History of Nursing in Pacific Canada

The Vancouver Medical Association Bulletin: January, 1942 Vancouver Medical Association Jan 31, 1942

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of the
Vol. xvni
With Which Is Incorporated
Transactions of the
Victoria Medical Society
Vancouver General Hospital
&f. Paul's Hospital
No. 4-
In This Issued ft
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*Dr. Noah D. Fabricant says:
"For the most part, 1 find that the pH of nasal secretions in
situ during an attack of acute rhinitis or of acute rhino-
stnusitis is alkaline—the secretions are more alkaline than
normal. This finding has clinical significance, for those
. nasal vasoconstrictors which can lower the nasal pH from
an abnormal alkaline status to a desirably normal acid
status may perform a valuable function."
"It is therefore suggested that during an
attack of acute rhinitis or acute rhinosi-
nusitis the employment of a nasal vasoconstrictor which lowers the alkaline pH to a
level between 5.5 and 6.$.—approximating
the normal pH status of nasal secretions in
situ—is most desirable."
•k Noah D. Fabricant, M.D. of Chicago, received
the   Casselberry    Award   of   the    American
Laryngological Association for 1941 for   the
most outstanding nose and throat study of
the year.
is more effective ... because it
is an aqueous isotonic solution of
Here is a stable aqueous solution of Ephedrine and
being aqueous, Aquaphedrin rapidly diffuses into
the natural secretions of the nasal mucosa, without
inhibiting ciliary action. Being isotonic, it diffuses
rapidly and without osmosis, thus producing more
effective absorption of Ephedrine, and permitting
it to exert its unique decongestive effect.    '
Unlike most Ephedrine solutions, Aquaphedrin
E.B.S. is effective without stinging and its application is followed by grateful relief. This freedom
.from irritation is achieved both by isotonicity of
the solution, and by buffering to a pH approximating that of the nasal mucosa. The pH is so
adjusted that, although the solution is not irritating, it conforms with the recent discovery that a
slightly acid reaction is much more effective in the
treatment of colds and sinus conditions.
Aquaphedrin is effective in reducing swollen or
congested turbinates and in relieving congestion
of the mucous lining in head colds, nasapharyngeal
inflammation, sinus blockage, hay fever, asthma
and other nasal conditions.
AQUAPHEDRIN E.B.S. is packaged in %-oz. and 1-oz.
dropper bottles, with detachable labels for convenience in
dispensing. Also supplied in bulk for use in an atomizer.
E.B.S. alSO Of f GTS for those who prefer it:
Phedronol Inhalant E.B.S.—A 1% Solution of
Ephedrine Alkaloid in a bland neutral oil, and
Phedronol Jelly E.B.S.—Ephedrine.37%,Chlorbutanol
.8.2%, combined with Menthol and Sodium Chloride
in correct proportions for the reduction of congestion.
Specify E.B.S.
on your
Prescriptions I
Published Monthly under the Auspices of the Vancouver Medical Association
in the interests of the Medical Profession.
Offices: 203 Medical- Dental Building, Georgia Street, Vancouver, B. C.
Db. J. H. MacDermot
Db. O. A. Davidson Db. D. E. H. Cleveland
All communications to be addressed to the Editor at the above address.
. »»?
No. 4
OFFICERS, 1941-1942
Db. G. McDiabmid Db. J. R. Neilson Db. D. F. Busteed
President Vice-President Past President
Db. W. T. Lockhabt Db. A. E. Tbites
Hon. Treasurer Hon. Secretary
Additional Members of Executive; Db. Gobdon Burke, Db. Fbank Tubnbull
Db. F. Bbodie Db. J. A. Gillespie Db. W. L. Pedlow
Auditors: Messbs. Plommeb, Whiting & Co.
Clinical Section
Db. Ross Davidson Chairman Db. D. A. Steele:— Secretary
Eye, Ear, Nose and Throat
Db. A. R. Anthony Chairman Db. C. E. Davies Secretary
Pediatric Section
Db. G. O. Matthews Chairman Db. J. H. B. Gbant Secretary
Db. F. J. Bulleb, Db. D. E. H. Cleveland, Db. J. R. Davies,
Db. A. Bagnall, Db. A. B. Manson, Db. B. J. Habbison
Db. J. H. MacDebmot, Db. D. E. H. Cleveland, Db. G. A. Davidson.
Summer School:
Db. H. H. Caple, Db. J. E. Habbison, Db. H. H. Hatfield,
Db. Howabd Spohn, Db. W. L. Gbaham, Db. J. C. Thomas
Db. A. W. Hunteb, Db. W: L. Pedlow, Db. A. T. Henby
V. O. N. Advisory Board:
Db. W. C. Walsh, Db. R. E. McKechnie II., Db. L. W. McNutt.
Metropolitan Health Board Advisory Committee:
Db. W. D. Patton, Db. W. D. Kennedy, Db. G. A. Lamont.
Greater Vancouver Health League Representatives:
Db. R. A. Wilson, Db. Wallace Cobubn.
Representative to B. C. Medical Association: Db. D. F. Busteed.
Sickness and Benevolent Fund: The President—The Trustees.
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The  five  synthetic  factors  of the  B-Complex — in
Therapeutic   quantities — in   a   small   capsule   your,
patients can swallow.
Each Syntheplex-B Microcap contains 1 mg. Thiamine Hydrochloride, 1 mg. Riboflavin, 0.5 mg. Pyridoxine, 0.5 mg.
Calcium Pantothenate, 10 mg. Nicotinic Acid.
N.B.    1 mg.= 1000 micrograms = 1000 gammas.
When prescribing B-Complex preparations,specify SQUIBB.
For literature on B-Complex therapy write:
36 Caledonia Road, Toronto, Ontario
♦Microcaps and Syntheplex-B are registered trade marks.
E-R:Squibb & Sons of Canada, Ltd.
Total Population—estimated , ,. 272,352
Japanese Population—estimated . ] ■      8,769
Chinese Population—estimated 8,558
Hindu Population—estimated 360
Rate per 1,000
Number        Population
Total deaths 254 11.3
Japanese deaths        7 9.7
Chinese deaths 12 17.1
Deaths—residents only 1 218 9.7
Male, 227; Female, 215-
Deaths under one year of age 16
Death rate—per 1,000 births 36.2
Stillbirths (not included in above) 10
Nov., 1940
October, 1941
Cases   Deaths
November, 1941
Cases   Deaths
Dec. 1-15,1941
Cases   Deaths
[Scarlet Fever  15
Diphtheria ,  0
| Chicken Pox . 107
[Measles  4
Rubella  2
[Mumps  23
Whooping Cough  5
Typhoid Fever  0
Undulant Fever  0
Poliomyelitis  1
Tuberculosis  25
[Erysipelas  1
[Meningococcus Meningitis  0
[Paratyphoid Fever  5
| Flexner Dysentery  0
West North      Vane.   Hospitals &
Burnaby   Vancr.  Richmond   Vancr.     Clinic  Private Drs.  Totals
        0 0 0 2 16 27 45
 0 0 0 0 80 28 108
<<  A  "
Another Product of the Bioglan Laboratories, Hertford, England
Phone MA. 4027
Stanley N. Bayne, Representative
Descriptive Literature on Request
Vancouver, B. C.
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Page 103
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Lil- ti
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— an ideal adjuvant in
Respiratory Congestions
Sample and literature on request
The Denver Chemical Mfg. Co. -  153 Lagauchetiere St. W., Montreal
Made in Canada •«r
Founded 1898
Incorporated 1906
Programme of the Forty-fourth Annual Session
(Winter Session)
GENERAL MEETINGS will be held on the first Tuesday of the month at 8:00 p.m.
CLINICAL MEETINGS will be held on the third Tuesday of the month at 8:00 p.m.
Place of meeting will appear on the Agenda.
General meetings will conform to the following order:
8:00 p.m.—Business as per Agenda.
9:00 p.m.—Papers of the evening.
Dr. F. N. Robertson: "A Simple Test for Cancer."
Dr. J. H. MacDermot: "Epi-Sacro-Iliac Lipomata—A small cause of
much trouble."
Osier Lecture.
Dr. L. H. Appleby: "The Use of Snake Venom in Medicine."
,.♦ .f
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Miss M. E. Harvey
678 Howe Street
MArine 2015
Miss A. E. Markham
610-11, 718 Granville St.
MArine 6735
n O
Miss J. M. Law
610-11, 718 Granville St.
MArine 6735
The Vancouver Branch of the above Association, in wishing the Medical
Profession a happy 1942, and thanking them for their co-operation and support
in past years, wishes to call their attention again to the salient features of our
The Association is incorporated by Dominion Charter and has members working
in all parts of the Dominion of Canada.
The members are pledged to work only under Medical Supervision and the
Association is acknowledged by the Workmen's Compensation Board.
Signed on behalf of C. P. A.
President, Vancouver Branch.
Page 104
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Lyerst "10-D" Cod liver Oil maintains the sa
high standards of potency and purity, despite manufacturing difficu
resulting from the War. Richer in "Sunshine Vitamin D" ... biologfc
tested and standardized • • • possesses a fine, wholesome flavour.
Biological and. Pharmaceutical QltemUU
M *M
Once more we wish to all our readers a Happy and Prosperous New Year. Just what
meaning those words will have for each individual one of us in this fateful year of our
Lord 1942, only each one of us can know. But there will be nothing carefree about our
happiness—full well we know that—and nothing blatant about any prosperity that may
come our way.
Perhaps we shall have to find new meanings for happiness—a new prescription for
prosperity. The old ones no longer exist as we know them in an age already sharply
cut off from the one in which we now live—still more the one into which we are
moving, inexorably and with ever-increasing speed. A new world is coming into being
—perhaps it had to come. The one now gone, like the fabled Atlantis of old, was
doomed, perhaps, to sink under the weight of its own failures and sins and shortcomings
—selfishness, indifference to each other's rights and wrongs: wilful refusal to see and
heed the red signal that has so clearly and persistently stood against our path of so-called
progress, unheeded.
A thoughtful and interesting paper read by Dr. Wallace Wilson of Vancouver,
"Whither Medicine," deals with the trends of medicine in a changing world: and as medical men we shall do well to take stock, and consider what these trends will be, and what
we can and should do to direct them aright. One thing that seems beyond doubt, when
one contemplates the very indistinct and speculative future, is that things are never
again going to be the same as they have been. Germany, with all her faults, has taught
us one thing—that a nation can and should be a unit, working collectively—and that
there is no social necessity7 which cannot be met and satisfied, if the only obstacle is
financial. Health, education, social organisation, adjustments of human intercourse and
interrelation, are going to undergo very radical and searching scrutiny and re-casting
in the next few years. We cannot doubt that—because only by very drastic control and
reorganisation can they begin to meet the enormous calls that are going to made on them.
So it is high time that we began to look to our gear: and to consider in what way we
can most wisely, and with the greatest profit and benefit to all concerned—not only
ourselves—meet these changes, solve these problems, provide leadership——probably needed
and so utterly vital. Thre can be little doubt that one of the trends of the future will
be toward more definite collectivism: and this will inevitably affect us. We must avoid
a reactionary attitude, nor attempt to cling too closely to traditional patterns and
systems, even though at the same time we do all we legitimately may and should do to
safeguard our own interests.
One way we must explore, even if it is unfamiliar to us, and we have so far studiously
avoided it, is the way of publicity: of arriving at a better and clearer understanding at
least, between ourselves and the public at large. We feel strongly that one of the greatest
handicaps under which we labour is the complete lack of this understanding. We do not
advocate propagandising or lobbying—but we do feel that our traditional and bewhis-
kered attitude of monkish silence has not only done harm to ourselves, but has been a
disservice to the community at large, who, knowing little of the truth about medicine
and public health, have had to depend largely on one-sided, and often misleading information. We rejoice to see that the Canadian Medical Association has established a Committee on Public Relations, and consider this a notable step in the right direction.
In a recent issue of the Bulletin, letters from firms to their employees, urging them
to join the M-S-A, and detailing benefits, etc., were published.
A similar letter from the Mohawk Handle Company of New Westminster to its
employees is of interest. This Company has helped by assuming one-half the cost and
the registration f ee—ninety per cent of the employees and their f amilies are participating.
This will, we are sure, be a matter of interest to our readers. —Ed.
Page 105
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5i:i^i NEWS    AND    NOTES
We announce the arrival of five sons to members of the profession: Flight-Lieut.
Neil A. Stewart, Dr. R. E. McKechnie II, Dr. T. F. H. Armitage, Dr. W. W. Simpson
and Dr. B. F. Bryson.
Doctors will please note that a special form has been provided for
use in the examination of women for the Services. In some cases the
men's form has been used in error.
The profession extends sympathy to Dr. D. E. H. Cleveland in his recent bereavement, his father having passed away.
Congratulations to Dr. A. M. Johnson, Interne at the Vancouver General Hospital,
upon his marriage to Miss Marjorie McCullough. Doctor Johnson is awaiting appointment with the R.C.A.M.C.
* *      *      *
Dr. D. J. M. Crawford of Trail has recovered from a recent operation and is spending a vacation at Medicine Hat.
* *      *      *
Flight-Lieut. A. S. Underhill spent Christmas with his family in Kelowna.
*C «f *c
Capt. L. G. Wood spent Christmas with his f arnily in Vancouver.
Lieut. Col. S. G. Baldwin, O.C. No. 12 Field Ambulance, returned to Vancouver for
a Christmas vacation.
* *      *      *
Flying Officer H. B. McGregor spent a week-end at his former home in Penticton.
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Dr. J. Stanley Archibald, son of Dr. M. G. Archibald of Kamloops, a graduate of
McGill, 1939, has served as interne at the Montreal General Hospital and Children's
Memorial Hospital.   He is visiting his parents before entering the Naval Medical Service.
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Dr. R. W. Irving of Kamloops spent Christmas with relatives in Montreal and
Toronto, and will return to Kamloops.early in January.
Please note that surgical instruments for Great Britain need not
necessarily be in good repair. They will be renovated at headquarters
in Toronto.
Local Red Cross Units will accept instruments for trans-shipment to
Provincial Red Cross Depot. The Red Cross enjoys special shipping privileges.
Page 106 It is reported that the Municipality of West Vancouver has arranged to make payment in respect to medical care for relief recipients. There has been some delay in their
acceptance of this responsibility. There are very few municipalities in the Province
which do not accept their obligation with regard to relief cases and take advantage of
the contribution of the Provincial Government of I6J/2C per individual per month, in
consideration of a similar or larger amount having been contributed by the municipality.
Dr. J. B. Swinden of Ucluelet spent Christmas with his family at Whonnock.
Dr. H. Cantor, formerly of Atlin, is awaiting action on his application for appointment as Medical Officer with the R.C.A.F.
Dr. G. E. Bayfield, who has been Medical Officer in the logging area on Moresby
Island, spent a vacation at his home in West Vancouver.
Lieut. W. S. Huckvale of the R.C.A.M.C., late of Kimberley, called at the office
before leaving for an Eastern training centre.
Dr. John Brown of Sooke Harbour, Vancouver Island, dropped'in on us on Christmas Eve. He reports that he is too busily engaged in medical practice to do all the
fishing which he planned when he took up residence at Sooke.
Dr. H. F. Tyreman of Nakusp was down in Vancouver in December.
We had Christmas greeting cards from:—Colonel Lavell H. Leeson, A.D.M.S., 3rd
Canadian Division—he is very busy, and as cheery as ever; from Squadron Leader D.
Murray Meekison—he is with the R.A.F. and is very busy and apparently happy about
it, doing surgery in a special hospital; and from Major G. H. Clement, who is located in
Ottawa, Officer in Charge of a Hospital—apparently happily busy.
The Frost family is all busily engaged in some form of war work. Capt. A. C.
Gardner Frost is now Medical Officer with the 6th Field Regiment of the R.C.A. and is
located somewhere in Britain.
Surgeon-Lieut. John W. Frost has now joined the Naval Medical Services—ovearseas.
William David Frost is a Sergeant Wireless Navigator with the R.C.A.F. and is
serving with Squadron 455—overseas.
Dr. Max Frost is completing his internship at the Montreal General Hospital and has
made application for appointment to the R.C.A.M.C.
Mrs. A. C. Gardner Frost left some time ago for overseas and is now serving with
the Women's Transport Division somewhere in Britain.
Colonel G. C. Kenning, O.C., will require seventy-five non-commissioned officers and men at once.
Doctors  who  know of  possible material  should  recommend  their
application to Capt. F. E. Coy, Medical Board, 214 Vancouver Barracks.
Page 107
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Lieut.-Col. J. F. Haszard, O.C. No. 8 Field Ambulance, and Lieut.-Col. H. A.
DesBrisay, O.C. No. 9 Field Ambulance, often see one another and apparently both are
in good health, and somewhere in Britain.
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An interesting report on the activities of Capt. C. H. Gundry finds him doing work
for which he is admirably suited. When Capt. Gundry left the Metropolitan Health
Services in Vancouver, where he was doing special work in mental hygiene, the wisdom
of his entering the Service was the subject of comment in that there seemed to be some
wastage of his special qualifications. Capt. Gundry is now at Headquarters in London
and is working with others on a special board in the nature of a Psychiatric consultant.
The duty of this group is to aid in the classification of men dealing with such matters
as mental health, categorization of intelligence, and advising in the question of vocational
From Colonels Leeson and DesBrisay we often hear of Capt. H. R. L. Davis, Major
W. L. Boulter, Capt. A. R. J. Boyd, Capt. J. A. MacMillan, Capt. J. A. Wright, all of
whom are busily engaged with the R.C.A.M.C. in Britain.
When last heard of, Surgeon-Lieut. Commander W. M. Paton was in the Maritimes,
and Major Gordon Large was in a special hospital in an eastern port.
Major Roy Huggard is now overseas, and doing surgery.
While it has not been the policy of the Bulletin to announce movements of variow
units, we feel that some notice should be paid to the fact that No. 12 Field Ambulance
is now located at an eastern camp.   The various officers in this Unit are: Lieut.-Col. sr
G. Baldwin, O.C, Captains M. R. Caverhill, D. B. Collison, G. D. Oliver, L. G. Wood,
B. T. Dunham, late of Nelson, and Captains W. F. Bie, R. L. Whitman and T. S. G.
McMurtry, who were formerly internes at the Vancouver General Hospital. Lieut.-Col.
Baldwin and Capt. L. G. Wood were in Vancouver on short vacation at the New Year.
"fr St *C *r
No. 13 Light Field Ambulance is now overseas. The officers of that Unit are:
Lieut.-Col. C. A. Watson, Captains J. S. McCannel, G. L. Stoker, W. M. G. Wilson, G.
C. Johnston and T. K. MacLean. Lieut.-Col. Roy Mustard, who mobilizes the Unit, is
now doing special work in Toronto, according to latest reports.
Recent additions to the Medical Services of the R.C.A.F. are Flying-Officers J. L.
Parnell, A. W. Vanderburgh of Summerland, G. S. Rothwell and H. G. Cooper.
•L. *fc *C •£.
Lieut. M. Share, who is now serving with the R.C.A.M.C., will be remembered as a
former interne at the Vancouver General Hospital.
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Flight-Lieut. T. C. Harold, formerly of Ladysmith, is now with the R.C.A.F.
There has been considerable interest shown in the Officer personnel of the new 16tn
Canadian General Hospital and present reports would indicate that British Columbia will
be represented very creditably in this new Unit. Col. G. C. Kenning is the Officer
Major R. Scott-Moncrieff has been in Vancouver enlisting non-commissioned officers
and men who will accompany the advance party.
Major T. W. Sutherland, O.C, Prince Rupert Military Hospital, called at the office.
Page 108
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"extbook of Ophthalmology, 2nd ed., 1941, by Sanford R. Gifford.
lody Mechanics in Health and Disease, 3rd ed. 1941, by Joel E. Goldthwaite, et al.
Medical Clinics of North America, Symposium on Military Medicine, November, 1941.
rhe Doctors Mayo, 1941, by Helen Clapesattle.
fhe Doctor and the Difficult Child, 1940, by William Moodie.
Nelson Loose Leaf Medicine, refills including—
Chemotherapy of Meningitis (Recent progress) by W. W. Herrick.
Toxicology, by Henry G. Barbour.
The Pneumoconioses, by Leroy U. Gardner.
Pulmonary Abscess and Gangrene, by Brian Blades and Evarts A. Graham.
Public Health—Completion of revision of this volume.
Vancouver Medical  Association
, ^
Since the Japanese blitz a committee of the Vancouver Medical Association has con-
erred with Dr. Stewart Murray of the Metropolitan Health Board regarding organiza-
ion of local medical men for action in the event of an air raid on the city or neighbor-
ng municipalities. This organization will eventually be correlated with a Province-wide
jcheme. At the beginning only local activities could be arranged because of the confusion in respect to responsibility that existed between Civic, Provincial and Federal
Officials in other branches of A.R.P. work.
The city is divided into twenty-three A.R.P. districts, each with an A.R.P. post.
\\t the present time these posts are nearly all located in schools, unsuitable though they
pay be. A medical officer-in-charge of each A.R.P. district has been appointed. In most
Instances a medical officer has been chosen whose home is in his A.R.P. district and at a
tonvenient distance from the A.R.P. post. In a few of the outlying districts it has
been necessary to appoint medical officers who live close by but not actually within their
K.R.P. area. The medical officers-in-charge are now meeting with the Senior and Deputy
! hardens of their district to survew the local situation. It is not necessary for them to
littend their post unless there is an air raid alert. Medical officers-in-charge are requested
po survey the list of doctors in their neighborhood and enlist the tentative support of a
imall group who will act in a relief capacity during a blitz period. In the outlying dis-
:ricts where there are few doctors the personnel committee will help to arrange for relief
doctors from adjacent areas.
In addition to the twenty-three A.R.P. posts throughout the city, six Divisional
Posts are being organized. These Divisional Posts will have reserves of personnel and
pquipment, and will be mobile. They will be used to supply A.R.P. posts in harassed
.ireas, and to set up emergency posts at the scene of any major disaster. The medical
personnel of these Divisional Posts has not yet been brought up to strength. A.R.P.
[posts in the city have already been equipped with necessary medical supplies and a mini-
pium of blankets, stretchers, etc., by the Red Cross and St. John's Ambulance Associations. These supplies will be augmented in a short time. The chief purpose of the
A..RJ*. posts is to sort out the casualties, separate the badly scared from those who are
really injured, commence the treatment of shock, and arrange for immediate transfer of
casualties to hospital. All of the existing arrangements will be subject to change from
tune to time.   At present it is imperative that every doctor in Vancouver should register
Page 109
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as an A.R.P. worker, filling out the forms in duplicate. Forms are available in the!
V.M.A. office. This applies to doctors on the staffs of hospitals as well as those who!
have no specific hospital responsibilities. If an emergency occurs every medical man willl
be needed. A compensation scheme under the aegis of the Federal Government has been]
arranged for registered A.R.P. workers who are injured in the course of their duties.!
Every doctor should acquaint himself with the name of the medical officer-in-charge of j
his home district and the site of the local A.R.P. post.
Dr. R. A. Palmer, Secretary, November 13 th, 1941.
Vancouver, Medical Association,
925 West Georgia Street,
Vancouver, B. C
Dear Doctor Palmer:
The Private Duty Nurses of Vancouver as a result of the increased cost of living
have decided after careful consideration to increase their fees.
The proposed fees are:
In Hospital—S-Hour Duty—
Surgical and Medical Cases $5.00
Maternity Cases _  5.00
Mental  and  Infectious 5.00
Alcoholic Cases <  6.00
Home Cases—
12 Hour Duty. I $7.50
24 Hour Duty (with 4 hours off duty and 6 hours sleep) 8.50
These rates are to take effect November 17th, 1941.
This increase in fees has been submitted to and approved by the Executive Council
and General Meeting of the Vancouver Graduate Nurses' Association.
Trusting this meets with the approval of the Vancouver Medical Association.
Sincerely yours,
(Signed)     Janie E. Jameeson, R.N.
1942     —     MEMBERSHIP     —      1942
College Dues for 1942 . $15.00
C. M. A. Membership, 1942 8.00
This will make your cheque total for 1942 $23.00
New Members are reminded that prompt response will assure
receipt of the January number of the Journal.
Page 110
Surgeon Rear-Admiral Gordon Gordon-Taylor, Senior Consulting Surgeon of the
British Navy, was guest of honour at a special luncheon of the Vancouver Medical
[Association on December 12th.  He is Senior Surgeon at the Middlesex Hospital, London,
land at the Chatham Naval Hospital.
As his visit coincided with our period of anxiety about possible imminent attack by
[the Japanese, his address after luncheon was of particular interest. He confined his
[remarks to highlights of his experiences in the treatment of blitz casualties in Great
The following is a brief resume of his remarks:
Among air raid casualties there is a very high percentage of seriously shocked patients.
They have found in many instances that it is necessary to give not only one but several
transfusions to a patient before he was in shape even to undress.  After initial recovery
[from the shock, patient may need further transfusions to tide him over the necessary
[operations.  The blood bank system has been an invaluable asset in obtaining sufficient
blood for this work.
Numbers of serious injuries occurred in individuals who suffered no outward con-
I tusions or lacerations but were exposed to the blast of a high explosive. The organ that
seems to suffer most is the lung. The patient at first is badly shocked and after recovery
from the shock may show pulmonary signs suggesting bronchial pneumonia. Mortality
rate in these patients is very high. A somewhat similar mechanism is the cause for
injuries in sailors who are in the vicinity of a depth bomb discharged while they are
swimming in the water. On several occasions ships have gone down with the charge
of the depth bombs not fixed and when the resulting blast occurred, all those who were
holding onto rafts in the neighbourhood, dropped off. The survivors have pulmonary
symptoms similar to those exposed to a high blast through the air.
Owing to the caving in of buildings and homes in air raids, many people are pinned
down by one or more extremities and it may be several hours or a day before they are
extricated. These patients, on admission, may be quite conscious and appear to be in
relatively good shape. The contused limb appears swollen and may be quite bruised.
In a considerable percentage of such cases, within 24 hours of admission to hospital,
suppression of urine develops, which may progress to complete anuria. The cause of this
complication is unknown. Some recent evidence suggests that it may be averted by
placing the affected limb in a Paavex machine.
In respect to A.R.P. stations it has been found that medical work should be confined
to sorting out the injured and treating shock, as well as the application of emergency
dressings. If any attempt to suture lacerations is made, it is likely that missiles within
the body will be overlooked.
It has been repeatedly demonstrated that the use of tannic acid or any coagulant is
contra-indicated for burns on the hands or face. Various types of moist dressings and
ointments are being used for the burns of the face and moist dressings entirely for the
burns of the hands.
Page 111 m
British  Columbia  Medical  Association
President 1 Dr. C. H. Hankinson, Prince Rupert
First Vice-President : Dr. A. H. Spohn, Vancouver
Second Vice-President Dr. P. A. C. Cousland, Victoria
Honorary Secretary-Treasurer Dr. A. Y. McNair, Vancouver
Immediate Past President Dr. Murray Blair, Vancouver
Executive Secretary Dr. M. W. Thomas, Vancouver
from  the  Cy resident
It has been said that coming events cast their shadows before them, and fat
British Columbia medicine this has been our experience to a great extent.
Your directors and committees continue their study of the problems which
require solution from year to year, regardless of the calendar. The threshold of
1942 finds them engaged in many more activities which are associated with
There is no doubt that, with the co-operative application of the professional
intelligence in this province, much constructive planning and provision for the
future will be accomplished this coming year. Our unity betokens our strength.
May great happiness accrue to each during the coming New Year. Be ready
to give your share.
THOUGHTS FOR THE NEW YEAR: Another year has come into being and, as
is the custom of this time, individually and collectively we citizens of this great Empire
are taking stock of ourselves and our Country, thinking of events that have happened
and the events that may take place.
Many of these events have changed our mode of life; many will possibly change it
much more. What the future holds in store for us we cannot tell, but we must carry
on in the meantime, and, be prepared to practise our profession "in primum artibus,
not withstanding the turmoil of this upset world.
In preparing for the new problems that we shall have to face, it is wise to learn from
those that have been faced previously. A quiet evening spent in review of the past
year's work will amply repay the physician for the time and effort he expends. The
warm thrill of accomplishment of a successful case, brought back to memory by a half-
forgotten name on a case record is worth a lot. The wonderment about a case that has
dropped out of sight, but should be brought into the office for a recheck is conducive to
the practice of good medicine.   Above all, those cancer cases that were diagnosed early
Page 112 [ should make the physician grateful that he is a physician, for each early diagnosis means
a life saved.
Thus let us resolve that in 1942, and in years to come we will practise our great
l profession with studious care, learning from the past, and trying always to do our best
| for our patient no matter how much time and energy that best demands.    Remember
also that, year by year, cancer is becoming a bigger problem, and, that the problem can
be solved if we direct our efforts and our studies untiringly to diagnose cancer early.
Anonymous $25.00
M. G. Archibald, Kamloops   (additional)  25.00
Albert McBurney, Langley Prairie  10.00
W". H. White, Penticton  15.00
|;|     JiliflK        EQUIPMENT "m
The Bulletin has received from Ottawa (Department of Transport) a letter and
circular dealing with this matter. In view of .the large number of medical men who
have electrical equipment as part of their office set-up, and considering the fact that
every hospital now has X-ray machines, short-wave and diathermy apparatus, it behooves
all of us to look carefully into this matter.
The Federal authorities are taking active steps now to curtail or abolish such radio
interference. When one considers the vital necessity for keeping radio channels-open
in time of war, one can readily see why this must be done. Ndbody is exempt and on
and after January 1st, 1942, there will be compulsory interference suppression.
We are asked by the Department of Transport to publish two circulars dealing with
(1) electro-medical equipment in general, (2) spark-gap equipment. This copy of the
Bulletin should be kept for reference by all who operate electro-medical equipment in
their offices, in hospitals, etc.
1. This circular explains, in detail, how the regulations controlling radio interference from
spark-gap electro-medical apparatus referred to in circular SII-13-15, will be applied, and, also,
states the proposed method of controlling interference from other types of electro-medical equipment, including tube-type therapeutic generators.
2. Regulations will be applied according to sound engineering and economic practice. Our
inspectors will be pleased to offer advice regarding satisfactory and economical means of suppression, and all cases, 'where it appears that special treatment might provide satisfactory and
more economical means of suppression, 'will be given individual consideration.
3. Interference -with "Vital Communications: Any sources of interference with radio communications of the armed forces and of government and commercial stations will be dealt with
immediately. All cases of this kind shall receive special consideration and be dealt with on their
4. Spark-gap Electro-medical Apparatus: Interference from spark-gap electro-medical
apparatus, including diathermy apparatus, mechanical rectifiers for X-ray installations and
Violet-ray equipment, will be controlled on and after January 1st, 1942, according to circular
5. Tube-type Therapeutic Generators: Interference from radio frequency generators not
used for communication, including tube-type diathermy machines, induction furnaces, etc., will
be brought under control as soon after January 1st, 1944, as metal for shielding becomes available -without diverting supplies from more urgent requirements for the war effort. The exact
date of this control cannot now be fixed but  an endeavour will be  made  to; give  reasonable
Page 113
Ii' ■
fe Ki
Fund. Freq.
+ or —0.05%
Wavelength Equivalent to
notice before applying regulations to this type of apparatus. Full details of these regulations)
have not yet been decided upon but it has been decided to control the interference along the
following general lines:
When the additional restrictions are put into effect, all radiations from non-communication
more frequencies, which may probably be allotted for use of non-communication generators]
generators  (with the exceptions noted in paragraph 6)   will be prohibited, except on one or
Consideration is now being given to the allotment of the following frequencies for this
Upper Freq. Lower Freq.
Limit Limit
(kc/s) (kc/s)
13,666.8 13,653.2
27,333.7 27,306.3
41,000.5 40,959.5
It is not economically feasible to convert the present type of diathermy generators so that
they will operate satisfactorily on the desired frequency within the allowable tolerance of plus
or minus 0.05%.
A number of manufacturers in the United States have already submitted samples of therapeutic generators constructed to operate within the narrow frequency tolerance. These samples
are now being tested both for therapeutic requirements and frequency stability. Details of the
test used for frequency stability may be obtained, on request.
It will probably be over a year before therapeutic generators having the desired frequency
stability will be available commercially. It is estimated that the cost of such generators may
be considerably greater than apparatus now in use. It, therefore, appears probable that the
most economical and satisfactory method of suppressing interference from therapeutic generators
is by operating the same within a thoroughly shielded room having filters in the power supply.
The shielded room having filters in the power supply for the suppression of interference from
spark-gap apparatus will be satisfactory for the suppression of interference from tube-type generators. It is conceded, however, that therapeutic generators are required to be used in cases
■where the patient cannot be brought to a shieldd room and, for this purpose, the new design of
generator, having the desired frequency stability 'will be required.
6. Special Cases: Special consideration should be given in all cases where it appears that
exceptional conditions exist, in which a departure from the general procedure may be satisfactory and more economical.   Such consideration may be given to the following:—
(a) Hospitals and other medical establishments, ■where no interference is heard outside the
premises: Many modern buildings are so constructed as to form a natural shield, and the power
supply fed underground forms an effective filter, so that apparatus operated within the building
Where a radio receiver within such premises is adversely affected, an endeavour should be made
by all parties concerned to reduce the interference in the most economical and satisfactory way.
Such means may be applied either to the receiving installation or to the interfering apparatus.
Noise-reducing antennae are frequently useful in such circumstances.
(b) Locations where no receivers are within range of the interference: Temporary exceptions may be made •when apparatus is operated where it is probable that no interference (exceeding tolerable limits) is produced to radio receiving stations, but if a complaint of interference
be later received, the situation should be immediately reviewed.
Partial suppression of interference by the installation of filters in the power line without
shielding may be sufficient to suppress the interference from receivrs remote from the source.
Many hospitals are located within large grounds, so that reasonably economical means may be
applied to reduce the interference to such a level that it would not exceed the tolerable limits
at the locations of radio receiving stations. There are several alternative means of suppressing
the interference from X-ray equipment.   One of these is shielding the room and installing filters
in the power supply. On large installations, however, this is usually found to be very costly.
A method -which is economical for many installations, consists of the installation of radio
frequency choke coils in the four high tension leads from the rectifier, and a filter in the power
supply. We cannot guarantee this method, as the effectiveness has been found to vary with the
different types of installations, but, in many cases, it has been found to satisfactorily reduce the
(c) Industrial Districts: When interfering electro-medical apparatus is operated in districts
where the noise level from uncontrollable sources is exceptionally high, it will not be necessary,
for the present, to suppress the interference from such equipment to a point where further
suppression would not benefit the operation of the radio recivers concerned. If, however,
spark-gap electro-medical apparatus should detrimentally affect reception, at times when the
interference from uncontrollable sources is at a low level, it will be necessary to apply the
necessary suppression.
(d) Emergency Cases: Interference caused by the operation of interfering apparatus in
cases of emergency is dealt with under Section 4 of the Regulations for Controlling Radio Interference. This privilege of emergency operation should not be abused. Cases involving the use
of electro-medical apparatus for patients who cannot be moved to a shielded room or otherwise
Page 114
warn given the desired treatment without causing interference should be classed as emergencies. The
use of Violet-ray and diathermy apparatus in private homes, hospital wards, beauty parlours or
barber shops, and in all cases where the patient can safely be moved to a shielded room, should
not be considered cases of emergency. Hospitals in the habit of using interfering equipment in
the ordinary wards should be provided with a shielded room or other means of suppressing the
interference, in order that no interference may be caused by the treatment of patients whose
conditions would permit them to be moved with safety.
(e) Intermittent Sources of Interference: Interference from rectifiers of X-ray apparatus
used only for radiography and interfering apparatus necessary for surgery, operated occasionally
for periods of a few seconds, will not require suppression at the present time, provided it does
not interfere with vital communications.   The exact time limits have not yet been determined.
7. Shielding Material: Prefabricated shielded cubicles may be obtained from some contractors who specialize on this means of suppression.
"Copper armoured Fibreen" which consists of copper foil mounted on heavy paper and reinforced with fibre may be mounted on the walls and bonded as describe din circular SII-10-35.
Other material referred to in circulars dealing with shielding (SII-10-3 2) and SII-10-3 5)
may probably be obtained from dealers. Should difficulty, however, be experienced in obtaining
such material, the radio inspectors of the Department of Transport will be pleased to advise
regarding where the material may be obtained or recommend satisfactory substitutes.
8. Filters and Shielded Transformers: Shielded transformers, which were previously recommended for the suppression of interference, are difficult to obtain at the present time. The
Department is co-operating with manufacturers of suppressors in the development of suitable
equipment and it is anticipated that several new types will appear on the market in the very
near future.
The installation of filters and all electrical work should be in accordance with local municipal or provincial electrical inspections regulations.
9. Extension of Time, after January 1st, 1942: There may be unavoidable delay in providing the required suppression of interference before January 1st, 1942, due to difficulties in
obtaining the required material, skilled labour or other unavoidable causes. Users of interfering
equipment of the spark-gap type may apply to the nearest Radio Inspector of the Department
of Transport for permission to operate their apparatus until such time as the necessary suppression can be effected, provided that they submit proof with the application that they have made
a reasonable effort to suppress the interference and that the interference will be suppressed as
soon as possible. Such proof should contain sufficient detail to enable the radio inspectors to
assist in hastening the completion of the suppression by advising where the desired material can
be obtained or recommending suitable substitutes.
Ottawa, Ontario, December  11th,  1941.
sE* s£ & s5*
The necessity of protecting radio communications, including those used by the fighting
services, as well as broadcast reception, has obliged the Department of Transport to bring in
regulations prohibiting, after January 1st, 1942, the use of spark-gap type diathermy apparatus
and mechanical rectifiers for X—ray installations,. unless such equipment is adequately shielded,
thereby confining the radiation within reasonable limits, or its interference otherwise suppressed.
The severity of the radio interference created by spark-gap discharges is, of course, well
known to the operators of this equipment; it is quite capable of seriously interfering with
normal reception over wide areas on broadcast frequencies and the detrimental effect to shortwave commercial and war communications is equally pronounced, even at greater distances.
In 1925, engineers of the Department initiated research work on the problem with a view
to developing an economic means of suppressing this interference. From the mass of material
accumulated it has become clear that filters alone will seldom provide the answer; complete
shielding of the operating room or rooms, together with a suitable surge trap in the supply
lines has been found necessary. Perhaps -the most exhaustive researches along this line are those
carried out by technical officers of the British Governmnt and, here again, published reports
indicate that complete shielding is a primary requisite for the suppression of this type of interference and is now being enforced in Great Britain.
For the present, the regulations in Canada will not apply to short-wave therapy installations, unless they seriously interfere with some vital radio communication. It is not unlikely,
however, that they will ultimately be extended to include this equipment as well.
From the foregoing, the desirability of immediate action to suppress radio interference
affecting vital communications will be apparent, and it is anticipated that appropriate steps will
be taken by practitioners, without delay. In order, however, that no undue hardship be caused
the parties concerned, the Department of Transport has set the date for compulsory interference
suppression as January 1st, 1942.
Ottawa, January 20, 1941.
Page 115
•i 1 ■ w •
* i;
o   ege o
I Ph
ysicians an
d Su
Members of Council
 Dr. Wallace Wilson, Vancouver
 Dr. W. A. Clarke, New Westminster
 Dr. F. M. Bryant, Victoria
Auld, Nelson; Dr. F. M. Bryant, Victoria; Dr. W. A.
Dr. F. M.
Clarke, New Westminster; Dr. Thomas McPherson, Victoria; Dr. H. H. Milburn,
Vancouver; Dr. Osborne Morris, Vernon; Dr. Wallace Wilson, Vancouver.
Registrar Dr. A. J. McLachlan, Vancouver
Executive Secretary Dr. M. W. Thomas, Vancouver
i/T   ^// lessage from,  ike  d^y resident
On behalf of the Council I bring to all members of the College of Physicians and Surgeons, be they old or young, greetings for the year 1942.
In a very special way the Council desires to convey its very best wishes to
those members who, at home or abroad, are wearing the uniform of His Majesty,
the King. With a decision made and action taken they are indeed the happier
warriors who, free from inner conflicts, are finding contentment in giving the
answer to what they felt was a clear and personal call. We wish them luck and
success, and when bt Winston. Churchill's own time Peace and Victory have
arrived we hope they will return unharmed to their families and their friends.
In offering our best wishes to those who remain civilians let it be said that
there will fall to them much work and great responsibility. We believe that
neither work nor responsibility will be shirked. The old way of life is on the
way out, a new way will take its place and the system of the practice of Medicine will not be the one in which we grew up. With vision, courage and a
liberality of thought that will accept new ideas Medicine can take its rightful
place in shaping the coming new world.
The Committee on Economics has been asked to reply to the following question.
Question: "Regarding our position with the North Pacific Health and Accident
Association" — "Our members are in doubt as to what to do with cheques received from
this company" — "They are apparently subjecting our surgical fees to a 25 per cent
discount" — Could you inform us regarding this matter?
Answer: Application was made by the representative of the North Pacific Health
and Accident Association for recognition of its claim for special privilege in the matter
of a discount and upon investigation extension of such privilege was declined by our
Page 116 Plans which have received approval have been devised to serve definite employee
groups and have been developed in consultation with the Committee on Economics. The
Committee has insisted upon,making all such plans as comprehensive as possible in their
coverage. The Medical Services Association may be described as the most comprehensive
plan on this continent. The plans of the British Columbia Electric Railway Office
Employees, the B. C. Telephone Employees and the Vancouver School Teachers were all
developed in consultation with our Committee. These might be described as non-profit
plans operated for the benefit of the employees, the funds being entirely devoted to the
provision of medical care in all of its phases.
Many large insurance companies have during many years sold policies covering payments towards the cost of surgery ("cutting operations"). These payments are not
proposed to pay the whole of the surgeon's fee and in many cases do not. In all such
policies the obligation is to the insured person and not to the doctor. No discount has
ever been asked by an insurance company.
Associations which sell the same form of partial protection cannot be expected to be
treated differently than the insurance companies.
Insurance companies make certain that their policy-holders understand their relationship with both the company and the doctor. It is common knowledge that insurance
companies attempt to meet their obligations without asking doctors to underwrite their
When a doctor provides surgical care to a patient who is covered by a contract with
these associations, his fees should be such as would normally be charged to his patient
and on the basis of service rendered. The Committee feels that any suggestion that the
doctor be bound to adhere to a Schedule of Minimum Fees would be an interference
with the conduct of medical practice. The transaction is as between the patient and
doctor with no intervention by a third party. The patient must look to the company
or association to fulfil its obligation without quibble or question.
i i
(These are all vouched for as genuine, and taken from the Pocket-book of Boners.)
If anyone should faint in church put her head between the knees of the nearest
medical man.
Adolescence is the stage between puberty and adultery.
Isinglass is a whitish substance made from the bladders of surgeons.
The letters "M.D." signify "mentally deficient."
A sinecure is a disease without a cure.
Caviar is the eggs of a surgeon.
Celibacy is a disease of the brain.
A gelding is a stallion who had his tonsils taken out so he would have more time to
The seats of Senators shall be vaccinated every six years.
Sanhedrin was a Jewish virgin who went up to Jerusalem every year to be circumcised.
Shelley's most famous poem is-"Adenoid."
Pax in bello: Freedom from indigestion.
Notre voisin est mort d'une congestion pulmonaire.
Our neighbour died in a crush on a Pullman car.
Mexico was conquered by Kotex.
The Greek phenolax went straight through the Persian Army.
Obstetrical—The dog came bounding down the path emitting whelps at every
Page 117
Tti    .*
*>*'• if
Eye Section Please Note—'The principal parts of the eye are the pupil, the moat, and
the beam.
Some vitamins prevent beri beri; some prevent scurry scurry.
If you are sick, a physician should be insulted.
Doctors say that the increased birth rate shortens lives.
The way people contract consumption is as if a well man spits and the sick man
sees the well man spit, well the sick man thinks he has a right to spit as the well man has
to spit so he spits, so it is not well for anyone to spit.
rf When Quackery No Harm Meant"
Our readers will be interested in the following extracts from the advertising columns
of the Victoria Colonist of the date September 29, 1876.
It is hardly necessary, perhaps, to say that there was no Medical Act in British
Columbia in those days. Nor was there any of the absurd modern nonsense about limiting one's practice. You specialised in everything. (For the matter of that, we have one
or two lineal descendants of that type even now.)
Nor was cancer the dread plague that it is now—one expert even disdained the use
of the knife in its treatment. Office hours were longer, however, and few of us today
have the Spartan constitution which would enable us to practice from 9 a.m. till 9 p.m,
daily.   Probably time out was taken for visits to the neighbouring pub.
Has removed to Broughton street opposite the City Chambers. Philip James, M.D.,
Diplomatized Eclectic Physician. Extracts Polypus and Cancer without the use of the
knife. Rheumatics cured in one hour without pain." He is now using the Electric
Magnetic Machine with good effect in many diseases of Rheumatic, Palsy or Paralysis and
Fits.   N.B.—Special attention given to all diseases of women and children.
(Late of Virginia City, Nevada)
Physician and Surgeon,
Graduate of-the Universities of Berlin and Warburg, German Empire.
Office one door below Mr. Lowenberg's Real Estate office, Government street, between Fort and Broughton.  Office hours from 9 a.m. till 9 p.m.
Eye and Ear, Chronic Diseases, Obstetrics Specialty.
References—Hon. ex-Governor Barsdell, Gold Hill, Nev.; Hon. Wm. Patterson, Dist.
Attorney, Carson City; Hon. Judge C. C. Goodwin, of the Enterprise, Virginia City,
Nev.; Capt. H. H. Day, late Superintendant of the Raymond & Ely Mine, Pioche, Nev.
(From Canton)
Surgeon and Physician
Cormorant St., opp. Orleans Hotel.
Certified by English and American Consuls at Canton as being duly qualified,
respectfully solicits the attention of the afflicted.
Copied from Daily British Colonist, Victoria, British Columbia, Friday morning,
September 29, 1876.
Page 118
F. E. Saunders, M.D.
(Read before Vancouver Medical Association Dec. 2, 1941)
Starting with Biblical times the problem of sterility in the female has occupied a
position of importance in the scheme of life which has never failed to receive constant
attention.   The processes of treatment in olden times are amusing, to say the least, but
I suppose our efforts of today will also supply a few smiles in the future.
Still the ancients have recorded in their writings many points of interest.. The most
usual method of treatment was divorce, or its equivalent, always of course putting the
onus of the problem on the female. Never for a moment did the male submit to such
a degrading thought or insult to his ego as that he might be the offender. It is interesting to note that these mores have carried over into the present day, and it is not at all
uncommon for the male to refuse to submit himself to a proper examination by a competent man. The notable progress made in the last twenty years has demonstrated not
only that the husband carries a considerable share of the responsibility, but also that
constitutional states are causative factors, almost if not quite as important as are local
genital disorders. A complete investigation and treatment of sterility must therefore
involve work in several non-gynaecologic fields of practice, particularly in urology,
internal medicine and endocrinology. The gynaecologist by himself sees only a limited
aspect of the problem.
Definition of Sterility
Sterility is best defined as inability to initiate the reproductive process. This definition is in one sense narrow and in another particularly inclusive. It is narrow in that
it denotes only the failure of conception and does not include the many accidents which
may prevent the fertilized ovum from completing a normal career. Ectopic gestation
and uterine miscarriage are important types of failure of the reproductive system, but
they are not sterility, however, as here defined, and in practice should be regarded as
separate though related problems. In another way this definition has a broad application. It refers equally well to the individual of either sex, or to a mating. It covers
unfruitfulness due to social circumstances as well as sterility due to normal or abnormal
incapacities. It includes the special clinical meaning of sterility, which is inability to
initiate the reproductive process on the part of a couple who have desired and attempted
to reproduce for a reasonable length of time—ordinarily at least one year.
Absolute fertility means physiological perfection of the mechanism of conception.
Happily this state only exists in a small minority of human matings. In the clinics in
the East it was not uncommon to be asked if it was natural to have a period after
marriage. This person I am thinking of had been married for 16 years and the pregnancies were so close together that it left no time for such a commonplace happening as
denudation of the endometrium at menstruation.
Infertility is an inconclusive term covering all grades of fertility short of absolute
and all grades of sterility. Absolute sterility denotes the state in which the initiation of
the reproductive process is, at any rate for the time being, definitely impossible. This
results from conditions of two general sorts. First, those suppressing entirely the production of gametes, and secondly those entirely preventing the access of the male
gamete to the female. Absolute sterility may be temporary or permanent, in the case
of the former when inhibiting conditions are removed by nature or science, and the
latter of the gonads are removed or atrophied.
The exact incidence of voluntary sterility is difficult to determine. Vital statistics
provide a record of births in relation to marriages and to population, but do not distinguish the failure to conceive or the accidents of early pregnancy, and take no account
of the use of contraceptives. A conservative analysis of the best available data indicates
that somewhat more than 10% of modern marriages are barren. There are therefore in
the United States today at least two million childless couples who are still at the age of
potential reproduction. The magnitude alone of this situation offers sufficient evidence
of its importance.    Not nly is sterility a matter of supreme personal concern in the
Page 119
'-« iK
» "
; r
life of a very large number of individuals, but it is also a point of importance in the
social and economic factors of a nation. As has been very aptly said, a fruitless union
is one of Nature's saddest tragedies, and from whatever point of view it is considered
the result is detrimental to the best interests of society.
The following points may be mentioned as requisites of absolute fertility or physiologic perfection of the conceptive mechanism:
(1) Production of normal spermatozoa.
(2) The male genital tract must allow free passage of sperm from testicle to urethral
(3) The prostato-vesicular secretions must be favourable to the sperm.
(4) Ejaculated sperm must be safely delivered to and received by the cervix.
(5) The endo-cervical secretion must be favourable to the sperm.
(6) The uterus must allow the free passage of sperm from the cervix to the ostia
(7) The tubes must allow the free ascent of sperm and descent of ova.
(8) The ovario-tubal hiatus must allow the free passage of ova from the ovaries to
the ostia abdominalis.
(9) The ovaries must produce normal ova.
Factors of Infertility
If any of these nine conditions fail the result is some depression of the reproductive
capacity below the level of physiologic perfection. The degree of such depression is in
direct proportion to the details iri which the requisites of absolute fertility are unfulfilled. Conversely, when any degree of infertility exists it is obvious that one or more
of the requisites above named must have fallen short of complete fulfilment. The factors
of infertility may therefore be conveniently grouped according to a physiologic classic
fixation under nine major headings.
The first four dealing with the male I shall leave with a G.U. group for discussion
The fifth, concerning the hostility of endocervical mucus, starts the group set aside
as gynaecologic disturbances. This mucus, normally a favourable medium for sperm,
may become so altered as to become definitely antagonistic, and this hostility may be
listed as chemical, bacterial, serologic and mechanical.
Chemical hostility has been thought to occur in the form of acidity on the one hand,
and excessive alkalinity on the other. Recent studies, however, have shown that endocervical mucus is always moderately alkaline. Bacterial hostility is of small importance,
as any direct harm done to the sperm by the organism or its toxin is negligible. The
■serologic type presents itself as an interesting theoretic possibility. Experimentally the
subcutaneous injection of semen will sensitize the female against sperm so that temporary sterility results. There is, however, no direct evidence to show that natural sperm
immunity ever exists because of inherent incompatibiUty, or that it ever develops as a
result of repeated vaginal inoculations.
Machanical sterility is the most common and only important type. Abnormal vis-|l
cosity of the endo-cervical mucus may result primarily from perverted secretory action.
This is particularly likely to happen in chronic passive congestive conditions in which
the background is often a fault of sex hygiene. Secondary factors are infection and
inadequate drainage, especially the latter. If the internal os is small the secretions do
not escape freely and instead become thickened and inspissated within the canal. Ultimately the mucus forms a tenacious plug, the endo-cervical glands are affected, the
secretion becomes more and more abnormal and thus a vicious circle is obtained.
Subsequently to fertilization of the ovum the uterus plays a major role in the process
of reproduction. Prior to fertilization the function of the supracervical uterus is simple
—it serves only as a passage-way by which the sperm may .ascend.
If infertility be understood to be diminished ability to produce a conception then the
only directly uterine factors are those of blockade which may prevent free transit of
Page 120
< I* * spermatozoa. The commonest of such conditions is pregnancy—a pregnant woman is,
of course, temporarily sterile so far as the possibility of another conception is concerned.
Other sorts of blockade result from congenital absence of the uterus, from its surgical
removal, from complete atrophy, and from obliteration of the uterine cavity by tumour.
Thus, as far as infertiUty is concerned, the uterine causes are of more academic than
practical importance.
There are numerous uterine abnormalities more or less related to the sterile state
which in the past have erroneously been regarded as causes. For example, pregnancy
fails to occur in the infantile uterus not because of the maldevelopment of that organ
but because the associated infantile ovaries fail to ovulate. Retro-displacement of the
body of the uterus does not by itself impede conception, but it may be complicated by
other conditions such as cervical anteversion, which prevents proper insemination, or
inflammatory damage to the tubes, or congestive changes in the ovary. The frequent
coincidence of fibromyomata and sterility has oben been noted. It now appears that
these tumours are the result of the nulliparous state rather than the cause of sterility.
Defects of tubal patency may be of any degree from the simple temporary blocking
by mucus, to the complete and permanent obliteration of the tubal lumen. It is convenient to distinguish partial and complete impermeability by using the term obstruction
for the former and occlusion for the latter. The chief causes of patency fall into three
groups—developmental, malformation, inflammatory damage and spasm. Of these three
the inflammatory type is the most important. G.C. produces the most common, and
from the viewpoint of fertility the most serious of tubal inflammations. Even the
slightest degree of G.C. salpingitis causes some damage to the tubal mucosa, and if complete closure of the lumen does not occur at once there is still a great possibility of
strictures, kinks, and adhesions later. In the more severe cases the tubes are, of course,
hopelessly destroyed. Tubercular infections in this area progress more slowly, but in the
end produce results similar to the extensive G.C. type. It is remarkable, however, how
severe some of these inflammations may be without destroying tubal function. Peritonitis
of non-pelvic origin, the exanthemata, and anaemia are a few of the many diseases which
have been known to seal the fimbriated ends of the tubes.
The ovary is unique among the endocrine glands in that it has no direct connection
with its duct. Among lower animals the passage of the ovum is facilitated by various
arrangements, such as an ovarian bursa, ciliated peritoneal epithelium, prehensile fimbria,
and a capacious tubal infundibulum. In the human these structures are at the best
vestigial, and, moreover, the erect posture renders conditions even more unfavourable.
Ovarion underdevelopment is usually only one detail of a more extensive state—
female genital hypoplasia—which affects all the pelvic organs. True infantilism is rare,
but juvenilism, a developmental arrest at the pre-pubertal or early adolescent stage, is
exceedingly common. Neither the frequency nor the importance of this condition has
been generally appreciated. The cause of the female genital hypoplasia is some depressing
influence which operates during the adolescent years at the time when the organs of
reproduction should be undergoing their most rapid differential development. Many
different depressions seem to be able to produce these genital retardations. Among the
most important are transient endocrine failures, chiefly the anterior lobe of the pituitary,
and less often of the thyroid. Congenital syphiHs, anaemia, rickets, malnutrition, and
all types of dietary fault, poor hygiene, and particularly forcing, which makes excessive
demands on the strength of the adolescent girl.
Functional under-activity of the ovary, normally developed, results on the one hand
from certain local abnormalities which act as mechanical impediments to ovulation, and
on the other hand from various constitutional and endocrine disorders. The maturation
and rupture of a Graafian follicle is a delicate process easily deranged by adverse
mechanical conditions. A thickening of the tunica albuginea, or the presence of persistent retention cysts or corpora lutea, may raise the intra-ovarian pressure to a degree
which renders normal ovulation impossible. Chronic passive congestion is another
unfavourable condition.    The development of a perfect fertile ovum is likely to be
Page 121
$ prevented by depressed constitutional states which have already been mentioned in
relation to deficient spermatogenesis, chronic intoxications, unbalanced nutrition, conditions of debility and faulty hygiene. Endocrine failure of a major gland usually results
in deficient dovogenesis. As a matter of fact a wife who has some demonstrable endo-
crinopathy usually has a primary focus of failure in the anterior lobe of the pituitary,
less often in the ovary, and least often in the thyroid. Associated symptoms such as
obesity and anaemia are not in themselves causes of sterility as may be thought; they are
concomitant results of the same underlying cause, a metabolic depression which is
usually, but not always, in the nature of an endocrinopathy.
Clinical Diagnosis
In the past the clinical investigation of a case of sterility started with examination of
the female pelvic organs and progressed only to a point where the first real or fancied
cause was identified. The normality of all other items was then taken for granted,
investigation ceased and treatment began. From what is now known about the distribution and causative factors of human infertility it becomes evident that the adequate
diagnostic study of a sterile mating is necessarily a complex procedure. It must deal
with the husband no less than with the wife, and must consider the general health of
both partners as well as the condition of their reproductive organs. The essential feature
of such an investigation is always completeness in the sense that every etiologic possibility
is surveyed. Thus it can be stated in each case not only that certain factors are present,
but also, and with equal certainty, that all other demonstrable factors are absent.
The advantages of complete diagnostic study are threefold. In the first place it
makes a research contribution. In the second, it eliminates much worthless and harmful
treatment, and in particular, such disasters as operations done for sterility upon the wives
of absolutely sterile men. In the third place complete diagnostic study identifying every
factor in the etiologic sum total points the way to treatment which is complete and
therefore most efficient.
The following details of a gynaecologic history are of particular importance in cases
of sterility:
(1) A former marriage; pregnancies in that or the present marriage; abnormal
features of pregnancy, labour or puerperium.
(2) Venereal disease; appendicitis; "inflammation of the bowels", or any other
trouble suggesting pelvic inflammation.
(3) Leukorrhcea, past or present.
(4) Urinary symptoms, past or present.
(5) Pelvic or abdominal operations of any sort.
(6) Menstrual behaviour, age of onset, behaviour during adolescence, subsequent
changes in habit, present type of menstruation with details of periodicity, duration, amount and dysmenorrhcea.
(7) The sex life from the viewpoint of the wife, which does not always coincide
with that of the husband.
All deviations of female genital organs from the normal status are naturally of
interest if the function of reproduction is under consideration. Experience has shown
that certain items deserve special notice where sterility is the complaint.
(1) Malformations and deformities interfering with normal coitus.
(2) External vestiges of old G.C; chronic infection of Skene's glands; inflammation of Bartholin's ducts.
(3) Urethrocele; vulvar or anal lesions productive of dyspareunia.
(4) Positions of the cervix interfreing with normal insemination.
(5 ) Stenosis of the external os.
Page 122 (6) Chronic endocervicitis.
(7) Evident stigmata of hypoplasia; a long and conical cervix; a small uterus.
(8) Fixed retrodisplacement of the uterus.
(9) Chronic passive congestion of the pelvic organs.
(10) Indications of pelvic inflammatory disease.
(11) Palpably pathologic conditions of the tubes.
(12) Palpably pathologic conditions of the ovaries. Ordinary methods of examination are not always adequate to detect in the ovaries retention cysts and similar
minor abnormalities, which are unimportant enough in most other respects but
in relation to sterility are factors of the first magnitude. Accordingly, considerable effort, if necessary, should be made to palpate the ovaries. This may
require a repetition of bimanual examination under anaesthesia.
The endocervical mucus is routinely subjected to three tests; its chemical reaction
is determined, a stained smear is examined microscopically and viscosity is noted. This
endocervical mucus is invariably found to be alkaline when normal, ranging in hydrogen
ion concentration between 8 and 9. Moreover, these findings are not modified by parity,
menstrual cycle, or viscosity. The microscopic examination may reveal leukocytes,
bacteria and thick mucus in addition to epithelial cells.
The uterine index is a quantitative expression of the degree of differential development which the womb has achieved. In a truly infantile uterus the cervix constitutes
about two-thirds of the organ and the corpus one-third. In the normal adult uterus
these proportions are reversed. Accordingly, the ratio of corpus to cervix is a fair
gauge of the extent to which a given uterus has progressed from infantilism toward
adult perfection. Thus infantile ratio is 1:2—in the adult it is 2:1. In the various
degrees of juvenilism the ratios fall between these extremes. It is understood, of course,
that these observations apply to conditions developmental and not hypertrophic in
character.    Next in the list of importance is the Rubin's test.
For testing the patency of tubes there are now two well established procedures—the
insufflation of gas and the injection of iodized oil. In most cases of sterility a complete
evaluation of tubal conditions requires two insufflations at least. Trans-uterine insufflation involves the introduction of a gas under pressure, usually carbon dioxide. If at
least one tube is patent some of the gas passes through into the peritoneal cavity. The
occurrence of this phenomenon is evidenced in several ways: the gas pressure within the
closed system of the apparatus drops as the tubes are forced open; the passage of a gas
can be heard with a stethoscope applied to the lower abdomen; a subdiaphragmatic
pneumo-peritoneum is demonstrable by X-ray when the patient assumes the erect posture, and the resulting irritation of the subdiaphragmatic peritoneum gives rise to characteristic shoulder pain. In eases of bilateral non-patency all of these evidences are
If two insufflations are done with an interval of at least one day, the first after a
large dose of some anti-spasmodic drug, and the second without preliminary medication,
a comparison in the two results often reveals additional information. Patency demonstrated at a lower gas pressure on the first occasion than on the second indicates a
factor of tubal spasm. If on the other hand a second test demonstrates patency at lower
pressure than does the first, one may draw the conclusion that some pre-existing factor
of partial obstruction was mechanically removed by the first test.
Hysterosalpingography is the X-ray visualization of the uterine and tubal cavities
after injection of a medium opaque to roentgen rays, most commonly a compound of
iodine and oil. This procedure gives certain information about tubal patency not always
obtainable by gas tests. It differentiates unilateral from bilateral permeability. It also
locates accurately any point of obstruction, and in that way shows what may be
expected from surgical intervention. Apart from patency and occlusion of the tubes
many other pelvic conditions can be demonstrated by this method.. Important amongst
•these with reference to sterility are utering hypoplasia and malformation.
Page 123
>  I
j l
'4 *•,
fl With regard to post coital exarnination, the wife is seen within two hours after con-j
tact, and therefore material from her genital tract is microscopically examined with a;
view to the presence or absence of spermatozoa and the condition of those present.   As a!
matter of interest one usually studies a drop from the vaginal pool.    Practical importance, however, attaches mainly to the findings in the cervix.   This post-coital examina-i
tion gives unique information on two points—the function of the mechanism of deliveryi
and reception and the effect of the endocervical mucus upon spermatozoa.    It never!
eliminates the need for examination of semen and for the usual study of the endocervical secretions, but is often to be correlated with those observations.    Endometrial
biopsy lately has received more and more attention.    The impossibility of determining
with certainty whether or not normal ova are produced, leaves in doubt a most important
item in the investigation of the sterile mating.   Symptoms such as Mittelschmerz and
mid-interval bleeding are no more than suggestive.    The cellular content of the human
vagina does not show cyclic variations definite enough to be taken as a criterion.   It has
been demonstrated that the differences in electric potential between a suprapubic and a
vaginal electrode reach a peak in or near the time of rupture of a Graafian follicle.
More significant and practical, however, than any of the data are the findings
obtained by endometrial biopsy. The technique of this procedure is simple. No
anaesthesia is required if one uses the suction curette rather than the ordinary curette
or punch. Thus the biopsy may be performed in the physician's office and repeated, as
is commonly advisable, several times during a menstrual interval. Tissue is taken prefer- i
ably from the upper regions of the anterior and posterior uterine walls.
With regard to fertility and sterility the practical information obtainable from endometrial biopsy may be summarized as follows:
If the findings are normal then one is justified in assuming that normal follicular]
activity goes on in at least one ovary.    There is, however, no proof that highly fertile
or even completely mature ova are liberated.    If, on the other hand, the endometrial
reactions are found to be subnormal it is highly probable that the cause lies in an insuffi- j
ciency of ovarian stimuli.    A familiar case in point is that of the patient whose endo- j
metrium never exhibits an adequate secretory phase.    Reasoning backward from this]
phenomenon one deduces a lack of progesterone, then the absence of functioning corpora i
lutea, and basically the failure of Graafian follicles to mature and rupture.   Such a
patient often menstruates regularly, and to all appearances normally, but her flow is
what can be called anovulatory bleeding.   Recognition of this state of affairs explains
not a few sterilities for which no other cause may be discovered.
The last step in complete diagnostic study of a sterility problem is correlation of the
data obtained by the several different investigators. At almost every stage of the analysis
of a case it is found that independent studies are inter-related and complementary. For
example, the urologist discovers a subnormality of the semen, but is unable to identify
any causative local lesion in the male genital tract. His observation is confirmed by the |
gynaecologist, who reports deficient post-coital findings without evidence of any hostile
factor in the cervix. The explanation is provided by the internist or the endocrinologist
in the establishment of some depressed constitutional state which has lowered the fer-j
tility of the male. The final result is the reduction of each problem of causation to its
simplest terms, a definite number of demonstrated factors. Thus the way to treatment
is clearly indicated.
Page 124
1 V
By Frank Turnbull
Read at the meeting of the Vancouver General Hospital Staff on November 25, 1941, from the
sub-department of Neurology and Neurosurgery.
A moving picture which illustrates the case-report will be shown at the February meeting
of the Vancouver Medical Association.
Twenty years ago the removal of a loose piece of cartilage from within the spinal
canal was a rarity and every case justified a published report. The fragments of cartilage
were usually regarded as tumours and called chondromata. Today extrusion of a ruptured disc causing sciatica has become almost the most frequent lesion that orthopedic
and neurological surgeons are required to treat.
Etiology: Each intervertebral disc contains a central soft, cartilaginous substance
called the nucleus pulposus and a surrounding ring of fibrous tissue which is the annalus
fihrosus. Outside of the nucleus pulposus and thus separating it from the cartilage plates
of adjacent vertebra, as well as from the annulus, is a thin layer of fibrocartilage.
The extruded intervertebral disc which causes sciatica is more accurately described
as an example of postero-lateral rupture of the annulus fibrosus with protrusion of
nucleus pulposus and part of the inner wall of the annulus. As there is commonly no
history of trauma or back strain the lesion probably represents the culmination of a series
of mechanical insults to the affected discs. For reasons that result chiefly from our
upright stance the discs of the lumbrosacral region are subjected to the greater strains.
The majority of cases of extruded disc occur between lumbar five and sacral one, where
a lateral protrusion will cause pressure against the first sacral root. The next commonest
;site is at the interspace above, i.e., between lumbar four and lumbar five. Lesions at one
or other of these two sites comprise about ninety-six per cent of cases. Occasionally the
protrusion is directly backward in the midline and it may be of such a size as to cause
symptoms like a spinal cord tumour. More commonly, the protrusion is from the
postero-lateral angle and the resulting root pressure causes sciatica.
History: Most of the patients are in the middle age group. There may be no history
of injury or back strain. Usually there is an initial period of pain in the back. This
pain is periodis. The patient avoids lifting and bending because he has found that this
may result in a lame, stiff back for a Variable period. Later on the pains shift to one
hip and this area becomes more bothersome than the back. Suddenly, after a strain, or
gradually with repeated attacks, the pain spreads further down his leg to the back of
the thigh, outside of lower leg and foot. A sensation of numbness may gradually develop
over the lower leg and/or foot. The location of this numbness is an excellent guide in
respect to the nerve root which is affected.
Physical Findings: There is no noticeable stiffness of the back and frequently a tendency to tilt markedly to one $ideT When standing, the knee on the affected side is
usually held in a semi-flexed position.. Backward bending, especially if accompanied by
a twist to the affected side, may cause radiation of pain down the thigh. There is hamstring spasm on both sides, most marked on the painful side. Firm pressure just lateral
to the midline beside the spinous process of lumbar five will usually cause pain on the
side of the sciatica.
The motor, sensory and reflex signs depend on the root which is affected. The choice
in almost every case is between the fifth lumbar root and the first sacral root.    Signs of
Page 125
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il - j' involvement of sacral one are most common. In this syndrome there is weakness of
plantar flexion of the foot, diminished sensation over the lateral surface of the ankle and
foot, as well as the outer toes, and absent ankle jerk. When lumbar five is involved
there is usually weakness of dorsi-flexion of the foot, diminished sensation over the dorsal
inner surface of the foot and great toe, and diminished or normal ankle jerk.
The stage in the development of our knowledge of extruded disc when we had to
depend on lipiodol myelography to confirm or disprove the diagnosis, was unhappy for
the patient, radiologist and surgeon alike. We now know that special X-ray studies of
the spinal canal after injection of lipiodol or air are rarely necessary. Providing that
other causes of sciatica, which will be mentioned under Differential Diagnosis, have been
ruled out, the diagnosis of extruded disc is certain when the history and physical findings
that have been described above are found.
During the past five months we have operated upon eight consecutive cases in the
Vancouver General Hospital, with this syndrome, without myelography, and in every
case have found a grossly extruded disc. During this same period- myelography with
thorotrast was employed in a case where extruded disc was suspected but the history was
uncertain and the root signs equivocal. Our X-ray findings were negative and the case
was discharged. He was later operated upon elsewhere and it is reported that extruded
disc was found. In two cases where we explored for extruded disc with history and
physical signs that were not clear-cut, no extrusion was found. We may have missed
an extrusion laterally placed in an intervertebral space or have been dealing with cases
of so-called "concealed" discs of Dandy where there is intermittent protrusion through a
thinned annulus fibrosus without any actual point of external rupture of the disc.
Differential Diagnosiss Other causes of sciatica should be ruled out effectively by a
careful history, general physical exarnination and routine X-ray plates of the lumbosacral area. The diseases which need to be particularly kept in mind are malignant
tumour of spine, * primary or metastatic tumours of prostate, rectum, or pelvic viscera,
and cauda equina tumours. When there is symmetrical involvement of the sacral roots
in an individual who has done much heavy work, hypertrophy of the ligamentum flavunr
should be suspected. Other less frequent conditions which may give rise to a history
similar to extruded disc are spondylolisthesis, neurofibroma of the sciatic nerve, and
hypertrophic osteoarthritis.
Sacroiliac and lumbosacral strains are responsible for many low back pains and
these are frequently associated with radiation of pain out into the hips. But when there
is severe and persistent disability it is well to review the situation, because the fundamental lesion may not be disruption of spinal articulations, muscle and fasciae, but
rupture of disc.
Treatment: The acute case of low back pain and sciatica should be treated at first by
conservative or orthopedic measures. Many of these patients, even with-abnormal neurological signs, will recover and stay well after a period of rest on a hard mattress with
Buck's extension or plaster fixation of the affected leg. If the pain recurs with resumption of normal activities, it is usually a waste of time to repeat the conservative treatment. Occasionally when pain is restricted to the back an expert or lucky manipulation
may result in dramatic cure, but manipulation may make matters much worse when a
well-defined sciatic syndrome is present.
If symptoms do not improve with adequate conservative treatment laminectomy is
indicated, provided that the characteristic subjective and objective findings of extruded
intervertebral disc are present. At operation a very limited removal of laminae on the
affected side is sufficient to expose the extruded disc. It can nearly always be removed
extra-durally. The operation does not weaken the back or result in any limitation of
Typical Case Report: Mr. H., age 3 8, executive, referred by Dr. H. Powell of Vancouver. During the 1920's he had an occasional "lame" back. In January, 1941, he
slipped and twisted his back. For a few days he suffered from pain in the lower back.
Then the pain shifted to the left hip.    Off and on during the next few months he was
Page 126 troubled with stiffness of the back and aching in the left hip. When he sneezed he felt
pain behind the left knee. In May, 1941, the pain spread down to the knee and occasionally to the foot. An area of numbness was then noted over the outside of the left
foot and heel, behind the knee and over the back of thigh. He was admitted to hospital
with severe sciatica.   Rest and physiotherapy gave no relief.
General physical examination was negative. He stood with his spine tilted to the
left and marked flattening of his lumbar curve. Forward bending was grossly restricted
but not painful. Forced backward bending caused discomfort in the left thigh. He
could rise up on the ball of the right foot alone, but'could not get the left heel off the
floor when this leg was tested alone. The circumference of the left calf muscles was
l/z inch less than the right. There was slight hamstring spasm on the right side, and
moderate spasm on the left. Both knee jerks were active. The right ankle jerk was
brisk, but the left ankle jerk was absent. There was diminished sensation to pin prick
over a strip on the back of his thigh and over the outer half of his foot and the lateral
two toes.
On the basis of this examination diagnosis was made of extruded disc on the left side
between lumbar five and sacral one, pressing against the first sacral root. Myelography
was not employed.
At operation June 26, 1941, a large, loose fragment of fibrocartilage was removed
after retracting medially the first sacral root and adjacent dura. He returned to work
six weeks after operation. When re-examined three months after operation he was
entirely free of his former symptoms.
Summary: Extrusion of an intervertebral disc causing sciatica produces a well-
defined clinical syndrome. Diagnosis can be made in the majority of cases without
myelography. Treatment in the early stages should be conservative. If this treatment
is not effective an operation is indicated to remove the loose piece of extruded fibrocartilage.
The author wishes to acknowledge his indebtedness to Dr. K. G. McKenzie of Toronto
and Dr. Glen Spurling of Louisville, for his present conception of the disc problem.
For those particularly interested in this subject, the monograph by Bradford and Spurling on the "Intervertebral Disc" published this year by Thomas, is highly recommended.
G. F. Strong, MD.
Department of Medicine, Vancouver General Hospital
A. M. Johnson, M.D.
Senior Resident in Medicine, Vancouver General Hospital
A fifty-six-year-old male was admitted to the Medical Service, Vancouver General
Hospital, on August 14, 1941, complaining of "indigestion" for six weeks. He had been
awakened at three o'clock in the morning with a severe pain in his right lower abdomen
which lasted only an hour, then he went back to sleep. The pain did not recur with the
same severity but since then he has had attacks of moderate pain, always on the right
side of the abdomen with no special localization. These pains were not periodic in character, had no relation to meals and no relation to the type of food eaten. He had never
had any intolerance for any particular food. Three days before admission the pain
became steady and was localized in the right upper quadrant. He took aspirin with some
relief, but the pain became more and more severe. His usual weight is one hundred and
twenty-seven pounds (127 lbs.), but he thinks he has lost a great deal in the past six
The past history showed that he had dysentery in England in 1918, and again in
Vancouver in 1919. There has been no recurrence since that time. He is single, has
spent several years in the Orient and has always used alcohol moderately.
On physical examination, he was thin but did not appear very ill. His temperature
was 101°2'.   There was tenderness in the right upper quadrant but no mass or liver was
Page 12T
■ i
fc* palpable. There was moderate spasm of the muscles of the right upper quadrant. Examination was otherwise negative. His weight was one hundred and thirteen pounds (113
lbs.), a loss of fourteen pounds in six weeks.
Laboratory investigation showed: Urinalysis, 1020 Specific Gravity, no albumen or
sugar, -j- 1 white blood cells and an occasional granular cast. Haemoglobin was 76%,
red cell count 3,720,000, and white cell count 15,250. The differential count was
normal. The sedimentation rate was 9/70. Gastric analysis showed a normal hydrochloric acid.
Three days after admission, the patient became slightly jaundiced. The icterus index
was 9, but returned to normal in two days. There was no bile present in the urine. In
the ensuing weeks, the following investigations were carried out:
Flat plate of the abdomen revealed no pathology.
Gastro-intestinal series showed retention of one-half the barium in five hours, and a
definite ulceration in the pyloric third of the stomach, with considerable obstruction or
spasm in this region.
Barium enema was negative.
A gastric tube was passed the next morning and there was found no residual stomach
A gall-bladder series showed a non-functioning gall-bladder.
Retrograde pyelogram was done and found to be within normal limits. Ureteral
catheter specimens were within normal limits.
Thus, he had a gastric ulcer with obstruction, a non-functioning gall-bladder and
mild transient jaundice.
During the time in hospital, he had a temperature as high as 103° daily. The pain
disappeared shortly after admission to hospital but in view of the radiographic findings
of ulcer and pyloric retention, the patient was started on an ulcer diet. His weight at
the end of this week's investigations had fallen to one hundred and five pounds (105
lbs.). After two days on the ulcer regime, the patient began to vomit. Examination
found the abdomen slightly distended but no fluid demonstrable. He continued to vomit
and complained of passing a great deal of gas orally. During this time, the patient was
having normal bowel movements. It was deemed advisable to insert a Levine tube with
suction to relieve the distention. Three hours after feeding the gastric contents were
aspirated, measured, and then the suction was started again. This procedure kept the
distention fairly well under control. However, on the third day of this management,
the whole quantity could be aspirated at the end of three hours. The abdomen became
more distended and there was free fluid in the flanks. Consultation was sent to Surgery,
and in view of the pyloric obstruction an exploratory laparotomy was advised. The
differential diagnosis at this point rested between pyloric obstruction due to ulcer, empyema of the gall-bladder, Charcot's fever from stone in the common duet, or cirrhosis of
the liver.
At operation, the liver was found to be definitely abnormal. It was not enlarged
but studded with many coarse pebbles. On-the under surface of the liver, these projections had a reddish character. One of them was incised and cut easily, resembling a
haemangioma. The appearance as a whole was very unusual. Very little pyloric obstruction was felt but a posterior gastro-enterostomy was done. The post-operative course
was steadily downhill. There was no remission of the fever, and the patient died on the
twelfth post-operative day.
Post-mortem examination revealed a markedly cirrhotic liver, not greatly increased
in weight, which on section was found to be filled with carcinoma. There was no gross
evidence of a primary lesion. No flukes ,were found. The final diagnosis was primary
carcinoma of the liver, with terminal bronchopneumonia.
Conclusion: A case of primary carcinoma of the liver in a white adult is reported.
Though he had cirrhosis and had lived in the tropics, no liver flukes were found.
(From the Medical Service of the Vancouver General Hospital. I would like to
thank Dr. G. F. Strong for permission to publish this case.)
Page 128 JttiSi,
William Magner
Synopsis of Lecture given at the Summer School of the Vancouver Medical Association,
Vancouver, June, 1940.
Haemopoiesis.—In early intrauterine life the formation of blood cells is widespread
throughout the body, but is most active in the liver and in the spleen. About the fifth
month foetal bone marrow is developed and from this time the production of red cells
and granular leucocytes becomes progressively more active in the marrow and less active
in liver, spleen and other tissues. Under normal conditions extra-medullary hcemopoiesis,
that is, the production of bloods cells outside the marrow, ceases very shortly after birth.
Red and Yellow Marrow.—Red marrow is composed of masses of red and white
corpuscles in various stages of maturation, numerous thin walled blood vessels and scattered clusters of fat cells. Yellow marrow is composed almost entirely of adipose tissue
with few patent blood vessels but between the closely packed fat cells there are innumerable collapsed capillary channels and many potentially active reticular cells. Yellow
marrow is marrow in an inactive or resting state and in many conditions of disturbed
haemopoiesis it is transformed into active or red marrow.
At birth and during the early years of life all the bones contain red marrow, but
during adolescence the red marrow of the long bones and of the bones of the hand and
feet is gradually replaced by yellow marrow. In the adult the greater part of the red
marrow is distributed between the sternum, the ribs and the bodies of the vertebrae.
Origin and Maturation of Red Cells.—The red corpuscles or erythrocytes arise from
the endothelium of the capillaries of the bone marrow as nucleated haemoglobin-free cells
which are known as megaloblasts. By a series of mitotic divisions each meglaoblast
gives rise to a number of smaller haemoglobin-containing cells known as normoblasts.
Finally the normoblasts lose their nuclei and leave the marrow as young erythrocytes or
reticulocytes. Reticulocytes are so-called because they contain a reticulum of blue-
staining threads which is demonstrated by supravital staining. The percentage of reticulocytes in the blood is an indication of the activity of red cell formation in the marrow.
The Red Corpuscles in the Circulating Blood.—In the blood stream reticulocytes
lose their basophilic reticulum and become mature erythrocytes, and these cells finally
break up into minute fragments (schistocytes) which are engulfed by the cells of the
reticulo-endothelial system. Within the reticulo-endothelial cells the haemoglobin of
the disintegrated red cells is split into haematin and globin, and the haematin in further
reduced to an iron-containing pigment, haemosiderin, and an iron-free pigment, bilirubin
or haematoidin. The haemosiderin is utilized in the production of fresh haemolobin and
gthe bilirubin is excreted in the bile.
Conditions Necessary for Normal Erythropoiesis:
1. The marrow must be healthy.
2. The marrow must be supplied with certain substances which are necessary for
the normal maturation of the red cells.
3. There must be no excessive wastage of red cells.
Failing any one of these conditions the output of red cells from the marrow is insufficient to maintain the red cell count and haemoglobin percentage at normal levels, and
the patient becomes anaemic. •
Classification of the Ancemias:
A. Anaemias due to deficient production of red cells (dyshaemopoietic anaemias):
1. Due to injury to the marrow;
2. Due to deficiency of haemopoietic substances.
B. Anaemias due to excessive wastage of red cells:
1. Post-haemorrhagic anaemias;
2. Haemolytic anaemias.
A. Anemias due to Deficient Production of Red Cells (Dys hemopoietic Anaemias):
1.   Anaemias due to Injury to the Bone Marrow.
Page 129
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The red marrow may be injured by chemical poisons such as benzol or arsenic, by
physical agents such as radium, radio-active substances or X-rays, and probably by
bacterial toxins in acute and chronic infections and by poisons of tissue origin in nephritis. It may be progressively destroyed by the growth of neoplastic or inflammatory
tissue within the bones, as in cases of multiple myeloma, secondary carcinoma and osteosclerosis. The erythropoietic or red-cell-prdoucing tissue may be crowded out by proliferating leucocytes, as in leukaemia.
In all cases such injury to the marrow leads to anaemia from deficient production of
red cells, but the changes in the marrow and in the blood depend upon the nature of
the harmful agent and upon the intensity and duration of its action. Destruction of
primitive blood cells with hypoplasia or aplasia of the marrow is by no means a constant
finding. Often the injurious substance causes an irregular hyperplasia of these cells
with failure in the normal process of maturation, and in such cases the marrow is hyperplastic. Anaemia from injury to the marrow is usually of normocytic, normochromic
type; that is, the average size of the red cells is normal and their haemoglobin content
is normal (normal colour index). Variations in the size and shape of the red cells
(anisocytosis and poikilocytosis) are rarely marked, and in cases of aplastic anaemia, in,
which there is widespread severe injury to the marrow and a rapid reduction in the
numbers of all the formed elements of the blood, these features are absent.
2.   Anaemias due to Deficiency of Haemopoietic Substances.
Certain substances are necessary for the normal development of the red cells. Of
these the "pernicious anaemia factor" or "anti-pernicious-anaemia principle" and iron
appear to be the most important, as deficiency of either of these substances inevitably
leads to the development of anaemia of dyshaemopoietic type. Prolonged deficiency of
vitamin C or of thyroxin (hypothyroidism) also leads to anaemia from deficient production of red cells.
(a) Anaemias due to Deficiency of the Pernicious Anaemia Factor:
The pernicious anaemia factor or anti-petnicious-anaemia principle is a product of
normal gastric digestion. Castle's work indicates that it is formed by the interaction of
a substance contained in the food (the extrinsic factor) and a substance produced by
the gastric mucosa (the intrinsic factor). In its absence the transformation of megaloblasts into normoblasts in the marrow is impeded, the marrow becomes crowded with
proliferating megaloblasts, the output of red cells falls and those red cells which do
enter the blood are unduly large (megalocytes). As there is, as a rule, no deficiency of
iron, the large cells of megalocytes are filled with haemoglobin, so that the anaemia as
well as being large-celled (megalocytic) is also hyperschromic (colour index high). Examples of anaemia of this type are true (Addisonian) pernicious anaemia, the pernicious
anaemia of pregnancy, the pernicious anaemia of sprue and idiopathic steatorrhoea, the
pernicious anaemia of tape worm infestation, and the pernicious anaemia associated with
organic lesions of the gastro-intestinal tract. In all these cases administration of the
missing substance, in the form of liver, liver extract or ventriculin, leads to rapid
maturation of the megaloblasts, disappearance of marrow hyperplasia and restoration of
a normal blood picture.
(b) Anaemias due to Deficiency of Iron:
The iron of the body is obtained from iron-containing foods. A deficiency of iron
may be due to the use of a diet poor in iron, to a need for iron which is greater than
can be supplied from a normal diet, to failure in the utilization of ingestion iron (faulty
digestion), to loss of iron as a result of chronic haemorrhage or to a combination of
two or more of these factors. Iron is essential for the formation of haemoglobin and
the transformation of normoblasts into erythrocytes. If the supply of iron is deficient
red cell production is retarded at the normoblastic level, the marrow becomes crowded
with normoblasts which fail to mature, the output of red corpuscles is reduced and
those red cells which do reach the blood stream are poor in haemoglobin and, as a rule,
smaller than normal.    The anaemia of iron deficiency is, therefore, characterized by
Page 130 microcytosis (unduly small red cells) and hypochromasia (low colour index). Examples
of anaemia of this type are idiopathic hypochromic anaemia or chronic microcytic anaemia,
the hypochronic anaemia of pregnancy, the hypochromic anaemia of infancy, the hypochromic anaemia associated with organic lesions of- the gastro-intestinal tract, and
chronic post-haemorrhagic anaemia.
B. Anemia due to Excessive Wastage of Red Cells.
The healthy bone marrow is capable of a very much greater output of erythrocytes
than is necessary under normal conditions, and wastage of red cells by haemorrhage or
haemolysis is followed by functional normoblastic hyperplasia of the marrow and a rapid
outpouring of young erythrocytes (reticulocytes) into the blood. Following a single
profuse haemorrhage or a transient attack of haemolysis of the red cell count is more or
less rapidly restored to a normal level by the hyperactive marrow. If, however, haemorrhage is continuous or recurrent or if there is persistent haemolysis the marrow, in spite
of its increased activity, is unable to supply a sufficient number of erythrocytes to keep
the red cell count at a normal level, and chronic anaemia appears.
1. Haemolytic Anaemias:
Haemolytic anaemias, that is, anaemias due to destruction of red cells within the blood
vessels, may be grouped into those due to the action of an extrinsic agent (B. welchii,
haemolytic streptococci, the malaria parasite, Bartonella bacilliformis, certain chemical
poisons), those due to some abnormality of the blood (familial haemolytic icterus, sickle-
cell anaemia, paroxysmal haemoglobinuria), and those of unknown aetiology. All anaemias
of haemolytic type are characterized by the following features: (1) functional or compensatory hyperplasia of the bone marrow (2) an increased percentage of young cells
of reticulocytes in the blood (due to hyperactivity of the marrow, (3) an increase in
the amount of bilirubin in the blood (due to the liberation of large amounts of haemoglobin from the disintegrating red cells), (4) an increase in the amount of urobilinogen
in the urine (due to the excretion of excessive amounts of bilirubin into the intestines,
(5) a deposition of haemosiderin in the liver and other organs (due to excessive formation of this pigment from the liberated haemoglobin). In familial haemolytic icterus,
other features are spherocytosis and increased fragility of the red cells. When large
numbers of red cells are rapidly destroyed within the body, the resulting severe anaemia
is accompanied by leucocytosis, jaundice with an indirect van den Bergh reaction and
haemoglobinuria. The reticulocyte count is greatly increased and owing to the intense
regenerative activity of the marrow, nucleated red cells and immature leucocytes may
appear in the blood. With less active haemolysis the anaemia and jaundice are of minor
grade, haemoglobinuria is absent, and while the reitculocyte count is high, immature
cells are less likely to be found in the blood.
2. Post-haemorrhagic Anaemias:
For some hours following a sudden profuse haemorrhage there is little change in the
haemoglobin percentage or red cell count, but as the blood volume is restored by the
passage of fluid from the tissues into the vessels, severe anaemia becomes apparent. Such
an acute post-haemorrhagic anaemia resembles haemolytic anaemia in that there is functional hyperactivity of the marrow, leading to leucocytosis and reticulocytosis. It differs from haemolytic anaemia in that there is no increase in the amount of bilirubin in
the blood, no excess of urobilinogen in the urine or faeces and no disposition of haemosiderin in the tissues. If haemorrhage is very profuse or if bleeding is recurrent, so much
haemoglobin is lost in the extravasated blood that the body's store of iron is exhausted
before the normal blood picture is restored. Cell regeneration then becomes less active,
and unless large doses of iron are administered, anaemia of hypochromic microcytic type
may persist for many months. The anaemia of chronic haemorrhage is actually an iron
deficiency anaemia. When haemorrhage occurs into the tissues or body cavities, the disintegration products of the extravasated erythrocytes are available for the formation
of new red cells. The picture therefore may resemble that of haemolytic anaemia, in
showing reticulocytosis, hyperbilirubinaernia with an indirect van den Bergh reaction
an an excess of urobilinogen in the urine and faeces.
Page 131
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194 2      —     MEMBERSHIP     —      1942
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effective treatment suggests the use of
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increase cellular activity, and ■enure
adequate elimination  of toxic waste.
orally given, supplies ealeium, sulphur,
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effective solvent. Amelioration of
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