History of Nursing in Pacific Canada

The Vancouver Medical Association Bulletin: October, 1947 Vancouver Medical Association Oct 31, 1947

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Published Monthly under the Auspices of the Vancouver Medical Association
in the interests of the Medical Profession.
Offices: 203 Medical-Dental Building, Georgia Street, Vancouver, B.C.
Dr. J. H. MacDebmot
Dr. G. A. Davidson Dr. D. E. H. Cleveland
All communications to be addressed to the Editor at the above address.
No. 1
OFFICERS, 1947-48
Dr. G. A. Davidson Dr. Gordon C. Johnston Dr. H. A. DesBrisay
President Vice-President Past President
Dr. Gordon Burke
Hon. Treasurer
Dr. W. J. Dorrance
Hon. Secretary
Additional,Members of Executive: Dr. Roy Huggard, Dr. Henry Scott
Dr. A. M. Agnew Dr. G. H. Clement Dr. A. C. Frost
Auditors: Messrs. Plommer, Whiting & Co.
Clinical Section
Dr. Reg. Wilson..     Chairman Dr. E. B. Trowbridge... Secretarv
E<ye, Ear, Nose and Throat Section
Dr. Gordon Large Chairman Dr. G. H. Francis Secretary
Paediatric Section
Dr. J. H. B. Grant Chairman Dr. E. S. James Secretary
Orthopaedic and Traumatic Surgery Section
Dr. J. R. Naden Chairman Dr. Clarence Ryan Secretary
Neurology and Psychiatry
Dr. J. C. Thomas Chairman Dr. A. E. Davidson Secretary
Dr J. E. Walker, Chairman; Dr. W. J. Dorrance, Dr. D. E. H. Cleveland,
Dr. F. S Hobbs, Dr. R .P. Kinman, Dr. S. E. C. Turvey.
Dr J  H. MacDermot—Chairman: Dr. 1). E. H. Cleveland, Dr. H. A.
DesBrisay, Dr. J. II. B. Grant, Dr. D. A. Steele.
V.  O. N. Advisory Board:
Dr. Isabel Day, Dr. H. H. Caple, Dr. E. J. Curtis.
Summer School:
Dr. A. B. Manson. Chairman: Dr. E. A. Campbell, Dr. J. A. Gansiiorn.
Dr. G. Large, Dr. D. S. Munro, Dr. D. A. Steele.
Dr. H. A. DesBrisay, Dr. H. H. Pitts, Dr. Frank Turnbull.
Representative to B. C. Medical Association : Dr. H. A. DesBrisay.
Sickness and Benevolent Fund: The Presidfnt—The Trustees.
PERTUSSIS VACCINE (For Prevention of Whooping Cough)
A modification in the concentration of pertussis vaccine has recently
been made by the Connaught Medical Research Laboratories, so that the
vaccine formerly containing 15,000 million killed organisms (H. pertussis
from strains in Phase 1) per cc. now contains approximately 22,500 million
killed organisms per cc, permitting the administration of three doses of 1 cc.
at monthly intervals, ond a reinforcing dose of 1 cc. after an interval of at
least three months.
Diphtheria toxoid has been combined with the new concentration of
whooping cough vaccine. The new combined product is also administered
in three doses of 1 cc, with a reinforcing dose of 1 cc.
For protection against tetanus as well, a triple antigen has been introduced by the Laboratories. This product contains diphtheria and tetanus
toxoids combined with the new concentration of whooping cough vaccine and
is administered in three doses of 1 cc, followed by a reinforcing dose of 1 cc
Two   important  advantages  have  been  made
possible by this change:—
A dose of 1 cc. replaces the dose of 2 cc. as formerly
The reinforcing dose is included in each package.
For the inoculation of one child—Package containing Four 1-cc. Ampoules.
For a  group  of   nine  children—Package  containing   Six  6-cc   Ampoules.
University of Toronto Toronto 4, Canada
Founded 1898; Incorporated 1906.
October 21    CLINICAL MEETINGS—Vancouver General Hospital.
November    4    GENERAL MEETING—"Symposium on Peripheral Vascular Disease."
Dr. Rocke Robertson and associates.
November 18    CLINICAL MEETING—St. Paul's Hospital.
December    2    GENERAL MEETINGS—"Symposium on Pre-frontal Leucotomy."
Dr. Frank Turnbull
Dr. Allan Davidson
Dr. R. Whitman.
December    9    CLINICAL MEETING—Shaughnessy Hospital.
Royal Jubilee Hospital, Victoria, B. C, 480 beds, invites applications
for position of Medical Superintendent. State administrative training
and experience. Preference given to man under 40. Starting salary
$7,000.00 per annum. Address full particulars to Secretary, Royal
Jubilee Hospital, before January 10th, 1948.
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
circulation and thereby encourages a
normal menstrual cycle.
k A
b_ M© !_M_m STMIT. NIW TO-K. M. T.
Full formula and, descriptive
literature oifc 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 cap-
sule is cut in half at seam.
Page 1 i
In the treatment of 1,400 men with early syphilis1 (from
June 1944 to Feb. 1, 1945) with 2,400,000 units of penicillin
in aqueous solution, satisfactory progress was obtained in:
943 percent of 600 cases of seronegative primary syphilis
89-9 percent of364 cases of seropositive primary spyhilis
83.0 percent of 236 cases of secondary syphilis
In addition to favorable clinical response, the chief advantages of treating syphilis with penicillin are: (l) marked
freedom from toxicity; (2) convenience with which it may
be given and (3) the short period of time required for the
administration of a full course in adequate amounts.
VIALS {with Buffer)
for aqueous solution
•T. M. Reg. Becton
Dickinson & Co.
1. Sternberg. T. H., and
Leifer, W.: J.A.M-V.
133:1 (Jan. 4) 1947.
The presence of a buffer (4 to 5% sodium citrate) makes Crystalline
Penicillin G Sodium SQUIBB considerably more stable in solution than
unbuffered solutions of crystalline penicillin G sodium. Buffered
solutions maintain essentially all their initial potency for as long as
7 days under refrigeration. In diaphragm-capped vials of 100,000t
200,000 and 500,000 units.
Penicillin G Sodium squibb in Oil and Wax provides prolonged-action
penicillin in double-cell cartridges. One cell contains 300,000 units
of penicillin in refined peanut oil and 4.8% bleached beeswax. The
other cell contains sterile aspirating test solution to guard against
accidental intravenous injection. 300,000 units in 1 cc. double-cell
cartridges in B-D* disposable syringes, or for use with B-D* permanent
syringe.  Also in 10 c.c vials, 300,000 units per cc.
For Literature write
Total Population—Estimated . ; 3 39,3 50
'Chinese Population—Estimated        5,9 8 0
Hindu Population—Estimated x T  118
Rate Per 1000
Number Population
Total  deaths   %     265 9.2
Chinese   deaths   ■&-        12 23.6
Deaths,  residents only «.       243 8.4
Male .     418
Female   . ~     3 62
INFANT MORTALITY: August, 1947 August, 1946
Deaths under 1 year of age ' *»■'- _        9 17
Death rate per 1000 live births        11.5 21.2
Stillbirths   (not included  above) £__  5 3
Scarlet  Fever         - 	
:, 1947
>er, 1947
Diphtheria   _     	
Diphtheria Carrier              ]l§l|
      '           0
Chicken  Pox  - „ -        - .
        .                       8
Measles   _ -       .. .   	
l&*^l8^fc-_j ;3ifes     n
Whooping  Cough     	
• V-^_fer           {_p       0
Typhoid   Fever
 i     o
Typhoid   Fever   Carrier	
Undiilar"" F**vpr
    - .   0
   ft.   _       62
'P*     2
Meningococcus   (Meningitis)
  J...              0
 $          1
_$                         196
Cancer  (Reportable):
.__:        30
Page 2 m
**'% illi/fol% *
Urinary Stimulation
Stimulation of urinary secretion with
Salyrgan-Theophylline appears to be
due chiefly to its renal action
consisting of depression of tubular
reabsorption. In addition, there is a
direct influence on edematous tissue,
mobilizing sodium chloride and water.
Salyrgan-Theophylline is indicated
primarily in congestive heart failure
when edema and dyspnea persist
after rest and adequate digitalization.
Gratifying diuresis usually sets in
promptly and often totals from 3000
to 4000 cc. in twenty-four hours.
Injections at about weekly intervals •
help to insure circulatory balance for
long periods of time.
Good results may also be obtained in
chronic nephritis and nephrosis.
m   111    M
ll  j 1
Brand of Mersalyl and Theophylline
Ampuls of 1 cc. and 2 cc. for
intramuscular and intravenous injection.
Enteric coated tablets for oral use.
New York 73, N.Y.     •     Windsor, Ont.
SALYRGAN. trademark Reg. U. S. Pm. Off. ft Canada 7<&e CdifoA Paae
In the near future all B. C. medical men will receive a notice from Shaughnessy Hospital, which is of very great importance to all medical men engaged in general practice.
The notice explains itself, and we should like to say that in our opinion this is an outstanding contribution to the general practitioner of medicine. It is to be hoped that this
offer will meet with a very large response from the profession.
This is, we believe, exactly the right approach to the problem that one so often hears
discussed, the problem of the general practitioner, and the coincident problem presented
by the trend towards specialism-rather than general practice. Constantly one hears discussion of the two main aspects of this situation—the first being the shortage of general
practitioners or family doctors, to whom the public may apply for diagnosis and treatment—and the second being the growing tendency of medical graduates to undertake
specialism ab ovo, and to bypass general practice.
When one sees an ever-increasing trend in a certain direction, it is idle either to
ignore it, or merely to deplore it. To dwell nostalgically upon "the good old days" is
also futile and a waste of emotion. To begin with, they weren't altogether good old
days. They were the best old days one could have under the circumstances, but the
present days are much better. Diagnosis is more accurate, treatment fuller and better,
and the results incomparably improved. And we shall go on having specialists, and more
of them—and this is all to the good, and to the advantage, not only of the patient,
which is after all the main thing, but of doctors themselves. Medical practice has
become so complicated and so highly specialized, that the best work in the most difficult
cases, can only be obtained by special application. Browning's line, "Where e'en though
better follow, good must pass" expresses, no doubt, the feeling that many of us have,
that it is a sad thing that a very good period of medicine, the day of the family doctor,
with all that he meant to his patients, is apparently passing—but it is the inevitable law
of life, nevertheless. And, if we use it aright, the new period of more exact knowledge,
of a higher degree of technical skill, will more than compensate for the loss, if there
must be a loss, of the William McLures of medicine, who made up in self-sacrifice and
even heroism, what they lacked in scientific knowledge.
There are two desiderata, however, that present themselves, and that must be met.
The first is the need of more general practitioners—of an adequate supply of general
practitioners. The public needs them—and from an economic standpoint, they are a
necessity. Specialists are necessarily expensive, and the average person cannot afford as
many as he will need, if he is to depend entirely on specialists. Nor can any scheme of
health insurance be built around specialists.    So we must meet this problem, and solve it.
The second is the training of good, well equipped, well rounded specialists, who will
be doctors first, with all that means, and specialists afterwards. We are probably old-
fashioned, and are no doubt inviting a diagnosis of senile decay, but we still feel that the
best approach to specialism is through general practice. If this were the rule, the
problem of genearl practitioner shortage would be largely solved. This is, of course,
rather, an over-simplification of the problem, but we think it deserves consideration.
And general practice, with its width of outlook, and its training in human relations, is
quite irreplaceable as a training for later specialization. It would make, we feel sure,
for better specialists.
In any case, we are faced with a situation, and it will take much study, a lot of
patience, and great wisdom, to clear it all up. In the meanwhile, the first step is to
make general practice more attractive, and to make general practitioners better, and
more highly trained men.    General practice is, in a way, a specialty in its own right,
Page 3 and need not take a back seat to any other specialty. In the American Medical Association, they have a section of their own—and the Canadian Medical Association might
well follow suit, in establishing such a section.
We should back up this new plan with all our hearts and energies, and make the
fullest use of this course. It will add immensely to our resources, will be of the greatest
help to us personally, and will add immeasurably to our usefulness to the community
we serve. $M
Acetanilid, A Critical Bibliographic Review, 1946, by Martin Gross, M.D. (Gift of
the Author.)
Medical Clinics of North America, Symposium on Specific Methods of Treatment,
Boston Number, September, 1947.
Personality and the Behaviour Disorders, 2 vols., 1944, by J. McVicker Hunt.
A Bibliography of Infantile Paralysis, 1789-1944, Morris Fishbein, Editor.
Surgical Clinics of North America, Massachusetts General Hospital Number, October, 1947.
Supplements to Acta Medica Scandinavica
No.  186    On the reabsorption of chlorides in the kidney of rabbit.
No.  187    Sherrington's "Endeavour of Jean Fernel" and "Man on his Nature"—Comments by
No.  188    Diabetes mellitus in Sweden—Statistical  data on the number of  diabetes,
their state of health, working capacity, diet and treatment.
No.   189    A Study on Gastric Sediment.
No.   190    A Study on oxygen toxicity at atmospheric pressure—with reference to the
pathogenesis of pulmonary damage and clinical oxygen therapy.
No.   191     The splenic circulation with special reference to the function of the spleen
sinus wall.
No.   192    Arterial hypertension:   (1)  Variability of blood pressure,  (2)  Neurosurgical
treatment, indications and results.
The American Urological Association offers an annual award of $1000.00 (first prize
of $500.00, second prize $300.00 and third prize $200.00) for essays on the result of
some clinical or laboratory research in Urology. Competition shall be limited to urologists who have been in such specific practice for not more than five years and to residents
in urology in recognized hospitals.
The first prize essay will appear on the program of the forthcoming meeting of the
American Urological Association, to be held at the Hotel Statler, Boston, Massachusetts,
May 17-20, 1948.
For full particulars write the Secretary, Dr. Thomas D. Moore, 899 Madison Avenue,
Memphis, Tennessee.   Essays must be in his hands before March 1, 1948.
Page 4 The Committee on Medical Economics
Chairman DR. H. H. MILBURN
Vice-Chairman DR. G. F. STRONG
Secretary DR. F. L. WHITEHEAD
1. At the meeting of the Committee on Medical Economics on September 16th, 1947,
it was decided to form an Executive Committee of five and a Reference Committee of
three members.
(a) The Executive Committee has been formed and held its first meeting on October
16th, 1947.    This committee is composed of:
Dr. G. F. Strong, Chairman; Dr. G. A. McLaughlin; Dr. W. J. Dorrance; Dr. Bruce
Cannon; Dr. Frank Turnbull; Dr. H. H. Milburn, ex-officio; Dr Lavell H. Leeson,
ex-officio; Dr. E. J. Lyon, ex-officio; Dr. F. L. Whitehead, Secretary.
It is anticipated that this Committee will be able to deal with correspondence and
queries more expeditiously than has been possible under the large main committee.
(b) The Reference Committee has been set up to deal with complaints and matters of
dispute between doctors and the approved schemes.
At the meeting of the Executive Committee it was decided that the Reference Committee's primary function is to deal with disputed accounts, and that it is not concerned
with matters of broad policy.
At a recent meeting of the Executive of the Committee on Medical Economics it
was re-affirmed that a specialist in any particular branch of medicine is entitled to
specialist's fees only in his own field of practice. He is not entitled to, and should not
ask for specialist's fees when treating patients in a field of practice other than his own
particular specialty.
The M-S-A has the right, under its contract, to ask any doctor to have a consultation before elective surgery is undertaken. In any case of doubt, or in the case which is
a semi-emergency, the doctor will get a sympathetic hearing of the problem and, in most
cases, an immediate decision, if they will contact the Medical Director of the M-S-A by
telephone and present the facts.
The Specialists' Scale of Fees has been approved in all sections with the exception of
orthopaedics and there are a few additions and alterations yet to be made. A special
committee has been appointed to review the fees of the orthopaedic section and it is hoped
that this will be done expeditiously.
This organization has improved its contract considerably in recent months; some of
the exclusions have been removed, e.g., hernia, and they now pay from the first dollar
instead of only for accounts of $25.00 or more. The documentation has been simplified
by the adoption of forms similar to those used by M-S-A. The Executive Committee
re-affirmed its approval of the organization.
Page 5
It has been brought to the attention of the committee that quite a number of the
younger men now in practice in British Columbia are not aware of just what the
approved schemes are, and the terms of the contracts in each case. It was agreed that
a letter be prepared, giving the names of the approved organizations, the highlights of
the contracts in each case, and any other pertinent information available. These letters
are to be sent to each doctor in practice in British Columbia.
This letter will take some little time to prepare but it is anticipated that it should
be in the hands of the doctors in about a month's time.
(a) "Approval" is only given to schemes which fulfill certain requirements. When a
scheme is "Approved" the doctors of British Columbia, under present conditions of
agreement, agree to accept a 25 per cent discount on the minimum Scale of Fees in
force, and remuneration is paid directly to the doctor.
At the Committee meeting on September 16th, 1947, it was resolved that: "we are
in favour of the abolition of the 25 per cent discount on M-S-A and other approved
schemes." This information has been passed to the Board of Directors of M-S-A, with
the request that they study the cost involved and report. Preliminary reports suggest
that a considerable increase in the fees paid by employee members will be necessary to
abolish the discount, and particularly if the new 1947 fees for general practitioners
and for specialists are to be paid in full.
The 1947 Schedule of Fees for General Practitioners has not yet been adopted by
M-S-A or by other approved schemes.
The following schemes in the Province of British Columbia are approved by the
College of Physicians and Surgeons:
Medical Services Association
B. C. Electric Railway Co. Ltd. Office Employees' Medical Aid Society
Telephone Employees' Medical Services Association of British Columbia
The B. C. Provincial Government Employees' Benefit Society
B. C. & Vancouver School Teachers' Federation Medical Services Association
Cunningham Western Drugs Limited Sick Benefit Association
The Blue Cross (Associated Hospitals) is approved by the profession, but does not
enter into the field of payment for doctor's services.
A number of doctors have enquired recently about the manner of dealing with
patients insured with associations not approved by the profession. The following advice
is given which appears to cover the situation as it exists at the present time:
(a) Emphasize that the patient is responsible to the doctor for the bill incurred for
services rendered by the doctor concerned.
(b) The Insurance Company or Benefit Association is a third party only.
(c) Any money offered by the Insurance Company or Benefit Association is an
assistance to the patient in paying his bill.
(d) Some associations issue cheques to the doctor personally, some to the patient.
In either case statements under (b) and (c) still hold good. Jfpi
All doctors in British Columbia are requested to forward any comments, suggestions
or criticisms they may have regarding prepaid medical schemes, either approved or unapproved, to the Executive Secretary of the British Columbia Medical Association, who is
also Secretary of the Committee on Medical Economics. In particular we would like to
have any matters dealing with advertising by unapproved schemes.
Vancouver Medical  Association
Honorary Treasurer.
Honorary Secretary_
 Dr. H. A. DesBrisay
 Dr. G. A. Davidson
 Dr. Gordon Burke
—Dr. Gordon C. Johnston
 Dr. J. H. MacDermot
The City Hospitals (continued)
In February, 1894, came the long awaited resolution by the Health Committee:
"That a Women's ward be provided for." Forthwith there began the erection of a second
wing on the hospital grounds. Like the first, it was really a detached building linked to
the central frame one by a covered passage way. Like the other wing, too, it was constructed of a dark red brick, and, as may be seen from examining it, was entirely different in architectural construction from the orthodox hospital building of today.
At last the city had its long discussed women's ward. We are not certain of the
exact date on which it was opened to receive patients, but it was probably as late as
1897. In January of 1898 the Medical Board resolved that admission of female patients
to the newly-opened building should be limited to those of medicine and surgery. No
midwifery cases would be allowed. S The Board insisted that the inclusion of these would
be extremely dangerous and unwise. It would seem that the hazard of childbed fever,
so prevalent within the period of time covered by the memories of many of the staff,
made them cautious. No maternity cases were admitted to the City Hospital while it
was located on Beatty Street.
At a meeting held in May of that same year, the Board discussed the best ways of
utilizing space in the new building.    It was resolved,— ||||
1. That ward rooms for private cases should be reserved exclusively for women.
2. That so far as possible the building should not be used for chronic or incurable cases.
3. That a strong room should be placed in the basement to be used for D.T.'s and other
uncontrollable cases.
Throughout the 'nineties the nursing staff continued to grow in numbers. It still
had its living quarters in the hospital buildings where in 1898 it was thought to be of
sufficient importance to record that a bathtub had been installed for its use. It was in
March of that year that there took place an event of the first importance in its relation
to the Nursing Profession in Vancouver. At that time the Medical Board of the Hospital received a communication from Dr. McGuigan, Chairman of the Board of Health,
relative to the feasibility of establishing a training school for nurses in connection with
the institution. The suggestion was received with favour by the Board and acted upon
at once.    A training school was established forthwith.    In the August minutes of the
Page 7 Health Committee there appears an item to the effect that "Miss Pert, Acting Matron,
be permitted to engage temporarily a probationer nurse, at a salary of ten dollars a
month." This appears to have been the beginning of the system of pupil nurses in Vancouver.
Since at that time no maternity cases were being admitted to the hospital, the nurses
had to look elsewhere for that part of their training. In December of 1898 Dr. McEwen, the Resident Medical Officer, received a letter from the City Clerk that: "Permission is granted to send pupil nurses to the women's ward at New Westminster, for
obstetrical training; in exchange for nurses from there." This arrangement did not last
long. It was discontinued when Nurses Roycroft and Burgess opened their own private
maternity hospital in Vancouver, and took in City Hospital nurses for training.
With the completion of the second wing, the hospital now had a bed capacity of
between forty and fifty. This seems few enough for a city whose population had that
year—1898—reached 24,000 persons. But the institution was now sufficiently large
to warrant more modern equipment. A new operating room was erected at a cost of
$149.00. It,was also detached from the other buildings comprising the hospital, but
was connected with each by a covered passage way. A fee of five dollars was at first
charged for the use of the operating theatre, to include the anaesthetics and the first
dressings. This was soon increased to'ten dollars. As mentioned previously, it was
required that when an operation was booked for a certain day, the whole hospital staff
be notified, so that they might attend.
In 1900 an X-ray machine was installed at a cost of $300.00. It was put in by a
Mr. H. Hutchison, a Vancouver man who had some knowledge of Roentgen apparatus.
The first picture to be taken was that of the hand of Matron Clendenning. It is still in
the possession of the institution. The Resident Medical Officer, Dr. McEwen, was the
radiologist, the first in Vancouver. An extract from the Daily World, dated April,
1902, states that: "A sarcoma of the jaw is being treated by Dr. Poole, by X-rays. If
it succeeds it will mark a new era in medical practice in Vancouver." The first X-ray
machine to be placed in the private office of a medical practitioner in the city, was installed by Dr. Riggs about this same date.
Not until September, 1906, when the hospital was located in Fairview, was a new
X-ray machine required. It was at first placed in the care of the Pharmacist, Mr. A. S.
Faucett, for operation and care. The following year, however, all X-ray work was taken
over by Dr. H. H. Mcintosh, the newly-appointed Hospital Superintendent. In 1909,
Dr. Mcintosh resigned from the latter position and gave all his time as radiologist of
the institution.
Something in which at this time the Hospital Staff and the city as a whole, took
considerable pride, was the ambulance. This had been purchased in 1898 and was under
the control of the hospital. It was placed in charge of the Palace Livery Stable, owned
by a certain Mr. Sparrow. Here it was housed, and with horses standing by, was at all
times ready for immediate use. It might not be called out except by permission of Dr.
McEwen. The fee charged was three dollars a trip. By 1902 the old yellow ambulance
had become rather out of date. A patient complained that he suffered more during his
trip to the hospital than he did during the subsequent operation.
In April of this year the local newspapers announced with pride that a new ambu--
lance was coming; that it would arrive in the early summer, and that it was a beauty!
It was being built in Illinois, had pneumatic rubber mattresses, plate glass windows with
blinds which might be drawn, three silver conductor lamps inside, full coach gear,
Swedish springs, a leather driver's seat which would accommodate three persons, an 11-
inch gong on the dashboard, carriage lamps, large rubber tires, was painted green striped
with gold, and had "Vancouver General Hospital" in large letters on the sides.
The new ambulance arrived in due time, but the Board of Health Committee was
loath to accept the responsibility of managanig it. After standing for two months in
the livery stable it was finally put into use, the old ambulance being handed over to the
Page 8 City Council for use in transporting infectious cases. In spite of its modern equipment
and high polish, the new vehicle was for a time rather a joke with the citizens of Vancouver. A local paper contained the following item, dated October, 1902. 'Taking
forty minutes to go five blocks from the hospital to the corner of Granville and Hastings
Streets, the ambulance galloped up at fifteen miles an hour, after a man had collapsed
on the street. Half a dozen citizens pulled their watches to time it. A city policeman
said, 'I hope there are no newspaper reporters around.' When the man was loaded into
the ambulance a horse fell down. It got up and the other horse fell down. Then both
horses were down and refused to stir. Even when unhitched they still refused to move.
No coaxing nor whipping could budge them. Finally half a dozen young men pulled
the ambulance to the hospital."
Again quoting from a daily paper of February, 1903: "Complaints of the slowness
of the ambulance service continue to come in. A call was put in to the Palace stables
by the C.P.R. The ambulance took forty-five minutes to arrive. The driver walked
the horses and was in no definite hurry. He said: "This is no hurryup ambulance. We
have no patent harness and do not keep racehorses.' In 1910 the hospital ambulance
was handed over to the City Council.
Meanwhile, in the opening years of the new century there occurred two events which
were to have an important bearing on the destiny of the city's hospital. The first was
the incorporation of the institution under the name, The Vancouver General Hospital,
and the placing of its management under a Board of Directors. The second was the
decision to build a completely new hospital.
In each of these undertakings the Vancouver Medical Association played an important part. At its meeting in November, 1901, the following resolution was adopted by
the 23 members present: "That the management of the City Hospital be invested in a
Board of Governors independent of the Board of Health and the City Council, and that
a committee of the Association be appointed to consider what powers should be invested
in that Board." We shall see later what part the Society played in the selection of a
new site.
In May of 1902 the Provincial Government passed a bill authorizing the building
of a new City Hall in Vancouver, and its incorporation under the name of The Vancouver General Hospital, provided that a by-law approving the same be favourable voted
on by the people of the city. The voters endorsed the plan and a Board of Directors was
appointed pro tern by the Government. This Board took over control of all City Hospital property in December, 1902.
The need for increased hospital accommodation was made imperative by the rapid
rise of the city's population which by 1900 had reached 30,000. The first recommendation for such an increase came from Mayor Townley, who in February of 1901 addressed
the City Council on the subject. He suggested that additional hospital space be supplied by augmenting the present buildings by others to be built on the Beatty Street
grounds. The Medical Board considered the proposal, but their expressed opinion was
that the old site was not sufficiently large to permit of further expansion, and recommended that an entirely new hospital be built on the Cambie Street recreation grounds,
an area which has recently been taken over by the B. C. Electric Railway as a motorbus
terminal. Again the Vancouver Medical Association had very decided views on the
question, and at its meeting of November in 1901 referred to above, it insisted most
vigorously that neither location was large enough, and that an entirely new site be
chosen in the Fairview district. At the time this area seemed to be a long way from the
centre of the city. It was still a wilderness, covered by stumps. A lively controversy
was for a time carried on in the newspapers relative to the merits and demerits of the
three proposed sites, but in the end the Council accepted the proposal of the Medical
Society, and within a month it purchased from the C.P.R. a block of 5*/_ acres where
the hospital now stands.
Page? In September of 1903 tenders were called to excavate in preparation for the erection
of North East and North West wings of the new institution. The -former wing was
ready for occupation late in 1905. It was known as the Mount Stephen Wing, in recognition of a generous donation to the hospital by Lord Mount Stephen, at that time President of the C.P.R. Company. The North West wing, which was opened the following
May, was known as the Princess Christian wing.
By late December, 1905, with the exception of a few chronic cases, the patients
from Beatty Street buildings (forty-two in all), had been transferred to the new hospital. The older buildings were for a time used as an annex to the Fairview institution,
to house infectious cases, leaving some excess accommodation which was made use of
by the Children's Aid Society. By 1907 a series of small huts which had been erected
on the hospital grounds provided sufficient accommodation to house all infectious cases,
and the Beatty Street buildings were handed over to the city. For the succeeding four
years they housed what was later to become the University of British Columbia, at that
time known as the McGill University College of B. C. The three main buildings are
still standing. The frame one has been moved to a location farther south on Beatty
Street, which it now faces. As mentioned before it is now used as headquarters for the
labour organizations of the city. The brick buildings are used by the Social Service
The City Hospital in Fairview, henceforth to be known as The Vancouver General
Hospital, began modestly as a building which consisted of two wings, which housed six
wards. They are still known as A, B, C, D, E and F. By October of 1906 there were
101 beds available for use. Before building had begun it was necessary to clear the
site of stumps and standing timber. A deep ravine in which ran a small stream, cut
through the grounds where the Private Wards Pavilion now stands. Reference is made
to complaints about droves of pigs which wallowed in the mud of this ravine, at a time
when the hospital was in operation. They came from piggeries which belonged to persons who lived outside the city limits, the southern boundary of which at the time
ran along Sixteenth Avenue.
• •••*
■tints j|
It is the policy of the Division of V.D. Control to refer all requests for drugs for
cardiovascular syphilis to our specialist in cardiology. In order that appropriate treatment may be outlined, the following information should be supplied to the department
when drugs ar erequested:^
History of symptoms, physical examination, X-ray plates and screenings of the heart
and great vessels, electrocardiograms, urinalysis and the type and amount of treatment
already given.
If such examinations are not available in the locality where the patient resides,
arrangements may be made for this examination to be done by the Vancouver Clinic.
Enquiries should be addressed to the Director, Division of V.D. Control, 2700 Laurel
Street, Vancouver, B. C.
Page 10 British  Columbia  Medical  Association
(Canadian Medical Association, Britsih Columbia Division)
President 1 Z. ^.Dr. Lavell H. Leeson
President-elect _ Dr. Frank Bryant
Vice-President ! . Dr.  w". Laishley
Honorary Secretary-Treasurer j .Dr. J. C. Thomas
Immediate Past President Dr. Ethlyn Trapp
Another annual meeting has come and gone. In retrospect it appears to have been
a worthy successor to the many meetings of high standard in the past. About 450 doctors in all attended the various clinical sessions and social functions.
The visiting speakers were a well-balanced clinical team headed by our genial ffiend
Dr. Fred McGuinness of Winnipeg, President of the C.M.A. His "circus" consisted of
Doctors Mathewson, Trueman and Blair, each of which dealt in a masterly manner with
their specialty, the complete "circus" being guided by Dr. A. D. Kelly, Assistant Secretary of the Canadian Medical Association, who was on hand in Dr. T. C. Routley's
unavoidable absence in Europe.
In addition we had the privilege of hearing one of the younger up-and-coming
pathologists of Canada, Dr. G. Lyman Duff of Montreal; and the former head of the
Department of Otolaryngology of the University of Manitoba, Dr. E. J. Washington.
Although not on the prepared programme, Dr. William Boyd kindly consented to
conduct a Clinical Pathological Conference at the Vancouver General Hospital, which
was highly successful and probably held the record for the week so far as attendance
is concerned.
The public meeting on "Cancer" was a huge success, under the able chairmanship of
Dr. C. W. Prowd. Dr. Blair, of the Canadian Cancer Institute, was the principal speaker.
Platform guests included prominent persons in the field of cancer control. Nearly a
thousand people crowded the ballroom and apparently really enjoyed the proceedings.
The meeting went with a swing, getting off to a good start right on the dot at 8 p.m.
and finishing on schedule.
On the executive side a large amount of work was accomplished. The Joint Committee on Medical Economics met all day on Tuesday the 16th, revising the specialist
schedule of fees, and also went on record as in favour of the abolition of the 25% discount for M-S-A and other approved schemes. The annual meeting of the College was
held on Wednesday night and was well attended. A real highlight was the annual
meeting of The British Columbia Medical Association on Thursday. The chief matter
under discussion was our stand in relation to the establishment of a medical school in
British Columbia. After full discussion the stand of the physicians as already published
in the press was re-affirmed, and the report and action already taken by the Committee
on Medical Education was endorsed.
The official luncheon and the annual dinner, both ladies' and men's, were highly
successful. Over 200 doctors attended the luncheon and 215 attended the dinner. The
ladies' tea at Shaughnessy Golf Club attracted a large number and nearly 100 ladies
attended their dinner. Professor F. H. Soward, Professor of History and Director of
International Study of the University of British Columbia, was guest speaker at the
Annual Dinner. His learned address on "The International Outlook" was much appreciated and probably more markedly so because it was not dealing with scientific medical
Page it A word should be said about the various suggestions for next year which One heard
from a number of sources. First, that it would be perhaps agreeable to try to hold a
combined banquet for a change, and secondly that the exhibitors should not be in the
main lecture hall.
The Committee on Programme is to be congratulated on a well-run and highly successful Annual Meeting.
Now that I have turned over the reins of office to my successor, may I keep you
here just a little longer while I make a few valedictory remarks. Our last annual meeting was held at Banff in the spring of the year. It was a hurried meeting, following that
of the College of Physicians and Surgeons, and neither Dr. Meneely, the retiring President, nor I myself had an opportunity for more than the briefest of remarks.
Our membership has been growing rapidly until now there are 1407 doctors in the
Province. Through the years the affairs of both the College of Physicians and Surgeons,
and of the British Columbia Medical Association have been assuming an ever increasing
importance, so that your officers have come to feel tha'j each body should have a complete evening for its annual meeting. It would also seem suitable that the retiring president have opportunity to summarise the events of the year, and I frankly welcome this
First, I must tell you how deeply I have appreciated the honour of being your president, and since I haven't the art to find the words equal to my feeling on this occasion,
I am going to use those of the late MacNeile Dixon in introducing his Gifford lectures
and recently quoted on a similar occasion to this, by Dr. Smithers of London: "If it be
said, and it is no more than the truth to say, that I owe my position here to the friendship of my colleagues, I would wish this to be added, that I take more pleasure in the
regard of my friends than in any honour that could be done me."
Recently I have been going over some of the early medical history of thel province
compiled by the Committee on Archives, now under the Chairmanship of Dr. Kidd. It
makes very interesting reading and I take pleasure in bringing it to your attention.
There is among other articles, a short monograph by the late Dr. A. S. Monro, which
is particularly entertaining, dealing as it does with political as well as medical history and
ranging from the time of the landing of Captain Cook at Nootka in 1778 to the years
following the First Great War.
One might say that the B. C. Medical Association was born in 1850 when Dr. James
Helmcken, a surgeon to the Hudson Bay Company, arrived at Esquimalt and there met
Dr. Alfred Benson, who had a short time before come from England—where two or
more doctors are gathered together, there exists the nucleus of a medical society. It must
have been an exciting reunion for these first two medical practitioners in B. C, for they
had worked together in London and graduated at the same time from Guys.
Though more doctors continued to arrive each year, the first medical meeting recorded was in 1885. This was held at Victoria and was attended by Doctors from New
Westminster, Vancouver, Nanaimo, Cowichan, as well as Victoria. It was called for the
purpose of bringing some sort of order into the then chaotic condition of medical practice in the province, and from this beginning a British Columbia Medical Sqciety was
organized within the year. One must remember that this was just at the end of the
Gold Rush period when people had arrived in droves from San Francisco and other places
south and east, all bound for the new gold fields on the Fraser, and there were of course
among them the usual medical quacks and fly-by-nights. It is recorded that in 1858
alone, over 35,000 people arrived in British Columbia, practically all passing through
Victoria, causing, as one can well imagine, a fantastic upheaval in this small town of
only a few hundred inhabitants.
Page 12 The following years many more doctors came to the province, among them names
still well known; in reading over this early history, one is impressed by the important
part played by these early physicians in community affairs; for instance, Dr. Helmcken
was elected speaker of the first Vancouver Island House of Assembly and took a conspicuous part in the stirring political events of the day, leading as they did to the annexation of Vancouver Island to B. C, and later to Confederation with the Dominion. Dr.
Helmcken's work was by no means neglected for his political activities: it was said of
him that he was the leading physician from San Francisco to the North Pole and from
Asia to the Red River. Later, he, with other members of the Legislative Council, notably
Dr. Israel Powell, formulated the terms for Confederation with the Dominion.
It is also noteworthy that the Government of Sir John A. Macdonald offered the
first three B. C. Senatorships to three doctors: Helmcken, Powell and Carrall, names
perpetuated in our Vancouver streets. Dr. Helmcken's house, a few steps from the Parliament Buildings, has been taken over by the Provincial Government as a historical
monument. If you have not already been there it is a must for your next visit to Victoria.
It was not until 1900 that the first scientific meeting of the British Columbia Medical Association was held. It took place at the Parliament Buildings and the late Dr. R. E.
McKechnie, then of Nanaimo, was the first president. At that time Vancouver was just
fourteen years of age and had only three or four medical practitioners, men who had
found their way here in connection with C.P.R. construction work. Previously medical
service had been supplied from New Westminster.
From now on, except for a period during and just after the first world war, regular
annual meetings are recorded, though the fortunes of the Association have been subject
to great fluctuations. Dr. Cousland recently compiled a history of the Victoria Medical
Association and Dr. Kidd is now writing a series of articles on the medical history of
Vancouver. These are appearing in the Bulletin so I shall pass over the period from
1900 to 193 8, when we became the British Columbia Division of the Canadian Medical
Association. Since then we have functioned as an integral part of that great body while
still maintaining our own Provincial autonomy. We stand in much the same relationship
to our parent body as do the Provinces to the Federal Government except that, as Dr.
Wallace Wilson pointed out in his valedictory address, we do not depend on a British
North America Act to define authority, but are held together by the united support of
the Divisions. This support is happily maintained because of complete freedom and
frankness of discussion in Executive and Council, on which bodies all the Provinces are
represented. Under this united regime the C.M.A. has grown rapidly in stature, and
membership has increased each year. At the time of the last annual meeting in June of
this year the membership was 8,482, a figure never previously attained.
In our own Provincial affairs this has been an important year for the Association and
much has been accomplished. The reports of standing committees have been published;
those of yo_ who have read these reports and listened to the discussions will have some
conception of the tremendous amount of work that lies behind them and will be pleased
that Dr. MacDermot, the editor of the Bulletin, has paid tribute to the Chairmen and
members of these Committees for their unselfish service, and I would sincerely echo that
tribute. From these reports it will be evident to you that the real work of the Association is carried on through its Committees. One of the most important of these is the
Conunittee on Medical Economics. This year, the formation of a joint committee of
the College of Physicians and Surgeons and the British Columbia Medical Association
paved the way for effective action in the field of economics, with the result thati fee
schedules have been revised and prepaid medical care plans from across Canada have been
studied. Dr. Milburn and his committee are to be congratulated on an important accomplishment. Dr. Strong, as chairman of the Canadian Medical Association Committee on
Economics, has worked in close collaboration with the Provincial Committee. A four-
day conference on plans for prepaid medical care, held in Winnipeg last June at the time
of the Canadian Medical Association meeting, did much to clarify the uses as well as
the limitations of such schemes in relation to community health. Dr. Milburn again
Page 13
lit '..'• .*
.   . merits our thanks for taking over another important Committee, that on Medical Education, and in giving him this credit one does not forget the previous spade work so
ably done by Dr. K. D. Panton.
It is gratifying to have the Committee on Cancer in the able hands of Dr. Ddn
Williams, especially at a time of great potential activity, when the development of
nuclear energy has initiated a whole new era of research and opened up untold possibilities both for research and treatment.
You will all agree that the Programme Committee has done an outstanding job.
The scientific sessions are excellent. We are fortunate in having Dr. McGuinness with
us as one of our scientific speakers, as well as in his official capacity as President of the
Canadian Medical Association. We note with regret the absence of Dr. Routley and miss
him very much indeed, in spite of the fact that his duties are being so ably carried on
by Dr. Kelly. I cannot remember an annual meeting without the presence of Dr. Routley; his absence, however, is indicative of the esteem in which our Association is held
by the Government of Canada, for, as you know, Dr. Routley is representing them on
the Interim Commission of the World Health Organization, just come to the end of a
fortnight's meeting in Paris. In addition he is one of the delegates from our association
to the World Medical Association now meeting in Paris.
I shall not take your time by going over each Committee in turn but I should like
at this point to express my sincere gratitude to all their Chairmen and members. It seems
to me that this has been an outstanding Committee year and in spite of the fact that
through much of it there was jio Executive Secretary to call on for assistance. Now after
a gap of nearly six months Dr. Whitehead has come to fill the post and we cordially
welcome him.
You will know from the report of the Council of the College of Physicians and
Surgeons that a Benevolent Fund has been set up and that monies to the amount of
$16,020.00 have been handed to the three trustees, Dr. W. E. Ainley, Dr. D. F. Busteed
and Dr. A. J. MacLachlan, for investment, and disbursement as required.
As the retiring president I have one suggestion to leave for your consideration. It is
this: That an Advisory Council be set up composed of past presidents. This, I am told,
is done by other professional groups, and insures that experience gained by presidents
while in office remains at the disposal of the Association.
This need not be a very active body and would have no executive power—it could,
however, be very useful—for instance, in helping to solve problems that require a lot
of research of one kind or another, some will, no doubt, have come up in previous years
and been forgotten. It would also tend to maintain the interest of these retiring officers
in the Association—-an obvious mutual advantage.
Before going further, may I express my personal regret as well as that of the Board
of Directors at Dr. Lyon's resignation as First Vice-President. We had been looking
forward to having him as President of the Association. However, he is serving us well
as President of the College of Physicians and Surgeons and one can readily understand
his hesitation at taking on two such onerous posts.
As you all know, the B. C. Medical Association has under its jurisdiction the scientific and educational affairs of the profession in contradiction to the College of Physicians
and Surgeons whose duties are legal and financial. One of the important ways of carrying out our own particular duties is by trips throughout the Province. In the course of
the year it is customary for your President and Executive Secretary, with a team of
scientific speakers, to attend the annual meeting of each district society—some of these
being held in the autumn and some in the spring. A year ago, meetings were held in
Cranbrook, Trail and Penticton. At these meetings we were privileged to have with us
Dr. Archer, consultant on Economics o£ the C.M.A., as well as the scientific speakers.
Dr. Dave Johnson was sent by the D.V.A. and Dr. Caverhill, at that time our Executive
Secretary, was in attendance. Victoria and Upper Island meetings were also attended and
late this spring we made our way north to Prince George and thence to Prince Rupert.
Page 14 I do not believe that the importance of these district meetings can be overestimated,
discussions were free and frank, yet always friendly. We in Vancouver were accused of
being smug—perhaps we are, and perhaps we can be criticized for not giving as much
consideration as we might to the problems of men practising in smaller towns, and
especially in the isolated districts of the Province. This aspect of our Association affairs
should, I believe, be taken under consideration by the incoming Board of Directors.
In this connection, a panel of speakers has already been made available under the
committee on programme and finance, and we hope it will be widely used. It is one service that the Association is in a position to give, but the service should be requested
and it is desirable that speaker and subject be chosen by the district society. Speaking
personally, these trips through the Province will be some of the most treasured memories of my year as your President. Everywhere we were greeted with such warmth and
enthusiasm, and friendships made will, I hope, continue through the years. One came
away with a great respect for the skill and resourcefulness of those medical men who
have chosen to work away from the larger centres, but might I suggest that they themselves take a more active part in their own meetings. It is only fair that the exchange
of experience should be mutual and the meetings would be much more valuable for all
concerned by virtue of that exchange. In order to maintain and strengthen the status
of the General Practitioners, a Committee within the Canadian Medical Association has
been formed under the Chairmanship of Dr. Wallace Wilson. The possibilities ofclinical
research for the general practitioner and the certification of the General Practitioner as
such are under consideration. Dr. Wilson is known well enough in these parts for us to
be sure that anything he undertakes will be carried to a useful conclusion.
Too much emphasis cannot be put on the importance of membership in our parent
body. In British Columbia, it is entirely voluntary and we have felt it to be desirable
to keep it so. Dr. Saxton has done a splendid job as head of the Membership Committee,
but still a number of Doctors do not belong. Unity is of particular importance in these
changing times, especially with respect to the supplying of health services. As physicians, the main responsibility for community health is ours and we must play our part
in this reconstruction of medical practice which is developing so rapidly and without the
realization of many of us. The C.M.A. has been studying the matter for some years and
it has come to be the most urgent of the problems confronting the profession today.
The appointment of Dr. Archer as Medical Economics Consultant has helped to correlate
the activities of the Provincial Economic Committees, so that, in spite of the fact that
health is a provincial prerogative, we are gradually acquiring an over-all picture for the
Dominion. The following basic requirements for the improvement of health services
have been adopted by the Central Committee:
1. A full programme of preventive medicine.
2. Provision of an adequate number of hospital beds.
3. Provision of medical and allied services for remote areas.
4. Provision of diagnostic services  (laboratory and x-ray).
5. Full coverage for the Welfare group.
6. Improved standards of living.
7. Education:  (a) of the public, (b) of the medical profession.
These basic requirements are acceptable to all. The question is how to fulfil them.
The complexity of this problem of the people's health has become so great that one is
apt to become discouraged at the very thought of it. Dr. James Macintosh of Glasgow
says, "It is understood nowadays by doctors and laymen alike that this problem, the
Nation's health, goes far beyond the consulting room. It is the problem of the houses
we should live in, the food we should eat, the hours we should work, the habits we
should learn at school. To have a healthy community, we must get all t|hese things
right, and that gives us a social objective, linked with economic and political questions
of the deepest complexity. As in all other aspects of planning for the future, we find
that the health aspect is inseparable from the others."
Page 15. The conferences on economics at the last Canadian Medical Association meeting fully
demonstrated that organized medicine is more than anxious for the establishment of a
sound and adequate medical service for the people of Canada, but that is not enough;
we are living in a democracy, the people themselves must also want it, therefore they
must be educated as to what the requirements for such a service are. As physicians, we,
of necessity, must have a large part to play in this educational effort. In England, the
coming of government controlled medicine found a profession absolutely unprepared,
and the same thing has happened in nearly every country in the world where government schemes have been introduced. This has resulted in unfortunate conditions, both
for the public and the profession. In Canada, we still have time, but not so much, and
it is rapidly running out—the question is, shall we have the perseverance and the wisdom to impart this knowledge to our people? Before we can do this we must study the
question for ourselves. We must first have a vision before we can impart it to others and
in the words of the Old Testament proverb, "Where there is_no vision the people perish."
That vision must be both broad and intimate, it must embrace this one world of which
we almost overnight found ourselves to be citizens, it must also be part of the daily
round in our own particular community. In order to achieve this, both the doctors and
the lay public must take the trouble to really inform themselves about health services
and their implications. A rather frightening attitude of indifference on the part of many
reminds me of what Norman Cowin, the radio playwright, had to say, when he received
the Willkie One World Award. He was speaking of the man who would not interest
himself in public affairs, even those of his own community, let alone of his nation or
the world at large. This man, he said, is not even a fence sitter—at least the fencer-
sitter knows there is such a thing as a fence—he just floats in air like the prop in an
Indian rope trick. Panics, depressions, and wars come to him like weather. He suddenly
peers out of his window and says, "Look, it's warring."
Through the ages, the medical profession, above all others, has been able to transcend
. international boundaries and to our credit we are continuing to do so in this desperately
unhappy post-war world. Peace, although ushered in as it was by the release of nuclear
energy, seemed to promise so much. After two years of this so-called peace, we realize
what a misnomer it is for the state of the world today. Perhaps another term could be
found so that we need not continue to take in vain that beautiful word, with its associations of tranquility. How far away we are from that peace we have looked forward'
to. In 1771, a Frenchman, in a letter to Frederick the Great, remarked, "My instinctive
desire is for the accomplishment of this hope of peace, but it remains to be seen whether,
all things considered, it is a benefit for the sad human race to prevent it from self-'
destruction." Although that was said nearly two hundred years ago, today nuclear
energy makes that possibility an even more frightening one, because we are standing in
terror before a discovery whose peaceful development could promise untold benefits
to mankind.
The United Nations Organization embodies within itself our only hope of survival.*
It is a truism to say thati we must be one world or none, and yet the obstacles to this
unity seem to become more insurmountable month by month. Perhaps medicine is the
easiest sphere in which to attain international understanding, at least we haven't human
selfishness to overcome in the same degree as in the economic sphere; the more of health
and well-being a nation has, the better it is for the rest of the world, and conversely,
disease in one country is a potential danger to all others. With these considerations in
mind, the British Medical Association, just after the setting up of the World Health
Organizations, under the United Nations, sent invitations to the national medical associations of the world, asking them tx> take part in an international medical conference.
This took place just a year ago, out of it emerged the World Medical Association, whose
first plenary session is now being held in Paris.
The Canadian Medical Association-is represented at this meeting by Dr. Wallace
Wilson, Dr. Leon Guerin-Lajoie, both past presidents of the Association, as well as Dr.
T. C. Routley, our general secretary, and Dr. Donald Cameron, Deputy Minister of
Page 16 Nationl Health for Canada, thus the Canadian Medical Association has filled with distinction the four seats to which it is entitled.
The objects for a World Medical Association were drawn up at the first meeting in
London—you will find them enumerated elsewhere. The final all-embracing one is this:
"To assist all peoples of, the world to attain the highest possible standard of health."
This is also the avowed object of the World Health Organization, so working together
and within the United Nations the possibilities of accomplishment are tremendous: It
must be a source of deep satisfaction to us all that thus have the physicians of the world
lighted the proverbial small candle rather than curse the darkness, and in so doing signified their willingness to share in another attempt to shape man's destiny according to a
pattern of universal tolerance and mercy, fulfilling the vision of the good physician and
becoming, in the words of our own Canadian Medical Association code of ethics, "Planners of New Worlds, Counsellors of the people of a new day."
Obiit November, 1947
In the recent death of Dr. Fred Trousdale, the medical profession of Vancouver lost
one of its best men. Dr. Trousdale had practised medicine in Vancouver for a long
time, and had a large circle of friends. Quiet and unassuming, he devoted himself to
his work, and had a very large practice. He was fortunate that, beyond one or two
minor spells of illness, he was able to carry on continuously, and in fact, was busy up to
the day of his death.
Fred was a Mason, and a very keen one—and exemplified in his life the principles
of Freemasonry, which set a very high standard for a man to follow. He had at
various times occupied all the offices which pertain to the craft, and he had the confidence and affection of all the brethren. He will be greatly missed by all who knew
The annual meeting of the Southern Interior Medical Society was held in Revelstoke
on Friday, October 10th. Twenty-six doctors attended the clinical section in the afternoon, and about sixty people enjoyed a very sumptuous dinner in the evening.
Interesting and instructive addresses were given by Dr. Rocke Robertson, on "Acute
Obstruction in the Small Intestine," and Dr." A. W. Bagnall, on "Rheumatoid Arthritis."
At the business meeting of the Society, the following officers were elected:
President: Dr. H. Campbell-Brown, Vernon; Vice-President: Dr. W. A. Drummond,
Salmon Arm; Secretary-Treasurer: Dr. Wm. Finlayson, Vernon; Representative to B.C.
M.A.: Dr. H. Campbell-Brown; Representative on Committee of Economics: Dr. W. H.
White, Penticton.
The 1948 annual meeting of the Society will be held in Vernon, B. C.
After the banquet, Dr. Lavell H. Leeson, President of the British Columbia Medical
Association; Dr. E. J. Lyon, President of the College of Physicians and Surgeons; and
Dr. F. L. Whitehead, Executive Secretary, presented short papers on current events in
organized medicine in the Province.
As an added attraction Dr. G. L. Watson, recently appointed Medical Director of
M-S-A, and Dr. D. W. Johnstone of D.V.A., attended the meeting representing their
respective organizations, and took part in the proceedings briefly.
The committee in charge, Dr. A. Llewlyn Jones and Dr. H. E. Hamer, are to be congratulated on the excellence of their arrangements for the meeting.
A regular meeting of the Upper Island Medical Association was held at Crayharven
Inn, Parksville, on the evening of Wednesday, October 15 th. A very pleasant dinner
was indulged in followed by the regular business meeting, under the chairmanship of
the President of the Association, Dr. H. A. L. Mooney, with the able assistance of Dr.
E. R. Hicks, the Secretary.
After the regular business meeting, short addresses were given by: Dr. Lavell H.
Leeson, President of The British Columbia Medical Association; Dr. J. C. Thomas,
Honorary Secretary-Treasurer of The British Columbia Medical Association, and Dr.
F. L. Whitehead, Executive Secretary of the College of Physicians and Surgeons.
Dr. W. W. Simpson gave a very interesting discourse on the recent concept regarding
the mechanism of diabetes, which was followed by a surgical paper on "Injuries of the
Hand," by Dr. G. H. Grant of Victoria.
About thirty doctors attended this meeting, which was well organized and very
The Annual Meeting of the East Kootenay Medical Association was held in Cran-
brook on Tuesday, October 21st.
A clinical programme of high merit was given in the Nurses' Home of St. Eugene
Hospital in the afternoon, at which Dr. J. C. Thomas spoke on epilepsy. Dr. Ross
Robertson discussed recurrent dislocations of the shoulder and Dr. R. A. Palmer gave a
paper on acute renal suppression.
An enjoyable dinner was held at the Cranbrook Hotel in the evening, and this was
followed by the regular business meeting at which the following officers were elected:
President, Dr. M. McRitchie, Fernie; Vice-President, Dr. J. Hazard, Kimberley;
Secretary-Treasurer, Dr. C. W. Brockington, Cranbrook; Representative to the B.C.M.
A.: Dr. F. W. Green, Cranbrook.
It was decided that the Annual Meeting next year will be held in Kimberley, B. C.
The Annual Meeting of the West Kootenay Medical Association was held in Nelson
on Wednesday, October 22nd.
The same team of clinical speakers who visited Cranbrook the previous day, addressed
the meeting in the afternoon.   There was lively discussion after each address.
Dinner was served in the hospital, after which the regular business meeting was held
when the following officers were elected for the ensuing year:
Honorary President, Dr. W. A. Coghlin, Trail; President, Dr. Wm. Leonard, Trail;
Vice-President, Dr. R. B. Brummitt, Nelson; Secretary-Treasurer, Dr. W. Laishley,
Nelson; Representative to the B.C.M.A.: Dr. Wm. Leonard, Trail.
At both of the above meetings Dr. Lavell H. Leeson, President of The British
Columbia Medical Association, and Dr. F. L. Whitehead, Executive Secretary of the
College of Physicians and Surgeons, gave short addresses.
Dr. J. L. Watson, Medical Director of M-S-A, and Dr. D. W. Johnstone, representing
the D.V.A., were present at the meetings and both spoke briefly and answered a number
of queries.
Preparations are now being made to publish the new, Eighteenth Edition of the
AMERICAN MEDICAL DIRECTORY! The last edition of the Directory was issued
late in 1942. Since that time, it has been impossible to publish a new edition because of
wartime restrictions and the shortage of paper and labor.
About November 15, a directory card will be mailed to every physician in the United
States, its dependencies, and Canada, requesting information to be used in compiling the
new directory. Physicians receiving an information card should fill it out and return it
promptly whether or not any change has occurred in any of the points on which information is requested. It is urged that those physicians also fill out the right half of the
card, which information will be used exclusively for statistical purposes. Even if a
physician has sent in similar information recently, mail the card promptly to insure the
accurate listing of his name and address. There is no charge for publishing the data nor
are physicians obligated in any way.
The Directory is one of the most important contributions of the American Medical
Association to the work of the medical profession in the United States. In it, as in no
other published directory, one may find dependable data concerning physicians, hospitals,
medical organizations and activities. It provides full information on medical schools,
specialization in the fields of medical practice, memberships in special medical societies,
tabulation of medical journals and libraries, and, indeed, practically every important fact
concerning the medical profession in which anyone might possibly be interested. ,
Therefore, should any physician fail to receive one of these Directory Information
cards by December 1, he should write at once to the Directory Department requesting
a duplicate card be mailed.
K. R. TRUEMAN, M.D., M.Sc.(Minn.)
Winnipeg, Manitoba
Division of Surgery, Winnipeg Clinic, Winnipeg, Manitoba
The surgeon of today is in a stronger position than his predecessors whose fine technical skill he has inherited. This is so since there is now available knowledge and information which has resulted from the extraordinary advances made in recent years in
clinical and laboratory research. As a result, the surgeon is learning that, in order to
achieve success in the care of serious conditions, he must apply more and more comprehensive measures. It is accepted that certain surgical diseases, once they are well established, affect in various ways the whole organism. Thus infection, nutritional disturbances, increased metabolism and tissue damage may produce marked physiological and
bio-chemical disturbances. The fuller understanding of these secondary effects and the
means to correct them forms the basis of safe, modern surgery. The surgeon must
remain alert to their possibility and to the increased risk to the patient when they are
not corrected. In order to meet these fuller problems, the surgeon must adopt a total
surgical plan. (Fig. 1.) Just as a nation involved in modern or total warfare must
mobilize all its material and human resources, so the surgeon must make use of all the
means at his disposal. No longer can emphasis be placed chiefly upon technical skill to
eradicate disease and provide a successful issue while it is hoped that the patient possesses
the necessary vital reserves to match the inroads of his illness and the burden of the
operation. Over-concentration on the operative or mechanical phase almost to the neglect or exclusion of other important phases has been the cause of many failures or at the
best, incomplete recoveries.
Every case deserves the most careful general consideration. There should be no
shortcuts in the history taking or physical examination or the performance of routine
blood and urine analysis. It is advocated that all patients undergoing surgery of some
moment receive an x-ray examination of the chest. On the public wards of our teaching
hospitals in Winnipeg we freely seek and receive consultation on our patients from the
medical departments in the matter of the status of their cardiac, pulmonary, and renal
function. In our own group practice among private patients the same principle is
followed. It is based upon the understanding that time and knowledge are limited and
proper surgical ability does not always mean equal medical acumen. The result provides
a more complete picture of the patient's general position and a greater familiarity with
his weaknesses and provides protection for him in the ordeal he is to undergo.
In this discussion, which deals with the preparation of the patient for surgery, some
of the major therapeutic measures available to reduce morbidity and mortality in a great
variety of pathological states will be considered. Specifically, I wish to refer to the
problem of dehydration, malnutrition, avitaminosis and anaemia.
I. DEHYDRATION. This condition may exist in patients who have been unable
to take fluids for a few hours as well as in those who have suffered a marked loss of
weight over a considerable time because of illness. It becomes a distinct certainty where,
in addition to failure to take food and fluid, there are abnormal losses by vomiting,
diarrhoea, a faecal fistula or excessive sweating. The clinical picture is well known. In
the absence of renal disease the urine will be scanty and concentrated. Estimation of
the blood or constituents of the plasma may be misleading in moderate to severe dehydration because of falsely high readings due to concentration. It has been demonstrated
by Maddock and Coller on the basis of human experiment that when an individual is
dehydrated clinically he is lacking fluid equivalent to six per cent of his body weight.
(Fig- 2.)
Page 20 WM When the intake of fluids orally is partly or wholly impossible, intravenous administration is usually employed. For those patients depending upon this manner for their
fluids, a* minimum of 3000 cc. daily is required. This permits a normal loss of 1000 to
1500 cc. by kidney excretion which is necessary for the elimination of waste products,
while another 1000 to 2000 cc. are lost ordinarily for decompressing the gastro-intestinal
tract or external fistulas, the replacement of these amounts as accurately as possible is
indicated. Thus a continuous gastric suction will remove 1000 cc. or more of secretion
in 24 hours. Estimation of the amounts lost may be determined by a careful collection
of such fluids or by the daily accurate weighing of the patient as advocated by Wan-
One of the chief problems in intravenous fluid therapy involves the quantity of
sodium chloride to be given. There has been a distinct tendency for the routine use of
saline in all parenteral administration of fluid without regard to whether sodium chloride
is needed or not. There are serious drawbacks to such a practice. Thus it is known
that the body's requirements for sale are not more than 7 gms. daily. Salt given in
excess of this amount cannot be excreted by the kidneys, and there follows a diminution
in renal function and a retention of waste products as evidenced by the reduced urine
output and an elevated blood urea nitrogen. More subtle may be the oedema in the
tissues, including the lungs, due to chloride retention, which will delay wound healing
and cause obstruction at gastro-intestinal anastomoses. Therefore, apart from providing
salt for normal requirements and what may be lost through suction, etc., great care must
be employed to avoid the too free use of chloride over lengthy periods in the pre-operative
phases. Rather it is better to revise the salt requirements downward than to give in
In order to overcome dehydration and yet have satisfactory renal secretion, a solution of 5 per cent glucose in distilled water can be used over and above what is given as
saline. The glucose not only provides some osmotic effect, but it is a source of nutrition.
However, as the body can metabolize only 10-12 grams per hour, it must be given
slowly or glycosuria and diuresis develop, thereby reducing the number of calories available, and the undue loss of water may have an ill effect upon the already dehydrated
patient. Examples of this are seen daily in urinalysis showing sugar following intravenous adniinistration. In addition, the slow administration offsets the very definite
hazard of overloading a weakened cardio-vascular system.
II. MALNUTRITION. In recent years the problem- of malnutrition and its correction in the surgical patient has been brought increasingly to the attention of the
surgeon. It involves chiefly a deficiency of proteins in tissues due to a relative or absolute reduction of food intake over a relatively long time.
Proteins of the diet are reduced in digestion by pancreatic trypsin and other enzymes,
and are generally absorbed as amino acids. In this form they are available for the
synthesis of body protein, for gylcogen, for storage or combustion, by deaniinization in
the liver, and finally for synthesis into other essential nitrogenous compounds. When
the subject is fasting, the bodyfs supply of glycogen and fat is converted to supply
energy. As they are consumed, protein is converted into glycogen to meet the body's
needs. This conversion or deaminization is a liver function and one in which the liver
is sacrificed as well as other tissues, yielding as it does a large part of its amino acids.
Where measures are being employed to treat protein deficiency, an important principle
to remember is that sufficient additional calories in the form of glucose, or fat where
food is taken, must accompany protein therapy to meet energy requirements. Otherwise part or all of the protein administered will be converted to glycogen for energy, and
very little will be available for the manufacture of cellular protoplasm or the constituents of body fluids.
In malnutrition or protein deficiency, the following effects take place.
1. Wasting. Because of lack of proteins (and lack of calories), gross or subclinical
wasting occurs. This is revealed by progressive weight loss in spite of adequate hydra-
Page 21
,;*' V
mm tion.    Muscular tissue exhibits this, but the liver yields 40 per cent of its protein as
compared to an 8 per cent loss by muscular tissue.
2. Oedema. Should this occur without obvious cardiac or renal disease, the question
of dietary origin must be raised. The oedema of starvation may be considered as due to
hypoproteinemia because of the relation of osmotic pressure to hydrostatic pressure. The
cedema in wounds and gastro-intestinal stomata may be due to protein deficiency as well
as to excess of chlorides.
3. Anaemia. As haemoglobin is composed of the iron containing pigment, haemo,
and a histone protein, globin, adequate supplies of protein are necessary for proper blood
It has been shown by Whipple that haemoglobin may be deprived of its globin in
protein depleted states.
4. Antibody Formation. The work of Cannon and others reveals that proteins are
necessary for antibody formation and it is the serum globulins which contain the antibodies. Although the total requirements for antibody production must be small, nevertheless, the competition in the poorly nourished subject is intense. Therefore protein
deficiency may be a factor in reduced antibody formation.
5. Susceptibility to Liver Damage. It is known that the liver gives up large amounts
of its protein in fasting states and it has been conclusively shown that proteins are necessary to protect the liver from damage. Hence the liver becomes increasingly suscp-
tible in protein deficiency.
6. General Effects. These may be subtle and general. One of the most important
of these in anorexia, which further influences an inadequate protein intake. Other*
effects include mental irritability and lassitude and unwillingness to undertake muscular
activity as may be noted in the convalescent phase of any illness.
7. Failure of Wound Healing. The problem of delay in healing of decubitus ulcer,
burns, and wounds and disruption of wounds is closely related to protein deficiency. No
doubt such a deficiency adds to the oedema at the sites of stomata and incisions and is
partly responsible for failure of healing. Excess chlorides and a deficiency of Vitamin
C are further important factors in healing.
8. Hypoproteinemia. Plasma proteins have assumed increasing importance in clinical practice partly because of their accessibility and ease of estimation. However, in
diagnosis the reduction of the value of the plasma proteins is a late manifestation of
general protein deficiency since their relationship to body proteins is not constant under
all conditions. Plasma proteins in early deficiency are maintained at the expense of other
tissues. Conversely, in the recovery phase the plasma proteins return towwards normal
on a high intake before tissue requirements are met.
Diagnosis of Protein Deficiency—Diagnosis of this condition obviously in most
scientifically done by accurate nitrogen balance estimations. This is, however, tedious
and time-consuming, and is best left to the field of investigation. Clinically, the diagnosis is based upon observation and prediction. The situations in which protein may
be lacking are known, and so in a given case the deficiency can be predicted at least
qualitatively. The estimation of weight and tissue loss is an integral part of clinical
sense and is a valuable guide to therapy. When means are available, the repeated estimation of the various plasma protein factors is important especially when dehydration
is being corrected, since the readings will be falsely high due to concentration and will
vary downwards as fluids are restored. Attention should be directed to the value particularly of albumen.
The Occurrence of Protein Deficient States—In gastro-intestinal disorders such as
carcinoma of the stomach or stenosing peptic ulcers in which anorexia and vomiting may
be present, there is almost invariably some degree of protein deficiency.
In thyrotoxicosis there is gross wasting which is associated with liver damage and
requires diets of 5-6000 calories, with a high protein element for control.    It is well to
Page 22 mention the work of Co Tui in the treatment of peptic ulcer with high protein diet.
The rationale of this method does not depend upon control of gastric acidity, but it is of
value because patients with chronic ulcer often have a long history of a protein deficient
diet. The Sippy diet is low in protein, and in some other diets meat is prohibited. This,
together with loss of appetite, vomiting, and perhaps haemorrhage, should easily deplete
the body proteins. Thus it is quite reasonable that the high protein Meulengracht diet
should be successful in the therapy of ulcers associated with bleeding. Certainly high
protein diets have an important place in ulcer treatment.
In diseases associated with rapid passage through the intestinal tract, as in ulcerative
or amebic colitis, there is often impaired digestion and absorption of protein. In addition, there is protein loss from the ulcerating lesions of the mucosa. It is felt that the
greatest contribution to the medical care of sufferers from these diseases is the availability of a satisfactory diet to maintain tissue protein reserves. In febrile atrophy
associated with a severe fracture, burns, and other open lesions, the so-called "toxic
destruction" of protein occurs. In such conditions tissue protein is rapidly consumed,
and this loss is estimated as high as 1 per cent of body protein per day.
Protein Nutrition of Hospital Patients—As our interest in this problem developed,
an inquiry was made into the dietary standards of the Winnipeg General Hospital.
Theoretically, the ward diet was a satisfactory one. In the ordinary ward diet, an
attempt is made to provide 70 grams of protein per day to the patient. It was a matter
of concern, however, to observe the very large amounts of food left on the trays by
patients, especially of meat, milk, bread and butter. On inquiry, many reasonable explanations were forthcoming, but no satisfactory solution. In patients preparing for
surgery or convalescing from operation or serious medical illnesses, even if the whole of
the diet were taken it did not provide the extra grams of protein required not only to
maintain tissue but to repair the ravages of trauma, fever and fasting. The provision
of a high protein diet containing 100 grams or more of protein was more useful when
the patient would take it. Certain factors do prevent a proportion of patients from
handling their diet. A more readily assimilated form of nourishment was needed to
supplement ordinary oral diets. For years jejunostomy diets, high in calories and protein, had been used as drip feedings in special cases. More recently, we have used the
Casec drink but find it seems to satisfy the patient's appetite so that his regular diet is
only partially consumed. The reason for this, it is felt, is that Casec drink contains a
very large proportion of fat (104 grams in one quart) which would cause it to remain
in the stomach for a long time. We make use, therefore, of a formula suggested by
Doctor Jessie McGeachy of Winnipeg. (Fig. 3.) This formula contains less fat but
ample protein. The patients tolerate it well, and it does not appear to affect the appetite
unduly. It is suggested, however, that a glass be given soon after a meal in order to
allow the stomach to empty, and at bedtime. For ulcer patients it can be used for
interval feedings.
Such a preparation supplemented with further protein, fat, and glucose to which
are added vitamins and salt, can be used for tube feedings. The use of continuous drip
feedings by a gastric catheter fitted with a Murphy drip, is of great value in feeding ill
patients whose anorexia prevents the ordinary use of food. Post-operatively, it may be
employed where it is unwise to introduce even moderate amounts of material into the
stomach, and its administration can be controlled to meet the patient's tolerance.
Finally, certain cases undergoing preparation for surgery will not tolerate oral diets
of any kind. Some of these patients may be suffering from extreme protein deficiency.
To correct this state with large quantities of plasma or blood is expensive and requires
many donors. Thus 500 cc. of plasma representing two donors contains only 30 grams
of protein, or what is found in three glasses of milk. Amino acids are now available tor
intravenous administration. Some of these preparations contain 50-60 grams of ammo
acids in a litre of distilled water, and at least one (Amigen) contains 50 grams of dextrose.   This addition makes therapy easier, since a high caloric intake is assured to spare
Page 23
M amino acids for protein synthesis. Two or three litres of this amino acid-carbohydrate
combination may be used daily provided it is given slowly. In this manner, sufficient
amino acids to meet the average maintenance requirement of one gram of protein per
kilogram of body weight per day are provided, plus an additional amount to care for
existing protein deficiencies, while fluids are maintained. Sufficient sodium chloride is
not included in the amino acid preparation to equal body needs. Therefore, it must be
provided by separate administration in whatever quantities are indicated.
Where the preparation is lengthy and requires two to three weeks, and if the condition is critical, the addition of whole blood to provide red blood cells once or twice a
week is advisable. Much time and consideration must be given the preparation in the
serious case where surgery can be delayed. Patience and forbearance will be rewarded by
a smoother post-operative course if a vigorous nutritional programme is pursued.
Avitamhtosis — This condition will exist in malnutrition or in cases treated for
lengthy periods parenterally. When present, it is usually a multiple vitamin deficiency.
It has also been shown recently that vitamin requirements are increased in the presence
of fever, trauma and elevated metabolism. The function of the liver is seriously impaired if thiamine chloride (Bi) is not available. This possibility can be averted by
administering the vitamin along with other B factors orally or parenterally. Ten to
fifteen milligrams of thiamine chloride daily is indicated. Vitamin C, which is so
important in wound healing and in maintaining capillary impermeability, should be
provided in doses of over 300 milligrams. Vitamin K for prothrombin formation should
never be overlooked in gastro-intestinal and biliary tract surgery. It has perhaps not
been a common experience, but we have had several cases of colostomy closure followed
by severe bleeding. Prothrombin estimation indicated avitaminosis K, because we had
failed to remember the vitamin is absorbed from the diet in the colon, which in these
instances had been defunctionalized for long periods.
Anaemia—This state may occur as the result of prolonged fasting due to disease or
loss of blood due to trauma or a major operation. In malnutrition, if time permits, the
anaemic state will be corrected as the deficiencies are met with proper diet supplemented
by iron. If surgery is contemplated, the condition will be more speedily treated if 500
cc. of whole blood is administered every 2-3 days, until the blood is at a suitable level.
With a haemoglobin below 75-80 per cent, a serious operative procedure should not be
undertaken unless the anaemia cannot be corrected or the operation cannot be delayed.
It is now, or should be, generally accepted that increasing success in major operations
depends upon the prevention of shock during and after the operation. Nowhere in
modern medicine can the principle of teamwork be evidencd as well as in the operating
theatre where a modern anassthtist is present. His training, as well as his new methods
of anaesthesia, permit him to remove much responsibility from the surgeon. The possibility of shock is usually met by the administration of fluids which begins with the
anaesthetic. The changes in the patient's condition, because they are anticipated, are
rarely permitted to continue without early means taken to correct them. Blood should
always be available, and if a blood bank is maintained, it should be used freely if the
patient's condition warrants it. In the performance of extensive resections in gastrointestinal or biliary tract disease, or dissections elsewhere, at least one or two pints of
whole blood should be in the theatre and the transfusion should continue after the
operation if the patient's condition appears unsatisfactory. It has been shown that very
substantial losses of blood may occur without recognition during even moderate procedures, and a definite anaemic state is present on the return of the patient to the ward.
The use of blood as a supportive measure has become a "must" in major surgery.
Its use has protected may during lengthy and risky undertakings. The incidence of
shock has been practically eliminated by the freer use of blood or plasma during and after
major surgical procedures. There can be little doubt that the experience of military
surgeons will demand that blood be available for their civilian patients, and that measures
will be sought in even the smaller rural hospitals to provide for such needs. It might be
Page 24 almost reasonable to argue that the major operations should not be performed where
facilities for providing transfusions are not found.
In conclusion, the great advances in surgery over the past twenty-five years and the
progress into newer fields is attributable to a very large degree to better preparation of
the seriously ill patient, based upon a more complete understanding of the nutritional,
bio-chemical, and physiological upsets which attend major surgical lesions. Fortunately,
the means are becoming increasingly available to correct them.
Figure 1
1. Investigation Phase.
2. Pre-operative Phase.
3. Operative Phase.
4. Immediate Post-operative Phase.
5. Rehabilitation Phase.
6. Follow-up Phase.
Figure 2
Body Weight 6 Per Cent
10 Kg., or    22 lbs._ .  600 cc.
20 Kg., or    44 lbs |  1200 cc.
60 Kg., or 132 lbs  3600 cc.
80 Kg., or 176 lbs.,  4800 cc.
40 oz. milk
60 gms. skim milk
2 eggs
60 gms. sugar
36 gms. cocoa
P. -    76 gms.
Totals:      F. -    72 gms.
Totals calories 1600
CHO - 162 gms.
Figure 4
Skim Milk Powder
100 gm.
60 gm.
Brewer's Yeast
20 gm.
Orange Juice
3 oz.
8 oz.
Evaporated Milk
14 oz.
40 oz.
(Cals. 3774)
2 quarts
Page 25 Vohx&uaj&l QenetoU cttoAfuicd
R. W. BOYD, M.D.
Department of Radiology
Vancouver General Hospital, Vancouver, B. C.
Unlike animals or birds, man consistently has a gall bladder but the explanation of
its function in the normal and diseased state is as inconsistent as the extreme developmental variations in animals. Radiological information regarding the gall bladder is no
exception and the following is a discussion of two of the least understood aspects of
"What is one to infer from a cholecystographic report that a gall bladder 'fills poorly,
incompletely, shows delayed or increased emptying time'?" Cholecystography involves
the use of a substance which is eliminated in the bile via the duct and the gall bladder.
The substance is concentrated in the gall bladder until the organ becomes of such density that it may be clearly visualized on an X-ray film. Following a meticulous technique the examination may be most accurate. A dense filling followed by a prompt
emptying, non-filling or visualization of calculi, presents strong evidence of a normal or
diseased biliary tract.
The gall bladder examination developed by Graham and Cole in 1924 was the outcome of the knowledge that phenolphthalein dyes were secreted by the liver, with the
eventual development of the well-known drug tetraiodophenolphthalein. Recently a
new product, diodophenyl-proprionic acid has been replacing the phenolphthalein drug.
The former has not the drastic purgative or nauseating side effect of phenolphthalein.
The new dye is administered in a tablet form. It results in fewer and milder reactions
and it is rapidly and completely absorbed. It does not leave confusing radiopaque
shadows in the gastro-intestinal content.
It is unnecessary to prepare freshly made solution to administer the diodo-proprionic
acid.pftThe gall bladder shadows are said to be of better diagnostic contrast. The new
drug is marketed under the trade names of Biliselectan, Phenoidal, Priodax and Dikol
and is rapidly replacing the other preparation. Diodo-phenyl-proprionic acid cannot be
given intravenously, as it causes excitement, respiratory stimulation and convulsions.
The significance of "pale" gall bladder shadows and "delayed emptying," is only
understood by a knowledge of each step leading to shadow production and disappearance
during roentgen gall bladder studies.
1. Sufficient dye must be given. It must be freshly suspended in the case of iodo-
phenolphthalein. Vomiting may occur and is often unreported. Much of the drug may
remain in the glass. Double and triple doses have been found necessary with tetra-
iodophenalphthalein in order to be certain of adequate absorption.
2. The absorption from the gastro-intestinal tract may be influenced by many factors.
For example the high acidity associated with peptic ulceration lowers the pH of the
intestinal content, changing the soluble tetraiodophelphthalein into the non-absorbable
insoluble compound. This would predispose to a faint filling or a non-filling. Diodo-
proprionic acid is said to be unaffected by high gastric acidity. Pernicious anemia, carcinoma of the stomach or pyloric stenosis may inhibit absorption.
3. The liver must be capable of transferring the iodine molecule from the blood to the
bile. Cholecystography originally developed from a liver function test and parenchy-
Page26 matous liver disease, replacement or toxic destruction of the liver cells, or impaired portal
circulation will diminish the amount of iodine entering the hepatic duct.
4. The hepatic duct must be patent.
5. The cystic duct must allow the bile to flow freely in either direction.
6. The gall bladder mucosa must be sufficiently healthy to absorb water in order to
concentrate the iodine in the gall bladder bile. About 2.5 mg. of iodine per gm. of
bile is required to produce a faint gall bladder shadow in the average adult. Nine mg.
per gram will produce a dense shadow. A gall bladder containing 50 c.c. of bile, to be
faintly visualized, would have to contain about 4 per cent of the iodine in the average
dose taken by mouth. The process of concentration may be studied by roentgen methods;
The faint shadow may be seen one to two hours following the intravenous injection of
the dye and the density may be quite marked after six hours.
7. The gall bladder must remain at rest and retain its bile for long intervals without
emptying or dilution.
8. The radiographic factors are most important. A gall bladder having a certain shape,
volume and iodine concentration will present a varying shadow density depending upon
its surroundings. In a thin patient it will be recorded as "dense" while in a stout individual it would be reported as "pale" or "poor filling."
A true faint shadow indicates some integrity of the mucous membrane. A pale filling also represents only a degree or a grade of function and one cannot be certain that
disease exists without repeated examination.
9. Gall bladder emptying requires preliminary stimulation. The hormone, cholecystoki-
nin, initiates an integrated propelling mechanism, correlating the action of the gall
bladder muscle and the sphincter of Oddi. Reduction of the gall bladder to at least a
miniature shadow or its complete disappearance within three hours, the greatest degree
of shrinkage being in the first hour, is generally accepted as normal.
An accelerated emptying time, as demonstrated by a rapid and pronounced disappearance of a dense shadow, associated with gall bladder tenderness and contractions
observed fluoroscopically, are considered indicative of cholesterosis or "strawberry" gall
bladder by Levene1. There is no doubt that patients have been subjected to cholecystectomy merely because they presented right upper abdominal complaint and roentgen
evidence of delayed emptying of the gall bladder, although the general examination
revealed no demonstrable cause for their symptoms. Delayed emptying of the gall
bladder is frequently reported as the so-called poorly functioning gall bladder without
stones. In many instances symptoms were unrelieved and histologically such gall bladders have proven to be normal. To attach such significance to the x-ray examination
infers a lack of completely established concepts concerning the normal physiology of
the biliary tract.
"Is not the Roentgen appraisal of so-called normal motor activity of the gall bladder
made under the most abnormal circumstances?" Consider one's own mental and physiological reaction, if after fasting for fifteen to twenty hours, one is ordered to swallow
five egg yolks mixed with half a pint of cream. This is routine procedure in cholecystography from which we are to expect a normal response. It would seem that this procedure, while of great scientific interest, is not indicative of the gall bladder function
conforming with routine dietary habits of the individual.
Dann and Koritschoner2 have attempted a study of the gall blaclder under normal
eating habits and their preliminary report is at least thought provoking. Their method
of study is as follows:—
1. From the out-patient's clinic individuals of different ages, sex and nationality are
selected, with no history, past or present, of abdominal complaint.
2. On the day preceding the roentgen examination the patient is instructed to abstain
from all fatty foods at lunch.
Page 27
).l 3. At four p.m. a dose of the tetraiodophenolphthalein is given. (Priodax is to be
used in future studies.) No food is taken until eight o'clock the next morning following
the x-ray examination.
4. The patient takes his usual breakfast and one hour later, films are again made.
5. Further x-ray studies are made one hour after each subsequent routine meal until the
dye disappears.    In the meantime the patient pursues his daily routine.
The findings in twenty-one patients were inconclusive but certain trends seem apparent. There was a wide range of normal emptying rate within twenty-four hours. Only
one case required forty-eight hours to empty although her meals contained ample fats.
A sixty-year-old man showed complete emptying after a breakfast containing no fat.
Two cases presented no appreciable contraction after breakfasts consisting of considerable
fat but emptying occurred after subsequent meals variable in fats. These facts (remembering that the experiment has been carried out on healthy persons with no abdominal
complaint), indicate the necessity for correlating such findings with those obtained with
the use of the conventional fat meal and the determining of the emptying characteristic
in people accustomed to eating large quantities of fats. It is hoped that the effects of
such investigations will "take the problem of the delayed emptying of the gall bladder
out of the realm of empirical speculation and place it on a scientific basis."
"Is cholecystography contraindicated in jaundice patients? Does it invariably result
in non-visualization?    Will it cause a reaction or damage to the liver?"
There is fairly conclusive evidence to substantiate the belief that cholecystography
does not profoundly affect the patient with obstructive or extra-hepatic jaundice. There
could be a theoretical contraindication to cholecystography in toxic or infectious jaundice,
but even after damage to dog's liver by chloroform anaesthesia, the drug could be used
in amounts equal to four times the human dose. A bromsulfalein retention over 40 per
cent is said to indicate sufficient liver damage to prevent gall bladder visualization. It
has been shown experimentally that jaundice does not increase the toxicity of the dye,
and only isolated cases have been noted where jaundic occurred following the administration of iodophenolphthalein.
McWhirter3 in 1935 reported a death which could be attributed to the drug. In a
patient with slight jaundice a good shadow was obtained. The patient died ten days
later from sub-acute yellow atrophy.
The latest and most complete analysis of cholecystography in jaundice patients is the
fifty unselected cases reported by Huber4 in 1944. These examinations were conducted
by the oral method. There were no intravenous injections. No deleterious effects due
to the procedure were noted. Practically all the cases had one or more determinations of
the icterus index.
The largest group of fifteen cases was that of common duct stone. Eleven showed
no shadow of the gall bladder.   Faint gall bladder shadows were seen in four.
There were three cases of cholecystitis without cholelithiasis of which two had faint
shadows, the other one no shadow. The second largest group (eleven cases) had no
final diagnosis. A very faint shadow was obtained in only one case and the other ten
cases had no shadow. The only other large group (ten cases) was that of toxic and
infectious hepatitis including the so-called "catarrhal jaundice." Good shadows were
obtained in seven, faint shadows in three. The smaller group consisted of cancer of the
pancreas, common duct and liver, cirrhosis of the liver and one case of duodenal ulcer
associated with jaundice.    Of this group only three cases showed a faint filling.
A study of these cases suggests that the cholecystographic examination may be of
some help in differentiating the toxic and infectious type of jaundice from obstructive
jaundice. From a practical point oi view, radiography in jaundice patients resolves itself
into an attempt to distinguish between surgical and medical cases. This was possible
to a large extent in thirty-six of Huber's cases in which the jaundice was decreasing.
Since a patent common duct is here predicted, the same diagnostic criteria are used as in
cases without jaundice.   With increasing jaundice (remaining fourteen cases), diagnostic
Page 28 information is usually not obtained, since apparently no difference exists in the degree of
impairment of dye excretion whether due to back pressure or parenchymatus liver disease.
It may be concluded from Huber's study that cholecystography is of little or no differential value when jaundice is increasing, and when jaundice is decreasing the examination
may be well deferred.
1. Levene, G., Lowman, R. M., and Wissing, E. G.: Roentgen Diagnosis of the Strawberry Gall Bladder.
Radiology.    34: 391, 1940.
2. Dann, D. S., and Koritschoner, R.: A Clinical Study of Normal and Pathologic Motor Activity of the
Gall Bladder.    Radiology.    47: 495, 1946.
3. McWhirter, R.: Cholecystography, Its Present Clinical Value.    Brit. Jour, of Surgery..  23: 155, 193 5.
4. Huber, F.: Cholecystography and Jaundice.    Am. J. of Roentgenol and_ Rad. Therapy.    51: 12, 1944.
W. N. BELL, M.D.
Vancouver General Hospital
Presented May 27, 1947
Since the introduction of thiouracil in the treatment of thyrotoxicosis, great endeavors have been made to find a derivative which would lower the significant toxicity
attached to this drug. One such derivative which has been introduced is 6-propylthiour-
acil. It rates its antithyroid action is approximately ten times that of thiouracil, and
although it is more toxic than the latter on a weight basis it is less toxic in quantities
having a comparable therapeutic effect.
The purpose of this report is to present five cases of thyrotoxicosis treated by propylthiouracil.
Case 1. Female aged 23 with diffuse thyrotoxicosis. She was treated with Lugol's
solution from May, 1946, to September, 1946, quite successfully. In September she
began to have increased dyspnoea on exertion, perspiration, loss of weight and an increased appetite. At this time her B.M.R. was plus 16, her pulse 78 and weight 114
pounds. She was carried along for six weeks on phenobarbital. She then appeared more
toxic, her B.M.R. being plus 47, pulse 100 and weight 115. On October 21, 1946, she
was put on propylthiouracil 25 mgm. t.i.d. In three months her B.M.R. had dropped
to plus 5, her pulse was 74 and she had gained 12 pounds. The propylthiouracil was
reduced to 25 mgm. daily and three months later her B.M.R. had gone up to plus 34
so the propylthiouracil was increased to 25 mgm. ti.d. A month later her B.M.R. was
plus 11, pulse 88, and she weighed 129 pounds. She felt subjectively much better.
There has been no change in the white blood cell count and she has presented no other
evidence of toxicity.
Case 2. Female, aged 67, with diffuse thyrotoxicosis. On August 20, 1946, her
B.M.R. was plus 82, pulse 80 and weight 102 pounds. She was treated with Lugol's
solution, minims 10 t.Ld. with some subjective improvement. On March 13, 1947, her
B.M.R. was still 34, pulse 100, and she had lost 5 pounds. She was put on propylthiouracil, 25 mgm. t.i.d., and a month later her B.M.R. was 0, her pulse had dropped
to 74, and she had gained 5 pounds, with much subjective improvement. There has
been no change in the white blood cell count and no other evidence of toxicity.
Case 3. Female, aged 24, with diffuse thyrotoxicosis. On November 18, 1946, her
B.M.R. was plus 30, pulse 84, and weight 103 pounds. On December 6, 1946, she
was given propylthiouracil, 25 mgm. t.i.d. A month later her B.M.R. was minus 2 and
she had gained 4 pounds. She was given Lugol's solution, minims 10, t.i.d., along with
the propylthiouracil.    Ten days later she underwent sub-total thyroidectomy and the
||§| Page 29 surgeon was pleasantly surprised at the relative avascularity of the gland compared with
the friable, vascular organ which had been his experience with thiouracil. This patient's
post-operative course was uneventful and 2 months later she felt well and weighed
105 pounds. At no time was there any significant change in'the white blood cell count
nor other evidence of toxicity.
Case 4. Female, aged 49, with a toxic adenoma. She had been treated more or less
continuously with iodine for a year prior to February, 1946. At this time she was
given a two weeks' course of thiouracil plus iodine. The thiouracil had to be discontinued because of either leukopenia or a skin rash. On February 8, 1947, her B.M.R.
was plus 36, pulse 90 and weight 133 pounds. On February 11, she was given 100
mgm. of methylthiouracil over a 24-hour period, and then was switched to propylthiour-
avil, 25 mgm. q.i.d. Two weeks later her B.M.R. had fallen to plus 17, her pulse to 72,
and she had maintained her weight. She was then given propylthiouracil, 25 mgm. t.i.d.
plus Lugol's solution, minims 5 t.i.d. Two weeks later her B.M.R. was still plus 17.
The Lugol's solution was discontinued and the propylthiouracil was increased to 25
mgm. q.i.d. A week later her B.M.R. was plus 8, pulse 80 and she weighed 135 pounds.
The propylthiouracil was discontinued and Lugol's, minims 10 t.i.d. was begun. On
March 19, she underwent thyroidectomy. The adenoma occupied one whole lobe and
was removed. In addition, a small portion of the remaining normal-appearing lobe was
also removed. Her convalescence was complicated by a short spell of auricular fibrillation occurring 24 hours post-opera tively which responded to digoxin. She was discharged from hospital on April 2, considerably improved. At no time was there any
appreciable leukopenia nor other evidence of toxicity.
Case 5. Female, aged 28, with diffuse thyrotoxicosis. In November, 1946, her
B.M.R. was plus 91, and she was 7 months pregnant. She was given 0.1 gm. thiouracil
t.i.d. In a month her B.M.R. had fallen to plus 64 but her W.B.C. had fallen from
6,000 to 4,150 with 10 per cent polymorphs. She was given pyridoxine, 200 mgm.
intravenously daily, plus liver plus whole blood. There is no record of further W.B.C.
estimations, but she was discharged on December 23, 1946, after having been delivered
of a healthy male child. She was re-admitted to the Surgical Department on February
6, 1946, when her B.M.R. was plus 47, W.B.C. 2,500, P. 21, L. 75. She continued on
thiouracil, 0.1 gm. t.i.d., plus pyridoxine, 200 mgm. intravenously daily, and three weeks
later her B.M.R. was plus 41 and her W.B.C. 4,700, P. 38. On February 27, she was
given Lugol's, minims 40, and the next day thyroidectomy was attempted. Because of
her general condition, only ligation of the superior thyroid arteries was done. Postoperatively, she was given thiouracil, 0.2 gm. q.i.d. plus sodium iodide intravenously.
On March 11, her B.M.R. was plus 32 and her W.B.C. had remained about 5,000. On
March 19, the W.B.C. was 2,250, the thiouracil was discontinued and the pyridoxine
was increased to 400 mgm. intravenously daily. She was also gicen penicillin, 66,000
units intramuscularly q.3.h. The W.B.C. dropped to 950, P. 2, L. 97, but by March 25
it had gone up to 4,100, P. 8, L. 84. On April, 1947, it was 11,100, P. 56, L. 39, and
her B.M.R. was plus 53. On May 2, the B.M.R. was plus 100, and the W.B.C. 4,750
with P. 75. The B.M.R. remained plus 60 to plus 80 and the W.B.C. 4,000 to 5,000
with 60-80 per cent polys. On July 27, on Lugol's, minims 5 t.i.d., the B.M.R.
dropped in three weeks from plus 65 to plus 52, and her weight went from 112 to 118
pounds. The pyridoxine and liver were discontinued at the end of July. On August
19, the B.M.R. was plus 52, the W.B.C. 3,250, P. 63r and weight 118 pounds. She was
put on propylthiouracil, 25 mgm. q.i.d. On September 13, her B.M.R. was plus 54, the
W.B.C. 4,150, P. 44, and she had gained 9 pounds. The propylthiouracil was reduced
to 25 mgm. daily and also Lugol's, minims 10 t.i.d. was added. A week later her B.M.R.
was plus 37, the W.B.C. 4,600, P. 54, and weight 129 pounds. Sub-total thyroidectomy
was done on September 21. Post-operatively her condition was good, except that she
developed tetany which was controlled by calcium and viosterol. Following this she
gained weight slowly and felt subjectively much improved. Her W.B.C. remained
about 11,000 with 60 to 70 per cent polys.
Vancouver, B. C.
Presented: Staff Clinical Meeting, May 27, 1947
I have been allotted 15 minutes to deal with Obstetric Haemorrhages which will not
permit me to do anything more than touch briefly on the most important points.
It is gratifying to be able to say that the number of puerperal deaths on this continent is steadily declining. Probably the expansion of maternal welfare services has
played an important part in this reduction and undoubtedly continued education of the
physicians doing obstetrics is an important factor. The studies carried out by medical
groups with the close co-operation of vital statisticians have had a profound effect upon
the national death rate. While this steady decline in the number of obstetrical deaths
is taking place the percentage of reduction is lowest in the number of deaths due to
haemorrhage and shock. This would appear difficult to understand in view of the life-
saving measures on hand with prompt blood transfusions, plasma, etc., except that even
greater means have been found to combat the other killers—infection and toxaemias.
Therefore haemorrhage still remains the most frequent and important cause of puerperaL
deaths. It is true that during pregnancy there is an increase in blood volume and that a
parturient woman is often able to survive the loss of a large amount of blood, but it is
exactly this impression that is responsible for failure to carry out proper prophylaxis or
made adequate preparations for blood replacement. Haemorrhage cannot always be prevented but the results of blood loss are largely controllable.
In the first place we must consider the causes of haemorrhage during pregnancy and
labor. In the first three months of pregnancy bleeding occurs in a fairly large percentage
of all pregnancies and is mainly due to abortions whether threatened, complete or incomplete. Other causes are ectopic pregnancies, hydatidiform moles, polypi or rarely
erosions, carcinoma of the cervix. Bleeding in the last trimester is almost certainly to
be caused by placenta praevia or a premature separation of the placenta. Post-partum
haemorrhages may be caused by any procedure which interferes with proper contraction
of the uterus. Probably the most common cause is mismanagement of the third stage
with resulting retention of the placenta, but the condition which causes the most violent
and sudden haemorrhage is that of loss of tone of the uterine muscle which is a condition
of secondary inertia due usually to uterine exhaustion. This condition may be predisposed to by many causes such as prolonged labors with difficult instrumental deliveries, over-distension of the uterus from twins, hydramnios, etc., and is certainly influenced
by over-sedation with drugs, deep anaesthesia and debilitated conditions of the mother.
This condition is very serious and unless promptly recognized and treated will rapidly
cause death. It is not always easy to recognize as the bleeding may at first be entirely
intrauterine, and the relaxed uterus may be filled with blood until it is almost the size
it was before labor began, and while filling there may be very little blood from the
vagina. The physician must be on the alert to recognize that bleeding is taking place.
Other causes of post-partum haemorrhages are lacerations, cervical tears, fibroids, inversions, etc. It must also be mentioned that caesarean sections may be associated with
unexpected and serious haemorrhages—particularly the classical operation—and these
are difficult to control. The usual history is for the patient to return to the ward
bleeding and in shock, to continue bleeding in spite of attempts to check it, till death
results in a few hours.
So much for the usual causes of haemorrhage; now to deal briefly with the treatment. The first essential to remember in all cases is that every ounce of blood is important during and immediately after labour and none must be wasted. Delay in initiating
treatment and in replacing lost blood is probably the outstanding cause of maternal
deaths. Every physician knows that lost blood must be replaced by blood or a satisfactory substitute but often undue confidence is placed in almost anything else and
Page 31
mm-: valuable time is lost. Large blood losses cannot be replaced by saline, but only large
amounts of blood will save life. If blood banks are not available, plasma which is next
best should always be on hand in even the smallest hospitals.
I shall not deal with abortion haemorrhages except to say that bleeding is usually
repeated before it becomes serious. Treatment and watching over several hours during
which bleeding continues should not be allowed. This, followed as it often is by slow
or incomplete removal of retained tissues, may be followed by free bleeding and the
woman reaches a serious state.
In ectopic pregnancies delay in operating is the outstanding cause of deaths and this
delay is usually due to difficulty in diagnosis. Operation should be done without delay
in spite of the apparently poor condition of the patient to stand a laparotomy. A trans^
fusion, of course, should be started immediately. It has been estimated that 50 per
cent of ectopic deaths could be prevented if women consulted a physician and entered
hospital at the onset of symptoms. Immediate operation, transfusion with whole blood
and other supportive measures give excellent results.
Placenta praevia and accidental haemorrhage both have a serious prognosis for the
mother and an extremely high foetal mortality. A standing rule should be that every
woman who bleeds in the last few months should be sent to hospital without examination or any attempts to stop the bleeding at home. It is rare that the first haemorrhage
is fatal. On admission her blood should be typed and Rh tested and no vaginal examination should be done except in a delivery room where irnmediate steps can be taken to
control any bleeding. In mild cases, if in doubt, x-rays will probably show the position
of the placenta. Until recently caesarean section was reserved for central placenta
praevia and severe partial types, but now the operation is done by probably most obstetricians regardless of type without even a previous vaginal examination. The days of
vaginal packing, Braxton Hicks extraction and bags have gone by, but one must remember that in mild cases with a lateral placenta conservative treatment with rupture of
the membranes, abdominal binder, and possibly scalp traction, usually is quite satisfactory
and may be preferred if the baby is dead. With accidental haemorrhage there is still
no uniformity of opinion regarding the treatment. In mild cases with the patient not
in labour, caesarian section would appear to be the best solution, but in severe cases
carries a high mortality rate, and the result may be better if the shock is treated by blood
and morphia. As her condition begins to improve pains will often begin, and a success- ,
ful termination can be reached by rupturing the membranes and applying a binder—
delivery usually taking place in 12 hours. In severe cases where the uterine muscle is
damaged and will not contract a hysterectomy is occasionally necessary.
Post Partunt Haemorrhage
After the birth of the baby any imperfection of the mechanism of contraction and
retraction of the uterine muscle causes the blood vessels to remain open and permits the
free escape of blood. Any amount over 20 ounces constitutes excessive bleeding but if
thre has been loss of blood before birth a small loss post partum may cause death. There
are three varieties of post-partum haemorrhage.
(1) Imperfect retraction, (2) Laceration, (3) Inversion of the uterus, and of these
the first variety, imperfect retraction, has three causes: (1) Retention of the placenta.
(2) Loss of tone of the uterine muscle. (3) Fibroids. Retention of the placenta is
most commonly due to its being partially adherent, and its chief cause is mismanagement
of the third stage. If bleeding occurs before the placenta is delivered the usual methods
of expression should be tried out, but if not successful the placenta should be manually
removed without delay. If you delay until the woman's pulses rate has gone up and
there are signs of shock manual removal is a major obstetrical procedure and is highly
dangerous. Give blood transfusions before and after the manual removal and be prepared to pack the uterine cavity as bleeding sometimes continues. If there is no bleeding
there is no actual hurry in removing the placenta but the time of waiting seems to be
becoming more brief with most obstetricians.   If no line of cleavage can be found it is
Page 32 not right to try to tear off the placenta as it may be adherent and the only remedy is a
hysterectomy. The danger in manual removal is not in the removal itself but in allowing too much blood loss before it is done.
Lack of tone of the uterus is the cause of those cases of furious haemorrhage which
may be rapidly fatal. It is so sudden and serious that there is no time to obtain help and
every one doing obstetrics should have a clear and definite line of treatment which he
will follow without delay. Haemorrhages of lesser severity can usually be controlled by
massaging and grasping the fundus and injecting pituitrin and ergometrin. With any
.delay in contracting, ergotrate should immediately be given intravenously. If the bleeding is severe the uterus should be emptied immediately and attempts made to check the
bleeding by direct pressure. The uterus should be gathered up and pressed firmly into
the lower abdomen and massaged to excite contraction. If it does not contract or if the
fundus cannot be found owing to extreme flaccidity no time should be lost in inserting
the right hand into the uterine cavity and attempting to stimulate contraction between
it and the left hand on the abdominal wall. If it is still not contracting, bi-manual
compression which presses the anterior and posterior walls of the uterus together and
checks haemorrhage by direct pressure on the bleeding surface should be done. This bimanual pressure can be kept up until the uterus regains its tone. It is well to remember
that a profuse haemorrhage can often be quickly checked by the injection of pituitrin
directly into the fundus through the abdominal wall. One hand in the uterus raises
it to the abdominal wall and the needle is inserted through the abdominal midline,
usually within J_ minute the uterus is contracted. It happens occasionally that the
usual methods are not sufficient to continue bleeding and that blood even seeps through
a tightly placed intrauterine pack. In these cases, which are fortunately rare, hysterectomy is indicated. It is a life-saving procedure and not too radical. Many a physician
has regretted waiting too long before making this decision.
Other conditions which may cause serious loss of blood are fibroids in the uterine
wall, laceration of the cervix and perineum and inversion of the uterus. In the case of
fibroids the muscle fails to contract and packing of the uterus or even hysterectomy
may be necessary. In dealing with cervical tears, it is usually necessary to grasp the
cervix and pull it down so that the bleeding point can be seen before suturing. From
perineal wounds and episiotomies oozing of blood may lead to considerable loss. Amounts
up to 500 c.c. have been lost in this manner, which is quite unnecessary as such bleeding
can usually be controlled by simple firm pressure. The difficulty with haemorrhages
from inversion of the uterus is to recognize that an inversion has taken place. Any prolonged bleeding after delivery should make the physician suspicious.
Finally, no matter what methods are used to control obstetric haemorrhages, the
physician must be impressed with replacing the blood lost as soon as possible. There is
no branch of medicine in which the benefit of blood transfusions is more evident than
in obstetrics, and while whole blood is undoubtedly best the results with plasma are also
striking, and no obstetric hospital is properly equipped unless plasma is available for
immediate use. If a patient's pulse remains rapid after delivery, give blood plasma and
be on the safe side. Sometimes, particularly after a severe haemorrhage, much to the
attendant's distress he finds it impossible to give a transfusion as the peripheral veins
have been collapsed. When it is evident that the venous route is impossible bone marrow
infusions into the sternum may be done with great advantage. A sterilized set is kept
in the case room of this hospital for. this purpose. Considerable study of this method
and experimentation in its use has been done here chiefly under the direction of Dr.
Murray Blair and I would like to refer you to his article on the procedure in the Canadian Medical Journal, February, 1945.
In conclusion, while endorsing the free use of blood transfusions, one must always
keep in mind the possibility of serious reactions. There is no doubt that innumerable
lives have been lost from transfusion reactions and it is essential that the blood given
must be of the same type and Rh groups as the patient receiving it.    The Red Cross
Page 33 requires approximately 1 % hours to have a transfusion ready to give but this time could
be shortened if all women about to have babies would have their blood determination
and Rh factors slated routinely when they are admitted to hospital. Unless this examination has been done don't give blood in an emergency—give plasma.
1936 — 1946
Vancouver General Hospital
My part in the discussion tonight is to present the statistics of maternal mortality
for the Vancouver General Hospital, and for the sake of some comparison I have included
some of the figures for Grace Hospital. By doing this I felt that a truer picture of the
maternal mortality might be given, as Grace Hospital has a larger proportion of normal
cases than are admitted to the Vancouver General.it The statistics presented tonight
cover the period 1936-1946 inclusive.
When I was first asked to present this paper I thought it would be a comparatively
easy matter to get out the charts of the maternal deaths and to summarize them. However, when I asked Mr. Fish to get me the charts of the maternal deaths over this period,
his first question was—"What is a maternal death?" Until this time I had thought the
answer was comparatively easy, but to sit down and actually define a maternal death
isn't quite as simple as it would first appear. We agreed on the definition that a maternal
death is one which is caused by conditions arising from the existence of pregnancy. I
would like to suggest that, in the future, deaths in relation to obstetrics could probably
be more accurately defined as either obstetrical deaths, where the death was definitely
due to an obstetrical complication such as post-partum haemorrhage, or maternal death
for other than obstetrical reasons, e.g. a diabetic patient who becomes pregnant, has a
difficult time controlling the diabetic condition during pregnancy, and dies in diabetic
coma following delivery. Again, a patient with far advanced carcinomatosis who is
pregnant, delivers a living baby and then dies shortly after delivery. Is this a maternal
death? Numerous other examples of a similar nature could be given. So when I began
going over the charts there were several cases that I questioned as being true maternal
deaths. However, the cases which Dr. MacDonagh and I, after reviewing the charts,
decided were definite maternal deaths will now be presented. We found there had been
fifty maternal deaths in the ten-year period. We then attempted to classify these deaths
under one of the four headings:
1. Shock and haemorrhage.
2. Toxaemia.
3. Infection.
4. Other causes.
This again proved to be more difficult than I originally had expected.J| In a great
many cases there was not one definite cause but two or three, e.g. a severely toxic
patient, delivered by Caesarean Section, who died twenty-four hours post-partum, apparently of shock; and at autopsy the abdomen was full of blood. Should this patient be
classed under toxaemia or as a death due to shock and haemorrhage? There were numerous other examples of a multiplicity of causes of death, but we did our best to pick
out the most important cause and classify the case accordingly, realizing at the time
that other men reviewing the cases would probably put them into different classifications.
Page 34 I wish to stress at this point how woefully inadequate were a great many of the
records. In case after case there would be no operation report though an operation had
ben done, and frequently no autopsy report was found even though an autopsy had been
performed. It was often only from the nurses's notes that any information about the
case could be obtained. If our records are to be of any value they must be kept in better
condition than they have been in the past ten years.
Report on Cases and Deaths, 1936 to 1946
Grace Hospital
1936    : .    405
1937       455
1938 p    504
1939       440
1940    |    664
1941    747
1942    | If 1    902
1943 1,159
1944    1,237
1945    : 1,133
1946 1,665
Vancouver General
9,311 32,752
This shows the number of deliveries in both the Vancouver General Hospital and
Grace Hospital for the ten year period. As you can see, the number of deliveries in
both hospitals is increasing rapidly, from 1702 at the Vancouver General Hospital in
1936 to 4601 in 1946; and for Grace Hospital from 405 to 1665. At both hospitals
the curve is still on the rise. For the first three months of 1947 there have been 1307
cases at the Vancouver General Hospital and 518 at Grace. In 1941 I presented a paper
before this staff on the statistics from the maternity.building for the years 1933-1941
inclusive. At that time we felt the maternity building was working at nearly one hundred percent of its capacity, and that the curve of deliveries would soon flatten out.
That was in 1941 when we had 2756 cases, and in 1946 we had 4601. However, I do
think that the curve of deliveries will soon cease to rise, as a good many patients are now
refused admission to both the Vancouver General Hospital^and Grace, and have to find
accommodation in some other hospital or have the baby at home. It is a backward step
to begin doing home deliveries again, but until more hospital beds are available it is a
physical impossibility to have all patients delivered in hospital. Approximately ninety-
five percent of all deliveries in British Columbia last year were in hospitals, for the
whole of the United States last year the figure was seventy-five per cent.
Table II
Grace Vancouver General
Hospital Hospital
1936          0 6
1937           1 2
193 8   _____       0 5
1939    ___._•_,       0 1
1940    -       0 4
1941          1 2
1942       0 8
Page 35
Si 1943   1
1944   0
1945   0
1946   1
The total number of deaths in the Vancouver General Hospital series of 32,752
deliveries was fifty, and for 9,311 deliveries at Grace Hospital was four. As you can
see from the graph, there is a marked fluctuation nearly every second year. I can find
no logical explanation for this observation. The best year was 1939 with only one death,
in the Vancouver General Hospital, and the worst was 1945 with nine. So far we have
made a bad start in 1947 with three deaths, all in toxic patients. The interesting line on
the graph is the percentage of deaths to deliveries. One would have expected, with better
pre-natal care, sulfonamides and penicillin, as well as more generous use of blood and
plasma, that the curve of percentage of deaths would have shown a considerable drop
in the past ten years. So far this is not apparent, but we will hope that ten years from
now, if the statistics are again reviewed, that the improvement will be more encouraging
than it is at the present. The figures from both the Vancouver General Hospital and
Grace Hospital compare very favourably with other figures of maternal mortality that
I was able to find in the literature. Davis, from Chicago, reporting on a series of 47,945
obstetrical patients, reported eighty-one deaths, or a rate of 0.17%. The rate for the
Vancouver General Hospital is 0.15% and Grace Hospital 0.04%. For the two hospitals the rate is 0.12% for 42,063 deliveries.
Table III
„_          2
. 0
1939^1-     _
     _      0
__    __.         1
|        2
1944   —   _ .
1946   -    ___
 :_       0
We find that the fifty deaths from the Vancouver General Hospital are divided as
Shock and Other
Infection Toxaemia Haemorrhage Causes
16 (32%) 6 (12%) 12 (24%) 16 (32%)
In Davis' series the figures are
38% 25% 26% 11%
The group of "other causes" were divided as follows:
Carcinoma with metastases—2 (1 Ca of ovary, one Ca of cervix).
Page 36 Anaesthetic—4 (2 aspiration, 1 spinal, 1 atelectasis).
Embolism—4. slpf
Status epilepticus—1.
There pere thirty-five prirniparae and fifteen multiparae. The average age was thirty,
the youngest being seventeen and the oldest forty-four. In Davies' series the ages ranged
from nineteen to forty-three, the average being 29.4, which is very close to our figure.
Of the fifty maternal deaths there were thirteen patients delivered by Caesarean
section and thirty-seven delivered vaginally. There were two hundred and two Caesarean
sections done in the Vancouver General Hospital in 1936 with no deaths. I believe we
are becoming more conservative about using Caesarean section, reserving it for cases
with definite indications. This is especially true in treating toxic patients, as fewer sections are now being done in the presence of toxaemia than there were ten years ago. So
far in 1947, as I mentioned previously, we have had three toxic patients die, two of
these having had Caesarean sections.
This brings us to the question of how we can still further reduce the maternal mortality.   I would like to suggest the following ways:
1. Education—by teaching medical students and internes the difficulties and dangers
in obstetrics. Also by instruction of men in the specialty and those in general practice by regular conferences and discussions of obstetrical problems. This has been
started in our department by a weekly conference on Saturday morning.
2. Formation of a committee, possibly of one doctor from each hospital, to act as a
board to review' all the maternal deaths in the city and attempt to classify them as
preventable or not preventable. This is done in a number of the larger cities in the
States, and is believed to help in lowering the maternal mortality. If a doctor, knows
that he might be called upon to exp'ain his actions in delivering a difficult case I
think it might make him hesitate and possibly seek better trained assistance for the
patient and thereby possibly prevent serious trouble.
When I began working on this paper, I had hoped to show a marked reduction in our
maternal _nortality. As you can see, this is so far not the case. However, I have hopes
that it will gradually be lowered and that ten years from now there will be a very
appreciable difference from the figures presented tonight.
We are to consider tonight those conditions which arise in individuals under the age
of two years which can be classed as emergent and which are not treated by surgical
methods. It would seem proper to divide this age group into two periods: (1) the neonatal (the first four weeks of life) and (2) the age following this through infancy until
the age of two years is reached.
It could be supposed that the number of conditions fulfilling the requirements outlined in the opening paragraph would be few, but this is not so. I propose to list, in
each period, the emergencies which may arise and then discuss each one briefly.
In the neonatal period:
1. Erythroblastosis foetalis.
2. Anoxia of the newborn.
3. Haemorrhagic disease of the newborn.
4. Infections of the newborn.
5. Prematurity.
3.   Haemorrhagic disease of the newborn.
6.   Tetany of the newborn.
Page 37 7. Adrenal haemorrhage, or acute adrenal insufficiency.
In infancy:
1. Infantile tetany.
2. Diabetic coma.
3. Suprarenal haemorrhage with infection.
4. Severe diarrhoea and vomiting with intoxication.
5. Acute laryngotracheobronchitis.
6. Asthma in the acute attack.
7. Convulsions from any cause.
8. ^f_cute primary congestion of the lungs.
9. Meningitis.
10. Diphtheria.
11. Haemophilia with haemorrhage.
12. Poisoning.
As far as recognition and treatment is concerned, each of the conditions listed can
properly be considered as an emergency. There may be other conditions which have been
overlooked but not intentionally.
If I am to cover the ground in the brief time allotted you will forgive me if I use
the device of making, in connection with each condition, two or three bald statements
of opinion without supporting evidence. I hope to emphasize the important aspect in
each case.
1. Erythroblastosis Foetalis.
If anaemia is severe in the erythroblastotic infant, the use of Rh negative compatible
blood by transfusion is the present concept of correct therapy. If jaundice is severe
it would seem reasonable to support the liver by giving 2 c.c. of crude liver extraqt
intramuscularly twice a week. It is not proven that transfusion, replacement in type or
otherwise, has altered the prognosis in regard to incidence or severity of sequelae.
2. Anoxia of the Newborn.
The autopsy findings in fatal cases of anoxia of the newborn are generalized venous
congestion of oedema, dark fluid blood, petechial haemorrhages into all organs, sometimes frank haemorrhage into various organs. If one remembers that the thymus gland
at birth has been recorded as weighing from 5 to 3 0 grams in apparently normal infants,
one may doubt very much the diagnosis of "thymic death" in an infant presenting this
pathological picture coincidentally with a thymus that weighs a little more than average.
3. Haemorrhagic Disease of the Newborn.
There would seem to be no conclusive evidence for the argument that it is not
necessarily good obstetrical practice to give Vitamin K routinely to mothers at the onset
of labour. Yet there are babies born in this hospital without the benefit of this procedure. Evidence has been produced in other centres that the haemorrhage due to birth-
trauma has been lessened by the use of Vitamin K as a routine.
4. Infections of the Newborn.
The prompt recognition of umbilical sepsis in the newborn is imperative. Early
administration of chemotherapy or antibiotics is effective, late administration is not.
Remember that the newborn infant is nature's perfect culture tube and the treatment
of any sepsis of skin, of genito-urinary tract, of gastro-intestinal tract is urgent.
5. Prematurity.
I include this state only because I consider the early establishment of a modern
premature service in our Hospital to be an emergency and the paediatric supervision of
the same to be urgent.
6. Tetany of the Newborn.
The occurrence of muscle twitchings and convulsions may not mean intracranial
haemorrhage, it may mean tetany. The blood calcium is regularly reduced. The etiology
of the condition is not clear. It apparently does not occur in breast-fed babies. It
responds readily to calcium by mouth.
Page 3 8 7.   Adrenal Haemorrhage or Acute Adrenal Insufficiency.
This occurs in the newborn as a result of trauma, as in breech presentations, the
extreme friability and vascularity of the glands and hypoprothrombinaemia. The infant
is suddenly cyanotic, cold and clammy to the touch, but with high fever. The recognition of this condition existing apart from sepsis is a new development1. Treatment is
adrenal cortical extract 5-20 cc. intravenously in glucose saline. I have yet to recognize
such a case and have probably missed them heretofore.
1. Infantile Tetany.
I would mention here only that type of infantile tetany that occurs in the form of
laryngospasm. If unrelieved death may occur. The infant with a high-pitched inspiratory crow, without infection, is suspect. Calcium gluconate can be given intravenously,.,
it should not be used intramuscularly. If the infant can swallow, calcium chloride by
mouth is all that is necessary, giving 40-60 grains as initial dose in 10% solution, followed by 15 grains q. 4 h.
2. Diabetic Coma.
This can occur at any age, it is most severe and sudden and most often not diagnosed
under the age of two years. The best aid in diagnosis is a healthy suspicion of its presence.
3. Suprarenal Haemorrhage.
This occurs coincidentally with severe sepsis, as with meningococcemia. The chance
foi survival is very poor even when the condition is recognized and treatment attempted.
4. Severe Diarrhoea and Vomiting with Intoxication.
The single greatest stride in the management of this common emergency is, in my
opinion, the careful assessment and daily recording of amounts of fluid, electrolyte,
glucose and protein required and given. Dodd and Rapaport outline such a p'an2. We
now all recognize the danger of the administration of too much electrolyte.
5. Acute Laryngotracheobronchitis.
Tracheotomy must be done early before the infant is exhausted. Too often fear of
such an apparently heroic measure causes delay until too late.
6. Asthma; the Acute Attadk.
The differential dignosis between this and the preceding condition discussed is often
extremely difficult when the first attack of asthma occurs in an infant just under the
age of two. Infection in the respiratory system is very often the precipitating factor
in the attack. The attack is often atypical. If adrenalin does not give prompt relief,
then suspect that you are wrong in your diagnosis.
7. Convulsions—from any cause.
Control the convulsion by sedation, by anaesthesia if necessary. Look for the cause
afterwards.  Prolonged convulsions are harmful.
8. Acute Primary Congestion of the Lungs.
The infant who is apparently well in the morning can be shocked and very ill by
mid-afternoon. Clinical findings in the chest are often not found. The pneumonia becomes apparent a considerable time later. Oxygen is life-saving and is needed promptly.
Steam inhalations are definitely harmful.
9. Meningitis.
If an infant is acutely ill, with or without meningeal signs, and the diagnosis is not
positive, do a lumbar puncture. Don't start penicillin and sulfonamides and do a lumbar
puncture three days later to find a cloudy fluid with organisms disorganized and impossible to recognize.
10. Diphtheria.
Carry antitoxin in your bag—even in this modern, enlightened community. I have
seen two infants die of diphtheria in a large Canadian city, gasping, choking and black
in the face, after they had been treated for a "sore throat" for several days.    Recently,
Page 39
"...   v^i
■'. -■■ I-
«_]_*___ I missed three cases in one family—mild, I'm thankful to say—because my suspicions
were not alive.   Now there is antitoxin in my bag.
11. Haemophilia with Haemorrhage.
Haemophilia is fortunately rare. Uncontrollable haemorrhage from a wound needs
prompt transfusion. For this disease, as for haemorrhagic disease of the newborn, we
need fresh blood—not blood from a blood-bank.
12. Poisoning. ||||
As soon as an infant becomes a successful walker and climber, he becomes an explorer. Parents must be constantly warned by their medical adviser that even medicine
cabinets and kitchen cupboards are not safe repositories for potentially dangerous substances.
I feel that I must apologize to you for this sketchy presentation. Any one of these
conditions can be made the subject of a worthwhile discussion. If I have left with you
the impression that there are medical emergencies occurring in infancy, and the thought
that special care is needed in their management, I have done what I wished to do.
1. Jaudon, J. C, Journal of Pediatrics, 29; 696; 1946.
2. Dodd, K., and Rapoport, S., Journal of Pediatrics, 29; 758; 1946.
Vancouver General Hospital
Presented: May 27, 1947
This history concerns a girl aged 15 who was first seen by Dr. Leeson on the 3rd
of February, 1947. She complained of discharging, painful ears of about one week's
duration. The drum of the right ear was red and bulging in its posterior half. After
Bonain's drops had ben instilled a right myringotomy was done. Subsequent treatment
included sulfadiazine gr. XV every four hours, which was stopped three days later because of general symptoms of intolerance.
Oer condition deteriorated and on the 7th of February she was admitted to the General with a temperature of 102.6 degrees and a pulse rate of 80. A thick creamy pus
was exuding from the right external auditory meatus and moderate tenderness existed
over the entire right mastoid region.    A blood count revealed the following features:
W.B.C.—15,000 of these 54% polys, and 33% lymph.
X-rays showed obliteration of the normal feather structure of the mastoid area consistent with a diagnosis of mastoiditis. Treatment ordered was 300,000 units of Penicillin in beeswax daily. For a few days subsequently she improved and the mastoid pain
disappeared but an x-ray taken on the 18 th of February showed increased involvement
so it was decided that the patient should undergo an operation. On the 20th of February
right mastoidectomy was performed by Dr. Leeson. The following features were
1. Subdural abscess—J/_ inch in diameter.
2. Lateral sinus thrombosis.
Page 40 The sinus plate was eroded and the sinus filled with thick fibrinous granulations.
The sinus was left unopened and the clot was not evacuated. After packing with iodoform gauze between skull and dura and over the sinus the wound was sutured, leaving
rubber tubing and the gauze at the upper end of the wound. Subsequent drainage was
good but twelve days later, March 5 th, she developed grossly choked discs, slight weakness of the external rectus, nystagmus, slight lower facial weakness and intense headache.
She was seen by Dr. Turnbull, who felt that a brain abscess had developed and thought
that the skull should be opened. This he did on the 8 th of March and exposed the
temporo-parietal lobe of the brain. A needle was inserted into the temporal lobe anteriorly and posteriorly without encountering any abscess. Two days later the spinal fluid
revealed absence of W.B.C, a pressure of 300 mm., and 280 R.B.C. per cm.
The patient's condition was distressing. Her headaches were most intense and persistent and she became hysterical at times. On March 17th a diagnosis was made of
apicitis and two days later Drs. Leeson and Tanton opened up the right mastoid intra-
aurally.    The apex was inaccessible without removing the cochlea.
The patient, however, subsequently improved; her headache and nystagmus disappeared; the ear became drier and vision improved.
When re-examined on the 26th day of May she had no complaints. She looked well,
was bright and alert. The right eye showed a choked disc and indefinite margins.
Vision 20/20. The left eye—the nasal border of the disc was ill defined. Vision 20/20.
There was no diplopia and convergence was normal. The right auditory canal showed
I Conclusion: The patient had the following conditions:
1. Acute Right Mastoiditis.
2. Lateral Sinus Thrombosis.
3. Subdural Abscess. ,
4. Circumbscribed Serous Meningitis in the middle cranial Fossa (Gradenigo's Syndrome).
The sixth nerve lies in a groove at the apex of the petrous portion of the temporal bone
and a small inflammatory exudate at this point may interfere with the function of the
Clasically in Gradenigo's Syndrome (1904) the patient is young with mastoiditis.
There is severe pain over the tempora-parietal area caused by irritation of the Gasserian
ganglion at the tip of the petrous pyramid. The motor part of the fifth nerve is occasionally involved with spasm or paralysis of the muscles of mastication. Then diplopia
suddenly develops.
On lumbar puncture the C.S.F. is under increased pressure but otherwise normal.
Within two months following surgical interference and sometimes in its absence the
pain and diplopia vanish. ,
Vancouver General Hospital
Presented: Staff Clinical Meeting, March 24, 1947.
Sometime ago I was given the task of reviewing the cases of acute cholecystitis treated
in this hospital for a period of one year. After a brief survey of the medical histories it
was immediately apparent that a statistical study was impossible. The records were so
grossly defective and so few cases were operated upon that a true picture of the condition
could not be obtained.
A review of the contemporary literature was then undertaken in order to learn some
pertinent facts regarding the pathogenesis of the disease, the specific indications for operation, when operation should be done, and the results that could be expected. No satisfactory answers to these questions could be found. The conflicting opinions which have
been prevalent for over half a century, on this continent and in Europe, still persist
among the authorities of today. By most it is accepted that the etiological factor is a
stone blocking the outlet of a previously diseased gall bladder. No definite signs are
laid down as indications for operation. The time to operate is generally signified by such
ill-defined terms as "Early," "Delayed," "Immediate" and "Late," which hold different
significance for different writers. Large series of cases from different clinics report
results which are diametrically opposed.
So after studying the inadequacies of our own records and after reading the conflicting
literary efforts designed to clarify the problem one has the temerity to present and draw
conclusions from five personal cases of acute cholecystitis operated upon in this hospital.
M. W., female, age 63, was admitted to ho'spital June 20, 1940, operated upon June
20, 1940, and discharged on July 8, 1940. No previous history. Severe upper abdominal
pain for 48 hours.
Signs: Marked right upper abdominal tenderness and rigidity with rebound tenderness.    Temperature 102.    W.B.C. 29,400.
Operation: Small subcostal incision. Gall bladder was isolated by colon and omentum. Omentum peeled off black necrotic fundus. Thin brownish fluid leaking from
gall bladder fundus. Gall bladder contained thin dark bile under pressure and a few
small pigment stones. No stones obstructed cystic duct. Gall bladder was drained.
Bile appeared in drainage in 24 hours.
Biopsy: Acute necrotic cholecystitis.
G. K., male, age 65, was admitted to hospital March 26, 1946, operated upon March
26, 1946, and discharged April 4, 1946. No previous history. Severe right upper abdominal pain for 72 hours.
Signs: Exquisite tenderness and rigidity in right upper quadrant with marked rebound
tenderness.    Temperature 101.   W.B.C. 11,600.
Operation: Subcostal incision. Omentum stuck to black hard fundus of gall bladder.
Gall bladder contained bloody black bile and clots under pressure and 50 cholesterol
stones. No stones obstructed cystic duct. Gall bladder was drained. Bile appeared from
drainage tube within 24 hours.
W. O., male, age 84, was admitted to hospital April 5, 1946, operated upon April 5,
1946, and discharged on April 21, 1946. No previous history. Severe right upper
abdiminal pain for 60 hours.
Page 42 Signs: Exquisite tenderness and rigidity in right upper quadrant with rebound tenderness.    Temperature 99.8.    W.B.C. 17,900.
Operation: Subcostal incision. Fundus of gall bladder black, soft and friable and
walled off by transverse colon. Gall bladder contained thin black bile under pressure
and three mixed pigment and cholesterol stones. No stones obstructed the cystic duct.
Gall bladder was drained.    Bile appeared from the drainage tube within 24 hours.
Biopsy: Acute necrotic cholecystitis.
A. W., male, age 64, was admitted to hospital June 5, 1946, operated upon June 5,
1946, and discharged June 18, 1946. No previous history. Severe upper abdomonial
pain for 26 hours.
Signs: Marjked tenderness and rigidity in right upper quadrant with rebound tenderness.    Temperature 99.2.    W.B.C. 15,000.
Operation: Subcostal incision. Gall bladder greatly enlarged, thick walled, cyanotic,
adherent to duodenum and under great pressure. It contained thin dark bile and a few
mixed cholesterol and pigment stones. So stones obstructed cystic duct. Gall bladder
was decompressed and removed.
M. S., female, age 75, was admitted to hospital December 11, 1946, operated upon
December 11, 1946, and discharged January 28, 1947. Presented no previous history.
Severe upper abdominal pain for 48 hours.
Signs: Marked right upper abdominal tenderness, mild rigidity and marked rebound
tenderness.    Temperature 99.4.    W.B.C. 21,000.
Operation: Small subcostal incision. Gall bladder covered by a thickened omentum,
covered by a fibrinous exudate. The fundal wall was soft, friable and cyanotic. Gall
bladder contained a milky fluid under pressure and the mucosal areas covered with
fibrino-purulent exudate. Gall bladder contained one mixed pigmeat and cholesterol
stone. No stones obstructed cystic duct. Gall bladder was drained. Bile appeared
within 24 hours.
Complications: Wound infections; two intraperitoneal abscesses that drained into
bowel; persistent fistula till February 1, 1947.
Average number of Hospital Days—21.
Average age of patient—70 years.
Average duration of symptoms before operation—50 hours.
Average temperature—100 and varied between a low of 99.2 and a high of 102.
Average W.B.C. was 19,000 with a low of 11,600 to a high of 29,000.
Results—no recurrences, no deaths. One patient had two intraperitoneal abscesses
which drained spontaneously into the bowel.
It should be noted that no patient gave a previous history of gall bladder disease, nor
was any evidence of chronic inflammation noted at operation. Stones were present in
most cases but usually they were few in number and in all cases were devoid of calcium.
One should emphasize also, that in no case was a stone found impacted in Hartman's
pouch or in the cystic duct. Those present were lying freely and harmlessly in the
body of the gall bladder. This observation, made at operation, was confirmed by the
free drainage of bile within twenty-four hours post-operatively in those cases having a
It is apparent that the prevalent concept of the etiology of this condition does not
apply to these cases. The generally accepted explanation of the phenomenon is that a
chronically infected organ becomes suddenly obstructed by a stone in or about the
cystic duct and, following this, an empyaema develops, or that this stone interferes with
the arterial, venous or lymphatic circulation leading to gangrene. In the patients under
discussion no stone blocked the duct area.    Stones were present in about 70 per cent of
Page 43
i, i
£ 4«i
K all cases but they were not neccessarily the initiating factor.   Nor does this explain the
etiology in the 3 0 per cent having acute cholecystitis and no stones. After all, stones are
a common inhabitant of the gall bladder.    Crump found that 33 per cent of patients
coming to autopsy had gall stones.
The pathogenesis in these cases «can best be explained by an acute arterial hyperaemia
of a previously healthy gall bladder wall, the offending bacteria, toxins or chemicals
originating in the general circulation rather than in the gall bladder mucosa. The
sequence of events would then be occlusion of the cystic duct by swelling and a rapid
progressive distension of the viscus by a thin inflammatory exudate leading ultimately
to pressure necrosis of the fundus.
The experimental work of Rehfuss and Nelson lends support to this view. In 2,162
routine gall bladders removed at operation, the antigen found in the wall was the same
as that found in the nose, sinuses, infected teeth, and in the bowel—namely the staphylococcus aureus, the colon-typhoid group, and the non-haemolytic streptococcus. Using
the last they were able by intravenous injections to produce cholecystitis in rabbits in 65
per cent of cases. Further, Eliason and Stevens found negative cultures in 50 per cent
of their acute cases and came to the conslusion that the process is at first toxic or chemical and is only later invaded by organisms.
Whether or not this is so it is all-important to know if a given patient should be
operated upon or treated expectantly. One would be very bold to make a dogmatic
statement based on so few cases when world opinion on the subject is so confused. However these cases seem to indicate that acute cholecystitis is a progressive disease which
will inevitably lead to necrosis and perforation. The indications for operation are peritoneal signs consisting of rigidity and rebound tenderness. If the former is absent, owing
to inflammatory walling off of the lesion or a deeply buried gall bladder, then rebound
tenderness, the most sensitive sign of peritoneal irritation, is sufficient. These signs,
indicative of peritoneal insult, are evidence that the process in the gall bladder wall has
reached the serosa and is already far advanced. Expectant treatment is definitely contra-
indicated and often deluding, because the general condition of the patient may appear
to improve while the gall bladder, now isolated by omentum and bowel, is perforating.
Perforation occurs most frequently on the sixth or seventh day of the disease but it may
occur within 24 hours. When it does the mortality jumps from about 3 per cent to as
high as 45 per cent and the morbidity is likewise increased.
Statistics tend to show that the best results are obtained by cholecystectomy. This
is probably true and certainly the organ can be removed with comparative ease at this
state. It is difficult, however, to bring one's self to separate protective adhesions in the
presence of exudate and gangrene. In young patients and in early cases this is probably
the best procedure, but in older people and in very ill patients with complications, cholecystectomy is the operation of choice and appears to give very satisfactory results.
Finally it would appear that acute cholecystitis is a primary condition of the gall
bladder wall; that the toxic agent is probably blood borne; that acute cholecystitis is a
progressive disease; and lastly, that if peritoneal signs are present, operation should be
undertaken at the earliest possible moment.
Eliason, E. ., and Stevens, L. W.: Acute Cholecystitis, Surg., Gyn. and Obst., 78:  98,  1944.
Smith, B. C: Acute Cholecystitis, S. Clin. North America, 25: 285, 1945.
McGuigan, W. J.: Acute Cholecystitis, Am. J. Surg., 68: 219, 1945.
Cottis, G. W.: Treatment of Acute Cholecystitis, New York State J. Med., 45:  1765, 1945.
Blumberg, N., and Zisserman, L.:  Acute  Suppurative  and Gangrenous Cholecystitis, Am. J.  Surg.,  70:
38, 1945.
Rehfuss, M. E., and Nelson, G. M.: Experimental Cholecystitis, Surg., Gyn. and Obst., 81: 455, 1945.
Page 44 We regret to record the death of Dr. E. P. Fewster, Vancouver's well-known poet-
physician. Born and educated in England, he came to Canada in 1877 and studied
medicine at Dunham-Hering Medical' College and the University of Chicago. He registered in British Columbia in 1910 and has been an active member of the profession.
Sincere sympathy is extended to Mrs. Fewster and family.
Dr. M. A. Menzies is now at the Ottawa Civic Hospital, where he is doing postgraduate work.
Dr. H. L. Ormsby, formerly of Vernon, is now practising in Vancouver.
The members of the profession note with interest the gift of $15,000 towards the
proposed Children's Health Centre. This centre when completed will become the focal
point of treatment and studies relating to child health in British Columbia. It is being
organized by a group of city medical and business men. Dr. D. H. Paterson, well-known
pediatrician, will assist in the development of the centre.
Dr. J. R. Wilson is at present doing post-graduate work in neurology and psychiatry
at the University of Pennsylvania.
The profession extends sympathy to the family of Dr. Arthur I. Brown, who died
recently at Barry, Illinois. Dr. Brown graduated from Trinity College in 1899 and
received the E.R.C.S. at Edinburgh in 1913. He registered in British Columbia in 1913,
but has been retired for the past few years.
Dr. R. E. Simpson has gone to Kingston General Hospital to do post-graduate work
for a few months.
Belated congratulations are extended to Dr. and Mrs. B. B. Moscovich, who were
married recently.
Congratulations are also extended to Dr. and Mrs. W. J. Charlton on their recent
We note with interest that Mrs. H. P. Swan has joined her husband, Dr. H. P. Swan,
in Hamburg, Germany, where he is serving as relief gynaecologist in the North British
Zone of Occupation.    Dr. and Mrs. Swan are well-known residents of Vernon, B. C.
Dr. F. W. Andrew of Summerland has been honored with the presentation of a certificate of Honorary Life Membership in the St. John Ambulance Association.
At a recent meeting of the Defence Medical Association in Ottawa, Dr. L. H. Leeson
was elected chairman.    Our genial president adds some more to his many duties.
All members of the profession extend deepest sympathy to Dr. F. L. Wilson of Trail,
on the recent tragic death of his wife.
Deepest sympathy is also extended to Dr. John Struthers Gunn, whose father, Mr.
A. D. Gunn, died recently, and to Dr. Wm. George Gunn, brother of the deceased.
Deepest sympathy is extended to Dr. Joseph Tassin of Duncan on the loss of his
Dr. R. S. Woodsworth, recently of Kelowna, is now practising in Langley in association with Dr. A. O. Rose.
We are pleased to note that Dr. L. R. Williams has returned to active practice after
a lengthy illness.    He is associated with Dr. Lee Smith of Vancouver.
A host of friends extend their sincere wishes to Dr. A. Y. (Scotty) McNair for a
speedy recovery.
Congratulations to the following parents: Dr. and Mrs. M. L. Allan, a son; Dr. and
Mrs. K. C. Boyce, a son; Dr. and Mrs. H. G. Cooper, a daughter; Dr. and Mrs. W. C.
Gibson, a son; Dr. and Mrs. E. S. James, a daughter; Dr. and Mrs. Ben Kanee, a daughter; Dr. and Mrs. H. R. Robertson, a son; Dr. and Mrs. J. A. Sinclair, a daughter.
Page 45
ilsil "There is now sufficient evidence to show that free folic acid
is an essential factor for continuation of normoblastic blood
formation and that a deficiency causes a reversal to the megaloblastic condition."
Brit. Med. Journal, May 3, 1947, p. 604.
There is an impressive weight of evidence to show that a
striking haemopoietic response follows the administration of
Folic Acid in cases of macrocytic anaemia with a megaloblastic
bone marrow. The haematological changes follow a definite
pattern; according to Sturgis (J.A.M.A. 132:963), there is "a
prompt rise in reticulocytes in the circulating blood, a standard
increase in the red blood cell and haemoglobin and all the
well know dramatic clinical manifestations of recovery ..."
It has been demonstrated that Folic
Acid will neither prevent the development of subacute combined degeneration in this disease, nor relieve
it once it has developed. In pernicious anaemia, therefore, Folic Acid
B.D.H. is recommended only for
persons who are sensitive to liver
extract and then only while they are
awaiting desensitization.
The suggested therapeutic dose
in macrocytic anaemia other than
pernicious anaemia is 5 mgm. to
10 mgm. daily until the blood count
is normal after which a maintenance
dose may be required.
Folic Acid Tablets B.D.H. are
issued in tablets of 5 mgm. in bot-
des of 100 and 500 tablets.


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