History of Nursing in Pacific Canada

The Vancouver Medical Association Bulletin: June, 1925 Vancouver Medical Association Jun 30, 1925

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 THE VANCOUVER MEDICAL
ASSOCIATION
a
BULLETIN
Published monthly at Vancouver, B. C.
oJXledical Evidence^
Summer School Trogramme^
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JUNE, 1925
Tublished iry
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PETROLAGAR
No. 4 (UNSWEETENED)
FOR THE DIABETIC
DESHELL LABORATORIES, LTD.
LONDON
W.C.I.
TORONTO
245 Carlaw Avenue
PRESCRIPTIONS
filled exactly as written
Phones I Seymour 1050 * 1051
Day and Night Service
Qeorgia Pharmacy Ltd.
Qeorgia and Qranville Sts.
Vancouver, B. C.
Page Two
.a THE  VANCOUVER   MEDICAL  ASSOCIATION
BULLETIN
Published Monthly under the Auspices of the Vancouver Medical Association
in the Interests of the Medical Profession.
Offices:
529-30-31 Birks Building, 718 Granville St., Vancouver, B. C.
Editorial Board:
Dr. J. M. Pearson
Dr. J. H. MacDermot Dr. Stanley Paulin
All communications to be addressed to the Editor at the above address.
VOL. I.
JUNE 1st, 1925
No. 9
Dr. J. M. Pearson
Auditor
Dr. A. C. Frost
OFFICERS, 1925-26
President Vice-President
DR. J. A. Gillespie Dr. A. W. Hunter
Secretary Treasurer
• Dr. G. H. Clement Dr. A. B. Schinbein
Past President
Dr. h. h. Milburn
TRUSTEES
Dr. W. F. Coy Dr. W. B. Burnett
Representative to B. C Medical Association
Dr. A. J. MacLachlan
SECTIONS
Clinical Section
Dr.   W.   L.   Pedlow	
Dr. F. N. Robertson	
Physiological and Pathological Section
Dr. G. F. Strong -	
Dr. C H. Bastin -
Eye, Ear, Nose and Throat' Section
Dr. Colin Graham      ------
Dr. E. h. Saunders	
Genito-Urinary Section
Dr.G. S. Gordon	
Dr. J. A. E. Campbell	
Chairman
Secretary
Chairman
Secretary
Chairman
Secretary
Chairman
Secretary
COMMITTEES
Library Committee
Dr. Wallace Wilson
Dr. A. w. Bagnall
Dr. W. D. Keith
Dr. W. F. McKay
Orchestra  Committee
Dr. f. N. Robertson
Dr. J. A. Smith
Dr. L. Macmillan
Dr. A. M. Warner
Dinner Committee
Dr. n. e. MacDougall
Dr. A. W. Hunter
Dr. F. N. Robertson
Credit  Bureau   Committee
Dr. Lachlan Macmillan
Dr. J. W. Welch
Dr. G. A. Lamont
Credentials Committee
Dr. Lyall Hodgins
Dr. R. Crosby
Dr. J. A. Sutherland
Summer School Committee
Dr. Alison Cumming
Dr. Howard Spohn
Dr. G. S. Gordon
Dr. Murray Blair
Dr. W. D. Keith
Dr. G. F. Strong
Page Three VANCOUVER MEDICAL ASSOCIATION.
Founded 1898. Incorporated  1906.
28th Annual Session
GENERAL MEETINGS will be held on the first Tuesday of the month
at  8   p.m.
CLINICAL MEETINGS will be held on the third Tuesday of the month
at 8 p.m.
Place of meeting will appear on Agenda.
GENERAL MEETINGS  will conform  to  the following order:
8 p.m.—Business as per Agenda.
9 p.m.—Paper of Evening.
The regular work of this Session will commence on Tuesday, Oct. 6, 1925.
Programmes  to  be  announced   later.
HEALTH DEPARTMENT STATISTICS.
APRIL, 1925.
Total copulation—estimated 	
Asiatic population—estimated p	
Rate per
Pop. pe
Total  Deaths     122
Asiatic Deaths         9
Deaths—residents only       91
Total Births—Male,   159
Female,  162   321
Stillbirths—not included in above      11
Infantile Mortality—
Deaths under  1  year of age        7
Death rate per   1000  births 21.8
Cases  of Contagious  Diseases  Reported.
126,747
9.960
1000 of
r annum
11.7
11.0
8.7
30.8
March.
Cases.  Deaths.
April.
Cases. Deaths.
Smallpox    92 0 30         0
Scarlet Fever    66 0 29         0
Diphtheria     11 1 15          0
Chicken-pox     83 0 77         0
Measles   2 0 10
Mumps     47 0 15         0
Erysipelas      2 0 0         0
Tuberculosis      14 10 7          9
Whooping  Cough    8 0 4         0
Typhoid  Fever    '3 0
Ep. Cerebro-Spinal
Meningitis   1 1
(Cases from outside City—included in above.)
Diphtheria   |  11 10
Smallpox   l  4 0 0         0
Scarlet  Fever    6 0 3         0
May
to 15th
Cases.
5
31
3
33
0
11
1
28
15
0
0
i
3
Page Four X'Ray Laboratory of Dr. A. D, Willmoth, Louisville, Ky, Victor Equipment Throughout
Time and Use Reveal Victor Quality
As1 months and years pass, the Victor X'Ray
machine installed in the physician's office or in
the specialised roentgenological laboratory un'
failingly responds to the demands made upon
it. Day after day, the same trustworthiness in
operation, the same certain results as in the
beginning.
Thus time and use reveal the quality pains'
takingly built into every Victor X'Ray machine.
There are simple Victor X-Ray
machines which meet the de-
mands of general practice, and
powerful diagnostic and dzep*
therapy apparatus for institu*
tions and laboratories. The
same Victor quality is built
into all.
We shall be glad to suggest the
type of Victor installation best
calculated to meet the require-
ments of the physician in general
practice, the hospital or special-
iz;ed laboratory.
VICTOR X-RAY CORPORATION, 236 South Robey St., Chicago, Illinois
Territorial Sales and Service Stations:
Vancouver:
Victor X-Ray Corporation of Canada, Ltd.
910 Birks Building
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pPi|
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llilOllllillllllllllllllllllllllllllllllllllllllllillllllllllllllllllllllllllllllllllillllilU "HOLDTITE"
Scrotal Rupture    -    Single or Double
TriDate fitting <rRgom
body ^Attendant
Canadian Surgical Supplies Limited
Robson and Burrard Streets
Vancouver, B. C.
Page Six EDITOR'S PAGE.
By the time this issue of The BULLETIN reaches our readers
the graduation exercises of the Training Schools for Nurses at the
General Hospital and at St. Paul's Hospital, Vancouver, will be
completed.
In addition a number taking the courses in Nursing at the
University of British Columbia received the degree of Bachelor of
Science in Nursing at the hands of the Chancellor.
At the General Hospital the largest class in the history of
that institution has finished its training. All of which moves us
to a few reflections on Nurses and Nursing. As fellow labourers
in the same vineyard we wish these most recent alumnae well. In
the chronicle of the discoveries in medical science during the last
50 years, the discovery and development of the modern trained
nurse takes a highly important place. As an efficient "activator"
of the resources and methods of medicine the nurse contributes in
no small degree to their success. We feel sure that these latest
representatives of their profession have justly earned their titles.
Apart from the hazardous nature of the occupation which yearly
takes its toll of the less fit or less fortunate, the training is arduous
and calls for mental, moral and physical qualities of no mean
order.
On its theoretical side it may not inaptly be compared to the
training required for a medical student of not a great many years
ago. Always the laudable desire has been to stimulate intelligent interest in the practical side of nursing by extending the
scope of the theory (shall we call it?) acquired from books and
lectures.
Increasingly a more highly finished and therefore more expensive article is produced, and a question may be pertinently
asked as to what end such a road will lead. We can agree at
once with the validity of the lately established University course.
For those nurses who have in view teaching or administrative
careers or occupation in the public services, no training can be too
thorough or too extensive. When we come to that part of the
work which will always interest and occupy the great majority—
bedside nursing—the answer is not so simple. Obviously the
longer and more expensive the course, the higher should be the
tendency of the remuneration, though we doubt whether the
analogy holds good in the case of the medical profession, which
during thirty years has raised its requirements from four years to
seven years. No one can justly deny that the trained nurse of
to-day is entitled to all and more than all she at present demands.
At the same time it is important that no considerable portion of
our people should be denied nursing service because they are not
able to pay the current price.
The solution may be for nurses as for many it appears to
be for doctors in some form of state aid in case of illness.
Page Seven Apart from this we have to consider the effect of theoretical
training upon the development of the nurse herself. We confess
ourselves to be in a quandary. Under present circumstances it is
probable that much of this part of the course goes over the heads
of the pupils and constitutes a mere memory exercise for the purpose of satisfying examinations.
But how much of all our "education" is of the same nature.-
Even if one grants that abolition of all theoretical training would
not make any nurse one whit less efficient at the bedside, that
does not solve the question. For our hope of civilization, our
idea of progress in the human race is based largely on the spread
and increase of that development of the mind which we term
education. To deny this to the rank and file of a calling which
requires intelligence, alertness as well as all the virtues of the
Decalogue, seems futile.
Perhaps, as our space is limited, our best advice to those in
charge of training schools and thinking much on this subject, is
to go slowly. The modern wider outlook of women and a praiseworthy enthusiasm has possibly tended to overstress what may be
regarded at present as perhaps ornamental rather than fundamental.
A pleasant little note about THE BULLETIN appears in the
editorial comment of the April number of the Journal of the
Canadian Medical Association.
To tyros like ourselves such a word from those who know
is immensely encouraging.    Thank you, Mr. Editor.
We have much pleasure in calling attention to the excellent
programme arranged by the Summer School Committee, which
our readers will find in detail on another page of this issue. We
may confidently assert that never in the history of the Summer
School has such an array of talent been gathered together. We
are quite sure that none of our readers in or out of town can afford
to miss this meeting. Co-operative arrangements of this sort,
whereby speakers of eminence are brought to a central point in the
province, are worthy of every encouragement, and we trust that
the medical practitioners of B. C. will rise to the occasion and
give the Summer School Committee the support it so well deserves. Applications for registration can be addressed at any time
to Dr. G. F. Strong, the earlier the better. We would also call
the attention of those intending to come from out of town to the
advisability of making hotel reservations a reasonable time before
the meeting begins.
Page Eight Summer School Clinics
of th&s
VANCOUVER MEDICAL ASSOCIATION
JULY 2nd - 3rd - 4th
All meetings will be held in the Lecture Room of Wesley Methodist
Church,   on   Georgia   Street,   two  blocks   west  of   the
Hotel Vancouver.
Speakers
SIR HENRY M. W. GRAY, Surgeon in Chief, Royal Victoria Hospital,
Montreal.
DR. HUGH CABOT, Professor of Surgery, University of Michigan,
Ann Arbor, Michigan.
Dr. JAMES G. CARR, Associate Professor of Medicine, Northwestern
University,  Chicago,   111.
DR. ALAN BROWN, Professor of Paediatrics, University of Toronto.
DR. ROSCOE GRAHAM, Department of Surgery, University of Toronto.
Tragi ammes
THURSDAY,  JULY  2nd.
9.00  a.m.—Dr.   Hugh  Cabot:     Non-tuberculous  Infections  of  the
Kidney.
10.00  a.m.—Dr. Alan Brown:    Nutritional Disturbances in Infancy.
11.00  a.m.—Dr. James G.  Carr:     Auricular Fibrillation.
3.30  p.m.—Dr. Roscoe Graham:     Surgery of the Thyroid.
4.30 p.m.—Dr. Hugh Cabot: Nature and Prevention of So-called
Catheter  Cystitis.
8.00 p.m.—Sir Henry Gray: Developmental Abnormalities Affecting the Colon; Their Far-reaching Effects; Suggested
Treatment.
9.00  p.m.—Dr. Alan Brown:     Deficiency Diseases.
FRIDAY, JULY 3rd.
9.00  a.m.—Sir Henry Gray:     Carcinoma Mammae.
10.00  a.m.—Dr. Alan Brown:     Eczema.
11.00  a.m.—Dr.   Jas.   G.   Carr:      Intrathoracic    Complications    of
Pneumonia;    Diagnosis  and Principles  of Treatment.
2.30  p.m.—Sir Henry Gray:    Acute Osteomyelitis.
3.30 p.m.—Dr. Alan Brown: Intestinal Indigestion in Older
Children.     Wgg
4.30 p.m.—ANNUAL MEETING of the B. C. MEDICAL
ASSOCIATION.
6.30 p.m.—DINNER (Informal), B. C. MEDICAL ASSOCIATION, at the Hotel Vancouver. Speaker: Sir Henry
Gray.
8.30  p.m.—Dr.  Jas.  G.  Carr:     Treatment  of  the  Anaemias.
9.30 p.m.—Dr. Hugh Cabot: Ulcer of the Stomach and Duodenum.
SATURDAY, JULY 4th.
9.00  a.m.—Dr. Jas.  G.  Carr:     Coronary Sclerosis.
10.00  a.m.—Dr. Hugh Cabot:     Diseases of the Gall Bladder.
11.00  a.m.—Sir   Henry  Gray:     Acute  Intestinal  Obstruction.
The Registration Fee for the Course is Ten Dollars, payable in
advance.
Secretary:    DR.   G.   F.   STRONG,
736  Granville  Street,  Vancouver,  B.  C.
Page Nine NEWS AND NOTES.
Dr. J. C. Farish and Dr. J. A. Smith left recently on the
Empress of France for a trip as far as New York, via the Panama
Canal.
The Annual Convention of the British Columbia Graduate
Nurses' Association was held in the Royal Columbia Hospital,
New Westminster, April 13 th, and the Vancouver General Hospital April 14th. Besides the usual committee reports, an interesting paper was read on "The Present Status of Psychotherapy"
by Dr. S. C. McEwen, and a demonstration of the administration
of.insulin by Misses Smith and King during the first day.
On the next day Dr. W. D. Keith gave a paper on "Goitre."
Mrs. H. H. Mcintosh read a paper, "On the Private Duty Nurse's
Contribution to Public Health." Dr. G. A. Lamont gave an address on "Child Welfare." A health play was given by the children of Strathcona public school.
In the evening a very enjoyable banquet was held at the
Ambassador Cafe, at which about  125 were present.
In a recent communication the District Superintendent of the
Victorian Order of Nurses has called our attention to the fact that
their central office for Greater Vancouver is now located in the
Lee Building at Main and Broadway, and their new telephone
number is Fairmont 1040. She states further that the V. O. N.
maternity nurses are now provided by the Provincial Board of
Health with capsules of silver nitrate solution for prophylactic use
when requested by the attending physician.
B. C. MEDICAL ASSOCIATION NEWS ITEMS.
Readers will find a full account of Mr. Justice Murphy's able
address, given on April 29th, to the B. C. Medical Association.
This will be found very well worth reading and keeping for purposes of reference. The speaker covered many important points
with admirable conciseness and lucidity, and we are very grateful
to him for the trouble and care that he obviously took in the preparation of this address. There is no subject on which the average medical man needs advice and help more than on the matter
of giving evidence in court.
We would call our readers' attention to the fact that the
Annual Meeting of the B. C. Medical Association will be held on
Friday, July 3rd. The Vancouver Summer School is holding its
meetings at this time, and we hope to secure a speaker for a dinner
to be given by the B. C. Medical Association on the evening of
that date. The- business meeting will be held in the afternoon,
and the election of officers immediately following the dinner.
A meeting of the full Executive Committee of the B. C.
Medical Association was held on April 29th, when a number of
matters were dealt with.
Page Ten The B. C. Medical Association will recommend, at the Annual Meeting, the election of Dr. G. L. Milne, of Victoria, as an
honourary member of the Association.
Dr. Wallace Wilson, chairman of the Publicity and Educational Committee, gave an interim report of the work of his committee. The question of vaccination came up, and it was decided
that the Association should endeavour to obtain as much material
from the chairman of the Provincial Board of Health as possible,
for distribution to doctors' offices. It was also suggested that the
publication "Hygeia" be brought to the attention of medical men,
who should be asked to keep copies in their offices for the benefit
of their patients.
The monthly meeting of the Fraser Valley Medical Society
was held on Thursday, April 30th. Clinical cases were given by
Dr. G. W. Sinclair, Dr. H. L. Collins, Dr. W. A. Robertson, and
Dr. G. S. Purvis.    There was a good attendance of the local men.
Dr. G. B. Henderson, Creston, is leaving on May 7th for a
well earned six weeks' holiday. His practice will be cared for by
Dr. J. M. Burnett.
The deepest sympathy of the members of the B. C. Medical
Association is extended to Dr. A. J. Stuart, of Mission, in the
irreparable loss he has sustained in the death of his wife, who
passed away on May 2nd.
Dr. D. J. McDonald, who has been spending the winter
months in Vancouver, has returned to his practice at Kincolith,
Naas River, B. C.
Dr. D. W. Davis, late of Coleman, Alberta, is now associated
with Dr. D. P. Hanington, of Kimberley, B. C. The people of
Kimberley are to be congratulated on their new and very up-to-
date hospital, opened recently. It will make the work of the doctors there much more pleasant.
PACIFIC COAST OTO-OPHTHALMOLOGICAL SOCIETY
The Annual Meeting of the Pacific Coast Oto-Ophthalmo-
logical Society will be held in Vancouver June 18, 19 and 20.
Headquarters will be at the Hotel Vancouver, and a very interesting and instructive programme has been arranged, with a number of distinguished guests. The Entertainment Committee is
arranging to see that there will be no idle moments for the visiting doctors and their wives.
The following are a few of the many interesting papers that
will be read at the meeting:—
"Advance in the Treatment of Congenital and Acquired Deformities of
the Face and Neck," by Dr. Gordon B. New, of the Mayo Clinic.
"Ophthalmic Aspects of General Medicine," by Dr. Edward Jackson, of
Denver,  Col.
"Sinus Infection in Children," by Dr.  Francis N.  Shook.
"Malignant Disease of  the Antrum,"  by Dr.  M.  J.  Keys.
Page Eleven "The Diagnosis and Symptomatology of Allergic Conditions in the Upper
Respiratory Tract,"  by Dr.  George Piness.
"Some Applications of Ultra Violet Rays in the Eye, Ear, Nose and Throat
Field," by Dr. H. V. McBeth.
"Thrombosis of the Sigmoid Sinus and Blood Stream Infection," by Dr.
G. F. Chase.
"Visual Economics," by Dr. Harry Wurdemann.
"Ligation of the External Carotid Artery for the Control of Idiopathic
Nasal Haemorrhage," by Dr. Frederick P. Hyde.
LIBRARY NOTES.
(The Library is situated in Rooms 529-531, Birks Building, Granville Street,
Vancouver.     Librarian:   Miss Firmin.     Hours:   10 to  1,  2  fo  6.)
Crime and Insanity, by W. C. Sullivan, M.D., Medical Superintendent, Broadmoor Criminal Lunatic Asylum. E. Arnold
8 Co., London.    1924.    12s. 6d. net.
This work is based on a course of post-graduate instruction
given by the author at Maudsley Hospital, Denmark Hill. Considerable space is given to classification of crime, and some very
interesting tables are to be found in that and other chapters.
General paralysis, senile and alcoholic psychoses, mania depressive psychoses, dementia praecox, delusional insanity, epilepsy,
transitory nervous disorders, hysteria, mental deficiency and moral
imbecility are described in a brief but up to date manner, and many
interesting illustrative case histories are quoted at some length.
It is interesting to note that among 631 male patients admitted to Broadmoor during the last 20 years for murder, attempted murder and manslaughter, only six were suffering from
G. P. I. This disorder is responsible for many minor offenses,
but apparently, because of the type of early degeneration, rarely
figures in the more serious crimes. Criminal responsibility, from
the legal and medical points of view, is fully discussed.
The McNaughton case and the origin of the McNaughton
rules in 1843, which to-day constitute the authoritative procedure
of the law in British courts with respect to criminal responsibility
of the insane, is gone into with some detail.
This book covers a wide range of subjects in its 250 pages,
and forms a handy reference volume and is also presented in form
for easy reading.
W. A. D.
RECENT ADDITIONS TO THE LIBRARY.
Trans. Amer. Laryng. Rhinol and Otol. Society for 1924.
Medical Clinics N. America.    Jan., 1925.   Mayo number.
Surgical Clinics N. America.   Feb., 1925.   New York num
ber.
Trans, of Amer. Proctologic Society for 1924.
Collected Reprints, Vol. 3.    Thos. S. Cullen.
Page Twelve Clinical Examinations of Surgical Cases.   Renfrew White.
Electrotherapeutics and Diathermy.   Betton Massey.
Fertility and Sterility in Human Marriages.   Reynolds and
McComber.
U. S. Treasury Health Reports for 1924.
Medical Clinics N. America.  March, 1925.   Boston number.
Clinical Therapeutics.   A. Martinet.   2 vols.
Well's Gynaecology, Compend.   J. B. Harer.
Life of Sir William Osier.   Harvey Cushing.
Orations and Addresses.   Sir John Bland Sutton.
Physiological Principles in Treatment.   Langdon Brown.
Heart Disease.   Heatherley.
Clinical Index of Radium Therapy.   A. E. Hayward Pinch.
INFLAMMATORY DISEASES OF THE EAR.
Dr. R. B. Boucher.
Part III—Of the Middle Ear.
In connection with this, I propose briefly to take up the
symptoms and etiology of acute catarrhal and acute suppurative
otitis media, then deal briefly wtih acute infection of the mastoid
and give you the differential points between mastoid and furunculosis in tabulated form.
Howell says that acute catarrhal otitis media comprises about
13% of all ear diseases. It is a condition that the general practitioner is frequently called upon to treat.
General Etiology—The causes are numerous and may be considered under three different heads:
(1) Exciting causes or pathogenic micro-organisms.
(2) External influences or those conditions external to the
body which act as predisposing causes.
(3) Internal influences, or those conditions within the
body which predispose to otitic inflammations.
1. The exact relation of micro-organisms to the inflammation of the middle ear is not yet fully determined. That they are
found in healthy ears is probable, as the investigations by Zanfal
have shown them to be present in the ears and epi-pharynx of rabbits. We know that the various infectious fevers—as scarlet fever,
measles, diphtheria, etc.—are often accompanied by acute catarrhal
otitis media, although complications from these sources are very
prone to take on the suppurative type. There is no special bacteria
which causes this type of inflammation, but there is usually a combination of two or more, such as the Diplococcus pyogenes, the
staphylococcus pyogenes albus and aureus, and the bacillus pyo-
cyaneus, are usually next most frequently found.
Friedlander's bacillus is less frequently found in combination
with the staphylococcus cereus albus, bacillus pyocyaneus and the
Page Thirteen micrococcus tetragenus. These and other organisms may be present in the tympanic cavity without exciting inflammation. It is
necessary that the conditions of the secretions and the tissues be
favourable for their rapid propagation before they are able to excite an inflammatory process, such as the entrance of a new microorganism. At any rate the presence of micro-organisms per se is
not sufficient to cause acute inflammation. They must be of the
proper virulency, the soil must be prepared to favour their activity,
and the cellular structure must be so modified in their functional
activity as to be unable to resist their influence.
Channels of Invasion—In a great many instances microorganisms gain access to the tympanum through the Eustachian
tube. They may, however, enter by the blood vessels, which carry
them to the mucous membrane of the tympanum, where they may
be thrown out with the serum. They may also gain access through
the drumhead, when it is perforated, either from congenital or
pathological states. In rare instances they may gain entrance from
the cranial cavity through the bony walls, or through the internal
auditory canal and labyrinth.
External Influences—Badly clothed, badly nourished people, exposed to inclemencies of the weather, are most susceptible.
Any condition which has to do with the lowering cell vitality,
is a predisposing cause. People living in damp, chilly climates are
more affected. The skin becomes chilled more easily—vaso-motor
nervous centres are disturbed and many of the functions of nutrition and metabolism are disturbed and modified in such a way as
to excite inflammatory processes in the mucous membrane, especially those of the upper air passages.
Males are more subject than females, and young people most
susceptible.
Internal Influences—The internal conditions which predispose to catarrhal inflammation of the middle ear and upper respiratory tract, have a more intimate clinical relationship to acute
catarrhal otitis media than the external influences. It is well established that middle ear disease is almost invariably preceded by some
form of nasal or epipharyngeal disease. Whatever causes the preexisting infection and inflammation of the nasal mucous membrane
or the mucosa of the epipharynx will also directly or indirectly
lead to a similar condition within the Eustachian tube and middle
ear. The mucosa of the nose, epipharynx, Eustachian tube and
middle ear are lined by columnar ciliated epithelium, hence there
is no bar to the extension of the inflammatory processes from one
to the other. Consequently anything which creates disturbance
in the nose may, under favourable conditions, create trouble in the
middle ear. Any inflammatory condition, any nasal obstruction,
ethmoiditis, any form of sinus trouble, tonsils, adenoids, etc., are
all responsible for much trouble.
General Symptoms-—The onset' is usually signalized by a
slight chill, which is quickly followed by a temperature ranging
Page Fourteen from 99 to 102. Frequently the fever is so slight that the attention of the patient is not attracted to it. The symptom which
quickly develops is pain, which may be characterized as a dull,
boring, aching sensation, or it may be excruciating in character. It
may be throbbing in character, synchronous with the pulse beat.
It is due to swelling of the drum and mucous membrane of the
middle ear, whereby the sensitory nerve filaments are put on the
stretch, and frequently forcing the drum into the meatus. There
is a great amount of intercellular fluid thrown out at this stage of
the disease, which, together with the congestion of the vessels, renders the mucous membrane and drumhead much thicker than
usual.
In the first stage, then, the drum is red. and thickened, the
handle of the malleus obscured from view or very much injected.
Its surface may present the appearance of a piece of raw beef, except that it is more velvety in texture. The drum may or may
not bulge into the external meatus, depending upon the amount
of secretion within the middle ear. The more secretion in the
middle ear, the more bulging of the drum and the more pain. If,
however, it is only partially filled, it may remain in its normal
position.
Auricular tenderness is sometimes present, especially over the
tragus. The mastoid process may or may not be tender on pressure, but pressure over the antrum nearly always elicits tenderness.
Tuning forks show catarrhal change reactions, except in
labyrinthine involvment when bone conduction is shortened.
Second Stage—The second stage is characterized by a subsidence of the pain, fever and redness of the drum. The drum,
instead of being beefy or purplish in colour, is yellowish or greenish in tint. The change in colour is due to the fact that there is
less congestion and the pale, slightly greenish secretion in the
middle ear is seen through it. The greenish-yellow colour often
gives rise to the idea that there is pus in the middle ear.
Another symptom of considerable importance is the presence
of a dark, wavy line, extending in a nearly horizontal direction
across the drum. This line is due to the peculiar refraction of
light at the junction of the viscid secretion and the air in the tympanic cavity. If the middle ear is completely filled there will be
no line. The line is often not visible on account of the thickness
and congestion of the drum.
This, then, is the beginning of subsidence and frequently
from this on the case is one of uninterrupted recovery.
The duration of the acute type varies from one to six weeks.
Pain disappears first, then the redness and thickness of the mucosa.
Hearing begins to return. Later tinnitus—when present—passes
away. This symptom may remain, however, for months. On
the other hand, where the symptoms are very slight, and where
the drum shows only redness of the handle and slight congestion,
with very little thickness and no bulging, in these cases under suitable treatment the symptoms will clear in three or four days.
Page Fifteen The acute catarrhal condition may readily progress and pass
into the more aggravated form of an acute suppurative otitis media.
The diagnosis between a well-marked case of acute catarrhal otitis
media and the early stage or an acute suppurative condition is
neither easy nor simple.
Probably two of the most important points to remember are:
(1) Pain—In suppurative otitis media the pain, previous
to perforation is very intense and boring in character, whereas in
catarrhal otitis it is a dull, boring and aching sensation.
(2) Temperature—Temperature in acute suppurative conditions is higher, ranging one to three degrees and more in children.
Adults do not show such a high rise. Children frequently run to
103-104. In acute catarrhal otitis media the temperature does
not usually exceed one to two degrees.
The appearance of the drum head in both cases is similar
before perforation, except that the suppurative type may show a
whitened bulging area, where it is getting ready to perforate.
Prognosis—The prognosis in the acute catarrhal type is good
if seen early before adhesions have begun. The prognosis, on the
other hand, in the suppurative type must be guarded, as in this
type nobody knows when untoward symptoms may develop.
Treatment in the Acute Catarrhal Type—The first symptom
to relieve is pain, and this may be done in several ways.
A mixture of equal parts of carbolic-glycerin and cocain
hydrochlor gives excellent results. A few drops into the meatus
—warmed.
My own choice for the relief of pain is: Carbolic and glycerin, 5'/(, dropped warm into the meatus every three hours and
continued until symptoms subside.
Laudanum and oil is frequently used warm, but I must confess I have never seen much result.
Chloroform fumes, blown into the meatus, sometimes gives
relief, and some busy people even use tobacco smoke.
Leeches applied to the tragus or posterior to the auricle also
relieves the pain, and favours the reaction of inflammation. The
result from this is sometimes prompt and should be more frequently employed.
Cold—heat dry or moist—leukodescent light, and so on,
have been used. Some of the coal tar derivatives may be used to
quiet the patient. Should the pain persist, then a myringotomy
should be done.
After the subsidence of the acute condition gentle inflation
of the tube and tympanic cavity should be done. This must be
done gently and favours drainage and prevents adhesions.
So much, then, for the actual treatment, but let me once
again impress upon you that 90 odd per cent, of these cases is due
Page Sixteen to nose and throat trouble. Conseqently, then, this point should
not be overlooked. In infectious cases a good routine is a mild
organic silver salt dropped into the nose two or three times a day.
Where the ear condition is established, an astringent spray of some
sort, followed by a drop of, say, argyrol, 5% or 10% solution,
is useful. After the attack, nose and throat conditions should be
checked up and corrected.
Acute Suppurative Otitis Media.
Symptoms—The symptoms are an aggravated type of the
catarrhal otitis. The main differential diagnosis I have already
told you, namely, pain and temperature.
Before considering the prognosis and treatment of this type,
I would like to mention something which may interest you.
In scarlet fever the commonest time for ear complications
to occur is the second or third week. In diphtheria during the
acute symptoms and in measles during the acute stage—fever still
being present.
And while at this point, let me briefly review the symptoms
of an acute otitis in children.
In children with cachexia there are often no subjective symptoms. Objectively the drum may be a little reddened, especially
about the short process, and along the handle of the malleus. A
small amount of slimy secretion may be found in the canal. It
may be questioned whether the cachexia is the cause of the ear condition, or the ear condition the cause of the cachexia. It is quite
certain, however, that even a mild suppurative process in infants
is quite sufficient to cause pronounced disturbances of nutrition.
Every case of malnutrition, peevishness, twisting of the head, or
dropping it to one side, should lead to the careful inspection of
the ears. Boring the head, or occiput into the pillow; hanging it
to one side (usually the affected ear) ; placing the hand to the affected ear; going to sleep when lying on the ear to which the head
is inclined; refusing to take the breast except on the side which
allows the patient to lie with the affected ear against the bosom—
all point to acute inflammation of the ear. The infant cannot tell
its sufferings, but if the physician carefully observes its actions,
they will often speak louder than words.
In older children the symptoms are more pronounced and
just prior to rupture the pain is usually intense. There may be
signs of labyrinthine and meningeal irritation. Rupture of the
ear drum gives immediate relief, and the treatment then resolves
itself into one of an acute suppurative otitis. The tendency to
frequent relapses is prominent in children, but not nearly so much
now as formerly, because the naso-pharynx and throat receive
earlier attention now than formerly.
Prognosis—The prognosis of an acute suppurative otitis
media is always guarded until better. Uncomplicated cases run in
adults about three weeks;    in children from one to two weeks.
Page Seventeen 1
I say "guarded" on account of the apparent harmlessness of the
disease in many cases, whereas in reality it is a grave and destructive
one.    It is not the disease that is feared, but the sequelae.
For convenience let me tabulate Politzer's classification of
terminations:—
1. Cure.
2. Catarrhal.
3. Adhesive processes.
4. Permanent deafness.
5. Mastoiditis.
6. Loss of mucous membrane-ossicles and infection of the
Chronic suppuration.
8.     Death  from  meningitis,  sinus  thrombosis,   septicaemia
or brain abscess.
Treatment—The treatment of an acute suppuration really is
free drainage, and asepsis. In the early stage a most valuable thing
is Carb.-Glyc. 5%, freely dropped in. It is hygroscopic, antiseptic, reduces the oedema of the mucous membrane and thus establishes a more rapid flow of blood through the tissues. The resistance of the tissues is thus raised. I have used this alone in a number of cases with excellent results, after perforation. Before perforation, with a bulging drum, fever and pain, free incision should
be done. This should be curved and in the posterior quadrant.
It should also be free and should h.e done with a good light. An
ordinary puncture does not allow sufficient drainage, and is obsolete. Drainage is the object, and it should be free. After incision
fill the ear with Glyc.-Ac.-Carb. 5%. This may be used throughout or later warm irrigation or drainage by wick. That is either
the wet or the dry treatment. If the secretion is thick and tenacious, a warm, alkaline solution is useful. The canal should be
mopped out gently at each treatment.
As the mastoid is always more or less involved, an ice bag
is useful to mastoid process.
The naso-pharynx should be treated as outlined before, and,
if adenoids are present, they should be removed on the subsidence
of the attack, or if a mastoid intervenes and operation is indicated
they may be done then, provided there is no acute infection in the
epipharynx.
Ordinary cases, on subsiding, require gentle inflation of the
tube to prevent adhesions.
The mastoid is always more or less congested during all
suppurative middle ear inflammations. Establishment of drainage in a large number of cases causes clearance. Some cases progress—and mastoiditis ensues.
Page Eighteen MEDICAL EVIDENCE.
An Address Delivered at a Luncheon of the B. C. Medical
Association, April 29, 1925, by Mr. Justice Murphy.
Mr. Justice D. Murphy, speaking at a luncheon of the B. C.
Medical Association in Vancouver on April 29th, addressed the
doctors present on the subject of "Medical Evidence." .He told
the doctors that, both from the standpoint of good citizenship
and also from the standpoint of their own personal advantage,
they should inform themselves of how to give evidence effectively,
because the public is likely to confuse a man's ability as a doctor
with the way in which he gives evidence.
The Doctor a Poor Witness.
Mr. Justice Murphy said: "Doctors should become informed of the best way of giving evidence. One would think," he
said, "that doctors would be the best of all witnesses because they
are trained in the principles of minute observation, and observation
is the basis of good evidence. The reason medical men do not
make good witnesses is because their standpoint is different from
the standpoint of the courts.
"A doctor's business and interest in regard to his patient is,
first of all, to try and bring about a cure.    If the patient should
die then his duty is finished. So far as the law is concerned that
is very often the starting point of its interest. Inasmuch as every
practitioner, who has any practice at all, is bound to be called into
court as a witness sooner or later in the course of his practice, it is
essential that in cases of death from accident or violence the doctor
should remember that he is liable to be called as a witness, and
should take steps accordingly.
Minute Observation Absolutely Essential.
'The first thing to do is to make minute observations of all
the facts, no matter how non-essential they may at first sight appear to be. First, the time should be accurately noted, and the
condition of the body of the dead person. If a wounded person,
then a very minute and careful observation of the wound should
be made." To show the importance of this, Mr. Justice Murpljy
refrered to a case in which Sir Astley Cooper, a famous member of
the medical profession many years ago, was called on one occasion
to attend a person who had been stabbed, and the person died.
Sir Astley made a very minute observation of the wound and
found that it was straight on one side and round on the other.
A man was subsequently arrested on whom a knife was found,
which knife could have occasioned that wound, and the reason he
was arrested was because of the doctor's close observation of the
wound. With that clue the murder was brought home to that
man.
Results of Lack of Minute Observation.
'To show what may happen when the doctor is not keenly
observant, a case is reported where a woman was found dead in
bed with numerous lacerated wounds over the skull.    When the
Page Nineteen authorities arrived (the doctor had seen the woman, but had made
no observations) there were some nails driven through the head of
the bed, and the son put that fact forward as a defence, arguing
that the woman had struck her head against these nails and they
had caused her death. In all murder cases the jury is told that the
facts must be proved beyond reasonable doubt. There was reason
to believe that the nails had been put there afterwards, but the
doctor, not having made minute observations, this fact could not
be proved.
Condition of Body.
"The doctor must note the condition of the dead body, and
if there be any weapon about he must also note its condition. He
should also note the condition of the clothes, the position of the
body, and the possible direction of the wound.
"To give another instance in which the doctor was instrumental in bringing the murderer to justice. A man was found
shot in his private room. He died, and the doctor carefully examined the direction of the shot. He concluded from his observations that the pistol must have been fired by a left-handed man.
It is very necessary a doctor should make careful observations
immediately he is called to the case, because, as you know, people
rush in and move things about. This doctor informed the authorities that the shooting had been done by a left-handed man.
There happened to be a friend of the dead man in the house, and
with that clue the murder was brought home to him.
Importance  of Immediate  Note-taking.
"So you see the necessity of close observation, and having
made your observation take notes, and keep those notes, and the
sooner you make your notes the more weight they will have in
court. You will not be allowed to read your notes, but you will
be allowed to refresh your memory from them. It is for the judge
to say whether you will be allowed to read them or not. If you
wait days before making your notes, instead of writing them down
within an hour, the jury will attach so much the less weight to
them. The reason you should take notes is because no man can
depend upon his memory, and criminal law moves slowly. All law
moves slowly, but especially criminal law, as you will some day
find.
The Coroner's Court.
"You will be called to various courts, and the first court you
will appear in will be the coroner's court. Many people regard
the coroner's court as of no importance at all, but remember that
every word you use in the coroner's court will be used afterwards
in the assize court. You should therefore take your notes with
you to the coroner's court and give a very careful statement there.
You should treat the coroner's court in exactly the same way as
you would treat the assize court, because if, later on, you make any
change in your statement—if there be any difference in it at all—
you may be sure that counsel will seize on every change and make
Page Twenty much of it. And, referring to the close observation of facts, counsel will endeavour to find something you have overlooked, and he
may make much of that omission to the jury. So, whether things
look important to you or not, put them down in your notes, and
remember that everything you say in the coroner's court will be
available in the assize court later on. And remember to have with
you your original notes, you will not be allowed to use copies.
Facts, Not Opinions, Wanted.
"Good doctors, as well as many other witnesses, fail to realize
what a witness is called for. Witnesses are called to testify to
facts. You should therefore tell your story in some logical order
—chronological order—and confine yourself to facts, and not
make use of words that imply opinions. For instance, if, when
you are giving evidence in a case where the person has died, you
refer to him or her as 'the murdered person,' you are giving your
opinion on the very point that is being tried. The dead man or
woman may not have been killed. So your statement should be
clear, it should be entirely one of facts, and of facts that you have
observed yourself, not what other people have told you.
"Doctors are placed on a sort of pedestal, and if a slip of the
sort I have just mentioned is made by a doctor, you may be quite
sure that counsel will make the most of it before the jury. We
should, as citizens, be desirous of seeing justice done, of seeing the
perpetrators of a crime punished, and of seeing that innocent people are not unjustly found guilty.
Use Simple Language.
"Use simple language. Doctors are fond of using technical
terms, but the average layman knows nothing about technical
terms. It may be that when you are speaking you unconsciously
use technical terms, but if you should do so, then immediately
translate them into simple language. Some doctors think they
impress people and therefore use all sorts of technical terms, and
finally they are told they are ridiculous.
"You remember the case of the young doctor who was called
to give evidence in a case of assault, and was asked to describe the
injuries, and he said there was 'a severe contused area with extravasation of blood and ecchymosis into the surrounding cellular
tissues,' etc., etc., when he should have just said quite simply that
the person had a 'black eye.' You should not use technical language, but if you do unconsciously drop into it, you should immediately explain what you mean. Do not indulge in exaggerations. Exaggerations are very dangerous things in courts of law.
Words are to lawyers what the human body is to doctors, and
while sometimes the use of words leads to pettifogging, this precise
use of words is a necessity, and is the only' way we lawyers have
of dealing properly with the matter in hand. We deal in words,
and therefore we have to pay very close attention to words. Medical men in the course of their practice are not called upon to use
any such exact language, and this fact, perhaps, leads to some carelessness in their use of words.
Page Twenty-one "In a recent case in Victoria this principle was involved, and
the point attracted a great deal of attention. The doctor went before the coroner's court. The time of the killing was of very
great importance. The doctor stated that the bodies were absolutely cold. Now the ordinary layman would gather from that
statement that rigor mortis had set in. When the case came on in
the high court the doctor stated that the bodies were cold in death.
When the Crown case was put in, the time of the killing was
proved beyond all question, and the doctor had used that language
to show he had not got there until after death. This was made
much of by counsel. It was unfair, because later on the doctor
had expressed the opinion that the bodies were dead only an hour,
but the changes were rung on this to the detriment of the doctor.
I did what I could to see that he did not suffer an injustice, but
first impressions are very hard to eradicate and we often have to
deal in criminal matters with very ordinary people. So be very
careful about first impressions.
"To sum up: The first thing to do is to observe keenly
everythingI It will be expected of you. Then make your notes
and avoid technical language and avoid exaggeration. That is all
you have to do. It is very easy to talk about, but not so easy
to do.
"I do not think I need say anything further about evidence
as to facts.
Dying Declarations.
"I would like to say something to you about dying declarations. You may have to take a dying statement. Men in practice
in the city can send for a magistrate if they know a person is going
to die as the result of violence, but then again they may not have
time, and may have to do it themselves. In the interests of justice it is frequently essential that a dying person's account should
be obtained, and obtained in such a fashion that it can be produced in court later on. If not obtained in the right way, no
matter how thoroughly we may be convinced of the facts, the
crime cannot be brought home to the guilty person.
"You remember the doctrine of reasonable doubt. There is
only one thing to be remembered about that. You, as medical
men, have to decide first of all whether you will tell a person that
he or she is going to die. As a matter of justice I think you should,
but that is for you to decide. The only thing to remember with
regard to a dying declaration is this. The person—he or she—
must know he or she is dying, and have no hope of recovery. If
anything is said to indicate that the injured person has a hope or
chance, however slight, of recovery, the dying declaration cannot
be received. It is not given under oath, and there is no opportunity to cross-examine. The only reason a dying declaration is
received at all is that a person on the threshold of eternity, knowing he or she is going to die, is not likely to tell an untruth. That
would be about the only thing you would have to remember in
regard to the actual law.
Page Twenty-two Expert Evidence.
"I have told you all about evidence as to facts. There is another class of evidence—expert evidence. There is a saying in the
legal profession that there are three classes of witnesses who should
not be trusted—liars, damned liars and experts. That is a grave
injustice, for we cannot get along without experts in any technical subject. Here you must remember that you are not testifying
to facts. You will be given a basis of fact. Having got through
with that, you will be asked your deductions and your opinions.
Whenever you know that you are going to be summoned into
court, read up your books and read the latest authorities, because
you can rely upon it if you have counsel who is worth his salt,
that he will spend weeks in familiarising himself with all the details, both from books and from leading practitioners, and he will
have these books in court, and he will have them marked, and he
will put questions to you, and if he can find you tripping so much
the better. Therefore be prepared, not only for the purpose of
protecting yourself, but for the purpose of proving yourself a
good witness and a good citizen. Whenever you are going to be
called into court, even the coroner's court, read up all about it.
No one need be an expert witness unless he wants to, he can decline. All experts are somewhat under suspicion. This is unfair,
because anyone can differ in opinion. About facts they may differ
to a slight extent—people do not all observe facts in the-same
way, but if they are telling the truth they will agree in the main.
But it is quite different with expert evidence—that is based on
opinions.
"The whole facts will be recited to you in court. You
should apply through counsel to be allowed to remain in court
whilst the evidence is being taken. It is an advantage to hear all
the facts narrated. You will grasp the situation better if you have
heard all the evidence given. If you are an expert you are not
testifying to facts. You must take the facts as given to you,
though they may seem to you absurd. You are only asked to give
your opinions on a certain set of facts, and you are not acting honestly if you eliminate one of these facts because you think it is
not so.
"People will naturally differ in opinion as the result of difference in intellect. Just to show you how judges disagree. A
case was originally tried in Vancouver. It went on to the Court of
Appeal, where I was sustained by 3 to 2. It went up to the Supreme Court of Canada. There were two points at issue. I had
decided in favour of the plaintiff. The total number of judges before whom the case came was 13. In the Supreme Court the court
divided in such a way that, counting myself, it was 6 to 6, so that
the eventual decision depended upon one man. The thirteenth
man took the other view, and the result of his taking the other
view was to give judgment to the plaintiff. The criticisms of experience when they are honest are invaluable, but unfortunately in
Page Twenty-three obtaining expert witnesses each side seeks to get professional men
who will advance their particular views.
"The doctor who is asked to give evidence as an expert witness should get his facts from counsel, but he should form an absolutely unbiassed opinion, and if he finds he cannot support the
case he should say so at once. In B. C. I cannot recall any case
where the integrity of expert witnesses has been in question, but
you know what it has led to on the American side. It has had
the most disastrous effects.
"The best way to show you are trying to be fair is to put
yourself in the other fellow's place. Consider you are interested
on that side, then you are likely to prove a perfectly qualified
expert witness.
Insanity—A Plea.
"Doctors are very often called to give evidence as to the
mental condition of people. Now insanity from the standpoint of
the law is a very different thing from insanity from a medical
standpoint. The legal definition of insanity is that laid down in
1846. The sciences of psychology and psychiatry have made enormous strides since then, yet in 1896, when the British government referred this definition to the Medico-Psychological Society
of Great Britain, those gentlemen considered the definition, and
it was afterwards taken to their annual convocation, and their report to the government was that, while they did not agree with
that definition, they were unable to suggest any change.
"The trouble with the medical man who is called as an expert on insanity is that he looks at it from a medical standpoint.
I think in the main medical men are of the opinion that 'insanity'
has been brutally treated in the law courts. They are influenced by
the idea of the consequences. Usually the defence of insanity is
made in murder cases. If a man is found guilty of murder the
judge has no discretion but must sentence him to be hanged. To
allow yourself to be influenced by this fact is to fail in your duty
as a citizen. If you do not agree with capital punishment, the
court is not the place to air your views. Parliament can alter the
law, but so far as the courts are concerned they are there to administer the law as it is, and it would be a sad day for any country
if the courts were at liberty to depart from that, because then you
get away from law to the point of view of the individual. Therefore, when you go into court remember the legal definition of insanity which is this:
"Every man is presumed to be sane. He is only insane legally
if he does not know the nature of the act that he has committed
and does not know it is wrong. That definition does not involve
any question of morality. As regards the first part of this definition, if the person knew when he pulled the trigger that he was
firing a pistol, then insanity cannot be put forward as a defence.
Secondly, the person must know that what he did was wrong.
Now that is where medical witnesses are apt to go astray. This
does not mean 'morally wrong,' but it means that the person is
conscious of doing something that the law will punish.  It may be
Page Twenty-fovr that he thinks some person is attacking him. If he kills, with
this conviction, he is acting in self-defence and is not guilty. If,
however, he does the act through revenge, although insane, the
law will hang him. The plea of loss of control does not consti-
tue a defence. Dozens of medically insane men have been hanged
in Canada, because the law takes no cognizance of the power of
control.
"The medical men may say that the man does not know he
is acting against the law—-he has mental disease, and as a result he
has an irresistible impulse to kill. This leads us into positions
that may have the most serious consequences. You remember the
society I mentioned just now declined to recommend any change
in the definition of insanity to the British authorities. The American definition is the same as ours, and yet it has been abused to
an enormous extent.
"Now what are the consequences of the admission of this
plea of temporary insanity, leading to an acquittal in murder
cases? The man is sent to an asylum. Here he has the right to
apply for a writ of Habeas Corpus. If he is then sane he must be
let out and you cannot prevent it. You are dealing with a man's
liberty. He may, and probably will, have another violent impulse
to kill, leading to another crime. This is the reason we lawyers
say we will have no brainstorm defences in murder trials in Canada. It may be argued that the man is insane and can be kept in
the asylum, but insanity is always a matter of opinion, and you
can get experts on both sides..
"'Therefore remember the legal definition of insanity, and
remember that the court must adhere to that definition. When,
therefore, you are called as a medical witness, do not use the word
insanity at all, because you will be asked what you mean by it.
You should let the definition be given to you and base your evidence on that. It is a difficult position. Every word you say
will be combed over with a fine toothcomb for weeks, and perhaps
months afterwards. If you use the word 'insanity' it may prove
a very serious matter, it may mean having the trial all over again.
I understand the medical point of view perfectly well, but what
the medical man says may have undue weight with the jury, who
like to believe the doctor's evidence.
Drunkenness.
"With regard to drunkenness, how does the law regard this?
Originally it was no defence at all because it was a voluntary act.
If a man took liquor, and became intoxicated he was supposed to
have to bear the consequences, but the law has been modified to a
certain extent and is now a little more merciful. The law now
says that where a crime involves 'intent,' the defence of drunkenness cannot be raised. Here you see the difference between the plea
of drunkenness and the plea of insanity. In insanity the man
does not know the nature of the act and does not know it is wrong.
In drunkenness the only defence can be that the man was so intoxicated that he could not form an intent, and it is important to
note that a man who was intoxicated cannot plead temporary in-
Page Twenty-five sanity. He must choose. If he is going to plead insanity he must
plead it as such. If he is going to plead drunkenness he must
show that he was incapable of forming an 'intent.' Mere weakening of the will is not sufficient. The 'intent' is an operation of
the will, a faculty of the soul. I cannot define it more closely,
but it is something 'not material.' How are we to determine
whether the man was capable of forming an 'intent' or not? This
can only be determined by what he says or does at the time of the
act. This point may not appeal to medical men, but, again, it is
the law. You are apt to be called to give expert evidence in cases
where an attempt will be made to reduce the plea to insanity.
I have heard some medical men say, 'The man was insane—insane through drink.' Remember, a man must plead either insanity
or drunkenness.    He must choose."
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direct to
WILLIAM J. TWISS
402 Pender St. W. Vancouver, B. C.
Burns Druq Company
limited
732 Qranville Street, Vancouver
TELEPHONE
SEYMOUR 606
To the Doctor out of town:
We will look after any Mail Order Prescription
promptly.
INSULIN DEPOT FOR B. C.
Dispensary Specialists.
Page Twenty-seven B* Q Pharmacol Co. Ltd,
329 Railway Street,
VANCOUVER.
Manufacturers of Hand-made Filled Soluble
Elastic Capsules.
Specimen  Formulae:
No.  10— No. 15A—
Blaud Pill, 10 gr. Blaud Pill, 15 gr.
Arsen. Acid, 1/50 gr.   Liq. Ext. Cascara. 10 m.
Strychnine, 1/50 gr.     Ext. Nux Vomica, 1/8 gr.
Arsen. Acid, 1/50 gr.
Special Formulae Made on a Few Hours' Notice.
Price Lists and Formulae on
Application.
k.       » 1
Say it with Flowers
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.
Phones Sey. 988 and 672
Phones Sey. 9513 and 1391
Phone Sey. 1370
Brown Bros, & Co, Ltd.
VANCOUVER, B. C.
Page Twenty-eight Prescription Service'—I
That merits your confidence*
Free Delivery Service anywhere in the city
from 8 a. m. to 11 p. m.
Distributors:
Mulford's Biologicals       Fraisse Serum
Capitola Pharmacy Ltd*
(FRED G. BROWN)
Seymour 158       New Address : Davie and Bute Sts.
Stevens
Pink Back Z* CX Adhesive
Plaster
Made in England
Adheres to the limit, yet will not irritate.
A Perfect Plaster.
Fully Guaranteed.
Stocked in Rolls 12 in. by 5 yds. and in Spools of
5-yd.  and   10-yd.
1 in., 2 in., 2y2 in., 3 in. widths.
THE B. C. STEVENS CO., LTD.
730-732  Richards  Street,
Page Twenty-nine Orthopedic Appliances
Extensions for short limbs, Trusses, Arch Supports,
Abdominal Belts, Sacro-Iliac Supports, and
Artificial Limbs, manufactured and
made by Experts and
guaranteed by
A. LUNDBERQ CO.
938 Pender Street West
Vancouver, B. C.
The Owl Drug
Co., Ltd.
lAU prescriptions dispensed
by qualified Druggists.
l]ou can depend on the Ou?l
for Jlccuracu. and despatch.
IPe deliuer free of charge.
5 Stores, centrally located.    We
would appreciate a call while
in our territory.
Ambulance
Service
TELEPHONE
Fair. 58 & 59
ls/Lount Pleasant
Undertaking Co.   Ltd.
R. F. Harrison    W. E. Reynolds
Cor. Kingstvay and Main
Page Thirty US*?-
=K5W>
Pituitrin
THE    ORIGINAL
PITUITARY
EXTRACT
TJITUITRIN was the first preparation of its kind ever
used in obstetrics as an aid in labor.     It is a standard
product employed the world over in uterine inertia, and
for other definite indications as well.
Among pituitary extracts Pituitrin should be preferred
because it is always the same. Every lot is doubly tested—
for its effect on blood pressure and for its effect on uterine
muscle. What the physician wants in a preparat.on of
this kind is not excessive activity, but uniformity so that
he may avoid both the danger of an overdose and the
embarrassment of ineffectiveness.
In addition to the security afforded by double standardization, every package of Pituitrin is dated.
These advantages are yours if you specify on your orders
for pituitary extract "Pituitrin, P. D. & Co."
If Surgical Pituitrin is wanted specify Pituitrin 'S."
This preparation is twice the strength of Pituitrin—1 cc
equivalent to 2 cc of the latter. Pituitrin "S" is not
recommended for obstetrical use.
1    PITUITRIN and PITUITRIN " S " are supplied in liquid form
only, in ampoules, six to the box—Pituitrin in 1 cc and %-cc
ampoules; Pituitrin "S" in 1-cc ampoules only.
Ask for our booklet "Pituitary Therapy"; requests from
physicians are welcomed and gladly complied with.
PARKE, DAVIS & COMPANY
PITUITRIN  IS INCLUDED IN THE N. N. R. BY THE COUNCIL ON PHARMACY
AND CHEMISTRY OF THE AMERICAN MEDICAL ASSOCIATION
*©«=
jfsy* 

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