History of Nursing in Pacific Canada

The Vancouver Medical Association Bulletin: June, 1938 Vancouver Medical Association Jun 30, 1938

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 '*?*■%.
The BULLETIN
OF THE
VANCOUVER MEDICAL
ASSOCIATION
Vol. XIV.
JUNE, 1938
No. 9
In This Issue:
NEWS AND NOTES
ORGANISATION NEWS
SUMMER SCHOOL PROGRAMME, pp. 196-197
|| GOLF, pp. 204-5
INTESTINAL OBSTRUCTION, p. 213
SUMMER SCHOOL CLINICS: JUNE 21 to 24 INCL., 1938 BULKETTS
(With Cascara and Bile Salts)
. . FOR . .
Chronic Habitual
Constipation
BULKETTS POSSESS ENORMOUS BULK
PRODUCING PROPERTIES AND BEING
PROCESSED WITH CASCARA AND
BILE SALTS PRODUCE JbULK WITH
MOTILITY.
WE WILL BE PLEASED TO PROVIDE
ORIGINAL CONTAINERS FOR TRIAL
ON REQUEST.
Western Wholesale Drug
(1928) Limited
456 BROADWAY WEST
VANCOUVER   -   BRITISH COLUMBIA
(Or at all Vancouver Drug Co. Stores) THE    VANCOUVER    MEDICAL   ASSOCIATION
BULLETIN
Published MontIili/ 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.
Editorial Board:
Dr. J. H. MacDermot
Dr. M. McC. Baird Dr. D. E. H. Cleveland
All communications to be addressed to the Editor at the above address.
Vol. XIV
JUNE, 1938
No. 9
OFFICERS   193 8-1939
Dr. Lavell H. Leeson Dr. A. M. Agnew Dr. G. H. Clement
President Vice-President Past President
Dr. W. T. Lockhart Dr. D. F. Busteed
Hon. Treasurer Hon. Secretary
Additional Members of Executive: Dr. J. P. Bilodeau, Dr. J. W. Arbuckle.
Dr. F. Brodie
Dr. Neil McDougall
TRUSTEES:
Dr. J. A. Gillespie
Historian: Dr. W. D. Keith
Auditors: Messrs. Shaw, Salter & Plommee.
If §    SECTIONS v
Clinical Section
Dr. R. Palmer Chairman     Dr. W. W. Simpson Secretary
Eye, Ear, Nose and Throat
Dr. S. G. Elliott Chairman     Dr. W. M. Paton Secretary
Pediatric Section
Dr. G. A. Lamont Chairman     Dr. J. R. Davtes Secretary
Cancer Section
Dr. B. J. Harrison Chairman     Dr. Roy Huggard Secretary
STANDING COMMITTEES
Library:
Dr. A. W. Bagnall, Dr. H. A. Rawlings, Dr. D. E. H. Cleveland,
Dr. R. Palmer, Dr. F. J. Buller, Dr. J. R Davtes.
Publications:
Dr. J. H. MacDermot, Dr. D. E. H. Cleveland, Dr. Murray Baird.
Summer School:
Dr. J. R. Naden, Dr. A. C. Frost, Dr. A. B. Schinbein, Dr. A. Y. McNair,
Dr. T. H. Lennte, Dr. Frank Turnbull.
Credentials:
Dr. A. B. Schinbein. Dr. D. M. Meekison, Dr. F. J. Buller.
V. 0. N. Advisory Board:
Dr. I. Day, Dr. G. A. Lamont, Dr. Keith Burwell.
Metropolitan Health Board Advisory Committee:
Dr. W. T. Ewing, Dr. H. A. Spohn, Dr. F. J. Buller.
Greater Vancouver Health League Representatives:
Dr. W. W. Simpson, Dr. W. N. Paton.
Representative to B. C. Medical Association: Dr. G. H. Clement.
Sickness and Benevolent Fund: The President—The Trustees. Indications  for use of
Perfringens  (Gas  Gangrene) Antitoxin
Use of Perfringens (Gas Gangrene) Antitoxin is indicated in treatment of infections caused by B. perfringens (B. welchii). In the case of certain contused and
puncture wounds such as gunshot wounds, danger of
infection with B. perfringens is great and administration of Perfringens Antitoxin as a prophylactic is
recommended. Where gas gangrene is feared or has
developed as a sequela of such infections, prompt
administration of large amounts of this antitoxin has
been proved of definite value. Clinical observations
have shown the value of this antitoxin both before and
after abdominal surgery in cases subject to toxaemia
due to severe peritonitis or acute intestinal obstruction.
The value of the antitoxin has also been demonstrated
in treatment of gas gangrene occurring with puerperal
sepsis following abortion.
Information and prlces\ relating to Perfringens
(Gas Gangrene) Antitoxin as prepared by Con-
naught Laboratories, University of Toronto, will
be supplied gladly upon request.
CONN AU G H T 4 ABOR ATO RIE S
UNIVERSITY   OF   TORONTO
Toronto  5
Canada
Depot for British Columbia
Macdonald's Prescriptions Limited
MEDICAL-DENTAL BUILDING, VANCOUVER, B. C. VANCOUVER HEALTH DEPARTMENT
STATISTICS—APRIL, 1938.
Total Population—estimated I  259,987
Japanese Population—estimated ~  8,685
Chinese Population—estimated -  7,808
Hindu Population—estimated       335
Number
Total deaths    228
Japanese deaths        6
Chinese deaths 1      10
Deaths—residents only    190
BIRTH REGISTRATIONS:
Male, 165; Female, 171.-     336
INFANTILE MORTALITY : April, 1938
Deaths under one years of age        9
Death rate—per 1,000 births      26.8
Stillbirths (not included in above)        8
Rate per 1,000
Population
10.7
8.4
15.6
8.9
15.7
April, 1937
7
22.2
6
CASES OF COMMUNICABLE DISEASES REPORTED IN THE CITY
May 1st
to 15th, 1938
Cases Deaths
March, 1938
Cases Deaths
April, 1938
Cases Deaths
Scarlet  Fever    89           0 46           0
Diphtheria        0           0 10
Chicken Pox  327           0 211           0
Measles    25          0 9          0
Rubella        9           0 7           0
Mumps  106           0 36           0
Whooping Cough    41           0 33           0
Typhoid Fever      10 10
Undulant Fever      10 0           0
Poliomyelitis        0           0 0           0
Tuberculosis    38         17 33         15
Erysipelas      6           1 3           1
15
0
74
5
1
9
12
4
0
0
18
1
0
0
0
0
0
0
0
0
0
0
0
V. D. CASES REPORTED TO PROVINCIAL BOARD OF HEALTH,
DIVISION OF VENEREAL DISEASE CONTROL
Vancouver Hospitals and
Clinic private doctors Totals
Syphilis      45 23                       68
Gonorrhoea       47 23                       70
A PRESCRIPTION SERVICE • . .
Conducted in accord with the ethics of the Medical
Profession and maintained to the standard suggested by
our slogan:
Pharmaceutical Excellence
McG!ll 6 Ormo
FORT STREET (opp. Times)      Phone Garden 1196     VICTORIA, B. C.
Page 193  EDITOR'S PAGE
In a recent number of the Bulletin we had something to say about the
question of cancer organization in B. C, and enumerated some of the principles that we believed (and still believe) should govern such organization,
if the object at which we are all aiming—the effective control of cancer—is
to be realized in any adequate degree.
We gave the reasons for the faith that is in us that such organization
must follow certain lines. It must be honestly an entity apart from any
existing organization; it must not be an extension or annex of any hospital;
it must be provincial in scope, and not limited in any way to one locality;
it must contain provision for the education of the public about the measures
that they can and must adopt, in order to forestall and detect cancer long
before it has become active and a subject for radical, merely life-saving
action—such measures as periodical examinations and so on—and it must
also provide for the education of the medical profession, whose wholehearted
co-operation and sympathy it must command from the beginning. These
objects can only be secured through a genuinely self-contained organization,
representing freely and fully every section of the community. Any attempt
to corral it by any group, any selfish and self-seeking attitude on the part of
those who are directing it, will infallibly doom the whole affair to failure, or
at least very serious curtailment of its value and efficiency. This is not our
opinion, but is the sum of the advice given by all the leading workers in
cancer all over the civilized world.
Having said this, and we think it should be said, we would refer to the
progress being made by the B. C. Cancer Foundation; as our readers know
the history of this from the press, we will not dwell on it here. Suffice it to
say that a fifty-thousand-dollar gift has been made, on certain well-defined
terms and subject to certain well-defined conditions, amongst which are the
following:
That a gramme of the radium now available be processed forthwith and
made ready for use.
That a building now on Vancouver General Hospital property, on 13th
Avenue West, be remodelled .and equipped as the first unit of the British
Columbia Cancer Foundation (i.e., of a provincial organization).
That this be provided with essential hospital services, heat light, power,
as well as nursing services and social services, by renting or hiring these
from the Hospital.
That when further funds are available, this gift and the terms governing
it shall be subject to revision, with a view to the absorption of this unit into
the larger, provincial scheme. This will entail the construction of a larger
building elsewhere. It will also provide, as we understand it, for suitably-
equipped units in Victoria, the Interior and elsewhere, as envisaged in the
original plans of the B. C. Cancer Foundation.
There are other conditions, but these are fundamental to our discussion.
We are assured by those who have been named as directors of this new
unit that it is the sincere intention of themselves and their board that this
shall be a truly provincial scheme as outlined above, that it is emphatically
not attached to the Vancouver General Hospital nor in any way controlled
by it, and that at the earliest opportunity this unit will be absorbed, as stated,
into the larger plan.
We accept their statements, of course, without reserve, and welcome this
expression of policy from them. We cannot but ^sympathize, however, with a
number of those who have worked hard and long in the cause, and who are
Page 19k bitterly disappointed that the plans for which they laboured, and which they
honestly believed were the best, have apparently come to nothing. There have
been various points of view in conflict here, and one had to prevail. It is for
us to examine the existing situation in the light of the categorical statements
of policy referred to, and to see whether it may not still be possible to reconcile these conflicting views; whether it may not be the case that real progress
has been made, and that development of this scheme along what we believe
to be the right lines is yet fully possible and to be expected; finally to consider very carefully what is to be our attitude as a profession towards the
new venture.
In the first place, it must be admitted that a definite step has been taken
in the direction of action. For over two years there has been a sort of deadlock, and, whatever the reason may be, three grammes of radium have lain
idle; more important still, nothing has been done towards cancer organization,
or towards public education in the matter. We cannot but feel that it is rather
a pity that there have been three parallel organizations, each autonomous,
each quite sincere, and each with a slightly different point of view. Attempts
to correlate these have been in progress, and we think that there is much
promise in a suggestion made by Dr. B. J. Harrison, Director of the Unit, that
a single central body be formed to control the situation, in which each of
these three would be fully represented. We think that this should be effected
speedily, in the interests of all concerned.
Now, at any rate, there is action, and this will naturally appeal very
strongly to the public at large. We must not, any of us, do anything at this
juncture which, through apparent or real disagreement amongst ourselves,
would hold up progress and create an atmosphere of bickering and dispute.
And we are confident that, in saying this, we are in accord with the feelings
and intentions of those referred' to above, who, while they may differ in detail,
yet have only one desire, to see progress made in the control and conquest of
cancer. Here is an accomplished fact. For good or ill, this money has been
given, and is.being spent, for the purposes and in the way laid down. Those
responsible for its administration are bound to go ahead; they have no
alternative. They have asked us all for our co-operation and help in carrying
out the terms of this trust, and we must give them willingly and freely. The
public reaction will undoubtedly be all in favour of any scheme which offers
action and will improve the existing cancer situation—and we cannot leave
this feeling out of our reckoning.
Moreover, we can best secure our Objects by a true and sincere attempt
at a united effort. It is for all of us to put our whole weight behind what
progress has been made, to stay with it, and help with all our power to guide
this new venture along right lines. This can only be done if we are willing
to sink individual differences of opinion and work together.
The medical profession must get together as a unit in this matter, must
insist rigidly on the following out of certain well-considered principles, and
meantime must shew in every way its honesty of purpose, and its sincere
desire to give this new body every chance to make good. There is every reason
to believe that now that the ice has been broken and a start made, the going
will be easier. It is for those who control this present unit to adhere to the
policy they have stated to be theirs, and to carry out in full the promise they
have made. It is for the rest of us to help them in every way to fulfil their
present trust, and by no word or deed of ours to hamper the fullest develop-
men of this work. Working together, we should reach the objective at which
we believe we are all aiming— -the defeat of man's greatest enemy; the relief
of the most terrible suffering man can endure, and the fullest service to those
who depend on us all for the prevention, the control, and finally the conquest
of cancer.
Page 195 VANCOUVER MEDICAL ASSOCIATION
SUMMER SCHOOL, 193 8
Hotel Vancouver, June 21st, 22nd, 23rd, 24th.
PROGRAMME
9:00 a.m.
10
00 A.M
11
OOa.m
12
30 p.m
2
30p.m
8
00 P.M
9:
00 P.M.
TUESDAY, JUNE 21st
-Dr. Farquharson : "Anaemias of Iron Deficiency : Diagnosis and
Treatment."
-Dr. Spurling : "Painful Arm and Shoulder."
-Dr. Ormsby : "Mycotic Infections."
-LUNCHEON: HOTEL VANCOUVER.
Speaker : Dr. Andrew Hunter : "Edinburgh School of Medicine:
Historical Notes and Personal Recollections."
-CLINIC : ST. PAUL'S HOSPITAL.
Dr. Farquharson :
-Dr. Walters : "Types of Operation and Their Indication in the
Treatment of Lesions of Stomach and Duodenum."
-Dr. Spurling : "Surgical Treatment of Intractable Pain."
9:00a
10:00 a.
11: 00 a.
2:00 p.
3:00 p.
\ 8: 00 p.
9:00 p.
WEDNESDAY, JUNE 22nd
m.—Dr. Spurling : "The Epileptic Problem."
m.—Dr. Walters : "Obstructive Jaundice."
m.—Dr. Hunter : "Acid-base Balance and Its Disturbances."
(Part I.)
m.—CLINIC: Dr. Ormsby : "Skin Diseases."
m.—CLINIC : Dr. Spurling : "Head Injuries."
Both Clinics at VANCOUVER GENERAL HOSPITAL.
m.—Dr. Spurling : "Low Back and Leg Pain from a Neurological
Standpoint."
m.—Dr. Farquharson :   "Enlargement  of  the  Superficial  Lymph
Glands; Diagnosis and Treatment."
THURSDAY, JUNE 23rd
9: 00 a.m.—Dr. Ormsby : "Contact Dermatitis."
10:00a.m.—Dr. Hunter: "Acid-base Balance and Its Disturbances."
(Part II.)
11: 00 a.m.—Dr. Walters : "Preparation of Handicapped Patients for Surgical Operations."
AFTERNOON—GOLF TOURNAMENT.
Jericho Golf and Country Club.
S: 00 p.m.—Dr. Ormsby : "Pre-cancerous Dermatoses."
9: 00 p.m.—Dr. Farquharson : "Diseases of the Liver."
FRIDAY, JUNE 24th
9: 00 a.m.—Dr. Hunter : "Chemical Aspects of Pregnancy and Its Toxaemias."
10: 00 a.m.—Dr. Farquharson : "Leukaemia."
11:00a.m.—Dr. Ormsby: "Cutaneous Syphilis."
2 : 00 p.m.—CLINIC : VANCOUVER GENERAL HOSPITAL.
Dr. Walters : "Lesions of Biliary Tract and Stomach."
8: 00 p.m.—Dr. Hunter : "The Chemistry and Biochemistry of Sulfanilamide and Related Chemo-Therapeutic Agents."
9: 00 p.m.—Dr. Walters : "Surgical Treatment of the Diabetic Patient."
Page 196 VANCOUVER MEDICAL ASSOCIATION
SUMMER SCHOOL, JUNE 21st-24th
In this issue is printed the programme for the Annual Summe rSchool,
and a perusal of it will convince you that this year's "feast of good things"
is in no particular below the standard set.in former years. Although the
speakers are specialists in their own fields, they have undertaken to present
their topics in such a way as to particularly interest the General Practitioner.
The Summer School is an occasion that one cannot afford to miss. The
high standing of the lecturers, the wide diversity of the subjects presented,
to say nothing of the clinics held in the hospitals in the afternoons, assure
those who attend of a new stimulus in their work, and possibly some information as to new methods and concepts in the treatment of disease.
LECTURES.
Dr. Ray F. Farquharson, from the University of Toronto Department
of Medicine, will lecture on the following:
1. Anaemias of Iron Deficiency: Diagnosis and Treatment.
2. Enlargement of the Superficial Lymph Glands: Diagnosis and Treat
ment.
3. Diseases of the Liver.
4. The Leukaemias.
Dr. Andrew Hunter, also from the University of Toronto, Professor of
Pathological Chemistry, will speak from the pathologist's point of view, and
will deal with subjects which are receiving more and more attention today:
1. He will give two lectures on Acid-base Balance and Its Dusturbances.
2. The third lecture will be on Chemical Aspects of Pregnancy and Its
Toxaemias.
3. At the request of some of the local men he will give one lecture on The
Chemistry and Bio-Chemistry of Sulfanilamide and Related Chemo-
Therapeutic Agents.
Dr. Oliver S. Ormsby, Professor of Dermatology at the Rush Medical College, University of Chicago, will give four lectures on skin diseases. It is some
years since we have had a specialist in Dermatology and his four lectures will
be of wide interest:
1.   Mycotic Infections.
Contact Dermatitis.
Pre-cancerous Dermatoses.
Cutaneous Syphilis.
Dr. R. Glen Spurling, Associate Professor of Surgery at the University
of Louisville, Kentucky, states in a letter: "I believe the problem of Low Back
Pain is one of the most important ntew developments in the whole field of
neuro-surgery." One of his lectures will deal with this question. Although Dr.
Spurling specializes in neuro-surgery, his remarks will have great interest for
all who meet these difficult conditions' in everyday practice. His lectures are
as follows:
1.   Painful Arm and Shoulder.
The Epileptic Problem.
Surgical Treatment of Intractable Pain.
Low Back and Leg Pain from a Neurological Standpoint.
Dr. Waltman Walters, Professor of Surgery at the Mayo Clinic, Rochester, Minnesota, will bring practical advice for the surgeon, as well as speak
of some of the present-day methods of treatment of surgical problems. His
lecture on "Obstructive Jaundice" should prove most interesting, in view of
the recent reports on the use of Vitamin K in relation to Haemorrhage. Following are his four lectures:
1.   Types of Operation, and Their Indication in the Treatment of Lesions
of Stomach and Duodenum.
2.
3.
4.
2.
3.
4.
Page 19' 2. Obstructive Jaundice.
3. Preparation of Handicapped Patients for Surgical Operations.
4. Surgical Treatment of the Diabetic Patient.
CLINICS
Clinics, which are always such a popular feature at the Summer. School,
have been arranged as follows:
Tuesday, 2: 30 p.m.—Dr. Farquharson, at St. Paul's Hospital:
Diseases of Gastro-Intestinal Tract or of the Endocrine Glands.
Dr. McNair has promised to be responsible for suitable clinical material.
Wednesday, at Vancouver General Hospital:
2: 00 p.m.—Dr. Ormsby on Skin Lesions and Diseases.
3: 00 p.m.—Dr. Spurling on Head Injuries.
Friday, at Vancouver General Hospital:
2:00 p.m.—Dr. Walters : Lesions of Biliary Tract and Stomach.
Dr. Cleveland will be responsible for the clinic on Skin Diseases, Dr.
Frank Turnbull for the clinic on Head Injuries, while Dr. Schinbein will take
charge of the Surgical Clinic to be held by Dr. Walters. The visitors always
give generously of their time and knowledge at these clinics, which prove to
be of inestimable value to those who attend.
LUNCHEON
The Luncheon will be held on Tuesday, June 21st, at 12: 30 p.m., in the
Spanish Grill at the Hotel Vancouver. This is always a happy occasion when
men who have not met for a year or more have a chance to get together for
a chat. The Committee is very happy to announce that the speaker at the
Luncheon this year will be Dr. Andrew Hunter. Dr. Hunter is no stranger
in Vancouver, and has many friends here. This year, for his luncheon address,
he will depart from Medical Practice and Medical Economics and will speak
on "The Edinburgh School of Medicine: Historical Notes and Personal Recollections." He will illustrate his lecture by some suitable slides.
GOLF
Dr. Fraser Murray will have charge of the arrangements for the Golf
Tournament to be held on Thursday, June 23rd. The tournament will be
held at the beautiful Jericho Golf and Country Club. Special prizes will be
given for the various events and players are asked to register with the
attendant at the Summer School, in the Hotel Vancouver.
Vancouver players are especially urged to make a point of getting in
touch with players from out of town, to see that they have transportation,
and have a chance to meet some of the local players.
INFORMATION
Any further information regarding the Summer School may be obtained
from Dr. Frank Turnbull, Medical-Dental Building, or from the office of the
Vancouver Medical Association, Medical-Dental Building, Vancouver, B. C.
FEES
The fee for the Summer School, for the four days, including attendance
at all clinics, is $7.50.
CORRECTION!
Summer School Programme
At the request of Dr. Farquharson, his lecture at 9 a.m. on Tuesday morning, June 21st, will be on "Anaemias of Iron Deficiency; Diagnosis and Treatment" and not on "Jaundice," as is set out in the printed programmes. The
correction came too late for the alteration to be made in the programmes,
which have already been sent out.
Page 198 NEWS AND NOTES
June is "convention" month and there is no lack of entertainment of this
kind arranged for the medical men this year. Members of the profession on
the West Coast are particularly fortunate in this respect.
The American Medical Association will hold its Annual Meeting in San
Francisco on June 13th to 17th inclusive, and just prior to this meeting a
number of meetings of special groups have been arranged. Several Vancouver
men are making plans to go to San Francisco, either driving their own cars,
going by train or flying. Both rail and air services are offering special rates
and schedules for this meeting.
Among those intending to drive down are Dr. and Mrs. C. H. Vrooman
and Drs. G. H. Clement and D. E. H. Cleveland.
The Canadian Medical Association meeting, of which mention is made
elsewhere, will also meet in June. Dr. Wallace Wilson, Dr. G. F. Strong, Dr.
Earle Hall and Dr. M. W. Thomas are among those who will go east for this
meeting.
Dr. Hall will first attend the meeting of the American Medical Association
in San Francisco, then go to Halifax, where he will read a paper before the
Urological Section of the Canadian Medical Association.
The Annual Meeting of the Pacific Coast Oto-Ophthalmological Society
will be held in Victoria on June 20th to 24th inclusive. Headquarters1 will be
at the Empress Hotel, and Dr. J. W. Keys will have charge of local arrangements. Many of the members of the Eye, Ear, Nose and Throat Section of
Vancouver will attend.
The Annual Meeting of the Eye. Ear, Nose and Throat Association of
British Columbia will be held simultaneously with the' Pacific Coast Oto-
Ophthalmological Society in Victoria.
*      *      *      *
Dr. J. Stuart Daly of Trail has returned from a post-graduate tour of
Eastern centres.
Dr. J. Bain Thorn of Trail attended the Annual Meeting of the Council
of the College of Physicians and Surgeons on May 2nd.
!£ % *K ^
Dr. J. P. McNamee of Kamloops was in Vancouver on May 2nd for the
Annual Meeting of the Council.
* *      ♦      *
Dr. Osborne Morris of Vernon, who is the new member of the Council
representing No. 4 District, attended the Annual Meeting of the Council on
May 2nd.
sfc sfc sje $
Dr. S. Cameron MacEwen of New Westminster and Drs. Thomas McPherson and Gordon C. Kenning of Victoria attended the Annual Meeting of the
College of Physicians and Surgeons. |
* *      *      *
Dr. and Mrs. William Leonard of Trail have left for Great Britain. Dr.
Leonard will do post-graduate work in obstetrics and gynaecology.
* #      ♦      #
Dr. John G. MacArthur of Prince George has returned after several
months' post-graduate study in Eastern centres. He is reported in fit condition.
# * ♦ ♦
Dr. E. Aielo has been doing locum tenens during Dr. MacArthur's absence.
* *      *      *
Dr. Bruce W. and Mrs. Cannon of New Westminster are en route to Great
Britain and will be absent during several months. Dr. Cannon will do postgraduate study. Dr. L. R. Williams will be associated with Dr. F. R. G.
Langston during Dr. Cannon's absence.
Page 199 Dr. J. A. Shotton of Armstrong will be absent during the month of June.
Dr. A. G. Duncan will do locum tenens.
* *      *      *
Dr. H. P. Swan of Duncan will be away for several weeks. During his
absence Dr. G. F. Young will carry on the practice.
* *     ♦      *
Dr. W. Bramley-Moore will be away during several months engaged in
special work. Dr. R. D. Millar will do locum tenens.
* *      *      *
Dr. Norman H. Jones of Port Alberni and Miss Margaret Ruth Swanson,
R.N., of Swansea Lodge, were wedded on May 14th at Enderby. They have
the best wishes of the profession.
* *     *      *
Dr. J. A. Ireland of Kamloops travelled to Kelowna to attend the funeral
service of the late Dr. J. McK. Large.
* ♦     *      *
Dr. R. W. Irving of Kamloops has been off to Winnipeg to watch his ponies
perform. We will have a report on their standing.
* *      *     *
A letter from Dr. E. J. Lyon of Prince George announces his intention of
coming to Victoria for the Annual Meeting on September 15th, 16th and 17th.
t> t* H* *P
Dr. R. E. Coleman has been invited to Prince Rupert to open and operate
a clinical laboratory. He arrived on May 18th and is very busy setting up his
valued adjunct to practice at Prince Rupert.
* *      *      *
Dr. and Mrs. R. Geddes Large are leaving for England and Scotland on
June 15th, when Dr. Large will do post-graduate study.
* *     *      *
Dr. W. A. Drummond of Ashcroft is spending a well-earned vacation on
the Prairies.
* *      *      *
Dr. D. A. Dunbar of Vancouver is going to Great Britain to do special
work. Dr. John Brown will carry on the practice.
♦ V W *
Dr. Dorothy E. Saxton, wife of Dr. George D. Saxton, has registered
recently. She has done special work in Obstetrics and Gynaecology.
* *     *     *
Dr. Sidney G. Baldwin, formerly of Vernon, has recently returned from
Europe. While in England he did special work and secured a degree in
Obstetrics and Gynaecology to which he intends to limit his practice. He has
taken up offices in the Medical-Dental Building.
Dr. G. B. Helem of Port Alberni is on holiday in the South and Dr. H.
Smith is assisting Dr. C. T. Hilton pro tern.
♦ ♦ ♦ ,♦
Dr. E. K. Hough is temporarily associated with Dr. George T. Wilson of
New Westminster while the latter is having a bit of relaxation and the trout
are having a strenuous time.
♦ ♦ ♦ ♦
Dr. T. W. Sutherland is located in Revelstoke and is doing some of the
work formerly carried on by the late Dr. Hamilton.
* #      ♦      ♦
Dr. J. T. Lawson, formerly with Drs. McLean and Thorlakson in Winnipeg, is now associated with Dr. R. S. Manson in New Westminster.
* #      *      *
Dr. W. K. Blair, a brother of Dr. J. H. Blair of the Workmen's Compensation Board, has taken up practice in Nelson.
Pane 200 Dr. C. P. Jessop has joined the staff of the Sanatorium at Tranquille.
* *     *     *
Dr. E. S. Hoare is now established in Trail with the C. S. Williams Clinic.
* *     *     #
Dr. G. G. Stewart, formerly of Edmonton, is now registered in this province and resides at Cadboro Bay, near Victoria.
Dr. M. G. Archibald of Kamloops called at the office when in Vancouver.
♦ ♦ ♦ ♦ *
Dr. W. Moir G. Wilson is now associated with the Burris-Archibald group
in Kamloops.
lie ifc 3k ik
Dr. W. Truax of Grand Forks visited the office during his stay in Vancouver.
* ♦ ♦ ♦ ♦
Dr. Walter S. Turnbull has returned from a motor trip to Edmonton,
where he attended the graduation of his son-in-law, Dr. E. White, of Vancouver.
* *      *      *
Dr. Paul Phillips of Princeton was in Vancouver for a brief vacation. He
looks well.
Dr. Stewart A. Wallace of Kamloops attended the Board of Directors'
meeting on May 11th. He is getting ready for the Halifax meeting, when he
will read a paper to the Section of Urology, "Recurrent Bleoli Infection in
Women."
)k )k $ )fc
Dr. C. T. Hilton of Port Alberni came to Vancouver for the Board of
Directors' meeting.
* *      #      ♦
Doctors Gordon Kenning, Allan Fraser and Clyde Cousland of Victoria
attended the Board of Directors' meeting on May 11th.
* *      *      *
Dr. Gordon E. Wride of Hedley and Margaret Ann, daughter of Mr. and
Mrs. E. Barr Hall of Princeton, were married on May 21st. They carry with
them the sincere good wishes of the profession in British Columbia.
GREATER VANCOUVER HEALTH LEAGUE
At its Annual Meeting, held in May, the Greater Vancouver Health League
elected Dr. G. F. Strong as the new President. This choice augurs well for
the League, as its new President is si man of energy and imagination, and
is thoroughly keen and interested in all matters of health and medical organization. The Vancouver Medical Association worked in conjunction with the
League this year in the putting on of a Health Week. This was really a much
bigger success than appeared, and with public interest and support, if the next
Week receives the proper degree of preliminary preparation, will, without
any doubt at all, in the light of the lessons we learned this year, be one of
the outstanding events of 1939.
ANNOUNCEMENT
The Vancouver General Hospital announces to the medical profession that
it now has a completely equipped artificial fever therapy department in
operation, under the direction of a specially trained physician and graduate
nurses. For information regarding charges and treatments apply to the
Physiotherapy Department at the Vancouver General Hospital.
Page 201 OBITUARY
DR. T. C. ACHESON
DIED MAY 1st, 1938
One of the old-timers of the Vancouver medical profession passed
away recently in the person of Dr. Thomas C Acheson. He had been in
practice in Vancouver for well over twenty years, and all of this time
he lived and had his office in the same building on Kingsway. Some time
after he started practice there, he had the misfortune to lose both legs in
a car accident, and thereafter he walked stiffly, but so well with his
artificial legs, and with so little fuss, that many people were quite
unaware of his loss, and thought he had two normal legs. He took his
misfortune gallantly and did not let it disturb the equanimity of his being.
He was essentially a family physician, quiet, unassuming, and. always
ready to do his duty. He leaves a good name and a clean record.
Kequiescat in pace.
DR. JOHN McKAY LARGE
Dr. J. McKay Large of Kelowna passed away suddenly on April 28th,
following a brief abdominal illness.
An Appreciation
It is difficult to express the loss which the residents of Kelowna and
the members of the medical profession feel in the death of Dr. J. M. Large.
His friendly manner and cheery disposition endeared "Mac" to all who
knew him, and one can truthfully say of him what can be said of few
of us—"He was ever tolerant and good-natured."
The late Dr. Large was born in Carstairs, Alta., in 1906, later moving
to Cranbrook, B. C, where his parents, Dr. and Mrs. H. L. Large, still
reside. He graduated from University of Alberta in 193 0, and interned
in the Edmonton Hospital, the University of Minnesota Hospital, and the
Montreal General Hospital. In January, 1934, he began practice in
Kelowna, and in 193 6 he went into partnership with Dr. A. S. Underhill.
The sympathy of his many friends is extended to his wife, Monica,
whom he married in December, 193 6, to his mother and father, Dr. and
Mrs. H. L. Large, and his brothers, Dick and Fred. —R. E. W.
CANADIAN CONFERENCE ON SOCIAL SERVICE
A very important convention, that of the Canadian Conference on Social
Worki is scheduled to be held in Vancouver from June 21st to 23rd. This
conference will be very largely attended by representatives from all parts of
Canada and the United States, and their programme is a most imposing one.
Dr. W. H. Hatfield is the man in charge of the organization at this meeting,
and this guarantees that a tremendous lot of work has been done to make
the meeting a success.
There are several things in the programme of great interest to us as
medical men. For instance, a paper by Dr. Holmes of Essex County, Ontario,
on "The Medical Care of the Indigent," which will be an important contribution; also several papers dealing with mental hygiene, child problems,
round table discussions on these and kindred topics, and last but not least, a
discussion on Health Insurance, which will be led by certain men of international note, who will be laymen, and deal with the subject from the public's
point of view. It is a pity that the meeting conflicts with the Summer School,
but there will no doubt be opportunities to work in some of the more important
meetings or parts of them.
Details as to meetings, programmes, etc., may be obtained from Dr. G. F.
Davidson, Hon. Secretary, Welfare Federation, 1675 W. 10th Ave., Vancouver.
Page 202 VANCOUVER  MEDICAL  ASSOCIATION
ANNUAL MEETING, APRIL 26, 193 8
RETIRING PRESIDENT'S REMARKS
There are many lessons to be learned during a term of office as President,
but the one which has seemed most important to me is this: There is only
one way of seeing things rightly and that is to see them as a whole.
All things must come to an end. Tonight you elected your new President;
the die is cast; the old is out and you welcome the new. I bespeak for your
new Executive the same loyal support you have given the old. You have
chosen well in your new President, but your duty is not over. Don't say, "Here
is your job, go to it." Stay with him, help and counsel him if he asks for it.
The main reasons of failure of all governing bodies are' the indifference and
apathy of the people who put them in.
This brings me to another condition, one that more than one of your own
retiring presidents have remarked upon and even begged for action—the
indifference of our profession to the man on the street, the organized bodies
of lay people and the many groups of people who are asking for guidance on
their way to health. For want of timely care many have died of medicable
wounds. Our relations to the public are not as intimate as they should be.
People are, and have been, more and more turning to the quacks and dietitians for their many ailments. I know of one woman here in town whose
income from dietetic advice would make many of us green with envy. Sooner
or later these people come back into the fold and ask organized medicine for
the cure. Why not sooner? The laymen are reading every book they can get
their hands on and often they ask us questions that would puzzle even the
most highly trained physiologist or internist. They are determined to have
information. Why not from the leader in this who will tell them what is best
and most useful for them in their own particular case or condition? The for-,
mula for one does not fit all, and this is to be emphasized to them; that is
what we are for. A feeble body makes a weak mind. The education of lay
bodies and clear thinking on their part will be a great boon to us in the
coming fight, for I firmly believe that this present is the calm before the
storm, greater even than the squall we passed through a year ago. We did
more to raise our prestige in the last fight in the eyes of the thinking man
of the street than has been accomplished for many years. The public accept
only the value we place on ourselves. We usually find that men despise those
they do not understand or value.
The recent Health Week has brought many comments from the press and
laymen. For years they thought we didn't care, in spite of the Health Boards
and prevention campaigns. They seem (to think that we are out for the money
and as much as we can get out of their misfortune. We must convince them
that it is for their own good, and keep Jthem intelligently informed of the best
and latest in the treatment of diseases that affect them. But in nothing be
over-zealous.
In June there will be an international convention of social disease held
in the Hotel Vancouver. The live questions pertaining to Medicine, Public
Health and Health Insurance will be discussed. Are we ready to present our
side? We must be prepared to take our place, in fact, demand it, in the community in which we live; we must become a powerful organization of educated men to advise the powers what is best for the general public in matters
of Public Health—at the present time how often are we even considered?
I seem to see this organization—or are we organized?—as a group of individualists, each striving to do his owd job in the community, following his
own ideas and ideals. There is a grave danger of forgetting that whe ndanger
assails us from without, the hope is in organization and absolute loyalty to
the high ideal of our profession, the absdlute subjection of each individual
Page 208
-* or section for the common weal to face the gravest dangers. Now, I believe,
the greatest danger comes from within—in spite of the advance notices from
political circles of a new fight that will be on our.hands shortly. Let us stand
together in a firmer organization of men who will not sacrifice our rights,
ideals, or aims, at the behest of any political charlatan or misguided idealist.
The public is wise enough to follow scientific men, when they are agreed.
I cannot pass on without mentioning the various committees of your
organization—above all, your Treasurer, who has laboured long and faithfully among you. I have found him to be a tower of strength and a bulwark
against the inroads of the wolves of high finance that are in your organization.
Your Belief Committee is even paying dividends. I hope they may be
allowed to carry on for some time—a quiet, unostentatious group of men,
who work for you and never receive even a passing thought or thanks from
our individual members.
The Dinner Committee this year was all that is to be desired. The Dinner
and entertainment of last year set a high mark for the new committee to
aim at. In this I would plead that more men be willing to do their share.
Each year, year after year, we find the same loyal group working for your
enjoyment.
I wish this organization had an official greeter or committee of entertainment ; these men to meet our increasing number of distinguished visitors and
speakers. Vancouver is at crossroads of travel and will be entertaining more
and more famous men of medicine. We enjoy an enviable reputation for
hospitality from coast to coast second to none, and I am sure the high place
we now occupy your new Executive will carry on, never letting this Association down.
Lastly, the Executive you gave me last year has given constant help in
all emergencies and has been an unfailing source of comfort in the trials and
tribulations of the office of President.
Now I call upon your new President to carry on the ideals of this Association. I wish him a happy year and pledge to him my unfailing support and
loyalty during the year of his tenure of office.
G. H. Clement, M.D.
GOLF
As that well-known sport writer, Robert Louis Stevenson, once said, "It is
better to travel hopefully than arrive." The exact source of the quotation
has escaped us for the moment, but we think it was in his "Travels with a
Donkey," and we hope none of our readers will attach any personal meaning
to what we have to say in this present recital.
It was on May 12th, following one of the most unusual wet spells in our
history (only the gallant spirit of the voyagers prevented them from giving
up the idea altogether—that and the fact that one can always play bridge if
it rains, and that is as good a wajr of earning your way as any). We resume:
Some twenty-five or more 100% hremoglobinous Vancouver golfers journeyed
down to Seattle, on the very kind and hospitable invitation of our brethren
in those parts, with blood (white count nil) in their eye, intent on wiping ou€
some real or fancied insult. Some equally good sportsmen from Victoria also
made the trip.
By boat and bus and train they journeyed, under the captaincy of the
well-known (notorious, some call it) Joseph Bilodeau, and in due course
arrived at the first tee of the Seattle Golf Club, where they were right royally
entertained by their American cousins and friends. All day the battle raged,
and the divots flew, and back and forth the fortune of battle swung, so that
Seattle won in the morning, and Vancouver in the afternoon. The sky was
cloudless, clear-washed by the rain, and the air the sweeter therefor, the
greens were true, and this, the fifteenth anniversary of this international
event, was a complete success.
0 Page 204 Much credit for this is to be given to the genial Seattle skipper, Dr. Dan
Houston, whom everybody here knows. He was the guiding spirit in organizing the meet, and saw that everyone had a good time, and that the nineteenth hole, of alcoholic memory, was up to par.
According to Captain Joe Bilodeau, while it may be true that Seattle
won, technically speaking, it was no bloodless or easy victory, and Vancouver
acquitted itself right manfully. The challenge has been thrown down to
Seattle to come up here next year and give us our revenge, and they have
accepted it. It is hoped that the British Pacific Properties Golf Course will
be available for the meet, and we shall be able to give our friends a special
treat. The call has gone out for a large response to the request of Joe and
his fellows for specially good co-operation and support. "More sports, more
golf, more fun, more good fellowship and good feeling" is the slogan for next
year, according to Joe, and "so say all of us."
COLLEGE OF PHYSICIANS & SURGEONS OF B. C.
The Annual Meeting of the Council of the College of Physicians and
Surgeons of British Columbia was held in an all-day session on May 2nd.
Dr. S. Cameron MacEwen, last year's president of the Council, presided.
The new officers and Chairmen of Committees were named:
President: Dr. Gordon C. Kenning, Victoria.
Vice-President: Dr. W. E. Ainley, Vancouver.
Treasurer: Dr. L. H. Appleby, Vancouver.
Chairman of Legislative Committee: Dr. Gordon C. Kenning, Victoria.
Chairman of Committee on Economics: Dr. S. Cameron MacEwen, New
Westminster.
Health Insurance Committee: Chairman, Dr. Thomas McPherson, Victoria ; Vice-Chairman, Dr. Wallace Wilson, Vancouver.
Other members of Council are Dr. J. B. Thorn of Trail, District No. 5,
and Dr. Osborne Morris of Vernon, District No. 4.
Registrar and Secretary: Dr. A. J. MacLachlan.
Executive Secretary: Dr. M. W. Thomas.
The Committee on Economics will be enlarged to include members from
each district. This committee was authorized to add to its number.
The Council voiced its appreciation to the retiring member from No. 4
District, Dr. F. P. McNamee, for his valued services during three years.
BRITISH COLUMBIA MEDICAL ASSOCIATION
The Board of Directors of the British Columbia Medical Association held
its regular meeting on Wednesday, Maiy 11th, following dinner at the Hotel
Georgia.
Present: Dr. Gordon C. Kenning, President; Doctors George T. Wilson of
New Westminster, W. E. Ainley, P. A. Clyde Cousland and W. Allan Fraser
of Victoria, Wallace Wilson, G. F. Strong, C. T. Hilton of Port Alberni, F.
R. G. Langston of New Westminster, H. H. Milburn, Stewart A. Wallace of
Kamloops, A. H. Spohn, H. Carson Graham of North Vancouver, C. H. Vroo-
man, D. Murray Meekison, J. R. Naden and M. W. Thomas, Executive
Secretary.
Messages regretting inability to attend were read from Doctors C. H.
Hankinson of Prince Rupert, J. S. Henderson of Kelowna, F. M. Auld of
Nelson, Walter S. Turnbull of Vancouver, and D. E. H. Cleveland, out of city.
It was announced that application for making British Columbia a Division
would be made in writing to the General Council of The Canadian Medical
Association.
Proxies would be arranged that would make it possible for Doctors
Stewart Wallace and Earle Hall to serve on General Council.
Page 205 m A letter from the Vancouver Medical Association informed the Board of
the appointment of Dr. G. H. Clement as its representative to the British
Columbia Medical Association. Dr. Clement will serve on the Board after
the Annual Meeting in September, when Dr. N. E. MacDougall's term will
expire.
The name of Dr. Gordon Kenning of Victoria, President, was placed in
nomination as representative from British Columbia on the Executive of the
Canadian Medical Association.
Dr. G. F. Strong, member from British Columbia, reported on the April
meeting of the Executive Committee of the Canadian Medical Association
held in Toronto, dealing particularly with the proposed new Constitution and
By-laws, membership, the Royal Commission, the Journal, Hospital Department and Research Committee.
It was decided that steps be taken to amend the Constitution of the British
Columbia Medical Association to permit of the inclusion of sections. Certain
other changes in the Constitution and By-laws will be required and the
Committee will prepare these for presentation at the Annual meeting in September. Dr. Milburn, Chairman of the Committee on Constitution and
By-laws, said his committee will prepare the necessary resolutions.
Dr. G. F. Strong, Chairman of the Committee on Programme and Finance,
reported on the development of the proposed programme of lectures for the
Annual Meeting at Victoria. Dr. Clyde Cousland of Victoria reported that the
Committee on Local Arrangements had been appointed and were busy now
preparing for the special features and entertainment of the convention. Subcommittees have been struck and the spirit shown by the Victoria members
augurs well for success.
Committee on Cancer :
Highlights of this committee's report dealt with the development of—
1. The British Columbia Branch of the Canadian Society for the Control
of Cancer.
2. Promotion of educational programme for (a) Profession, (b) Layman.
3. A Sub-committee to for a Speakers' Bureau and provide not only
speakers but material for addresses, lay groups and public meetings.
Committee on Public Health :
Dr. A. Howard Spohn, Chairman, stressed the need of a full consideration
of the milk situation in this province and a firm stand being taken by the
profession on the supply, handling, distribution and consumption of milk. It
was hoped that the whole matter would be discussed freely by members at
the Annual Meeting.
Committee of Medical Education :
Dr. D. Murray Meekison reported on the effort to supply information t<
1. Pre-medical students;
2. Members interested in post-graduate education;
Effort made to place men in search of special work in contact with
certain centres and workers.
Dr. Walter S. Turnbull's report on behalf of the Committee on Maternal
Welfare dealt with the study of conditions in this province. A full report has
gone forward to the Committee of the Canadian Medical Association.
Page 206 PATHOLOGY OF DISEASES OF THE LIVER
AND GALL-BLADDER
[Read before the meeting of the Vancouver Medical Association, April, 1938]
Dr. H. H. Pitts
In dealing with the pathological lesions to which the liver and gall-bladder
are heir, I propose only to treat briefly the more common ones and show
microprojections of as many as we have characteristic sections of, and as
time will permit.
It is probably well to have some fairly definite plan upon which to formulate a paper, and consequently I will endeavour to adhere as much as
possible to the following: Congenital abnormalities ; circulatory disturbances;
degenerative changes and necroses; cirrhosis; inflammations; tumours, and
parasites.
The liver is the largest gland in the human mechanism, weighing on the
average 2% to 3 pounds, and although its functions are many and varied, its
cellular structure is relatively simple. It plays an extremely important r61e
in the metabolism of fats, carbohydrates and proteins, and in detoxication.
There are two distinct types of functioning cells in the liver, the liver cells
themselves and the reticulo-endothelial system cells or Kuppfer cells, which
line the sinusoids. It is considered that they are concerned largely in the
catalysis of haemoglobin and phagocytosis. An understanding of the mechanism of the former function is important in evaluating the whys and wherefores of the Van den Bergh reactions (direct, indirect and biphasic). McNee
explains these reactions on the hypothesis that the bilirubin is formed by
the breaking down of the haemoglobin, which, to gain access to the biliary
channels must pass first through the Kuppfer cells and then the liver cells,
and that the bilirubin is actually formed in the Kuppfer cells and not in the
liver cells. Some alteration of the bilirubin probably occurs in its passage
through the liver cells, the altered bilirubin giving the direct, the unaltered,
the indirect reaction. In obstructive jaundice there is a damming back of the
altered bilirubin, which is reabsorbed into the blood, the serum giving the
direct reaction. In hsemolytic jaundice more bilirubin is produced'than can
be absorbed by the liver cells and a residue of unaltered bilirubin that has
not passed through the Kuppfer and liver cells remains in the blood serum,
giving an indirect reaction. In toxic or infective jaundice there is a cholangitis
of the bile capillaries and degenerative change in the liver cells as well, so
that there is a damming back of bilirubin which may have been altered by
passage through still normal liver cells of reabsorbed and other unaltered
bilirubin because of the inability of the great bulk of damaged liver cells to
alter it, so that a biphasic reaction, a combination of the direct and indirect,
results.
Congenital Abnormalities
There may be anomalies in shape, chiefly in the form of lobulations, and
very rarely small accessory livers have (been found. The sagittal furrows on
the superior convex aspect or surface, the so-called Liebermeister grooves,
are a frequent finding at autopsy. These vary in depth and number but there
are generally not more than three and they are supposedly due to folding of
hypertrophied muscle bundles in the diaphragm, either as a congenital condition or as a result of emphysema. Occasionally the Riedel's or beavertail
lobe is seen in the liver, probably due to tight lacing and consequently a rarity
nowadays. Congenital cysts are sometimes associated with congenital polycystic kidneys, although in our own autopsy material we have not encountered them.
Circulatory Disturbances
Passive venous congestion, either acute or chronic, results generally from
cardiac or respiratory disease. This varies in degree depending on the progress of the initiatory lesion and may go on to definite pressure or cyanotic
atrophy of the liver cells, resulting in the characteristic "nutmeg liver," and
Page 201 the liver may be considerably reduced in size. This may progress into a condition where considerable periportal fibrosis occurs but not radiating out to
insulate masses of liver cells, as in typical periportal cirrhosis. Some of the
liver cells in less involved areas may undergo compensatory hypertrophy and
hyperplasia. This condition has been called "cardiac cirrhosis" by the French
writers.
Infarcts, i.e., aseptic ones, are a very infrequent finding at autopsy but
can be produced by embolism of the hepatic artery or portal vein. However
infected emboli from inflammatory lesions in the gastrointestinal tract,
probably most notably the appendix, a pylephlebitis may ensue with resulting
liver abscesses. Hepatic abscesses, of course, may be due to septic or bacterial
emboli in pyaemia, often acute vegetative endocarditis or subacute bacterial
endocarditis, or from a suppurative cholecystitis with cholangitis. The
amoebic abscess is usually single, but may be multiple, and is of course due to
the entamoeba histolytica. Fortunately it is not particularly common in this
country.
Necrosis and Degenerative Changes
Chief among the degenerative changes in the liver are the amyloid, fatty
and parenchymatous or cloudy swelling. The first, amyloid, a special protein
substance in colloidal solution, is deposited in the blood vessel connective
tissue, usually first in the intralobular artery, is seen quite frequently in
chronic tuberculosis, osteomyelitis and syphilis. The two latter are seen chiefly
in most acute constitutional infections such as pneumonia, typhoid, various
septicaemias, etc., and along with fatty degeneration might be mentioned fatty
infiltration. In this the fat is added, one might say, to the liver cell in response to need, while in fatty degeneration fat is thrown out of the protoplasmic emulsion and appears with appropriate stains as fine globules within
the cell membrane.
Eclampsia provides a very typical type of necrosis in the liver, characterized by haemorrhagic necrosis about the periphery of the liver lobules. In
acute yellow atrophy the necrosis is central, as it is also in chloroform poisoning, while in typhoid, pneumonia, diphtheria, etc., it is usually focal, i.e.,
scattered here and there.
Acute yellow atrophy may show three gradations, i.e., acute, subacute and
chronic. It may suffice to treat with the acute form briefly here. It usually
occurs in women during the middle or third trimester of pregnancy with an
acute onset characterized by nausea, vomiting, rapidly deepening jaundice,
delirium, coma and death. Haemorrhages into the skin and mucous membrane,
diminished urea output in the*urine and leucine and tyrosine crystals in the
urine are features. At autopsy the liver may be diminished by as much as
one-third its normal size, with a wrinkly capsule, has a soft either bright
yellow or deep red colour or mottled red on yellow background. The severe
cases are practically all fatal, but there are milder forms which recover and
progress to the chronic stage. Fortunately it is a relatively rare condition.
It has been reported as occurring in children and in males.
Cirrhosis
In Mallory's opinion five types of cirrhosis may be recognized: (1)
Atrophic (Laennec's, alcoholic) ; (2) Toxic (healed yellow atrophy) ; (3)
Biliary or Infective; (4) Pigment or Hsemochromatosis;  (5) Syphilitic.
One could almost devote a whole paper to the discussion of these various?
types but time does not permit of more than a hurried glance over this interesting group of lesions. The atrophic is the time-honoured "gin-drinker's
liver," although it has never been satisfactorily proven that John Barleycorn's potent brew per se has thus defaced the hepatic architecture. It is
associated with marked ascites, enlarged spleen, oedema, haemorrhoids, caput
medusae latterly and oesophageal varices, rupture of which frequently writes
the final chapter in the life of not only a disciple of Bacchus but even a pillar
of the church. Jaundice is usually late. The liver is generally small and hard,
but may be normal in weight and even heavier, its surface nodular, giving
Page 208 rise to the "hobnail liver" appellation. The microscopic picture is one of diffuse periportal fibrosis with lymphocytic infiltration and frequently fatty
infiltration and evidence of liver cell regeneration.
The toxic or healed yellow atrophy, biliary cirrhosis (subdivided into
obstructive and infective), are also of the periportal type, but in the former
the liver is not as small as in the atrophic type and there is marked degree
of what is spoken of as nodular hyperplasia, i.e., the nodular areas are larger
than in the atrophic type generally being about 2 cm. in diameter on the
average. Here there is usually the antecedent history of subacute yellow
atrophy. Obstructive biliary cirrhosis is usually due to obstruction by stone
in the common duct, carcinoma of the head of the pancreas or benign stricture
of the common duct. The degree of jaundice will be more marked and the
history probably significant. Ascites and other evidences of a more marked
portal obstruction is lacking but the spleen may be enlarged. The liver at
autopsy is usually normal in size or may be enlarged, surface smooth or
finely granular. The bile ducts are tortuous,' elongated and enlarged, and
microscopically an increase in periportal fibrous connective tissue and lymphocytic infiltration is evident. Infective biliary cirrhosis is uncommon but most
frequent in children, apparently due to cholangitis and pericholangitis.
Marked jaundice, but no ascites and a spleen sometimes quite markedly
enlarged, are features. The liver is considerably enlarged and smooth, dark
green in colour and microscopically shows-marked periportal fibrosis, lymphocytic infiltration, but only the peripheral cells of the liver lobules atrophy.
Hanot's cirrhosis is characterized by marked jaundice, no ascites, markedly
enlarged liver (often twice normal size) and spleen, fever and pain. The
liver is smooth or very finely granular, shows both a perilobular and intralobular fibrosis chiefly and well-marked fatty infiltration. Pigmentary
cirrosis is the type seen in haemochromatosis or "bronzed diabetes." Here the
presence of glycosuria with brownish pigmentation of the skin give the clue
to the underlying process. In this condition two pigments are deposited in
the skin, liver, pancreas and adrenals—haemofuscin or iron-free, and haemo-
siderin or iron-containing pigments. There is an accompanying diffuse fibrosis
or periportal type but it is fairly evenly distributed and the liver is smooth
and enlarged in the early stages. Syphilitic cirrhosis usually progresses to
the formation of gummata and the so-called hepar lobatum, which is due to
deep scarring and consequent irregular coarse lobulations. Microscopically
the cirrhosis is of a diffuse type, i.e., both intra- and peri-lobular. Clinically
there is usually ascites, epigastric pain, loss of weight and frequently jaundice, an enlarged, nodular liver, a picture almost impossible to differentiate
from a malignant process either primary or secondary in the liver. A positive
Kahn and the amelioration of signs and symptoms under antiluetic therapy
tend to establish the spirochaetal origin. Tuberculosis of the liver is seen
chiefly in the form of miliary tubercle's in generalized miliary tuberculous
infections, but very rarely large, solitary tubercle formations or tuberculomas
are found presenting as a caseous mas^ sometimes the size of an orange and
difficult to distinguish grossly from a gumma, and in truth it may be necessary to stain for tubercle bacilli to determine the exact nature of the lesion.
Actinomycotic abscesses in the liver are a very rare lesion and usually
secondary to intestinal actinomycosis. They appear as honeycombed, fairly
thick-walled masses, from the cut surface of which the yellowish, sulphur
granule actinomycotic bodies exude.
Tumours
A common finding at autopsy is a reddish purple, subcapsular structure,
generally on the antero-superior aspect, sometimes multiple and usually about
1 cm. in diameter but occasionally the size of a walnut and even larger. These
are cavernous hemangiomas. Generally speaking they are not productive of
any symptoms or untoward sequelae, but the large ones may, by trauma, rupture and result in fatal haemorrhage, intraperitoneally. About eight years
ago I performed an autopsy on a newborn infant which had died suddenly
Page 209 after a relatively normal delivery, and found the abdominal cavity filled with
blood, the source of which was a large cavernous haemangioma 4 cm. in
diameter on the anterior aspect of the right lobe of the liver, which had ruptured. Very occasionally hepatomas or benign encapsulated liver cell tumours
are found, but considerable controversy exists as to whether these may not
be localized areas of liver cell regeneration, notably the nodular hyperplasia
seen in chronic or healed yellow atrophy. Occasionally retention cysts, probably due to separation of newly formed biliary channels, are seen, and also,
rarely, cysts due to lymph-channel occlusion.
The liver is probably one of the most frequent sites for secondary
malignant growth, both carcinomatous and sarcomatous, in the whole human
mechanism, but these will not be described in detail, merely mentioned in
passing, and we will go on to a more detailed description of the primary
malignancies of the liver. Sarcomas, the spindle and round cell type, have
been reported but are very rare, while of the malignant tumours carcinoma
is the most common. In an organ so prone to pathological processes the incidence of primary carcinoma is relatively infrequent, especially in the white
race, but in the Oriental, and notably the Chinese, it appears to be a relatively
common lesion. During the past 17 years, 30 cases have been autopsied at the
Vancouver General Hospital, and of these 21 were in Orientals, 20 Chinese and
1 Japanese. Without exception a marked diffuse cirrhosis was found, and the
fact .that there is a well-defined regenerative process in cirrhosis may account
for this neplasia, i.e., the regenerative process progresses beyond its normal
limits into a frank neoplasia. These carcinomatous lesions develop from both
the liver cells and bile ducts, resulting in what are classified as hepatoma
and chOlangioma types respectively, the former predominating 24 to 6 in the
series of 30 cases previously mentioned. Loss of weight, weakness, anorexia,
vague gastrointestinal symptoms, ascites, possibly jaundice, cachexia and
enlarged liver are the usual signs and symptoms. The presence of these in an
Oriental should call to mind, as first choice in diagnosis, a primary carcinoma
of the liver.
Parasites
Ecchinococcus cysts are not as frequent in this country as they are in
Australia and Iceland, although in Manitoba, where a fairly large numbei
of Icelanders are resident, they are not uncommon. Pigs, sheep, dogs and marj
are the intermediate host. Occasionally at autopsy on Chinese we find fairly
large numbers of liver flukes in the hepatic and common ducts and gallbladder. These are somewhat lance-head shaped, flat greyish to yellowish
brown structures, on the average about 1.5 x .2 or .3 cm., and of the Clonorchis
Sinensis type. Infestation is thought to be through the eating of raw or poorly
cooked fish, the snail acting as the intermediate host. They may produce varying degrees of cholangitis, and in one case in our autopsy material at the
Vancouver General Hospital multiple cystic dilatations were present throughout the liver, the ducts dilated and filled with a purulent-appearing mucus.
It might be well to mention here what is termed "liver death." Consequent to
gall-bladder or common duct surgery or trauma to the liver there may be
marked and sudden collapse, and hyperpyrexia which comes literally like a
bolt from the blue, i.e., within 24 to 48 hours, or after four or more days. In
both types there is a marked degeneration and necrosis of liver tissue, but in
the second or delayed type, renal damage is associated. It is felt that death
is not due to shock, as it is too delayed for this, and there is not enough evidence of infection to account for the fatal termination. Experimental work
of Boyce and McFetridge, by causing subcapsular trauma to the liver, and by
obstructing the biliary system which was then suddely relieved, exhibited a
typical chain of the above signs and symptoms in rabbits. Their contention
is that the two types are degrees of the same process, and that owing to
pathological changes in the biliary system, the detoxifying function of tho
liver cells is impaired, the circulation is flooded with toxins which may pro*
duce early death by direct action on the liver parenchyma, or if not suffi-
Page 210 ciently toxic to the liver may damage the renal epithelium, with a subsequent
but delayed fatal termination.
Gall-Bladder
Complete absence of the gall-bladder is an extremely rare finding, while
reduplication or double gall-bladder is another rarity. I saw one of the latter
while in Cleveland. This has two cystic ducts and stones in both loculesi At
that time it was the only one reported with all of these factors present.
Complete embedding of the gall-bladder in the liver substance, reduplication
and absence of the common duct, and congenital atresia of the bile ducts
are some of the anomalies encountered.
Inflammations
Cholecystitis is the commonest affection of the gall-bladder. Usually the
streptococcus is the offending organism, but B. coli, B. typhosus and other
organisms may be the agents. The infection is haematogenous in origin chiefly,
but may be also lymphogenous from the hepatic lymphatics. Culturing streptococci from the gall-bladder is difficult owing to the inhibitory action of the
bile, but Wilkie has shown that culturing the sentinel gland is more successful. The symptoms of cholecystitis are too well known to need repetition here,
but they nevertheless are quite confusing at times. In acute inflammation the
gall-bladder is red, the wall may be somewhat thickened due to inflammatory
oedema and infiltration with polymorphs. There is generally quite extensive
desquamation of the mucosa and the process may progress to an empyema
and even necrosis and gangrene. In chronic cholecystitis the wall may be
more or less thickened, due to fibrous connective tissue increase and lymphocytic infiltration, the mucosa fairly well preserved or islands of epithelium
with intervening areas of desquamation may be the rule. Pressure from
stones may produce pressure atrophy with areas of ulceration which may
progress to mural abscesses or even perforation with resultant bile peritonitis.
When stones become impacted in the cystic duct more or less dilatation of
the gall-bladder may occur, the lumen being filled with a clear mucus secreted
from the lining mucous glands, giving rise to the mucocele or hydrops of
the gall-bladder. Cholecystitis is associated with stones in a large percentage
of cases, and while, as someone has said, "Gallstones are tombstones erected
to the memory of dead bacilli," some of these stones are thought to be metabolic and not infective in origin, notably the pigment and cholesterin stones,
although some consider that a low-grade infection probably is an adjunct to
the formation of even these. Infection, stasis and cholesterolemia form the
essential triad for cholelithiasis. It is not necessary to recall to your minds
the classical symptoms of gallstone coMc instituted by the passage of a calculus from the gall-bladder to the common duct. Cholesterolosis, or what is
more commonly spoken of as the "strawberry gall-bladder," is characterized
by a rather reddened mucosa flecked or studded with fine yellowish bodies
which are deposits of an ester of cholesterin in the villous-like projections of
the gall-bladder mucosa. In some veryichronic cases of cholecystitis the walls
may become markedly sclerotic and so adherent to the calculus mass that
the mucosa, or what remains of it, peels off in attempting to remove the
stones, and the gall-bladder may be almost lifted from its bed with but little
haemorrhage. Occasionally gastro- or duodeno-cholecystic fistulae may be produced due to ulceration of stones, usually a large one, by pressure atrophy,
through the adherent wall of the duodenum or stomach.
An interesting condition known as chronic cholecystitis glandularis pro-
liferans is sometimes seen, probably more frequently than is generally supposed, in which, either due to inflammation or congenital ectopia of the
mucosa, glandlike aggregations of mucosa are found deep in the submucosa
Or muscularis, where they may become cystically dilated and form tumour-
like masses which may even extend onto the serosal aspect.
In a certain percentage of cases calculi are present in the intrahepatic
ducts and these may be productive of many and varied symptoms and afford
very little hope from either medical or surgical therapy.
Page 211 In general, it is stated that the incidence of cholelithiasis is three to four
times as frequent in women as in men, parous and obese women in middle life
being the chief sufferers.
Syphilis may involve the gall-bladder in the form of a gummatous lesion,
but is very rare. Very rarely the tubercle basillus is the offender, either in a
miliary form or with large, caseous lesions difficult to distinguish grossly and
even microscopically without appropriate stains from the gumma. We have
had one such case in our surgical pathological material at the Vancouver
General Hospital. m
1 Tumours
Benign tumours are quite rare, and of these the papilloma and papillary
cystadenoma are the commonest. Of the malignant tumours, sarcoma is
extremely rare, while carcinoma occurs in 5 to 7 per cent of all carcinomas.
It occurs in two forms chiefly, the adenocarcinoma and squamous cell types,
the latter by metaplastic change of the columnar epithelium into the lower
scale squamous. The adenocarcinoma type may, due to excessive mucus production, present a typical so-called adenocarcinomatous structure. The fundus
and neck are the favored sites, but it may occur in any area, and in approximately 90 per cent of cases stones are present, a fact which is often used as
an argument in favor of chronic irritation as the basis of cancerous neoplasia.
The malignant process may also begin in the intrahepatic or common ducts.
Jaundice, usually painless, with vague gastrointestinal symptoms, are the
chief signs, and the condition must be differentiated from a carcinoma of
the head of the pancreas and large stones in the gallbladder which may, by
pericholecystic inflammation and thickening, produce obstruction of the
common duct. We have had three or four such cases in our autopsy material.
Metastases to the liver are early, and to both peritoneum and regional lymph
glands, the colloid and adenocarcinoma types being more liable to involve
the former than the squamous cell type.
In closing, I must apologize for the brevity (it probably does not seem so
to you) with which some of the pathological processes have been treated, but
the purpose of the presentation was merely to refresh your memories on
some of the lesions most frequently met with in the liver and gall-bladder.
#     WHERE THE TROUT ARE RISING
The time has come to talk of rivers, streams and lakes.
A prominent Eye, Ear, Nose and Throat specialist of Vancouver, clad in
strangely sporting attire, was seen dashing to the Nanaimo ferry with a fixed
expression which made the Rainbows in the upper reaches of the Cowichan
River shudder at the danger which lurked in every strange-looking fly that
fluttered before them during that week-end. These trout are not timid because
of their size; they are large, stout-hearted fish and wise in their generation.
But this worthy veteran placed that fly—was it a Haggard or the Service-
free?—so appetizingly on that stretch above the Gillespie Pool that it was
seized by the oldest and most experienced Rainbow in the river. It struck
with such vehemence that it imperilled both the fisher and the canoe—that
fast, whitened water is cold in May. An insistent fish and an equally determined angler—the fight was on; plenty of line—plenty of water—Cowichan
Bay twenty miles away—a worthy rod, a screeching reel—and so this battle
waged—a gain here and a run there—back and forward: all was tense—
the line—-the fisherman—and all was quiet but for the hum of the line—
tugging, straining—-all in fast current—would everything hold ?—the struggle
was grim—but—something happened—that sickening slackening of a taut
line—the rod straightened—more silence—too silent for words.
The exception proves the rule, "What the eye does not see, the heart does
not grieve." Too bad—that fish was not seen—but there was disappointment
which saddened the party. That wise old fish is still in the Cowichan and
awaiting the return of an angler who felt him but never knew him. Life is
just that way.
Page 212 INTESTINAL OBSTRUCTION
Dr. W. Le Roy Pedlow, M.D.
(Based on a study of the records of the Vancouver General Hospital)
Under the heading of this title, a great number of very different pathological conditions have been conveniently grouped. There are those of a
mechanical nature, including such conditions as volvulus, intussusception,
incarcerated hernia, strangulation by bands or adhesions, stricture of benign
or malignant origin, and obstruction by the impaction of foreign bodies.
Again, there are those of a nervous toxic nature to which the term paralytic
or adynamic ileus has been applied. This latter group conveys to all of us the
picture of a motionless distention of the intestine, with an absence of any
obstructive lesion. Finally there is a third group, known as dynamic ileus.
This is a physiological, defensive mechanism, and is due to inhibitory nervous
impulses. It is frequently referred to by our old country authors as "active,"
"protective," "inhibitory" or "physiological." An example of this type of
intestinal inertia is that to be seen associated with such conditions as renal
colic, fractures or dislocations, and certain disturbances of a psychic origin.
Its High Mortality.
While intestinal obstruction is about six times as rare as appendicitis,
yet on a basis of mortality it is about six times as fatal. Roughly, their respective mortalities are quoted as 36% and 6%. Until fairly recently it could quite
truly be said that neither in the diagnosis nor surgical care of obstruction
had modern medicine kept pace with the advances made in other abdominal
emergencies. Various reasons might be advanced in explanation of this. Many
factors tend to confuse and to complicate the picture. The initial lesion of an
obstruction may vary enormously in its severity, even to the extent of being
much more lethal than almost any of the other peritonitic emergencies. For
instance a mesenteric thrombosis, a hernia through the foramen of Winslow,
or a volvulus of sizeable proportions could be decidedly more serious than
any of the other abdominal emergencies with the possible exception of acute
haemorrhagic pancreatitis.
Again by contrast, the early symptoms may be so obscure, or so indefinite,
that even the boldest surgeon is inclined to await more definite indications
for interference. Too often, also, there is an unwillingness on the part of the
patient to appreciate that an alarming condition of the greatest urgency has
arisen, with a resultant delay, while soap-suds, milk and molasses, soda bicarbonate, or this or that favoured enema is being repeated.
How often'do we see such acute abdominal conditions as acute perforations or ruptured ectopic long delayed in their rush to the hospital? The
marked tenderness and rigidity of the former, the collapse and pallor of the
latter, are such outstanding objective signs that hospitalization is the first
consideration.
Finally, any operative interference for an obstructive lesion usually
results in a more extensive laparotomy, often with an unavoidable amount of
handling of hypersensitive viscera. The operative shock is consequently out
of proportion to what might be expected with the average abdominal
operation.
These various points may in a measure explain why it is that, in a survey
of the various acute abdominal conditions, the "duration of symptoms" in the
cases of intestinal obstruction is so far in excess of that in other abdominal
emergencies. They are also suggested as a few of the variQus reasons explaining the high mortality of acute obstruction." A mortality which is between
30% and 40% is unnecessarily high for any illness in which such an outcome
is not absolutely inevitable."
Symptomatology.
The diagnosis of an acute obstruction must be made from a study of the
history, and of those various phenomena which form a fairly characteristic
symptom complex. Clinically these may vary considerably, chiefly according
Page 213 to the location, or to the underlying cause of the obstruction. Usually they
appear with dramatic rapidity—"a bolt from the bhie"—pain, vomiting,
shock, collapse following one another in hurried succession. This is especially
true in those conditions where there is not only an obstruction to the faecal
stream but where there is an embarrassment of the circulation of the segment
of bowel involved. A patient may survive for days or even weeks, the arrest
or imprisonment of the faecal stream, but his downward course Will be rapid
and eventful if the circulation, particularly the venous circulation, has been
shut off.
Pain: Pain is almost a constant symptom. It is not relieved by enemata,
it persists as a steady, constant pain, frequently with exacerbations of a
colicky nature, as the bowel above vainly struggles and strives to overcome
the blockade. In small bowel obstructions it is usually referred to the umbilical area, and to the hypogastrium when the large bowel is involved.
Vomiting: Many of our surgical text books emphasize faecal vomiting as
a sign of obstruction. In reality it should be regarded not as a sign, but as an
end result. It will vary in character and urgency with the location and with
the rapidity of the onset of the obstruction. With obstructions in the upper
jejunum there will be an earlier and more violent type of vomiting; not so
when the obstruction is low down, as for example in the sigmoid. Here, for
several reasons, chiefly owing to the larger capacity of the bowel above the
obstruction and to the inherent abiltiy of the colon to distend, vomiting comes
on later, and does not attain for some time the urgency associated with
obstructions at the higher levels. It is in this group that, after a series of
vomiting spells with the vomitus gradually deteriorating in character, we
ultimately get truly faecal vomiting. #
Constipation must ultimately be constant and complete. Enemata are
returned clear. It is always well to remember, however, that the bowel below
the obstruction is physiologically as well as anatomically normal, and will
often expel an enema with the return of some gas or faeces.
Examination of the abdomen may yield considerable information. Active
peristalsis may be seen, or a localized mass observed. Distention, which is
entirely absent during the earliest stage, becomes a steadily progressive
symptom, and is of itself a very important sign. Gentle palpation may disclose
a tumour mass or indicate the presence of an intussusception. More often it
helps us to rule out—by a process of elimination—other acute conditions.
Abdominal auscultation is a much neglected custom and will often'yield some
valuable information. To quote: (Burgess Manchester) "The contrast between the turbulent gurgling sounds of mechanical obstruction and the
death-like silence of paralytic ileus is indeed marked."
Shock and collapse form a part of the terminal picture, and many who
have contemplated them in sad reality need not be reminded of their grim
actuality.
The disturbed physiological functions associated with intestinal obstruction, and the various theories that have been evolved in their explanation,
form a very interesting study. They are, however, beyond the bounds of a
paper we hoped to make of practical value.
X-Ray Examination.
While from time to time some doubt has been cast upon the value of an
x-ray examination in intestinal obstruction, it is now quite generally conceded
that in the hands of a careful, experienced radiologist such examinations are
of the utmost value. The x-ray findings will often be evident before the clinical
findings are definite. I believe that if we were to make use of x-rays more
frequently in the doubtful cases pre-operatively, in the obvious case as a
means of localizing the obstruction, and as a check on the post-operative case
showing evidence of ileus, it would definitely tend to lower our mortality rate.
Page 21 )t
-„ Treatment.
Before making any comment on treatment I wish to assure you that I
shall not emphasize the thread-worn admonition of authors the world over
that "early diagnosis and early surgical intervention is the essence of treatment." As an axiom it cannot be questioned, but if in your need you are
searching for a little practical assistance, such a truism is of little help.
Fortune presents such favous all too rarely. Far too rarely. Too often neither
the diagnosis nor the interventions will be early.
We may best consider treatment under pre-operative, operative and postoperative headings. Early cases, particularly those of a mechanical nature,
may of course be hurried through with every reasonable hope of a perfect
result. On the other hand, delayed cases, especially where symptoms of
obstruction, such as vomiting and dehydration, are pronounced, will usually
die within a few hours if operated upon as soon as they are admitted to the
hospital. The restoration of the chloride balance by a liberal use of intravenous salines, and gastric or upper intestinal drainage, will often convert a
poor risk into a reasonably fair one.
Operative Treatment: Of the operation itself, there are several points that
it is always wise for us to bear in mind. It has been said that "a sound old rule
is to regard the caecum as the cardinal landmark of the operation. For not only
does a full distended caecum point to an obstruction lower down, but an empty,
collapsed, contracted caecum is the proper place to start investigation for the
source of obstruction in the small bowel."
Bands as a cause of obstruction are more commonly due to appendicitis
than to any other cause, and again direct our attention to the right lower
quadrant.
In strangulated obstructions, where the bowel is no longer viable, exteriorization of the involved segment should be the procedure of choice. Resection of gangrenous bowel with primary anastomosis not only prolongs the
operation but increases the hazard. In very late cases, a blind caecostomy or
ileostomy under local or spinal anaesthesia may be a measure of necessity.
Speed in any operation for obstruction is essential, yet every care must
be taken to avoid any undue exposure or handling of the intestine. To allow
many coils of bowel to escape from the abdomen during the operation is to
expose the patient to grave risk, both from shock at the time and the danger
of subsequent ileus.
The Post-Operative Treatment: This period is of equaLor greater importance than either of the other two. It is here that the battle is often won or
lost. 2,000 to 4,000 or even 5,000 cc. of saline or glucose and saline mayr be
indicated. Plain glucose solution 5% to 10% may be used to replace one or
more of the daily saline injections once the^chloride balance has been re-established. Repeated injections of glucose solution without the addition of
saline is not rational therapy in the post-operative treatment of obstruction,
as, without the addition of saline it dilutes the blood temporarily, causes an
increased excretion of salt through renal stimulation, with the result that the
blood is much poorer both in electrolytes and in its fluid content. Continuous
suction is now recognized as an indispensable routine in all cases where
vomiting or distention is present.
A blood transfusion during the first 24 hours is wonderfully supportive
treatment. It may often be repeated on the second or third day with advantage.
The liberal administration of morphine is essential. Sufficient should be
given to assure physiological rest, not only of the general nervous system,
but of the gastro-intestinal tract as well.
Fowler's position is more comfortable; it relaxes the abdominal muscles
and permits peritoneal fluid to gravitate to more innocuous sites.
Page 215 Purgatives must be withheld. They tend to accentuate intestinal inertia.
They are indicated when, and only when, there is a return of normal intestinal activity.
Hypertonic saline solution, acetylcholine, eserine, and pituitary preparations each have a place in post-operative treatment. Personally I feel that at
the present time they are being used most indiscriminately, often without any
proper understanding of the underlying physiological effect they are intended
to achieved. Used injudiciously at any and all stages of the post-operative
period, they will often have the effect of causing still further fatigue to an
already worn-out bowel muscle.
As a basis of a study for this paper a review of all obstructive cases
admitted to the Vancouver General Hospital during the past five years was
undertaken. The diagnosis of intestinal obstruction appears either as the
primary cause of their admission, or as a contributing complication arising
during the period of their hospitalization. A total of 290 cases are recorded,
and in order to summarize these findings as concisely as possible, I have prepared a few slides outlining some of the more salient findings.
Slide No. 1
SUMMARY OF INTESTINAL OBSTRUCTION
Vancouver General Hospital, 1931-1936
Cause
Sex
M. I   F.
Age
Site
S.B.IL.B.I
Days or hrs.
Duration
<-<
o
1
• i—i
03     .
t
"H
(^
0
c   *-.
a> oq
4)
4->   rl
rt "SQ
i-S
< a
Intussusception
8
2% months
to 20 years
Av. of 8:
13 hours
10
Volvulus
9
1 month to
81 years
11
Av. of 12
32 hours
Carcinoma
Inguinal Hernia
Femoral Hernia
17
42
41 to 75 years
Av. 58 years
6     16
Chronic
Indefinite
13  10
1  2 mths.-93 yrs.l 42 I 1 | 1 to 2 hrs. to I 39  4
80% over I 8 days
40 years 1 over 24
7  I
14     44 to 79 years    21
I Av. 59 years
1 to 2 hrs. to    21
4 days
6 av. 24 hours
Intussusception : 10 cases— ages 2^ months to 20 years; 75% occurring
during the first few years of life. Reduction was possible in all cases. Anastomosis performed in one. It is interesting' to note the duration of symptoms in
these cases—an average of 13 hours for 8 cases in which a fairly accurate
estimate could be made from the history. This is no doubt one of the chief
explanations for the satisfactory results, which will be shown on another
slide. No deaths.
Volvulus: 16 cases—9 male, 7 female. These cases occurred chiefly during
volume of gas, faeces and pus which escaped on incising the mass in the groin,
for 75 cases, 48.15. Freeing adhesions, 69; enterostomies, 26; anastomosis, 10:
anastomosis, 2 : resection, 1.
Carcinoma: Those causing obstruction: 25 cases—17 male, 8 female: 41
to 75 years, with an average of 57. Site: small bowel, 6 cases; large bowel,
16 cases; 3 not stated. Enterostomies, 13; anastomosis, 10; resection, 6.
Inguinal hernia: 43 cases—42 male, 1 female; ages, 2 months to 93 years;
80% over 40 years. Site: 42 small bowel. Duration: 1 or 2 hours to 8 days.
Reduction, 39; enterostomies, 4; resection, 1.
This one case of 8 days come under my care on the staff—an elderly
Chinaman with a Rickers type of hernia, and if one might judge by the
Page 216
I      a
6
Vent. P.O. and
Int. Hernia
5
6
3 months to
85 yrs.
10
1
Indefinite
1    8
2
1
....
Total 126
88
38
90
23
85
24
13
8 volume of gas faeces and pus which escaped on incising the mass in the groin,
there could be little doubt that the history of 8 days was quite correct.
Femoral, ventral, post-operative and internal hernia show nothing of
unusual interest.
Slide No. 2
SUMMARY OF INTESTINAL OBSTRUCTION
Vancouver General Hospital, 1931-1936
Freeing
Adhesions
Enterostomy SB. LB.
Anastomosis
Hi
c
Cause                 |     Sex
| M. |  F.
1          Age
Site        Days or hrs.
S.     L.        Duration
00!
Acute intestinal          56 1 50
obstruction
1
1
1 yr. to 85 yrs.
62 1 14
6 hrs. to 6
days
Av. of 75
cases: 48.15
hours
69
26
10
«
Foreign Body Obstruction:
Gall Stones 2 Watermelon Seeds.
Obstruction by Bands or Adhesions	
Seaweed.
671
Secondary Operation for Obstruction:
17 cases: 1-5 days P.O.; 6 cases 7-14 days P.O.
Duration of Symptoms:
Living (48), 39.8 hours; Dying (27), 59.5 hours.
Acute Intestinal Obstruction:
Total, 106; Mortality, 37.
Mortality Divided into Two Groups:
Peritonitis '  23
Appendicitis 1 15
Pelvic and Post-Part    4
Diverticulitis 2
Empyema of G.B.    2
Bands or Adhesions  14i
Acute intestinal obstruction: 56 male, 50 female; age 1 year to 85 years.
Site: small bowel, 62; large bowel, 14. Duration: 6 hours to 6 days; average
for 75 cases, 48.15. Freeing adhesions, 69; enterostomies, 26; anastomosis, 10;
resections, 5. (It is interesting to note that where such major procedures as
anastomosis or resections were undertaken the mortality rate was over 50%.)
Foreign body obstructions: Gall stone, 2; watermelon seeds, 1; seaweed, 1.
Obstruction by bands or adhesions: 67.
Secondary operation for obstruction: 17 cases, 1-5 days P.O.; 6 cases, 7-14
days P.O. /
Note particularly the duration of symptoms. In 75 cases it was possible
to estimate from the history the time of onset and to arrive at a reasonable
estimate of the duration of symptoms' prior to operation. Of these 75, 48
survived, their average duration being 39.8 hours. Of those dying, 27 showed
an average duration of 59.5 hours.
Surely when we consider obstruction on a basis of these figures, is it not
reasonable to hope that a diagnosis should be arrived at and some active
surgical measure undertaken during that first 40 hours?
Total number of acute obstructions, 106, with'a mortality of 37. These 37
were further divided into two groups, viz.—those having acute peritonitis
(of infective origin) as the cause of obstruction, 23; and those following the
more definite mechanical obstructions such as bands, adhesions, etc., 14. The
23 cases of acute peritonitis were further subdivided as shown on above slide.
Fifty-eight additional cases: This last group was a rather interesting one
—really the culls of the survey, as none of these cases came to operation.
Many of them were older people, 50% being over 60 years of age. The his-
Page 211 tories in several cases were interesting—cases admitted with well marked
symptoms of obstruction, and yet relieved without operation. Others developed obstructive symptoms as a complication of some surgical procedure
other than abdominal—as for example 3 cases of paralytic ileus following
the reduction of fractures of long bones.
Slide No. 8
SUMMARY OF INTESTINAL OBSTRUCTION
Total Number Operative Cases I 232
Site : Small Bowel, 152; Large Bowel, 37;
Not Definitely Stated, 43.
Sex: Male, 144; Female, 88.
58 Additional Cases recorded as Obstruction, No operation:
Lived 44; Died, 14.  50% of this group over 60 years
of age.
Total number of operative cases, 232. Site: Obstruction localized to small
bowel, 152 cases; large bowel, 37; not stated, 43. Sex: males predominated
by a ratio of about 5 to 3—144 males, 88 females.
I had the opportunity of seeing one of these cases, a young man, 30-35
years of age, who had had a fractured femur, surgical neck, reduced under
general anaesthesia and a plaster spica applied. It was on the third day postoperative that I was asked to see him and he than had a rapidly developing
ileus—pain, faecal type of vomiting, increasing distention—in fact so much
so that the window in the cast had been enlarged twice and the abdomen still
looked as thought it were trying to herniate through the opening. The doctor
was seriously considering removing the whole cast. However, the patient
responded promptly to deflation by continuous nasal suction and rectal
syphonage, morphine and intravenous salines.
Another interesting case of a hernia through the foreamen of Winslow
occurred in this group. This man, a mining engineer, steadfastly refused to
consider operation, even though the diagnosis was definitely confirmed by
x-ray. He also refused to die, and after a month's observation was discharged
from the hospital, only to die six weeks later in a mining town up country.
The local doctor obtained permission to do an autopsy and confirmed findings.
Of the 14 who died, a number were admitted very late and were considered inoperable. Two or three refused operation; others had complications,
as uraemia, pelvic cellulitis, and in one or two cases, it appears, the diagnosis
was made by the pathologist.
Slide No. 4
SUMMARY OF INTESTINAL OBSTRUCTION
Cause
No. of
Cases
r
Lived
Died
Mortality
Intussusception 	
Volvulus -  -
10
16
25
43
21
11
106
10
10
17
33
20
5
69
0
6
8
10
1
6
37
0
37.5%
Carcinoma  	
Inguinal Hernia  	
Femoral Hernia	
Vent. P. 0. Internal	
32   %
23   %
5   %
54   %
Acute Intestinal Obstruction ...
34.3%
Totals  	
232
164
68
29.3%
This slide summarizes the results of 232 cases operated on during the
stated five-year period. The mortality rate of 29.3% compares quite favourably
with those from larger centres both in America and in Europe. Undoubtedly
the mortality rate of acute obstruction has improved very appreciably during the past 10 years. I believe we may look forward to a still greater improvement during the next ten years.
Page 218 In conclusion, I should like to leave you with the thought that a new
conception of intestinal obstruction is gradually developing.
As a result of better pre-operative and post-operative treatment, directed
towards the correction of a perverted blood chemistry, a notable advance has
been achieved.
Again, continuous suction has been the means of saving many lives, not
only by lessening the number of those coming to operation, but by improving
the risk, of those requiring surgical interference.
The increased use of spinal anaesthesia, and the more frequent use of
x-ray as a diagnostic measure, are also proving an important factor.
Finally, there is a definite trend on the part of the surgeons to restrict
surgical measures to such measures as are only essential to obtain relief of
the obstruction.
I wish to express my appreciation to Dr. B. J. Harrison for the x-ray pictures and their interpretation which had been appended to this paper. Also to
Dr. George Elliott for his generous assistance in reviewing the histories summarized in this survey.
Graduate Male Nurses9 Association
1 OF BRITISH COLUMBIA
Approved by the Vancouver Medical Assn.
This organization, the only one of its
kind in Canada, has Graduate Male
Nurses available in Vancouver, or any
part of British Columbia.
All Enquiries Carefully Attended to.
16 West 5th Ave. Phone: Fair. 3794-Y
YOU GET
ALL THREE IN ALL-BRAN
When you recommend—or use—Kellogg's
All-Bran, you are summoning the aid of
three important benefits. This natural
laxative cereal supplies these great helps
in relieving common constipation: "bulk"
and vitamin Bj, the intestinal tonic vitamin. As an extra bonus, All-Bran gives a
plentiful supply of iron. Made by Kellogg
in London, Ontario.
7
Sl/l^C
ALL-BRAN
THE NATURAL LAXATIVE CEREAL
oz. of
■■$3 THE COUNCIL ON FOODS REPORTS:
A BOOKLET FOR
PHYSICIANS
—You are invited to
write for "Simplified
Infant Feeding," an
authoritative publication treating of
the use of Irradiated
Carnation Milk in
normal and difficult
feeding cases. . . .
Carnation Company, Ltd., Toronto,
Ontario.
"There is, of course, abundant evidence that infants and
very young children need extra vitamin D. ... It seems to
the Council to be in the interests of the public as a whole to
recognize and accept the fortification of food with vitamin D.
... Of all the common foods available, milk is most suitable
as a carrier of added vitamin D."—COUNCIL ON FOODS,
American Medical Association: J.A.M.A., Jan. 16, 1937.
IN Irradiated Carnation Milk, the physician has available a milk of accepted
quality, to which vitamin D has been
added by exposure to ultraviolet rays. Bio-assays insure
the vitamin-D potency of this
milk, and utmost care in processing guarantees purity
and uniformity in food value.
Cl    IRRADIATED   •%     JT
arnation Milk
A CANADIAN PRODUCT - "/roxn contented cows"
CARNATION COMPANY LIMITED, 134 Abbott Street, Vancouver.
$*&***£ INDIVIDUAL   TOWELS   PREVENT   WASHROOM   INFECTION
ONLIWON TOWELS
Hzducz wititojQrvnt
inairitcrianoi ctfts.
because the INTERFOLD prevents
'wasteful delivery of towels
The Onliwon "inter-fold" ensures foolproof operation of the
cabinet and prevents delivery of more than one towel at a time.
The exclusive Onliwon "double-fold" feature gives you a
bigger towel—more drying area—although the cabinet
actually occupies less space than most.
Onliwon towels are crepe finished for added absorbency, and
tough—they can be used like a cloth towel without falling to
pieces in wet hands.
You'll find that one Onliwon towel is ample for'the average
user—no extravagance . . . no waste . . . and low washroom maintenance costs.        •
Why not get all the facts? Call your nearest E. B. Eddy Co.
branch or distributor.
£&'*ffis5$^-$$&i£ffi:$ffiffi&
TOWE1S
THE E. B. EDDY CO., LIMITED     •     Tissue Division
HULL        —        QUEBEC Doctors--
YOUR
PRESCRIPTION
AND   S      w::
RECOMMENDATION
Is Our Guide
Always--
OUR
'■ |§       MECHANICAL
and
SCIENTIFIC
glji ORTHOPAEDIC
"•p?     EQUIPMENT
Is At Your Service
Avail Themselves
of   our   experience   in   last
making to aid correction in
Minor Foot Ailments.
PHONE
Pierre Paris
FOOT CLINIC
Sey. 3778       51 W. Hastings
The Purified
ACTIVE PRINCIPLE
i OF
SANDALWOOD OIL
•
Ua ^ECONOMICAL
Dosage Form
Doctor, why use ordinary sandalwood
oil when you can just as easily administer the active principle of the oil
with the irritating and therapeutically
inert matter removed—and at a cost
to your patients of only a very few
pennies more?
You can do this by prescribing the
new, economical 50-centigram capsules of
ARHEOL
(ASTIER)
now obtainable in bottles of 12, 24 and
100 capsules at $1.00, $1.75 and $6.00
a bottle respectively.
ARHEOL is the purified active principle of sandalwood oil. It is a uniform, standardized product with which
prompt and dependable results may
be expected. Undesirable sequelae
often associated with sandalwood therapy are either absent or reduced to a
negligible degree.
A3-BVMA
Dr. P. Astier Laboratories
36-48 Caledonia Rd., Toronto.
Please send me a sample of
ARHEOL (Astier) in the new
economical dosage form.
 M.D.
Street	
City  Prov	
Dr. P. ASTIER LABORATORIES
36-48 Caledonia Road, Toronto The New Synthetic Antispasmodic
Trasentin "Ciba"
(Diphenylacetyldiethylaminoethanolester-hydrochloride)
SUPPRESSES SPASMS OF THE GASTRO-INTESTINAL
TRACT, GENITO-URINARY SYSTEM AND
|       OTHER SMOOTH MUSCLE ORGANS
Tablets—bottles of 20 and 100. Ampoules—boxes of 5 and 20.
1 tablet or 1 ampoule contains 0.075 grm.
of the active substance.
CIBA COMPANY LIMITED
MONTREAL
#^!$t*jR|x
13 th Ave. and Heather St.
Exclusive  Ambulance  Service
FAIRMONT  80
PRIVATE AMBULANCES AND INVALID COACHES
WE SPECIALIZE IN AMBULANCE SERVICE ONLY
J. H. CRELLIN
W. L. BERTRAND (SQUIBB ACTIVE COLLOIDAL SILVER OXIDE OINTMENT)
A simple test proves that the silver oxide in Novoxil
is rapidly absorbed even by the unbroken skin.
/f/l/eac Um4ua/ji&et r^a^atum
NOVOXIL* is an ointment containing 5 per cent colloidal silver
oxide dispersed in a petrolatum base. It offers
these distinct advantages:
1. Bactericidal.
2. High  tissue  penetrating
power.
3. Not precipitated in the tissues but apparently completely eliminated.
4. Non-poisonous.
5. Non-irritating.
6. No caustic action.
7. Highly stable.
8. Does not stain viable tissues
but will permanently stain
clothing and bandages.
NOVOXIL is useful in any of these conditions:
1. Infected cutaneous eruptions.
2. Chronic ulceration.
3. Erysipelatous lesions.
4. Bed sores.
5. Herpes.
6. Minor wounds.
7.
9.
10.
11.
Major infected wounds (deep
and superficial).
Proctological conditions.
Infected tooth sockets.
Blepharitis.
Infections   of   lower   female
genital tract.
In order that you may test the product for yourself we shall be pleased
to send you a free package of  Novoxil with  literature explaining  its
actions and uses in greater detail. Address your request to the Professional Service Department, 36 Caledonia Road, Toronto, Ont.
NOVOXIL (Squibb Ointment Colloidal Silver Oxide) is supplied
in ^.-ounce tubes and J/^-pound jars.
* Novoxil is a trade-mark of E. R. Squibb & Sons.
E. R. SQUIBB   &   SONS   OF   CANADA, LIMITED
Manufacturing Chemists to the Medical Profession since 1858. STEVENS' SAFETY PACKAGE
STERILE GAUZE
is a handy, convenient, clean commodity for the "bag or the office. Supplied
in one yard, five yards and twenty-five yard packages.
ESTABLISHED  NEARLY A
B. C. STEVENS CO.
Phone Seymour 698
73 0 Richards St., Vancouver, B. C.
S. BOWELL & SON
DISTINCTIVE FUNERAL
SERVICE
Phone 993
66 SIXTH STREET
NEW WESTMINSTER, B. C.
jSS&SSsJ
Breaks the;j[^us:^pe of pefverted
menstrual functio&Vin clpfts of amenorrhea,
tardy peri§^J|n^n-physiological) ai|fd dys-
relief 'bj .stimulafirig the innervatioi|^pf the
uterus and£fstabilizing the tone dj| its
musculature!''$ontroji^-H'e,>ti^^r6yat:ian
circulation and ;tj|ereby encourages a
fe.    normal .menstrua! ;cycfe^^^^J^^E
# MARTIN H. SMITH COMPANY
JL.   ■ ' l MO. lAFAVlTTI STRUT. NfW TORK, NT. -'<;,;<*
V
Full formula and descriptive
literature on request
Dosage: 1 to 2 capsules
3 or 4 times daily. Supplied
in packages of 20.
Ethical protective mark MHS
embossed on inside of each
capsule, visible only when capsule  is cut  in half  at seam.
m
it
m
is;
888S
i¥SS
II
WSUS^SMMSn^H^MI^^^SKSMn^ Nttnn $c
t
2559 Cambie Street
ancouver
'/ D. C
Colonic
Irrigation
Institute
Superintendent:
E. M. LEONARD, R.N.
Post Graduate Mayo Bros.
Up-to-date treatment rooms;
scientific care for cases such as
Colitis, Constipation, Worms,
Gastro-Intestinal Disturbances,
Diarrhoea, Diverticulitis, Rheumatism, Arthritis, Acne.
Individual Treatment. $ 2.50
Entire Course 910.00
Medication (If necessary)
$1 to $3 Extra
631  BIRKS BUILDING,
VANCOUVER, B. C.
Phone: Sey. 2443
506-7 CAMPBELL BUILDING
VICTORIA, B. C.
Phone: Empire 2721
For
Arthritis
and Clironic
Rheumatism
Prescribe
JLyxanthine
Astier
• Its formula — iodo-
propanol-sodium sul-
phonate, lysidin bitar-
trate, calcium gluconate,
sodium bicarb, tartaric
and. citric acids—supplies calcium, iodine and
sulphur, with a powerful   uric   acid   solvent.
LYXANTHINE
ASTIER
GRANULAR
EFFERVESCENT
clinically effects rapid
disappearance of tissue
infiltration, relieves
pain, promotes protein-
waste elimination, exerts
cholagogue action.
DOSAGE, 1 teaspoonful well
dissolved in a glass of water
every morning, on an empty
stomach, for 20 days. Rest 10
days.   Repeat if necessary.
Please send Sample and
Literature of Lyxanthine Astier
Dr.	
Address  _	
City  	
Province ,	
L1BVMA
ft P. ASTIER LABORATORIES
36-48 Caledonia Road, Toronto B.D.H. SEX HORMONE PREPARATIONS
Complete endocrine therapy in obstetrics and gynaecology is
possible with B.D.H. Sex Hormone Preparations.
For Ovarian Stimulation Therapy
SEROGAN
Serogan is obtained from the serum
of pregnant mares; its action upon
the ovary is mainly that of follicle
stimulation.
GONAN
Gonan is the gonadotropic hormone
from the urine of pregnancy; its
effect upon the ovary is primarily
luteinising.
For Ovarian Substitution Therapy
OESTROFORM     | PROGESTIN B.D.H.
The oestrogenic hormone in an accu-     The standardised corpus luteum
rately-standardised form.
hormone.
Stocks  of  B.D.H.  Sex Hormone Preparations are held by  leading  druggists
throughout the Dominion and full particulars are obtainable from:
The BRITISH DRUG HOUSES (Canada) LTD.
Terminal Warehouse Toronto, 2, Ont.
Hor/Can/386
Ylfoount flMeasant XHnbertakino Co. %ib.
ONGSWAY at 11th AVE. Telephone Fairmont 58 VANCOUVER, B. C
R. F. HARRISON W. R. REYNOLDS In all quarters of the globe
^1OT only in countries of the
Temperate Zone, but within the
Arctic Circle, as well as in the
Torrid Regions, Antiphlogistine
is known and prescribed regularly by the Medical Profession.
Inflammation's antidote
Sample and literature on request
THE   DENVER   CHEMICAL   MFG.   COMPANY
153 Lagauchetiere St. W.
Montreal
Made in Canada. *?*f PABLUM 0*11fo44* VaccMoA
VACATIONS are too often a vacation from protective foods. For optimum benefits al
vacation should furnish optimum nutrition as well as relaxation, yet actually this is thd
time when many persons go on a spree of refined carbohydrates. Pablum is a food that]
"goes good" on camping trips and at the same time supplies an abundance of calcium j
phosphorus, iron, and vitamins B and G. It can be prepared in a minute, without cooking!
as a breakfast dish or used as a flour to increase the mineral and vitamin values of staple!
recipes. Packed dry, Pablum is light to carry, requires no refrigeration. Here are some
delicious, easy-to-fix Pablum dishes for vacation meals:
Pablum Breakfast Croquettes
Beat 3 eggs, season with salt, and add all the Pablum the eggs will
hold (about 2 cupfuls). Form into flat cakes and fry in bacon fat oi
other fat until brown.  Serve with syrup, honey or jelly.
Pablum. Salmon Croquettes
Mix 1 cup salmon with 1 cup Pablum and combine with 3 beaten eggs.
Season, shape into cakes, and fry until brown.  Serve with ketchup.
Pablum Meat Patties
Mix 1 cup Pablum and l'/fc cups meat (diced or ground ham, cooked
beef or chicken), add 1 cup milk or water and a beaten egg. Season,
form into patties, and fry in fat.
Pablum Marmalade Whip
Mix % cups Pablum, V4 cup marmalade, and Va cup water.  Fold in 4
egg whites beaten until stiff and add 3 tablespoons chopped nuts. For the
Hypersensitive
Patient
Accepted for advertising by the
Publications of the
American Medical
Association.
ALMAY
COSMETICS
OPBMAIX
MIOMT
TELEPHONE: SEYMOUR
2263      W.OIOROIA
GEORGIA PHARMACY
M  I T E D
STREET
(Hunter $c ijatma Mb.
Established 1893
VANCOUVER, B. C.
North Vancouver, B. C.   Powell River, B. C.
Published Monthly at Vancouver, b. c. by ROY wrigley ltd.. 300 west Pender street Hollywood Sanitarium
Limited
For the treatment of
Alcoholic, Nervous and Psychopathic Cases
Exclusively
Reference—B. C. Medical Association
For information apply to
Medical Superintendent, New Westminster, B. C.
or 515 Birks Building, Vancouver
Seymour 4183
Westminster 288
Zl-4)<*^l*X*<zs&
4&ZL4X
:l~<)&.!l.<4)&2!>*)i

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