History of Nursing in Pacific Canada

The Vancouver Medical Association Bulletin: May, 1941 Vancouver Medical Association May 31, 1941

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 Tfhe BULLtopP.
of the
MAY, 1941
No. 8—
With Which Is Incorporated
Transactions of the
Victoria Medical Society
Vancouver General Hospital
%St Paul's Hospital
In This Issue:
NEWS AND NOTES-H- ||fr — '''^^^ —j --'   If-- '^^^^^214
SPECIAL CANCER SYMPOSIUM-J| §£ JjgL _^__^_„^_^ 225
SUMMER SCHOOL&JUNE 17th to 20th inclusive, 1941
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• The most rapidly assimilated form of iron
• Stable • Palatable
Modern medical opinion believes that
anaemias due to iron deficiencies respond best
to treatment with inorganic salts, preferably
in the ferrous state.
Recent medical literature'*' contains frequent
references confirming the superiority of ferrous
chloride over other forms of iron therapy.
Ferrous chloride is less toxic than other
forms of ferrous iron. It is suitable for use
in the hypochromic anaemia which develops
frequently in pregnancy due to the demands
of the infant on the mother, and unless an
adequate metabolism of iron is established
in the mother prenatally, the child may be
born with an iron deficiency and, in addition,
leave the mother anaemic.
The practical disadvantages of ferrous chloride
(instability and unpleasant taste) have been
overcome in Ferrochlor E.B.S. and the full
dose of ferrous chloride is always present
and in palatable form.
Ferrous chloride 16 grs. per fid. ox.
Plain or with Vitamin BI, 2,0001.U.
per ounce.
The liquid form permits a wide range of
dosage to satisfy the needs of every patient
from new-born infants to adults. Its pleasant
flavour makes this form particularly suitable
for children. Ferrochlor Liquid E.B.S. is
permanently stable.
Ferrous chloride 2^ g**. per tablet.
No. 338 plain or No. 338-A with
Vitamin Bi, 50 I.U. per tablet.
Where tablet form is preferred No. 338 and
No. 338-A provide ferrous chloride in permanently stable form in pleasantly coloured
and coated tablets.
Ferrochlor E.B.S. is available on prescription at all progressive pharmacies.
irl. Starkenstein, E.: Uber die Resorbierbarkeit von Eisenverbin*
dungen a us dem Verdauungskanal, Arch. f. exp. Path u. Pharm.,
1928, 127: 101.
2. Sullman, H.: Zur Frage der Eisenresorption, Biochem. Zeitschr.,
1931, 234: 241.
3. Lintzel, W.: Zum Nachweis der Resorption des Nahrungseisens
als Ferroion, Biochem. Zeitschr., 1933, 263: 173.
4. Reimann, F. and Fritsch, F.: Vergleichende Untersuchungen xur
therapeutischen Wirksamkeit der Eisenverbindungen bei den
sekundaren Anamien, Zeitschr, f. klin. Med., 1930, 115: 13.
c.f. also—Elvehjem, C. A. and Sherman, W. C.: Action of copper in
iron metabolism, J. Biol. Chem., 1932, 98: 309.
"The Therapeutic Action of Iron," by L. J. Witts, M.D., Manch.,
F.R.C.P., Lond. Professor of Medicine in the University of London
at St. Bartholomew's Hospital Medical School. The Lancet 1936—
1, 1, for further information on the action of Ferrous Iron.
fa<*'?' I
Published Monthly under the Auspices of the Vancouver Medical Association
in the interests of the Medical Profession.
Offices: 203 Medical- Dental Building, Georgia Street, Vancouver, B. C.
Dr. J. H. MacDermot
Dr. G. A. Davidson Dr. D. E. H. Cleveland
All communications to be addressed to the Editor at the above address.
Vol. XVn
MAY, 1941
OFFICERS, 1940-1941
Dr. W. M. Paton Dr. C. McDiarmid Dr. D. F. Busteed
President Vice-President Past President
Dr. W. T. Lockhart Dr. R. A. Palmer
Hon. Treasurer Hon. Secretary
Additional Members of Executive: Dr. Gordon Burke, Dr. Frank Turnbull
Dr. F. Brodie Dr. J. A. Gillespie Dr. G. H. Clement
Auditors: Messrs. Plommer, Whiting & Co.
Clinical Section
Dr. Karl Haig Chairman Dr. Ross Davidson Secretary
Eye, Ear, Nose and Throat
Dr. J. A. McLean Chairman Dr. A. R. Anthony Secretary
Pasdiatric Section
Dr. R. P. Kinsman Chairman Dr. G. O. Matthews Secretary
Dr. F. J. Buller, Dr. D. E. H. Cleveland, Dr. J. R. Davies,
Dr. A. Bagnall, Dr. A. B. Manson, Dr. B. J. Harrison
Dr. J. H. MacDermot, Dr. D. E. H. Cleveland, Dr. G. A. Davidson.
Summer School:
Db. H. H. Caple, Dr. W. W. Simpson, Dr. Karl Haig, Dr. J. E. Harrison,
Dr. H. H. Hatfield, Dr. Howard Spohn.
Dr. A. W. Hunter, Dr. W. L. Pedlow, Dr. A. T. Henry
V. O. N. Advisory Board:
Dr._W. C. Walsh, Dr. R. E. McKechnie II., Dr. L. W. McNutt.
Metropolitan Health Board Advisory Committee:
Dr. W. D. Patton, Dr. W. D. Kennedy, Dr. G. A. Lamont.
Greater Vancouver Health League Representatives:
Dr. R. A. Wilson, Dr. Wallace Coburn.
Representative to B. C. Medical Association: Dr. D. F. Busteed.
Sickness and Benevolent Fund: The President?—The Trustees. 1
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Ready for Prompt Use
First-aid stations and the medical departments of large industrial and commercial
establishments keep Antiphlogistine on
hand ready for immediate use.
Because of its osmotic, decongestive,
bacteriostatic and detergent qualities, physicians find it an application of eminent
merit in the treatment of injuries of the
soft tissues, such as burns, scalds, cuts,
abrasions, sores,  bruises,  sprains,  strains.
Sample on request
The Denver Chemical Mfg. Co., 153 Lagauchetiere St., W. Montreal
Total population—estimated _  272,352
Japanese population—estimated  8,769
Chinese population—estimated .  8,558
Hindu population—estimated . '  360
Rate per 1,000
Number       Population
Total deaths 308 13.3
Japanese deaths        3 4.0
Chinese deaths        9 12.4
Deaths—residents only    269 11.6
Male, 229; Female, 244.
Deaths under one year of age      14
Death rate—per 1,000 births .      29.6
Stillbirths (not included in above) _.       9
March, 1940
Scarlet Fever —
Chicken Pox	
Whooping Cough
Typhoid Fever _
Undulant Fever .
_- 13
__ 0
_ 1484
_ 302
_      10
 :  o
Tuberculosis  21
Erysipelas  3
Miningococcus Meningitis  3
Paratyphoid Fever  0
March, 1941
Cases   Deaths
April 1-15,1941
Cases   Deaths
West North        Vane.  Hospitals &
Burnaby  Vancr.  Richmond   Vancr.      Clinic  Private Drs.  Totals
Syphilis 0 0 0 0 18 24 42
Gonorrhoea 0 0 0 0 53 24 77
<<  A   "
Another Product of the Bioglan Laboratories, Hertford, England
Phone MA. 4027
Stanley N. Bayne, Representative
Descriptive Literature on Request
Vancouver, B. C.
Page 211 f ;*;*)'
J      M
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wS$y> active
oestrogenic, placental hormone
llf Liquid : .   .'mSki- Tablets
. . . convenient from the standpoint of
both physician and patient.
In the treatment of menopausal symptoms, dysmenorrhoea, menstrual migraine and premenstrual tension, the
therapeutic dependability of this natu-
raUy-occurring oestrogen is substantiated by an extensive bibliography.
Literature on request.
"Emmenin" does not induce nausea.
Biological and PltaAmacetUical GUemi&U
Founded 1898 . . . Incorporated 1906
GENERAL MEETINGS will be held on the first Tuesday of the month at 8 p.m.
CLINICAL MEETINGS will be held on the third Tuesday of the month at
8:00 p.m. Place of meeting will appear on the Agenda.
General meetings will conform to the following order:
8:00 p.m.—Business as per Agenda.
9:00 p.m.—Paper of the evening.
The following is a partial list of instruments which I am offering for sale at
greatly reduced prices:
Artery forceps. Uterine packing forceps.
Abdominal retractors. Vaginal retractor.
Axis traction obstetrical forceps. Needle holders.
Pelvic calipers. Suture carriers. Up
Rectal speculum. Dilating sounds.
Vaginal speculum. Dilating instrument.
Folding operating table, etc., etc.
The above can all be seen at my office.
:#     I DR. BENJ. H. HARRY ^jf'    ' M   H
631   BIRKS BUILDING Phone PAcific 2850
Both are claimed to be allergic.
Both suggest mineral deficiency and
impaired elimination. Clinically,
each is symptomatically improved
by the oral use of
which combines the therapeutic
actions of iodine, calcium, sulphur,
and lysidin bitartrate — a potent
eliminator of endogenous toxic
Since the best evidence' is clinical
evidence, write for literature and
sample. L_1<f
Canadian Distributors
350  Le Moyne   Street,  Montreal
Nlttttt   $C
2559 Cambie Street
, B. C.
Page 212 im
(Vitamin B, Hydrochloride Squibb)
Colored *«<*<><«*
10 mS- ^^
ofl00 and 1000
Bottles of |      ^^^
Microcaps Thiamine Hydrochloride Squibb thus
offer the clinician Vitamin Bi for oral administration in a wide range of dosages. Attractive
in appearance, easy to swallow, they give distinction to your prescription, yet they cost your
patients no more than the tablets.
For literature write 36 Caledonia Road, Toronto/ Ontario
*"Mierocaps" is a registered Trade Mark of E. R. Squibb & Sons of Canada Ltd.
E-R:Sqjjibb & Sons of Canada. Ltd.
M Last year, about this time of year, we seem to remember writing something in this
column about the forthcoming Summer School. At that time, the horizon looked dark
and threatening: ominous rumbles and flashes broke forth now and anon: but we felt
then that our job, like that of the bridge-builders in Kipling's story, was to "stand by
the day's work, and await further orders." Just how really appalling the danger was at
that time, we have since come to know: just how much worse it may be, and it can
hardly be much worse without being catastrophic, is still in the womb of the future:
the principle remains the same—we must carry on with the work at hand.
And the Summer School comes next month, June, and we have the programme
before us, and are printing it in this issue. We think it is splendid, and that the
work of the Summer School Committee is beyond all praise. Theirs has been a specially
difficult job this year, and they have done it most excellently well. They have a list of
speakers, whose names assure us that we shall have a Summer School at least well up to
the usual high standard we have come to expect.
Another, and as we think a wise move on the part of the Committee, has been to
reduce the fee from $7.50 to $5.00. These are difficult days from the financial angle,
and this reduction will make it possible for many men to attend the School, who have
felt the extra $2.50 rather a tax on their resources. (Mind you, we think that even $7.50
is ridiculously cheap for what one gets.)
So we urge all our readers to roll up, and take advantage of this Summer School.
There is no way in which we could possibly invest to such advantage the time and
money involved. To those readers outside Vancouver, we would add our welcome and
invitation to attend: and if they can possibly so arrange their affairs as to take in this
year's Summer School, we are sure they will feel it well worth while. Date—June 17-
20, inclusive.
And then, right after this, comes the Annual meeting of the Canadian Medical
Association, at Winnipeg. This extends from June 23-27 inclusive, and just gives nice
time to get there after the Summer School in Vancouver. The programme is published
in the C. M. A. Journal, of course, and is a very full one: all specialties are amply provided for. In these days, when travel to the South is so restricted, and, one may add, so
expensive, it is good to realise that there is ample opportunity given to Canadians in their
own country, to keep up with the latset and best work in medicine.
WINNIPEG, June 23 rd to 27th.
Please notify Dr. Thomas if you are travelling by rail.
Special cars are contemplated.
Page 213
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Our best wishes to Squadron Leader D. Murray Meekison, who is leaving for
England to do Orthopaedic surgery with the R.A.F.
Dr. G. F. Strong has been doing post-graduate study in Eastern centres and attending
special meetings of the College of Physicians. While in Toronto, Dr. Strong conferred
with the Central Committee of the Canadian Medical Association on the Programme of
the 1941 Annual Meeting of the British Columbia Medical Association, to be held in
Vancouver in September.
Dr. D. S. Munroe is leaving for Ontario to join the Air Force.
Dr. Dallas Perry has closed his office and is taking up residence on Salt Spring Island.
He leaves practice with the good wishes of all his colleagues and a large clientele.
Dr. C. E. Gould, who was associated with Dr. Lyall Hodgins, left for Saskatchewan
to join a Hospital Unit.
*{• %• * sfr
Dr. C. H. Gundry and Dr. A. .R J. Boyd of the Metropolitan Health Committee
have entered the R.C.A.M.C.   Dr. H. G. Baker joined the Navy.
The passing of Mrs. H. A. Macdonald is noted, and sympathy extended to Dr.
Macdonald in his bereavement.
Dr. D. W. Moffatt and Miss E. M. D. Gillies, daughter of Dr. B. D. Gillies, were
married recently in Vancouver.
Dr. E. B. Trowbridge of Vancouver was married to Miss F. E. Tidmarsh of Nova
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Dr. and Mrs. S. E. C. Turvey are receiving congratulatoins on the birth of a
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Dr. and Mrs. W. A. Morton are receiving congratulations on the birth of a son.
When Drs. E. J. Curtis, J. R. Naden and M. W. Thomas were en route to Qualicum
for the meeting of the Upper Island Medical Association, they visited Lieut.-Col. F. W.
Lees, who is very busy with the medical arrangements in the new hospital. Major R.
L. Miller, Major M. McC. Baird, Capt. Douglas R. Learoyd, Capt. G. L. Stoker, Capt.
J. K. Kelly were very busily engaged in Board work. The hospitals being established
are well-equipped and should provide ample opportunity for the medical officers to do
excellent work.
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Dr. T. W. Walker, Superintendent of the Royal Jubilee Hospital, is showing continued improvement following a rather serious operation.
Dr. and Mrs. A. N. Beattie of loco are receiving congratulations on the birth of
a daughter.
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Dr. G. McL. Wilson, now associated with the medical group of Trail, was married
in Vancouver to Miss D. G. Vickery.
Page 214 Dr. and Mrs. W. J. Knox of Kelowna were visiting in Vancouver and Victoria.
*P *T 3r f
Dr. Sidney Evans and his wife, Dr. Ella Cristall, were down from Tofino on a visit
to Vancouver.
*       *       *       #
Drs. W. T. Barrett, G. B. Bigelow, F. M. Bryant, George Hall, M. J. Keys, J. W.
Lennox, Thomas McPherson, E. L. McNiven were over from Victoria on the occasion
of the visit of the Seattle golfers on May 1st.
Dr. J. P. Ellis of Lytton visited the office.
Dr. W. O. Green of Cranbrook called at the office when last in Vancouver.
Lieut. B. H. Cragg of New Westminster is doing eye work in a hospital in England,
and Major Andrew Turnbull, formerly Radiologist of St. Joseph's Hospital, is with
the same unit.
Capt. Rocke Robertson, nephew of Dr. Hermann M. Robertson of Victoria, is doing
special work on an organized team which is dispatched from one bombed area to another
in Great Britain.
The following members from this Province attended the Sixth Annual Spring Post-
Graduate Course of the Oregon Academy of Ophthalmology and Oto-Laryngology held
in Portland, March 31st to April 5th: Drs. Harold Brown, G. H. Francis, R. Grant
Lawrence, J. A. McLean, M. W. Paton, J. A. Smith of Vancouver, N. C. Cook of Victoria, A. W. Bowles of New Westminster and Wilfrid Laishley of Nelson.
Dr. J. Stuart Daly of Trail has left for the East and will do post-graduate work in
Dr. and Mrs. H. R. Christie of Rossland were visiting in Vancouver.
Dr. and Mrs. H. A. L. Mooney of Courtenay are to be congratulated on the birth
of a son.
Dr. W. H. White of Penticton attended a medical meeting in Spokane.
Major S. G. Baldwin, who has been stationed at Vernon, is back with his Unit, No.
13 Field Ambulance.
Dr. W. G. Lyall of Winnipeg, who is associated with the Canadian National Railway,
was in Kamloops examining employees. Dr. Lyall will be remembered by many as Major
Lyall serving during the last war.
Capt. W. M. G. Wilson has been in Kamloops examining recruits.
Fourth year bacteriological student, University of British Columbia, available for four months' laboratory work with physician or small clinic. References: Phone KErr. 1026.
Page 215 : a*
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New Books Received in Library
Transactions, Section of Ophthalmology, American Medical Association  (91st Annual
Session), 1940.
Medical Clinics of North America—Symposium on Legal and Industrial Medicine, March,
Electrocardiography in Practice, 1940, by Ashton Graybiel and Paul White.
Pathogenic Microorganisms, 11th ed., 1939, by W. H. Park and Anna W. Williams.
Principles of Hematology, 2nd ed., 1940, by Russell L. Haden.
Published by Interscience Publishers, Inc.
This little pocket-size book of 296 pages is a compilation of laboratory technique
for the biochemical tests which are used in clinical medicine. This includes tests on the
blood, urine, faeces and gastric contents. No attempt is made to deal with the theoretical
application of the tests, and the author confines herself strictly to a clear and detailed
description of the exact laboratory procedure, including the preparation of all the necessary reagents in each test.
The book contains a number of clarifying illustrations, and useful tables. A feature
is the fact that for each of the tests there are given leading references to papers dealing
with the dvelopment of them.
This book does not pretend to be a complete laboratory manual in the sense of including such common clinical tests as blood counts, microscopical observations on the urine,
stools, etc. Within its field, however, it appears to be very complete and up to date, and
includes, for instance, detailed descriptions of the estimation of sex hormones and vitamins in body fluids.
This manual should be a highly useful reference in any hospital laboratory and in any
other clinical laboratory where these tests are required. R. A. P.
Vancouver Medical Association
The Publications Committee has little new to report for 1940—we have made no
changes in the setup which we adopted over a year ago. Our various sections have
co-operated loyally in providing material, and in this regard we must especially thank
Dr. M. W. Thomas, Executive Secretary of the B. C. Medical Association, who has made
the collection of personal news and notes from all parts of the Province his especial care,
and as we believe you will all agree, has done it extremely well. His extensive and
intimate acquaintance with all the medica population of British Columbia makes him
especially fitted for the job.
We have ended the year with a small margin of profit on operation. The cost of
publication has been fairly heavy as on many occasions we have'exceeded our standard
size—but our advertising income has grown steadily. A glance at the advertising pages,
and we believe a close study of them will repay every man, will show that a very large
proportion of our advertising has been obtained from firms whose operations extend all
Page 216 ver Canada, and very often the United States as well. This speaks well for the esteem
i which the Bulletin is held as an advertising medium. We ask our readers to do all in
heir power to show these friends of ours that they appreciate their presence in our local
ublication's advertising pages.
We have an increasing number of exchanges and are constantly being asked to send
he Bulletin to places far away. For instance—from Brazil, Argentina and Mexico—
se have received requests for exchange privileges. Just how the Bulletin got to these
.laces is a mystery, but it evidently did.
Last year's Summer School papers were collected and handed in, and have been edited,
fhey have not been put in supplement form for various reasons. One was that the
ctual work of editing them, although shared by all the members of the Publications
"ommittee, has been a gargantuan one, and was undertaken very late. Another is
hat the Committee felt rather loath to embark on an enterprise which would have cost
t least $300, when only some hundred men signified their willingness to buy the Supple-
tient. We have therefore thought it best to give up the idea of publishing these papers
a collected form. Many men, however, had sent in a dollar to pay for a copy, and we
re considering the best way to deal with the situation.
It has been suggested that we write to each of these men, thanking them for their
Qterest, and offering to do one of two things according to their wishes in the matter,
either (1) to return the money or (2) to canvass the profession with a view to securing
ubscriptions for a supplement to be made up of this year's Summer School papers. If
:nough of these can be secured, the previous subscriber's dollar could be applied if he so
vished, to the purchase of the 1941 Supplement.
The success of the Bulletin from a financial standpoint is mainly due to the untir-
ng effort on our behalf of our Business Manager, Mr. G. Macdonald, of the Roy Wrigley
Minting Company. He has unique opportunities for securing advertising, and has
tlways done his very best for the Bulletin. He has increased our volume of advertising
:onsiderably and so enabled us to indulge periodically in larger issues.
The Committee has held regular meetings, and has discussed these and other matters.
Vlay I, as Editor, express my personal thanks to Drs. Cleveland and Davidson, who have
vorked with me in such a loyal and friendly spirit.
I beg to move the adoption of this report.
J. H. MacDermot.
Seven General Meetings were held during the year, as well as one Special Meeting in
:tober, which was called for the purpose of hearing a lecture by Dr. Hamilton Montgomery of the Mayo Clinic. Papers on an interesting range of subjects were given by
members at the regular meetings, and on the March programme we were privileged in
(laving Dr. Henrik Dam of Copenhagen, as guest speaker. Following the business meeting on April 1st an open session on Cancer was held. This was arranged by the Committee on Cancer, B. C. Medical Association, and proved to be a very interesting programme.
Total membership of the Association, including applications for membership which
are pending, is 302.   This number is made up as follows:
Life Members   11
Active Members  |  241
Associate Members  ..  4 0
Privileged Members   10
17 new Members were elected during the year.
Page 217
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The Association has lost four members by death since the last Annual Meeting:	
Dr. J. P. Bilodeau, Dr. W. S. Turnbull, Dr. W. F. McKay, Dr. W. Y. Corry.
The Average Attendance at General Meetings was 70, which was an increase of 14
over the previous year.
The Executive Committee held 16 Meetings during the year.
Respectfully submitted,
R. A. Palmer, M.D., Honorary Secretary.
The President, Vancouver Medical Association.
During the past year the Trustees as such and in the capacity of Sickness and Benevolent Committee have held several meetings.
Expenditures of $175.00 from the Sickness and Benevolent Fund were made since
the last report and further commitments are already allocated for the fiscal year 1941-42.
All current assets of the Sickness and Benevolent Fund have been expended and capital
investment must now be drawn upon. It is gratifying that the Executive has seen fit
to make a levy for the Fund this year and if dues are promptly paid realization by sale of
invested securities may be obviated.
Details of the moneys in various funds have already been given by the Treasurer.
Among them are Corporation of Burnaby bonds to the par value of $1500.00. During
the past year a Refunding Bill has been enacted enabling the Corporation of Burnaby to
alter the capital structure of its indebtedness. In the new set-up the old bonds can be
exchanged for new ones of the same par value adted January 2nd, 1941, and maturing
January 2nd, 1966. They will bear interest of 2^4 per cent for the first five years, 3^4
per cent for the next ten years and 4 per cent for the remaining ten years. Provision
for adequate sinking fund is also to be made. One thousand dollars of these bonds are
in the Sickness and Benevolent Fund. Already there is an appreciable advance in the
market value of these securities.
On account of his time being fully occupied with military duty, Dr. F. W. Lees
tendered his resignation and the Executive with its customary savoir faire made the
excellent appointment of Dr. Geo. H. Clement in his stead.
The Trustees wholeheartedly approve the action of the Executive in assessing a Sickness and Benevolent Fund levy this year. If the members at large could be cognizant of
the enormous good disbursements from this Fund do I am sure their natural feelings of
generosity and human kindness would insist on a much larger levy being made.
All of which is respectfully submitted.
Signed on behalf of the Trustees.
Frederic Brodee.
I    SECTION, 1940-1941
Mr. President:
The Eye, Ear, Nose and Throat Section of the Vancouver Medical Association has
held monthly clinical meetings in the evening at the Vancouver General Hospital. The
Section also has had several noon hour luncheon meetings.
The loss of Doctors Day, Leeson, Large, Galbraith and Mustard to the country'?
services is keenly felt by the Section.   We hope that we shall soon welcome them back
Winter and Spring post-graduate courses in Los Angeles and Portland were very
popular and were well represented by the local Section.
Respectfully submitted,
J. A. MacLean, M.D., Chairman, E., E., N. and T. Section.
A start has been made on the gathering and arranging of material bearing on the
listorical activities of the Vancouver Medical Association, with a view to making them
ivailable, in concise form, either for reference or for publication at some future date.
Doctors Keith and Pedlow kindly consented to assist on the Committee.   The work
b/ill be continued during the ensuing year.
G. E. Kidd, Chairman, Historical Committee.
Mr. President:
During the past year the Section has met regularly once each month. At present we
u*e making arrangements for the expected meeting of the North Pacific Paediatric Association, here, in Vancouver, on June 21st.
Respectfully submitted,
R. P. Kinsman, M.D., Chairman.
Books Added to Library:
General Collection:
66 new books at a cost of 1 $   365.33
23 Gifts
Nicholson Collection:
3 Books Added a cost of        11.68
TOTAL—92 Books Added, at a cost of $   377.01
Nicholson Fund:
3 Books purchased at a cost of $11.68, leaving a balance.in this fund
of $118.22.
Medical Journals:
*70 Journals are subscribed to at a cost of $   750.06
37 Journals are received as gifts.
107 Total Number of Journals received in Library.
123 Volumes bound at a cost of —     335.65
Other Expenses:
Boxes for Storing Books $20.38
Subscription to Medical Library Association  16.83
New Journal Rack  43.50
Book Plates      9.72
Reference Cards   10.26
Metal Book Supports 1 - i - %     4.50
Sundry Expenses   17.63
Total Expenditure 1 —*-$ 1,585.54
Ine increase in the cost of journal subscriptions is largely accounted for by the fact that a 10 per cent
War Tax is now imposed on all U. S. journals.
In the past year various matters have been dealt with by the Library Committee:
(1) The Library Rules have been revised and copies sent to all members of the Association.
Page 219
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(2) The Librarian has been faced with the fact that books and journals have been
taken from the Library without being signed for, and other books and journals
which have been signed for have not been returned promptly. The Committee has
tried to bring this to the attention of the Association in various ways, and the
revised Library rules were designed with a view to correcting this condition.
(3) The Committee is endeavouring to build up a body of literature on Military Medicine and Industrial Medicine. The need for the latter is now becoming more
evident, owing to the establishment of war-time industries in British Columbia.
(4) It will be noticed that a greater number of publications is now being bound than
formerly, which we hope will increase the usefulness of the Library.
(5) During the year a sub-committee met a number of times for the purpose of clearing out obsolete texts from the shelves, and some 300 books were transferred to
the basement for storage or to be destroyed.
(6) The Committee wishes to emphasize that there is a very pressing need for further
shelf space for books and bound journals. This matter has been referred to the
attention of the Executive of the Vancouver Medical Association. We trust that
a solution to this problem will be found in the near future.
(7) We acknowledge with thanks gifts to the Library from the following:
Doctors J. H. MacDermot, D. E. H. Cleveland, W. N. Kemp, Gustav Schilder, and
All of which is respectfully submitted.
J. E. Walker, M.D., Chairman, Library Committee.
Dr. K. J. Haig, Chairman of the Clinical Section, reported seven meetings during
the year—three at the Vancouver General Hospital, and three at St. Paul's, alternately,
with one at Shaughnessy.
He stated that there had been some difficulty during the year in securing members
to present cases, and he proposed the formation of a committee in each hospital to prepare suitable programmes.
Mr. President and Members of the Vancouver Medical Association:
I have the honour to submit the Auditor's Report. A copy will be placed in the
reading room where it may be examined by members at their leisure.
Each of the trust funds show a substantial savings account available for the purpose
of the trust.
That of the Sickness and Benevolent Fund was getting rather low and a levy of
$1.00 per member will be made in order to re-establish the account as authorized by
the Executive Committee by virtue of Amended By-law No. 4.
The increase in membership during the year has been reflected in an increase in our
income from annual dues.
This, however, is likely to diminish during the coming year owing to the number of
our members on Active Military Service whoes dues will be remitted during the period
of their service.
Our income for the year from all sources totalled $5,501.80. Expenditures for the
year totalled $4,471.12, leaving a credit balance for the year of $1,030.68 (includes
$150.00 paid in advance dues).
This excess of income over expenditure is chiefly made up by the $600.00 received
from the Medical Relief Committee. Interest on securities of $194.14 and a small balance
of $20.16 from the Bulletin, making a total of $814.30.
In view of the absolute necessity of providing increased Library accommodation in
the immediate future this addition to our liquid resources is most opportune.
Page 220
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For the information of the Society and the Library Committee when considering this
^question of increased accommodation, I may say that the present worth of the investments back of our General Fund is $5,644.16.
We have a cash balance of $4,628.87 against which is the Summer School Fund of
$3,201.69, leaving our available cash, $1,427.18, which includes the balance for the
year referred to above of $1,030.68.
Estimating our income for next year, we have 237 active members (excluding four
in process of election) of whom 14 are on military service, and one in a sanatorium,
leaving 212 liable for annual dues. There are 40 associate members of whom three are
on military service, leaving 37 liable for dues. Income from annual dues will be $4,425.00
or less if more members volunteer for service with the Red Cross, Army or Navy.
Interest on investments of $194.00, making a total of $4,619.00. Expenditure will
approximate the same as the present year, apart from any increases due to increased
Library accommodation, or $4,471.00—leaving a credit balance of $148.00. To this
there may be added the $600.00 received from the Relief Committee should the present
set-up be continued and profit, if any, from the Bulletin.
In view of the above considerations I would suggest that the Library Committee
limit their expenditure for new books and journals to twelve or thirteen hundred dollars
for the coming year.
All of which is respectfully submitted.
W. T. Lockhart, Honorary Treasurer.
E. J. Curtis, M.D.
To determine the amount of fluid required by infants and the methods of administration certain facts must be considered. These patients are not to be regarded as small
adults, for they have a relatively higher production of heat and therefore require three
times as much fluid as an adult. The infant retains two per cent of its intake of fluid
and this reserve supply of water is largely dependent on the intake of sodium chloride
and carbohydrate. Daily requirement of water in an infant is 2 to 2l/z ounces per
pound; in a child of six years it is 1 ounce per pound. Because these patients are more
hydrolabile these quantities must be doubled in the presence of dehydration. Negative
balance of water results from innumerable causes but is always accompanied by a marked
diminution of kidney function due to the general decrease in volume of blood and
capillary stasis. Hippocrates said, "Of sucklings that pass much water are least inclined
to illness."
The existence of thirst and a specific craving for sodium chloride make the oral
administration of fluid the ideal route. This method of giving fluid is often neglected.
Oral fluids can be given to combat dehydration, acidosis, and alkalosis. All methods of
coaxing the child to drink should be exhausted before resorting to one of the parenteral
routes.  A few of these methods are:
(1) Gavage, which is most useful;
(2) Nasal drip, which is rather uncomfortable;
(3) Proctoclysis, which is riot efficient unless tap-water alone is carefully used;
otherwise a rapid evacuation occurs and it is felt that glucose solution produces distention.
Page 221
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1 Brill
Parenteral methods are valuable when a rapid administration of fluid is desired, as
in diarrhoea or vomiting or in fevers. It is also indicated to restore the value of blood
or when certain medications are necessary. The total fluid-intake by any or all methods
of administration must not exceed 150 to 190 c.c. per kilo body-weight per day.
The subcutaneous route is most often used in the following order of frequency:
Normal saline, Ringer's solution, isotonic sodium racemic lactate, and either isotonic
(5.5%) or hypotonic dextrose. It is often noted that if delayed absorption follows an
interstitial injection of normal saline, the administration of slightly hypertonic (10.0%)
glucose intravenously will speed up the utilization of the saline.
The intramuscular method of giving fluid is usually reserved for small amounts of
blood and certain medications.
Normal saline and Ringer's solution have been injected intraperitoneally in the past
in amounts of 150 to 300 cubic centimetres every six or eight hours after first ascertaining that the bladder is empty, but the method is only applicable to infants. Citrated
blood and sulpharsphenamine have been administered in this fashion, but the method
has largely gone out of use.
Intravenous injection of the various fluids is common practice. It should not be
necessary to open the vein except rarely. Injection into the sagittal sinus should be
regarded as potentially dangerous. Ordinary precautions such as rate of administration,
temperature control, and careful preparation of the fluid must be observed. Normal
saline or Ringer's solution are most commonly used at a rate of 20 to 25 c.c. per kilo
body-weight every5 six to eight hours. Blood is very useful when there has been a loss
of plasma.
In acidosis a number of potentially alkaline solutions containing sodium lactate can
be given by one of the various methods already mentioned.    If 1 in 6 sodium lactate,
60 c.c. per kilo body-weight, or Ringer's solution fortified with lactate, 100 c.c, is
given, it will be found that the alkaline reserve is elevated 35 volume per cent. Sodium
lactate is of no value if the circulation is not sufficient to cause oxidation. Sodium bicarbonate solution has been given intravenously in severe acidosis with relief. One gram
of sodium bicarbonate raises the carbon dioxide 40 volume per cent.
Alkalosis as a result of hyperpnoea, pyloric or other intestinal obstruction, or excess
alkali administration, is relieved by the administration of saline by any route. Hydrochloric acid with the saline is indicated when the carbon dioxide is 90 volume per cent
or over. It is well known that starvation or toxaemia may convert an alkalosis into an
acidosis in children.
Other substances given parenterally include calcium chloride, magnesium sulphate,
hypertonic and hypotonic saline or glucose and acacia. These have their special indications and at times are valuable. Transfusion of blood is not used so frequently nowadays. In lymphatic leukaemia the use of blood seems futile; in septicaemia it may be
of value on occasions but the diluting effect on the antibodies is a disadvantage. Perfusions of immune blood to increase immunity are logical but transfusions with simultaneous exsanguinations are of no known clinical value. Transfusions are helpful in
chronic severe anaemias.
One factor which is at times overlooked is the possibility of injury to the adrenal
cortex, particularly in excessive burns. In these patients retention of water occurs in
extravascular depots and the administration of adrenal cortical substance assists inj
establishing the normal fluid exchange. ■
Page 222
. i ii* I*—
British  Columbia  Medical  Association
(Canadian Medical Association, British Columbia Division)
President  -Dr. Murray Blair, Vancouver
First Vice-President j Dr. C. H. Hankinson, Prince Rupert
Second Vice-President Dr. A. H. Spohn, Vancouver
Honorary Secretary-Treasurer. Dr. Walter M. Paton, Vancouver
Immediate Past President Dr. F. M. Auld, Nelson
Executive Secretary Dr. M. W. Thomas, Vancouver
Formerly the emphasis was upon kidney damage in pregnancy: today we tend more
m consider the importance of blood pressure. Common pressures in pregnancy are 100
Jo 115 and the upper limit of normal is 130-135/70. A rise above this figure is usually
[he earliest evidence of toxaemia. An "early warning rise" may occur as early as the
third week, followed by a prolonged interval of normal, and then by a permanent rise,
klso, pressure may rise up to six weeks after delivery.
It used to be thought that chronic nephritis was the sequel in a large percentage of
cases after pre-eclampsia and eclampsia. During the past decade emphasis has been placed
Instead on vascular injury as the residual lesion: probably chronic nephritis is a rare
result if it occurs at all.
An elevation of blood pressure raises the question, "Is it a case of essential hypertension complicating pregnancy or is it due to pre-eclamptic toxaemia?"
Points in Diagnosis as Follows:
Essential Hypertension Complicating Pre-Eclamptic Toxxmia
I.   Previous history of hypertension,
p.  Earlier rise of B.P.—usually from the
S.  Higher B.P.
k.  B.P. remains high in spite of rest,
p.  Albumen often absent,
p.  Cardiac enlargement often.
Prognosis and Treatment of Essential Hypertension in Pregnancy
Many can go to term or viability. In some, the hypertension is aggravated by pregnancy, but often only temporarily. Probably the ultimate prognosis in most is unaffected
by pregnancy and they go along the same course regardless.
There are two special dangers (these apply to toxaemic cases also):
(a) Foetal death in utero; |
(b) Accidental haemorrhage.
Most moderate cases can be carried to viability if oedema and albuminuria can be
controlled. These need rest, sedation and termination of pregnancy after 36 weeks to
avoid foetal death.
In pre-eclamptic toxxmia, prognosis depends very greatly on early diagnosis and
treatment. When blood pressure first rises about 130-135/70 it should be an indication
jfor reity restricted diet and more frequent examinations.
The incidence of resultant hypertension is more dependent upon duration than upon
[the intensity of the toxxmia: hence the importance of induction of labour before term
m incompletely controlled cases.
Page 223
Permanent rise is  usual before the  20th
B.P. usually responds to rest and diet.
Albumen usually present.
■  i
i  .
RrUf Ml
ilif 4
• ■■• r
*f ill
Comparison of Plans for
Medical Care for Information of Doctors
Insurance Companies
Lay Associatm
Requirement-r^Qroup  of
70% of 10-20  (minimum
of 9)
60% of 21  and over
75%—50 and over (minimum of 50)
Individuals accepted
number in a group!
Medical Care:
In Office, Home or Hospital—
Consultations, X-Ray and
Diagnostic Aids
None   except   X-RI
to   $25.00)
Surgical Care
Insured paid  on Schedule
up to $150.00
Member paid up to j
Hospital Care:
(1) $3.00 room
(2) Operating Room
(3) X-Ray
(4) Laboratory
(5) Anaesthesia
(6) Medicines and Dressings
21 days one illness
i                  Paid
70 days one disability
J    (3)   Up to $15.00
I   (5)
$25.00 a week fori
(2)   Up to $25.00
(3)  Up to $25.00
(5)  Up to $25.00j
Nursing—Outside Hospital
$25.00 a week for
Paid after  10  months
Up to $50.00  for doctor
paid  insured—14  days in
$50.00  to member
$500.00 for 12-month
period  per each person
Dependent—Hospital $600
Surgical $450
$500.00   per  famil
or Certificate for
Waiting Period—Sickness
6 months except  $50.00
paid from 1st day
90 days
Monthly Cost:
Employee and wife
Employee, wife and children
Med. and
Surg.        Hosp.       Total
$1.00        $ .50        $1.50
2.50           1.25           3.75
3.50           1.75           5.25
or 1.00 and .50 each person
Surgical    Hospital      Total
$ .40         $ .50         $ .90
1.10           1.17           2.27
1.80            1.50            3.30
Maternity, Extra:
.60             .45            1.05
3.00 or 25c for ;
Registration Fee:
Each Employee
$7.00 and adjusted
Liable for Assessment
Plan   developed   and   approved   by   Medical   Profession,    who    are    represented   on  Board.     Secretary   bonded   for   $5,000.
Administration  costs  cannot exceed  10% of dues.
Under  supervision  of Insurance Acts.    Agents licensed and bonded.
Services   underwritten  by
Medical Profession of British Columbia.
Ample—Deposits  required
with Government
No information
a j>J»»
The above table is published for the information of our members to illustrate the di
between a comprehensive service with early attention and treatment and catastrophic plan
Please retain it for reference.    Doctors are being asked for their opinions on the rr
various plans.
Complete medical care is desired, but many persons do not appreciate the difference
plans for complete medical care and those providing limited service.
Page 224 1 ifl
Tuesday, April 1st, 1941
Opening Remarks by Chairman, Dr. D. F. Busteed
It may be remembered that some 10 or 12 years ago, under the energetiq leadership
F the late Dr. Mason, a Cancer Section was formed in the Association and continued
[;tive and did valuable work for several years until its activities were taken over by the
fewly reorganized B. C. Medical Association, and quite rightly so, because cancer work
organized on a Dominion-wide and Province-wide basis now, and as far as I am aware
pere is no definite place for the Association's work in that programme.   But one thing
le can do, and should do, is to co-operate in every way possible and show the liveliest
iterest in all work undertaken.
This meeting is an example of a very practical type of meeting—a meeting of the
incouver Medical Association in which the programme is arranged by the Cancer
pmmittee of the B. C. Association. Being Province-wide, it was thought wise to hold
lie meeting open to all members of the profession and we are pleased to welcome tonight
number of men from outside points.
With these few words of explanation and introduction, I will call on Dr. H. H.
|.   Cancer Organization: j|
Dr. H. H. Millburn.
Ir. President and Ladies and Gentlemen:
I had the good fortune to attend the Second Annual Meeting of the Pacific North-
rest Medical Association in Spokane, Wash., in 1922, and to hear the late Dr. Blood-
ood of Baltimore give a series of lectures on Cancer. He spoke on pre-cancerous
isions, early diagnosis, the importance of biopsies, and other phases of cancer, and
articularly stressed radical removal of suspicious growths—better to remove many
mocent growths than miss a single malignant one.
One can safely say that Dr. Bloodgood was a pioneer in this field, and by his vigorous
fforts the campaign against cancer was greatly strengthened, particularly in North
Lmerica. Today cancer is one of our major health problems in which both medical
nd lay interests are actively involved.
What are we doing here in British Columbia in this regard?
In answer to this I refer you to the May, 1939, issue of the Vancouver Medical
lssociation Bulletin. There you will find a very excellent and comprehensive
eport by Dr. Ethlyn Trapp on The Department of Cancer Control of the CM.A.:
lso one by Dr. B. J. Harrison on the B. C. Cancer Institute, and one by Dr. A. Y.
tcNair on the Canadian Society for the Control of Cancer. These three organizations
re in the field of cancer control here, are very active, and are doing very considerable
ood, I would say. Dr. Wilson will probably tell us about the activities of the B. C.
^ancer Institute and I shall not say more, except to mention that the formation of the
>. C. Cancer Foundation, the parent body of the Institute, was begun in the Cancer
Pmmittee of the B. C. Medical Association in the spring of 1935.
The Department of Cancer Control of the Canadian Medical Association and the
Canadian Society for the Control of Cancer were created by the C. M. A. in 1937,
argely through the efforts of Dr. J. S. McEachern of Calgary, who was then chairman
f the Study Committee on Cancer of the C.M.A. Some $14,000 per annum was
Hotted to the C. M. A. by the Trustees of the King George V Jubilee Cancer Fund of
Page 225
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4 •
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i i^ii.
Canada to develop these two organizations, one for the education of the medical profession and the other the education of the laity. Cancer committees of the various provincial medical organizations became part of the Department of Cancer Control of the
C. M. A. Although the war has considerably hampered the activities of this body of
late, nevertheless it has accomplished a good deal since its inception and is still doing
valuable work. The "Hand Book on Cancer" has been published and sent to every
medical practitioner in Canada. It is a very handy and instructive work and medical
men generally have expressed their appreciation of its value. The creation of canctr
study groups in hospitals is part of the programme of this department, also the institution of a system of reporting cases and the collection of data that undoubtedly will be
valuable in the fight against cancer. Speakers on cancer subjects are being provided at
provincial meetings, and special articles on the subject appear in the Journal of the
C. M. A.   Time does not permit me to mention other activities of this body.
As to the Canadian Society for the Control of Cancer, I wish to say that it is an
active body, endeavoring to do its part in the matter of Cancer Control. Here in
British Columbia we have procured a number of movie films which have been in very
considerable demand and are being shown in many centres throughout the Province at
meetings that are very well attended. Last Thursday night this Auitorium was fillec
to capacity and all available extra chairs were needed to accommodate the people that
attended a meeting of this society. I feel that this education of the public is very
important in any plan of Cancer Control; people must know the danger signals and bi
encouraged to respect them im improvement is to be made in our statistics in the treatment of cancer. The Canadian Society for the Control of Cancer should receive oui
whole-hearted support.
Thank you, Mr. President.
Dr. Wallace Wilson: Mr. President, Ladies and Gentlemen: Dr. Milburn ha:
given you one or two points in connection with the history of the B. C. Cancer Insti
tute and I would like to give you one or two more. Dr. Milburn has stated that th(
B. C. Cancer Foundation is largely the result of the original activity of the B. C
Medical Association, and that is quite true. Prior to the opening of the B. C. Cancel
Institute in November, 1938, the B. C. Cancer Institute, knowing that the B. C. Medica
Association had been very active in causing the foundation of the B. C. Cancer Insti
tute, approached the B. C. Medical Association and asked that they nominate a panel ol
names, out of which the active staff should be drawn and should be drawn withou
exception. That was done and the B. C. Medical Association sent up to the Institute :
panel of names from the Association of men who had signified their co-operation in wor
of this kind. We also sent up the names of 29 or 30 men scattered throughout thi
province who were to be appointed as honorary consultants on that staff. This was alsi
done. We had certain negotiations with the Institute prior to our accepting the respon
sibility of sending up a panel of names. We asked, among other things, that a repre
sentative from the B. C. Medical Association should be appointed to the Board o
Management of that Institute. The Board of that Institute complied with that and ther
is now present on this Board a representative of the B. C. Medical Association. So tha
you can see that from the start and at the present time the B. C. Medical Association i
very intimately connected with the B. C. Cancer Institute.
This latter I think you all know very well—as to what its activities are at the presen
time, how much it can do and how much it cannot do and what it hopes to do in th
future. We have much to thank the Vancouver General Hospital for at the presen
time. We hope that we shall not always be beholden to that institution. At the presen
time the house in which we work is given rent free, is serviced by the hospital, an
in the Institute at the present time all that is available is diagnostic facilities an
the treatment by radium of ambulatory cases.   The more serious cases are sent to th
Page 226 ancouver General Hospital and the hospital has co-operated up to the limits of its
bility in providing us with beds for the indigent cancer cases that come to us.   That
iks meant a very definite increase in load on the work of the Vancouver General Hospital.
You all know the difficulties that the Vancouver General Hospital has at the present
Ime for providing facilities for the people of Vancouver alone.  The Laboratory is overtaxed, the X-ray is overtaxed, and there is always a shortage of beds.   About 50% of
jfiie cases that come to the Institute come from outside the City of Vancouver and over
10% are indigent, and a very definite percentage of those require X-ray treatment or
laboratory or X-ray diagnostic work, or require to be sent into the hospital for surgery,
|[nd so on.  So that the work of the General Hospital has been increased in that way for
[Hie indigent patients that come to the Institute from outside the City of Vancouver.
Now, I know very well, and you know, that the work of the Institute is very much
[landicapped because of the lack of complete facilities. We hope that this will not
always be the case. I may say that the laymen on the Board of Management are all the
lime striving for the time when they will be able to provide a complete diagnostic treatment for cancer cases at the Cancer Institute. The War is on and at the present time
ill we can hope to do is keep going. TheJ Gymkhana of last year and the year before
Irovided $5000.00. That is off the map for this year. We must find other ways. We
[hall get them. They are beginning I believe—the people of Vancouver and the people
If the Province—they are beginning to realize what the set-up of cancer work in this
Province is. At the beginning there was a great deal of confusion and even friction
where there should not have been. Most of it was on account of ignorance—a lack of
Knowledge. There was the Society for the Control of Cancer, the Association for the
ducating of the medical profession and the B. C. Cancer Institute, which was getting
leady to handle all cases that were sent to it. The lines of activity of these three bodies
lertainly run together and they will gradually merge closer and closer until they unite
n a cancer foundation to decrease cancer in this Province.
Dr. Amyot: Mr. Chairman, Ladies and Gentlemen: The fact has been stated that
lancer is one of our serious problems in the Province of British Columbia. It may
interest you to know that it is the second leading cause of death in our Province, and
lias been for many years. You have heard of the organizations, three in number, that
nave been set up, all with the one object of controlling cancer and preventing the deaths
knd the morbidity as far as possible from this disease:
(1) To educate the medical profession;
(2) To educate the public;
(3) To provide certain treatment faculties.
Vancouver has fairly good facilities. Vancouver, or Greater Vancouver, represents
ibout 47% of the population of the Province. The other 53% are spread all over the
province. There are many problems outside of the larger centres. Dr. Milburn and Dr.
wilson have told us that certain cases are brought in from outside, showing that the
problem is important from that point of view, but there are many people who cannot,
tinder any circumstances, get into the larger centres. And there are centres throughout
[the Province that your committees are working on, developing a programme that will
fit all those particular areas.
Some years ago the B. C. Medical Association asked the Provincial Board of Health
'to place cancer on the list of communicable diseases. That was done. In spite of that
fact we still have so few cases reported that the mortality of cancer is well over 100%
of those reported. The B. C. branch has been working on a programme to develop a
new type of report card, as far as the Provincial Board of Health is concerned—to
make it so that there are three or four items only to put on that card. The Metropolitan
Health Board has been working along those same lines so that the physician will not
have to report so much on these cards. Questionnaires as in the past will be sent as
decided on for the whole of: the Dominion of Canada and filled out as in the past and
sent to Toronto for their analysis.  Now, everyone is bored with statistics, but unfortu-
Page 227
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nately we have got to have our statistical house in order if we are going to tackle a
problem. Our Director of Vital Statistics is East at the present time arranging to allow
us to change our report card of communicable diseases so that cancer will appear on
that card.   It is hoped that that will be ready in a few weeks' time.
Now, one or two other points. With three organizations there are always gaps
between. One of the problems that we must face in B. C. is the problem of cancer
and then a re-allpcation of the problems that are left between the three organizations
so that there will not be any blank spaces. There are certain services that can be used
along with the other services, but they should not replace the services of the other
groups. There is our local public health nursing service, our local public health service,
but these must not overlap with the other work, and I believe that by working together,
and perhaps a bringing together of the problems by the three organizations, and a
re-allocation of the things that are not being undertaken by any of the other organizations, I think we shall be able to cut cancer down, and I think it can be done with the
knowledge that we have at present.
2,   Cancer of Lip:
■••  - ;
I I'
Dr. T. H. Lennie.
Those of us who have been in practice for several years will recall that at one time
in all cases of cancer of the lip it was advised that a surgical resection of the primary
growth be performed accompanied by a block dissection of the neck. Since the advent
of radiation therapy, however, malignant lesions of the lip have passed largely out of
the hands of the surgeon and we have been led to believe that cancer in this situation, as
in the cervix, is the province of the radiotherapist.
Surgeons themselves and the profession generally have been a party to this change
of opinion, as frequently the surgical results were anything but satisfactory. It is possible that the pendulum has swung just a little too far in this direction and that we
have now reached a stage where a re-survey of the situation might indicate that surgery
still has a place in the fight to eradicate this scourge.
As in the case of cancer in any part of the body, treatment of whatever kind should
be started early, and in this particular position there is very little excuse, except where
the patient refuses to seek advice, in delaying treatment. In all ulcerated lesions of the
lip biopsy should be performed and thus the diagnosis is a simple matter. Treatment
should of course follow immediately.
In general it may be said that these tumours do not tend to spread rapidly to the
regional lymph nodes, and that as a result of early diagnosis in a reasonable proportion
of cases the results of adequate treatment should prove satisfactory.
The treatment of cancer of the lip falls under two headings: (1) That of the
primary tumour; (2) that of the lymphatic drainage.
Under the first heading Dr. D. Waldron Smithers of the X-ray Department of the
Royal Cancer Hospital, London, has among other things this to say: "There is still some
difference of opinion as to the best method of treating the primary tumour, due largely
to the fact that the surgeon tends to see the failures fror radiation, and the radiotherapist the failures from surgery. Failure to control the primary growth should be a
rare occurrence and is usually due to underdosage of portions of the growth by the
radiotherapist or too conservative an excision by the surgeon. Good surgical treatment
is better than inadequate radiation, and good radiation better than incomplete excision,
but it is possible to effect the complete removal of all malignant tissue present with
equal certainty by either method. The selection of the best methods of treatment
depends upon the assessment of the advantages to the patient inherent in the various
forms employed"; and again: "As soon as involvement of the regional lymph nodes has
occurred the patient's chance of survival is materially reduced."
Page 228 ■I*
As has been said before, surgical treatment has been replaced largely by radiation,
: d locally about the only cases a surgeon is called upon to see are those who have already
J:eived radium or deep x-ray and in whom recurrence has taken place.   From my
Jnited experience I have wondered if the situation should be reversed, i.e., that recur-
nces from inadequate surgery should receive radiation.    In any event a wide excision
ould be undertaken and the cosmetic result should be a secondary consideration.    In
ry small lesions the usual V excision is adequate, but in more extensive lesions where
|e greateer part of the lip must be sacrificed a plastic operation is necessary, borrowing
-ssue from the upper lips and cheeks by triangular flaps.
I should like to emphasize the importance in all oral cancer lesions of cleaning up
1 infections before actual treatment of the cancer is begun. It seems to be the rule to
nd in these cases a filthy condition in the mouth. Pyorrhoea should receive attention,
id it will frequently be necessary to have all the teeth extracted.
To treat or not to treat surgically the lymphatic drainage is still a moot point.   In
Kiis connection the problem must be considered from three different standpoints:   (1)
hose cases with no palpable lymph nodes; (2) those with small movable lymph nodes;
\) those with fixed lymph node masses.
One authority makes this statement: "Excision of the lesion without dissection or
idiation therapy of the cervical nodes is sufficient when a carcinoma of the lip is of
rade I malignancy, less than 1 cm. in diameter, With no evidence of deep infiltration
r deep ulceration of the lesion, with no evidence of extension into the cervical
rmphatics, and when the lesion is of brief duration." Other considerations which should
lfluence one in his plan of treatment in these small lesions with no palpable lymph
odes are: (1) the low percentage of cases which develop lymph nodes subsequent to
ure of the primary growth; (2) the mortality which follows a really radical dissection
f the neck. This latter has been estimated to be as high as 11 per cent. In this group,
hen, it would seem that no treatment of the neck is necessary.
When small movable lymph nodes are present, block dissection or dissection asso-
iated with radiation would seem to be indicated. When lymph nodes are fixed radiation
Is the only possible form of treatment.
Realizing that in the treatment of carcinoma of the lip both surgery and radiation
Iherapy have a place, one should not be too dogmatic in expressing his opinion as to the
nethod which should be employed.   Each case should be considered individually, and
|he best results will probably be attained by teamwork between both branches of the
healing art.
Dr. Prowd: Mr. Chairman, Ladies and Gentlemen: Dr. Lennie has given you an
jbxcelknt summary of the surgical aspects of cancer of the lip and it is my privilege
[to discuss the radiological approach as it is identified in the treatment of the same lesion.
Cancer is a very discouraging problem up to date but not a hopeless one. We have
a history of 20 or 30 centuries of cancer and we have a history of at least a century of
intensive surgical approach to the disease, and during that time surgery has advanced
well toward finality in its technique or in the medical knowledge which deals with
cancer generally and cancer of the lip in particular. A generation ago another method
came into vogue, and that is the radiological approach, but as a result of all this both
cancer and surgeons are on the increase. About thirty years ago, after many different
types of treatments had been advocated by medical and lay authorities, radiation came
in as a result of the discoveries of Roentgen and Becquerel. Of course, the approach
to cancer by radiation was very difficult and I can recall those days very well. For the
first five or ten years we didn't have much to deal with except surgical remains and
hospital cases, but the treatment gave some unexpectedly good results and, finally, it
proved itself to have a real value in the attack, particularly of successful operations
on cancer.
Page 229
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I happen to have a report which we made in 1933 in the Canadian Medical Association Journal, reporting 156 cases of cancer of the lip and mouth, if I may be permitted
to quote just a bit from that. The 156 cases had 45 cases of glands—a high percentage.
There were pathological reports on 35 of them only, and 78 of those treated were dead
at the time of the report. 28.8% had palpable submaxillary glands. Cases presented
themselves in all the stages of the disease. 78 are dead at the time of report; not a single
patient with involved glands lived for more than five years and most showed recurrence
within one year. I don't know that the results of our present day treatments are much
better than those and it emphasizes what I feel is one outstanding fact with regard to
cancer of the lip. We have it discussed from so many and so varied angles. In the ultimate, the greatest governing factor of them all is the clinical extent of the disease—
whether we attack it surgically, or whether we attack it medically, or whether we
attack it by radiation. Our results in the sum total are practically the same and they
are determined by the extent of the disease when it is first seen.
The radiological approach of today, whether it be by X-ray or by radium, has
advanced and changed and can scarcely be recognized by those things which we did 25
years ago. Today the radiological approach to cancer of the lip is either by radium or
by X-ray and in either case there has been a decided improvement in the technique;
there is much less discomfort to the patient, much less time consumed; and I think the
lessened discomfort and the improved results have been a very justifiable reward to the
attempts in treatment along radiation lines. When these cases were reported, and from
much of the literature that you read today along the lines of technique used then, they
used to speak of giving radium for four or five days on implants, X-ray treatment was
given off and on pretty much until the patient got tired of coming to you or you got
tired of giving the treatments, but in spite of that certain cases are limited as to the
cancer content which presents itself. Glands in the neck were mentioned by Dr. Lennie,
and Dr. Lennie also went back to the days when surgical excision of the lip and block
dissection of the glands. Only about 13% had demonstrable malignant glands of the
cases as they present themselves to you. That is not a very large percentage. That went
into disrepute but it was not eliminated by any means. These radiological approaches to
glands of the neck depend on the condition. We mentioned the extent of the lesion. If
the musculature of the Up is involved or if there is a single gland palpable, I don't think
we shall ever cure a case of cancer. Our results are purely from a complete attack on
the lesion which aims at its total destruction. If you get an early cancer and it recurs
it is because the surgeon has not excised widely enough or the radiologist has not
irradiated widely enough. If it is attempted to remove it surgically, a wide excision is
necessary. There are many contraindications to surgical excision. Radiation is the only
hope if you get a mass of glands or if the primary lesion is a very extensive one. Radiation is given for palliative reasons only, not for cure. Statistics are not needed—you can
get them anywhere. We are here for a practical purpose. The greatest enemy to
radiation therapy, as in surgical therapy, is infection, and it is very necessary to have
a period of preparation to look after and to clear up infections in the mouth and teeth,
if necessary, the same as in surgical attack.
The technique that is used for radiation varies according to the lesion, whether you
are treating for a cure or for palliative reasons. The causes of failure are the extent of
the lesions. I am satisfied, irrespective of type, that if you get a lesion that involves
more than a limited area, speaking of cures is a false hope. Dr. Lennie mentioned that
the approach ought to go back to the surgical approach of years ago. From the radiation
angle, inadequate surgical approach or surgical approach adequate but with failure,
naturally interferes with the blood supply and you cannot get the same response to
radiation. The same is true also where "snow" is used. I believe that we should evaluate
the case, decide on the medication that we are going to us, and whatever is used by you,
employ it to its fullest but don't refer a case in for a shot of radiation after a surgica^
massacre. This includes, in our particular practice, radium to the local lesion and X-ray
to the glandular areas where indicated.  We should be familiar with the after-effects of
Page 230
41* radiation. For a long time the immediate post-radiation results were looked upon as an
extension of the disease. One now recognizes that you must have an increase in the
local oedema in order to get a cure. We should remember, too, that radiation has its
limitations. Recurrences cannot be cured by radiation. Sometimes they can be, cured by
the cautery but to think that a radiation attack can be done on a recurrence following
surgical cure is also a false hope. The physical condition of the patient has a great deal
to do with any attack on cancer of the lower lip. The great majority of cancers are
of the lower lip. Just why, I don't know.
Finally, I would make a plea for justifying the tendency of the day to radiation
therapy for accessible cancers, particularly in discussion of cancer of the lower lip—
that the accuracy and the ease in the application of radium is a factor in its favour.
The trifling inconvenience to the patient compared to that of surgery is a factor and the
end results are quite comparable, whether we are speaking in terms of cure or palliation.
If we must insist on palliation, you will get more results from radiation than from surgery. The cosmetic result, as you all know, is excellent. It is often difficult to tell
whether the radiation was given following cancer of the lower lip.
Dr. SchInbein: I wish to thank Dr. Prowd and Dr. Lennie for presenting this subject of treatment by surgery and by radiation of cancer of the lip to us. This fact
stands out predominantly; that in the treatment of cancer it must be recognized early
and treated early while the lesion is still local, and it does not make much difference
whether you do it radically by surgery or adequately by irradiation. That fact stands
out very definitely.   It doesn't matter whether it's cancer of the lip or anywhere else.
With respect to removal and block dissection of the neck, I was doing surgery on
cancer of the lip before the advent of radium and at that time we did local excision and
block dissection of the glands of the neck, and I can definitely state that I would never
go back again to block dissection of the glands of the neck. The results are no different
than if you did not touch the glands of the neck, as far as the ultimate cure is concerned, but the condition that may result in the neck may be terrible.
3.   Cancer Research:
Mr. President, Ladies and Gentlemen:
It is indeed a privilege to address the Vancouver Medical Association, especially so
when the opportunity is given to join with the other speakers on this evening's programme.    I deeply appreciate your invitation.
At the very beginning I must make one point perfectly clear—each of the speakers
who have already addressed you this evening and all of those who follow (with the
exception of Dr. Macpherson; who very kindly arranged to open the discussion on this
phase of the programme) presented, or will present, to you some phase of the Cancer
problem with which they are daily identified and naturally they speak to you with that
fullness of knowledge, that clearness of insight and that certainty of vision that can
come only with doing. I am to bring before you some aspects of the question of cancer
research but I am not -a cancer research worker—I can attempt only to classify and
correlate the work, the hopes and the dreams of others. To cover the field adequately
I would have to speak to you as a surgeon, a radiologist, a physiologist and a biochemist.
A discussion of the work in any one of these fields would occupy the whole evening, so
it has seemed to me that in a cursory glance like this, we might gain somewhat by
attempting to analyze how far the various trends in cancer research are condition by the
various theories we accept, discuss or reject regarding the cause of cancer.
I would ask you this evening not to take too narrow a view of research when applying the word to the cancer problem. I would ask you to think of all clinical investigation and treatment of cancer as research work if properly carried out and followed up.
Page 231 *
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It is obvious that the research worker in any field must begin with a theory and his
task is to prove or disprove this theory.
It is natural that between 18 50 and 1900 that cancer research should have concerned
itself with cellular pathology as developed by Virchow between 1850 and 1860. How
excellent that work was will be brought home to us all perhaps when we remember that
staining methods as we know them were introduced in 1872. Now remember that all
the knowledge garnered in those momentous years is not lying dormant—in the words
of the Psalmist it is "A lamp unto our feet and a light unto our path"1. It is the
only sure guide in our daily work and is the yardstick by which all cancer work today
must be measured.
Virchow put forward the theory that chronic irritation plays a large part in cancer
development—a theory that still dominates our medical thought—perhaps more especially
in the surgical field. In 18 80 Cohnheim advanced the theory of new growths of a malignant character arising from embryological remnants—so called developmental faults
and today this is accepted as an explanation for certain cysts and tumours such as
Inasmuch as the enigma of cancer is not yet solved, the great controversy of the
nineteenth century still concerns us. That controversy was whether cancer was a local
or a constitutional lesion. Is the primary tumour the beginning of a disease that may
later spread to every tissue and organ of the body, or is that primary tumour merely the
first evidence of a constitutional disorder? If the primary tumour is indeed primary,
then local measures such as surgery or radiation if skilfully used should control the
disease, but obviously if the cancer when first found is merely a local expression of a constitutional disorder or a so-called blood condition, then it is equally clear that local
measures must be ineffectual. I here class radiation therapy with surgery as local measures
as irradiation of the whole body has as yet played but a small part in the treatment of
malignancy.   I might say here that some constitutional factor must be predicated.
With the great advances in bacteriology in the Nineteenth Century it was natural
that much research should be directed to attempts to connect cancer with some form
of bacillus or micrococcus. This has never been proven. It is accepted that cancer is
not infectious—and yet, and yet—in the British Journal of Radiology, July, 1937,2
J. H. Douglas Webster of the Radiological staff of Middlesex Hospital records the following cases:
The first was—"a case of a Paris medical student, who in removing some serum from
a post operative breast cancer pricked his hand accidently owing to the sudden movement of the patient. Two years after the puncture he developed a sarcoma of the hand."
Dr. Webster states that this has been described as "the first authentic observation of
cancer inoculation," that is, of course, in the human being.
The second case reported by Dr. Webster was originally reported from Bucharest.
"It was the case of a woman of 36 who had a lump in her breast for two years to which
she paid no attention. A child was born and she suckled it from both breasts. After
nearly eight months suckling, the breast began to ulcerate but she continued to nurse
the child until she saw on the infant's lower lip a small tumour which grew rapidly.
Both patients were operated on—the mother had a typical breast carcinoma with scirrhus
formation in parts and the child had a typical fusiform sarcoma."
These two cases at least suggest a parasitic origin of cancer. Now Dr. Webster
records that Besredka has claimed to produce an immunity to cancer by vaccination of
small quantities intradermally—and this again suggests the possibility of a virus origin.
It was natural that when some attempts to connect cancer with some form of
microbic life were unsuccessful, research workers should turn to the theory that it might
be due to a virus. About 40 diseases in man and animals produce viruses that have been
shown to pass through efficient bacterial filters. In 1911 Peyton Rous described a sarcoma of the chicken which was transmissible by means of a filtrate but he was not
willing to say whether this substance was a chemical or a living substance.   Later, W. E.
Page 232 Gye of London and others maintained that it was probably a living substance like bacteria. Later, Stanley and Wyckoff and others have shown that certain viruses like that
of the tobacco plant possess some of the properties of living organisms in that they can
multiply and further that they are crystallizable. An enormous amount of work has
been done on this Rous Sarcoma, on the Shope papilloma and epithelioma of the American
cotton tail rabbit and as Dr. J. J. M. Shaw says3 "An adenocarcinoma of the kidney
described by Lucke has recently allowed the leopard frog of America to jump into this
select circle."
In the present century three sign posts along- the way have directed the trend in most
of the cancer research work—
1. Jensen in Copenhagen and Leo Loeb in Chicago succeeded in transplanting carcinoma and sarcoma in rats for apparently an unlimited time and here we have a direct
approach to the whole problem of growth, cell differentiation and cell de-differentiation.
2. In 1914 two Japanese workers produced carcinoma in rats by long continued
application of tar. This is a direct application of Virchow's theory of long continued
irritation. Already about 50 or 60 carcinogenic agents hace been investigated and a very
interesting development is the isolation of the active carcinogenic substance in tar by
Kennaway and his associates working at the Cancer Hospital in London. Later, the
investigation of this chemical and its relation to sterol metabolism and to oestrin has
brought us certainly one step nearer the solution of the problem.
3. Extensive work on the question of heredity. You are all familiar with the work
of Miss Maud Sly of Chicago and her development of two strains of mice, one cancer
free and one almost 100 per cent cancer subject. We may well pause here and ask how
far we can apply the data proven by experiments on mice to mankind and it is probable
that we can go no further than to accept the dictum of Gideon Wells, the Pathologist
of Chicago, who has briefly stated the position as follows: "If we can apply to mice the
Mendelian laws of inheritance learned by that French Monk and Biologist from a study
of peas then we must apply to man the data we have learned from the study of mice
(as men differ less from mice than mice from peas)." i
It is doubtful if even in a dictator state you could conduct such controlled studies
in human genetics as Miss Sly has done with her mice so that today the question of heredity in human cancer is by no means finally settled. On the one hand we have the
extreme view of Ledoux Lebard to the effect that it should be taught authoritatively to
the public that heredity plays no part in cancer—and then we read paper after paper
on the various known cancer families—we know that such precancerous conditions as
polyposis of the colon has an hereditary factor and we read of hereditary melanomata in
grey horses4.
In this vexed question I am reminded of Browning's poem—"Bishop Blougram's
Apology." Those of you who are familiar with it will remember that the Bishop has
suggested that he throws overboard his beliefs to accept the newspaperman's doubts and
skepticism and when faced with a sunset or a chorus ending from Euripides he finds
Faith creeping in again so that all he has succeeded in doing is to exchange a life of faith
diversified with doubt for one of doubt diversified with faith.
When we turn to the great research done by industry, unintentionally at first and
more recently so well planned and executed, on occupational cancer, we no longer have
to translate animal experimentation into terms of possible human reactions. I shall only
mention a few—cancer of the lung and its relation to radio active substances; its relation
to certain types of coal rnining. The relation of cancer of the larynx to the production
of alcohol; the type of cancer of the urinary bladder which has become so common in
workers in certain chemical dye factories. In some countries this has become recognized
by the Workmen's Compensation Boards as an occupational disease and in some instances
has been eliminated by proper control of dust and by proper exhaust ventilation in the
plant combined with closed systems of production. Cancer of the skin from prolonged
irritation by soot, shale oil, creosote, anthracene, petroleum,  tar and pitch.    Cancer
Page 233
i ft IW'J
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developing in old scars, especially those following burns; cancer from working with
luminous paints. Remember, in all these cases we have a real check on the time element
necessary to produce the cancer and without exception, the time is long—usually a
matter of years, from ten to twenty. The one exception to this is "Acute traumatic
malignancy" as described by Dr. William B. Coley in his discussion of Bainbridge's
paper5. This was first described by Barwell in England in 1882. Coley described a
case of his own where a Ewing's sarcoma followed a crushing injury to the hand in a
period of eight weeks. In this whole question of the relation to trauma to malignancy
we are all probably well advised to remember th epostulates first stated by Segond in
19076 and later recognized by the French statutes.   These are—
1. The authenticity and sufficient importance of trauma.
2. Previous integrity of the wounded part.
3. A reasonable time relation—three weeks to three years or more in certain cases.
4. Continuity of pathological changes or symptoms in the wounded part and the
appearance of the tumour.
Microscopical proof of the existence of a tumour.
It is very natural that with the recent development of chemotherapy in medicine
that research in the fi/eld of cancer should also proceed along chemical lines. I have
already mentioned the discovery by Kennaway Cook and associates of the active carcinogenic factor in tar7. The relation of this chemical to certain bile acids and to
cestrin is an interesting story of careful work and later the production of mammary
cancer in male mice by the administration of large doses of cestrin. Personally, I could
have wished that we had not been given the sex hormones by the Research Laboratory
until we knew more of the basic principles governing growth. When we do a roentgen
sterilization and two years later the clinician gives that patient sufficient cestrin to start
the menstrual function, again I fear very much that we may be unconsciously playing
with the cancer problem. Just here I would like to quote a paragraph from J. J. M.
Shaw's paper8—
"It becomes increasingly evident that the nature of the cancer process is so clearly
linked with the nature of life itself that finality of opinion will only be reached if and
when we understand the phenomenon of growth, of differentiation and de-differentiation,
and of how the living cell as a complex of chemistry and physics can generate and maintain and reproduce what we must, in our present state of knowledge, call the spark of
We must admit clearly here that while carcinogenic agents, whether chemical or
viruses, can produce cancer in laboratory animals, we are completely ignorant of the
exact mode of action9. In no branch of research work do I feel we are treading on such
uncertain ground as when we come to deal with statistics regarding malignancy. A
certain group of statistics is true only for the limited group followed and to say that
the ordinary death certificate merits statistical study from the point of view of malignancy seems to me to be worthy of a Gilbert and Sullivan opera.
I have made no reference to many of the newer developments—the adventures in
nuclear physics; the role of vitamins in the production of cancer and the use of Cryotherapy as these are all of too recent development to be covered in this paper.
In conclusion, I would remind you of those words attributed in the Apocrypha to
Jesus and later cast into verse—
He who hath a quest sublime
Wgr; Triumpheth over space and time.
He who followed a star
Feareth not to travel far.
He who seeketh shall attain,
He who wondereth shall reign.
Page 234
iW> 1. Psalms 11-105.
2. British Journal of Radiology, July, 1937.
3. Dr. J. J. M. Shaw: "Causation of Cancer."   Edinburgh Medical Journal, December, 1937.
4. Webster: op. cit.
5. Medical Times and Long Island Bulletin, May, 1934.
6. Segond, P.: Ass. franc, d. chir., 1907, Vol. XX, p. 745.
7. Voegtlin: Science, July 15th, 1938.   Age 42.
7. Voegtlin: Science, July 15th, 1938, p. 42.
8. Shaw, J. J. M.: "Outlook on Cancer." Edinburgh Medical  Journal,  193 7, XLIV:758  ,December.
9. Voegtlin: quoted above.
Dr. McPherson: First of all, may I thank your Society for the honour you have
done me in asking me to come over and open a discussion on this question of Cancer
Research, and may I say, with Dr. Murphy, that I have done no cancer research, that
I am in no way qualified to do cancer research, and that all I know and the only excuse
that I have for coming in here is what one reads in regard to this particular subject.
May I say to you that those of you who are interested in this subject, as far as I know,
would be well advised to read the American Journal of Cancer which is in your Library
and which each month has long articles on Cancer Research in various parts of the
world. The thing that struck me in reading these articles in the Journals was not so
much the lack of results that appear tangible, that we could tell our patients or ourselves
about, but the infinite labour that is being shown by workers throughout the civilized
world. For instance, an article which describes work on 688 rats and 720 mice which
were given from one to twelve injections apiece, and another article where 70 experiments were done on 537 rats; and this sort of thing going on during the research work,
and that they do not expect to get results in this work until a comparatively lengthy
period has passed. One repeatedly comes across this statement "in these mice who live
more than eight months."
Now, this question of cancer research is a big one and I think the fundamental
problem might be put in this way (this is not original at all), that the thing must be
considered under two heads: (1) What it is that causes transformation of normal cells
to cancer cells? and (2) wherein do cancer cells differ from the normal cells? External
factors come into it. We all know a lot about them—the cancer of the urinary tract
amongst workers in aniline dyes, the skin cancers in wrokers in soot and tar, the lung
cancers in workers in certain mines. Incidentally, cancer of the lung is on the increase
and one wonders whether the increase in smoking has anything to do with that cancer
of the lung. (I notice that Dr. Appleby took his cigarette out of his mouth when I
suggested that it might have something to do with it.) And in all these groups, the
old, old story of chronic irritation comes in. Now, there must be another side to it,—
the endogenous side, that has to do with this problem of cancer. What is it that occurred
in those cases of mice which Maud Sly bred and which iri some families have nearly
100% of cancer? What happens in those mice? What happens in the mice that are
practically cancer free? I feel personally that until we have something more definite
than the history of a few families where cancer occurred more frequently than it should,
until we have something more definite than that, we should continue to state to the
relatives of the patients with cancer that cancer is in no way hereditary. I know I am
starting an argument when I say that. Again, in spite of the incidence of the Paris
student who punctured his hand and in two years developed a sarcoma of the hand, and
in the other case where- a woman with cancer of the breast had her infant develop a
sarcoma of the lip, surely if cancer was in any way infectious or contagious then the
records of medicine and surgery throughout the world would have something more than
two doubtful cases in support of it being contagious.
To get back to the endogenous factor, I want to mention some work published last
year in the American Journal of Cancer for August and reviewed in one of the February
numbers of the Lancet, the work of Vandenberg and others, or production of
new growths in mice by the injection of liver extract.  These men made a liver extract
Page 23 5
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and they took great care as to how it was made, from patients dying from cancer, and
they got a stock of control mice. The interesting fact is that they were able to produce in the first group given liver extracts from patients dying from cancer, they were
able to produce a variety of tumours in 57.4% of those mice and that in 45% of those
developing tumours lung adenomata were present. Of the series of liver extract dying
from other causes than cancer, 24% of them developed tumours throughout the body
and 26% of those were lung adenomata. These tumours were of great variety and
affected many organs and of the total number produced, only six were at the site of
injection. This is very different from the cancer work done by the use of various
carcinogenic substances. In this connection, a worker in South Africa, using extract of
liver from a cancer patient was able to produce cancer of the skin by rubbing this
extract on the skin, so that apparently there is beginning to be available some evidence
of what an endogenous factor in cancer may be.
One or two things more and then I am through. In this research work, the desirability of something in the way of a diagnostic test that we could use in suspected cases
of cancer, and the only thing that I have been able to find is a recent report by two
men in Chicago, that they were able to develop a specific precipitin from cancer material
that reacted in cancer patients and did not react in non-cancer patients. The other
thing to keep in mind is the possibility of the development of some particular substance
which would be as specific for the treatment of cancer. This, I know, does seem pretty
far-fetched to us at the present time, but I think pretty nearly everybody will remember the development of the arsphenamides and the wonderful results that have been
obtained by them, and still much more recently the development of sulphanilamide and
what it has done in infections, so that I think we must be hopeful of the possibility of
a development of that nature.
One more thing, and that is that I think all of us might do something in regard to
cancer research along an altogether different line to these workers who are putting their
whole time on the job, and that is this: If and when we have time ,in going into the
history of a cancer patient, try and get all the details that we can of the life of that
patient, 10, 20, 30 years ago, his environment, his diet, his occupation, and anything
else that is relevant, and it is possible that somebody may find the factor coming in
there, just like the wonderful work of the late Sir James-McKenzie with regard to heart.
Dr. J. H. MacDermot: I was listening to Dr. McPherson and he said he had only
come across one instance of a possible test for the presence of cancer. I think if Dr.
McPherson will read the last number of the Bulletin he will come across an excellent
piece of work that is being done in this city—a report of well over 100 cases, work
that is being shown to be of a high degree of accuracy, and which, as we all think here,
may be of considerable importance.
Dr. Boak, Victoria: In reading over the mass of literature that occurs on cancer
research, it seems that most of the research workers have tried to find out a vast number
of carcinogenic stimuli and I think they are now realizing that there are many substances
that can act as irritants, and now they are turning to try and find in the individual
what it is that makes him susceptible, and our literature for the next five years or so
may not be so loaded on the subject of a new irritant. And I think, also, that perhaps
the day will come, not so faraway, when someone will have a vision, just as Banting and
Best, who worked out the pancreatic gland, that man who has the vision, after the
accumulation of the knowledge after many many histories, and then we may be able to
find the basic cause of the lowered resistance that allows the normal cell to go wild in
the body without control.
Page 236 4.   The Biopsy:
H. H. Pitts
Probably one of the most important procedures in the diagnosis of malignancv, is
the biopsy. In general, it is a relatively minor surgical procedure, especially in superficial skin lesions, but in other sites, such as the rectum, sigmoid, oesophagus, larynx,
trachea, etc., the ultimate securing of the biopsy specimen entails more elaborate and
painstaking technique, generally relegated to the specialist's province.
When malignancy is suspected, I believe a dictum applicable in almost all cases
should be laid down, that "no therapy should be instituted until a biopsy has been done."
The reason for this is two-fold: (1) It establishes the diagnosis; for lesions which grossly
have all the characteristics of malignancy often prove, on histological examination, to
be benign. (2) It furnishes a basis for the type and degree of therapy to be used, and a
provisional third point: it may serve as an index for prognosis to some extent.
Even when the lesion may not grossly or clinically suggest malignancy, it is probably
a good general rule to do a biopsy, for, even as grossly malignant appearing lesions may
histologically prove benign, the reverse also holds true.
The biopsy may be of the excision type or consist of a small section from the growth.
In small superficial lesions about the face, total excision may be performed with subsequent histological examination of the lesion, but if extensive, so that the total excision
might prove disfiguring scars or the need for plastic surgery, then a small biopsy specimen from a representative area is sufficient.
Melanotic tumours should all be widely excised, I believe, especially if the specimen
has to be sent, for examination, to some fairly distant laboratory, which of necessity
means several days before the report is received by the attending physician.
After infiltration with the local anaesthetic, a thin wedge at the edge of the lesion
and at right angles to the skin surface, is taken to include also a portion of the adjacent
supposedly normal tissue. A "shaving-like" piece, parallel to the tumour surface, is
usually not satisfactory, nor the pulling off of a papillary projection from the main
tumour mass. I have had to retract my diagnosis of benignancy on a few occasions
when this was done, on finally receiving a properly procured biopsy specimen, but on
re-examination of the previous specimens, one could not truthfully say they were
malignant even with the subsequent information in mind.
Frozen-section examination, especially of tumours of the breast, is a great boon to
the patient, for it may mean respite from an extensive radical breast amputation, or a
second operation, the first being for the purpose of procuring the specimen for examination, which is the procedure that probably has to be adopted in communities where
no facilities for frozen sections are available. It might be stated at this point that
under these circumstances, it is always a better procedure to completely excise the
tumour mass rather than excise a piece of it and await the ultimate histological diagnosis,
for there is the ever present possibility of "seeding" the adjacent tissue with cancer cells.
I believe that it is a good rule to regard all tumours of the breast as possibly malignant
until proven otherwise, and they should be excised and examined histologically. We have
all, on more than one occasion, felt tumour masses in the breast, which were freely
movable, probably painful, suggestively fluctuant to palpation and possibly in a relatively young woman—in short, having all the attributes of a clinically benign process—
only to find, on either gross or histological examination, a carcinomatous growth. On
the other hand, one sees the clinically malignant growth prove benign on histological
examination. Even the clinician, with an extensive experience in this particular field,
will show a goodly percentage of erroneous gross clinical diagnoses, and so it would
appear almost imperative that all mammary tumours should be excised for diagnosis.
There has always been considerable controversy regarding the safety of routine
biopsy sections from tumours. By many, it is felt that this procedure opens up channels
for the widespread dissemination of cancer cells through the cut blood  and lymph
Page 237
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Channels. However, it is the experience of the large cancer clinics where thousands of
biopsies have been done annually for years, that this is not the case, and this tenet has
been supported by animal experiments. There is almost immediate thrombosis of the
cut vessels so that the tumour cells1 are confined more or less to the local area, and at
any rate, appropriate therapy will be instituted within a very short time.
While the question of the value of grading of carcinomas, especially the squamous
type, is still a controversial one, I believe it is of value as an index for treatment and
prognosis. In general most radium and X-ray therapists base their therapeutic attack
on the lesion on this factor, and as to prognosis, the grades 1 and 2 being of a more
differentiated or mature cellular structure than grades 3 and 4, offer a somewhat more
favorable prognosis. However, I believe that too much dependence cannot be placed on
this grading, for the rate of growth and cellular structure of a carcinoma may change
so that a grade 1 squamous may, when examined histologically 6 months hence, present
a grade 2 or even 3 structure. At any rate, whatever the shortcomings of this grading,
it nevertheless gives us some basis or guide, with other features taken into consideration
as well, for therapy and prognosis.
Before closing, it might be well to put forth a plea on behalf of the pathologist.
Because of the anatomical location of the tumour, it is often impossible to obtain more
than a very minute biopsy specimen but, where possible, the larger the section the better
the opportunity for diagnosis. Where specimens are sent in from outside the city, they
should be immersed in a 5 % formalin and water solution and not in chloroform, carbolic,
alcohol, or even saline in which we have received them, when in general it is almost im-
sible to make a satisfactory histological diagnosis of such tissue. The patient's name
and age, a few short notes as to the anatomical location of the lesion, its appearance
and duration, are sometimes of great assistnce in arriving at a diagnosis.
In conclusion, then, I wish to leave with you the thought that too much dependence
cannot be placed on the gross appearance of a lesion despite the presence of all the
attributes of benignancy; the skill and experience of the clinician and the history. It
remains for the biopsy to reveal the intimate cellular structure of the tumour to serve
as a guide to subsequent therapy and prognosis.
Dr. McNair: Mr. Chairman, Ladies and Gentlemen: From what Dr. Pitts has haid
tonight, I think it is quite clear that it is even difficult enough for the Pathologist to
make up his mind as to whether a tumour is malignant or not quite apart from its
clinical findings. This brings up a very interesting question and that is, making available a biopsy service for practically the entire Province. Now, biopsies cost money, but
mistaken diagnoses, I think, cost more. The value of a correct diagnosis, or as correct
as one can get at, both clinically or pathologically, I think is certainly essential. 1
think Dr. Pitts will bear me out when I say that tumours are still coming in that have
been excised rather locally with very little normal tissue surrounding this tissue that is
obviously grossly carcinomatous. That is rather alarming, because these cases are obviously carcinoma and the operation is subsequently finished. It is a great pity that man)'
doctors have not the opportunity to review their gross pathology at least every two or
three years, because most of these tumours can be diagnosed, in 75% of the cases, by
the gross appearance and by their history, and I feel that this subject of provincial
biopsy service is an exceedingly important one. Dr. Pitts has stressed this throughout
his paper. Mistaken diagnosis and mistaken treatment is certainly a costly thing for
the individual and for the municipality in which he lives. Dr. Pitts is Chairman on the
Commttee that took up the subject and made a survey last year and we got a great
many valuable reports. We hope that we will get the co-operation of the entire medical
profession in actually doing something about the establishment of a biopsy service.
Whether it will be free or at a nominal cost will have to be decided upon.
The importance of biopsy is perfectly obvious to most of us and I think it is exceedingly important that if we are going to do anything in cancer control—we are working
hard on histories and working hard on education and working hard on therapy—I think
Page 238 this is just as important as any of the branches that I have mentioned. If this question
comes up again I would like to see other men in this Province give this very serious
thought, and it will be of benefit to practically every man in the medical profession in
this Province and would be available to practically everyone living in this Province.
Dr. Don Williams: I don't think there can be any physician in the past two or
three years that cannot be impressed with the efforts in reducing cancer . I think all
of us have given this problem some individual attention, both from the standpoint of
ourselves and our fellow citizen. When one does a little thinking, one wonders what
can be done about the problem. First of all, we have no knowledge regarding the cause
of cancer. We have no specific treatment today. We do fortunately have a means of
diagnosis. We all know that early diagnosis means early treatment. Early treatment
very often means early cure. Along with an effort to educate individuals there must
be an effort on the part of the physician to make an early diagnosis, and one feels that
in this problem of biopsy one expresses the opinion that the punch biopsy, particularly in easily accessible places, is far too little used. One would like to demonstrate
a simple instrument which is well known to all dermatologists and should be on the
table of every physician in Canada. It is known as a biopsy punch and it has a hollow
centre at the tip. It is possible to take a punch biopsy in about two minutes from practically any accessible place. It should be a procedure that every physician should use,
and if every physician used it, undoubtedly this simple treatment may be a very effective weapon in the early treatment and possible cure of many forms of epithelioma.
5.   Pain in Cancer:
Dr. F. A. Turnbull, whose paper will be published elsewhere and so can only be ab-
tracted here, opened his remarks with some general observations. He referred to the
uselessness of pain in cancer as a warning or a guide to treatment; since it is practically
always a late sign, coming when the growth is already long past the stage when either
surgery or radiation will result in cure. The pain of cancer is an increasing pain, and
demands ever more and more to relieve it. One has inevitably to face the problem of a
drug addiction in the later stages; with all that this implies: and even heroic doses of
morphia may fail to control an agony which may in some cases surpass description, if
not controlled by other means.
Dr. Turnbull stressed a point too often overloked, that all too frequently we tend
to order dosages insufficient to control pain. If, as he neatly put it, the surgeon himself
had the pain, it is quite probable that the drug bill would be tripled. It is not, perhaps,
that we grudge the patient relief, but that we are trying to avoid the danger of drug
addiction, and to keep down the dosage to the minimum necessary. Since the patient's
expectation of life is short in any case, Dr. Turnbull suggested, it seems absurd and
unnecessarily cruel to deny him or her relief for a doubtful benefit of this sort.
Of course relief of pain will be obtained by successful surgery or radiation therapy
—but if this should fail, and secondary implants occur, a more severe type of pain may
As long as the pain of cancer is moderate, and as long as drugs control it, the neurosurgeon will have little or no part to play in the treatment of the case: and till recent
years, he was rarely if ever called in: but more and more neurosurgery is being summoned to the relief of the intractable pain which "all our poppies and mandragora"
cannot touch.
P'age 239
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Drugs have two serious limitations, as Dr. Turnbull pointed out. First, in very
severe pain, even very large doses fail to relieve. Second, they have other toxic effects
on the patient. Given in large doses over considerable time, they cause mental, moral
and physical deterioration out of all proportion to the progress of the malignancy.
Hence, if we can obtain relief by other methods, we confer an inestimable benefit on
the patient.
The surgical methods employed consist of alcohol injection of nerves, subarachnoid
injections of alcohol, section of nerves, and cordotomy. One or more of these may be
used, according to the situation of pain, the patient's general condition, the state of
tissues, and the operator's technical ability and experience.
Dr. Turnbull went at some length into details of treatment in various parts of the
body. One was impressed by the immense advances that have been made in this
department of surgery, and by the ingenuity and nicety of operative detail.
The difficulties of operation are of course considerable, the results not always all
that one could hope for—but there are certain points that the speaker emphasized.
One is, that we tend to postpone surgical measures too long. As he said, at the beginning of cancer, we overestimate our prognosis of life expectancy, while in the later
stages we underestimate it, and let the patient go on suffering for months when we
might relieve him. Again, if patients are in reasonably good condition, the immediate
operative risk is slight: and symptomatic relief can be very precious to a patient.
Dr. L. H. Appleby: Mr. Chairman, Ladies and Gentlemen: Dr. Turnbull's discussion of the surgical measures designed for the relief of pain in cancer covers the subject
thoroughly, yet it must be apparent to you at once that it is necessarily confined to
the hands of a very few men highly technically trained in neurosurgery and is not for
the great mass of the public.
Dr. Turnbull has emphasized the failure in many instances of most of the profession
to keep up with treatment and with the increase of knowledge in measures of diagnosis. It has fallen behind in many instances, and I think that in the matter of the
relief of pain we are very much in the same position as we were twenty-five years ago—
we fall back upon morphia; and Dr. Turnbull has drawn the picture pretty truthfully
of these patients who become addicted to morphia. This is a drug whi^h produces a
narcosis and hypnosis which gives relief from pain, but if given in adequate doses the
man pays for his relief from pain by being reduced to a state of being more like a
vegetable than a man. He pays for his relief of pain at the price of a serious mental
deterioration. The disadvantages of morphia are its short duration and the possibility
of addiction.
I am sure most of you have used cobra venom for the relief of pain. I took a trip,
last winter down into the deep South and in the University of Florida I found a group
of workers working on this drug, and they have certainly revolutionized the theories.
This drug, if it is active and potent, will relieve pain, but it will also relieve pain for
as long as 28 days with a series of 3, 4 or 5 inoculations. It will relieve! pain without
narcosis or hypnosis and will permit the patient to enjoy a reasonable degree of mental
clarity which he does not get with the relief of pain from morphia. Cobra venom is a
labile substance. I repeat what I have said, I have had it proven to me that this drug,
if active, will relieve pain. Now, this is exactly the same as rattlesnake venom except
that the venom of the cobra is three times as potent as the venom of the rattlesnake.
I have used this in Vancouver with almost startling results until it lost its potency.
Now, I am not trying to tell you that you can buy products which are of value in the
relief of pain. I am going to pass on to you a prophecy. We are today very much in
the position that I was in as a small boy when my grandmother used to push my head
back and push down my throat about a quart of Scott's Emulsion in order for me to
get my vitamins. Cobra venom will soon be synthesized and we shall be able to buy it
crystallized for the relief of pain, that will relieve pain without narcosis and without
Page 240 hypnosis. I was very taken up with this and I have used it a great deal. If they are
successful in the synthesis of cobra venom we are going to have a substance which will
blot out Dr. Turnbull's picture.
Dr. Trapp: May I thank the members of the Vancouver Medical Association for
handing over the programme to the Cancer Committee. One hopes that the obvious
success of the meeting will inspire them to do likewise another year. May I also congratulate the speakers on the excellent presentation of the various subjects and to
thank them for making this meeting successful. I should particularly like to thank the
gentlemen who have come from Victoria.
By G. R. Barrett, M.D.
The administrative authorities of the hospital are always acutely -interested in the
parenteral use of fluids and it is from this point of view that these remarks are made.
The basic problems are much the same in all hospitals, but one tends to think more
about those which relate particularly to one's own hospital. Generally speaking, we
must take three main things into consideration:
1. Availability. This includes the quantity of solution, the reserve stock of solution, the intravenous sets which deliver it to the patient; also the fact that such
solution may be obtained on a moment's notice; and that a variety of solutions
must be on hand at all times.
2. Sterility.   This means cleanliness from foreign particles as well as bacteria.
3. Cost. The materials and the method of making must be kept low but the quality
must be high.
In the consideration of the quantity of solution made in the Vancouver General
Hospital, some very interesting figures came to light. These are best shown on the following chart:
Per day Per year Costs per year
Solution produced 87,209 cc. 31,395,240 cc. $5,838.47
Solution   used     38,466 cc 13,845,240 c.c. $2,574.17
Solution   discarded '.     48,743 cc 17,550,000 cc $3,264.30
(* The above are average figures.)
The enormous daily discard is accounted for by two things—the reserve of solution
necessary and the present method o£< safeguarding sterility. Not only must reserves be
kept at the point of manufacture, but in various operating rooms, in various surgical
supply rooms and in different buildings. This effort to make solutions quickly available
brings into use many more flasks of solution than would be necessary in a single reserve.
The intravenous sets must be made up daily and sterilized. They must be uniform
because of the quantity made up and to eliminate errors. They must be as simple as
possible, but we believe ours contain everything necessary for safe and adequate intravenous treatments.
Sterilization of the solution involves more than just autoclaving it. It must be free
from particles of gauze, and other foreign matter found in different components, for
example, sugar, salt, etc. This involves long and tedious filtering. It must be free from
pyrogens. There are now thought to be products of certain bacteria, some of which may
be found in distilled water after it has stood even twenty-four hours. These products,
while not of a septic type, can nevertheless cause marked febrile reaction.
Page 241
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From our experience in this hospital, we apparently have a sterile solution at the time
of manufacture which remains so in the case of glucose for at least twenty-four hours
growth in cultures from standard glucose solutions kept as long as sixteen days and
cultured (in incubation) for as long as three days after that. The enormous discard on
solutions really amounts to another premium on safety insurance. It may be noted here
that we are the only hospital on the continent which discards its glucose after storing it
for only twenty-four hours.
The third consideration is cost. We have computed our cost of manufacture at
18.16 cents per 1000 c.c. of solution. This price includes material, sterilization arid
labor involved. It compares favourably with other hospital centres making their own
solutions at the present time. We found the cost to the hospital to be $5,838.47 to
make the solutions ourselves. If we were to buy these solutions at even an average cost
of 50 cents per 1000 c.c, our cost would be $15,697.50 per year. During the investigation of this problem we contacted various firms manufacturing solutions and found
their average lowest price to be at least 50 cents per 1000 c.c.
Because intravenous or interstitial medication is usually regarded as part of the
hospital treatment, no separate charge is made for it, so it is imperative that the cost
be as low as possible. In spite of this, no sacrifice of the availability, reserve, or sterility
can be made. We have, however, recently adopted a method by which we can lower
our costs still further. This is by capping and hermetically sealing flasks of solution
immediately on manufacture. Presumably, the flasks should then keep forever. Thus,
while still having a reserve, we would eliminate all discard. Practically, the flasks would
seldom be kept longer than a few weeks or a month because over the total scheme fewer
flasks would be used. If the Medical Board decides that the sealing of solutions in flasks
will give as perfect a solution as you have been using, we shall follow the lead of other
large hospitals on the continent, and adopt this method.
J. R. Neilson, M.D.
A busy surgical service affords and demands the exercise of considerable skill in
parenteral fluid therapy. One might even suggest that such a service should have some
very definite routine for the administration of this important form of treatment.
Remarks to be made concern entirely intravenous therapy as it is this form which
is in common use at present. The facts presented are those derived chiefly from a review
of the literature together with a few personal observations.
Hospital statistics in general show some very pertinent factors regarding fluid
therapy. Mortality rate among patients receiving fluid is definitely higher than in those
not requiring the treatment, and the more fluid given as shown by the patient's chart
the higher the mortality rate. One can always say that it is the patient most seriously
ill .who requires the administration of fluid, in varying amounts, but that as the whole
answer is open to debate. The pathologists find in their examination evidence of oedema
in bodies and in tissues where the only solution is that fluids have been given injudiciously, regarding the kind and the amount. To drown a patient is possibly worse
than to neglect his fluid balance altogether.
The physiological action of water, salt and glucose when taken into the body by
the parenteral group has been discussed and here we propose a clinical application of
these principles.
Water comprises approximately 65% of the total body weight. Water loss occurs
in three ways:
(1) Vaporization or evaporation from the skin surface in amounts ranging from
1000 to 1500 cc. daily with a practical average of 1250 cc.
Page 242 (2) Urinary excretion varies with the ability of the kidney to concentrate. It is
given as 500 to 1500 c.c. with an average of 1000 c.c. for 24 hours in normal health
from a renal standpoint.
(3) Loss by the intestinal tract is minimal and negligible when a normal bowel
routine is present and there is no vomiting.
Several dehydrations can cause a loss of as high as 6% of the total body weight,
which in a patient weighing 150 pounds would be a loss of 4200 c.c. of water. This
amount would be required to return him to a normal state of hydration.
Fluid loss in the operating room can frequently be considerable. This can be minimized by less coverings and draping and, of course, by an air-conditioned surgery. As
a general rule when fluid is given subcutaneously during an operation, an often neglected
procedure, the amount given serves only to replace that lost during the operation and
need not be considered in the calculation of the day's requirement except that the
amount of sodium chloride must always be noted and allowance made for this in the
further administration after return to the ward.
Fluid loss from the gastro-intestinal tract, stomach, bowel or gall-bladder, by suction or simple tube drainage, should always be carefully measured and recorded on the
chart, for a patient can easily become dehydrated from an intestinal fistula even though
what appears to be adequate amounts are being taken orally.
Chloride balance is the most important phase of the whole subject. Normal blood
chloride estimation is given as approximately 450 mgm. per cent and the average daily
required seems to be agreed upon as being 5 gm. as sodium chloride.
One frequently hears the statement that almost any amount of saline can be given
with impunity for the kidneys will excrete the excess. This fact holds true in health, no
doubt, but most writers agree that in the presence of disease chloride retention easily
and quickly occurs, and it is this we must remember. Jones and Eaton in a recent paper
have stated that oedema due to salt retention can cause obstruction in a gastroenterostomy stoma during the post-operative period. Other evidence such as pulmonary and
cerebral oedema are only too familiar to us.
Excessively high or low blood chloride content give symptoms similar to shock and
have an increased mortality rate. A blood chloride of 350 mgmi. per cent indicates a
severe condition of the patient.
Chloride administration guided by a daily blood estimation is an ideal method and
is necessary in a critical condition. A rule for the administration has been worked out
as follows: For each 100 mgm. fall in blood chloride one must give 0.25 gm. of chloride
per pound of body weight to bring the blood chloride to normal (450 mgm. per cent.).
To avoid the laboratory cost of this procedure a method has been evolved by Fantus
for estimation of the urinary chloride. This is a simple procedure which can be done on
the ward and is very useful in the estimation of the chloride balance.
Glucose in solution given intravenously should be regarded chiefly as a means of
supplying water and water should be thought of as glucose solution, not saline. In addition to the supply of water glucose solution provides readily available calories, protects
the liver and prevents ketosis.
Daily glucose requirement is considered to be 50 gm. and here an excess is excreted
by the kidney.
Regarding the amount which can be given, it has been definitely shown that in the
human 3000 c.c. of 5% glucose can be given over 24 hours at the rate of 300 to 500
c.c. per hour without evidence of spill-over in the urine.
A 5% solution of glucose is isotonic but the hypertonic form 10% frequently
used, is quite safe apart from the occasional vein irritation seen, and at times is quite
necessary. When 10% solution is used it is advisable to reduce the rate to 150 to 200
c.c. per hour to prevent loss by excretion in the urine.
Page 243
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Insulin administration to cover excess glucose is not considered practical.
Glucose solution given in saline, a common procedure, has no scientific basis whatever and is not recommended. It is not an isotonic solution but fortunately has a wide
range of safety. One writer has expressed his opinion that if we use this solution why
bother to have the saline isotonic just to upset it with the addition of glucose. This is
probably the easiest method of giving too much chloride which, as has already been
said, is the pitfall of intravenous fluid therapy.
A few examples of the prescribing of fluid for a 24-hour period in a typical hospital
patient are given:
1250 c.c.)      I
1000 c.c. ^4-hour amount.
1500 c.c.   (covered by interstitial?)
Post-operative Fluid Requirements
1.    (Average Case)
Loss by Vaporization,
Urinary Excretion,
Loss in operating room,
Daily chloride requirement,    5 gm.
Daily glucose requirement,    50 gm.
Therapy for 24-hour period:
Normal saline, 500 c.c. or NaCl. 5 gm. and water 500 c.c,
5% glucose 1750 c.c. or glucose 87.5 gm. and water 1750 cc.
In the post-operative 24-hour period the operating room fluid loss must be
compensated unless given there by subcutaneous route, and if this is done the
chloride content must be considered.
2.    Very Severe Dehydration
Adult, 150 lbs.  Blood chloride 300 mgm. %.
Water loss estimated at 6% is approximately 4200 c.c.
Daily fluid requirement 2,250 c.c.
Total Fluid Requirement 6450 c.c.
Chloride requirement
X  -25   X   150  : 25.25 gm. NaCl.
Normal Saline, 5625 c.c. or NaCl. 56.25 gm. and water 5625 c.c.
10% glucose 825 c.c. or glucose 82.5 gm. and water 825 c.c.
When such large amounts of fluid are to be given the estimation would
probably be better made on a 48-hour basis instead of 24.
3.    Post-operative Patient with Increased Metabolism
(Fever, hyperthyroidism, etc.)
Interstitial saline given in O. R.    1,000 c.c.
Vaporization loss (increased) 2,000 c.c.
Urinary excretion  _.       1,500 c.c.
Therapy for 24-hour Post-operative Period:
Fluid loss in O.R. has been covered with interstitial.
100 gms. Chloride has been given.
3500 c.c. water given as 5% glucose (not saline).
Hyperthyroid patients are usually given subcutaneous saline during the
operation and the amount frequently meets their chloride requirement for that
24-hour period, but they need water as glucose solution.
Page 244 4.   Patient with Fluid Loss from Gastro-intestinal Tract
Suction, Lavage, Drainage, or other loss    1,500 c.c.
Normal loss by vaporization 1,250 c.c.
Urinary excretion 1,000 c.c.
Total 3,750 c.c.
Therapy for 24-hour Period:
Gastro-intestinal tract loss replaced by normal saline    1,500 c.c.
5 gms. supplied by normal saline 500 c.c.
Glucose solution 5%   (glucose 87.5 gm.) 1,750 c.c.
A good rule to follow in the continuous suction cases is to replace the aspirated material with a like amount of saline and then proceed with the calculation in the ordinary way.
In conclusion, certain repetitions are justified and a few suggestions may be in order:
(1) Sodium chloride is a drug and merits the same respect as other commonly used
agents, insulin, digitalis, prontylin, etc.
(2) Glucose solution is a means of supplying water intravenously.
(3) Saline solution should be used alone and similarly glucose solution according to
their individual requirement.
(4) Loss of body fluid and their proper replacement is of utmost importance in the
care of the post-operative patient.
(5) For the patient requiring parenteral fluid therapy some one responsible person
should, after a study of the elimination chart and laboratory findings, write a prescription covering the next twenty-four hours and specify the amount of fluid, the kind, and
the time it is to be given.
Victoria  Medical  Society
Officers, 1939-40.
Honorary Secretary
Honorary Treasurer
Dr. A. B. Nash
Dr. D. M. Baillie
Dr. O. C. Lucas
Dr. P. A. Cousland
Now that the new agreement has been reached between the Victoria Medical Society
and the City of Victoria for the medical and surgical care of indigent patients, we are
happy to state that, although the negotiations were long, a satisfactory result has been
attained, and feel that the position taken by the medical men has been fully understood
by the members of the City Council. s^.
We are receiving, as before, a flat rate for the work done, and this agreement is to
remain in force until such time as one of the parties thereto may, for obvious reasons,
seek a revision of it; for which purpose two months' written notice is to be given by
either party.
It may be of interest to the medical profession in other parts of the Province to learn
that we are now receiving approximately 45 per cent of the amount of work charged
(minimum schedule of fees).
;||| DIAGNOSIS        |jg|; -
Dr. D. E. Alcorn, Dr. B. L. Newton
The presence of a neurosis in a case where surgical interference is being considered
complicates the picture.   Many surgeons are unwilling to operate at all in the presence of
a neurosis, while others proceed without considering the possible psychological factors
Page 245 '- .>
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which may enter into the picture.   It is our purpose here to outline briefly some of these
Surgery in the presence of a neurosis may have three effects:
1. It may not affect the neurosis at all, the neurosis being related to other factors. The
neurosis, it is true, may be more marked during the general lowering of body functions during convalescence, but it will return to its usual state as convalescence
2. It may have a definitely beneficial effect by removing factors which interfere with
the general health and hence the psychological functions of the individual. Foci of
infection play important roles as contributing factors in neuroses. The functions
of the thyroid, ovaries, and other endocrine glands are closely connected with the
personality. Even adequate treatment of flat feet may be followed by a marked
improvement in the social relations of the individual. In our opinion, however,
surgery should only be carried out in those cases where the physical and laboratory
findings are sufficient to justify surgical interference in any event.
3. It may satisfy some unconscious trend of the individual.    Some of these trends are:
(a) trends associated with the ego instinct:
(1) Desire to gain attention — these patients usually return again and again for
operation on various organs and then adhesions.
(2) Vindication — a patient who has been to a number of physicians and been
assured that there was nothing physically wrong and that his problem was
essentially psychological, will often show marked, even dramatic, improvement
after he has persuaded a surgeon to operate. The improvement is, however
rarerly sufficient to enable the patient to return to a normal life and is often
very temporary in character.
(3) As a means of gaining security—surgery is a proof of illness, which may increase
one's chances of gaining compensation, pension, or other form of economic
security. In our experience, however, this has rarely played a role, as the
patient feels that the doctor might remove a profitable condition.
(b) trends associated with the sexual instinct (masochistic trends).
Freud1 has a conception of what he calls the "death" instinct. This destructive
instinctual trend may be combined with sexual trends to give pleasure in pain and
injury to the body. Such trends are usually very thoroughly repressed, but manifest
themselves in loud complaints out of all proportion to the suffering one would expect.
These trends seem to be associated with the genitalia in particular, ^lale lunatics
often castrate themselves or injure their genitalia; while a great many apparently
normal women seek the removal of their ovaries and other genitalia.
The above analysis has proceeded entirely upon the supposition that it is possible to
segregate mind from body and tell which is which. In practice and in the vast majority
of cases however, such is not the case. Actually, mind and body cannot be separated2,3.
Aphasia, paralysis, etc., are associated with lesions in definite portions of the brain—
lesions in the frontal lobe gravely interfere with the social behaviour of the individual
by almost eliminating the normal manifestations of his "conscience"4'5; and lesions in
the hypothalamic area lead to loss of rage reaction and other changes in the emotional
responses of the personality6. On the other hand, the physiological changes associated
with hypnosis demonstrate the possibilities of psychological factors in physiological functions7.
Every symptom which the patient reports to the physician contains the patient's own
evaluation of his sensations. The patient receives these sensations, associates them with
something definite in his memory, and by this means identifies them; this being the
Page 246
Mil !■ process involved in perception. It is this perception that he reports to the doctor. Without perception only the most confused memory survives. Thus, the patient's own
memories and conceptions enter into the picture. This picture may be disturbed by the
instinctual trends and other purposes of the patient as listed above, or it may be disturbed
by fear lest the physician may have missed some disease. In these circumstances, the
patient centres his attention on that portion of his body and, in doing so, observes many
sensations which he does not ordinarily observe. These physiological sensations he frequently insists are pathological in character.
Philosophy has been unable to make the distinction between mind and body. All
our knowledge begins with sense 8"14; sense involves "being" 15-17, which when conceived
as actually existing by itself, has been called by some philosophers "substance" 18, 19,
the "absolute" 20, "Logos" 21, "God"22'28, or "Brahma"29. This "substance" has been
identified with "spirit"30"32 and with "matter"33, but most of the recent philosophers
prefer "reality" and do not wish to define it more clearly 34> 35. By logical process, in
scientific method or otherwise, we compare, differentiate, classify and organize these
sense experiences36"38; but such classifications remain inferences from sense experience.
Even the differentiation between time and space, formerly regarded as almost absolute
39, 40^ jjas now broken down. The same applies to mind and body. Even those philosophers who believe that they are separate entities are not prepared to tell us which is
which; nor is the psychologist, or the physiologist.
Conclusion: When physical and laboratory findings are sufficient to justify surgery,
it should be carried out even in the presence of a neurosis. When these physical and
laboratory findings are absent or equivocal, surgery should be avoided.
*Freud, S.: "New Introductory Lectures  on Psychoanalysis"  trans,  by  W".  H.  Sprott.     Hogarth  Press,
London, 1936, p. 133-134.
^Editorial, Journal American Medical Association, vol. 113, 1939, p. 503.
3Cobb, S.: "Review of Neuropsychiatry for 1939," Archives of Internal Medicine, vol. 64, 1939, p. 1332-
4Nichols, I. C, and Hunt, J. M.:  "Partial Bilateral  Frontal Lobectomy"   (case), American Journal of
Psychiatry, vol. 96, 1940, p.  1063.
5Bianchi, L.: "The Mechanism of the Brain and Function of the Frontal Lobe," trans, by J.  H. MacDonald.    E. and S. Livingstone, Edinburgh, 1922.
cWright, S.: "Applied Physiology," London, 1940, p .190-191.
7Bramwell, J. M.: "Hypnotism," Moring, Ltd., London, 1906, p. 74.
8Kant, I.: "Critique of Pure eason," trans, by J. M. D. Meiklejohn ,New York, 1900, p. 276.
9Hobbes, T.: "Leviathan," Rutledge & Sons, London, 1894, p.  15.
10Locke, J.: "Modern Classical Philosophers," Houghton Mifflin & Co., Massachussetts, 1924, p. 254.
"Berkley, G.: IDEM, p. 263.
12Hume, D.: IDEM, p. 309.
13Hegel: "Selections, Modern Student's Library/'Scribner & Sons, London ,1929, p. 70.
14Mills, J. S.: "A System of Logic," Rutledge & Sons, London, 1892, p.  10.
15Hegel: IDEM No. 12, p. 70, 104.
16Descartes, R.: IDEM No. 10, p. 123.
"Whitehead, A. M.: "Process and eality," McMillan & Co., New York, 1929, p. 228.
18Spinoza, B.: "Ethica," Modern Student's Library, Scribner & Sons, U.S.A., 1930, p. 94.
19Hegel: IDEM No. 13, p. 114.
Bradley, T. H: IDEM No. 10, p. 788.
^'Acts of Peter," "Apocryphal New Testament," M. R. James, Oxford, 1924, p. 335, ch. xxix.
^"Hermetica," trans. W~. Scott, Oxford, 1924, p. 237.
*"Ecclesiasticls," ch. xliii, 27.    "Old Testament Apocrypha," Revised Version, London, 1906.
24Spinoza, B.: IDEM No. 18, p. 103.
25Berkley, G.: IDEM No. 10, p. 205.
^egel: IDEM No. 13, p. 300.
^Hacckel, E.: "The Riddle of the Universe," trans, by J. McCabe, Watts & Co., London, 1934, p. 236.
Page 247
m, TP I1* 1
28Paulsen, F.: "Introduction to Philosophy," trans, by F. Thilly, H. Holt & Co., London, 1908, p. 232.
^Rig.  Veda, X-90,  quoted  in "Hinduism,"  M.  Williams,  London  Society  for  Promotion of .Christiaaj
. Knowledge, London, 1878, p. 30.
30Berkley, G.: IDEM No. 10, p. 279.
31Hegel: IDEM No. 13, p. 50.
32Paulsen, F.: "Ethics," trans, by F. Thilly, Scribner & Sons, New York, 1899, p. 219.
33Marx, K.: "Handbook of Marxism," V. Gollancz, London,  1937, p. 212 .
34Joad, C. E. M.: "Introduction to Modern Philosophy," Oxford Press, London, 1924, p. 6.
35HaEckel, E.: IDEM No. 27, p.  12.
36Hegel: IDEM No. 13, p. 98.
37Kant, I.: IDEM No. 8, p. 94.
^Mills, J. S.: IDEM No. 14, p.  13.
39Kant, I.: IDEM No. 8, p. 45.
40Hegel: IDEM No.  13, p. 70.
June 17 th to 20 th, Inclusive.
Dr. Perrin H. Long, Professor of Preventive Medicine, Johns Hopkins
University School of Medicine, Baltimore, Md.
Dr. R. M. Janes, Department of Surgery, University of Toronto, Toronto, Canada.
Dr. E. E. Osgood, Assoc. Professor of Medicine, University of Oregon
Medical School, Portland, Ore.
Dr. C. Frederic Fluhmann, Assoc. Professor of Obstetrics and Gynaecology, Stanford University School of Medicine, San Francisco,
Dr. R. R. Struthers, Professor of Paediatrics, McGill University, Faculty
of Medicine, Montreal, Canada.
Fee $5.00 Hotel Vancouver, Vancouver, B.C.
Information: Dr. K. J. Haig, 203 Medical-Dental Building,
Vancouver, B.C.
Always Maintain the
Ethical  Principles   of
the Medical Profession
Guildcraft Opticians
430 Birks Bid?.       Phone Sey. 9000
Vancouver, Canada.
Page 248


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