications for nephrectomy. In malignant disease of the kidney, as elsewhere, it is most essential that diagnosis be made early to
insure the best prognosis. Unfortunately, extensive advancement often occurs silently so
far as subjective symptoms are concerned, and operability frequently is questionable at the
time that the diagnosis is made by virtue of metastases or extensive extrarenal invasion with
fixation of the kidney. Most malignant lesions of the kidney tend to metastasize rapidly
through local extension to perirenal structures and the renal vein; the latter provides a
direct avenue for remote metastases. In the absence of demonstrable metastases and fixation,
of the kidney by direct extension to surrounding structures, nephrectomy affords the best
In a review of sixty cases of carcinoma of the kidney in which I did a nephrectomy,
it was noted at the time of operation that the renal vein was involved by the tumour in
eleven cases.   In twelve other cases the tumour had invaded surrounding structures and
Page 43 11
ii '
involved regional or retroperitoneal glands and was incompletely removed. In other words,
in approximately 3 8 per cent of the cases of hypernephroma or carcinoma of the kidney
radical nephrectomy failed as an operation curative in purpose in attempting to extend the
operation to include all involved tissue. Without taking into account those cases which are
directly inoperable by virtue of fixation or demonstrable metastases and are not even
explored, I am confident that the inoperability of malignant tumours of the kidney, as
determined by exploration or in which palliative nephrectomy is done, approaches 50 per
cent. Adding a surgical mortality rate of approximately 8 per cent leaves but a relatively
small percentage of cases in which one has reasonable hope for obtaining a cure by nephrectomy unless the diagnosis is established early and nephrectomy is instituted while the
disease is confined to the kidney.
Papillary epithelioma of the renal pelvis is the most favourable malignant lesion of
the kidney for it does not invade the kidney or extrarenal structures but progresses by
direct extension along the mucous membrane to calices and the ureter and often to the
bladder. Furthermore this lesion usually is of low grade malignancy and does not tend to
metastasize early. Preoperative recognition or identification of this particular type of
tumour at operation is essential to the best prognosis, for1 in addition to nephrectomy complete ureterectomy to include the intramural portion of the ureter at the uretero-vesical
juncture is necessary for the complete eradication of the lesion and the prevention of its
Unquestionably radiotherapy merits a place in the treatment of malignant tumours
of the kidney. It has frequently been observed following radio-therapy in large fixed inoperable tumours that marked regression in the tumour occurs, particularly as to size, and
in many instances the vascularity of the tumour has decreased, and often hematuria has
been at least temporarily controlled.
Hydronephrosis.—About 14 per cent of the surgical lesions of the kidney is comprised
of the various types of hydronephrosis with or without infection. In the absence of intrinsic obstruction at the uretero-pelvic juncture by stone, the vast majority of the cases of
hydronephrosis are caused by accessory blood vessels to the lower pole of the kidney. Often
so much dilatation of the pelvis and calices has occurred with resultant damage to the kidney
that nothing short of nephrectomy is advisable. There are many cases in which renal
function has been sufficiently preserved so that conservative surgical procedures may be
instituted. Often simply division and ligation of the accessory blood vessels to the lower
pole with fixation of the kidney is sufficient to provide relief of obstruction at the uretero-
pelvic juncture with restoration of renal function. In the presence of considerable dilatation
of the pelvis with sufficiently good renal function in which restoration of the major
capacity of the kidney may be anticipated, one or the other of the various plastic operations on the pelvis of the kidney or at the uretero-pelvic juncture have proved most satisfactory in many instances. However, in five to 10 per cent of the cases in which a plastic
operation has been done, a satisfactory result has not been obtained and because of persisting infection or inadequate drainage of the kidney subsequent nephrectomy has been
Metastatic Cortical Abscess with Perinephritic Suppuration.—Multiple cortical abscesses of one or both kidneys are not infrequently encountered in some of the acute fulminating types of generalized infection. Likewise cortical abscesses are at times encountered in the acute obstructive lesions of the upper urinary tract in the presence of infection, particularly by stone. These are all of interest, however, their clinical recognition
is not difficult. The cortical abscess to which I desire briefly to refer is that which fails to
resolve but involves perirenal structure with the development of a perinephritic abscess,
to the exclusion of those instances of perinephritic abscess secondary to renal tuberculosis,
pyonephrosis and definitely ascertainable intrarenal disease. I have reference to that particular type of perinephritic abscess which develops secondary to a metastatic cortical
abscess of the kidney in which the primary infection was a superficial one of the skin,
usually a series of boils, a carbuncle, or a superficial infection which had occurred weeks
or months previously and in many instances had healed and had been entirely forgottten.
The clinical manifestations are those of fever persisting for days or weeks, leucocytosis
of 12,000 to 20,000, often dull ache in the kidney area or under the costal margin. Physical examination usually discloses nothing except in some instances suggestive or slight
tenderness in the kidney area. A strikingly uniform observation has been the absence in
most cases of any positive findings on urologic examination. There usually is an absence
of microscopic cellular elements in the urine, for not unless a cortical abscess communicates with the pelvis or a calix, which seldom if ever occurs, do pus or blood cells appear
in the urine. Pyelographic examination of the kidneys likewise is usually negative and
were one to rely upon urologic data the diagnosis is not evident.   A pWratfe finding in the
Page 44 majority of instances is the absence in the roentgenogram of a clear outline of the outer
margin of the psoas muscle in the presence of a perinephritic abscess.
I have presented this subject for the purpose of directing attention to the necessity of
carrying in mind this very distinct clinical entity which is characterized usually by an
absence of signs and symptoms on which one may rely but presents diagnostic problems
which may be readily solved by developing a sequence of events emanating from superficial infections existing weeks or months previously. I would emphasize the statement
that a very definite relationship exists between superficial infection, such as furuncles,
carbuncles, paronychia: and so forth, and the subsequent development of cortical abscess
and perinephritic suppuration. The latter should always receive due consideration if there
is unexplainable septic fever and leucocytosis with or without localization of pain or tenderness. The diagnosis usually is made not on the indeterminate evidence at hand at the
moment but on the knowledge of the relationship of the present indeterminate evidence
as to what the patient had and apparently recovered from weeks or months previously.
"Absolute Accuracy'I
In filling the eye physician's prescription, nothing short
of absolute precision will saJpfy us.
We take a pride in maintaining
Guild standards to the utmost.
Dispensing Opticians
631 Birks Bldg., Vancouver, B. C
M   Palatable"   ;gi|
Your patients will cooperate willingly
when delightfully palatable Petrolagar is
prescribed in the treatment of constipation. May we suggest that you taste
Petrolagar and note the pleasant flavor.
Petrolagar is a mechanical emulsion of
liquid petrolatum (65% by volume)
and agar-agar.
Samples free on request
Petrolagar Laboratories of Canada, Ltd.
364 Argyle Road
Walkerville, Ontario
that really are nicer
300 WEST
Page 45 2   ^i4 Service to the Profession ||11
FOR some while the Medical Profession has felt the need of a local
institution giving treatments in COLONIC IRRIGATION.
COLONIC IRRIGATIONS are valuable in such cases as Constipation,
Impaction, Worms, Colitis, Cholecystitis, Stomach Disorders, also in diseases where the primary cause is found to be improper elimination of the
contents of the Colon, such as Rheumatism, Rheumatoid Arthritis, Neuritis,
Bright's Disease, Nephritis, Nervous Disorders, etc.
Obstetrical cases are benefitted by internal baths at measured periods,
as advised by their physician.
We take pleasure therefore, in announcing to the Medical Profession
an institution to which they may send patients whom they know would
benefit thereby.
1 li
View of the Treatment Room, -which shows the Irrigation Table
to advantage.
Colonic Irrigation Institute
Superintendent: E. M. LEONARD, R.N., Post Graduate, Mayo Bros.
631 Birks Bldg., 718 Granville Street, Vancouver, B. C.
Telephone:  Seymour 2443 Phenylazo ■ Alpha • Alpha ■ Diamino
Pyridine Mono - Hydrochloride
FOR prompt relief of distressing symptoms
and the treatment of urinary infections.
The pharmacologic and clinical investigations
conducted with Pyridium, and reported in
medical journals, have been substantiated in
communications received from thousands of
general practitioners. They are practically
uniform in their expression that Pyridium,
orally administered, yields prompt clinical
i'Ml :•
renders prompt action in the relief of functional derangements
arising from such affections.
In Brovalone Hartz, a special Menstruum promotes rapid absorption without stomach irritation and, to give the maximum
antispasmodic and sedative action, the finest quality Valerian
Root, with Sodium Bromide, Cascara and Hyoscyamus Niger,
is carefully proportioned in a palatable and stimulating vehicle.
Brovalone Hartz is a valuable adjunct to tonics.
Dose—One to four fluid drachma,
A Canadian Product from the laboratories of
The J. F. HARTZ CO. Limited
Pharmaceutical Manufacturers
are uncoloured tablets of
Ovol «APCC"
Acetylsalicylic   Acid  3% grs.
Phenacetine    2% grs.
Caffeine   Citrate       V2 gr.
Codeine   Phosphate     % gr.
qvol "APC"
Acetylsalicylic   Acid  3% grs.
Phenacetine   2% grs.
Caffeine   Citrate ;„;;-....    % gr.
qvol «A"
Acetylsalicylic  Acid     5 grs.
qvol "APCC2"
Acetylsalicylic   Acid  3% grs.
Phenacetine    2% grs.
Caffeine   Citrate      y2 gr.
Codeine   Phosphate      »4 gr.
No packages for laity demand. In bottles of 100 and 500 Tablets only.
Request literature and samples from our Vancouver Branch,
2051 Stephens Street.
Supplied in bottles containing 6,
10 and 16 ounces. The average
dose is one tablespoonful.
William r. Warner & CO.
727 King St., West, Toronto, Ont
I I I I I I M I tl 1 I I I 1 I I t t t I. M I 1 1 I t I t 1 I I Ml I 1 1 1 I t I I 1 M 1 I
A good emulsion should pour
freely. Agarol does. It is a mineral oil and agar-agar emulsion
with phenolphthalein that mixes
thoroughly with the intestinal
contents, supplies unabsorb-
able moisture, lubricates the
tract and gently stimulates peristalsis. And, of course, it may
be added to water, milk, or
to any other liquid. Agarol is
emulsified to such exceptional
fineness that it will not be broken down in any dilution.
Agarol is palatable without artificial flavoring, because highly purified ingredients imparl no taste
that needs disguising. It contains
no sugar, alkali or alcohol—suitable for any age period, under any
condition, for the relief of acute
constipation and in the treatment
of habitual constipation.... Trial
supply gladly sent on request. I
THE use of a food to promote
normal taxation is usually more
satisfactory than the continued
use of medicines. Particularly,
cathartics. These tend to form
harmful habits, as dosage has to
be increased constantly.
Millions of people use Kellogg's ALL-BRAN to correct constipation due to insufficient "bulk"
in meals. For ALL-BRAN supplies generous, mild "bulk," which
continues to be effective when
used for months. ALL-BRAN also
furnishes vitamin B and iron.
This delicious cereal is a natural laxative food for normal
people. Some few individuals
with diseased or highly sensitive
intestines should not take "bulk"
in any form—either in leafy vegetables, or in bran. Except in these
special cases, Kellogg's ALL-
BRAN may be used with perfect
ALL-BRAN may be served as a
cereal or made up into muffins,
breads, waffles, etc. It is much
more effective than part-bran
products. Sold by all grocers in
the red-and-green package. Made
by Kellogg in London, Ontario.  STEVENS' SAFETY PACKAGE
is a handy, convenient, clean commodity for the bag or the office. Supplied
in one yard, five yards and twenty-five yard packages.
Phone Seymour 698
73 0 Richards St., Vancouver, B. C.
Phone °93
F   Breaks the vicious circle of perverted
menstrual function in cases of amenorrhea,
tardy periods (non-physiological) and dysmenorrhea. Affords remarkable symptomatic
relief by stimulating the innervation of the
uterus and  stabilizing the tone of its
musculature. Controls the utero-ovarian
\   circulation and thereby encourages a
|H normal menstrual cycle.
Full formula and descriptive
literature on request
Dosage: 1 to 2 capsules
3 or 4 times daily. Supplied
in packages of 20.
Ethical protective mark MHS
embossed on inside of each
capsule, visible only when capsule is cut in half at seam.
,\4 Nupercainal "Ciba
A Non-Narcotic Analgesic Ointment
for the relief of pain or itching in affections of
the mucous membranes or skin.
Nupercainal has been found to be highly effective to secure
prompt and prolonged rehef from discomfort in:
Issued in one ounce tubes with a rectal applicator.
flDount pleasant ITlnbertakino Go- %tb.
KINGSWAY at 11th AVE. Telephone Fairmont 58 VANCOUVER, B. C
:. pi.
For bland diet therapy, « 1
especially ULCER cases IJ
f  ■ || PABLUM
FAR too often the bland diet prescribed for gastric ulcer, colitis, and similar]
gastro'intestinal disorders is a deficient diet. An analysis made by Troutt ofJ
ulcer diets used by 6 leading hospitals in different sections of the countrw
showed them to be "well below the Sherman standard of 15 milligrams" in
iron and low in the water-soluble vitamins.1 "Vitamin B would appear to be
represented at a maintenance level in most cases," writes Troutt, "but the
possible relation of vitamin B to gastro-intestinal function and appetite should
make one pause before accepting a low standard."
how in Fiber — High in Iron
Pablum is the only food rich in a wide variety of the accessory food
factors that can be fed over long periods of time without danger of
gastro-intestinal irritation. Its fiber content is only 0.9%. Yet Pab- j
lum contains 37 times more iron than farina and is an excellent
source ( + + +) of vitamins B and G, in which farina is deficient
Supplying 8*4 mgms. iron per ounce, Pablum is 8 times richer than
spinach in iron.
Rich in Vitamin B
The high vitamin B content of Pablum assumes new importance in
light of recent laboratory studies showing that avitaminosis B
predisposes to certain gastro-intestinal disorders. Apropos of thisj
Cowgill says, "Gastric ulcer is another disorder which can conceivably be related to vitamin B deficiency. Insofar as the treatment or this condition usually involves a marked restriction of dies
the occurrence of at least a moderate shortage of this vitamin is by
no means unlikely. Obviously the length of the period of dietary!
restriction is an important determining factor. Dalfdorf and Kellogg
(1931) observed in rats subsisting on carefully controlled diets that
the incidence of gastric ulcer was greatly increased in vitamin B
deficiency. Observations of this type merit serious consideration."2
30 mom.
H— w
H— io
™     0.8msTm.
Although Pablum has a
low fiber content it is 37
times richer than farina
in iron and in calcium, 4
times richer in phospho-
rusf and 4J^ times richer in copper.
Requiring no further cooking, Pablum is especially valuable during the healing stage of ulcer when the patient is back at work but still requires frequent
meals. Pablum can be prepared quickly and conveniently at the office or
shop simply by adding milk or cream and salt and sugar to taste. Pablum has
the added advantage that it can be prepared in many varied ways—in muffins,
mush, puddings, junket, etc. Further, Pablum is so thoroughly cooked that its
cereal-starch has been shown to be more quickly digested than that of farina,
oatmeal, cornmeal, or whole wheat cooked four hours in a double boiler
(studies in vitro by Ross and Burrill).
Pablum consists of wheatmeal, oatmeal, cornmeal, wheat embryo, alfalfa, yeast, beef bone, iron salt and sodium chloride.
1-2 Bibliography on request.
MEAD JOHNSON & CO. OF CANADA, Ltd., Belleville, Ont.
Please enclose professional card when requesting samples of Mead Johnson products to cooperate in preventing their reaching unauthorized persons At the Right Haod
of the Doctor
—stands the Georgia Pharmacy .  .  . filling his
prescriptions just as they should be filled  .
with drugs that measure up to highest standards
of purity and in the exact quantities ordered . . .
day and night—at the right hand of the Doctor.
(&mttt $c ijatma Mb
Established 1S93
North Vancouver, B. C.    Powell River, B. C
' 1 111
Hollywood Sanitarium
For the treatment of
Alcoholic, Nervous and Psychopathic Cases
Reference—B. C. Medical Association
For information apply to
Medical Superintendent, New Westminster, B. C.
or 515 Birks Building, Vancouver
Seymour 4183
Westminster 288


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