History of Nursing in Pacific Canada

The Vancouver Medical Association Bulletin: April, 1929 Vancouver Medical Association Apr 30, 1929

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 Vol. V.
APRIL, 1929
The Bulletii
of the^
Vancouver Medical Association
Osier (Lecture
Undulant ^ever
^ffiospital <3Beds
Tublished monthly atTJancouver, 1B.Q., by
McBEATH-CAMPBELL LIMITED
^Tric&s $ 1.50 per yeav^~ Patient Types:
THE ELDERLY PATIENT
It is often a task to keep an elderly patient in active service. Constipation may be the borderline between invalidism and good health.
Cathartics are particularly harmful in such a case but Petrolagar and
"Habit Time" will help the senile bowel to normal function.
Petrolagar is composed of 65% (by volume) mineral oil with the
indigestible emulsifying agent, agar-agar.
Petrolagar
DESHELL  LABORATORIES  OF
CANADA, LTD., DEPT. V.M.,
Deshell Laboratories of Canada      24Toroantaor on&io.
T imitf>A Gentlemen:     Please   send   me   copy   of
idiiuucu ^   new   brochure   "Habit   Time"    (of
bowel movement) and specimens of Pet*
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Dr _
TORONTO,   ONTARIO Address    	 THE   VANCOUVER   MEDICAL  ASSOCIATION
BULLETIN
Published Monthly under the Auspices of the Vancouver Medical Association in the
Interests of the Medical Profession.
Offices:
529-50-31  Birks Building, 718  Granville St., 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 above address.
Vol. V. APRIL, 1929 No. 7
OFFICERS, 1928 - 29
Dr. T. H. Lennie Dr. W. S. Turnbull Dr. A. B. Schinbein
Vice-President President Past President
Dr. G. F. Strong Dr. J. W. Arbuckle
Secretary Treasurer
Additional members of Executive:—Dr. A. C. Frost and Dr. F. N. Robertson
TRUSTEES
Dr. W. F. Coy Dr. W. B. Burnett Dr. J. M. Pearson
Auditors:    Messrs. Price, Waterhouse & Co.
SECTIONS
Clinical Section
Dr.  L.  H.  Appleby Chairman
Dr. J. R. Davies Secretary
Physiological and Pathological Section
Dr.  C.  E.  Brompn Chairman
Dr.  R,  E.  Coleman t Secretary
Eye, Ear, Nose and Throat
Dr. W. E. Ainley Chairman
Dr. F. W. Brydone-Jack. 1 : Secretary
Physiotherapy Section
Dr. H. R. Ross ..  ;—Chairman
Dr. J. W. Welch Secretary
Pediatric Section
Dr.  E.  D.  Carder Chairman
Dr. G. A.  Lamont Secretary
STANDING COMMITTEES
Library Orchestra Summer School
Dr. D. F. Busteed Dr. A. M. Warner dr# g. £>. Gillies
Dr. C. H. Bastin Dr. W. L. Pedlow £>R- l. h. Appleby
Dr. W. A. Bagnall Dr. J. A. Smith Dr. W. T. Ewing
Dr. Lyall Hodgins Dr. L. Macmillan Dr., J. Christie
Dr. S. Paulin Publications j)R# ^. l. Graham
Dr. W. A. Wilson Dr. J. M. Pearson £>r. r. p. Kinsman
Dinner £**■• J- **• McDermot
Dr. E. M. Blair ^r* ^* ^- ^ Cleveland Hospitals
Dr. L. Leeson Credentials Dr. F. Brodie
Dr. H. H. Pitts Dr. J. T. Wall Dr. A. S. Monro
Rep. to B. C. Med. Assn. Dr. D. D. Freeze Dr. F. P. Patterson
Dr. Stanley Paulin Dr. W. A. Dobson Dr. H. A. Spohn
Sickness and Benevolent Fund   —   The President   —   The Trustees VANCOUVER MEDICAL ASSOCIATION
Founded 1898 Incorporated 1906
PROGRAMME OF THE 3 1st ANNUAL SESSION
GENERAL MEETINGS will  be  held on  the  first  Tuesday  and
CLINICAL MEETINGS on the third Tuesday of the month at 8 p.m. from
October to April inclusive.   Place of meeting will appear on the Agenda.
April 2nd—General Meeting.
Paper—Dr. F. P. Patterson: Subject to be announced.
April 16 th—Clinical Meeting.
April 23 rd—Annual Meeting.
VANCOUVER HEALTH DEPARTMENT
STATISTICS, FEBRUARY,  1929
Total Population   (Estimated)
Asiatic   Population    (Estimated)
Total   Deaths   	
Asiatic  Deaths  .
Deaths—Residents   only
TOTAL   BIRTHS
Male       194
Female   197
INFANTILE MORTALITY—
Deaths under one year of age
Death   rate  per   1,000   Births
Rate per 1,000 of
177
24
150
391
7
17.90
... 228,193
   12,300
Population
10.11
25.36
8.57
22.34
CASES OF INFECTIOUS DISEASES REPORTED IN CITY
Smallpox
Scarlet   Fever   	
Diphtheria    	
Chicken-pox   	
Measles    	
Mumps     _ 	
Whooping-cough     	
Tuberculosis 	
Erysipelas     	
Poliomyelitis    	
Typhoid   Fever    	
Cerebral-Spinal Meningitis..
79
19
80
94
6
116
3
15
11
0
0
1
0
0
4
0
0
0
0
16
I
0
0
1
55
0
22
0
62
0
45
0
19
0
138
0
1
0
11
16
9
0
0
0
0
0
2
1
37
0
15
0
15
2
45
0
51
0
239
0
4
0
7
-
9
1
0
0
2
1
0
0
N.B.—Typhoid cases from outside City.
Page 13B 4o% More Snooks Installed in 1928
' I 'HE increasing requirements in an X'ray machine due to the newer technics
■*• in more recent years, have served to bring about a greater appreciation of
the Snook. While the number installed during 1927 far exceeded the records
of previous years, the year 1928 saw the 1927 Snook record exceeded by 40%.
Was this because of low price? No, for
there are any number of machines offered
in competition at considerably lower prices,
and claiming to do the same class of work.
Proof thru actual performance and the visualization of end results, plus the enthusiastic endorsement of an army of satisfied
Snook users the world over, are the concrete
reasons for this increasing popularity.
There is only one Snook—it is distinguished
from others by the double cross arm type of
rectification, as originally designed by Mr.
Snook in 1906. While the present-day Snook
machine offers certain definite refinements
over the original, such as added convenience
of operation, improved control system, greater
capacity and more artistic design of cabinet,
the original principles remain unchanged.
Thus it has adapted itself to the advances
in X-ray technic through the years and is
equal to the most critical requirements of
the present.
All of which is eloquent proof that the
fundamental principles are right.
Victor X*Ray Corporation of Canada, Ltd*
Manufacturers of the Coolidge Tube
and complete line of X'Ray Apparatus
524 Medical Arts Building, Montreal
Motor Transportation Bldg., Vancouver
Physical Therapy Apparatus, Electrocardiographs,  and other Specialties
2 College Street, Toronto
Medical Arts Bldg.,Winnipeg
A  GENERAL  ELECTRIC
O RB ANIZATION Credo
We believe in quality—all pharmaceutical
preparations must be chemically pure.
We believe in knowledge—our nine graduate pharmacists must know the properties of
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We believe in service—service to the medical profession and to the public at any time,
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Phone Seymour 1050
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in cystitis and pyelitis
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MARK
PYRIDIUM
Phenyl-azo-alpha-alpha-diamino-pyridine hydrochloride
(Manufactured by The Pyridium Corp.)
For oral administration in the specific treatment
of genitO'urinary and gynecological affections.
Sole distributors in Canada
MERCK & CO. Limited
412 St. Sulpice St.
Montreal
-^» EDITOR'S PAGE
We publish in this issue of the Bulletin the annual Osier Lecture
o£ the Vancouver Medical Association. The lecturer this year was Dr.
H. M. Cunningham and the subject the peculiarly appropriate one of
"Ourselves"—not "as ithers see us" but as we hope we are.
The title is one which would have been dear to the heart of Osier
and in the matter and method of Dr. Cunningham, he would have delighted as an example of the dissertation in which he himself excelled.
If the choice of future lecturers ranges never so wide, always there will
be some point of contact with the many facetted Oslerian mind, so it
touch Medicine even remotely. The Lectureship was founded several
years ago shortly after Osier's death, Dr. Brodie being then President of
the Association. This Society had a special interest in the. foundation,
in that Sir William Osier was for many years an Honorary member,
manifesting his lively interest by not infrequent letters of suggestion and
advice and by an occasional more material contribution to our funds.
What these letter and contributions meant to the small struggling
Society only those of our older members can fully realize. Such a broad
catholicity of mind had this busy professor at Baltimore and at Oxford.
No Chauvinism there.
We do well in these annual events to ponder such traits, such best
portions of a good man's life. His little, nameless, unremembered acts
of kindness and of love.
NEWS AND NOTES
We are glad to learn that Dr. F. C. Bell is convalescing from his
recent operation.
Dr. G. E. and Mrs. Gillies have left for a trip to Europe. They
e'xpect to be away for about six months.
Dr. J. C. Farish has returned from a holiday in Honolulu.
The "School of Seven"—not to be confused with another group
of artists of the same title in Eastern Canada—spent a profitable week
end in Victoria recently. The Western group are not pre-eminently
colourists, their best work being rather manifestly confined to the greens.
Lt.-Col. A. S. Monro has recently been honoured in his election to
the presidency of the Medical Officers Association.
It is understood that the new Maternity wing of the Vancouver
General Hospital is at last open for the reception of patients. We wish
we could report the same of the Private Ward wing. *
Page 139 UNDULANT FEVER IN BRITISH COLUMBIA.
By
H.   W.   Hill,  M.B.,   D.P.H.,   L.M.C.C.;   Director   and  Bacteriologist,
Vancouver  General   Hospital  Laboratories;   Professor   of   Bacteriology; and of Nursing and Health, The University   of   British   Columbia.
Synonyms—Undulant fever—Malta fever—Mediterranean fever—
Cyprus fever—Gibraltar fever, (all in human). (Allied diseases—
Malta fever infection .of goats; contagious abortion in cattle and hogs;
tularemia in the human; tularemia in rabbits; perhaps deer fly fever, in
animals and man).
Cause—Undulant fever in the human in North America is caused
by a bacterium (B. abortus) which appears to be identical with that
which produces contagious abortion in hogs, (B. abortus, Bang, porcine);
closely similar to that which produces contagious abortion in cattle
(B. abortus, Bang, bovine); and at times indistinguishable from that
(Mic. melitensis) which produces Malta fever in the human (itself
derived from an infection of goats). A closely allied but probably not
identical form of bacterium (B. tularense) produces tularemia in rabbits
which is transmissible as a serious infection to man.
Sources of Infection—Undulant fever in the human in Europe,
and sometimes in North America, would apear to be derived from goats
infected with Mic. -melitensis; but, in North America, more often from
hogs infected with B. abortus, (Bang, porcine); sometimes from cattle
infected with B. abortus (Bang, bovine); cattle may be infected at times
with the porcine strain, and so transmit the porcine strain to man.
(Clinical or epidemiological relationships between undulant fever in the
human, and tularemia in the human, have not yet been worked out).
Vehicles of Infection—Undulant fever in the human would
appear to be carried from animals in—the raw milk of goats affected by
Mic. melitensis; discharges of the genito-urinary tract of affected cattle
and hogs; the raw milk of affected cattle at times; and the feces of infected animals. Infection from human to human appears to be not as
yet established, but is probable.    "Typhoid precautions" are indicated.
Routes of Infection—Undulant fever in North America appears to
be contracted by the human rarely through the use of raw infected
milk of goats; sometimes through the use of raw infected milk of cattle;
usually, through the handling of infected animals alive or dead, and
especially of their genito-urinary discharges. (In tularemia, through the
handling of infected rabbits, especially skinning same).
Portals of Entry—Undulant fever in the human would appear to
be contracted (like most other infections) by way of the mouth, nose
and eyes; the former certainly in the cases of infection from raw goats'
milk or cows' milk; and probably, through the hands going to the mouth,
in the cases of infection from handling discharges of animals. In
human tularemia the initial infection has usually been from the carcases
of rabbits, *through cuts, etc., in the hands of persons skinning or other-
Page 140 wise handling the carcases. It is possible that undulant fever may be
contracted through cuts, etc., in the hands of those handling infected
animals.
Incidence—Undulant fever in the human in North America has
been found so far, chiefly in adults, and more in men than in women.
Children, although drinking more milk, have relatively escaped. The
higher incidence in men over women would appear to be occupational
and related to more intimate contact with the infected animals on the
part of the former.
Morbidity—While found in numbers approximately that of typhoid
fever in Iowa, Ontario has reported to date only 14 cases; British Columbia 2.
Mortality—Deaths are rare, perhaps 1 or 2% of cases. These
studies are so incomplete, and the cases and deaths found bear so little
proportion to the (probable) numbers of each existing, that none of these
figures can be considered final. Undulant fever may easily exist in considerable amount in the human without identification, in the absence of
agglutination tests.
Infected Well Persons—Judging from the results of our agglutination tests in the human, British Columbia has so far yielded more
well persons showing agglutination than sick. We have two positive
sick persons on our records, and five positive well persons. Of the latter,
three were intimately associated with infected cattle over long periods,
one with (infected?) goats; of one, nothing definite was learned. On
the other hand, over 40 tests on various persons sick and well, were
negative. The positive reactions were obtained in dilutions of the
general order of 1 in 160.
Immunity—While well worked out in cattle, immunity following
infection in the human is as yet nebulous, but probably at least as good
as immunity following typhoid.
Course of the Disease—Undulant fever in the human is held to
show in incubation period of about two weeks, i.e. from infection to
first symptoms. The evidence is not extensive however. In mild cases,
two weeks of fever ranging 101°—104° F. may terminate in recovery;
such cases may be ambulatory; and difficult to distinguish clinically from
"flu." In typical cases, two weeks of fever is followed by an interval
of two days up to two weeks of intermission and the attack recurs.
This may continue for four months. In severe cases, fortunately rare, a
stormy attack with high fever, delirium, stupor, may terminate rapidly
in death.
Onset and Prodromes—Ordinarily like those of typhoid, but rising to the fastigial range of temperatures more rapidly (in 3 or 4 days
rather than a week). There is constipation, and no rose spots, but
otherwise typhoid is suggested, and in the early stages, undulant fever
may, like typhoid, be mistaken for influenza.
Fastigium—"Coated tongue, tender palpable spleen, anemia with
normal total white, but low polymorphonuclears may be the only signs."
Page 141 (Headache, sleeplessness, sweats, nose bleed, palpable spleen, leucopenia,
may be present). Later neuritis, arthritis, orchitis, joint pains, emaciation, palpitation, prostration, premature ageing may be found in prolonged cases.
Diagnosis—Agglutination tests and blood cultures should be made
in clinically erratic cases of "influenza" or "typhoid" or "paratyphoid,"
or of "undiagnosed continued fever." These agglutination and blood
tests should include those for typhoid, the paratyphoids, and Shiga, as
well as for B. abortus and its congeners. Fortunately one withdrawal
of serum for the varied agglutination tests and one blood culture is
sufficient for making all the above. One set taken as soon as the need
for diagnosis arises, should, if negative, be followed by a second set
within a few days. Blood cultures should be observed for nine days, as
the bacterium grows very slowly. A proper clinical picture, elimination
of other causes, and a positive abortus result from agglutination and (or)
blood culture gives an acceptable diagnosis.
I am indebted to many recent articles for the above accumulation
of data—particularly to Blumer—New England Medical and Surgical
Journal, January 28, 1929.
Prevention—Avoidance of infected animals; aseptic precautions
in handling such; pasteurization of milk. Physicians encountering obscure typhoid-like cases, or otherwise undiagnosed erratic fevers, are
urged to send in blood for the agglutination tests above outlined, and for
culture. This work is done free for the human under the Provincial
grants at any of the Provincial Board of Health Laboratories—at the
Vancouver General Hospital; Royal Inland Hospital, Kamloops; Royal
Jubilee Hospital, Victoria; or Kelowna General Hospital.
HOSPITAL BED SHORTAGE
A Special meeting of the Vancouver Medical Association was held
in the Outdoor Department of the Vancouver General Hospital on
March 14th to hear a report by the Hospitals Committee on the meeting
with the Hospital Board on March 8 th re the acute bed shortage which
had arisen in the General Hospital. Mr. McVety and Alderman Mclnnis
attended the meeting on behalf of the Board.
Dr. Monro, said the shortage had become so acute that during a
short period recently the order was given for no admissions to the wards
of the Vancouver General Hospital. This was followed by an order
limiting admissions to emergencies and accident cases only. At the
meeting on March 8 th between the House Committee of the Board of
Directors and the Hospitals Committee of the Association, methods of
relieving this situation were considered, with the fact always before
them that there could be no increase in the number of beds for a long
period of time. It was agreed that if certain measures could be adopted
an increase of 15-25% in admissions could be secured. The House
Committee of the Board suggested the appointment of a Registrar to
scrutinize admissions and discharges.    In the event of a difference be-
Page 142 tween this Registrar and the attending physician a Referee would be
necessary and the appointment of this Referee or Committee should
be made by the Association.
Mr. McVety, called on by the Chairman, considered the present
situation to be due to a lack of foresight on the part of the City Council
and the public. The shortage was anticipated by the Board many years
ago. He explained that all bed patients must be removed from the
Annex within the next few weeks by order of the Fire Warden, and
further, when the new wards were opened and other wards rearranged
the present number of beds would be increased by only sixty. He estimated the bed shortage at the present time at 325.
The causes leading to the need for more beds were given by Mr.
McVety as (1) increase in the number of families living in flats, (2)
the difficulty of caring for patients in the home, (3) the tendency of
medical men to get their patients into hospital to save time in visits to
outlying districts, (4) the admission of large numbers of patients who
could be treated in their homes, and (5) patients remaining longer than
necessary. In his opinion the hospital should be kept for acute cases.
Conditions with regard to Ward X were gone into and the speaker complained that cases were dumped into hospital by medical men and the
police and the hospital authorities were left with the problem of getting
in touch with the relatives and obtaining the completion of the necessary
forms before the patients could be removed to Essondale. Mr. McVety
added that the suggested methods for improvement could only be carried
through with the whole-hearted co-operation of the medical men.
Alderman Mclnnis considered community service should be given
first to those unable to supply the service for themselves. Someone
should be appointed by the Hospital to supervise the cases in regard to
admission and discharge. The question was one of co-operation between
the Hospital Board and the medical profession.
Dr. F. P. Patterson referred to the necessity for a campaign for the
provision and equipment of hospitals. If there was no immediate possibility of this then the best use must be made of the accommodation already at their disposal. He considered the present congestion due to a
difference in opinion among medical men as to the cases which should be
admitted and the length of hospitalization necessary. He thought if the
Association passed a resolution approving the procedure outlined by Dr.
Monro the Hospital Board was prepared to put the scheme into operation and in his opinion once the arrangements were in working order
there would be a very small percentage of cases in which any difference
of opinion would arise between the Registrar and the attending doctor.
Nothing in the nature of discipline was intended—it was a question of
trying to arrive at an average hospital stay in any particular type of
case. He thought the Association should support the scheme which
worked well in other hospitals. Dr. Patterson went on to say that the
hospital had neither sufficient equipment nor sufficient nurses to take
care of more patients so that the situation could only be met by reducing the length of hospital stay.
Dr. Brodie said they only had equipment and nurses to care for
800 patients and they continually had an excess of 200 over that number.    Only one solution was possible—to speed up egress.    The average
Page 143 Igjjff
hospital stay per patient was now 19-4 days; it should be 12-14 days.
He thought many cases could do with a hospital stay of seven days and
convalesce at home for another week. He then moved the following
resolution:
"That this Association goes on record as sympathizing with the
Board of Directors in the difficulty they are having in supplying
hospital accommodation for the public of this City and is willing
and anxious to co-operate with the hospital authorities in relieving
this condition, and this Association recommends to the Board of
Directors the appointment of a Registrar to supervise the admission
and discharge of patients, and that the Association appoint a Committee to confer with this Registrar in cases of dispute which may
arise."
The motion was seconded by Dr. F. P. Patterson.
Dr. McLellan deprecated the present system of sending patients for
physiotherapy treatment and laboratory tests to the Hospital when there
were doctors competent to treat such cases either in their offices or in
the patients' homes. He advocated more instruction in Home Nursing
by the St. Johns Ambulance. He thought the appointment of the proposed Registrar should be made by the Superintendent of the Hospital.
Dr. Hunter said they must not lose sight of the fact that the present suggestions were an emergency measure only. Someone outside the
profession was wanted to survey the whole hospital situation of the City.
Dr. Sutherland referred to the large number of staff cases which had
no homes to go to.    What was to be done with these?
Mr. McVety thought it might be possible to utilize the Annex for
cases which could be efficiently cared for by Ward Maids thus relieving
the Nursing Staff. The Board had a Committee at work surveying the
hospital situation and had under consideration a proposal to bring in
some outside authority to advise what is actually required. He thought
it probable in view of the recent amalgamation that the scheme for extension originally contemplated by the General Hospital would be
amended and hospitals erected in other parts of the larger city. The
Council had in mind a hospital in South Vancouver of 300 beds and
another in Point Grey of 300 beds.
The question was then put and the Resolution carried.
The following resolution was then moved by Dr. F. P. Patterson:
"That the appointment of the Referee Committee be considered by
the Executive and the appointment left in their hands."
In moving the resolution Dr. Patterson said that even when the
Registrar and the Committee got working and cases were moving rapidly
there would still be a large number of cases remaining longer than necessary as there was no place to which they could be sent.
Alderman Mclnnis promised to bring this matter immediately before
the City Council.
Dr. Patterson's resolution was seconded by Dr. Sutherland and carried and the meeting adjourned at 10 o'clock.
Page 144 OURSELVES
Being The Osler Lecture delivered before a meeting of the Vancouver
Medical Association, on March 5 th, 1929
By Dr. Henry M. Cunningham
Our avocation has been variously described as a Profession, a
Science, and an Art. We have been told, "one must always remember
that the Practice of Medicine is not a Science, but an Art." However
true this may have been in the past, it is fast becoming less so. This
may be inevitable but should we not strive to retain whatever we can
of the Art of Medicine?
Nothing is further from my thoughts than to disparage the debt
we owe to those who have given and are still giving us more scientific
aids to diagnosis. They are of inestimable value; but are they entirely
an unmixed blessing? Is there not a growing tendency to depend toe
much on the laboratory and too little upon our own skill in matters of
diagnosis and prognosis? If this be true, must it not necessarily follow
that our powers of observation, tactile sense and diagnostic acumen will
either atrophy from disuse or fail to develop, as the case may be? To
thoroughly appreciate this danger one must, I think, have started his
medical career before most of these aids were available and have watched
them gradually usurp the field. When I graduated 34 years ago, the
only diagnostic implements we had were our five senses, the thermometer, stethoscope, forehead mirror, nasal, aural and vaginal specula,
tongue depressor, laryngeal mirror, ophthalmoscope and microscope. Our
laboratory aids were urinalysis and microscopy. Looking back I am
struck by the comparatively high degree of attainment reached by the
microscopist of those days. His diagnosis of the various new growths
was not far short of the present. The recognition of most of the pathogenic micro-organisms and the significance of their presence, was as well
understood as now. Examination of the blood included percentage of
hemoglobin and red and white cell count. The morphology of the
erythrocyte was studied and the plasmodium of malaria searched for.
We could recognize anaemia, chlorosis, pernicious anaemia, leukaemia,
pseudoleukaemia and leukocytosis. Recognition of the importance of
the differential count as we have it today, came later.
In our education considerable stress was laid on our ability to use
the microscope. With the exception of the diagnosis of new growths and
the making of cultures, the work was done by the internes. Complete
qualitative and quantitative urinalysis was, of course, done in the laboratory and the laboratory expert called upon when deemed necessary.
We did not have that greatest of all boons the X-ray, nor did we
have the Wassermann Test, Widal Test, Schick Test, metabolism estimation and biochemistry. Blood pressure and the tension of the eyeball
were estimated by the sense of touch.
When studying the heart and aorta we did not have the radiogram
nor the electro-cardiograph. We had to trust to our skill in observation,
palpation and auscultation.
A slight consideration of what it would mean, today, to be deprived
of the help of the roentgenologist and bronchoscopist in the diagnosis of
Page 145 chest diseases, will bring a realization of the necessity imposed upon former diagnosticians of developing to the utmost whatever skill they could
acquire.
In the diagnosis and treatment of fractures and dislocations it is
almost malpractice not to avail ourselves of the help of the X-ray if
obtainable; but if forced to do without,- what result can be expected by
one who has neglected to acquire a fair degree of skill in the older
methods of observation and palpation?
As an instance of the blind faith that many have in laboratory tests,
permit me to mention that of the Wassermann Test for syphilis. In
this the laboratory people are in no way to blame, they can only report
on what they find and have repeatedly warned us not to regard a single
test of the blood as conclusive. In spite of this many consider that they
have done their whole duty, so far as excluding syphilis is concerned,
when they have received a single report of a negative blood Wassermann. However valuable laboratory tests for syphilis may be the time
has not yet come when the physician is relieved from the responsibility
of arriving at a diagnosis without them. A reasonable persistence will,
however, enable him to obtain laboratory confirmation in most cases, if
he cares enough about it.
In syphilitic manifestations of the nervous system nothing but a test
of the spinal fluid is of any value. One may try a test of the blood first
—and possibly get a positive reaction—if one clearly understands that a
negative report means absolutely nothing. As an illustration let me
mention two cases. One was a child that I saw in the Out-Patients
Clinic; she had been through the various departments for several years
and now presented a suspicious condition of her cornea. I remarked to
the nurse that the first thing to do was to send her for a Wassermann
test; she replied that every other department had done the same and
that three negative reports were in her voluminous case history record.
That being the case, I put the child on provocative treatment and got a
report of 4 plus. The other was a man with optic nerve atrophy. I
sent him first for a test of the blood which was negative, then for a test
of the spinal fluid which was also negative; being unconvinced, I put
him on provocative treatment for four days after which I received a
report of 4 plus positive. The clinical evidence of syphilis still holds
good regardless of repeated negative Wassermann tests and I cannot help
repeating that we are in danger of losing our ability to make a diagnosis
by observation alone. It is astonishing that many—who have had a
supposedly first-class medical education—do not understand what is
meant by "provocative treatment" in relation to the Wassermann Test.
I should like to spend a few moments in considering the use of our
senses, sight, hearing, smell, taste and touch. Of those, the power of
observation and the trained tactile sense are, of course, the most important. I shall never cease to be grateful to one of my teachers, Francis
Delafield, for constantly directing our attention to the amount that
may be learned by observation alone. In summing up a case, after
giving us all the finding, temperature, pulse, respiration rate and those
of physical diagnosis, he invariably wound up by one of the following
Page 146 remarks; "and the patient looks sick;" "but the patient does not look
sick;" or, "but the patient looks sick." In estimating the gravity of the
situation the appearance of the patient had, to him, almost more significance than all the other findings put together. Is not this to a large
extent still true? I know it to be so in many cases of disease of the ear
and should, I think, be a large factor in deciding as to the urgency of
a mastoid operation and often be a guide as to the necessity of further intervention.
Delafield taught us to always make a careful observation as to the
appearance of a patient before proceeding further; does he look sick?
does he look worried, anxious, or apprehensive? is he nervous, excited or
apathetic? is he anaemic or plethoric? is he well nourished or emaciated?
does he look toxic? notice the colour of his skin and mucous membranes.
How much may be learned from the appearance of the tongue; the older
practitioners paid great attention to this, a dry, brownish coated, furrowed tongue meant to them the so called "typhoid state," now usually
spoken of as the "septic state." What apparatus or laboratory method
will take the place of the power of observation? The older men paid
more attention to the tongue because of a limitation in available modern
methods. Is it not likely that with the numerous appliances and laboratory aids of today the younger men will pay less attention to what
might be learned by observation than their predecessors?
I also learned a good deal from observing another man who was in
many ways the direct opposite to Delafield, who, as they used to say,
spent five years of his life in the "dead house" and was, as you know, an
eminent pathologist before he became a clinician. This man had a very
inadequate medical education and unlike many with the same handicap,
he made no attempt to gain further knowledge by reading or taking postgraduate instruction. He was however, a past master when it came to
knowing when it was advisable to call in a consultant and was uncanny
when it came to prognosis. I often wondered how it could be possible
for a man so ignorant to be so accurate in this. Largely through this
faculty and his cleverness in getting out from under, he gained a great
reputation arid built up a large practice. I have said I learned something from this man which was, an appreciation of how much may be
learned through observation when forced to depend on it. This can
also be seen in the high development of the senses of touch and hearing
of the blind.
The sense of touch has, I think, suffered less from the advent of
modern innovations than have the other senses. The diagnostician of
today still depends a good deal upon the use of his trained fingers to supplement the X-ray plates. I doubt whether the average practitioner
cultivates this talent to the same extent, as did his colleagues of the
past. I may perhaps be wronging him but it seems to me that he is
too apt to leave it all to the X-ray man, without trying to see how much
he can find out himself. I feel sure that this is so in regard to fractures
and dislocations. It is really wonderful how much can be learned by
delicately trained finger tips. Being inexpensive, always at our disposal
and occupying no office space, it seems a pity not to develop and retain
this marvellous gift which is within the reach of all.    Take the tension
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618 Georgia Street West - Vancouver of the pulse and eye with the finger tips before appealing to the really
accurate blood pressure apparatus and the tenometer; the time will not
be wasted. Try to detect cripitus, friction rubs, enlarged liver, distended gall bladder and the like before resorting to the X-ray. Also try to
determine the presence of pus or other fluid in a swelling and register a
positive opinion with yourself before cutting into it. Notice the presence or absence of the granules of actinomycosis and the odour, if any,
before sending a specimen of pus to the laboratory. Only by such means
can we hope to advance.
The sense of hearing is, of course, indispensable when we come to
auscultation of the chest but it is also of service in detecting the bruit
of aneurysms in other regions and the friction rub of beginning peritonitis. Although the ordinary man cannot hope to attain the proficiency
of the heart and lung specialist, it lies largely with himself as to how
nearly, by study and practice, he can approach him.
The sense of smell, while playing a minor role, is often of great
value. A number of odours are quite distinctive and may almost be
said to make the diagnosis; such for instance as the acetone breath, the
odour of bone necrosis, gangrene and that of lung abscess; the odour of
the colon-bacillus is often most significant. When pus from the maxillary
sinus has this odour one can strongly suspect that the infection came
from the mouth and search the teeth for the probable tract. Other
illustrations, drawn from diseases of the ear, are the odour of bone
necrosis already mentioned and that of decaying skin, which is present
in cholesteatoma. It is said that some of our fathers in medicine could
diagnose many of the fevers and diseases, such as typhoid fever and
diphtheria, by their odour; the statement may not be so fanciful as it
seems since several of my colleagues assure me that they are able to do
the same.
It is of the greatest importance to be able to recognize at once the
symptom of acetone breath. Upon its early recognition followed by
immediate steps to remove the underlying cause, the life of the patient
may depend. No opportunity to teach our internes and nurses to recognize this symptom should be neglected. It is they who often have the
first opportunity to detect it. That this has not always been done when
it might have been I know by personal experience. One does not expect
case histories in an Osier Lecture but I feel so strongly the need to emphasize this point that I hope you will bear with me while I make brief
mention of three cases seen in consultation, two of which I believe owed
their fives to the fact that the presence of acetone breath was recognized
at the time. The first was a young woman who was to have an operation for toxic goitre—at which I was to assist. Immediately before
being taken to the operating room, I visited her in company with my
colleague. When near her I detected the acetone odour which he had
not noticed until his attention was called to it. Needless to say the
operation was postponed—as a matter of fact was never done—all her
symptoms clearing up under treatment. This would certainly have been
a fatality had the operation proceeded as scheduled.
Another was a case of water hunger due to functional stenosis of
the oesophagus which a colleague was treating by bouginage without
Page 14S result. I accidently happened to be present at one of the treatments
and was astonished to hear him tell the patient to "come tomorrow."
I hastily called him to another room and enquired if he had not noticed
her breath. He replied no. I cannot yet understand how this could
have escaped him for he was a man of long experience and one whose
ability I greatly respect. He told me afterward that he thanked me
for saving his patient's life.
The third was less fortunate. A young girl had been ill for several
months but was supposed to be convalescent and had been advised by
her physician to take a long railway trip to visit friends for a change.
She still had a troublesome headache and was sent to me in the hope
that this could be relieved by glasses. Before beginning an examination
I noticed her acetone breath and immediately called up her physician and
acquainted him with the fact. In this case I could not make the man
realize the gravity of the situation and the child was dead in forty-eight
hours.    I never could ascertain what her previous illness was.
Of all the senses that of taste is, I suppose, the least important,
nevertheless it should not be neglected. Is it asking too much to expect
the trained physician to be able, when it is possible by taste and smell,
to identify those drugs which are in common use?    I do not think so.
In dispensing and administering drugs or using topical applications
and solutions eternal viligance is required to avoid mistakes. In the
handling of bottles the druggists have a rule that we should all adopt.
They look at the label before taking the bottle down, again before they
pour from it, and again when they replace it. Nothing should go for
a moment without a label. I have often thought that a druggist should
put the label on the bottle just before starting to fill it. When unfamiliar with the taste of a drug physicians and nurses should taste preparations before adrninistering them. I once ordered ten grains of
chloral for a hospital patient to be given at once. We had a stock solution of ten grains to the drachm. The nurse made the portion in a small
medicine glass, filling it to about three-quarters full with water. I
asked her if she had ever tasted chloral, and being answered no, advised
her to taste it. She did so, and ran spluttering and coughing to the
water tap.
Before closing this chapter of my subject, I should like to quote a
few passages from the writings of our revered master in whose honour
we are assembled tonight. "Lack of critical judgment is another serious
obstacle in the way of the young man." The faculty of right judgment
in all things is granted to few men; but the physician to be of any value
must, at least, aspire to that round-about common sense which was so
distinguishing a feature of Sydenham." "Our work is an incessant collection of evidence, weighing of evidence and judging upon the evidence." "Credulity is of the very essence of human nature and we
physicians are not exempt from the common lot." He quotes Epichar-
mus of Syracuse as saying: "be sober and distrustful; these are the
sinews of the understanding."
How true it is that the physician who has assumed the responsibility
of caring for his patient's welfare should be a man of sound judgment.
Page 149 He must steer a middle course between rashness and timidity and be able
to properly balance indications and contra-indications. Before deciding
as to the time for operative interference he must carefully consider its
urgency; must it be done at once or would it be possible by pre-operative
treatment to lessen the risk and shorten the convalescence? It is always
a choice of evils.
Judgment is to a large extent the fruit of experience but is dependent on something more. A man may grow old in experience without
acquiring judgment. It is only by the conscious effort to apply it that
sound judgment is attained. The reference to credulity is also
most timely. We should be open minded and willing after proper consideration, to change our opinions; but to go to the other extreme,
veering with every wind that blows, is, perhaps, worse. Cultivate a
healthy scepticism; hold fast to what appears to be truth until it has
been proven otherwise. A chart of our beliefs and disbeliefs should not
resemble the temperature chart of a case of pyaemia.
Let us now consider the relations which should exist between our
patients and "ourselves." There is an old saying, "do not make patients
of your friends but make friends of your patients." The latter half of
this quotation is, I am sure, a very valuable admonition and essential to
getting the best results in the most pleasant way.
It requires considerable tact and some natural aptitude to do this.
I think one may lay as the "corner stone" in the construction of all
friendship, "Sincerity." When patients have been commenting on
physicians, it often occurs to me that they place more value upon sincerity than skill, perhaps rightly so. Doubtless most of you have heard
them say, "he may be a good doctor, but I don't trust him." What
more damning thing could a patient say. Skill may not be attainable
by all of us, but we can at least be sincere.
The next in importance is the patients' confidence in our knowledge
and skill. By knowledge I do not mean our abstract knowledge alone, but
an understanding of the individual case. To acquire this it is necessary
to make a careful and thorough examination, for the modern patient has
been educated to expect it. This was not always so. I once practised
in a place where one-half of what we now consider a moderate attempt
at thoroughness was thought to be an evidence of incompetence. The
man who had the largest and best paying practice in a city of twenty
thousand people rarely used a thermometer or a stethoscope. He did
not need them, for he knew at a glance just what ailed his patient. His
stock phrase was, "don't tell me a thing, I know what's the matter,"
and proceeded to write a prescription. This may sound like, at least,
an exaggeration, but I give you my word that it is the exact truth.
He was regarded as a wonderful man, and just what a real physician
should be. Times have changed, however, and such powers of discernment are now accredited only to the occult.
Having confidence in our sincerity and our knowledge, the patient
must next have confidence in our skill in putting this knowledge into
effect. His confidence, to a large degree, depends upon the confidence
we have in ourselves. None but a consummate actor can inspire con-
Page 150
-*P fidence in others if he lacks it himself. The patient is abnormally acute
in observing his physician; his whole mind is centered on his own case,
and by the physician's manner, rather than by what he says, he judges
the situation. Is the doctor really interested in me? Does he know
what he is doing? Is he worried about me? Does he think that I will
recover? Is he rough or gentle? Is he interested only in my recovery?
Is he interested also in my comfort? In the course of our examinations,
treatments, operations and dressings, the patient forms a decided opinion
as to whether we are skilful or not. Finally, of course, comes the end
result. In our operative procedures, we must never lose sight of the
patient's chief complaint; this is what he hopes and expects will be relieved. If his expectations are not realized he will be a dissatisfied
patient. I do not mean to say that we are not often called upon to
perform an operation which is very necessary to the welfare of the
patient but has no direct bearing on the symptoms for the relief of
which he first consulted us. I know this to be often true in my own
work. In such a case, however, the patient should be fully informed
as to the reason for the operation and as to what results we hope to
achieve. If you will pardon an illustration, which I feel sure can be
applied to other conditions, let us take that of asthma. Many of these
patients can be relieved by a nasal operation but the outcome is by no
means certain. A patient presents himself with the chief complaint of
asthma; we find that his nose is packed with polypi, producing nasal obstruction. Most of such cases are either completely or at least very
much relieved by a nasal operation; some, however, receive no relief
whatever so far as their asthma is concerned. It would be folly, therefore, to make an unqualified promise. One can say, however, "you need
a nasal operation regardless of whether or not you have asthma; I can
promise that you will be much more comfortable, and there is strong
hope that your asthma will be relieved; but please understand that I
cannot be positive as to the latter." With such an understanding one
need fear no dissatisfaction and should the asthma disappear gratitude
and pleasure will be greater than had it been a foregone conclusion.
Fortunately it is rarely necessary to give our patients pain but if
compelled to resort to a disagreeable procedure, prepare your patient for
it. Above all do not minimize it; nothing is so destructive to future
confidence and present tolerance. If fortitude is required inform him
so that he may be prepared to manifest it; on the other hand, remove
all unwarranted apprehension. After having told him what he has to
endure, by all means tell him what he has no need to dread. Encourage him by the assurance that he is quite able to acquit himself
creditably and show him that you expect him to do so. Please notice
that I said "show him," not "tell him;" the terms are quite different.
When I set out I expected to have a separate chapter on children
but I now see that such a sub-division is not only unnecessary but misleading. The only variation necessary is a slight modification in our
vocabulary. For instance, when about to do something unavoidably
painful to a child I always say, "now, son, this is going to hurt you a
little," and before he has time to react to this " but not more than you
can stand."    As a rule, a beautiful expression of relief passes over his
Page 151 face. He seems to be saying to himself "not more than I can stand,
oh that's all right so long as I know how much. I don't like those
people who tell you it is not going to hurt at all, or only a little, and
then they hurt you like everything." You have given him the only
scale of measurement that he can understand. How does he know
what you mean by "just a little," and to tell him "not at all" is a
treachery that he will never pardon. Another important rule in managing children is not to permit anyone to attempt to hold them unless
absolutely necessary. Just think for a moment what your own reaction
would be if you had no idea what was to be done to you and the first
step was to be seized by two or more strong men and forcibly held in a
helpless condition while a strange man prepared to perform some sort
of operation. Is it any wonder that a child under such circumstances is
filled with terror. There is no field here for half way measures; either
do not touch them at all, or, mummify them with a sheet so tightly
that they cannot move. I am glad when a parent starts to hold a child
for it gives me the opportunity of saying "no, do not hold him, he can
hold himself." This gives him added assurance that nothing very dreadful is going to happen. A mother will often remark "I don't know that
you can do anything with her, doctor, she is so nervous." My stock
reply is, "I am not surprised, when her mother will speak so in her
hearing." I have lost patients by that retort but never regretted it, and
will continue to do that much in the interest of the child's future. It
may do some good sometime, and such people are not apt to be satisfactory persons to work for.    The sooner we part the better I like it.
I never cease being amazed at how much children will stand without complaining if they like you and have confidence in you. Confidence that you are kind and not going to spare trouble to prevent all
needless discomfort and pain. The confidence of a child is one of the
most beautiful and satisfying experiences in a doctor's life.
Having gained a patient's confidence or, hoping to do so, how important it is not to cause more pain than he can bear. Here one must
use the greatest judgment as to the individual. How much has this
one already gone through? How much available fortitude still remains? Temperament and general circumstances play an important part
in the' estimate. I used to have an idea that ordeals developed strength
and fortitude; I no longer believe it. My experience is that the more one
has gone through, the less able one is to endure more. Instead of developing tolerance we are using it up. This, of course, does not apply
to those procedures which are in themselves painless, but have been made
so by apprehension and resistence; here considerable tolerance may be
acquire and unfounded apprehension overcome.
The modern surgeon with all his mechanical skill and scientific
technique often fails to get the result that he might, or be the blessing
that he should, because he fails to realize that he is operating on the mind
as well as on the body of his patient. The surgeon is too often satisfied
with doing a brilliant operation regardless of the fact that he has failed
to satisfy his patient. Much needless misery might be avoided and the
period of convalescence be made shorter, happier and more complete,
if the surgeon had the ability, and gave the subject sufficient considera-
Pagel51 tion, to enquire into his patient's state of mind both before and after
an operation.
The surgeon who feels that he has fulfilled his whole duty after
discharging his patient with a normal pulse, temperature and respiration rate, leaving it to him to fight his way back to health and strength
unaided, is falling short of his opportunity. Many patients expect to
feel almost immediately well after undergoing an operation to relieve
them of a disability which they have been told was the cause of their
previous illness. This is, of course, ignorance but it is a pardonable
ignorance based on inexperience and is pitiful when based on an exaggerated idea of the magic of the skilful surgeon.
The period of convalescence is often tedious and depressing; why
wonder that some become hopeless and turn to Christian Science, or some
form of quackery; or that such institutions, rather than the surgeon,
finally receive credit for curing them.
A cheerful optimism is, of course, essential in radiating hope and
courage to the patient; without hope, life would be intolerable. Faith
and hope are the sheet anchors which enable us to outride periods of
storm and stress and keep us headed right during the sometimes trying
period of convalescence.
Some persons cheer us as soon as they enter the room, others have the
opposite effect. How often one hears a patient say that his physician's
visit alone make him feel better. Some men try to be cheerful without
the tact requisite to do it properly. Nothing is so offensive to a sick
person as a boisterous exhibition of exuberance; we should try to find
a happy medium between the manner of a romping school boy and that
of an undertaker. A proper sympathy is also essential, but there are
two sorts of sympathy; one is a tonic and the other a poison. Sympathy
also requires tact; some when trying to be sympathetic become maudlin.
I do not altogether like the word sympathy as ordinarily applied, I should
prefer sympathetic kindness to kind sympathy. This may be a rather
fine distinction but conveys the shade of difference that I am trying to
express. I shall never forget a grotesque incident that once happened
me when as a patient, I was soon to be taken to the operating room. A
strange interne came in and without saying so much as "good morning"
asked abruptly—"how old are you." I gave him my exact age to the
day and there must have been something in my smile that exposed my
thoughts for he asked the nurse in the office, "is the man in that room
a doctor?" Imagine the effect such an incident might produce upon
the mind of a nervous, apprehensive patient.
Speaking of optimism, I doubt if any of us realize how far its influence extends. We know very little of the forces which activate and
govern the metabolism of the tissue cells and the functions of the body.
We do know that grief, fear, worry and anxiety have a detrimental
effect, causing loss of sleep, loss of appetite, improper digestion and
assimilation. We have often seen people lose ten or more pounds of
body weight under their influence. How far then can optimism produce an opposite effect? We realize that the frequent beneficial effect
of the various forms of "faith cure' 'are due to the return of hope and
Page 153 confidence, but do we make sufficient use of this knowledge in our
practice? There is a valuable little book, written by a layman who
knows what he is talking about, called "Optimism in Medicine." It
is well worth reading. I got one idea from it that is worth ten times
the cost of the book. The writer admonished us never to think that a
patient is not deeply concerned about himself, because he makes light
of the necessity for an examination. If he were not anxious he would
not go to the trouble of consulting us and we should make a point of
assuring him definitely, when we can do so, that he has no serious
disease. Shortly after reading this, an opportunity to test it out presented itself. A man consulted me about his throat; said that he felt
sure that I would find nothing much wrong, he had a little cough probably
from smoking too much and his wife wanted him to see me about it.
He treated the affair as a piece of ridiculous nonsense. As a matter of
fact his own diagnosis was correct, and he had nothing more than a
"smoker's throat." Ordinarily I would have treated the matter as lightly
as he seemed to do; but bearing in mind what I had recently read, I
assured him that he had no evidence of disease whatever, no sign of
cancer, tuberculosis, nor any other disease. He asked immediately if
he could use my phone, called up his wife and told her that the doctor
had just made a thorough examination of his throat and found not the
slightest sign of cancer nor anything else, closing the conversation by
saying "so you see, dear, we have had all our worry for nothing" It
was most evident that this man, in spite of his bravado, had really been
fearing that he had cancer. Had I not relieved his mind, by definitely
telling him that he did not have cancer, he would not have called up his
wife, she would have asked him that evening what I had said; he would
probably have replied, "Oh! nothing much" and neither of them would
have been completely satisfied.    The moral of this story is self evident.
When speaking of inspiring confidence in others I remarked that the
first essential was to have it ourselves. The same is true in inspiring
hope. I trust that you will allow me to dwell somewhat on this subject
for it is one that I feel to be of the utmost importance. It is true that
it will not help us in certain conditions, such for instance as deafness
and others of like nature, but I believe that it is almost always a factor
in recovery and often the chief factor. In such a material condition as
a fractured bone, I believe that the chance of a better union will be enhanced by a hopeful and cheerful state of mind. I also believe that we
can do better work if we are hopeful ourselves. You may say that
this is often impossible. I grant you that it is sometimes so, but often
is too strong. As many of you know I have a lot to do with cancer,
usually cases that are inoperable, and a more difficult test of one's ability
to be hopeful I think you will admit would be hard to find. In spite of
the difficulty I must manage it, if I am to give these unfortunate people
all that I can. In the first place, I regard myself as the buffer between
the individual and the realization of his horrible fate. To do this I
must alleviate his symptoms so far as possible, and above all keep him as
long as possible from hopelessness. The latter I can do only by refusing
to accept the situation myself. I tell myself that the diagnosis may be
a mistaken one—such things have happened. Then I fix my mind on
the possibility of giving him considerable relief which fortunately can
Page 154 often be done. Unfortunately I am a poor actor, and when confronted by some specially untoward evidence am apt to show it by my
expression. In spite of this I manage fairly well and have had a number
of patients reach the end without ever knowing that their condition
was hopeless. So far as I know, none have committed suicide because
of my lack of effort to prevent it. I do not wish to be understood as
regarding this as an awful tragedy from their point of view but I do
not wish to be responsible for it myself. To manufacture confidence,
fortitude and hope out of nothing is, I admit, a difficult task, and takes
a lot out of one.
I have sometimes been criticised for my attitude in the matter of
handling patients with cancer. Some say why bother with them, why
not let them die as quickly as possible. My answer is this—no one shall
die of slow strangulation or thirst, if I can help it. Furthermore many
can be kept comfortable to the end. Others say, these patients should
be told of the situation, so that they may make terms with the Almighty
or get their worldly affairs in shape. To this I reply, that I have not the
slightest belief in the efficacy of death bed repentance and that if their
spiritual advisor wishes to take the responsibility of telling them that
they are dying, that is within his province, not mine. As to straightening out their business affairs, very few of my patients have any. In
any case I always inform the immediate family or friends, as the case
,may be, and am glad to help out if necessary. Even this can be managed tactfully, without passing the "death sentence." The death sentence of a judge is not so bad as it sounds; there is always a hope of
appeal, mitigation, or what not; so, that the condemned man does not
lose all hope, up to the moment the trap drops. It is quite different
with the death sentence of the physician. The criminal may deserve his
fate, but what has the poor victim of cancer done that he should be
condemned to a lingering death of torture—such as no one would inflict
upon the worst criminal. Although I may be unable to prevent it, he
will not be sentenced by me.
As a .rule the seriousness of the situation gradually dawns on these
people, and they do not need telling. A rather large experience satisfies
me that my method is the correct one. I am speaking, of course, of inoperable cases; with those that are operable, the situation is entirely
different but always demands the greatest tact. Some of you may think
that if you had cancer yourself you would prefer to know it. I am
afraid that if such were really the case, you would find you were sadly
mistaken and that your present idea was due to a lack of mature consideration an dexperience. In this, as in all other situations in life, the
"Golden Rule" holds good—"do unto others as you would have others
do unto you." This is not only the golden rule of conduct but also the
golden rule of tact.
Just a few words as to the duty of the older members of our profession to the younger. We must not expect them to be altogether
wise in choosing the most important things to learn. I am thinking
chiefly of our hospital internes. They are naturally most attracted by
major surgery. Should not minor surgery and emergency operations
form a larger portion of their training, so that they will be fitted to take
Page 155 up the routine work of their practice? Is it not of greater importance
that they should be able to treat an infected hand properly, or do a
tracheotomy safely, than to attempt an operation on the gall bladder?
I trust that you will pardon me, if I make special reference to the
operation and after care of tracheotomy, since this has come particularly
to my notice. If there be one operation more than another, that a
hospital interne should be competent to perform it is, I think, that of
tracheotomy; and yet I feel safe in saying that not one in ten of our
internes, when they leave our hospital, know anything about it. Another emergency condition which often requires immediate recognition
and relief, is retro-pharyngeal abscess. Granted sufficient time, the attending surgeon should, of course, be called for both of these operations,
but there are times when he would arrive too late. The same is true to
a certain extent of post operative tonsil haemorrhage and nose bleed.
I mention these things because they come more immediately in the
line of my work; many other illustrations will doubtless occur to you.
Most of all they should strive to learn to make a correct diagnosis. In
the preface to a recent book on Surgical Diagnosis, the writer so well
expresses my though that I will take the liberty of quoting an excerpt
bearing on the point. He says: "there is a tendency for the knowledge
and practice of operative treatment to outstep that of surgical diagnosis
and the opinion has been widely expressed that in this lies the weakness
of modern surgery. It is undoubtedly more difficult to determine when
and how to operate than to carry out the details of any given operation.
There is also, in this and in other countries, a growing tendency to lay
stress—and perhaps an undue stress—upon the value of laboratory and
other special methods of investigation. The careful consideration of the
clinical history and the physical examination of the patient still remain
the most valuable methods of diagnosis, to which the other methods
should be regarded merely as accessory."
The correct diagnosis of the various forms of dyspnoea should be the
subject of a lecture every year, and every opportunity taken for demonstration, so that the interne can differentiate the dyspnoea due to laryngeal stenosis from all other forms. I have several times been asked
to perform tracheotomy for the relief of pneumonia.
The young practitioner may very well manage such cases as permit
of study and reference to his books, but certain emergencies give him no
time for this, and it is such things that demand previous training in
order that he may prove equal to the occasion. As I have suggested, it
devolves upon those of us who know this by experience to see to it that
those who receive their training under our administration go forth adequately equipped both to save lives and do credit to themselves and to
our institution.
Finally, does it not seem that our skill in surgery has outrun our
knowledge? Who can say how far the various dyscrasias may go in
the causation of what we now regard as chronic surgical diseases, and
operate on so smugly? From the results already obtained in the study of
biochemistry it does not seem unlikely that the pendulum will swing
back to more constitutional treatment and less surgery, especially in
chronic conditions.   It seems doubtful whether we are yet in a position to
Page 156 be positive in most of our conclusions, and we are now between
what might be termed the Surgical Era and the Era of Physiology and
Biochemistry. Having developed our surgical skill to a high degree,
let us now try to bring our other knowledge to the same level.
The time has, I think, already arrived when the interne—if he be
what he should—need no longer be envious of the surgeon. In other
words, future advancement depends upon the study of the pathology
of function rather than anatomy.
I recall the time when, in my youthful folly, I fancied that I had
arrived too late; that no field remained for future research. I now feel
that the little we have learned is as nothing in comparison to what remains to be discovered.
Knowledge is to be gained only by study. The profession, as a
whole, is surrounded by vast fields of the unknown, while each of us is
surrounded by lesser fields of what is known to others, but, not to
"ourselves."
WANTED
Young physician and surgeon to take charge of district
and   hospital.    Subsidy    $800.00.    Free   living   quarters.
Furher particulars, apply to
Secretary, Francois Lake Hospital, Southbank P.O., B.C.
<5Very ^Diphtheria £ase
Should 'Recover
If diagnosed EARLY
and if enough Diphtheria Antitoxin is used
FREQUENTLY the physician is not called until dangerously late.   Then, especially,
a most dependable Diphtheria Antitoxin is required and repeated injections may even
be needed.
Under such circumstances select Diphtheria Antitoxin, P. D. & Co.   It is highly
concentrated and purified; limpid and water-clear, with a minimum content of protein
substances.   The syringe contains 40% more antitoxin units than the label calls for.
This provides for possible lessening of activity with lapse of time, assuring full label
dosage up to the date stamped on the package.
Diphtheria Antitoxin, P. D. & Co., is supplied in syringe packages of latest improved
type, ready for instant use.
.*,  ... ■♦•
1,000 UNITS   h   3,000 UNITS   S   5.000 UNITS   4   10.000 UNITS   •*.   20,000 UNITS
.« . •+.
Parke, Davis & Company
License No. 1 for the Manufacture of Biological Products
DIPHTHERIA ANTITOXIN, P. D. V CO., IS INCLUDED IN N. N. R. BY THE COUNCIL ON PHARMACY AND
CHEMISTRY OF THE AMERICAN MEDICAL ASSOCIATION
Page 15/ FIBROSITIS
Although the true nature of musclar rheumatism or
fibrositis is not yet determined, authorities generally agree
that this affection of the voluntary muscles is almost
always due to cold or damp, inducing, in chronic cases,
an inflammatory proliferation of the connective tissue.
With rest as the first indication, the local application
to the affected muscles of a hot
dressing will do much toward the stimulation of a free
flow of lymph through the painful part and constitutes
a rapid and successful treatment in acute cases.
"In cases of neurofi brositis kaolin poultice
(antiphlogistine) affords in the majority of
cases great benefit."
Fibrositis—The Prescriber, Nov., 1926
Antiphlogistine is no ordinary poultice.    By virtue of its
thermogenetic property it strengthens the tissues by
increasing the activity of the circulation, and by
diffusing the products of congestion, muscular rigidity and tenderness is diminished bringing with it almost instant
relief from pain.
The Denver  Chemical Mfg.  Co.
163 Varick St., New York City
Dear   Sirs:
Please   send  me   clinical   data
and sample of Antiphlogistine.
.M.
.St.
City.
Pro-\
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Cut Flowers, Potted Plants, Bulbs, Trees, Shrubs,
Roots, Wedding Bouquets.
Florists' Supplies and Funeral Designs a Specialty
Three Stores to Serve You:
48 Hastings St. E.
665 Granville St.
151 Hastings St. W.
One Phone:
Seymour 8033
Connecting all three stores.
Brown Bros* & Co* Ltd*
VANCOUVER, B. C.
H* K* Lewis & Co* Ltd*
~bAedical Publishers and Book Sellers
Very Large Stock of Text-Books and Recent Literature in all Branches
of Medicine and Surgery
Large Stock of SECOND HAND BOOKS always available at   140,  Gower Street
Catalogue post free on application
COLONIAL LIBRARIES, COLLEGES AND
SIMILAR  INSTITUTIONS—
Special facilities for executing Large Orders for Shipment to all parts of the world.
Effectually protective packing used without charge.
To Residents in Canada, South Africa, India, Australia,
etc., H. K. Lewis & Co. can supply (direct by first mail)
the Publications of all Publishers.
Books sent C. O. D. or V. P. P. where available.
Any Books in General Literature not in stock supplied
to Order.
London: H. K. Lewis & Co. Ltd., 136 Gower St.,
W.C.I. DR. C. S. McKEE
^ AND
DR. R. E. COLEMAN
announce that in future their Clinical Laboratory
Services will be combined and a twenty-four hour
service maintained.
Telephones
Seymour 2996, Bay view 268 and Bay view 5194
Offices:
201, 206 and 214 Vancouver Block
McBeath-
|; Campbell
Limited
Printers and
Publishers
Vancouver, B. C.
The Owl Drug
Co*, Ltd*
All prescriptions
dispensed by qualified
Druggists.
You can depend on the
Owl for Accuracy
and despatch.
We deliver free of
charge.
5    Stores,   centrally   located.
We would appreciate a call
while in our territory. 536 13th Avenue West Fairmont 80
Exclusive Ambulance Service
FAIRMONT 80
ALL ATTENDANTS QUALIFIED IN FIRST AID
"St. John's Ambulance Association"
WE SPECIALIZE IN AMBULANCE SERVICE ONLY
R. J. Campbell J. H. Crellin W. L. Bertrand
STEVENS'
SAFETY PACKAGE
STERILE GAUZE
is a handy, convenient, clean commodity
for the bag or the office.
Supplied in one yard, five yards and
twenty-five yard packages.
B. C. STEVENS CO.
Phone
Seymour 698
730 Richards Street
Vancouver, B. C. "♦*©«
3K*H~
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Ri?fS
3
Hollywood Sanitarium
LIMITED
*i?or the treatment 0/
Alcoholic, Nervous and Psychopathic Cases
Exclusively
'Reference ~ *5B. (?. ePttedical Association
For information apply to
Medical Superintendent, New Westminster, B. C.
or 515 Birks Building, Vancouver
Seymour 4183
Westminster 288
v®r-
SKSSy

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