History of Nursing in Pacific Canada

The Vancouver Medical Association Bulletin: October, 1935 Vancouver Medical Association Oct 31, 1935

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Vol. XII.
No. 1
In This Issue:
Radiation Ointment
Obtainable at:
or any
Western Wholesale Drug Co.
(1928) Limited J
Tublished ^Monthly under the ^Auspices of the Vancouver <Medical ^Association in the
Interests of the ^Medical Profession.
203 Medical Dental Building, Georgia Street, Vancouver, B. C.
Editorial Board:
Dr. J. H. MacDermot
Dr. M. McC. Baird Dr. D. E. H. Cleveland
All communications to be addressed to the Editor at the above address
Vol. XII. OCTOBER,  193 5 No. 1
OFFICERS  193 5-1936
Dr. C. H. Vrooman Dr. W. T. Ewing Dr. A. C. Frost
President Vice-President Past President
Dr. G. H. Clement Dr. W. T. Lockhart
Hon. Secretary Hon. Treasurer
Additional Members of Executive—Dr. T. R. B. Nelles, Dr. F. N. Robertson
Dr. W. D. Brydone-Jack Dr. J. A. Gillespie Dr. F. Brodie
Auditors: Messrs. Shaw, Salter & Plommer
Clinical Section'
Dr. J. R. Neilson Chairman
Dr. Roy Huggard Secretary
Eye, Ear, Nose and Throat
Dr. E. E.- Day _.     Chairman
Dr. H. R. Mustard Secretary
Paediatric Section
Dr. G. A. Lamont : . Chairman
Dr. J. R. Davies JKI l : Secretary
Cancer Section
Dr. J. W. Thomson  Chairman
Dr. Roy Huggard 1 Secretary
Library Summer School
Dr. G. E. Kidd Dinner Dr. H. A. DesBrisay
Dr. W. K. Burwell ^    T I Dr. H. R. Mustard
„    „   .   r, Dr. Lavell Leeson" - „    T tot t
Dr. C A. Ryan -.    T „ tt Dr. J. w. Thomson
ts    tot tn tt- Or. T. h. Harrison „    i, t. r,
Dr. W. D. Keith _.    J.   T Dr. C E. Brown
t>.    tt   »   t> Dr. A. Lowrie _.     T _ __
Dr. H. A. Rawlings Dr. J. E. Walker
Dr. A. W. Bagnall Dr. J. W. Arbuckle
Publications Credentials
Dr. J. H. MacDermot Dr. H. A. Spohn
Dr. Murray Baird Dr. J. W. Thomson
Dr. D. E. H. Cleveland Dr. W. L. Graham
V. O. N. Advisory Board
Dr. I. T. Day Rep. to B. C. Medical Assn.
Dr. W. H. Hatfield Dr. W. C "Walsh
Dr. A. B. Schinbein
Sickness and Benevolent Fund — The President — The Trustees
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Diphtheria Antitoxin
Diphtheria Toxin for Schick Test
Diphtheria Toxoid   (Anatoxine-Ramon)
Scarlet Fever Antitoxin
Scarlet Fever Toxin for Dick Test
Scarlet Fever Toxin
Tetanus Antitoxin
Anti-Meningitis Serum
Anti-Pneumococcic Serum. (Type 1)
Anti-Anthrax Serum
Normal Horse Serum
Smallpox Vaccine
Typhoid Vaccine
Typhoid-Paratyphoid Vaccine
Pertussis Vaccine
Rabies Vaccine   (Semple Method)
Price List Upon Request
Connaught Laboratories
University of Toronto
Depot for British Columbia
Macdonald's Prescriptions Limited
Medical-Dental Building, Vancouver, B. C. VANCOUVER HEALTH DEPARTMENT
Total Population (EfSjinated)  244,329
Japanese Population   (Estimated)  8,037
Chinese Population  (Estimated)  7,803
Hindu Population  (Estimated) •  276
Rate per 1,000
Number Population
Total   deaths : ;        190 9.2
Japanese deaths             4 j.8
Chinese deaths            6 <j.l
Deaths—Residents  only , .        162 7.8
Birth Registrations: Male, 159; Female, 146        305 14.7
INFANTILE MORTALITY— August, 193 5 August, 1934
Deaths under one year of age       10 6
Death rate—per 1,000 births     32.8 18.8
Stillbirths (not included in above)       9 10
September 1st
July, 193 5 August, 193 5 to 15th, 193 5
Cases     Deaths       Cases     Deaths Cases     Deaths
Smallpox         0             0                  0             0 0 0
Scarlet   Fever     20             0 20             0 8             0
Diphtheria            0             0                  0             0 0 0
Chicken Pox     87            0 11             0 2             0
Measles 111             0 15              0 5             0
Rubella         0             0                  0             0 0 0
Mumps            2            0                 2             0 10
Whooping-cough        10             1                  7             0 0 0
Typhoid Fever       5             1                 2             0 2 0
Undulant Fever        10                  3             0 0 0
Poliomyelitis        0             0                  0             0 0 0
Tuberculosis       46             9 36             9 14
Meningitis   (Epidemic)       0             0                  0             0 0 0
Erysipelas         10                 10 10
Encephalitis Lethargica       0             0                  0             0 0 0
Paratyphoid        10                 2             0 0 0
JLP JL %J? Hjl"mJi J~$L X% drlk. Male and Female
ffA Dynamic General Endocrine Tonic"
Indications-: Premature senility, lack of mental and physical energy
and concentration, reduced resistance to infection, impotence, sexual
frigidity, muscular weakness and debility, neurasthenia.
Formula (Male)—Each 1 cc. ampoule contains:
Anterior Lobe Pituitary     8 grammes of fresh substance
Suprarenal Cortex     4
Testis     10
Embryonin       2
Biological and Research
Fonsbourne Manor, Hertford, England.
Rep., S. N. BAYNF.
1432 Medical Dental Building       Phone Sey. 4239       Vancouver, B. C.
References: "Ask the Doctor who has used it."
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Obtainable from B. C. Drugs Limited, Vancouver; Georgia Pharmacy, Vancouver; McGill & Orme, Victoria.
Founded 1898
Incorporated 1906
Programme of the 3 8 th Annual Session
GENERAL MEETINGS will be held on the first Tuesday of the month
at 8 p.m.
CLINICAL MEETINGS will be held on the third Tuesday of the month
at 8 p.m.
Place of meeting will appear on Agenda.
General Meetings will conform to the following order:
8:00 p.m.—Business as per Agenda.
9:00 p.m.—Paper of the evening.
Dr. G. F. Strong: "Cardiac Pain."
Discussion opened by Dr. H. A. DesBrisay.
Dr. A. M. Agnew: "Vaginal Plastic Surgery."
Discussion opened by Dr. J. J. Mason.
November 5 th—GENERAL MEETING.
Dr. J. R. Naden: "Epiphyseal Injuries."
Discussion opened by Dr. F. P. Patterson.
Dr. J. H. MacDermot: "Early Medical History of the B. C. Coast."
Dr. Lyall Hodgins: "Diabetes."
Discussion opened by Dr. Wallace Wilson.
Dr. Frank Turnbull: "The Early Diagnosis of Brain Tumours."
Discussion- opened by Dr. F. W. Emmons.
Dr. Walter M. Paton: "Tumours of the Head and Neck."
Discussion opened by Dr. H. H. Pitts.
Dr. B. J. Harrison: "Roentgenology of Cardiac Diseases."
Discussion opened by Dr. G. F. Strong.
Mr. J. W. deB. Farris: "Medico-Legal Problems."
Dr. C. E. Dolman: "Serum Therapy."
Discussion by Dr. Howard Spohn and Dr. A. Y. McNair.
The Annual Meeting of the British Columbia Medical Association,
which was held this month, is in some ways the most important in its history.
In the first place, be it said that it Was an outstanding success from a purely
academic standpoint. The functions of the B. C. Medical Association are
mainly scientific and educational, and the programme arranged by the
Executive ensured the adequate fulfilment of this. Dr. G. F. Strong, Chairman of the Programme Committee, is especially to be thanked for his work
in this regard. It seems to be generally conceded that we have never had
saner or more practical addresses.
Then as regards attendance. The large number of out-of-town members
is very gratifying, especially as this is a rather difficult time of year for
many. It would be hard, of course, to find a date which would suit everyone
and the choice of September for this year by the Executive was a very
good one, in view of other conditions.
But, of course, the real centre of interest was the Annual Meeting of
the College of Physicians and Surgeons, and the report by Dr. W. E. Ainley
of the work of the Committee appointed by the Council to study Health
Insurance. We think that nobody could any longer question the value of
the step that was taken by the Council some two years ago in reorganizing
our profession in British Columbia. In taking this step, the central idea was
a closer connection between the College through its Council and the individual medical man. The practice of holding its Annual Meeting as an open
meeting for all to attend and hear of the doings of the CounS for the past
year is of the greatest value, and we believe that the wisdom of this will be
more clearly seen each year.
Our readers will be getting copies of the Amended Report of the Committee, and we will not comment on this here, except to say that it was
heart-warming to see the unanimity of the profession as evidenced by the
reports of accredited! delegates, who, one after the other, reported the full
and complete support of the various electoral districts of B. C. There can be
no doubt that our Council, in presenting our Report to the Government as
a brief for the profession, will be speaking for a united profession.
Certain definite conclusions have emerged from the various discussiosns:
the first, and perhaps one of the most important, being the general feeling
that health insurance should be regarded as a national and not a provincial
problem. We agree entirely with this, and would suggest that in the long
run (and not so long at that) it would be the part of statesmanship and
vision to postpone action, at least until an adequate survey of the whole
Canadian field can be made as the basis of a co-ordinated scheme into which
each piece of the mosaic will fit accurately and without conflict. One almost
despairs at times, as one sees the preponderance! of disruptive forces in this
country of ours. We are not, even now, a nation—we are a collection of
provinces—and the trend of events seems inexorably to be towards more
complete disintegration. In education, for instance, the isolation of the units
is complete; in taxation it has long been quite recognized.
Health, it has been said, knows no national boundaries. Surely, a majori,
it should not recognize provincial boundaries. Any scheme which is not
immediately capable of homogeneity with that of any other province is
another possible source of irritation and discord; and we hope sincerely that
Page 3 it may prove to be the case that we have not yet committed ourselves irrevocably to localised action, desirable as this may, in some ways, appear to be.
There are many other things that were brought out at this meeting, but
this is not the place, perhaps, to discuss them. We applaud the choice of
officers—and see a bright future for the Association.
One other matter of immense significance invites our comment. This
was the adoption by the British Columbia Medical Association of a resolution proposed at last year's meeting whereby the B. C. M. A. becomes an
integral part of the Canadian Medical Association as its B. C. Division.
We have no hesitation in saying that we think this is definitely a forward
step. As Dr. Meakins pointed out in his able address, a united profession is
a vital necessity, not only selfishly from the doctor's point of view, but as
a bulwark against forces which, under the plea of socialisation of various
activities, are tending to impair our usefulness to the public at large, and
to lower the standards of medical practice. Such an outcome would be a
disaster to the whole community, and it is our duty to see to it that our
organization is adequate to resist any such detrimental agencies.
Our readers will remember a note on a case of cancer given us by Dr.
Neil McNeill of this city and published in the Bulletin of March last.
It is of great interest to note that the July number of the Canadian Medical
Association Journal contains a letter on the relation of magnesium and
calcium to cancer from the National Research Department at Ottawa.
Dr. McNeill himself has received a private letter commenting on his paper.
We take pleasure in publishing this month a short note by Dr. Earle
Hall, who has recently started practice in Vancouver, specialising in urology.
Our readers will probably notice one or two minor changes, and one
major change, in this first number of a new volume of the Bulletin. The
minor changes are the colour of the cover, which is darkened somewhat,
and the texture of the paper. The glossy surface of the paper hitherto used
was trying to the eyes, and the new"eggshell" finish will be found more
The major change is the emblem. For the previous emblem we are
indebted to Dr. Murray Meekison, and it is with no little regret that we
change it, as it was very neat and very appropriate. The new emblem, however, conforms with the new book plate of the Association—and will, we
hope, be accepted as our official badge. The motto was chosen by our
Librarian, and is, we think, an admirable choice, being not only good Latin,
but perfectly sound from an ethical point of view. One could hardly have
a better motto for an Association, and we hope, by placing it on every copy
of the Bulletin, to inculcate its observance in the mind of every reader.
The meeting of the B. C. Medical Association brought many old and
familiar faces back to our midst, and) we were very glad to see them. Dr.
Archibald of Kamloops, looking as fit as ever, as if some fount of perennial
youth' was at his disposal. Dr. Drew of New Westminster, that grand old
man of British Columbia medicine—long may he be with us—and our
Page 4 newest member, Dr. Thornton, so well known in the medical politics of
And there were many others, too numerous to mention. We were glad
to see the large contingent from the interior, and several from the far north;
they brought us not only the greetings of their comrades in the outposts,
but assurance of their loyalty and support. We do not, perhaps, sufficiently
realise the difficulties and handicaps under which many of these men work.
One man apologised for the members of his district, in that they had not
held a meeting. But thei nearest man to him on the East was ninety miles
away, on the West one hundred and fifty, and so on—and so it was "difficult" for them to meet. When we hear of these astronomical distances
between practising physicians, we begin to understand what practice in
the country means. And the depression has hit many of these men much
harder than we can know; and it is no easy thing for them to say no to any
promise of relief and financial succour. So more honour to them.
The death of Dr. Andrew Henderson, that very well-known medical
man, saddened the hearts of all that knew him. He was a great old chap—
full of humour and' kindliness, an addition to every gathering of medical
men. He will be missed wherever doctors gather to relax and have a good
time, for he contributed nobly his share of goodfellowship and jollity.
Dr. M. Fox has been quite ill during the past few weeks. We wish him
a speedy recovery.
Also on the sick list is Dr. A. M. Warner. The entire faculty is trying
to find something wrong with him. So far all tests are negative—and may
they all continue to be so. Our private opinion is that the blighter works
too hard, and needs a rest.
Holidaying at Savary Island have been many of our more eminent
members: Drs. David Freeze and Jack Wright from the V. G. H, and Dr.
F. N. Robertson. Dr. Wright was seen boarding the steamer with large
numbers of tennis racquets, balls, books on tennis, and a beaming smile.
We are informed on good authority that the standard of tennis as played
on the Island is noticeably higher.
!l ■[*%
We note with regret a serious injury suffered recently by Dr. Eleanor
Riggs of the V. G. H. Laboratory Staff, in a motor accident. We understand she is making a good recovery.
Dr. G. D. Oliver has gone to Alexis Creek to practise.
Dr. H. H. Boucher has left on an extetnded postgraduate trip. His place
is being taken by Dr. Kenneth Groves.
Dr. R. E. McKechnie, Junior, and his wife were in town recently.
Dr. J. Bain Thorn has recently been elected to membership on the
Council of the College of Physicians and Surgeons to take the place of
Dr. Douglas Corsan, deceased.
Page 5 Dr. J. G. Robertson, formerly associated with Dr. J. G. McKay, and
now practising at Tofino, has recently acquired a son as an addition to his
Dr. J. S. Cull has recently been awarded the degree of D.P.H., and has
been appointed Medical Health Officer to the Peace River District.
The Annual Meeting of the B. C. Medical Association was held at the
Hotel Georgia from September 19 th to September 21st, inclusive.
The hotel management deserves our thanks and congratulations for the
perfect smoothness and efficiency of all its arrangements for the meeting.
Everything ran without a hitch of any kind, as far as the hotel was
The attendance was hard to compute exactly, as* many local men came
to meetings who did not register. A total of 254 registered. The Annual
Dinner was attended by over 150 members, and the Luncheon by approximately the same number.
The Association was honoured by having as its guests Dr. J. C. Meakins
of Montreal, President of the Canadian Medical Association, and Dr. J. Tate
Mason, of Seattle, Wash., President-elect of the American Medical Association. Dr. T. C. Routley, General Secretary of the Canadian Medical
Association, was also present, and spoke on two or three occasions. It is
always a great pleasure to hear from Dr. Routley, whose encyclopaedic
knowledge of medical affairs in Canada is quite invaluable, and who has
always a sane and moderate opinion to give, while his devotion to the interests of the Canadian medical profession is apparent in every word.
The golf tournament held on Thursday afternoon was very successful,
some 80 or 100 members taking part. The prizes, which were kindly donated
by various business firms of the city, were presented at the dinner in the evening, with a witty running commentary by Dr. J. P. Bilodeau, O. C. Golf.
Some of the prizes particularly excited our envy, for example the ten pounds
of tea awarded to Dr. G. C. Draeseke, while the Rolls razor went to Dr. L. W.
McNutt for making a hole in one om the tenth. The writer of this was in
Dr. McNutt's foursome, and is happy to testify to the hospitality afforded
by Dr. McNutt immediately after the game. Dr. J. A. Sutherland's winning
of a surgical bag was very appropriate, as his own had been stolen out of his
car only a day or two before.
At the Annual Dinner in the evening, a very delightful time was had by
everybody. Mr. Ernest J. Colton, well-known Vancouver singer, delighted
us with several songs beautifully sung. One regrets only that the singer was
not given a clear space, so to speak, in the dinner. His songs were sandwiched
between the fish and entree, and between the ice cream and coffee, and this
was not fair to him, as waiters were travelling back and forth continually,
and he had to face the rather unfair competition of spoons and plates and
glasses. It is a tribute to his singing to say that he overcame all these handicaps.
The Annual Meeting of the British Columbia Medical Association was
held on Friday afternoon, and the really important feature of this was the
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lli adoption of a resolution which looks toward making the B. C. Medical
Association an integral part, or division, of the Canadian Medical Association. This, all will agree, is a very important step. The resolution follows:
That our Executive be given the power to so change our Constitution that
we be known as the British Columbia Division of the Canadian Medical Association, and that in addition our Executive take such steps as are necessary to finance
this undertaking.
In the evening the College of Physicians and Surgeons held its open
meeting, attended by nearly 200 of the profession. Dr. T. McPherson of
Victoria, President of the Council, presided. Dr. A. J. McLachlan read the
minutes of the last year's meeting at Kamloops, and Dr. McPherson then
called on Dr. W. E. Ainley to present the Report of the Committee appointed by the Council to study the Draft Act on Health Insurance now
being considered by the Government of B. C.
Dr. Ainley gave in a clear and concise fashion a full account of the
Report, reading many excerpts, and announced that this Report was to be
presented before the Hearings Committee of the Government on this
Dr. J. C. Meakins and Dr. T. C. Routley both spoke, assuring us of the
complete moral support of the Canadian Medical Association, and the readiness of this body to give any help possible if we deserve it.
Certain conclusions were come to by the meeting, and others may fairly
be drawn. The meeting adopted Dr. Ainley's report without a dissenting
voice. This included several recommendations, of which the first was that
the whole matter of Health Insurance should remain in abeyance till an
adequate Canadian survey is made; that a national scheme should be considered rather than many provincial schemes. That the income-level of those
coming under the Act be fixed] by the need of the group for help, and not
by considerations of expediency. That the remuneration of doctors be on a
definite basis, and not on the basis suggested in the Act. That we as a profession favour the adoption of a Health Insurance scheme, if it be properly
conceived, to maintain the standards of medical practice at a high level, and
to afford real relief and service to those who need it, as far as they need it.
Members from each electoral district of British Columbia spoke in turn,
and as accredited delegates testified to two facts: First, they were opposed
to the Act as at present drawn; secondly, they were unanimously behind ppi
Committee's Report, and would support the Council in any action it might
A resolution was passed authorizing the Council to engage in such publicity as they should see fit; another formally asking the Canadian Medical
Association for its support and assistance.
Dr. Routley, in his remarks, stated that it was a question largely of union
and organization. He recounted the history of the efforts made to secure
the appointment of a Royal Commission to make a nation-wide survey, and
summarized his remarks by suggesting that we go as a united profession to
the government and make clear to them the following points:
(1) The plan as suggested for B. C. in the Draft Act has not the support of the medical profession of B. C.
(2) Actuarial data for B. C. are not available.
(3) It is said by the Life Insurance companies of B. C. that there are
no actuarial data available for Canada.
Page 7 (4)  We should propose that such actuarial information be secured.
( 5) The Life Insurance companies of Canada have told the Canadian
Medical Association that they are prepared to sit in with any Commission
formed, and make, through their own actuaries, an accurate actuarial survey
of Canada.
Below is appended a list of books which have recently been purchased
with moneys from the fund donated by Dr. F. J. Nicholson. Dr. Nicholson
has expressed a wish that, in choosing books to be bought with this money,
we choose books which will appeal to the cultural side of medical life, rather
than strictly scientific medical works. This list includes works on History,
Biography, et|| Such literature has an important place in any well balanced
medical library, and the committee will be glad to have recommendations
from members for the purchase of such books as they are desirous of seeing
added to this collection.
Dr. Cleveland has generously donated to the Library a group of scientific
books, dealing largely with Biology, Genetics, and the evolutionary development of animal lif e.
We would draw especial atention to our new book plate which has been
officially adopted by the Association's Executive, and will eventually be
placed in all books and bound volumes in the Library. Ift will also appear on
the cover of the Bulletin—and will, in fact, be the" Association's especial
emblem. The motto, "Non sibi, sed omnibus" or Anglice, "not for self but
for all," is particularly appropriate in its present use in the books of the
Library, and is especially commended for notice to all users of the said
Arches of the Years—Halliday Sutherland.
Lodgings for Twelve—H. H. Bashford.
All in the Sty's "Work—Abraham Groves.
Introduction to the Study of the Vertebrates—Allan.
The Joy of Living—Franklin Martin: An Autobiography.
Skeleton of British Neolithic Man—John Cameron.
History of French Medicine—Lavastine.
History of Japanese Medicine—Fujikawa.
The Doctor's Bill—Hugh Cabot.
The Great Doctors—Sigerist.
American Medicine—Sigerist.
Lectures on the History of Medicine.
Inherited Abnormalities of the Skin and Appendages—Cockayne.
Doctors in Elizabethan Drama—Yearsley.
The Sanity of Hamlet—Yearsley.
iJlHtory of Scottish Medicine to 1860—Comrie.
Fracastor Syphilis.
Life of Hugh Owen Thomas.
History of the Great Plague.
Memoirs of John Abernethy.
Bibliotheca Osleriana.
Other recent additions to the Library are:
Transactions of Section of Laryngol., Otol. and Rhinol. of A. M. A.
Medical Annual, 193 5.
Mayo Clinic volume for 1934.
Page Medical Clinics North America, May and July, 1935.
Surgical Clinics North America, June and August, 1935.
Treatment of Rheumatism in General Practice—Copeman, 193 5.
Human Embryology and Morphology—Sir Arthur Keith. 1933.
Applied Anatomy—Davis.   9th Ed.  1934.
Surgical Diseases of the Chest—Evarts Graham, et al. 1935.
Intracranial Tumours-—Percival Bailey.
Textbook of Gynaecological Surgery—Berkeley and Bonney.
Three new subscriptions have been added to our list of Journals, namely Journal of
Allergy, Journal of Immunology, Science.
Earle R. Hall, M.D.
Vancouver, B. C.
I have observed that whenever transurethral resection of the prostate
is mentioned, it invariably arouses a1 discussion of the value of this method
as compared with that of prostatectomy by open surgery. At the present, I
do not think it is fair! to compare one procedure with the other. It is only
during the past few years that transurethral methods have been adopted in
varying degrees by urologists in general, and it requires time and an assurance of absolute honesty on the part of the operator before results can be
definitely accepted as reliable facts. As, for example, when Young (dean of
urologists on this continent) first brought out his punch operation, it was
used by many urologists in general, but with the passing of time it was used
less and less.
For true opinions we must have more time and know the results obtained
by men who have made no selection of cases, but have used transurethral
methods in all cases of bladder neck obstruction, where for many years previously they had used open surgery, i.e., complete prostatectomy by the
suprapubic or perineal route.
Notable examples of this are Kretschmer of Chicago, and Alcock of
Iowa. Both these men for years relieved all cases of bladder neck obstruction
by suprapubic prostatectomy. During the past four years they have each
performed over 700 transurethral prostatic resections, and during this time
they have made no selection of cases, but have used this method in all cases
of prostatic obstruction brought before them, irrespective of the size of the
prostate or its pathological condition. Today they will not commit themselves as to which they consider the "best" method of dealing .with the
enlarged prostate. They declare that more time should elapse, so that these
cases can be studied to something nearer completion in their end results.
There are many others who are dealing with this subject in a similar manner,
and who, while yet unable to give a definite final answer, are able to put
forth some very interesting and illuminating facts that have arisen in the
natural sequence of performing transurethral prostatic resection.
A few brought to my consideration are given) very briefly as follows:
1. From the standpoint of the patient resection is a less formidable procedure than open surgery.
2. Economic saving; especially important during these times. There is
less hospitalization and less time away from occupation.
Page 9 3. Patients in earlier prostatic years will accept this relatively simple
appearing procedure^ where previously, before submitting to open
surgery, they would struggle along suffering varying degrees of distress till they were forced to sipSnit to the inevitable operation in
later life.
4. Patients in older years (eighty years onward) can be relieved, where
in many cases they would be unable to withstand complete prostatectomy.
5. Patients at any age with prostatism, but considered "bad risks" due
to co-existing disease, i.e., heart lesions, diabetes, central nervous system involvement, etc., can withstand resection where one would
hesitate to perform prostatectomy.
6. The resectoscope can be used to great advantage in many cases of
bladder tumour, and in giving relief from urinary distress in many
cases of carcinoma of prostate and bladder.
7. The resectoscope can be used for resection of the trigone where this
is necessary in certairi cases requiring prostatic relief.
It is not my purpose to discuss pre- and post-operative care, technique
or complications, as these features alone give rise to considerable comment.
They are as important with transurethral resection as with any other surgical procedure, and are of course influenced by the supervision, discretion
and ability of the operator.
In closing I would say that in urologic surgery in the past, different
routes to an apparently equally satisfactory result have been travelled by
different men in their own special manner, as exemplified in the brilliant
perineal operations of Hugh Young, Geraghty, Edwin Davis; the suprapubic
results of Kretschmer, Hunt, Harris; the previous closed methods of Caulk,
Bumpus, Braasch, Davis (South Carolina), Stern, McCarthy, and Lower's
amazing suprapubic closure immediately following prostatectomy with
urethral drainage. These are but a few of the large number of men and
methods, but serve to illustrate the fact of personal ability in choosing an
operative procedure—an important factor often not considered in comparison of diverse methods.
Verne C. Hunt, M.D.
Los Angeles, California.
Even though the question of medical treatment versus surgical treatment of uncomplicated peptic ulcer remains entirely unsettled among many
surgeons and internists, there is quite definite uniformity of opinion regarding the treatment of the peptic ulcer in which certain complications have
To consider peptic ulcer in general and not too specifically in terms of
whether the lesion is duodenal, gastric or recurrent postoperative, it may
reasonably be stated that indications for surgical treatment are quite absolute in the presence of a serious complication and relative in the uncomplicated peptic ulcer. The complication of acute perforation of an ulcer is
recognized by all as an absolute indication for surgical intervention. High
*An abridgement of lecture presented at the Vancouver Medical Association Summer
School, Vancouver, June 1, 193 5.
Page 10 V    I 1'ii
grade pyloric obstruction incident to chronicity and cicatricial pyloric
stenosis rarely responds permanently to medical management and is too often
procrastinated with by the enthusiastic exponent of medical treatment. It
is usually true that the extreme need for surgical intervention in high
grade pyloric obstruction and gastric retention seldom exists as in acute
perforation. All of us have on occasion, however, observed cases in which
high grade pyloric obstruction has resulted in marked dehydration and
marked disturbances in the blood chemistry, presenting a situation urgently
surgical, not necessarily as an emergency, but at an early time following
preoperative treatment directed toward combating dehydration and the
many sequela; of prolonged gastric retention.
The complication of repeated haemorrhage from an ulcer in the duodenum or stomach is one that occasions much concern and question regarding surgical intervention. Haemorrhage of a minor or major degree occurs
sufficiently often from an ulcer in which chronicity has been established, or
from an ulcer that has been symptomatically silent except for bleeding, to
call on the part of those interested in the management of peptic ulcer for
rather well planned methods of treatment. Of the various complications
that occur, it seems that the one of bleeding, either as intermittent small'
haemorrhages or as single or multiple massive haemorrhage provides more
confusion and uncertainty as to the manner of management than do other
complications. The slowly developing anaemia from continued loss of blood
through intermittent small haemorrhages over a period of weeks provides no
great emergency. Even so, intermittent repeated haemorrhage from a peptic
ulcer is as deserving of the application of the fundamental principles of
surgical control of bleeding as is haemorrhage from any other accessible
source. The statement has frequently been made, and has been accepted
by many who through its repetition believe its truth, that acute massive
haemorrhage from a peptic ulcer is rarely fatal and that the effects of such
loss of blood may be successfully compensated for by transfusion. Some time
ago Allen and Benedict reviewed the subject of haemorrhage in 1804 cases of
duodenal ulcer treated at the Massachusetts General Hospital. There was a
history of gross bleeding or where bleeding occurred in amounts recognizable
macroscopically in 34 per cent of the cases. Acute massive haemorrhage
producing prostration and shock occurred in 138 cases or 22 per cent of
those in which bleeding had occurred. The haemorrhage was fatal in 20 cases,
eight of which were operated upon without success. The mortality rate in
the cases of massive haemorrhage was 14.5 per cent. Most of us have observed
massive fatal hxmorrhage from duodenal and gastric ulcer which has
brought to our minds the question of how often and how much shall a
patient bleed before surgical intervention is justified. I have previously
stated on a number of occasions that, to my mind, repeated small haemorrhage is often enough and one or more massive hxmorrhages is too much, and
that either type of haemorrhage is sufficient and just indication for direct
surgical attack upon a known or suspected bleeding lesion after sufficient
rehabilitation of the patient to insure relative safety for a surgical procedure. It is worthy of emphasis that the direct operation of gastroenterostomy is not one upon which great reliance should be placed and serves little
or no purpose in the surgical treatment of massive haemorrhage, even though
it has permanently controlled bleeding from duodenal ulcer in many instances. Direct attack upon the bleeding lesion with its complete excision
in accordance with general principles of surgical control of bleeding in other
accessible situations provides the only justification for surgical intervention
Page 11 for the control of massive haemorrhage f^)m a peptic ulcer, be it duodenal,
gastric, or a postoperative recurrent ulcer.
It is generally agreed that the uncomplicated duodenal and gastric ulcers
are those in which neither acute perforation, pyloric obstruction, gastric
retention nor bleeding has occurred, and these comprise the group in which
so much question arises as to whether the treatment shall be medical and
continue to be medical until one of the previously discussed complications
occurs, or whether it shall be surgical. At the outset it may be justly stated
that an uncomplicated ulcer should usually if not always have the benefit
of medical treatment, for it is well known that many if not the majority
of uncomplicated peptic ulcers may be symptomatically controlled without
serious recurrence, and unquestionably many will heal under adequate and
proper medical treatment. Certainly in no uncomplicated peptic ulcer should
surgical treatment receive consideration without a period of adequate medical management, and even though symptomatic controllable recurrences
may develop from time to time medical management should not be discouraged too readily. However, following the most diligent and thorough
medical treatment in the hands of the most enthusiastic exponents of medical
treatment, failure has not infrequently occurred not only to cure but to
provide symptomatic relief in uncomplicated peptic ulcer. There is a relatively large group of ulcers where definite chronicity has been established
over a period of years, in which medical management has not been particularly successful by virtue of impossible or incomplete co-operation of the
patient, or because of other influences over which the physician may have
had little control. Furthermore, not all people in whom an ulcer has developed and has continued over a period of time are so situated economically or
occupationally that they may indulge their own or the physician's preference for medical treatment. This group comprises many cases in which surgical treatment may or may not be instituted and the decision may be
dependent upon many factors, among which the degree of disability is perhaps the most important. The attendant risk of operation and the surgical
skill available to the patient are added factors which must be reckoned with,
for the mortality of medical treatment of benign uncomplicated ulcer is nil.
It is also well known that the mortality rate of conservative surgical procedures in uncomplicated duodenal and gastric ulcer is likewise extremely
low in the hands of the experienced, skillful surgeon. On the other hand,
the problem of postoperative recurrence is one which must receive due
Such general principles may properly serve to direct judgment as to
whether a case of uncomplicated peptic ulcer should continue on medical
treatment despite symptomatic intermittent recurrence or whether surgical
measures shall be instituted. These principles apply more specifically to
duodenal ulcer than to ulcer on the gastric side of the pylorus. In gastric
ulcer it is not so easily determined that the lesion may be a benign lesion.
This statement does not refer particularly t» the question of malignant
degeneration of gastric ulcer, nor would I have it infer that such malignant
degeneration occurs with any great regularity. There is some recent apparent
concurrence of opinion that such sequence does occur in a small percentage
of the cases of gastric ulcer. Newcomb, working in the department of
pathology of St. Mary's Hospital in London, has reported an incidence of
nearly 4 per cent malignant degeneration in gastric ulcer. Also Gomori,
of Budapest, stated recently that cancer secondary to gastric ulcer is not
the rarity is has been believed to be. In 64 cases of chronic peptic ulcer and
Page 12 ll);
26 cases of carcinoma of the stomach carefully studied by him, six cancers
were secondary to ulcer, an incidence of 6.6 per cent. The important relationship which does so frequently exist between benign gastric ulcer and a
malignant lesion is the difficulty of clinical differential diagnosis. The only
diagnostic procedure which may accurately localize a lesion on the gast||||
side of the pylorus is competent roentgenological examination and the differentiation by this method between a benign gastric ulcer and an early
gastric carcinoma is not always easy nor entirely accurate. There are many
lesions of the stomach in which only through surgical exploration and microscopic study of sections may an accurate diagnosis1 be made. Consequently
many gastric lesions localized on fluoroscopic vision and depicted in the
roentgenogram must be regarded with suspicion until they are proved to
be benign lesions. To advise medical treatment in the presence of uncertainty as to the true nature of the lesion places the responsibility for the
assumption that a malignant lesion does not exist directly upon him who
possesses the temerity to make such recommendations.
So far as the relative indications for surgical procedures in uncomplicated duodenal and gastric ulcer are concerned, they present no particular
difficulties to the internist and the surgeon, when each is f amiliar with the
excellent results that may be obtained in many cases by adequate medical
management, and the large percentage of cures that occur following the
institution of well directed surgical procedures in properly selected cases.
Another has stated that neither the physician nor the surgeon should entertain any conceit concerning the virtues of his particular mode of treatment
under all circumstances. The former should be mindful of the invariably
permanent effectiveness of timely operative intervention in the case of an
acutely perforated ulcer, of advanced cicatricial stenosis, of chronic, penetrating, calloused, resistant lesion, or of chronic haemorrhagic lesions, when
his own efforts may have proven unsuccessful even in less formidable cases.
Likewise the surgeon must be mindful of reactivation or recurrences in
more vulnerable situations which, although proportionately few "when the
patient is in competent hands, may frequently have far more serious import
than the lesion for which the operation was originally done.
It is not my purpose nor is it my desire at this time to deal specifically
with the various surgical procedures that are available in the treatment of
peptic ulcer, but simply to emphasize the important fundamental principles
which may or may not justify their usefulness. In general the surgical procedures may be considered as conservative and radical, the latter embracing
the various procedures of partial gastrectomy. A fundamental principle in
the treatment of peptic ulcer, be that treatment medical or surgical, has
been the control of gastric secretion and the neutralization of gastric acidity.
A second fundamental principle in the surgical treatment of the ulcer is
adequate emptying time of the stomach and the avoidance of postoperative
gastric retention. Surgical efforts therefore are directed toward control of
gastric secretion, neutralization of gastric acidity and the avoidance of
gastric retention. No modern surgical procedure accomplishes all of these
in all cases. It is furthermore well known that failure to accomplish all these
essentials sets the stage, so to speak, even though other factors may be concerned, for reactivation, recurrences and unsatisfactory results. Control of
gastric secretion has been most difficult to achieve by any surgical procedure
and it would seem that the satisfactory results that have been obtained
following any surgical procedure have not been dependent upon the control of gastric secretion but have been due to adequate neutralization of
Page 13 gastric acidity and adequate drainage of the stomach with an emptying time
shorter than that of normal. The operation of posterior gastroenterostomy
as it was conceived and applied to the cicatricial stenosing lesions of the
duodenum and pylorus has met the demands of the fundamental principles
of surgical treatment of ulcer better than has any other operation since
devised, and remains the operation of choice in many instances by virtue of
tipjiexcelled results, whether it is instituted for duodenal or gastric ulcer with
or without excision of the lesion. The operation of gastro-enterostomy
during recent years has been subjected to unjustified attack through the
frequency with which anastomotic, gastrojejunal and jejunal ulcers have
followed its execution. It is my opinion that in judiciously selected cases in
which the operation has been carefully and skillfully executed to fulfil the
fundamental principles of adequate drainage of the stomach without angulation and obstruction and postoperative gastric retention, the incidence
of such recurrent ulcer is less than five per cent. To obviate such recurrences various plastic operations upon the duodenum and pylorus with or
without excision of the lesion have been developed. These have likewise been
followed by a high percentage of rcurrence, chiefly because neither is gastric
secretion controlled nor gastric acidity neutralized in all cases by these
procedures. Some logic emanates from the realization that seldom if ever is
an ulcer encountered below the first portion of the duodenum. Furthermore, ulcer seldom if ever develops in a highly alkaline medium. The highest
degree of alkalinity of the contents of the duodenum is in that portion, in
which ulcer is practically never encountered, immediately below the ampulla
of Vater, the site of the outpouring into the intestinal tract of bile and
pancreatic secretion. There is little reason to believe that the contents of
the first portion of the duodenum is highly alkaline, and little reason to
expect that it might be unless the duodenum is possessed of a mechanism
for reverse peristalsis of which evidence or proof is entirely lacking. I do
not wish to infer that surgical procedures devised' for direct attack upon a
peptic ulcer are not in order, for the bleeding duodenal ulcer should be
excised in all instances when possible, but to add some type of pyloroplasty
for the purpose of neutralizing gastric acidity through the anticipated
interchange of duodenal and gastric secretion after division of the pylorus
or excision of the major portion of the pyloric sphincter, seems hardly in
keeping with physiological principles. Experience has proved that the surgical procedure of pyloroplasty with or without excision of the duodenal
ulcer is accompanied by the best results in the absence of a pre-existing
hyperacidity in which postoperative neutralization of gastric acide is apparently not particularly vital.
The conservative operation for the treatment of gastric ulcer includes
excision of the lesion when readily accessible. Disturbance or gastric
motility incident to the presence of a gastric ulcer, or that due to loss of
continuity of the gastric musculature following conservative excision,
usually necessitates gastro-enterostomy to provide adequate emptying of
the stomach and neutralization of gastric acidity.
The radical operation of partial gastrectomy has received much support
during recent years as a primary operation for both duodenal and gastric
Splcer, on the basis that excision of the major part of the acid producing
portion of the stomach was highly desirable in the control of gastric secretion and gastric acidity. There is an occasional case of duodenal ulcer,
usually a bleeding ulcer, which cannot be satisfactorily excised except by
partial gastrectomy, and there are certain gastric ulcers in which their
Page 14 w.
excision is best accomplished by partial gastrectomy. I have seldom been
forced to employ partial gastrectomy as a primary operation for duodenal
ulcer and have employed it as the procedure of choice or of necessity in only
23 per cent of the cases of gastric ulcer that I have operated upon. Omitting
the evidence here, it has very definitely been proved by many that the
original premise for partial gastrectomy as a primary operation for peptic
ulcer is no longer strongly tenable. The excision of the major part of the
acid secreting stomach does not in all cases permanently control gastric
secretion and gastric acidity, but in many cases after some months the
degree of gastric acidity returns to its preoperative level. Also experience has
proved that partial gastrectomy as a primary operation does not provide
assurance against recurrence in the form of anastomotic and jejunal ulcer.
Furthermore, few execute the operation of partial gastrectomy with a
justifiable mortality rate for benigri lesions of the stomach and duodenum.
It has been stated by others that the frequency of secondary operations for
recurrent ulcer following the primary conservative surgical procedures for
peptic is sufficiently great to justify the radical operation of partial gastrectomy as a primary procedure. Inasmuch as partial gastrectomy fails to
provide assurance against recurrence either as a primary or secondary operation, if for no other reason, it hardly rates as a first choice over secondary
conservative operations for recurrence. Furthermore, few skilled in the
various surgical procedures for peptic ulcer are able to consistently execute
the operation of partial gastrectomy as a primary operation with a mortality
rate equal to the combined mortality rate of primary conservative operations and the secondary operations actually required through recurrences.
From the Physician's Standpoint
Dr. Charles Hunter, Winnipeg.
(Concluded from last issue)
Between the attacks of pain of all three varieties, the patients may be
perfectly fit, with perfect digestion, though a percentage may be well aware
that special indiscretions in diet, especially in fatty food or in over-rich and
bulky meals generally, are punished swiftly by an attack of colic.
The pain, however, may be much less severe and shortlived; an aching
soreness or discomfort in the upper abdomen, a little more marked on the
right side, with sudden spells of fullness and distension, may occur, with
marked tenderness at the ninth rib attachment to the costal margin. Such
pain or discomfort may be induced or aggravated by jarring, as in auto
riding, or by some unusual activity.
II. The second class of symptoms associated with gall bladder pathology
are gastric—fullness and distension in epigastrium soon after meals, eructations of gas, nausea with occasional vomiting, a vague indigestion referred
to the upper abdomen—the "inaugural symptoms" described by Moynihan.
These may be the only complaint over many years; there may be no
physical findings or at most tenderness in the gall bladder area, elicited by
the sudden jab of the fingers upwards as the patient completes a deep inspiration (Murphy's sign)—a finding in my experience of none too great importance.
Now such gassy dyspepsia alone is no evidence of gall bladder disease, and
even when combined with non-visualization of the gall bladder is unrelieved
Page 15 in about 50% of cases by cholecystectomy, as Graham, Stanton and others
now admit. Less often, the gastric symptoms resemble those of ulcer, with
sour stomach late after meals, heartburn, belching and vomiting.
HI. There is, finally, the third group, where a gassy dyspepsia is associated with occasional attacks of definite biliary colic, or at least of aching
soreness or dull pain referred to the riglp costal margin. The history of a
passing jaundice, of chilly sensations, of sudden bouts of unaccountable
painful distension, may strengthen the suspicion of underlying gall bladder
It should be added that, in a small percentage, lack of appetite, loss of
weight and a vague dyspepsia may rouse the spectre of gastric carcinoma.
I would remind you, as noted in the preliminary remarks, that with the
enormous frequency of gall bladder disease (more than 50% of adults past
30 years of age have abnormal gall bladders and 20% have gall stones,
according to Blackford, King and Sherwood), obviously the great majority
have few or no symptoms at any time—at least, such symtoms are too
trifling to have been seriously considered
Calculous gall bladders and inflamed gall bladders without stones give
rise to similar symptoms, except that severe biliary colic is more suggestive
of ga|| stones, though a history of biliary colic was obtained in 3 3 % of
Graham's 153 stoneless gall bladders and in 54.5% of 434 cases in Smithies'
Diagnosis: A careful history is the most important factor in the diagnosis.
In view of the great frequency of gall bladder disease in middle and advancing years, its presence even with demonstrable gall stones is no proof at all
that the symptoms complained of are connected with the diseased gall bladder or likely to be relieved by its removal. This fact is being emphasized by
Graham and other prominent surgeons from analysis of the end results of
Definite biliary colic is all important in the history, not only in clenching the diagnosis of active gall bladder disease but in indicating improved
chances of successful surgical interference. Coronary thrombosis may simulate acute cholecystitis closely; in both, the sudden onset of intense pain
coming without exertion, out of a clear sky; while typically in coronary
thrombosis this pain is behind the lower sternum, radiating possibly to the
arms, it may be high epigastric and may from the engorged liver give tenderness in the right hypochondrium; fever and leucocytosis are common to
both; collapse, dyspncea and cyanosis are, however, peculiar to coronary
thrombosis, though an acute pancreatitis exceptionally present in longstanding gall bladder infection may give collapse, dyspncea and cyanosis
similar to coronary thrombosis; nausea and vomiting may occur in coronary
thrombosis though commoner in gall bladder; the weak, rapid pulse with
gallop rhythm of the heart and later a light pericardial rub and cardiographic
changes are peculiar to coronary thrombosis.
Acute appendicitis, a perforated peptic ulcer and a right-sided pneumonia with pleurisy, must be exceptionally differentiated; lead colic and the
gastric crises of locomotor ataxia must pass in mental review. Renal colic
must be differentiated by the different site and radiation of the pain, by the
microscopic urinary findings, and should doubt still exist, by an x-ray of the
In less acute cases, spastic colon is, in my experience, one of the main
difficulties in differential diagnosis. Spastic colon is, like gall bladder disease, more common in women, but of the lean nervous type usually. The
Page 16
11 »•'
1   '
1 1 "if i
».i '
I  m
pain is a dull continuous ache with sometimes a much more severe pain in
the region of the ascending or transverse colon, which may be palpable as a
firm, tender cord. It may last for hours or even days; it is often precipitated
by cold and fatigue and is frequently associated with mental depression.
Rest and warmth are beneficial and even food may give temporary relief.
Constipation is common and responds unsatisfactorily to salts or most purgatives, except, I think, castor oil, which usually will terminate an attack.
Occasionally myalgia of the abdominal wall, localized near the gall
bladder area, causes difficulties; I have seen a number of such cases relieved
by local injections of Yzfo Novocaine in normal saline into the neuralgic
spot of the abdominal wall.
Arthritis of the spine may give neuralgic pains in front, simulating
cholecystitis: a thorough examination of the spine should be a routine procedure in all doubtful abdominal cases and an x-ray may be necessary.
Turning now to a consideration of the symptoms other than biliary
colic and local gall bladder pain, we are on much more treacherous ground.
Only 58% of Graham's stoneless gall bladder cases, operated on mainly for
gaseous dyspepsia and positive radiological evidence of gall bladder pathology
but -without biliary colic, were cured or relieved by cholecystectomy: this
is in contrast to 76 % of stoneless gall bladders cured or improved when there
was a definite history of biliary colic; Stanton's end results following operations on stoneless gall bladders without colic are equally unsatisfactory.
The reason, no doubt, is, as Palmer suggests, that upper abdominal distension with gaseous dyspepsia is not in the least peculiar to gall bladder
disease—it is met with in chronic gastritis generally, in chronic appendicitis
(though this diagnosis is now made with extreme reserve in the absence of
a preceding acute attack), in run-down conditions associated with enterop-
tosis. Enteroptosis, which may be associated with spastic colon, is indeed a
possibility to be seriously considered in every case of indefinite dyspeptic
symptoms, as operation will only aggravate the condition.
In every case where the least doubt exists, Graham's cholecystography
should be employed. Kirklin's technique has reduced the margin of error,
in using the dye by mouth, to the minimum. At 6:00 p.m., supper of usual
amount, but without eggs, cream, butter or other fats. Immediately after
supper, 4 grams of sodium tetraiodophenolphthalein dissolved in 1 ounce of
distilled water (freshly dissolved) is emptied into a glassful of grapejuice,
stirred well and drunk; no laxative or other medicine; at 7:00 o'clock next
morning, a rectal injection of warm salt solution is taken until the water
returns clear; no breakfast, but water, black coffee or clear tea may be
taken. X-rays of the gall bladder are taken at the 14th and 16th hour after
the dye is taken, and again at the 20th hour after the patient has taken a
glassful of milk and cream in equal parts with his lunch.
Following such technique, 732 cases were operated on: of these, 287
had normal cholecystograms, but on operation, chiefly for diseases other
than that of the gall bladder, only 89.5% had normal gall bladders while
10.5% had either definite cholecystitis or gall stones, in spite of a normal
cholecystogram. This makes the main error with the dye test, for of the
remaining 445 patients with some abnormality in the gall bladder plates,
98.6% had some form of gall bladder disease. Altogether, 415 cases were
found to have gall stones; the calculi showed up in 70.8% while 99% gave
some evidence of disease in the cholecystogram. It may be added that 124
cases showed stones in a normally functioning gall bladder, 92 showed stones
in a non-functioning gall bladder.
Page 17 One must remember that this wonderful accuracy of gall bladder technique does not imply equal accuracy of clinical diagnosis, as the pathological
changes in the gall bladder may have no bearing on the symptoms complained of by the patient. The onus is on the physician to satisfy himself
clinically that such gall bladder pathology is responsible. Much of the discredit attaching to the surgery of the gall bladder depends on faulty
diagnosis: it is a poor consolation for the patient, whose symptoms continue
unimproved, to have the surgeon assure him that his gall bladder was actually
diseased, or even to be shown the confirmatory report of a complacent
Gastric analysis is sometimes of service; gastric anacidity is present in
over 20% and subacidity in at least an equal number, especially in gall
bladder disease of some years' standing, while hyperacidity is comparatively
rare and then in cases of recent date. These findings help to exclude duodenal
ulcer, where hyperacidity is the rule and anacidity is never found.
In all doubtful cases, a gastro-intestinal x-ray is advisable.
Duodenal drainage may be of service. The presence or absence of the
concentrated gall bladder bile confirms the findings of the visualization
method; crystals of cholesterol or of calcium bilirubinate in quantity are
presumptive evidence of the presence of biliary calculi.
Prognosis and Treatment: One should steadily bear in mind that, from
the enormous post mortem records in many countries, the great majority of
gall stones and gall bladder inflammations either lie latent through life or
cause comparatively slight, or comparatively infrequently severe, symptoms.
The very frequency of gall bladder disease in middle and advancing years
should make the physician wary; the definite proof of gall stones or of
cholecystitis is far from meaning that indefinite symptoms of upper abdominal dyspepsia and pain must be due to this pathology.
In outlining treatment, I again remind you that many cases of gall
bladder disease belong unreservedly to the surgeon. Severe phlegmonous
cholecystitis, empyema of the gall bladder, recurring attacks of cholecystitis
persisting in spite of medical treatment, obstinate gall bladder dyspepsia with
occasional colic, cases associated with fever, other than the passing temperature of acute cholecystitis, stone in the common duct persisting for more
than two or three weeks, all demand, in my judgment, surgical intervention.
The onset of jaundice, even if slight, in undoubted biliary tract diseases
places a heavy responsibility on the medical man who opposes surgery, but
one must remember that a primary disease of the 'liver, like cirrhosis or toxic
hepatitis, is not favorably influenced by cholecystectomy even when the
gall bladder presents definite pathological changes. Angina pectoris and
myocardial disease, with associated gall bladder infection, often rather
increase the necessity for early surgical interference; in passing, one may
note that patients with high blood pressure of the essential type stand gall
bladder operations extraordinarily well.
But there remains the huge number of cases with disturbance of the
neuromuscular mechanism, with gall bladder dyspepsia or with infrequent
attacks-of colic without jaundice, who can be relieved by appropriate medical
treatment. It was assumed till recently by most prominent surgeons that
whenever possible gall stones should be removed and chronic cholecystitis
relieved by cholecystectomy as soon as a positive diagnosis was made; the
earlier the operation, the more complete the relief and the more permanent
the cure. It is even argued that acute cholecystitis should operated on as an
emergency, like acute appendicitis.
Page IB
f i
i ■
• \
1 mm
A physician who ventures, as I have long had the temerity to venture,
to oppose such radical surgical opinion, must obviously buttress his own
convictions by citing whatever confirmation he can obtain feiam outstanding surgeons dissenting from the prevailing surgical trend. Listen then to
Evarts Graham, of St. Louis, as found in the Journal of the American
Medical Association, November 17, 1934: "Several writers (Whipple,
Muller, Judd, Stanton and others) have called attention to the frequency
of unsatisfactory results after cholecystectomy on patients whose gall bladders showed a minimal amount of change from the normal condffijpn. . . .
In most other conditions, the idea has gained ground that one should attack
a disease early, in order to obtain the most satisfactory therapeutic results.
. . . There is some reason to think, howefver, that this principle does not
hold for diseases of the biliary tract."
Graham emphasizes that many common conditions (osteoarthritis of
the spine, chronic constipation, surgical diseases of the right kidney and
urinary tract and duodenal ulcer) are often confused with the less severe
forms of cholecystitis and that the removal of the gall bladder will not give
satisfactory relief in these cases, despite the existence of well marked disease
in the latter organ. Graham continues: "Statistics in general have shown
that the best results have followed the operations which have been performed
in cases not of early or minimal pathologic change but rather in those associated with relatively advanced changes." He analyzes 161 cases of his own,
in whom the gall bladder had been removed without calculi being present;
57 of these had a minimal lesion of the gall bladder, the wall not greatly
thickened, the organ containing concentrated bile and, on microscopic
examination, a few lymphocytes in the wall. Only 60% of these patients
considered themselves well after the operation; 33%, however, of the total
number gave a history of biliary colic, and in these, 76% considered themselves well or improved—while only 5 8% of those without biliary colic
were well or improved. Graham adds that, of 10 patients with a normal gall
bladder shadow and 75 cases with a faint shadow, 60 and 59% respectively
felt well or improved after the operation, the coincident removal of the
appendix being perhaps more responsible for the relief of symptoms than
the removal of a normal gall bladder. Graham concludes: "In the absence
of severe pain, the beneficial results to be obtained by cholecystectomy in
cases of a stoneless gall bladder are likely to be unsatisfactory in approximately 40%. There seems at present to be little justification for the subjection to operation of patients who have only the early beginnings of cholecystitis dicease, unless one is interested in the prevention of complications."
Professor Wilkie, of Edinburgh, who thinks the death rate in uncomplicated cases of gall bladder disease should not be more than 2%, finds over
70% of his patients relieved by the operation—the poor results and the
qualified benefit are found, for the most part, in the cases in which the preoperative symptoms were somewhat atypical and the pathology disclosed at
operation was not gross.
Stanton remarks that approximately one-third of all gall bladders
removed contain no calculi, though some enthusiastic surgeons report as
high as 60% of their gall bladder operations on non-stone cases. Stanton
finds that in both calculous and non-calculous cases, he has relieved the
colics and the sudden gas attacks as weil as the complications caused by duct
obstructions and active infections, but he has "very largely failed to relieve
those less definite complexes of indigestion," which he hoped were of gall
bladder origin but which were not accompanied by quite recognizable
Page 19 attacks of gall bladder colic. He adds: "If the gall bladder were really
responsible for the symptoms ascribed to cholecystitis without biliary colic,
the removal of the gall bladder should promptly and permanently do away
with the symptoms, but in my experience this has not been the case, unless
biliary colics were the dominating feature of the clinical picture."
Palmer, of Chicago, notes that the diagnosis of biliary tract disease may
be made with very great accuracy upon a history of biliary colic supported
by confirmatory cholecystography evidence; the value of either of these
alone is very much less than that of the two combined. The best therapeutic
results are obtained when cholecystectomy is performed for biliary colic,
and are much less satisfactory for "gall bladder dyspepsia"; in fact, Palmer
doubts if these so-called gall bladder dyspepsias differ materially from those
seen in patients not afflicted with cholecystic or other forms of organic
disease and usually relieved by a bland diet, a restoration of normal bowel
function, and general hygienic measures such as rest, adequate sleep and
exercise. In appraising the results of operations on the biliary tract, one
must not forget that the operation itself is a powerful psychotherapeutic
procedure, with many successes accruing from that all too overlooked
influence. On the medical side, Blackford, King and Sherwood followed
approximately 100 unoperated cases of biliary colic for 9 years and found
that in only two-fifths of these did colic continue after the initial examination—i.e., in 60%, the attack of colic subsided either as the result of medical
treatment or in the natural course of the disease.
These remarks on prognosis, especially culled from the surgeons, may
serve as an introduction to the prophylaxis and medical treatment of extrahepatic' biliary tract disease. The scope of prophylaxis is naturally limited.
Vincent Lyon suggests the following in the way of prevention of gall bladder disease in general:
(1) Avoid typhoid and the enteric group of fevers.
(2) Avoid infection in tonsils, teeth, sinuses and respiratory tract.
(3) Avoid the incautious use of drugs like atophan or cinchophen.
(4) If a woman, avoid having a large family.
(5) Eat three meals a day but avoid getting fat.
(6) Don't be a "meal skipper" but don't be a glutton.
(7) Don't be a Jack Spratt and eat no fat or the surgeon will get your
gall bladder before "you know where you're at."
Especially, stout women towards middle age may often, with advantage,
have their mode of life regulated, their sedentary life controlled and foods
rich in cholesterol (as liver, kidney, sweetbreads, yolk of egg) and in fat
(as fat of meat, pork, salmon, bacon) restricted, both in the hope of keeping
the blood cholesterol from rising unduly and especially to limit increase in
After childbirth, the blood and bile cholesterol are high, and I think
nursing women are encouraged unnecessarily to stuff in rich food in order
"to have plenty of milk" for the baby. Sufficient fluids should be insisted
on, as the amount of bile is definitely influenced by the fluid intake; 1J4
tumblerfuls of hot water an hour before meals and at night may be well
advised; cascara or other mild aperient may be necessary.
Food at comparatively short intervals is the best means of emptying
the gall bladder, and this should contain some easily digested fat, such as
cream, butter, yolk of egg. Exercise in the open air is valuable; deep breathing exercises should be practised systematically if other activities be unavailable; freedom from mental strain and worry counts. Stooping over a table
Page 20 II
while sewing or reading should be avoided. Foci of infection, especially in
the mouth, should be removed and dentures may be necessary.
These prophylactic measures are helpful, too, in preventing stasis of bile
when symptoms of biliary tract disease have already arisen. Epsom salts in
dose sufficient to produce satisfactory evacuation without purgation may
be given in concentrated solution in hot water, in the early morning; if the
patient lies on the right side with the pelvis high, the hot solution passes
apparently more readily into the duodenum and may replace duodenal
drainage which Lyon and others use systematically in the treatment of
«arly cases of gall bladder and biliary disease. Medicinally, three to five
minims of oleic acid in gelatin capsules one hour before meals or three hours
after meals, or one to three grains each of sodium oleate, sodium glycocholate
and sodium salicylate with one minim of oil of peppermint may be given in
a soft mass pill after meals. Decholin (sodium dehydrocholate) in 3 %-grain
tablets, three times a day after food, is excellent, having been proved experimentally to increase the flow of bile, but is, unfortunately, expensive. Two
teaspoonf uls of olive oil at night is very useful in emptying the gall bladder.
The concentrated solution of sodium phosphate (P.D. & C), a teaspoonful or more in the hot water an hour before breakfast, has proved in
my hands a very satisfactory aperient and seems to be of definite service in
preventing recurrence of symptoms, especially if a smaller dose (% teaspoonful or thereby) be given also an hour before dinner and supper. There
is no doubt that repeated duodenal drainage is useful in getting rid of biliary
stasis and low grade infection, when continued with the other means already
mentioned. In duodenal drainage, the presence of dark bile after the initial
flow of lighter bile is additional evidence of a functioning gall bladder, while
Lyon points to flocculi of yellow to greenish mucus in slimy masses from
which oily droplets melt out, as evidence of catarrhal cholecystitis, and this
is confirmed by finding, microscopically, an excess of bile-stained mucus or
pus cells. In gastric anacidity, drachm doses of dilute hydrochloric acid are
indicated to diminish the chances of ascending infection and often to relieve
The frequent presence of dyskinesia—of reflex interference with the
orderly emptying of the gall bladder and relaxation of the sphincter of Oddi
—must be constantly remembered, sometimes occurring early and preceding
all evidence of organic disease, but when frequent, usually complicating
coexisting gall stones or cholecystitis. In these cases, too large meals, perhaps
eaten hastily, fatty foods with high melting point, coarse vegetables, even
emotional disturbances, may give rise to a sudden spasm of the sphincter of
Oddi and rise of pressure in the whole biliary tract.
The treatment of this phase is extremely satisfactory. General supervision of the patient's life, of his work and play, of his philosophy of life,
and especially of his emotional reactions when this is possible, combined, it
may be, with 2 l/z grains of adalin or % grain of luminal after meals and at
night—these general measures are often of great value; liquor should be
forbidden and even tobacco should be used with discretion. The diet should
be smooth, the meals not too large and taken leisurely; it is necessary to
avoid condiments, coarse indigestible vegetables, pickles, radishes, new and
whole wheat bread, hot buttered toast, nuts and raisins, pork, salmon, veal,
duck, lobster, things fried in fat, raw apples. Newman avoids mixtures of
fats and starches in one meal. Lying down should be avoided for some time
after a meal, though rest in a comfortable chair for half an hour is advisable.
One to two tablespoonfuls of olive oil at night lead to a freer flow of bile
Page 21 overnight; 1/200 grain of atropine four times a day is useful in lowering
vagal irritability; Newman prefers tr. belladonna: minims 10 or more,
sodium bicarbonate: grains 15, with infusion of rhubarb, t.d.s., p.c.
Should, as often happens,, an attack follow too large or too indigestible
a meal, especially if swallowed hurriedly or under emotional stress, early and
complete emptying of the stomach usually ends an attack, and the patient
should be instructed to induce this at the earliest sign of an attack—a measure which is much too infrequently stressed by physicians. There is something to be said for the vomatorium of the old Roman residence—that convenient retiring room where excesses of food and drink were conveniently
got rid of. Of course, hot fomentations, the hot water bag and large linseed
poultices are most valuable for relieving pain; atropine gr. 1/100, hypo-
dermically, allays the underlying spasm and is specially serviceable after the
stomach is empty, should, exceptionally, the pain persist; morphia leads to
spasm of the sphincter of Oddi and should therefore be avoided if possible.
The general practitioner sees this type of attack from neuromuscular derangement far more often than the hospital surgeon, as it is! less severe as a
rule and shorter in duration than that associated with acute cholecystitis or
movement of calculi. It must be remembered, however, that such attacks,
when frequent, are usually associated with chronic cholecystitis or gall
stones, both of which heighten the nervous irritability and so give rise more
readily to upset of the neuro-muscular mechanism.
I suggest that this neglected neuro-muscular disturbance may partly
explain why Judd finds his operative results in younger patients not so good
as in his older subjects, and why, as Wilkie suggests, a few attacks of colic
frequently follow soon after an ultimately satisfactory operation. This is
an additional reason for urging medical treatment of the above type for
months after gall bladder operations, to diminish the very considerable percentage of incomplete results. Roscoe Graham, of Toronto, has recently
emphasized the latter point. Lyon claims extremely good results from the
systemic use of duodenal drainage.
In acute cholecystitis the mistake is often made in allowing the patient
up as soon as the pain subsides; the inflammation naturally takes many days
or longer to subside, and during this period rest and warmth in bed, mild
diet, mild doses of epsom salts or sodium phosphate in hot water in the morning, hasten recovery and tend, particularly, to prevent recurrence of cholecystitis which may otherwise occur in the early future and necessitate operation. Large linseed poultices are very valuable in relieving pain and in getting
rid of inflammation; they are, in my experience, much more useful than the
hot water bag and are not employed nearly as often or as systematically as
they should be. They should be applied hot enough to give rise to broad
brown pigmentation later. I have been using, lately, the massive doses of
urotropine recommended by Hurst after cholecystitis, to try to disinfect the
biliary tract; just get the urine alkaline and keep it so with gr. 60 to 100
each of sodium citrate and sodium bicarbonate, three times a day after
meals; then give 100 grains of urotropine three times a day along with the
alkali. I can testify that these massive doses of urotropine produce no irritating effect on the urinary tract. Hurst also recommends such treatment
preceding and following all serious operations on the biliary tract.
There is no doubt in my mind that when one or two attacks of chole-
cystiBs have occurred within a comparatively short time, latency of
symptoms may often be induced by three weeks in bed, light diet, large
linseed poultices twice in the morning and twice in the afternoon, with 1 l/z
Page 22 I   p   '
J^raablerfuls of hot water an hour before meals and at night, combined with
the use of sodium phosphate or epsom salts as already described. Avoidance
of chilling is important. Should the attacks recur in spite of such rest and
treatment, operation should be urged.
Speaking generally, from an experience of over thirty years in which
gastro-intestinal cases have figured largely in my private practice, I have
been impressed with the comparatively mild symptoms of the average gall
bladder case and with the readiness with which it responds to the general
measures outlined above; I would again remind you that I speak of the
uncomplicated cases, which only relatively seldom develop complications
calling for surgical intervention. Like duodenal ulcer, in these days much
less frequently operated on than twenty years ago, gall bladder disease seldom cuts short life but it does interfere frequently with the patient's enjoyment of a good time and calls for a spartan diet and mode of life.
I have been encouraged, since writing these lines, to find that T. R.
Brown, Chief of the Division of Digestive Diseases at the Johns Hopkins
Hospital, holds very similar views, and has recently expressed himself thus:
"A very large proportion of cases may be helped by such (medical) method
of treatment if the patient is willing to follow the treatment in principle
for a long period of time, perhaps even indefinitely. In my own practice, I
have a very large number of patients who have been comfortable and symptom-free for long periods of time by such procedures alone; even cases with
demonstrable stones or with definite evidence, from an x-ray viewpoint at
least, of considerable gall bladder pathology, cases in which there is no
■evidence of any progressive damage being done to liver, biliary tract, gall
bladder or pancreas by such an expectant therapy, and where for long periods
there have been no recurrences of acute or subacute infection, enlargement of the liver or
■of any other finding suggiesting any damage to liver function. But, to repeat, here, as in any
case of chronic disease elsewhere, the patients must follow certain general directions as
regards diet and personal hygiene if they hope to remain symptdgti-free." Brown adds that,
■of 84 cases in bis private practice where he advised surgery and where he had been able to
find out exactly what the ultimate results of the operation were, there was a surgical mortality of 4.7% (Eusterman gives 3.6% in 804 cases); 59% had complete cure, relative cure
or relief, while in 41%, operative treatment was unsuccessful. Hence Brown adds: "Surgery
has a definite mortality, it has many post-operative possibilities which may make the second
state of the patient the same as, or even worse than, the first."
Newman—Lancet, April 15, 22, 29, 1933.
Kirklin—Journal American Medical Association, Dec. 30, 1933.
Wilkie—Lancet, April 7, 1934.
Crump—Surgery, G. and O., October, 1931.
Stanton—American Journal of Surgery, November, 1932.
Ivy and Sandblom—Annals of Internal Medicine, August, 1934.
Greene et alii—Archives of Internal Medicine, April, 193 5.
Graham—Harvey Lectures, 1933-1934.
Eustermann—Yearbook of General Medicine, 1934.
Cheney—Oxford Monographs on Diagnosis and Treatment: Stomach and Intestines, 1928.
Carnett—Journal American Medical Association, February 3, 1934.
TViss—Journal American Medical Association, March 18, 1933.
Graham—Journal American Medical Association, November 17, 1934.
Blackford et alii—Journal American Medical Association, September 16, 1933.
Muller—Journal American Medical Association, September 3, 1927.
TViss and Green—Journal American Medical Association, December 9, 1933.
Hitzrot—American Journal of Medical Sciences, August, 1933.
Palmer—International Clinics, March, 1935.
Phillips—Oxford Monographs on Diagnosis and Treatment: Liver and Gall Bladder, 1930.
Brown—American Journal of Digestive Diseases and Nutrition, June, 1934.
Lyon—American Journal of Digestive Diseases and Nutrition, March, 1934.
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the milk "was properly pasteurized. It is, accordingly, of
interest to note what he says regarding the pasteurization
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"I would lay stress\ upon the fact that the milk which was
used for the purpose of the experiment was milk which had been
pasteurized by the low temperature process—a process which
implies adequate thermostatic control.
"The milk was a daily sample of the milk-supply in Kensington from the local pasteurization plant. The source of the
milk was not selected for the experiment, nor had the firm
supplying the milk any knowledge at all of the test.
"I know of no evidence hu support of the contention that
the nutritive value of milk, as a whole, or of its vitamins or of its
protein* is damaged by pasteurization to an appreciable degree.
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to lower the charges of milk distribution.
"No milk is really safe that has not been pasteurized.
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