History of Nursing in Pacific Canada

The Vancouver Medical Association Bulletin: October, 1949 Vancouver Medical Association Oct 31, 1949

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< <^3  Bl C medical centre library
Vancouver Medical Association
■  ■
Volume XXVI.
ACTH and CORTISONE—J.   S.  L. Browne 146,
ACTH and  CORTISONE  COURSE—B. C  Medical  Association	
ACTH and  CORTISONE—Some  Practical  Considerations  Regarding  the  Use  of—
Strong   G.  F., Athans,  G.  D., Bagnall, A. W.  et al	
ACTH and' CORTISONE—University  of  British  Columbia   (letter)—J.  Eden	
ALCOHOLIC ADDICTION—Group Psychotherapy in the Treatment of—A. J.  Schulman
AMERICAN   GOITER   ASSOCIATION—Van   Meter   Prize   Award	
ANAEMIAS, Some Recent Advances and Theories in—R. E. Beck	
AORTIC ANEURYSM,  Treatment—Bruce   Shallard	
ATHANS,  G.  D.  et al—ACTH and Cortisone I	
AULD, F. M.—Honoured by Canadian Medical Association	
BAGNALL,  A.  W.  et al—ACTH and Cortisone..-.	
BECK,  R.  E.—Some Recent Advances and Theories in  Anaemias-. :
BENTLEY,  F.   H.—Blood  Vessels  of   the   Stomach   (reported) —:.	
BENTLEY,   F.   H.—British   National   Health   Service	
BLOOD  VESSELS   OF   STOMACH—F.   H.   Bentley   (reported)   	
Authority  and  the  Individual—Bertrand  Russell	
Atomic Medicine—C.  F.  Behrens	
Diseases of the Nervous System in Infancy, Childhood and Adolescence—F. R. Ford
Heart—A.   A.   Luisada.....! 1	
Medicine and Health in the Soviec Union—H. Sigerist ~~
Regional   Ileitis—B.   B.   Crohn	
Sir  Frederick  Banting—L.   Stevenson	
Sir  William   Gowers—Macdonald   Critchley	
Surgery of the Hand—S. Bunnell .— | Pi--—-	
Virus as  Organism—F.   M.  Burnet :....:
Annual Meeting,  1950,  Programme	
Annual   Reports,    1949-50 i
Course on ACTH and Cortisone :	
District   Meetings   	
Golden  Jubilee  	
General   Practitioners   Meetings ;..	
BROWNE, J. S. L.—ACTH and Cortisone 146,
tJANDAIAN   RED   CROSS—Blood   Transfusion   Service	
CAWKER   C.  A.—Recent  Advances  in  Urologic  Surgery	
CLEVELAND, D. E. H.—Report of Lecture on ACTH and Cortisone by J.  S. L. Browne
CLEVELAND,  D.  E.  H.  et  al—ACTH and  Cortisone ,	
CITY   OF  VANCOUVER .p;+.....:.2,   31,   55,   103,   127,   155,   178,   211,   237,   268,
CO-ORDINATING   COMMITTEE   ON   MEETINGS—Vancouver   Medical   Association	
CORTISONE  and  ACTH—J.   S.   L.  Browne 146,
CORTISONE and ACTH,  Some Practical Considerations Regarding the Use of—
Strong,  G. F., Athans, G. D., Bagnall, A. W.  et al —	
CORTISONE and ACTH—University of British Columbia  (letter)—J.  Eden	
CRETINISM—P.    M.    Ransford.	
DAVIDSON, G. A.—Osier Lecture, 1950—Men of Osier's
DAVIES, J.  R.  et al—ACTH and  Cortisone	
DEATH,   Medical   Certificates  Regarding   Cause   of—..	
Time j  183
tbtfo. DEPARTMENT   OF   HEALTH  AND  WELFARE—Morbidity   Survey  218
DERMATOLOGY,  Tenth International  Congress  of—Notice  180
DIABETES,   Peripheral  Vascular  Disease   in... :  66
DYSLEXIA—S. E.  C.  Turvey ..     15
EAR AND SINUS DISEASE, Intracranial Complications—P.  E.  Ireland     59
EDEN, J.—ACTH and Cortisone—University of British Columbia  (letter)  216
EDEN, J.  et  al—ACTH and Cortisone ,  308
EDITOR'S PAGE 3,  32,  56,   75,  104,  128,   156,  179,  212,  238,  269,  299
EDUCATION,  Quid   Pro  Quo  in  Medical—M.  M.  Weaver:  134
ELECTROLYTE  BALANCE—J. A. Lueschar,  Jr     62
EMBOLISM,   Fat—D.   S.   Munroe     .. 168
ERYTHROBLASTOSIS   FETALIS,   Practical  Problems  in—F.   C.   Moll..... 206
FRASER,  G.. A. and TELFORD,  D.—Non-specific  Mesenteric  Lymphadenitis.
GIBSON,  W.  C.—Social Burden  of Mental  Disease	
GRAUER,   F.   W.—Gall   Bladder   Perforations !'_;.....;	
HARRISON,  J.  E.  et  al—ACTH  and  Cortisone	
HEADACHE—L.  R.  F.  Zeldowicz | _	
HEPATIC CIRRHOSIS, Some Fundamental and Clinical Aspects of the Problem—
C. J. Watson   (reported) , jj	
HERTZMAN, V.  O.—Heart in  Myxoedema	
HOARSENESS,   Symptoms  and  Treatment—P.   E.   Ireland	
McCoy,   E.   C. g§g| I	
HUNT,   C.   L.—Interpretations  of  Serology  in  the   Diagnosis   of   Syphilis	
HYPERTHYROIDISM,   Exophthalmos   Related  to—J.   R.   Sidall...	
HYPERTHYROIDISM,   Treatment   of—B.   F.   Paige |g| :. 5	
INCOME TAX RETURNS, Doctors on Salary -...	
IRELAND, P. E.—Hoarseness,  Symptoms and Treatment §£<	
IRELAND,   P.  E.—Intracranial  Complications  of  Ear and  Sinus  Disease	
JOHNSON,  A.  M.   et al—ACTH and  Cortisone.
LIBRARY NOTES — 10,   33,   76,   129    157,   181,   213,  239,  270,
LEUSCHAR,  J.  A.,   Jr.—Electrolyte  Balance	
MacDERMOT,   J.  H.—X-Ray  Machine  for  Fitting   Shoes— $&■■&
McCOY,  E.  C,  THOMAS,  J.  C. and TURNBULL,  F.—Hospital  Insurance—
Whither Bound?-£L b wSci	
McINTOSH,   H.  W.  et al—ACTH  and  Cortisone	
MEN  OF OSLER'S  TIME—Osier Lecture    1950—G.  A.  Davidson...—fel	
MENTAL DISEASE,   Social  Burden  of—W.   C.   Gibson	
MINNES, J. F. et al—ACTH and Cortisone.... , :.-,	
MOLL,   F.   C.—Blood   Derivatives	
MOJL.L,  F.  C.—Practical  Problems  in Erythroblastosis Fetalis	
MORBIDITY   SURVEY—Department   of   Health   and   Welfare	
MOWAT,   D.—Hypothyroidism   and   Myxoedema |p|	
MUNROE, D.  S.—Fat Embolism .igJ ; -i&. 1
MURPHY,   H.   H.—Utopias,  Past and  Present—Perhaps  to  Come ..: :*^^&l	
MYXOEDEMA,  Heart  in—V.   O.  Hertzman :MimmL	
NECK,   Tumors   of   the—H.   H.   Pitts jj	
NEWS AND NOTES :;..-^L 125,
153, 176,   210,  266,  294,
Conklin,  J.   S	
MacLachlan, A.  J....
Mcintosh, H. H	
Pedlow,   W.   L	
Riggs,  H. |&*3&Spsi
Todd, J.  t^MM-^M.
Vrooman, C. C	
Whitelaw,  W.  A	
-"■V-*-V T-
209 OSLER LECTURE,  1950—Men of Osier's  Time—G.  A.  Davidson  183
OSLER,  T.  R.—Physiology and Endocrine Relationships of  the Thyroid  112
ORTHOPEDIC  SURGERY,  The  New  World  of—R.  Watson-Jones   (reported)  160
OSMUN,   P.   M.—Sinusitis -   161
PAIGE,  B.  F.—Treatment  of  Hyperthyroidism  114
PALMER,  R.  A.  et  al—ACTH and  Cortisone ■-  308
PITTS, H. H—Tumors of the Neck  255
PSYCHOTHERAPY  (Group), in the  Treatment of Alcoholic Addiction—A.  J.  Schulman 274
RADIO-IODINE—A.   J.   Wood  201
RADIOACTIVE ISOTOPES, Recent Developments in the Use of—S.  H. Zbarsky  252
RANSFORD,   P.   M.—Cretinism -  152
RENNIE, C.  S.—Amyloid Disease  107
ROBERTSON,  A.   E.—Haemorrhagic  Diseases .-.  278
ST.  PAUL'S  HOSPITAL,   General  Practitioners  Section     14
ST. PAUL'S HOSPITAL—Premature Unit  106
SHALLARD,  BRUCE—Treatment  of Aortic  Aneurysm     70
SHOES, X-Ray Machines for Ftting—J. H.  MacDermot ,  243
SHULMAN, A. J.—Group Psychotherapy in the Treatment of Alcoholic Addiction  274
SIDALL, J.  R.—Exophthalmos Related to Hyperthyroidism     36
SILICOSIS IN B.  C.—C.  H. Vrooman     80
SINUSITIS—P.   M.   Osmun    161
SKINNER, F. L.—Summary of Lecture on ACTH and Cortisone by J. S.  L. Browne  148
SPECIALISTS,  Recognition of—College of Physicians and Surgeons of B.  C     58
STOKES   JOHN H.—The Practitioner and the Antibiotic Age of Veneral Disease Control    88
STOMACH,  Blood  Vessels  of—F.   H.   Bentley   (reported)  208
STRONG, G. F.  et al—ACTH and Cortisone  308
SYPHILIS, Interpretations of Serology in Diagnonis of—C. L. Hunt  291 i
TELFORD, D. and FRASER,  G. A.—Non-specific Mesenteric Lymphadenitis  ^86
THOMAS, J. C,  TURNBULL,  F.  and McCOY,  E.  C.—Hospital Insurance—
Whither Bound?  .- -  139
THYROID, Physiology and Endocrine Relationships to—T. R. Osier  112
THYROID, Surgery of—L. W. Warcup ..--.  117
TURNBULL, F.,   THOMAS,  J.  C. and McCOY   E.  C.—Hospital  Insurance—
Whither   Bound? pSI - -  139
TURVEY,  S.  E.  C.—Dyslexia |  15
UNIVERSITY OF BRITISH COLUMBIA—ACTH and Cortisone  (letter)—J. Eden  216
UROLOGIC   SURGERY,   Recent  Advances—C.   A.   Cawker..'     19
UTOPIA, Past and Present—Perhaps to Come—H.  H. Murphy     40
Cases of Communicable Diseases Reported—2, 31, 55, 103, 127, 155, 178, 211, 237, 268,  298
Annual   Meeting,   1950 1  215
Annual  Reports  220
Co-ordinating  Committee  on  Meetings,   Report       5
Executive Committee  Report—Summer   months,   1949        7
Summer School Committee Report, 1949       8
VENEREAL DISEASE CONTROL,  The Practitioner and the Antibiotic Age of—
J.   H.   Stokes —-JtL .[S- i^Slpp      88
VROOMAN, C. H.—Silicosis in B. C     80
VUESCHAR.  J.  A.—see Lueschar,  J. A.
WARCUP, L. W.—Surgery of the  Thyroid  117
WARREN,   A.   J.   et  al—ACTH  and  Cortisone :  308
WATSON, C. J.—Some Fundamental and Clinical Aspects of the Problem of
Hepatic   Cirrhosis   (reported) ~  234
WATSON-JONES, R.—The New World of Orthopedic Surgery  (reported)  160
WEAVER, M. M.—Quid Pro Quo in Medical Education  134
WHITBREAD,   J.   D.—Act  Respectiong  Coronors     79
WILSON,   REGINALD   et   al—ACTH   and   Cortisone  308
WOOD,   A.   J.—Radio-Iodine -•.  201
X  Y  Z
ZBARSKY, S. H.—Recent Developments in Use of Radioactive Isotopes  252
Published By
The Vancouver Medical Association
dr. j. h. MacDermot
Editorial and Business Office
203 Medical-Dental Building
Vancouver, B. C.
Publisher and Advertising Manager
OFFICERS, 1949-50
Dr. W. J. Doebance       Db. Henby Scott
President Vice-President
Db. Gordon Burke
Hon. Treasurer
Dr. Gordon C. Johnston
Past President
Dr. W. G. Gunn
Hon. Secretary
Additional Members of Executive:
Dr. J. C. Grimson Db. E. C. McCoy
Db. Gi H. Clement Db. A. C. Fbost Db. Mubbay Blair
-   Auditors: Messrs. Plommer, Whiting & Co.
Dr. M. M. MAcPHERSON-Chairman Db. W. H. S. Stockton Secretary
Eye, Ear, Nose and Throat
Db. J. F. Minnes Chairman Db. N. J. Blaib . Secretary
Db. J. R. Davies. Chairman Db. C. J. Tbeffby Secretary
Orthopaedic and Traumatic Surgery
Db. R. H. B. Reed Chairman Db. D. B. Stabb ..Secretary
Neurology and Psychiatry
Db. G. H. Gundby. Chairman De. G- M. Kirkpatbick—Secretary
Db. W. L. Sloan Secretary De. Andbew Tubnbull Chairman
Db. R. A. Palmeb, Chairman; Db. E. F. Wobd, Secretary; Db. J. E. Walkeb;
Db. S. E. C. Tubvey; Db. A. F. Habdyment; Db. J. L. Pabnell.
Summer School:
Db. D. S. Munboe, Chairman; Db. A. C. Gaedneb Fbost, Secretary;
Db. E. A. Campbell; Db. J. A. Ganshobn; Db. Gobdon Labge;
Db. Peteb Lehmann.
Medical Economics:
Db. J. A. Ganshobn, Chairman; Db. Paul Jackson; Db. W. L. Sloan;
De. E. C. McCoy; Db. J. W. Shieb; Db. T. R. Sabjeant; Db. John Fbost.
Db. H. A. DesBbisay; Db. G. A. Davidson; Db. Gobdon C. Johnston.
Representative to B. C. Medical Association: Db. Gobdon C. Johnston.
Representative to V.O.N. Advisory Board: Db. Isabel Day.
Representative to Greater Vancouver Health League: Db. L. A. Patteeson
Representative to the Board of Trustees for the Medical Care of
Social Assistance Cases: Db. J. A. Ganshobn Special notice to Members
We are now engaged in enrolling members of your professional group in a disability program that provides protection,
which gives LIFE-TIME BENEFITS and is not subject to cancellation on account of age, leaving you without protection when your
loss of time is most valuable. It pays benefits for one day or
more; it covers all sicknesses and every disease except insanity
and venereal diseases. It provides a total-disability provision for
either sickness or accident for One-Day to LIFE-TIME BENEFITS.
This plan does not terminate at the age of sixty as do most
policies, and may be continued as long as you remain in your
profession regardless of age. The Non-Cancellable Guaranteed
Renewable feature assures you a plan of income protection as
long as you remain in your profession.
Under this plan we underwrite the loss of your income because of illness or accident NOT JUST FOR ONE YEAR BUT
FOR LIFE—as long as you live. This program will give you an
income of $200.00 per month, $2400.00 per year, which is
equivalent to an income of 4% on an investment of $60,000.00.
For Complete Information, Write or Phone
British Columbia Branch Office
Telephone PAcific 3848
Founded 1898; Incorporated 1906
Programme for the Fifty Second Annual Session
(Fall Session)
AUGUST   30th—SPECIAL  GENERAL  MEETING—Discussion  of  "Medical  Economics."
OCTOBER 4th—GENERAL MEETING—"Cardiac Radiology," Sir John Parkinson,
London, England.
OCTOBER 18 th—CLINICAL MEETING—Vancouver General Hospital.
NOVEMBER 1st—GENERAL MEETING—"Medical Economics."
NOVEMBER—"ANNUAL DINNER"—Wednesday, November 23rd.
DECEMBER 6th—GENERAL MEETING—"Quid Pro Quo in Medical Education",
Dr. M. M. "Weaver, Dean, Faculty of Medicine, University of British Columbia.
DECEMBER 13 th—CLINICAL MEETING—Shaughnessy Hospital.
All General Meetings will be held in the
FAir. 0080
NW.   60
Page 1
Hi m
Oral Penicillin
in PediatrieiPractice
148 children from 8 months to 10 years of age were given
50,000 I.U. of oral penicillin before breakfast and supper each day
for 12 months. Their average number of febrile days decreased
from 16.76 in the previous year to 4.24. A control group of
100 children experienced no reduction over the previous year1.
143 infants and children with acute respiratory infections were
treated with tablets of crystalline potassium penicillin G.
In 65.7%, fever subsided within 24 hours and clinical improvement
occurred. Fair results were achieved in 18.2% and poor in 16.1%2.
There are two forms of Ayerst penicillin tablets available
especially for pediatric use. Each tablet contains 50,000 I.U.
Potassium Penicillin G (crystalline).
possess a pleasant mint flavor and may be taken alone
or mixed with fruit juice or jam.
Supplied in vials of 6 or 12.
are designed for rapid disintegration in the infant's
formula or other liquid.    Supplied in vials of 12.
i. Lapin, J. H.:J. Pediatrics 32:iiq (February) 1948
i. Hoffman, W. S.: J. Pediatrics 32 :i (January) 1948
Other "Cillenta" Products indude:
Ayerst,   Nic
Total   Population—Estimated 376,000
Chinese Population—Estimated I       7,455
Hindu Population—Estimated  275
Total deaths I     322
Chinese deaths _^_       12
Deaths, residents  only 291
August, 1949
Rate Per 1000
BIRTH REGISTRATIONS—Residents and Non-residents:
(Includes Late Registrations) '^^
Male . 474
Female , 463
August, 1949
Deaths under 1 year of age	
Death rate per 1000 live births	
Stillbirths   (not incuded in above item).
August, 1949
Number   Rate Per 1,000 Population
Scarlet Fever	
Diphtheria l_
Diphtheria Carriers-
Chicken Pox	
Mumps -„..,
Whooping Cough	
Typhoid Fever	
Undulant Fever	
Infectious Jaundice.
Salmonellosis Carriers.
Dysentery Carriers-
Cancer (Reportable):
, 1948
Page 2 m
Liver Extract Injectable is prepared specifically for the treatment of
pernicious anaemia. The potency of this product is expressed in units
determined by actual responses secured in the treatment of human cases of
pernicious anaemia. Liver Extract Injectable as prepared in the Connaught
Medical Research Laboratories has the following advantages:—
1. Assured potency—Every lot is tested on cases of
pernicious anaemia.        ill
2. High concentration of potency—Small dosage
and less frequent administration.
3. Low total solids—Discomfort and local reactions
occur very infrequently because of the high purity
of the product.
Liver Extract Injectable (15 units per cc.) as prepared by the
Connaught Medical Research Laboratories is supplied in packages containing
single 5-cc. vials and in multiple packages containing five 5-cc. vials.
Liver Extract for Oral Use in powdered form is supplied in packages
containing ten vials; each vial contains extract derived from approximately
one-half pound of liver.
University of Toronto Toronto 4, Canada
MEDICAL-DENTAL BUILDING, VANCOUVER, B. C. Recent developments in Great Britain seem to indicate at least some small rifts, if
not definite cracks, in the new structure of medical care. We note with interest that the
government proposes to charge the patient a shilling for each prescription filled in
future. This may not seem a very radical procedure, but in reality it looks to us like a
very far-reaching step. The government is apparently beginning to realise the fact that
"free" medical care is no more free than is the kind that is paid for by the individual—
only that the cost is distributed. And actually this cost can be a great deal higher. The
experience in Australia and New Zealand, if we are to believe all we hear, bears this
statement out.
One reads of patients getting more glasses than they need—two or three sets of
false teeth at a time, and so on—and added together, these items of waste put a very
great additional burden on the Health Insurance Scheme. But, given a condition of
affairs where the sky is the limit, and everyone can have what he asks for, this was
bound to come. It has been an open secret for quite a while that the scheme has been
costing far more than the country can properly afford. And we cannot but hope that
the powers that be in this country, and the United States, will take careful note of these
things. No amount of wishful thinking, no amount of academic theorizing, can make
it possible to buy a dollar's worth of anything for fifty cents. And nothing can make
good modern medical care cheap. We can make it available, perhaps, but we cannot
make it cheap. One way or another the cost must be paid for. We agree that all possible
checks and safeguards should be applied, that it should be made possible for everyone
to have full medical care at a cost they can afford, by whatever scheme it is given, but
we do not believe that any plan which allows for reckless and uncurbed waste, and
that adds tremendous operational overhead expense through a huge administrative force,
can end eventually in anything but financial disaster.
The world is full of good and well-meaning folk who dream of Utopias, and
proceed to preach their doctrine, with promises that if it be only embraced, all want and
misery will disappear for ever. The public, beset by constant worry and anxiety over
financial matters, by everlasting and mounting taxation, is only too ready to listen to
these rosy promises. But Utopia (its very name means that there is no such place) cannot be given—it must be earned, and the earning is a long and painful process. Mankind ever seeks the shortcut, the easy way, and hopes for miracles, which the do-gooder
readily promises to perform. History shows no successes, however, along this line. This
is not meant to say that we should not go on aiming high and trying to improve things—
but it must be done gradually.
Dr. H. H. Murphy of Victoria, has sent us a paper he read before the Victoria
Medical Society recently on "Utopia" and we hope to publish it very soon. It deals
with the history of Utopias, and from it one derives a feeling that this habit of mind
which dreams of a perfect state achieved without any effort on the part of the beneficiaries, and controlled and administered by a few superior minds, is a very bad and
dangerous thing. It is at the base of Nazism, Communism, Marxism, and all the other
isms that beginning with assurances of Heaven upon earth for all, end eventually in the
realisation of Hell upon earth for most of the people concerned. But we are getting too
far afield. We recommend very heartily Dr. Murphy's paper, written in the scholarly
style that all who know him have come to associate with his speeches or writings. If any
of us has any leanings towards Utopia, history is a very great disillusioner, and this brief
history of Dr.  Murphy's will do a good deal to clear our thinking an the matter.
Page 3 \,i
VancouverlMedical   Association
President  Dr. W. J. Dorrance
Vice-President Dr. Henry  Scott
Honorary Treasurer Dr. Gordon Burke
Honorary Secretary... Dr. W. G. Gunn
Editor I Dr. J. H. MacDermot
The American Goiter Association again offers the Van Meter Prize Award of Three
Hundred Dollars and two honorable mentions for the best essays submitted concerning
original work on problems related to the thyroid gland. The Award will be made at the
annual meeting of the Association which will be held in Houston, Texas, March, 9, 10
and 11, 1950, providing essays of sufficient merit are presented in competition.
The competing essays may cover either clinical or research investigations; should not
exceed three thousand words in length; must be presented in English; and a typewritten
double spaced copy in duplicate sent to the Corresponding Secretary, Dr. George C.
Shivers, 100 East St. Vrain Street, Colorado Springs, Colorado, not later than January
15, 1950. The committee, who will review the manuscripts, is composed of men well
qualified to judge the merits of the competing essays.
A place will be reserved on the program of the annual meeting for presentation of
the Prize Award Essay by the author, if it is possible for him to attend. The essay will
be published in the annual Proceedings of the Association.
Dear Mr. MacDermot:
The British Columbia Academy of Sciences would deem it a favor if you would
kindly bring the attention of the members of the Medical Association to the program
of lectures enclosed. We are anxious that all interested may receive a cordial invitation
to our meetings, which are held on the second Thursday of each month at 8.15 p.m. in
Room 202 Physics Building at the University.
While all the topics are very worthwhile the one selected by Dean M. M. Weaver,
"Medical Education" (Oct. 13) and the subject "The Modern Concepts of Arthritis"
by Dr. A. W. Bagnall and Miss Mary Pack (Mar. 9) should be of particular interest to
the members of your Association.
Any publicity you could give through the Bulletin would be greatly appreciated.
Yours very truly,
D. J. Wort.
Thursday, October 13—Medical Education—M. M. Weaver, Ph.D., M.D., Dean, Faculty
of Medicine, University of B.C.
Thursday, November 10—Birth of an Oil Field and Crude Oil Distillation—films and
commentator, Shell Oil Company.
Thursday, December 3—Land and Land Utilization—C. A. Rowles, Ph.D., Department
of Agronomy, University of B.C.; D. H. Turner, Ph.D., Assistant to the Deputy
Minister of Lands, Victoria.
Thursday, January 12—Open House, Department of Physics, University of B.C.—
G. M. Shrum, O.B.E., M.M., E.D., M.A., Ph.D., F.R.C.S., Chairman of the Department.
Page 4 Thursday, February 9—The. Biology and Conservation of Salmon—F>_Neave, M.A.,
Senior Biologist, Pacific Biological Station; E. S. Pretious, M. Sc, Department of
Civil Engineering, University of B.C.
Thursday, March 9—The Modern Concepts of Arthritis—A. W. Bagnall, M.D?, Chairman, Arthritis Section of B.C. Medical Association; Mary Pack,"-Executive Secretary,
B.C. Division, Canadian Arthritis and Rheumatism Society.
This committee was formed in April, 1949, on authority of the Executive of the
Vancouver Medical Association. The purpose of the Committee was "to coordinate the
meetings of the various medical societies and sections in Vancouver." The Chairman was
given authority to appoint the members of the Committee and the following have served:
Drs. F. L. Whitehead, Gordon Large, Henry Scott, F. L. Skinner and the undersigned.
The following were considered by your committees:
1. The setting up of some central clearing house or committee or office whose purpose it would be to list all medical meetings in Vancouver.
2. Publicity of Meetings.
3. The Regularly Scheduled Meetings of the Vancouver Medical Association.
4. The Summer School.
5. The application of the recommendations of this committee to the meetings of the
British Columbia Medical Association.
1. Central Clearing House or Registry
With the great increase in the number of doctors in this area and the great increase
in medical organizations, there has been a corresponding increase in the number of
meetings of medical interest. In the past, it has not always been possible to avoid clashes
in dates of these meetings. It is the feeling of the committee that some sort of central
registry for meetings should be established. Every medical organization should be advised of this registry and be encouraged to report to the registry each meeting it plans
to hold. The Registry would then ensure that adequate dates had been chosen or suggest
alternate date. It is recommended that each medical organization be asked to report to
the Registry as follows:
1. In September of each year, an outline of its proposed meetings for the ensuing
academic year.
2. %)n the first of each month, the organization should report in detail its meetings
for the following month. This detail should include the time of the meeting, the place,
the speakers and subjects, etc.
2. Publicity of Meetings
The Registry of meetings should endeavour to publicize as far as is possible all
medical meetings in Vancouver. The chief recommendation of the committee in this
regard is that the "Bulletin" should be asked to publish monthly two calendars—1. The
first calendar would be an outline of all meetings for the year. 2. The second Calendar
would be a monthly calendar and should be very detailed with respect to every meeting
to be held in the following month.
It is felt that such publicity would ensure that everyone was aware of all meetings
and that any individual could make plans in advance to attend the meetings of his
Page 5 3. The Regularly Scheduled Meetings of the Vancouver Medical Association
These are now held on the first and third Tuesdays of each month. The general
meetings of the Association are held on the first Tuesday and it is on this date that the
annual meeting, various dinners and so on are held.
The third Tuesday has been the time for the meeting of the Clinical Section. This
clinical meeting has usually been held at one of the Hospitals in the city. Because of
the growth and development of the staff of the various hospitals, this clinical meeting has
often been a "joint meeting" of the Clinical Section and the Staff of the particular
hospital. If the meeting has not been a "joint meeting," the result has often' been two
clinical meetings in one of the hospitals in one month—both put on by the same group
of men. The Committee therefore feels that the meetings of the Clinical Section are
unnecessary and recommends that the Clinical Sction be abolished.
Shaughnessy Hospital staff holds its meeting on the second Tuesday of each month
and the General Hospital meeting is on the fourth Tuesday. The committee feels that if
St. Paul's Hospital was to hold its clinical meetings on the third Tuesday of each month,
a permanent schedule of Tuesday night meetings would be established to the advantage
of all.
4. The Summer School of the Vancouver Medical Association.
The Summer School is perhaps the most important of all the educational activities,
of the Association. It was first held in 1919 and has been an eminently successful institution. A list of the names of its distinguished speakers throughout the years would constitute a veritable "Who's Who" of North American Medicine. That the Summer
School is still an essential part of medical life in Vancouver is evidenced by the fact
that 294 men attended the 1949 sessions.
In spite of these considerations, in. recent years considerable criticism has been directed
at the Summer School. This criticism may be largely received into the following
1. That it has not progressed with the times. No essential change has been made
in its character in its 27 years of existence.
2. The Summer School is no longer necessary-because its functions have to a large
extent been taken over by the highly developed staffs of the various hospitals in Vancouver, by the several post-graduate courses offered in Vancouver by various organizations
—e.g. Shaughnessy Post-Graduate Course—Paediatrics Refresher Course, etc., and by the
meetings of the Specialist Societies.
3. That it offers little to certain groups of specialists who have their own specialized
meetings to attend.
4. That it makes no use of home talent. This criticism has been made mostly by
visiting speakers.
In spite of these arguments, your committee feels that the Summer School remains a
required educational activity of the Association. Your committee feels however that
certain changes should be made and wishes to make the following recommendations:
1. That the Summer School should be carried on as usual with the usual team of
visiting speakers. That each year, the Summer School Committee should continue to
strive to obtain the best speakers and to vary the type of programme.
2. Each year, two or more Specialist Societies or sections be invited to meet during
the week of the Summer School. No one Specialist or Section should be invited more
often than every second year.
3. That the Scientific sessions of the Specialist Society or Section be open to all
practitioners attending the summer school.
4. That the fee collected for the Summer School be the only fee charged for attending the meetings of the Summer School and those of the Specialist Societies or Sections.
The Specialist Society or Section would of course charge its members its usual fees.
Page 6 5. That the Vancouver Medical Association import gratis for the meeting of the
Specialist Society or Section any speaker of their choice from any place in North
6. That the Vancouver Medical Association provide gratis a meeting place for
the Specialist Societies or Sections.
7. That for 1950, the offer be made to two Specialist Societies' or Sections.
The Committee feels that such an arrangement would greatly augment the educational value of the Summer School and that it would have wide appeal. It would offer
the man attending the Summer School the added knowledge to be obtained at the
Specialist meetings. To the Specialist, there would be the attraction of being able, at
least on some years, to attend his own meeting as well as that of the Summer School all
in one week—more education with less travelling and less time away from his practice.
The Specialist organization would have the great advantage of a distinguished imported
speaker (few Specialist Societies can afford such a luxury) and of a free meeting place.
The arrangement also offers a means of using home talent because of the bulk of the
programme of the Specialist Society meeting is and would be presented by local men.
The Vancouver Medical Association stands to gain under such an arrangement. Its
important educational duties would be enhanced and it would be the sponsor of a grand
clinical week in Vancouver. Very little extra cost is entailed and this would be easily
overcome by increased attendance at the Summer School. There would be no extra cost
for Speakers but the Speakers would have to work harder.
5.   The Application of the Recommendations of this Committee to the Meetings
of the British Columbia Medical Association.
Dr. F. L. Whitehead was one of the members of the Coordinating Committee and
it was his opinion that a similar arrangement as that proposed for the Summer School
should be brought into effect for the annual convention of the British Columbia Medical Association. The Committee concurred and it is our feeling that meetings of the
various Specialist Societies or Sections could also be held during the week of the British
Columbia Medical Association meeting under much the same arrangements. The same
advantage would result for all concerned. It is therefore recommended that a copy of
this report be sent to the President of the British Columbia Medical Association.
This report accepted at general meeting, Vancouver Medical Association, October
4, 1949.
||| pfc Si
Five regular meetings were held during the summer months and the regular business
of the^.ssociation was kept up to date.
A special meetings of the Vancouver Medical Association, a "Medical Economics"
meeting, was held Tuesday, August 30th, in order that the material might be ready for
the Annual Meeting of the British Columbia Medical Association which was held in
Victoria, September 27th to 30th.
Considerable time was spent on the finances of the Association and satisfactory
action taken regarding space and rental amounts. The special Committee on finances is
still working in conjunction with the Publications and Library Committees and a great
deal of discussion took place at each meeting with regard to the erection of an Academy
of Medicine Building. The Executive feels the urgent need for such a building and together with the Library Committee have taken adequate steps to bring the matter to a
The Annual Dinner Committee have been appointed, with Dr. J. C. Thomas as
Chairman.  Arrangements are being made to hold the dinner the latter part of Novem-
Page 7 W:
ber.   Programmes for the Fall and Winter sessions have been arranged by our Vice-
President, and we think it will prove interesting throughout.
The Coordinating Committee, under the able Chairmanship of Dr. D. S. Munroe
have done excellent planning, and their report will be presented at this meeting.
We wish to announce that the Executive Committee have changed their meeting
time. The members have dinner in town and meet immediately after in order that a
full evening may be devoted to the affairs of your Association.
Respectfully submitted,
W. G. Gunn, M.D., Hon. Sec.
The Annual Summer School of the Vancouver Medical Association was held on
May 31st to June 4th inclusive. The distinguished group of speakers included the
Dr. D. L. C. Bingham, Professor of Surgery, Queen's University, Kingston, Ontario.
Dr. Alexander B. Hepler, Senior Visiting Urologist, Children's Orthopedic Hospital,
Consultant and Visiting Urologist at the Swedish Hospital, Seattle^ Washington.
Dr. P. E. Ireland, Professor of Oto-laryngology, University of Toronto, Toronto,
Dr. John A. Luetscher, Jr., Assistant Professor of Medicine, Stanford University,
San Francisco, Cal.
Dr. John L. McKelvey, Professor of Obstetrics and Gynaecology, University of Minnesota, Minneapolis, Minn.
In addition the following Vancouver men took part in the one Round Table discussion on Peripheral Vascular Disease:
Dr. Rocke Robertson
Dr. T. R. Sarjeant
Dr. H. B. Graves
Dr. Murray Baird
The total registration was 294 and of these 257 were paid admissions. This figure
is 65 more than last year.
The net profit for this year was $462.57 in contrast to a loss of $178.68 in 1948.
This brings the net profit to the Vancouver Medical Association for the last nine years
to a total of $1,057.06.
The Committee feels that the Summer School is a very important educational institution—the most important educational activity of the Vancouver Medical Association.
It therefore recommends:
(1) That ways and means of increasing the value of the Summer School to an ever
increasing number of medical men be continuously studied. A start in this direction has
already been made by the Committee on correlation of meetings of the Vancouver
Medical Association.
(2) That serious consideration be given to changing the locale of the meeting. This
recommendation is prompted primarily by the ever increasing cost which the Hotel
Vancouver autocratically charges for its space, and secondarily by the fact that each of
the three large hospitals in Vancouver and the Division of Tuberculosis Control now has
a very good auditorium, and each would be provided gratis.
All of which is respectfully submitted.
D. S. Munroe, Chairman.
Page 8
SOCIETY     .    -f|    p; ■ "t|g|
74 Sparks Street, Ottawa, Ont.
A sixteen-page booklet  "Arthritis—Plan for Attack" has  been published  by  the
Canadian Arthritis and Rheumatism Society recently.   Prepared With the advice and
approval of the Society's Medical Advisory Board, the booklet will be of interest  to
many members of the medical profession.
The pamphlet is concerned with the problem of rheumatic diseases in Canada, a plan
for a concerted attack upon them is presented, and the role of the Canadian Arthritis
and Rheumatism Society is discussed. An extract from the booklet's preface indicates the
general nature of the Society's aproach to this problem; "In preparing this Plan, the
Canadian Arthritis and Rheumatism Society has been deeply conscious of the magnitude
of the problem which arthritis presents. It has been equally aware that a very great
deal can be done, to relieve both the suffering of individuals, and the present drain on
the nation's economy.
It is also recognized that a plan of attack on arthritis can be carried out only through
the effective co-operation, interest and participation of many agencies and groups,
notably the medical profession, health and hospital authorities, medical schools and the
general public. The Plan herein proposed discusses the role of such groups in a coordinated attack, and describes the Society's own position in relation thereto as but
one active part of a great whole."
Copies are available free from the Canadian Arthritis and Rheumatism Society, 74
Sparks Street, Ottawa.
Ottawa, Aug. 12.—The recent revision of the food and drug regulations (P.C. 1536,
5 th April, 1949) has effected a clarification of the so-called prescription drug order
which limits sale to the general public of certain drugs to prescription only, officials of
the Department of National Health and Welfare point out.
1. One obscurity has been removed by the definition of prescription which has to be
in writing. A telephoned order does not constitute a prescription, but a pharmacist may
execute an order over the telephone in an emergency for any of the drugs in question
provided he be supplied with a written prescription covering them within 24 hours. If
he fails to obtain that prescription, he has' committed an offense under the Food and
Drugs Act: he has sold the drugs otherwise than on prescription.
2. Tn the food and drug regulations, a prescription is defined (A.02016) as "a
written order issued and signed by any person authorized to treat patients with drugs in
any province of Canada directing the dispensing of a stated amount of any drug or
mixture of drugs to the patient named in such order." This prohibits refills, but the
prescriber is free to specify in writing how many times it may be repeated, e.g., twice,
five times or 10 times, as need be, and the pharmacist is entitled to honour such directions.  But the actual number of refillings must be specified on the original prescription.
3. A pharmacist is within his rights to decline to fill a prescription if he has reason
to believe it has not been presented in good faith or that it is an attempt to circumvent
the law or that it has been tampered with. In such cases, tactful questioning usually
brings out the facts. WjM
4. Seeing that a pharmacist is responsible for having in his possession properly authorized prescriptions for drugs on this list which he has sold, it is the duty of prescribers
Page 9
Iii! to supply such prescriptions immediately. As the merchant sells goods on credit, believing in the honesty of the purchaser to pay for them, so likewise the pharmacist,
accepting a telephone order for these drugs in an emergency, relies, on the good faith of
the prescriber to cover him with a prescription within 24 hours after giving the order
for them. Prescribers, therefore, are urgently requested to cooperate with pharmacists
in this important detail. (This does not apply to narcotics of the opium derivative group
• • • • •
POST-GRADUATE SCHOLARSHIP of $1500.00 is offered to a Canadian medical
woman for 1950-1951.  The grant will be made in April, 1950.
This grant is being made by the Western Canada Region of Soroptimist Clubs,
which is interested in fostering improved medical care in general in Canada, and particularly in supporting the work of Canadian medical women.
The object of this grant is to promote special training in any field of Medicine for a
Canadian medical woman, subject to the following conditions:
1. The applicant is to be a woman whose graduation from a Canadian medical college
has been within five years* of application.
2. The grant is to be used for purposes of post-graduate training in the special field of
the applicant's choice.
3. Such post-graduate training need not necessarily be obtained in Canada, but preference will be given to applicants who show intention of carrying on medical work in
Canada on completion of such training.
4. Application is to be made in writing, giving details of name; address; age; date of
graduation; name of medical school; details of medical work since graduation; details
of proposed training for which scholarship is intended. Two recommendations attesting character and ability are to accompany application.
5. Application is to be made in duplicate to: Mrs. Anna Sprott, Chairman, Selection
Committee, 812 Robson St., Vancouver, B.C., not later than January 15, 1950.
Further information available by writing the undersigned or Chairman Selection
Greta K. Currie,
Director, Western Canada Region,
Sorootimist Club.
Monday, Wednesday and Friday. 9:00 a.m.—9:30 p.m.
Tuesday and Thursday , 1 _.9:00 a.m.—9:00 p.m.
Saturday    9:00 a.m.—1:00 p.m.
Recent Accessions
A Clinical Atlas of Venereal and Skin Diseases (two volumes) 1889 (Gift from Dr.
A. J. MacLachlan).
Ciba Collection of Medical Illustrations by F. H. Netter  (Gift).
Manual of Serologic Tests for Syphilis, prepared by the U.S. Venereal Disease Laboratory,
U.S. Public Health Service, 1949.
Symposium on Recent Advances in Medicine, Medical Clinics of North America, September, 1949.
Page 10 Symposium on Traumatic Surgery, Surgical Clinics of North America, August, 1949.
Surgical Anatomy by Joseph Maclise, 1851  (Gift from Dr. A. J. MacLachlan).
Among the accessions listed above are three volumes which have been donated by
Dr. A. J. MacLachlan and we publish below the letter of thanks and appreciation sent
to him on behalf of the Library Committee:
October   14th,   1949.
Dr. A. J. MacLachlan,
925 West Georgia Street,
Vacouver, B. C.
Dear Doctor MacLachlan:
May I, on behalf of the Library Committee, thank you very sincerely for the volume
on Surgical Anatomy, 1851, and the two volumes on Venereal and Skin Diseases, 1889,
which you recently donated to the Library.
Your gesture in presenting these volumes to the Library is greatly appreciated as
the Committee feels that such gifts as these make a most acceptable acquisition to a
medical library and promotes interest in the historical aspects of medicine.
Yours very truly,
(Sgd.) E. FRANCE WORD, M.D.,
Secretary, Library Committee.
The list of journals taken by the Library is quite an extensive one and in view of
this fact, the Library Committee think it would be helpful to members to present a list
of the journals in the various .fields and the following is for those primarily interested in
American Journal of Surgery.
Annals of Surgery.
Archives of Surgery.
British Journal of Surgery.
Journal of Bone and Joint Surgery.
Journal of the International College of Surgeons.
Journal of Thoracic Surgery.
Journal of Urology.
Surgery, Gynecology and Obstetrics.
Western Journal of Surgery, Gynecology and Obstetrics. §J||
g| Luisada, A.A.: Williams & Wilkins Co.: Pp. 653: 1948
Dr. Luisada was formerly Professor of Medicine at Ferrara, Italy. He is at present
lecturer in Medicine at Tufts College Medical School in Boston. He has published a
new text on diseases of the heart which differs in some, particulars from the former
standard texts. He deals briefly with the development and physiology of the heart. A
long chapter is devoted to the technical study of the cardiac patient with particular
reference to cardiography, phonocardiography and various recordings of pressure curves.
The diseases causing valvular defects, particularly rheumatic heart diseases, are dealt
with at considerable length and there is a mass of detail concerning the mode of origin
of heart murmurs and other abnormal heart sounds. Numerous phonocardiographic
recordings are included which illustrate most of the adventitious sounds. This section
of the book is of special interest because of the new role that phonocardiography is
playing in the study of heart disease, replacing for research purposes the subjective
Page 11 impressions yielded by the ordinary stethoscope*. The use of this instrument has altered
some of our conceptions of the frequency and importance of murmurs. In proportion,
a much smaller part of the book is concerned with other diseases of the heart. The section
on hypertension is brief and does not attempt to deal with any of the controversial
questions, such as, the merits of the rice diet or the Smithwick procedure. The section
on diseases of the arteries and veins is hardly more than a list of the various conditions
which are encountered. The book provides a survey of the field of cardiology which will
be of use and interest to those dealing with heart disease. Its main value would appear
to be the extensive illustrations of the various aspects of valvular heart disease.
D. M, W.
President ', Dr. Frank M. Bryant, Victoria
President-Elect Dr. J. C Thomas, Vancouver
Vice-President \ Dr. Stewart A. "Wallace, Kamloops
Honorary Secretary-Treasurer . Dr. J. A. Ganshorn, Vancouver
Immediate Past President Dr. L. H. Leeson, Vancouver
Dr. L. R. Williams
Dr. A. Turnbull
Scientific Sessions:
The following papers were presented at each District Meeting:
Dr. J. C. Thomas (1)     Psychosomatic conditions simulating organic disease.
(1) Haematuria.
(2) Common Problems in Urology.
(1) Importance of X-ray examination of cervical spine  and
(2) Urography in General Practice.
There was lively formal discussion on all papers and a great deal of informal discussion.
At the meeting in Kelowna three of the local men presented interesting cases. Dr.
J. B. Moir presented a case of dual primary carcinoma. Dr. J. A, Rankine, two cases of
head injury with which the local men were forced to deal, in both cases with excellent
results. Dr. Gordon Wilson presented a paper on "Gall Bladder Surgery." In addition
Dr. George R. F. Elliott presented a paper on the value of penicillin in the treatment of
It is of interest to note that the scientific papers presented were suggested by the
local men at various times during the past year. It may not be known to all members
of The British Columbia Medical Association that these district meetings are planned
at least six months in advance, and it is the aim of the Committee in charge of the
arrangements to obtain speakers on topics which have been suggested by the local district
associations.   Plans for the 1950 Meetings are already under consideration.
Page 12 Business and Economic Affairs:
The following officers were elected:
East Kootenay Medical Association
President—Dr. J. Vernon Murray, Crgston
Vice-President—Dr. T. J. Sullivan, Cranbrook
Secretary-Treasurer—Dr. C. W. M. Brockington, Cranbrook
Representative to B.C.M.A. Board of Directors—Dr. F. W. Green
Representative to Committee Medical Economics—Dr. F. W. Green
Representative to Committee Arthritis and Rheumatism—Dr. C. W. M. Brockington.
1950 Meeting—Kimberley.
West Kootenay Medical Association
Honorary President—Dr. W. A. Coghlin, Trail
President—Dr. Marion Irwin, Kaslo
Vice-President—Dr. Frank Wilson, Trail
Secretary-Treasurer—Dr. G. R. Barrett, Nelson
Representative to B.C.M.A. Board of Directors—Dr. M. Irwin
Representative to Committee Medical Economics—Dr. R. B. Brummit
1950 Meeting—Kaslo.
Southern Interior Medical Society
President—Dr. T. S. Perrett, Kamloops
Vice-President—Dr. J. J. Gibson, Penticton
Secretary-Treasurer—Dr. M. J. Edworthy, Kamloops
Representative to B.C.MA. Board of Directors—Dr. T. S. Perrett   Ufk
Representative to Conunittee Medical Economics—Dr. W. H. White
Representative Arthritis and Rheumatism—Dr. T. P. Watson, Dr. H. P. Barr.
1950 Meeting—Kamloops.
A great deal of interest in the business side of medicine was demonstrated at each
meeting. There are numerous problems facing the profession and it seemed to be the
general wish of the men that more information be made available to them. This fits in
with the policy adopted by the Council of the College at its meeting on October 1st.
An effort to meet this need is being made in the publishing of News Letters containing
a little more of the background to the problems, and by issuing News Letters more
frequently. Doctors are encouraged to comment upon the contents of the News Letters,
particularly if things are not made clear.
Social Activities:
The visiting team were all entertained at all centers, the major affairs being:
Cranbrook—an informal dinner at the Cranbrook Hotel, followed by a social evening
with an informal Round Table on Economics, at the Cranbrook Armouries.
Nelson—the visiting team and local members and their wives were entertained at the
home of Dr. and Mrs. R. B. Brummitt on Tuesday evening. On Wednesday evening
an informal dinner was enjoyed by the visitors and members of the West Kootenay
Medical Association, after which the business meeting took place.
Kelowna—on Thursday evening the visiting doctors and the local doctors and their
wives were entertained by Dr. and Mrs. Walter Anderson at their home. On Friday
evening the members of the profession and their wives enjoyed a banquet at the
Eldorado Arms Hotel.
Page 13 We would like to congratulate Dr. Marion Irwin of Kaslo on her election as President of the West Kootenay Medical Association. Dr. Irwin is the second lady to hold
a position of this nature in the Province.
Scientific Sessions:
The following papers were presented:
(1) Dr. A. M. Hall. "Anaesthesia in General Practice."
(2) Dr. J; C. Thomas. "Psychosomatic conditions simulating organic disease."
(3) Scientific film dealing with "Leucorrhoea."
Business and Economic Affairs
The Upper Island Medical Society elects its slate of officers to serve for a period of
two years, and this is the interval year. The following officers, therefore, will continue
to serve until the annual meeting in the fall of 1950:
President—Dr. C. C. Browne, Nanaimo. ^£-%
Vice-President—Dr. A. B. Hall, Nanaimo.
Secretary-Treasurer—Dr. G. R. Blott, Nanaimo.
Social Events
The visitors and. some of the local men were entertained at the home of Dr. C. C.
Browne at the tea-hour. The business meeting of the Society got underway at 5:00 p.m.,
at the Island Hall, Parksville, and was followed by a delightful dinner.
Value of District Meetings
The attendance at all meetings this year was equally as great as in the past, and in
two cases a great deal better. In one district 90% of the doctors attended the meetings
at some time during the day.
When it is recalled that some men have to travel great distances to attend these
meetings it seems apparent that the local men do look forward to the events and derive
oenefit from them.  This is equally true of those who comprise the visiting team.
The primary purpose of any form of medical scientific meeting is to advance:
knowledge and it is felt that progress is being made.
1 i*
The following notice has been received from Dr. G. A. Lamont, of St. Paul's Staff.  We
believe it will be of considerable interest to our readers.
Recently, action has been taken by St. Paul's Hospital which shows an appreciation
of the importance of the role that General Practitioners should play in the organized
work of the Medical Staff of a hospital. Giving a lead to B. C. hospitals, St. Paul's has
formed a section of General Practitioners in the associate division of its medical staff.
This action is in anticipation of the Canadian Medical Association in creating a General
Practitioner Section thus to be ready to take new members on this basis when this new
development takes place. The closer the association established between them and the
organized specialty groups in a hospital the higher will be the standard of the practice
of medicine and the better the care of the patient. This forward step should be of great
encouragement to the General Practitioners who have been working towards organization and recognition.
DYSLEXIA literally means difficulty in reading but should be broadly applied to
any difficulty in interpreting or understanding language, i.e., speech, reading, writing and
spelling. Perhaps the better clinical name for the condition would be "specific disability,"
and if the difficulty is oniy with reading, it is called "specific reading disability," or
strephosymbolia" (Orton). It is a fascinating problem to try to discover why children
with good vision and of average or superior intelligence should have great difficulty in
learning to read, though they may be proficient in subjects as seemingly more difficult
as arithmetic. The incidence has been calculated by several competent observers to be
between fifteen and twenty-five per cent. This may seem like a large percentage until
one realizes that at least twenty-five per cent of children have difficulty in learning and
that learning difficulty is largely related to reading. Of all the children having some
degree of dyslexia, the number of boys exceeds the number of girls by four to one. It
almost always occurs in children under twelve years of age. Economic, social or community status of the child or his family do not have any bearing on its occurrence. It
is particularly common in the children of professional men.
Abnormal peripheral ocular variations may be the only etiological factor present
or they may be present as an aggravating factor. These include poor vision in one or
both eyesy distant and near phorias, poor adduction or abduction, poor fusion, poor
stereopsis, or no simultaneous binocular vision. However, in these patients whom we are
about to discuss, peripheral vision was either normal or adequately corrected in all, and
eyedness did not seem to play any part in their disability. Parks in the Dyslexia Clinic
in Chicago has stated that seventy-five per cent of these patients have normal vision,
twenty per cent have subnormal vision in both eyes, and five per cent have subnormal
vision in one eye only. In true dyslexia, the incidence of subnormal vision is a relatively
rare finding. The motility of the eye is usually normal, and all the ocular and extra
ocular muscles function well. Fifty-five per cent of children have orthophoria and
forty-five per cent have heterophoria. The favoured eye seems to have nothing to do
with the problem.
There are few or no known facts concerning the etiology of this condition, certainly
no tkrtiories, and everyone who has considered the problem thoughtfully has had to deal in
terms of hypotheses. An hereditary or congenital word-blindness has been postulated
and has been said "to have a basis of pathology in the cerebral cortex," but usually has
been ascribed loosely to "lesions of the brain." I have been unable to find any adequate
investigation of dyslexia occurring in tumours of the cerebral cortex in children. Extreme
caution, however, must be exercised in drawing conclusions from the disturbances,
due tojtumours, abscesses, etc., with regard to the physiology of the central nervous
systems' still more if the disturbances are produced by unilateral lesions. Also, an inherited sex-associated weakness has been suggested because the condition occurs mostly in
boys. It seems too facile to try to explain all these cases on the basis of a psychosomatic
^disorder, even though it is admitted that the emotional training of a child begins a few
minutes after he is born. It has not been explained why these children are usually late
learning to talk, why they are apt to lisp or stutter, why they are apt to be ambidextrous,
or why their family trees also contain many other similar cases in many instances.
Even more fundamentally, it has never been explained why seventy-five per cent of
the human race has been right handed ever since the Stone Age. Blau's statement that
"potentiality for cerebral dominance is inherent congenital capacity, that the choice of
left or right is decided by experience and learning," is undoubtedly applicable to some
instances of dyslexia, but does not explain the basic query "Why must there be cerebral
dominance and why is it more often left than right." Children who are born without
arms have no opportunity to decide by experience and learning which is their cerebral
dominance, yet they can read quite well, and do not necessarily have any language
Page 15 I
difficulty. Re-training of the non-preferred hand to become the dominant one after
disabling accidents can be successful without any emotional complications. It would
seem, according to the psychosomatic concept, that youngsters with reading difficulties,
who have had difficulty in handedness have a difficulty in reading not because of their
handedness problem but have both the reading and the handedness problems because
their earlier orientation in regard to the direction or laterality of their make-up has not
been properly trained by their environment.
It is more than probable that there are several etiologies for this condition. I would
like to suggest the following classification:
Table 1.    1—Hereditary
2—Lesions of the central nervous system
3—Psychosomatic disorders
4—Mixed types. |J||
I would also like to suggest that there are also three types of handedness—hereditary,
acquired, mixed types. Of course, it is possible to maintain that anybody-with obvious
damage to his central nervous system will be the victim of a psychosomatic disorder
on the basis of the "organ-inferiority" complex, but unfortunately for this premise, one
sees far more people with gross damage to their central nervous system dating from
birth, who have no dyslexia than otherwise. This would be the "post hoc propter hoc"
type of argument which can be so fallacious. The individual case must be studied from
the physical, the intellectual, the emotional and the environmental standpoint. The
learning achievements and the work habit must be investigated. In an ideal dyslexia
clinic there should be an ophthalmologist, and internist, a neurologist, a psychiatrist, a
psychologist and a social worker, not to mention the staff for remedial training.
The following six cases have Dyslexia of varying degrees and all have normal peripheral vision and fusion, normal or above average intelligence, but it is difficult to find
any common denominator to explain their handicap. Four of them were referred to me
by oculists who found their vision to be normal and had found no defect in their fields
of vision; two were referred to me by general practitioners, one because of severe behaviour disorders and the other because of suspected .mental deficiency and the possibility
of committing him to an institution for the mentally defective.
Case No. 1—Male, aged 8
This child was a full term baby who had a rather severe and definite birth injury
resulting in a left spastic haemoplegia. He walked at two years, used words at 1%
years and formed sentences at two years. He stopped wetting the bed at two years.
Ever since he was four years old his mother had noticed that "he did not seem to see like
other people." Thus, though he could pick a pin off the floor or see a fine spot of dust
across the room, he could not learn to put his alphabetical blocks in order.
On examination, there were fine, athetoid movements of both arms and hands; his
speech was moderately dysarthric. He appeared quite intelligent and co-operative during
the examination but had great difficulty in writing words and could not seem to decide
which hand he should use. However, he could write a number that was spoken to him
and seemed to prefer the left hand. At times, the number might be written in mirror
script and occasionally was reversed. He had done extremely poorly at school but after
explaining the problem to his teacher and to his parents, he was able to pass tenth in his
grade after a year and a half special instruction.
Case No. 2—Male, aged 8
Left spastic hemiplegia with congenital failure of ocular fixation but good visual
acuity and normal fusiorf. His speech was normal. At school he did very well in arithmetic and in those classes in which auditory instruction was the rule, but was unable
to read properly. At times he showed mirror writing, read from right to left at times,
and made the usual absurd mistakes in spelling. Auditory training has helped him
somewhat, particularly to give him an insight into the nature of his condition, but his
Page 16 parents are unable to provide proper facilities for more skilled teaching. At the present
time he is barely able to keep up with his fellows in school although his intelligence is
above average.
Case No. 3—Male, aged 7
Patient has had a spastic paraplegia ever since birth and, according to his parents,
seemed to see quite normally until he started school. At this time he seemed to be unable
to see words on the blackboard or in books and would make varying postural movements
of his head or the book in order to see them. His peripheral vision is normal and his
intelligence is also normal. He was particularly adept at mechanical gadgets, did quite
well in arithmetic and because his parents had read the Bible to him he knew long
passages by rote, but he was still unable to read by himself. He showed some insight
into his problem insofar as he stated that he seemed to be able to see the letters properly
at times but at other times they seemed backwards or upside down. He has only been
training for three months so his progress has not been adequate to make any prognosis.
Case No. 4—Male, aged 10
Mild spastic dysarthria and mild right-sided athetosis ever since childhood, but development otherwise normal. Has always used the left hand in writing and in feeding
himself although his parents state that when he is playing with toys they are fairly
sure that he is right handed. He shows a moderate degree of dyslexia but no mirror
writing. He has failed three years in school and has always resented the implication
that he is "dumber than other kids." He has now had seven months training and is
about the middle of his class at the end of the last term of school.
Case No. 5—Male, aged 9
On examination, this boy is barely of average intelligence but the tests were extremely poor, owing to his lack of co-operation. He has always shown an awkwardness
of both hands and legs but no actual neurological signs could be demonstrated. Because
his parents and school teacher have been particularly intolerant of his reading disability,
he has become quite a problem in behaviour. He has been destructive, fights constantly
with his playmates, has stolen frequently, has rage attacks and is negativistic. He seemed
to be ambidextrous but it was difficult to decide which hand he preferred because of
the generalised awkwardness. At times he would try one hand and at times the other.
In drawing blocked letters he showed mirror and reversal writing. He was able to
perform complicated problems when told to him orally and his school reported that he
is above average in his knowledge of arithmetic. His father states that he is mechanically
Case No. 6—Male, aged 15
This patient is included in this series to demonstrate the possible hereditary role of
dyslexia. He has a disabled right arm due to an injury to his brachial plexus at birth
so that he has always been left handed. He has failed twice in school although his intelligence is above average. His father was exposed to a long and expensive education
but had great difficulty in reaching Grade 6, and it was always recognized in his family
that he never seemed to be able to read properly. The father became a master mechanic
and diesel engineer and has made a good success of life, though his inability to read
properly has persisted, thus it requires over an hour for him to read a short story in
the newspaper, and he rarely has been able to finish a book because he has to scan each
word separately and at times even the simplest words do not seem to make sense to
him. On the other hand, he can perform advanced problems in physics and mechanical
engineering. The patient's paternal aunt and paternal grandfather also are said to have
the same disability in reading. The patient exhibits no neurological signs. He undoubtedly is a moderately severe behaviour problem.
In reviewing these cases, there does not seem to be any common anatomical defect
that would explain the disorder of function.   Instances have been described in which
Page 17
V . ft
occlusion of the angular branch of the Sylvian artery have produced alexia, anarthria
and left-handed mirror writing, though no actual paralysis, aphasia or apraxia had been
present. But here the condition is a loss of function, not a disordered function as in dyslexia. Critchley states that mirror writing is common fn the less severe grades of spastic
diplegia in children, but he does not mention any associated dyslexia. Recently it has
become increasingly obvious that we must revise some of our ideas of the phylogenetic
significance of the lobes of the brain. Thus, the frontal lobes have not enlarged relatively
as much as the parietal or temporal lobes. This makes it doubtful if man's highest mental
functions are a function of the frontal lobes. It is even doubtful if the hippocampus is
concerned with olfactory mechanisms. Le Gros Clark suggests that the frontal cortex
is primarily an afferent projection area comparable with the visual and auditory areas of
the cortex. Chief fibres from the medial nuclei of the thalamus stream into it, especially
area 8 and forwards (cf. slide 1) and to area 24 from the anterior nucleus of the thalamus.  The medial nucleus is a relay station for impulses from the hypothalmus.
It is suggested, therefore, that the visual cortex is the projection area for retinal
activities and that the greater part of the frontal cortex is the projection area for the
hypothalamus via the thalamic nuclei. Areas 8 and 6 have short interconnections but in
dyslexia the role of the motor cortex is negligible; of more importance is the long
association tract between area 8 (the frontal eye-field) and area 18 (the para-striate
area of the occipital cortex). Areas 18 and 17 are also connected by fibres so that the
visual system is intimately connected with the frontal cOrtex. Another long association
fasciculus extends from area .18 to area 20 (in the inferior temporal convolution).
The temporal cortex is unique in that it receives no afferent fibres from the thalamus,
but does from other areas of the cortex and it may well represent the area in which
cortical activities as a whole are co-ordinated.
.The possible role of the suppressor bands of the cortex (19, 2, 4S, 8, 24) in dyslexia
is still conjectural. These are areas in the cortex, which if stimulated, lead to a suppression
of the spontaneous electrical activity of the entire cerebral cortex. Some physiological
derangement of this vaguely understood mechanism could conceivably cause disorders
of cortical interpretations. It is noteworthy that area 8 is the only suppressor area which
gives rise to any callosal fibres and it connects solely with area 18 of the opposite side
while non-suppressor areas giving rise to callosal fibres connect with symmetrically
placed areas in the opposite cerebral hemisphere. A dysfunction of area 8 could interfere
with the proper functioning of visual reception in the cortex.
As stated before the etiology of dyslexia is complex and unknown, but the chief
purpose of this presentation is to bring the few known facts of it to your attention.
Treatment is not only remedial but also preventive. The ideal programme would
include a dyslexia centre and special dyslexia classes in schools for the more severe types
of cases, but usually with cooperation of the school teacher and the parent the milder
cases can do well in ordinary schools. If the patient, the parent and the teachers understand the nature of the disability there is rarely any serious problem in the future
education of these individuals.
Box 404
Six Room House
Separate entrance to Doctor's office.
On acre of land with
landscaped garden.
Phone 18-X-l
"Conservation" sums up the recent advances that are taking place in modern urology.
Reasonable salvage of the urinary tract whenever that is possible has been emphasized.
There has been a constant improvement of diagnostic procedures; more accurate knowledge of renal physiology; and the advent of better urinary antiseptics.
The ability of the kidney to recover following restoration of physiological relationships is truly astounding. It is now generally conceded by urologic surgeons that the
conservation of renal substance is of fundamental importance whenever this can be
accomplished without endangering the life of the patient. Conservative renal surgery
is illustrated by our plastic operations on the renal pelvis and its junction with the ureter
to correct hydronephrosis due to abnormalities in this area. An "attempt to provide
adequate renal drainage is always justified if the age of the patient and the renal parenchyma fulfil their part of the equation. Unsatisfactory results from these operations
are reported as being from 10 per cent to 20 per cent of cases. Ureteral splinting and
nephrostomy or pelviostomy drainage for 3 to 6 weeks is considered to give the best
results. Others favour no splints at all and their results are comparable. These uretero-
pelvioplasties should always be accompanied by a ureterolysis and a nephropexy. Of the
operations in common use, I prefer the Foley Y pelvio-ureteroplasty and the Davis intubated ureterotomy. This latter procedure is readily adaptable to handle ureteral strictures of almost any length, as well as abnormalities at the ureteropelvic junction. Generally speaking, the more simple the technique the better the end results. Gentleness in
handling the tissues, the use of fine instruments and fine sutures all aid the surgeon
to achieve a good result. Uncontrolled infection is the greatest obstacle to a satisfactory
result. The most important principles of plastic renal and ureteral surgery are: preservation of blood supply, the absolute control of bleeding, accurate closure of wounds
without tension, and immobilization. A satisfactory plastic procedure should accomplish relief of pain, satisfactory emptying, improvement in function and anatomic involution. It must be remembered that kidney tissue that has been destroyed cannot be
restored and a large distorted renal pelvis will rarely assume a normal size and contour.
Conservation should still play a part in the management of renal and ureteral calculi.
The formation and growth of calculi in the kidney leads all other pathological processes
in destruction of renal tissue. Approximately one-third of all nephrectomies are due to
destruction precipitated by stones. Calculi are bilateral in from 10 to 20 per cent of
cases, and thus, as far as the kidneys are concerned, calculous disease is almost as dangerous as malignancy. In spite of the fact that our knowledge of the etiology of s ones has
improved and many useful regimens for its control have been practised, urosurgery
plays an exceedingly important part in the treatment of calculi. Mere removal of the
stone is usually readily accomplished, but this is not enough. Partial obstruction with
stasis and infection are practically always associated with stone formation and these
must be sought for at the time of the original investigation and corrected at the initial
operation. Post-operatively, the infection must be cured, otherwise stone recurrence is
almost a certainty. Where complex or almost complete obstruction has existed for
periods longer than 3 months conservative renal surgery is usually a failure. In many
of these cases a complete nephro-ureterectomy is necessary to obtain a symptom-free,
pyuria-free state of health. |i|
In some cases a partial nephrectomy may be successfully done for caliectasis with
stone and evidence of infundibular structure.  Not only does this rid the patient of the
Page 19
'«: .ii '>«
area causing the symptoms and pyuria but it leaves behind good functioning renal tissue.
This procedure is also indicated in some localized renal carbuncles or abscesses. Enucleation of the pysemic area may be practised with the addition of chemotherapy and adequate drainage.
Neoplasm in a solitary kidney has been reported to have been successfully removed.
Reduplication of the pelvis and ureter are often accompanied by destruction of the
smaller upper segment. This too can be successfully removed, leaving behind the
larger, functioning renal portion.
Little progress has been made in the improvement of our end results as judged by
five-year cures. The problem is one of early diagnosis. The mode of approach is
optional. The transperitoneal route and the lumbar routes each have their enthusiasts.
I have used, and have seen others use both approaches. In all cases the pedicle is handled
as much by one route as by the other. Lately the transthoracic route for large inaccessible tumours of the upper pole has been added to our list of approaches. The lumbo-
abdominal extraperitoneal approach of Sweetser seems to have merit above each of the
others. We no longer hesitate to open the vena cava and aspirate when tumour has
been found in the renal vein. This may improve the long range picture. I feel that
post-operative irradiation should be done in all possible cases even though most renal
tumours are rather radio-resistant.
The operation of nephropexy has been, and still is, one of the most abused and yet
the most maligned of kidney operations. In the past, the many cases so treated which
did not give relief caused doubts to arise in the minds of urologic surgeons as well as
the medical profession in general. Added facilities and improvements in method of
diagnosis with better understanding of renal physiology have been available in recent,
years so that the role of nephropexy is more clearly defined. Some centres do not believe
it should be done at all, whereas other surgeons will operate on any mobile kidney if the
patient will consent.
Ptosis is present in from 10 to 20 per cent of females and about 2 per cent of males
but the instances in which there is demonstrable disease and sufficient discomfort to
require operation are relatively few. It must be remembered that all kidneys are mobile
as was intended by nature. Pathological changes in the kidney are not at all dependent
upon the degree of renal mobility—actually it is interference with normal mobility.
Remember that a kidney that is entirely palpable on physical examination may be physiologically normal. The outstanding pathological changes are hydronephrosis and pyelonephritis caused by interference with renal drainage and are usually associated with
adhesions to the perirenal fascia or peritoneum with angulation of the ureter, or kinking
of the ureter over an aberrant blood vessel. These prevent the ureter from descending
with the kidney. When the kidney is excessively movable, rotation on the pedicle may
occur, resulting in the congestion of the kidney.
Nephropexy is indicated when palliative measures have failed, when there is retention
of urine in the renal pelvis, when there is infection of the kidney unrelieved by medical
therapy. Some surgeons add to this where the patient does heavy manual work or takes
part in athletic sports. Palliative treatment consists of attempting to improve the
patient's posture, muscle tone and weight. The kidney is held up in position by intraabdominal pressure and secondarily by the perinephric fatty tissue. A snug, well-fitting
two-way stretch girdle, put on after the patient has been reclining for fifteen minutes
with the hips elevated and put on in that position, will do all and more than any ptosis
belt yet designed. In addition to being more comfortable, it is more useful to your
female patients. Where operative treatment is required, merely fixing the kidney up in
position is insufficient; a ureterolysis must be done and, where necessary, exploration of
the renal pelvis and ureter with appropriate procedures in addition. The older fashioned
method of nephropexy of decapsulating and splitting the capsule of the kidney is not as
Page 20 satisfactory as the physiological nephropexy of Deming. It is obvious to any urologic
surgeon that the kidney is well fixed in position following any kidney operation—all he
has to do is to operate on a kidney previously operated on to confirm this! In addition,
the capsule-splitting operation has the disadvantage of producing a "cellophane" kidney.
As you are well aware, hypertension can develop from renal lesions and this is a probable
way to establish it. Any patient having had a kidney operation other than nephrectomy,
should have his or her blood pressure checked at regular intervals. This would unmask
any such unfortunate occurrence early enough to do a secondary nephrectomy providing
the other kidney is capable of sustaining life. The ureteritis associated with pathological
changes due to nephroptosis will respond to chemotherapy and instrumentation after
Conservation is again the byword. Urography as soon as possible after the injury
will aid in determining the proper course to follow. Excretory urography is preferred,
as a pictorial record of renal function is obtained. Where satisfactory pictures or sufficient information cannot be obtained retrograde study should be carried out without
delay. In any case of doubt, retrograde pyelograms must be obtained. Correlation of
clinical picture, urography, degree of haematuria and lab. findings are necessary. Many
cases will not require operative treatment. Operative treatment should not be put off
when in doubt. The haematoma can be drained, and pulped kidney tissue removed, with
conservation of the remainder of the kidney where feasible. It is also possible to restore
a not-too-badly fragmented kidney to anatomical and functional use by the discreet
use of ribbon catgut slings. After such conservative measures the patient's blood pressure must be followed over the years because of possible secondary changes with cellophane kidney, atrophy, and hypertension. I feel that this is more likely to happen if a
large haematoma is left undrained than if it is surgically evacuated.
Polycystic Disease of the kidneys is always bilateral. In the past, medical treatment
has offered these patients nothing. Death is from renal insufficiency due to progressive
destruction of renal tissue. Surgery cannot change the course of the disease but it can
lengthen the duration of fife and improve the comfort of the patient. The destruction
of renal tissue results from pressure exerted by the gradual increase of the size of the
congenital cysts interspersed throughout the renal parenchyma. It seems to me that it
is logical to operate as soon as the disease is recognized, excise a portion of each superficial cyst, and aspirate as many as possible of the more deeply situated cysts. One can
even inject a sclerosing solution into these cysts, being careful that it does not enter the
renal pelvis or calices. The operation is completed by marsupialization of the kidney
so that the cysts can be re-aspirated through the skin as required and as demonstrated
by urography and the patient's symptoms.
Reduplication of Renal Pelvis and Ureters—so-called double kidney. These are often
accompanied by some uropathy of the upper segment. It is unnecessary to sacrifice the
whole kidney when the removal of the segment will cure the condition. Occasionally
incontinence or day and night wetting, not associated with the act of voiding, is cured
by the removal of this segment which leads to an ectopic ureteral opening.
Horseshoe Kidney—Because of the number of anomalous blood vessels and malinser-
tion of the ureter to pelvis, normal mobility can lead to nephropathy. Constitutional
symptoms may also accompany this anomaly. Symphysiotomy can be done with nephropexy on both sides. If one kidney is destroyed it can be removed and the remaining good
kidney fixed in position.
Ectopic Kidneys cannot be moved into better position, because of the shortness of
their renal pedicle. However, where any nephropathy arises, it should be dealt with
according to conservative urologic principles.
Decapsulation of Kidneys for Anuria—Some recent experimental work by Vermeulen
and Snead of the University of Illinois in determining the effect of decapsulation in the
Page 21 ifr:
mercury nephrosis lends no support to the clinical use of decapsulation in the treatment
of anuria. The development by Kolff of an artificial kidney and its latter modifications
would seem to make its use the treatment of choice when conservative medical therapy
has failed. 0fe
Ureter |pjg
Much of what has been said about the kidneys applies to the ureter. There is one
point I wish to bring out and that pertains to ureteral stones, high or low in the ureter.
The use of multiple ureteral catheters, or even better the looped ureteral catheter, has
enabled us to extract stones that would have been missed by the usual stone basket. In
addition to this, I feel they cause less trauma and are therefore safer.
Uretero-Intestinal Anastomosis
The original Coffey technique has worn well with the years. However, it is not
entirely satisfactory and the constant striving for improvement is evidenced by the
variety of modifications. Basically they all have much in common. This procedure
was first used extensively in exstrophy of the bladder. The preferred time of transplant
in these infants is within the first year of life. Lately, the radical treatment of bladder
Ca, has increased the use of this operation. In all cases the pre-operative care is very
important. Simplicity of operative technique is of paramount importance. Transperitoneal approach is the one of choice in infant, child, and adult. Meticulous attention
to detail of the operative steps is absolutely necessary. Pre- and post-operative urograms
are very necessary to determine the degree of operative success. The recent mucosa to
mucosa ureterosigmoid anastomosis of Nesbit, Cordonnier and Hinman appeals to me
and I have used it successfully. Previously I had used the Coffey1 modifications of
Hinman and Wharton.
Uretero-Cutaneous Anastomosis
This procedure has been more or less moved into the background. However, it is
the procedure of choice in some cases. The. use of the Singer Ureterostomy cup which is
cemented on over the rosette has made it more acceptable to the patient and has enabled
me to obtain and retain sterile urine from each kidney in two patients so treated. This
eliminates the need for a ureteral catheter with its accompanying ureteritis and pyelonephritis and thus improves the long-term prognosis.
Ureteral ligation is estimated to occur in 1 to 3 per cent of female pelvic operations.
Unilateral is to bilateral as 6:1. Deligation may be done immediate iy if discovered; or
the abdomen re-opened after ureteral catheters have been passed as tar as possible. Re-
implanation of the ureter into the bladder may be the procedure of choice. Surgically
damaged ureters may also be re-implanted into the bladder or re-anastomosed by several
different methods. Ureterocutaneous anastomosis may be done as a t ;mporary procedure.
Uretero-intestinal anastomosis is another possibility. The emphasis here again is on renal
conservation. Ligating the severed ureter is condemned and nephrectomy is a last resort
—a confession of defeat.
The stump of a grossly dilated, infected ureter must be totally removed to cure the
patient of his pain and pyuria. In operations for renal tbc. the whole ureter should be
removed as leaving the stump can be a cause of continued tubercul>us infection.
The greatest advance in urosurgery here has been in the approach to the problem of
cancer. This is far from satisfactory yet, however the success of uretero-intestinal
anastomosis has encouraged us to be more radical in our surgical treatment of this problem.    The causes for low curability are: -S|fe
1.   Late diagnosis, at which time there is usually extravesical spread. WSm
Page 22 2. Ineffectual treatment, which allows a tumour without extravesical spread to persist,
too often unrecognized, in the bladder wall until it has extended outside the bladder
or has metastasized.
The programme to combat this is one of education of the patients and the medical
profession and the presence of trained urologic surgeons in the community. Unfortunately, the microscopic picture of the tumour indicates neither the presence nor absence
of metastases or the depth and degree of infiltration of the bladder wall. Accurate diagnosis is established by cysto-urethroscopy with pyelography, biopsy and bimanual palpation under anaesthesia. The biopsy must always include some of the muscularis. Carcinoma, when deeply infiltrating, has metastasized in the majority of cases. When
superficially infiltrating, metastases are not frequent. Deeply infiltrating tumours cause
a stony hard induration in more than 80 per cent of cases. Superficially infiltrating
tumours practically never cause stony induration. Rubbery induration without extravesical extension denotes a slightly lower incidence of metastases. It is in cases of this
type that radical treatment should result in a fairly high percentage of cures. When
there is no palpable induration a high potential curability exists. However, those patients
with induration and/or metastases present should not be denied palliative surgical treatment. Transplantation of the ureters into the bowel will divert the urinary stream and
relieve them of the distressing urinary symptoms that rapidly tear down the patient.
Even when the bladder cannot be removed, this allows the patient to complete his span
of life with relative comfort. In some cases this procedure causes a temporary regression of the bladder growth.
In discussing bladder tumours one must remember that not all require radical
surgery. However, I would like to impress on all of you that clinically there is no
such thing as a benign tumour of the bladder, even when the pathologist is kind enough
to encourage us with the report of benign papilloma. These are of very low-grade
malignancy; they will often recur and as they recur they become progressively more
malignant until one must consider the advisability of radical surgery. These tumours
and larger papillary growths can be satisfactorily handled by transurethral fulguration
or by resection and fulguration. One should include a bit of the muscularis too. When
seen sufficiently early most of these are curable, but as recurrences are common, the
patient should be rechecked cystoscopically every three months for a year, every four
months for another year and then at least semi-annually. If recurrences are caught
early, they can usually be readily handled. The use of radon seeds and radium is quite
controversial. Some groups favor its use in selected cases and their results are good.
My experience with it has been to see the unfortunate effects. The cancer might be
controlled or cured but the patient is too often left with a radio-cystitis that either is so
distressing that he wishes he had died, or else calls for ureteral transplantation. I do feel
that patients with cancer of the bladder will benefit from a post-operative course of
deep x-ray therapy. I admit that one runs some risk of producing a radio-cystitis but
I tHink the incidence is much lower.
Segmental resection of the bladder is valuable and is best suited for a growth that
is well removed from either urethral vesical orifices, that is situated high in bladder,
either in the dome or on one of the walls, and is within reasonable limits of size.
Suprapubic excision and fulguration of the tumour is seldom now the procedure
of choice in threatment for any vesical neoplasm. This method is reserved for lesions
which involve the base of the bladder, including one or both urethral orifices. That
is, it is employed only for lesions for which total cystectomy should be done, but for
some reason or other is not performed.    It is purely palliative.
In all bladder tumours, when in doubt, it is wise to do a suprapubic exploration to
determine the extent and depth of invasion and extension. Exploration should include
the liver, the peri-aortic and regional lymph nodes as well as the bladder.
Total Cystectomy has been re-evaluated and it is now felt that its field of usefulness
is considerably broader than had been appreciated in the past.    Exploration with a
Page 23 ■ll"
view to cystectomy is to be done in the following types of malignant lesions of the
1. An extensive, low-grade lesion which involves most of the bladder.
2. A low-grade lesion which involves numerous and diversified regions in the bladder.
3. Repeatedly recurring low-grade lesion.
4. A high-grade infiltrating lesion which can be removed completely by total cystectomy, but probably not by any less extensive procedure.
5. Any vesical tumour that involves portions of the bladder,- such as the vesical neck
and ureteral-vesical orifices, which cannot be removed completely without seriously
affecting vesical function.
Urosepsis all too commonly is left following the use of radon, radium, suprapubic
fulguration, etc., even for palliative purposes. Urosepsis will kill as surely, and more
unkindly, as the malignancy. The operative mortality in transplantation of ureters
and cystectomy has been improved tremendously by our knowledge of pre- and postoperative care, the introduction of more effective urinary antiseptics as well as improved
surgical technique. The consensus of urologic opinion is that one should attack a
tumour of the bladder as boldly as the surgeon would attack a tumour of the stomach
or bowel.
Vesical Neck Obstruction
The treatment of paraplegic bladders, cord bladder of tabes, disseminated sclerosis,
etc., has been advanced largely through the initial efforts of the Mayo Clinic group.
Transurethral resection in these patients has accomplished wonders for their urinary
tract. The mechanical defect only is corrected, not the neurologic cause. I consider
this one of the most important examples of conservation. All one has to do is recall
the hopelessness of the World War I paraplegic compared to his brother of World War II.
It is indeed gratifying to me to see more and more articles and discussions in the
literature indicating that the transurethral prostatectomy is not the answer for all prostatic hyperplasias. My belief has always been that the type of operation chosen should
be the one best suited to the particular gland. Do not misunderstand me. The transurethral prostatectomy is a good operation in properly selected cases and can never be
replaced. There are relatively few urologic surgeons who can almost completely remove
a large gland. The majority of us are not so blessed with manual and instrumental
dexterity. I beg your indulgence while I quote the words of Dr. Joseph F. McCarthy
of New York City, one of the master urologic surgeons of our time. He is the man
responsible for the development of the foroblique lens system and the McCarthy Resecto-
scope, without which transurethral prostatectomy would never have reached the position
of prominence that it enjoys today. He says "The prostate gland, this delightful object
of our retrospect ruminations, has long been a source of acrimonious debate and a bone
of contention. Endoscopic prostatic resection ushered in an era of dogmatic, assertion-
contentious debate, vapid sophistry and muddled conclusions; because of its lure and
ready patient-acceptance, a beautiful job of verbal landscaping is being done on this
procedure. However, the artists neglected to incorporate the sombre details. In New
Yorkese, there is too much Ballyhoo. It was also a period of what Bransford Lewis
described as 'Moonlight and Roses.' In this latter there has appeared a disquieting recrudescence.    What are the drab details?
It   The more than occasional multiple operations;
2. The repeat operations;
3. The terminal prostatectomies  (in other hands)  on a considerable number of reported successful resections;
4. The annoyingly frequent post-operative urethral stricture;
5. The constant pushing back and forth of an instrument, anywhere from a 28 to a
32 F. calibre, with its attendant desquamation of the delicate epithelial lining;
Page 24 6. The occasional massive haemorrhage;
7. The relatively prolonged post-operative urethral morbidity;
8. The highly technical nature of the proceeding;
9. The vicissitudes of apprenticeship;
10. The disquieting number of cases of post-operative incontinence.
Prior to the advent of resection about 100 incontinence clamps were sold annually,
since the advent of resection there were 6,000 such clamps sold last year alone. This is
not to mention the ingenious Foley operation for incontinence and the reports of ure-
terosigmoidostomy for t\he same reason.    What do our enthusiasts say?
1. They call it transurethral prostatectomy. This is a presumptuous piece of dialectic
2. It is practically a replacement of open operation, and that the individual who disputes this, just hasn't the 'know-how.'    The answer: auto euphoria or marihuana;
3. The operator should use the method he does best. Best for whom: the operator or
the patient? Isn't it incumbent upon the operator first to equip himself in all the
acceptable methods, so that he is capable of detached, objective selection of operation? Some of these colleagues, friends of mine—I think—I hope,—have both misconstrued and taken too seriously a remark of mine many years ago when I stated
in a moment of enthusiasm: 'that if the profession were alerted and saw to it that
early prostatism called for early resection, then slippers for the old man would go
out of fashion as Christmas presents, and night clubs and conjugal felicity would
find an added reason for their continued existence.' I certainly did not mean, the
big, succulent, bleeding type, and large intravesical type, the subtrigonal invasive
type and others along similar lines.
What should be done about it? I surmise that most of my auditors in this room
believe that modern urology cannot be adequately practised today, without familiarity
with the panendoscope and the visualized electrotome; that endoscopic resection of the
prostate gland and of bladder tumours has marked an epoch in our specialty; that they
should not, however, be over-extended or abused; that in our reporting, the untoward
incidents should accompany the gratifying. Thus and thus only, can we protect on-
comers in this field. Fulfil our duty as teachers and justify our presence in this the
greatest of all specialties, in this the noblest of professions. Let's call off the honeymoon."
The retropubic and the closed one-stage transvesical suprapubic prostatectomies in
properly selected cases give comparable results with minimum morbidity and average
hospital stay of 10-14 days. In these cases, as well as in as complete as possible transurethral prostatectomies, I have the urine clear in 2-3 months after operation or earlier
in private practice. After a prostatectomy of any type the urine should be pus free or
show a very minimum of microscopic pus in 3-4 months. If your patient still shows pyuria or haematuria he should be re-examined and the probability is that further operative
interference will be required. The urosepsis left in some of these unfortunate patients
who have had quick transurethral tunnelling jobs on large prostates is distressing, and
as bad or worse than their original difficulty.
So far I have omitted mention of the perineal procedure. I feel that it is the best
approach to early Ca of the prostate or to prostatic cancer that has responded to hormonal treatment sufficiently to be considered for radical surgery. Radical extirpation
can be accomplished by the retro-pubic approach, but in my experience, the perineal
approach is preferable. In these patients, I am not so much concerned with the approach
as that they be given the benefit of a radical removal of their cancer. Only by this
can the Ca be cured.
The subtotal perineal prostatectomy of the Lowsley type is worthy of mention. It
is the only way to deal adequately with the troublesome problem of prostatic calculi
that cause intractable symptoms. The enucleating operation has its advantages, but I
feel its disadvantages are more numerous.   Not the least of these is the high percentage
Page 25 ,
of impotency following perineal operations and due to trauma of the perineal muscles,
Thus, for the open prostatectomy I prefer one of the suprapubic approaches to the
enucleating type of perineal prostatectomy.
Recently it has been shown that deaths from lower nephron syndrome can occur
following transurethral prostatectomy, owing to the fact that the hypotonic irrigating
media dan enter the systemic circulation during the course of the operation or in the
immediate post-operative period. This unfortunate occurrence can be prevented by
using an isotonic fluid as irrigating media. I have used 4 per cent glucose in distilled
water as suggested by Creevy and 2 per cent and 1.1 per cent glycine as suggested by
Nesbit, also 1.8 per cent Urea Solution as suggested by Belt. I feel that the use of such
a fluid is very necessary when one realizes that large venous sinuses can be laid open as
well as other vascular supply opened when one is attempting to remove the prostatic
tissue down to the capsule. Much of the post-operative anaemia can be traced, not to
the blood loss at the time of operation, but to haemolysis caused by hypotonic irrigating
fluid entering the systemic circulation in sufficient amounts to caure haemolysis but not
enough to cause anuria. This can occur at operation and in the immediate post-operative
period. llli
Urosurgery in Relation to Pregnancy
I feel that an excretory urogram should be a part of your initial routine investigation
of pregnant women. In fact, I would go even farther and add that it would be advisable as a part of the examination of any woman contemplating marriage. Adequate
renal function is indispensable to any pregnancy. The eradication of any factor which
may jeopardize this must be accomplished to protect the future welfare of the expectant
mother. In no field of surgery is conservation more to be desired^? It, is warranted only
in the presence of complete necessity, and if possible, should be confined to the postpartum period and the interval between pregnancies. Because of the availability of good
urinary antiseptics conservatism is the treatment of choice in pyelonephritis of pregnancy. Cystoscopic intervention is now required in a much smaller group. Where
medical and instrumental measures fail, pre-existent or co-existent disease exists in addition to the physiologic changes that accompany any pregnancy. Unfortunately, these
lesions are usually asymptomatic before and become-activated only in the gravid state.
I.V.P. would discover them if done before pregnancy, and forewarn one if done as a
part of routine investigation of early pregnancy. These conditions may become so
intense that palliative urosurgery may become imperative during pregnancy.
Corrective surgery should be carried out about four months post-partum in order to
allow for the complete regression of the physiological changes. Elective urosurgery in
the early months of pregnancy, before the physiologic changes appear, may be done if it
is thought that the condition, if allowed to remain, might endanger the lives of both
mother and child. Ptosis with kinking and angulation of the ureter, non-calculous ure-
teroplevic obstruction, stricture of the ureter, calculous disease and congenital anomalies
are encountered and require correction. Miscarriage due to surgery in the early months
of pregnancy is unusual. Nephrostomy in severe, intractable pyelonephritis may be
required to permit sufficient control for a successful pregnancy and is done only as an
emergency procedure. This procedure is preferable to terminating the pregnancy. Between gestations ureteral strictures may be dilated or repaired; ureteropelvie obstruction
corrected; calculi removed and the results of ureteritis and periureteritis corrected.
With the addition of chemotherapy this will eliminate stasis and infection and make
the patient safer for her next pregnancy. A solitary kidney per se does not contra-
indicate future pregnancies, nor does the presence of congenital anomalies. But in both
cases detailed care and prophylactic treatment will carry them through repeated successful pregnancies.
Urologic Care of the Normal Obstetrical Patient
Enquiry about symptoms of urinary tract disease at each antepartum visit—including frequency, dysuria, renal or ureteral pain.   If these are not present the examination
Page 26 of a voided specimen of urine is all that is required. A microscopic examination should
be done as well as the chemical. If the vulva and introitus are cleansed with soap and
water and carefully separated out of the way of the stream, a clean uncontaminated
specimen can be obtained and will give a true urinalysis. At the first visit you will
get a routine urine culture using a catheter, as well as an excretory urogram. If symptoms of urinary tract infection develop, a catheter specimen of urine for culture should
be obtained. At all times, a liberal fluid intake should be advised and fluids forced in
the presence of symptoms. If culture is positive, it should be treated as for pyelonephritis. Sulfacetamide 1 gm. t.i.d. for one or two days, then l/z gm. q.i.d. for the
balance of the week is usually sufficient, if the urine has been made alkaline to a ph of
7.5-8.0. Repeat culture and continue treatment until culture is negative. Thereafter
urine culture should be done monthly until three to four months postpartum. Sulfa-
thalidine 1 gm. q.i.d. may be used as an alternative sulfonamide, especially where there
is a previous history of infection. This can be used safely in intermittent courses
throughout pregnancy if necessary. Mandelic acid therapy can be used as a preventative—with no restriction of fluids. Remember that the pregnant woman who has had
a urinary tract infection has better than twice the usual chance of developing an acute
attack during pregnancy. "Conservatism" surely begins here with prophylaxis. This
type of therapy has reduced the incidence of pyelonephritis of pregnancy by 5 0 per cent,
the febrile phase by 66 per cent, and the serious sequelae largely are avoided until corrective urosurgery can be applied.
Paediatric Urology
The role of urology in paediatrics deserves special mention. Pyelonephritis of infancy
and childhood is very common in girls, uncommon in boys unless associated with some
congenital defect. The female urethra is short and straight and is so placed that it is
constantly exposed to infection which is rubbed into it by soiled diapers, clothes, washcloths, and vaginal discharges. Fortunately, between attacks most children recover
completely as far as symptoms are concerned. Recurrent attacks can be fresh reinfections or exacerbations of residual infections. Complete urinalysis with cultures is
required. In females of any age there is a tendency for urinary tract infections to recur.
Usually initially as a urethritis and trigonitis. About fifty to sixty per cent of your
pregnant patients have had urinary tract infections as infants and children.
The methods of urologic examination and diagnosis in infants and children are fundamentally identical with those employed in adults. Excretory urography has been a
boon in this field, often enabling one to obtain all the information required. Where
pyuria persists longer than 3-4 weeks of medical therapy, or recurs repeatedly, complete
urologic investigation must be done. Enuresis, usually a behaviour problem, may be due
to organic causes such as an ectopic ureteral orifice, posterior urethral valves, neurogenic dysfunction and overflow incontinence, meatitis, nieatal stricture; long redundant
foreskin and phimosis can cause urethral irritation. These are usually associated with a
smaJU meatus. When you do a circumcision calibrate the urethral meatus and if it is
too small do a neat meatotomy. Infant cystoscopes are available as well as other special
instruments for the examination of the small, delicate external genitalia—especially of
male infants.
In paediatric urosurgery the same general principles apply. One must remember
that these tissues are smaller and more delicate than their adult counterparts and must
be handled with the utmost care.
Urinary Antiseptics
No discussion on urosurgery is complete without mention of urinary antiseptics.
Without their help the success of the reconstructive surgery discussed could not be
The recent availability of Aureomycin and Chloromycetin will force us to revise
the status of our urinary antiseptics.    These two antibiotics are very effective against
Page 27 w*.
most of the gram-negative bacilli that plague us. They are also effective orally and are
of unusually low toxicity. Both are rather uniquely effective against certain virus
infections. Resistance to them develops much more slowly than to streptomycin. The
high cost of these two antibiotics at present prohibits their routine use. When this is
adjusted downwards they will supersede all our own known antiseptics as the ones of
choice for the routine treatment of urinary tract infections, of gram-negative organisms.
Penicillin is a great adjunct to treatment, although in urology is has fallen far short
of the initial high expectations. Staph, albus and aureus, strep, haemolyticus, viridans,
and fecalis and diphtheroids yield to penicillin as well as does the gonococcus. The
greatest antibacterial action is in an acid urine. It has proven extremely valuable in
prophylaxis.    High dosage is recommended.
Streptomycin is most effective if the urinary PH is 7.5-8.5 and has produced some
spectacular results in some cases of gram-negative bacillary infections. Relapse is common if the urosurgical criteria are not fulfilled, as is the case with Chloromycetin and
aureomycin. It is best used by repeated intramuscular injections. Orally it is ineffective
systemically, although it is used to sterilize the bowel prior to bowel surgery and can
be used here in urology before uretero-intestinal anastomosis.
At present the sulfonamides and Mandelic acid remain the drugs of choice for ambulatory and prophylactic treatment. The reaction of the urine is an important adjunct
to their effectiveness. Sulfonamide action is enhanced with a urinary ph of 7.5 to 8.0.
Fluid intake is kept high without loss of effectiveness. Mandelic acid requires a urinary
. ph of 4.5 to 5. It should be used in intermittent course of 10 to 14 days. Prophylaxis prior to instrumentation is beneficial. It is rarely necessary now to resort to the
full therapeutic dose. The compound mandelic acid tablets such as Uromand and
Prohydrion are the most palatable.
Pyridium and the other azo dyes have a weak antiseptic action and are used mainly
for their analgesic qualities to the urogenital mucosa. Mapharsen still has a limited field
of usefulness. It will eliminate some micrococci and other coccal urea-splitters. Until
recently it has been the only drug of any value in the treatment of acute interstitial
cystitis due to abacterial pyuria. Chloromycetin is reputed to be quite effective in this
This discussion of the recent advances in Urologic surgery is necessarily incomplete.
Many topics have not been discussed at all. I have attempted to highlight only the
more common, every-day procedures which you are encountering in your practice. It
is my sincere hope that you may have gained some helpful points that may be of use to
you and your patients.
1—Presented at the Shaughnessy Post-graduate course for General Practitioners March 10, 1945*.
Baker, W. J., J. of Urol., 60-2-48.
Campbell, M. F., Pediatric Urology, 1937.    MacMillan Co.
Crabtree, E. Granville, Urological Diseases of Pregnancy, 1942.    Williams & Wilkins.
Dodson, A. I., Urological Surgery, 1944.    Mosby.
Dodson, A. I., J. of Urology, 58/5/47.
Everett, H. S., Gynecological and Obstetrical Urology, 2nd edition, 1947, Williams & Wilkins.
Goldstein, Avram, New England Journal of Medicine, 240/5/49.
Kickham, C. J. E., A. J. of Urol.,  59/5/48.
McCarthy, J. F., A. J. of Urol., 60/1/48.
Scholl et al, Archives of Surgery, 56/3/48.
Wharton, L. R., Gyn & Female Urology, 2nd edition, 1947.    W. B. Saunders.
Page 28


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