History of Nursing in Pacific Canada

The Vancouver Medical Association Bulletin: March, 1948 Vancouver Medical Association Mar 31, 1948

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Full Text

 THE
BULLETIN
Published By
The Vancouver Medical Association
EDFTOR:
DR. J. H. MacDERMOT
EDITORIAL BOARD
DR. D. E. H. CLEVELAND
DR. H. A. DesBRISAY
Editorial and Business Office
203 MEDICAL-DENTAL BUILDING
VANCOUVER, B. C.
DR. J. H. B. GRANT
DR. D. A. STEELE
Publisher and Advertising Manager
W. E. G. MACDONALD
Vol. XXIV
MARCH, 1948
No. 6
De. G. A. Davidson
President
OFFICERS, 1947-48
De. Gobdon C. Johnston
Vice-President
Db. H. A. DesBbisay
Past President
Db. Gobdon Bubke
Hon. Treasurer
Db. W. J. Doebance
Hon. Secretary
Additional Members of Executive: Db. Roy Huggabd, Db. Henby Scott
TRUSTEES
Db. A. M. Agnew Db. G. H. Clement Db. A. C. Fbost
Auditors: Messes. Plommee, Whiting & Co.
SECTIONS
Clinical Section
Db. Reg. Wilson Chairman Db. E. B. Tbowbbidge Secretary
Eye, Ear, Nose and Throat Section
Db. Gobdon Labge Chairman Db. G. H. Fbancis._ Secretary
Paediatric Section
Db. J. H. B. Grant Chairman Db. E. S. James_: Secretary
Orthopaedic and Traumatic Surgery Section
Db. J. R. Naden Chairman Db. Clabence Ryan Secretary
Neurology and Psychiatry
Db. J. C. Thomas Chairman Db. A. E. Davidson Secretary
STANDING COMMITTEES
Library:
Db. J. E. Walkeb, Chairman; Db. W. J. Doebance, Db. D. E. H. Cleveland,
Db. F. S Hobbs, Db. R .P. Kinman, Db. S. E. C. Tubvey.
Publications:
Db. J. H. MacDebmot—Chairman; Db. D. E. H. Cleveland, De. H. A.
DesBbisay, Db. J. H. B. Gbant, Db. D. A. Steele. m&.
G
TABLETS
No. 815
INJECTABLE
(DRIED)
No. 495
CONCENTRATE
No. 926
COMPOUND
^    No. 924
?m>.
GRANULES
No. 925
LIQUID
No. 923
WITH  IRON
AND LIVER
No. 816
J& INJECTABLE
■g^-ft-r (SOLUTION)
/ No. 491
&
WITH
VITAMIN C
No. 817
FOR   VITAMIN   B   FACTORS
To meet the varying requirements of vitamin B
deficient patients, a wide variety of forms and
dosages is incorporated in the "Beminal" group.
Whether the patient suffers from a mild deficiency or exhibits a marked degree of avita-
minosis-B, there is a "Beminal" preparation to
suit his needs.
Cfyvtd
514
AYERST, McKENNA & HARRISON LIMITED * Biological and Pharmaceutical Chemists* MONTREAL, CANADA March 16th       CLINICAL MEETING—Children's Hospital.
April   6th GENERAL MEETING—Auditorium, Medical-Dental Building.
Speaker—to be announced.
April 20th CLINICAL MEETING—Place of meeting to be announced.
May   4th
ANNUAL MEETING—Auditorium, Medical-Dental Building.
;s*k
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?t»fc*$F$5l
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VANCOUVER MEDICAL ASSOCIATION
Founded 1898    :    Incorporated 1906.
Programme for Fiftieth Annual Session
(Spring Session)
February 17th   CLINICAL MEETING—St. Paul's Hospital, Nurses' Auditorium.
I---.'.-:*■*xtyy fit
*- V;<;«:-.- .••:■      •*
March   5th (Friday)    OSLER DINNER AND LECTURE—Hotel Vancouver, Banquet Room.
Osier Lecturer—Dr. Murray Blair.
:-^>?^^aM!WaiftWft:fiS.<a
Breaks the vicious circle of perverted
menstrual function in cases of amenorrhea,
tardy periods (non-physiological) and dysmenorrhea. Affords remarkable symptomatic
relief by stimulating the innervation of the
uterus and stabilizing the tone of its
musculature. Controls the utero-ovarian
k   circulation and thereby encourages a
normal menstrual cycle.
k A
. « MARTIN H. SMITH COMPANY
§5. ISO l»»«TITTI  SHUT.   N(W   TO«K,  N. T.
Full formula and descriptive
literature &* request
Dosage: 1 to 2 capsules
3 or 4 times daily. Supplied
in packages of 20.
Ethical protective mark MHS
embossed on inside of each
capsule, visible only when capsule is cut in  half at seam.
.-•*-/
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Page 187
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CRYSTALLINE   PENICILLIN G
\
%
ns,
V
It has bee widely established that Pennicillin G is a highly effective
therapeutic agent. The crystalline form of Penicillin G prepared and
supplied by the Connaught Medical
Research Laboratories is highly purified. Because of this high degree of
purity, pain on injection is seldom
reported and local reactions are
reduced to a minimum. Crystalline
Penicillin G is heat-stable, and in the
dried form can be safely stored at
room temperature for at least three
years.
PHOTOMICROGRAPH
OF PENICILLIN   CRYSTALS
CRYSTALLINE PENICILLIN  G IN VIALS
Highly purified Crystalline Potassium Penicillin G is supplied by the Laboratories in sealed rubber-
stoppered vials of 100,000, 200,000, 300,000, 500,000 and 1,000,000 International Units. No refrigeration is required.
LIQUID CRYSTALLINE PENICILLIN G IN OIL AND WAX (ROMANSKY FORMULA)
A heat-stable and conveniently administered form of Crystalline Potassium Penicillin G in peanut
oil and beeswax is available in 1-cc. cartridges for use with B-D* disposable plastic syringes, or as replacements -with B-D* metal cartridge syringes. Each 1-cc. cartridge contains 3 00,000 International Units of
Crystalline Potassium Penicillin G.
Liquid, free-flowing Penicillin in Oil and "Wax, prepared from Crystalline Potassium Penicillin G, is
also supplied in  10-cc.  vials  each containing 3,000,000  International Units.    No  refrigeration or pre-
warming is required.
* T.M. Reg. Becton, Dickinson & Co.
CRYSTALLINE PENICILLIN G IN TABLETS FOR ORAL USE
Buffered tablets of Crystalline Potassium Penicillin G are distributed by the Laboratories in tubes of
12. Two strengths are supplied, 50,000 and 100,000 International Units per tablet. No refrigeration is
required.
CONNAUGHT MEDICAL RESEARCH LABORATORIES
University of Toronto Toronto 4, Canada
DEPOT FOR BRITISH COLUMBIA
MACDONALD'S PRESCRIPTIONS LIMITED
MEDICAL-DENTAL BUILDING, VANCOUVER, B.C. VANCOUVER HEALTH DEPARTMENT
CASES OF COMMUNICABLE DISEASE REPORTED IN THE
CITY
STATISTICS—JANUARY, 1948
Total Population—Estimated 354,045
Chinese Population—Estimated ;       7 -97-9
Hindu Population—Estimated 275
Number    Rate'Per 1,000 Population
Total deaths   = 3 89 13.0
Chinese deaths 13 19.2
fBDeaths, residents only 362 12.1
BIRTH REGISTRATIONS:
Male = 425
Female 408
833
27.8
INFANT MORTALITY:
Deaths under 1 year of age  20
Death rate per 1000 live births  31.5
Stillbirths (not included above) 8
14
18.
6
CASES OF COMMUNICABLE DISEASE REPORTED  IN THE CITY
Number    Rate Per 1,000 Population
December, 1947 January, 1948
Cases        Deaths Cases        Deaths
Scarlet Fever-
Diphtheria.
Diphtheria Carrier	
Chicken Pox !	
Measles	
Rubella , _ , 331
Mumps	
Whooping Cough-
Typhoid Fever	
Undulant Fever-
Poliomyelitis	
Tuberculosis	
Erysipelas	
Meningococcus (Meningitis).
Infectious Jaundice	
Salmonellosis	
Salmonellosis (Carrier)	
Dysentery.
Dysentery  (Carriers).
Tetanus—	
Syphilis (not available)	
Gonorrhoea (not available).
Cancer (Reportable)—
Resident—!	
Non-Resident	
Februa
12
ry, 1948
0
January,
18
1948
0
7
0
4
1
15
0
1
0
125
0
71
0
331
10
0
0
157
7
0
0
14
0
30
0
2
0
10
0
0
0
0
0
1
0
0
0
0
0
0
0
40
0
33
8
1
0
1
0
1
0
2
0
0
0
0
0
1
0
3
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
63
3
0
0
257
0
69
0
92
0
13
0
18
0
Page 188 ANTACID   MAINTENANCE
Healing of peptic ulcer must be followed by
effective antacid maintenance therapy to
prevent recurrence. This can be achieved
most conveniently with agreeable, easy-to-
carry Creamalin Tablets.
Through sustained reduction of gastric acidity
without the danger of alkalosis, nonabsorbable
Creamalin provides reliable and safe antacid
control for the ambulatory ulcer patient.
UrsJ^nmi <H oioninum b^oxide gil
Tablets
Tins of 12, bottles of 50 and 200
new York 13, N. V.    Windsor, Ont.
CREAMALIN. tr.dem.rk Rcf. U S. P.I. Otf. & Cn»d.
The businesses formerly conducted by Winthrop Chemieol Compony, <**■ v
<Ond Frederick Stearns & Company Of* now owned by Winrtirop-Steo"» '*<■
QUEBEC PROFESSIONAL OFFICE: DOMINION SQUARE BUILDING, MONTREAL, QUBK
019 Elliott Street, West, Windsor, Ont. • 423 Ontario Street, East, Montreal, P-Q- We publish in this issue a letter from Dr. Wallace A. Wilson, together with "a brief
discussion," to use his own words, "Of some of the problems which confront the General
Practitioner." We think that every medical man would do well to read both of these
very carefully. No medical man in Canada has more justifiably earned the confidence
and respect of his colleagues in the practice of medicine than has Dr. Wallace Wilson—
his record is one of continuous and aggressive fighting on behalf of the medical profession—and in no particular department of medical practice, either. Himself a specialist
in internal medicine, he has yet grasped clearly, and held intact, the principle that all
medical practice is one—and that it is only at the peril of all of us that we allow any
deviation from that principle. Advance in the practice of medicine must not—indeed
it cannot—be confined to specialties. It must proceed along the whole front. Dr.
Wilson re-states what we all accept as a truism, that the majority of the profession,
numerically speaking, are general practitioners—and he sees clearly, and urges it upon
us, that as much attention must be paid to the raising of the standards of general medical
practice as to those of any specialty.
This is so obvious that it has been generally overlooked and it is time we thought a
bit about it. It is indeed true that in the main, new methods, advanced techniques and
so on are most likely to come through the work of men who are devoting their whole
time to the particular subject involved—but this is not the whole of the problem. The
general practitioner is the first line of defence—he it is whom the sick man first sees, as
a rule—many of us feel that he should always be the first man seen; but there is some
room for argument here. At least it is the general rule. Everything depends therefore
upon the quality of the general practitioner—he must be of a high quality if we are
to avoid serious defects in our system.
Medicine as it is today is a very complicated structure, and no man in general practice can expect, nor should he expect, to be able to handle efficiently ,and according to
the highest standards, everything that comes his way. But neither should he be merely
a clearing house for the specialties. Far from it—he has his own place to fill and it is a
big and important place. If he is conscientious, alert and receptive, keeping up to date
as he can very easily do, he can fill with perfect competence and an enhanced safety to
the patient, this place that is his, and he can do it better and with less loss and expense
than even a group of specialists. His personal relation to the patient, to the family, his
intimate knowledge of their personalities, give to the family doctor a position that is
peculiarly his own—and in these days of emphasis on psychomatic medicine, we are
coming to realize this more and more.
Dr. Wilson, in his wisdom, points out that this is up to the general practitioner himself. He must think of general practice as itself one of the special departments of
medicine—not merely as either a corridor through which men pass on their way to a
specialty or a dump where are thrown the unsuccessful or unenterprising. It is in itself
a career, and one of equal status with any specialty. Dr. Wilson feels that a considerable
step in helping us to realize these facts would be for the general practitioners to form
a section of their own within the general structure of the C.M.A., as do other specialties,
and he has several other ingenious and provocative suggestions to make.
While we do not believe in overmuch organization, we feel that Dr. Wilson is right,
and that his suggestions deserve very careful consideration. We who are in general
practice are more or less inarticulate, and have no way of expressing our needs and
wishes. We are like the membership of the usual golf club. The course is designed, the
fairways and traps laid out, not to suit our incapacity, and to make the game easier and
Page 189
'.'.&
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isy II'
less hyperpietic for us, but to suit the pros and low handicap players.   We merely go on
paying the bulk of the dues.
There is no doubt that the leaders of organized medicine are thoroughly in sympathy
with this idea. They would, we are sure, be only too glad to help us to attain what we
need. But we should do our share in the matter, and it is up to us to figure out for
ourselves what we need in our work, and what we need to make further progress. We
need refresher courses—we owe very much to the generosity of the men in the specialties in this regard—we need post-graduate courses, we need to be assured of hospital
contacts, and constant access to hospitals. We need to have our point of view made
vocal when necessary,, and only by a certain degree of organization can we ensure this.
Lastly, we need to realize, and then to prove to others, that general practice is just
as essential, just as valuable, just as interesting, as any specialty—that there is just as
much satisfaction and self-fulfilment to be obtained from it, that it affords as many
opportunities for research and progress. It may not have quite as alluring financial
prospects, but in these days of high income-tax, who wants a big taxable income anyway?
The pendulum is slowly, but surely, swinging back to general practice. Any scheme
of national health insurance that may be evolved will greatly hasten the swing. The
G.P. must mend his fences, and prepare his defences. He must be ready to meet any
demand, by raising his standards and maintaining them—and he should do it himself.
Either we go on, or we go back—we cannot stay in one place. He must prove to the
recent graduate in medicine that it is well worth while to engage in general practice—
not only because of monetary reward—but because the opportunities are great, of good
work, interesting work, and work which leads somewhere, not to a dead end or to frustration, whether he specializes later or remains in general practice. We hope the day
wlil come when every man graduating in medicine will begin his career by engaging in
general practice, even if it be only for a time. We are sure it would do him a lot of
good, and it would certainly be good for the community as a whole.
ANNOUNCEMENT OF DR. RAY F. FARQUHARSON'S VISIT
VANCOUVER GENERAL HOSPITAL, APRIL 12-16, 1948
The medical profession of Vancouver will long remember the visit of Dr. A. H.
Gordon, of the Medical Faculty of McGill University, last summer. This year, a similar
week has been arranged for by Dr. G. F. Strong, the Chief of the Medical Staff of the
Vancouver General Hospital, and the guest clinician will be Dr. Ray F. Farquharson,
Head of the Department of Medicine, of Toronto University. The programme is an
excellent one and will last from April 12 to 16 inclusive. It is a very full programme
and is open to any medical man who wishes to attend—and it is not limited to Vancouver
—all will be welcome.
Dr. Farquharson will be' in charge of three Clinical Conferences, at which the subjects will be (1) Disorders of Gallbladder and Biliary Tract; (2) Hasmatology; (3)
Disorders of Metabolism. There will be numerous other conferences clinics, ward rounds,
etc., covering all the* activities, medical, surgical, obstetrical, as well as anassthesia,
cancer, etc. It is an extremely good programme and there will be luncheons and dinners
as well. asa
Page 190 LIBRARY NOTES
HOURS—
Monday, Wednesday and Friday. 9:00 a.m. to 9:30 p.m.
Tuesday and Friday. 9:00 a.m. to 5:00 pjnu
Saturday :   9:00 a.m. to 1:00 p.m.
RECENT ACCESSIONS TO LIBRARY—
Skin Manifestations of Internal Disorders, 1947, by Kurt Wiener.
Allergy in Theory and Practice, 1947, by Robert A. Cooke.
Diseases of the Chest, with Emphasis on X-ray Diagnosis, 1947, by Eli H. Rubin.
Peripheral Vascular Disease, 1943, by Saul S. Samuels.
Handbook of Neurological Examination and Case Recording, 1946, by D. Denny-
Brown.
A Primer for Diabetic Patients, 8th ed., 1947, by Russell M. Wilder.
The Early Diagnosis of the Acute Abdomen, 9th ed., 1947, by Zachary Cope.
The American Illustrated Medical Dictionary, 21st ed., 1947, by W. A. Dorland.
Neurosyphilis, 1946, by Merritt, Adams and Solomon.
Sexual Behavior in the Human Male, 1948, by Kinsey and Pomeroy.
The Physical Background of Perception, 1947, by E. D. Adrian. (Hist, and Ultra-
Scientific Fund.)
New Aspects of John and William Hunter, 1946, by Jane M. Oppenheimer. (Nicholson Fund.)
George Crile—An Autobiography, 2 vols., 1947, edited by Grace Crile. (Nicholson
Fund.)
'•■ft*./":
BOOK REVIEW
DISEASES OF THE NERVOUS SYSTEM—F. M. R. Walshe
This is the fifth edition since 1940 of this small volume which is intended for the
use of students and general practitioners, and its merits fully justify its continued popularity. The print and paper are good, and the choice of words, phrases and sentences is
superb. The author has made the matter of diagnosis seem simple by avoiding rare and
vague syndromes, and by avoiding the use of sub groups in the broad classifications of
neurological diseases. His summary of anatomical or localizing factors in diagnosis,
compressed into fifty pages is a model of lucid description of a complicated scientific
subject. The reader is not led into the mazes of controversial hypotheses and the various
diseases are explained on simple physiological principles, varied more by the sequence of
events in the history than by anatomical localizations.
It is safe to make several generalizations about this volume: first, with the aid of its
descriptions, an adequate history and a physical examination within the capabilities of
the student or practitioner, diagnosis of nervous diseases it made possible for all; second,
the advice concerning treatment and handling of the patients is common sense, not
theory or fancy; third, the book is sufficiently succint t© be within the reading time of
the busiest practitioner; lastly, it is a valuable addition to a medical library. The chapter on vascular disorders of the brain has been re-written to accord with the newer
ideas of "stroke" and is one of the best in the book. The last section of the book, concerning the Psychoneuroses, attempts to sum up this subject in twenty-four pages, and
as might be expected, falls far short of the standard of the rest of the book, and might
have been omitted, without loss. S. E. T.
OUR AGE OF UNREASON—Franz Alexander
The author, whose father was a Professor of History and Philosophy at the University
of Budapest, has been Director of the Chicago Institute of Psychoanalysis since 1932.
Alexander is an author of wide experience.
Page 191
m
m
'Mlpflif.
mmm
[:'&•■ In the present volume he points out that human relationships are not governed primarily by reason but by essentially irrational emotional forces.
He discusses the unconscious reasons for the attitudes of Germany and Japan. The
views of philosophers for the past few hundred years are given and reasons for the need
of a totalitarian form of Government for these peoples is brought out.
Alexander then compares individuals with groups of people carrying through with
the theme that many (if not most) individuals have a need for dependence on others and
dislike to accept responsibility. This is hardly what we should wish for in a democracy.
Alexander says "I have observed one emotional factor emerging with impressive regularity in the majority of my patients which illuminates the growing pessimism about
democracy: Insecurity."     (Remember he is dealing largely with psychoneurotics.)
He points out that the conditions of the Frontier have changed in a short time to
those of organized, standardized, industrial structure—"instead of initiative, a mechanical standardized performance is required; instead of an enterprising and adventurous
spirit, rigid subordination to a trade union is demanded."
This is a thoughtful book and one that will give the average medical man a change
in his reading material and at the same time a better understanding of people as groups
and as individuals.
G. A. D.
|g      §      CORRESPONDENCE
ANNOUNCEMENT IN THE VANCOUVER MEDICAL ASSOCIATION
BULLETIN
Reference is made to our 'telephone conversation of 8 th March, 1948. Would you
kindly insert the following announcement in the next issue of the Bulletin:
"Dr. W. Edward Chamberlain, Professor of Radiology, Temple University, Philadelphia, U.S.A., who is the Guest of Honour at the Meeting of the Pacific Northwest
Radiological Society, will present an address on "APPLICATIONS OF ATOMIC
ENERGY IN BIOLOGY AND MEDICINE" at 8.00 p.m., Friday, April 16th, in Salon
A, Hotel Vancouver. The medical profession is cordially invited to hear this timely
subject discussed by an authoritative and interesting speaker."
Yours truly,
R. W. BOYD, M.D.,
Chairman, Programme Committee.
THE AMERICAN SOCIETY FOR THE STUDY OF STERILITY
February 18, 1948.
Dear Sirs:
The American Society for the Study of Sterility is holding its Fourth Annual National Session on June 21 and 22, 1948, at the Congress Hotel in Chicago. The two-day
programme will be divided into a special series of panel discussions on male infertility,
with papers to be read on female and miscellaneous infertility aspects on the second day.
The chairman this year is Professor Edwin C. Robertson, Chairman of the Department of Obstetrics and Gynecology of Queens College, Ontario, Canada.
Additional information may be obtained from the secretary, Dr. John O. Haman,
490 Post Street, San Francisco 2, California.
Sincerely yours,
JOHN O. HAMAN, M.D. IMPORTANT NOTICE
Below is reproduced the text of a letter received from Chief Constable Mulligan
of Vancouver. We are printing this at the request of the Executive of the V.M.A., and
there is no doubt that it contains a very constructive suggestion. There are several
conditions that make it possible that a man or woman might be found unconscious in
a public place, and be unjustly suspected of intoxication—diabetic coma, as one example.
Probably each medical man might have his own ideas as to the wording of such
certificates—but the exact wording is not so important as the fact that a patient would
be protected, not only from an erroneous suspicion, but by the fact that anyone finding
him would know that it was vital that medical help be summoned immediately, and
would know, too, whom to call.
In Chief Mulligan's letter, it will be noted, he uses the expression "very serious
heart ailment." It was suggested by the Executive that it might be better to omit the
word "heart," and simply say "a very serious ailment." This would cover a wider
ground, and not do so much to focus the patient's attention on his heart—a thing
which is sometimes very undesirable.
Police Department,
Vancouver, B. C.
November 26, 1947.
The Secretary,
Vancouver Medical Association,
925 West Georgia Street,
Vancouver, B. C.
Dear Sir:
A few days ago I received a visit from a citizen in regard to sudden deaths which
had occurred in the Vancouver City Jail, the deceased persons having previously been
arrested by the police charged with intoxication.
My caller showed me a card which had been given to him by his doctor, which
certified that the bearer was suffering from a very serious heart ailment, and that if
found prostrate, he was to be rushed to hospital.
My informant felt that if doctors generally would issue similar cards to such of
their patients as were in similar condition to himself, it would serve a very useful purpose,
as the bearers would be assured of immediate attntion, should they at any time be found
on the streets in a state of collapse.
This suggestion has a great deal of merit, and I am passing it on to you for whatever
action you might wish to take in bringing it to the attention of your Membership.
The card issued to my caller was the doctor's professional card (calling card),
with form of certificate typed on the back, as in sample attached.
Name:  j—	
Address: —	
This man is suffering from a very serious ailment. If found prostrate,
please rush to hospital.
(Doctor's signature)
Faithfully yours,
W. H. Mulligan,
Chief Constable.
Page 193
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■ .  ■ ■■■' ' ' ■
'  >      "■■»#*H ancouver Medical  Association
President. , Dr. G. A. Davidson
Vice-President Dr.  Gordon C. Johnstone
Honorary Treasurer ; Dr. Gordon Burke
Honorary Secretary Dr. W. J. Dorrance
Editor _— Dr. J. H. MacDermot
VANCOUVER MEDICAL ASSOCIATION
ANNUAL SUMMER SCHOOL
June 1st to 5 th, inclusive, 1948
HOTEL VANCOUVER, VANCOUVER, B. C.
SPEAKERS:
Dr. Douglas G. Campbell, Assistant Professor of Psychiatry, University of
California Medical School.
Dr. Laurence S. Fallis, Surgeon-in-Charge, Division of General Surgery,
Henry Ford Hospital.
Sir William Fletcher Shaw, Professor of Clinical Obstetrics and Gynaecology,
Victoria University of Manchester.
Dr. James J. Waring, Professor of Medicine, University of Colorado.
Dr. Samuel Ayres, Jr./Dermatologist, Los Angeles.
Please make your reservations at the Hotel early.
HISTORY OF THE VANCOUVER MEDICAL ASSOCIATION
THE CITY HOSPITALS—(Continued)
Those were the Horse and Buggy days of the private practitioner in Vancouver.
When the Fairview hospital was opened, automobiles were just beginning to appear on
the city streets. Amongst the medical men Dr. Riggs was the owner of the first car,
having in 1904 gotten himself a two-cylinder Ford, the maximum speed of which was
eight miles an hour. At that time there were less than half a dozen cars in Vancouver.
The city, was now spread over such an area as to make it necessary for each doctor to
supply himself with a horse and buggy. Unlike the practitioners in Eastern Canada,
it had been the rule from the first for Vancouver physicians to have home and office
separate. With the office downtown and within reach of a livery stable, the horse was
stabled here and was readily available for a call. At home each doctor might have a
stable in his back yard.
While visiting at the hospital the horses were tethered along Heather Street, until
such time as Dr. Brydone-Jack made a donation of $200.00 towards building a shelter
on the hospital grounds between Heather and the northeast wing. Flies and bad odors
were among the lesser evils with which the hospital had to contend in those days.
When the hospital was opened, no road south of False Creek had ever been graded,
much less gravelled. Broadway and Heather Streets were during the wet season bottomless seas of mud. Doctors prayed that some member of the City Council might break a
leg and be forced to make the trip to the hospital over such roads. By 1906 a single
streetcar track had already been laid along Broadway, with a siding opposite the hospital.
The ties were laid on the mud. Late in 1907 gravelling of Heather and Ninth Avenue
was begun. The city's milk supply at the time was a problem, and pure milk for the hospital
was almost impossible to get. It is on record that proposals were made to have cow
stables built on the grounds from which a supply of pure milk might be drawn. This
was never carried out, but it seems that chickens were for a time kept as hospital
property.
At time passed the older section of the hospital took on the appearance such as we
know it today. In 1908 a southeast wing was added, followed in 1911 by one on the
southwest. The present nurses' home on Tenth Avenue was begun in 1906, but for a
time was used to house maternity cases, while the nurses lived in one of the new hospital
wings.   In 1907 arrangements were made whereby they might occupy their own quarters.
The evolution of the medical staff kept pace with the growth of the institution. In
1902 it was made up of the following members: Doctors Johnson, Langis, Poole, Tuns-
and consultant sections. In the former group were Doctors Johnson, Tunstall, Robertson, Brydone-Jack, Weld, Poole, Drier, Monroe, Boyle, R. E. McKechnie, Mills and
Pearson. The members of the consultant staff were: Doctors D. H. Wilson, LeFevre,
McGuigan, Carroll and Underbill. The latter was Health Officer for the City. In 1906
the staff was further divided into surgical and medical sections.
The position of hospital superintendent evolved from that of hospital intern. In
1897 there was only one full-time man on the staff of the institution, viz.: Dr. Bentley,
afficially known as House Surgeon. In 1898 he was succeeded by Dr. McEwen who,
besides acting as Intern, is now referred to as Hospital Superintendent. In addition,
he gave all the anaesthetics, and later when the hospital came into the possession of an
X-ray machine, he was given the duties of radiographer, the first in Vancouver.
In 1904 Dr. A. M. Robertson, a longtime practitioner in the city, replaced Dr. McEwen.   He is variously spoken of as Medical Officer and Medical Superintendent.    In
1905 Dr. Robertson asked for an anaesthetist, and when in January of 1906 the hospital
moved from Cambie Street to Fairview, the doctor found that he had still more than he
could do and applied for an assistant resident house surgeon. Pending the appointment
of a permanent man, a local physician held the position as a stated salary.
Later in 1906 Dr. Robertson resigned his position as Superintendent and for a time
it was held in rotation by Doctors Bayfield, Carder, J. L. Robinson and H. H. Mcintosh.
Finally in the spring of 1907 Dr. Mcintosh received a permanent appointment, which
he held until 1908, when he resigned to become "X-ray Specialist" to the hospital. This
was work he had already been doing during his tenure of office as superintendent. Dr.
Mcintosh was succeeded in the latter post by Dr. Whitelaw. In 1909 arrangements
were made whereby the Medical Superintendent became a permanent official of the hospital staff and Chief Executive of the Institution. He was henceforth to be known as
General Superintendent.
We have seen that previous to 1906 the permanent staff consisted of one man whose
duties may have included almost anything pertaining to the running of a hospital.   In
1906 the duties of House Surgeon ceased to be merged with those of superintendent,
and when in April of 1907 Dr. Mcintosh took over the latter position, he found himself
with two interns, viz., Doctors McConkey and Beech. Later on in the year these were
replaced by Drs. W. A. Whitelaw, J. W. Thompson and Allison Cumming. During
1908 Drs. Arbuckle, Prowd and Gourlay filled the positions. In 1909 the interns were
Drs. Patton, Turnbull, Scott and Gray, and in 1910 Drs. Schinbein, Bastin and H. McMillan. By 1911 the fourth wing had been completed, the city's population was 111,000,
an increase of 59,000 in four years—and the hospital's 265 beds were filled to overflowing. During that year seven interns were required. Their numbers have gradually
increased until at the present time the hospital's quota is 55, although it is not completely filled.
As the hospital increased' in size it became mode modernized. The old haphazard
methods of keeping records was revised, and a trained clerk, George Maddden, attended
Page 195
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■
liiil for four hours daily, to record all admissions and discharges. This was the beginning
of that comprehensive system of keeping records as it exists today under the supervision
of Mr. Fish. It is one of the most important departments of the hospital. In 1906
Dr. Pearson instituted a hospital formulary. The same year Dr. D. B. Gillies was
appointed pathologist, and two years later Dr. McKee was made his assistant, and was
placed in charge of bacteriology. In 1906, too, a dietitian, Miss Graham, was engaged,
and in 1910 a trained masseuse was added to the staff. About this time the fresh air
treatment of tubercular cases was in vogue, and these patients, which had always been
a problem for the hospital, were for a time housed in tents on the grounds of the institution.
Maternity cases, for which no accommodation had ever been supplied in the Beatty
Street building, but which were subsequently temporarily housed in the new nurses'
quarters on Tenth Avenue, were in 1908 moved into the main hospital, where they
were to remain until the present maternity building had been prepared for them. At
that time obstetrics came under the care of the surgical section of the staff, and all
indigent cases were segregated in the room now occupied by the heart station. Dr.
Burnett was placed in full charge and thus became the first obstetrician in Vancouver,
and the foundation was laid for his subsequent career as a specialist in that work.
The first operating rooms were that which are at present used by the Eye, Ear, Nose
and Throat Department. When, later on, the space between the southeast and southwest wings was partly filled in by the present brick building which houses the Emergency
Department and some of the administrative offices, space was provided for the series of
operating rooms which now flank the old hallway which originally connected the upper
floors of the east and west wings.
When in 1910 it was decided to provide the province with a university, the vacant
space on the city-owned hospital grounds was utilized by the government on which to
erect a series of one-storey huts which might be used as temporary classrooms. Only
the administration building was to be permanent, and the understanding was that when
it was no longer required by the university authorities, the building should become the
property of the hospital to be used for the treatment of TB patients. This was done,
and with a recent addition the building now houses the Provincial Headquarters of the
Division of Tubercular Disease Control.
After the university had moved to Point Grey in 1922, many of the huts were, and
still are, used by the hospital for outpatient clinics, nurses' classrooms, etc., but they are
gradually being torn down and replaced.
The nurses' training school, which had been organized in 1898, the following year
got away to a good start with a group of eight pupil nurses under the tuition of Matron
Margaret Clendenning. The first graduation ceremony was held in 1902, at which time
five graduates received their diplomas. These were: Nettie Miller, Maud Squarebriggs,
L. Fransesca, A. Morrison and Miss Milne.
In 1908 we find the nurses still housed in the Beatty Street hospital buildings, but
with the increase in numbers which followed the opening of the training school, accommodation had to be found in an adjacent private house. During 1903-05 we find them
living as far abroad as the corners of Seymour and Georgia, and of Dunsmuir and Howe
Streets. Matron Clendenning put in a requisition for eighteen pairs of long rubber boots
for the use of the girls in their long walk from their homes to the hospital. "No nurse,"
she said, "could appear on duty spick and span after walking for half a mile through
mud and rain." Following the hospital's removal to Fairview the nurses were housed
for a time in one of the hospital wings until their new home on Tenth Avenue was completed. The present nurses' home was built in the early '20's, but the staff has long
outgrown it. Two years ago a money grant to build a new home was voted by the people
of Vancouver.
Matron Clendenning resigned in 1904 and was replaced by Miss Turner. The latter
held the position for one year, when it was taken over by Miss A. MacFarlane.    The
Page 196 training school rapidly increased in size. Nine nurses were graduated in 1908, twelve
in 1909, seventeen in 1910 and fourteen in 1911. During the past two years the number
of graduates has reached one hundred, including about a dozen who took the special
course in nursing at the University of British Columbia leading to the degree of B.A.Sc.
Since Miss MacFarlane resigned in 1912 the following have successively been in
charge of the V.G.H. training school. They have been variously known as Matron,
Superintendent of Nurses, and, as at present, Director of Nursing. Miss Randall, 1912-
1916; Miss Snyder, 1916-1917; Miss McLeod, 1917-1919; Miss Johns, 1919-1921; Miss
Ellis, 1921-1929; Miss Fairley, 1929-1943. The present Director of Nursing is Miss
Palliser.
In 1930 an important change in the policy of the hospital was introduced. This pertained to the attendance on indigent cases on the wards, and also to the method of
appointments to the General Staff. Heretofore all indigent cases might be attended by
the doctors who sent them in. It was now proposed to reserve the treatment of such
cases for the staff. All other doctors in the city who are in good standing, and who
wish to do so, may still have their paying patients admitted to the hospital under their
own care. This group is known as the Visiting Staff. Considerable opposition to the
proposed changes developed within the ranks of the Medical Association, and several
meetings were held to discuss the question.    The new policy was finally adopted.
Previous to this it had been the rule that recommendations for appointments to the
staff should come from the Association. These were elected by vote at a general meeting,
and the names passed on to the Board of Directors for appointment. These elections
became quite lively at times, and were associated with considerable electioneering. At
present, staff appointments are recommended by a committee of the staff itself.
Dr. Whitelaw resigned the position of General Superintendent in July, 1919, and for
a three months' interim Dr. George Clement took over, pending the arrival of Dr.
Malcolm McEachern. The latter was succeeded by Dr. Fred Bell, who resigned in 1930,
giving place to Dr. Haywood. The latter held the position until 1947 when a change
of policy was instituted whereby a layman, under the title of Director of Hospital, was
placed in charge. He is Mr. Leon Hickernell, and has as Assistant Director, Dr. Seymour, in charge of all medical work.
We have given considerable space to this chapter as the interests of the Vancouver
Medical Association, since its inception, have been closely blended with those of the
hospitals of Vancouver. The professional careers of most of its members have been
centered on one or more of these institutions.
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Page 197 CANADIAN MEDICAL ASSOCIATION
ili
Dr. J. H. MacDermot,
Editor, The Bulletin,
Vancouver Medical Association.
Veterans* Affairs Building,
Bute and Haro Streets,
Vancouver, B. C.
February 21, 1948.
Dear Dr. MacDermot:
At the last meeting of the Executive of the Canadian Medical Association held in
Ottawa on October 27 and 28, a Committee was appointed to explore ways and means
of helping General Practitioners in their work. I hove to have the opportunity to discuss these matters at the time of the April meeting of the Vancouver Medical Association, and I also hope to have an opportunity to do the same thing in Victoria.
I have just been through the west on D.V.A. business and had the opportunity to
speak to medical groups in Saskatoon, Regina, Winnipeg and Calgary, and at all centres
found considerable interest shown by the General Practitioners in what I had to say. I
enclose copy of the lines along which I spoke. These lines, of course, do not begin to
cover all the problems with reference to General Practioners today. There are also
such questions as .the position of staffs of hospitals and the question of General Practitioner divisions in the staffs of hospitals. This, of course, applies more particularly to
closed or semi-closed hospitals, but I found a general concern about it. Also, the question of "once a General Practitioner, always a General Practitioner" in the future
concerns some of them very much.
I am anxious that the meeting we propose to hold of General Practitioners in Toronto
at the time of the Annual Meeting of the Canadian Medical Association will be largely
attended. I am also anxious that General Practitioners who are not going to the meeting
will write to me and express their views so that I may go to Toronto with a definite
expression of opinion from the men who are not going to be at the meeting, as well as
to receive an expression of opinion of those who will be there, so I am wondering if you
would put a notice in the Bulletin using what you like out of the notes that I am enclosing, emphasizing that every General Practitioner who plans to be in Toronto should
also plant to attend this meeting and further emphasizing that those who are not gonig,
should write to me care of the Veterans' Affairs Building, 1231 Haro Street, Vancouver,
B. C.
Yours sincerely,
WALLACE WILSON, M.D.,
Chairman, Committee on General Practioners.
For the interest of all General Practitioners, herewith is a brief discussion of some of
the problems which today confront the General Practitioner. The Canadian Medical
Association has been concerned about these problems for some time and as a result of
many discussions, the Executive, at its last meeting, appointed a committee to be known
as the General Practitioners' Committee and charged it with the responsibility of studying and reporting back on ways and means of helping the General Practitioner in his
work, and of improving his status, both within and without the Association.
What does this committee propose to study, and what sort of a report does it intend
to take back to the Executive?   Let us make a short list.
1.   The Establishment of a General Practitioners* Section Within
the Canadian Medical Association.
As you all know very well, the Scientific Programme at the Annual Meetings of our
Association is divided into sections—medicine, surgery, obstetrics, etcetera, and while it
is true that the programme is designed primarily for General Practitioners, nevertheless,
Page 198 the papers are nearly all given by specialists. Should there be, specifically, a General
Practitioners' Section? A section of which the Chairman and Secretary are General
Practitioners? A section where the Scientific Programme is drawn up by General Practitioners and given largely by General Practitioners with specialists appearing on the
programme only by invitation of that Section? Should the Section also hold a business
session at the time of the Annual Meeting at which would be discussed problems peculiar
to present day general practice and from which meeting might come resolutions to be
sent forward for consideration to the Executive and Council of the Association?
The Committee asks all General Practitioners to think over this question of this
Section because it proposes to call a meeting of General Practitioners on the Wednesday
of the 1948 Annual Meeting of the Associations in Toronto in June, next, and there
get your views.
The Committee, in its recommendations to the Executive, will be guided entirely
by the wishes of the General Practitioner members of the Association, so, if you are
planning to go to the Toronto Convention, be sure to be present at the meeting to be
held at 5:00 p.m. on the Wednesday and there let us hear what you think. If you are
not going to be there, please write to me here in Vancouver and let me have your views.
The Committee is anxious to obtain a strong body of opinion, either for or against the
Section, from all parts of Canada, and to that end will send a notice of the meeting to
the Journal and also invite correspondence.
Personally, I think General Practitioners would be well advised to have such a section.
They should not only be taking a much larger part in the Scientific Programme, but
they should also be more active in the administrative and business affairs of the Association. More of you should be on the Executive, in Council and have greater representation on the various committees. After all, General Practitioners constitute the majority
of the Canadian Medical Association membership and the Canadian Medical Association
is the only organized scientific body that really does represent you across Canada. In
a special way, it is your own Association, and you should be taking a far larger part in
all its affairs than you are.
2.  The Certification of General Practitioners.
These days much is being done for the specialist. Most of our medical schools and
teaching hospitals are carrying out very special programmes that make it possible and
comparatively easy for picked students to engage in planned post-graduate training
leading towards specialization. When this training is completed and these students
have successfully passed certain examinations, the Royal College stands ready, either to
admit to fellowship or certify and the specialist is launched.
Out in practice, the specialist may, in addition to membership in the Canadian
Medical Association, join the national body representing his own specialty. And so,
whether we like it or not, specialists are becoming more and more organized within
their own groups and more and more their hallmark in Canada will be fellowship in or
certification by our Royal College. Further, I look to the time in the not-too-distant
future when certification qualifications and examinations will be done away with and
then when a man successfully meets one standard of education and one set of examinations, he will be both admitted to fellowship and certified.
And that all brings us to another of the problems confronting the man in general
practice today. Gone are the days when, after some years in practice, he can go away,
concentrate his studies for a year or two on a particular branch of medicine and then
return home or moving to a city, set up as a specialist. From now on, as a general rule,
it will be, once a General Practitioner, always a General Practitioner; only rarely will it
happen that after some years in practice a man will be able to take the time and money
to qualify and prepare to sit for fellowship or certification examinations.
Now if General Practitioners are going to remain General Practitioners, is there any
way of recognizing the good ones—those who are doing first-rate work and keeping
abreast of modern medicine?    This question has been raised by some of you yourselves,
Page 199 -
Ml'
and the answer would possibly appear to be also in certification. Certification of a first-
class or Grade A General Practitioner would require the setting up of certain standards
such as (a) five or ten years in practice; (b) during that time the publishing of the
results of at least two or more pieces of clinical research work carried out while in practice; (c) the attendance at a certain number of refresher courses such as the one you are
attending now, and finally (d) the passing of an examination which might be oral or
both oral and written, and might or might not be conducted entirely by General Practitioners. Which would be the responsible body to undertake the setting up and the
maintenance of the standards, the conduction of the examinations and the certification?
It would appear on first consideration that the Canadian Medical Association would be
the logical body. It does represent the General Practitioners, and there is somewhat of
a precedent in that it already certifies hospitals for junior rotating interneships.
This whole question of certification is again something in which no action will be
taken except at your own express wish.- So again, think it over; if you are going to
Toronto, be prepared to speak to it and if not, write me your views.
3.   Clinical Research by General Practitioners.
In general practice, there are limitless opportunities for doing first-rate clinical research. Studies in environmental influences on disease, the earliest beginnings of many
of the chronic diseases, the course and results of others, nutrition, the results of preventive measures, etcetera—the list is endless. The undertaking of a bit of clinical
research in your practice means carrying it on as a rule for a matter of years. The work
is done and the records are kept as the cases come along, and with each case it means
just a little more work and just a little more care.
Do General Practitioners want to engage in clinical research? Again, it is for you
to tell us. We do not expect the older men to be interested; we do hope the younger
men will be keen.
What the Committee hopes will develop is something along the following lines:
(a) That there will be made available for the committee sufficient annual sums of money
from sources outside the Association.
(b) That with this money, they will be able to set up awards to be given annually for
the best piece or pieces of clinical research carried out by general men in their
practices.
(c) The Committee, with expert advice, to be prepared to advise on request as to—
1. Suitable types of clinical research to be undertaken.
2. Methods of carrying on the work, e.g., records, questionnaires, etcetera.
3. Literature to be consulted and where it can b eobtained on loan from libraries.
4. The Committee to make all arrangements for the annual judging of the papers
sent in and to make all awards.
If you approve of a programme along some such lines, and we obtain the funds, it is
hoped that as part of the over-all programme, the medical schools will cooperate and in
the final year give to undergraduates some instruction in principles and methods of conducting clinical research in General Practice.
Once again, this is a proposal that I hope you would approve in principle. I am convinced that a man who starts practice imbued with the idea of carrying out clinical
research and who sticks with that idea, will find his professional life much richer; he
will practise better medicine and he will make definite contributions to medical knowledge.
Page 200 OSLER LECTURE
A PRIEST OF LUCINA
(WILLIAM SMELLIE)
By MURRAY BLAIR, M.D.
Read before the Annual Meeting of the V.M.A., Friday, March 5th, 1948
No one can be insensible to the great honour bestowed on the individual who is
chosen by the Executive of this Association to give the Annual Osier Lecture. Each of
my predecessors must have experienced the same sense of responsibility that accompanies
such honour.
I presume that one is, in effect, the voice of this Association, whose duty it is to keep
green in our memories for another year the name of a great physician and a great Canadian, William Osier.
Some twenty-nine years have passed since Osier died, and in that time a new generation of doctors has come into the field. So very many have had Osier's System of
Medicine placed in their hands as they began their studies in Internal Medicine: so many
have used it as a guide and reference ever since. The name of Osier has become revered
in every country on the face of the earth. This Canadian of ours has far outgrown the
confines of his native land: his reputation is limited only by civilization itself.
As the years progress then, and as the great figure slips further and further back into
the shadows of the years it is but natural that one so revered should become remote, a
mystical, even a mythical figure in the shadows.
For this reason, and by way of change, it might be permissible that tonight we bring
the great figure back to earth and have him walk with us and talk with us for a little
while.
The story is told of Osier's visit, as a Consultant to a Canadian Military Hospital in
England in 1917. Of the cases shown him, two were problem cases presented for the
Consultant's aid in diagnosis.
One was the case of a man with an afebrile collection of fluid in one pleura. Sir
William was very much interested indeed. He found fluid in both pleura, some ascites,
and even a small hydrocele, all of which had been overlooked by the staff. Sir William
thanked the staff for permitting him to see a Polyserositis which he called Pick's Disease.
The second case was that of a man who was admitted for the third time, each time
with a generalized rash which cleared under treatment, only to recur on his return to
duty. Sir William made careful scrutiny of the skin, then grinned and addressed the
patient rather than the audience. He told the boy his trouble was to a great extent the
result of war environment, that if he would change his clothing more often and "read"
his shirt more diligently, he would have no more trouble. He called the rash Dermatitis
Pediculi.   Again the medical staff were somewhat chagrined.
After dinner in the mess that night Sir William spoke at some length. He spoke to
young doctors who would some day go out into civilian practice. He said that from
his years of experience and observation among students he fores^sv that most of the
men present would make money, but few would be able to keep their earnings. He
deplored the fact that few professional men were business men. He warned them of the
wily stock salesmen for whom medical men were always a prey.
He said, however, that all doctors were not poor business men and related a story
of his early life in Montreal in illustration.
His story was that after graduation he was attached to the Pathological Department
of the Montreal General Hospital and was particularly interested in autopsies. One day
a request came from a doctor in the Eastern Townships asking that someone come down
and perform an autopsy for him.    Young Osier immediately volunteered.    With horse
Page 201 and sleigh he drove nearly forty miles in the dead of winter and arrived at a farm house
late at night and nearly frozen. While he was getting thawed out in the kitchen, it
soon became apparent that all was not well between the old doctor and the husband of
the deceased patient whom it was proposed to autopsy. There was an uncomfortable
dearth of conversation in the kitchen, but occasionally the old doctor would motion the
husband to accompany him to the back door step. There they would stand in the cold,
but eventually return still with no decision in the matter. Osier said he spoke to the
old doctor and told him that it was all right, that he would get well warmed and drive
back to Montreal and not to worry. The old doctor told him in no uncertain terms
that he would do well to mind his own business and keep out of the matter altogether.
Later on the doctor and husband returned from the back steps and the old and young
doctors repaired to the wagon shed where, with the aid of two or three lanterns, and in
bitter cold the autopsy was performed.
Osier said he was curious to know how the doctor had won out and he so inquired
of the older man. The old man explained, "I finally told the husband he would either
agree to the autopsy or I would foreclose." Sir William submitted that here was one
doctor who was a business man.
One of the chief attributes of greatness, it seems to me, is the life-long habit evidently ingrained in so many of our medically great, the habit of taking notes. The
biographies of these men are so very often sprinkled with references to their notes.
Indeed there are those medically great whose lives and achievements are literally pieced
together through the medium of the notes they kept throughout their lives and have
left to posterity. Even had they lived in this modern day of hospitalization and hospital
records, I believe they would have appended to the record their personal opinion and
reaction to the case, thus adding immensely to the value of the record in subsequent
years.
William Osier took copious notes, day after day and year after year. He made notes
during the day and at the end of the day, no matter how tired he was. More than that
he consistently reviewed his notes, and his notebooks were not destroyed. Note taking
was not a burden to Osier, it was a joy.
From these notes, and through the medium of his biographies it is evident that Osier
was not interested only in the concrete problems of every day practice. His notes and
his biographers relate again and again his unfailing interest in the nebulous domain of
history and people. And I believe, that we as a profession should ever be on guard
against the danger of materialism leading to the total eclipse of the abstract. Someone
has said that he who regards the practice of medicine as a commercial enterprise will find
at harvest time that he has gleaned ashes. And so tonight I suggest it might be good for
us to abandon for a little time these turbulent professional lives of ours, to betake ourselves to some sheltered cove such as this, there to muse on the benefits which have
accrued to mankind through the unselfish endeavours of our predecessors.
As Oslr was interested in people and their place in history, and as I hope you are
too, I propose to tell you about another amazing figure in the history of medicine. Another great man, among the medically great; another prodigious note-taker, one who
deserves our admiration and respest, even as does William Osier. I propose to talk to you
for a little while about William Smellie.
In order to get*some perspective of Smellie and his place in the development of
Modern Obstetrics, it is well to have some idea of the extraordinary medical environment
in which he lived.
That period in history known as the Renaissance is arbitrarily fixed as within the
limits of the sixteenth, seventeenth and part of the eighteenth centuries. It was a time
of intellectual liberty there developed a mighty revival in the realms of science, art,
loosed at last from the shackles of ecclesiastical authority, and with the growing sense
of intellectual liberty there developed a mighty revival in the realms of science, art,
literature, and nowhere more than in the science of midwifery.
Page 202 The story of the Renaissance is a veritable romance. With the aid of the newly
invented compass, Columbus discovered a new World. The invention of the printing
press disseminated knowledge to the masses. Gallileo denied the ancient Copernician
System and propounded the heresy that the world was round. Vesalius robbed the
gibbet and the grave for dissecting material. Leonardo da Vinci and Rembrandt produced their masterpieces on a basis of anatomical study. Shakespeare and Milton made
literary history. Paracelsus substituted chemical therapeutics for alchemy. Leewenhouck
invented the microscope. William Harvey discovered the circulation of the blood.
Malpighi laid the foundation of histology. Martin Luther founded Protestantism. Pare
laid the cornerstone of Modern Surgery. And in this time of intellectual awakening
even midwifery began to stir in its bed of ignorance, superstition, cruelty and bigotry
where it had lain dormant since the dawn of time.
In Smellie's time it was considered highly immodest and immoral for women in labor
to be attended by men. Gradually, however, midwives were turning to doctors to help
them in their troubles. But doctors knew little more than midwives. No book had
been written in English as an aid to midwives since Reynoldes' "Byrth of Mankynde"
in 1540 and its content was little more than a recital of mediaeval superstitions. Britain
was to await 210 years for Smellie's Treatise of Midwifery. On the continent, medical
men were practicing midwifery and presenting their methods and ideas in pamphlet
form, but these pamphlets by Van der Venter in Holland and Moriceau, Portal and Peu
in France offered little improvement on the nonsense of mediaevaldom. The Chamber-
lens, five generations of them, had practised midwifery to some extent among Royalty
and the wealthy with some success, but their invention, the obstetric forceps, was still a
secret. No university in Europe permitted the teaching of midwifery. The first chair
of Obstetrics in Britain and probably in the world was instituted in Edinburgh in 1726
but it was a city, not a university appointment and taught midwives only. It was not
until 1756 that Thomas Young, the third professor, was finally admitted to the-Eacuity
and Senate of the University and permitted to teach students. Smellie retired in 1759;
three years later, after forty years of practice. No, there was no one to teach Smellie
midwifery.   He is himself, as I shall attempt to show, the origin of obstetric teaching.
Into such an obstetric environment came William Smellie. Born in Lanark, Scotland, in 1697, he was articled for some years to a Dr. Inglis of that town and in 1720,
at the age of 23, he began to practise in the community that wals his birthplace. It
would seem that he acquired neither reputation nor financial position as a general practitioner, though he did acquire some property. However, he took notes of the things
he did and saw from the beginning of his practice. During the nineteen years that he
practised in Lanark his notes state repeatedly his disgust at the horrors he saw about him,
perpetrated by midwives. He speaks of the midwives as ever ready with the blunt
hook and crochet when labor seemingly failed! Of the few cases he saw in his practice
at Lanark he evinced a very decided interest, evidently made careful examinations and
certainly made meticulous notes.
Just what prompted Smellie to drop his practice in Lanark after 19 years is not
known, and Smellie offers no explanation in any of his notes or writings. He had never
been the leading doctor in Lanark and certainly must have met with little financial success. As one delves into his life and work from all available sources it would seem probable that two factors influenced him in making his decision to leave his practice at the
age of 42 and begin again in London.
In the first place he had long been imbued with the belief that something could and
should be done to improve the practice of Midwifery. A number of times he records
the brutality of the work and the stupidity and ignorance of the midwives. His original
idea for improvement was to teach midwives, and only later he realized that the more
doctors who would improve their knowledge of Midwifery the better. He also had
long entertained the idea that he could teach himself and others Midwifery through the
medium of mechanical devices which would simulate mother and child in pregnancy
Page 203
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festfaaf-kw J and labour.    It is also probable that he had heard that Gregoire in Paris was teaching
by such devices and wanted to see his method. .:g||
The second factor was the appearance of two articles published at about the same
time—1733-34, both of which made a profound impression on Smellie. Each was an
article concerning the use of forceps in midwifery. One was by Mr. Alex. Butter,
Surgeon of Edinburgh, which appears in the Edinburgh Essays. It described and included an engraving of the Duse Forceps which Butter had seen in Paris. The other
article was a pamphlet published by Edward Chapman of London in which he described for the first time perhaps, an obstetric forceps as invented by Chamberlen. It is
reasonable to suppose that Smellie read these articles and grasped their importance. The
only obstetric instruments then in use to his knowledge were the blunt hook, the crochet,
the noose, the perforator and like instruments, all of which tended to destroy the child.
Here at last was an invention designed to save life, not to destroy it.
In any case and whatever his reasons, Smellie gave up his practice in Lanark in 1739
and went to Paris where he sat under Gregoire for about six months. There he saw
Gregoire's cumbersome and nearly useless "Machines" or "Phantoms," listened to his
teachings and came away disappointed with both. He settled in London in 1740 to find
the state of midwifery as bad or worse even, than in Scotland. He took a house and
began to accept pupils in 1741.    It is evident that he immediately met with success.
Smellie is described as a large framed, angular man with large and powerful hands.
William Hunter describes him as "a tall, gaunt man with few if any of the social graces,
but with large hands." McClintock states that "He is said to have been coarse in his
person, and awkward and unpleasing in his manners, so that he never rose into any great
estimation among persons of rank." William Douglas, one of the severest of his many
critics, describes him as "a rawboned, large handed man," and in the course of his ridicule discusses his monstrous hands, "fit only to hold horses by the nose whilst they are
being shod by the farrier, or stretch boots in Cranbourne Alley," Perhaps McClintock
sums it up by saying "Smellie would seem not to be endowed with those personal attributes in regard to appearance, manners and address which sometimes take the place of
real ability."
It is evident that the man possessed three attributes which could be termed hobbies..
He was musical and in his will he left his music books and his flutes to the grammar
school at Lanark, which he had attended as a boy. He drew and painted well. He published a volume of "Anatomical Tables" in 1754. It consists of thirty-nine beautifully
executed drawings. Twenty-six of these were done by Mr. Rymsdyke under Smellie's
direction, eleven by Smellie with the technical assistanc of Dr. Camper, Professor of
Anatomy and Botany at Amsterdam. The origin of the other two plates is not explained. A more extraordinary proof of his. talent as an artist lies in the proven fact
that the only surviving picture of Smellie, which hangs today in the Royal College of
Surgeons in Edinburgh, was drawn and painted by himself in 1719. The picture was
in more recent times examined by experts at the instigation of the College. It is their
authoritative opinion that it is the original picture painted by Smellie himself, and not
a copy.
His third hobby stemmed from the fact that Smellie was mechanically inclined and
was an adept with tools. It is this last attribute which was probably of the greatest use
to him in his teaching. He had determined to teach through the medium of "dummieS,,
or "phantoms" or "machines," which he believed he could make himself, and which
would more closely simulate the phenomenon of labour than any previously made. The
following excerpt is taken from his notes written in 1742.
"I considered there was a possibility of forming machines which should so exactly
imitate women and children, as to exhibit to the learner all the difficulties that happen
in midwifery, and such I actually contrived and made by dint of uncommon labour and
application."
Page 204 All his teaching life Smellie depended in great part on his mannikins. He continually added to his collection and when he retired from active teaching in 1759 he gave
his models to Dr. John Harvie, his successor.
Smellie's success as a teacher must have been marked and immediate. In his first
six years in London he was at three addresses. Each move was made in order to acquire
more space for his ever-enlarging classes. He immediately drew students, chiefly male,
from London and then from many parts of Britain and from the continent. He states
that in his first ten years he had more than nine hundred pupils (exclusive of females)
and gave two hundred courses of lectures.
Very early he realized that mannikin teaching was not enough, but that practical
teaching on the patient was essential. And so he instituted an obstetric practice among
the poor of London. He took a class with him to almost all cases, and he has left careful
notes on 1140 women whom in the role of instructor he delivered in ten years, in the
slums of London. We must realize that Smellie was teaching, for the first time, normal
obstetrics as well as its complications. Few male practitioners had ever experienced the
opportunity of observing normal parturition. The doctor's function began only when
abnormal phenomena presented themselves. His subsequent treatise in 1751 is then the
first authority on the phenomenon of normal labour. His persistent note taking was
simply his honest observation of his cases regardless of the tradition, dogma, and supervision of his day.
It is hard for us to realize the difficulties under which Smellie taught as he worked
in these slum areas. He was living at the beginning of a new era, when the practice of
midwifery so long monopolized by women was slowly changing hands. It was slowly
and painfully becoming a part of the medical profession, moreover it was even more
slowly changing from the superstitition and ignorance of mediaeevalism to a modern
science of the Renaissance. Not only were midwives opposed to the passing of their
livelihoods but the patients themselves were decidedly averse to any such change. The
calling in of a medical man had in the past meant fearful torture, mutilating operations
and a wake of dead babies and dead mothers. Lying-in patients then dreaded the
appearance of the man midwife at their bedsides, and this was the environment in which
Smellie lived and worked and taught.
Some of his notes tell of his troubles. In case 319 he says, "Having sent for my
principal midwife and the rest of my pupils, I desired her to keep the patient quiet in
bed, which indeed was only a little straw laid in a cold garret, for at that time we were
obliged to,.smuggle our patients on account of the barbarity of the churchwardens."
Again in case 502, he was called to a narrow lane in St. Giles where the arm of the
child presented. I quote: "When I came in, the room was crowded with the pupils to
the number of twenty-eight. Such a number going in had so alarmed the lane that a
great mob assembled and began to exclaim that we were trying practices. Some of the
women also told us that the parish officers were sent for, who at that time were glad
of showing their authority. On these accounts I was glad to deliver the woman in a
hurry. The child was alive and when this was told the mob, and that the woman also
was safe, they all dispersed."
It was in this environment that Smellie worked for many years. It was under such
conditions that he made those accurate observations which were to bring about a metamorphosis seldom equalled in the annals of medical history. Smellie swept away mediaeval midwifery and replaced it with the beginnings of scientific obstetrics.
It was Smellie who first described the mechanism of labour. His treatise, published
in 1751 is probably the first attempt in any language. It is remarkably accurate. It was
Smellie who first recognized Occiput-Posterior Positions, and realized that here was a
hazard that could be manually corrected. He performed manual rotation many times
and describes his method. "If," he says, "the forehead sticks in its former situation
without turning into the hollow of the sacrum, it may be assisted by introducing some
fingers or the whole hand into the vagina and moving it in the right position." —
Page 205
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Smellie, in the slums of London, without anaesthesia or relaxation or co-operation from
his fearful patients, two hundred years ago and more—this man with the large and
powerful hands.
Smellie was a great advocate of the obstetric forceps. The forceps had been invented perhaps 100 years before he was born, by Peter Chambrlen, but as is well known,
they were kept a secret by the family through four or five generations. Through the
first 13 or 14 years of his practice, Smellie knew little or nothing about the instrument.
As has been said it may well have been the appearance of Chapman's and Butter's articles
describing the forceps in 1733 that decided Smellie to leave Lanark and go to London
in 1739.
In any case there can be no doubt that Smellie immediately recognized the forceps,
crude as it was, as a tremendous boon to midwifery. Here was an instrument that might
save, not destroy the child.
Although the original invention of the forceps belongs to Chamberlen (and possibly others independently) the instrument we know today may be credited in great part
to Smellie. He early realized that the original short, straight tongs of Chamberlen were
of use chiefly as outlet forceps, but could not be used in the area where he needed them
most—the mid pelvis; and so he first lengthened the forceps in 1744 and a little later
added his joint or lock now known as the "English' or '"Smellie" lock. This lock hsa
come down to us unchanged and is the lock used on most of our modern instruments
today.
In 1751- he published an account of his improved forceps with the pelvic curve for
use in the mid pelvis. The fact that Leveret of France published an account of his
forceps, with the same pelvic curve, in the same year, detracts nothing from either man.
Each published the same improvement at the same time quite independently of eacn
other.
While Smellie realized the advantages of his new instrument in his own hands he
recognized its danger too, in less experienced hands. In case 352 dated 1755 he relates
a case he completed by employment of the long, double curved forceps and he adds—
"They were contrived some years ago by myself as well as other practitioners on purpose
to take a better hold of the head when presenting and high up in the pelvis, but I do not
recommend their use in such cases for fear of doing more harm than good, by bruising
the parts of the woman when too great force was used."
It has been said that Smellie practised manual rotation of the posterior occiput. In
recent years there has been a trend toward the use of forceps as the rotary force in the
rotation of the occiput. Some of us may regard forceps rotation as newer or more up
to date. The notes on case 258 delivered in 1745 give further insight into the ingenuity
of this remarkable man. The position was an occiput posterior which he endeavoured
repeatedly to deliver with forceps but each time the instrument slipped and the attempt
failed. He says "I first thought of using the blunt hook, but after considering the
matter decided on the following procedure. I luckily thought of trying to raise the
head with the forceps and turn the forehead to the left side of the brim of the pelvis
where there was more room, an expedient which I immediately executed with greater
ease than I expected. I then brought down the vertex to the right ischium, turned it
below the pubes and the forehead into the hollow of the sacrum, and safely delivered
the head by pulling it from the perineum and over the pubes. This method, succeeding
so well, gave me great joy and was the first hint in consequence of which I deviated
from the common method of pulling forcibly along and fixing the forceps at random
on the head. My eyes were now opened to a new field of improvement in the method
of using the forceps at random in this field." Smellie is undoubtedly the originator of
both manual rotation and forceps rotation of the posterior position.
Here too we observe the probable origin of foetal application of the forceps to the
child's head, rather than "Fixing the forceps at random on the head."   Until then for-
Page 206 ceps had been applied by pelvic application to whatever part of the head was most readily
grasped.
Just why forceps rotation should be identified with the name of Scanzoni is not
apparent. Friedrich Wilhelm Scanzoni was borne in 1-821 and died in 1891. He was
Professor of Midwifery at Wurzburg, Germany, and is perhaps best known for his work
on Chronic Metritis, published in 1871. As Smellie first practised forceps rotation in
1745, he probably preceded Professor Scanzoni in this procedure by at least a hundred
years.
Podalic Version was a commen practice in Britain, as on the Continent. Smellie
describes "Turning" in many of his cases and in his Treatise. The af tercoming-head in
version and in breech, then as now, was the great problem. Many times the head and
body were wrenched apart in the struggle. Occasionally decapitation was deliberately
practised. In his Treatise, Smellie describes in detail his method of removing a head,
floating free in the fundus uteri. His notes describe three cases of arrest of the after-
coming head which he tried to deliver with the short straight forceps. Each attempt
failed. In 1746 he used the new long forceps with the pelvic curve, his own invention,
with good results. His publication of his new instrument did not appear until 1751.
As far as is known, he is the first to use forceps on the aftercoming head.
Smellie knew about Caesarean Section. He devotes a chapter in his Treatise to this
subject. It was only the second time that such discussion appeared in English. Sir
Fielding Ould of Dublin mentions it in 1742, only to thoroughly condemn the operat'on.
Smellie has indeed little more to offer in its favour. He recites in some detail situations
in which delivery from below is utterly impossible and adds, "In such emergencies, if
the woman is strong and of good habit of body, the Caesarean Section operation is certainly advisable, and ought to be performed becaus ethe Mother and Child have no other
chance to be saved, and it is better to have recourse to an operation which hath sometimes succeeded than leave them both to inevitable death. Nevertheless if the woman
is weak, exhausted with fruitless labour, violent floodings or any other evacuation which
renders her recovery doubtful, even if she were delivered in the natural way; in these
circumstances it would be rashness and presumption to attempt an operation of this kind,
which ought to be delayed until the woman expires and then immediately performed
with a view to save the child." Smellie, himself never performed the operation on a
live patient. He relates three cases when he so operated after the patient's death in an
attempt to save the child.
Because of the horror of the people toward the attendance of the man midwife with
his instruments of torture and destruction, Smellie was led into certain errors in judgment. These errors called down upon him criticism and ridicule. In Smellie's day all
instruments were brought to the bedside with the greatest secrecy and caution. The
unfortunate clink of steel in the accoucheur's bag or during the handling of them, too
often gave the secret away, and so Smellie devised and made wooden forceps, but states
that he used them only three times, and then returned to the steel instruments. He then
covered the steel blades with leather which again brought down on him the scorn and
ridicule of his critics. It was held by them that "The blood soaked leather became
harsh and harmful and stinking."
Another characteristic of the man which may permit of criticism was that he kept
his obstetrical accidents secret. Probably because man midwifery was in the melting
pot, there was the tendency to blame all bad results whether avoidable or unavoidable
on the accoucheur. Certainly Smellie practised secrecy and repeatedly advised it in his
lectures to his pupils.
His own laconic explanation may explain. He saw a case in Lanark, the 40-year-old
servant of an old personal friend. A long labou resulted in delivery by perforation
and crochet. On manual removal of the placenta, Smellie encountered intestine protruding into the fundus uteri.    The patient lived 12 hours, and then follows the sig-
Page 207
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nificant remark, "In order to avoid reflexions this accident was kept secret."   It is prob-
able that secrecy was Smellie's persistent teaching.    One of his pupils writing to him i
in 1746 concerning an obstetrical accident says, "According to your prudent advice, I
spoke nothing of the matter."
As Smellie's reputation grew, so grew the number of his critics and the vehemence
of their attacks. Almost from the time of his arrival in London until his retirement
19 years later, Smellie seems to have been the continuous object of attack from mid-
wives and his fellow practitioners alike. The utter malignancy, the cruelty and the
ridicule with which he was constantly bombarded is unbelievable. Pamphlet after
pamphlet by many authors are available today, showing the vitriol and hatred with
which he was attacked. Midwives saw the gradual passing of the day and age that had
been in their hands since the Druids. Those doctors who criticized so harshly were
doubtless prompted by envy. They all realized then, as we do today, that the most
powerful weapon in argument is not logic, but ridicule. To some of his tormentors,
Smellie made courteous reply, but to most attacks he was silent.
Perhaps one could best present the quality of the man by including an excerpt from
one of his lectures to his pupils in 1748. He is describing the-qualifications necessary in
an accoucheur, and discusses the relationship that should be obtained between midwife
and male practitioner and this at the height of his criticism. Concerning the midwife
he says, "She ought to live in friendship with other women of the same profession, contending with them in nothing but knowledge, sobriety, diligence, and patience. She
ought to avoid all reflections upon men practitioners, and when she finds herself at a
loss, have recourse to their assistance." And to his male students, "On the other hand
this confidence ought to be encouraged by the man, who when called, instead of openly
condemning her method of practice (even though it be erroneous), ought to make
allowances for the weakness of her sex and rectify that which is amiss without exposing
her mistakes. These gentle methods will prevent that mutual calumny and abuse which
too often prevails among male and female practitioners and redound to the advantages
of both. For no accoucheur is so perfect but that he may err sometimes. This conduct
will effectually conduce to the welfare of the patient and operate as a silent rebuke upon
the conviction of the midwife, who finding herself treated so tenderly will be more apt
to call for necessary assistance on future occasions, and to consider the accoucheur a
man of honour and a real friend."
Such a man was William Smellie, such was his character. With his face steadfastly
toward the horizon, he seemed above the simple carping jealousies of his contemporaries.
His "Treatise of Midwifery" which is his monument to posterity was first published
in 1751. He retired from his teaching and practice in 1759 and returned to his native
Lanark. He died there on March 5th, 1763, aged sixty-six years. His wife, Eupham
Boland, seven years older than he, outlived him.   There were no children.
Smellie stood at the dawn of a new day, a Renaissance, and not very far behind
him lay the mediaeval darkness of all time. Whilst other arts and sciences had already
crept forth to be clothed with the garments of reason and progress, midwifery still lay
couched in superstition, stupidity and ignorance. Midwifery was still quite outside the
realm of education, it was still in the hands of seemingly the lowest type of British
womanhood.
And out upon this stage stepped a big, rawboned Scot. He was uncouth and shy,
he had none of the social amenities, but he had big and powerful hands, and he was
filled with a great purpose. In the thirty-nine years that he practised, he wrested midwifery from mediaeval darkness and made it a science. He placed it belatedly on a par
with medicine, and surgery. He was indeed a priest of Lucina, the Roman Goddess of
Reproduction.
It is because of these things that tonight I place William Smellie even on the same
pedestal as William Osier.   Each is a giant in the history of Medicine, each has stood as
Page 208 ftp; 't
a beacon on the pathway of life, lighting the pathway for the stumbling feet of thousands of practitioners who have succeeded them. Thereby each has given comfort to
millions of humankind.
And well they should stand side by side this night, for William Osier and William
Smellie are immortal.
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REFERENCES:
Cameron, S. J.—"Biography," J. Obs. Brit. Emp. XXXVI: 521,  1929.
Cashing, Harvey—"The Life of Sir "William Osier," 1925.
Findlay, Palmer—"Priests of Lucine"—1939.
Glaisters, J.—"Dr. William Smellie, Glasgow"—1893.
Osier, Sir William—"Aequanimitas and other addresses"—1906.
Smellie's Treatise, edited by A. H. McClintock, New Sydenham Soc.—1876.
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SECTION OF NEUROLOGY AND PSYCHIATRY
VANCOUVER MEDICAL ASSOCIATION
The Section of Neurology and Psychiatry held its monthly meeting in the Lecture
Room of the Vancouver General Hospital on February 23, 1948.
For the past two meetings this section has devoted considerable time to a discussion
of "The Problem of the Sex Delinquent." This has been in response to a letter from
the Canadian Medical Association, requesting suggestions from interested parties and
groups. At the last meeting of our Section the following recommendations and suggestions were approved to be forwarded to the Canadian Medical Association:
1. It is recommended that the Federal and Provincial Governments undertake the
necessary legislation to provide that all sex offenders be placed in categories according to
the type of treatment considered to be the most salutory by a board of competent authorities including penologists, psychologists, psychiatrists and social workers. Some of
the offenders would be transferred to the probation services or ordinary penological
institutions as belonging to a group of what must be empirically considered as normal
people, some to mental hospitals having been diagnosed as psychotic, mental defective
or epileptic, others to special institutions for those with psychopathic personalities. While
it is obvious there are great difficulties of definition involving such classification the
purpose of this recommendation is to serve as a basis for further work involving the
clarification of terms.
2. It is also recommended that the sex offender's return to society be on the recommendation of a similar board of experts who would evaluate the effectiveness of the
treatment in each case, which would of course imply the use of the indeterminate sentence.
3. In view of the difficulty in so many cases of proving guilt in court it is recommended that provision be made for psychiatric examination of many whose guilt has
not been legally established but who would consent to treatment.
Two interesting papers on "Incipient Schizophrenia" were presented. Dr. R. L.
Whitman's paper dealt with the diagnosis and recognition of early Schizophrenia and Dr.
George Davidson's paper dealt mainly with the therapeutic aspects of this disorder. A
very interesting discussion followed the presentation of these two papers.
Page 209
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I      '.■•*|!iVlfl OVARIAN TUMORS
By DR. D. N. HENDERSON, University of Toronto
m\w
Ovarian tumours occur from infancy to old age and present many unusual clinical
and pathological features. The relatively recent discovery of the hormone-secreting group
of neoplasms have greately stimulated the study of all ovarian neoplasms. Despite this
study, however, many problems, particularly pathological ones, remain unsolved. The
histogenesis of most ovarian tumours is undetermined, their classification is unsatisfactory
and the whole problem of their malignancy is mingled with clinical confusion and pathological uncertainty. A proper appreciation of the main pathological characteristics of
ovarian tumours, however, is esential for correct clinical diagnosis and proper surgical
treatment. Without such knowledge, the surgeon will needlessly remove many ovaries
and perform many inadequate and incomplete operations for ovarian malignant disease.
These various clinical and pathological problems will be discussed in relationship to three
common varieties of ovarian tumours—retention cysts, malignant neoplasms and endometrial cysts.
RETENTION CYSTS
Retention cysts of the ovary occur with great frequency. Follicular maturation,
rupture, and corpus luteum formation are the normal cystic changes that occur each
month in the ovary. Incomplete maturation of the follicle or the failure of rupture may
result in a follicular cyst. Incomplete retrogression of the corpus luteum may result in
a corpus luteum cyst. These cysts rarely reach a size greater than three cm. and never
become true neoplasms. They vary in size from month to month and as a rule the fluid
content is eventually absorbed and the cyst disappears. The presence of two o rthree retention cysts in one ovary may cause appreciable enlargement so that a neoplasm is suspected. Re-examination in a month or six weeks will as a rule reveal a reduction in size
rather than an increase, which is characteristic of cystic rather than neoplastic disease.
The ovary, which contains multiple retention cysts may cause pelvic pain and discomfort
and be tender when palpated. The pain and tenderness are usually of a temporary nature
and will spontaneously disappear. The mere presence of an enlarged, tender, cystic ovary is
not an indication for its removal. The surgical removal of an ovary, because of retention
cysts is rarely justified. The frequency with which one encounters patients who, because
of right sided abdominal pain, have had the right ovary removed at the time of appendectomy is a glaring example of the failure of many surgeons to appreciate the physiological changes that occur in the ovary.
The physiological rupture of the Graafian follicle at the time of ovulation may be
accompanied by intra-peritoneal bleeding of sufficient severity to cause clinical symptoms.
If the blood loss is extensive, and this is unusual, a clinical picture similar to ectopic
pregnancy will result. In the majority of instances, however, the blood loss is slight. Rupture and bleeding takes place most commonly at the time of ovulation twelve to fourteen
days after the first day of the last menstruation. Pain is usually sharp in character, sudden
in onset and associated with nausea. Vomiting is rare. If the bleeding has occurred from
the right ovary, acute appendicitis is usually suspected. The white blood count is usually
raised but rapidly falls to within normal limits in ten to twelve hours. In one' case
under observation, the white blood count fell from 36,000 to 26,000 to 14,000 to 5,000
when taken at two hour intervals. The temperature is usually normal or only slightly
raised, but if more than slight bleeding has occurred, the temperature may reach 101 •
Tenderness on abdominal and pelvic examination is usually present but muscular rigidity
is rare. While acute appendicitis is frequently suspected, the history and findings are not
typical. After a few hours the pain will usually subside and the white blood count will
fall, which should lead to a recognition of the true cause of the trouble. Operation is not
indicated except in those rare cases in which haemorrhage is severe.
Page 210 MALIGNANT OVARIAN NEOPLASMS
Before proceeding to the specific discussion of malignant ovarian disease, certain
general characteristics of both benign and malignant tumours will be mentioned and the
incidence of the various types of tumours as found in a large series of nearly 500 will be
presented.
INCIDENCE OF MALIGNANCY
19% of all cystic neoplasms were malignant
49 % of all solid neoplasms were malignant
18% of genital tract malignancy is ovarian.
BILATERAL OCCURRENCE
10% of benign tumours are bilateral
25% of malignant tumours are bilateral
COMMON TYPES OF CYSTIC BENIG     NEOPLASM
IN ORDER OF FREQUENCY
1. Serious cystadenoma
2. Papillary cystadenoma
3. Dermoid cyst
4. Pseudomucinous cystadenoma
COMMON TYPES OF MALIGNANT CYSTIC AND
SOUD NEOPLASM IN ORDER OF FREQUENCY
1. Papillary cystadenocarcinoma
2. Solid adenocarcinoma rMM,
3. Granulosa and theca cell
4. Pseudomucinous cystadenocarcinoma
Most ovarian tumours completely replace the ovaries and grow in a peripheral
manner to rise out of the pelvis into the general peritoneal cavity. As a result they have
a relatively long, flat pedicle made up of the inf undibulo-pelvic ligament, broad ligament
and tube, a feature which makes their surgical removal easy but also makes torsion of
the pedicle a relatively frequent occurrence. Some tumours, however, grow centrally
through the hilum of the ovary between the two layers of the broad ligament and as a
result do not develop any pedicle. They displace the uterus to either one or the other
side of the pelvis, obliterating the usual landmarks. The burrowing tendency of such
intraligamentous cysts is remarkable. They may grow retro-peritoneally into the pouch
of Douglas or under the sigmoid and rectum. Surgical removal of these intraligamentous
neoplasms may present very great difficulties and injury to bowel and ureter may occur
unless great care is exercised in dissecting the cyst out of its retro-peritoneal situation.
Most tumours reach a large size before all functioning ovarian tissue is destroyed.
This fact is of clinical importance when early pregnancy is complicated by an ovarian
neoplasm. The tumour may contain the corpus luteum of pregnancy and if removed
during the first three months, abortion will occur. Removal should be postponed in the
absence of acute symptoms until the pregnancy is of four months' duration. The possibility of malignancy, rupture of the cyst, torsion of the pedicle or obstructed labor
warrant the removal of ovarian neoplasm during pregnancy. If, however, its presence is
not recognized until late in pregnancy, and, owing to its situation obstruction of labour
seems unlikely, then removal may be postponed until after delivery.
The diagnosis of an ovarian neoplasm rarely presents difficulty. Most tumours are
cystic and push the uterus to one side of the pelvis or rise out of the pelvis, and are
palpable on abdominal examination. Occasionally, however, they become partially incarcerated in the pouch of Douglas and force the uterus upwards against the bladder, causing pelvic pain, frequency of urination or even acute retention. The similarity between
Page 211
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V
an over-distended bladder and an ovarian cyst has been so frequently mentioned by all
who discuss the diagnosis of ovarian neoplasms that it is only with hesitancy mentioned
again. Nevertheless, even the most experienced may make this mistake unless the passage of a bladder catheter forms part of every bimanual examination in cases of suspected
pelvic tumour.
Not infrequently pregnancy is mistaken for an ovarian neoplasm, owing to the
extreme softness of the uterine wall and cystic consistency of early pregnancy. This mistake is most frequent in illegitimate pregnancy and in pregnancy which occurs during
the late reproductive period, when both the patient and the doctor falsely assume that
pregnancy is most unlikely. The error may be avoided if an accurate menstrual history
is obtained and care exercised in bimanual examination. Ovarian tumours rarely cause
amenorrhoea, nearly always displace the uterus from its normal position, and softening
and bluish discoloration of the cervix do not occur. It should be remembered that the
body of the uterus is the landmark of the pelvis to which all masses should be related,
and if the uterus cannot be outlined on bimanual examination, any supposed tumour
palpated may be the body of the uterus. Occasionally, however, the diagnosis remains in
doubt. In such case an Aschheim-Zondek test for pregnancy or bimanual examination
under anaesthetic may be required before a correct diagnosis can be made.
Diverticulitis and carcinoma of the recto-sigmoid are not infrequently mistaken for
an ovarian cyst arising from the left ovary. Here again an accurate history will usually
reveal symptoms which point to a large bowel lesion. If doubt exists, however, in regard
to the nature of any left-sided adnexal pelvic mass, X-ray examination of the sigmoid
and colon should be made, particularly if the patient is middle-aged or older.
While the diagnosis of an ovarian tumour is not difficult, diagnosis of the type of
neoplasm in most instances cannot be accurately made. The granulosa cell tumour may
be suspected owing to the biologic effects caused by the estrogen secreted by the neoplasm.
The dermoid cyst occasionally may be recognized by X-ray which may reveal the presence of bone or teeth in the tumour. In the majority of instances, however, no such clues
will be present and the diagnosis of the type of tumour often remains in doubt until the
pathologist examines the specimen. The pre-operation diagnosis of malignancy is equally
uncertain. The presence of ascites, fixation of the tumour, rapid growth and pain usually
indicate malignancy, but all may occur with a benign tumour. Meigs' Syndrome is a
condition in which a benign ovarian neoplasm, usually a fibroma, is accompanied by hy-
drothorax and abdominal ascites. The hydrothorax may precede the development of
ascites and a primary chest lesion may be suspected. If the presence of a pelvic tumour is
known, the ascites and hydrothorax may be mistakenly considered as evidence of hopelessly advanced ovarian malignancy. We recently encountered a case in which both
paracentesis abdominis and thoracentesis were performed on ten occasions. Removal of a
benign fibroma of the ovary resulted in a complete cure and return of the patient to
normal health.
Exploratory laparotomy is indicated in nearly all cases of malignant ovarian tumours.
Occasionally what appeared before laparotomy to be an inoperable carcinoma will prove
operable when the abdomen is opened, and if post-operative high voltage is employed,
. added years of comfortable fife or even cure may result.
All ovarian neoplasms possess malignant potentialities. They may start as a primarily malignant tumour, or may exist for months or even years as a benign tumour
and then develop secondary malignant characteristics. This secondary development of
malignancy is most liable to occur in the papillary and pseudomucinous varieties of
ovarian cysts. In the group of papillary cystadenoma, there is a gradual transition from
the frankly benign to the frankly malignant neoplasm and between the two extremes
is a group of cysts which fall into a border-line category between benignancy and
malignancy. The diagnosis of these will depend on the individual pathologist's conception
of what warrants a diagnosis of malignancy in this type of growth. Certainly a number
of these tumours will show marked degrees of hyperplasia, multiple friable projections on
the surface of the tumour and even secondary tumour nodules on the peritoneum, with-
Page212 out exhibiting the true invasion qualities, histologic appearance or distant metastases
which are indeed characteristic of carcinoma. Such tumours may be so adherent that their
surgical removal is impossible and death may result from ascites, exhaustion, or intestinal
obstruction. In some cases, however, when the primary tumour is removed, the secondary
implants on pelvic peritoneum may regress and disappear. On the other hand, it is
occasionally true that a papillary tumour of benign clinical and pathological appearance
will follow a malignant course and the patient may eventually die from both local and
distant metastases. As a general rule, however, it may be said that with the definitely
carcinomatous tumours of the cystic papillary type the prognosis is poor, whereas with
the border-line group the prognosis is usually good but occasionally a malignant clinical
course will occur. The value of high voltage X-ray therapy in the treatment of ovarian
malignancy is difficult to assess. It is, however, in the papillary type of tumour that
roentgenotherapy appears most effective and its routine post-operative use in tumours of
this type can be recommended.
The uncertainty of the pre-operative diagnosis of malignancy plus the occasional apparent cure following the incomplete removal of the papillary variety of cyst, if postoperative X-ray is employed, is further evidence of the value of exploratory laparotomy
in practically all cases of ovarian malignancy.
The pseudomucinous type of multi-locular cysts is extremely common, and occasionally $hows secondary malignant change. The diagnosis of malignancy in this type of
tumour as a rule presents none of the difficulty encountered with the papillary tumours.
About 5 % of all pseudomucinous cysts are malignant, and unless the malignant degeneration is localized to a central area of the large tumour, the prognosis is poor indeed. High
voltage X-ray therapy is of doubtful value for this type of malignancy.
Pseudomyxomatosis peritonei may occur with either the benign or malignant variety
of tumour. It usually results from spontaneous rupture of the cyst or spilling of the
contents of the cyst during operation. Cells are implanted on the peritoneum and continue to secrete large quantities of pseudomucin. If the ovarian tumour has been removed, then further surgical treatment other than repeated paracentesis is without value.
High voltage X-ray has little if any effect arid most patients eventually die from exhaustion, cachexia or intestinal obstruction.
Solid varieties of carcinoma of the ovary with the exception of the granulosa cell
group of tumours have a very grave prognosis. The five year survival rate is very low,
approximately 50% of the patients dying during the first post-operative year.
The low five year survival rate for the solid, papillary and pseudomucinous type of
ovarian carcinoma is essentially due to late clinical diagnosis. Ovarian malignancy is a
silent disease, and has frequently extended beyond the limits of surgical removal before
the patient has symptoms of sufficient severity to consult a physician. It is becoming
more and more evident that the main hope for the "reduction in deaths from carcinoma
of the female reproductive system lies in regular, routine, vaginal and bimanual examination, with visual inspection of the cervix. This can be most conveniently performed by
the patient's family physician who should recommend this type of examination on every
opportunity, particularly for those patients in the middle and later years of life.
Inadequate and improper surgical treatment is, however, partly responsible for the
poo rresults obtained in carcinoma of the ovary. The frequency of bilateral ovarian
malignancy warrants bilateral ophorectomy in all cases even if this requires a second
laparotomy. The frequency with which ovarian malignancy spreads by lymphatics to the
endometrium and uterus, indicates total hysterectomy. Care and gentleness in handling
the tumour will prevent rupture and dissemination of malignant cells throughout the
peritoneal cavity. Whenever technically possible, ovarian tumours should be removed
without previous tapping. If at the time of laparotomy doubt exists in regard to the
malignancy of an ovarian tumour, a quick section report should be obtained before the
abdomen is closed. If the suspected diagnosis of malignancy is confirmed, the radical
operation should be performed.
Page 213
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As a general guide to diagnosis at operation, it may be said that most thin-walled
cysts are benign, while the majority of solid tumours with the exception of the easily
recognized fibroma, are malignant. Large cystic tumours which contain solid areas, particularly if those areas show necrosis and haemorrhage, are malignant. The papillary type
of neoplasm showing discrete papilla; is usually benign, whereas those in which the
papillae are abundant and confluent are usually malignant. Such criteria are by no means
infallible, but they do offer a fairly reliable guide to the surgeon for the differentiation of
benign from malignant tumours.
The hormone-secreting tumours of the ovary are of special clinical and pathological
interest. The granulosa and thecal cell tumors comprise the feminizing group and secrete
varying amount of the sex hormone, estrogen. The clinical evidence of this excessive
estrogen secretion by the tumour varies with the age of the patient. When the neoplasm
occurs during infancy or childhood, signs and symptoms of precocious puberty develop.
Uterine bleeding occurs. The external genitalia enlarge, fat is deposited in the labia and
breast hypertrophy takes place. Auxiliary and public hair makes its appearance. Ovulation, however, does not occur and pregnancy is not possible in precocious puberty that is
due to the granulosa cell tumour. When the neoplasm is removed, bleeding ceases and the
incompletely devolped secondary sex characteristics usually regress. When the tumour
occurs during the years of sexual maturity, endometrial hyperplasia results from the
continued stimulation of the endometrium by estrogen and complete irregularity of
menstruation usually follows. If the tumour first appears after the menopause, uterine
bleeding and uterine hypertrophy result and carcinoma of the endometrium is usually
suspected. In the majority of instances, the ovarian tumour is of sufficient size to be
readily palpated on abdominal or bimanual examination. Occasionally, however, small
tumours will secrete sufficient quantities of estrogenic hormone to cause bleeding, yet be
too small to palpate. The possibility that such a small lesion may be responsible for postmenopausal bleeding in which the endometrium is of the hyperplasia pattern. Such cases
should not be treated with uterine radium or high voltage X-ray. A period of observation
after the curettage is indicated, then if the hyperplasia and bleeding recur, a second
examination under anaesthetic is warranted. If the uterus is enlarged, then laparotomy is
indicated even if no ovarian enlargement can be determined.
The granulosa cell tumours are by no means uncommon. They comprise about 10%
of all carcinomas of the ovary. The present a variety of appearances under the microscope, with atypical microscopic forms all being common while often their true nature is
not recognized. In the gross, the tumour is usually solid with small areas of cystic degeneration and haemorrhage. The surface is of soft, brain-like consistency and usually has a
distinct yellowish colour. These tumours are of low grade malignancy and offer the
best prognosis of all malignant ovarian neoplasms. Long follow-up observation is important, however, as late recurrence is not uncommon. Surgical treatment depends on the
age of the patient. If the tumour appears before puberty or in a young woman desirous
of having children, simple oophorectomy is justified. These tumours, however, most frequently occur after thirty years of age, with the maximum incidence being about ten
years later. In these age groups bilateral oophorectomy and total hysterectomy is indi-
catedf. It is impossible to estimate the clinical malignancy of these neoplasms by miscro-
scopic examination. The prognosis should be guarded in all cases. The value of post
operative high voltage X-ray therapy for the granulosa cell tumour has not been determined.
The theca-cell tumour is usually considered a special variety of granulosa-cell neoplasm and is relatively rare. It has the gross appearance of a fibroma, usually occurs after
the menopause, and produces the same clinical picture as the granulosa cell tumour. This
variety of estrogen secreting neoplasm, however, is benign and simple ophorectomy is
adequate treatment.
The arrhenoblastoma or masculinizing tumour of the ovary is extremely rare and
mentioned only because of the striking biological effect it has on the patient. The tumour
secretes androgenic hormone which causes amenorrhoea, breast atrophy, hypertrophy of
Page 214 the clitoris, deepening of the voice and facial and body hirsutism. The extent o fthese
striking physical changes vary in different cases. The tumours are generally considered
benign although we have encountered two cases both of which were malignant.
ENDOMETRIAL CYST
Endometrial cysts of the ovary were first described as long ago as 1896. Their frequency and importance, however, were not appreciated until Sampson made his classical
contribution in 1921, entitled, "Perforating Hemorrhagic Cysts of the Ovary."
Endometrial cysts of the ovary are strikingly different in both clinical and patho-
logcal characteristics from other ovarian tumours. These differences are largely due to
the unusual behaviour of the endometrial-like mucinous membrane that lines the cystic
space. This tissue reacts to the ovarian homones in a manner similar to that of the
endometrium of the uterus. It is dependent upon estrogen for its continued growth and
during the menstrual cycle shows pre-mentrual congestion and menstrual bleeding. The
cyst gradually increases in size due to the accumulation of mentrual blood within the
cyst. This blood becomes of tarry consistency and of dark chocolate colour, forming the
so-called chocolate or hajmorrhagic cyst of Sampson. Owing to invasion of the cyst wall
by its own epithelial lining, plus the increased intra-cystic pressure of the accumulated
blood, perforation or rupture is a frequent occurrence. It is this frequency of rupture
which is the major factor in the further implantation of endometrial-like tissue, particularly in the pouch of Douglas and upon rectum and sigmoid. As a result of continued
menstruation of the ectopic endometrium in the pelvis, small areas of peritonitis occur
leading to the formation of firm, fibrous adhesions. Actual invasion of the wall of the
rectum or sigmoid may take place and cause partial obstruction and occasionally rectal
bleeding. This may lead to an erroneous diagnosis of carcinoma of large bowel, a particularly serious mistake if radical operation is employed in treatment. This is by no means
of only theoretical importance. We have seen three cases in which such an error had been
made and abdominal-peritoneal resection of the rectum performed. The symptoms and
signs of ovarian endometrial cysts vary with the extent of the endometriosis elsewhere
in the pelvis. Uterine fibroids which occur in approximately 30% of cases of endometrio-
osis further complicate the diagnosis. Symptoms are be no means characteristic, and they
vary markedly in severity in different patients with endometriosis of equal extent. Menstrual and premenstrual pain, continuous pelvic pain and discomfort, dyspareunia, sterility and painful defaecation during the menstrual period are symptoms that occur with
greatest frequency. Menstrual irregularities of flow and cycle are not uncommon, particularly when uterine fibroids are associated with the endometriosis. Endometrial cysts
present rather distinct characteristics in bimanual examinations—firstly, fixation, and
secondly, increased tenderness during the immediate premenstrual period. Other findings
are dependent on the extent of the endometriosis. In some cases the adnexa on both sides
are matted together, tender and fixed, suggesting inflammatory adnexal disease. In nearly
all cases of endometrial cysts of the ovary, there is an associated endometriosis of the cul-
de-sac and utero-sacral ligament which causes a nodular tender thickening in the posterior fornix close to the cervix. On rectal examination the utero-sacral thickening is
particularly well appreciated. The diagnosis of endometriosis is not easy. Findings suggestive of pelvic inflammation without a clinical history, fixation of the uterus, particularly if it contains fibroids and tender nodular thickening in the cul-de-sac, are strongly
suggestive of the disease.
Surgical treatment depends on the extent of the disease. The aberrant endometrial
tissue is dependent on the physiological activity of the ovary for its persistence and
growth. Absolute cure of the disease is therefore dependent upon cessation of ovarian
function. If both ovaries are the site of endometrial cysts and endometrial implants are
present throughout the pelvis, then bilateral oophorectomy and hysterectomy are indicated. If, however, the endometriosis is confined to one ovary, and there is only moderate
endometriosis elsewhere in the pelvis, less radical treatment is justified, particularly in
the young patient. The proper management of these cases requires the exercise of careful
judgment. The general trend, however, in surgical management of endometriosis is to-
Page215
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ward more conservative rather than radical operative procedures. It is impossible to
predict the future of small areas of endometriosis that remain after a conservative operation, but in a satisfactory number of cases, symptoms do not recur and pregnancy may
result.
In summarizing this discussion of retention cysts, malignant neoplasms, and endometrial cysts, it may be said that retention cysts of the ovary rarely require treatment,
and that the mere presence of a tender, enlarged cystic ovary is not an indication for its
removal. Bleeding from a Graafian follicle cysts may cause symptoms closely resembling
those of acute appendicitis. Care in history taking, examination, and the awareness of
the similarity will lead to a correct diagnosis. Malignant ovary neoplasms comprise about
one fifth of all gynaecological malignancy and have a very poor prognosis. Certain types
of ovarian neoplasms, such as the papillary tumours and the granulosa cell group offer a
better prognosis than the solid adenocarcinoma variety. The frequency of bilateral ovarian
carcinoma and of lymphatic spread to the uterus warrants bilateral oophorectomy and
total hysterectomy in all cases of ovarian malignancy. The only exception is in the granulosa cell group of tumours when they occur during the years of adolescence or early
sexual maturity. The value of post-operative high voltage X-ray varies with the types of
tumour. As most unexpected apparent cures and prolonged survival may occur after its
use, it seems reasonable that all patients should receive such treatment. The greatest
hope for reduction in the deaths due to malignant disease of the genital tract rests in
earlier diagnosis; The family physician has a great opportunity of assisting in this early
diagnosis by making bimanual examination with visual inspection of the cervix as a
part of his routine physical examination, particularly in those patients of middle age or
older. Endometrial cysts are nearly always associated with endometriosis elsewhere in the
pelvis. While the cure of endometriosis is assured by bilateral oophorectomy, the trend
in surgical management is away from such radical treatment and toward a more conservative aproach with conservation of the reproductive function. Endometriosis of rectum and sigmoid may closely resemble carcinoma in clinical manifestations and should
always be considered a possibility when carcinoma of the rectum is suspected in women
during the reproductive period.
ATELECTASIS
By DR. J. E. WALKER
Definition:
Atelectasis may be defined as the collapse of pulmonary tissue due to the blocking
of a division of the bronchial tree, with subsequent absorption of the air contained in
the pulmonary tissue supplied by the obstructed bronchus.
This type of collapse must be distinguished from that in which collapse of pulmonary tissue is brought about by increased pressure in the pleural cavity such as is
found in pleural effusions or pneumothoraces. The two forms of collapse pose very
different problems as to treatment and prognosis.
Pathogenesis:
In the mechanics of atelectasis due to bronchial obstruction, two phenomena occur—
first there is obsorption of the alveolar air and secondly there is the elastic recoil of the
lung tissue. 	
When a bronchial division is completely obstructed it is obvious that no air can
enter or leave the alveolar cells, distal to the obstruction, by way o fthat bronchus; thus
any escape of aid from the alveolar cells must be by way of the circulating blood; the
gaseous tension in arterial blood is approximately the same as that in the alveoli, but
the gaseous tension in the venous blood, by reason of the lessened amount of oxygen,
Page 216 is less than that in the alveoli; thus the trapped alveolar air, by reason of its higher
tension, is readily and completely absorbed by the venous circulation.
The second factor of elastic recoil: the lung is constantly striying to contract down
in size because of the continuous envelope of elastic tissue which ensheathes the air
conducting passages down to their ultimate divisions. This tendency is counteracted
by the negative intra pleural pressure; any occurrence in the lnug that favours the contractile tendency of the lung tissue, is immediately taken advantage of; when the
alveolar air is lost, the elastic tissue contracts down to eliminate the vacuum so
created and the atelectatic lung tissue is consequently smaller in volume than the inflated lung. To fill in the space thus vacated, certain structures of the thorax become
changed in position. If the amount of pulmonary tissue involved has been extensive,
these secondary changes will be marked; if the amount of pulpaonary tissue involved
has been slight, these secondary changes may be so slight as to escape notice. The
outstanding features to be noted are: a narrowing of the intercostal spaces on the
affected side, shifting of the mediastinum to the affected side; elevation of the diaphragm on the affected side, compensatory emphysema of normal or unaffected lung
tissue and differences in the level of the hila shadows on the two sides. Even in well
marked cases, all of these signs need not be present. When present they are best demonstrated by means of the radiograph.
Atelectasis is due to bronchial obstruction. It is probable that bronchial occlusion in
the human very seldom occurs in a normal bronchus. When bronchiel occlusion results
from such extrinsic causes as tumours or enlarged glands, the process is a gradual one;
as narrowing takes places, infection is very prone to involve the structures distal to
the stenosis because of disturbed drainage; by the time complete occlusion takes place,
infection has already been established in the structures distal to the occlusion. The same
statement may be made regarding stenosis and occlusion from intrinsic causes. Postoperative atelectasis, which is due to an intrinsic obstruction, usually a plug of bronchial secretions, occurs in the individual who has an acutely and chronically irritated
bronchial tract.
It is obvious therefore that when atelectasis occurs, unless the obstruction can be
relieved within a short time, infection will be very likely to develop in the involved
lung tissue which is ill equipped to combat such an infection; complete resolution
may follow such an infection, but fibrosis or bronchiectasis may be the end result.
Etiology:
The causes of atelectasis are of necessity those conditions that cause bronchial obstruction. They may be divided into extrinsic and intrinsic causes. First extrinsic causes
of bronchial obstruction:
(a) Peribronchial tumor growths—bronchogenic carcinoma, Hodgkin's disease, lymphosarcoma, lymphatic lleukaemia or almost any of the lymphoblasomas.
(b) Peribronchial lymph glands which have been the sat of inflammation past or
present; in children particularly, tuberculosis, whooping cough and measles may
be incriminated.
(c) Fibrosis of lung tissue adjacent to bronchi may cause sufficient distortion to obstruct the bronchus.
(d) Such widely different conditions as intrathoracic aneurysms and kypho-scoliosis
have been known to cause bronchial distortion with obstruction.
Secondly—intrinsic causes of bronchial obstruction:
(a) Strictures of a bronchus—due to active or healed endobronchial tuberculosis or to
scar formation from a localized pyogenic infection.
(c) Foreign bodies.
(d) Inflammatory swellings of the bronchial mucosa from a variety of causes, among
which may be noted the pneumonias.
(e) Mucous plugs or plugs from the secretions of irritated bronchi as in post-operative
cases or in asthma; also from the spilling over of blood or inflammatory products
Page 217 niggl
w.
in upper respiratory or thoracic operations. The aspiration of vomitus, either
during or after the completion of an operation is more likely to set up an intense
pneumonia rather than lead to atelectasis.
It can be seen from this fist, that, apart from such cases as occur after operation,
where the condition of atelectasis itself is of primary importance, the finding of atelectasis poses a problem for diagnosis and that the finding of atelectasis is not an end in
itself.
Post-Operative Atelectasis:
This condition, when it occurs, is almost always in an individual who has increased
bronchial secretions previous to operation. These cases will almost always give a
history of acute, sub-acute or chronic upper respiratory infection; or of chronic cough
which may be due to any one of a great variety of conditions. The various restrictive
measures that frequently accompany an operation are not conducive to eliminating
these secretions which, if not assisted in their elimination, tend to accumulate in and
obstruct some part of the bronchial tree. These various rsetrictive measures may be of
different kinds: inhibition of ciliary action and abolition of cough reflex by sedatives
and anaesthetics; restriction of chest expansion by pain or misplaced abdominal binders;
elevation of the diaphragm by intestinal distension; drying of bronchial secretions by
inadequate fluid intake; difficulty in drainage of bronchus owing to position and insufficient changing of position and other factors with which you are all familiar.
The clinical picture of post-operative atelectasis varies within wide ranges depending on the size of bronchus involved and the suddenness with which the obstruction is
brought about; there may be practically no signs of symptoms if a small division of a
bronchus is involved or there may be most alarming and even fatal pictures when a
massive collapse takes place. Typically, the disturbance makes its appearance within
forty-eight hours post-operatively; any pulmonary consolidation that appears within
this time is much more likely to be atelectasis than pneumonia. Dyspnoea, rise in
temperature and pulse rate, cyanosis, diminution in excursion of the affected side,
diminished or absent breath sounds, dullness to percussion and shifting of the mediastinum will be found in varying degrees depending on the amount of involvement. If
die obstruction is unrelieved, the picture may be complicated by pneumonitis which
may in turn lead to fibrosis or bronchiectasis; other cases, particularly if the area is
small in extent, appear to suffer very litle inconvenience, and recover spontaneously
with no apparent bad end results.
Radiology is of help in these cases and the signs to be found have already been
mentioned earlier in this paper. It should not be forgotten that any lesion, such as
fibrosis which causes a shrinkage in lung volume, may give the same x-ray picture as
atelectasis.
Treatment:
(1) Prophylactic. This should consist of measures designed to increase plumonary
ventilation, remove upper respiratory infections and eliminate or aid the evacuation of
bronchial secretions. Measures designed to this end should be practised both pre- and
post-operatively and I believe if consistently carried out would eliminate a good percentage of this complication. If, in spite of these measures or more often because they
are not practised, atelectasis develops, more active measures must b employed: the use
of adrenalin to relieve broncho-spasm, promotion of coughing and force applied to the
chest wall; C02 inhalation or steam inhalation may relieve some cases. Intra-tracheal
catheter suction or bronchoscopic aspiration may be necessary. The condition of the
lung following relief by the above measures should be checked by x-ray, for what
appears to be clinical relief does not necessarily indicate complete anatomical relief.
Also a recurrence in the same bronchus or another bronchus may take place so that a
careful watch for future developments should be kept.
As a measure against infection it is usually advisable to start chemo-therapy or
anti-bio tic therapy at the same time that atelectasis is diagnosed.
Page 218 DOCTOR RUSSELL C. NOVAK
The late Dr. R. C. Novak passed away suddenly at Ponoka, Alberta, on
January 21, 1948, at the age of 44. At the time of his death he was on the
staff of the Provincial Mental Hospital, Ponoka.
Dr. Novak was born at Buchanan, Saskatchewan, on July 24, 1903. He
was educated there and obtained his B.A. from the University of Saskatchewan.
He graduated in Medicine from the University of Manitoba in 1931. He
served his interneship in the Misericordia Hospital, Winnipeg, and was in general
practice in Watson, Saskatchewan.
Dr. Novak joined the staff of the Provincial Mental Hospital, Essondale, on
September 18, 1941. He was a keen diagnostician, worked very hard on the
female service and in great part helped to carry the hospital along during the
war period.    He leaves a brother, Dr. M. Novak, practising in Yorkton, Sask.
rilwlfc*
OFFICE SPACE AVAILABLE
New Building specially designed for doctors.
Location—2660 East Hastings Street.
Already occupied by one doctor and one dentist.
Space available for one doctor, preferably E. E. N. and T., or other specialty.
Available now.   Contact Dr. B. Prosterman, HAstings 4234 or CEdar 3283.
S&$pi
Page 219 3,
W
The post-graduate course for general practitioners was held during the first two
weeks in March at Shaughnessy Hospital. Forty-six doctors registered for the course,
of which 31 were from outside Vancouver. At a dinner given to those taking the course
many complimentary remarks were made regarding subject material and the well balanced curriculum. The success of this year's attempt should encourage those in charge
of arrangements to repeat a similar course each year in the future.
The first scientific session of the British Columbia. Surgical Society was held March
18th and 19th and proved very successful. Dr. R. M. Janes, Professor of Surgery at
the University of Toronto was the guest speaker. Sixteen papers were given during the
two-day session.
Our deepest sympathy is extended to Dr. G. A. Davidson on the death of his mother.
Dr. FL J. MacKay has left Vancouver and is settling in Revelstoke.
We welcome Dr. S. E. Evans back to B. C. Dr. Evans has just completed a postgraduate course in London, England.
IV
At a recent meeting of the Chilliwack Medical Society the following officers were
elected for 1948-1949: President, Dr. R. W. Paton; Vice-President, Dr. G. A. Roberts;
Secretary-Treasurer, Dr. E. J. Wilford.
Dr. K. C. Boyce has recently taken up practice in Woodfibre.
Dr. C. P. Green, a new registrant in the province, is now associated with Dr. B. St.
John at Alert Bay.
Dr. G. M. Crawford is relieving Dr. A. J. Venables at New Denver for a short period
during the latter's holiday.
Congratulations are extended to the following doctors and their wives on their
recent good fortune: Dr. and Mrs. S. A. Creighton, a son; Dr. and Mrs. B. T. Dunham,
a daughter; Dr. and Mrs. A. M. Johnson, a son; Dr. and Mrs. J. A. Marcellus, a son.
REPRINTS
Owing to the scarcity of type metal, contributors of THE BULLETIN who require reprints of articles should advise the office of the
librarian within thirty days after publication. Arrangements are being made to keep the metal standing for this period and contributors
are asked to order their reprints before that period of time elapses.
Page 220

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