History of Nursing in Pacific Canada

The Vancouver Medical Association Bulletin: November, 1930 Vancouver Medical Association Nov 30, 1930

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 The Bulleti
i'K::-H   0FTHE WfflBM :
Vancouver Medical Association
Health Insurance
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Pyloric Stenosis
JUNE 22—26, 1931
Vol. VII
Published Monthly By McBeath-Campbell Ltd., 326 West Pender St. under the Auspices
of the Vancouver Medical Association in the Interests of the Medical Profession.
203 Medical and Dental Building, Georgia Street, Vancouver, B. C.
Editorial Board:
Dr. J. M. Pearson
Dr. J. H. MacDermot Dr. D. E. H. Cleveland
All communications to be addressed to the Editor at the abovs address.
Vol. VII.
No. 2
OFFICERS 1929-30
Dr. G. F. Strong Dr. C. Wesley Prowd Dr. T. H. Lennie
President Vice-President Past President
Dr. E. M. Blair Dr. W. T. Lockhart
Hon. Secretary Hon. Treasurer
Additional Members of Executive:—Dr. A. C. Frost; Dr. W. L. Pedlow
Dr. W. B. Burnett Dr. W. F. Coy Dr. J. M. Pearson
Auditors:   Messrs. Shaw, Salter & Plommer
Clinical Section
Dr.  S.  Seevenpiper Chairman
Dr. J. E. Harrison Secretary
Eye, Ear, Nose and Throat
Dr.  F.  W.  Brydone-Jack Chairman
Dr.  N. E. McDougall ...Secretary
Pediatric Section
Dr. C.  F.  Covernton .Chairman
Dr.  G.  O.  Matthews I Secretary
Library Orchestra Summer School
S      ^   „   „ 1>>      T   D    T^ Dr.  W.  T. Ewing
5R- 5' F; ^STEED ?' Jt  » 5"?? Dr. R. P. Kinsman
SR- £  ~ ¥rEEKISON £R- l' S" MacDermot Dr. W. L. Graham
Dr- y-H- Hatfield Dr. F. N. Robertson Dr       ^^
Dr. C. H. Bastin Dr. J. A. Smith Dr   q £   Brqwn
Dr. C. H. Vrooman Dr. T< l. Buttars
Dr. C. E. Brown                                     Publications
Dr. J. M. Pearson Dr. J. W. Arbuckle
Dinner Dr. j. H. MacDermot Dr. j. a# Gillespie
Dr. L. H. Webster Dr- d- e- h- Cleveland Dr. W. C. Walsh
Dr. G. E. Harrison Dr. F. W. Lees
Dr. E. E. Day                                           Credentials V.O.N. Advisory Board
„   ^   i, j   a Dr. W. S. Turnbull Dr. Isabel Day
Rep. to B. C. Med. Assn.   Dr. A. j. MacLaChlan Dr. H. H. Caple
Dr. H H. Milburn Dr. P. W. Barker Dr. G. O. Matthews
Sickness and Benevolent Fund — The President — The Trustees  Taking unusual care in the preparation of
prescriptions is a habit we have formed
through years of experience as
prescription specialists.
efts  .
Granville atCeortCi^v.
All Night
in cystitis and pyelitis
Phenyl-azo-alpha-alpha-diamino-pyridine hydrochloride
(Manufactured by The Pyridium Corp.)
For oral administration in the specific treatment
of genitourinary and gynecological affections.
Sole distributors in Canada
MERCK & CO. Limited      Montreal
412 St. Sulpice St. EDITOR'S PAGE
"They that dig foundations deep
Fit for realms to rise upon
Little honour do they reap
Of their generation,
Any more than mountains gain
Stature till we reach the plain."
A few weeks ago our readers may have noticed in the daily press a
brief item to* the effect that Dr. F. T. Underhill, the Medical Health
Officer of Vancouver, will be superannuated at the end of this year, and
so will retire from a position which he has held for some thirty years.
During this time he has given himself, body and soul, to the service
of the city, and of the excellence and worth of his work, those of us
who know him can bear true witness.
"We feel that it is not enough that he should be allowed to go from
the post that he has so ably and conscientiously filled, without a word
of gratitude and regret. In this connection, we should like to acknowledge the editorial in the Vancouver Daily Province, which paid him
a well-deserved tribute, in a most gracious way. But apart from this,
very little notice seems to have been taken by anyone of the fact that
Vancouver is losing one of its ablest and most faithful servants—a man
who for thirty years has been the guardian of our public health
It was his duty, of course, and he was paid to do it—though the
less said about the latter, the better—for when one considers the miserable salary that was all this city could afford to pay to a man who for
thirty years has filled one of the most important offices in its service,
one feels rather ashamed. Still, he was paid a salary. Yet we feel that this
does not quite discharge the debt that Vancouver owes to Dr. UnderhilL
His was a particularly difficult and thankless task. Blame in plenty would
have been his share, if owing to carelessness or neglect on his part, any
great disaster had occurred—yet, when he did his duty, and, in spite of
themselves, protected the citizens against infectious disease, against epidemics, against impure milk and bad sanitary conditions, all too frequently
he was attacked and opposed bitterly—and all too seldom did he receive
the support and backing that should have been given him. But none
of this prevented him from doing his duty. Patiently, courageously, but
courteously withal, he did what he knew should be done, and insisted on
those in authority doing the right thing. No easy job for any man, but
he did it exceedingly well and Vancouver today, with its pure milk, and
its pure water, its well-kept food stores, and its comparative freedom
from slums and disease-traps, may thank Dr. Underhill for its blessings
along these lines. Handicapped by lack of funds, by lack of staff, and by
public apathy he never gave up the fight against dirt and disease, and
in his quiet unspectacular way, he achieved great victories.
Always courteous and gentle, he could yet be firm and insistent—
could even flame into righteous indignation. To all who knew him, it was
a pleasure and an inspiration to have dealings with him, and one never
failed to secure from him the fullest consideration, the most sincere and
honest response, for he never attempted to dodge an issue put squarely
to him. All too often he was unable to do what he would like, or wanted
Page   24 to do, but he gave his reasons frankly and candidly, and did the very
best he could.
So we are sorry, very sorry, to see him go, and we feel that we
should say so. We feel, too, that the medical profession of this city should
pay a tribute, a sincere and thankful tribute, to this man who has done so
much honour to his profession, and been loyal to its very best traditions.
It would be most fitting that we should make some formal acknowledgment to Dr. Underhill of the esteen in which we hold him, and of the
regret with which we see him leave the service of the city.
He has, we hope, many years of happy and peaceful life ahead of
him, and we find it in us to envy him the satisfaction and peace of mind
with which he can face these years. We wish him long life and every
happiness, and we say to him "Well Done!"
With the first number of the new volume, we are introducing some
changes which we hope our readers will find an improvement. Till now
the Bulletin has been very modest of mien, almost homely indeed in its
outward appearance. This was partly a natural modesty becoming to one
so young, but partly an "enforced habitation," for where outgoings so
closely balance incomings, no mere frippery of self-bedecking could be
afforded. But we have felt for some time that as "oft the apparel doth
proclaim the man," so the cover of a book may be wisely or foolishly
chosen, with respect to its contents—and while the most gaudy cover
is no index to what lies within, yet it is only seemly to express in our
outward garb, our pride and self-confidence, rather than wear for ever
sad-coloured rainment.
The new cover does credit, we think, to the designer, Dr. Murray
Meekison, and we should like here to express our thanks to him for his
interest and keenness in the matter of the Bulletin. He is a "find," as the
newest recruit to the Publications Committee.
Our readers will also notice a change in the paper of the magazine
and we hope that they will like our new departure.
Of which, too truly, there is no end. There is too much being
published along medical'lines. There is too much undigested, ill-considered
stuff, filling our journals, filling the sample cases of representatives of
publishers, calling for review and fattening the medical magazine, till it
has grown to twice and three times and four times its original size.
Enormous numbers* of abstracts, does anyone read them all, and are they
worth reading? Here is a duty of the Library, to direct our reading, and
to winnow all this heap of chaff, till the few grains of wheat be found.
Indexes, or the ridiculous sample copies (pp 18, 76, 239 in sequence, with
some especially seductive pictures) are of no value, or help. The books
should be passed on by a Library Committee, at leisure and dispassionately,
uninfluenced by salesman or laudatory reviews.
By doing this a Library could save the members of its medical association so much in time and money that no amount spent on the Library
could be regarded as a waste. Some way should be found of classifying
and rating the books that are offered us in such abundance, so that
only   those   which   have  more   than   a   passing   and   ephemeral   worth
Page 25 would be bought by the Library, or would be listed as desirable for the
medical man to own. The busy man in office hours cannot possibly
judge   of   the   real   value   of   the   books   offered   for   his   inspection.
Vancouver, B. C, June 22-26, 1931
In selecting Vancouver for its 1931 convention the Canadian Medical
Association wrought better than it knew. Combining the sea and the
mountains as it does in its setting Vancouver is the ideal spot for such a
meeting. The social amenities, out-door recreations and delights of the eye
which are now recognized as important factors contributing to the success
even of scientific gatherings, are all offered to visitors from other provinces
in great diversity.
One feature in particular, the freedom from excessive heat which
we- enjoy in Pacific Coast summers, will make a special appeal to those
who come from prairie and eastern provinces.
Every member of the profession in Vancouver can, and will be expected to do something to make the 1931 convention a conspicuous success. Commence by suggesting to your friends in the east that they cannot plan a finer vacation than one which will bring them through the
Rockies down to the sea to foregather with the other representative
physicians and surgeons in Canada for a week of instruction and entertainment. Jf. * *
The Dinner this year will be held at the New Commodore 870
Granville Street, on Wednesday, November 26th. The New Commodore
is excellently adopted for large functions and will prove a pleasant surprise to those who visit it for the first time. The whole top floor of the
new building will be given over to the Medical Association for the
evening. The Programme will be absolutely fresh—there will be no
left-overs from previous Dinners. Please remember the date Wednesday,
November 26th.
In accordance with By-Law No.  5  Section A of our Constitution
and By-laws drafts have been prepared and will be presented on November 3rd to all members whose dues for the year 1930-1931  are unpaid
on October 31st.
Oct. 4th, 1930.
The Editor: V. M. A. Bulletin, Vancouver, B. C.
Dear Sir:-
I have read page 2 of this month's issue, but I didn't stop there.
Your bulletin is splendid and for fear of having a copy lost in the mail,
I would like to remind you that my initials are E. L.—not A. L.
With best wishes.
E. L. McNiven.
A Special Meeting of the Association was held in the Medical Dental
Building Auditorium on Wednesday, October 1st, to hear addresses from
Dr. R. D. Rudolf and Dr. Frank Scott. These gentlemen had been touring
the Province under the Sun Life Assurance Company's grant for Postgraduate instruction. Dr. Rudolf discussed the question of "High and
Low Blood Pressures" and Dr. Scott spoke on "Intestinal Obstruction."
There was an attendance of over 100 and the thanks of the Association
are tendered to the Canadian Medical Association for sending these
speakers to Vancouver.
Jfr 9fr Jfr
A Special General Meeting was held in the Auditorium, Tenth and
Willow Streets on the evening of Monday, October 6th, for the purpose
of receiving the report of the Special Committee re the Vancouver
General Hospital Regulations and to hear an address from Dr. J. B.
Collip, who was passing through Vancouver on his way to San Francisco.
Dr. Gillespie, Chairman, read the report of his Committee which was very
full and complete. The report was adopted unanimously at a very representative meeting and resolutions were carried (1) That copies of the
report be sent to the Provincial Government,, the Board of Directors of
the Vancouver General Hospital, the City Council and to Dr. A. K.
Haywood, the new superintendent of the Vancouver General Hospital:
(2) That a Committee be appointed by the President and Dr. Gillespie
(of which Committee Dr. Gillespie should be Chairman) to meet Dr.
Haywood on his arrival in Vancouver and present the report. The report
is on file in the Library and can be seen by any member wishing to read it.
The first General meeting of the winter Session was held in the
Auditorium of the Medical Dental Building on Tuesday, October 7th.
Dr. Strong, President, was in the chair. Seventy members were present.
The Summer School reported a very successful session in June 1930
with a substantial credit balance. Drs. C. H. Vrooman and J. W.
Arbuckle were appointed to the Committee in place of Drs. Christie
and Ewing whose term had expired.
The Treasurer reported on the receipts and expenditures in connection
with the entertainment of the British Medical Association visitors in
September. A question arose as to the disposal of the balance of the funds
collected. After a considerable discussion a resolution carried that the
balance be held for the entertainment of distinguished visitors as occasion
Dr. Prowd reported on behalf of the Executive on the negotiations with
the B. C. Medical Association re amalgamation. After some discussion
a resolution was passed giving the President power to appoint a Committee
to meet the Executive of the B. C. Medical Association to arrange the
necessary changes in the bylaws and constitution.
The following were nominated for membership in the Association:
Drs. C. A. Eggert, E. Trapp, E. Sheffield, T. R. Whaley, J. W. Shier,
R. Miller-Tait, G. Kennedy, H. Dyer, A. T. Henry, S. G. Elliott and
H. R. L. Davis.
Page   27 The speaker of the evening was Dr. M. F. Dwyer, of Seattle, who gave
a very interesting talk on "The Interpretation of Gastric Symptoms."
This included a clinical and roentgenological study of some 3000 cases.
A good discussion followed and after a hearty vote of thanks to the
speaker, the meeting adjourned at 10:30.
Speaking at a dinner given by the McGill Graduates' Society of Vancouver to the Chancellor, Mr. E. W. Beatty, and his party, on Thursday
night, September 25 th, Dr. W. W. Chipman, Professor Emeritus of
Obstetrics, replied to the toast to the guests. Some of his remarks were of
particular medical interest, and not only to those in Vancouver who are
graduates of the McGill Medical School.
He referred to his predecessors, Dr. Girdwood, professor of Gynaecology, who retired in 1910, and to Dr. Cameron, professor of Obstetrics, who died in 1912, and eulogized the excellent traditions they
had established. Dr. Girdwood indeed was the founder of his subject
His own contribution he modestly described as having united the two
chairs, and retiring at a time which might have been considered too
early, but was better than being to late.
The Women's Department of the Royal Victoria Hospital, with its
220 beds, was described as an institution which*has no superior elsewhere,
and is under the capable direction of Dr. J. R. Fraser, whom many
Vancouver graduates recall.
In speaking of the work of the medical staff in other connections,
Dr. Chipman told in the most enthusiastic way of the great research
work in endocrinology being prosecuted by Dr. J. B. Collip. His placental
extract, called emmenine, with which he has been working in conjunction
with Dr. A. D. Campbell, who conducts the clinical side of the research,
promises to work a revolution in the treatment of delayed maturity,
with its accompanying dysmenorrhea and other distressing symptoms.
A joint paper on this subject was read before the recent meeting in
Winnipeg, which will shortly be published.
The following is inspired by a paragraph in the Vancouver Star
appearing under date of Sept. 24th, 1930.
Mr. Justice Gait, a member of the Manitoba Court of King's Bench,
argues that Privy Council appeals should be continued. His reason is,
quite frankly, that Canadian lawyers and judges cannot compare with
their colleagues in the British Isles. He compares that situation, as
quoted by a Canadian newspaper, with what he believes to be that
in the medical profession, namely, that a certain widely-known surgical
clinic in the United States has better facilities and greater knowledge of
human disorders than are to be found in Canada, and thereby suggests
that Canadians who are ill and can afford the expense should lose no
time in going across the line.
We do not presume to argue with his Honour over the possible
deficiencies of the Canadian Bar, but we refuse to admit the justice
of his comparison. With all respect to our eminent American colleagues,
we  do  not  recognize   that  mass  production  methods  in  treatment  of
Page 28 •disease invariably mean maximum efficiency, or that a "greater knowledge of human disorders" needs be sought beyond the confines of Canada.
Mr. Harold R. Dew, who fills the Chair of Surgery at the University
of Sydney, Australia, was entertained at Luncheon by the Association
at the Hotel Georgia on Tuesday, October 14th. Mr. Dew was passing
through the City on his way home after studying certain phases of
medical education in the States and Europe. Mr. Dew gave a short talk
on the hospital situation in Australia and discussed the changing economic
conditions in medicine thoughout the wold, in their relation to hospital
. and private practice and also in relation to State medicine. He spoke of the
different kinds of State medicine in various countries and their effect
on the general practitioner.
Drs. Dallas Perry, W. C. McKechnie, B. S. Elliott and C. W.
Prowd recently returned from a holiday spent mostly on the Finlay
and Parsnip Rivers and in the Peace River country. They are full of
amazement at the enormous area already under cultivation and the
wonderful opportunities of the district.
*'-'*.'. »(■
Rams Horn Trophy
Presented by Daniel McLellan
for the Aggregate Low Net Score of the season.
Page 29 This is a perpetual trophy to be played for yearly, and to be held
by the winner for one year, or until wrested from him by another player.
This includes the two practice tournaments in the Spring, and the Fall
tournament. Players from Greater Vancouver, North Vancouver, and
New Westminster are eligible. Rules to be those governing medal score.
Handicaps: For the purposes of this trophy, the handicap under
which a player plays in the first Spring tournament shall prevail
throughout the season.
In case of a tie, the winner shall be decided by a play-off of
eighteen holes or any lesser number agreeable to all concerned. The
course on which such play-off is played shall be a neutral course to
all concerned, unless this point is waived by any player.
All cases of dispute shall be decided by the Golf Committee, whose
decision shall be final.
Meeting with approval of the Library Committee, a shield or placque,
bearing the name of the winner for each year, will be placed in the
The final golf match of the year took place over the links of the
Jericho Golf and Country Club on Thursday afternoon October 9th.
Sixty three players took part in the match and the majority of these
remained to dinner.
During the course of the dinner the presentation of the prizes for
the days achievements was made by the Captain of the team. The following stars received the awards:
Worthington Cup
Medical & Dental Bldg.
B. C. Stevens
Canadian Surgical Supplies Dr. Geo. Clement
Victor X-Ray Corp. Dr. Geo. Wilson
B. C. Clean Towel Supply Dr. Wm. Ewing
Henry Birks & Sons Dr. D. M. Meekison
High Gross for Season   Ram's Horn Trophy Dr.  G.  C.  Draeseke
High Gross for Match Fisher & Burpee Dr. W. C. Walsh
Low   Gross   for   Season Dr. T. K. McAlpine
The election of officers for next year was i-hen held, with the following results:
Captain: Dr. E. E. Day
Vice-Captain. Dr. J. P. Bilodeau
Dr. McLellan desires to extend his sincerest thanks to all members
of the Club for their hearty co-operation during the year, most especially
to Dr. E. E. Day, the Vice-Captain, for his hard work and loyalty at all
Low Gross 1
Low Gross 2
Low Net 1
Low Net 2
Short Hole
Long Drive
Hidden Holes 1
Hidden Holes 2
Dr. J. E. Harrison
Dr. L. H. Webster
Dr. Colin Graham
Dr. Lee Smith
He also extends best wishes for-success to the incoming Executive.
Abstracts and Reviews
Conducted by the Osier Society
Cysts of The Long Bones of The Hand and Foot. Harry Piatt.
British Jour. Surg., XVIII., 20-27. July 1930.
Piatt presents a series of 20 cysts of the miniature long bones occurring
in 17 patients, in his usual careful and illuminating manner. The literature on this particular aspect of bone pathology is very scanty and this
article provides an opportunity for the surgeon to acquaint himself with
this little known condition. He states that the bones involved in order
of frequency are the phalanges (of the hands), metacarpals and more
rarely the metatarsals. The cysts originate in the growing ends (meta-
physis). The favourite digit is the little finger. The majority of cysts
remain latent for a time, and are discovered after the occurrence of a
local injury. Spontaneous fracture is a fairly common phenomenon.
In 13 cysts, in which a microscopic examination was made of material
removed at operation, two varieties of lesion were distinguished (a)
chondroma (myxochondroma) (b) osteitis fibrosa. For practical purposes these two lesions comprise the whole morbid pathology of the
miniature long bone cysts. Alternative lesions, such as giant cell tumour
(myeloid sarcoma) or malignant tumours are almost unknown. The
differential diagnosis between the two standard lesions is almost impossible on clinical and radiographic evidence alone. In both types of
cyst, spontaneous arrest or healing may occur, particularly in young
patients. For such cysts, no form of -operative treatment is required.
Cysts which are actively extending, or where the bone shell is perforated
by fracture, should be explored. The most effective method of eradicating
the lesion is to curette the contents and cauterize the interior of the cyst
with pure carbolic acid. This procedure is best combined with the insertion of one or more autogenous bone grafts which hasten the obliteration of the cystic area. A complete bibliography is appended.
D.   M.   Meekison.
Mediastinal Pleural Effusion. Sagel, Jacob, and Rigler, Leo G. The
American Jr. of Roentgenology and Kad. Ther. 1930, Vol. XXIV.,
The authors discuss in detail the aetiology, classification, diagnosis
and to some extent the treatment of this interesting and comparatively
uncommon   condition.   Aetiologically,   they   describe   two   chief   types:
1. the serous type, generally associated with pulmonary tuberculosis and
2. the purulent type, which is pneumococcic, or rarely, streptococcic in
origin. There are five points of invasion: the lung in the presence of
pneumonia or tuberculous foci; the tracheobronchial nodes especially in
children; the pericardium, when an inflammatory process is present, and
from the mediastinum and chest wall as a result of direct extension from
Page 31 inflammations and tumours, paravertebral abscess and miscellaneous other
rare conditions. Diagnosis is very difficult, if not impossible, by means of
physical examination and depends upon radiological investigation. The
specific points of importance in the latter form of examination are described in detail and the need of combined fluoroscopic and radiographic
examination emphasized. A review of the literature and a summary of
case reports concludes this interesting article.
H. A. Rawlings
October 15 th, 1930.
Inflammatory Diseases of The Large Intestine. J. Arnold Bargen,
M.D. International Clinics, Sept. 1930, 202-210.
The three most common chronic infections of the large intestine are
considered, namely, chronic ulcerative colitis, tuberculous colitis and
parasitic infection. The history is always suggestive, but the important
step to a diagnosis is the gross and microscopic analysis of the stools
or rectal discharges, proctoscopy and roentgenoscopy. The differential
diagnosis is discussed in some detail. The author feels that in chronic
ulcerative colitis that the diplostreptococcus is not the sole instigator of
the disease, but it probably one of primary importance. Recent work
has suggested the possible significance of mutation forms of this organism
or of a closely related group of streptococci. In the treatment of chronic
ulcerative colitis the less severe cases are given a vaccine prepared from
the diplostreptococcus, in the more severe cases an antibody solution is
administered. The removal of foci of infection and the importance of
the dietary regime are also stressed. At the present time he believes that
one should speak more of control of the disease rather than cure.
Surgical interference is reserved for the treatment of complications
or those few cases that resist medical treatment.
In intestinal tuberculosis treatment leaves much to be desired. In
the localized hyperplastic types surgery is the method of choice.
The most satisfactory of all chronic infections of the large bowel
to treat are those caused by amebiases. The simple regime of emetin
hydrochloride and stovarsol or treparsol is followed.
W. H. Hatfield.
Osteoperiosteal Bone Grafts.
XCII, 161—168, August, 1930.
G. M. Dorrance. Annals of Surgery.
Dorrance,'from the laboratory of research in surgery of the University of Pennsylvania, describes an extremely interesting method of bone
grafting, citing a case and describing experimental work. He uses an
osteoperiosteal graft obtained from the tibia. One end of the graft is
secured to the roughened bone or fragment above the region to be fixed
and the graft is passed through a tunnel in the subcutaneous tissues to the
roughened bone or fragment below. The graft is first wrapped in rubber
dam and this is removed when it is fixed in position. The wounds are
then closed. Startling success attends the operation. His conception of
the ideal conditions for this procedure are:-
Page 32 (1) The osteoperiosteal bone graft should contain a good supply
of bone with the periosteum. The periosteum that is stripped from the
bone will not develop bone.
(2) One must be just as careful to fasten the graft to the bone
as in full thickness graft.
(3) The same care must be used in preparing the bed for the
reception of the graft as in a full thickness graft.
(4) It requires a longer time for the graft to become solid.
(5) In all bone graft surgery one should secure as complete immobilization as possible during the first two months.
(6) The thickness and strength of the graft depend on the amount
of weight-bearing that is required.
The possibilities of this manoeuvre are enormous and the article will
well repay reading.
D. M. Meekison.
Prophylaxis of Asthma in Children.       M. Murray Peshkin, M.D.
International Clinics. September, 1930. Page 262-266.
The author points out that whereas the diagnosis and treatment
of asthma has been placed on a rational basis, the subject of prophylaxis
in allergic conditions has scarcely been mentioned in the literature. The
onset of asthma may be acute or insidious, 61 % being in the latter group.
One should endeavour to recognize the pre-attack stage and institute
preventive measures. The family history will in most cases indicate
any predisposition to the disease. In 21% of cases intercurrent infection
has initiated the onset of asthma. Recurrent rhinitis and bronchitis, when
unaccompanied by fever are often manifestations of allergy and the
forerunner of asthma. This has preceded the onset of asthma in 33% of
cases; 14% of cases the onset occured following pneumonia. The impression that enlarged tonsils and hypertrophied adenoids plays a part in
the causation of asthma is discredited.
In a series of children with asthma it was found that 22% had
eczema—7% urticaria and 2% angioneurotic oedema. Children with
eczema frequently showed positive protein skin tests for foods. All sensitizing substances should be tried and positive ones avoided as a preventive of asthma.
The injection of therapeutic sera and nonspecific antigens was
responsible for some cases of asthma. Skin tests with horse serum should
be preformed before administration of therapeutic serum. Various nonspecific factors may be responsible for hastening the onset of asthma in
allergic individuals, e.g. physical over-exertion and indiscretion in diet.
As stated by the author, prophylaxis in asthma has scarcely been mentioned in the literature. Preventive medicine is more and more coming
to the fore and in this most debilitating condition it has a very obvious
place which cannot be stressed too greatly.
W. H. Hatfield.
* * *
The July issue of the British Journal of Surgery is particularly
informative.  It contains articles on "Endothelioma of the Cauda Equina,"
Page 33 "Gas Gangrene in Civil Surgery," "The Approach to the Hip Joint,"
"Splinting in Tuberculosis of the Hip," "Carcinoma of the Duodenum,"
"Volvulus of the Stomach," "Hypertrophic Charcot's Joints," "Tumours
and Inflammations of the Gasserian Ganglion" and "Obstruction after
The Results of an Investigation and the Treatment of Streptococcal Puerperal Sepsis at the Toronto General Hospital.
W. A. Dafor, MB. American Journal of Obstetrics and Gynaecology
August 1930.
Since a survey of the literature reveals puerperal sepsis to be the
cause of 30% of the deaths following childbirth and that the organisms
found in the blood stream in from 70 to 90 per cent of the fatal cases
is the Streptococcus Haemolyticus, this investigation was carried out, in
the hope that information might be obtained which would be of practical
value in either decreasing the incidence, or in treating cases already affected
In classifying the Streptococcus Haemolyticus, Shottmuller's suggest-
tion was adopted.
1. Streptococcus Haemolyticus.
2. Streptococcus Ahaemolyticus.
3. Streptococcus Viridans.
During the years 1927-28 cultures were taken from 1378 patients.
1. The latter weeks of pregnancy—yielding    7 positive cases
2. During labour —yielding 14 positive cases
3. The puerperium in normal and     /
all morbid cases )   —yielding 52 positive cases
2. Out of these 14—Streptococcus Haemolyticus disappearing during
the puerperium in 7 cases but produced definite evidence of infection
in the other 7.
3. Thirty-two were cases of puerperal sepsis—20 showed no evidence
of puerperal infection.
1. Complete physical.
2. Blood—R.B.C.—W.B.C.—haemoglobin and blood cultures.
3. Cervical smears and cultures.
Treatment: included.
1. General Measures.
2. Non-specific measures
(1) Transfusions.
(2) Intrauterine injections of carbolic & glycerine (1-16)
3. Intravenous and intramuscular (buttocks) of scarlet fever antitoxin—30 to 40 c. c. in 36 hours.
Of these cases, 17 were considered to be seriously ill, 4 had positive
blood cultures  (Streptococcus Haemolyticus)   There was one death
the only one in the public obstetric wards, caused by Streptococcus
Haemolyticus, from spring of 1926 up to the present date.
Page   34 Conclusions:
1. Thirty-two per cent of the morbidity in the cases reported was
due to puerperal sepsis and in over 50%, the Streptococcus
Haemolyticus was the causative organism.
3. Seasonal in appearance—winter and early spring.
3. Occasionally present in genital tract during pregnancy, more often
during labour, and most often in the pueperium.
4. Streptococcus Haemolyticus, when found in the cervical canal
during the puerperium is always a source of danger.
5. Early investigation and immediate treatment of puerperal sepsis
cases is essential.
6. Scarlet Fever antitoxin has a special value in the treatment of
puerperal and postabortal cases of sepsis due to the Streptococcus
7. The possible value of antenatal immunization for all patients
would seem to offer a fruitful research problem.
W. L. Boulter.
"Read, Mark, Learn and Inwardly Digest"
* * *
Brief presented to the Royal Commission on behalf of the
B. C. Medical Association.
The following are the views in summarized form of the medical
profession of British Columbia, as represented by the British Columbia
Medical Association. Local branch societies, in Vancouver, Victoria, New
Westminster, Nanaimo, the Okanagan, the Kootenays, and Northern
British Columbia, have all authorized the provincial association to represent them and express these views, which have been arrived at after
several years' study of the situation—reviewing Health Insurance measures as now in force in other countries, taking into account conditions in
Canada, and notably in British Columbia, and having regard to the interests, not only of the medical profession, but also and chiefly of the
community at large, and especially that section whom Health Insurance
is designed to benefit.
The medical profession has no scheme or plan or Health Insurance
to submit. It feels, however, that there are defects in our present system
of treatment of the sick, chiefly caused by the difficulty in meeting
the cost, in the case of people of small and moderate incomes; that this
leads to inadequate treatment of the sick, delay which is often harmful,
and notably to a lack of properly carried out preventive measures. It
would support a measure of Health Insurance, if the latter were carried
out in accord with certain principles which it is proposed to define, these
principles being, as we see it, essential to efficiency, harmony, and the
public good. While it is manifestly necessary to enquire into the Health
Insurance Acts in force in other countries, we believe that especial regard
should be had to conditions of life in Canada, and notably in British
Columbia an dthat the system of medical practice that has obtained in this
country should be adhered to as closely as is possible.
Diphtheria Antitoxin
Diphtheria Toxin for Schick Test
Diphtheria Toxoid (Anato^-ine-Ramon)
Scarlet Fever Antitoxin
Scarlet Fever Toxin for Dick Test
Scarlet Fever Toxin
Tetanus Antitoxin
Anti-Meningitis Serum
Anti-Pneumococcic Serum (Type 1)
Anti-Anthrax Serum
Normal Horse, Serum
Smallpox Vaccine
Typhoid Vaccine
Typhoid-Paratyphoid Vaccine
Pertussis Vaccine
Rabies Vaccine (Sempk Method)
Price List   Upon Request
University of Toronto
Depot fir British Columbia
Medical-Dental Building Vancouver In this connection we would draw especial attention to the report
of the General Council of the British Medical Association for 1929-3 0, in
Appendix IV of this report, which brings forward "Proposals for a General Medical Service for the Nation." While it is true that this report is
prepared by a medical body, careful reading of it will show clearly that
it is actuated by a sincere desire for the public good equally with that of
the profession—stress is everywhere laid on the patient, and his best interests consistently sought for. The report is a very full one, is based on
eighteen years of experience of Health Insurance, and is the fruit of long
We would refer also to the Supplement to the British Medical Journal of November 3rd, 1928—hereto appended, especially with regard to
its remarks on maternity, antenatal work, and the relation of health
work to the general practitioner.
Lastly, the Brief for Health Insurance prepared by the American
Association for Labour Legislation in 1916, is worthy of consideration,
thought, of course, much of it is slightly out of date.
Scope of Act
We believe that as regards scope, the following are essential conditions.
1. The Act should cover all those persons in the community whose
incomes are below a certain limit. The fixing of this limit is a matter of
dispute, but we believe that at first, $1500 yearly for married men, and
$1200 for single men, might be taken as a fair figure. Later, as the Act
proves itself a success, these figures might be raised, but people with these
incomes are the ones that need relief most.
Another suggestion made has been to take all the workers in a given
industry, even if some have incomes above this figure, and include them
in the industry.
This is as regards the compulsory feature of the Act. Optional clauses
might be inserted to admit others who come in higher wage-levels.
Special arrangements for casual workers, floating labour, and the
indigent, will no doubt be necessary. As regards the latter, adequate Health
Insurance and preventive medicine will doubtless greatly reduce indigence by eliminating that part of it due to sickness and invalidity. (See also
Brief for Health Insurance 242, Section 4.)
2. It should provide for all illnesses.
Possibly at first, some limitation will be necessary, in the case of
chronic illness preceding the entrance of legislation.
Tuberculosis, mental disease, and other institutional diseases might
perhaps best be still treated institutionally. It is probable that here again,
thorough care of the early cases, and preventive medicine, will do much to
lessen later incidence.
Accidents. These would, we presume, be treated under the separate
Workmen's Compensation Act, as in Great Britain and elsewhere.
3. It should include the wives and families, of those who come under its
This is done under the French Act, and we believe is essential if
preventive measures, pre-natal work, maternity care  and child welfare
Page  36 work are to be efficient. It may be noted that in Great Britain the British
Medical Association is urging this inclusion.
(British Medical Journal Supplement April 26th,  1930.)
Those who have dependents would probably pay a higher rate proportionately as industry cannot be held responsible for sickness in the
3. The Act should provide a complete service, including consultations,
specialists where necessary, hospital and nursing service, also dental service.
As regards nursing, we believe that much could be done in the way
of pre-natal* and post-natal care and education, as well as infant welfare,
by visiting nurses. But the nurse should in all cases be answerable to the
practitioner in charge of the case, and should not undertake diagnosis or
treatment in any form.
This necessity for a complete service is recognised both by labour
and the medical profession. In Great Britain, the latter have again and
again urged its importance, and in their latest reports (British Medical
Journal Supplement) are still urging that this be given.
Operation of The Act.
We believe that the following main principles are essential:
1. The act should be compulsory for all those who come within its
scoe. We do not believe that any voluntary scheme can ever be efficient
and we find that the consensus of opinion everywhere is in favour of
2. Every one who comes within its scope should be on the same
basis. By this we mean that we do not believe it would be wise to allow
any organization, industrial or commercial, to administer its own sickness
insurance as is now done in certain cases, by voluntary grouping of employees. We feel that the Act can be administered more efficiently and
economically with one administration, that preventive medicine will be
better carried on and that much better control can be exercised. In certain
areas, namely lumber and mining camps and certain agricultural districts,
it is probable that special local arrangements will have to be made to
suit local conditions. If the plan of local committees in areas of the
Province is adopted, they will be able to work out plans for their own
locality to co-ordinate with the general scheme.
3. The Act should be administered by an extra-political Board, as is
the Workmen's Compensation Act. On the whole, we believe it best that
this Commission should be the final Court of Appeal, as in the Workmen's
Compensation Board. Appeal Boards otherwise, do not, we feel, offer any
advantage and increase the cost greatly. We believe that the medical
profession should be represented on this Board.
We feel, however, that there may have to be some degree of devolution from this Board, which would be supreme. The local conditions
vary so much in different parts of the Province, that it might be wise
to set up local Committees.
This would have several advantages. It would make for more widespread interest in the Act, and a wider knowledge of its workings, and
would undoubtedly lead to saving of time and effort, especially in cases of
dispute.  These local Committees  should have representation  from  the
Page 37 Medical Profession (see later under Discipline) and should be autonomous to as great a degree as possible while being, in the final analysis, subordinate to the main Board (see pp. 259, 260, Brief for Health Insurance).
This is done in Great Britain and France, as well as elsewhere.
Questions of methods of payment of doctors, of hospitalization etc.,
could be dealt with by these local Committes to suit local conditions.
4. As regards medical aid. The system of practice should be, we feel,
as nearly as possible the one following at present by those who are sick,
and who expect to pay for their doctor's services etc., themselves. This
is applicable, in our opinion, to the indigent as well as those who pay.
We would refer especially here to Section II (b), on pages 164-170 of the
report of the British Medical Council for April 26, 1930. We strongly
endorse the views expessed in this and subsequent paragraphs dealing with
the medical treatment of disease.
The aim should be to provide every family or individual with a
family doctor. This has many undoubted advantages of which the following are a few.
It is in accord with the present system to a great extent, and will
mean less machinery and rearrangement.
It is in accord with the ordinary instructive desire of people to
have their own medical attendant, whom they feel they can trust and
like and who gets to know them better than anyone else can. He is
interested in them personally, feels responsible for them and to them,
and must satisfy them in order to build up his practice, and make a
successful career. Every qualified registered medical man should be eligible to practice under the Act, provided he shows himself competent and
does his work properly.
The question of discipline is an important one.
We believe that as far as possible, the responsibility for discipline
should be placed on the organized medical profesion. This is done in Great
Britain through local Insurance Committees of medical men. Dr. Cox of
the British Medical Association assures us that this has worked so satisfactorily that the Government is placing more and more responsibility on the
organized medical profesion, for the control of medical men. Here again
we feel that the paragraphs from 25 to 30 of the same report on pages
170-171 are worth careful consideration.
There should be free choice of doctors allowed to every insured
person as is enjoyed by those who pay their own bills. This we believe to
be the best method by far and it has proved successful with the Workmen's Compensation Act. It makes for competition among doctors, and
this leads to efficiency and keenness and is, we believe, the most satisfactory
method from the patient's point of view.
The working of the British National Health Insurance Act shows the
recognition of this in Great Britain. Here at first, the panel patient had
to choose his doctor and stay with him six months. The period has been
shortened till now there is practically complete freedom of choice. Dr.
Cox, of the British Medical Association assures us that this has led to very
little changing, but a more satisfied feeling.
Page 3 8 B. Ample provision should be made for the employment of specialists and conssultants where necessary. The term "specialist" and "consultant" will need definition—but encouragement and incentive should be
provided for men to become specialists, as they become expert in some
particular line. This will ensure adequate and high-class medical care for
every kind of work.
Payment of Doctors
C. We believe that the best method, in the long run, is payment for
services rendered, according to a schedule of fees, based on the scale at
present in use by the medical profession of British Columbia. This is done
under the Workmen's Compensation Act and, we believe, is quite satisfactory.
The capitation fee, as paid under the British Act, has, to our mind,
several disadvantages, though it may seem at first to be simple and to
avoid offering temptation to unnecessary work.
It is not as flexible as the fee list. If a patient changes doctors under
the latter arrangement no bookkeeping changes are necessary.
It introduces the element of speculation as between the employer
viz. the Board and the doctors employed. Payment for actual work done is
the more businesslike method.
It is an arbitrary change in the system of practice to which our
people in this country have become accustomed and has apparently been
adapted from the "lodge practise" or club practise method, to which the
poorer people in the older countries had long been accustomed.
Exceptions to the method of payment we suggested, would be in
the following cases.
Officers of health, and medical men in the health service.
In localities where population is small, and, as is done at present,
subsidies are necessary.
In logging and mining camps under certain conditions
These local variations could be dealt with under the system of Local
Who should be allowed to practise under the Act?
We believe, that in this matter it is the duty of the legislature to
protect the public against uneducated or ill-educated practitioners
of any kind. The principle we would urge is that no one should be
allowed to treat the sick by any method of treatment whatever, who has
not shown before responsible bodies that he has received a sound, basic
education both general and scientific according to accepted modern scientific views and who does not give proof of adequate knowledge of the
construction and functions of the body both in health and disease, modern methods of diagnosis, full knowledge of health and sanitary laws.
Page 39 They should also show proof of adequate scientific training in the system
that they employ.
Prevention of Disease
This we believe, should be an essential and primary part of any
scheme of Health Insurance. The following principles should, however, we
feel, be observed.
1. The preventive department should, as far as possible, be divorced
from the therapeutic department, and health offcials and nurses should
not undertake treatment beyond what cannot possibly be avoided. This
will ensure the goodwill and co-operation of the medical practitioner, and
will be more equitable, besides being, we believe, the more efficient
2. The general practitioner, or family doctor, should be used wherever possible, as an adjunct to the health service. His sympathy and
support will add greatly to the value of this work at no extra cost, and
his knowledge of family conditions should be very valuable. We note that
this recommendation is also made by the British Medical Association
Insurance Committee.
In this connection, it has been urged that periodical health examinations should be included in a health insurance scheme. We do not
know if this is feasible, but checking of individuals while well should be
the means of detecting early trouble, and avoiding serious illness later
on. We believe that this question deserves the consideration of the Commission.
Cost of the Act
We believe that the Act should be and can be self-supporting. The
contributions being made by three parties concerned, namely beneficiary,
the employer and the State and based on a due appraisal of their responsibility for disease.
The Fund
This, we believe, should be contributed to by
1. The Beneficiary
We note that in the French Act this is done by a levy of 5% of
wages and upward. The exact percentage is a matter for actuarial investigation, but the percentage method would seem fairer than the flat rate,
as the low wage earner would not then be unduly taxed, and the higher
would pay more, which is fair.
As to the proportion of the whole to be assessed against the beneficiary, we have no opinion.
2. The Industry
The proportion to be paid by industry, the employer, is, again, a
matter for the Commission to decide. We feel, however, that industrial
Page 40 conditions have a large bearing on sickness, and that it would be more
equitable, as is suggested in the Commission's Interim Report, if all
employees were assessed fairly and equally.
3. The State
Here, again, we cannot suggest a ratio but feel that ultimately the
taxpayer would probably pay less, if beneficiary and employer paid their
fair share.
Hospital service, where necessary, should be part of the service provided by the Act.
The doctor treating the case should be in all cases, able to treat
his patient in the Hospital. This we hold to be essential, for several reasons.
1. He knows his patient better than anyone else can, his family
conditions etc., and is personally interested in the patient's welfare.
2. The immense educative value to the doctor, of hospital practise,
is beyond all doubt or question. He is able to be in touch with the latest
developments of modern medicine, to use the best methods of treatment
under the best conditions, and this adds immensely to his keenness and
efficiency, a matter of the greatest importance to the community he serves.
This should apply to .the indigent, if any there be.
As regards hospitalization.
Ultimately, we believe, this should be completely free, and included
as part of the provisions of the Act.
At first, some limitation may be necessary on account of questions
of expediency. This will no doubt be considered by the Commission but
we believe should be temporary. In this connection, the Bush Hospital
Scheme of Queensland in Australia is worth consideration, as outlined
by Sir James Barrett recently. This is based on regular contributions
to the fund and does not give absolutely free hospital service, but gives it
at greatly reduced rates. This tends to reduce days' stay in the hospital,
and removes possible danger of free hospitalization. Alberta, we notice,
charges a daily fee to those who come under the operation of the Act
dealing with municipal hospitals.
Maternity Benefits
We believe that in the matter of maternity benefits, cash grants
should not be given, but provision should be made for adequate pre-natal
and post-natal care, for care during confinement and for nursing service.
Here we would refer to paragraph 5, page 177-8 of the Supplement of
the British Medical Journal, April 26, 1930, where further reference is
made to a full scheme suggested in the British Medical Journal of June 29,
1929, page 258.
Page 41 Sick Benefits
It would seem obvious that in a complete scheme of Health Insurance
provision should be made for the wage earner to receive a proportion of his
wages while sick, as this greatly relieves the problems caused by sickness;
invalidity insurance should also be included. Both these measures are
adopted under the Workmen's Compensation Act and are an important
part of any scheme.
Other Considerations
1.    The Indigent.
By this we mean, those from whom no payment can be collected,
as they are either unable to work, or at least to earn a minimum wage.
We include in this group widows, or orphans, where there is no
We believe that indigents will be few, and fewer under a Health
Insurance system. If the health of the community is improved, there will
be less invalidity and crippling, which now constantly recruit these ranks.
But those that do exist, should be treated as patients, not as charity
cases. They should have the same privilege as others, of choice of doctor
etc., and they should be paid for, as regards medical expenses.
We quote from British Medical Journal Supp. April 26, 1930-VII
(4) Paragraph 3 3, pages 171-2 and would point to Denmark, where all
hospital "free work" as we would call it, is paid for. There are no charity
cases in Denmark.
Insurance Companies
We do not believe that these should have anything to do with the
operation of the Act, as it involves private profit in the first case, and in
the second, the Act could be much more economically administered by a
Board. This has been shown in the case of the Workmen's Compensation
Benevolent Societies, Fraternal Orders, etc.
We understand that in Great Britain these are debarred from any
connection with medical benefits. We do not think they should have
anything to do with the Act at all. In the first case, there is nothing
to be gained that we can see by using them as carriers, even for sick
benefits. Every penny that is collected from the beneficiary should go
back to him, and no percentage should be taken from it for the upkeep
of any organization.
In the second place, these organizations tend to.act as a brake on
improvements, this at least is the experience in Great Britain, according
to views frequently expressed. They are largely kept in being now on
account of the cheap and poor medical service that they can offer their
Page 42 members, and if they could not survive without that, they would be
hardly worth keeping alive. It is our belief, however, that they fulfil useful purposes in the community, and could still function inother ways
than as insurers against sickness, by the exercise of their social and
benevolent functions.
In this connection, the remarks on page 262 of the Brief for Health
Insurance are worthy of note.
By Dr. G. O. Matthews
The first description of pyloric obstruction in an infant was given
by Armstrong in England in 1777. Beardsley, of Connecticut, published
an account of a case in 1787. Modern interest in obstruction of the
infantile pylorus, however, did not begin until Hirschsprung published
a full account of two cases. That was in 1888 and since then our literature has had an ever increasing number of cases recorded until at the present time it is common to see the records of series of literally hundreds
of cases by dozens of different men.
Before delving any further into this subject of hypertrophic pyloric
stenosis, it is necessary to consider a condition that, clinically, goes hand
in hand with it, namely pylorospasm. In spite of a voluminous literature
and a wealth of clinical observation, pylorospasm and true hypertrophic
stenosis remains obscure as to aetiology and in their relationship to each
Many observers who claim to be able to differentiate them by X-Ray
and by clinical methods are frequently proved wrong by the clinical
course, at operation, or at autopsy. I feel that the only sure way to
differentiate these two conditions is by the end result. Both conditions
are rightly put in the classification of hypertonic infants and if, after
medical treatment, the condition improves and remains improved, the
case is one of pylorospasm; if, on the other hand, there is no improvement
or if improvement is but temporary, one is safe in assuming true organic
Hirschsprung regarded the condition as primarily a muscular hypertrophy. A hypertrophic pylorus has been found in a foetus and as
pyloric spasm in a foetus is impossible it follows that the hypertrophy is
primary; but the hypertrophy alone is not sufficient to give obstruction
and the explanation has been offered that there is a secondary spastic
contraction of the muscular coat which is superimposed upon primary
hypertrophy. This contraction may, in certain cases, relax at times and
let food pass.
Read before the Osier Society of Vancouver, March,  1930.
Page 43 Pfaundler's theory was, and it is still held by competent observers,
that the spasm is primary and that the hypertrophy is a compensatory
one caused by it. It has definitely been shown, however, that the hypertrophic tumour may persist long after the spasms have been relieved and
although one sees that a true explanation of the full cause of pyloric
obstruction is still more or less obscure, from what we do know we are
able to form the conclusion that in the early weeks of life there is a
predisposition to the development of hypertrophy of the pylorus and that
the symptoms are caused by some obstruction of the pyloric canal made
easy by the foregoing hypertrophy. In short, that hypertrophy precedes
spasm. Always remember, however, that one may have spasm without
a tumour, but that with a fully developed tumour there must always be
some spasm.
Now what might cause this peculiar congenital tumour formation?
Here again there are many theories, but few, if any, proven facts, but
all investigators agree that the disorder is somewhat due to an imbalance
of the involuntary nervous system, which, as we all know, has two opposing divisions, the sympathetic and the parasympathetic.
Moore of Portland has done the most recent work on this subject.
He submits a fairly plausible explanation for this upset in the sympathetic
balance. He found, quite by chance, when working on vitamin deficiencies in the diets of Albino rats, that these rats, particularly the young,
of the second generation, showed typical pyloric obstruction when fed
on a diet deficient in Vitamin B. Investigating a little farther he was
able to demonstrate myelin degeneration in the vagus or motor nerves
of these animals which type of finding is typical of beri beri, a known
disease of Vitamin B deficiency. He concludes that true hypertrophic
pyloric obstruction appears to be just one manifestation of a Vitamin B
deficiency in the diets both of mother and offspring and which will occur
more frequently in each succeeding generation. He thus is able to explain its increasing incidence and its tendency to run in families.
There is one other aetiological theory that I wish merely to mention
in passing. To me it is rather far fetched and does not seem to explain
at all satisfactorily what it is supposed to, but at the present time it is
used as a posible cause for many varied ailments of doubtful aetiology. It
is a great 'pinch hitter' as at were—I speak of allergy. One result of
allergy is smooth muscle spasm, which in certain cases may be localized.
With this point to go on Cohen of Cleveland studied pyloric stenosis
from an allergic viewpoint and found that in 40% of his 27 cases there
was a family history of allergic manifestations, 40% of these same 27
patients, before the age of 12, themselves developed one or other of the
allergic phenomena. Four infants, at the time of their pyloric obstruction,
gave positive reactions to eggs, milk or cereals. I only mention this work
for what it is worth. Cohen's comment is, "That allergy may be present
and may be demonstrated in cases of infantile pyloric obstruction and
that the physiological change in these cases is similar to that in allergy."
The incidence of congenital hypertrophy of the pylorus is not accurately known.    Ten years ago it was considered fairly rare.    Today
Page  44
m it is estimated as occurring about once in 200 births. This figure is
probably high and may include cases where no tumour has been proved
to be present, but we know that this condition is no longer a rare one
and any one who treats babies should be as conversant with its clinical
picture as he is with that of appendicitis. The condition usually occurs
in breast fed male children between the ages of 3 and 5 weeks; onset after
six weeks is unusual and after eight weeks is rare. It may occur in one
only of twins but in the case of twins, both are, I think, more commonly
affected, and two or more cases are often reported in one family.
Physiology and Pathology
There is marked increase in the peristalsis of the stomach but in spite
of this the gastric contents are unable to pass through the pyloric ring.
One authority says that there is reverse peristalsis in the stomach, but
as the peristaltic waves are so readily seen and are always going in the
one direction, left to right, I think this is doubtful. The cause of the
vomiting is purely mechanical. The stomach contracts, the pylorus is
closed and there is only one open door, up the oesophagus.
The stomach becomes dilated, its walls thickened and its added
weight causes a sagging which produces a kink at the pyloric antrum
which still further interferes with the emptying of the stomach.
Wollstein, who has examined more pyloric tumours pathologically,
both before and after operation, than perhaps anyone else, describes them
as follows:—"The tumour is made up of greatly thickened circular muscle
tissue, composed of the unstriped muscle cells but with no increase in the
connective tissue fibres. Its gross appearance is that of hyaline tissue.
The pyloric lumen is much reduced and may be almost completely
obstructed. After operation, with division of the circular fibres, the
wound heals in about 2 weeks. This healing is brought about by the
growth of the serous and submucous layers, and after one to two years
there is only a thin connective tissue line to mark the site of the wound.
What I have to say on diagnosis will in part, at least, be more or less
a repetition of what has already been said. Except for congenital atresias
and malformations the only necessary differentiation is from the aforementioned pylorospasm, and I feel that it is only the theurapeutic test
that will differentiate pylorospasm, which, after all, is spasmodic pyloric
obstruction, from true hypertrophic congenital pyloric stenosis, which is
of a combined spasmodic and organic origin.
The symptoms of the two conditions are identical except for one
fact: A young baby, usually breast fed and thriving, suddenly commences to vomit. The vomiting is persistent and forcible, shortly there
is marked constipation and loss of weight. The vomiting is characteristic,
sometimes the food is shot out of the mouth for a distance of several
feet. Remember that the symptoms always come on fairly suddenly in
a baby that, whether breast or bottle fed, was thriving. This fact is
most important, because if a baby is doing well and then begins to vomit
Page 45 when there is no change in diet, it is almost certain to be one or other of
these two conditions.
If the vomiting is not after every feeding the amount ejected will
be greater than the amount of a feeding. Definite gastric peristaltic
waves may always be seen. There is no fever and the infant usually remains hungry. There is a gastric retention which may be demonstrated
by emptying the stomach three hours after feeding, or by X-Ray.
Rarely is the X-Ray necessary, but if there is any doubt do not hesitate to
use it.
I spoke of the signs and symptoms of these two closely allied conditions differing in only one thing namely, the presence or absence of the
typical pyloric tumour. With a palpable pyloric tumour and visible
peristalsis, diagnosis of a true hypertrophic pyloric obstruction is not
a matter of opinion but is demonstrable; such a combination occurs in
no other condition. How often are we able to palpate with certainty
this tumour? There is a great difference of opinion in this matter and it
is because one man says he can palpate these tumours in 100% of cases
and because another man says he has given up trying to palpate them
because he was unable to find them in nearly 100% of cases, that we have
any argument as to the relative merits of medical and surgical treatment.
In this controversy I still take the stand of my old chief Dr. Boiling.
At times I have wavered but still feel, if sufficient time and care is taken,
the tumour, if present, can be felt in the great majority of cases. In the
New York Babies Hospital, on Dr. Boiling's service, no baby was operated upon unless the tumour was palpated by him and demonstrated to
us, his interns. I want you to get this—with him, unless the tumour was
felt, there was no operation. He took sometimes hours of time and was
extremely patient and the baby was kept relaxed and quiet, but if after
such an examination there was no tumour then there was no operation.
I know, too, that in my service with him there were no babies dying
without operation from pyloric obstruction. Like many other things,
there is a big personal equation in ability to palpate pyloric tumours.
Boiling knew he could feel them in 100% of cases. I only feel that I
can palpate them in the majority of cases but I am convinced that those
men who admit their inability to definitely demonstrate this tumour
except occasionally, are being most unfair to themselves. One can
make a true diagnosis of hypertrophic pyloric stenosis withous feeling the
tumour, but only by the aid of our therapeutic test, of which I have
spoken, and that means a delay of at least a few days. On the other
hand, once the tumour is felt the diagnosis is certain.
From what I have already said it is fairly evident where I stand
as regards the proper treatment of this condition. Once the diagnosis
is made and it is certain that the condition to be dealt with is one of
hypertrophic congenital pyloric stenosis, the only treatment, in my opinion, is surgical.
If the tumour, however, can not be felt, then our therapeutic test
must be applied, namely:—thick feeding and atropine—along with gener-
Page 46 al means such as subcutaneous fluids, transfusions and external warmth.
If the baby does not improve steadily, but continues to vomit and has
visible peristaltic waves and apparent gastric retention, then also must
we have recourse to surgery.
This last paragraph is really superfluous and a repetition, but once
more, when the diagnosis is made, whether by palpation of the tumour or
by the therapeutic test, operation is indicated. Unless the tumour can
be felt, however, in all cases medical treatment should be instituted.
Many cases will do well, stop vomiting and begin to gain, but as my
whole paper indicates, I feel that if they do they are probably seldom or
never true pyloric obstruction with its typical tumour formation, but
rather the closely allied condition of pylorospasm.
The usual medical treatment is:—thick cereal feeding every three
hours, fed with a spoon, plus atropine, 15 minutes before each feeding,
starting with 1/1000 gr. to the dose and increasing it gradually up to
the infant's tolerance. These babies are usually greatly dehydrated and
frequent clyses of pain saline, or glucose and saline should be given as
routine. Blood transfusions are often life saving, whether the case
proves to be true pyloric stenosis or not. Certainly before operation one
or two tranfusions should always be given. An operation is never a
midnight emergency. These babies as I have just said, are usually, when
first seen, dehydrated, more or less marantic and poor surgical risks.
Even, therefore, if the diagnosis is made in the first examination, waves
seen, history typical and tumour felt, do not rush the baby to the operating room but take one or two days or even longer to give the little
patient a better chance to stand the shock of its operation.
Moore's work with Vitamin B, may prove a real discovery.
It is possible that this condition is caused, as he suggests,
by a lack of Vitamin B throughout one or more generations and
that if concentrated Vitamin B, as in the form of yeast, is fed as a routine to nursing mothers, the present high incidence of the disease may be
lessened. Moore found, as you remember, degeneration of the motor
nerves to the pylorus and Barnett's theory as to why luminal should
cure this condition, is based on that finding. Luminal is shown to be
a central nerve depressor so he theorizes that the vomiting may be partly,
at least, of central origin from excess nerve stimulation rather than purely
mechanical, and thus the reason for its success.
So much for the medical treatment, and now briefly and not in great
detail let us consider what surgery can do for this condition. The first
consideration is to see to it that the baby is in as good condition as possible to stand the shock of an operation. The maintenance of body heat,
before, during, and after operation helps to prevent surgical shock. While
on the operation table, therefore, protect the child with plenty of hot
water bottles and a warm room. Local anaesthesia is the one of choice.
It requires a little more time and dexterity and often considerable patience but if at all possible will well repay the operator. The baby can
usually be kept quite quiet by the continual use of sugar pacifiers.. A
small catheter may need to be passed several times during the operation
into the stomach for the relief of gas.
Page 47 Gastroenterostomy was the surgical treatment in years gone by,
but its resultant operative mortality was so high that the patient's life
was seldom saved. Nowadays the Fredet-Rammstedt technique is the
only one in common use. It consists of a right rectus incision above the
umbilical level, the delivery of the pylorus through the peritoneal incision
and a simple division of the hypertrophied muscular wall by an incision
along the longitudinal axis of the pylorus, through all muscle tissue and
down to the mucosa. This incision is then stretched until the mucous
membrane is seen to bulge through the gap. After all bleeding has been
stopped, either by heat or fine ligatures, the wound is closed carefully in
layers. If the skin incision is high enough the liver will largely prevent
any resultant herniae. The operation is simple but must be done gently
and with considerable dexterity. There are several pitfalls, chief among
them, perhaps, being the ease with which the mucosa may be incised,
particularly on the duodenal end of the pyloric incision. On the whole
it is not an operation to be attempted by the amateur surgeon or even
by the trained surgeon who is not thoroughly initiated into ks difficulties.
The jobs that look the easiest by not being taken seriously often prove the
most difficult, and if surgeons will take advise from paediatrists it will
be to consider the simple Rammstedt operation worthy of their best
Post-operative care is as important even as the pre-operative preparation. I carry out the routine of the New York Babies Hospital, which is
essentially a gradually increasing schedule of breast milk, if possible, or a
suitable formula and water. The first feedings should be very small, only
a few c.cs. to be increased by a few ccs. each feeding. The baby usually
may be returned to the breast in a week's time. If there is post-operative vomiting, as sometimes happens, it is wise to continue thick cereal
and atropine until gastric retention becomes normal. If a case vomits
persistently after operation it is probable that all the muscular coat was
not divided and a second operation may be necessary.
The longer the baby vomited before suitable treatment was instituted, the worse the prognosis. Thus a definite prognosis can be given, based
upon the loss in body weight from the time of onset of symptoms. If
this weight loss is 20% the prognosis is only fair; if over 20% it is poor.
This is the reason why every operator gives a different mortality. I helped
compile a series of 454 successive cases at the Babies Hospital which gave
a mortality of 15'*. These cases were not picked but were taken as
they came and all operated upon by Boiling, put through our routine,
and fed breast milk, if we could get it. The majority of them, when
first admitted, were much underweight, many even marantic, and so I
feel that a 15'o mortality is quite as high as it should be.
In the year before his death, Dr. Boiling, in a series of about 70
cases, cut his mortality down to 10% by a more intensive pre-operative
preparation, which essentially was more frequent blood transfusions.
Page 48 Prevents
in Oil,
250 D*
W 1
OCTOBER 1st, 1930
in proper
I  Mead's Viosterol in Oil is
now designated   250   D  because, in accordance with the provisions of the Wisconsin Alumni Research Foundation, we are now assaying
the product by the Steenbock method. Before October 1, 1930, this same product was
assayed by the McCollum-Shipley method and
was designated 100 D. This was done in the belief
that this method gave results comparable with that prescribed by the Wisconsin Alumni Research Foundation for
its licensees. It was discovered, however, that when assayed
by this method the potency of the product was virtually 250 D in
comparison with products standardized by the Steenbock method.
Mead's Viosterol in Oil, 250 D (Steenbock Method)—in normal dosage—
is clinically demonstrated to be potent enough to prevent and cure rickets
in almost every case. Like other specifics for other diseases, larger dosage may be
required for extreme cases. It is safe to say—based upon extensive clinical research
by authoritative investigators (reprints on request)—that when used in the indicated
dosage, Mead's .Viosterol in Oil, 250 D, is a specific in almost all cases of human rickets,
regardless of degree and  duration, as demonstrated serologically, roentgenologically and
clinically. The change in Mead's Product is in designation only—not in actual potency. Mead's
Viosterol in Oil, 250 D—in proper dosage—continues to prevent and cure rickets.
MEAD JOHNSON 8bCO. of CANADA, LTD.,Belleville, Ont.
lllliUlllllllllill miMftH*
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RATES—are   reasonable—no   more  than   ordinary  first   class   hotel   accommodation,   with
meals and treatments included.
Direct patients to Rest Haven from Victoria by the Vancouver Island Coach Lines,  Ltd.,
at the  Broughton  Street   Station.    Private car 'will meet boats  if  desired.
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