History of Nursing in Pacific Canada

The Vancouver Medical Association Bulletin: July, 1926 Vancouver Medical Association Jul 31, 1926

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Page Two THE   VANCOUVER   MEDICAL   ASSOCIATION
BULLETIN
Published Monthly under the Auspices of the Vancouver Medical Association
in the Interests of the Medical Profession.
Offices:
529-30-31 Birks Building, 718 Granville St., Vancouver, B. C
Editorial Board:
Dr. J. M. Pearson
Dr. J. H. MacDermot Dr. Stanley Paulin
All communications to be addressed to the Editor at the above address.
VOL. 2.
JULY 1st, 1926
No. 10
OFFICERS, 1926-27
Dr. A. W. Hunter
President
DR.  A.  B.   SCHINBEIN Past President
Vice-President DR.   J.   A.   GILLESPIE
Secretary Treasurer
Dr. F. W. Brydone-Jack Dr. W. S. Turnbull
TRUSTEES
Dr. W. F. Coy Dr. W. B. Burnett
Representative to B. O Medical Association
Dr. A. C Frost
Dr. J. M. Pearson
Auditor
Dr. F. W. Lees
SECTIONS
Dr. F.
Dr. L.
Dr.   C
Dr. C
Clinical Section
N. Robertson   -
LEESON -------
Physiological and Pathological Section
H.  Bastin       -        -        - -
E. Brown -                                           -       -
Eye, Ear, Nose and Throat Section
Dr. Colin Graham       .---..
Dr. E. H. Saunders	
Genito-Urinary Section
Dr. G. S. Gordon -       -        -        -
Dr. J. A. E. Campbell	
Physiotherapy Section
Dr. H. A. Barrett      -       -       -
Dr. H. R. Ross      - -        -
COMMITTEES
Chairman
Secretary
Chairman
Secretary
Chairman
Secretary
Chairman
Secretary
Chairman
Secretary
Library  Committee
DR. W. F. MACKAY
Dr. W. D. Keith
Dr. C H. Bastin
Dr. W. C Walsh
Orchestra   Committee
Dr. f. N. Robertson
Dr. J. A. Smith
Dr. L. Macmillan
Dr. W. L. Pedlow
Dinner Committee
Dr. C F. Covernton
Dr. A. C. Frost
Dr. g. B. Murphy
Credit   Bureau   Committee
Dr. Lachlan Macmillan
Dr. D. G. Perry
Dr. D. McLellan
Credentials Committee
Dr. E. H. Saunders
Dr. B. H. Champion
Dr. T. R. B. Nelles
Summer School Committee
Dr. W. D. Keith
Dr. G. S. Gordon
Dr. Murray Blair
Dr. G. F. Strong
Dr. H. R. Storrs
Dr. R. Crosby
0' fl 311 ifeitrornmt
Since the publication of our last issue the medical profession of Vancouver has sustained a serious
loss in the death of Dr Alison Cumming, which
occurred in the early hours of Saturday, June 5 th,
after an illness extending over sixteen months.
Born in Truro, N.S., where he received his preliminary and High School education, Dr. Cumming went to Dalhousie where he graduated in
Arts. He then proceeded to McGill, graduating-from
that University in Medicine in 1905. After two
years internship in the Royal Victoria Hospital,
Montreal, he came to Vancouver. During his student days Dr. Cumming was an enthusiast in football and hockey and latterly was much interested in
golf. He married in 1909 Miss Edith Rawlings
of Montreal.
In Vancouver he was early appointed to the
Staff of the Vancouver General Hospital, being
Assistant Pathologist from 1908-1914,, Pathologist
1914-1916, and Physician to the Tuberculosis
Wards 1916-1918. From that time until his death
he was a member of the Senior Medical Staff of the
Hospital. He restricted his practice largely to Internal Medicine and occupied a prominent position
in that branch. During his later years of practice
he was especially interested in the various advances
in the pathology and treatment of diabetes and was
a leader in this line in Vancouver. His death at
the age of 49 ended a professional career of great
promise. His funeral was held at St. John's United
Church and was largely attended by the general public and by the medical profession of the city. The
pall-bearers were Drs. C. F. Covernton, J. W. Thomson, L. Hodgins, Mr. R. E. Burns, Mr. J. Patterson,
and Mr. A. P. Foster. Honorary pall-bearers were
Drs. R. E. McKechnie, W. D. Brydone-Jack, B. D.
Gillies, A. W. Hunter, W. D. Keith, A. Monro, A.
P. Proctor, and T. R. B. Nelles.
The sympathy of the whole profession goes
out to his Widow and family in their bereavement.
Page Four EDITOR'S PAGE
We went to Victoria for the Annual Meeting of the Canadian
Medical Asociation full of expectations and in the certain anticipation of
a good time. These expectations and this anticipation were more than
amply fulfilled.
This meeting was the 57th we were told in the history of the
Society and one's mind goes back in an endeavor to realize the sure
vision and colossal nerve of those who inaugurated this Society so far
back as the year 1869, a time almost co-equal with that of the Federation of the Provinces.
Could any of those hardy pioneers have been present, what a
lusty growth this early fledgling would show to them to justify and
confirm their early foresight as to the greatness of their profession and
their country.
For on this occasion 452 members of that profession were registered at the meeting. They came mostly, of course, from Canada, from
the far East and from the North and all the spacious land which lies
between. But also they came from all over the North American continent, the Western States as usual sending a bounteous contingent.
Delegates to the meeting were there from Great Britain, from far South
Africa, from official United States in the person of Dr. Tate Mason
of Seattle, from China whence a Canadian came to bring fraternal
greetings from his colleagues.
Mnay well known names were inscribed; quite at random we
noted Dr. Austin from Kingston, Dr. Starr, Dr. Hendry, Dr. J. G.
Fitzgerald and many others from Toronto. With them came Dr. Banting of Insulin fame whose short address on Medical Research was heard
with great interest by a crowded house. Montreal sent Dr. Chas. Martin, Dr. Cushing, who ably supplemented Dr. J. G. Fitzgerald's talk on
Scarlet Fever and the newer conceptions of that disease. Dr. J. C.
Meakins and many others were also present.
Those two stalwart Canadians whom we have temporarily loaned
to the Mayo Clinic—Dr. Rowntree and Dr. Lemon—came back to
the land of their birth bearing with them the fruits of their latest
researches.
They came from everywhere, Calgary and Edmonton did exceptionally well; Winnipeg, of course, sending Dr. Montgomery, our old
friend  Dr.  Hunter  and  many  others.
British Columbia must have been sadly depleted of medical attendance, so many of its professors were at Victoria and we were especially glad to see such a strong registration of the members of the Vancouver Medical Association.
Despite the heat—and the heat on Wednesday and Thursday was
very great—the attendance at the lectures was uniformly good and was
well rewarded.     For  the  papers   were  many  and   the  subjects  varied.
Page Five While most were good—and in our editorial capacity we heard them
all or nearly so—some, of course, were better.
If we can bring ourselves to criticize, where every effort had been
made to satisfy, it would be to suggest even more attention to the
problem of acoustics. Also while we realize that the voice and delivery
of the performer are individual traits, possibly a few concise suggestions,
especially to those less accustomed to public speaking, might well be
sent to each speaker beforehand. Thus the number of words which
can with ease be read aloud in a specified time should be well known for
we suppose that most papers will continue to be read, despite the manifest advantage in speaking at an audience instead of conversing with
the desk immediately below the lecturer. We note that even practised
hands tend to try to pack in considerably more than the alloted time
will contain. The consequence of this is a high speed delivery and a
hurried denoument when the hand of the Lord High Executioner signals that time is up.
But more in keeping with the spirit of the occasion we should like
to bear witness to the hard work which must have been done by the
Victoria men and women before and during the meeting in order that
such a large affair could run with the efficiency of a well-oiled machine.
We can understand, as the genial President observed during his
inaugural address, how the local Secretary, Dr. Thomas, from being a
debonnair young man prior to all these preparations, had now become
thin, grey and bowed.
In any event we are sure that there is no better place or more
satisfactory climate in which  to recuperate than Victoria.
The Empress Hotel made an excellent centre for the meetings and
the doctors took possession of it from basement to attic. A large and
very nicely arranged selection of exhibits was on hand, effectively but
not too conspicously arranged.. Dr. Maude Abbott of Montreal was
there with a new Osier Memorial volume on which she also gave a
short talk.
The lighting and platform arrangements were good and we must
not forget to commend the lantern and its custodian, the former only
too often a source of irritation. At this meeting both were comfortably
efficient, inconspicuous and noiseless.
Of the lighter side of the meeting much might be said did publication exigencies permit.
Victoria lends itself seductively easily to the holiday mood and the
work of the Committee was nobly assisted by the well known climatic
and geographical advantages this charming city possesses. The call of
the out-of-doors was almost irresistible. Even, we noticed, the most
stern and naturally undeviating fell ready victims. The numerous and
beautiful or difficult or lone or tortuous or whatever it is that con-
stitutes Paradise in golf courses, anyway these courses must have been
just naturally filled from sunrise to sunset, judging by the sunburn manifested on all hands and most faces.
Page Six Luncheons, dinners, teas, receptions, drives, dances and concerts
mostly I think or ostensibly at any rate for the ladies of the party,
followed one another in almost bewildering confusion. None could
go to all, all went to some and the combined picture of sound scientific
work and light-hearted play leaves a pleasant sense of appreciation of
Victoria and its medical men on the mind.
1926 SUMMER SCHOOL
The Summer School will be held in the week of September 13 th
and will last four days. There will be lectures in the morning and
evening, with additional clinical demonstrations, arrangements for which
will be announced later. The Committee has been fortunate this year
in obtaining particularly good speakers and this year's School gives every
promise of being a great success.
The lecturers will be:  —
Dr. A. S. Warthin, Prof, of Pathology, University of Michigan, Ann
Arbor; Dr. Geo. Gellhorn, Prof. Obstetrics and Gynaecology, St. Louis;
Dr. C. A. Hedblom, Prof, of Surgery, University of Illinois; Sir Henry
Gauvain, Orthopaedic Surgeon, London, England; Dr. George Hale,
Prof, of Medicine, Western University, London, Ont.; Dr. Fraser Gurd,
Associate in Surgery, McGill University; Dr. R. R. MacGregor, Prof,
of Paediatrics, Queen's University, Kingtson.
CORRESPONDENCE
The Editor, Vancouver Medical Association BULLETIN,
Dear Sir:—Various members of our Association are visiting eastern
parts from time to time partly on pleasure but also with the desire to
see some of the medical Institutions and what others are accomplishing
in different scientific fields.
It is always well to know where one can see the most in the usual
limited time and so I thought it might be of interest if I related a few
interesting features of the Cleveland Clinic. Dr. Crile has become well
known especially on account of his work in goitre cases.
I might state that it seems to be the policy of every member of
their Clinic from Dr. Crile down to the Junior Fellow, to take particular care that medical visitors should receive every attention and courtesy.
No matter how busy, they are always ready to discuss the subjects in
which they are specially interested.
The Clinic building is a sort of clearing house and receives all
cases except the very sick, which go direct to the Hospital. Here there
is a staff all told of 150 people. All the necessary diagnostic work is
done, as well as the treatment of other than hospital cases. The record
number of cases handled in one day was over 400.
Page Seven The surgical cases are referred to the Cleveland Clinic Hospital
near by, an institution of HO beds which is being increased to 220. On
account of lack of room there is a waiting list of 200 patients at present. The medical cases for hospital care are handled in temporary
quarters with accommodation for about 60. There is a well equipped
Physiotherapy section.
The majority of the surgical cases are thyroid and with a few exceptions these are operated on by Dr. Crile, assisted by a wonderfully
co-ordinated group of assistants.
The first morning of my arrival I had the good fortune to renew
acquaintance with Dr. McCullough, till recently practising in Vancouver, and now a Fellow at the Clinic. Later I met Dr. Pitts, pathologist to the Clinic, who is joining us in Vancouver in August. He is
very highly spoken of by all his associates.
The average number of thyroid operations each morning is 15, with
a record of 34. They are almost invariably done in the patient's room
under local anaesthesia of very large amounts of three-quarters of one
per cent, novocaine injected until the whole neck is bulging, and gas-
oxygen analgesia given by nurses. The patient is conversing most of
the time and very few are heard to complain of any pain.
Fewer ligations are being done. The morning I attended operations
there were 11 cases, all for lobectomy or thryroidectomy. There was
practically no blunt dissection. Many of the more severe cases are not
sutured but packed with Flavine gauze and sutured within 24 hours or
if the condition warrants a second lobectomy is done at this time. The
actual time of each operation is but a few minutes. The operation
mortality rate is around 0.8 per cent.
The treatment which averages 6-8 days before operation consists
in the administration of digitalis, of Lugol's solution with a nightly
dose of bromide. A large fluid intake is insisted upon. On the night
before and morning of operation thyroid ext. gr. ii is given and morphia
with atropine. Post-operatively the large fluid intake is maintained
with such morphia as is necessary in small doses for the first 24 hours.
Lugol's solution is given per rectum or mouth. Drainage is removed in
12-24 hours, and the patient allowed up in 3-4 days.
Practically all are of the opinion that the indiscriminate use of
"iodized salt" is the cause of many cases of adenoma becoming toxic,
but Dr. Pitts has shown that since its use has become more general the
incidence of the severe hyperplastic form has very appreciably diminished.
Much of interest was seen in the very well organized departments
of Internal medicine, metabolism, X ray diagnosis, etc. Considerabl:
experimental work is being done in the physiological and chemical sec
tions. One is impressed by the enthusiasm of the staff and especially
in the seemnigly unlimited energy of its Chief, who is already beyond
the "chloroform age."
C. E. BROWN.
Page Eight B.C. MEDICAL ASSOCIATION NEWS ITEMS
The Annual Meeting of the B.C. Medical Association was. held at
the Empress Hotel, Victoria, on June 22nd. The fact that the Canadian Medical Association was in session at the same time rather conflicted with our activities, but we had the pleasure of entertaining the
members of Council of the Dominion body at dinner in the evening,
when some 125 men were present and had a very pleasant time. Dr.
Stewart Cameron, of Peterboro, Ontario, was the guest of honour and
spoke at some length regarding the history of the Ontario Medical
Association and its difficulties and triumphs since its reorganization in
1918. Apparently the history of one association is very much like the
history of another and it was with very sympathetic feeling that one
listened to Dr. Cameron's account of the afflictions out of which his
Association seems to have eventually obtained a happy issue. He emphasized, however, the advantages that have accrued to the Ontario
profession as a result of their organization. When one hears of 47
District Societies all running full blast with some $25,000 expended
in five years upon extension work and postgraduate lecturing, one's
mouth waters and one looks forward with a somewhat shaky optimism
to the time when B.C. will have attained a similar degree of vitality
in the work of its organization.
The Election of Officers took place following the Dinner. Dr. J. H.
MacDermot was elected President, Dr. H. E. Ridewood, of Victoria,
President Elect. Dr. T. H. Lennie was elected Secretary-Treasurer, and
Dr. Wallace Wilson was elected Vice-President.
Excellent reports were obtained from the various Committees. A
fuller account of these will be given at some future date in the Bulletin,
but owing to the exigencies of time and space it is impossible to deal
with  these now.
A rather pleasant touch was given by the presence of Dr. G.
L. Milne at our Dinner and meeting in the afternoon. The B. C. Medical
Association has the right to nominate a certain number of honorary
life members of the Canadian Medical Association where certain conditions as to age and duration of service are fulfilled. Dr. Milne, who
is already and honorary life member of the B. C. Medical Association
was our nomination for this year and it is a great pleasure to be able
to do this. This pioneer of medicine in B.C. claims 76 years of an
active life, a great deal of which has been devoted to the service of his
profession. He was one of the little devoted band that against great
opposition was instrumental in bringing into effect the Medical Act
under which we now work. In speaking after his nomination Dr.
Milne gave a brief account of the days in which he first practised in
B.C.    "Truly there were giants in those days."
We cannot let this occasion pass without tendering our hearty
congratulations to the Victoria Medical Society for the truly amazing
way in which they have "put over" the C.M.A. Meeting. Those of us
who remember the meeting here in 1906 can fully appreciate the difficulties of such a venutre and looking on the smoothness of working and
Page Nine the wonderful completeness of detail of the Victoria meeting one is
filled with sincere adrniration. "Fortune favours the brave" and no
more delightful weather could have been prayed for by the Victoria
medical men. Added thus to the natural advantages of Victoria one
feels that the meeting of 1926 will long remain a mark to be aimed at.
Important Notice
The lock on the Library door will be changed on
July 15th. Members holding keys can have them
exchanged free of cost. Others desiring keys can
procure same from the Librarian on payment of
35 cents.
11 it
CITY HEALTH DEPARTMENT
Vancouver, B.C.
STATISTICS—May, 1926.
Total  Population   (estimated    ._.  128,366
Asiatic  Population  (estimated)    ~     10,100
Rate per 1000 of
Population per Annum
Total   Deaths     131 12.0
Asiatic  Deaths       11 12.8
Deaths   (Residents  only)     102 9.4
Total   Births     302 27.7
Male, 158
Female, 144
Stillbirths—not included in above       15
INFANTILE MORTALITY—
Deaths under one year of age        9
Death Rate per 1000 Births    29.8
CASES OF INFECTIOUS DISEASES REPORTED IN CITY
June 1st to
15th,  1926
Cases    Deaths
April, 1926
Cases    Deaths
0
IS
27
Smallpox	
Scralet   Fever
Diphtheria   ....
Chicken  Pox  47
Measles   101
Mumps     120
Erysipelas   4
Tuberculosis     43
Whooping   Cough.— 9
Typhoid  Fever...-.  0
0
0
"3'
..0
0
0
0
13
2
0
May,
Cases
1
13
18
70
180
111
2
7
34
1
1926
Deaths
0
0
3
0
1
0
1
8
1
0
0
5
7
41
121
34
0
4
9
2
Cases from Outside City—included in above.
Diptheria          5 2                 2              1
Scarlet   Fever       2 0                 3              0
Typhoid   Fever       0 0                  10
Page Ten
0
0
0
0
0
0
0
0
0
0
0
0 PHYSIOLOGICAL   FACTORS   OF   MUSCULAR
WORK AT HIGH ALTITUDES
By Dr. R. E. Coleman
The development of aerial transportation during recent years has
again brought to the fore many old phsiological problems. As is to be
expected experience was gained in the early stages by the hit or miss
method characteristic of our savage ancestors; but even yet the trial
and error method pervades to an undue extent. Though the most
highly educated man of today has more resemblance to, than differences
from, the savage in this respect, it is that modicum of difference which
distinguishes between the relative successes and failures of the two
groups. "The modern conception of man as a product of and a part
of nature brings the subject of man's individual physical adjustments
into its proper place as the fundalmental study." The application of the
science and art of conscious physical adjustment between man and his
surroundings in the universe, distinguishes the educated man's adjustment from that of the savage. It is true that the savage element
in all of us frequently drives us, hit or miss, to hard won successes;
but the careful analysis and experimental study of individual factors
in the end place the educated group far in advance of their savage
ancestors.
One of the most recent attempts at an elaborate physical readjustment is our attempt to conquer our aerial surroundings. Chiefly
to improve our transportation, we have set out to make ourselves as
much at home as we can in the air. At first this new venture appeared
to many as entirely different from all previous ventures, but again we
find some old physiological factors entailed, differing in degree rather
than in kind from those we meet every day. That such relationships
might exist between flying and the climbing of high mountains was
more or less predictable; but it was not anticipiated that we would
encounter many of the same factors as would be found in such conditions as surgical shock, starvation, diabetic coma, insulin excess, death
from exposure, the care of premature infants, athletic fatigue, Graves'
disease, anaemia, and many other clinical conditions in which there is
evidence of a failure to maintain an adequate rate of energy supply.
For this reason the "Conquest of Mount Logan," which appeared in
a recent issue of the Bulletin has even more interest for the clinician and
the physiologist than it has for the mountaineer. To the mountaineer
it was only a glorious adventure; but to the clinician and the physiologist it also supplied valuable data towards "man's conscious physical
adjustment to his surroundings." As a physiological experiment its
beauty lies partly in the fact that it was only partly successful. Two of
the party were compelled to turn back, and there is evidence that some,
if not all, of the other members of the party pushed the experiment into
a "critical" physiological zone. We can therefore expect that a careful
analysis of the data may reveal a clue to some of the various "critical"
factors.
Page Eleven Briefly, the physiological experiment consisted of eight selected men
attempting to walk a particular two hundred and eighty miles without
becoming reduced below a certain rnimimum of physiological efficiency.
If they should become reduced below this minimum of physiological
efficiency, they would not be able to make satisfactory observations.
Frequent examples of the latter condition are to be found in the literature of altitude flights in aeroplanes and balloons, where the pilots have
lost the power of judgment (or have even lost consciousness) at the
higher altitudes when the only records made were made by automatic instruments. In addition to this loss of records a further slight reduction of
physiological efficiency might lead to death. Of those who started^ a
party of eight, six, or seventy-five per cent., successfully completed
the experiment. Why did twenty-five per cent fail, and how much of
a margin of safety was exhibited by the individual members of the
successful group? Since the essential factors of the experiment revolved
chiefly, if not entirely, round the rate of energy production only, the
factors of energy production will be considered in detail.
The base line for all measurements of rate of energy production is
the "basal metabolic rate." This basal metabolic rate is the rate of
energy production during complete muscular rest and in warm surroundings. From the very nature of the Mount Logan "experiment" it is
apparent that this base line could never have a comparable value, for the
members of the party were never in warm surroundings.. Above 8,000
feet it was always distinctly cold and, with the high wind velocity, the
rate of body cooling was often considerable. Even when sleeping three
in a robe on the higher levels, the effect of excessive body cooling could
be appreciated, since they did not feel actually warm. In other words
each member of the party, even when at rest, had to maintain a rate of
energy production in excess of his basal rate merely to maintain his normal body temperature— The work of Coleman and Dubois and others
make it highly probable that in this experiment all energy production
in excess of the basal rate would be produced by muscular work (through
sensible or insensible contractions—shivering) so that for twenty-four
hours of the day the muscular system of the climbers was continually
at work and no period of complete muscular rest for recuperation was
available. It is true that for such a group under normal conditions the
added amount of work, due to shivering, would be insignificant, but in
this experiment a critical physiological zone of rate of energy production was entered and such factors, though small under other conditions,
might assume relatively large proportions in such a zone. Certainly
the account of the last attack on Mount Everest indicates that the energy
production necessary to maintain normal temperature of the climbers
may have assumed vital importance and since Mount Everest has not
yet been conquered all factors which may reach critical values should
be carefully studied.
It would therefore be well worth while determining by actual experiment the relative efficiency of various types of clothing for reducing
the rate of body cooling. As a preliminary experiment it would be
worth while determining the rate of cooling through the clothing as
worn by the Everest climbers, the clothing as worn by the Logan climbers, and the native winter clothing of the Esquimaux, of whom Stefan-
Page Twelve sson remarks, "they lead a tropical life, sleeping in the open, even during
a blizzard." (By making use of the windways developed in modern
aeroplane research laboratories this factor could be accurately determined) . That the clothing used by the Mount Logan climbers or the
Everest climbers was not one hundred per cent, efficient was clearly indicated during both climbs. The Mount Logan climbers suffered from
"frost bites" which is simply due to excessive cooling. The Everest
climbers also suffered from frost bites and they considered it suicidal
to sleep in the open because of the difficulty of keeping warm. In both
cases the clothing had been developed by the "hit and miss" method. If
we really wish to surmount the obstacles of high altitudes by conscious
physical adjustment and experimental study of all the factors which may'
reach critical values should be attempted.
The factor which exhibits the widest fluctuations in rate of energy
production is one which frequently reached "critical" values in the present experiment and on the high levels was constantly in a "critical"
zone. This factor is the rate of energy demand for the performance of
conscious muscular work such as walking and dressing. Above 14,000
feet all unacclimatized human beings experience symptoms indicating
that a "critical" physiological zone of rate of energy production has
been entered. By acclimatization and adaption these symptoms may not
appear till much higher levels are reached. For example some native
Thibetians do not show symptons even at 19,000 feet or even higher.
But in the present experiment all the members of the party began showing signs at 14,000 feet. Therefore since this one factor was constantly
important (and as will appear later, probably entailed most of the elements of success or failure), its various components are worthy of careful analysis.
From the work of A. V. Hill and others it would appear that in
the first instance when a muscle contracts it yields energy quantitatively
equivalent to the glycogen converted at the time into lactic acid. This
glycogen-lactic acid reaction is anaerobic, taking place in the absence
of free oxygen. During the recovery period free oxygen (from oxyhemoglobin) is used to further oxydize a part of this lactic acid,
permitting at the same time a reformation of glycogen from the remaining lactic acid. The net loss of glycogen is probably replaced
chiefly from the glucose of the blood in the presence of insulin, though
Krogh has shown that it may, under certain conditions, be replaced
from fat. When muscular work is performed at such a rate that no
fatigue develops, as in the normal heart rhythm, the rates of lactic
acid production and of the redeposition of glycogen in the muscle cells
continue equal. It is apparent then that muscular work is at the expense of preformed carbohydrate and that the recovery process necessitates an adequate supply of free oxygen.
When muscular work is performed at high altitudes, limiting values for several of the above factors manifest themselves. At an altitude of 14,000 feet the oxygen tension is considerably less than at sea
level. Therefore, since the rate at which oxygen is given up to the
tissues by oxyhaemoglobin depends indirectly upon the tension at which
the oxygen is received into the lungs, the low oxygen tension of high
Page Thirteen altitudes will decrease the rate at which the oxyhaemoglobin will yield
oxygen to the tissues.
The physiological adaption to this deficiency of oxygen tension is
one of the chief factors of acclimatization and has received considerable attention. It consists partly of a compensatory increase in the
haemoglobin concentration. Dwellers in high altitudes have regularly
an increased haemoglobin concentration in the blood, partly through
an increase in the total number of red cells and partly by an increased
concentration of haemoglobin within the individual cells; but it has
not yet been definately established that the compensation is ever complete. Certainly the data available from the Mount Logan and Mount
Everest experiments indicate defective compensation on the part of the
climbers.
As stated above, the first stage of muscular contraction is accompanied by conversion of glycogen into lactic acid. If a contracting
muscle is suspended in saline solution, the lactic acid accumulates with
the coincidental development of fatigue. If after the development of
fatigue a recovery period of sufficient length is provided during which
there is an adequate supply of free oxygen, the lactic acid and the fatigue disappear; but in the absence of free oxygen the lactic acid persists
and recovery from fatigue does not occur. Similarly in the body, an
inadequate oxygen supply is always accompanied by early muscular
fatigue. Familiar clinical examples of the onset of early fatigue following slight exertion in the absence of an efficient rate of oxygen supply are simple anaemia from haemorrhage, CO poisoning and the condition under discussion, namely the low oxygen tension of high altitudes. Many examples of this phenomena are to be found in the literature of high altitudes. In both the Mount Logan and Mount Everest
expeditions particular note was made of the fact that a recovery period
of deep breathing was needed after every few paces forward. According to Krogh, however, in altitude flights, not all muscular work is at
the expense of pre-formed glycogen; for this worker has shown that
during muscular work in the absence of an adequate CHO supply some
sustenance of a fatty nature may be converted into a carbohydrate,
(glycogen). The compensatory mechanism which provides for CHO
deficiency however, would only accentuate any oxygen deficiency, for
the conversion of fat into a carbohydrate requires extra oxygen. As a
result Krogh's reaction requires even more oxygen than the simple
glycogen-lactic acid reaction. Therefore, the conditions of oxygen deficiency characteristic of high altitudes would be accentuated if Krogh's
reaction were invoked. Krogh has also shown that the mechanical efficiency of this source of energy for muscular work is distinctly less
than the glycogen-lactic acid reaction and as a result a given quantity
of work would require even more energy than normally. Thus such adaption as the body does possess to compensate for a deficient supply of preformed CHO is of such a character that it exaggerates any oxygen
want and by impaired mechanical efficiency calls for a larger total rate
of energy supply both of which would serve to exaggerate factors already critical.
An efficient rate of oxygen supply is then a pre-requisite for efficient muscular work.    If the rate at which oxygen is supplied to the
Page Fourteen tissues is not efficient then lactic acid will accumulate in the muscle,
from hence it will diffuse into the blood and finally may be excreted in
the urine. If a normal individual under normal conditions performs
severe muscular work lactic acid will appear in the urine. That is,
the body can compensate in part for a deficient rate of oxygen supply
by a wasteful combustion of pre-formed glycogen, losing energy which
would be obtained had the lactic acid been completely burned.
It is now apparent that the deficient rate of oxygen supply con»-
stantly present when severe muscular work is attempted at high altitudes would throw an ever-increasing strain upon the available supply
of pre-formed glycogen. It was also noted that in our present experiment the rapid cooling of the body caused the muscles, even when the
climbers were at rest, to use up glycogen for the maintenance of their
normal temperature. It is essential then that all of the factors affecting
the production of, and the consumption of, glycogen should be carefully
studied with a view to supplementing the production of glycogen and
to conserving its use.
It was noted above that during muscular work glycogen is first
destroyed and later a part of the glycogen is replaced from the
lactic acid produced. The replacement of glycogen was noted to occur
only during the recovery period and in the presence of an adequate
supply of oxygen. It is apparent from this that the breathlessness experienced by both the Mount Logan and Mount Everest climbers may
have more significance than simply to indicate an embarrassed circulatory reserve. For this reason in future experiments it would be
worth considering reducing the rate of locomotion to a minimum of
breathlessness. In the Mount Everest expedition Col. Norton aimed at
twenty paces without stopping. He found about thirteen his limit. If
he had aimed at five or six followed by an adequate recovery period he
might have saved enough glycogen waste to more than compensate for
the time lost. Col. Norton's marked loss of weight would seem to indicate a continued drain on his glycogen reserves.
The relation of diet and the maintenance of body temperature is
also worth considering. It was noted that at high altitudes the climbers when once cooled off had considerable difficulty getting warm again,
even in a sleeping robe. The nature of this difficulty becomes apparent
when it is recollected that if the body at rest is warmed by shivering,
it is accomplished by the consumption of glycogen. If the glycogen
reserve becomes depleted then Krogh's reaction becomes the only source
of new glycogen and since this reaction is relatively slow and inefficient
a rapid recovery would not be expected. A few lumps of sugar might
have shortened the recovery period by supplying a ready and economical source of pre-formed CHO.
After conserving glycogen waste as much as possible, the next step
would be to provide a maximum supply of pre-formed CHO from the
diet. After ingestion, all available CHO in the food is quickly and
economically converted into glucose in the body and as such is available
for storage as glycogen. Therefore, it would seem that a high CHO
diet would be the diet of election at high altitudes. That such diets
were  actually  chosen   by  the   climbers   was   clearly   indicated   by   Col.
Page Fifteen Foster's account, as given before the Section of Physiology and Pathology. The climbers had actually planned to use the meat and vegetable
extracts of their iron rations for making soup because the extracts were
thought to be strengthening. From the above discussion it is evident
that such extracts, consisting as they do chiefly of salts and the simpler
nitrogen derivatives of protein, would yield little or no energy. They
were in fact really contra-indicated, for such products require water
for their elimination and water was always scarce. As a matter of experience and in spite of their firm belief in the efficacy of these extracts, the members of the party found them distasteful. On the
other hand the diet actually eaten was largely CHO.
In the earlier part of this discussion it was suggested that even
those who successfully made the climb showed signs of their having
been in a critical physiological zone. To show this it will be necessary
to leave the consideration of the muscles and to consider the body as a
whole, particularly the nervous system. The muscles are by no means
the only tissues which do work at the expense of pre-formed CHO. On
the contrary, for equal units of weight, nervous tissue consumes more
glucose and oxygen than muscle tissue. Though the exact quantitative
relationship between rate of energy produced and glucose used up has
not been determined for nerve tissue still we do know that the consumption is high. Unfortunately the nerve cell has little if any capacity for storing CHO and it is therefore dependent upon the glucose
of the blood from minute to minute. It is apparent then that under
conditions in which the muscles are keeping the blood depleted of glucose the nervous system will suffer. A familiar example of this is seen
today when an excessive dose of insulin is given to the diabetic patient.
In this condition the sugar of the blood is reduced to a very low concentration. The nervous system is thus starved of its CHO supply and
all of the symptoms resulting are referable to this starvation.
Clinical experience in diabetes mellitus furnishes another example
of the effect of deficient CHO combustion. In diabetes there is an
abundant supply of pre-formed CHO but the body is unable to burn
it. In many ways the symptoms are similar to the above and their
particular application in the present discussion is that one of the members of the Mount Logan expedition was diagnosed a diabetic. The
frequency of symptoms referable to the nervous system, even in the
mildest diabetic, suggest very strongly a connection between this climber's, disease and the fact that after being exposed to the above conditions, this individual became ill, one symptom being numbness of the
legs with loss of function. Further suggestive data of a similar nature
is obtained from the Mount Everest account; the only overweight member of the party developed a neuritis. Clinically the association of
overweight, diabetes and neuritis is familiar. The dry gangrenous frost
bites which occurred on the Mount Everest climb also suggest the possibility of a physiological deficiency in rate of glycogen combustion
being common to the two conditions.
Returning to the two young athletes who were compelled to turn
back a consideration of the above discussion suggests some of the factors
which probably contributed to .their failure. In the first place, as A. V.
Hill says of young athletes in general, it can usually be assumed that
Page Sixteen such individuals will go "all in," so we have only to consider why
such a group will go "all in" before the older men who Col. Foster reported were not as strong at the start. Col. Foster remarked that these
two young athletes could and would pick up more than their alloted
loads and walk off as easily with no more effort than the older men
would exhibt under a regulation load. It is possible that this was their
very undoing for when such a rate of energy demand was met by a deficient oxygen supply all of the above mentioned critical values would
be sooner reached. As a result, their very prowess would precipitate
their breakdown. There is also another factor which probably contributed: neither of the young athletes had been in very high altitudes before and experience has shown that the acclimatization is slowest during
the individual's first ascent. That they were not efficiently acclimatized is also indicated by the fact that one at least developed Cheyne-
Stokes respiration.
In conclusion then, if we are to adapt ourselves to life at high altitudes, the attempt should be made to study all of the physiological factors. Many of these factors are capable of experimental investigation
and even many experiments are cheaper than a few lives. They would
also lead to our "conscious physical adjustment" in contrast to the
hit or'miss successes which may or may not be capable of repetition and
are so costly in lives. The chief factors are rate of energy production,
rate of energy supply, degree of acclimatization and rate of body cooling.
VANCOUVER GENERAL HOSPITAL
LABORATORIES
Miss Donna E. Kerr, Biochemist of the Laboratory, recently made
her 10,000th collection of blood, by venous puncture.
The literature on Blood Grouping and on the Kahn Precipitation
test, placed last month in the physician's room at the V.G.H., has disappeared rapidly.   Good—that is what they were placed there for.
Congestion of the rapidly increasing work of the staff in the Clinical Laboratory has necessitated shifting the autopsy room from its
present situation on the second floor of the Laboratories building to the
first floor. The autopsy room will occupy what has hitherto been the
View Room, which latter will in turn be shifted to the Morgue proper.
The space thus gained for the Clinical Laboratory will be so assigned
as to relieve the overcrowded "Front Room." The new autopsy room
will be much more convenient to the Morgue than the present one,
better fitted up, and equally roomy and well lighted.
Dr. C. H. Vrooman and the Director of the V.G.H. Laboratories
returned May 24, 1926, from the first of several trips to be made for
the Federal Government, in the attempt to determine the incidence and
factors of the tuberculosis amongst the B.C. Indians. The first trip
yielded first-hand clinical and fluoroscopic data concerning about 175
to 190 Bella Bella Indians.    The examinations were conducted at the R.
Page Seventeen W.  Large Memorial  Hospital,  Bella  Bella,   with  the  invaluable  aid  of
Dr.  George Darby,  Medical  Superintendent,   and his  staff  of  Nurses.
WANTED.—Attention has been drawn again recently to the occurrence of a small bluish patch in the skin of the sacral region and
neighborhood in new-born Indian babies. This same marking is also
found in Japanese babies, and (said to be) in Chinese babies. It is
stated to last until the child is from eight months to one year old. The
V.G.H. Laboratories will be glad to secure appropriate autopsy material
for the microscopic study of this area, in an attempt to determine its
nature.
Dr. A. W. Hunter, President of the Vancouver Medical Association and Pathologist to the Vancouver General Hospital, has tendered
his resignation from the latter, taking effect July 1st, 1926, in order
to devote himself more completely to private practice. He will, however, continue as consulting Pathologist. Dr. H. H. Pitts, originally
of Nelson, B.C., at present and for some years past doing pathological
work in Dr. Crile's clinic at Cleveland, Ohio, is to succeed Dr. Hunter,
as part-time pathologist to the Hospital. He is expected to begin his
work here August 1, 1926.
Dr. R. E. Coleman, Assistant Director, was called away suddenly
to Toronto at the end of May, on account of the illness of his father.
Dr. Coleman returned on June 28 th.
DISEASES OF LOWER GENITO-URINARY
TRACT
Paper read before a meeting of the Vancouver Medical Association on
April 6, 1926, by Dr. B. H. Champion
My purpose in presenting this paper on the diseases of the lower
urinary tract, is to refresh our minds on what we have already learned,
for I have little or nothing new to offer. By the lower urinary tract
I mean the bladder, prostate and urethra with their adnexa. I shall
deal principally with the prostate as time will only permit a mere mention of the pathological conditions of other portions of the lower urinary tract.
According to Sir Everard Home, prostatism has existed from time
immemorial. In the Book of Ecclesiastics, we read ". . . . ere the
pitcher be broken at the fountain, or the wheel broken at the cistern";
this suggests two principal effects of the disease: the involuntary
passing of urine and its total stoppage.
Niccol Massa, a Venetian physician, about the middle of the 16th
century was the first to suggest that the bladder could be obstructed
by a swelling of the prostate.
John Hunter, Sir E. Home, Brodie and others, practised piercing
the prostate with a catheter, but this method was too painful and soon
fell into disfavour.
Page Eighteen Perineal operations were performed in the  17th century.
Covillard, in 1639, successfully removed a prostate by the perineal
route, by crushing it with the forceps. Perineal prostatectomy, combined with lithotomy was frequently done in the early part of the 18th
century. The first regular work on the prostate was done in 1834 by
Guthrie.    He divided the bar at the neck of the bladder.
Then came Mercier, Bottini, Freuderberg, Young, Horwitz, Keyes,
Chetwood, Sir Henry Thompson, Freyer, Sir Thomson Walker, etc.,
all of whom gave to the world many improvements thus making operation on the prostate gland safer for the patient.
EMBRYOLOGY
You will recall that the genito-urinary tract is developed from three
main sources—the Wolffian bodies and ducts, the Mullerian ducts and
the Allantois. The Allantois juts out from the primitive gut, near
its posterior end, in the second week, and becomes the urinary bladder.
The prostate is now held to be formed from the mesoblastic tissue that surrounds the urogenital sinus and the genital cord. Into this
annular mass of mesoblastic tissue which surrounds the lower end of
the Wolffian and Mullerian ducts, offshoots of epithelial lining from
the urethra project to form the glandular portion of the prostate.
Lowsley claims that the glandular portion is derived from 5 sets
of tubules in contra distinction to the older view of only 3. He claims
the median lobe has an independent origin   (Albarran's tubules).
There is a bursa between the prostate and the rectum called the
aponeurosis of Denonvilliers; it is a down growth from the peritoneum.
ANATOMY OF PROSTATE
The prostate measures 4 cm from base to top; 4 cm tranversely and
is 7}A cm thick.    It weighs 15 to 24 grms.
The capsule of the prostate is the condensed peripheral portion of
the fibro-muscular stroma and is inseparable from the gland. The
surgical capsule, so-called, is derived from the pelvic fascia. The
stroma constitutes about half the bulk of the gland. The number of
prostatic ducts varies from 15-20, and the acini are lined with columnar
epithelium. . The ejaculatqry ducts empty into the floor of the prostatic
urethra.    (Lowsley).
The prostate is made up of 5 lobes, viz—
Median   lobe   10  tubules
Right   lateral   16
Left   lateral   16
Post,  lobe „     9
Ant.  lobe     7
In all    58  tubules
BLOOD SUPPLY
Internal pudic and middle hemorrhoidal arteries and the prostatic
branch of the hypogastric axis.
Page Nineteen NERVE SUPPLY
From the sympathetic,  through  the inferior  hypogastric  plexus.
LYMPHATICS
There are two groups, the lateral which communicates with the internal iliac glands and the upper which drains into the obturator lymph
nodes.
The lateral lobes have a thin capsule at-the base, especially where
the uretha enters them and for this reason: Neoplasms arising in
them have a tendency to invade the bladder by way of the urethal orifice.
The tubules enter the urethra on either side of the verumontanum.
Lowsley compares the posterior lobe to a wedge with its base at
the apex of the gland. Benign hypertrophy rarely, if ever begins in
the posterior lobe, while primary cancer rarely, or never, begins in any
other portion of the prostate.
Accessory glands—subcervical group of Albarran, consist of 30
or more branched tubules whose ducts open into the nndline of the
floor of the urethra. In 24 per cent, of autopsies on men over 30
years of age, Lowsley found these glands enlarged sufficiently to cause
obstruction to the vesical outlet.
PHYSIOLOGY
The function of the prostate gland is to furnish fluid to liquify
the sperm and facilitate its passage from the genital glands. Testicular
fluid is acid.    Prostatic fluid is alkaline.
CAUSES OF HYPERTROPHY
Little has been added to our knowledge of the etiology of prostatic hypertrophy within the past 50 years. Some observers claim that
inflammation  precedes hypertrophy  and vice-versa.
Rousing, Pilcher, Young and Keyes oppose the inflammatory theory
because the usual result of inflammation is atrophy rather than hypertrophy.
Henry Wade offered the hypothesis that benign hypertrophy is
due to some alteration in the normal internal secretion, and suggests
the name "chronic lobular prostatitis" in differentiation from the in-
terstital prostatitis, the end product of which is a sclerosed gland.
Vulpian held that prostatic hypertrophy was analogous to fibroid
disease of the uterus, because of the common embryological origin.
Reginald Harrison claimed that the prostate enlarged to compensate for a primary descent of the bladder floor.
At the present time we cannot hope to reach any definite conclusion as to the influences exerted by occupation, personal habits, previous disease of the generative organs and similar possible causes of
prostate enlargement.
The man v with hepatic and portal congestion, with a tendency to
hemorrhoids, or varicose veins of the legs, is not an infrequent victim
of enlarged prostate. Over-indulgence in sexual intercourse has long
been considered a possible factor.     J. William White states that it is
Page Twenty quite as logical, if not more so, to blame the enlarged prostate with exerting unnatural desires.
Hodgson claims that the extra work upon the prostate in supplying
a fluid after the secretion of the testicles had become insufficient for
that purpose, causes hypertrophy. Here again the many theories are analogous to the many remedies for an incurable disease—not one of them
is of any specific value.
PROSTATITIS
The prostate becomes infected in about 75 per cent, of all cases of
gonorrhoea. The prostate may become infected from other causes; this
is far more prevalent than is generally known.
It may become infected locally from the urethra, from fissures
about the rectum, hemorrhoids, congestion due to constipation, and
through the blood stream from other possible foci as the teeth or tonsils. I have had numbers of cases .following 'flu. Some of those cases
have had few or no symptons, except, perhaps, a little urgency or frequency, or something a little unusual noticed about the act of micturition.
Mostly, in G.C. prostatitis, only one portion of one lobe becomes
involved. These can be easily felt per rectum. The affected area or
areas are first somewhat painful and soft, but as the condition becomes chronic, cellular infiltration is replaced by fibrous tissue. The
area becomes hard and later on becomes indented by the contraction of
the fibrous tissue. So one can usually determine whether an infected
prostate is acute or chronic by the consistency under the finger. Smears
of the expressed fluid will usually determine whether G.C. is the offender or other bacteria are causing the inflammation. Broadly speaking,
in all smears, male or female, the presence of G.C. denotes gonorrhoea.
The presence of polynuclear leucocytes and absence of bacteria, is in
favor of G.C. Strangely enough, the usual flora of the anterior urethra
and cervix are not found in the presence of gonorrhoea, so if you
stain a smear and find pus and no germs of any kind, be suspicious
until you get another smear. On the other hand, the presence of polynuclear cells and presence of bacteria other than G.C, is in favor of a
secondary infection.
The presence of epithelial cells in abundance, is suggestive of over-
treatment.
Instrumentation causes  posterior  urethritis  and prostatitis.
PROSTATIC ABSCESS
This may result from a prostitis. If the gland is enormously
enlarged, painful, and the two lobes cannot be differentiated, the centre
or mid-sulcus greatly swollen, you have a prostatic abscess. The temperature is elevated to, perhaps, 105. These cases often cause retention
of urine, necessitating the passage of a catheter.
TREATMENT—Rest in bed. Gentle massage (with emphasis on
gentle) to facilitate drainage through the urethra; urinary antiseptics
administered internally; suppositories containing morphia and belladonna.    Hot or cold rectal washes through psychophore.
Page Twenty-one If pus shows at meatus, all well and good, if not, the abscess
should be opened by perineal section or may open spontaneously into
rectum, or urethra.    Rupture into other situations is rare.
EPIDIDYMITIS
This occurs in 2 5 per cent, of all cases of G.C. Here, rest with
withdrawal of local treatment and application of ice or heat. Some
surgeons incise the epididymis and relieve the pressure of a hydrocele
which is always present. Instrumentation of the urethra and prostatic
massage should be withheld if possible. Rectal examination may be
done, with caution, to determine the condition of the prostate. Sometimes it is found to be swollen over the infected side; gentle massage may
start drainage of pus into urethra, which relieves the situation.
Generally speaking, all urethral treatment should be stopped until
the "fire burns down."
CALCULI
They occur in the prostate as a result of strictures of the urethra;
may only be detected by X-Ray.
RETENTION CYSTS    •
of the prostate are not very common. When they occur, they may
cause obstruction.
SYPHILIS
of the prostate is rare and has no definite characteristics.
TUBERCULOSIS
of the prostate and seminal vesticles, is often associated with T.B. of
the kindney finding its way down through the bladder and through
the vesticles and testis, the prostate becoming infected secondarily.
T.B. of the lower genital tract is slow in development and there is in
the beginning little local or constitutional evidence of its presence. T.B.
infection is found in early life. The globus major is more likely to be
involved in T.B., the globus minor, in G.C. The absence of acute
symptoms should make one suspicious of T.B.
CARCINOMA OF THE PROSTATE
Malignant disease of the prostate ,to quote Deaver, "is chiefly of
the adeno-carcinomatous variety. The rapidly-growing medullary carcinoma is rarely seen on the prostate. One of the chief characteristics
of prostatic carcinoma is its tendency to metastasize early and widely.
Practically all organs are subject to these metastases, but the bones are
particularly liable. The medullary cavities of long bones are frequently
involved. It must be remembered that carcinoma of the prostate is far
commoner than is usually believed. Young states that 20 per cent,
of all hypertrophied prostates are carcinomatous. Some authorities give
even a higher percentage. The symptomatology of early cancer of the
prostate is almost identical with that of benign hypertrophy, with which
indeed it is often associated. The differential diagnosis between these
conditions is an impossible one to make, or, if made at all, is based entirely on physical signs. There is, however, one exception to this, i.e.,
pain, independent of micturition, which is very suggestive of malignancy
Page Twenty-two At first localized in the region of the prostate, and constant in character, later it becomes referred to the perineum, to the back, the buttocks
and the thighs. Referred pain is a late symptom of carcinoma. It
means the involvement of the prostatic sheath in the vicinity of the
large nerve  trunks.
On rectal examination, increased density, with or without nodules,
is very suggestive of carcinoma. Then, areas of stony hardness are the
most important physical finding in carcinoma of the prostate, especially
when associated with pain and independent of micturition.
The large, soft, adenomatous prostate may contain areas of carcinoma, but I think if one carefully palpates the lateral sulci, he will find
one to be fuller and more resistant under the finger than the other.
Carcinoma of the lateral lobe may spread laterally towards the pelvic
wall. Lowsley says: "Benign hypertrophy rarely, if ever, begins in
the posterior lobe, while primary carcinoma rarely, if ever, begins in
any other portion." Carcinoma of the posterior lobe is easily detected,
and in these cases good results are obtained from prostatectomy. Hematuria, especially after catheterization, is mostly found in benign hypertrophy, and is favorable evidence against carcinoma.
CYSTOSCOPIC DIAGNOSIS
Deaver states that the diagnosis of prostatic hypertrophy cannot
be said to be complete without a cystoscopic examination.
True, a large hypertrophied prostate may be felt on rectal examination, but the vesical complications and vesical picture of the prostate
should be determined before operation.
There are six reasons for cystoscopic examination:—
1. To determine whether the enlargement is lateral, or of the
middle lobe. Median lobe enlargement can only be determined by
cystoscopy.
2. To ascertain whether the enlargement encroaches upon the
urethral surfaces.
3. To ascertain the presence of:—
(a) Bladder tumors, if any.
(b) Stone.
(c) Diverticulae, in which case if these are not detected, the
patient has little or no relief after operation.
(d) A median bar.
If every case of obstruction of the bladder neck was carefully
cystoscoped before operation, we would have fewer cases of bad results
seeking relief elsewhere.
A WORD ABOUT POST-OPERATIVE TREATMENT
1. A troublesome complication following prostatectomy, is epididymitis. The French, to avoid this, divide the vas deferens, which
does away with the fear of this complication, and a catheter may be
inserted, without fear, into the bladder.
2. Control of hemorrhage: The French have abandoned packing and put  patient on  calcium lactate prior  to operation.
:W,
Page Twenty-three 3. About 2 to lYz inches of the urethra is torn away, leaving a
large cavity to fill in with scar tissue. When healing is complete, the
new urethra in this area may be narrowed. It may be above the floor
of the bladder; it may be distorted, or it may be encroached upon by
folds of mucous membrane causing obstruction. Also, granular tissue
may persist and this raw surface causes frequency of urination. I believe that cases of prostatectomy should be treated in the same way as
strictures of the posterior urethra, by the passage of sounds until no
more bleeding is detected; and if the urine is dirty, irrigate the bladder
after each dilation until it becomes clear.
A WORD ABOUT THE USE OF THE CATHETER
The more one has to do with genito-urinary cases, the more cautious
one becomes in the use of the catheter and sound.
We all have had experience with the so-called urethral fever. I
have two sudden deaths to my debit as a result of urethral instrumentation. In case of urinary obstruction, where a catheter or sound has
never been passed, one should proceed with caution. The anterior
urethra harbors germs which in the healthy urethra do no harm, but if
the mucos membrane is broken or they are carried back into the posterior urethra, a urethritis is set up. Lowsley states that he believes in
every case of catheterization a posterior urethritis is set up. To avoid
this, the anterior urethra should be syringed out with an antiseptic
before a catheter is introduced into the bladder.
In cases of obstruction, the utmost care should be exercised in attempting to enter the bladder. A small coude is perhaps the safest. If
it fails to enter the bladder easily, discontinue and try the filiform to
avoid damaging the urethra which is always congested in prostatic
enlargement. Every general practitioner should have a set of filiforms
with followers. On failing to enter the bladder, after a reasonable trial,
without force, suprapubic puncture and drainage should be done.
ACUTE AND CHRONIC CYSTITIS
Time will permit of only a few words on this common disease. The
essential cause of cystitis is bacterial contamination, but such bacterial
invasion to produce cystitis must be in the presence of a contributing
factor which renders the organ readily susceptible to microbic infection. In the commonest form of cystitis, the susceptibility thereto
and the bacterial infection are derived simultaneously; and this refers
to that type of cystitis which comes as a result of extension of inflammation, be that from the posterior urethra which is the commonest of
all, from the ureter, or from a neighboring focus of suppuration outside
the bladder. The less common method of invasion is by way of the blood
current or lymph stream. In this case, the predisposing and infecting
agencies derived separately. The predisposing factors in general are
embraced in an enumeration of all causes of vesical irritation or congestion, namely:—
Highly irritating urine due to an excess of acid or alkaline constituents. The presence in the urine of certain chemical substances in
excess, such as turpentine, copaiba, cubeb, cantharides, over-indulgence
in alcoholic beverages, etc.
Page Twenty-four Physical strain, and anything that may produce traumatism directly
or indirectly, such as violent exercise, falls, and other injuries, and
direct wounds, such as the unwise and careless introduction of instruments.
The microorganisms that are responsible for cystitis, are the staphylococcus, streptococcus, proteeus vulgaris, penumococcus, bacillus coli,
and the specific organisms of gonorrhea and tuberculosis, as well as
those of typhoid, glanders, anthrax, etc.
One word about the results of chronic cystitis. Here we get a
condition not unlike that seen sometimes following prostatectomy, namely a contracture of the neck of the bladder. Chronic inflammation in
this area results in fibrotic contraction producing partial occlusion
with elevation of the opening above the floor of the bladder. This
condition is found both in men and women. The mucosa of the bladder presents a polypoid appearance or a hob-nailed condition caused by
fibrotic contraction.
Treatment of acute cystitis should be carried out by rest and daily
lavage and by injecting one of the milder silver preparations. Operation is often the only means of relief of the contracture mentioned
above. This is done by removing the obstructing portion on the floor
of the bladder, thus leaving the floor of the bladder on the same plane
as the urethral floor.
TUMORS OF THE BLADDER
Dr. Champion concluded his paper by a brief reference to tumors
of the bladder.    These he divided into 3 groups:—
1. The epithelial group which includes papilloma, carcinoma, adenoma and cysts.
2. The connective tissue group which includes sarcoma, myxoma,
fibroma and angioma.
3. The muscle tissue group as myoma.
Page Twenty-five ■| OFFICE 1
STATIONERY
Of the better kind.
PHONE SEYMOUR 2487
McBeath Spedding Ltd*
569 Howe Street
Vancouver, B.C.
Miss R. Backett, R.N.
c^YCasseuse^
PRIVATE   HOSPITAL
1436 Harwood St.,Vancouver, B.C., Phone Sey.3147
Overlooking English Bay
^>c?3reatments<^.
SWEDISH and  MEDICAL   GYMNASTICS, London, England, Certificate
ELECTROTHERAPY, HYDROTHERAPY, and ACTINOTHERAPY
Patients attended in own homes.    Special Dietary.    Graduate  Nurses  in
Attendance.    Visited by Qualified Physicians
Page Twenty-six  The Basis of all Artificial
Infant Feeding
The basis of infant feeding is human milk, and
the principle involved in the artificial feeding of normal infants is the imitation of human milk.
Cows' milk is the basic material used in practically all artificial feedings. It is modified one way
or another to make it better suited to the infant's
digestion, and to have more or less the same proportions of food elements as human milk.
Pediatrists say that fresh cow's milk is, therefore, a logical diet for normal infants, provided that
it is diluted with water to reduce its fat and protein
contents and that a suitable sugar is added to the
mixture to give it approximately the same percentage
of carbohydrate as in human milk.
Mead's Dextri-Maltose
is a special sugar to be added to diluted milk, which
has been found to be more easily assimilated by infants and less likely to produce diarrhoea than cane
sugar or milk sugar. «
DEXTRI-MALTOSE is advertised only to
the profession in order that the physician may control each case and be the sole judge of the proper
formula to suit the needs of the individual baby.
On request, a Mead's Feeding Calculator, showing usual formulas for normal infants suggested by
the results of pediatrists, will be supplied to physicians, together with samples of Dextri-Maltose.
Mead, Johnson & Company
OF CANADA, LTD.
BELLEVILLE, ONT.
liTSU
Mfftv
Page Twenty-eight  SPECIAL OFFER
Doctors9 Bags
Of Exceptional Value
Manufactured in England
Solid Cowhide Leather
Hand'sewn and rivetted frames
Adjustable bottle loops and pocket
Orders will be filled in sequence
We have a stock on hand and another shipment coming
Special price during run of this advertisement:
CLUB STYLE   -   M   .   ££
A saving of about 25%
B. C. Stevens Co. Ltd.
730 Richards Street Vancouver
The Ou?l Drug
Co., Ltd.
■All prescriptions dispensed
bu qualified Druggists.
IJou can depend on the Ou?l
for ^Accuracy and despatch.
VJe deliuer free of charge.
5 Stores, centrally located.    We
would appreciate a call while
in our territory.
Ambulance
Service
TELEPHONE
Fair. 58 & 59
Mount Pleasant
Undertaking Co.   Ltd.
R. F. Harrison    W. E. Reynolds
Cor. JCingsway and Main
Page Thirty  —*-Js©e
JM. -   	
-)3^+-
Hollywood Sanitarium
LIMITED
^or the treatment of
Alcoholic, Nervous and Psychopathic Cases
Exclusively
"Reference - <\B. (?. (£M.edical (Association
For information apply to
Medical Superintendent, New Westminster, B. C.
or 515 Birks Building, Vancouver
Seymour 4183
Westminster 288
=<©<?
?*3»»
Page Thirty-tun

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