History of Nursing in Pacific Canada

The Vancouver Medical Association Bulletin: December, 1950 Vancouver Medical Association 1950

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The Vancouver Medical Association
dr. j. h. MacDermot
Publisher and Advertising Manager
OFFICERS  1950-51
Dr. Henry Scott Dr. J. C. Grimson Dr. W. J. Dorrance
President Vice-President Past President
Dr. Gordon Burke Dr. E. C. McCoy
Hon. Treasurer Hon. Secretary
Additional Members of Executive:
Dr. J. H. Black; Dr. D. S. Munroe
Dr. G. H. Clement Dr. A. C. Frost Dr. Murray Blair
Auditors: Messrs. Plommer, Whiting & Co.
Eye, Ear, Nose and Throat
Dr. N. J. Blair Chairman Dr. B. W. Tanton Secretary
Dr. C. J. Trefry. Chairman Dr. Peter Spohn Secretary
Orthopaedic and Traumatic Surgery
Dr. D. E. Starr..: Chairman Dr. A. S. McConkey.,—Secretary
Neurology and Psychiatry
Dr. P. E. McNair Chairman Dr. R. Whitman Secretary
Dr. Andrew Turnbull Chairman Dr. W. L. Sloan Secretary
Dr. E. France Word, Chairman; Dr. A. F. Hardyment, Secretary;
Dr. F. S. Hobbs, Dr. J. L. Parnell, Dr. S. E. C. Turvey, Dr. J. E. Walker
Co-ordination of Medical Meetings Committee:
Dr. R. A. Stanley Chairman Dr. W. E. Austin .Secretary
Summer School:
Dr. E. A. Campbell, Chairman; Dr. Gordon C. Large, Secretary;
Dr. A. C. Gardner Frost; Dr. Peter Lehmann; Dr. J. H. Black;
Dr. B. T. H. Marteinsson.
Medical Economics:
Dr. F. L. Skinner, Chairman; Dr. E. C. McCoy, Dr. T. R. Sarjeant,
Dr. W. L. Sloan, Dr. J. A. Ganshorn, Dr. E. A. Jones, Dr. G. Clement.
Dr. G. A. Davidson, Dr. Gordon C. Johnston, Dr. W. J. Dorrance
Special Committee—Public Relations:
Dr. Gordon C. Johnston, Chairman: Dr. J. L. Parnell. Dr. F. L. Skinner
Representative to B. C. Medical Association: Dr. W. J. Dorrance
Representative to V.O.N. Advisory Board: Dr. Isabel Day
Representative to Greater Vancouver Health League: Dr. L. A. Patterson VANCOUVER MEDICAL ASSOCIATION
Founded 1898; Incorporated-1906.
(Spring Session)
JANUARY 2nd—GENERAL MEETING—Speaker:  Dr. R.  B.  Kerr, Professor and
Head of the Department of Medicine, University of British Columbia.
FEBRUARY 6th—GENERAL MEETING—Devoted to Medical Economics.
MARCH 6th—OSLER DINNER—Dr. H. A. DesBrisay, Osier Lecturer.
APRIL 3rd—GENERAL MEETING   (Speaker to be announced).
MAY 28th to JUNE 1st (inclusive)—ANNUAL SUMMER SCHOOL.
FIRST TUESDAY—GENERAL MEETING—Vancouver Medical Association—T. B.
Clinical Meetings, which members of the Vancouver Medical Association are invited
to attend, will be held each month as follows:
Notice and programmme of all meetings will be circularized by the Executive Office
of the Vancouver Medical Association.
Dates of Refresher Courses and weekly fixed meetings in the various hospitals.
Refresher Courses for the General Practitioner
NEUROLOGY, NEUROSURGERY and PSYCHIATRY—January 15th, 16th, 17th,
SURGERY—February 12th, 13 th, 14th, 1951.
EYE, EAR, NOSE and THROAT—March 5 th, 6th, 7th, 1951.
OBSTETRICS and GYNAECOLOGY—April 9th, 10th, 11th, 1951.
Regular Weekly Fixtures in the Lecture Hall    |$|t
Monday, 12:15 p.m.—Surgical Clinic. mm
Tuesday—9:00 a.m.—Obstetrics and Gynaecology Conference.
Wednesday, 9:00 a.m.—Clinicopathological Conference.
Thursday, 9:00 a.m.—Medical Clinic.
12:00 noon—Clinicopathological Conference on Newborns.
Friday, 9:00 a.m<—Paediatric Clinic.
Saturday, 9:00 a.m.—Neurosurgery Clinic,
edition, 1950.
Regular Weekly Fixtures
Tuesday, 9:15 a.m.—Paediatric Ward Rounds.
Wednesday, 9:00 a.m.—Medical Ward Round*.
Second and Fourth Wednesday's in month—Obstetrical Clinics.
Friday, 8:00 a.m.—Surgical Clinic  (and alternate weeks)   Clinical Pathological Conference.
Tuesday, 9:00 a.m. to 10:00 a.m. (weekly)—Clinical Meeting.
B. C. Surgical Society meeting dates:
Spring meeting—March 30th-31st—Vancouver Hotel (open to all members of the
Regular Weekly Fixtures
Tuesday, 8:30 a.m.—Dermatology.
Wednesday, 10:45 a.m.—General Medicine. Wm
Wednesday, 12:30 p.m.—Pathology.
Thursday, 10:30 a.m.—Psychiatry.
Friday, 8:30 a.m.—Chest Conference.
Friday, 1:15 p.m.—Surgery.
Publishing and Business Office — 17 - 675 Davie Street, Vancouver, B.C.
Editorial Office — 203 Medical-Dental Building, Vancouver, B.C.
The Bulletin of the Vancouver Medical Association is published on the first of
each month.
Closing Date for articles is the 10th of the month preceding date of issue.
Manuscripts must be typewritten, double spaced and the original copy.
Reprints must be ordered within 15 days after the appearance of the article in question, direct from the Publisher. Quotations on request.
Closing Date for advertisements is the  10th of the month preceding date of issue.
Advertising Rates on Request.
Page 54 The expectorants in
Scilexol E. B. S. increase the mobility
of respiratory tract
fluids, aiding in their
E. B. S.
£««A fUiJ aimer Tcfrne»l"
£»»™»ium CWorld. -      »6 «'*
£* Hj-drocy.nic Dj| B p.      4 *■«'•
s»n»P Tolu . 120 ""■"
"W On. to |wo  t.«poo»f»t» >*
"•«•<» .v.ry (out hou„ until i.!*'*'
A» Efficient Expectorant-
Re»P«ratory Sed»tive
and Anodyne-
'-\ "•Ww*cn«iNc cmi mist* 'Is
Coughing spasms can be controlled by
giving Scilexol E.B.S. with the following sedatives.*
1 Codeine'   -    -    - • -    -    -     1  gr. per ounce
2 Methadon -----     10 mg.  per ounce
3 Tincture Opium Camphorated 80 min. per ounce    •
^Narcotics Order Required
Representatives: Mr. V. Garnham, 3228 West 34th Avenue, Vancouver, B.C.
Mr. F. R. Clayden, 3937 West 34th Avenue, Vancouver, B.C. VANCOUVER HEALTH DEPARTMENT
Total   Population—Estimated j 1 3 85,500
Chinese  Population—Estimated    ._       6,877
Hindu   Population—Estimated    : _  133
October, 1950
Total   deaths   (by   occurrence) — 355
Chinese  deaths        19
Deaths,   residents   only     321
Rate per
1000 Pop.
(Includes late registrations)
Male   ..
October, 1950
October, 1950
Deaths   under   1   year  of   age       22
Death rate per 1000 live birth       36.2
Stillbirths   (not included in above item) '.  8
Scarlet  Fever-
October, 1950
Cases       Deaths
       23 —
Diphtheria Carriers	
Chicken Pox	
Mumps j	
Whooping Cough	
Typhoid Fever	
Typhoid Fever Carriers.
Undulant Fever	
Erysipelas j	
Infectious Jaundice	
Salmonellosis   Carriers-
Dysentery Carriers	
Cancer   (Reportable)   Resident-
October, 1949
Cases       Deaths
7 —
Page 55 -C CONNAUGHT >
Following an extended period of clinical trial there is now
generally available a modified Insulin preparation known as NPH
Insulin. The product is distributed as a buffered aqueous suspension
of  a  crystalline preparation  of  Insulin,  protamine,   and  zinc.   It  is
supplied in 10-cc. vials containing
either 40 or 80 units per cc.
Ifs   ■
NPH Insulin exerts a blood-
sugar-lowering effect extending for
slightly more than a 24-hour period.
In most instances this new preparation has been found to act more
quickly than Protamine Zinc Insulin
but for a shorter period. Probably
because of the fact that NPH
Insulin is a suspension of crystals,
its use has been found advantageous
in cases where it is desired to administer Insulin and a modified form of Insulin in a single injection without
appreciable alteration of the effect of either of the two preparations.
■ □
University of Toronto Toronto 4, Canada
Established in 1914 for Public Service through Medical Research and
the development of Products for Prevention or Treatment of Disease.
Crystals   formed   of   Insulin,   protamine   and   zinc
in  NPH  Insulin
MEDICAL-DENTAL BUILDING, VANCOUVER, B.C. The recent announcement by the Government of Alberta that it intends to take
over the licensing of those who desire to practise the professions—medicine, law, engineering and the like—cannot but cause in our minds considerable misgiving and distrust.
This is especially the case, when one considers the reasons that have been given, namely,
that the professional licensing bodies have abused their powers, and have witheld the
right to examination and license from candidates who should have been admitted.
The fallacy of these arguments is not hard to expose. In the first place, however,
we should like more information on the facts. The names, for instance, of those whom
the Medical Council of Alberta has rejected—their reasons and so on. A recent editorial
in the News-Herald referred to men of high attainments who had been rejected. Who
are these men? Or is this just a tour de force on the part of the writer? Also, there was
more than a hint that some men had been refused on account of their race or creed.
Such a suggestion is unworthy of more than the comment that it is entirely untrue.
The bodies appointed under the various professional acts are, in one sense, an arm
of the government of the province involved. Their duties are to administer the Act
under which they work, to institute standards of professional attainment, of professional
examinations, and through these to judge the qualifications of any candidate to be admitted to practice. Under the law, as it now stands, and has always stood, they have no
other powers. If they abuse their power, and deny these privileges without cause, the
right of appeal exists, and has before now been used.
Their standards by which they judge are the highest of the day—and on what
other basis could any government adjudge the fitness of any applicant? We are told
that any such applicant would have to satisfy requirements laid down by the University
of Alberta. In what way would these be any different or less stringent than those laid
down by the College of Physicians and Surgeons of Alberta, or the Bar of Alberta, or
the Engineering Professional Act's regulations? Then where would these hitherto
rejected applicants be any better off?
Nowhere, unless one admits a rather nasty application, namely, that political pull
or influence might have an effect. And such political influence would have other, and
evil, effects. The professions would be at the mercy of the political party in power—
and it is easy to imagine conditions under which this might constitute a very great
menace not only to the professions themselves, but to the public good.
While we can only speak, perhaps, for the medical profession, we believe that
anything we may say will apply equally to the other professions—law, engineering, etc.
What we wish to say is simply that these charges, if they have been made as reported,
are entirely baseless and untrue. The applications of medical men to enter Canada and
become practising physicians here are, and have always been, and always will be, judged
on absolutely the same standards* that apply to graduates from any Canadian university.
Previous education, medical training, the source of this, and ability to meet the requirements of the Dominion Medical Council, are the bases of qualification, and apply equally
to all. Till it has been shown that any unfair and unjust action has been directed against
a fully qualified man, whatever his nationality, race, colour or creed, we shall not accept
the charges made. And we believe that no such action has been so taken—in medicine
certainly, and we believe the other professions have been equally fair and just.
We hope with all our hearts that this decision will be reversed. We believe it to
be unfair, reactionary, and retrogressive—it will throw professional standards of practice
into a political melting pot—it will lower such standards—it is quite unnecessary, and
it will be harmful.
Page 56 All this, too, makes us more than certain the action of the profession some weeks
ago in altering the constitution of the B. C. Medical Association, and making it more
truly representative of all those in the profession, was a wise and fortunate step to have
taken. We cannot believe that the Government of British Columbia will follow the
lead which has been set by Alberta, but political action is unpredictable at any time—
and it is well for us to be thoroughly alert to the possibility. In this connection, wa
should seek to cooperate with the other professions—and with them, to plan concerted
and united action. But primarily, we must look to our own organization, and make it
strong and harmonious.
Dr. J. H. MacDermot,
Editor, "The Bulletin",
Vancouver Medical Association,
1701 West Broadway
Vancouver, B. C.
Dear Sir:
Will you please enter the following in the next issue of "The Bulletin"?
"In order to comply with the regulations in force at the new Out-Patients5
Department of St. Paul's Hospital, the Canadian Arthritis and Rheumatism Society
regrets that only those patients whose income is $75.00 a month or less plus $25.00
for each dependent can in future be accepted for diagnosis and treatment at the
Arthritis Clinic at that hospital. Appointments may be made by the family doctor
at the Canadian Arthritis and Rheumatism Society's office by phoning CEdar 5114.
For those whose income is higher than the specified amount, physiotherapy
treatments may be prescribed through privately practising members of the C.P.A."
Thanking you for your co-operation,
Yours sincerely,
Executive Secretary.
(or meals by arrangement)
Close to 41st and Granville
Phone KErr. 1820-R
Page 57 .'1'.
Library Hours
Monday, Wednesday and Friday Sgl 9:00 a.m.
Tuesday   and   Thursday 9:00 a.m.
Saturday  iS-SI : 9:00 a.m.
- 9:30 p.m.
- 5:00 p.m.
- 1:00 p.m.
Recent Accessions
American Medical Association, Transactions of  the Section on Ophthalmology,  98th
Annual Session, 1949.
Glasser, Otto (editor-in-chief)—Medical Physics, vol. 1, 1947, and vol. 2, 1950 (His-
,    torical and Ultra-Scientific Fund).
Hertzler, A. E.—The Peritoneum, 1919  (gift of Dr. W. D. Keith).
Hill, A. Bradford—Principles of Medical Statistics, 5 th edition, 1949.
Maingot, Rodney—Abdominal Operations, 2nd edition, 1948.
Medical Clinics of North America—Symposium on  (1)  Infectious Diseases, and  (2)
Current Concepts of Pathogenesis and Treatment, November, 1950.
Meigs, J. V., and Sturgis, S. H.—Progress in Gynecology, vol. 2, 1950.
Or,, Thomas G.—Operations of General Surgery, 2nd edition, 1949.
Piatt, Sir Harry—Modern Trends in Orthopaedics, 1950.
Rolnick, H. C.—The Practice of Urology, 2 vols., 1949.
To provide information on matters relating to Medicine, the British Council publishes the British Medical Bulletin, which first appeared in 1943 as an abstracting journal,
adding one or two short review articles in the second number. Since that date, the
publication has grown and today it reviews the important advances in British medicine.
It is published mainly for the specialist and medical research worker, but others will
find in the journal many interesting items. Recent numbers have dealt with New
Currents in Biochemistry; Lactation—Function and Product; Chemical Carcinogenesis;
Background to Chemotherapy; Congenital Factors in Disease; Mental Health and Mental
Health Services and Neurophysiology. The publication is in two parts, the second section
containing historical notes, annotations and news, reviews of medical books and films
and a guide to the contents of all important British medical periodicals. The library
of the Vancouver Medical Association receives the Bulletin regularly and it may be
obtained on request to the librarian by all members, including associates.
Attractive medical office in the beautiful new
17th and Marine Drive West Vancouver, B. C.
Agents: Turner, Meakin & Co., Ltd.    TAtlow 3345
Page 58 The following is a letter of thanks and appreciation sent to Dr. W. B. McKechnie
for his recent donation to the library. ^|
October 30th, 1950.
Dr. W. B. McKechnie,
Armstrong, B. C.
Dear Doctor McKechnie:
Once again, it is the privilege of the Library Committee to thank you most sincerely on behalf of the members of the Association for your most general gift of $100.00
to the library, which was handed to us recently by Dr. Keith.
The Committee agreed at a recent meeting that the money be assigned to the
Historical and Ultra Scientific Fund, as was your last gift. The books bought from this
fund form a special collection which is an important part of the library.
We cannot help feeling that your interest shown in the library is an inspiration
and we hope that others will follow your example, especially with the advent of the
Academy of Medicine building where the library is to occupy a prominent place.
Yours sincerely,
Secretary, Library Committee,
(sgd.) A. F. Hardyment, M.D.,
Vancouver, B. C, 1st December, 1950.
Dr. J. H. McDermot, Editor, The Bulletin,
Vancouver Medical Association,
203 Medical Dental Bldg., Vancouver, B.C.
Dear Doctor:
Subject:   Intravenous Therapy by Registered Nurses.
We have been advised by Miss Alice Wright, Executive Secretary of the Registered
Nurses' Association of British Columbia, that early in 1951 the School of Nursing of
St. Paul's Hospital will give a course on Intravenous Therapy to a small group of
registered nurses. You will recall that last year the College appointed a special committee
to meet with the Registered Nurses' Association and bring in recommendations with
regard to this subject.
Miss Wright has requested that the list of drugs to be administered by nurses and
approved by Council, be given publicity in the Bulletin in order that bot^i doctors and
nurses throughout the Province may be familiar with the recommendations of the
Council of the College of Physicians and Surgeons.
Following is the list of medications for intravenous therapy by nurses which was
compiled by this sub-committee:
A. Intravenous Feedings:
1. Blood and plasma.
2. Saline.
3. Glucose solutions, not above 20%.
4. Protein digest solutions (Amigen, Parenamine, etc.).
5. Vitamins suitably prepared for LV. Therapy—(Vitamin B. Complex, Vitamin
C, Vitamin K.)    (Not separate Nicotinic Acid.)
B. Stimulants:
1. Coramine.
2. Caffeine Sodium Benzoate.
3. Purified Digitalis Derivatives—(Digoxin, Digitoxin).
C. Other Drugs:
1. Insulin, only into an LV. flask.
2. Sulphonamides, only into an LV. Flask.
3. Heparin.
Yours very truly,
Lynn Gunn, M.D., Executive Secretary.
Treatment consists of:—
I.    Basic Programme.
II.    Pseudo-specific Therapy.
III.    Aids to Basic Programme.
Basic Programme.
(1) Appropriate Rest. Wage-earning ambulatory activity should be forsaken for combined rest and non-weight-bearing exercise, when
(a) Rheumatoid activity reaches such a degree that ordinary gainful- occupation
is not tolerated. Clinically, the best test for this is a rising sedimentation rate,
a falling haemoglobin, and marked pain on prodding the erector spinae muscles
with the thumbs.
(b) Systemic reaction to rheumatoid activity results in shrinking body height,
impending flexion deformity of back, hips or knees, or
(c) Occasionally, swelling and deformity of peripheral joints such as feet or ankles
demand that weight-bearing be forsaken.
Arthritic Aphorisms. ||||
(1) Never put a spondylitic to bed without arranging for exercises to preserve maximal
range of movement of spine and any involved peripheral joints—done at least once daily.
(2) A spondylitic, like any rheumatoid patient, must not be allowed to go to bed to
vegetate, but to work hard on exercises designed to maintain and improve power of
back and peripheral musculature—done hourly throughout the day.
(3) At any stage, the muscle-building exercises demanded of the patient should just
fail to be sufficiently energetic to aggravate significantly his pain and disability.
(4) Any measure that is worthwhile to curb the pain is good because it will then permit
"range of movement" and "muscle-building" exercises that otherwise would be impossible. Phenobarbital gr. %-J4 Q.I.D. serves to increase cerebral pain threshold and
peripheral nerve threshold to pain is increased by routine use of aspirin compound (e.g.
2 x Frosst 217 with each meal and with milk at bedtime—or enteric-coated sodium
salicylate gr. x with each meal and 10-20 gr. at bedtime). Diminution of pain means
less muscle spasm and more preservation of movement for more hours more days a week
and therefore less restriction of movement as a result of the inflammatory process in any
given period of time.
Deep X-ray Therapy. Clinically, there does not appear to be any curative action in
deep X-ray therapy. There is little demonstrable effect on the primary inflammatory
process—but rather, deep X-ray therapy acts as a prolonged anodyne—thus minimizing
painful muscle spasm with its secondary restriction of movement. Spondylitis is subject
to sudden and often severe exacerbations of painful restriction of movement—of ten these
last but a few hours or days and X-ray therapy in such instances is not worth wile (Phenobarbital plus 217's suffice). When exacerbations persist longer than two weeks, particularly if there is acute restriction of important movement (e.g. of cervical spine), that
does not respond to rest and the above symptomatic therapy, deep X-ray treatment is
well warranted to eliminate unnecessary, permanent, spinal fixation. In the cervical
region, sometimes diathermy followed by vertical (transitory 10-25 lbs. traction for
10-30 mins.) traction, with rotation exercises while in traction, will preserve function
during the flareup—but if temporomandibular arthritis has occured in the past, much
caution should be exercised with the traction.
When inflammatory muscle spasm does not resolve rapidly with complete rest in
bed (more severe cases should not be allowed up even in wheelchair to bathroom or
spasm recurs), it may be necessary to use Intocostrine—best preparation, if obtainable, is
Introcostrine in oil. However, it has not been necessary in the past two years at Shaughnessy
Hospital to use this to obtain the best results. Hydrotherapy (Hubbard tank), lowgrade
fever therapy (in diathermy box or steam bath) may be substituted, all on the principle
Page 60 that persistent heat relaxes spasm and permits the movement which is the objective of
all treatment. Since significant contraction of fibrous tissue cells does not take place in
less than 24 hours, range of movement may be maintained if maximal range is ensured
by one or other of the above means once daily. Great care and supervision are necessary
but, if provided, will assure that in only the most serious cases will the use of the term
"ankylosing" spondylitis be appropriate.
Breathing Exercises. Respiration is affected not only by the intercostal fibrous tissue
inflammation but by the rib-fixing inflammation around the costovertebral joints. Hourly
deep-breathing exercises may be supplemented where necessary by passive exercises in
the newer "plastic-lung respirators". In the acute stages chest expansion may become
restricted to Yz"—but if deep-breathing exercises are practised hourly, almost normal
chest expansion may be regained in convalescence.
In convalescence, the patient is pushed to develop even better than average anterior
and posterior spinal muscle power—thereby assuring that, to protect his affected interspinal joints from everyday strains on resumption of ordinary activity, more than
average muscle power will be available.
It is an exceedingly important principle that if a spondylitic is protected until
clinical rheumatoid activity is negligible, recurrence will be deferred for months, years
or forever. If protection is continued only to semi-quiescence, reawakening to activity
is infinitely easier as a result of minor physical or emotional strain. The sedimentation
rate is not nearly as important in such an assessment in a long-standing case as is the
clinical estimate and the obvious development of muscle-power. Anaemia is, however,
a poor prognostic sign. It is typically normocytic, normochromic, does not respond to
iron or liver. Much benefit in acute or severe cases may accrue from transfusions, if
Therapeutic "tricks" in M.S. Spondylitis consist of (a) X-ray therapy to persistently
painful ischial bursae, or other bursae about the hip—in these the results are among the
best offered by radiotherapy, (b) Occasionally, injection with novocaine (or long-acting
Quinocaine) of the 12th costovertebral joint region will terminate persistent nagging
or sudden excruciating "loin pain", (c) Deep X-ray therapy of those joints uncommonly
involved in other rheumatic disorders—i.e., temporomandibular, sternoclavicular, manu-
briosternal, costrovertebral or costochondral may give excellent results—novocaine injection may likewise give good results so prolonged as to seem incompatible with the pharmacologic action of the injected anaesthetic.
It must be remembered that women cannot have their ovaries satisfactorily protected
during X-ray therapy of the sacroiliac joints—ischial bursae and hip joints, however, are
not such a problem. Any radiologist to whom one would send a second male patient
for therapy will have protected the scrotum of the first with a lead shield. Radiologists
overlooking such aspects in therapy of patients in the reproducing period should not
be given a second chance. In the course of X-ray therapy, the most common complication
is nausea—treatments may be so spaced as to reduce this to a minimum or Dramamine
may be used prophylactically. Leukopenia from X-ray therapy is usually generalized,
affecting equally the granulocytes and lymphocytes—the rebound is easy to normal count
if therapy is stopped—a W.B.C. should be done after every 2nd treatment of 100 r (or
more). Rarely should more than three courses (of 800 r) be undertaken to any one
region of the spine in less than 18 months—and if continuous therapy is undertaken
the results are usually disappointing.
In any discussion of pediatric advances the tendency is to discuss the more obvious
modern facts. The antibiotics, transfusions, anemias, etc., come in for their share of
To a large extent they are not advances in pediatrics. They are advances in medicine
and sciences as applied, to pediatrics. The modern trained pediatrician can treat the
sick child better than the physician who treats adults also, but in a sense this is really
not practice of pediatrics in itself. The practice of pediatrics should embrace a complete
understanding of the development of the infant from birth to adulthood. Actually the
pediatrician uses this knowledge in the understanding of the sick child. It is this understanding plus the modern therapeutic methods that make for the successful handling of
the sick child.
Let us go into lesser known paths of pediatrics.
1. For decades the child from the broken home and the child-without parents has
been put into an institution for care. They bear various names. The commonest one is
orphanage. In the past there have been many types, good and bad and in-between,
which served a purpose. No doubt they turned out many good citizens. They were
no substitute for home life. I think the more recent use of foster homes is a great
pediatric advance. It is a real step forward in salvaging children by the sheer application
of the understanding of the needs of the developing child. Among other factors the
developing child needs security and above all a feeling of being wanted for himself as
an individual. Institutional care of a normal child falls far short in this regard. They
usually fulfilled the acceptance of the child as part of a group but not as an individual
for himself. The lack of fulfilment of this important factor makes for an individual
who cannot as a rule develop fully, emotionally. This can produce a very crippling
emotional defect in the future.
2. Before the work of Gesell was begun there was no concerted effort to understand
the development of the child. Through the centuries parents, doctors and philosophers
had made certain statements with relation to children. Many of these were untrue,
some were based on superstition, or prejudice and ignorance. There were truths in some
of the beliefs, but they were isolated facts which did not make any organized pattern
such as had been given to us by Gesell and others who are studying children objectively.
This material by itself is of no value. Its application by people practicing pediatrics
is just as important. This is just getting underway. Gesell's material and methods are a
recent advance. Their application is not yet an advance. It has barely begun. One can
look into the future and see the change in the handling of children, when these already
known facts are used by doctors. Gesell has recently pointed out that in the development
of the normal child not only are there physical and mental changes but also emotional
ones. Unless one understands these to be normal there is a tendency to label them as
having a psychiatric taint. He points out that they are pediatric problems which should
be recognized by the pediatrician for what they are and thus kept in their proper place.
They are not psychiatric problems. He states that a proper understanding of the
development of the child in its various facets will eliminate the seeming need of more
psychiatric training of the pediatrician.  This is an advance in pediatrics.
There is a unique recent advance in the understanding of children. Gradually, as
doctors we are giving up the method of handling children as laid down by the behaviour-
istic school. Based on the mechanistic approach of the animal laboratory the behavi-
ouristic school of child psychology was evolved.  We, as doctors, have much to answer
Page 62 for in having allowed ourselves to accept and apply this method of study of child
development. Its weaknesses soon became evident and it has gradually lost favour. The
doctors who applied this method of child study and practice gradually realized that
children are not just bundles of reflex arcs. As this became apparent two positive
methods became more obvious. The first was the previously mentioned work of Gesell
which was gaining momentum. The second was the application of psychoanalytical
methods in the understanding of child behaviour. This is another great recent advance
in pediatrics. The most productive force has been in the field of play therapy. The
probing of the deep chaotic forces of a psychotic adult is done by certain well
established methods. It soon became apparent that in children they did not work. There
have evolved the various play techniques for the unleashing of the individual problem of
unhappy children. Similarly there is just coming to the fore the concept that some
children can work off their unhappy states in special homes such as the Ryther Institute.
In homes of this type understanding adults allow the children to work off the pent-up
emotional states over a period of time. Many Ryther institutes will be built when their
true value becomes apparent.
Even a cursory evaluation of the foregoing remarks will show that the emphasis
has been placed on an understanding of the development of the child, especially the
emotional facet. Some authorities feel that this is the* only really true pediatrics. It is
becoming more apparent that in the years to come the general practitioner will be in a
better position to take over the care of the sick child. In spite of this there will always
be the place for the pediatrician in the handling of the sick child because of his special
knowledge and training. However, the pediatrician in the future will have to know
more of the development of the child in order to hold his place.. There is a great deal
of work going on to provide this knowledge.
In this whole discussion the author has restricted himself to advances which affect
pediatrics primarily. It is obvious that the value of good social service work affects the
progress of the whole field of medicine and surgery. It effects the field of pediatrics
so forcefully that it must be considered a special advance in pediatrics.
The social worker's approach to the handling of children's problems is a real advance
in pediatrics. At present there are not enough of them. Based on past practices many
are still asked to do work which a well trained admitting officer should do. It is a waste
of good manpower to keep a social worker from the type of work which he or she has
been so well trained to do in pediatrics. Their growing place in the practice of pediatrics
is a large one. Its appreciation has only become apparent in the past few years. This
is an advance in pediatrics.
These few points emphasize the highlights of some advances in pediatrics which
are not commonly stressed. Actually they are single parts of a large allover pattern of
the study of children. They show a very healthy trend in pediatrics. As they each in
turn blossom and begin to produce fruit the crop will be very valuable. Each of the
above stressed factors represent a lifetime of study and, of course, cannot be enlarged
upon in a short paper like this.
By MEYER WIENER, M.D., Emeritus Professor Clincial Ophthalmology,
"Washington University Sch. of Med., St. Louis.
This is a subject so broad and inclusive that I shall attempt to cover only a few
things in detail, rather than treat the whole subject in a most superficial way.
Uppermost in my mind is something rarely stressed. I mean by that, what one
expects from the other when a case is referred for a report as to general findings. I do
not mean the exceptional case, but those falling in the ordinary category.
It has not been unusual for me to receive a report from the medical man, when
asked for a report for a workup on an eye case, that**his heart, lungs and urine are normal.
Nothing more. I must admit that such a report is just as often the fault of the
ophthalmologist in not telling the internist the details of his own findings and at least
suggesting just what type of information he would like to obtain.
It is the duty of the ophthalmologist to send him his findings with his suspicions
and suggestions of the various possibilities as to causes, so that when the internist begins
to examine the case, he may at least have a clue as to how he shall proceed and what
he is to look for. What is usually wanted is not only the prevailing report including
urinalysis, blood pressure, blood Wasserman, etc., but careful search for focal infection,
sensitivity to food or external irritation, or a test for tuberculosis, brucellosis, or whatever
the ophthalmologist may suspect.
When the suspected tuberculosis is intraocular, the internist must be warned of
the possibility of grave danger to the eye should the patient be unusually sensitive to
tuberculin, and cautioned that the initial dose must not be more than 1/10,000 of a
milligram. I have seen a terrific reaction from a smaller dose than this, seriously endangering the safety of the eye.
I am not giving my fellow oculists a clean bill by any means. Too often their
reports are sorely lacking in essential details. When, for example, a case is sent to us
for examination to help clear up a situation, the practitioner cannot and must not be
satisfied with a report that nothing abnormal was found. I have often seen such reports.
Again, I have seen reports that choked disc was present in each eye, measuring so many
diopters in one and so many in the other. Nothing more. The central vision, fields
of vision, both central and peripheral, should be included in every case suspected of
having increased intracranial pressure, even though they may seem to be perfectly
normal. A detailed description of the fundus of each eye, describing media; size, colour
and outline of the disc; systematic search for hemorrhage and exudates, their type, size,
depth and location and number. This is most important in view of subsequent examinations to follow, as it is impossible to recall these details from memory. Lastly the size,
colour and contour of the vessels. This is of double importance, since the follow-up may
not be made by the same examiner.
A report is not complete without comment, interpretation and recommendations.
I believe that all of these things can be brought about by a better understanding of what
one wants from the other and the determination of both parties not to be satisfied with,
nor to accept inadequate reports, one from the other.
There are times when it becomes necessary for the practitioner to have at least
a basic knowledge of diseases and abnormalities of the eye. However, unless he is
acquainted with what constitutes the normal it is not likely that he will be able to
recognize what is abnormal.
The pupil, for example, not only varies in size under different conditions of light,
but changes with the emotions and with accommodation, with age and with sleep. The
newborn infant's pupil is small and responds very little to light. In youth it is large,
and responds quickly and extensively to light and accommodation; whereas in old age
it reverts to type and becomes very small again.   This has a most important aspect
Page 64 which I shall mention shortly. Our professor of medicine used to tell us that if we
wished to note the reaction of stimulation of the sympathetic, to tickle one's girl under
the chin and watch her pupils dilate.
p£ During sleep the pupil is very small, just as in the first stage of anesthesia, the eyes
are rotated up and are divergent, and the conjunctival vessels are engorged (owing to
vaso-motor change); while during feigned sleep the pupils are large, the eyes parallel
and the conjunctival vessels normally bleached. These are just a few exampls of how
the tissues and organs may vary under different, non-pathologic conditions.
The iris varies in the amount of pigmentation in the various races and in blondes
and brunettes of the same race. It may change under certain pathological conditions,
but this can always be differentiated from the physiological change. All babies are born
with blue eyes, but the color may change within a few hours or days. The width of the
palpebral fissures and the shape of the inner canthus and slant of the fissure may vary
considerably in different races. What is normal for one race may not be for another.
However, the two sides must be approximately alike. I say approximately in a guarded
manner, for the two sides of a person's face are never exactly alike. The artist knows
this when he paints or photographs your likeness.
Even the size of the eye varies with individuals. The eye at birth measures about
17.5 mm. and is quite flat, or hyperopic. It rapidly elongates and assumes a more or
less spherical, shape. Sometimes it forgets to stop lengthening and we then have progressive myopia. It now seems to be generalLy admitted that the greatest factor in
progressive myopia is heredity.
Before taking up the subject of what the man in general practice is able to take
care of in ophthalmology, let us discuss the systematic, routine method of examination
to which he should subject that patient, before he decides that it is a case for him to
handle. You may easily realize that unless he is aware of the possible pitfalls into which
he may stumble, he will be unable to determine the type of case he may safely treat.
The first essential is a good light. The general appearance, gait, expression, color
of the skin: all may have a bearing on the eye condition. One first looks at the width
of the palpebral fissures, external muscular movements tested, the tear sac expressed (and
it is essential that it be expressed properly). Then comes the feeling of the intra-ocular
tension. If this were done as a routine, and I do not exclude ophthalmologists, the number
of cases of blindness from glaucoma would be reduced considerably.
Examination of the lids, character of the skin, lashes and conjunctival surface.
Those engaged in public health and school work must know how to expose the retrobulbar folds. Next comes the bulbar conjunctiva and lastly, the cornea. The conjunctiva can tell us a lot, the colour, extent, depth and location of the injection, and may
be a clue to foreign body or ulcer in the cornea, inflammation of the iris, foreign body
in the punctum. Subconjunctival hemorrhages have little significance except in children.
I need not tell you that the eye lesions of the acute exanthemata are among the
earliest to appear. I assume that you have been taught that patients afflicted with measles
should be shielded from the light; at least that was formerly an axiom. Many years
ago I discovered the opposite to be true, and now recommend that the room of a child
with measles be flooded with light. Light is a great healer and, while it may hurt the
eyes for a little while, it does not harm them. In addition, we use very thin, moist, cold
compresses over the closed lids and permit the children to read, look at picture books
and play games.
There is no good reason why you should not remove foreign bodies from under
the lids and even when imbedded in the cornea, under ordinary circumstances. Be sure
that everything is clean. When digging it out, don't try to transfix it, because, if it
is an iron scale or every, it is quite fragile and will break into minute pieces. Dig it
out from the side as though you were lifting out a stove lid, and be sure to remove
it all. When finished, dust in some Xeroform powder, which is an impalpable, non-
irritating antiseptic powder which clings to the surface. Besides, it is slightly anaesthetic.
Page 65 I do not advise a bandage or pad for several reasons.   Penicillin ointment helps prevent
When a patient presents himself immediately after a lime or lye burn, or acid
burn, first aid is to get rid of the irritating substance as quickly as possible. If it happens
to be a child, put your hand over his nose and mouth and hold his eyes under the bathtub
faucet, turned on full force. Similar modified treatment is applied to the adult. If the
burn is superficial, apply cold; if deep, apply heat.
' Acute conjunctivitis will generally respond to cold compresses and is usually self-
limited and gets well often quicker with no treatmeht. I am not in favor of a darkened
room for inflammatory eye conditions. This is usually considered heresy by most
ophthalmologists. Light is a great healer. The tears contain a natural enzyme which
is antibactericidal. If you dilute these with drops or with eye-cups too much, the
favorable effect is weakened. Besides, blinking both bathes and cleanses and stimulates
the lacrimal glands to further secretion. That is one reason that I do not like bandages
or dressings. §Mk
Most men, even oculists, prescribe yellow oxide of mercury ointment for marginal
blepharitis. It is really about the worst thing one could give, as it is insoluble in about
everything and is quite irritating. If one wishes to prescribe mercury, use 2% ammoni-
ated mercury ointment; or, if the lashes are infected with crab lice, use mercurial
ointment.  It is not always what one uses as much as how he uses it.
Blepharoconjunctivitis due to the Mbrax-Axenfeld bacillus is cured with zinc
ointment and zinc drops. It is recognized clinically by cracks in the skin at the outer
canthus. In using ointments, it is essential to soften the crusts on the lid margins first
before gently removing them and then applying the ointment. In ordinary marginal
blepharitis it is also necessary to get rid of dandruff of the scalp to effect a permanent
Hordeola, or styes, should be punctured with a quick stab of a very sharp knife
or needle, followed by use of hot compresses. If the styes are recurrent, they can usually
be brought under control by prescribing Dilute Sulphuric Acid, U.S.P. 30 drops in
half a glass of water taken with meals three times a day. It should be taken through
a straw or tube to protect the teeth.
Chalazion, or Meibomian cyst, should have a crucial incision on the conjunctival
side, followed by thorough curetting with a small, toothed curette. If one then trims
off the points of the triangles with a small cuticle scissors, the opening will drain and
heal without further treatment. This procedure can be accomplished without any pain
by instilling a drop of 2% pontocain and then injecting a few drops of 2% procain,
to which a drop or two of adrenaline has been added, into the retrotarsal fold.
Some of you who are doing public health or school work are smetimes called
upn to pass upon a case suspected of being trachoma. Naturally, when a trained ophthalmologist is available, he should pass final judgment. Briefly, one can differentiate
between follicular conjunctivitis and trachoma as follows. Both may be either acute
or chronic. In trachoma the follicles are more numerous in the upper than the lower
retrotarsal fold; in follicular conjunctivitis the reverse; in trachoma, always pannus, following conjunctivitis none: in trachoma the continuity of the blood vessels passing over
the follicles is broken; hot in follicular catarrh; in trachoma, nearly always a history of
trachoma in the family; none in follicular catarrh; besides, in the latter, adenoids will
usually be found. Naturally, the diagnosis is clinched by microscopic findings from
In this automobile age every physician comes across some cases of injury to the
eyes and eyelids. Unfortunately, eye cuts, especially across the cornea, are not always
easily recognized. A fresh cut, even across the entire cornea may evade recognition.
I would therefore urge every doctor who comes across an eye injury to instill a drop of
2% fluorescein in any case where windshield glass has been broken, even though the
patient does not complain of his eye at the time.
All of you know that with the shock accompanying injury, one feels little or no
Page 66 pain and one can often repair wounds immediately after an accident without anaesthesia
with the patient feeling no pain. If there be a cut or scratch on the cornea, the fluorescein
will stain it yellowish green so that it cannot be mistaken. Fluorescein is also very useful
to determine the depth and extent of an ulcer of the cornea. Sometimes, when the
patient lives at a distance where it is not practical to see the oculist as often as he should
be seen, the practitioner treats him between times and gauges the progress of the ulcer
through staining.
In this progressive age all doctors are taught the use of the ophthalmoscope as an
aid to diagnosis, as well as to prognosis. There should be a systematic routine method of
examination as well as that of the external examination of the eye, of which I have already
spoken. In order to secure a satisfactory view of the macular region, especially in those
past middle age, it is necessary to dilate the pupil with euphthalmine or some other
mydriatic. Having observed the state and reaction of the pupil before dilating, one
sits at a distance of about a foot, throws the light into the pupil and observes whether
the media are clear or not. If clear, a red reflex will be seen. Otherwise, one can
determine whether the opacity is in the cornea or lens by throwing the light in from
the side, holding the light close to the eye. Incidentally, this is a good way to look for
a foreign body in the cornea, or a small corneal lesion; or to detect a very fine nystagmus.
The next step is to throw the light in the patient's eye with the ophthalmoscope as
close as possible without touching it. With the patient looking straight ahead, the
observer directs the light a bit to the nasal side of the patient's eye, when he will observe
the optic disc. It would take more than the time at my disposal to describe all of the
variations of the normal disc. However if he acquaints himself with the usual run of
cases he will not stray far. The size, shape and color and outline should be observed and
recorded. Also, the surface makings, excavation and immediate surroundings. We now
begin a systematic search for hemorrhages and exudates. Since these are found where
one would naturally expect to find them—namely along the vessels, we begin at the
disc and trace each one of the four main vessels and their branches as far out as possible.
Last, we describe the size, colour and contour of the vessels and any unusual manifest
One of the first things we observe in arteriosclerosis is the change in calibre of
the retinal vessels. Following a small artery, we see it alternately become smaller and
larger in width. Small, flame-like hemorrhages appear. These are superficial. The tiny,
round, deep ones appear later. As the arteries become harder, the veins become compressed at the crossings. The vein will always cross at right angles to the artery and then
resume its regular course. The small hemorrhages are usually found in the region of the
disc. Later, they may be found anywhere. The central light streak in the arteries is
an early manifestation.
Medical men practicing in outlying districts, who, for obvious reasons, must take
care of some cases of iritis, often inquire how they can protect themselves from mistaking glaucoma. Sometimes it is very difficult. The case may start out as a simple case
of uveitis and then develop an increase in tension. Our answer then is for them always
to be on the lookout for glaucoma, even though the case starts out as a simple,
uncomplicated case of iritis. In iritis, the pupil must be kept dilated. Not that atropine
has any curative effect, but it puts the iris at rest and prevents adhesions of the pupil
to the lens.
In treating a case of iritis, the tension must always be watched. Always compare
the give, or feel of one eye to that of the other, just as you would compare the limbs
in treating an arm or leg. In iritis, the anterior chamber is generally of normal depth;
whereas in glaucoma the iris is pushed up toward the cornea, making the chamber
shallow. In iritis, the more severe inflammation, the more difficult it is to dilate
the pupil. In glaucoma, it dilates without the use of a mydriatic. The pain in glaucoma
is usually even more severe than in simple iritis and the vision will most likely be more
impaired. If at all in doubt, send the case to the oculist immediately, for these are cases
difficult even for the oculist to handle.
Page 67 We are often asked the question by students: What is the indication for the use
of atropine and when is it safe to stop using it? The indication for atropine is pericorneal
injection, which means iritic irritation or inflammation, provided the tension is normal.
For it always means inflammation of the cornea or iris, or both. When the pericorneal
redness has disappeared, there is no further use for atropine.
Occasionally, the patient consults his family physician, especially in the country,
and is told that he has cataract, that it is not ripe or ready for operation, as he still
can see to get around, and that he must wait until it is "covered", before it is ready
for operation. Often he is right. The patient has cataract and his advice is sound.
On the other hand, the patient may have glaucoma simplex, with or without cataract,
and waiting until the "cataract" gets "ripe", or until the patient can no longer see
may mean permanent blindness for him when it might have been avoided. Flis is the type
of case where the patient can be helped if the case is caught and treated early; whereas
waiting means eternal blindness.
In uncomplicated cataract in an old person, the pupil is small. In simple glaucoma
the pupil is large, regardless of age. This, to my mind, is the most important singly
factor in the early diagnosis of glaucoma in advanced years for the man in general practice; and such a case should always at least be under suspicion. In glaucoma the anterior
chamber is usually shallow. Not in cataract. In glaucoma the tension is hard compared
to the feel of your own eye. In cataract it will feel about the same. There will be field
defects in the glaucomatous eye and none in the cataract.
How do we know, in a case of mature cataract, whether it is operable? By taking
the fields. This is done by having the patient close his eyes and throwing the light into
the patient's eye from all angles to determine whether he can see the light from all
directions. The further away the light is held, the more delicate the test becomes. If
while throwing the light directly into the eye the patient sees a black spot in the centre,
it would indicate that he has a defect in his central retina.
In closing, let me stress the fact that the eye is only one of many parts of the
body and that it cannot be treated without considering the body as a whole. Just the
fact that a man has a plus Wasserman does not necessarily mean that his eye trouble is
due to syphilis; for a syphilitic may have any acute or chronic infectious disease, or
deficiency disease, as well.
I would not think of treating a case of interstitial keratitis due to syphilis with
anti-luetic treatment alone. If I did, I would probably soon lose my patient because
he would not get well; or, at least, not for ages. They must all be built up with tonics
and proper feeding. Cod liver oil, combined with the anti-syphilitic measures, cures
them. The same holds good for phlyctenular kerato-conjunctivis and other eye conditions. This is where we need the practitioner to help us. Their diet must be well regulated; they must be fed the proper food; and at regular intervals; and they must have
sunshine. We tell the parents to lock them out of doors. This type of patient always
wants to get into a dark corner and cover his eyes, which, in my experience, is the worst
possible thing to do.
We won't touch upon vitamines or deficiency diseases as that would get us too
involved; but we realize now that not only are some of the diseases which formerly
baffled us due to lack of vitamines, but even over-supply of vitamines. This is one of
the reasons why we have laid so much stress on treatment of the patient as well as
the disease.
Emeritus Professor Clinical Ophthalmology,
Washington University Sch. of Med., St. Louis.
Before discussing what the man in general practice shall do in the way of treating
eyes, we cannot lose sight of what he may do in the way of prevention. When one in
the family has an infected eye, not alone should he be cautioned to use a towel for his
exclusive use, but that he must wash his hands every time he touches his eyes so as
not to convey the infection to others in the house.
Children should not be given sharp instruments to play with. Scissors used to cut
out paper dolls, etc., must have blunt points. Guns, loaded or unloaded shall never be
pointed at another. In the light of our present day living, this is almost impossible to
carry out.
Those men doing industrial work, in the absence of an ophthalmologist on their
staff, should insist on a preliminary examination of the eyes and record the vision of
each and every employee, see that they wear protective glasses or goggles where indicated;
take measures to prevent electric ophthalmia and see that machines are properly guarded
against flying particles.   Training of personnel is also of utmost importance.
Chemical burns, either acid or alkali, should be given immediate treatment by
forcibly flushing out the eyes with water. The hand is held over the mouth and nose
while the eyes ate held open under a faucet or hose, flushing out all foreign material.
If this is done immediately, relatively little permanent damage will be done. Acid burns
are not nearly so serious as alkali, as the latter penetrates into the tissues and continue
to do damage. If the burn is superficial, use frequent cold applications over the closed
lids. If deep, use heat. Don't be deceived into thinking a burn not bad because there
may be no ciliary injection. The cornea may remain clear for several days and then
suddenly drop out. These are the bad ones and a bad prognosis must be given.
Flash burns are usually not serious and get well with rest and cold applications.
Powder burns are best left alone for a few days, as trying to remove all of the
particles sometimes leaves more scars than if they are left alone. I recommend waiting
to see which ones irritate and then remove only those. The same applies to other non-"
irritating substances.
In cases of auto injury where glass has been broken, do not be satised with a cursory
examination of the eyes but instill a drop of 3 % fluorescein into the eye and then wash
out with water or saline. If there be a cut or scratch it will be stained green. If you
suspect that glass may have penetrated, or any other foreign substance, and X-ray is
indicated, try to get some pieces of the glass so that they may be laid alongside of the
X-ray plate. Some glass containing more lead will show very easily on the plate. If
the sample doesn't show, then a negative finding on the plate means nothing.
We have seen children and adults with a load of bird shot in both eyes. We generally
have them X-rayed and attempt localization; but seldom attempt to remove them, as
we may do more damage than by leaving them alone. Intraocular foreign bodies, even
suspicion of them, must be sent immediately to the ophthalmologist, as early removal
is of vital importance.
I see no reason why the man in general practice, providing there is no qualified
ophthalmologist available, should not remove foreign bodies from the cornea. Use two
or three drops of 4% cocaine, or Yz% pontocain with one drop of 1/1000 adrenalin.
Then don't try to dig out a scale of iron rust or emery by transfixing it in tBe centre;
Page 69 for it will crumble and then you will have several piece instead of one to remove.
Push the spud on the edge of the foreign body, then under and try to lift it out as you
would a stove lid. Be sure to remove the ring of rust as well as the foreign body. Dust
in some bland antiseptic powder, such as xeroform. Or you may use one of the antibiotics to prevent infection.
When the face and skin around the eye is badly lacerated, unless you have all the
necessary facilities at your disposal and plenty of time, do not attempt to sew up the
wounds, but get the patient to a hospital where everything you need is available. Many
cases of plastic repair can be prevented by proper first aid.
If there be a penetrating wound from a sharp instrument such as knife or scissors
and the iris is prolapsed into the wound, after flushing out the conjunctival sac with
force, cut the iris close to the cornea. It is safer to excise it than to take chances of
infection by trying to replace it.
Marginal blepharitis may be safely treated by you. Two per cent ammoniated
mercury ointment will control most of these provided it is used properly. It is not so
much what is used as the way it is used. First, get rid of all the crusts by soaking
with warm water and then gently brushing them off. The salve will not soak or penetrate through the crusts to reach the inflamed part of the lid. Then have the patient
close the eye and tell him to take a very little on his finger, rub the thumb and finger
together until there is just enough to make the finger look wet, and rub into the margin
of the upper lid. Then have the patient look up, and do the same with the lower lid.
A little stimulates. Too much irritates. Also, be sure to treat the seborrhoea of the
Recurrent styes or hordeola can be controlled by giving the child 30 drops of
Dilute Sulphuric Acid, USP., in half a glass of water with meals. It is taken through
a straw or glass tube.
In order to remove a foreign body from the upper lid, where it usually lodges, it
is easier to relax the lid by telling the patient to close his eyes gently and then evert it,
than the usual way of telling him to look down. Try it.
In instilling a drop in the eye, it is much easier to have the patient look up and
then drop it on the eyeball. Capillary attraction takes it immediately all over the conjunctival sac. In treating an infected meibomian gland (chalazion) instil several drops
of pontocain, then, with a fine hypodermic needle, balloon out the retrotarsal fold just
beyond the infection and this will thoroughly anaesthetize the area so that it can be
opened and curetted without the patient feeling any pain whatsoever.
In new-born babies, secretion will sometimes be found in the tear sac. If this is
expressed properly and often and started early enough, most of these are cured in a short
while. If not they should be sent to the ophthalmologist. Dacryocystitis in the adult
lies in the sphere of EENT men.
Most cases of acute conjunctivitis are self-limited and will get well without treatment just as fast, or sometimes faster than with treatment. The patient can be made
more comfortable with frequent cold applications over the closed lids. I have already
spoken to you about this in the treatment of conjunctival irritation in the acute
exanthemata and also about flooding the room with light.
I have had men in general practice treat cases of corneal ulcer when they lived too
far away or could not afford to stay in the city. This, however, only under direction.
The same holds good for inflammation of the iris. How does the physician know whether
the case is one of inflammation of the conjunctiva or whether .the iris is involved? In
conjunctivitis the redness is greater in the periphery than immediately surrounding the
cornea. It is also a brighter red. The complaint is generally of irritation rather than
pain. The pupil is normal and reacts promptly to. light. The eye is not sore to the
touch. In iritis, the congestion is pericorneal, it is darker,, because of its greater depth,
there is pain in the eye and often headache, the pupil is small and does not react to light,
or faintly. If the case has gone on for a long time there will be adhesions of the iris to
the lens, making the outline of the dilated pupil irregular. 1§||
Page 70 I do not think that the practitioner should treat iritis unless an ophthalmologist is
not available. Then he should dilate the pupil with atropine, if it can be dilated, and
send him to the nearest eye doctor. Sometimes all of these signs of iritis are present
in acute congestive glaucoma, except that the pupil in this case is dilated and the pain
much more intense.   In this case, atropine can do irreparable damage.
Sometimes a patient comes to the practitioner with cataract and wants to know
whether it is ripe for operation. It may not be cataract; or it may possibly be cataract
complicated by chronic glaucoma. He can generally tell this, as in uncomplicated
cataract, which generally afflicts the aged, the pupils are small; whereas whenever one
sees an aged person with unusually large pupil, he must immediately suspect glaucoma
and send him to the ophthalmologist. This is not invariably so, for we do see people
with high blood pressure with large pupils also.
When you wish to examine the fundus of a patient, it is almost always necessary
to dilate the pupils so that we may easily get a good view of the entire fundus. This is
best done with either a couple of drops of 10% neosynephrine or 5% euphthalmine.
When the examination is complete, the pupil should always be contracted with pilocarpine, especially in adults.   Euphthalmine 5% is preferred by some as a mydriatic.
Emeritus Professor Clinical Ophthalmology,
Washington University School of Medicine, St. Louis, Mo.
Does it hurt the eyes to read by poor light? It may hurt them, but it doesn't harm
them. It is unquestionably a strain on the eyes to read in either a poor light or too
strong a glare; it may make the eyes red or feel irritable, but it cannot do them any
harm. Abraham Lincoln read by the light of the fireplace, and one has never heard of
him having had trouble with his eyes. The eyes may tire and may not have the same
efficiency and endurance with improper light. This has been proven in industry; it
has been found that there is a definite slow-up in sorting mail in the Post Office Department with insufficient light. Also that industry is slowed and there is an adverse reaction
on the nervous system in many workers who do not have the proper lighting. This
applies to glare as well as to insufficient light.
ARE EXERCISES GOOD FOR THE EYES? There is never a moment during the
waking period when the eyes are not moving; that is, when the eye muscles are not
being exercised. Even when we think that we are looking fixedly at a given point, the
sensitive, fast moving camera discloses that there is a constant, rhythmic movement of
the eyes not noticeable to the unaided eye. Hence, the so-called "rhythmic movements",
or "rhythmic exercises" advocated by the late Dr. Bates, known as the Bates System,
is a tricky fraud on the face of it, devised merely to extract the shekels from a guileless
public. Naturally, there are definite exercises we use to develop certain muscular
weaknesses, but these must be done with apparatus which will eliminate the opposing
muscles from equal action so as to change their relative strength. Of course, this is only
orte of the many schemes practised by Bates' followers, and it would not be so tragic if
this were all; but too often valuable time is lost in certain cases where prompt and
efficient treatment or operation might have prevented much pain and suffering; and in
some cases, blindness itself avoided.
DOES OVER USE OF THE EYES HARM? It does, in the opinion of many authorities: but I personally, have never been able to figure out how. The normal eye can be used
for close work all day and day after day and year after year without doing any damage
Page 71 to its function in any way. This is proved by the watchmakers of Switzerland, who
have eyes no different from other people's who do not use their eyes for close work at all.
Many ophthalmologists feel that over-use of the eyes for close work has a tendency to
produce near-sightedness, or myopia; or to increase the amount or degree of the myopia
already present; but I do not subscribe to this premise and have many reasons for discarding it. I do feel that indirectly, this may have an influence: Not by the use of the
eyes per se, but through the child reading overtime when he ought to be out of doors
exercising and improving his health. This, however, is an academic question that could
be discussed for hours.
)My eye doctor has prescribed glasses for me and insists that I wear them all the
time. I dorft like glasses and would like to wear them for reading only, or for picture
shows. Witt it injury my eyes to go without them? I do not think so. If a person is
farsighted or has astigmatism he may have headaches or his eyes may burn from not
wearing his glasses enough; or, he may have other reactions such as nervous ones; but
going without his glasses cannot do the eyes themselves any harm, aside from the discomfort he may experience and making them red or irritable. If he is in good physical condition, he can overcome a fairly high refractive error without experiencing any symptoms
Doctor! Do you think I am getting a cataract? The patient often asks this question
of his physician and expects him to answer it. Well! He cannot, but must tell his
patient to consult his oculist. However, there are some cases where the lens is obviously
dense from just a casual glance or examination. When a person has cataract, I believe
that he should be told. There are many ways of telling a patient the same thing and the
doctor must understand his patient in order to know just how to break the news. In
some cases where we know the patient to be nervous, we may tell him that he has a
cloudiness in his lens which is not of a serious nature and that, should it get worse,
it can easily be removed. We can always explain to someone in the family the exact
nature of the trouble. A very serious question sometimes arises as to whether the cataract
is uncomplicated. Even a competent oculist cannot always tell this off-hand; but
sometimes the general practitioner can be of immense help to the patient by observing
the condition of the pupils. We know that the size of the pupils varies with age. When
the baby is born the pupils are very tiny and react very little to light. In youth they are
very large, while in old age they revert back to type and again become very small. This
is of great importance, for if we see a man who has cataract and he has unusually large
pupils, we immediately suspect glaucoma, feel the tension and look for other suspicious
signs. Of course, he should be sent to the ophthalmologist immediately, even under mere
suspicion, for the time element in treating glaucoma.is of vital importance.
And while we are on the subject of pupils, aren't you sometimes asked by a patient:
Doctor! look at my pupils; how big they are. We know that the size of the pupils vary
with and under many normal conditions. We have just mentioned age. It varies with
the amount of light; also, whether the eyes are focussed for distance or close; and with
the emotions. My old teacher in medicine used to tell the class that if they wanted to
see the effect of stimulation of the sympathetic just to tickle their girl under the chin
and watch her pupils dilate. Don't forget, either, that the drug you are prescribing
may affect the size of the pupils. Here again, enlarged pupils, in a patient predisposed to
glaucoma, can bring on an acute attack. In a survey of the blind made in Pennsylvania,
it was found that more than 11% were blind from acute or chronic glaucoma. There
is hardly any excuse for anyone going blind from glaucoma if it is discovered in time.
One of the most frequent questions asked by a nervous patient when his eyes are
involved is: "Doctor! Am I going blind? Fortunately, the usual answer can be No,
because there are very few eye diseases which cannot be controlled if caught early. When
it happens to be a case of cataract, although the lens may become cloudier and gradually
result in blindness in that eye, we can reassure the patient that one eye almost always
develops faster than the other so that it can be taken care of before the second one
Page 72 becomes blind. Or, should they progress at about the same time or rate, that he does
not have to wait until he is blind to be operated upon. The answer to the question as
to when they will be ready for operation is this: Whenever the time arrives that the loss
of vision seriously interferes with the patient's daily routine of life, that is the time for
operation. We do not have to wait until the cataract is mature.
It is not unusual for the patient to walk into the office and say: Doctor! I have
granulated lids. On examination, a simple case of inflammation of the lid margins is
found with accumulated crusts. This is not serious, of course, and quickly responds to
treatment. True granulations, or trachoma, is entirely different and fortunately is being
eliminated in this country except for a few restricted areas and among certain Indian
tribes. Don't forget that this marginal blepharitis is usually associated with seborrhoea
of the scalp and will not get well, or stay well unless the scalp is treated (Resorcin in
Why is it necessary for me to have drops put in my eyes to dilate the pupils in
order to have my eyes tested for glasses? They will tell you that they know ever so
many people who have gone to doctors and been given glasses without having the pupils
dilated; and many more who have gone to their optician, who never use drops. It is
true that a very satisfactory examination can be obtained in most adults without the use
of a cycloplegic. There are, however, certain cases, even in patients past 40 years of age,
who are unable to relax their accommodation so that they can be refracted satisfactorily
and who will require a mydriatic. It is seldom that one can secure a good result in
children without dilating the pupils. People have been frightened, mostly by optometrists
who are not permitted by law to use drops, who tell of the danger of glaucoma and
other dire consequences from the use of drops. It is true that the intraocular tension
does rise sometimes from the us of mydriatics in persons who are predisposed to glaucoma.
This happens only in the rarest instances with a careful oculist, who always follows the
ue of any mydriatic in the adult with a few drops of pilocarpine, which controls the
tendency for the tension to rise.
Doctor! Can you give me some drops to strengthen my eyes? If the eyes are normal
they do not need strengthening; and if not, then they need a careful examination to see
what is the matter and correct the defect, if it is correctable. Also, a frequent request
is for drops to prevent infection during an epidemic of ''Pink Eye". There is no tonic
drop or drops which one can use as antiseptic for prevention which will not do more
harm than good. The tears contain a natural enzyme which is strongly antibactericidal.
In fact, much more so than any drops which we can prescribe. Anything that will lessen
or dilute this flow of tears lessens the resistance to the inroads of pathogenic organisms.
It is different when one already has an infection, for then the normal composition as well
as the volume of flow of normal tears is interfered with and we must use a substitute.
WUl eating carrots or taking vitamines make me see better in the dark? Or improve
my sight? Or cure colorblindness? Only in those cases where there has been a definite
deficiency in the diet of vitamines will there be any benefit; and these cases are quite
rare. Red green blindness is a congenital condition which cannot be helped by treatment
or diet, since it is due to a failure to develop some of the elements in the retina. There
are cases of temporary central colour blindness due to toxic substances, such as tobacco;
but that is anther matter.
Will my bad eyes be apt to be inherited by my children? This is another one that
we have to answer not infrequently. That all depends. Some eyes which are diseased,
say from syphilis, can be made safe before the baby about to come arrives, by proper,
pre-natal treatment. On the other hand, such things as Leber's disease, or inherited optic
nerve atrophy, cannot be prevented. Patients with hereditary cataract, hereditary glaucoma, extremely high degrees of nearsightedness should either have no children or be
advised against marriage.
I do not wish this to be interpreted so that a person who has had cataract or
glaucoma in his family should not marry: but I refer to the hereditary type. We do know
Page 73 that cataract and glaucoma patients' children inherit a predisposition to develop these
conditions; but that is something entirely different from the hereditary forms.
While on the subject of nearsightedness, may I say that if several of the family are
nearsighted, the strong probability is that some the children will inherit this tendency.
For, since tall parents are apt to beget tall children and the reverse, so an elongated
eye tendency is also likely to be inherited. You probably know that nearsightedenss
itself is not inherited, but the tendency to become that way is; for all normal babies
are born with flat eyes, or farsighted eyes, which lengthen as they develop. Sometimes
they forget to stop elongating and then we have a nearsighted eye.
I know that you are often asked when the parent should take the child to the eye
doctor for a check-up, or for first examination. I wish that more people would ask
this question, for then a lot of trouble would be saved for many people. Providing that
there has been nothing unusual noticed about the child's eyes, I would say at about the
age of three or four years. The mere fact that a child is hyperopic or astigmatic to a
slight degree does not necessarily mean that he must wear glasses. If he has no symptoms
of strain or headaches, let him alone, for some are able to overcome a relatively high
degree of error without doing any damage or causing any distress; whereas others ars
compelled to have the slightest error corrected in order to be relieved of symptoms.
This is sometimes due to a temporarily lowered resistance, but may often be psychic.
Or, occasionally, a child admires another who wears glasses and wishes to imitate him.
This may account for many of the cases "cured" by the Bates system, Christian Science
and other fads. Should there fcfe some hereditary eye trouble in the family, then the child
should be brought to the oculist at a much earlier age. Before entering school he should
be examined again; and then at regular intervals during the entire school age for further
check-up once or twice a year. The tendency for myopia to develop and increase is
greatest during the period of greatest growth; that is, between the ages of 6 and 18.
After that, the increase is generally negligible.
Most people resent the fact that they are compelled to wear glasses for close work
in the early forties, just as they resent approaching old age generally; but it is a foolish
and prevailing idea that because one starts to wear glasses for reading, the mere fact
that he started wearing them means that he will always have to wear them. Of course,
he will, but he would feel the increasing need for them regardless of the fact that he
*once started to wear them, for the eye ages just like the rest of the body does. That
question probably comes up oftener than any other one about the eyes. Doctor! If I
once start wearing glasses for reading does it mean that I never will get rid of them?
Of course, he will never get rid of them; but without them, on the other hand, he
would never be able to read fine print with comfort, if at all, providing he has had
normal eyes in the first place.
So when you see a patient stretch out his arm to see newsprint, or, perhaps do it
yourself, tell him that he may as well become resigned and get himself fitted with proper
glasses, for, willing or not, it means that he is getting older. On the other hand, when
one has already been compelled to wear glasses for close work and comes to you saying,
"My eyes are getting stronger, for I no longer need them for reading and see better
without them," it is not a good sign, but generally means that he has commencing
Doctor! What colour will my baby's eyes be? We know that all babies are born
with blue eyes, because the pigment in the stroma of the iris does not develop until
shortly after birth, whereas the pigment on the posterior surface of the iris is fully
developed when the child is born. Even most colored babies have blue eyes at birth, but
the pigment stroma develops rapidly in them; whereas in the white race it takes from
a few hours to several weeks before the colour of the eyes becomes permanent. Should
v there be no pigment at all in the iris, then we have an albinotic eye, which is pathological
and is usually associated with a high refractive error and nystagmus, resulting in poor
Page 74 vision.   Thus you see that a blue eye may sometimes turn brown; but, on the other
hand ,an eye never turns from any other color to blue. j^g
Do babies see when they are first born? And during the first few weeks of infancy?
They do see, but they do not observe and they do not focus the eyes together. For this
reason, an infant is often thought to be crosseyed for the reason that one eye will sometimes wander off. Unless this is continuous, it need have little significance. It is well
to keep these cases under observation until such a time when we can definitely determine
whether the case is a pathological one or not. We do, occasionally, have a sixth nerve
paralysis, due to injury, probably hemorrhage in the nucleus, or near it. These often
disappear after a few months, or even after a period of as long as a year or more. After
the child is two years old the power of the muscles can generally be measured and the
condition definitely determined.   Conjugate vertical movements are developed earlier.
Dr. George Athans, formerly of the Vancouver General Hospital, is now practising
in Kelowna, B. C. •
Dr. R. M. Lane, of Tranquille, is now doing post-graduate work at the Kingston
General Hospital.
Drs. Walcolm Allan and S. H. Fishout have taken time out in the East to further
their studies in tuberculosis control.
Dr. Bruce Bryson, of Essondale, spent three months recently in the Lengley Porter
Clinic in San Francisco on a government bursary in public medicine.
Dr. N. D. Knott is on a post-graduate course in the U.S.A. preparatory to enlisting,
with the Navy Airforce.
A new medical clinic building is now being erected in Nelson. Dr. N. E. Morrison
has been on an extended holiday in England with his family.
New doctors at the Williams Clinic in Trail are G. 7. Piercey, H. B. Dimock, J.
Stefanelli and his wife, the former Elaine MacLean. A new clinic building has recently
been opened. Drs. C. G. Morrison and W. J. Endicott are away on post-graduate courses
at present.
Dr. W. J. Mahahir is now on a special course on ACTH study at the Vancouver
General Hospital.
Dr. F. L. Wilson, of Trail, has been elected head of the West Kootenay Medical
Association. President for East Kootenay is Dr. T. J. Sullivan, of Cranbrook. At their
annual meeting a panel of four addressed the group. These were Dr. S. A. Wallace, of
Kamloops, and Drs. F. S. Hobbs, A. W. Bagnall and Lynn Gunn, of Vancouver.
Dr. T. H. Patterson, of Prince George, has been awarded a year's stu*dy in medicine
at the University of Michigan by the Dominion government.
Dr. R. B. Burroughs has left Vancouver to undergo post-graduate training in eye
in the East.   His practice has been taken over by Dr. Bruce Cotes.
Page 75 Dr. J. E. Edmison has been appointed to the Radiology Staff of the Veterans' Hospital in Victoria.
Dr. Fred Elliott, formerly of Port Renfrew, is how in practice in Victoria with
Dr. G. F. Homer.
Dr. T. F. Rose has established a practice in Victoria.
The Annual Dinner of the Victoria Medical Society in conjunction with the Bar
Association was held on December 8 th. Dr. Myron M. Weaver was the guest speaker. Dr.
Henry Scott, of Vancouver, was also present.
and Mrs. F. W. Hurlburt, of Vancouver, a son.
and Mrs. Grant Gould, of Vancouver, a son.
and Mrs.i H. Cantor, a son.
and Mrs. John dePew, of Campbell River, a son.
and Mrs. G. A. Nicholson, of Essondale, a daughter.
arid Mrs. C. E. Battle, of Vancouver, a son.
and Mrs. Sidney Kaplan, of Vancouver, a son.
and Mrs. George Walsh, of Vancouver, a son.
and Mrs. W. G. Evans, of Vancouver, a daughter.
and Mrs. W. H. White, of Vancouver, a daughter.
Dr. L. H. Crimp, of Victoria, to Margery Hatchell, Vancouver.
Dr. Ying Chou, of Vancouver, to Wynnie Wong, of Toronto.
Dr. James Frazee, of Vancouver, to Mary Nightingale, of Montreal.
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