History of Nursing in Pacific Canada

The Vancouver Medical Association Bulletin: August, 1934 Vancouver Medical Association Aug 31, 1934

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 Vol. X
In This Issue:
1934 SUMMER SCHOOL
STAPHYLOCOCCAL PROBLEMS
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Vancouver, B. C. 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:
Dr. J. H. MacDermot
Dr. M. McC. Baird Dr. D. E. H. Cleveland
All communications to be addressed to the Editor at the above address
Vol. X. AUGUST,  1934 No. 11
OFFICERS  1934-1935
Dr. A, C. Frost Dr. C. H. Vrooman Dr. W. L. Pedlow
President Vice-President Past President
Dr. W. T. Ewing Dr. W. T. Lockhart
Hon. Secretary Hon. Treasurer
Additional Members of Executive:—Dr. H. H. McIntosh, Dr. L. H. Appleby
TRUSTEES
Dr. W- L. Brydone-Jack Dr. J. A. Gillespie Dr. F. Brodie
Auditors: Messrs. Shaw, Salter & Plommer
SECTIONS
Clinical Section
Dr. W. L,- Graham - Chairman
Dr. J. R, Neilson Secretary-
Eye, Ear, Nose and Throat
Dr. R. Grant Lawrence Chairman
Dr. E. E. Day...  -  Secretary
Paediatric Section
Dr. E. D. Carder Chairman
Dr. R. P. Kinsman : Secretary
Cancer Section
Dr. A. B. Schinbein Chairman
Dr. J. W- Thomson . . Secretary
STANDING COMMITTEES
Library Summer School
Dr. W. D. Keith Publications Dr. J. W. Thomson
Dr. C H, Bastin Qr | h McDermot Dr. C. E. Brown
Dr. A. W Bagnall ■    | R ClevelAND Dr. C. H. Vrooman
Dr. G. E. Kidd Dr Murray Baird Dr. LW Arbuckle
Dr. W. K- Burwell Dr. H. A. Spohn
Dr. C. A. Ryan Dr. H. R. Mustard
Credentials tr    .., i
n. Hospitals
Dr. R. A. Simpson ^    w r W.TC„
Dr. J. W. Thomson Dr. j. | Wall Dr. W C Walsh
Dr. F. W. Lees Dr. D. M. Meekison Jf*' „ „ "LE „ ^T
Dr. W. G- Gunn Dr- H-H- MILburn
Dr. S. Paulin
V. Q. N. Advisory Board
Dr. I. Day Rep. to B. C. Medical Assn.
Dr. H. H. Boucher Dr. Wallace Wilson
Dr. W. S. Baird
Sickness and Benevolent Fund — The President — The Trustees Present Typhoid Cases Come
B|j Largely from Carriers ■«
SINCE the public water supplies in practically all cities
have been safeguarded and a large part of the milk supplies have been pasteurized, it is the increasing experience of
health workers that a majority of the individual cases of
typhoid which appear in a community can be traced to
carriers.
Additional information pointing in this direction is offered in the
Connecticut Health Bulletin for March, 1934, as follows:
TWO CARRIERS FOR ONE TYPHOID CASE
"In searching for the source of infection for a recent case
of typhoid fever two carriers were found in the family of the
patient.
"It is not unusual to find two or more cases of typhoid
fever infected by one typhoid carrier, but it is somewhat
unusual to find two carriers for one case.
"In this instance one of the carriers gave a history of having had typhoid fever forty years ago, while the other gave no
history of having had the disease.
"Intensive investigation of individual cases of typhoid fever
often leads to the discovery of a heretofore unrecognized carrier. Another recent case became ill while visiting in the family
of a relative and investigation disclosed the presence of a typhoid
carrier in the relative's family.
"These cases illustrate the recognized fact that residual
typhoid fever at present is due to carriers and that carriers can
be found for individual cases by careful intensive study."
It is an unfortunate fact that carriers are rarely found until after
they have become responsible for additional cases of the disease. When
the infection is spread through raw milk, as is too often the case, the
result is too often an epidemic instead of a single case. It should be
remembered that about seventy per cent of the milk-borne epidemics are caused in this way.
ASSOCIATED DAIRIES
LIMITED
DISTRIBUTING
RICH—SAFE—CLEAN—MILK
Fairmont 1000
service phones:
North 122     New Westminster 144 5 STATISTICS—JUNE, 1934
Total Population  (Estimated).= :  243,711
Japanese Population   (Estimated) 1  7,866
Chinese Population   (Estimated) !  8,315
Hindu Population (Estimated) .-  251
Rate per 1,000
Number Population
Total Deaths  154 7.7
Japanese   Deaths  3 4.6
Chinese  Deaths    10 14.6
Deaths—Residents only  13 5 6.7
Birth Registrations—
Male 134; Female 141    275 13.7
INFANTILE MORTALITY—
June, 1934 June, 193 3
Deaths under one year of age  4 5
Death rate—per 1,000 births  14.6 19.1
Stillbirths (not included in above)  8 7
CASES OF CONTAGIOUS DISEASES REPORTED IN CITY
July   1st
May, 1934 June, 1934 to 15th, 1934
Cases    Deaths Cases    Deaths        Cases    Deaths
Smallpox   0 0 0 0 0 0
Scarlet   Fever  206 0 133 0 33 0
Diphtheria  0 0 5 2 2 1
Chicken Pox  67 0 56 0 3 0
Measles  0 0 0 0 0 0
Rubella    10 10 0 0
Mumps           45 0 30 0 0 0
Whooping-cough     52 0 50 0 1 0
Typhoid Fever  10 0 0 0 0
Undulant Fever  0 0 3 0 0 0
Poliomyelitis   0 0 0 0 0 0
Tuberculosis    57 12 51 15 20
Meningitis   (Epidemic)  0 0 0 0 0 0
Erysipelas    0 0 0 0 0 0
Encephalitis Lethargica  0 0 0 0 0 0
Paratyphoid     0 0 0 0 0 0
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MACDONALD'S PRESCRIPTIONS LIMITED
Medical-Dental Building, Vancouver, B. C. EDITOR'S PAGE
THE  1934 SUMMER SCHOOL
The Twelfth Annual Session of the Vancouver Medical Association's
Summer School has come and gone. Difficult as the feat was of accomplishment, this our latest venture has fully equalled or even surpassed the best
of its predecessors. When one remembers that this is Anno Depressionis 5,
the fact that our attendance was the biggest on record—and that the level
of addresses and papers reached such a high standard—is most gratifying.
We heartily congratulate our Summer School Committee—and record our
gratitude to them for their work—but we are quite sure that as they contemplated the results of that work from Tuesday till Saturday, they felt a
deep and abiding satisfaction which is better than any thanks we may give.
The registration reached the surprising figure of 204, and it was very
delightful to see the large number of men and women who came from points
outside Vancouver. There were many from New Westminster, Victoria,
and the interior—but perhaps the most pleasing thing was the number of
our American colleagues from Washington, Oregon and even California,
who came such a long way to take in the School. We are quite sure they
received full value.
The arrangements for the School all worked excellently—there were no
hitches. Even the rabbits behaved as they were supposed to—and Dr.
Dolman did not have to make use of the alibis that he assured us he had
ready. One does not somehow associate alibis with Dr. Dolman, whose
delightful personality made a very deep impression upon us all.
The lighting arrangements were good, the projectoscope performed
without a hitch; the machine for summoning doctors to the telephone was
an innovation that we hope will become a fixture. It was such a relief to
know that the speaker was not continually being interrupted.
But all this is only the setting of the stage—and our chief thanks are
due to the performers who gave so ungrudgingly of their best to us. One
cannot pick out any speaker for special mention—one can only say that we
have never had a better team—or more genial and friendly personalities to
minister to us—from the jovial Dr. Alvarez, "full of wise saws and modern
instances," who may be regarded perhaps as the senior member; by way of
Dr. Naffziger, who really made lectures on the nervous system a living
thing, so that one could derive new vitality in one's conceptions of this most
difficult subject; to Dr. Aldrich, whose lectures on children's diseases will
contribute greatly to the realisation of what is obviously his heart's desire,
that we should develop the artist's attitude in our care of children; next to
Dr. Max Cutler, whose unbounded keenness and enthusiasm have given new
hope to those of us (and that includes us all) who look forward to the day
when the unfortunate victims of that dread disease, cancer, will be given
a longer and a happier life, and even a cure in many cases now doomed to
slow and painful death; then to Dr. Frank Lynch, who gave such an excellent series of talks on the questions of displacements and other uterine
disorders; till we come to Dr. Dolman, especially our own member 6f the
team, whom in placing last we still reckon first amongst his equals, whose
work shews a promise and a fineness that mark him out, in spite of his
Page 203 notable modesty and self-effacement, as one of the great names of medical
research.
One of the things that must have struck us all most forcibly about all
the speakers was the fact that in everything they said to us, they thought
always of the needs of the general practitioner of medicine: the clinical
aspect of disease, and treatment, were continually stressed. Perhaps nowhere
was this more apparent than in the talks given by Dr. Aldrich on certain of
the commoner, more homely, ailments of childhood, which form the subject of more telephone conversations between doctor and patient than we
can count—earache, stomachache, bed-wetting, unwillingness to eat spinach
or to take cod-liver oil—when a paediatrician comes down from the Olympian heights, where most of them dwell, to discuss these things with us, and
give us the remedies that he himself, by bitter experience, has found effii-
cacious, we hang on his words. Nor, in his remarks on "mint and anise,"
(perhaps cummin too, though we forget whether he mentioned that rare
medicament) did he forget the "weightier matters of the law"—and his
addresses on nephritis in children were the most masterly things we have
listened to for a long time.
But in mentioning Dr. Aldrich we merely cite one of the speakers as an
example of the style and method of them all. We wish we could have had a
dictaphone there to record all that they said; perhaps some other time we
will. In the meantime, we have to thank Dr. Aldrich for the abstracts that
he painstakingly dictated, and that we publish herewith. Other speakers
we have abstracted ourselves, and have endeavoured to record their main
points; but the addresses were all extempore, and indeed owed much to the
informality with which they were given. But it is very trying for a humble
editor—the dream of whose life is a Summer School where all the papers,
as they are read, will be handed in, neatly typed (double-spaced, of course)
and ready for publication.
Lastly, we owe a word of gratitude and appreciation to the Vancouver
press. All three papers were most friendly and co-operative, and we feel
that by their sympathetic (and accurate) reporting we have gained much,
especially |lo. being able to bring before the public the dire necessity for
better care of cancer patients, and a more adequate solution of the problem
as a whole.
OBITUARY
In Ontario, where Doctor Crosby was born sixty-five years ago, during
the heat of summer, not infrequiiitly a thunder-storm with its lightning
flashes would appear quite suddenly and with very little warning.
Doctor Crosby's passing in its suddenness and definiteness reminded me
of one ofj^hose storms.
In his death many of us lost a cherished friend and associate.
Robert Crosby was of compact build, rather under medium size, of spare
but well-knit frame. His mentjjjpty was just as active and alert as his
physical appearance would lead one to expect. I liked the way he carried
himself, the straightness of his spine and the judgment he exhibited in the
conduct of his cause. It was always refreshing to discuss a case with him,
as his reasoning was sound and his deductions definite and clarifying. His
sense of business was acute; probably some gift handed on through his race
Page 204 made him a natural careful trader. He often told me that when a small boy
at school he used to swap knives, marbles, etc., with his school-mates, and
that he there learned how to make a bargain.
He studied medicine at Toronto University, graduating in 1898, and
his first practice was in Parry Sound; later he settled for a few years
at Byng Inlet. As an interne in the Toronto General Hospital he met Miss
Isabel Peters, whom he married in 1901. Their four children, Geoffrey,
Helen, Kathleen and Gordon, are all living.
Dr. Crosby, however, had ideas of becoming a specialist, and with this
end in view he went to New York in 1906 for postgraduate study and
practice.
In 1908, when he settled in Vancouver as an eye, ear, nose and throat
specialist, the way was not easy, but his natural ability and capacity for
application and of making friends enabled him in a few years to build up
one of the largest special practices in Vancouver.
His work in his chosen field was first class—could not be otherwise, as
that was his character. His associates in the same specialty recognized his
skill and the high standard of his work.
Outside his professional life he took a keen interest in his church, and
in national, provincial and civic matters. I often enjoyed having a chatty
gossip with him over Provincial and Dominion affairs.
As a hobby he had a farm on Lulu Island, where he built up a fine herd
of Guernseys under the management of his eldest son, Geoffrey.
There was a straight-forwardness, a naturalness, and a helpfulness about
Robert Crosby that endeared him to his friends and which will make him
very difficult to replace.
William D. Keith.
It is with great regret that we record the death of Dr. Aubrey T. Fuller,
who died on July 15 th. Dr. Fuller was, perhaps, not well known to the
younger generation of medical men, since he was a very quiet and retiring
man who had his office in his house, did mostly family work, and was seldom
seen in the hospital. But to those of us who are now in the sere and yellow,
Dr. Fuller was well known since he started practice in Vancouver some 30
or more years ago.
Dr. Fuller had at one time one of the big practices in Vancouver, and
did a great deal of obstetrical work. He was extremely skillful in this
department—and needed to be, for in the days when he came here there
were no well-appointed maternity hospitals—not even any specialists—
and maternity work was expected to come by nature to every doctor—
one just had to be a competent obstetrician, that was all. Work was done
in houses, with elderly ladies in attendance, whose chief claim to proficiency
as a nurse lay in the fact that they had raised large families of their own, or
"had buried six, and ought to know something about it." So the doctor
had to be nurse, anaesthetist, accoucheur and family friend in one and
the same person, and it was not always easy.
Dr. Fuller did a lot of work, too, with the Salvation Army Maternity
Home on Eighth Avenue. He was one of the rank and file, who never
belonged to associations, or made speeches, or had a cure for all the world's
ills. He only worked along, doing the day's meed of work, and accepting
life as it came; never specialising—but nevertheless doing good and useful
Page 20% work. One likes to think, in connection with such men, of the beautiful
words of the Apocryphal writer, Ecclesiasticus, who speaks thus of the
Martha's sons of the world: ,'These men maintain the fabric of the world,
and in their handicraft is their prayer." No better or finer epitaph will ever
be written of any one of us.
NEWS AND NOTES
Our sincere sympathy is extended to Dr. H. H. Milburn, in his recent
bereavement through the sudden death of his wife on July 22nd.
Dr. A. W. Hunter has returned from an extended trip in Eastern parts.
He looks well, and reports that he has seen no place where he would rather
live than Vancouver.
Dr. J. C. Farish is being congratulated on his recent marriage.
Dr. Hobbs has returned to the Vancouver General Hospital as senior
interne in Obstetrics, after spending the past year in Montreal hospitals in
Obstetrics and Gynaecology.
The Publications Board is feeling somewhat chesty these days. Dr.
Murray McC. Baird is the proud father of a bonny daughter, while the
Editor has attained to the exalted position of grandfather of a boy whose
personal appearance is best left alone, except to say that it is improving.
We have not yet heard from the third member of the Board, Dr. Cleveland,
but if Don has one defect, it is that he does not take life seriously, and we
can only hope that he will see and do his duty sooner or later—even if it
be only in an avuncular capacity.
Dr. C. G. McLean of Woodfibre has left on a trip to Europe and will be
absent for a year. Dr. A. Leigh Hunt is substituting for Dr. McLean during
his absence.
Dr. Gordon C. Large, a relative of Dr. 0; S. Large, has started practice
in Vancouver, and is confining himself to ear, nose and throat work. He
has had a very intensive training in this work, and especially in bronchoscopy, both at Harvard and in Dr. Crile's clinic in Cleveland.
How about Kamloops? We trust everyone is thinking about the September 17-18 meeting of the British Columbia Medical Association. It is
going to be more than simply an annual meeting. The scientific programme
is excellent, and we have alluded to it before. Every member of the profession will have received a letter from Dr. W. S. Turnbull, president of the
B. C. M. A., about this.
Dr. J. S. McEachern, president of the Canadian Medical Association,
will be there with Dr. T. C. Routley, general secretary, to give an account
of the national body's doings, while the College of Physicians and Surgeons
of B. C. will hold a meeting, and be addressed by members of the B. C.
Medical Council.
Page 206 It is hoped to arrange a special meeting of the Association late in August,
to hear from Drs. Vaughan and Darling, who are connected with health
authorities in Battle Creek and Detroit, Michigan. The meeting should be
of intense interest to medical men. They will deal with the employment of
medical men in practice, as part of the health machinery of a city or municipality. We understand that in Detroit, for instance, some 3000 medical
men work with the city health authorities, in immunization against diphtheria and smallpox, and in pre-school and school examinations of children; by this means the f amilies concerned are sent back to their own doctor, and he does the work himself.  Further particulars will be given later.
STAPHYLOCOCCAL PROBLEMS
{Abstract from an address by Dr. Dolman, Toronto, at the Vancouver Summer School.)
In this, which was the first of a series of addresses, Dr. Dolman opened
by stressing the fact that the chief importance of his work, in his own view,
was the clinical aspect.  He divided the subject into three main parts:
1. Laboratory aspects of the preparation of staphylotoxin, and its
properties; the significance of antitoxin in human beings, and the methods
whereby this is prepared;
2. The applications of staphylococcus toxin, in so far as concerns the
preparation of toxoid and antigens;
3. The potential uses of staphylo-antitoxic serum.
History.—This begins in 1874 with Billroth, who first recognized and
described cocci in inflammatory tissue.
In 1880 Ogston isolated cocci from pus, and called these "staphylococci,"
on account of their arrangement.
In 1901 Neisser discovered a haemolysin in staphylococcic cultures.
In 1906 Kraus prepared lethal filtrates from these cultures.
Dr. Dolman's own attention was first definitely centred on this question
following the well-known tragedy in Australia, at a small town called
Bundaberg, in 1928. This was the tragic death of some 12 children, following the administration of toxin-antitoxin by the medical health officer.
Contamination of the cultures by some other toxin seems to have been
a factor here, and Burnet, one of the medical men conducting the investigation, deserves special mention, since he recognised the presence of an exotoxin of the staphylococcus.
Another very important discovery was made by Jordan in 1930, when
he recognized the relation of the staphylococcus to food poisoning, formerly
attributed to ptomaines.
Staphylococcus toxin. This has three main, and some secondary, pathogenic properties.
1. Hemolytic. Dr. Dolman reminded us that haemolysis is a property exhibited by a wide range of substances, of very varying degrees of
toxicity. Thus even water possesses it in a considerable degree, and at the
other end of the scale of toxicity one finds it in the venom of snakes, the
poison of spiders, and of bees and wasps.
A wide variety of bacteria—amongst them streptococcus, diphtheria,
tetanus—also shew haemolytic powers under certain circumstances. This
property of bacteria is responsible for the anaemia of bacterial disease, but it is
Page 207 remarkable how little damage is shown, in view of the tremendous potency
of certain strains of staphylococcus. Human beings, as a matter of fact,
along with guinea-pigs, shew a very remarkable resistance to the haemolytic
powers of ths germ.
2. Necrotoxic: causing skin-necrosis. This is perhaps more important in man than haemolysis. The speaker shewed slides illustrating this in
varying grades of severity.
3. Lethal Power. The toxin of S. is extremely powerful, and the
speaker illustrated this rather dramatically on two rabbits. The experiment
illustrated also the potency of the antitoxin. Into the ear vein of the first
rabbit he injected 1.0 cc. of toxin, mixed with O.J cc. of antitoxin. Some
of this was also put with a cloudy suspension of the red corpuscles of the
rabbit. Into the vein of the other rabbit, the same size and weight, he
injected 1.0 cc. of unneutralized toxin. This rabbit, within a few minutes,
shewed marked hyperpnoea and some restlessness. It then shewed dragging
of the hind legs, then of the front legs—fell over and was unconscious with
some twitchings. Convulsions, which commonly accompany the comatose
state, were not seen here. The other rabbit, after a certain somewhat justifiable display of excitement, turned its back on the audience, but remained
alive and well, and was, we understand, returned to the laboratory, where
Dr. Gee will utilise it for her Ascheim-Zondek tests—probably the worse
fate of the two.
The suspension of R.B.C. which was treated with neutralised toxin,
remained unchanged, while a similar specimen, to which a few drops of the
straight toxin had been added, rapidly cleared and shewed complete
haemolysis.
The necrotoxic properties of the toxin could not, of course, be demonstrated, but slides shewing the effect in this direction on the skin of a rabbit
gave a vivid idea of this important property. The terrific potency of the
toxin, its short period of delay, and its profound effect on the central
nervous system, made a deep impression on the audience.
The toxin has, of course, other properties beside the three mentioned,
especially the leukocidic factor (of which more later), but the problem of
preparing antitoxin is best met by a determination of the three main properties: the haemolytic, the necrotoxic, and the lethal.
The first thing to do is to obtain a standard "toxic unit," or unit of
toxicity. Perhaps arbitrarily, a standard has been chosen, where the toxin
must conform to these requirements:
1. Hemolytic: the volume that will haemolyse 1 cc. of a 1% suspension of corpuscles after 1 hour at a temperature of 37° C.
2. Necrotoxic: the volume that will cause a necrosis of a patch 0.5 cm.
in diameter.
3. Lethal: the volume per kilo body weight that will kill a rabbit in
one hour.
Having obtained a toxin unit, we are now in a position to get an antitoxin unit—namely the amount by volume that is necessary to neutralise
the toxin unit.
In getting this, it is found by experience that the haemolytic powers are
the cheapest to assay, and are a sufficiently accurate index.
In an estimation of the toxigenic powers of the staphylococcus, we test
cultures of germs taken from various sources. Those isolated from the blood
Page 208 stream are not necessarily the most toxic.  It is found, as a matter of fact,
that those from boils, carbuncles, shew the highest degree of toxicity.
To ascertain the antitoxic powers of blood, we titrate that blood against
a toxin unit, testing the anti-haemolytic power of the blood, and using this
as an index.
All human blood, for example, has a certain titre, or index, of anti-
toxicity. This varies widely in health and disease, and varies in two healthy
individuals. To begin with, humans as a genus have a high anti-haemolytic
titre, sharing this characteristic with the humble but useful guinea-pig.
In septicaemia, the titre is low, 20-24 units, as against the normal 80-100
units.
In a patient with recurrent boils, the titre is as low as 8-10 units. After
the administration of toxoid, the titre can be raised as high as 3000 units—
this after the giving of several doses—8 or more.
The toxigenic properties do not necessarily correspond with the virulence of a given strain; other factors, such as the individual antitoxic power,
enter into the equation.
We find other properties, with substances displaying these properties,
in staphylococcus toxin.
Leukocidin is one of these substances. There are, too, a plasma-coagulating substance and a food-poisoning substance. This has been at the basis
of cases of food-poisoning on a large scale, e.g., at picnics, etc.
These properties of staphylococcus toxin are much more variable than
the first three mentioned, the haemolytic, the dermonecrotoxic, and the
lethal. These three run more or less parallel, and this fact is made use of in
preparation, for clinical use, of toxoid and antitoxin.
There is laboratory and clinical evidence that the virulence of the toxin
varies with the exotoxin of the germ.
Dr. Dolman spoke next of the properties of the antitoxic serum, which
has been undergoing careful testing. The number of cases is, as yet, not very
large, and the results are not by any means finally evaluated, but certain
facts are very illuminating.
More than 100 cases have been treated, and carefully observed.
There were 24 cases of cutaneous and subcutaneous infection: in a
majority of these unexpectedly rapid recovery occurred.
Of 33 staphylococcus septicaemias in children following osteomyelitis,
2 3 recovered; while there were 22 cases of staphylococcaemia in adults, with
5 recoveries.
As the titre of antitoxin in the blood rises, a leucocytosis appears and
increases.   But early diagnosis is of supreme importance.
Symptomatology. Some forty cases of staphylococcaemia were observed,
17 of which were fatal. Four were adolescents following osteomyelitis; two
were middle-aged, with fulminating recrudescence of an old focus in bone,
and four (two male and two female) followed surgical operations. The
question of portal of entry is always of importance—the nose and throat
being perhaps the most frequent.
The symptoms include:
Migratory pains, general malaise, occasional rigours. There are abdominal
pains and gastro-intestinal disturbance; sometimes vomiting, more often
Page 209 than in streptococcus septicaemia.   There is persistently high temperature
and pulse rate.
The face is congested and sometimes cyanotic; the patient is restless,
with dilated pupils; there is usually a leucocytosis, though in severe cases
a leucopaenia may be the result. The spleen is enlarged. There are great
sweating, cyanosis with pallor, and rapid loss of weight. Mentally there is
usually stupor, as opposed to streptococcus infection, where the patient is
bright-eyed and alert. There is some meteorism.
We see erythematous rashes, pustules, macules, etc. The latter carry
the most unfavourable diagnosis. A coffee-coloured rash, petechial or in
large macules, may appear.  This is also a very bad sign.
Treatment. Dr. Dolman gave us the welcome news that within the
next few weeks the Connaught Laboratories propose to make the antitoxic
serum available for general use.
Intramuscular injections are the method of choice in acute carbuncles,
and in acute infections generally; 30 cc. given in this way will abort a carbuncle which is not discharging.
In a large discharging carbuncle, 60 cc. should be given.
In cellulitis, give not less than 60 cc. and repeat.
In septicaemia in children, e.g., after osteomyelitis, give not less than
60 cc. daily till 3 negative blood-cultures are obtained.
In adults, the antitoxin may be given intravenously. We should look
out for serum reaction, but, as Dr. Dolman pointed out, in certain rapidly
progressing cases it may be necessary to go ahead, serum reaction or no
serum reaction.
In making toxin, it is important to have a potent toxin, and the standard
is set by the three main properties of the toxin, haemolytic, dermonecroti:,
and lethal.
The arbitrary standard of virulence is one where we find:
1 minimum haemolytic dose (m.h.d.)  (see above) in not more than
.001 cc;
1 min. dermonecrotic dose (m.d.-n.d.) in not more than .005 cc.
1 min. lethal dose (m.l.d.) in not more than .25 cc.
Having obtained a standard toxin unit, we proceed by addition of small
amounts of formaldehyde to detoxicate the preparation till it does not
contain:
1 m.h.d. in less than 2 cc.
1 m.d.-n.d. in less than 2 cc.
1 m.l.d. in less than 3.0 <Ss|2i
■:
In 300  cases treated with toxoid, every sort of manifestation  was
included, e.g.:
Furunculosis: 87 cases. These do very well and become free from boi'.s,
with 2 cc. given in 8 doses.
Chronic and subacute osteomyelitis: 59. Thiols a very important, one
of the most important, applications of toxoid. These 59 cases were of bad
types, mostly children. They had a sword hanging over their heads all the
time, as so many of these cases flare up some day with rapidly fatal consequences. It was found that these children improved rapidly in general.
They welcomed and even asked for the injections. The pus at first increased
Page 210 in amount, later dried up. The antitoxin titre in the blood rose; persistent
sinuses healed up; amputations which had been booked were avoided.
Ordinarily, recurrent boils or surface infections do not confer immunity on the sufferer therefrom. There is no increase of antitoxin in the blood.
But if we give toxoid, the antitoxin titre rises at once.
In deep-seated infections, on the other hand, there is an increase of
antitoxin in the blood, but not to a great enough extent. Toxoid increases
the titre in favourable cases.  Dr. Dolman is "very hopeful" of these cases.
Acne vulgaris is not a simple staphylococcus infection. It is a symbiotic
infection. Toxoid may reduce the pustular aspect, but is not a definite cure
for the disease. But sometimes by persisting with a long series of injections
we discourage the acne bacillus so much by depriving it of its pal, the
staphylococcus, that it gives up the struggle and dies out.
In acute infections, during convalescence recovery may and should be
hastened by reinforcing the newly acquired immunity by the giving of
toxoid.
Infections of nose and accessory sinuses.
We must be careful here to get cultures as soon as we possibly can. If a
pure staphylococcus culture is obtained, we shall probably get results with
toxoid.
Dr. Dolman then referred to the question of diabetes, and its relation to
staphylococcic infections. There is a special susceptibility to this infection
in diabetes, and undoubtedly many cases improve under toxoid treatment,
or on the removal of foci of infection. Again, the use of toxoid may stabilise these cases.
In skin infections, if pure staphylococcus culture be obtained, toxoid is
useful.
Carbuncles. If large, painful and accompanied by marked toxaemia,
antitoxin is better—but as the slough appears and the temperature falls,
toxoid should be given for its immunizing value.
Other types, even if large, should be treated by toxoid.
Asthma. This is very doubtful yet. Some asthmatic children have been
benefited, but unless in all respiratory conditions staphylococcus is obtained
by careful culture, the use of toxoid is of unproven value as yet. In recurrent colds and other respiratory infections, cultures should be taken.
HOW TO EXAMINE A PATIENT
Some of the UAphorisms of Alvarez
i)
A good history, well taken, is the best agent in making a diagnosis, even
better than x-rays and laboratory tests.
History should repeat itself.  Take the history several times if necessary.
Take plenty of time over history—take enough time.
Notice the mannerisms and characteristics of a patient.   The fidgety,
jumpy type; the emotional; the indifferent; the sullen, mask-like face of
Page 211 dementia praecox, with slow cerebratory response—each of these tells its
tale and awakens the detective in us.
Do not forget that a patient may be an absolute nut, and yet have an
organic disease.
Two patients will he to you—yea, three:
(1) The one who conceals facts through fear of an operation;
(2) The neuropath who wants an operation;
(3) The patient who hides his or her worries, about her husband or
mother, or son, and so on.
Always find out the background, domestic, social and business, of a
patient.
Do not be a slave of routine—that is what the interne does, before he
knows anything. When a patient says she had a "nervous breakdown," do
not neglect this clue: it opens up all sorts of possibilities of worries, etc.;
there may have been a divorce, or a broken engagement, or some major
disappointment.
Has the patient a functional or an organic condition? It is of primary
importance to answer this question rather than to diagnose immediately
exactly what is the matter.
As regards complaints of pain: Is it actual pain, or just discomfort?
Get the exact location of the pain—and especially with regard to the
navel, above or below: as the nerve-segments are completely different, and a
definite limitation to one of these localities simplifies diagnosis greatly.
Remember that pain every day, all day for years is an impossibility.
Watch out for the psychopath always.
Intervals of relief occur, often for long periods, of their own accord.
This is especially true of duodenal ulcer, and gall-bladder colic.
If an abdominal pain needed morphine, it was probably du
bladder colic.
e to gall
The relation of pain to natural functions should always be ascertained.
To food—better or worse, before or after.
To urination, def aecation, and so on.
An ulcer pipfient gets to sleep, but wakes up wit%;the pain or distress.
A gall-bladder patient can't get to sleep.
Avoid optiifiistic gastroenterostomies—if you wish to remain an optimist.
Look out for the misfit, whose symptoms rationalise his unfitness for his
job, for ordinarypfe, and the strain of living; the hysteric, the generally
useless "white trash" of our social makeup.
Page 212 The man who was always a reader should be asked the question: "Can
you read today? How much are you reading?" A serious falling-off
betokens grave fatigue, boredom, exhaustion, and should be a danger signal.
Every medical man should have at least one religion—the religion of
disinterestedness, that does not seek to prove a theory in the face of ascertainable facts, nor craves to operate for the sake of operating, nor to cover
laziness and poor work—but puts the patient really first, and has no other
personal axe to grind. Of such is the kingdom (medically speaking) of
heaven.
Do not fail to use consultants; it will greatly increase your popularity,
to say nothing of your value to your patients.
Abdominal pain has its value. It should not be ignored, nor too hastily
relieved, until we have made it give up to us all the information that we
can get from it.
DIAGNOSIS AND PROGNOSIS IN NEPHRITIS
IN CHILDREN
By Dr. C. A. Aldrich
In order that misunderstandings be avoided in classifying nephritis, a
strictly clinical method is used here. The clinical method of differentiating
types of nephritis has the advantage that the physician at the bedside may
make a diagnosis from clinical facts which can be compared with similar
cases by other physicians on the same definite criteria. He does not have to
surmise anything as to pathological changes which may or may not actually
be present in the kidneys.
As a result of the application of this method to more than 300 patients
with various types of nephritis, the following list of conditions found in
children is submitted with the diagnostic criteria.
(1) Acute post-infectious hemorrhagic nephritis.
(a) Acute onset following febrile disease.
(b) Haematuria (gross).
(c) Benign course or death in the attack.
(2) Chronic non-specific nephritis.
(a) Oedema.
(b) Haematuria.
(c) Hypertension.
(d) Increase in the non-protein nitrogen elements of the blood.
(e) Chronic course usually ending in death.
(3) Nephrosis.
(a) Oedema.
(b) Marked albuminuria.
(c) No haematuria at any time.
(d) No increase in the non-protein nitrogen elements of the blood.
(e) No hypertension.
(4) Sub-acute bacterial endocarditis with nephritis.
(a)   Symptoms of chronic non-specific nephritis plus those of subacute bacterial endocarditis.
Page 213 (5 )  Syphilis with nephritis.
(a)   Symptoms of chronic non-specific nephritis plus those of active
syphilis.
(6) Tuberculosis with nephritis.
(a)   Symptoms of chronic non-specific nephritis, plus those of miliary
tuberculosis. •
(7) Renal Infantilism.
(a)   Symptoms of chronic non-specific nephritis plus dwarfism.
(8) Amyloid disease of the kidneys.
(a)   Symptoms of chronic non-specific nephritis plus those of generalized amyloid disease.
It is necessary to allow plenty of time in making the diagnosis, as some
of the diagnostic criteria may not be present at the time of the first observation. A tentative diagnosis is made and this is changed as situations arise
in the care of the patient.
Differential Diagnosis
The main sources of difficulty in differentiating the types of nephritis
arise when the physician has to decide between acute post-infectious
haemorrhagic nephritis and chronic non-specific nephritis at a time of
exacerbation due to infection.
The points in favour of acute nephritis are:
(1)  Definite history of acute infectious illness preceding any symptoms of nephritis.
( 2)   Relatively high specific gravity of the urine.
(3 )   Relatively slight changes in renal function tests.
(4)   Rapid improvement in symptoms with early recovery.
The points in favour of chronic non-specific nephritis are:
(1) History of renal symptoms preceding the onset of the infectious
symptoms.
(2) Relatively low specific gravity of the urine.
(3) Marked impairment of all renal function tests.
(4) The resistance of symptoms past the usual period of the acute
disease.
(5) Uraemic symptoms are not of differential importance.
Another difficult situation arises when the attempt is made to differentiate between chronic non-specific nephritis and nephrosis at a time when
the patient with chronic non-specific nephritis has no blood in the urine.
The differential points between these two conditions are clearly cut and
should cause no confusion if time is devoted to observation.
Points in favour of chronic non-specific nephritis are:
(1) Haematuria at some time in the course of the disease.
(2) Low specific gravity of the urine.
(3 )   Hypertension.
(4)   Increase in the non-protein nitrogen elements of the blood.
-Points in favour of nephrosis are:
(1) No haematuria at any time in the disease.
(2) High specific gravity of the urine.
(3) No arterial hypertension.
(4) No increase in the non-protein nitrogen elements of the blood.
Page 214 The other differential -points are sufficiently Brought out by the diagnostic criteria used in classifying the diseases.
Prognosis :
The prognosis when clasification is made in this matter becomes relatively simple.
(1) Acute post-infectious hemorrhagic nephritis—the prognosis should
be very good. The only deaths we have had in this type of disease
occurred many years ago before modern methods of treatment were
applied. They are nearly always due to the infection which caused the
nephritis rather than to the nephritis.
(2) Chronic non-specific nephritis. In this condition the prognosis has
been in our experience absolutely bad until the last three years, during
which time the patients have been treated with high protein, high
vitamin diets. We have had in this period some apparent recoveries so
that the prognosis can now be tinged with some degree of optimism.
(See under treatment.)
(3) Nephrosis. About one-half of the children with nephrosis recover
completely. This process of recovery may be a gradual abatement of
symptoms lasting over years, or it may be startlingly sudden, following
an acute streptococcic infection with fever.
(4) Syphilis with nephritis. Prior to the use of stovarsol we have not seen
recoveries in this type of disease.  In the last year under this method of
treatment we have had two recoveries.
The prognosis in the other types of nephritis may be summed up by
saying that in our experience none of them have made complete recoveries.
Sub-acute bacterial endocarditis with nephritis is a particularly malignant form of disease and causes death usually within a few weeks.
TREATMENT OF NEPHRITIS IN CHILDREN
By Dr. C. A. Aldrich
The speaker dealt with three types of nephritis: acute post-infectious
haemorrhagic nephritis, chronic non-specific nephritis, and nephrosis.
Post-infectious Acute Nephritis
This is a condition in which we must treat the patient rather than the
disease. It may be necessary even to ignore the nephritis for a time in the
treatment of the general condition of the patient.
(1) We must look for and treat the condition that caused the nephritis.
If fever is present, it is almost certain that the original condition is
still active.
Such causes may be:
Such causes may be:
Abscesses somewhere: in glands, in the retropharynx, in the middle
ear, in the skin, and elsewhere.
Pus anywhere.
The presence of nephritis in these cases is an indication rather than
a contraindication for surgical interference. We must not wait for the
nephritis to clear up; if we do the patient may die. Drainage of an
infected focus may often lead to rapid recovery.
Page 215 As regards anaesthetics, gas is perhaps better than ether—but we
must not be afraid of ether.
(2) Treatment of toxic conditions. These must be treated energetically.
The intoxication which is nephritis, causes the tissue cells to swell.
Unfortunately we have no antitoxin. So we must treat as we do any
intoxication.
It is Dr. Aldrich's policy to force fluids: and this regardless of
oedema. Plenty of fluid dilutes toxin, and hastens and facilitates elimination; and it is an essential part of treatment.
Even if we increase the oedema, this does no harm, if no vital spot
is involved. Even if there is some oedema of the brain, give fluids.
Do not withhold fluids if you wish to reduce toxin. Further, it
gives relief and comfort to the patient.
Dr. Aldrich gave it as his opinion that he would rather withhold
antitoxin from a diphtheritic than water from a nephritic.
Do not sweat patient, for the same reason that we give fluids.
Sweats are dangerous and very uncomfortable. The kidney cannot
excrete water unless it is free in the blood stream.
The kidney is a filter, not a pump.
Do not use purgatives. Mag. sulph. is used in cerebral oedema, but
this is a different thing.
(3) Diet. Dr. Aldrich does not believe that protein has anything to do
with nephritis, and as far as he is concerned, does not care greatly how
much protein the child gets. In cedematous patients it is well to lessen
the supply of salt, but in the ordinary child this is of little importance.
But we must never gi\e salt intravenously.
(4) Drugs. The ordinary diuretics are probably of no value. Salicylates or
aspirin are of value and mag. sulph. is used in certain cases, as stated.
(5) Take blood-pressure every day, as an index of cerebral oedema.
Dress patient warmly.
Keep in bed.
If the patient has infected tonsils or throat infection, remove these
before he or she leaves hospital.
(6) Prophylaxis. There are no certain measures of prophylaxis. Alkalies
may be given in acute infections, but are of doubtful value.
(7) Cerebral oedema. This may occur at any time during illness, and is
best treated by mag. sulph.
Chronic Non-specific Nephritis
Here Dr. Aldrich in his remarks made a very decided contribution to the
sane treatment of this condition. It was startling to hear the conclusions
to which he had come, but it is probable that a great many lives, formerly
sacrificed on the altars of traditional misunderstanding and faulty observation, may be saved and made useful by the rational methods he has here
outlined.
These cases have for long been the tragedies of paediatric clinics. Month
after month, sometimes for several years, they would come back, engaged
in a battle which always ended in defeat. Their oedema grew gradually,
their N. P. N. climbed gradually, their urinary output and quality of urine
passed diminished steadily, and they eventually died, all of them.
Page 216 In despair at the futility of all treatment, based on ideas of chronic
infection or toxaemia as the underlying causes of this disease, Dr. Aldrich
went over in his mind all the facts connected with these patients—and it
dawned on him that practically never do we find this condition in private
patients, or in well-fed and well-nurtured children; and he asked himself
this question: "Are we dealing here with a dietary deficiency, with hygienic
failures, or is this, as we have always thought, a chronic infective or inflammatory condition of the kidney?"
So he started feeding up these children, giving them high protein and
vitamin diets, meat or eggs three times a day, vegetables twice a day, cod-
liver oil and yeast, orange juice and good food generally. He took them out
in the sunshine, or gave them ultra-violet rays. He sent workers to investigate living conditions, and where these could not be improved, put the child
in hospital and gave it special care.
And the improvement was spectacular. In three months, for example,
one child who had been sick for 3 years came back with no albumen in his
urine.
In 6 months the entire group was back at school. The N. P. N. diminished in all except one. One boy is now head of his school football team and
perfectly well.
For 4 years this has been the routine, with no contraindications developing. In many cases complete recovery has taken place. With the former
treatment of restricted diet and removal of salt they got thinner and
thinner, and worse and worse, and died eventually.
If infections occur, we treat them pro re nata, but elimination of foci
of infection does not affect the disease.
B. P. and renal function are watched carefully.   Fluids are given freely.
Prevention. As a result of our experience with this condition, Dr.
Aldrich is inclined to feel that this disease is a dietary and class condition.
Therefore measures promoting good hygienic care of children should eliminate this disease as a problem.
Nephrosis
This is an oedema disease, and the treatment is that of oedema.
Plenty of fluids should be given—as much as the patient wants, regardless of the degree of oedema present. The patient may look worse on an
abundant fluid diet—but he will feel better.
Salt restriction. Dr. Aldrich has not satisfied himself that this is of any
value, but thinks that KCL should be given rather than NaCl in any case.
Ordinary diuretics are of little or no value. Thyroid, thyroxin, calcium
gluconate, urea, parathormone, have all been given, sometimes with good
results, sometimes with none. In great emergencies it may be advisable to
inject acacia solutions intravenously, with 1 % NaCl, but this should always
be done in the hospital. It is rarely necessary to do paracentesis of abdomen
or chest.
The disease appears to be self-limited, and the patient usually recovers
in one of two ways, either slowly and gradually, or with spectacular suddenness, following some acute infection, where temperature may go to 105°.
For this reason Dr. Aldrich feels that malarial treatment, or artificial fever-
production, may be of value, though so far he himself has not tried this
method.
Page 217 Great care should be used in preventing these patients from getting
contact infections, as many of them die from terminal peritonitis.
It is agreed by all authorities that a high protein diet should be given in
nephrosis, to compensate for the extreme loss of proteins by the urinary
tract.
Treatment of Acute Cerebral Symptoms
"These symptoms occur only in the haematuric types and should not be
called uraemia, because the symptoms have no relation whatever to the
accumulation of urea in the blood: they are more of the eclamptic type.
We have seen patients with marked increase in blood urea who showed no
cerebral symptoms on the one hand, and, on the other, patients in coma who
had normal bloom chemical estimations. I will divide the treatment into
that given before, and that given after coma.
(a) Before coma we urge fluids upon the patient and do not administer
sweats and diaphoretics. In addition we give them large doses of magnesium sulphate by the mouth. If they are unable to retain it, we give
it intra-muscularly. Anywhere from 1 to 6 ounces daily may be given
orally, and from 2 to 8 cc. of a 5 0 % solution every six or eight hours
into the muscle, the dose depending upon the size of the child and the
severity of the symptoms, using the blood pressure estimations as a
control. This treatment should be persisted in until the blood pressure
remains at an approximately normal level.
The diet we consider unimportant and are often glad to have these
patients take any kind of nourishment whatever.
(b) If the patient is in coma or unable to retain food, intramuscular or
intravenous treatment must be resorted to. Intravenously we administer 2% magnesium sulphate solution at a rate no faster than 1 or 2
cc. per minute. The injection is continued until the blood pressure
reaches a point just above normal, at which time the injection is
stopped. By using this method our patients have always emerged from
coma within an hour after the injection is stopped. If the solution is
given too rapidly, one loses completely the blood pressure control as to
dosage. After the patient emerges from his coma, the treatment is
continued as in (a) until the blood pressure remains low* In our experience with over 35 consecutive patients having cerebral complications
with nephritis in the last eleven years, we have not lost a single patient
and we consider that magnesium sulphate is a specific for this condition."
POINTS  IN  TREATMENT   OF   SOME   COMMON
PEDIATRIC CONDITIONS
By Dr. O E. Aldrich
Winnetka, Illinois
1.   Infantile colic and pylorospasm.
Some of the pundits of paediatrics declare that there is no such thing as
colic in infants, but Dr. Aldrich does not agree with them, nor with their
dictum that so-called colic is really pylorospasm. To his mind, while it :s
hard to make a sharp distinction between the two, there is nevertheless a
conditionpnot obstructive as is pylorospasm, which can be described as
"colic."
Page 218 This is where babies scream, generally after feeding, without concomitant indigestion, vomiting, or loose stools. These babies are not spoiled. Dr.
Aldrich suggests that the baby should be stripped completely, laid on a
blanket and given a bottle or nursed by the mother. You will see definite
waves passing over abdomen during the height of the cry—not as large as
obstructive waves.
Is this pain and crying due to hunger or something else?
First, give an adequate amount of food. Dr. Aldrich has no sympathy
with the standardised amount of food for a given age. His advice is, as a
general rule, to give babies all they want. If adequate feeding stops or
relieves the pain, it is not a true colic, and the problem is solved. When a
healthy baby cries, it is often that he is hungry—and wants and expects
food. By giving it to him, we comfort and satisfy him, and teach him to
associate food with pleasure. This is a valuable piece of training for later
life, and helps to avert the revulsion to food that we sometimes find in
older children. But if the baby still yells, we proceed to our second expedient
of giving sedatives and antispasmodics. Of them all, in Dr. Aldrich's
opinion, atropine is probably the most efficient and safest. A dose of gr.
1/1000 may be given to start with. It is a drug for which babies exhibit
great tolerance, and may be pushed. If the baby has a flush, never mind;
give less next time.  Some men use tr. camph. co, some phenobarbital.
2. Vomiting due to pylorospasm.
The use of thick feedings here is very valuable, and, in pronounced cases,
very small feedings repeated often. X-ray treatments over mediastinum
will often cure condition of pylorospasm, Dr. Aldrich finds. The rationale
is not clear—possibly an enlarged thymus may be present, and the treat-
by which we must judge the case:
3. Otitis media.
When should we open an ear drum? What are the criteria? A bulging
ear drum is not necessarily an indication for paracentesis. Dr. Aldrich has
satisfied himself completely that conservative treatment of otitis media
offers very great advantages over routine incision. He offers five criteria
by which we must judge the case:
1. The disease which caused the otitis media—scarlet fever, septic sore
throat, flu, etc.; the toxicity and virulence of the infection.
2. What is the course of the fever? Is it steadily rising, or does it tend
to fall?
3. What about pain? Is it continuous? or increasing? or does it diminish
under expectant treatment.
4. Degree of tenderness on motion of ear, or on pressure over mastoid.
5. Appearance of ear drum. When we speak of a bulging drum, we
must not simply refer to the posterior and superior part round the handle
—this is just bogginess. The anterior and inferior part must be involved
as well.
Even with a real bulging drum, if symptoms are subsiding we may not
need to incise.
Mastoiditis. In some 570 cases of otitis media, treated conservatively,
only 26 developed mastoid symptoms.
What should be our rule about mastoids? Open them early? No, in
Dr. Aldrich's opinion.  He believes in waiting, unless there is any symptom
Page 219 of petrositis, of which more in a minute; or definite cerebral or sinus
symptoms.
Ordinarily, he advocates a wide paracentesis and heat over mastoid bone.
Unless there are signs of cerebral involvement or petrositis, both of which
are positive indications for immediate surgery, he waits at least three weeks.
Of the 26 referred to, only 6 had to be operated on, and all got better
except one, who had petrositis.
Petrositis. A rare but dangerous complication. One symptom which
warns us of it is a deep boring pain back of the eye on the affected side.
The petrous bone can be reached by a special approach, and must be dealt
with.
As regards the danger of meningitis, Dr. Aldrich has never seen this
develop by passage through the mastoid region.
4. Roseola infantum. A clinical entity not usually described. A baby 2
years old or under has a high fever (103°-105°). Complete examination of
the baby shews nothing—chest is clear; throat negative; urine negative.
On the fourth day there may be a drop by crisis to normal, following
which a rash comes out resembling measles, but not involving the face or
mucous membranes of the mouth; there is no coryza or cough. The temperature drops to normal before the rash develops. This is a pathognomonic
sign, since in measles there is always a fever when the rash comes. The rash
usually lasts about 36 hours.
Roseola is much commoner than mumps, and as common as chicken-pox,
but is seldom recognised for what it is.
5. Vomiting attacks. Babies who vomit for 1, 2 or 3 days with no apparent
cause. This often occurs in epidemics. All the members of a family, even
adults, may be attacked. The attack may or may not be accompanied by
clay-coloured stools.
It is most likely due to some form of hepatitis or cholangitis; and is
not an acidosis, though there is a ketosis.
There is no pain in the abdomen, except just before vomiting, and
vomiting relieves the pain. There is flushing of the face, not due to pyrexia,
and a dry hot skin. It may go on to mild delirium.
Physical examination shews little or nothing in abdomen.
Here, Dr. Aldrich says, we have a chance to be a little spectacular—and
work a fairly economical miracle. The condition is one of hypoglycaemia,
and easily cured, with the hearty co-operation of the child, by giving some
candy or a lump of sugar every hour or so. Water should be given sparingly,
not more than an ounce or so at a time. Gradually give orangeades, gruel,
broth, etc., but no milk and no fats.
The type with clay-coloured stools persists the longest, and very small
doses of calomel have a good effect here.
6. Allergic rhinitis. We must be on the lookout for this in "repeaters"—
children continually having colds, asthmatic attacks or allergic manifestations on the skin. Observe the appearance of the nasal mucous membrane.
Instead of being a bright red, we see a pearly grey, boggy mucous membrane.
This is very susceptible to secondary infection; primarily the condition is
Page 220 not of bacterial origin—but the signs of infection are due to invasion of a
more than usually susceptible area.
We must remove from the food and environment of these children what
is hurting them—and we can usually do this by a process of elimination. A
little ingenuity will help us greatly here.
What time of day do attacks come? Is the child well all day, only to
suffer throughout the night? We suspect feather pillows, or something in
the nocturnal environment. Or is it after certain meals, e.g., after eggs?
or in winter, when the child wears wool? and so on. Even cod-liver oil has
been a cause of these attacks, and we must think of this too—pets also,
e.g., cats and dogs may be the cause. If we cannot eliminate by simple
methods, skin testing may be necessary; and in eliminating foods, Dr.
Aldrich pleads for a liberal use of common-sense.
Calcium in large doses, with vitamin D, given for a month at a time,
3 or 4 times a year, is often of great value.
Occasionally, shrinkage of the mucous membrane does a little good.
7. The ammonia diaper in babies. This is found usually in the morning
after a long sleep; sometimes after a long day sleep it is found in the evening.
The cause is a micro-organism present on the skin, which ferments urea.
The treatment consists of impregnating the diaper with any mild antiseptic.
8. The tonsil and adenoid problem. When should tonsils be removed, and
when left alone? It is an important and not always easy question to answer.
Dr. Aldrich gives the following main indications for removal.
1. The infection element. If we are convinced that the tonsils are
definitely infected.  This is not necessarily a question of size.
2. Obstruction element. If we have definite obstruction of nose or
throat.
3. If generalized symptoms—e.g., rheumatism—are present.
4. Repeated attacks of otitis media. These are especially caused by
adenoids.
5. Persistent cervical adenitis.
Recurrent colds are not an indication for removal. This is useless as a
remedy.
Mere size, too, must be disregarded in the earlier years, since till the
age of five the tonsils often grow rapidly, receding after this.
9. Cardiac murmurs. These are very common in children, and as regards
their significance, Dr. Aldrich takes the attitude at the present time that he
"wouldn't believe any heart murmur under oath." One may hear all the
signs of stenosis where no actual lesion is present. These murmurs frequently disappear after a while.
It is a cardinal rule never to tell a mother that a child has a murmur till
you have watched it for some time—and never before he is a year old. It is
wiser to do it, since the parents may find it out otherwise, and feel alarmed,
or blame one for not having discovered it; but the unimportance of the
murmur should also be explained; most of them are functional.  Before we
Page 221 diagnose organic disease of the heart, we must have other signs, e.g., cyanosis,
dyspnoea or enlargement of the organ.
10. Enuresis. This most trying of childish ailments is largely, in Dr.
Aldrich's opinion, a psychological problem rather than a pathological one.
He quoted Ralph Hammond, a well-known psychiatrist, who states: "The
trouble is that the child hasn't learned to take responsibility for his own
condition." Children of this kind are frequently the victims of too solicitous a mother, who never allows her child to assume responsibility, to grow
up and be a man (or a woman). If she could go to the bathroom for him,
and perform nature's functions for him, she probably would.
In the treatment of enuresis, the child must gently but firmly be put
on his honour to assume the management of his own bodily affairs; must
learn to wake up himself; he must learn that this is apart from his mother,
and is his own personal business. She must be removed from the picture.
This may often best be done by the doctor having a friendly tete-a-tete
with the boy, and sharing with him a separate relationship on a man-to-man
basis. The child must not be cajoled or bribed or threatened—but its self-
respect must be assumed as a matter of course and an appeal made to its
ability to run its own life, carry on its own consultations with the doctor,
etc.—instead of living secondhand as so many of them do.
Distinctive ♦  ♦  ♦
PRINTING
CARDS - STATIONERY
that really are nicer—
and COST YOU NO MORE
ROYjWRIGLEy LIMITED
3 00 West Pender Street    Vancouver, B. C.
Page 222  Dislocations, Fractures
and Injuries to the Joints
MUCH can be done to avoid stiff joints in such
accidents by the use of hot applications of
Antiphlogistine.
The malnutrition and stagnation of waste products
in the surrounding structures, as well as the contraction of muscular fibres in the vicinity, will be
ameliorated as a result of the increased flow of
lymph and of arterial circulation induced by an
Antiphlogistine Dressing.
Used in conjunction with physio-therapy, Antiphlogistine, through its decongestive, bacteriostatic, thermogenic and analgesic actions, has a salutary and sustaining effect.
ANTIPHLOGISTINE
Made in Canada
Sample and literature on request.
The Denver Chemical Mfg. Co.
153 Lagauchetiere Street W.
MONTREAL Announcing ♦ I ♦
A CHANGE IN THE NAME OF CIBA'S SURFACE ANALGESIC
OINTMENT, FROM PERCAINAL TO
Nupercainal "Ciba"
Also Two Improvements in the Presentation of
NUPERCAINAL "CIBA"
(1) Nupercainal "CIBA" will no longer be issued in lithographed
containers; it will now be available in tubes with an easily-
detachable paper label.
(2) Each package of Nupercainal "CIBA" will now contain a rectal
applicator.
CIBA COMPANY LIMITED
MONTREAL
Messrs. Macdonald's Prescriptions Ltd.
and Georgia Pharmacy Ltd., of Vancouver, B. C.
and Messrs. McGill & Orme Ltd., Victoria, B. iglpy
keep a full range of "CIBA" specialties.
For the Failing Heart
B Theocalcin H
(theobromine-calcium salicylate)
Council Accepted
Give Theocalcin to increase the efficiency of the heart
action, diminish dyspnea and to reduce edema.
Dose: 1 to 3 tablets, three times a day, with or
after meals.
In 7l/z-grain Tablets and as a Powder.
Literature and samples upon request
MERCK & CO. LTD.
412 St. Sulpice St. Montreal
BILHUBER-KNOLL CORP., Mfrs., JERSEY CITY, N. J. Portable  X-Ray Work   Now  Possible
IN THE HOME
A Convenience to All Doctors.   Totally Efficient and Shock Proof
For full details, phone or write
W. C. ECCLES
X-Ray Department, St. Paul's Hospital, Vancouver, B. C.
SPENCER BELT
Designed to meet the special needs of
the individual. You can prescribe and
obtain exactly what the patient needs.
CORSETS and SURGICAL BELTS
Spencer Corsets (Canada) Limited
MARGARET LESLIE, Manager
445 Granville St. Sey. 7258 Vancouver, B. C.
Ntttttt Sc Stynmaott
2559 Cambie Street
V
ancouver
, B. C. Effective and Dependable  ^HHH|
■ General Stimulation  |
without
||Hm After-Depression
KOLA ASTIER ^^^H        IH|
GRANULATED •
^s,
/gs«^
SfsSr
@
If
Restrainer of Tissue Waste
Anti-Neurasthenic
Heart Regulator
Muscular System Stimulant
/
or
Cardiac Adynamia
Neurasthenia
Post Influenzal Asthenia '
Post-Operative Shock
Senile Involution
Mental and Physical Overstrain
Convalescence
A large percentage of the cases treated by the
general practitioner are of an asthenic type and
call for the use of some supportive and stimulant
treatment.
In all materia medica there is no drug that is
so admirably adapted to such a class of cases as
Kola—the seed, or nut, of the Sterculia AcunM-||
nata.
The stimulation of Kola is peculiar in that it is
tonic in effect and that, unlike that of ordinary
stimulants, it is never followed by after-depression. Its co-operating tonic action maintains its
beneficial stimulation.
In KOLA ASTIER GRANULATED, the physician has available to him in convenient form a
skilfully prepared standardized extract, con-
'taining all the active principles of the Kola Nut:
Caffeine, Theobromine, Kola-Red and Tannin.
Kola Astier is not habit forming.
Write for Sample and Literature
ROUGIER FRERES
DISTRIBUTORS FOR CANADA
350 Le Moyne Street
Montreal, Que. When an ARMY OFFICER
H Gives A COMMANDS
—he expects it to be followed exactly. When a Doctor
writes a prescription he also expects implicit obedience. The GEORGIA PHARMACY fills prescriptions exactly as the Doctor orders—with the purest,
freshest drugs—exact quantities—without substitution of the "next best thing" for the "very best."
SEYIOSO
on* »u
 MICHT
OPEN
ALL
NIGHT
GEORGIA PHARMACY
LIMITED
W. GEORGIA
STRE E T
SEYMOUR
1050
fl&ount [pleasant TUnbertafcing Co. %tb.
KINGSWAY at 11th AVE. Telephone Fairmont 58 VANCOUVER, B. C
R. F. HARRISON W. R. REYNOLDS B.C. FUNERAL CO.
HAYWARD'S LTD.
^Mr°
Phones: E. 3614 and G. 7679
734 BROUGHTON STREET VICTORIA, B. C.
STEVENS' SAFETY PACKAGE
{•'STERILE GAUZE
is a handy, convenient, clean commodity for the bag or the office.  Supplied
in one yard, five yards and twenty-five yard packages.
B. C. STEVENS CO.
Phone Seymour 698
73 0 Richards St., Vancouver, B. C. Why Starch of PABLUM Is More)
Quickly Digested than that of
j^^B Long-cooked Cereals K|y 1
BOTHERSOME and expensive long
cooking, which is often recommended
for infants' cereal, is proven unnecessary
with Pablum. For, being precooked at 10
pounds steam pressure and dried, it is so
well cooked that it can be served simply
by adding water or milk of any temperature. Photomicrographs show that this
method of cooking thoroughly ruptures
starch granules and converts Pablum ini»
porous flakes which are readily permeable
to the digestive fluids. This is supported
^^^^_ by studies in vitro showing
that the starch of Pablum
prepared with cold water
is more rapidly digested
than that of oatmeal, farina,
cornmeal, or whole wheat
cooked 4 hours**
• 40 X, STAINED
Large photomicrograph: Pablum mixed with cold water—portion of large flake.
Pablum flakes are honeycombed with, "pores" (note light areas) which allow
ready absorption of digestive fluids. Inset: Farina cooked V2 hour—clump of tissue
including starch granules. Note density of clump and lack of porosity. Many
starch granules, such as are present in raw cereal, remain unchanged in form.
FIFTEEN cereals (both cooked and uncooked) studied microscopically were
revealed as containing many starch granules, most of them massed into dense
clumps. Such unruptured clumps were
never observed in hundreds of examinations of Pablum. Each tiny flake is filled
with holes, and like a sponge it drinks up
liquids. Hence Pablum can be entirely
digestive  secretions,
cooked  and
saturated by the
Besides being thoroughly
readily digestible, Pablum supplies essential vitamins and minerals, especially
vitamins A, B, E, and G, and calcium,
phosphorus, iron and copper. It is a palatable cereal consisting or wheatmeal, oatmeal, cornmeal, wheat embryo, alfalfa
leaf, beef bone, brewers' yeast, and salt.
'Ross and Burrill, J. Pediat., May 1934. Reprint tent on request of physicians.
MEAD JOHNSON & CO, of Canada, Ltd,, Belleville, Ontario
profes;
! card when requesting samples of Mead Johnson products to cooperate in preventing their reaching unauthorized pernoM iiittii
&s88§&j>
^'jjftp*ftY^y^yrtooa£^i
;ffiyuWAW<WlM^^ .....".".' ."''!&!
536 13th Avenue West
Fairmont 80
Exclusive
Ambulance
FAIRMONT 80
Service
ALL ATTENDANTS QUALIFIED IN FIRST AID
"St.
John's Ambulance Association"
WE SPECIALIZE IN AMBULANCE SERVICE ONLY
R. J. Campbell
J. H. Crellin
W. L. Bertrand
(tote $c lawita 111.
Established 1893
VANCOUVER, B. C.
North Vancouver, B. C.    Powell River, B. C.
Published monthly at Vancouver, b. c by ROY wrigley LTD., SOO West Pender Street i^s^s^s^s^s^9&s&s&fss^!^9^
H
i   #*
Sanitarium
Limited
Tor the treatment of
Alcoholic, Nervous and Psychopathic Cases
Exclusively
Reference—B. C. Medical Association
For information apply to
Medical Superintendent, New Westminster, B. C.
or 515 Birks Building, Vancouver
Seymour 4183
Westminster 288
SSSSSSSSSSSSSSS^SSSSSSSSSS

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