History of Nursing in Pacific Canada

The Vancouver Medical Association Bulletin: July, 1933 Vancouver Medical Association Jul 31, 1933

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JULY. 1933
NO. 10
of the
Vancouver Medical Association
Transurethral Prostatic Resection
News and Notes
Hotel Vancouver.       July 4, 5, 6, 7,1933.
made from
the finest quality Acetylsalicylic Acid so compressed
as to insure immediate disintegration in the
We commend VANASPRA to the profession as
of the highest standard at less than half the price
of other makes.
Western Wholesale Drug
456 Broadway West
Publishrd  Monthly  tender  the  Auspices  of  the  Vancouver Medical  Association  in  the
Interests of the Medical Profession.
203 Medical Dental Building, Georgia Street, Vancouver, B. C.
Editorial  Board:
Dr. J. H. MacDermot
Dr. M. McC. Baird Dr. D. E. H. Cleveland
All communications to be addressed to the Editor at the above address.
Vol. IX. JULY, 1933. No. 10
OFFICERS 1933-1934
Dr. W. L. Pedlow Dr. A. C. Frost Dr. Murray Blair
President Vice-President Past President
Dr. "W. T. Ewing Dr. W. T. Lockhart
Hon. Secretary Hon. Treasurer
Additional Members of Executive:—Dr. C. H. Vrooman; Dr. H. H. McIntosh
Dr. W. D. Brydone-Jack Dr. J. A. Gillespie Dr. F. Brodie
Auditors: Messrs. Shaw, Salter & Plommer
Clinical Section
Dr. W. H. Hatfield  Chairman
Dr. W. L. Graham Secretary
Eye, Ear, Nose and Throat
Dr.  R.   Grant  Lawrence    Chairman
Dr.   E.   E.   Day    Secretary
Paediairic Section
Dr.   J.   R.   Davies .. Chairman
Cancer Section
Dr. A. Y.  McNair   Chairman
Dr. A. B. Schinbein , _   Secretary
Library Summer School
Dr.   H.   A.   DesBbisay Dr-  1   W Thomson
Dr. G. E. Kidd Dr-  C- E- Brown
Dr   J   E   Harrison Publications                Dr. C H. Vrooman
Dr. w/'d.  Keith Dr. j. H. MacDermot          ^ J' \ ^f*
Dr. C. H. Bastin Dr. Murray Baird                  ^ § £ SJ°H*
Dr    A   W   Rat*, att r^      t-v   t_    o   ^ Dr.   H.   R.   MUSTARD
UK.   A.   W.  J5AGNALL £)R.   D.   E.   H.   CLEVELAND
Dinner Dr.  W. C Walsh
Dr. J. G. McKay Credentials Dr   S. B. Peele
r>     v  T   „     t-. JJR.   1.  ri.  J-ENNIE
Dr. N. E. MacDougall Dr.  f.  p.  PATTerson Dr. C. F. Covernton
Dr. U E. Gillies Dr. S. Paulin , I
Dr. F. W. Brydone-Jack V.O.N. Advisory Board
„ .        „   ,_,   ,, . Dr. I. Day
Kep. to B. C. Med. Assn. Dr   j   w. Shier
Dr. G. F. Strong Dr. H. H. Boucher
Sickness and Benevolent Fund — The President — The Trustees VANCOUVER HEALTH DEPARTMENT
Total  Population   (Estimated)    [■■■•-■■ ■*-:        247,251
Japanese Population   (Estimated)         8,429
Chinese   Population   (Estimated)      7,759
Rate per 1,000 Population
Total   Deaths       196 9.3
Japanese  Deaths       11 15.4
Chinese Deaths      11 I 6.7
Deaths—Residents only  .  179 8.5
Birth   Registrations        315 15.0'
Male      156
Female 159
Deaths under one year of age   9
Death  Rate—Per   1,000  Births  _.   28.6
Stillbirths   (not included in above)     11
June 1st
April, 1933 May, 1933 to 15th, 1933
Cases     Deaths Cases    Deaths Cases    Deaths
Smallpox              0              0 0              0 0 0
Scarlet   Fever             7              0 10              0 10 1
Diphtheria _         0             0 10 2 0
Diph.   Carrier   _          0              0 0              0 0 0
Chicken-pox        141              0 147             0 88 0
Measles            2             0 0             0 0 0
Rubella              -             - 10 0 0
Mumps           _        90              0 119              0 39 0
Whooping-cough        23              0 4             0 6 0
Typhoid   Fever            2             0 3             0 0 0
Paratyphoid             10 0              0 0 0
Poliomyelitis              0             0 0             0 0 0
Tuberculosis             84           11 77           16 23 -
Meningitis    (Epidemic)              0              0 0              0 0 0
Erysipelas             3              0 10 2 0
Encephalitis   Lethargica            0             0 0             0 0 0
is a handy, convenient, clean commodity for the bag or the
office. Supplied in one yard, five yards and twenty-five
yard packages.
Phone Seymour 698 730 Richards St., Vancouver, B. C.
The American Journal of Public Health, official organ of the
American Public Health Association, the Editorial Board of which
is composed of well known students of public health, with Dr. M. P.
Ravenel, former President of the American Public Health Association,
as Editor in Chief;  published  the following editorial in May,  1933.
"The actual changes in milk produced by pasteurization are an
increase in. insoluble calcium of about 6%, a reduction in the
iodine content of about 20%, and some destruction of Vitamin C.
Milk is not rich in Vitamin C at best, though the amount is
usually adequate for nutrition, but in actual practice, it is generally supplemented both for raw and pasteurized milk.
"In considering the effect of these changes, it may be that pasteurized milk is not as suitable for certain animals whose calcium
needs are greater than, those of calves, but it seems there is no
evidence that this is injurious to infants whose calcium needs are
lower. The pasteurization of cow's milk brings it somewhat nearer
to human milk as regards available calcium and phosphorus, and
the change may be regarded as beneficial. Animal experiments as
well as nutritional experiences on a large scale certainly give no
support to the idea that pasteurized milk is in any way inferior
to raw for infant feeding. These statements may not be entirely
trite for older children, since they require a greater amount of
. calcium for bone formation, and this is especially true for those
who may be on a diet that is otherwise deficient in calcium, but
apparently there is at present not much evidence on which to make
such an assertion.
"We have an immense volume of clinical evidence gathered from
many countries which shows that pasteurized milk has fulfilled the
needs for the feeding of infants and children over many years, with
no evidence of damage, provided the possible loss in Vitamin C is
made good. The Editorial Board above referred to holds that in view
of this mass of clinical experience, it is up to opponents of pasteurization to demonstrate nutritional harm done by the process, and
points to the fact that such experimental work as has been done
proves that they have conspicuously failed to do so up to the present.
"When we add to this the marked lessening of intestinal troubles
and contagious diseases carried through milk, it is hard to understand
how any opposition to pasteurization can be justified."
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Selling Agents
Manufacturers: Bilhuber-Knoll Corp., Jersey City, N.J. EDITOR'S PAGE
By this time every member of the medical profession in Greater
Vancouver will have received a letter from the Committee appointed by
the Vancouver Medical Association to deal with the whole question of
treatment of the indigent. As readers of this periodical know, we have
for a long time advocated a firm stand by the medical profession against
the exploitation (we can find no milder word that will suit the case) of
our good-nature and generosity, that has gone on for many years and, be
it said, has gone on largely, if not mainly, because of our own mistaken
attitude with regard to this matter.
We are hopeful that Vancouver will act firmly and unitedly.
Winnipeg has already acted and is a month ahead of us in its action.
That is very courageous of Winnipeg and very helpful to us, since it is
always easier to follow than to lead. But we believe that the will to
action has been present all the time in our men, and we believe, too, that
it was wise leadership that advised us to explore every avenue of conciliation and compromise before proceeding to a definite rupture. We
know that Winnipeg, too, exhausted every means of arriving at a fair
The truth is that governments of all kinds are at their wits' ends for
money—and have to spread the little they have as thin as possible, that
it may cover as wide an area as it can. We know this, and sympathise
with it: and by our actions have shown that we are willing to do our full
share in helping to bear the burden; but it has come to a point where,
whether we like it or not, we must refuse to carry the load any longer—
at least we must have some help in carrying it. Even if our modest demands were met, we should still be bearing a heavier load than does any
other taxpayer; we are called on to pay our full share of ordinary taxation
and we cannot bear this extra load, unaided.
What is the remedy for it all? for nobody pretends that the compromise suggested by the medical associations is adequate, or anything
more than a temporary arrangement. We cannot but feel that the only
answer is some method by which the cost of medical care can be distributed over the whole community by some system of insurance. Sickness
is bound to come to every family and every individual at some time, and
the doctor is as necessary to the community as the repair shop is to the
automobile industry. The trouble is that sickness is not evenly distributed—nor is it spread evenly over the life of the individual or family.
It comes "in bunches". Another difficulty is the fact that treatment of
sickness after it happens is the most expensive and most inefficient method
of handling the problem.
We have not yet, as a profession—let us be honest—seriously considered what relief we can offer to a harassed community for one of its
major problems. All sorts of panaceas are suggested—all sorts of plans
brought forward. We are the ones who should make the suggestions and
work out the plans. If we leave it to laymen, two evils will arise, or may
arise, from any scheme brought forward. One is, as regards ourselves,
that we shall run the risk of being forced to accept unfair treatment; the
Page 176 other is equally serious, in fact more so, that the community as a whole
will suffer. A cheap, imperfect, hurriedly-conceived scheme can not do
good, it may do much harm, and in the long run be wasteful and inefficient; prevention of disease will be ignored, unless those who know its
importance are there to emphasize it and to guide the counsels of those
who are framing a practical scheme of action.
It is by no means enough that we should merely protest against our
own injuries, we must, to prove our sincerity of purpose, also bring forward and insist on the other aspect of the case, namely the fact that
under the present system of medical care as doled out to the unfortunates
tin relief, the sick themselves, (and they are the really important people in
this matter) are not getting the best care. This is no reflection on the
medical staffs who are treating them. Never has the care given to the
indigent been so good and so full of constructive thought as has been the
case during the last two years. The staff at the Vancouver General Hospital has done excellent work, and we gladly acknowledge this fact. But
the care that each family should receive from a family physician, the
emphasis on prevention of disease, are, and must be lacking, and these are
essentials. And the staff has been overloaded, and unable with the best
of intentions to meet all the demands. We refer to post-institutional care,
amongst other things.
Meantime, let us all do as they have done in Winnipeg, one hundred
per cent of them, back up the considered action of our Committee and
our Association. We have put our hands to the plough, we cannot look
The members of the Vancouver Medical Association were fortunate
in meeting two of the delegates to the Pacific Science Congress in the
persons of Dr. T. Furuhata and Dr. L. L. Ride at a dinner held at the
Shaughnessy Golf Club on June 8th. Both gentlemen gave addresses.
Dr. Furuhata is perhaps one of the greatest authorities living on the blood
espesially from the standpoint of Forensic Medicine and his paper will
appear in an early issue of the Bulletin as he was kind enough to leave it
with us. We cannot but admire the competence of a man who studied,
his profession in German and then rendered into English such a difficult
paper as this was. Dr. Ride's paper was on "Finger and Palm prints and
their Heredity" and was intensely interesting and keenly enjoyed by
We learn that Dr. Wackenroder is leaving his practice for six months
or so as he has the opportunity of working in a special clinic in Germany.
Mrs. Wackenroder is accompanying her husband to Europe.
Page 177 In connection with the subject matter of this month's editorial it
is interesting to note that a letter has just been received from the Saskatchewan Medical Association dealing with the same problem. We think
that they are handling this matter in Saskatchewan with some improvements on our methods, inasmuch as conferences are being held where
Hospital Associations, Unions of Municipalities and others are present as
well as representatives of the Medical Association. We think it is a distinctly wise move, since nothing can be lost and much gained by a free
and frank discussion of this matter by all parties concerned. We feel
that labour, and representatives of those on relief might well be invited to
contribute their ideas, so that a comprehensive and workable scheme may
be ultimately formulated.
It is hoped that everyone who can do so will attend the Dinner of
the reorganized B. C. Medical Association which will be held in the Hotel
Vancouver, on Monday, July 3rd, at 6:30 p.m., the day before the opening of the Pacific North West Medical Association.
The History of Medicine in the Province of Quebec, by Dr.
Maude E. Abbott, now on our shelves, is deceptive, in that the small size
of the volume gives no hint of the wealth of anecdote and detail which
it contains.
As Dr. Abbott explains in the introduction, the earlier part represents the uncompleted work of the late Dr. Georges Ahern, who had at
his disposal the fruits of his father's researches into the period of the
French regime. Then, as now, charlatans and quacks flourished, and
were the subject of complaint. One wonders how the practitioners of
those days found time to ponder these grievances, when so many of their
number were tortured to death by Indians, or drowned in travelling up
and down the river. The atrocities of the Indians were not the only peril,
for we read of a young physician, who, for forgery, was publicly flogged,
branded, and then transported to the slave galleys of France, for life. In
the midst of such alarms these men were busy collecting botanical specimens, Sarrazin being commemorated in the pitcher plant, (Sarracena
purpurea),' and Gaul tier in the winter green, (Gaultheria procumbens).
There is not space to mention all the interesting features, but the
account of the introduction of vaccination into Canada is of general
interest, the evolution of the various hospitals is traced, and there is an
account of the woman who successfully practiced as Dr. James Barry.
The founding of the Royal Victoria Hospital and McGill University, and
more recent events close the book. The later chapters are based on original work of the author in the Dominion Archives. One of its merits is
the collection of illustrations.
C. H. Bastin.
Page 178 Gray's Anatomy, Descriptive and Applied. Twenty-fifth edition.
Edited by T. B. Johnston, Professor of Anatomy, Guy's Hospital Medical
School, London.
Since Gray first published his text book on Human Anatomy in
1858, it has run through twenty-five editions in the British Isles and
almost as many in America, yet much of the original text and many of
Gray's 363 drawings are still found incorporated in the latest edition.
An attempt to simplify the terminology, which since the introduction of the B. N. A. system has added so greatly to the difficulties of
the student of anatomy, is being made by a committee of the Anatomical
Society of Great Britain, and the Editor of the 25 th edition of Gray has
adopted the Committee's suggested nonenclature in the section on joints.
He uses the B. N. A. system elsewhere, as the final report has not been
considered by the Society at the time of publication. He hopes, by the
time another edition is due, that the vexed question of terminology will
have been settled.
While most recent advances in anatomy have been made in the field
of embroyology, yet occasionally in gross anatomy well established teachings must be revised. For example, most of us were taught that there
were two intercostal muscles, internal and external. The new Gray
teaches (accepting observations made by Walmsley, of London, in 1932),
that there is, in addition, an intracostal muscle lying deep to the other
two, and that the arteries and the nerve lie, not between internal and external intercostals, but between the internal intercostal and the intracostal muscles.
The book, besides having separate sections on history, embryology,
and surface markings, has a short paragraph on applied anatomy following each gross structure described. Although the general make-up
of the text has changed from earlier editions, yet the reader will find himself quite at home with the book, as at frequent intervals he will meet
with illustrations or paragraphs with which he was familiar in student
G. E. Kidd.
Rectal Surgery.    Gabriel, 1933.
Obstetrics,    de Lee, 6th Ed., 1933.
Colon, Rectum & Anus.    Rankin, Bar gen & Buie, 1932.
Gray's Anatomy.    1932, 25th Ed.
History of Medicine in Quebec.   Maude Abbott.
Mental Healers (Freud, Mesmer, Eddy).    Stefan Zweig, 1932.
Diseases of the Heart.   Sir Thomas Lewis, 1933.
Pulmonary Tuberculosis.    Fishberg, 4th Ed., 2 vols., 1932.
Mayo Volume for 1932—1933. Internal Derangements of Knee Joint.    2nd Ed., Timbrell Fisher.
Shorter Oxford Dictionary in two volumes.
Harvey Lectures for 1932.
The attention of the members of the Association is drawn to the
fact that frequently books or journals are returned to the Library in a
damaged condition. Quite recently a page was found torn from an important article in a bound volume of the J.A.M.A. It is in the interests
of all Library users that this practice be discouraged.
Library users are again asked to go through their shelves and return
any books or journals they may have which belong in the Library. Several
books and journals have now been out of the Library for over a year.
The members quite naturally resent incessant requests for a return of
borrowed books. But what is a Librarian to do?
By W. L. Middleton, M.D., Vancouver
Since bladder-neck obstruction was first recognized as a definite,
serious pathological condition ways and means of dealing with it have
been sought by urologists and only within recent years has its correction
been free from an exceedingly high risk.
Early operations on the prostate dealt only with that portion of the
gland showing intra-vesical enlargement. The removal of this portion
lessened or relieved the symptoms of obstruction, but relief depended
upon whether or not intra-urethral hypertrophy was present. If it was,
the results of the operation were poor; the obstruction not being relieved
the supra pubic wounds did not heal, and the patient's condition remained as bad, if not worse, than before operation.
Later Freyer in England and Fuller in America, practised complete
removal of the gland, with considerably better results in those patients
that survived the operation. But from that time to the present the
mortality rate has been the highest for any surgical procedure directed
towards a benign condition. No matter what the operative procedure
or the means of approach, the end results of prostatectomy have been all
too often unsatisfactory, even when done by men highly trained in the
It does seem unnecessary to remove the whole gland when usually
only a small portion of it is actually causing obstruction. The normal
Page 180 urethra is less than one centimetre in diameter and the distance from the
verumontanum to the vesical neck is less than two centimetres, so
it can readily be seen that it does not require a great deal of tissue to
obstruct this passage.
It is not the actual size of the gland that matters but the location
of the increase in tissue—a small adenoma in an apparently normal sized
gland, if strategically placed, can cause as much obstruction as a gland
several times its normal size where the enlargement is chiefly away from
the urethra. It has been estimated that the tissue removed during a
prostatectomy is less than fifty grams in weight in two-thirds of the
cases, and of this tissue about one-fifth represents the amount actually
obstructing the urethra.
Until recent years no instrument had been devised embodying the
main principles of (1) adequate removal of tissue; (2) clear vision of
the operative field and (3) effective haemostasis, but with the advent
of greatly improved high frequency electric units, great impetus has been
given to transurethral surgical procedures in the treatment of bladder-
neck obstructions, and several instruments have been devised that can do
the work quite efficiently.
Bottini, in 1879, was the first to use electricity in his galvano-
cautery. His instrument was similar to a lithotrite, the male blade of
which could be heated by an electric current. It controlled, to some
extent at least, the haemorrhage resulting from its use. The cutting of
a narrow passage through the obstructing tissue chiefly by destruction,
was its main use.
Frendenberg, in 1897, added a cystoscopic lens system to Bottini's
instrument, but though vision was thus provided it was evidently inadequate as he states that he employed it but once, depending upon his
sense of touch to carry on the procedure.
Chetwood in America performed the operation through a perineal
incision, thus removing it from the transurethral field, but making the
operation so nearly a major surgical procedure that many thought prostatectomy was preferable and when it was found that recurrence was
the rule the method was generally abandoned.
In 1907, Goldschmidt perfected the first urethroscope, making possible the accurate examination of the structures beyond the verumontanum through irrigating fluid.
Five years later Luys described his operation of "forage", or tunnelling through the prostate. The operation was done in a dry field through
an endoscope and consisted of destroying the obstructing portions of the
gland by either electrocoagulation or a galvanocautery. To Luys must
be given the credit for meeting, if only to a partial degree, the three main
requirements of success. Obstructing tissue was removed by destruction,
bleeding was satisfactorily controlled, chiefly because of the limited
amount of tissue that could be removed, and vision, though inadequate,
was provided. In 1911, Young presented his prostatic punch; though vision was
provided in this instrument by means of reflected light, it was of little
use after the first bit of tissue was excised, on account of the bleeding.
In 1918, Braasch described his median bar incisor, which was a modification of his use of the direct cystoscope. Though adequate vision was
provided, there was no means of controlling haemorrhage.
In 1920, Caulk brought out an instrument which provided for
haemostasis by cautery and for the removal of tissue, instead of the
destruction of it in situ. Vision was obtained by the reflected light of
the original Young instrument so that only after the obstructing tissue
was projecting into the lumen of the instrument could it be seen. Its
relation to the vesical neck or other adjacent tissue could only be determined by sense of touch. This was its greatest drawback but credit is
given to Caulk for demonstrating, during the past ten years, and often
under adverse criticism, that this method of attack on bladder neck
obstruction was feasible in many cases.
Bumpus used a Braasch cystoscope of the same calibre as the Caulk
instrument, cutting in the barrel a fenestrum similar to that of the
Caulk instrument. In this way adequate vision was provided, also ability
to remove as much tissue as necessary. At first to control bleeding the
resectoscope had to be removed and replaced by a cystoscope and the
bleeding points and areas coagulated by means of a Bugbee electrode.
Later a special sheath and guide to carry the electrode was added so that
the removal of the instrument became unnecessary.
More recently a multiple needle electrode was added which is thrust
into the tissue projecting into the lumen of the instrument, coagulating
it sufficiently to make the course of the tubular knife blade more or less
bloodless. All but the larger vessels are taken care of, the bleeding from
these if profuse is readily stopped by the use of the Bugbee electrode,
thus coagulation is reduced to a minimum.
In 1922, the Wrappler company began experimenting with a high
frequency current of low voltage, evolving an instrument that by its
tremendous number of oscillations (millions per second) allowed cutting,
under water, by destruction of tissue cells. It was upon this principle
that Stern, Davis and, later, McCarthy and others based their instruments, using a wire loop through which the current is passed, to excise
the tissue. These instruments have all the requirements for successful
work, as they are adaptations of lens-system instruments, vision is unsurpassed, tissue can be removed when excised and bleeding can be efficiently controlled.
The instrument I am using is a Braasch Bumpus resectoscope. My
choice of it in preference to the others was due chiefly to the remarkable results obtained by Bumpus and Thompson of the Mayo Clinic in a
large series of cases extending over several years, compared to the results
obtained by other workers using various other instruments.
With this resectoscope the coagulation of the tissue is reduced to a
minimum, consequently the danger of the sloughing away of a remaining
Page 182 M__-l
thin portion of bladder wall, resulting in perforation or delayed bleeding,
is greatly reduced; there is less absorption of tissue and less chance of
infection. Many cases, especially those with a carcinomatous prostate,
can be resected with but little use of the coagulatory needles, and in most
instances the last bit of tissue can be removed by the knife punch above.
The oozing areas and bleeding points are lightly touched with the Bugbee
electrode, so that very little coagulated tissue is left. This leaves an incised wound that heals much more rapidly than a cauterized wound.
Anyone reading the many published papers on transurethral prostatic resection during the past two years must be amazed at its advance
even in this short space of time and be convinced that a procedure has
been developed that apparently relieves bladder neck obstruction very
readily and very efficiently.
One is frequently asked what are the chances of recurrence after
resection and what is the risk? In a report on this work in a recent
number of the Proceedings of the Staff Meetings of the Mayo Clinic,
Dr. Bumpus reports 499 cases operated upon during the past six years.
In this group recurrence has been known to occur eleven times. Two of
these patients were relieved by subsequent prosstatectomy and the other
nine underwent a second resection.
During the year 1932, 276 patients received transurethral resection
and in this number no deaths occurred. There was a mortality rate of
1.4% in the series of 499 cases. Prostatectomy was done only three times
since August 1932.
The majority of patients are out of bed and voiding freely on the
second day after operation, can usually be discharged from hospital
within a week and from active observation within three weeks, with
practically no pain or discomfort during this time. Comparing this with
prostatectomy, with its high mortality rate, one, two or more resections
seem preferable.
There are fundamentally three types of pathological change in the
bladder neck causing urinary obstruction (1) prostatic glandular hypertrophy, (2) median bar, and (3) carcinoma.
Prostatic carcinoma was thought always to have its origin in the
posterior lobe and the infallible sign was supposed to be an obliteration
of the groove normally felt per rectum between the two lobes. Rectal
examination helps in diagnosing this condition when it is definitely present, but is of no help when the growth is in that portion of the gland
not reached by the examining finger.
There are two types, one that proliferates near the surface of the
urethra, the other remaining intracapsular, until it invades the bladder
musculature and retro-vesical areas.
Median bars are the result of long standing prostatic infection which
produces a fibrosis of the gland and overlying mucosa and stenosis of the
vesical neck. The urinary obstruction and residual urine in this type
are due to hampered function and not hypertrophy.
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William R. Warner & Co., Ltd., 727 King Street, West, Toronto, Ont. Injuries of MUSCLES,
When treating injuries of the muscles, joints, and
tendons, it is now generally agreed that the effort
should be towards certain definite directions with
certain objects in view. These are:
1. The alleviation of pain.
2. The promotion of repair.
3. The restoration of function.
by supplying continuous moist heat, produces
analgesia; by its plasticity it induces rest; by its
osmotic action it reduces the effusion and absorbs
the exudates. These, coupled with graduated exercises to restore function, constitute the rational
circle upon which is based the therapy for the.
modern treatment of injuries of muscles, joints and
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-BBSS Glandular hypertrophy is due to enlargement of one or more of the
five more or less definite glandular masses. This hypertrophy may be
limited to one, two or more of these areas, possibly starting and progressing a different times in the patient's life. This may account to some
extent for recurrences, when a period of time has elapsed after the removal
of all obstructing tissue.
The glandular hypertrophies may be divided into five types. The
first is a simple bilateral enlargement with the glandular masses separately encapsulated. This type often causes symptoms of obstruction
without any signs. There may be a fluctuation between complete retention and complete emptying after the bladder has been drained by a
retention catheter for a few days. The obstruction is due to intracapsular tension causing lateral urethral pressure beyond the ability of
the musculature of the bladder to evacuate the urine.
The second type is the solitary commissural hypertrophy, one of the
two varieties of middle lobe enlargement. It is highly obstructive to the
action of the trigonal muscle and results in its marked hypertrophy.
Relief is afforded by the removal of a large portion of this muscle as well
as prostatic tissue.
The third is a combination of the above two types and usually shows
the lateral lobes to have herniated through the vesical neck, the lobes then
becoming intravesicular as well is intraurethral. The results after
operation in the first and third types of hypertrophy are not as good as
in the others.
The fourth type is an enlargement in the subcervical glands (Alber-
ann's glands) and is the other variety of middle lobe hypertrophy. It is,
due to its strategic location, highly obstructive, the obstruction being of
a mechanical type.
The  fifth  type  is  a   combination  of  subcervical   and  lateral  lobe
growth in unison.   This is the type that usually causes huge growths with
sphincter   dilatations,   intravesicular   protrusion,   bladder   distension   and.
failing function.
Diagnosis of the presence of urinary obstruction presents no difficulties. Rectal palpation of the gland enables one to determine fairly
acurately its size, consistency, and the presence or absence of malignancy. Miscroscopic examination of the expressed secretion will determine the presence of infection, which if active or extensive should be
treated by appropriate measures before a resection is done. A cystogram
will show the conformation of the bladder and any projection of the
prostate into its cavity, the type and degree of obstruction, also the presence of any complicating condition such as bladder tumour, stone, diverticula, etc., which would have to be taken care of.
The presence of marked renal impairment secondary to obstruction
or marked urinary infection, necessitates continuous drainage, either by
a retention catheter or, in the more severe cases, by the supra-pubic route.
A good rule is "when in doubt drain from above" and in some patients
drainage may be required for months or a year or more before their kidney
Page 184 function is bettered sufficiently to warrant any operative interference.
Clean cases with good kidney function are better operated upon without
preliminary drainage.
Spinal anaesthesia is the anaesthetic of choice. 100 mgs. or 150
mgs. of novocaine disolved in 3 cc. of spinal fiuid usually gives anaesthesia lasting long enough for one to complete the operation; if not it
can be supplemented with gas or oxygen. In very old and the debilitated
patients, especially when a high blood pressure is present, 25 mgs. of
ephedrine should be given to counteract, as much as possible, the drop in
pressure (sometimes marked) that usually accompanies the giving of a
spinal anaesthetic. It is advisable to think of this drop in blood pressure
before completing the resection as many slight bleeders, if not taken care
of, may later cause considerable haemorrhage when the pressure returns
to normal. The patient on return to the ward is comfortable, and able
to continue his fluid intake without interruption, a decided advantage in
urinary surgery. Post operative complications attributable to this type
of anaesthetic are extremely rare, and as the patients are usually up and
about in a few days after operation, lung complications, even in the aged,
are very infrequent. Occasionally a headache follows the anaesthetic and
may be quite severe and prolonged. Warning the patient not to raise
his head and dispensing with a pillow for several hours usually prevents
this. It is not our aim, in the use of this treatment, to send the patient
from the operating room with the bladder drainage absolutely blood free.
The large bleeders are always taken care of as they will cause considerable haemorrhage before thrombosis takes place and many of the smaller
ones and oozing surfaces, if difficult to get at without considerable coagulation, are usually efficiently controlled by the insertion of a No. F 22
catheter which is left in place from 24 to 72 hours, depending on the time
it takes for the urine to become clear.
If there is considerable oozing it is necessary to prevent the formation of clots by washing out the bladder frequently. These clots, besides blocking the catheter, are very irritating to the bladder which, in
its effort to expel them, usually goes into repeated spasms which aggravate the bleeding.
The patient is allowed out of bed as soon as the catheter is removed.
About six hours later he is catheterized, after voiding, to estimate the
amount ,if any, of residual urine. Quite often a fair amount of residual
urine will diminish and disappear entirely after a few days when the
oedema about the vesical neck subsides.
The ease with which the patient voids and the absence of residual
urine after operation are sure indications of a successful result.
Daily bladder lavage is necessary for one, two or more weeks to keep
the bladder clean and hasten recovery.
Soreness at the end of micturition is a usual complaint and, along
with frequency, is present until healing has taken place. Dribbling and
a slight incontinence when the patient is walking and subjecting the body
to a certain amount of jarring, occurs in some patients, but if the internal
sphincter has not been injured at operation it will be only temporary.
Page 185 Delayed post-operative bleeding usually occurs between the 10th
and 21st days, rarely later, and is caused by the separation of sloughs,
straining, or over activity of some sort. If the bladder is emptied of
any clots either through a large catheter or the resectoscope and a catheter
tied in, it rarely causes much trouble. Epididymitis does occur but not
so frequently as to warrant vasectomy as a preliminary procedure in all
Case L, F. L., Age 73
Complaints: Frequency and difficulty in voiding.
H. P. I.—Urinary complaints present—past 5-6 years, especially
during last two years. Frequency—night 5-6 times; day 4-7 times—
accompanied by bladder spasm. Stream small and hard to start. Admitted Jan. 13th, 1933. N. P. N. 35 Mgs. B. P. 130-50. Residual
urine 50 cc. General physical condition poor (very much underweight),
chronic bronchitis, gastric trouble, etc.
Jan. 15th, 1933—Cystoscopy—Obstruction due chiefly to one small
adenoma projecting into posterior urethra.
Jan. 16th, 193 3—Transurethral prostatic resection—(spinal anaesthesia) 13/2 gms. tissue removed. Pathological diagnosis—Adenofibroma
of prostate.
Jan.  18th,  193 3—Allowed out of bed, voiding freely, no residual
Jan. 30th, 1933—Discharged.
There was a sudden rise in temperature to 102° on the 3rd P. O. day
and to 104° on the 4th P. O. day. Frequency, during the day only, persisted for 1^2 months, since then he has had normal micturition in all
Case II., M. D., Age 61
Complaints: Frequency, difficulty in starting stream, straining and
passing of bloody urine.
H. P. I.—Frequency—night 5-6 times, day every l/2-2 hours off
and on for past six years. Sudden stopping of stream during micturition.
Complete stoppage 5 times, swelling of right testicle three times. No
history of g. c.
Admitted Jan. 13th, 1933—N. P. N. 47 mgs. B. P. 170-90. Residual urine 100 cc.    General physical condition fair.
Jan. 14th, 1933—Cystoscopy showed obstruction due chiefly to
middle lobe hypertrophy.
Jan. 23rd, 1933—Transurethral prostatic resection (spinal anaesthesia) 3.6 gms. tissue removed—Pathological diagnosis—Adenofibroma
of prostate and chronic prostatitis.
Page 186 Jan.  25 th,  1933—Allowed out of bed, voiding freely, no residual
Feb. 9th, 1933—Discharged.
Slight dribbling for two weeks—Micturition normal and symptom-
free since fourth post operative week.
Case 111., Mrs. J. S., Age 68
Complaint: Complete urinary obstruction.
H. P. I.—Obstructive symptoms present for past several years.
Admitted Aug., 1932—Cystoscopy showed "A large gland, probably malignant." Operation thought inadvisable due to possible malignancy and poor physical condition of patient. Retention catheter drainage
Jan. 25th, 1933—Re-admitted—N. P. N. 53 mgs. B. P. 140-80.
General physical condition fair.
Jan. 27th, 1933—Transurethral prostatic resection (spinal anaesthesia) 11 grams tissue removed—Pathological diagnosis—Carcinoma of
Jan. 28th, 1933—Allowed out of bed, voiding freely, no residual
Feb. 8th, 193 3—Discharged.
A very large carbuncle developed over the lumbar vertebrae which
caused patient considerable distress. Owing to the retention catheter
and invasion of the bladder wall with growth, the bladder was considerably contracted, causing frequency for several weeks. He is now able
to hold his water for 4-5 hours during the day and rarely gets up more
than once at night. His health is fair, but he is complaining now more
frequently of the pains of the metastatic involvement.
Case IV., Mr. J. J., Age 66
Complaints: Frequency, difficulty in starting stream, small stream
with considerable straining.
H. P. I.—Symptoms present off and on for twelve years.
Frequency night 6-8 times, day 1-3 hours. Often would walk the
floor for ten minutes before being able to void.
Admitted Feb. 24th, 193 3—N. P. N. 3 8 mgs. B. P. 210-80. Residual urine 130 cc.    General physical condition poor.
Feb. 25th, 1933—Transurethral prostatic resection (spinal anaesthesia) 53^2 gms. of tissue removed. Pathological diagnosis—Adenofibroma of prostate and chronic prostatitis.
Page 187 Feb. 28th, 1933—Allowed out of bed, voiding freely, residual urine
5 cc.
March 2, 1933—Left hospital against advice.
More tissue perhaps should have been removed in this case but on
account of his blood pressure falling to 90-30 and his poor appearance,
the operation was hurriedly terminated. He had no treatment for almost
a week after leaving hospital and developed a bladder infection that was
quite resistant to treatment until just recently. He had no residual urine
and is able o hold his urine normally during the day but gets up once or
twice each night.
Case V., Mr. R. B., Age 74
Complaint: Unable to void.
H. P. I.—1916, acute retention, in hospital several weeks. 1917,
acute retention, has been catheterizing himself off and on since this attack.
Aug. 1932—Patient unable to pass the catheter, admitted to local
hospital, condition treated by indwelling catheter up to time of transfer
to hospital in Vancouver.
Admitted Dec.   16th,  1932—N. P. N. not taken.    B. P.  190-70.
General physical condition very poor—treated by an indwelling catheter.
Jan. 16th, 193 3—N. P. N. 62 mgs.—3 days later 70 mgs.
Jan. 20th, 193 3—Supra-pubic drainage established.
Feb. 4th, 193 3—N. P. N. 43 mgs.
Feb. 16th, 1933—Transurethral prostatic resection (spinal anaesthesia) 8 grams of tissue removed—Pathological diagnosis—adenofibroma
of prostate and chronic prostatitis.
Feb. 18th, 193 3—Allowed out of bed—unable to void freely, considerable residual urine.
March 16th, 1933—Cystoscopy showed the presence of considerable
adenomatous prostatic tissue which however did not appear to block the
March 31st, 1933—Second transurethral prostatic resection (spinal
anaesthesia) 3.8 gms. of tissue removed.
April 6th, 193 3—Spinal fluid tested to rule out a cord lesion. Colloidal gold and Kahn negative.
May 26th, 193 3—Third transurethral prostatic resection. 15 gms.
of tissue removed.
May 29 th, 193 3—Allowed out of bed, voiding freely, no residual
urine. Supra-pubic bladder drainage will usually cause a decrease in blood
N. P. N. far more quickly and completely than will drainage by an indwelling catheter in patients with a badly damaged renal system.
Page 188 After the first resection, though large soft rubber catheters could be
passed easily into the bladder and there appeared to be no obstruction to
urinary outflow, the patient was unable to void freely. This was found
at the third resection to be due to several distinctly adenomatous portions of the prostate hanging down from the upper portion of the vesical
neck which were not seen till most of the gland had been resected, the
resectoscope drawn well out into the posterior urethra and the inflowing
irrigating fluid practically stopped while viewing the area. Poor results
are more often the result of removing too little tissue than too much.
The three resections done on a patient who was a poor operative risk
demonstrate the safety of the procedure.
Case VI., Mr. W. C, Age 55
Complaint: Frequency, difficulty in voiding and inability to pass all
his urine, dribbling.
H. P. I.—Symptoms first noticeable two years ago—have been gradually getting worse.
Feb. 4th, 193 3—Cystoscopy showed bladder neck obstruction of the
median bar type.
Admitted April 24th, 193 3—N. P. N. 39 mgs. P. B. 125-80. General physical condition fair—Residual urine 165 cc.
April 26th, 1933—Transurethral prostatic resection (spinal anaesthesia) 5.4 grams of tissue removed—Pathological diagnosis—adenofibroma of prostate and chronic prostatitis.
April 28th, 1933—Voiding freely—no residual urine.
May 1st, 193 3—Allowed out of bed.
May 5th, 193 3—Discharged.
Haemorrhage occurred between the second and third weeks being
effectively controlled by the evacuation of clots from the bladder and
the insertion of an inlying catheter for about 36 hours. Dribbling still
present in spells but will likely be much lessened or eradicated when the
bladder is free of infection and the tone of the external sphincter is improved. The dribbling complained of before operation is usually worse
for a time after the resection.
Case VII., Mr. E. R., Age 68
Complaints: Frequency, difficulty in starting stream.
H. P. I.—Several g. c. infections resulting in stricture in 1890.
Tumour of bladder neck removed by f ulguration five years ago. Marked
frequency during past 5-6 years.
March 4th, 1933—Cystoscopy showed scarring about the vesical
neck with large median and very large lateral lobe hypertrophy.
Page 189 Admitted April 4th, 193 3—N. P. N. 36 gms. B. P. 150-100. Residual urine 150 cc.    General physical condition fair.
April 6th, 1933—Transurethral prostatic resection (spinal anaesthesia) 11 gms. tissue removed—Pathological diagnosis—Adenofibroma
of prostrate and chronic prostatitis.
April 8th,  1933—Allowed out of bed, voiding freely—no residual
April 10th, 1933—Discharged.
Profuse bleeding started about a week after discharge following the
use of some sort of electric vibration. Bleeding lasted off and on for six
days. Patient able to get rid of clots—no inlying catheter used. When
last seen two weeks ago he was able to hold his urine throughout the
night, with normal control.
Case VII., J. McK., Age 67
Complaints: Frequency, difficult micturition, dribbling.
H. P. I.—Urinary symptoms gradually becoming worse during past
few years.
Admitted Feb. 27th, 193 3—N. P. N. 3 0 mgs. B. P. 120-60 General physical condition good.    Residual urine 90 cc.
March 4th, 1933—Cystoscopy showed the obstruction to be due
chiefly to enlargement of the subcervical glands.
March 10th, 1933—Transurethral prostatic resection (spinal anaesthesia) 2.2 grams of tisue removed—Pathological diagnosis—Adenofibroma of prostate and chronic prostatitis.
March 20th, 193 3—Allowed out of bed, voiding freely, no residual
March 24, 1933-—Discharged.
This patient when last seen over a month ago was free of all his
urinary complaints except lack of complete control when the desire to
void was experienced, and some dribbling.
Case IX., C. H., Age 65
Complaints: Frequency, very small stream with considerable straining, acute retention twice, dribbling.
H. P. I.—Two strictures in the anterior urethra, probably due to a
g. c. infection 25 years ago, and a false passage in the posterior urethra.
April 4th, 1933—Cystoscopy showed middle and considerable lateral
lobe hypertrophy.
Admitted April 7th, 193 3—N. P. N. 27 mgs. B. P. 164-86. General physical condition good.   Residual urine 120 cc.
Page 190 April 8th, 1933—Transurethral prostatic resection (spinal anaesthesia) 7.5 gms. of tissue removed—Pathological diagnosis—Adenofibroma of prostate and chronic prostatitis.
April 13th, 193 3—Allowed out of bed—voiding freely, residual
urine 15 cc.
April 14th, 193 3—Discharged.
Following the removal of the resectoscope, considerable manipulation was required to insert the catheter for bladder drainage and haemos-
tasis. This resulted in trauma to the operative area and considerable bleeding for two days. Subsequent convalescence was uneventful. He has
no residual urine and voids freely and has been working at his occupation
as longshoreman since about the middle of May.
Case X., Mr. H. L., Age 54
Complaints: Frequency of urination, dribbling and acute retention.
H. P. I.—Two weeks before admission, developed frequency following a chill and head cold. No urinary trouble before this time. g. c.
infection 24 years ago.    Denies lues.    Blood Kahn—negative.
Admitted Feb. 27, 1933—N. P. N. 34 mgs. Residual urine 600 cc.
General physical condition—good.
March 4th, 1933—Cystoscopy showed a comparatively normal prostate except for considerable enlargement of the right lateral lobe.
March 13 th, 1933—Discharged—Residual urine of from 10-20
ounces which continued to be present.
March 25th, 1933—Re-admitted N. P. N. 29 mgs.   B. P. 120-60.
March 28th, 1933—Transurethral prostatic resection (spinal anaesthesia) . Examination of the vesical neck showed some middle lobe and
a fair amount of lateral lobe hypertrophy of a distinctly adenomatous
type. Spinal fluid withdrawn for Kahn test. 5.1 gms. of tissue removed.
Pathological diagnosis—Adenofibroma of prostrate and chronic prostatitis.
March 30th, 193 3—Allowed out of bed, voiding freely, residual
urine on repeated tests 150 cc-300 cc. Spinal Kahn plus four. Blood
Kahn negative.    Tryparsamide injections started.
April 6th, 1933—Discharged.
The findings' at cystoscopy on March 4th did not appear enough to
cause the amount of residual urine found. The spinal fluid showed a positive Kahn in the presence of a negative blood and history, though later
the patient admitted lues in 1911 with three year's treatment. No
residual urine present. Three weeks after discharge from hospital voids
freely, slight dribbling which has about disappeared. Marked gain in
Page 191 Case XL, Mr. J. R., Age 78
Complaint: Difficulty in passing urine, dribbling, frequency and
nocturnal incontinence, acute retention.
H. P. I.—Symptoms present for the past seven years. Acute retention one week ago—sixty ounces of urine removed. Put on continuous
drainage at home after development of acute cystitis.
Admitted April 23rd, 193 3—N. P. N. 40 mgs. B. P. 13 8-84. General physical condition—fair.
April 28th, 1933—Cystoscopy showed both lateral and median lobe
May 3rd, 1933—Transurethral prostatic resection (spinal anaesthesia) . Spinal fluid taken for Kahn. Insufficient amount arrived at for
laboratory test. 8 grams of tissue removed. Pathological diagnosis,
adenofibroma of prostrate and chronic prostatitis.
May 5th, 1933—Allowed out of bed, voiding freely, residual urine
60 cc.
May 7th, 193 3—Discharged.
The bladder was very atonic and had been apparently subjected to
overdistention for several months or longer. Residual urine varied from
one to five ounces during the first two post operative weeks. Since then
there has been none. He is now able to go through the night without
Case XII., Mr. L. A. L., Age 69
Complaints: Frequency, difficulty in starting stream, small stream
with considerable straining.
H. P. I.—Symptoms present past five—six years.
Admitted May 2nd, 1933—N. P. N. 37 mgs. B. P. 140-86. General physical condition good.    Residual urine 110 cc.
May 3rd, 1933—Cystoscopy showed a very large median lobe and
slight lateral lobe hypertrophy.
May 4th, 1933—Transurethral prostatic resection (spinal anaesthesia) 18 grams of tissue removed. Pathological diagnosis—Adenofibroma of prostate and chronic prostatitis.
May 7th, 1933—Allowed out of bed, voiding freely, no residual
May 16th, 1933—Discharged.
One cannot over-emphasize to the patient the importance of avoiding over-exertion during the first three weeks. This patient's discharge
from hospital was delayed as long as possible as he lives out of town and
normally a very active person.    Though warned to be quiet he did not
Page 192 do so and had to be re-admitted to hospital for three days with an inlying
catheter for haemorrhage. Except for a slight frequency and urgency
he now has normal micturition.
Case XIII., Mr. B. N., Age 70
Complaints:  Difficult urination, dribbling.    Acute retention.
H. P. I.—Symptoms present for past several years. Two weeks
before admittance the patient developed acute retention. Repeated
catheterizations carried out for five days when acute epididymitis developed on the left side. A catheter was then tied in for continuous drainage.
Admitted May 21st, 1933—N. P. N. 32 mgs. B. P. 145-80. General physical condition fair.
May 22nd, 1933—Cystoscpy showed inflammation and oedema about
the vesical neck with middle lobe and very large lateral lobe hypertrophy.
The interureteric ridge was markedly hypertrophied being situated very
close to the enlarged prostate.
May 25th, 1933—Transurethral prostatic resection (spinal anaesthesia) 3.4 gms. tissue removed. Pathological diagnosis—Adenofibroma
of prostate and chronic prostatitis.
May 27th, 193 3—Allowed out of bed, unable to void freely, residual
urine 6-12 ounces.
June 5th, 1933—Second transurethral prostatic resection (spinal
anaesthesia)  8.4 gms of tissue removed.
June 6th, 1933—Allowed out of bed, voiding freely, residual urine
2-0 ounces.
This patient has just recently been treated with radium for a carcinoma of the pharynx with apparently an excellent result.
It is likely that the prominent interureteric ridge of tissue due to its
unusually close proximity to the vesical neck, was mainly responsible for
the failure of the first resection. . Several pieces of tissue were excised
making a trough along the base of the bladder to the posterior urethra.
Knowing that the patient's remaining years were limited it is also
likely that I was too conservative in the removal of all possible obstructing tissue at the first operation.
18 Years'
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Pabltjm is unique among cereals. For it is not only
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Like Mead's Cereal, Pablum represents a great
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