CONTENTdm
History of Nursing in Pacific Canada
Vancouver Medical Association
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Hi bulleM : tt. of the VANCOUVE MEDICAL ASSOCIATION Vol. XVIII. JUNE, 1942 With Which Is Incorporated Transactions of the Victoria Medical Society the Vancouver General Hospital and St Paul's Hospital In This Issue: NEWS AND NOTES-S. j|_ ^^^^^^^H ANNUAL REPORTS B. C. MEDICAL ASSOCIATION HOSPITAL PROBLEMS—Grace M. Fairle§.R.Np^ MASSIVE HEMORRHAGE INTO ADRENALS JjSB§i INTESTINAL OBSTRUCTION^: MB^B^B THE BODY WATER IN HEALTH AND DISEASEJlS No. 9 — Page . 260 268 . 274 276 . 281 ! 283 C.M.A. MEETING - JASPERtWUNE 15-19 ft . i* i »m E>if$ lilnm \tt Mf 1 !>l». In ORESTOL E*B*S* the Physician finds the Owe milligram Orestol by mouth is equivalent to one milligram of natural hormone by injection; and Orestol may be regarded as an effective substitute for the natural follicular hormone of the ovary. RESTOL Answer . . . to repeated demands for :«_?ji3***: Ores*i a substance with oestrogenic activity when administered orally... INDICATIONS: In the treatment 01 ovarian hypo-function, Orestol is of therapeutic value only in the first half of the menstrual cycle- while in the treatment of menopausal conditions, itaj; use may be more or less! continuous. till MM (4-4 Dihydroxy a-b Diethyl Stiiboestrol Di-propionate) Shuttleworth's Orestol is available in tablets of three sizes, pat up in bottles of 100 and 500 as follows: CCT. No. 530 X mg. CC.T. No. 531 1 mg. CCT. No. 532 5 mg. ORESTOL BOOKLET NOW AVAILABLE An interesting and informative booklet giving clinical studies and references may oe had upon request. Ask the Shutdeworth representative for a copy or write to Toronto. WHEN PRESCRIBING Specify E.B.S. PREPARATIONS Amenorrhea... due to malnutrition or temporary ovarian deficiency responds to ORESTOL as its use in this condition has produced oestrin withdrawal bleeding and epithelial growth of vagina, uterus and breast tissue. Dysmenorrhea ... may be treated with ORESTOL E.B.S. plus adequate water, iron and vitamin intake, for according to *M. C. Watson, fluid is important as : the oestrogens act by altering the local circulation and water metabolism in the tissues. ORESTOL can also be used for relief of menstrual pain. The Menopausal Syndrome & Atrophic Vaginitis: ORESTOL E.B.S. provides excellent symptomatic relief of hot flushes, lassitude, etc. and promotes great improvement in the local ulcerative condition of the vagina. Inhibition of Lactation: By its effect on the lactogenic hormone of the anterior lobe of the pituitary, ORESTOL inhibits lactation. Sterility: Where uterine hypoplasia is the cause, ORESTOL may be administered during the first half of the cycle. It increases circulation in uterus and vagina... stimulates epithelial growth. *Watson M. C. Academy of Medicine Bulletin, Toronto, March, &40, p. 127. jjjg^ • \ust H be sure, THE E. B. SHUTTLEWORTH CHEMICAL CO. LIMITED TORONTO MANUFACTURING CHEMISTS CANADA SI THE VANCOUVER MEDICAL ASSOCIATION BULLETIN Published Monthly under the Auspices of the Vancouver Medical Association in the interests of the Medical Profession. Offices: 203 Medical- Dental Building, Georgia Street, Vancouver, B. C. EDITORIAL BOARD: Db. J. H. MacDermot Db. G. A. Davidson Db. D. E. H. Cleveland All communications to be addressed to the Editor at the above address. Vol. XVIU. JUNE, 1942 No. 9 OFFICERS, 1941-1942 Db. J. R. Neilson Db. H. H. Pitts Db. C. McDiabmid President Vice-President Past President Db. Gobdon Bubke Db. A. E. Tbites Hon. Treasurer Hon. Secretary Additional Members of Executive: Db. J. R. Davidson, Db. J. A. McLean TRUSTEES Db. F. Bbodle Db. J. A. Gillespie Db. W. T. Lockhabt Auditors: Messbs. Plommeb, Whiting & Co. SECTIONS Clinical Section Db. Ross Davidson Chairman Db. D. A. Steele Secretary Eye, Ear, Nose and Throat Db. A. R. Anthony Chairman Db. C. E. Davies : Secretary Pediatric Section Db. G. O. Matthews Chairman Db. J. H. B. Grant Secretary STANDING COMMITTEES Library: Db. P. J. Btjlleb, Db. D. E. H. Cleveland, Db. J. R. Davies, Db. A. Bagnall, Db. A. B. Manson, Db. B. J. Habbison Publications: Db. J. H. MacDebmot, Db. D. E. H. Cleveland, Db. G. A. Davidson. Summer School: Db. H. H. Caple, Db. J. E. Habbison, Db. H. H. Hatfield, Db. Howabd Spohn, Db. W. L. Graham, Db. J. C. Thomas Credentials: Db. A. W. Hunter, Db. W. L. Pedlow, Db. A. T. Henby V. O. N. Advisory Board: Db. L. W. McNutt; Db. G. E. Seldon, Db. Isabel Day. Metropolitan Health Board Advisory Committee: Db. W. D. Patton, Db. W. D. Kennedy, Db. G. A. Lamont. Greater Vancouver Health League Representatives: Db. R. A. Wilson, Db. Wallace Cobtjbn. Representative to B. C. Medical Association: Db. C. McDiabmid. Sickness and Benevolent Fund: The Pbesident—The Tbostees. !t* ■'I Mm :;Jtq . \m m Plain? ^ TABLETS FERROUS SULPHATE EXSICCATED SQUIBB Each enteric coated tablet contains 3 grains of exsiccated ferrous sulphate equivalent to 60 mg. of elemental iron. H ■fl With %1 ? 1$ CAPSULES FERROUS SULPHATE WITH Bi SQUIBB Each capsule contains 3 grains ferrous sulphate exsiccated plus 1 mg. (333 Int. units) Thiamine Hydrochloride. Or with Civet and ft Complex? _^ CAPSULES HEBULON SQUIBB Each capsule contains 2 grains of ferrous sulphate exsiccated plus the equivalent of 16 grams of fresh liver plus 50 Int. units Thiamine Hydrochloride, and other B Complex factors found in the liver extract. These products are supplied in bottles of 100 and 1,000. Literature sent on request. Write, 36 Caledonia Road, Toronto I E-R:Squibb &. Sons of Canada. Ltd MANUFACTURING CHEMISTS TO THE MEDICAL PROFESSION SINCE 1859 VANCOUVER HEALTH DEPARTMENT STATISTICS—APRIL, 1942 Total Population—estimated 272,352 Japanese Population—estimated 8,769 Chinese Population—estimated ! 8,558 Hindu Population—estimated i 360 Number Total deaths 280 Japanese deaths . 3 Chinese deaths 16 Deaths—residents only 241 BIRTH REGISTRATIONS: Male, 278; Female, 240- _ 518 INFANTILE MORTALITY : April, 1942 Deaths under one year of age 13 Death rate—per 1,000 births 25.1 Stillbirths (not included in above) 8 Rate per 1,000 Population 12.5 4.0 22.2 io!s 23.2 April, 1941 10 20.2 11 CASES OF COMMUNICABLE DISEASES REPORTED IN THE CITY March, 1942 Cases Deaths April, 1942 Cases Deaths May 1-15,1942 Cases Deaths Scarlet Fever 28 0 47 0 37 Diphtheria 2 0 0 0 1 Diphtheria Carrier 6 0 4 0 2 Chicken Pox 348 0 177 0 55 Measles 45 0 23 0 11 RubeUa 54 0 34 0 17 Mumps 803 0 795 0 406 Whooping Cough 45 0 97 1 68 Typhoid Carrier 0 0 0 0 0 Typhoid Fever 0 0 0 0 0 Undulant Fever 0 0 0 0 0 Poliomyelitis 0 0 0 0 0 Tuberculosis 41 17 50 20 25 Erysipelas 3 0 4 0 2 Meningococcus Meningitis 4 0 5 0.2 V. D. CASES REPORTED TO PROVINCIAL BOARD OF HEALTH, DIVISION OF VENEREAL DISEASE CONTROL West North Burnaby Vancr. Richmond Vancr. Syphilis 0 0 2 1 Gonorrhoea 0 0 0 0 Vane. Hospitals & Clinic Private Drs. Totals A DYNAMIC MENTAL AND PHYSICAL TONIC INDICATED IN THESE DAYS OF STRESS << A »» BIOGLAN "A Another Product of the Bioglan Laboratories, Hertford, England Phone MA. 4027 Stanley N. Bayne, Representative 1432 MEDICAL-DENTAL BUILDING Descriptive Literature on Request THE SCIENTIFIC HORMONE TREATMENT Vancouver, B. C. Page 258 JU w*. €ARBACH@L B.D Carbamylcholine Chloride Carbachol B.D.H., an ester of choline, carbamylcholine chloride, possesses the potent cholinergic action of acetylcholine and it exhibits a marked stability and resistance towards enzymes; thus it has a sustained therapeutic action. Since Carbachol B. D. H. is resistant not only to choline-esterase but to digestive enzymes also, it possesses in addition the useful property of being active by mouth. The pharmacological action of Carbachol B. D. H. is identical with that of acetylcholine, namely, parsympathetic stimulation, and the principal effects of its administration are therefore contraction of smooth muscle, stimulation of glandular secretion and dilatation of blood vessels. The stimulant effect of Carbachol B. D. H. on the smooth musculature is valuable in such conditions as post-operative urinary retention and paralytic ileus. The action on blood vessels is employed in the treatment of peripheral vascular disturbances as, for instance, in Raynaud's disease. Its action in stimulating the terminations of the vagus and so retarding the heart is of value in the treatment of paroxysmal tachycardia. In most of its applications Carbachol B. D. H. is effective when administered orally; in consequence this is the route normally employed. When a more rapid action is required Carbachol B. D. H. may be administered subcutaneously or intramuscularly or even (slowly and in diluted solution) intravenously. Carbachol is issued in 2 mgm. tablets for oral administration and 1 c.c. ampoules each containing 0.25 mgm. for parenteral use. Stocks of Carbachol B.D.H. are held by leading druggists throughout the Dominion, and full particulars are obtainable from: THE BRITISH DRUG HOUSES (CANADA) LTD. Toronto Canada Carb/Can/426 MEASLES t*ij Modification »« Prevention In 1939 there were 197 deaths from measles in Canada. More than 95 per cent of these were in the age-group 0-5 years. Human serum prepared from the blood of healthy adults so as to involve a pooling from a large number of persons may be used effectively either for modification or prevention of measles. Modification is often preferable in that it reduces to a minimum the illness and hazards associated with measles, < but does not interfere with the acquiring of the active and lasting immunity which is conferred by an attack of the disease. On the other hand, complete prevention of an attack of measles is frequently desirable, and can be accomplished provided that an ample quantity of serum is administered within five days of exposure to the disease. For use in modification or prevention of measles, pooled human serum is available from the Connaught Laboratories in a concentrated form. While the recommended dose of this pooled and concentrated human serum for purposes of prevention is ordinarily 10 cc, the most usual dose is for purposes of modification and amounts to 5 cc. The serum is therefore supplied in 5-cc. vials. Prices and information relating to it will be supplied gladly upon request. - m :i*. .ii CONNAUGHT LABORATORIES UNIVERSITY OF TORONTO Toronto Canada DEPOT FOR BRITISH COLUMBIA MACDONALD'S PRESCRIPTIONS LIMITED MEDICAL-DENTAL BUILDING, VANCOUVER, B.C. f V, "Ira THE EDITOR'S PAGE 1? tt* One of the results of this war, and it may be one of the few good things that will come out of it, will be to teach us that there are very many things which we have come to regard almost as necessities, which are not really necessities at all. Under the grim compulsion of war's stranglehold on our sources of supply, we shall have to learn to "do without." Perhaps it will be a blessing in disguise. We hav ebeen getitng too soft and lazy, too prone to let someone else do it; we may have to learn to stand on our own feet, do our own work, and it will od us no harm. It may even teach us to be a little more considerate of others than we have been. At a recent meeting called by Dr. A. Haywood, Medical Superintendent of the Vancouver General Hospital, Miss Fairley, Director of the Nursing School, spoke frankly and quite seriously about the grave problem that is confronting the hospital, in the matter of nursing service. We recommend to our readers that they give careful study to her remarks, published elsewhere in this issue of the Bulletin. They deserve and demand our most careful attention. Dr. Seymour's remarks, also published, merely underline Miss Fairley's most reasonable appeal. We medical men have perhaps become rather spoiled of late years. The increasing excellence of nursing service has accustomed us to taking too much for granted. We order, perhaps a thought too casually, all sorts of treatments: intravenous, hourly fomentations, etc., and because they are always carried out to the minute and with a degree of perfection that is amazing, we feel that it is quite a natural hing. Yet it means, and for years has increasingly meant, a greater strain on the uncomplaining nurses who do it all so well. Long before we had to face the extra strain imposed by the war, some of us had been feeling that there was something not quite right. When one sees nurses unazle to take their legitimate and badly needed "hours off" and hears of them regularly having to stay on overtime, even missing meals, one feels disquieted and uneasy. Yet we have heard no complaints; perhaps it would have been better if we had. It behooves all of us to try to look at this thing through the eyes of "party of the other part" and the modest and most reasonable requests of the hospital authorities should receive from us, not merely an academic agreement, but an immediate response. We are under this compulsion here, of our own conscience in this matter. We must make things easier and better for these nurses, our most loyal and indispensable aides. Otherwise, quite apart from any sentimental considerations of fair play, we are going to find that an over-worked and overstrained machine may break down badly, and then we shall all suffer very severely. It is for us to welcome these suggestions and act on them willingly and to the fullest extent possible, and irnmediately. Nor is this the first time we have been asked to co-operate with the hospital authorities. For many years we have been asked to see that patients come in early the day before operation, that we avoid meal hours for the visits we have to make, etc. Yet we see these requests continually disregarded—and we fail to realize that when we disregard them, though our patients do not suffer, and we do not suffer, someone doe ssuflfe, and this is always the same person, the unfortunate nurse, who has to lose her precious privileges of rest and leisure (and these are very hard to come by anyway) because we were a bit thoughtless. Well, if we go on disregarding warnings, we may find that we ourselves may lose a privilege or two. We are sure that for most medical men, all that will be necessary will be to have this matter placed before them clearly and in a friendly spirit. Miss Fairley's courteous, kindly remarks on the subject challenge us to do our part, as her nurses have more than done theirs. (i w if hi Ki'. f* i •" •<v >.:, Page 259 •?S||: "I '.-: .* \M './• NEWS AND NOTES The regular meeting of the Board of Directors of the British Columbia Medical Association was held following dinner at the Devonshire Hotel on Wednesday, May 20th, 1942. Dr. A. H. Spohn, Chairman of the Board, presided. Present: Doctors G. F. Amyot of Victoria, Murray Blair, D. F. Busteed, W. A. Clarke of New Westniinster, P. A. C. Cousland of Victoria, Arnold Francis of New Denver, R. W. Garner and C. T. Hilton of Port Alberni, H. McGregor of Penticton, A. H. Meneely of Nanaimo, H. H. Milburn, K. D. Panton, Stanley Paulin, R. A. Seymour, G. F. Strong, Wallace Wilson, A. Y. McNair, Honorary Secretary-Treasurer, and M. W. Thomas, Executive Secretary. A letter from the Honourable John Hart, Premier of British Columbia, thanked the Association for its support and for the appointment of Drs. Spohn and McNair as representative and alternate respectively on the Advisory Council of the Provincial Protection Committee, of which Mr. W. C. Mainwaring is Chairman. A letter from Dr. W. B. Burnett thanked the Board of Directors for the honour which it had done him in placing his name in nomination for Senior Membership of the Canadian Medical Association. This honour will be conferred upon Dr. Burnett at the Jasper meeting. Medical Boards under the Department of National War Services have been appointed at Vancouver, Victoria, Nanaimo, Prince George, Prince Rupert, Trail, Cranbrook, New Westminster, Kamloops and Penticton. In the preparation of the nominations submitted the district medical associations had an opportunity to select the names. The Canadian Medical Association passed the nominations as collected to the Department of National War Services, by whom appointments were made. A committee was appointed to investigate the question of health and accident insurance on a group basis. The company, which had enrolled over 50% of the Vancouver Medical Association, presented a similar plan to the Board of Directors, with a view to extending such privileges to the general membership of the British Columbia Medical Association. It was reported that the final response of Health Insurance Questionnaires as from British Columbia reached 70%. A letter from Dr. Routley thanked British Columbia for its effort in support of the Committee of Seven of the Canadian Medical Association. A statement from Dr. Routley showed total contributions at April 27th to the War Benevolent Fund for British Doctors to be $4,925.71. Dr. Fred W. Routley, National Commissioner of the Canadian Red Cross Sociey, thanked the British Columbia Division for the splendid response made to the appeal for instruments and medical equipment for Britain. The Board was advised that Dr. Colin McDiarmid had been appointed as representative from the Vancouver Medical Association to the Board of Directors of the British Columbia Medical Association for its next association year. Dr. McDiarmid will become a member of the Board following the Annual Meeting. The resolution passed by the Vancouver Medical Association, bearing on the question of narcotic prescriptions, was presented to the Board of Directors, and the resolution was endorsed and forwarded to the Executive of the Canadian Medical Association, suggesting that some action be taken towards modification of the present regulations. Copies of communications from Colonel J. L. Ralston, Minister of National Defense, to Dr. Routley, were read, telling of the arrangements for assistance to medical students made necessary by the acceleration of medical training leading to early graduation and the provision of more medical officers for War Services. This correspondence was being published in the Bulletin. Page 260 fill The results of the first year final examinations of the University of British Columbia show Bert A. Auld with the highest standing and winner of the Royal Institution scholarship in arts and science. Bert is the son of Dr. and Mrs. F. M. Auld of Nelson. Congratulations to all three of them. Dr. M. G. Archibald of Kamloops is visiting in Eastern Canada and his old home in the Maritimes. He will go to Montreal where his son is finishing his medical course at McGill. Dr. Robert MacKenzie of Grantham's Landing is relieving Dr. F. A. Olocke of Ashcroft during the month of May. Dr. H. L. Burris of Kamloops visited Vancouver the other day. Dr. H. F. P. Grafton and Mrs. Grafton of Kamloops were in Vancouver. Dr. Grafton attended the meeting of the Committee on Maternal Welfare. When Dr. and Mrs. Grafton visited the office we were surprised to find that Mrs. Grafton's right forearm was in a splint and carried in a sling, she having suffered a fractured forearm. Dr. Grafton has his left forearm in a splint, and had it supported in a,sling, he having suffered a fracture of the left wrist. We trust that they will recover before Ripley hears of it. A daughter was born to Dr. and Mrs. R. H. Irish of Tranquille at the Royal Inland Hospital, Kamloops, on May 11th. Flight-Lieut. D. B. Ryall, R.C.A.F., and Mrs. Ryall, are receiving congratulations on the birth of a son on May 8 th, at St. Joseph's Hospital, Victoria. A son was born to Dr. and Mrs. Douglas Telford on May 18th. Major Gordon Large, R.C.A.M.C, and Mrs. Large left for Eastern Canada after spending leave in Vancouver. Capt. L. G. Wood, urologist from Vancouver, is now stationed at the Debert Military Hospital and has been at the Coast on leave. Capt. Wood reports that this is a very busy unit. Several officers of No. 16 General Hospital are stationed there, -among them: Captains E. F. Christopherson, W. H. Fahrni, E. F. Raynor, W. M. Toone formerly of Nelson, and W. S. Huckvale formerly of Kimberley. Capt. J. A. Wright, formerly of Vancouver, is the secretary-treasurer of the 3rd Canadian Division Medical Society, in the 3rd Canadian Division, which was sponsored by Colonel Lavell H. Leeson, A.D.M.S. in that Division. It is a thriving organization and holds regular meetigs, which are largely attended. The sympathy of the profession is extended to Dr. and Mrs. O. O. Lyons of Powell River in the loss of their daughter, Norma Joan, on May 14th. Dr. Gordon Richard Blott, an interne at the Vancouver General Hospital, was married on May 22nd to Miss Eleanor Mae Stewart. We are glad to announce that Dr. Roger G. Knipe has successfully passed the examinations of the Medical Council of Canada. Dr. Knipe is the son of the late Dr. G. W. Knipe. Capt. W. H. White, R.CA.M.C, has been in Penticton on a short visit. Page 261 Dr. JGeorge H. McKee, son of Dr. Josiah McKee of Courtenay, also obtained his L.M.C.C Both these young doctors are serving as internes at the Vancouver General Hospital and are accorded our congratulations. Dr. Frank L. Wilson of Trail is at Trout Lake in the Lardeau District and we hope is catching his full complement of big fish. Lucky Frank! The practising profession in Nanaimo is deeply appreciative of the courtesy extended by Lieut.-Col. F. W. Lees, O.C, and the officers of Nanaimo Military Hospital, who have welcomed the local doctors to their regular bi-monthly clinical meetings. A considerable amount of interesting and valuable material is being regularly accumulated and presented. At the last meeting on May 15th the following subjects were discussed: "Knee Joint Injuries"—Capt. K. H. Haig, "Phlebitis—Post Scarlet Fever"—Major S. A. Wallace, "Bronchiectasis"—Major J. E. Walker, "Laboratory Diagnosis—Typhoid"— Capt. J. D. Balfour, "Polypus of Stomach"—Major M. R. Dickie, "Virus Pneumonia" and "Post Diphtheritic Neuritis." These meetings are under the chairmanship of Major J. E. Walker. Capt. A. G. Naismith of Kamloops, who is Medical Officer to the 2nd Battalion Rocky Mountain Rangers (Reserve) and Lieut. W. F. Anderson of Kelowna, Medical Officer to the 9th Armoured Regiment, B.C.D. (Reserve), have been away at camp. During May two meetings of the Prince Rupert Medical Association were held, al which films from Davis and Geek were shown, and at the second meeting, very interesting coloured films of Hawaii, Manila, Hongkong were shown by Captain Cash of the U. S. Transport Section. We learn with deep regret of the recent death in Edmonton of Dr. W. A. McConkey, whom many of us remember very well, since he practised in Vancouver for a good many years. Dr. McConkey was a graduate of the University of Manitoba, and came to Vancouver before the first Great War. He was Chief Anaesthetist at St. Paul's Hospital for some years. He had a friendly, candid personality, and was very popular with his medical colleagues, so that we were all sorry to see him leave Vancouver. His death was sudden, but we rather envy him the manner of it. He was called to see a colleague who was dying, and eagerly responded. His own heart gave way suddenly and he died "on the job"—the happiest end any medical man can have. The following have left for Air Force training in Eastern Canada: Doctors B. F. Bryson, formerly on the staff at Essondale; H. L. Dobson, formerly an interne at the Royal Jubilee Hospital, Victoria; T. J. Durkin, formerly an interne at St. Joseph's Hospital, Victoria; M. R. Earle, formerly an interne at Vancouver General Hospital; G. R. F. Elliot, formerly Medical Officer at Quarantine Station, William Head; A. Herbert, formerly an interne at St. Paul's Hospital, Vancouver; F. L. Skinner, formerly in practice in Vancouver; J. F. Sparling, of Haney; W. D. Sharpe, formerly at Zeballos; R. C Talmey, formerly an interne at St. Paul's Hospital, Vancouver, and N. Woywitka, formerly an interne at St. Joseph's Hospital, Victoria. DONATIONS TO BULLETIN WAR RELIEF FUND Buller, F. J., Vancouver. . $15.00 Hilton, C. T., Port Alberni (additional) . 20.00 Weldon, R. C, Vancouver j 10.00 Page 262 N. British Columbia Medical Association (CANADIAN MEDICAL ASSOCIATION, BRITISH COLUMBIA DIVISION) President Dr. C H. Hankinson, Prince Rupert First Vice-President j Dr. A. H. Spohn, Vancouver Second Vice-President Dr. P. A. C. Cousland, Victoria Honorary Secretary-Treasurer Dr. A. Y. McNair, Vancouver Immediate Past President Dr. Murray Blair, Vancouver Executive Secretary 1 Dr. M. W. Thomas, Vancouver ANNUAL BUSINESS MEETING GENERAL PROGRAMME Friday and Saturday, June 12th and 13th> Executive Committee Sessions MONDAY, JUNE 15th 9.00 a.m.—Registration. 9.30 a.m.—Meeting of General Council. 12.30 p.m.—Luncheon. 2.00 p.m.—Meeting of General Council. 6.00 p.m.—Meeting of Nominating Committee. 7.30 p.m.—Barbecue for members of General Council and their ladies as guests of the Alberta Division. 9.00 p.m.—Medical Secretaries' Conference. TUESDAY, JUNE 16th 9.00 a.m.—Registration. 9.30 a.m.—Meeting of General Council. All Day—Golf Tournament. 12.30 p.m.—Luncheon. 2.30 p.m.—Business Meeting of Saskatchewan Division. 8.00 p.m.—Business Meeting of Alberta Division. 8.00 p.m.—Business Meetings of: College of - Physicians and Surgeons, Followed by British Columbia Medical Association. WEDNESDAY, JUNE 17th 8.30 a.m.—Registration. 9.00 a.m.—Round-Table Conference. 10.15 a.m.—General Session. 12.30 p.m.—Luncheon. 2.00 p.m.—Sectional Meetings. 3.45 p.m.—Annual Meeting Canadian Medical Protective Association. 8.30 p.m.—Annual General Meeting, to which are invited all members and their ladies, guest speakers, official delegates and official guests. Presentation of medals and awards. Installation of President. Reception by the President and Mrs. Archer. 10.30 p.m.—Dance. THURSDAY, JUNE 18 th 8.30 a.m.—Registration. 9.00 a.m.—^Round-Table Conference. 10.15 a.m.—General Session. 12.30 p.m.—Luncheon. 2.00 p.m.—Sectional Meetings. 2.15 p.m.—Meeting of Incoming Executive Committee. 8.45 p.m.—Presentation of Golf Prizes. 9.00 p.m.—Medical Economics Programme under the Chairmanship of Dr. Wallace Wilson of Vancouver. Federation of Medical Women of Canada 7.45 a.m. 12.00 noon- -Breakfast. Executive Meeting. -Reception—Luncheon. Annual Meeting. Guest Speakers: Dr. Edna Guest, O.B.E., National Chairman, War Services Committee. Dr. Lillian Chase, Vice-president, Saskatchewan. . Dr. Eleanor Percival, Convener, Maude Abbott Memorial Scholarship Fund. Dr. Mildred Newell, Edmonton, President. Dr. Katherine Ketchum, Toronto, Secretary. Dr. Agnes Moflfatt-Magee, Peterborough, Treasurer. FRIDAY, JUNE 19th 8.30 a.m.—Registration. 9.00 a.m.—Round-Table Conference. 10.15 a.m.—General Session. 12.30 p.m.—Luncheon. 2.00 p.m.—Sectional Meetings. Page 263 ■k- V. ■' " t_ SCIENTIFIC PROGRAMME ROUND TABLE CONFERENCES WEDNESDAY MORNING, JUNE 17th Section of Anaesthesia Problems of respiration and anoxaemia. Dr. D. C. Aikenhead {Chairman), Winnipeg Dr. Digby Leigh, Montreal Dr. E. H. Watts, Edmonton Section of Dermatology Syphilis. Dr. Donald H. Williams (Chairman), Vancouver Dr. D. E. H. Cleveland, Vancouver Dr. J. F. Burgess, Montreal Section of Medicine The selection of sulfanilamide and related compounds in medical treatment. Dr. Duncan Graham {Chairman), Toronto Dr. H. EL Detweiler, Toronto Dr. Irving Bell, Edmonton Section of Obstetrics and Gynaecology Rational endocrine therapy in obstetrics and gynaecology. Dr. Ross Mitchell {Chairman), Winnipeg Dr. Allan Day, Edmonton Dr. H. B. VanWyck, Toronto Section of Paediatrics Adolescent problems. Dr. A. H. Spohn (Chairman), Vancouver Dr. U. J. Gareau, Regina Dr. G. E. Swallow, Edmonton Section of Radiology Radiotherapy of non-malignant diseases. Dr. B. J. Harrison (Chairman), Vancouver Section of Surgery Problems in bile tract surgery. Dr. Roscoe R. Graham (Chairman), Toronto Dr. P. H. T. Thorlakson, Winnipeg THURSDAY MORNING, JUNE 18th Joint Conference Including All Sections The use and abuse of vitamins. Dr. F. F. Tisdall (Chairman), Toronto FRIDAY MORNING, JUNE 19th Section of Dermatology and Radiology Cutaneous cancer. Dr. Harold Orr (Chairman), Edmonton Dr. Norman Wrong, Toronto Dr. B. R. Mooney, Winnipeg Section of Medicine Recognition and treatment of poliomyelitis in general practice. Dr. J. D. Adamson (Chairman), Winnipeg Dr. O. J. Day, Winnipeg Dr. F. H. Mewburn, Edmonton Section of Obstetrics and Gynaecology The treatment of prolapse. Dr. J. R. Vant (Chairman), Edmonton Dr. T. E. Clarke, Edmonton Dr. Edwin M. Robertson, Kingston Section of Paediatrics Paediatric prevention of future foot disorders. Dr. Graham Huckell (Chairman), Edmonton Dr. R. P. Kinsman, Vancouver Dr. R. G. Townsend, Calgary Section of Radiology Presentation and discussion of interesting films. Dr. W. H. McGuffin (Chairman), Calgary Section of Surgery Principles and practice in wound treatment. Dr. C. W. Burns (Chairman), Winnipeg Dr. F. I. Lewis, Toronto Section of Urology Urinary complications following rectal surgery. Dr. Frank S. Patch (Chairman), Montreal , GENERAL WEDNESDAY MORNING, JUNE 17th History-taking. Dr. George S. Young, Toronto. Amputations and after-care. Dr. H. K. MacDonald, Halifax The Presidential Address Dr. Gordon S. Fahrni, Winnipeg The Osier Lecture Dr. C. D. Parfitt, Toronto THURSDAY MORNING, JUNE 18th Industrial medicine. Dr. J. G. Cunningham, Toronto National health as a post-war problem. Dr. R. E. Wodehouse, Ottawa The treatment of psoriasis (illustrated with coloured motion pictures) Dr. Paul OXeary, Rochester, Minn. Page 264 SESSIONS Iodized oil in the diagnosis of non-tuberculous pulmonary diseases by means of bronchography. Dr. Carleton B. Peirce, Montreal. FRIDAY MORNING, JUNE 19th Essential features concerning the proper nutrition of the infant and child. Dr. Alan Brown, Toronto. Head injuries in war. Dr. W. G. Penfield, and Dr. William Cone, Montreal. Common eye diseases, diagnosis and treatment (illustrated by kodachrome slides). Dr. Lloyd Morgan, Toronto Radiological interpretation in gynaecology. Dr. Leon Gerin-Lajoie, Montreal SECTIONAL MEETINGS Section of Anaesthesia WEDNESDAY AFTERNOON, JUNE 17th Intravenous anaesthesia. Dr. S. W. Johns, Calgary Mortality and morbidity following surgery in a large general hospital. Dr. D. C. Aikenhead, Winnipeg Oxygen therapy and resuscitation. Dr. Digby Leigh, Montreal Continuous spinal anaesthesia. Dr. E. H. Watts, Edmonton Section of Dermatology WEDNESDAY AFTERNOON, JUNE 17th Lupus erythematosus. Dr. A. G. Duncan, Calgary Sarcoidosis; systemic and cutaneous manifestations. Dr. G. S. Williamson, Ottawa Dermatoscleroses (illustrated with coloured motion pictures). Dr. Paul O'Leary, Rochester, Minn. Ointment bases. Dr. L. P. Ereaux, Montreal FRIDAY AFTERNOON, JUNE 19th Recurring vesicular eruptions of the hands. Dr. A. M. Davidson, Winnipeg The weather and the patient's skin. Dr. Norman Wrong, Toronto Vitamins in dermatology. Dr. J. F. Burgess, Montreal. The role of the medical profession in venereal disease control in British Columbia. Dr. Donald H. Williams, Vancouver Section of Historical Medicine THURSDAY AFTERNOON, JUNE 18th The social history of medicine—a commentary on newer trends. Dr. M. M. Cantor, Edmonton William Smellie. Dr. Ross Mitchell, Winnipeg The medical sources of Dr. Jekyll and Mr. Hyde. Dr. E. P. Scarlett, Calgary FRIDAY AFTERNOON, JUNE 19th Dr. Michael Clark. Dr. G. D. Stanley, Calgary. Jerome Cardan. Dr. H E. MacDermot, Montreal Baron Larrey—Surgeon General to the Army of Napoleon. Dr. A. R. Munroe, Edmonton The trails of the early doctors in the central prairies. Dr. J. A. Valens, Saskatoon. Section of Medicine WEDNESDAY AFTERNOON, JUNE 17th The recognition and management of the early apical lesion. Dr. A. H. Baker, Calgary Silicosis. Dr. E. P. Scarlett, Calgary Facts on rheumatoid arthritis. Dr. L. DeWitt Wilcox, London Vocational guidance, occupational adjustment and medicine. Dr. Donat Voghel, Montreal THURSDAY AFTERNOON, JUNE 18th Some common functional diseases of the intestines and their management. Dr. P. H. Sprague, Edmonton. Lipaemic hyperthyroidism. Dr. Eldon M. Boyd, and Dr. W. Ford Connell, Kingston Oedema. Dr. George C. Hale, London Bromide intoxication. Dr. H. K. Detweiler, Toronto FRIDAY AFTERNOON, JUNE 19th Some obscure pains in the chest, back or limbs. Dr. Gerard Allison, Winnipeg Cardiac pain. Dr. G. F. Strong, Vancouver The interpretation of faint heart sounds. Dr. Harold N. Segall, Montreal Climatic factors in disease. Dr. J. W. Scott, Edmonton Section of Obstetrics and Gynaecology THURSDAY AFTERNOON, JUNE 18th Sterility in the female. Dr. J. E. Harrison, Vancouver The management of the third stage. Dr. W. S. Holmes, Saskatoon Breech presentation. Dr. Arthur B. Nash, Victoria FRIDAY AFTERNOON, JUNE 19th The treatment of fibroids of the uterus. Dr. J. D. McQueen, Winnipeg Vaginal discharge; diagnosis and treatment. Dr. E. M. Robertson, Kingston Antepartum haemorrhage. Dr. H. B. VanWyck, Toronto A five year summary of maternal deaths in Alberta. Dr. J. R. Vant, Edmonton Section of Ophthalmology FRIDAY AFTERNOON, JUNE 19th Recent advances in medical therapy of the eye. Dr. A. E. Shore, Calgary Difficulties and complications in the senile cataract operation. Dr. R. J. P. McCulloch, Toronto. One of the phases of plastic surgery of the eyelids. Dr. Fulton Risdon, Toronto Vertical phorias, operative and non-operative. Dr. Charles E. Davies, Vancouver li§| Page 265 *Wr* a <': Iti ti: M M If -hi Section of Otolaryngology WEDNESDAY AFTERNOON, JUNE 17th Surgery of the mastoid. Dr. Joseph A. Sullivan, Toronto Headache of nasal origin. Dr. G. Edward Tremble, Montreal The sinus problem. Dr. Keith Hutchison, Montreal Recent advances in medical therapy in diseases of the ear, nose and throat. Dr. F. D. McKenty, Winnipeg Sudden deafness. Dr. A. L. Yates, Calgary Section of Paediatrics THURSDAY AFTERNOON, JUNE 18th Anorexia of childhood. Dr. G. E. Swallow, Edmonton Second year anaemias. Dr. A. E. M. Cairns, Lethbridge Allergic problems. Dr. Gordon Chown, Winnipeg Prevention of bullous impetigo in hospital nurseries. Dr. R. P. Kinsman, Vancouver FRIDAY AFTERNOON, JUNE 19 th Convulsions. Dr. H. W. Price, Calgary Meningitis in childhood. Dr. Nelles Silverthorne, Toronto Progress in poliomyelitis. Dr. O. J. Day, Winnipeg Clinical study of western variety encephalitis occurring in young infants. Dr. Harry Medovy, Winnipeg Section of Radiology WEDNESDAY AFTERNOON, JUNE 17th Luetic disease of the bone. Dr. S. M. Rose, Lethbridge Primary tumours of the bone. Dr. M. C. Morrison, London (Subject of choice.) Dr. J. E. Perron, Quebec Inherent filtration of x-ray tubes. Mr. Dale Trout, Chicago THURSDAY AFTERNOON, JUNE 18th An analysis of carcinoma of the colon, commenting on the accuracy of radiological diagnosis. Dr. M. M. R. Hall, Toronto Remarks on the nature of cancer. Dr. B. J. Harrison, Vancouver Tomographic studies of the thoracic viscera. Dr. Carleton B. Peirce, Montreal Section of Surgery WEDNESDAY AFTERNOON, JUNE 17th Surgical principles in compound fractures. Dr. R. G. Townsend, Calgary. The management of un-united fractures of the neck of the femur. Dr. F. I. Lewis, Toronto Surgical care of poliomyelitis. Dr. F. H. H. Mewburn, Edmonton Spondylolisthesis. Dr. R. I. Harris, Toronto THURSDAY AFTERNOON, JUNE 18th Failures in inguinal hernia. Dr. R. L. Anderson, Edmonton Present status of duodenal ulcer surgery. Dr. M. A. R. Young, Lamont The early diagnosis of cancer. Dr. M. R. MacCharles, Winnipeg Surgical problems of the navy. Surgeon Lieutenant Commander Walter C. MacKenzie, R.C.N.V.R., St. John's, Nfld. FRIDAY AFTERNOON, JUNE 19th Indications for thyroidectomy in the presence of a normal basal metabolic rate. Dr. J. K. Fife, Edmonton Clinical application of present-day knowledge of surgical shock. Dr. H. V. Morgan, Calgary Physiological problems in intestinal obstruction. Dr. Norman B. Taylor, Toronto The surgical treatment of congenital hydrocephalus. Dr. H. H. Hepburn, Edmonton Section of Urology WEDNESDAY AFTERNOON, JUNE 17th Retroperitoneal tumours in children. Dr. Frederick Pilcher, Calgary Strictures of the ureter. Dr. H. D. Morse, and Dr. C. B. Stewart, Winnipeg Carcinoma of the prostate. Dr. Frank S. Patch, Montreal FRIDAY AFTERNOON, JUNE 19th • Treatment of urinary infections. - Dr. A. W. Hunter, Vancouver Management of vesical neck obstruction. Dr. N. E. Berry, Kingston Further results in uretero-intestinal anastomosis. Dr. R. A. McComb, Toronto Renal tuberculosis, presentation of two interesting cases. Dr. Gordon Ellis, Edmonton The Canadian National Railway will provide for your acconxrnodation on the train on any leaving date. Where a large number of reservations are made in one car the railway officials have agreed to hold that car for doctors only. Advice has been received that the Government has found it necessary, in harmony with its conservation policy with regard to gasoline and tires, to prohibit sight-seeing drives and motor service this coming summer. This means that there will be no sight- Page 266 _ f seeing drives in Jasper Park, nor motor service between Jasper and Lake Louise via the Columbia Icefield. Motor service, however, will be available between Jasper station and Jasper Park Lodge. All double rooms are equipped with twin beds. In order to accommodate the entire party at the Lodge, it will be necessary for most of the delegates to go two-to-a-room. The golf tournament of the Canadian Medical Association will be held on Tuesday, June 16th, and will continue throughout the day. Special green fees to registrants at the Convention, $1.50 per day. Note: The Golf Tournament of the British Columbia Medical Association will be held on Tuesday afternoon. Dress informal. All functions of the Convention are to be strictly informal. You do not need to bring evening dress or dinner jackets. SUMMER SCHOOL Owing to the fact that the Canadian Medical Association and the British Columbia Medical Association are holding their Annual Meetings at Jasper in June, the annual Summer School will be held September 15 th to 18 th, inclusive, at the Hotel Vancouver. W; LIBRARY NOTES RECENT ACCESSIONS TO LIBRARY Surgical Clinics of North America, Symposium on Surgical Infections, New York Number, April, 1942. Vaginal Hysterectomy, by Kennedy, James William, and Campbell, Archibald Donald, 1942—F. A. Davis Company, Publishers—for review. Annual Report of the Surgeon General of the Public Health Service of the United States, 1941. Resuscitation: Equipment, Organization, Training and Procedures, The War Office, 1941. This is a 56-page booklet. STATE JOURNALS Tn an effort to acquaint members with some of the Valuable State Journals received in the Library, it is proposed that a sample index of one of them be given in succeeding numbers of the Bulletin for the next few months. Following is an index of original articles which appear in the May issue of The Journal of the Missouri State Medical Association: Intraspinal Protrusion of Intervertebral Disks. Observations on Diagnosis. Roland M. Klemme, M.D., Weldell Scott, M.D., and R. Dean Woolsey, M.D., St. Louis. Strangulated Hernia. Successful Reduction and Repair After Thirteen Days. Herman F. Burkwall, St. Joseph, Mo. Diverticula of the Duodenum, J. H. Hershey, M.D., St. Louis. Volvulus of the Stomach. Report of a Case. C. A. W. Zimmerman, M.D., Cape Girardeau, Mo. Fifty Years Ago. Surgery at the Time the St. Louis Surgical Society Was Founded. Robert E. Schlueter, St. Louis. Page 267 I t m ANNUAL REPORTS FOR 1941-L942 m :Mi Hsl REPORT OF THE COMMITTEE ON CONSTITUTION AND BY-LAWS Since the adoption of our new Constitution and By-laws in 193 8, when the British Columbia Medical Association became a Division of the Canadian Medical Association, no amendments have been offered. The business of the Association has been conducted without difficulty, and it was considered wise to carry on until a change was indicated. It seems advisable when a new Constitution has been adopted to allow it to operate for a time provided that the full range of activities of the body concerned is adequately covered. Fortunately, we are in that position. However, in making the above statement, one does not imply that the document is perfect, and it is felt that in the near future a careful study should be undertaken, and if any changes seem desirable they should be noted and the necessary amendments presented. I would recommend to the new committee that this be done, particularly since the new consolidated Constitution and By-laws of the Canadian Medical Association come up for ratification at the Annual Meeting of that body this year. It is just possible that some changes in our own By-laws may be necessary in order to maintain our proper relationship with the C.M.A., but these, probably, wiuld be very minor in character. 1 think one is safe in stating that our present Constitution and By-laws are satisfactory and workable and comprehensive enough to cover the various activities of our Association. All of which is respectfully submitted. H. H. Milburn, Chairman. REPORT OF THE COMMITTEE ON PROGRAMME AND FINANCE 1 Programme: The Committe has limited tours in conformity with our recent practice. ' During the past fall the Executive Secretary, Doctor M. W. Thomas, attended the annual meeting of the West Kootenay Medical Association held at Trail on October 8th Speakers were provided for the annual meeting of the Upper Island Medical Association held at Parksville on October 29th. Doctors J. R. Neilson and Lee Smith contributed to the programme, and Doctor Thomas also attended. It is to be hoped that a regular plan of post-graduate tours may be resumed in the near future. 2. Finance: The requests made to the Council of the College of Physicians and Surgeons for funds have been kept at a very minimum. It is a pleasure to report that during 1941 we were able to carry on our activities with the small sum of $1,000.00. All of which is respectfully submitted. G. F. Strong, Chairman. :h m M$ REPORT OF THE COMMITTEE ON MEDICAL EDUCATION Dear Sir: As Chairman of the Committee on Medical Education I would submit the following report, covering the work of the committee for the current year. Up to the present time it has been very difficult for students from British Columbia wishing to study medicine at Eastern Canadian Universities to take any part of their course here. The pre-medical subjects are taught here, but it has been difficult to arrange a curriculum which would meet the requirements of Eastern Universities. Students must take the First Year at the University of British Columbia, or Senior Matriculation, to obtain entrance to Eastern colleges. The Second Year would correspond to the First Year Medicine, and students who have taken it have found that it did not fully meet the requirements of Eastern Universities, and the First Year Medicine had to be taken over again. Page 268 The problem was discussed with President Klinck. He was very willing to co-operate, and a pre-medical second year course is now on the curriculum of the University of British Columbia which meets the requirements of the University of Toronto, and almost certainly of the other Eastern Medical colleges as well. This was facilitated by a simplification of the Toronto curriculum, and it is thought that the new arrangement will prove a boon to the British Columbia students. The curriculum is now being submitted to the Deans of the various Eastern Universities to ascertain if it meets their requirements, and whether British Columbia students who have taken it will be allowed their first year at Eastern Universities. Yours very truly, K. D. Panton, Chairman. REPORT OF THE COMMITTEE ON MATERNAL WELFARE Dear Sir: Since the last annual meeting of the British Columbia Medical Association your Committee on Maternal Welfare has completed the revision of the Maternal Record Card, and it has now been issued by the Provincial Board of Health. An addition for recording maternal and neo-natal deaths has also been added, and it has been so arranged that this can be easily removed, if not required, making the card less bulky for filing. The conxtnittee has begun to make a study of maternal deaths in British Columbia with the view of being able, when enough cases have been reviewed, to suggest the safest procedures to be adopted to help eliminate avoidable maternal deaths. As soon as enough neo-natal death records have been received they will also be reviewed. The committee strongly urges that all doctors doing maternity work fill in these cards, especially in cases of maternal or neo-natal deaths, and send them to the Provincial Board of Health for abstracting. By doing so they will greatly help the cornmittee in its study and save a lot of correspondence. These cards have been arranged so that they can be filled in with the minimum of time and trouble, and the examinations asked to be recorded are the least that constitute adequate prenatal care. They will also provide information for statistical purposes in a convenient and easily recorded form. |||p The committee also hopes to be able to publish more short articles on maternal welfare subjects. All of which is respectfully submitted. C. T. Helton, Chairman. REPORT OF THE COMMITTEE ON PUBLIC HEALTH The Public Health Committee is composed of the following members: Doctors H. H. Caple, W. W. Simpson, "J. R. Davies, Donald H. Williams, H. Carson Graham, and G. O. Matthews, Chairman. At present, this (_ommitt.ee has under organization a joint Committee to be formed from our own Committee with the addition of representatives from all other Public Health Provincial bodies, namely, The Canadian Red Cross Society, The St. John Ambulance Society, The Nursing Association, The Hospital Association, The Provincial Health Department and the Department of Pensions and National Health. The duties of this enlarged and representative conunittee will be to study the problem of a possible virus epidemic which may be expected to occur towards the end or shortly after the present war. This Committee is to be guided and directed by its representatives from the British Columbia Medical Association. As soon as all the appointments to this joint committee are made by the provincial organizations concerned it will be convened by your committee. Similar cornrnittees are being set up in each Canadian province and it is hoped that from them suggestions will be organized into active measures, not only to protect but also to combat any such national disaster as the 1918-1919 Influenza epidemic. G. O. Matthews, Chairman. Page 269 REPORT OF THE COMMITTEE ON THE STUDY OF ECONOMICS The Committee on the Study of Economics reports on certain questions that have engaged its attention since the last Annual Meeting. During the past several years Medical Economics has been given a prominent place on the programme of the Annual Meetings. In September, 1941, an evening was devoted to the subject. This session was largely attended and the papers presented by Doctor T. C. Routley, Doctor S. Cameron MacEwen and Doctor Wallace Wilson were valued contributions. During the winter, two plans were passed upon by the Board of Directors,—that of the British Columbia Teachers' Federation Medical Services Association and the other of the Cunningham-Western Drug Sick Benefit Association—the latter affecting only the Lower Coastal Mainland and Vancouver Island. The British Columbia Medical Association and this Committee lent its support in the distribution and completion of the Questionnaire on Health Insurance. The interest displayed by our members in this whole question was most encouraging, and the nature of the comments showed a very thorough knowledge of the principles involved. The thought given to the subject produced opinions which will no doubt prove of great value and help to the Committee of the Canadian Medical Association, which will discuss these matters with representatives of the Dominion Government. The attention of our members is directed to the Conference on Economics to be held on Thursday evening, June 18th, at Jasper, under the asgis of the Committee of the Canadian Medical Association. It is hoped that all will attend. Papers will be presented by Dr. Frank S. Patch of Montreal and Dr. J. H. MacDermot of Vancouver, on the subject, "The Relationship of the Specialist and the Consultant to the General Practitioner and the Public." The discussion will be led by Dr. A. E. Archer, President of the Canadian Medical Association and Dr. A. H. Spohn. This subject should attract a large attendance and lead to free discussion. The experience with the Medical Services Association has proven that medical care by prepayment under modern conditions is possible with adequate contributions and with the cooperation of those receiving the services as well as those who provide them. Respectfully submitted. W. A. Clarke, Chairman. M i REPORT OF THE COMMITTEE ON PHARMACY The work of the Committee during the year has been in conjunction with the committee of the Pharmaceutical Association in preparing the B. C. Formulary, which has now been published and has been presented to every medical man in the Province, with the compliments of the B. C. Pharmaceutical Association. A great many of the hospitals have already adopted this Formulary and report it being used quite extensively. We think that eventually all the hospitals in the Province will adopt it, as they will find it much to their advantage in a saving in the cost of medicine to the patient. It is urged on every medical man to make as much use of the Formulary as possible. By using it he will find that his prescribing will be much more scientific, the use of expensive proprietary preparations can be eliminated, and there will be a very considerable saving in the cost of the medicine to the patient. A permanent committee on revisions has been appointed which is prepared to receive suggestions for extension and correction. The secretary of the Pharmaceutical Association will be glad at any time to receive these suggestions. Your Committee trusts the medical profession of British Columbia will find this Formulary increasingly useful in their practice. Respectfully submitted. C. H. Vrooman, Chairman. Page 270 REPORT OF THE COMMITTEE ON HOSPITAL SERVICE Dear Sir: This brief report is submitted prior to the Annual Meeting in June, 1942. This Provincial-wide Committee met at the Annual Meeting in September, 1941, and since then no new problems have been submitted to it for consideration and report. However, the. Chairman wishes to draw attention that the shortage of internes continues but it has not yet become embarrassing. In this connection it should also be noted that medical staffs employed by hospitals such as anaesthetics, radiologists and pathologists, etc., as well as internes are needed to carry on the functions of the hospital in spite of demands of the armed forces for medical officers. In the Lower Mainland the civilian population will be subject to casualties as well as the armed forces in the event of enemy attack and that being so the hospitals serving these areas are a vital need. Such being the case the demands of the armed forces for medical personnel should not be permitted to weaken the services of the Lower Mainland Hospitals. This problem might be referred to your Divisional Advisory Committee for their serious consideration. Respectfully submitted, R. A. Seymour, Chairman. i)4 VI. REPORT OF THE COMMITTEE ON THE STUDY OF CANCER The Committee on the Study of Cancer, which comprises representatives from all districts throughout the province has to report: 1. The introduction in January, 1942, of the new Provincial Cancer Reporting Form, upon which all practising doctors and institutions are asked to report cases. The forms are distributed and collected by the Provincial Board of Health. In the Greater Vancouver area the completed forms are sent to the Metropolitan Health Board. We are pleased to learn that the response by all concerned has been very good and that we shall soon have a report from the Provincial Government on the information so obtained. 2. At the present time the Cancer Committee is applying itself to the development of Cancer Study Groups. A Sub-committee, under the chairmanship of Doctor F. J. Hebb, has laid down a plan for building this feature of the programme, and we anticipate good results. The Honorary Attending Staff of the British Columbia Cancer Institute has formed one of the most active study groups in the province and is working on several clinical research problems. We hope in time to have every part of the province engaged in such work through the active cooperation of the various study groups. 3. Short articles have been published in the Bulletin at regular intervals. Speakers have been supplied for radio addresses, and in conjunction with the Canadian Society for the Control of Cancer, films have been shown and talks given to lay audiences. 4. Dr. C. K. P. Henry of .Montreal came to the Annual Meeting in September, 1941, under the aegis of the Department of Cancer Control of the Canadian Medical Association. His contributions to the scientific programme and his address at the Public Meeting were very helpful and much appreciated. The Cornmittee on the Study of Cancer is grateful to the Bulletin for the publication of reports and other subject matter on Cancer. It is the ambition of this Committee to keep interest alive during these difficult war years and to have a definite programme developed upon which the work can be built when normality returns to this world. Respectfully submitted. Ethlyn Trapp, Chairman. Page 271 •fill •St w !*;§- mm • 'JH (») (b) ASSISTANCE TO MEDICAL STUDENTS Statement by the Minister of Defence, Hon. J. H. Ralston, in the House of Commons, March 19, 1942 1. It is estimated that the Armed Services will, during the ensuing fiscal year, require 800 Medical Officers, of which 50 will be needed by the Navy, 600 by the Army and 150 by the Air Force. As a matter of fact, the Army could take on almost at once probably 150 Medical Officers, and the Air Force, I am informed, probably 75 to 100. These requirements are being brought to the attention of the medical profession throughout Canada and the Canadian Medical Association is co-operating by sending out a questionnaire to all members of the profession. 2. In order to assist in increasing the future supply of Medical Officers for the Armed Forces the Medical Services of the Navy, Army and Air are co-operating in a scheme designed to aid worthy students of Medicine who propose to enlist. 3. This arrangement is the result of a thorough study of the medical needs of the Armed Forces and has been proposed after consultation with the Medical Faculties of the Universities throughout Canada. Briefly the scheme is as follows: The Universities will be asked to accelerate their courses, while maintaining the same standard of training, by reducing the normal summer vacation periods to a minimum. In this way a student will be able to cover his full course in a considerably shorter period. (c) By this acceleration of courses students will be debarred from earning in the long summer vacation. This plan is designed to make up for this loss of income. (d) It is proposed that the Armed Services will enlist students at any time during the two final years before they qualify for a licence to practice. They will thus, during this period, become members of the Armed Forces and will then be granted leave with pay and subsistence allowance which will enable them to complete their courses and to obtain a licence to practice. 4. This assistance to medical students who intend to join the Armed Forces will be supplemented by the Department of Labour (in co-operation with the Provincial Governments) by extending the present system of scholarships. These scholarships (up to a maximum of perhaps $300) will also be open to other worthy students who because of the acceleration of the courses will be deprived of the opportunity to earn during what would be the normal vacation period. 5. The students who will be eligible for these scholarships will be those who are in need of such assistance, who possess good academic standing and who give satisfactory assurance to serve in the national war effort in the capacity in which they have been trained. 6. There will also be some expenditure involved in connection with additional costs to Universities on account of the accelerated courses. 7. The Department of Labour is now in correspondence with the Provincial Governments with a view to enlisting their co-operation in implementing this extended plan. 8. In the result, medical students who intend to join the Armed Forces will (after the first year) receive assistance from the Department of Labour, in co-operation with the Provincial Governments, by way of scholarships, during the earlier years of their courses, and during the last two years they will receive pay and subsistence allowance as duly enlisted members of the Armed Forces. Page 272 COMMITTEE ON THE STUDY OF CANCER The Q>rnmittee on Tumour Clinics and Cancer Study Groups in meeting decided to adopt the following plan, as outlined by Doctor F. J. Hebb, Chairman of the Subcommittee, in an attempt to build throughout British Columbia a complete system of study, diagnosis and treatment of Cancer, and work towards this goal as far as possible throughout the war period, so that eventually the scheme may be accepted in its entirety. Cancer Study Groups Definition: A group of medical men vitally interested in the study of the diagnosis, treatment and subsequent history of cancer patients, and including one or more of the following specialists: pathologist, surgeon, internist, radiologist. Objects: 1. To encourage all physicians to be cancer conscious when exanuning patients. 2. To stimulate the interest of the general practitioner in the treatment of his own cancer patients by having him: (a) Examine his own patients in consultation with the group and when practicable perform the necessary tests to make a correct diagnosis. (b) Be present at and, when possible, assist in the treatment of his cancer patients. (c) Carry out follow-up examinations on his own patients and report results to the Study Group. 3. To improve the faculties for the diagnosis and treatment of Cancer in its own area, and work towards formation of a tumour clinic. 4. To have such a study group in all hospitals of 100 beds or over. 5. Travelling Cancer Clinic. Activities: 1. The formation of a diagnosis and consultation centre in its area, centred around the hospital staff. 2. The provision for such treatment as can be given with local facilities. 3. Initiation of clinical research problems related to local patients. 4. Regular meetings and arrangement for an occasional visiting speaker. 5. Abstracting of current cancer literature for the benefit of the group. 6. Reporting of cases. 7. Co-operation with the local branch of the Canadian Society for the Control of Cancer by stimulating a demand for cancer education by providing lectures and literature on cancer to various lay organizations and suggesting that each different group have one cancer meeting a year. RE APPOINTMENT AND RANK OF MEDICAL OFFICERS An order affecting rank of Medical Officers, R.C.A.M.C., (Active) C.A., provides that officers who held rank not below that of Captain in the Reserve Army will be appointed with that rank in the Active Force. Medical Officers recommended for special employment upon authority may be granted acting higher rank with pay and allowances. Candidates, who for more than two years have held a licence to practise in a Province of Canada, or are licentiates of the Medical Council of Canada, will be appointed to the R.C.A.M.C. (Active) C.A., with the rank of Lieutenant (A/Captain), and may be confirmed in the rank of Captain immediately upon qualification. This order was effective the 1st of February, 1942. Note: It is our information that the same rule applies to appointments in the R.C.A.F. Page 273 i\*M m m *'*•* HOSPITAL PROBLEMS—NURSING SERVICE Notes of a Brief Address by Miss Grace M. Fairley, R.N. Diretor of Nursing, Vancouver General Hospital Presented to the Medical Staff, May 21, 1942, when shortage of nurses was really serious. I was tremendously interested in the announcement in the press last week by the College of Physicians and Surgeons of British Columbia regarding the problems imposed by war conditions on medical practice. This is my method of announcing to the world that we are faced with just such problems as yours, only you are the cause of some of my problems—I cannot blame them on gasoline! No one is more conscious than we of the heavy load you (the members of the medical profession) are all carrying, but during the past year we have been equally conscious that the shortage of doctors has daily incraesed the nursing load. Now the shortage of nurses has reached a point when it is quite serious. I am endeavouring to conserve nursing energy by employing lay help and V.A.D.'s, but there is much that can only be covered by nursing personnel, and it is in the interests of the hospital and the nursing staff (many of whom are working too hard for too long hours at the present time) that I asked Dr. Haywood for an opportunity of placing the picture before you. I fear that we may come to the point when we may have to hmit admissions and that would be regrettable. We are anxious also to maintain existing standards, but there is a limit to the load the average nurse can carry. All Government services are making inroads on our staff. Shaughnessy has taken its toll, and now ten of our senior staff have been called, eight of them for No. 16—two executive assistants—with only a few days' notice. I am wanting your help. I think we should now develop a war-time policy and face it frankly. We should be remiss indeed if we waited until some serious situation developed and I had not acquainted you with the situation as it is at present, when I know that as far as nursing personnel is concerned it is likely to become much worse. This is not a local situation, it is Dominion-wide, only our local situation is particularly serious. There are a few points that I think if drawn to your attention might help. 1. Late admissions for operation on the following morning. This is one of the most disrupting of our problems. Not only do patients not get the desired rest because of history taking, preparation, tests, etc., but these late evening admissions are the most frequent cause of nurses, both graduate and student, being anything from 1 to 2 l/z hours late in getting off duty—and this at the end of a long tiring day. - ;5? 2. Frequency of treatments such as hourly fomentations—this refers of course to the less serious cases. 3. The great increase in emergency operations cannot be avoided, but added to this are the late afternoon cases which are not always booked as early as they might be—this in no way refers to emergency cases. 4. I should like to think that as a result of this conference you would help us by handing on this information to Visiting Staff and internes. 5. The time-consuming process of sending patients to physiotherapy department for massage, etc. 6. Visiting doctors doing a dressing when it has already been done by an interne or nurse. If the patient's doctor could let the head nurse know he wishes to do the dressing it would be left for him and thus save time and supplies. Page 274 ; W 7. Tonsillectomy cases coming in too late and disrupting the operating room schedule. This does not allow sufficient time for examination, specimens, etc. 8. Hemorrhoidectomy cases if possible should be admitted at least 24 hours prior to operation. 9. Repeated ward rounds by several doctors who are interested in the same cases. 10. Ward rounds by Junior interne, then by Senior interne, possibly later by staff doctor (this is a fairly frequent picture). 11. May I make the suggestion that doctors present summary notes for cases with long continued and unchanged treatment. 12. Lastly, it would be a time-saving plan if we could find a way of obtaining standing orders for Staff Surgical cases. [The above is brief and to the point. We must all be grateful to Miss Fairley for her frank presentation of this very difficult problem.—Editor.] "f- 1! HOW PHYSICIANS CAN CONSERVE NURSING HOURS [Below we publish a brief list of suggestions by Dr. R. A. Seymour, Assistant Superintendent of the Vancouver General Hospital. They serve to emphasize the points made by Miss Fairley, Director of Nursing.—Editor. ] Conservation is the order of the day and it can be usefully applied in many ways. Because of the shortage of nurses available for hospital duty and the need for preserving the present nursing standards, it is incumbent upon all of us to seek ways and means of saving nurses' time. This is urgent because we cannot expect nurses to rush and hurry all day long, maintain their poise, and also work several hours' overtime and still keep their health. If they become sick or resign because of overwork and fatigue, we shall be that much shorter of nursing staff. Therefore the following suggestions are listed for your thoughtful consideration. 1. Instruct your patients to be admitted as early as possible in the day and certainly before 5.00 p.m. A day's rest in bed before operation is good treatment and should take a hospital day off at the other end. 2. Notify the ward a day or two in advance when you think your patient may be discharged and tell your patient to plan to leave soon after lunch. 3. Do not visit wards during meal hours as this delays the meals for patients and nurses. This request has been made before and we hope your excellent co-operation in this will be continued. 4. Avoid unnecessary changes of dressings. Tell the nurse if you wish to be present when the dressing is changed. 5. Cancel or reduce treatment orders such as fomentations, etc., as soon as practical. Use infra-red lamps in place of fomentations if advisable. Keep intravenous saline injections down to minimum. 6. Instruct nurses to reduce standard daily nursing notes on case record to nursing summary notes as soon as possible. Page 275 \py\ "'A WM m m I 1 MASSIVE HEMORRHAGE INTO ADRENALS A Clinical-pathological Case Report Dr. W. J. Holley, by kind permission of Dr. A. W. Bagnall The following case of massive hemorrhage into both adrenals complicated an extensive erysipelas-like cellulitis of the tissues of the face, forehead and neck. The patient was an elderly white male who had previously been quite well, working as a night watchman in a sash and door factory using cedar wood. About four or five days previous to admission it was noticed that he had a slight reddening and swelling of the right side of his neck, in the parotid region. There was no previous injury or break in the skin at this site. This reddening and swelling, however, rapidly spread up the right side of his face to involve his right eye, the eyelids of which became so swollen he could not open his eye. The swelling had a dusky red color, was indurated, and rapidly extending over his forehead and scalp and down the left side of the face to involve the eyelids of the left eye in a similar manner. No treatment was given and no doctor called until Saturday March 21, 1942, when Dr. Bagnall saw the patient. At this time the swelling involved the face, forehead and neck. The skin over the area presented a dark red blush, with small areas which were greyish-purple, with almost a macerated appearance as if ready to slough, and the whole area oozed a great deal of reddish serum. The swelling closed both eyes and entirely disfigured the face. There was no involvement of the mucous membranes of the nose or mouth, and the conjunctive, although reddened and covered with mucus, did not appear ulcerated. The patient appeared in a critical condition. His mind was clear and there was no evidence of any intracranial lesion and no stiff neck. Fast History. Patient is suspected of having had hypertension with a fairly high blood pressure. Physical Examination. T. 1023 — P. 85 — R. 24. On admission, the patient's face is swollen beyond recognition. Swelling extends back beyond the ears, down over the clavicles. The swollen area is purplish-red, indurated, and there are areas of a slough with resultant hemorrhage. The pulse is rapid, weak and irregular. The heart sounds are faint, with an irregular rate and fibrillating. The blood pressure is surprisingly low—90/50—in view of a previous history of hypertension. There is no pain in the chest and no clinical evidence of coronary occlusion. The lungs show rales in both bases. The abdomen is negative. Progress and Treatment. March 22, 1942—Condition poor. Pulse rapid. Appears to have areas with purulent discharge under the skin, with areas of slough tissue over face and around the eyes. He was given intravenous glucose and saline, with boracic acid compresses and sodium sulphathiazol 3 grms. intravenously. Patient died March 23, 1942, of circulatory collapse. Cultures taken from the sloughed areas around the eyes and nose, at post mortem, show hemolytic streptococci, staphylococcus aureus (hemolytic) and non-hemolytic streptococci. Haemoculture (post mortem)—no growth. Autopsy Report The body is that of a 70-year-old white male who shows an extensive, diffuse, reddened swelling of the face, forehead and neck. There is a slight localized swelling in Page 276 k*\' both parotid regions. The skin in places has a purplish-grey appearance and, upon separating the bandages from the face, areas of skin around the inner canthus of both eyes and along the left side of the nose slough away, leaving ragged ulcerated areas covered with yellowish exudate. The skin of the forehead and left temple over an area 16x6 x 7 cms. is covered with a brownish-red scab. There appears to be no definite heaped- up reddened edge to the swelling which merges indefinitely with the surrounding tissue. The gross appearance is that of an edematous cellulitis of the subcutaneous tissues, with areas of purplish-red discoloration of the overlying skin which in patchy areas has become necrotic. Both eyes are closed shut from the edema, but the conjunctivas, which are slightly reddened and covered with mucus, do not appear involved in the process. Dissection of the subcutaneous tissues of the neck shows a diffuse, edematous thickening of the subcutaneous tissues and fat, which ooze a great deal of red serous fluid. The subcutaneous fat and fibrous tissue, in areas, is very soft and friable, suggesting gangrenous change. The parotid glands are reddened and edematous but on section contain no purulent material. The heart is moderately enlarged and shows concentric left ventricular hypertrophy. The valves show no vengetations. The other viscera are soft, showing toxic changes but no abscess. The adrenals both present a swollen, hemorrhagic mass which on the right side measures 5 x 2.5 x 3 cms. and on the left side 5.5 x 3 x 3 cms. On section there is massive hemorrhage into the medulla of both adrenals, with almost complete destruction and necrosis of both medulla and cortex. There are only a few thin patches of yellow, cortical tissue remaining. The hemorrhage has broken through the capsule of both adrenals, producing a mass of blood clot at the upper pole of each kidney. Microscopic sections through the adrenals show a massive hemorrhage which has completely destroyed the medulla and is tearing and destroying all but a few isolated strands and islands of cortical cells. Comment Massive haemorrhage into both adrenals is not infrequently found in new-born infants, due to the trauma of labor or the excessive degeneration of the inner layers of the cortex occurring at this time. In older children and adults, however, the condition is rare. It has been described in diphtheria and in fulminating cases of meningococcic septicemia and is probably due to the toxic action on the capillary walls. Massive hemorrhage into both adrenals is likely to cause death within 12 hours, the onset being sudden, with abdominal pain and, occasionally, large purpuric patches.of the skin and haemorrhage from mucous membranes. The final state is one of collapse, complete relaxation, heart failure and hyperpyrexia. The interesting features of this case are: (1) the rapid spreading and extensive ceUulitis which resembles erysipelas in location but appears to extend to the deeper subcutaneous tissues, with more edema and with a less well defined elevated red margin. (2) the terminal low blood pressure shown with little clinical evidence of shock, in a patient with previous hypertension. Cases of acute spreading gangrene of the skin, caused by an „robic hemolytic streptococcus, have been described by F. Meleny. A chronic gangrene involving the superficial skin, due to the synergistic action of an anaerobic, non-hemolytic streptococcus together with a haemolytic staphylococcus aureus, has also been described by the same writer. Two cases of a spreading cellulitis with gangrene of the skin of the face, both in diabetics, have been reported recently, which closely resemble our case. The organism recovered in both these cases was a hemolytic staphylococcus aureus. Whether the main causative organism in this case was the hemolytic streptococcus or the staphyloccus aureus, remains undetermined. The aerobic non-hemolytic streptococcus found appears to be a contaminant. Page 277 >-* * tg -.0 w ACUTE APPENDICITIS IN THE VANCOUVER GENERAL HOSPITAL IN 1940 From Surgical Service, The Vancouver General Hospital By L. B. Harvelle, M.D. Senior Resident in Surgery, The Vancouver General Hospital This paper is an analysis of the group of patients who had acute appendicitis in The Vancouver General Hospital during 1940. It includes only those proved at operation to have had acute appendicitis. Two cases proved at autopsy to have had ruptured appendices with generalized peritonitis are excluded. They are classified as: 1. Non-perforated. 2. Perforated with peritonitis. 3. Perforated with abscess. The histories gave insufficient data to analyze the following: relative frequency of site of incision, previous history concerning laxatives, technique of operations, effect of chemotherapy, the cause for the two known cases of faecal fistula which occurred in children, and the relative incidence of localized and generalized peritonitis. Table I shows the classification of the two hundred and seventy-three cases. TABLE I. Number of Cases Analyzed: Staff 1 68 Private 205 Total 273 (55% females) Classification of Cases (Condition at Operation): 1. Acute Non-perforated Appendicitis Staff 53 cases or 77.9% Private 155 cases or 75.6% Total 208 2. Perforated, with Peritonitis Staff 10 cases or 14.7% Private 32 cases or 15.6% Total 42 i. •»> 3. Perforated, with Abscess » Staff 5 cases or 7.3 % Private j 17 cases or 8.3 % Total : 22 Total Cases in which drains were used 163 (59.7%) Morbidity, Average Hospital Days: Acute Total Days 3,031 Abscess Total Days 738 Peritonitis Total Days 1,026 Total Hospital Days 4,726 Average stay per patient 17.9 Average 14.15/Pt. Average 39.40/Pt. Average 23.83 /Pt. Chemotherapy (Sulfa derivatives by mouth or intramuscularly): Staff: Simple Acute used In 45.3 % Perforated with Peritonitis- 100.0% Perforated with Abscess of cases 60.0 % . Private: Simple Non-perforated i used in 24.5 % Perforated with Peritonitis 67.6% Perforated with Abscess of cases 41.2% Page 278 Ira Wound Infections Staff: Simple Acute—Total Cases 53 Infected 17, or 32.1%. Of these 12 had drains in. Private: Simple Total Cases 155 Infected 27, or 17.4%. Of these 16 had drains in. The longest stay in hospital was ninety-one days. This was due to a ruptured appendix with an abscess, which was drained but the appendix was not removed. This was a male patient, aged twenty-eight, admitted under the "Private" service. He came in with a history of abdominal pain for seventy-two hours. The operation was delayed for six hours. He received sulphanilamide by mouth. The wound became infected too. The shortest stay in hospital was five days. This was due to simple acute appendicitis with a history of twelve hours' duration. The operation was performed immediately. No drains were used and there was no infection of the wound. This was a female patient, aged three and one-half years, admitted under the "Private", service. In eighteen patients (nine staff, nine private) the operation was "delayed" for one reason or another. Only three of these died, and in two the diagnosis was only made post mortem. These results appear in Table II. The total mortality rate appears in Table III. TABLE II. DELAYED OPERATIONS (18). Acute Non-perforated: Staff—3 cases—lived. Private—2 cases—lived. Perforated with Peritonitis: Staff — 2 cases—One for 20 hours resulted in death but due to other causes, and one in a seventy- five year old man who died on the twenty-fourth day. Private—1 case —lived. Perforated with Abscess: Staff — 4 cases—One on the seventh day with recovery. One in thirty-six hours with recovery. One in fifty-six hours with recovery. One in eighty-four hours with recovery. Private -6 cases—One One One One One in six hours with recovery, in fifteen "hours with recovery, in twenty-six hours with recovery, in twenty-six hours with death nine days later, n twenty-four hours with recovery. One in eight days with recovery. General: Staff Total Cases 68 Deaths 4 Mortality 5.88% Classified: Acute Non-perforated Perforated with Peritonitis - Perforated with Abscess TABLE III. MORTALITY RATE Private Total Cases 205 Deaths _ 5 Mortality 2.48% Combined Staff and Private Total Cases 273 Deaths 9 (Excluding 2 not operated on.) Mortality : 3.29% Staff 7.55% (4) 10.00% (1) 0.00% (0) Private 0.00% (0) 6.25% (2) 11.85% (2) Page 279 V t-fl !*> n rh m I .-■■' 5 on the twenty-fourth post-operative day.j Analysis of Deaths: Staff: 1. Cerebral embolus. 2. Death due to anaesthesia. 3. Seventy-five year old male, died in shock suddenly 4. Pulmonary embolus. Private: 1. Abdominal abscess with two operations. 2. General peritonitis with septicemia. 3. Peritonitis with pneumonia. 4. Appendiceal abscess. 5. Appendiceal abscess. This general mortality rate (3.3%) is not excessively high, but still is higher than that reported from several other hospitals and also higher than the mortality rate for the Vancouver General Hospital during the years 1936-1940. This is illustrated in Table IV. TABLE IV. Comparison of the Vancouver General Hospital with Other Hospitals Beth Israel Mt. Sinai University of Roosevelt New York New York Nebraska New York No. of Casesj 63 5 212 958 741 Acute 292*—.68%f 142— .7% 784— .3% 566—.53% Abscess 91—.66% 40— 0% 50— 8% 59—.78% Peritonitis 252—2.8% 30—10% 124—13.8% 116—2.7% Total Mortality— 2.2% 1.8% 2.6% 2.7% * Indicates the number of cases.. "{"Indicates the mortality rate. Mortality Rates, Vancouver General Hospital Chronic Subacute and Acute 403 Acute with Abscess Acute with Perforation and General Peritonitis Combined, All Operated On 494 Vancouver General 273 208—1.9% 22—9.1% 42—7.1% 3.29% 1936 1937 1938 1939 1940 Ops. D. Ops. D. Ops D. Ops. D. Ops. D. 403 3 480 2 445 1 497 2 501 5 .74% .41% .22% .4% .99% 22 1 22 0 23 0 21 3 17 2 . 4.5% 0% 0% 14.2% 11.8% 69 5 70 2 56 6 39 6 46 2 7.24% 2.85% 10.71% 15.4% 4.35% 494 8 572 4 524 7 557 11 564 9 1.62% .69% 1.33% 1.98% 1.58% '■.J1 Analysis of Deaths Staff Cases: Case I: On admission, the patient gave a history of complaints of twenty-four hours' duration. Operation was delayed eighteen hours. The appendix was of the acute, exudative necrotic type and was ruptured in removal. The patient died on the ninth postoperative day, two days after the sudden onset of symptoms which were thought due to cerebral embolus or thrombosis. Case II: This patient, a seventeen-year-old male, gave a history of acute abdominal pain of three days' duration. Operation for acute non-perforated appendix was carried out at once. The patient died in convulsions on the operating table. The autopsy report showed a final diagnosis of cerebral infarction, oedema of the brain, acute necrotic appendicitis, oedema of the lungs, fatty metamorphosis of the liver and cholangitis. Case III: This patient, a seventy-five year old male, gave a history of complaints of sixty hours' duration. At operation twenty-four hours after admission, the appendix was removed in pieces. On the seventeenth post-operative day, the patient was able to be up in a chair. Five days later, he suddenly became cold and clammy, with acute pain in the chest and shortness of breath and showed signs of shock. Autopsy was not carried out and cause of death is not recorded. Case IV: This patient gave a history of symptoms of twenty-four hours' duration. Operation for acute gangrenous appendix was carried out at once. The patient died Page 280 !f<' suddenly on the eleventh post-operative day following pulmonary embolus apparently sustained on the sixth post-operative day. Autopsy was not performed. Private Cases: Case I: This patient gave a history of symptoms of forty-eight hours' duration. Operation carried out immediately after admission revealed acute gangrenous appendix, but no mention of peritonitis is made in the operation report. Appendectomy and drainage tubes were used. On the seventh post-operative day, laparotomy for mtra-abdominal abscess was performed. The patient died twelve hours later. Case II: The patient was admitted forty-eight hours after onset of symptoms. At operation immediately following admission, the appendix was removed in pieces. Appen- Icfectomy and drainage tubes were used. The post-operative course was stormy and death due to generalized peritonitis and septicemia occurred on the sixth post-operative day. Case HI: This patient gave a history of complaints of twelve hours' duration. Operation, carried out immediately following admission, revealed a ruptured appendix with peritonitis. During a stormy post-operative course, the temperature mounted daily. Soludagenan was administered. Death occurred on the fifth post-operative day. The chart records a final diagnosis of pneumonia and acute appendicitis, but respirations were never above twenty-eight per minute. Autopsy was not carried out. Case IV: This patient, a thirty-nine year old female, gave a history of symptoms of six days' duration. Operation for gangrenous appendix with abscess was delayed twenty- six hours after admission. Incision and drainage only were carried out. Though the chart makes no mention of peritonitis in the progress notes or the final diagnosis, death, apparently due to generalized peritonitis, occurred on the sixth post-operative day. Autopsy was not performed. Case V: The duration of the complaints was not recorded. Operation for appendiceal abscess was delayed twelve hours after admission. Drainage only was carried out. Death occurred two days later. Conclusions 1. Two hundred and seventy-three patients with acute appendicitis received surgical treatment in The Vancouvre General Hospital in 1940. 2. The general mortality rate was 3.29 per cent. This is compared to other years in the same institution, and to that in other institutions. : i-k- '>* . ; AN UNUSUAL CASE OF INTESTINAL OBSTRUCTION " R. G. D. McNeely, M.D. Resident in Pathology, Vancouver General Hospital. (Pathological Conference—Vancouver General Hospital. H. H. Pitts, Pathologist.) A sixty-eight-year-old housewife was admitted to the Vancouver General Hospital complaining of severe abdominal pain and vomiting. For several months she had had vague "dyspepsia" which caused her no real discomfort. Four days before admission she suddenly developed a very severe colicky pain which involved the entire abdomen. She began to vomit frequently and persistently until the day of admission, when she was seen for the first time by her doctor. Nausea and vomiting of brown faecal-appearing fluid with the same colicky pain were her chief complaints. She was unable to eat anything. An enema was given and the patient passed a moderate amount of soft stool on two occasions. On examination, she was an obese and extremely ill patient. The temperature was 99.0° F., the pulse 115, the respirations 20. The tongue was swollen. The heart and lungs were normal. The abdomen was distended and was tympanitic to percussion with much pain on palpation especially about the umbilicus. There were no masses and no muscular spasm nor rigidity. On auscultation high-pitched peristalsis was heard. The liver and spleen were not palpable. A cutaneous ulceration, 4 cm. in diameter, was Page 281 c. i m present over the lateral aspect of the right ankle-joint. The lateral aspect of the left ankle-joint showed a whitish fibrotic scar, an old varicose ulcer. Examination of the urine showed a specific gravity of 1030, -j-2 albumen, -\-2 white blood cells, and -4-1 granular casts. The leucocyte count was 11,700, with 55% polymorphonuclears, 32% lymphocytes and 12% staff cells. Early the next morning a Millar-Abbott tube was passed and shown by X-ray examination to be in the duodenum. This lessened the distention and the pain was easier. By the third day in hospital 47 ounces of fluid had been suctioned off and the tube was in the jejunum. She was still very ill but the pain was less. The same evening, however, a sharp pain developed about the umbilicus and the abdomen became distended and generally tender. The temperature was 100° F., the pulse 100, and respirations 30. The extremities were cold and the pulse weak. She became restless, then unconscious, and died at 2:15 a.m. on the fourth day. The essential features of the post-mortem examination were present in the abdomen. On opening the peritoneal cavity about 100 c.c. of brownish-red serous fluid was present. There was marked distention of the stomach and of the small bowel to the junction 6f the jejunum and the ileum where a hard nodular mass was found obstructing the bowel. This on removal was seen to be a gall-stone, 6.5 x 4.0 x 3.5 cm. in size. Proximal to the point of obstruction 10 cm. of the jejunum was seen to be purplish-black in colour and appeared gangrenous. This was confirmed microscopically. The gall-bladder was found to be small and fibrotic and densely bound down to the anterior wall of the third part of the duodenum where ulceration had produced an artificial cholecystenteric fistula. The anatomical diagnoses were: 1. Chronic cholecystitis and cholelithiasis with adhesions to the duodenum. Ulceration of gall-bladder and duodenum causing artificial cholecystenteric 2. fistula. 3. 4. Intestinal obstruction due to impaction of gall-stone in terminal jejunum. Toxic degeneration of myocardium, liver, spleen and kidneys. Impaction of a gall-stone is neither a common nor a rare cause of intestinal obstruction. In 136 cases of the latter from 1935 to 1939 at the Mayo Clinic, 2 were due to gall-stone impaction1. Moore has estimated that 1 to 2% of all intestinal obstructions is due to gall-stones2. Nine cases have been reported with two episodes of acute intestinal obstruction due to gall-stones each time. This condition occurs chiefly in women. The average age is sixty-six years and the mortality rate is about 50%. Practically all stones make their way into the intestine through a cholecystenteric fistula3. The usual site of lodgement of the stone is the lower ileum but occasionally it is found in the jejunum or even the sigmoid flexure of the colon. Enlargement of the gall-stone may occur in passage4. Round stones are much more likely to cause obstruction than stones of equal weight but greater length. The obstruction may be caused by the stone itself being too large to pass onward, by producing an intussusception of the bowel or by becoming embedded in the wall of the gut and secondarily closing the lumen1. There is usually no history until the acute obstruction and the condition is rarely diagnosed before operation although X-ray exarnination occasionally reveals an opaque shadow in the bowel area. Treatment is that of intestinal obstruction. An enterotomy without enterostomy or drainage of the abdomen is the operation of choice3. I would like to thank Dr. L. W. McNutt for permission to present this case. REFERENCES: 1. Mayo et al: Acute Intestinal Obstruction, S. G. 6? O., 71:589, 1940. 2. Moore, G. A.: Gall-Stone Ileus, Boston M. 8? S. J., 192:1051, 1925. 3. Hinchley, P. R.: Recurrent Gail-Stone Ileus, New Eng. J. Med., 223-174, 1940. 4. Christopher: Textbook of Surgery, 1936 (Saunders), page 1213. Page 282 Victoria Medical Society President \ Dr. E. w". Boak Vice-President Dr. R. B. Robertson Honorary Secretary Dr. L. W. Bassett Honorary Treasurer Dr. P. A. C. Cousland THE BODY WATER IN HEALTH AND DISEASE By Dr. B. L. Newton of the Royal Jubilee Hospital, Victoria Given before the Victoria Medical Society on February 2, 1942. A proper understanding of the physiology of the body water in both health and disease is essential before intelligent therapy can be carried out. It is my purpose to discuss water balance under the following headings: 1. Distribution of fluids in the body. (a) Intake (b) Output (c) Maintenance of equflibrium. 2. Alteration of body fluids in disease. (a) Alterations in intake. (b) Alterations in output. (c) Alterations in equihbrium of body water. Figure 1. Tm fci ;*■*!• mi •ill Intake Stomach Intestines Output lOOcc 1200 Skin Lungs Kidney -1200cc BLOOD PLASMA 5 per cent Body wt. INTERSTITIAL FLUID 15 per cent Body wt. INTRACELLULAR FLUID 50 per cent Body wt. Page 283 n ?4tyf| A m\ «_ MS1' 3. Laboratory aids in the diagnosis and treatment of hydrated and dehydrated states. Water is necessary for the assimilation and eliniination of metabolic products; in the regulation of body temperature; and in building body tissues. It is thought that water exists in two forms, free water which can react chemically, and bound water which is linked with cell protoplasm. The new-born is approximately 70% water, while the adult's tissues are 60% water. Weight for weight, the child needs more water than the adult, due to its relatively greater metabolism and food intake. The distribution of water in the body tissues may be represented in Figure I. A. The daily intake of water and dissolved elcetrolytes into the body in the healthy adult may be subdivided as follows: 1. Water as such—and as present in other fluids 1200 cc. 2. Water present in food and that which may be available in the body tissues 1000 cc. 3. Water of oxidation of foodstuffs or of tissue metabolism 300 cc. Total intake 2500 cc. The excretion of fluid into, and the reabsorption of fluid from the intestinal tract is an example of conservation of body fluids. The daily total of this fluid, all derived from the blood plasma, which is in turn in equilibrium with interstitial and intracellular fluids, varies between 7,000 cc. and 10,000 cc, and of this amount 95% is reabsorbed. B. The daily output of body fluid may be broken down into the following components: 1. Vaporization through skin and lungs 1200 cc.j 2. Urinary water 1200 cc.' 3. Water lost in the stool ' 100 cc. Total output 2500 cc. Figure II. The relative concentration of acidic and basic ions in normal human plasma expressed! in milli-equivalents. K CA MG NA hco3 na CL Prot. < i 1 Organic Acids POa Page 284 lm\ Under normal, average conditions, the kidneys are the keystone of excretion. Vaporization may assume an important role, however, under various conditions and climates. C. The maintenance of equuibrium of the body water is dependent on many factors, namely, electrolyte balance of plasma, interstitial spaces and tissue cells, plasma proteins, permeability of capillary and cell membranes, capillary blood pressure, lymphatic drainage, tissue tension, and on the secretions of the pituitary, adrenal and sex glands. The body electrolytes consist of the basic ions, sodium, potassium, calcium, and magnesium, and the acid HCO-3, Cl, PO-4, SO-4 radicals. The bases also combine with protein, lactic acid, etc. Actually, sodium, potassium, chloride and bicarbonate, along with lactate comprise most of the electrolytes of the body. Thus, by determining the total plasma base, we have an index of osmotically active ions in the body. The relative concentration of acidic and basic ions in the blood plasma may be represented by Figure II. The base combined as bicarbonate is designated as the alkali reserve, which is an index of the reserve base available in the body. The ratio of carbonic acid to bicarbonate is important in controlling the pH of body fluids. If the bicarbonate is decreased, or the carbonic acid increased, there is a tendency to acidosis. Conversely, with increase in bicarbonate and decrease in carbonic acid, alkalosis ensues. Te metabolism of sodium may be represented by Figure III. tt* Figure III. NaCl Metabolism. M Salt 4-10 gms./day Stomach 8 -10 Litres 0.2 gms. NORMAL 100 mgm./day EXCESS - 3-8 gms./day • CONSERVE - Liver Pancreas Succus Entericus Adrenal and Conads Kidneys Skin ,0.3 gms./day EXCESS - > 2.0 gms./day Intake of salt varies between 4 to 10 gm. per day. In addition, between 8 and 10 litres of fluid containing salt are poured into the intestinal tract. Ninety-five per cent of all this salt is reabsorbed low down in the intestines. Excretion of salt occurs through the skin, kidneys and intestines. The role of the adrenals, the thyroid gland, and the Page 285 sex hormones in regulating sodium metabolism is as yet improperly understood. Sodium is inseparably linked with water metabolism. Renewed interest in this relationship resulted from the fact that in adrenal insufficiency, sodium and chloride decreased along with the body water. Much subsequent work has shown that where sodium goes in the body——so goes water. Let us now consider briefly the body chlorides. This radical is the most important acid radical in the body. The chloride content of the plasma is twice that of the cells, being 370 and 190 mgm. per cent respectively. The chloride ion and the bicarbonate ion are interdependent. If the chloride ion decreases—e.g. during early digestion, bicarbonate increases. Depending on salt intake, the plasma chlorides may be either elevated or decreased, to a certain point—above which the kidneys rapidly excrete chlorides and below which they conserve it. The plasma proteins, consisting of albumin, the globulin complex and fibrinogen, play an important role in maintaining the balance between plasma and interstitial fluid. They exert an osmotic pressure of approximately 25 mm. Hg within the capillaries— mostly due to the albumin fraction—tending to retain fluid within, or draw fluid into the vascular system. This force is opposed by the blood pressure—especially that within the capillaries. At the arteriolar end of the capillary, the blood pressure is between 30 and 3 5 mm. of Hg—and thus fluid tends to pass from the* vessel into the tissues. As the blood flows towards the venous end of the capillary, the blood pressure falls and thev osmotic pressure exerted by the plasma proteins is the greater. Thus fluid tends to flow from the tissues into the blood:. The amount of fluid within the lymphatic vessels has been estimated at between 1500-2500 cc, very similar in composition to tissue fluid. Lymphatic drainage is an important factor in maintaining the normal fluid balance of the body. The ability of the tissues to resist changes in their anatomical structure, their tissue tension, depends? to a certain extent on fluid content of the tissues. Recent work suggests the presence of dynamic equilibrium between plasma and tissue proteins. Thus, a reserve store of materials for plasma proteins is available if need arises; or this reserve may come from the splitting of tissue protein. Capillary permeability allows the free diffusion of water and electrolytes but does not allow the passege of more than traces of protein normally. On the other hand, the cell membrane tends to keep potassium within the cell, and sodium from the cells. Recent; work has established the importance of the cell impermeability to potassium ion, since alterations in the concentration of this ion has been shown to be one of the factors concerned in secondary shock and other conditions. Finally, it has been shown that both the pituitary through its posterior lobe and pars intermedia, the adrenal cortex and the liver influence water balance. A. Alteration in Disease. Alteration of body fluids due to intake deficiency or excess tend to produce changes in the interstitial fluid reservoir. The loss of 10% of the body water—from any cause will produce serious symptoms, and the loss of 20% may cause death. Along with; altered fluid intake, goes altered electrolyte pattern—especially of sodium and potassium. In starvation, electrolyte and water changes are of such a nature as to preserve the normal isotonicity of the body fluids. In diabetes and carbohydrate deprivation, when ketosis has occurred, base is lost to the body, as it combines with the ketone bodies and is excreted. B. Alteration of the body fluid due to abnormalities of output. The body fluid and electrolyte balance may be altered due to abnormalities in output. The sources are many, consisting of skin loss, loss from gastro-intestinal tract through vomiting or diarrhoea, loss through fistulas, unusual loss through urine, and loss from surgical wounds. An idea of electrolyte losses may be gained from the following table, which indicates the average sodium chloride content in grams per litre of the excretions listed. Page 286 Average NaCl gm/L Vomitus 3.3 G-I drainage 5.7 Hepatic bile 5.1 G-l fistula: 5.2 Diarrhoea, stool 4.3 In pyloric obstruction, the loss of chlorides, which is replaced by phosphates, sulphates and bicarbonate, is much greater than the loss of base; thus, the bicarbonate rises markedly. (_orresponding to loss of chloride, is marked loss of water. Similar changes occur in other intestinal diseases, all with decrease in chlorides but with different losses of base depending on the site of the lesion. Marked loss of chlorides occurs also in starvation, diabetic acidosis, pneumonia and emphysema. C. This brings up the question of alterations in the water balance in the body. I have mentioned that there is a ready exchange of fluid between the blood plasma and interstitial spaces—but that little electrolyte transfer occurs between interstitial fluid and cell fluid—because of the relative impermeability of the cell membrane to sodium. Space does not permit a complete discussion of the water exchanges in oedema, and I only intend to touch briefly on the subject. Oedema is the abnormal collection of fluid and electrolytes in the skin, subcutaneous tissues and serous cavities. The principal factors involved in oedema formation are: increased capillary pressure, decreased plasma proteins, permeability of the capillaries, alterations in tissue tension, as well as the state of the lymphatic radicles in the tissues. These factors may be brought into operation by a great variety of conditions, among which are the following: malnutrition, intestinal disorders, cardiac and renal diseases, toxaemias of pregnancy, etc. The problem of fluid and elctrolyte changes in shock are complex and I do not intend to consider them in this paper. This aspect of the problem has been dealt with in a paper by Dr. G. A. McCurdy published in a previous issue of this journal. 3. The clinician, in order to treat his problems in fluid balance successfully, must have an understanding of the value of certain diagnostic laboratory procedures. The following procedures are of value in determining the state of the body water. 1. Blood Chlorides The normal level of the plasma chloride is 270 mgm. % with a range of -j- 20 mgm. %. I have already mentioned the common diseases in which the blood chlorides are lowered. Owing to the chloride shift, which follows any escape of carbon dioxide which occurs even when blood is poured from one container to the other, the plasma chloride rises. Similarly, when any factor is present which increases the blood CO-2, such as prolonged standing at room temperature, the chloride decreases. Actually, the blood chloride concentration depends on the ratio of cell chloride to plasma chloride, and any interpretation must take this into account. 2. Co-2 Combining power. The normal level of the carbon dioxide combining power is 55-75 Vols. %. Values found in mild acidosis range from 55-40 Vol. %. In moderate acidosis from 40-30 Vol. % and in severe acidosis, below 30 Vol. %. Values of over 100 Vol. % are found in cases of alkalosis due to pyloric obstruction. 3. Estimation of total base. This is arrived at by adding the sum of plasma chlorides and the carbon dioxide combining power and then adding a constant for the remaining acid ions. Since the total number of acid ions is quantitatively equal to the total number of basic ions, the value for total base is arrived at. Total base gives a fair index of the total osmotically active ions, and hence its determination in fluid balance is of definite value. 4. Urinary Volume. It is well to remember that in the absence of renal disease a low urinary volume of high specific gravity signifies that the patient is not hydrated. Page 287 ..': m 5. Evidences of Haemoconcentration. The red blood cell count, haemoglobin and hematocrit determinations are reliable measures of haemoconcentration, unless previous complicating factors such as anaemia or haemorrhage are present, when they are individually fallacious. Taken together, they are reliable, especially when the specific gravity of plasma or blood is also determined. In acute water loss, the packed cell volume increases, as it does to a lesser extent in water and protein loss. In acute blood loss, water loss with anaemia, and in anaemia with oedema, the packed cell volume is decreased. 5. (b) Specific Gravity of Blood and Plasma. The determination of these values constitutes another aid in detecting haemoconcentration. The specific gravity of body fluids can be accurately and simply determinerJl by the use of the Falling Drop apparatus. As calculated by this technique, normal values for whole blood specific gravity in adults are 1.0566 in the male and 1.0533 in the female; for plasma, the normal is 1.0270. An example of the use of these determinations is in impending shock, where specific gravity changes in body fluids occur hours before the blood pressure falls. This value is increased in shock, acute obstruction, adrenal insufficiency, among other conditions.i (c) Plasma Proteins. The normal functions of the plasma proteins are well known and numerous. Hence, their maintenance at normal level is important. The normal value for total plasma- proteins is 5.9 to 7.9 gms. %. By use of a simple mathematical formula, this value] may be calculated from the specific gravity estimation. Calculation of total proteins^ is of definite value as a guide to the state of the osmotic pressure within the capillaries^ Finally, I would like to emphasize that these different determinations must be considered together, rather than individually, and that repeated estimations are the only known way to accurate diagnosis and successful therapy in problems of fluid balance. !■» II BIBLIOGRAPHY 1. Peters, J.—The Body Water, 193 5. 2. Peters, J., and Van Slyke—Quantitative Clinical Chemistry—Vol. I Interpretations. The Williams Wilkins Co., 1937. 3. "Wright, Samson—Applied Physiology, 7th Edition. Oxford Medical Publications, 1940. 4. Bodansky, Meyer—Introduction to Physiological Chemistry, 3rd Edition, John Wiley & Sons, 1934. 5. Best and Taylor—Physiological Basis of Medical Practice. Wm. Wood & Co., 1937. 6. Holt & Mcintosh—Holt's Diseases of Infancy and Childhood, 10th Edition, Revised. Appleton Century, 1934. 7. Cantarow, A.—Water and Electrolyte Balance, Edema and Dehydration. International Clinics, 1:266, 1939. 8. Hadfield & Garrod—Recent Advances in Pathology, 2nd Edition. J. & A. Churchill, London, 1934. 9. Scudder, J.—Shock—Blood Studies as a Guide to Therapy. J. P. Lippincott, 1940. 10. Coller, F. A., and Maddock, W. G.—Water and Electrolyte Balance. Surgery, Gynaecology and] Obstetrics, 70: 340, 1940. 11. Weiss, Samuel—Ascites. International Clinics, Dec, 1939. 12. Coller, F. A., and Maddock, W. G.—The Water Requirements of Surgical Patients. Annals of| Surgery, 98: 952, 1933. 13. Coller, F. A., Bartlett, R. M., Bingham, D. L. C, Maddock, W. G., and Pedersen, S.—Replacements of Sodium Chloride in Surgical Patients. Annals of Surgery, 108: 769, 193 8. 14. Drew, C. R., Scudder, J., Papps, Jean—Controlled Fluid Therapy. Surgery, Gynaecology and Obstetrics, 70: 859, 1940. Page 288
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The Vancouver Medical Association Bulletin: June, 1942
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