History of Nursing in Pacific Canada

The Vancouver Medical Association Bulletin: November, 1945 Vancouver Medical Association Nov 30, 1945

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 THE   VANCOUVER   MEDICAL   ASSOCIATION
BULLETIN
Published Monthly under the Auspices of the Vancouver Medical Association
in the interests of the Medical Profession.
Offices: 203 Medical-Dental Building, Georgia Street, Vancouver, B.C.
EDITORIAL BOARD:
Db. J. H. MacDermot
Dr. G. A. Davidson Dr. D. E. H. Cleveland
All communications to be addressed to the Editor at the above address.
Vol. xxn.
NOVEMBER, 1945
No.    2
OFFICERS,  1945 - 1946
Dr. Frank Turnbull
President
Db. H. A. Des Brisay
Vice-President
Dr. H. H. Pitts
Past President
Dr. Gordon Bubke
Hon. Treasurer
Db. G. A. Davidson
Hon. Secretary
Additional Members of Executive: Db. R. A. Gilchbist, Db. W. J. Dobbance
TRUSTEES
Db. J. A. Gillespie        Db. A. W. Htjnteb        Db. G. H. Clement
Auditors: Messes. Plommeb, Whiting & Co.
SECTIONS
Clinical Section -
Db. S. E. C. Tubvey Chairman Dr. E. R. Hall Secretary
Eye, Ear, Nose and Throat
Dr. Grant __AWBENC____President Dr. Roy Mustard Secretary
Paediatric Section
Dr. Howard Spohn Chairman Dr. R. P. Kinsman Secretary
Orthopaedic and Traumatic Surgery Section
Dr. D. M. M_EKisoN___C_iairman Dr. J. R. Naden Secretary
STANDING COMMITTEES
Library:
Dr. W. J. Dorrance, Chairman; Dr. F. J. Buller, Dr. R. P. Kinsman,
Dr. J. R. Neilson, Db. D. E. H. Cleveland, Dr. S. E. C. Tubvey.
Publications:
Dr. J. H. MacDebmot, Chairman; Dr. D. E. H. Cleveland, Dr. G. A.
Davidson, Dr. J. H. B. Grant, Dr. S. E. C. Turvey, Dr. Grant Lawrence
Summer School:
Dr. J. C. Thomas, Dr. A. M. Agnew, Dr. L. H. Leeson, Dr. L. G. Wood,
Dr. A. B. Manson, Dr. A. Y. McNaib.
Credentials:
Dr. J. R. Neilson, Dr. H. H. Pitts, Dr. A. E. Trites
V. O. N. Advisory Board:
Dr. Isabel Day, Dr. J. H. B. Grant, Dr. G. F. Strong
Metropolitan Health Board Advisory Committee:
Dr. W. D. Patton, Dr. W. D. Kennedy, Dr. G. A. Lamont
Representative to B. C. Medical Association: Dr. H. H. Pitts
Sickness and Benevolent Fund: The Pbesident—The Trustees LINKS IN THE CHAIN OF TREATMENT]
CORYPHEDRIN
INDICATIONS:—    GRIPPE,   CORYZA,   RHINITIS| SINUSITIS,   TRACHEi
ADULT DOSE:- ONE TO FOUR  TABLETS  PER  DAY:- IN CONTAINERS OF 20, 100, 500 AND 1000 TAI
SOLUSEPTAZINE
WITH
EPHEDRIN
Indications:— Nasal Congestion with  Obstruction, Coryza, Acute  Rhinitis,  Naso-phaiyi
APPLIED    BY   DROPPER   TUBE,    ATOMIZER   OR    SWAB:-   IN    BOTTLES    OF   30   C.C.    AND    250
PASTILLES
GONACRIN
INDICATIONS:-   ORAL   ANTISEPSIS,   TONSILLITIS^ PHARYNGj
ALLOW PASTILLE TO DISSOLVE SLOWLY IN THE MOUTH:- SUPPLIED IN BOXES OF 20 AND 40 PAST
'   I cnujenx: jt£/u
CANADA       LIMITED   —  M O N T R £ A VANCOUVER HEALTH DEPARTMENT
STATISTICS—SEPTEMBER, 1945
potal population—estimated . !  _ 31 j 799
rapanese Population—Estimated . Evacuated
.hinese population—estimated . g 395
-iindu population—estimated  335
Number
Total deaths     276
Chinese deaths ■       12
Deaths—Residents only     230
BIRTH REGISTRATIONS:
Male, 278;  Female,  263 . 541
INFANT MORTALITY: Sept., 1945
Deaths under one year of age ,       21
Death rate—per   1000  births 38.8
Stillbirths  (not included above)       15
CASES OF COMMUNICABLE DISEASES REPORTED IN THE CITY
Rate per 1,000
Population
10.8
22.8
9.0
21.0
Sept., 1944
22
35.6
13
August, 1945        September, 1945
Cases      Deaths      Cases      Deaths
Scarlet Fever 	
Diphtheria   	
Diphtheria Carrier
_hicken   Pox	
_easles	
Rubella	
_umps	
Whooping   Cough   .
ryph_id Fever 	
Jndulant   Fever   _
Poliomyelitis   	
ruberculosis   :	
Erysipelas
Meningococcus Meningitis
Paratyphoid Fever _	
Infectious Jaundice	
Salmonellosis    §	
Salmonellosis   (Carrier)   _
Dysentery	
Syphilis	
Gonorrhoea	
Cancer (Reportable)   :
Resident	
Non-Resident   ______
4
0
0
10
3
4
2
1
0
2
1
52
0
1
0
0
10
1
1
103
228
72
43
0
0
0
0
0
0
0
1
0
0
0
19
0
0
0
0
0
0
0
2
2
24
0
0
17
5
3
15
0
0
0
5
42
2
0
0
0
4
2
0
96
220
72
44
0
0
0
0
0
0
0
0
0
0
1
14
0
0
1
0
0
0
0
2
0
Oct. 1-
Cases
12
0
40
4
1
14
0
0
0
0
1
1
0
0
0
0
0
0
0
15,1945
Deaths
0
0
0
0
<*.
0
0
0
0
0
0
0
0
0
0
0
0
0
B I O G L A N "C"
Prepared: separately for male and female*
Composition: Anti-thyroid principles of the pancreas, duodenum, em-
bryonin, suprarenal cortex, tests (or ovary). Each 1 c.c. ampoule
contains the equivalent of approximately 29 grams of fresh substance.
Indications: Graves's disease, hyperthyroidism, exophthalmic goitre,
thyrotoxicosis.   The most effective therapy available.
Stanley N. Bayne, Representative
Phone MA. 4027 1432 MEDICAL-DENTAL BUILDING Vancouver, B. C.
Descriptive Literature on Request
THE SCIENTIFIC HORMONE TREATMENT
Page 21 SODIUM PENICILLIN • CONNAUGHT
SODIUM PENICILLIN is supplied by the Connaught
Laboratories in sealed rubber-stoppered vials as a dry
powder which remains stable for at least a year if stored at
a temperature below 10° C. (50° F.). Each vial contains
100,000 International Units.
PHYSIOLOGICAL SALINE, sterile and pyrogen-free, is
supplied in 20-cc. rubber-stoppered vials, permitting of the
convenient preparation of various dilutions of penicillin, e.g.,
by adding 20 cc. of saline to a vial of penicillin a solution
containing 5,000 units per cc. is obtained, or if 2 cc. be
used, a solution containing 50,000 units per cc.
As supplied by the Connaught Laboratories,
Sodium Penicillin is of high quality and
is free from irritating substances.
CONNAUGHT LABORATORIES
University of Toronto
Toronto 5, Canada
DEPOT FOR BRITISH COLUMBIA
MACDONALD'S PRESCRIPTIONS LIMITED
MEDICAL-DENTAL BUILDING, VANCOUVER, B.C. VANCOUVER      MEDICAL      ASSOCIATION
Founded 1898    ::    Incorporated 1906
PROGRAMME OF THE FORTY-EIGHTH ANNUAL
SESSION (SPRING SESSION)
GENERAL MEETINGS will be held on the first Tuesday of the month at 8:00 p.m.
OJNICAL MEETINGS will be held on the third Tuesday of the month at 8:00 p.m.
These meetings will continue to be amalgamated with the clinical staff" meetings of
the various hospitals for the coming year. Place of meeting will appear on the agenda.
January 15      GENERAL MEETING.    Symposium on Cancer of the Breast.
Presented by the medical staff of the B. C. Cancer Institute.
1. Review of Institute Cases—Dr. A. M. Evans.
2. Surgical Treatment of Cancer of the Breast—Dr. G. H. Clement.
3. Radiological Treatment of Cancer—Dr. B. J. Harrison.
4. Pathology of Breast Cancer—Dr. H. H. Pitts.
5. Research on Breast Cancer—Dr. M. Hardie.
January 22      COMBINED CLINICAL MEETING—VANCOUVER GENERAL
HOSPITAL.
Breaks the vicious circle of perverted
menstrual function in cases of amenorrhea,
tardy periods (non-physiological) and dysmenorrhea. Affords remarkable symptomatic
relief by stimulating the innervation of the
uterus and  stabilizing the tone of its
musculature. Controls the utero-ovarian
L    circulation and thereby encourages a    i
K   normal menstrual cycle. /
K ■ J
b|_ • MARTIN H. SMITH COMPANY
W ISO l*rATlItt STIIIT.   NtW   TOIK.   N   V. ,<_!
Full formula and descriptive
literature on request
Dosage: l 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.
I
\i
: M
Page 22 OESTROFORM
Trade Mark
For Effective Oestrogenic Therapy
Oestroform is the natural ovarian .estrogenic hormone. Being the
natural hormone it is tolerated in all cases and it never gives rise
to such toxic symptoms as often occur when the synthetic oestrogens
are used.
Oestroform is indicated in all conditions associated with defective
follicular activity of the ovary, including delayed puberty and underdevelopment, amenorrhcea, sterility and dysmenorrhcea, and climacteric and menopausal symptoms, both natural and artificial.
The menopause is the most important single indication for the use
of Oestroform, and whenever signs of this are present Oestroform
will be found to produce effective and rapid relief.
Stocks of Oestroform are held by leading druggists throughout the
Dominion, and full particulars are obtainable from
THE BRITISH DRUG HOUSES (CANADA) LTD.
Toronto Canada
Oes/Can/4511 *7<4e ZdUo>& Pafe
First of all, the Publications Board of the Bulletin extends to all its readers the very
[best wishes for a Merry Christmas and a Happy New Year. This is the first year since
1938, some seven years ago, when it has been possible to utter this wish, free from the
(shadow of war. At last a chance for peace has come to our shaken world. It is too
isoon, yet, to say that peace herself has come to stay; we have not yet built an abiding
place fit for her to dwell in—but at least we have the opportunity to devote our energies
[to that end: and never before in the history of mankind has so earnest an effort been
[made in the direction of universal peace and understanding between nations and peoples
jof various political schools of thought. The need for peace is greater than ever before:
and perhaps the very urgency of that need will supply the impetus to ensure its satisfaction.
The Library of the Vancouver Medical Association is the proud possessor today of a
(very valuable document—an original letter in his own hand writing, by Edward Jenner,
the great English physician of the seventeenth century, who fathered vaccination. It
is a priceless relic, in excellent preservation—and we owe it to the generosity of Dr.
jGeorge Kidd, our Archivist and Historian, to whom it was given by a patient of his,
[Mrs. Stone of Pendrill Street in Vancouver. She inherited it from her father—but does
jnot know exactly how he got it.
It was a generous gift on Mrs. Stone's part, and equally generous was the act of
Dr. Kidd, who has presented the original to the Vancouver Medical Association, to be
{their property. A photostatic copy of it has been made and appears in thjis) issue of the
[Bulletin. Every effort is to be made to provide permanent care for the letter itself.
Written, as it is, on the excellent old linen paper of Jenner's day, it shows little wear,
and the ink in which it was written has faded -very little, if at all—it is a vivid, dlear
brownish-black. Jeuner refers in the letter to the question of vaccination. It was felt
that every medical man should have an opportunity to see this letter—hence the reproduction. The original will be very carefully preserved. It cannot be subjected to
handling—as it would soon perish with rough usage—but a strenuous attempt will be
made to make it visible to everyone, while at the same time shielding it from indis-
crinate or frequent manipulation.
Suitable letters of thanks were sent by the Library Committee to Mrs. Stone and Dr.
Kidd.
The question of chlorination of Vancouver water will probably be brought before
our eyes again soon. As all our readers know, strong attempts are being made to do
away with this practice. Never has a public question reached greater extremes of bitterness and recrimination.
To us, there is no question at all: we are quite convinced that Dr. Dolman has all
the facts on his side: and we owe him a debt of sincere gratitude for his very gallant
refusal to allow the case to go by default.
We confess that we are rather surprised that it has been left to Dr. Dolman to bear
the whole brunt of the attack from those opposed to chlorination. The attack has been
a vicious and a bitter one, and we think it rather outrageous in many particulars. Fortunately, Dr. Dolman was not in any way cowed by it, and has given as good as he got.
But what do our Health Departments, Provincial and Municipal, think of it? So far,
we have not heard.    The battle is by no means over—and it is still quite possible that
Page 23
%
; the cause of scientific prevention of disease may suffer a reverse, which would reflect
very seriously on Vancouver's standing as a city, and relegate us to the village category!
from which we had hoped we had emerged some time ago:
The Annual Meeting of the Canadian Medical Association has at last found a suitabM
venue: and Banff, Alberta, will be the place chosen for this very important convention
Hotel accommodation has been the stumbHng block as far as Vancouver is concerned.
It is not an entirely solved problem yet—but it is hoped that, with a certain amount of
doubling up and willingness to give and take, all may find accommodation at Banff.
Dr. Wallace Wilson, the new President of the C.M.A., has a large and active committee
at his disposal, who, with their sub-committees, are going to put this thing over.
Get your applications in early, to Coniniittee on Housing, Dr. G. A. Lamont, Sec-:
retary, 203 Medical-Dental Building, Vancouver, B. C.
The date of the meeting is June 10th to 14th, 1945, inclusive.
CORRESPONDENCE
The Registrar, Vancouver, B.C., November 26th, 1945.
Vancouver Medical Association.
Dear Sir:
Would you kindly insert the following letter in the Bulletin:
"There is a point which should receive the attention of the physicians of this city in
order that uniformity of professional attitude should be established.   I refer to the filling
out of medical certificates for insurance companies.
"I have always asked a fee of $2.00 and feel I am within my rights, and would be
imposed upon if I did not make such a charge.    It should be understood by insurance
companies that they are not entitled to receive" this gratis, as it is something they have
imposed upon the patient, and the doctor is also imposed upon by having to fill it out.
As it is a requirement on the part of the company, I feel they should be forced to pay
the proper fee.
"The purpose of this letter is to urge upon fellow practitioners the propriety of
making; this charge." v- _    • i
8 S Yours smcerely, Benj. H. Harry.
LIBRARY NOTES
RECENT ACCESSIONS TO LIBRARY—
American Medical Practice in the Perspectives of a Century, 1945, by Bernhard J.
Stern.
Galen on Medical Experience, First Edition of the Arabic Version with English
.translation and notes, 1944, by R. Walzer.
Fundamentals of Psychiatry, 3rd ed. 1945, by Edward A. Strecker.
Medical  Clinics  of  North America,  Symposium  on  Gynecology  and   Obstetrics,
November, 1945, Philadelphia Number.
BOOK REVIEW
TECHNICAL METHODS FOR THE TECHNICIAN, Anson L. Brown, 3rd ed., 706
pp., illus.   $10.00, B. B. Printing Co., Columbus, O., 1944.
This book serves the purpose for which it is written, and very well indeed.    The
various laboratory tests are simply and clearly set forth and the system of questions and
answers gives the technician all the help needed for an understanding of her work, with i
a great saving of time for anyone engaged in teaching technicians.
C. S. McK.
Page 24 Vancouver Medical Association
ANNUAL DINNER—1945
The Annual Dinner of the Vancouver Medical Association was held in the banquet-
room of the Vancouver Hotel on November 30th. No annual dinner was held in the
years 1941, 1942, 1943 and 1944. The revival of this old and honoured institution
celebrates the victory of the Allied Nations and the return to their homes of most of
our colleagues who have served abroad.    The event was not unworthy of the occasion.
Having said at the beginning that the fare and the quality and quantity of the drinks
served were execrable, and that this was no fault of those responsible for organizing or
those furnishing the dinner, we will pass this over.
The attendance was a record one, 274 being present. Presidents of neighbouring
medical societies, with our own Dr. Wallace Wilson, representing the Department of
Veterans' Affairs, flanked the President at the head table, and each one made good use
of his opportunity and the microphone to contribute to the gaiety of nations by telling
a story. It will generally be understood that space considerations only prevent our publishing these stories.
The program of entertainment set a high mark for succeeding dinner committees
to aim at. Amateur and professional performers were featured and in the former class
new and valuable talent appeared. Dr. Lawson of New Westminster has a delightful
baritone and his selection of his numbers showed its capabilities without exhausting
them. We hope that Murray Meekison and Eddie Carder listened in and liked "The
Road to the Isles" and "Phil the Fluter's Ball" as much as we did. In accompanying
Dr. Lawson and the clarinet numbers of Dr. Gould, Dr. Piters showed himself at once
as an accomplished technician and a sympathetic accompanist. Is there any significance,
we wonder, in the predilection of psychiatrists for the plaintive registers of the clarinet,
viola and French horn, as we have noted it? That an obstetrician should incline himself
to the grunting wails of the saxophone, a proctologist to the trombone—or do we digress
too far? However! The melancholy abstraction of Dr. Gould's rendition of the E-flat
Nocturne, lightened with his encore of "Londonderry Air," seemed fitting and pleasing.
The nostalgic revival of scenes in the Medical Hut (Major Ross Davidson and able-
bodied accomplices) was either too true to be good or too good to be true. We are
undecided; but we do know that the performers enjoyed it as much as the audience, and
an absolutely new and original radio-personaHty was disclosed by the wearily cadenced
utterances of Major "Hank" Scott.
The professional team of cattle-rustlers aided by Master Ronnie Matthews was just
the sort of dish to serve up on such an occasion. We have seen some regrettable incidents offered as professional entertainment at previous dinners, but the Committee was
inspired in then: selection at. this time. The gentleman known as "Red" who thumped
the bull-fiddle sang appropriately and Ronnie Matthews showing us how Lily Pons would
sing "Meet Me in St. Louis" was something to admire. We doubt if Miss Pons could
have done better herself.
The outstanding record for broad and high humour was set by three young gentlemen from that eminent seat of learning on Burrard Street. The dead-pan precision of
the fan dance, told better than words how thorough the rehearsal had been, and the
contrast between the unemotional diseur and the emotional frenzy of his silent interpreter was subtle.   These 'young men will go far—we fear.
Page 25 GIFT TO LIBRARY
Original Copy of Letter by Edward Jenner
A gift of exceptional character and value has been presented to the Vancouverj
Medical Association by Dr. Geo. E. Kidd, in the form of a holograph letter written by|
Edward Jenner in January, 1807.
The letter was given to Dr. Kidd by Mrs. Violet Stone of Vancouver, and came from j
the collection of her late father, who formerly lived in Bath, where he acquired the letterf
It is to be noted that the letter, apart from the interest attaching to the name at its
foot, makes specific reference to the vaccination against smallpox, and also gives evidence
of the great Jenner's cordial and generous spirit which he exhibited towards his colleagues, of which there are many instances.
The original letter, it is planned, will be preserved in the Library in a form whicfi|
will be accessible to all those who wish to see it.   A photostatic reproduction follows:
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V
s* College of Physicians and Surgeons
President j Dr. F. M. Auld, Nelson
Vice-President Dr. G. S. Purvis, New Westminster
Treasurer ; Dr. H. H. Milburn, Vancouver
Members of Council -Dr. F. M. Bryant, Dr. Tbomas McPherson, Victoria (District No. 1);
Dr. G. S. Purvis, New Westminster (District No. 2); Dr. H. H. Mil-
burn, Dr. Wallace Wilson (District No. 3); Dr. E. J. Lyon, Prince
George  (District No. 4); Dr. F. M. Auld, Nelson  (District No. 5).
Registrar Dr. A. J. MacLachlan, Vancouver
JOINT COMMITTEE ON MEDICAL ECONOMICS OF THE
COLLEGE OF PHYSICIANS AND SURGEONS AND THE
BRITISH COLUMBIA MEDICAL ASSOCIATION
Dr. H. H. Milburn, Chairman.
Dr. G. F. Strong, Vice-Chairman.
Dr. M. R. Caverhill, Secretary.
Chairmen of Sub-Committees:
Dr. G. F. Strong, Health Insurance.
Dr. L. H. Leeson, Rehabilitation.
Dr. H. R. Mustard, Revision of Fees.
Dr. D. J. Millar, Medical Service Plans and
Contracts.
Dr. H. Carson Graham, Relationship with Allied
Groups.
Dr. J. H. MacDermot, Publicity.
Dr. Thomas McPherson, Legislation.
Dr. A J. McLachlan, Registrar.
Dr. G. O. Matthews, Representative C.M.A. Exec Com.
Dr. Wallace Wilson.
Chairmen of District Committees:
Dr. P. A. C. Cousland, Victoria Medical Society.
Dr. A. H. Meneely, Upper Island Medical Assn.
Dr. G. A. McLaughlin, North Shore Medical Soc
Dr. F. A. Turnbull, Vancouver Medical Assn.
Dr. G. T. Wilson, Fraser Valley Medical Assn.
Dr. R. W. Irving, District No. 4 Medical Assn. I
Dr. F. M. Auld, West Kootenay Medical Assn.
Dr. F. W. Green, East Kootenay Medical Assn.
Mr. E. J. Lyon, Central Interior Medical Assn.
Dr. C. H. Hankinson, Prince Rupert Medical Assn.
*
At a joint meeting of the Commitee on Economics of the British Columbia Medic»j
Association and the Committee on Economics of the College of Physicians and Surgeons,
held in the Auditorium of the Medical-Dental Building on November 27th,  1945, wk
was decided to form "The Joint Conunittee on Economics of the Council of the College
of Physicians and Surgeons and The British Columbia Medical Association."    The slate
of officers and committees were appointed as above.
It will be noted that the principle of establishing sub-conirnittees in the various diss
trict societies, which was started last year by the Conunittee on Economics of the College, has been carried into the set-up of the new Committee, and that chairmen of subcommittees on the main phases of activity of both the old committees have been appointed. This makes the central committee representative of the whole Province—the
object we have been striving to obtain.
When all sub-committees have ben formed, we should have a pretty effective
organization to handle medical economics in our Province, which is a consummation to
be wished, and also an urgent necessity with many problems facing us at the moment.
Rehabilitation is very important. Revision of our Scale of Fees, both for D.V.A.
and other purposes, is right on our doorstep. Medical service plans and contracts need
careful supervision from our angle. Relationship with allied groups like the B. C.
Nurses' Association, B. C. Hospital Association, B. C. Pharmaceutical Association, and
the B. C. Dental Association, particularly in relation to health insurance, must be maintained. A joint conunittee of representatives from all these groups was formed last year
and monthly meetings were held, which proved very instructive for all concerned. This
must be carried on. Legislation must be carefully watched. We must continue to study
and keep in touch with development in health insurance.
Page 28 It was the opinion of the members of the Committee on Economics of the College
last year, particularly of those from outside Vancouver, that medical economics and the
doings of the Committee on Economics should be publicized so that the profession could
be more informed of the problems of medical economics. There is also our relationship
with the press to be considered.
In the new set-up, all this work has been provided for in the selection of sub-committees. These sub-committees will, no doubt, take advantage of our new plan, and
have ramifications in all district committees. The chairmen selected are all very interested, and we can be assured that the interests of the profession in British Columbia will
be keenly watched.
We hope, when the committees have been appointed and get down to work that a
meeting of all committees will be held three or four times a year, and a yearly conference on medical economics in which all sub-committees, including district committees,
will meet for a least a full day's meeting.
At the conference on September 11th, last, nine out of ten district chairmen were
present, and the meeting was a success. It was a beginning, and we can hopefully look
forward to future conferences of that sort.
JOURNALS REQUIRED BY U. B. C. LIBRARY
The Library Committee is in receipt of a letter from Dr. J. S. Kitching, Director of
the University Health Services, in which he makes an appeal for back issues of certain
journals required by the Library of the University of British Columbia. We have told
him that we would bring this request to the attention of our readers all over British
Columbia. We feel there are many medical men in B. C. who have numbers of the
journals which are required, that they would be glad to dispose of where they would be
appreciated. It is requested that anyone wishing to donate any of the following journals, communicate directly with Dr. Kitching or Dr. Kaye Lamb, Librarian of the
University, who will give them the necessary information regarding delivery or shipment:
American Medical Association Journal—
1934    April 21 1942
June 30
1937 July to December, inclusive.
1938 January 22
1940 November 30
1941 January, all issues.
February 1, 8, 15.
March 1, 8, 15, 29.
April, all issues.
May, all issues.
June 7, 14, 28.
September 13, 20, 27.
October, all issues.
November, all issues.
December, all issues.
British Medical Journal—Everything after 1925.
Lancet—Everything.
January, all issues
February, all issues.
March, all issues.
June 6, 13, 20.
July 4, 1-1; 18.
October 10, 17, 24.
1943    January 9.
March _.
May 8.
June 12.
September 18.
October 9.
November 27.
Page 29 GENITO-URINARY TUBERCULOSIS
SuRGEON-LffiUTENANT-CoMMANDER JOHN T. MacLeAN, R.CN.V.R.
Read at the Annual Meeting of the British Columbia Medical Association, September, 1945.
Genito-urinary tuberculosis may strike the kidney, the prostate, the seminal vesicles!
the epididymis, or the bladder. It may be limited to any one of these organs, with the i
exception of the bladder. Its most characteristic feature is its marked tendency to spread.
It is this factor, perhaps more than any other, which plays such a predominant role inj
the treatment. In dealing with urogenital tuberculosis, one must never forget its tendency to spread.
It must also be borne in mind that tuberculosis is a generalized infection, and thai
urogenital tuberculosis is usually only a local manifestation. Such infection is usually,
in fact some people say always, secondary to a primary focus in the lungs, tonsils, bones,?
or intestinal tract. The primary focus can be found in approximately 80% of cases.'
In searching for a primary focus, one should also bear in mind that an early pulmonary
lesion may not be detectable by radiological means until six months after its onset.
AGE.—Genito-urinary tuberculosis is rare under the age of ten years, and if present!
at this age is almost always the acute fulminating type. Seventy per cent of the casesj
occur between twenty and forty years of age.
INCIDENCE.—The incidence of urinary tuberculosis and of genital tuberculosis
is not clearly recorded as such, as they are practically always lumped together under the
broader title of "Genito-Urinary Tuberculosis" without specifying the exact location.
The following figures on the incidence of genito-urinary tuberculosis are considered
to be from acceptable sources.
Investigator
Source of Material
Kapsammer    ' Routine autopsies
Hesse Routine autopsies
Lowsley and Duff Routine autopsies
Krzywicki Autopsies on tuberculosis subjects
Fowler & Godlee Autopsies on tuberculosis subjects
Kuster Patients dying of tuberculosis
Cabot . .154 cases of Tbc of epididymis
Cabot 1862 cases of genito-urinary Tbc. gathered from literature
No. Cases
Incidence of
Reviewed
G.U.T.B.C.
in Percent
20,000
1.0%
10,864
2.13%
52,070
2.1%
500
5.0%
5.27%
10.0%
had renal Tbc
18 also had
renal Tbc. The
genital   lesion   preceded   the
renal lesion
in 11.
821  had some lesion in the.
epididymis,
in 75% of these
the   lesion   was   Tbc    1169
out of 1675
(70%) had tu-
berculosis in
the prostate and
seminal vesicles.
Renal    Tbc
had   preceded
genital Tbc
in 11.
Keyes 100   patients  representing  Tbc.  infection in epididymis 153 times.
All the figures may be briefly summarized by saying that the incidence of genito-J
urinary tuberculosis is approximately:
1 — 2 % in routine autopsies
5% in autopsies on tuberculosis patients
10% in patients dying of tuberculosis.
The ratio of bovine to human tuberculosis, in the incidence of urogenital tuberculosis,
is extremely rare, but theoretically could occur.
In cases of genito-urinary tuberculosis the prostate, seminal vesicles, or epididymis,
are involved in 65% to 75% of the cases (Boethe; Lowsley and Duff; Young).  Primaryf
tuberculosis of the prostate alone is rare. Brasch of the Mayo Clinic reports that of all
the cases of renal tuberculosis treated in that Clinic, 25% had epididymectomy either
before or after nephrectomy.
RENAL TUBERCULOSIS.—In discussing the problem of the origin of urogenital
tuberculosis, it might be as well first to consider renal tuberculosis. The incidence of
Page 30 enal tuberculosis is gradually decreasing.  At the Barnes Hospital in St. Louis, the inci-
jence reported is:
Cases Admitted Raio to General Admissions    Operation
1916 -  1921—20 cases per year . :  1 : 300 11  cases year
1921 -  1929—16 cases per year  1 : 400 11  cases year
1930 - 1934—13  cases per year  1 : 450 6 cases year
(reduction of 50%)
Renal tuberculosis is the result of the introduction, implantation, and germination,
[if the tubercle bacillus in the renal bed. The extent of the lesion depends upon the
development of the bacillus, and the resistance of the host.
There are three main types of lesion in the kidney:
1. Acute miliary—fulminating bilateral renal lesions which is a part of a general
miliary tuberculosis.
2. Chronic form—i.e. surgical renal tuberculosis.
3. Toxic tuberculous nephritis—which is a renal manifestation of a grave general
tuberculosis, without definite involvement of the urinary organs.
ETIOLOGY.—Renal tuberculosis is practically always hematogenous in origin, the
primary focus being in the lungs, tonsils, bone, or intestine. The infection in the primary
urea may progress until finally the tubercle bacilli invade the blood stream. If the invasion of the blood stream is massive, general miliary tuberculosis results. If on the
Dtber hand the organisms enter the blood stream in showers, the phagocytic cells of the
body may overcome them. If the patient's general and local resistance is sufficient, the
secondary lesion in the kidney may heal; otherwise it progresses with eventual destruction of the kidney. Renal, and other secondary lesions in the prostate, seminal vesicles,
ind epididymis, may all originate from the same primary focus in the lungs, tonsils, intestinal tract, etc. On the other hand, the renal lesion may be derived from infection iii
the prostate, seminal vesicles, or epididymis, and carried to the kidney by the blood
stream. It is the consensus of opinion today that renal tuberculosis is blood borne, and
mat ascending tuberculosis infection of the ureter or up the lymphatics does not occur.
PATHOGENESIS.—It is now generally assumed that a bacillus-laden embolus is
_arried into the kidney in the blood stream and lodges in a capillary tuft. The glomerular
focus may be walled off; or a few bacilli may reach the capsular space and multiply,
while being washed slowly along the proximal convoluted tubule until they reach a
favourable soil for growth in the medullary loop, or they may reach the medulla by way
of the fine efferent glomerular capillaries, or finally, the cortical lesions may spread to
the medulla by the lymphatics.
Opinions differ as to whether the initial lesions in the kidney are predominantly cortical or medullary.
Ekehorn states that the bacilli usually lodge in one of the pyramids.
Eberback states that the kidney cortex is first attacked, and later the medulla.
Medlar, who did 100,000 sections on 44 separate Tbc. kidneys, found 367 definite
tuberculous lesions of which 75% were in the cortex, 11% in the medulla, and 14%
were cortico-medullary.
The initial glomerular lesion may heal, continue to grow slowly, or rarely develop
into the main lesion. The medullary lesion usually grows relatively fast; such a tubercle
will spread, and finally open into a renal tubule or papilla, discharging its contents into
the renal pelvis. If the medullary lesion is near a calyx it will give rise to early symptoms.
If it is deep in the parenchyma there may be extensive damage before there are any
clinical signs. Healing of this type of lesion is rare.
THE QUESTION OF INITIAL BILATERAL INVOLVEMENT.—Of the many
disputed points concerning renal tuberculosis none has been more discussed than the
question as to whether, at the outset, one or both kidneys are involved.
Van der Vurst de Vries (Belgium) says it is always bilateral to begin with and one
side heals spontaneously.
Medlar states bilateral infection is the rule.
I
11
Page 31 Hinman states there is no more reason to assume that both kidneys are infected, than
to assume that both knees are, simply because one is.
Many investigators believe the implantation is bilateral, but that the disease develops
in only one kidney.
THE EXCRETION OF TUBERCLE BACILLI IN THE URINE.—The recovery^
of tubercle bacilli from the urine is regarded by most observers as the essential evidence
of active disease within the renal parenchyma. Some people maintain that tubercle bacilli
may be excreted through a normal kidney, e.g. Albequerque and Poz. However, experi-1
mental and clinical observation by a number of observers refutes the theory of excretoryj
tuberculous bacilluria most conclusively.
Lepper—Whenever organisms were recovered in the urine following intravenous
injection, there were invaluable evidences of renal changes before the organisms were
found in the urine.
Dyke—Same conclusion.
Bumpus and Thompson—Same conclusion.
Sherrington states that at a time when the blood is teeming with micro-organisms,
there may not be the slightest transit of them into the urinary fluid then excreted.
This work was challenged by Biedle, Krause, and Von Kleechi, who put cannulas
into cut ends of ureters (using cocci).
Lawrason Brown (Saranac) confirmed the theory by demonstrating that 10% of
the patients at Saranac Lake with pulmonary Tbc. showed tubercle bacilli in the urine
without demonstrable evidence of renal disease.
Brown failed to take into consideration the possibility of: (1) early renal disease,
(2) lesions of the genital tract.
Helm hoi z (1925) showed conclusively that excretory bacilluria does not occur and
that the presence of bacteria in the urine represents a break in the integrity of the renal
secreting surface.
Corbitt in a very excellent paper points out that secondary infection occurs frequently in urine catheterized from a tuberculous kidney. Secondary infection was found
in 29% of his 213 cases of renal tuberculosis. He also points out that secondary bacteria
are found less frequently in the urine catheterized from the kidney than the urine
obtained from the bladder, and warns that it is important to exclude tuberculosis in all
cases of persistent urinary infection.
SYMPTOMS OF RENAL TUBERCULOSIS.
1. Frequency of urination—75% of cases.
2. Painful urination is a frequent accompaniment of the tuberculous disease.
3. Hasmaturia—microscopic or macroscopic in 50% of cases.
1. Terminal bleeding is common.
2. Smoky urine.
3. Microscopic R.B.C.
IS 4.   Gross hematuria—very rare.
4. Dribbling is usually a sign of pronounced vesical involvement.
DIAGNOSIS.
1. Symptoms.
2. The recovery of tubercle bacilli from the urine is regarded as the essential evidence of active disease within the renal parenchyma.
3. Alterations in the renal architecture demonstrated by retrograde pyelography.
TREATMENT OF RENAL TUBERCULOSIS.—We know that the incidence ofj
bilateral renal tuberculosis will vary depending upon the promptness with which obser-i
vation and urological investigation is carried out.  It is bilateral in 20% - 47% of cases.l
I believe each case of renal tuberculosis should be regarded as an individual problem,j
and evaluated accordingly.
We will all admit that there is a great deal we do not know regarding the pathogenesis of tuberculosis. We know little about allergy, resistance, immunity, dosage, viru-
Page 32 jlence, etc. Nevertheless, we do know that the personal equation is important. It is of
jthe greatest value to know the patient's ability to fight his disease, the pathological type
taf the disease, and the prognosis in so far as the pulmonary lesion is concerned.
1. Chronic destructive renal tuberculosis will never heal, and whenever unilateral,
(should always be subjected to early nephrectomy at the proper time. There are two
(extremely important facts to realize here:
(a) In chronic renal tuberculosis institution of operative measures at the appropriate stage has very seldom caused pulmonary flare-ups. Surgery should wait
whenever possible until the pulmonary lesion has become quiescent.
(b) The supposedly normal ureter is involved in 30% of the cases.
There is only one answer to this. The. whole ureter as well as the kidney should be
removed at operation. I think it is a great mistake to do only a nephrectomy. It takes
ten minutes longer to remove the whole ureter intact. The advantage of this type of
treatment is that the wound heals per primam. I have had one exception in ten cases,
and that was in a case where I accidentally soiled the wound.
2. If the lesion is bilateral, the treatment may be either:
(a) Conservative or Surgical.
Beach and Shultz report: Eight clinical instances of spontaneous healing
in bilateral renal tuberculosis as signalized by non-recurrent objective findings, and lack of subjective developments over a period of observation ranging from six to fifteen years.
(b) Bilateral Ureteral Transplant
(i)   to abdominal wall
(ii)  to bowel.
Neither of these appeals to me very much; the first as being unclean and a nuisance,
and the second as rather hopeless. I think the severity of the symptoms would be a strong
factor in determining the treatment. Nevertheless, Keyes reported the autopsy findings
on a patient twenty-two years after cutaneous ureterostomy for tuberculosis. The patient
was a doctor, and Dr. Keyes pointed out that the patient lived a most useful life with
comparatively little inconvenience.
TUBERCULOSIS OF THE BLADDER.—Tuberculosis of the bladder is probably
always secondary to tuberculosis of the kidneys or seminal tract. In the majority of cases
the primary focus is renal.
Involvement of the bladder, secondary to a tuberculous focus in the prostate and
urethra, apparently occurs by direct mucosal extension. In such cases the trigone is
practically always the point of first attack. Infection from the upper urinary tract
occurs frequently and the ureteral orifice on the affected side is involved in many cases.
In most cases, however, the bladder involvement is usually due to the planting of
tubercle bacilli from infected urine directly on the vesical mucosa, the resistance of
which has been lowered by continuous irritation by urine infected with tubercle bacilli.
This leads to inflammation, oedema, eventually ulceration; and finally infiltration and
fibrosis of the bladder wall, leading to a small contracted bladder.
SYMPTOMS.
1. Intense frequency.
2. Painful urination—intense chiefly at end of micturition.
3. Slight, intermittent, hematuria.
DIAGNOSIS.
1. Cystoscopic appearance of bladder.
2. Tubercle bacilli in urine.
PROGNOSIS.
1. If the source of the vesical infection, usually a tuberculous kidney, is removed,
the bladder condition often heals rapidly.   If, on the other hand, the original source of
Page 33 the dicease is not eliminated, it is practically impossible to cure or even materially relievd
a tuberculous cystitis.
2. The most effective treatment, of course, is prophylactic.
3. Hygienic sanatorium regime.
TUBERCULOSIS OF THE PROSTATE.—Tuberculosis of the prostate alone ii
very rare. It is usually part of a progressive infection that is extending throughout th<
genital or urogenital system.
Most commonly it is found in association with tuberculosis infections of the epididy
mis, vas deferens, and seminal vesicles; less often as an accompaniment of ordinary tuberculosis.
Tuberculosis of the prostate is present in about 70% of cases of urogenital tuberculosis.
In most instances it is probably an extension from the seminal vesicles.
Whether urogenital tuberculosis starts in the kidneys, in the epididymis, or in th(
seminal vesicles and prostate, it tends to spread from one portion of the tract to another
either by direct extension or lymphatics.
SYMPTOMS:
1. None.
2. Frequency; dysuria; hematuria; pyuria.
DIAGNOSIS.
1. Rectal examination—firm, irregular, nodular prostate.
2. Examination of prostatic fluid.
TREATMENT.
1. Total prostatectomy—poor results: frequently get chronic sinuses.
2. Energetic expectant treatment—the equivalent of sanatorium rest and hygienic
measures.
TUBERCULOSIS OF THE EPIDIDYMIS AND TESTICLE.—Tuberculosis fren
quently attacks the epididymis, but rarely the testicle. When tuberculosis does invadt
the testicle, the testicular lesion is practically always secondary to that of the epididymis
Whether the original focus is in the epididymis or in the prostate and seminal vesicle:
is a matter of controversy. Autopsy records show that a tuberculous lesion may be limited to the epididymis, seminal vesicle, or prostate, but that such limitation is rare
Hugh Young says primary is usually in the seminal vesicles.
Personally I cannot see that it makes a great deal of difference as to where it starts
The fact remains that the tendency is to spread, and clinically by far the majority oi
cases exhibit multiple lesions.
The infection in the epididymis' usually begins in the globus minor, and gradually
extends throughout the epididymis, and into the vas.
Tuberculosis of the testicle is almost always secondary to tuberculosis of the epi
didymis, and the process is usually intertubular. By extension and coalition, the entir<
testicle may become a callous mass. On the other hand, the tuberculous process in thi
epididymis may assume extensive proportions, and the testicle will be found as a smal
compressed organ, free from involvement
Eventually the scrotum becomes adherent, and the process ulcerates through, form
ing a chronic fistula discharging caseous material. The function of the affected organ i
destroyed, and should the process become bilateral, complete sterility is inevitable
Sinuses on the posterior surface are usually from the epididymis. Those on the an
terior surface are usually from the testicle.
Often the disease is apparently bilateral from the onset. When tuberculosis infect
one epididymis the opposite epididymis is likely to become infected sooner or later; per
haps years apart.
DIAGNOSIS.
1. History of trauma—in many cases.
2. Loss of weight
Page 34
-general malaise. 3. Bladder symptoms.
4. Fever is rare.
5. Pain and tenderness are mild and intermittent.
6. History of exacerbations and remissions.
7. Palpation—lumpy sensation.
DIFFERENTIAL DIAGNOSIS.
1. Tuberculous epididymitis.
2. Inflammation due to other causes.
PROGNOSIS AND TREATMENT.
The high morbidity of genital tuberculosis, even when properly treated, is not generally appreciated. The disease is progressive and fairly rapid in its evolution. Various
authors have placed the ultimate mortality from 27% - 60%. Ten years or more must
elapse before the danger is past.
TREATMENT.
1. Epididymectomy—with transplantation of the vas to the. skin of the groin.
2. The equivalent of sanatorium treatment.
CONCLUSIONS
1. Genito-urinary tuberculosis may strike the kidney,  the  prostate, the seminal
vesicles, the epididymis, or the bladder.
2. The incidence of genito-urinary tuberculosis is approximately:
1 — 2 % in routine autopsies.
5% in autopsies on Tbc. patients.
10% in autopsies on patients dying of Tbc.
3. Its most characteristic feature is its tendency to spread.
4. It is usually, if not always, secondary to a primary focus in the lungs, tonsils,
bones, or intestinal tract. The primary focus can be found in 80% of cases.
*   5.   In genito-urinary tuberculosis, the prostate, seminal vesicles, or epididymis are
involved in 75% of cases.  Usually more than one of these organs is involved.
6. Renal tuberculosis is practically always hematogenous in origin.
7. The presence of tubercle bacilli in the urine represents a break in the integrity of
the renal secreting surface.
8. The ureter is involved in 30% of cases.
9. In the treatment of genito-urinary tuberculosis, the personal equation is most
-important.
10. The best treatment for chronic unilateral renal tuberculosis is, I believe, nephro-
ureterectomy.
11. Bilateral disease must be treated conservatively.
12. Regardless of where the tuberculosis is lodged in the urinary or genital tract,
sanatorium treatment, or the equivalent thereof, is indicated in addition to any surgical
procedure carried out.
13. Tuberculosis of the epididymis is, I believe, best treated by epididymectomy
-with transplantation of the vas to the groin. Every effort should be made to make an
early diagnosis.
14. Tuberculosis of the prostate and seminal vesicles.is, in my opinion, best treated
.conservatively.
15. Tuberculosis of the prostate will usually clear spontaneously, if the source of
infection (usually renal) is removed.  The most effective treatment is prophylactic.
16. The cases for surgical treatment must be selected with care, and the optimum
time for operation must receive the most careful consideration in order to obtain the
most beneficial results.
Page 35 SOLITARY SYSTOLIC MURMURS
Col. A. B. Walter, R.CA.M.C
Read at the Annual Meeting of the British Columbia Medical Association, September, 1945.
The Canadian Army manual called "Physical Standards and Instructions" rules that
the presence of a systolic murmur unassociated with any other sign* of cardiovascular
disease shall not affect a soldier's grading; it states also that the finding of any diastolic
murmur shall cause rejection of the man. Similar advice from Sir Thomas Lewis was
applied in the war of 1914-18.
There is an important inference in this; that most systolic murmurs are normal and
that almost if not all diastolic murmurs are abnormal.
That is the most important which affects the greatest number of people to the
greatest degree. Systolic murmurs are infinitely more common than diastolics in the
general population, and the presence of one raises the most important question connected;
with cardiology: "Is this heart disease or not?" Probably a third of our population
could be affected for the rest of their lives by the doctor's opinion as to the significance
of a systolic sound, and to him it is a grave responsibility, the more disconcerting;
because making a judgment is sometimes difficult, we have all seen our predecessors*
mistakes and victims, the men and women told of a "leaking heart" who nursed themselves through the remaining seventy or eighty years of life, allowing themselves "a mere
crippled existence; and the dread of our repeating the mistake and causing similar ruin
weighs upon us.
While the diastolic murmur is a mark of abnormality, the systolic one is often a
great uncertainty; because it is so, and because the assessment of it means the determination not between degrees of disability, but between health and disability, it surely is
the more important and deserves the more careful study.
The chief problem, at least since the time of Mackenzie, has been the clarification of
distinctions between systolic physiological and systolic organic murmurs. Many have
written of them; of differences in intensity, differences in pitch, differences in transmission. Some have said that distinction is impossible, and that accompanying diastolic
sounds, cardiac enlargement and other confirmatory signs must decide the issue; these,
however, are useful accessories only in a fraction of cases. Intensity and pitch are variations of quantity, not of quality, and are open to unstandardized personal estimation.
The amount of discussion recorded on distinction alone is some indication not only of
its importance but also of its difficulty.
When confronted with a given example of a solitary systolic murmur, it seems practical to the writer to begin auscultation with a careful search for the point of greatest!
intensity. This may sound primitive, but it is based on the fact that most systolic murmurs are audible over all four cardinal areas and elsewhere, and can easily be assigned a
wrong origin if the maximum sound be not spotted.
The commonest of all systolics is of pulmonary origin but may be heard almost as
well, sometimes equally well, at the apex; because a comparison at the two areas was not I
made it has often come referred as an "apical" murmur, with all the implications of such.
Since this murmur is the commonest its identification is the most important; since
it has been credited with these two quantities it is suitable for discussion first. After all,
the principle of elimination is a good part of the system of differentiating systolic mur- :
murs, and it is well that elimination or recognition of the largest bloc should be given
priority.
This common murmur is generally recognized as "functional" or, to use a more pure I
adjective, "physiological." It apparently rises at about the root of the pulmonary artery, •
but by what mechanism is conjectural; it has been simulated experimentally by light
compression on the bared pulmonary artery but its characteristic intensification during
expiration, when potential compressions on the artery are being relaxed, rules out this j
causative possibility.  The most plausible explanation is one heard expressed by Professor
John Oille: that the murmur originates at the pulmonary valve by its relation to the
Page 36 wider artery beyond; that the arterv being wider when shortened in expiration than
when lengthened in inspiration, causes the murmur to increase as expiration progresses.
Alterations in velocity—threshold for sound—must counteract this somewhat. It is
interesting to note that the Valsalva experiment diminishes the sound. Whatever the
cause, several things point to its innocence—its prevalence in adults without illness or
[history of pertinent illness, its compatibility with normal work-tolerance throughout
active lifetime, and its tendency to disappear with more mature years.
The writer has reported in the Journal of the Canadian Medical Services, Nov., 1943,
on the incidence of this murmur in 400 soldiers referred consecutively for various unrelated complaints and examined personally; it was present in 119, or 29.75%. By
decades the ratio between its presence and absence was found as follows:
2nd decade 10 to 3.5
3rd decade 10 to 8.6
4th decade 10 to 12.0
5th decade 10 to 35.6.
This illustrates the recession with advancing age.   Baker, Sprague and White1 quote
Scott as stating that a systolic murmur in a person over forty should always be suspected
as a sign of heart disease.
Only in very faint examples is this murmur confined to the pulmonary area; it
seems to have an areated rather than a linear transmission, in keeping with the conformation of the pulmonary artery system, and in most cases is audible over the whole prae-
cordium or even beyond its limits. It is correctly enough called a pulmonary murmur,
but I fear that our conception of that term has become degraded to association with
murmurs heard only at the pulmonary area; the result has been some confusion with
apical murmurs, and I feel that the designation "praecordial physiological" might be
more discriminating.
The murmur has certain characteristics which allow one to be reasonably assured of
its identity in the great majority of cases.
It is blowing, sometimes a little rough if loud.
Jt is usually loudest at the pulmonary area, of praecordial transmission, moderately
less intense at the apical region; occasionally it is equally intense at the apex, but a
murmur which is louder at the apex should not be included in this type.
It is louder when the patient is in the supine position than when sitting or standing;
a faint murmur may become inaudible in the latter positions, and examination supine is
necessary to avoid missing examples.
It varies markedly with respiration, decreasing or disapearing on forced inspiration,
intensifying with expiration. Forced expiratioh may induce a murmur where none is
present during normal chest movement.
It will be noted that the last two characteristics are not a complete distinction from
organic murmurs, but it would seem that the variations with position and respiration are
more marked in the case of the physiological murmur, and taken in conjunction with
areas of maximum intensity and transmission they are confirmatory.
The murmur varies from day to week in presence and intensity; like other murmurs
it is intensified by exercise.
A caution is worth mentioning in assessing variations of intensity with position; the
patient should be made to stop breathing between comparisons, to obviate the factor of
respiratory variations; and the transitory changes due to exertion should be allowed to
pass over.
In the series referred to, 95.9% of all solitary systolic murmurs encountered fell
within the pattern described, and were considered physiological. In radiograms of forty
of them, no abnormality of heart shadow was found.
It is not suggested that the figure is representative of our general population, but it
must approximate this in incidence of physiological murmurs alone.
In Contratto's2 series of 2856 students at Harvard, a systolic of some degree was
heard in 350 cases   (12.3%),   In 208, murmurs were classified as functional;  that
Page 37 amounts to 59.1% of all systolic murmurs in an unselected group of young men. Of
the remainder, 9 (2.57%) were classified as rheumatic lesions, 6 (1.71%) as congenital,
and 127 (36.30%) as indeterrninate. This is a much larger group of indeterminatesi
■ than there appeared to be among soldiers.
At any rate it would seem that recognition of the physiological praecordical systolic
from critical appraisal of its several characteristics weeds out from 60 to 96 per cent of
problems of diagnosis where a systolic murmur is unaccompanied by other murmurs or
by other signs of cardiac abnormality.
I have said little of history of rheumatic fever; its presence if confirmed by careful
questioning is significant but not conclusive, its absence is less so on the opposite pan of
the balance; so also of the criteria of pitch and intensity which are so variable and so
open to individual interpretation that their diagnostic reliability is uncertain.
For the reasons that the murmur described seems the most diagnosticaHy important,
most frequently present and most usefully eliminated first, it has been discussed in
more detail than will be other solitary systolic murmurs. These others are probably all
1 of morbid origin.
Continuing the examination on the system of maximum intensities, other murmurs
heard best at the pulmonary area are those from congenital cardiac defects. Roger's is
the most relatively common, followed probably in frequency by that from infundibular
or pulmonary stenosis. These may be suspected by their more local character, making
the fall in intensity at the apex much greater than that of physiological murmur, by
intensity unchanged with the erect position and often by the presence of confirmatory
signs such as thrill.
More rare causes are pathological dilatations of the pulmonary artery from back
pressure through left ventricular failure or mitral stenosis, chronic pulmonary fibrosis or
other pulmonary disease, and pulmonary arteritis.
Systolic murmurs which are definitely maximum at the apical region are probably
best considered all morbid unless supporting evidence and time prove them otherwise.;
It is appreciated that exertion or anaemia or fever (including rheumatic fever) may permit temporary mitral dilatation and cause a murmur, but evaluation of long-term car-
. diac condition is not often made under such circumstances. Such a murmur is the true
apical or mitral; it may be of any intensity but can be much more loud than the apical
transmission of the physiological murmur. Dr. Paul White reminds us8 that whereas
the systolic murmur of aortic origin is transmitted mainly to the apex and up to the
neck, that of mitral origin is transmitted poorly to the base of the heart and mainly to
the lung bases.
Most authorities agree that an apical transmission leftward to the angle of the
scapula or further is indicative of an organic cause, either valvular deformity or left
ventricular dilatation.
Master4 states that a funnel-breast deformity frequently induces a systolic murmur
and even a thrill at the apex.
Baker, Sprague and White1 present disconcerting figures in a follow-up study ofj
187 cases showing systolics which were of maximum intensity at aortic and mitral areas.)
98.3% of degenerative etiology, 75.7% of rheumatic, and 80% of uncertain etiology]
in the series had died within ten years, 78.7% of them from heart disease. HoweverJ
the average age of these cases on beginning the study was 56 years, and only forty-nine
were under 50.
They quote Starr as reporting that persons having a transmitted apical systolic have)
a death rate of 8*4 times normal; with a transmitted aortic systolic, 12 times normal J
Of systolic murmurs which are maximum at the aortic area the one probably most)
often heard is in old people with atheromatous dilatation of the aorta, and it is not un-j
usual for this type to have a definite musical pitch. Next most commonly heard is that!
from aortic stenosis; rough, masking the first sound, transmitted mostly upward along
the artery but often heard confusingly loudly down the left eternal border; it may be
substantiated by a thrill. The stenotic murmur can be the loudest of all cardiac mur-
Page 38 murs, With the exception perhaps of that from a ruptured aortic cusp.  Murmur caused
by luetic aneurysm is a modern rarity; it is of blowing character.
It is very exceptional for a tricuspid systolic to be solitary; still more rare for it to
be due to tricuspid valvular deformity. Unless one is accustomed routinely to auscultating to the right of the sternum and in the epigastrium he may not appreciate how much
heart sounds are transmitted into these areas, and in the absence of signs of systemic
venous back pressure from congestive failure it is probable that murmurs heard in the
tricuspid area are transmissions from other valves or defects.
I feel that the assessment of the true apical systolic murmur is the most difficult of
them all; distinction between normalcy and morbidity will continue to be an argument
for a long time yet.
Evans3 considers that a murmur which disappears altogether on inspiration is innocent; he comments that organic systolics are more constant than functional ones.
An article by Parker and White5 indicates that most functional murmurs appear in
sound tracings to occupy only a part of systole, while most murmurs which mask the
first sound or commence with it and then persist through the full phase of systole are
considered to be organic.   On the other hand, some short murmurs may be organic.
It is pointed out also that the electrocardiogram, including notching of P waves and
depression of RST, fails in differentiating; that only 23% of organic cases show a P
wave of over 3 mm. height; also that radiographically only 43% of cases of mitral disease in their series showed left auricular enlargement, although 72% of mitral stenotic
cases did.
Probably hope for more complete discrimination among murmurs will rest almost
altogether on mechanical aids. Meanwhile, where evidence of valvular disease in a patient
is based on a systolic murmur alone, it would seem wisest, in his*interest, to tell him
that no sign of heart disease is present; better a few errors on this side than the making
of false cardiac cripples. If a physiological murmur is found and has to be promulgated
beyond one's secret case report, the patient should never be allowed to go without clear
assurance that many heart murmurs are normal and that his is one of such.
l.
2.
3.
4.
5.
6.
REFERENCES
Baker, Sprague and White: Amer. Journal of Med. Science, vol. 206, July, 1945.
Contratto: New Eng. Jour, of Med., 22 Apr., 1943.
Evans, BJvi.J., 2 Jan., 1943.
Master: U. S. Naval Med. BulL, Feb. 1944.
Parker and White: U. S. Naval Med. Bull., Jan. 1944.
White: Heart Disease, 2nd edition.
DISTRICT No. 4 MEDICAL ASSOCIATION
ANNUAL MEETING
The annual meeting of District No. 4 Medical Association was held in Kamloops on
October 27th.
Dr. R. W. Irving, President, presided over the sessions.
Papers were given by Dr. L. H. Appleby on "Treatment of Venous Thrombosis—
Post-Operative", and by Dr. Ethlyn Trapp on "Cancer of the Breast."
At the business meeting, which was held following a well-attended dinner, Dr. H.
H. Milburn, Chariman of the Committee on Economics, and Dr. A. H. Meneely, President of the British Columbia Medical Association, spoke on matters concerning the
profession.
The following officers were elected for the coming year:
Dr. J. R. Parmley of Penticton-—President.
Dr. T. W. Sutherland of Revelstoke—Vice-President.
Dr. H. P. Barr of Penticton—Secretary-Treasurer.
Dr. J. R. Parmley was appointed District Representative on the Board of Directors
of the British Columbia Medical Association, and Dr. R. W. Irving was appointed District Representative on the Committee on Economics.
The meeting next year will be held in Penticton.
Page 39 It is with regret that we record the passing of Dr. J. R. Atkinson of Vancouver, who
died on December 9th.
Dr. and Mrs. W. S. Huckvale of Trail are receiving congratulations on the birth of
a son. *      *      *      *
Dr. Howard and Dr. Josephine Mallek of Vancouver announce the birth of a
daughter.
Doctors M. McC. Baird, H. A. DesBrisay, G. F. Strong and S. E. C. Turvey went tol
Portland on October 26th to attend the meeting of the Northwest Section of Internal
Medicine, which was held on October 27th. At this meeting Dr. DesBrisay was elected
President for the ensuing year. Squadron Leader A. W. Lapin, R.C.A.F., and Dr. D. E.
H. Cleveland attended the meeting as guests, and with Dr. DesBrisay remained in Port-1
land for the following week, during which they attended a course in Internal Medicine,
sponsored by the American College of Surgeons, and given by the Medical Faculty of the
University of Oregon.
Dr. Alice J. McDonald, formerly of Vancouver, is now at YeUowknife, N.W.T.
Squadron Leader E. T. W. Nash "is now out of the Air Force, and with the Depart-|
ment of Veterans' Affairs.
_t~ 3_h        "     _fr     "'  "-'" w
Flight-Lieut. F. P. Patterson has received his discharge from the R.OA.F., and has
commenced practice in Vancouver.
*      *       *      *
The following Medical Officers have returned to Vancouver from overseas: Major
H. H. Boucher, Capt. P. H. Spohn, Capt. N. Shklov, Capt. S. E. Evans and Capt. W.
Al. Toone. *       *       *       *
Capt. T. Dalrymple, who served overseas, has received his discharge from the
R.C.A.M.C, and has resumed practice in Vancouver.
Dr. M. McRitchie, formerly in the Naval Medical Services, has returned to practice
at Fernie. *       *      *       *
Lieut.-Col. J. A. MacMillan of Vancouver has returned to civilian life following his
discharge from the R.C.A.M.C.
Major R. J. Wride has recenved his discharge from the Army and is in practice in
Victoria.
Major M. M. MacPherson, who returned from service overseas some weeks ago, is now
in practice in Vancouver, following his discharge from the R.C.A.M.C.
Lieut.-Col. A. R. J. Boyd, R.C.A.M.C., has received his discharge from the Services,|
and is Medical Health Officer in Kingston, Ont.
Dr. J. F. Haszard is with the Workmen's Compensation Board in Vancouver, following his discharge from the R.C.A.M.C.
*      *      *      *
Dr. R. W. Garner of Port Alberni was a visitor in Vancouver recently.
Page 40 INDUSTRIAL HEALTH
Management and labor are interested in Industrial Health and it is a matter of
interest and concern to the medical profession.
Industrial Health is not an experiment; it is in successful operation in nearly 900
industrial firms throughout Canada.
British Columbia is the third largest industrial province and the health of the workers and thei rhappiness and efficiency merit our earnest attention and thought.
Just what is Industrial Health, what are the benefits, and how may a health program be started?
Industrial Health is concerned wiht the following objectives:
1. To ascertain, by examination, the physical and mental fitness of employees.
2. To maintain and improve the health, morale and efficiency of employees.
3. To educate the worker in accident prevention and personal hygiene.
4. To reduce lost time and absenteeism due to illness and injury.
The cost of a health program is justified by increased health and efficiency and it
has been shown that the savings are almost double the cost of carrying out the plan.
But money is not the only consideration, because the resulting improved employer-
employee relations are of distinct value in increased happiness and efficiency.
The benefits of a Health Program may be summed up as follows:
1. Drastically reduces absenteeism.
2. Greatly eliminates serious illness among workers.
3. Creates a kindlier feeling throughout the plant.
4. Enables more intelligent placements of returning soldiers.
5. Is of value in the intelligent placement of the physically disabled.
* The question of starting industrial health programs is an important one, and considerable thought and co-operation is required. Management and labor are interested,
but more educational facilities are needed, the need and benefits must be stressed by
someone or some responsible agency. Who or what is going to do this? The plants concerned will bear the financial cost of operating the plan, but who will start the plan, and
see that efficient staff and records are maintained, and that the first duty of the staff
should always be to the workman who is examined or treated?
It is suggested that this is a matter for the Provincial Government and that a division
to handle this matter should be set up, and a suitable laboratory maintained.
Usually, illness or accident requiring treatment at home or in the hospital is referred
to local doctors, according to the patient's choice. Treatment of this type of illness or
. accident is not recommended as part of an industrial health program. Treatment may
form part of a contract or other plan, but that is a separate matter.
Much of the material contained in this article has been obtained from the Health
League of Canada, Toronto, and from the Division of Industrial Hygiene, Department
of Health and Welfare, Ottawa. Both of these agencies publish a free monthly bulletin
on Industrial Health. The former publishes a free booklet, "Industrial Health Plan," of
interest to medical men and to employers and employees interested in this vital service
for Canadian Industry.
The Committee on Industrial Medicine of the B. C. Medical Association is endeavoring to interest members and the public in these matters, and inquiries addressed to the
secretary will receive attention.
Page 41 ________
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Exclusive Ambulance Service
FAirmont 0080
PRIVATE AMBULANCES AND INVALID COACHES
WE SPECIALIZE IN AMBULANCE SERVICE ONLY
J. H. CRELLIN
W. L. BERTRAND
flDount pleasant TUnbertakin. Co. %tb.
KINGSWAY at 11th AVE. Telephone FAirmont 005S VANCOUVER, B. C
R. F. HARRISON W. E. REYNOLDS VANCOUVER HEALTH DEPARTMENT
STATISTICS—OCTOBER, 1945
Total population—estimated , *  311 799
Japanese Population—Estimated  L Evacuated
Chinese population—estimated ;  6 395
Hindu population—estimated ,  335
Number
Total deaths       341
Chinese   deaths       19
Deaths—residents   only ' 285
BIRTH REGISTRATIONS:
Male,   341;   Female,   347 |     688
INFANT MORTALITY: October, 1945
Deaths  under  one  year  of  age       21
Death  rate—per   1000   births       30.5
Stillbirths   (not included  above)         8
Rate per 1,000
Population
12.9
35.0
10.8
26.0
October, 1944
6
9.8
5
CASES OF COMMUNICABLE  DISEASES REPORTED IN THE CITY
September, 1945 October, 1945       Nov. 1-15, 1945
Cases      Deaths      Cases      Deaths      Cases      Deaths
Scarlet  Fever 24
Diphtheria	
Diphtheria   carrier    	
Chicken   Pox	
Measles	
Rubella	
0
0
17
5
3
Mumps    : 15
Whooping   Cough
Typhoid Fever 	
Undulant Fever _
Poliomyelitis 	
Tuberculosis     	
Erysipelas
  0
  0
  0
   5
  42
  2
  0
  0
  0
  4
  2
  0
Syphilis  96
Gonorrhoea .  220
Cancer  (Reportable)—
Resident	
Non-Resident ;	
Meningococcus   Meningitis
Paratyphoid Fever 	
Infectious Jaundice  __
Salmonellosis	
Salmonellosis    (Carrier)    _.
Dysentery	
0
0
0
0
0
0
0
0
0
1
14
0
0
1
0
■vo;:.
0
0
2
0
27
1
0
66
10
2
32
0
0
0
1
59
0
1
0
0
1
0
0
98
197
93
41
0
0
0
0
0
0
0
0
0
0
13
1
0
1
0
0
0
0
1
0
0
0
25
0
55
1
2
20
0
0
0
0
0
0
0
3
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
BIOG LAN "C"§
Prepared separately for male and female.
Composition: Anti-thyroid principles of the pancreas, duodenum, embryo-tin, suprarenal cortex, tests (or ovary). Each 1 c.c. ampoule
contains the equivalent of approximately 29 grams of fresh substance.
Indications: Graves's disease, hyperthyroidism, exophthalmic goitre,
thyrotoxicosis.   The most effective therapy available.
Stanley N. Bayne, Representative
Phone MA. 4027 1432 MEDICAL-DENTAL BUILDING Vancouver, B. C.
Descriptive Literature on Request
THE SCIENTIFIC HORMONE TREATMENT
Page 42 LIVER  EXTRACT  INJECTABLE
15 UNITS PERCC. 1
Liver Extract Injectable is prepared specifically for the treatment ofi
pernicious anaemia. The potency of this product is expressed in units
determined by actual responses secured in the treatment of human cases of
pernicious anaemia. Liver Extract Injectable as prepared in the Connaught
Laboratories has the following advantages:—
1. Proven potency—Every lot is tested on cases of
pernicious anaemia.
2. High concentration of potency—Small dosage
and less frequent administration.
3. Low total solids—Discomfort and local reactions
occur very infrequently because of the high purity
of the product.
Liver Extract Injectable (15 units per cc.) as prepared by the Connaught
Laboratories is supplied in packages containing single 5-cc. vials and in
multiple packages containing five 5-cc. vials. The larger package is for the
convenience of hospitals and clinics, and is also available to physicians.
CONNAUGHT LABORATORIES       I
University of Toronto Toronto 5, Canada
DEPOT FOR BRITISH COLUMBIA
MACDONALD'S PRESCRIPTIONS LIMITED
MEDICAL-DENTAL BUILDING, VANCOUVER, B.C. Vancouver    medical    association
Founded 1898    ::    Incorporated 1906
PROGRAMME OF THE FORTY-EIGHTH ANNUAL
SESSION (SPRING SESSION)
GENERAL MEETINGS will be held on the first Tuesday of the month at 8:00 p.m.
[CLINICAL MEETINGS will be held on the third Tuesday of the month at 8:00 p.m.
These meetings will continue to be amalgamated with the clinical staff meetings of
the various hospitals for the coming year. Place of meeting will appear on the agenda.
February    5—GENERAL MEETING.    Dr. D. H. Williams:
"Recent Advances in Dermatology."
February 19—COMBINED CLINICAL MEETING—St. Paul's Hospital.
March    5—OSLER DINNER—Hotel Vancouver.
Osier Lecturer: Dr. A. L. Lynch.
Vfarch  19—COMBINED CLINICAL MEETING—Vancouver General Hospital.
[_pril    2—GENERAL MEETING.
kpril 16—COMBINED CLINICAL MEETING—St. Paul's Hospital.
May    7—ANNUAL MEETING.
r    Breaks the vicious circle of perverted
menstrual function in cases of amenorrhea,
tardy periods (non-physiological) and dys-
[   menorrhea. Affords remarkable symptomatic
relief by stimulating the innervation of the
I uterus and stabilizing the tone of its
II musculature. Controls the utero-ovarian
circulation and thereby encourages a
normal menstrual cycle.
1
• MARTIN H. SMITH COMPANY
^ HO lAHmttl  STIIIT    NfW  TOM. ML T.
w
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.
Page 43 AT THE MENOPAUSE
Woodcut inspired by a study of Aristide Maillol
These orally-active natural oestrogens have proved effective for all
patients, regardless of the severity of their symptoms . . .
"Premarin" (No. 866) for the most severe symptoms; Half-strength
"Premarin" (No. 867) when symptoms are moderately
severe; "Emmenin" for mild symptoms."
"PREMARIN" and "EMMENIN"
conjugated   oestrogens    (equine)
Tablets No. 866; Tablets No. 867
conjugated   oestrogens   (placental)
Tablets No. 701; Liquid No. 927
NATURALLY OCCURRING —WATER SOLUBLE —WELL TOLERATED — ESSENTIALLY SAFE
IMPART A FEELING OF WELL-BEING
347
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AYERST,   McKENNA    &    HARRISON    LIMITED *1U* ZdtiwA Paae
One of the minor, but none the less definite, annoyances of a doctor's day, is the
patient who comes in and offers to lend him the latest copy of The Reader's Digest, or
pome other popular magazine, where he will find full details of the marvellous results
being obtained from the use of insulin in diabetes, or penicillin in the treatment of
syphilis, or Ertron in the treatment of arthritis, and so on. The article which our
patient wants to lend us is usually written by one of the more ardent females on the
ftaff of the journal in question (we mention The Reader's Digest because it is, beyond
doubt, the worst offender in this matter) and neither her style nor her enthusiasm nor
per regard for fact, know any boundaries, or are restrained by any inhibitions. As you
pad the article in question (if you care to waste the time), you are fascinated by the
imazing ease with which a disease which has hitherto commanded your deepest respect
« a worthy and dangerous foe, has been found to lose all its terror, and yield meekly to
pome treatment which you rather thought had been in vogue at least fifteen or twenty
jpears, and in many cases, had been found rather ineffective, after the first flush of
enthusiasm had passed. But it is very trying, nevertheless, and one ends up by cursing
the magazine or journal in question, and wishing to God they would either attend to
their own affairs, and leave medicine alone, or else, if they feel the missionary urge
getting out of control, that they would have some competent medical man (not the
egregious Paul de Kruif) edit their stuff before they print it.
One wonders what the remedy would be—and how one can either put an end to this
sort of publicity, or else put it to a good use, for there might be some value in it, if it
were properly done. As it is now done, at best it is harmless, besides being useless—
but at worst it can do definite harm, as any dermatologist will tell you. We refer to
the wild splurges of some years ago, on the part of The Readers Digest, about the wonderful, amazing, one-night treatment for Athlete's Foot, which, whatever effect it had
an the infection concerned, certainly wrecked a lot of feet, and gave dermatologists a
lot of trouble all over North America. And in some cases it does a great deal of harm
by raising false hopes of certain cure, one of the crudest things that anyone can do.
Arthritic sufferers, for instance, have been assured that massive doses of Vitamin something or other will cure their arthritis—this notwithstanding the fact that the honest
medical scientists who have given the treatment a thorough trial, unclarioned and
iunadvertised, have stated in reputable journals that their earlier hopes have not been
borne out as they had hoped. But the Digest says it is so, so it must be true, and we
[who try to explain are merely behind the times.
Some day, perhaps, our major Medical Associations will see both the possibilities and
[the perils of medical publicity, and will themselves undertake the task of public education in medical matters. It is hard to persuade the public that medical discoveries are
very rarely, if ever, the dramatic or spectacular miracles that the journalist tries to
imake them out to be. Even insulin and penicillin did not came suddenly into being as
[the wonder workers that we now know they are. Long years of patient trial and error
[were necessary, careful experiment and repeated checking and double-checking, were
needed before they could be tried on the human body—and even then great care had to
be taken. And it had all to be done quietly, almost secretly, with no fanfare of pub-
jlicity—since this could only hinder progress and not in any way help it. People often
ask why doetors don't tell the public what they are donig. It is because we. know,
[better than anyone, the truth of Hippocrates' maxim, "Experience is fallacious, and
I judgment difficult."   This is perhaps more true of medicine than anything else.
Page 44 But carefully done publicity of the right kind could be made to be of inestimably
value and help to the health of the public—and we hope that some day it will be under
taken along the right lines, by the right men—both are qually important. It would]
too, greatly assist our work, and help to remove that prejudice which is nearly alway
the result of ignorance, and which so often resists our best efforts towards progress.
We are pubUshing in this issue the first instalment of Dr. George Kidd's "HistoH
of the Vancouver Medical Association." It is intended to keep reprints of each install
ment. When the work is completed these will be bound in booklet form, and will b\
available for purchase by members of the Association.
LIBRARY NOTES
RECENT ACCESSIONS TO LIBRARY—
Essays on the History of Medicine, 1944, by Arturo Castiglioni.
One Hundred Years of American Psychiatry, 1944, by various authors.
Dietotherapy—Clinical Application of Modern Nutrition,  1945, Edited by M. G|
,       Wohl.
The Wisdom of the Body, 2nd ed. 1939, by Walter B. Cannon.
The Way of an Investigator, 1945, by Walter B. Cannon.
Medical Research Council Report No. 250—Chronic Pulmonary Disease in South
Wales Cx>alrniners, III—Experimental Studies.
Medical Research Council War Memorandum No.   10—The Medical Use of Sulphonamides.
CANADIAN MEDICAL ASSOCIATION
The plans for the Seventy-seventh Annual Meeting of the Canadian Medical Asson
ciation, to be held at Banff, Alberta, June 10-16, are now going full speed ahead. Dr
Wallace Wilson, President-elect of the C.M.A., and the committees working under him.
are determined that this Meeting, which is particularly British Columbia's, shall be one
of the best ever held.
All the omens are favourable. The war is over—our men are coming back—all eager]
for just such a meeting at this. The setting is ideal. Banff in June will be loivelyj
There is everything there—golf, tennis, hiking, swimming, fishing, horseback riding, etci
A word about accommodation. This is somewhat of a problem, but the Central
Committee believes that there will be room for all, if everyone is willing to cooperate
Nobody will get single rooms all to themselves, probably, and there will be a good deal
of doubling up—but after all, we shan't be in our rooms very much, except at night.
But make your plans early, and send in your request at once for reservations. To
save time and secure prompter and more accurate results, a Housing Committee has been
formed under Dr. George Johnson of Calgary, and all letters should be addressed to him.
He will be in close touch with the Local Housing Committee under Dr. D. F. Busteed
of Vancouver.
So we urge all members of the B. C. Medical Association to lay their plans now, and
get in their applications—since it is a matter of first come, first served.
Page 45 ITEMS OF GENERAL  INTEREST
The Institute of Life Insurance of New York announces the grants, totalling
S.26,000, that have been made to the medical schools of six universities in the U.S.A.
i the Life Insurance Medical Research Fund.
These grants are to be used for research into the causes of cardio-vascular diseases,
td should be of great assistance in the fight against this major cause of death among
iman beings.    The universities in question are:
Columbia University Washington University, St. Louis
University of Minnesota. Southwestern Medical College
University of Pennsylvania. Yale University.
During the next year, over $500,000 will be spent in this field of heart and arterial
sease—Research Fellowships will be established and maintained. A six-year programme
planned, to spend a total of $3j500,000.
We cannot but applaud this noble contribution to human welfare and to the fight
gainst our Enemy No., 1—cardiac and arterial deaths.
I
The Brazil Government Trade Bureau reports come to us regularly; most of their
mtents refer to general trade and investment matters, but occasionally we find refer-
tces to things that are more within our field of interest. Thus castor oil, our old
iend, bulks largely in the industrial world, as a lubricant, in the making of soaps and
pewriter inks, in the preparation of nylon fibre.
Soybean culture is also becoming an important activity in Brazil—and soybean oil,
ilk, meal and soybean plastics are features of increasing value in Brazilian trade.
Brazil became the best source of menthol for the United States during the war,
id supplied the bulk of the 400,000 pounds consumed by that country in 1944.
Other pharmaceuticals come from Brazil—caffeine naturally being one of the most
gnificant, and of course rubber textiles and rubber goods generally are a big item of
.port.
An interesting sidelight is the development of alligator oil, and the alligator, once
Jy used for his skin, is now contributing greatly to the preparation of lubricants,
tmbustible oils, motor fuel, etc. Mixed in equal parts with a combustible oil, it can
; used in motor engines—in the proportion of 70% alligator oil to 30% combustible
1, it serves to iUurninate the centre of the municipality of Tefe.
Indians and natives have long used alligator oil in the healing of wounds, and a
razilian doctor has used it, in combination with the name of a plant (name not given)
i the treatment of leprosy.
There is a lot of oil in an alligator. Three of them produce enough to fill an ordi-
ary gasoline can.
The judicious use of colour in the painting of various surfaces has a great deal to do
dth health and safety. Thus, .as regards the latter, the Canadian National Railways
ave found that distinctive colours, to refrigerator cars, and cabooses, make for greater
isibility, more ready identification in crowded yards, etc., and so for greater safety and
ie prevention of accidents.
Infra-red paints are being used on the roofs of buses, railway- and street-cars to
lake them cooler and more comfortable, _s these dull-finish infra-red paints reflect
most as much heat as aluminum paint.
*ge 46 We have mildew-proof paints to protect clothing, to eliminate mildew in food fa<
tories, and so on.
An interesting note is the use of a colour card as a guide in the famous Pentagc
building in Washington, D.C., largest building in the world, where so many legend
have come, of visitors and even habitues of the building losing their way, sometimes it
weeks at a time. It is, apparently, just one of those legends. Each floor is painted
different colour, and the corridors, walls and pillars of the respective floors are similar!
differentiated. Visitors are given a colour card, and by comparing the squares on thj
card with the colours they encounter, they can find their way very readily.
Monotony in colour slows down efficiency, according to a leading colour specialis
He finds that different colours, in corridors, rest rooms, lunch rooms, etc., produce
desirable "change of pace" in the mental attitude of workers.    One manufacturer r<
painted black boxes green and found that his employees didn't tire as quickly movir
them.    The men said that the boxes actually "seemed lighter."
The judicious choice of colour in paint makes a great difference in eyestrain pre
duced by long work in one environment. We know this to be true in hospitals a_
operating rooms: it is also true in industrial plants. Glare causes accidents—its elimins
tion lessens them: the wrong colour is fatiguing and trying to the temper: in ment:
hospitals colour is of very great importance, and so on. Colour experts have foun
that green and blue shades of paint in airplane interiors tend to avert nausea amor
passengers: while yellows and brown increase its likelihood.
In hospitals, paint and light are of vast importance to the morale of both staff an
patients. This is shown in the reconstruction of the Christie Street Military Hospiti
in Toronto, in whose dispraise volumes have at one time or another appeared in the pres
But that was in the past when it was a dingy, old-fashioned building, dark and dispiril
ing. Now that is all different. One hundred and ten thousand feet of acoustic ceilin
have been installed—new diet kitchens, wash rooms, etc.—along modern lines, nei
indirect lighting, new lounges and so on.
Old offices have been converted into fresh, clean, cheerful wards and corridori
painted a cool lettuce green. The buffs and tans and browns of walls and dados, whid
our fathers and grandfathers seem to have considered the only colours for walls, hav
been replaced by faintly-tinted undercoatings with a single coat of lettuce green finis!
ing enamel, restful and soothing to the eye; light has been increased by every trick a
painting and colouring known to experts.
We venture to state that this alone will improve morale and increase the generi
contentment of everyone in the Hospital.
We end this dissertation on paint with what we can only regard as a fish story—
A former health cornmissioner of St. Louis, Dr. Max Starhloff, gave it as his opinio!
that many lives, "more than 100," were probably saved because of the application d
paint which left no place on walls for dangerous germs to propagate.
"This occurred in a lying-in hospital of which I had knowledge," Dr.  Starhlo
said.    In a given period there had been more than 100 cases of puerperal fever with
high death rate.   After the walls were painted, it was noted that in a similar period folj
lowing, cases of puerperal fever had become almost nil.   Undoubtedly, paint was largel
responsible for the saving of many lives (!)"
We regret that we cannot share Dr. Max Starhloff's enthusiasm for paint in thj
respect. Perhaps someone else thought of having the attendants wash their hand
as well.
Page 4) llRliFf
PREVENTION OF SPREAD OF V.D. TO THE CIVILIAN
POPULATION BY VETERANS OF WORLD WAR II
The following measures have been taken by the Canadian Armed Forces to prevent
the spread of venereal diseases to the civilian population of Canada by Armed Forces
personnel who are being retired or discharged from the Services.
1. Case Finding of Syphilis.
A serologic test for syphilis is done on all personnel of the Navy, Army and Air
Force at the tune of retirement or discharge. To ensure further follow-up, the names
of all personnel with a positive or doubtful serologic test for syphilis are then submitted
to the Division of Venereal Disease Control of the Health Department of the province
where the former member of the Forces intends to reside.
2. Prevention of Spread of Venereal Infection,
Personnel of the Navy, Army and Air Force who are found to have venereal disease in a communicable form at die time of their medical examination prior to retirement or discharge, are retained in die Service until they have received such, treatment
as may be necessary to render their infection non-communicable.
3. Re-assessment of Every Syphilis Infection.
All personnel of the Navy, Army and Air Force with a history of syphilis infection
contracted either prior to or during their service, are given a complete medical examination for re-assessment of their syphilis infection. A summary of their case is then
submitted to the Division of V.D. Control of the Health Department of the province
where such personnel intend to reside. This summary of their case can, therefore, be
made available by the Provincial Health Department to any physician who may be
consulted by a former member of the Armed Forces for further medical care, observation and/or follow-up of a syphilis infection for which medical care was given in the
Armed Forces.
/
We take pleasure in inserting the following announcement by the Oregon Academy
of Ophthalmology and Otolaryngology. Ed.
IgjS       AMERICAN UROLOGICAL ASSOCIATION
UROLOGY AWARD
The American Urological Association offers an annual award "not to exceed $500"
for an essay (or essays) on the result of some specific clinical or laboratory research in
Urology. The amount of the prize is based on the merits of the work presented, and if
the Committee on Scientific Research deem none of the offerings worthy, no award
will be made. Competitors shall be limited to residents in urology in recognized hospitals and to urologists' who have been in such specific practice for not more than five
years.   All interested should write the Secretary for full particulars.
The selected essay (or essays) will appear on the program of the forthcoming meeting of die American Urological Association, to be held at the Netherland Plaza, Cincinnati, Ohio, July 22-25, 1946.
Essays must be in die hands of the Secretary, Dr. Thomas D. Moore, 899 Madison
Avenue, Memphis, Tennessee, on or Before July 1, 1946.
Page 48 Vancouver Medical Association
HISTORY OF THE VANCOUVER MEDICAL ASSOCIATION^
Foreword
In this issue appears the first.instalment of die Medical History of British Columbia,
upon which important work Dr. G. E. Kidd has been for some time engaged.
Anyone but superficially acquainted with the early history of British settlement upon
this Coast knows that by reason of its remoteness from early eastern settlements, the
directions from which it was colonized and the routes by which the early colonists
arrived, its history is peculiar and unique in Canada. That this should hold true of its
medical history follows naturally.
Dr. Kidd thus has material of exceptional interest to work with. No one could
come to this task with better qualifications. Dr. Kidd as a student, literarily gifted,
familiar with many and a recognized authority in at least one branch of science, and
withal a practitioner of the healing art, is conspicuously well fitted to do the work of
accumulating data, recording and presenting the early history of medicine in this
province.
Organization
• -      *
On the opening page of the first minute book of die Vancouver Medical Association
there appears the following short preamble.   Its source is not indicated.
"The objects of the Association are the encouragement of (1) Improved social relations between the members of the profession in Vancouver; (2) Helpful professional
intercourse.
"To this end be it agreed that, so far as possible, monthly meetings will be held,
when any subject of general interest to the profession will be brought forward and discussed. It is hoped that a short paper may always be forthcoming from the different
members in rotation, which in the absence of pressing business may serve as a basis for
this union."*
It was not until 1906 that the Association was regularly incorporated, and in the
articles of incorporation as drawn up, the objects of the Society were further stated to
be as follows: (1) For the purposes of the cultivation of the sciences of medicine and
surgery, with a view to advancing the character and honour of the medical profession;
(2) For the purpose of establishing a library for the promotion of literature and science,
and for the diffusion oi knowledge; (3) For the-purpose of making provision by means
of contributions, subscriptions, donations, and otherwise, against sickness, unavoidable
misfortune or death, and the relieving the widbws and orphaned children of the members deceased."
The earliest recorded activities of the Vancouver Medical Association are contained
in the minutes oi a meeting held in the office of a certain Dr. Jackson, dentist, located
over Atkins' drug store, on the southeast corner of Hastings and Homer Streets. This
meeting was held on the second day of October, 1898/\Wef shall give these minutes
in full.
Page 4# "Present, Dr's D. H. Wilson, LeFcvre, Weld, L. N. McKechnie, Poole,
Brydone-Jack, Bcntley, Underhill, Senkler, Munro, Kirby, McAlpine and Pearson.   Dr. Wilson was voted into the chair.
Dr. Pearson, who had sent out notices calling the meeting, spoke, explaining
its object, and dwelling on the desirability of forming a Medical Society.
On the motion of Dr. LeFcvre, seconded by Dr. Bentley, and after some
discussion, it was decided to proceed with the formation of such a Society.
Dr. Brydone-Jack moved and Dr. Bentley seconded, the appointment of a
committee consisting of Dr's Weld, Underhill and Pearson, together with the
President, to draft by-laws which will be presented for consideration at a meeting to be held this day week.   Carried.
Dr. Underhill moved, and Dr. LeFevre seconded, that Dr. Wilson be elected
President for the ensuing year.   Carried.
After discussion it was decided not to proceed with any further elections until
the report of the committee was presented.   The meeting then adjourned.
(Signed)—L W. McLean."
Although at the first organization meeting it was decided to meet again "this day
week,** it is not until a month later, on Nov. 3rd, that we have a record of such a second meeting. This also was held over Atkins* drug store and was attended by Drs.
McLean, Bentley, Kirby, Munro, Senkler, McPhillips and Pearson. Dr. McLean was in
the chair. Owing to the smallness of the attendance and the importance of the business to be considered, the meeting was adjourned for one week.
The third meeting was attended by Drs. Wilson (in the chair), Weld, Bentley, McPhillips, Underhill, Brydone-Jack, Kirby and Pearson. The Secretary read the rules and
By-laws, and the suggested scale of fees which had been recommended by the committee
appointed to draft them. These were adopted, and the elections of Dr. Wilson as
President, and of Dr. Pearson as Secretary-Treasurer, were confirmed.
Following a discussion as to the best method of building up a membership in the
•* newly formed Society, the Secretary was instructed to visit or communicate with each
member of the profession in the city, and invite him to associate himself with the new
organization. This method of enrolling members by appointment was in vogue for a
short time only, but between Nov. 10th and Dec 1st, 1908, nineteen doctors became
affiliated with the Association in this way, which speaks well for the enthusiasm of the
young organnization and the diligence of its Secretary.
"Early Progress of the Association
In 1898 Vancouver was a small but rapidly growing city of 24,000 people. The
telephone directory of that year lists twenty practicing physicians. Their offices were
scattered about the downtown area. Many were located along Westminster Ave. (now
Main St.) as far south as the nineteen hundred block. In the West End Dr. McPhillips
ventured farthest out, having Ins office at the corner of Pendrell and Burrard. An
office building at 306 Abbott St. was popular, and housed several doctors. Dr. P. A.
McLennan, in his paper on "Memories" recently read before the Association, has this to
say about the Vancouver of that time: "When I first visited the city in October, 1899,
it was simply a sprawling, overgrown village of 26,000 people. Very few houses existed
west of Burrard St., and St. Paul's Hospital seemed far out among the stumps. Main
St. (Westminster Ave.) was the eastern boundary, with a few houses in Mount Pleasant
and Fairview."
The present Vancouver Medical Association is not the first organization of its kind
among local medical men.   Back in 1888, when the city's population was around 8000
Page 50 inhabitants, who were served by a group of nine registered physicians, several of whom
were in the employ of the C. P. R. Company, there had come into existence a body
known as the Vancouver Medical Society. Its President was Dr. Bodington, who later
moved to New Westminster, and was for some years Superintendent of the Provincial ]
Mental Hospital there. This Society appears to have been formed to deal primarily
with the appointment of a medical staff to the new City Hospital then under construction on Beatty St. Due to a disagreement with the City Council, which did not accept
the proposals of the Society as to the personnel of the hospital staff, the medical organization was completely disrupted and would appear to have ceased to exist. No reference
to it can be found of a later date than 1888.
Returning now to die young Association which had been launched on the night of
Nov. 10th, 1898, we find that its first regular meeting was held on Dec. 1st following.
It was held in Dr. Jackson's office. There being no general business for consideration, a
paper was read by Dr. McPhillips. It had no given title, being the case history of a
young woman who had died from an undiagnosed condition. The discussion which followed showed a great diversity of opinion, and the question of the cause of death remained unsettled.
During the spring term of this year (1898-99), three regular meetings were held.
The only business worthy of note to be conducted was that of preliminary discussions
leading to the formation of a Provincial Medical Association, Details of this will be
given elsewhere. The attendance at these meetings was small—eight, seven and six
members respectively. In spite of of this three important papers were read, viz-, one on
Tuberculosis by Dr. Brydone-Jack; one on Bacteriology by Dr. Underhill, and one on
the Undescended Testicle by Dr. LeFevre. Following discussion of Dr. Brydone-Jack's
paper the Society made its first contribution to the welfare of the community by drawing up a series of recommendations tending towards the control of tubercular disease in
the city.   These were forwarded to the Health Officer, Dr. McLean.
To those who had the success of the young Association most closely at heart, there
must have been many discouraging moments during those early years of its history. On
not a few occasions the only minute entry reads: "Meeting not held lor lack of attendance." Gradually, however, new names appeared, names which are now well known in
Vancouver medical circles. The attendance at the meetings increased and soon rolled
along in full flood.
As noted before, membership was at first by appointment. At the second regular
meeting of the Society, held on Jan. 5th, 1899, this method gave place to affiliation by
nomination and election. For a time these took place on the same night, but later in
the year Dr. Monro made a motion to the effect that: "In future candidates to the Association shall be proposed at one regular meeting and balloted on at the next." In 1919
this was further changed to the method in vogue at the present tune, vie., the delay in
balloting on a candidate until one year after his nomination.
The following Doctors became affiliated with the Society by appointment, in the
autumn of 1898::
*v*Kov. 10th—Drs. Unddjiill, Brydone-Jack, LeFevre, Weld, D. H. Wilson, Bentley
and Kirby.    The last two members resigned from the Association a short time
afterwards.
Nov.  11th—Drs. Pearson, L. N. MacKechnie, Miss McPhee and Williams.    Drs.
' : McPhee and Williams resigned within a short time.
-Nov. 15th—Dr. A. S. Monro.
Nov. 17th—Drs. McGuigan and Senkler. *
Nov. 21st—Drs. W. D. Keith and Poole.   A short time afterwards, Dr. Keith left
the city, temporarily, resigning from the Association.   He rejoined in 1905.
Dec. 1st—Drs. Langis, McPhillips and T. H. Wilson.
Henceforth membership was attained by nomination and election.  'The first to join
itn^thir'way was Dr. Fagan, on Jan. 5th, 1899. HJe was followed by others in the following order:
Page SI Session of 1898-99 (Spring term)—Drs. McAlpine, Lawrence and McLean.
Session of 1899-1900—Drs.  Robertson, Glen  Campbell,  Riggs,  Hoops, Johnson,!
Burnett, Young and Jeffs.
Session of 1900-01— Drs. Tunstall, Boyle and W. C. McKechnie.
Session of  1901-02—Drs. Drier and Conklin.
Session of 1902-03—Dr. Graham Campbell. (He later resigned).
Session of 1903-04—Drs. R. E. McKechnie, McTavish and Fuller.
Session of 1904-05—Drs. Farish, McKay, Coy, McDiarmid and Stephen.
Session of 1905-06—Drs. W. D. Keith, Proctor, Greer, Hoyes, Ross, Gibson, Mc-
Kenzie, Rankin, Coulthard, Allan, P. A. McLennan, Dyer and Bayfield.
Session of 1906-07—Drs'. Boggs, B. D. Gillies, Nicholson, Mcintosh, Robinson, Connolly and L. McMillan.
The men whose names are listed above must be considered the pioneers of the medical profession in Vancouver.   Many of these names are among those of the leading citizens of the city, past and present.   Some are deceased, and some have retired from practice.   A goodly number are still engaged in active work, and will be so, it is hoped, fori
a long time to come. (To Be Continued)
VcMtcaiioen, Qetie/ial eJtoAj&ticzl Seciiaet
THE TREATMENT OF DEFECTS OF THE LONG BONES
BY CANCELLOUS CHIP BONE GRAFTS
By T. R. Sarjeant, M.D., FJl.CS. (Eng.) '   •
The subject of treatment of defects of the long bones was of paramount importance to every surgeon overseas and it will be just as important to those who are carrying
out the reconstructive work on the casualties. In civilian life this type of injury is
much less common, of course, but the treatment is just as difficult. Cancellous chip
bone grafting has been developed during this war, being used originally by the plastic
surgeons in the treatment of complete defects of the mandible. Their efforts were
so successful that we tried to find methods of applying the technique to die long
bones and we were rather surprised to find that we also met with some success.
The problem of treatment of complete bone defects tests the ingenuity of every
surgeon. /If cortical bone grafts are used to restore the full contour of .the bone it is
difficult to obtain sufficient cortical bone for the larger defects. It is well established
that a cortical graft serves only as a bridgework for the growth of new bone. This!
process has been well named by Mowlem as one of "creeping substitution". In th<
case of defects, this replacement can only occur through the ends of the graft, anc
not simultaneously throughout its whole length as occurs in a graft used for simple
non-union. Thefore the time required for the growth of new bone across a defect
will be very many months.
For many years large grafts from the ilium have been used* successfully in plastic
and orthopaedic surgery. But it is only within the last five years that it has beer
demonstrated that there is probably some advantage in using chips or stamps oi
cancellous bone. A "chip" is cut so that, it about 1 cm. long x 0.5 cm. wide x 0.2
cm. thick. It is claimed that such a piece of cancellous bone is kept alive by th<
serum in-which it is bathed and is readily invaded by capillaries. Hence it does not
die and undergo "creeping substitution", for its bone cells survive and the muftiph
chips inserted become fused into one mass in a much shorter period of time than th<
substitution of the cortical graft would require. It is also believed that these graft:
tolerate infection better than cortical grafts because they are living grafts from th<
beginning.
Page 52 Mowlem has recently reported a successful series of seventy cases of cancellous
chip bone grafts of defects of the facial bones and skull, and five cases of the long
bones. Tonight I am presenting the results of treatment in twelve cases of the long
bones—nine cases of defects and three cases of delayed union. This work was carried
out at No. 24 Canadian General Hospital at Hortey, England, during the last seven
months of the war. In general, we followed Mowlem's technique. Our results were
good in some cases and indifferent in others. Cancellous chip bone grafting of the
long bones is a rather new field of endeavour, still in the experimental stage. We
had to feel our way without much help and with precedent, Mowlem's report being
the only one we could find in the literature.
It must first be appreciated that cancellous bone grafts afford no internal fixation
whatsoever, yet complete immobilization of the fragments and die graft is just as
necessary as in any other type of graft. The method of immobilization must be carefully considered before operation. Piaster of Paris may be sufficient; skeletal fixation
with Kirschner wires or Roger-Anderson splints may be necessary; or internal fixation
by a sliding cortical graft may be best under the particular circumstances. We used
all of these methods and in two cases of delayed union we used vitallium screws and
a plate. No one method seems to have any advantage .over another, the important:
thing is that immobilization must be obtained and retained. ,
The cancellous bone is obtained from die ilium, usually by a second team in order
to save time. An incision is made below and parallel to the crest of the ilium from
just behind the anterior superior' spine to just below the posterior superior spine. The
outer border of the crest and the upper two inches of the wing are cleared of muscle.
With an osteotome the posterior four to five inches of the crest is cut and retracted
upwards like a lid. The outer cortex of the wing below this area is then cut anteriorly
and posteriorly and broken outwards. The greatest amount of cancellous bone is to be
found in the posterior third of the Ving where it begins to curve outwards toward its
posterior border. With a sharp osteotome the cancellous bone is then cut out in
strips about one centimetre wide and two millimetres thick and as long as possible.
Smaller pieces will be readily obtained but die thickness should not be more than two
millimetres (less than one-eighth of an inch). This bone should be placed in warm
normal saline or in moist gauze until used. The outer cortex of the ilium is pressed
back into position or discarded if it has become completely detached. The iliac crest
is replaced and held in position by No. 1 chromic catgut sutures through its strong
aponeurotic attachments, and the gluteal muscles are then sutured to the crest.
At the same time the other team b preparing die fractured bone. The defect is
exposed and all scar tissue carefully excised, for it is important that the grafts should;
be in contact with unscarred muscle from which they can more quickly derive a blood
supply. The bone ends are cut back until freely bleeding bone is reached. This should
be done obliquely in order to obtain a larger contact surface for the grafts. The bone
ends are then notched for a distance of about one inch to hold a central strut of
cancellous bone against which the smaller chips can be placed. When the bed for the
graft is thus prepared, but before the chips are placed in position, die main bone
fragments should be properly aligned and the skeletal pin fixation applied, if that
has been chosen as the means of immobilization and if the pins were not already in
position having been used to maintain alignment and length before die operation. If1
Plaster of Paris alone is relied upon it might be safer in some cases to do the graft j
through a window in the cast, replacing the window at the end of operation of course.
If a sliding bone graft is used for internal fixation, the bone ends should be freshened
as described but the notching is unnecessary since the cortical graft will serve as the
strut around which the cancellous chips c_n be placed.
Immobilization having been effected, the cancellous grafts are inserted. The central
strut, which should not be more than two millimetres in thickness, is fitted more or
less loosely into the notches. It is not used as a means of internal fixation, but merely
as a platform on which to build up the graft.    The other strips of cancellous bone
-^=-- -—  Page **| krhioh were taken from the ilium are cut with an osteotome on a block of wood into
fhe desired chips—1 cm. x 0.5 cm. x 0.2 cm. The full contour of the bone is then
(milt up by simply placing these chips loosely around and about the strut like flagstones; they should also overlap the bone ends for perhaps a centimetre or as far as the
beriosteum has been stripped. Mowlem suggests that the periosteum should not be
ttripped from the bone ends any farther than is necessary so as not to jeopardize their
:>lood supply to any degree whatsoever. The closure of the deep fascia and the skin
Completes the operation.
Post-operatively, the patient complains of considerable pain in the region of the
[liac crest for five to seven days but none had troublesome pain after the tenth day
and walking was permitted at the end of three weeks if the bone graft was in the
Upper extremity.
The bone defects were grafted at an average time of two and one-half months
|after wounding, the deciding factors being a completely healed wound and the disappearance of oedema. However, one case of a defect of the lower end of the tibia
pas grafted on the twenty-fifth day through on open wound and a delayed suture
carried out at the same time. Pus was drained from this case two months after oper-
jation but the graft was not lost; union was clinically firm at the end of nine weeks
and there was no sign of residual infection at the end of five months. No infection
(occurred in any of the other cases, their wounds all being healed at the time of the
jgraft.
The time required for union to occur seems to depend upon the bone grafted and
(probably upon the length of the graft. Our experience is too lirnited to permit
definite statements. After grafting complete defects, full use of the upper extremity
was possible in the case of a metacarpal in eight weeks, an ulna in nine weeks and a
(radius in ten weeks, but in another ulna only after eighteen weeks. In the lower
extremity, after grafting complete defects of two metatarsals, the patient was walking
jin twelve weeks, and in the case of a large but partial defect of the tibia in thirteen
and one-half weeks. The results in another tibia are described in the preceding paragraph. The other two cases of defects were not yet out of plaster when I left England;
[both were of the lower end of the radius and were progressing satisfactorily.
The champions of the cause of cancellous chip grafts claim that "clinical rigidity
(precedes complete radiographic fusion, so that careful examination and no x-ray is used
jto detenmne the point at which fixation can be discarded". We were using fluoro-
jscopic examination also and by the three methods trying to decide when to discontinue
| immobilization, but we were rather careful and tended to wait for definite radiological
(evidence of union.
We used cancellous grafts in three cases of delayed union, one of the femur and
I two of the tibia.    Inirnobilization was discontinued in the femur at seventeen weeks,
;One tibia at twenty-one weeks, and the second tibia was still springy at sixteen weeks
when I last saw him.    They were neither failures nor brilliant successes.    Our later
experience  showed  us  that   we  had  not  used  the   correct  technique  in   these   cases.
(Cancellous grafts can only be used in carefully selected cases of non-union, but they
j do command a very definite place in the treatment of this condition.    Their use obviates the necessity of shortening a limb in order to get apposition of the fragments
after the sclerosed bone has been excised.    In other words, after the excison of the
sclerosed bone has been carried out, the circumstances present are the same as if a
shell fragment had carried away that portion of the bone.    If a sufficiently vascular
bed has been provided for the chips, more rapid union can be expected than by the
use of a cortical graft.    However, if a sufficiently vascular bed cannot be provided,
such as when no defect had been surgically produced, then it is better to use a sliding,
inlay or onlay cortical graft.    A combination of both types of graft will frequently
be very satisfactory.
Lantern slides were shown demonstrating the methods used and the results of treatment in the twelve cases reported.
«_>>
O
3  •
£  3
I
Page 54 Conclusion:
1. It is felt that cancellous chip bone grafts have a definite place in the treatment of
complete defects of the long bones.
2. The filling of large partial defects with cancellous chips is worthwhile because it
greatly shortens the time required for the reformation of the bone.
3. Hrobably the ideal time for grafting is about two months after injury. This allows
time for complete healing of the wound, disappearance of oedema and assessment
of the possibility of regeneration of bone from residual periosteum or fragments.
4. The operative procedure is not difficult but care must be taken
(a) to provide an adequate, oblique contact surface on the bone ends and overlap
them with chips;
(b) to cut a sufficently deep notch for the central strut of cancellous bone;
(c) to not pack the chips in tightly;
(d) to ensure, if possible, that vascular muscle bellies are in contact with the graft.
5. Adequate imrnobilization must be effected. In the lower extremeity it would seem
logical to use a siding or onlay cortical graft along with cancellous chips.
6. Cancellous chip grafts can be used to advantage in selected cases of established
non-union.
THE CANADA YEAR BOOK, 1945
Price $2.00—on application to the King's Printer, Ottawa.
The 1945 edition of the Canada Year Book, published by authority of the Hon?.
James A. McKinnon, M.P., Minister of Trade and Commerce, is announced by the
Dominion Bureau of Statistics. .
This edition contains many special articles of great interest and importance—
amongst them Physical Geography of the Canadian Eskimo Arctic; Canadian growth
in External States and her part in Relief and Rehabilitation of Occupied Territories;
International Air Conferences; Canada's Northern Airfields; the work of the Wartime
Prices and Trade Board in Price and Rent Control, etc., etc.
The Chapters on Social Welfare and Reconstruction contain articles on Family
Allowances, Health Insurance, and so on. .There are important chapters on Internal
and External Trade, on Consumption of Foods, on Agriculture, Fisheries, Labour, etc.
There are maps, many charts and diagrams, and a complete index to the work.
Education, life insurance, currency and banking, national resources, transportation,
and in fact every department of national life, are included in this veritable encyclopaedia. The Chapter on Public Health, and the Dominion and Provincial activities in
its regard, are of especial interest to medical men. The supply is limited, so apply
early.
Page 5* PROTRUDED INTERVERTEBBAL DISC
(A Report on 60 Operative Cases)
By Major P. O. Lehmann
Read at the November, 1944, General Meeting of the Vancouver Medical Association.
Prior to the last decade, the treatment of sciatica was particularly unsatisfactory.
Therapy was directed along so many courses that now, in retrospect, it would seem that
none of the measures were based on sound principles, and that recovery, when it did
occur, was due to chance, time and nature, or was brought about in spite of treatment.
There were various techniques and agents for injection into the sciatic nerve or adjacent muscles and many forms of manipulation and traction, and, finally, immobilization of one of several joints might be accomplished by one of several extensive procedures. Over all the forms of therapy hung the spectre of heavy sedation and its consequent dangers, to say nothing of the economic loss to the individual.
Since the concept of the protruded intervertebral disc was established in 1925, it has
been the subject of considerable discussion. Originally, there was skepticism as to the
existence of the entity, but now neurologists and neurosurgeons generally believe that
90% or more of sciatica is caused by protruded intervertebral discs.
In order to assess the results of treatment, I have summarized the findings on the
first 60 operative cases at Shaughnessy Hospital between February, 1944, through April,
1945. These operations were performed on only 57 patients, as three of them required
two operations. Of the total number, three of the procedures were carried out by Dr.
Frank Turnbull, and the remainder by myself. Four classifications of personnel have
been under our supervision; i.e., Army, Air Force, Navy and D.V.A., of which 31 were
Army, 14 Air Force, 6 Navy and 6 D.V.A., with age range between 18 and 57 years.
The clinical entity of protruded intervertebral disc is, for the most part, fairly
circumspect. The usual complaint is that of low back pain associated with sciatica.
Usually, but by no means invariably, this is preceded by trauma which is usually of a
minor, twisting nature involving muscle action; i.e., lifting, sudden turning, etc.,
rather than severe trauma associated with fracture. There is usually a history of low
batk pain at the onset, with development in from two or three dayls to several months
later of radiation through the buttock to the back of the thigh, back of the calf and on
occasions into the foot. Patients usually describe episodes of exacerbation associated
with exposure to elements, particularly sleeping in wet blankets or clothes; secondary
trauma; lifting; walking; etc. Frequently, during one of these exacerbations, which
last a matter of a few days to a few weeks, the patient has been confined to bed with
aggravation of pain in the leg on coughing, sneezing, twisting in bed, or even flexing
the neck.
On examination, there is almost invariably obliteration of the normal lumbar lordosis
and occasionally scoliosis is seen, which may be to the affected or non-affected side. There
is also limitation of straight leg raising. This may be a matter of 10 degrees from
horizontal in severe cases to 70 degrees in the less severe. In those cases involving the
lumbo sacral disc, there may be, in addition, an area of hypoesthesia throughout the
distribution of the first sacral dermatome on the lateral aspect of the foot and calf.
Usually, this has its greatest intensity on the lateral aspect of the foot immediately
below the malleolus, and there may be a variable amount of weakness of the calf musculature. Frequently, there is obliteration of the ankle jerk, or, more often, a diminution of its activity. However, in those Cases involving the 4-5 interspace with compression of the 5 th lumbar nerve root only, there is usually no loss of ankle jerk and the hypoesthesia corresponds" to the medial aspect of the foot only, and in severe cases, there is
loss of power of dorsiflexion of the foot, rather than plantar flexion, as in the lumbo
sacral level. For the most part, the cases complained of pain in one leg only, but frequently there have been attacks of pain on the alternate side, and very occasionally
there has been bilateral sciatica.
Page 56 I am using the term "protruded intervertebral disc" to cover the condition frequently
referred to as: "ruptured disc," "ruptured nucleus pulposis," "retropulsed nucleus pulJ
posis," or simply "nucleus pulposis." I prefer the term "protruded intervertebral disc" as
it is more descriptive. The protrusion can take several forms. There may be a fusiform
swelling, or a distinctly sequestrated portion of disc tissue which may be lying posterior
to the body of an adjacent vertebra. The normal intervertebral disc is formed of a cenn
tral jelly-like globule called the nucleus pulposis which is surrounded by a firm banc-
of circularly arranged bundles of fibrocartilage called the annulus fibrosis. The latteij
acts like the casing of an automobile tire in retaining the nucleus in position. Invari-I
ably, the actual protrusion consists of a portion of the annular structure, or casing^
rather than the more centrally placed nucleus pulposis.
The protrusion, as I have described it so far, is responsible for the back pain. Thd
sciatica is caused by stretching of the nerve root over the protrusion. The protrusion is
only related to that portion of the nerve root which passes from the spinal dural sheath
to the intervertebral canal between the adjacent vertebrae. This portion of the root is
short, being approximately 1 to 1 l/z inches in length, and it is normally fixed in position;
at both ends. Consequently, the full thrust of the protrusion is applied to a relatively!
short segment of nerve which is unable to stretch sufficiently to adapt itself to the disn
tortion of its normal course. The obliteration of the lumbar lordosis and scoliosis arej
due to an attempt to provide a shorter course for the stretched nerve root. The aggravation of pain by coughing is due to engorgement of the meningo rachidian veins in the)
spinal extradural space, which increases the pressure within the dural sac and tension is!
transmitted to the already overstretched nerve root.
Clinical investigation of all personnel presenting the above clinical picture has- inn
eluded (1) plain X-ray film of the lumbar spine, (2) a myelogram, and (3) C.S.F.i
protein studies. As a routine, we have been performing myelograms using pantopaque,
rather than lipiodol. Pantopaque is a synthetic iodine preparation prepared by the Easffl
man Kodak Co. It is superior to lipiodol in that is does not produce any reaction in thei
meninges, is less viscid, and if retained in the subarachnoid sac, it is absorbable at the
rate of approximately 1 c.c. per year. Throughout the series, several variations in technique have been used, and latterly we have had most success using-6 c.c.'s of pantopaque
injected with the patient lying prone on the X-ray table with pillows under the abdomen to overcome the lumbar lordosis, and thus separate the vertebral spines. The lumr]
bar puncture needle, of large gauge, preferably No. 18 calibre, is inserted in the midline
at a high level, usually L2-3, in order not to involve the suspected areas. Fluoroscopic
control is used, and after inserting the oil and posturing the patient, fluoroscopic views
and spot films are taken for detail examination with the needle still in place. Typical
findings are a filling defect of the spinal sac at the involved intervertebral space level
and frequently only elevation or obliteration of the affected nerve root pouch at the
suspected level. Frequently, on this examination, evidence of a midline protrusion is
encountered by X-ray studies, with predominance of the protrusion to one or the other
side. On completion of the procedure, the pantopaque is removed through the needle
by aspiration, and posture controlled by fluoroscopy.
Although clinical examination is usually accurate in localizing the level, occasionally the wrong level is explored when myelography is not used, and one is quite incapable of determining the presence of multiple protrusions at various lvelis without
myelography—a condition which exists quite frequently. Anatomical anomalies of the
lumbar spine are a potent source of error in the clinical appraisal of the affected level.
Having made a diagnosis by a combination of history, physical findings and X-ray j
findings, we have subjected all our cases to a course of conservative therapy, consisting
of a period of three weeks' complete bed rest on fracture boards with Buck's extension
applied to the affected leg, using 6 to 10 pounds. Only those cases which fail to respond
adequately to a period of conservative treatment are considered for operation, and
amongst them are those who have exaggeration of their pain on being confined to bed,
those who are relieved of pain whilst at rest, but who have immediate recurrence, and
Page 57 hose cases who have received an adequate course of conservative treatment and are
jischarged from hospital, only to return after a period of from a few weeks to months,
|ith another acute phase of sciatica. Unfortunately, a large number of cases fall into
he latter group of failures, and it is on those we have operated.
At this point, considerable clinical judgement must be used as to the advisability of
^commending operative procedure. Of prime importance is the man's personality and
jegree of emotional stability. Many of the personnel complaining of low back pain
pth sciatica have neurotic trends and are emotionally unstable. It is frequently these
rho welcome and solicit an operative procedure. They rarely manifest a post operative
rill to be well, as compared to that seen in the individual showing no neurotic trends,
igain, there are, in this group, a certain proportion whose symptoms will be relieved
aerely by discharge from service. A major factor to be considered is the type of work
le patient has to return to. Frequently, a change of work to a more sedentary type
rill allow him to carry on without any extensive procedure. On the objective side,
by degree of associated arthritis of the lumbar spine, particularly of the apophyseal
pints, is a distinct contraindication in assessing the advisability of of operation.
I have no accurate statistics as to the number of cases treated conservatively during
(recisely the same time interval as those cases treated by operation, but for comparison
iurposes, I have the figure from September, 1944 to September, 1945. During that
period, there were 186 cases of protruded intervertebral disc diagnosed, and an additional
4 suspects, which makes a total of 260 cases, so that roughly one in four has been
roerated upon.
As with myelography, the technique of our surgical procedure has varied through-
ut the series. At the outset, we used general anesthesia with intratracheal ether,
ilateral separation of the muscles from the vertebral spines, and removal of the cre-
entric margin of both opposed laminae, whereas latterly, we have been performing
he procedure under spinal anesthetic with unilateral muscle exposure and resection of
small crescent of the lower margin of the upper lamina only. By this means, a smaller
pcision can be made (usually 3 or 4 inches), and consequently, less trauma is inflicted
n the back, and we contemplate less disturbance throughout. In this regard, I have
Ust learned, in a recent study of electromyography, that the muscles of the back on
ost-6perative laminectomy cases show abnormal muscle function persisting for as long
is 10 or 12 months after operation. This is believed to be due to eschemic change in
jerve supply to the muscles involved.
The amount of disc tissue removed has changed and varied throughout the series.
it the outset, the tendency was to remove smaller amounts, usually the protrusion only;
ut latterly, large amounts have been removed, wth excision of the portion of the
osterior longitudinal ligament overlying the protrusion and extensive piecemeal curet-
age of the contents of the intervertebral space. In this way, as extensive volumetric
emoval of the disc tissue as possible has been accomplishd. The closure is done in
jyers with interrupted silk sutures.
There was a single case in which operative exposure of the involved disc showed no
vidence of protrusion at operation, and in this man there was a swollen nerve root,
bhich undoubtedly accounted for the filling defect which was seen in the myelogram.
)ecompression of the nerve root alone in this case was sufficient to completely relieve
he symptoms. I have seen similar cases previously, which are usually associated with
minute laterally-placed circumscribed protrusion.
On four occasions, where there seemed to be greatly increased mobility at the
involved joint, an attempt at immobilization was made by means of a figure of eight
pop of No. 18 steel wire to approximate the spinous processes at their base, with good
esults. pll
There have been no immediate post operative complications, other than occasional
[espiratory infections. We have been fortunate in not having any post operative wound
nfections.   Frequently, there is a little disturbance of bladder control for  24 to 48
fage 58 hours.  This was extended to 3 weeks in one case in which the nerve roots were trauma
tized more than usual by a trans dural approach.
Frequently, there are post operative complaints of numbness in the dermatome*
supplied by the involved nerve root. This usually subsides after a few weeks, but ma
be persistent. It is of no significance and after a few weeks, there are no complaints
The oldest patient, aged 57, although relieved of his sciatica, complained of weaknes
of legs and pain on walking. This later proved to be vascular spasm, and he was relievec
by lumbar sympathectomy.
At the outset of the series, the post operative treatment consisted of approximate!
ten days to two weeks of bed rest. Now, we are encouraging patients to be ambulan
as soon as possible. They usually have a moderate degree of low back pain for 48 hours
and thereafter are anxious to be up, depending on their motivation. Before getting up
they are given tension exercises for 2 or 3 days. Following this period, an attempt i
made to get them up at intervals to receive physiotherapy in the form of exercises t
maintain their abdominal and skeletal musculature in tone. As they become more am
bulant, they go downstairs to the physiotherapy department for active exercises, anc
this is maintained for a period of ten days to three weeks, at which time they an
usually ready for discharge from hospital. It has been my experience that the averagt
case requires two to three months' post operative physiotherapy before his back i
entirely free of pain.
A patient who is anxious to get out of bed early usually has a better result than on
who is prepared to lie in bed and be waited on. I have been encouraging them to b
ambulant, partially in an attempt to allay the misconception that they have had a majo
operation on the back which will result in a high incidence of post operative invalidism
As to results—between February, 1944 and April, 1945, 60 cases have been oper
ated upon (3 of these were reoperative cases on earlier failures), and of these, 31 ar
symptom free, and may be considered as cures.    Of this number,  12 were R.CA.F.
11 Army,  5 Navy, 2 Pensions and I Nursing Sister.    From this, it is apparent tha
12 out of 14 Air Force have done well; 5 out of 6 Navy; whereas only 11 out of 31
Army personnel have been cured, and 3 out of 6 Pensions personnel. In this group
who are symptom-free are those who have been followed up at intervals and thosi
whose homes are in this District, and on whose Pension file there is no record of an)
further symptoms or complaints. The remaining group of 26 cases in which the
results have not been entirely satisfactory have varying degrees of disability. I havt
divided them into • groups.
The first group comprises those with minimal complaints in regard to the lo^
back. These men are working full time, but feel they cannot handle the heavy wort
they did prior to their original complaints. In this group are six men. They continu*
to improve, and are all greatly relieved from their pre-operative condition, but are noi
economically competent at this date. Amongst them, there are 4 whom I would esti
mate as eventually being totally cured.
Another group, totalling 12, is one from which I have learned the greatest lesson.
Included are nine Army personnel, all stationed in this area in the Home Defence
Army. They are all young men. Added to these are three veterans from the last
war, pensioned for sciatica due to G.S.W. of the thigh, although there is no evidenc<
to support injury to the sciatic nerve at any time. It is my present opinion that nont
of these 12 men should have been considered for operation, even though they hac
signs and X-ray findings to corroborate their symptoms. It is now apparent that they
all were aware of the compensation factor in their illness. The three older pension
cases obviously had to consider the prospect of a reduced pension, and the youngei
personnel had to consider remaining in objectionable Army service. None of them
had signs to corroborate their post operative complaints. They constitute failures in
assessment.
The third group of six cases had a recurrence of their original complaints, whicH
I consider to be legitimate. Three of these were re-operated upon with satisfactory endj
Page 59 results, while 3 others had return of symptoms and supporting evidence of involvement of the nerve root, however, their symptoms are at present not sufficiently severe
to warrant secondary operation.
The most puzzling group, and the final group, consisting of five men,  are those
iwho have residual low back pain following operation of an incapacitating nature. Their
sciatica,   which  was   a  predominant  pre-operative  complaint,   is   completely  relieved.
However, they are left with severe incapacitating low back pain.
These cases represent the group who possibly should have been fused at the time
of the original operation.    Some of them are relieved by wearing low back braces, and
some of them have domestic problems  which may be contributing factors.    Others
have had no relief as yet from any therapy.    It is my present contention that those
with the most mobile intervertebral joints fall into this group, and should be immobilized, as I believe their pain to be due to instability of the lumbar spine.    The question
of a combined procedure of fusing the lumbar spine and removal of the disc has been
mooted by many surgeons of late.    I am still of the opinion that this is an. unnecessarily extensive procedure to subject the entire group to.    As you see,  5  out of  57
present  the  problem  of  residual low  back pain.     I  think  that  the  cases  should  be
[followed for a short period of six months after operation, and if they are not relieved
fat then end of that time, they should be hospitalized with the prospect of fusing the
lumbar spine, rather than subject the entire group to the far more extensive procedure
[of spinal fusion.
In conclusion, I would like to say that these results are short of ideal, although
on questioning, all the patients admit improvement in their symptoms following oper-
I ation.   However,  I  want  you  to  bear  in  mind  th'at  the  patients  we  deal  with   at
(Shaughnessy are not typical of civilian nor, strictly, Army practice. Our Army
patients have been, for the most part, Home Defence personnel or men repatriated
| from overseas, who have been considered by either a neurosurgeon or a psychiatrist
as unlikely to obtain sufficient relief by operation overseas  to allow them to return
I to fighting capacity. Secondly, our D.V.A. patients have either obtained a pension,
or are contemplating one.     It  is  generally  agreed  that  the  results  in  the  operative
| Treatment of protruded intervertebral disc in private practice are considerably influenced by any compensation or insurance factor involved.
OREGON ACADEMY OF OPHTHALMOLOGY
AND OTOLARYNGOLOGY
The Sixth Annual Spring Post Graduate Course in Ophthalmology and Ootolaryng-
sology will be held in Portland, April  15-20,  1946.    Another fine program has been
arranged by the Oregon Academy and the University of Oregon Medical School.    We
are particularly fortunate in having two outstanding men in their respective field as
guest speakers.
Dr. Algernon B. Reese, Professor of Ophthalmology at  Columbia University,
New York City; Member of the American Board of Ophthalmology.
Dr. Gabriel Tucker, Professor of Bronchoscopy and Laryngology at University of
Pennsylvania Graduate School, Philadelphia.
There will also be lectures, clinical demonstrations and ward rounds.
Wives invited, social activities will be arranged later.
Preliminary programs will be out about February 15 th and you may secure yours,
[and further information, from
Dr. Harold M. U'Ren, Secretary, 624 Medical Arts £ldg., Portland 5, Oregon.
Page 60 MEDICAL SERVICES ASSOCIATION
BALANCE SHEET AS AT AUGUST 31, 1945
ASSETS
CURRENT ASSETS:
Cash in bank $ 49,294.94
Dominion of Canada Victory Loan Bonds—at cost
(quoted market value $41,160.00) $ 41,000.00
Add—Accrued interest  '.  350.00
     41,3 50.00
Dues receivable from members ;_      1,402.04
 $ 92,046.98
FURNITURE AND FIXTURES, less depreciation       1,342.34
DEFERRED CHARGE:
Unexpired insurance !  68.90
ORGANIZATION AND DEVELOPMENT EXPENDITURES RECORDED ON
BOOKS AS AT AUGUST 31, 1944 AND CREDITED TO CAPITAL RESERVE
—per contra \     11,708.20
$105,166.42
LIABILITIES
CURRENT LIABILITIES:
Xccounts payable I $ 22,578.48
DEFERRED CREDIT TO INCOME:
Members' contributions unearned 1 1,149.62
RESERVE FOR CONTINGENCIES, including medical accounts not presented
for payment       8,500.00
STABILIZATION ACCOUNT:
Balance as at August 31, 1944_|_£|| $  24,707.05
Add—Registration fees received  (non-recurring) $     8,928.00
Excess   of   income   over   expenditure   for   the   year
ended August 31, 1945   (Exhibit A)     27,595.07
     36,523.07
     61,230.12
CAPITAL RESERVE—per contra ! L .     11,708.20
$105,166.42
To the Members,
Medical Services Association:
We have made an examination of the books and accounts of the Medical Services Association
for the year ended August 31, 1945, and have obtained all the information and explanation which
we have required. In connection therewith, we examined or tested the accounting records and
other supporting evidence, and made a general review of the accounting methods and of the operating and income accounts for the year, but we did not make a detailed audit of the transactions.
We report that, based on such examination, the above balance sheet is, in our opinion, properly
drawn up so as to exhibit a true and correct view of the state of the Association's affairs as at
August 31, 1945, according to the best of our information and the explanations given to us and as
shown by the books of the Association.
Vancouver, B. C.
November 13, 1945.
PRICE, WATERHOUSE & CO.
Chartered Accountants.
Page 61 MEDICAL SERVICES ASSOCIATION
EXHIBIT «A"
STATEMENT OF INCOME AND EXPENDITURE
FOR THE YEAR ENDED AUGUST 31, 1945
INCOME:
Members' contributions ; $224 651.09
DEDUCT:
Medical care accounts paid and accrued $182 210.00
Administrative and other expenses:
Salaries $    9,048.25
Printing, stationery and supplies.
Postage	
Telephone and telegraph.
Travelling	
Insurance L	
Audit fees	
Rent	
Depreciation	
1,935.68
440.00
185.68
962.49
111.64
500.00
594.00
140.50
714.15
Interest and bank charges  (net) (credit)
Equipment rent and service charges 1,470.58
Miscellaneous    '.  171.35
14,846.02
197.056.02
Excess of income over expenditure for the year, carried to
stabilization account  (balance sheet)	
.$ 27,595.07
BOARD OF DIRECTORS
H. H. Grant Powell River Company Limited
D. J. Millar, M.D. College of Physicians and Surgeons of British Columbia
F. G. Crompton H. R. MacMillan Export Company Limited
J. F. Deane The Consolidated Mining and Smelting Company of Canada Limited
OFFICERS
H. H .Grant President
F. G. Crompton. Vice-President
A.  L. McLellan Secretary-Treasurer
Dorothy Myers Assistant Secretary
S. Cameron MacEwen, M.D Director of Medical Services
ASSISTANT DIRECTORS OF MEDICAL SERVICES
F. M. Auld, M.D Nelson, B.C.
J. S. Daly, M.D Trail, B.C.
R. W. Garner, M.D Port Alberni, B.C.
A. B. Hall, M.D Nanaimo, B.C.
C H. Hankinson, M.D—Prince Rupert, B.C.
Gordon James, M.D Britannia Beach, B.C.
W. J. Knox, M.D Kelowna, B.C.
E. J. Lyon, M.D. Prince George, B.C.
Thomas McPherson, M.D Victoria, B.C.
T. J. Sullivan, M.D Cranbrook, B.C.
Medical   Services   Association  is   a   service   organization  operating   a  non-profit
Medical Service Plan by and for its members—employers, employees and doctors,
and underwritten by the doctors of British Columbia.
Page 62 MEMBERS
A-l STEEL & IRON FOUNDRY LTD.    -    ALASKA PINE CO. LTD.    -    ALBERNI PACIFIC!
LUMBER CO. LTD.    -    ALBERNI PLYWOODS LTD.    -    ALBERTA MEAT COMPANY
ALLARD ENGINEERING LTD.    -    ARROW TRANSFER CO. LTD.    -    BAKER BRICK I
TILE CO. LTD.    -    BLOEDEL, STEWART & WELCH LTD.—Port Alberni and Vancouver
BRITISH  COLUMBIA  PULP  &  PAPER  CO.  LTD.—Vancouver   and  Woodfibre    -    BRITISH
ROPES CANADIAN FACTORY LTD.    -   BURRARD RIVET & FORGINGS LTD.    -    C. W.
LOGGING CO. LTD.    -    CAMPBELL & GRILL LTD.    -   CAMERON LUMBER CO. LTD.    -
-CANADA CHAIN  &  FORGE  CO.  LTD.     -    CANADIAN BOXES  LTD.     -     CANADIAN
FOREST  PRODUCTS   LTD.—Harrison   Mills,   Logging   Division,   and   Pacific   Veneer,   Plywood
Division   -   CANADIAN TRANSPORT CO. LTD.   -   CANADIAN WHITE PINE CO. LTD.   -
C. H. CATES & SONS LTD. -    CLARKE BROS. TIMBER CO. LTD.    -    CLAYBURN CO.
LTD.    -    COAST  MILLS  EXPORT  CO.   LTD.    -    COATES   LIMITED    -CONSOLIDATED
MINING   &  SMELTING   CO.   OF  CANADA  LTD.—Vancouver - G.   H.  COTTRELL
LTD.        -        CRANBROOK  CARTAGE  &  TRANSFER CO.  LTD. -        CRANBROOK
SASH & DOOR CO. LTD.        -       CROSSMAN MACHINERY CO. LTD.        -       DIETHERS
LTD. -        DOMINION BRIDGE  CO.  LTD.—Bridge  Plant        1        DOMINION  RUST-
PROOFING CO.  LTD. - DURAND MACHINE WORKS LTD. - ELECTRIC
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EVANS, COLEMAN & EVANS LTD.    -    EVANS, COLEMAN & JOHNSON BROS. LTD.    -
FINNING TRACTOR & EQUIPMENT CO. LTD.   -  FLECK BROS. LIMITED  -  GALBRAITH
& SULLEY LTD . -    GLLLEY BROS.  LTD.    -    GIRODAY & COMPANY    -    GOODMAN
MOTOR  TRANSPORT  CO.   LTD.       -       GRAHAM  ELECTRIC  CO.   LTD.       -      HAYES
MANUFACTURING CO. LTD.    -    HEAPS ENGINEERING  (1940)  LTD.    -    HUNTTING-
MERRITT SHINGLE CO.  LTD.      -      INTERNATIONAL PULPWOOD  SUPPLY CO.
KELLEY LOGGING CO. LTD.    -    M. B. KING LUMBER CO.   (NORTH SHORE)  LTD.    -
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CO. LTD.    -    MERCHANTS CARTAGE CO. LTD.    -    MOHAWK HANDLE CO. LTD.    I
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COAST SPRUCE  (CANADA)  LTD.    -    PACIFIC COAST TERMINALS LTD.    -    PACIFIC
PEAT PRODUCTS LTD.    -    PACIFIC PINE CO. LTD.    -    PATTERSON BOILER WORKS
LTD.    -    POWELL RIVER CO. LTD.—Vancouver    -    PRODUCERS SAND & GRAVEL CO.
LTD.    -    SEABOARD LUMBER SALES CO. LTD.    -    SHAWNIGAN LAKE LUMBER CO.
LTD.    -    SHELL OIL CO. OF B. C. LTD.    -    STANDARD OIL CO.  OF B. C. LTD.    -
STEELWELD   LIMITED     - ' STEWART  SHEET   METAL   WORKS   LTD.     -     STOREY  ■
CAMPBELL LTD.     -     THURSTON & FLAVELLE LTD.     -     TIMBERLAND LUMBER CO.
LTD.    -    TYEE MACHINERY CO. LTD.    -    UNIVERSAL BOX CO.  LTD.    -    VALLEY
LUMBER YARDS LTD.    -    VANCOUVER BREWERIES LTD.    -    VANCOUVER ENGINEERING  WORKS LTD.    -    VANCOUVER  EQUIPMENT  CORP.  LTD.    -    VANCOUVER ^
TUG BOAT CO.  LTD.     -     WESTERN CHEMICAL INDUSTRIES LTD.     -     WESTERN
PLYWOOD CO.  LTD.    -    WESTMINSTER BOILER & TANK CO.      -      WESTMINSTERS
CANNERS LTD.     -     WESTMINSTER HOG FUELS LTD.    -    WESTMINSTER PAPER CO.
LTD.    -    WRIGHTS' CANADIAN ROPES LTD.    -   YOUNG & GORE TUGBOAT CO. LTD. I
Page 61 UNITED NATIONS RELIEF AND REHABILITATION
ADMINISTRATION
The Bulletin has been in receipt of reports from this unique organisation—and we
I that medical men should have some knowledge, first of the terrible, ghastly prob-
is that face its officials in Europe, both enemy and friendly countries; and also of
| amazing work that is being done. We will keep the records on file for anyone to
^sult that wishes—but some brief abstracts should be of interest.
■ Greece is perhaps one of the most tragic countries in the whole of Europe, and with
iracteristic courage, the Greeks are rallying all their forces to take advantage of
sRRA's help. Tuberculosis is rampant in this little country, the incidence being ten.
itwelve times that in the U.S.A. Greece has 160,000 active cases, a large portion
png children.
j Underfeeding and malnutrition, which are almost beyond comprehension, are of
prse largely responsible for this. The total breakdown of transportation, the lack of
picines, heat, fuel, as well as local ignorance and superstition, all make the work of
i medical staffs a Herculean labour. But a tremendous lift has been given to the
?ek spirit by the knowledge that help is available, and gallant work is being done by-
caff of nurses, who, regardless of personal hardship, and overwhelming difficulties, are
omplishing miracles, no less. There are thirty-eight American nurses, many British
1 Canadian nurses, and the Australian Red Cross—and they have to work in moun-
h villages, where donkeys are about the only available transportation. Hygiene and
itation are unknown—^in one village, the drinking water came from a point in the
ler 30 feet below where most of the sewage was dumped.
j Typhoid is very prevalent, lice abound, skin diseases due to filth, malaria and so on..
e shortage of meats and fats, the systematic robbing of areas by the Germans, have
| to various deficiency diseases, which will take a long time to remedy.
! But UNRRA is doing wonders in Greece, and is its chief, almost its only, hope for
imate recovery. ||gi
| Other countries, too, are suffering greatly. Europe is threatened by epidemics of
)hus in the east, typhoid in the west and east, and malaria in the Mediterranean area.
| Tuberculosis, diphtheria and syphilis are generally prevalent—outbreaks of polio-
elitis are reported in Belgium and Czecho-slovakia.
I DDT is doing much against typhus and malaria; also plague and dysentery—but
\ still remains the greatest problem. An outbreak of plague occurred at Taranto, in
jly, and various projects for destruction of fleas by DDT, and rats by cyanide, are in
j>gress, besides vaccination against plague.
A plastic surgery team has been sent from England to Yugoslavia, to train doctors
_ nurses there: Sir Harold Gillies, the well-known English plastic surgeon, is the-
king spirit here. He visited Yugoslavia in July, 1945, and reported on conditions,.
_ the urgent need for this work.
Diphtheria is the leading epidemic disease in central and northern Europe and is
creasing rapidly in Finland and Germany; in Holland it is second only to TB as a
ase of death.    It is also the most important epidemic disease in Japan.
Sweden, one of the wonder countries of the world, has been conducting experiments
the building up of children starved by the Nazis. Many of them were considered
iolutery hopeless, were "mere skeletons draped with loose skin"—but wonders have
m accomplished: 40 of 48 of these apparently dying children are now normal,
dthy children.
Sweden, though not a member of the United Nations, has accepted through
^RRA a total of 31,000 slave labourers and war victims who were in especially bad
dth when liberated from Nazi prison camps last spring.    The Swedes provided them
e 64 with 4800 calories daily—though the normal ration for Swedish citizens is only 38001
"The rich diet caused some digestive disturbances, but these are of little consequenci
compared with the overall results," says Dr. Corgny, UNRRA's Medical Chief fol
Displaced Persons in Europe. "The enjoyment of plenty . . . has not only rehabilitated
them physically at an unusual rate, but has also helped restore their mental health witH
remarkable rapidity." They are housed in 150 centres of various types, all in beautiful
surroundings. The very best of medical care and welfare services are provided. The
morale and courage of these poor victims have been given back to them—-they now feel
that they can face life again, and are eager to get back to their homes, and start lifd
anew. As they return the Swedish government gives them a complete outfit of clothing and shoes, plus food rations for 10 days, 3 800 calories daily per person. Most on
them are Poles, eager to go back to Poland.
Sweden has borne the entire cost of their care—brought them to Sweden in Swedish
ships, and has placed no specific limit on the time they may remain in hospital or convalescent centres.    UNRRA is cooperating on plans for their repatriation.
In Germany itself, plans have been laid to take care of remaining displaced persons
in U.S.-occupied Germany (we assume that similar care is provided in the British-occun
pied and Russian zones). Here relief and rehabilitation are provided for, immunization]
against disease is being carried out, epidemics of typhoid, etc., are being forestalled, and
sanitation, dental services, nursing services are being provided. Organized hospitals
and dispensaries, with ambulance service, are in being, and everything possible is being
done to take care of these unfortunates.
NEWS    AND    NOTES
Dr. and Mrs. Frederic Brodie, of Salt Spring Island, are visiting old friends in Vancouver, where they are staying at the Hotel Vancouver.
It is with regret that we record the passing of two members of the medical profes-
scion of British Columbia: Dr. C. R. Syrnmes of Port Moody, who died on January 3rd,
and Dr. H. H. Planche, of Vancouver, on January 12 th.
*t *_ *_ *t
•_• ~e *_* *c
Sympathy is extended to Dr. R. V. McCarley of North Vancouver in the passing
of his mother.
Congratulations are being received by Dr. and Mrs. E. B. Gung of Vancouver on the i
birth of a son on December 18 th.
Mr. C. W. and Dr. Mary Garner of Vancouver are receiving congratulations on the
birth of a boy, on December l_th.
Lieut.-Col. M. R. Caverhill, O.B.E., R.C.A.M.C., has returned from four years
service overseas, and assumed the duties of Executive Secretary of the College of Physicians and Surgeons of British Columbia Dr. Caverhill practised in Victoria prior to
joining the Army. He will be remembered by many members of the profession in Vancouver as assistant to Dr. R. A. Seymour at the Vancouver General Hospital. We wish
him every success in his new work.
Page 65 Among the list of Naval promotions issued recently we note the name of Surgeon
Commander Gordon H. Grant of Victoria.
Major Milton Share has returned from service overseas.
Lieut.-Col. E. H. W. Elkington of Victoria has received bis discharge from the
LC.A.M.C, and has resumed practice in Victoria.
Major L. W. Bassett, R.C.A.M.C., is now out of the Service, and in practice in
Victoria.
Major N. C. Cook of Victoria has returned to civilian life following his discharge
from the R.C.A.M.C.
Colonel C. A. Watson of Victoria, who returned from service overseas some time
igo, is A/Command Medical Officer, Pacific Command.
Major U. P. Byrne of New Westminster has received his discharge from the R.C.
rVJM.C, and has returned to the staff of the Provincial Mental Hospital.
Major G. C. Johnston and Major T. K. MacLean, who returned from service overseas some weeks ago, are in practice in Vancouver, following their discharge from the
R..CA.M.C
Major Henry Scott of Vancouver has returned to civilian life.    Major Scott served
overseas, returning to Vancouver a few months ago.
*       *       *       *
Major W. A. Morton, following his discharge from the R.C.A.M.C, has resumed
practice in Vancouver.
Major C. H. Gundry of Vancouver has returned to civilian life, and is with the
Metropolitan Health Cornmittee in Vancouver.
Major J. Ross Davidson, who returned to Vancouver some weeks ago from overseas,
has now received his discharge from the R.C.A.M.C, and has resumed pra'ctice in
Vancouver.
Major W. L. Boulter, following his discharge from the R.C.A.M.C, is with the
Canadian Pension Commission, Shaughnessy Hospital.
Major H. H. Boucher, who recently returned from overseas service, has received his
discharge and has resumed practice in Vancouver.
Flight-Lieut. D. B. Ryall has received his discharge from the Air Force, and is in
practice at McBride.
Flight-Lieut. H. G. Cooper has resumed practice in Vancouver following service
with the Air Force.
Flight-Lieut. J. F. Sparling is now located in New Westminster, having received his
discharge from the Air Force.
Flight-Lieut. J. F. Arther has received his discharge from the Air Force.
•5* i,* *tf* *?*
«
Capt. Nathan Shklov has returned to civilian life, and is in practice at Vernon.
Page 66 Capt. W. M. G. Wilson, who returned from service overseas recently, is now in?,
practice in Port Alberni.
Capt. W. H. S. Stockton is out of the Army and in practice in Vancouver again.!;
Surgeon-Lieut. D. M. Whitley of Victoria has returned to civilian life, following his
discharge from the Navy.
From overseas we hear that Major R. E. McKechnie and Major Douglas Telford are;?
in charge of the surgical services at No. 24 Canadian General Hospital.
From Prince Rupert we are informed that Dr. J. J. Gibson has left that city tog
practise in Penticton.
<_)bttttanj l
DR. J. T. ATKINSON
Vancouver
Obiit December 9, 1945 mjk
With the passing of our late friend and colleague "Jimmy" Atkinson, as
he was known to all his friends, went a rather unique, and a very fine character: we shall not easily forget him: and his place, which he himself filled so
admirably, will be very hard to fill again.
Dr. Atkinson was one of a type of medical man which is becoming rather
rare, a really all-round general practitioner, thoroughly capable, a first-class
surgeon, and a man devoted to his profession, and to those he served. He had
for many years looked after the Indian population of the Coast, and they are
going to miss him very greatly. His care of them was an admirable thing to
behold—he gave them of his very best, and treated them as any other doctor
would treat his most highly valued patients. He did everything for them,
medicine, surgery, obstetrics, and did it all well. It is going to be extremely
hard to replace him here.
As a man, Jimmy Atkinson was one of the best fellows anyone ever knew,
in that division of the medical art, he would have gone far. He was an ingenious craftsman in surgery—had devised many of his own instruments, and
knew how to use them all. To see him do a mastoidectomy was a treat—he
was a survivor of the old days, not necessarily "good" in this respect—when a
general surgeon did any surgery that was to be done, including those operations
which are now becoming holy ground for other specialties.
Quiet and gentle in his ways, he was friendly and lovable, and everyone liked
and respected him. He was the "gentleman in character" which Hippocrates
in one of his Aphorisms says every medical man should be, and he did his job
supremely well. He was happy in that he worked right up to the very end of
his long and active life, and tarried not in the gate.
Page 67

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