History of Nursing in Pacific Canada

The Vancouver Medical Association Bulletin: September, 1934 Vancouver Medical Association Sep 30, 1934

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Vancouver, B.C. THE     VANCOUVER     MEDICAL     ASSOCIATION
BULLETIN
Published ^Monthly under the ^Auspices of the Vancouver ^Medical ^Association in the
Interests of the ^Medical Profession.
Offices:
203 Medical Dental Building, Georgia Street, Vancouver, B. C.
Editorial Board:
Dr. J. H. MacDermot
Dr. M. McC Baird Dr. D. E. H. Cleveland
All communications to be addressed to the Editor at the above address
Vol. X ■ SEPTEMBER, 1934 No. 12
OFFICERS   1934-193 5
Dr. A. C. Frost Dr. C. H. Vrooman Dr. W. L. Pedlow
President Vice-President Past President
Dr. W. T. Ewing Dr. W. T. Lockhart
Hon. Secretary Hon. Treasurer
Additional Members of Executive:—Dr. H. H. McIntosh, Dr. L. H. Appleby
TRUSTEES
Dr. W. L. Brydone-Jack Dr. J. A. Gillespie Dr. F. Brodie
Auditors: Messrs. Shaw, Salter & Plommer
SECTIONS
Clinical Section
Dr. W. L. Graham— Chairman
Dr. J. R. Neilson j  Secretary
Eye, Ear, Nose and Throat
Dr. R. Grant Lawrence Chairman
Dr. E. E. Day Secretary
Paediatric Section
Dr. E. D. Carder Chairman
Dr. R. P. Kinsman Secretary
Cancer Section
Dr. A. B. Schinbein Chairman
Dr. J. W. Thomson Secretary
STANDING COMMITTEES
Library Summer School
Dr. W. D. Keith Publications Dr. J. W. Thomson
Dr. C. H. Bastin Dr. J. H. McDermot £r. C.E-Brown
Dr. A. W Bagnall Dr. D. E. H. Cleveland °r" JJ "ALKER
Dr. G. E Kidd Dr MuRRAy Baird Dr. LW. Arbuckle
Dr. W. K. Burwell Dr. H. A. Spohn
Dr. C. A. Ryan Dr. H. R. Mustard
Credentials „    .■+ i,
7V Hospitals
Dinner Dr r a< Simpson
Dr. J. W.Thomson Dr. J. T. Wall ?"J'?r  ^L
Dr. F. W. Lees Dr. D. M. Meekison ^ | FR(JT™™
r>    w r WXS ! Dr. H. H. Milburn
Dr. w. Cx. Gunn m    „ _
Dr. S. Paulin
V. O. N. Advisory Board
Dr. I. Day Rep. to B. C. Medical Assn.
Dr. H. H. Boucher Dr. Wallace Wilson
Dr. W. S. Baird
Sickness and Benevolent Fund — The President — The Trustees Vitamin D Milk
IN JUNE, 1933, the report of the Committee on Milk of
the Conference of State and Provincial Health Authorities pointed out many problems in connection with Vitamin
D Milk. The following statements are of especial interest
at this time:
Surveys have indicated that more than half of the children
under two years of age in our cities show determinable evidence
of rickets, at least in a mild degree. This suggests strongly
that the supply of Vitamin D in their food and that derived
from sunlight together is not equal to their needs, particularly
as at that time their diet is largely milk which is a rich source
of calcium and phosphorus, the two other commonly important
factors in bone development.
This evidence is strengthened when rapid improvement in
bone conditions follows the feeding of Vitamin D milk.
Results From Use of Vitamin D Milk
The feeding of Vitamin D milk to rachitic children has produced rapid improvement and return to normal conditions in
the hands of a growing list of experimentors. The number of
children which have been successfully treated in this way is
already large and is being added to constantly. The use of such
milk is rapidly becoming routine practice in such cases.
Vitamin D is a much needed element of the diet which can be
well supplied by Vitamin D milk prepared by feeding irradiated
yeast to cows.
The Associated Dairies Limited is the sole distributor of the
only Vitamin D Milk produced in British Columbia.
When necessary, prescribe Brooksbank Laboratories Vitamin D Milk.
ASSOCIATED DAIRIES
LIMITED
DISTRIBUTING
RICH—SAFE—CLEAN—MILK
SERVICE phones:
Fairmont 1000     North 122     New Westminster 1445  ■| PUBLIC HEALTH
BIOLOGICAL PRODUCTS
Diphtheria Antitoxin
Diphtheria Toxin for Schick Test
Diphtheria Toxoid   (Anatoxine-Ramon)
Scarlet Fever Antitoxin
Scarlet Fever Toxin for Dick Test
Scarlet Fever Toxin
Tetanus Antitoxin
Anti-Meningitis Serum
Anti-Pneumococcic Serum   (Type 1)
Anti-Anthrax Serum
Normal Horse Serum
Smallpox Vaccine
Typhoid Vaccine
Typhoid-Paratyphoid Vaccine
Pertussis Vaccine
Rabies Vaccine   (Semple Method)
INSULIN
Price List Upon Request
Connaught Laboratories
University of Toronto
TORONTO 5 - CANADA
Depot for British Columbia
Macdonald's prescriptions Limited
Medical-Dental Building, Vancouver, B. C. EDITOR'S PAGE
"The family doctor is something more than a man; he represents an
institution which must be maintained if the profession of medicine is to
survive. It must be admitted that the day of individualism in the scientific
practice of medicine is over. Today and in the future this must be carried
on along co-operative lines."—McEachern, Presidential address, C.M.A.,
1934.
"Although the family doctor or general practitioner will maintain a
slightly different role from what he had in the past, he will continue to
occupy the centre of the medical stage, and by reason of his broad medical
training will be perfectly competent to take care of eighty-five per cent of
general medical practice, besides being equally competent to know when,
where and how to seek advice and aid in the other fifteen per cent. He will
likewise be the integrating force, the co-ordinator in establishing relations
with the specialist in the best interest of the patient."—Bierring, Presidential address, A.M.A., 1934.
The excerpts quoted above give some idea of what the leaders of organized medicine on this continent are thinking about, and anyone interested
in present-day medical problems should read these two addresses in full, as
published in the corresponding medical journals. Current comment in the
literature abounds in such headings as "New Problems," "The Trend of the
Times," and "The Changing Order," and it is obvious that there is considerable dissatisfaction both in medical and lay circles with the way in which
medical services are organized at the present time.
In the old days a doctor was a doctor; his apparatus was carried in his
little black bag, his hands and his head, and he earned the respect and affection of his clients. He practised all branches of his art and his patients
stayed with him for years. He was their guide, counsellor and friend as well
as their doctor.
Nowadays, like industry, medicine has become mechanized, and machines
by the dozen have been devised either for diagnosis or for treatment. Special
methods of diagnosis and treatment, using special instruments, have necessitated specially trained men to use these methods. It must be admitted that
today no medical man could possibly cover all the ground, even could he
afford the capital outlay involved for equipment. The public, too, is rapidly
becoming educated with respect to many of the newer methods. Metabolism
tests, electrocardiograms, blood counts, are becoming almost as well known
as the #-ray, and there is a large body of patients who demand these investigations whether they are likely to be of any service or not. The "specialist"
in. all lines has arisen, and the public is inclined to take the view that
although the family doctor is admittedly unable to do the impossible, this
is quite to be expected of the "specialist."
There is no doubt about the necessity for specialists or experts in various
lines—a good example is ophthalmology—nor is there any question about
the good work done by specialists, much of which it would be quite impracticable for the family doctor to attempt, either because of lack of equipment or of training.
Attempts have been made to combine the good points of the general
practitioner and of the specialist by group practice, where each doctor trains
himself along one particular line, but is essentially a general or family practitioner. Some of these groups have succeeded, and some have failed, and
we cannot help feeling that the most important point about a group is not
Page 224 the quality of the work, but the quality of the leadership. All groups must
have a leader or they become disorganized flocks. On the intelligence, character, and personality of their leaders, groups stand or fall, provided the
work is of average competence. "We have always felt that practice in a
group of keen men with competent and ethical leadership would be almost
ideal, but care would have to be taken that some one doctor should take
charge of the patient, guide him, advise him and follow his case, while
making use of the skill and advice of all the others.
It is this personal touch which the patient requires, if we as a profession
are to obtain good results. Medicine is not yet an exact science, nor is it
likely ever to be so. Medical services are the most personal services which
one human being can give to another, and it is often just as important to
know and understand the patient as it is to understand his disease. There is
no doctor more competent to do this than the general practitioner, who
probably knows his patient's heredity, his habits of life and his environmental difficulties. This close contact, this mutual respect and confidence
between doctor and patient, is one of the finest traditions of our profession
and one which cannot be allowed to die if medicine is not to become a purely
mechanical means of earning a living. A group of experts may make a
perfect diagnosis, but, as Bierring says, a good general practitioner "must be
the kind of person who can deal effectively with sick lives as well as damaged organs or impaired physiology."
The organization of medical services may now be in a stage of rapid
evolution. Radical changes are being mooted. The State for years has gradually been taking over various functions having to do particularly with preventive medicine and communicable diseases. It is possible that in twenty-
five years we may hardly be able to recognize ourselves as a profession. However, we would agree with Drs. McEachern and Bierring that whatever
changes take place, the basic doctor must be the general practitioner who,
when he knows "where, when and how to obtain expert assistance," is the
soundest man in the practice of medicine today.
B. C. MEDICAL ASSOCIATION
Annual Meeting, Sept. 17th and 18th, Plaza Hotel, Kamloops, B. C.
The 1934 meeting of the B. C. Medical Association, it is evident from
a consideration of the programme, is setting a new standard in the excellence and variety of the papers which will be delivered before its scientific
sessions.
Among the lecturers are included Drs. Conn of Edmonton, Grant
Fleming of Montreal, H. C. Jamieson of Edmonton, R. E. McKechnie of
Vancouver, J. C. Masson of the Mayo Clinic, Wm. C. Murphy of Boston,
and F. M. Pottenger of Monrovia, California. Addresses at luncheons and
dinners will be delivered by Drs. J. S. McEachern and T. C. Routley, President and Secretary respectively of the Canadian Medical Association, Hon.
Dr. G. M. Weir, Provincial Secretary, Mr. R. H. Carson, M.L.A., and J. R.
Moffatt, Esq., Mayor of Kamloops.
Other features of the meeting include a luncheon at and tour of the
Tranquille Sanatorium. Golfers and non-golfers and wives of both are
being specially catered for.
Every practitioner in the province who can possibly attend will find that
seldom has he combined social pleasures and scientific activities in a more
agreeable manner than at the Kamloops meeting.
Page 225 DR. ARTHUR PERCIVAL PROCTER
OBIIT AUGUST 20th,  1934.    ^ETAT 67.
The writer first met Dr. Procter in Nanaimo in 1894 when he
called to obtain some advice concerning University affairs—and since
then, for forty years, we have kept in touch.
As the years went on we became more intimate and since his
settling in Vancouver twenty-nine years ago our friendship has
deepened with the passing years. I ever found him a true and loyal
friend living up to the ethics of his profession and the higher ethics
of a Christian. His record of service embraced many activities and
the positions he occupied proved his worth, and the respect in which
he was held. For twenty-five years he was Chief Medical Officer of
the Canadian Pacific Railway for the British Columbia division. For
twenty-two years he was Registrar of the College of Physicians and
Surgeons here, and for seventeen years he was Chief Medical Officer
at Shaughnessy Military Hospital. This record of service is unique
and proves not only the esteem in which he was held but also his
capacity as an administrator.
In his railway and military work he had many trying problems
to solve in which truth and justice had to be maintained and in which
not always could he please by his decisions the parties involved. But
knowing the character of the man I am sure they were always treated
with understanding, with fairness and sympathy. Tact was needed
in much of his work and he was abundantly provided with that valuable resource.
In his twenty-two years of service to our profession his work was
carried on smoothly, without friction and in the best interests of the
profession. His sympathetic nature will long be remembered by many
of our members, newly coming to the province, for he was always
ready with advice ancTwise counsel and a sympathetic understanding.
As a friend he was a friend indeed as is evinced by the multitude
of friends he has left behind.
And as a man, he was a Christian gentleman. His many years of
service as people's and as rector's warden only prove further the
esteem and respect in which he was held and the abundance of the
service he was giving. I cannot close without quoting from a letter
received by Mrs. Procter from an old friend of the Doctor's, one who
had known him from the time of his first year in practice, when he
was stationed at Donald in the C.P.R. service in 1896. This friend,
himself a cleric, had kept in close friendship with him all these thirty-
eight years, and he says: "He was a lover of all that is good and noble
and the deep religious convictions he had received from his mother
followed him through life. . . . He had the unfailing cheerfulness
of a good conscience and no one who knew him well could fail to
admire and love him. I was never with him without experiencing
the happiness that comes from the friendship of a truly good and
upright man."
He was my friend, too, and I and his many other friends bid h'm
farewell with deep regret.
—R. E. McK.
Page 226. DR. THOMAS LOWELL BUTTERS
OBUT AUGUST 11th, 1934.    JET AT 67.
In the death of Dr. Thomas Lowell Butters, Vancouver has lost
one of its most outstanding general practitioners and the medical
profession one who stood very high in the affections of his medical
confreres. After an illness of six months duration he passed away at
the Vancouver General Hospital on August 11th, 1934, at the age
of forty-four.
Of United Empire Loyalist stock, he graduated in medicine from
Toronto University in 1913 and, as a matter of course, was one of the
first to proceed overseas, serving with the No. 1 Canadian General
Hospital at Etaples, then as medical officer of the 27th Battalion, later
as adjutant of the Canadian Convalescent Home at Epsom, returning
to Canada in 1918. He was in charge of occupational therapy and was
D.A.D.M.S. in Toronto. He attained his majority and was a recipient
of the 1914-15 Star.
On demobilization he practiced at Courtenay, Vancouver Island,
until 1926. He removed to Vancouver where, due to his capability,
zeal and personality, he soon had a large and growing practice and
in 1928 was appointed to the Vancouver General Hospital staff.
His was a pleasing personality. 'Wherever he went he was regarded
with affection. Everyone with whom he came into contact had a good
word for him. He had hosts of friends in every walk of life. In his
work he disregarded himself entirely, giving his best efforts to the
interest of his patients at all times.  They idolized him.
As a member of the medical association he worked hard on any
committee to which he was appointed and ■was particularly successful
as a member of the Summer School Committee in 193 2.
Among his intimate friends he was always a favourite. "There
was only one Tommy Butters," staunch and reliable under any circumstances.
He adored his family. He married in London, England, in 1915,
Helen, daughter of Dr. and Mrs "W. A. Richardson of Victoria. He
leaves his widow and three children, Thomas, Elizabeth and Dennis.
We have lost a friend.
-A. L.
Page 227 NEWS AND NOTES
Dr. W. A. Dobson, who has been ill for some time, is making good
recovery.
We hasten to announce that Dr. J. P. Bilodeau is feeling quite well in
spite of the recent savage onslaught of a newspaper cartoonist upon his
hitherto intact features.
Dr. T. R. B. Nelles has recently returned from a tour of eastern medical
centres.
Dr. F. W. Brydone-Jack has been away for three months, spent chiefly
in the United Kingdom. The report that he was thrown out of Albert Hall
by the Ozzy Mosy blackshirts is exaggerated—he walked out.
Dr. Rogers of Chemainus General Hospital called upon some of his
colleagues in Vancouver recently when going to Harrison Hot Springs. He
has been ill for some months but is improving.
Dr. E. T. W. Nash, who has been replacing Dr. Rogers at Chemainus,
has a new berth as ship's surgeon on the Empress of Russia and joined his
ship prior to her August sailing from Vancouver.
Dr. R. N. Dick, until lately a member of the Vancouver General Hospital resident staff, has replaced Dr. Nash at Chemainus.
Dr. W. H. Hatfield has left for an extended trip in Europe, during which
he will study the most recent methods in the fight against tuberculosis.
Mrs. Hatfield will accompany her husband.
A Victoria newspaper on August 3rd contained an interesting item of
news to the effect that Dr. Herbert W. Riggs, a prominent Vancouver surgeon, accompanied by his wife and daughters, would sail from Victoria for
New York via Panama and the West Indies on a Grace liner on August 5 th.
Unfortunately this was in the nature of the scoop for the Victoria paper
and did not appear in the Vancouver dailies, and Dr. Riggs, not being
informed in time, missed the boat.
We regret to announce that Dr. J. A. Gillespie has suffered a rather painful accident. While holidaying at Comox and watching the "children"
bathe he stepped on a plank which wasn't there. Contusions, excoriations
and invectives resulted.
It is rumoured that a certain Victoria practitioner has a telephone installed in his pew at church. He must have had in mind the lines of Shakespeare: "My master hath appointed me to go to St. Luke's, to bid the priest
be ready to come, against you come with your appendix."
Page 228 B. C. MEDICAL ASSOCIATION
^BS ANNUAL MEETING ^B
September 17th and 18th
H   PLAZA HOTEL, KAMLOOPS, B.C.   I
PROGRAMME
MONDAY, SEPTEMBER 17th
9:00 a.m.—The meeting will be opened by J. R. Moffatt, Esq., Mayor of Kamloops.
9:10 a.m.—Dr. Heber C. Jamieson, of Edmonton:
"Recent Problems in the Diabetic."
9:50 a.m.—Dr. J. C. Masson, of the Mayo Clinic:
"Malignancy of the Large Bowel."
10:30 a.m.—Dr. L. C. Conn, of Edmonton:
"Backache in Obstetrics and Gynecology."
11:10 a.m.—Dr. R. E. McKechnie, of Vancouver:
"Concerning Specialties."
11:40 a.m.—Dr. Wall, Department of Indian Affairs, Ottawa:
"Trachoma with Clinical Demonstration."
1:00 p.m.—Luncheon at Tranquille Sanatorium.   At the luncheon, addresses will be given
by Dr. J. S. McEachern, President of the Canadian Medical Association, and
Dr. T. C. Routley, General Secretary.
2:30 p.m.—Dr. F. M. Pottenger of Monrovia, California, will give an address at the
Tranquille Sanatorium on "The Role of the General Practitioner in the Diagnosis of Tuberculosis."
torium.
.  Speaker: Hon. Dr. G. M. Weir, Provincial
H.   Carson,  M.L.A.    Speakers:  Dr.  F.  M.
Pottenger, Dr. Grant Fleming and Dr. T. C. Routley.
TUESDAY, SEPTEMBER 18 th
9:00 a.m.—Dr. L. C. Conn:
"Relief of Pain in Obstetrics."
9:40 a.m.—Dr. J. C. Masson:
"The Use of Living Sutures in the More Difficult Abdominal Hernia;."
10:20 a.m.—Dr. H. C. Jamieson:
"Bright's Disease."
11:00 a.m.—Dr. William C. Murphy, of Boston, Mass.:
"Some Therapeutic Effects of Intramuscular Injections of Liver Extract."
11:40 a.m.—Dr. F. M. Pottenger:
"When a Diagnosis of Active Tuberculosis has been made, what should
the General Practitioner do for the Patient?"
12:30 p.m.-—Luncheon at the Plaza Hotel.
Golf at Country Club.
Afternoon tea at Paul Lake for the ladies of the party and those who do not
play golf.
7:00 p.m.—Annual Meeting of Okanagan Branch of B. C. Medical Association.
8:00 p.m.—Annual Meeting of B. C. Medical Association.
Presidential Address: Dr. W. S. Turnbull.
Reports of Officers and Committees.
Election of Officers.
9:00 p.m.—Open meeting of the College of Physicians and Surgeons with addresses by
members of Council on activities during the year.
Page 229
Tour through the Sanatorium.
7:00 p.m.
—Annual dinner at the Plaza Hote
Secretary.
8:00 p.m.
—Public Meeting.    Chairman:   R. OBESITY
Dr. J. E. Walker
Obesity is a popular subject; at the afternoon tea table it probably runs
the infant welfare circle a close second. The average woman watches her
weight with the greatest interest and she is better up in the latest method of
reducing than most physicians. Let us consider for a few minutes some of
the essential facts in the study of this popular subject. Fat metabolism in
the past has been neglected as compared to the study of carbohydrates and
of protein metabolism. Sugar, in its travels through the body, has been
followed with infinite trouble by countless observers. Protein diets, high
and low, have been discussed ad nauseam. Fats have not received the attention they deserve both from the scientific and the clinical standpoint.
I should like briefly to sketch the passage of a simple fat from its resting
place on the dinner table to its home in the human frame. Fats may be
classified as, first, simple lipoids—that is, ordinary fats which are esters of
the triatomic alcohol, glycerol; secondly, compound lipoids—commonly
known as phospholipoids. These are compounds of fatty acid and glycerol
plus phosphoric acid and nitrogen. The commonest examples of this group
are lecithin and cephalin. They are constant constituents of living cells and
are very active chemically. Thirdly, we have derived lipoids, of which the
outstanding example is cholesterol, one of the major mysteries of the biochemist.
Simple fat undergoes very little change in the mouth other than that
produced by mastication. In the stomach a certain amount of fat digestion
may, and probably does, take place, for the stomach does secrete lipase.
Lipase in the stomach is inhibited in its action by free hydrochloric acid. In
patients whose gastric acidity is low, a considerable amount of fat may be
•digested. Cream, as a fine emulsion of fat, is quite easily acted upon in the
stomach. A large fat meal takes upon itself the duty of inhibiting the
secretion of hydrochloric acid, and also slows up stomach mobility.
It is, however, in the small intestine that the great bulk of fat splitting
takes place. Fat entering the duodenum is broken up into a fine emulsion,
through the action of soaps, formed in that region. Steapsin, the lipase
secreted from the pancreas, is chiefly responsible for fat digestion, although
the small intestine also secretes a lipase of its own. The whole process of fat
digestion is too lengthy to epitomise here, as many factors enter into the
process. Lipase plus fat produces fatty acids and glycerol, and these in some
unknown way pass through the intestinal wall to enter the lacteals of the
mesentery. To add to the mystery, it is not fatty acid and glycerol that is
found in the lacteal, but fat again. From the lacteal, this fat, in the form
of exceedingly small particles, is carried by way of the thoracic duct to the
blood stream. At this point it is convenient to enquire into the fate of the
various kinds of fat as they enter the intestine. The animal body possesses
to a large extent the faculty of selective absorption. All fats that may
present themselves to the body metabolism are not necessarily accepted.
Those fats which have a melting point most approximating that of human
fat are most readily assimilated. Those whose melting point is too far
removed for that of the body fats, are rejected. It is interesting to note that
while the individual may eat beef fat, he does not lay down beef fat in his
own tissues, but human fat.   This rearrangement of molecules apparently
Read before the Osier Society of Vancouver, 1934.
Page 230 takes place in passing through the intestinal mucosa. If, however, an overwhelming amount of foreign fat is ingested, that fat may be laid down in
its original form.
Let us glance for a moment at the blood stream and its burden of fat.
Minute fat droplets enter the blood by way of the thoracic duct. Following
a meal there is first an increase in the amount of blood fat; soon after this
there is an increase in the amount of lecithin, and finally an increase in the
amount of cholesterol. It seems highly probable that these three substances
are very intimately bound up in the process of fat metabolism. The
mechanism of transference of these substances from the blood stream into
the tissue cells is quite unknown.
Lipoids are found in the tissues in two forms. First, cell lipoids—these
are phospholipoids and cholesterol—form part of the living tissue and take
an active part in life processes. Secondly, stored or inactive pure fat. This
fat is purely passive and is just so much dead weight to its bearer except to
the extent that its functions of insulation and protective covering justify
its existence. Excess storage fat tends to be deposited in certain well-defined
areas, such as the abdomen, subcutaneous and intramuscular regions, and
around various organs.
It is necessary to add that carbohydrate is very readily transferred into
pure fat and stored as such. Protein also may contribute. Fats, in the presence of an adequate ratio of carbohydrates are completely burned to their
end products. If, however, insufficient carbohydrate is being utilized by
the body, the combustion of fats becomes defective, and ketone bodies,
acetone, acetoacetic acid and b-oxybutyric acid appear in the blood and urine.
If I have indicated in a very incomplete manner the elaborate steps through
which fat metabolism passes, I have at least suggested to you that many
factors may govern these steps; as a corollary to this, it is quite evident that
disturbances of control at many of these steps might lead to obesity, that
is, the laying down of excess storage fat.
Let us look at the factors which one might expect to lead to increased
storage of fat. It is quite evident that before an individual can possibly
lay down excess fat, his energy expenditure must be less than his caloric
intake; that is, he must be in a state of positive energy balance. It is a
remarkable fact that in most individuals their body weight remains approximately constant in spite of changes of climate, appetite, exercise and other
factors. Obesity is a failure in some part of that mechanism which normally
keeps the weight of adults constant.
What are these factors which might influence the body weight?
1. Appetite. We are all familiar with those charmed persons who eat
everything their hearts may desire, and who yet retain that boyish figure.
On the other hand, we are all equally familiar with those who eat perhaps
only half that which their table fellow stows away and yet grow visibly in
stature before our eyes. It is a fact that many obese individuals eat more
than the average and we are apt to ascribe the overweight to increased
caloric intake; if one considers this point more carefully, might one not
ask if the increased diet is not due to deficient utilization of the food eaten.
The diet normally should contain carbohydrates, protein and fat. What
might take place is as follows, phe three main food stuffs are ingested,
absorbed from the intestinal tract, and then utilized for body building or
energy requirements. If in the case of fat, with which we are especially
interested at the moment, ther<||is some block in utilization, the fat is
merely stored inactively in the tissues, and the energy thus lacking in the
Page 231 animal economy must be supplied by more food, hence increased appetite.
Again, increased appetite does not necessarily imply increased growth when
the two phenomena are associated. In experimental dogs where acromegaly
has been produced, the animals develop a voracious appetite; but the increased appetite is probably due to the increased tissue demands during the
active changes taking place in the acromegalic animal, rather than the
increased growth due to increased appetite.
2. Depression of oxidative changes as expressed by the basal metabolism.
I rather think that the number of overweight individuals who have a significantly lowered basal metabolic rate is not very great. On the other hand,
it is much more common to find a significantly lowered basal rate in underweight individuals. I well remember one case at the Out-Patients' Department who was terribly emaciated and who had a rate of minus 3 5. I have
seen many cases of marked undernourishment who showed rates of minus
20 or less, while I can think of very few cases of obesity where the rate was
lowered to any extent. Racial characteristics also bear out this impression.
It has been reported that in the Eskimo, who is regularly more obese than
the European, the basal rate is higher than in the latter. Certain East Indians
who are characteristically under weight, as compared to Europeans, have a
lower basal rate than the latter. Thyroid extract in the treatment of obesity
has a limited application if one takes the metabolic rate as a guide.
3. Lowered specific dynamic action. It is well known that the metabolism of proteins exerts a speeding up effect on metabolism in general, and
it has been thought that in cases of obesity this effect has been lost. There
are clinical conditions where the specific dynamic action is considerably
lowered, but obesity does not result.
4. Decrease in the amount of muscular .energy. The amount of muscular
energy which an individual uses undoubtedly has some effect on fat storage,
but it is probably a minor factor. Many thin individuals lead a very sedentary life, while many overweight individuals lead a very active life as far
as exercise is concerned, yet they remain overweight. Exercise alone, as a
means of reducing, is usually limited in its practical application.
If we admit that none of the foregoing factors have any vital control
over the deposition of excess fat, what, then, is the controlling factor?
We are told that between the infinitely small, the electron, and the infinitely
large, the universe, man stands midway in size; it seems that we are placed
in the most favorable position to see both extremes of our environment,
but we will have to confess that we cannot state, or indeed have very little
idea as to what this controlling factor or factors of fat metabolism may be.
Many modern authorities take refuge behind what they call the "constitutional factor." As to what the nature of this constitutional factor may be,
they do not hazard a guess, but they all seem determined that it is not an
endocrine secretion. Bauer stated that 88% of cases showed a family history
of obesity, therefore there must be a defect in the congenital factor that
determines and regulates weight. Fat usually accumulates in definite
regions; it has been shown that transplants from the abdominal wall to
the hand still retain their fat, though the hand itself never accumulates fat
of its own volition. It has been found that patients suffering the most
profound degrees of emaciation may yet retain fat in certain favored areas.
It would seem that certain peripheral tissues, due to their constitutional
make up, play a leading part in this unhappy tendency to store up inactive
fat. A word as to the discredited endocrines might not be out of place at
this juncture. Many authorities say that while endocrine disorders may give
Page 232 rise to obesity, such cases are very rare. There is no doubt whatever that
disfunction of the ovaries, testicles, suprarenal cortex and pituitary may,
and do, cause obesity. It is just as certain that administration of preparations
of these glands is not very successful in combating such obesity; it is possible that the necessary factor is absent from our incomplete preparations.
On the other hand, many, and indeed perhaps the majority, of cases of
obesity one sees, show no other evidence of endocrine disturbance. They
also do not react to endocrine preparations. In a field where speculation is
the order of the day it would appear that one cannot rule out the endocrine
glands, and in view of the evidence at hand it would not be at all surprising
if this constitutional factor should one day be found to be under the
control of the various endocrine glands. Possibly our old friend the
diencephalon may have something to say about the matter. In latter years
a great deal of interest has centred in this "old brain," as it is called. Many
vital metabolic functions have been shown to reside in this ancient nerve
centre—water balance and heat control are believed to owe allegiance to
this part of the brain; possibly fat metabolism also is controlled from this
Treatment. In a field where theory is rife, one would expect many
forms of treatment, and one is not disappointed. Here is an every day
subject and everybody seems to feel they are quite competent to handle the
subject. Whole droves of quacks and charlatans make this subject their
own, and offer their own method of painless and quick reduction. Forms
of treatment may be divided into dietary and medicinal, and of these the
dietary is overwhelmingly the most important. Inseparably linked with
dieting is the psychology of the fat woman, for it is women who are most
anxious to shed their adipose burden.
I should like to consider the question of diet for a few minutes. The
average adult working man requires some 3,400 calories per day; the
average adult female about 2,800. Reducing diets in the past have commonly contained a little less than the basal requirement, that is, about 1,300
calories, with non-nutrient substances to supply the bulk.
The low caloric diet which I wish to describe is much more radical
than this, in that it contains only from 600 to 900 calories. It contains
no roughage. All this sounds very spartan, and if we analyze the scientific
principles underlying this diet there is indeed a fox, but he is gnawing, not
at the vitals, but at superfluous adipose tissue; for on such a low caloric diet
an active person must obtain calories from some source, and the stored fat
in his own body serves as the supply. In the first place one must figure out
the ideal weight for the patient, taking the height, age and sex as a basis.
The first item to be considered is the protein content. No diet is satisfactory that does not contain an adequate amount of first class protein. In the
United States it has been found that the average person consumes from
1.3 to 1.5 grams of protein per kilogram of body weight and that the total
amount of calories derived from this source is very seldom more than 18 %
of the total. There has been a tremendous amount of discussion as to whether
a high protein diet is harmful or not and probably 1.5 grs. of protein per
kilo is fairly high. It is entirely probable that the body can handle a high
protein diet more easily than a high carbohydrate diet, to which no one
seems to give a thought. This is, however, beside the point. What we wish
to know is how little protein we can safely give. It has been estimated that
1 gram of protein per kilogram of body weight is the safe minimum. In this
low caloric diet, that amount of protein, based on the ideal weight, is given.
Page 233
j There is a great difference in the quality of proteins from various sources.
Proteins of animal origin such as those found in meat, milk, eggs, fish and
cheese are of high biological value; they are known as first class. Vegetable
proteins, with few exceptions, are of low biological value; they are known
as second class. Pure vegetarians as a class, George Bernard Shaw to the
contrary, are not distinguished for good physique; as a matter of fact, a
great many vegetarians eat eggs and milk. They are no more consistent than
the anti-vivisectionists who wear fur coats. In the low caloric diet the
protein is given in the form of meat, fish, eggs, milk and cheese—all first
class proteins. I will cheerfully admit that a vegetarian would be quite out
of luck on this diet—he deserves to be.
I have lately been enquiring into the diet of some of the cases attending
the Maternity Clinic at the General Hospital; chiefly among those on City
Relief. I have been astonished at some of the diets. One woman told me
that for nine months she had lived practically on bread and butter—the
amount of protein was small. Others have been on low protein diets for as
long as two or three years and yet many of them appear to have retained
fairly good health. I think these diets cannot be condemned too strongly,
but I feel it emphasizes the fact that with the amount of protein in this
reducing diet, one is quite safe. I have had patients state that the amount
of meat and eggs was more than they were normally accustomed to take.
The next item in the diet is fat. One aims at giving as little fat as
possible.
Carbohydrates. Apart from its use as source of energy, the presence of
carbohydrate is necessary for the successful burning of fat to its natural end
products. Insufficient sugar intake results in the appearance of ketosis and
acidosis. In this diet a ketogenic anti-ketogenic ratio of 1 to 1.5 is aimed at.
This ratio will be satisfied if we supply two-thirds of a gram of carbohydrate
per kilogram of body weight. This carbohydrate is given in the form of
fruits, vegetables and milk. Some patients on such a regime will show some
ketone bodies in the urine, but appear to suffer no harm from its presence.
We have yet to supply vitamins. Vitamin D, and probably vitamin A,
are deficient, so that some concentrate of cod liver oil is given daily.
At the present time I have an obese woman who is four months pregnant
on this diet, except that we have increased her protein to 1.5 grams per
kilogram of ideal weight; in addition she is receiving calcium lactate by
mouth. I cite this case to emphasize the fact that it is believed that there
are very few contra-indications to reducing. Cases have been cited in
the literature where patients with myocardial damage, high blood pressure,
during adolescence and during old age have been successfully and uneventfully reduced. Cases of high blood pressure particularly have been reported,
where the pressure has fallen remarkably on this regime.
Many obese patients suffer from such symptoms as headaches, lassitude,
menstrual disorders and the like, often attributed, with the obesity itself,
to an endocrine origin. These symptoms will very often improve remarkably
as weight is lost. Patients look and feel better and younger; in fact, all the
claims of the newspaper advertisements are fulfilled.
I know that many will ask, why the small bulk of the meal, why not
give non-nutrient materials? Appetite is largely a matter of habit. If a
person is obtaining sufficient calories, why fill the stomach with rubbish?
An individual can soon become accustomed to a small meal and be perfectly
satisfied with it. I always make it a point to ask whether the patient is satisfied as to appetite, and after the first week, with few exceptions, the answer
Page 234 has been in the affirmative. How much weight may one expect to lose per
week on this diet? It seems to be the general idea that weight loss should be
slow—perhaps 1 J/2 to 2 lbs. per week, and that more rapid weight loss is
harmful. I cannot see why this should be so if all the requirements as stated
above are observed. Patients on this diet will lose from two to seven pounds
per week. The average loss per week is around three pounds in my experience. The patient will not lose the same amount every week and even may
remain stationary for a week at a time.
After the patient has reached his or her optimum weight one should
gradually increase the food allowed, using the original diet as a foundation
until it is found on what diet the patient can maintain the ideal weight,
limiting particularly such foods as bread, sugar, potatoes and fat.
Many patients, of course, once they have reached their optimum,
gradually begin to eat with less care; in spite of this a certain percentage
seem to have gained a new control of weight regulation and do not gain very
much, or at least keep well below their former weight.
Dieting is the foundation in the treatment of obesity, but can one keep
the patient on her diet? The spirit is doubtless willing, but the flesh, though
abundant, is weak. As Abraham Lincoln once observed, "Everybodv talking
about Heaven, ain't going there." Not only has the subject of our discussion to combat the lure of the fleshpots, but she finds society ranged solidly
aeainst her. Standards of hospitality have been handed down through the
ages and the standard of a good square meal has stood the test of time. The
primitive Indian considered his euest a most impolite member of society if
he could not devour several pounds of buffalo meat. In our own time Mrs.
Smith is just as much offended if her guest passes up a few hundred calories
of chocolate blanc mange. Add to this afternoon teas and bridges, and
perhaps a little sympathy is not out of order.
It is rare indeed for the doctor to encounter a patient who has not
already tried her hand at reducing. The newspapers, the radio, and the
health clinic are all prodigal of advice—much of it bad. The newspaper
offers her drugs, most of which contain either thyroid extract or purgatives
in the form of salts; the health clinic a 21-day orange juice fast. Now
thyroid extract may have its place in certain cases of obesity, but as a substitute for the less spectacular, but safe, procedure of dieting, one stands
aghast. Some cases of apparent obesity are doubtless due to water retention
.and in these purgatives are possibly indicated, but one cannot drive fat out of
the. body with Kruschen salts. Then again, irregular practitioners are not
altogether to blame for poor advice. In bygone days most illness was looked
"upon as an act of God. Old ideas die hard. The power of this theory is still
reflected in legal matters by the classification of such uncontrollable disasters as volcanic eruptions, tidal waves, earthquakes, etc., as acts of God.
Many surgeons and a few physicians still look upon the fat woman as a
small jest on the part of the Almighty. Many practitioners have, in their
portfolio of diets, a sheet which bears the title of "Reducing Diet." This is
handed out to all and sundry. A perusal of this sheet will often show that
it is quite inadequate in protein, or that the ketogenic-antiketogenic ratio
is far from ideal. As a result the experienced fat man will look askance at
"another diet sheet."
When all is said and done, fear is the most potent goad of all our
emotions. Gratitude and good intentions are emotions that too often meet
an early death; but fear of ridicule, or fear of fleeting charms, will often
brace a will that has been too indulgent. Practically all patients who volun-
Page 23 3 tarily seek a physician's advice because they are overweight, come for one
of these reasons. That is the time to give them a sermon according to their
deserts and the good cause may be lost or won at this first encounter. It is
best to have a patient return once a week to be weighed. When the patient
loses, as she must, if she stays on the diet, the meeting is one of mutual
congratulations. If the patient fails to lose on one or two or three successive weeks, the meeting is one of accusations. Never let a patient think
she is "getting away" with indiscretions of diet; discipline is good for the
soul and never more so than in those who are turning their backs on the
habits of a lifetime.
A discussion on obesity would be incomplete without some reference
to the latest innovation in treatment, namely, the use of dinitrophenol.
This drug in brief raises metabolism without raising the pulse rate. It is
being widely used at the present time by various clinics. I can do no better
than quote from an article in the February issue of the Canadian Medical
journal by Rabinowitch; he closes his discussion with this paragraph: "The
data thus clearly indicate that there is as yet much to be known about the
metabolism of these drugs before they can be recommended for application
in private practice. It is suggested that small amounts used for months in
many cases with no obvious deleterious effects, afford no positive proof that
these drugs cannot prove harmful if given over longer periods of time.
Experience with cinchophen may be recalled here. Toxicity due to overdosage is, of course, no contraindication for the use of this drug any more
than for morphine, arsenic, strychnine, or any other dangerous but, if properly employed, very useful drugs; but the ease with which dinitrophenol
increases metabolism, its known toxicity with excess dosage (irregular
response to the same dose in the same individual) emphasizes the necessity for
further study. In the opinion of the writers the use of this drug in clinical
work should as yet be confined to hospital practice."
SOME POINTS  IN THE TREATMENT
OF CANCER
Dr. Max Cutler
The treatment of cancer, in these modern days, is a much more complex
matter than it used to be, owing to the introduction of radiation therapy.
Cancer may be divided into three groups, according to the type of treatment best adapted to the various types of growth:
(1) Those that respond best to surgery;
(2) Those that respond best to radiation;
(3) The experimental group: i.e., all that do not yet fall into one of
these groups.
With regard to radium, the applicability of this is changing and increasing so rapidly that we are finding much trouble in keeping abreast of it.
Till five years ago radium was only used in inoperable cases, as a forlorn
hope, or for palliative purposes—hence it was an important, but not a crucial
matter, to decide about its use.
Today we undertake to treat operable cases by radium: hence the
responsibility of making a decision is great. We must answer three questions before we can decide whether or not to treat a given case with radium,
rather than surgery:
Page 23 6 (1) Is the equipment adequate? and have we enough radium, and in
the proper forms, for modern radio-therapy?
(2) Is the operator competent to undertake the treatment for the given
case?
(3) Should we radiate this case?
Remember that a good operation is better than incomplete or incorrect
radium or deep x-ray therapy—and in a given locality, or under certain
circumstances, it may be that we should recommend surgery rather than
radium.
A radiosensitive growth is one that can be completely destroyed without
permanent damage to other tissues. All growths can be ultimately destroyed
—but it may be at an unjustifiable risk to the patient.
Amongst the radio-sensitive growths are:
Skin cancers; cervical cancer; orificial cancers of epidermoid origin.
Lympho sarcoma-embryonal cancers.
Amongst the radio-resistant growths are:
(1) Absolutely radio-resistant:  neurogenic and fibro-sarcomata, and
melanomata.
(2) Relatively radio-resistant: Adenocarcinomata.
Cancer of the bladder and breast are in the intermediate group.
The radio-resistance of adenocarcinoma is based on the general rule that
when a cell is in process of secreting it is resistant; when in process of
dividing, it is sensitive.
Dr. Cutler sounded a note of warning about rectal carcinoma. This is
of the orificial type, and so should be sensitive; but the rule he laid down is
—never use radium except in inoperable cases, or where the patient refuses
operation. This, we take it, is because of the damage to surrounding tissues
and because of the danger of perforation. The same applies to oesophageal
carcinoma.
Where a lesion is papillary in character, it may be sensitive. Cancer of
the oesophagus should respond—but we cannot control it because the tumour
is already outside the tube and too close to the aorta.
We may have two methods of radiation:
(1) Caustic radiation, where the tumour is destroyed by removal of
tissue as with a cautery.
(2) Selective radiation, which performs a delicate dissection between
the neoplasm and the surrounding (normal) tissues.
Technique. This is intensely important, and is changing a great deal as
we develop our knowledge of radium. We are getting away from the use of
seeds, which are generally overloaded and not properly filtered. The
tendency is to use longer needles, with a heavier shielding of platinum;
apply more often and over longer periods in smaller doses.
The speaker then referred to certain types of cancer, and their treatment.
Carcinoma of the lip. This is radiosensitive and is best treated by radium.
But better good surgery than bad radium treatment.
The radical dissection of glands is not necessary—and no surgery need
be done at all in the absence of palpable nodes.
Prophylactic radiation is more or less useless.
How are we to determine the dose? This is a very difficult question to
answer; but Coutard of Paris gives, as a general rule, that the radio-sensitivity of the surrounding tissues is the test, and we must give enough to
destroy the growth, and just enough to avoid a serious burn.
Page 237 Under the methods now in use, Dr. Cutler has found that enormous
doses can be given without damage, and some very spectacular results have
been obtained, especially in carcinoma of the larynx.
We cannot give part of the dose and add more later. The radio-sensitive
tissues become less sensitive and more resistant—hence we must give the
right dose the first time.
Cancer of the cervix.
Regardless of histological structure and the stage of the growth, this is
a subject for radiation alone. Dr. Cutler is very emphatic about this, and
denies that any case of cancer of the cervix should be treated by surgery,
however early.
The chief reason of this is that very important and rapid advances have
been made in radiation treatment of cancer of the cervix.
We can give as much as 8000 mgm. hours, using a very small amount of
radium, and distributing it widely.
We are giving up use of emanation and going back to the use of the
element.
Carcinoma of the body of the uterus is always surgical if early.
Deep x-ray. 200 k.v. usually used, but Coutard of Paris goes as high
as 700 k.v., but not often.
He gives low milliamperage at a distance, twice a day, thus imitating
radium. It must be given continuously, as otherwise growth tends to get
away from control.
THE ART OF FEEDING CHILDREN
By Dr. C. A. Aldrich
The object of this talk was to emphasize the artistry of practice as
opposed to the mere prescription of diets.
The application of any art requires careful consideration:
(1) Of the object to be attained;
(2) Of the materials at our disposal;
(3) Of the methods of application
of these materials to the attainment of the object. In seeking to attain our
object, we must pay attention, not only to the child, but also to the parents
and othher adults who supervise his care. These, with the child, are the
medium in which we must work.
The general practitioner has the chief burden of the bringing up of
children; the paediatrician the lesser.
Our objects are:
1. To afford the growing human animal the best environment possible
(food, clothing, hygiene, mental and physical environment).
There must be no preconceived normal. We must utilize to the full the
capabilities of the given child. This is the constructive side of our programme.
2. As a corollary to this we must also have a destructive side. It is necessary to mould children to a pattern acceptable by the society in which they
live.
In many ways these two objects clash and tremendously increase the
difficulties of our art, e.g., eliminative functions—the natural impulses of
the child are in conflict with the restrictions imposed by society.
In studying these two objectives, no attempt is made to separate purely
Page 23 8 physical and purely psychological considerations. In youth there is no such
sharp distinction. It cannot be stated that such matters as habit formation
are one or the other—they belong to both and should be treated as such by
the careful physician. As a matter of fact, the mental growth of an infant
is determined and measured almost entirely by his physical growth.
In recapitulation it might be stated that our objective is the establishment of the best possible environment for the physical and mental growth
which is compatible with adjustment to modern society. I will attempt to
point out some of the measures which may be taken in furthering this end,
more or less from a chronological standpoint.
A preliminary talk with parents. We should sit down and talk it over
frankly with the father and mother, and before or soon after the baby is
born we should explain to them our objectives.
Point out to them that the mother or father did not make the child.
It grows—the mother delivers it—and we must then face the fact that the
baby does, and should do, its own growing, after birth also.
The dignity of this growth should be explained to the mother: and the
fact that the methods of both pre- and postnatal growth are beyond her
control—unless it be for harm. Hence she should not have preconceived
ideas. Standard weights and heights are not safely applicable to individuals.
Lay a foundation of defence for the congenitally small child: the petite
child, often the most winsome; and Dr. Aldrich deplored the tendency to
decry small size in children, because they do not come up to some mechanically-minded pedant's list of standard weights. To those of us who have
suffered from having to justify the existence, even the apparently undersized existence, of some perfectly healthy child, where a school nurse has
implanted in the parents' mind the idea that something must be wrong
because Jeanie is 10% under "standard weight" for her age, these remarks
of Dr. Aldrich came with considerable pleasure.
Condemn, too, as strongly as you possibly can, the comparison of children.  It is a crime.
Then the child's appetite. Dr. Aldrich had much to say on this. Appetite is a most important function, essential to growth and happiness.
We must associate food with pleasure and comfort, and not with restrictions and unpleasant duty.
The baby is born with a swallowing reflex, and soon finds that the
hunger pain is relieved by food and swallowing—so that he returns to a
feeling of contentment.
When a baby wakes at 8, hungry and crying with hunger pain, and we
keep it till 10, because this is the right time, we are wrong.
The first few times he cries let him have breast or bottle, till he associates
this with comfort. Later, as he gets the right amount of food, he will be
able to wait till the right time.
The giving of food should always be associated with pleasure and comfort; then the child looks forward to his food, enjoys it, eats it with appetite,
and gains. This should apply even to spinach and other foods. The quantity
should be left to the individual desires of the child, and increases made as the
need appears, physical or psychological. In this way we adjust the amount
to the innate appetite, large or small, of the child, and develop regularity of
the eating habit.
During this early period of the first few weeks or months, we can
appraise the child, make an estimate of his ultimate type, robust and vigorous,
Page 239 or small and delicate; whether he is of the active, "go-getter" type, or of
the passive type.
Risk a prognosis to the parents about the character of the child, especially if he shews evidences of being aggressive and combative.
About this time take up the question of training the child in eliminative
habits.
Here again, we must associate the act with relief and comfort, not with
duty and penalties—not with uncomfortable methods, such as suppositories, or the interruption of much-wanted sleep. The child will learn that
it feels better after a bowel movement, or emptying the bladder, and will
co-operate.
As regards food. We must cultivate the right attitude in children
towards food. It is not how much of a new food (e.g., cereal or vegetables)
a child takes, that is at first important, but how he takes it. Give the child
time to learn to like a food.
The spoon. The use of this should be an educational process—again a
baby should learn that he gets comfort from a spoon.
So with vegetables, soup, potatoes, fruit—the taking of them should
always be an educational process.
"It is important in these matters," says Dr. Aldrich, "that all new foods
be introduced with the proper degree of tact, and that they be never unduly
urged lest the entire programme be ruined by a refusal of the child to eat.
Introduce the child to things that he can chew about the time the teeth
Give cod-liver oil from birth, so that the child learns to like it.
Sleep habits. These should be regular; the question of how long he
sleeps should not be decided by any set standard.
Play habits. The baby should learn to play by himself and be self-
sufficient.
Many so-called "nervous" children are victims of the don't habit on the
part of the mother. If they are not doing actual damage that matters, let
them tear up paper, work off energy and so on till they learn better.
The problems of the first year are those of growth, and are mainly
physical.
The second year. In this year the problems are mainly psychological,
and our direction of the child must be guided accordingly.
During this year the child is learning to do everything an adult does,.in
a crude way. He has to become a social being. He has to learn to adapt his
schedule to that of other members of the family and especially to that of
other children who may be in the family.
Yet he must develop his own personality. He should be let alone while
eating, to develop his own capabilities. We must study and further his
natural impulses to walk, talk, reason, fight, play, feed himself, ask questions, etc.
These are all adult functions, which the child is anxious to develop with
his growing body and brain.
Remember that at two years of age the child brain has attained four-
fifths of its adult capacity.
The child is trying to grow—we must respect and help this growth.
There is no sin in the little child; there is merely bad form, and we have
to teach him good form.
Lead not a child into temptation. Do not make sins of natural impulses.
Never shame or frighten a child in an effort to attain discipline.
Page 240 The basis for nine-tenths of the neuropsychosis of adults is the fear and
shame that are inculcated in childhood, in the second year—and usually
fear is referred to the father.
Shew the child that conformity and social conduct are advantageous and
pleasant, non-conformity and anti-social conduct are disadvantageous.
To develop and maintain the constructive attitude outlined is an art,
and our reward will be paid us, not in dollars or cents, or avoirdupois, but
in colourful children.
Dr. Aldrich said in conclusion. "Medicine, particularly paediatrics, stands
on trial today. We have been eminently successful in teaching parents the
importance of proper nutrition on the one hand, and on the other we have
been distressingly successful in spoiling the children's appetites so that the
food we prescribe is not eaten. This is largely because we have neglected to
realize that there is no such thing as a purely physical problem in a child. We
are either going to broaden our viewpoints and abilities so that we are competent to be leaders in both physical and mental fields, or special groups of
workers are going to prove more adequate and wrest our leadership away.
One of the best ways to establish leadership is to show our enthusiasm for
the cause. In this case we must devote our brains and our hearts to the individual problems which arise out of the growth of children. In the perfection
of this art I see promise of a bright future, not only for our profession but,
which is more important, for the perfect development of the rising generation."
ABSTRACT OF ADDRESSES BY DR. F. W. LYNCH
Retrodisplacement of the Uterus
This paper by Dr. Lynch consisted of a review of the findings in a
follow-up of 1230 cases in the post partem clinic of his hospital. Dr. Lynch
starts out by making the statement that retrodisplacement of the uterus is
a prologue to prolapse of that organ and with the aid of his findings in
reviewing these cases stressed the importance of regular post partem
examinations and the early correction of this common condition.
These 1230 cases were examined at intervals of from four months to
one year following delivery and it was found that 58.9% had a uterus in
normal position, while 41.1% had a retrodisplacement. In looking for a
causative factor he found that forceps deliveries and the presence of relaxed
pelvic floors were as frequent in the group without displacement as in those
where the uterus was retroverted, so he considered that these were not
factors in the causation.
In this group of 500 cases it was found that one-third showed a retroversion during the first three months post partem, but that one-third of
this group developed a retroversion some time after the third month post
partem. This is an important finding and is due to damaged uterine supports, and eventually a retroversion is produced by long continued sudden
increase of intra-abdominal pressure in lifting and straining.
Of the 5 00 cases of retroversion found, only 20% had symptoms. All
cases were divided into two classes, first, those with a retroversion plus some
other pelvic pathology such as lacerated cervices, parametritis, varicosities
of the broad ligaments, subinvolution, etc., and, second, those with a retroversion and no other pelvic pathology.  It was found that of those in the
Page 241 first group 71 % complained of symptoms while of those in the second group
only 42% had symptoms.
The speaker referred to those cases that every one sees which have been
operated on for the correction of a retroversion and where symptoms have
not been cured. He stressed the following point, that care must be exercised
in selecting the cases that should be operated on. He stated that 50% of
retroversions are of the acquired type and 50% are congenital. In cases of
the latter the symptoms are due to other pelvic pathology and are not cured
by operation to correct the retroversion.
As regards prophylaxis, it is the custom in Dr. Lynch's clinic at the first
examination, five to six weeks following delivery, to insert a pessary in all
cases and where a retroversion is already present, this is first replaced
manually.
Fibroids
Dr. Lynch also reviewed a series of cases of fibroids of the uterus, 683
cases in all. He divided them all into two classes: (1) Large tumours, those
the size of a four months pregnancy or greater, and (2) small tumours,
those smaller than a four months pregnancy.
The age incidence in 5 72 cases was as follows:
2 0-29 years,    6%
30-39 years,  31%
40-49 years, 45%
50-59 years,  14%
60-70 years,    2%
This series shows practically one-third of the cases occurring in young
women between 30 and 40. The relative age incidence in the large and
small tumours was as follows:
Small Large
20-29 years  8%                   4%
30-39 years  31% 31%
40-49 years  41% 49%
5 0-59 years  15 % 12 %
60-70 years  3%                     1%
As regards symptoms, it was found that one-third had haemorrhage;
one-third had pain and pressure symptoms, and one-third had no symptoms.
In cases of submucous tumours, haemorrhage was present in 85% of
cases, while in intramural tumours haemorrhages occurred in only 23%.
The speaker asked why in one young woman there is excessive bleeding
while in another with an identical tumour there is no bleeding. There was
no answer. In older women near the menopause the bleeding is not necessarily due to the presence of fibroids, as these cases would probably bleed in
any case from some endocrine disturbance.
High blood pressure was found in only 33 cases of the 394 noted, and
was not felt to be a factor in the excessive bleeding in these cases.
Speaking of fibroids as a cause of sterility, Dr. Lynch felt that rather
than the tumours being the cause of the sterility that fibroid tumours were
more liable to occur in women who are relatively sterile to begin with.
Apparently he is suggesting an endocrine disturbance as the causative factor.
One thing always to be borne in mind is the associated malignancy in a
certain number of cases of fibroid tumours of the uterus. In this series there
Page 242 was an associated malignancy in 5 % of cases. In 3 % there was carcinoma
of the cervix.
In regard to treatment in this series, some were operated on, some treated
with radium or x-ray, and some received no treatment. Of the operative
treatment, some were treated by myomectomy, some by subtotal and some
by total hysterectomy; the age, symptoms and their severity and associated
conditions of the cervix, etc., helped to determine the procedure taken.
Those cases not treated when first seen should be kept under observation.
In his closing talk on peritonealization in pelvic operations, Dr. Lynch
said that in his last 2000 operations 20% had had previous laparotomies.
Of these cases with previous operations 80% had adhesions. He made a
strong plea for gentleness and consideration in the handling of tissues and
the covering of all raw surfaces with peritoneum, thus avoiding distressing
and serious post operative complications.
RECENT ADDITIONS TO THE LIBRARY
Recent Advances in Medicine. Beaumont & Dodds.   1934.
New and Non-Official Remedies.  1934.
Transactions of the American Assn. of G. U0$urgeons.  1934.
Report of the Henry Phipps Institute.   1933.
Medical Clinics of North America. March and May, 1934.
The Canadian Formulary.  1933.
Common Diseases of the Skin. Cranston Low.  1934.
Surgical Clinics of North America. April and June, 1934.
The Medical Annual.  1934.
Transactions of the American Laryng., Rhinol. and Otol. Society.  1934.
Mayo Clinic. Volume 25.   1934.
The Complete Works of Oliver Wendell Holmes, in 12 volumes.
The Modern Treatment of Syphilis. Joseph Earle Moore.  1933.
Modern Clinical Syphilology. W. H. Stokes.  2nd edition.   1934.
Diabetic Manual. Joslin.   1934.
To Be or Not to Be. Louis Dublin.  193 3.
Obstetrics and Gynaecology in 3 volumes. Ed. by Curtis.   1933.
Nervous Indigestion. Alvarez.  1931.
S. BOWELL & SON
DISTINCTIVE FUNERAL
SERVICE
Phone 993
66 SIXTH STREET
NEW WESTMINSTER, B. C.
Page 243  Withstanding the Test
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Thio- Bismol   is   in   solution
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Accepted for N. N. R. by
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and Chemistry of the American   Medical  Association.
Being soluble in tissue fluids it is not appreciably precipitated
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concentration of spirocheticidal bismuth salt in the tissues.
THIO-BISMOL (Sodium bismuth thioglycollate) contains
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Boxes of 12 and 100 2-cc. ampoules (No. 156), each ampoule
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R. F. HARRISON W. R. REYNOLDS  The  cereal-starch   of  PABLUM
pfH is more quickly digested B|
than that of long-cooked cereals
BOTHERSOME and expensive long cooking, which is often recommended for infants' cereal, is proven unnecessary with Pablum. For, being precooked at 10
pounds steam pressure and dried, it is so well cooked that it can be served simply by
adding water or milk of any temperature. Photomicrographs show that this method
of cooking thoroughly ruptures starch granules and converts Pablum into porous
flakes which are readily permeable to the digestive fluids. This is supported by
studies in vitro showing
that the starch of Pablum
prepared with cold water
is more rapidly digested
than that of oatmeal, farina,
cornmeal, or whole wheat
cooked 4 hours**
140 X, STAINED
290 X,  STAINED
Large photomicrograph: Pablum mixed with cold water—portion of large flake.
Pablum flakes are honeycombed with "pores" (note light areas A) which allow
ready absorption of digestive fluids. Inset; Farina cooked V2 hour—clump of
cereal including starch granules. Note density of clump and lack of porosity.
Many starch granules, such as are present in raw cereal, remain unchanged in form.
FIFTEEN cereals (both cooked and uncooked) studied microscopically were revealed as containing many starch granules, most of them massed into dense
clumps. Such unruptured clumps were never observed in hundreds of examinations of Pablum. Each tiny flake is filled with holes, and like a sponge it drinks up
liquids. Hence Pablum can be entirely saturated bll the digestive secretions.
Besides being thoroughly cooked and readily digestible, Pablum supplies essential vitamins and minerals, especially vitamins A, B, E, and G, and calcium,
phosphorus, iron and copper. It is a palatable c^ad consisting of wheatmeal, oatmeal, cornmeal, wheat^embryo, alfalfa leaf, beef bone, brewers' yeast, and salt.
fRosa and Burrill, Journal of Pediatrics, May 1934. Reprint sent on request of physicians.
MEAD JOHNSON V CO. OF CANADA, Ltd., Belleville, Ont.
Please enclose professional card when requesting samples of Mead JohnBon products to cooperate in preventing their reaching unauthorized persona INDEX   TO   VOL.   X
ABNORMALITIES IN THE APPARENTLY WELL—Murray McC. Baird.
ABSTRACTS	
ALDRICH, C. A.—"Diagnosis and Prognosis in Nephritis in Children"	
"Treatment of Nephritis in Children"	
"Points in Treatment of Some Common Pediatric Conditions"	
"The Art of Feeding Children"	
ALVAREZ, W. C—"Aphorisms of Alvarez"	
ANAEMIA—/. £. Walker l^flfi      	
ANAESTHESIA—W. N. Kemp	
ANNUAL MEETING	
APHORISMS OF ALVAREZ— W. C. Alvarez J|	
APPLEBY, L. ¥L.—"The Medical Life of Henry the Eighth"	
BAIRD, M. McC.—"Abnormalities in the Apparently Well"	
"Erythema Nodosum and Its Relation to Tuberculosis"	
BONE MARROW, THE—B. D. Gillies	
BRODIE, FREDERIC—"Head Injuries"	
BUTTERS, DR. T. L.—Obituary $$. jgt	
CANCER, A COMMUNITY HEALTH PROBLEM	
MODERN   TRENDS   IN   CANCER   RESEARCH,   CAUSES   OF—
Max Cutler	
OF THE UTERUS—/. W. Cathcart	
POINTS IN TREATMENT OF—Max Cutler	
CASE REPORT—R. G. Urge §1	
CASSELMAN, DR. V. E. D.—Obituary	
CATHCART, J. W.—"The Family Physician's Place in the Control of Cancer of the
Uterus"	
CHILDREN, THE ART OF FEEDING—C. A. Aldrich...
CLEVELAND, D. E. H—"Drug Eruptions"	
CLINICAL SECTION   Jl 28,
CROSBY, DR. ROBERT—Obituary ..
CUTLER, MAX—"Causes of Cancer and Modern Trends in Cancer Research"	
"Some Points in the Treatment of Cancer"	
DEATHS .27, 10J, 204, 20J, 226,
DESBRISAY, H. A.—"Pneumococcic Infection"	
DOLMAN, C. E.—"Staphylococcal Problems".	
DRUG ERUPTIONS—D. E. H. Cleveland ...
ERYSIPELAS—G. A. Greaves	
ERYTHEMA NODOSUM—Murray McC. Baird—
FRACTURES—E. L. Garner	
FULLER, DR. A T.—Obituary...
GARNER, E. L.—"Fractures"	 INDEX—Continued
GILLIES, B. D —"The Bone Marrow" -  107
GONORRHCEAL URETHRITIS, NOTES ON THE TREATMENT OF—Lee Smith 189
GREAVES, G. A.—"A report on a series of cases of Erysipelas treated at V.G.H. since
January, 1931, in which Quartz Light was used in the treatment" 1 57
HEAD INJURIES—Frederic Brodie   49
HENRY THE EIGHTH, MEDICAL LIFE OF—L. H. Appleby.—.  87
INTERNAL PROLAPSE OF THE RECTAL MUCOSA—/. A. Sutherland  187
KEMP, W. N.—"The Stillbirth Problem in Relation to Iodine Insufficiency"  52
"Combined Surgical Anesthesia with Basal Avertin Anesthesia"  136
LARGE, R. G.—"An Interesting Case Report"  181
LEUCOCYTE COUNT, THE NORMAL  160
LYNCH, F. W.—"Abstract of Addresses by Dr. F. W. Lynch"  241
LIBRARY COMMITTEE, ANNUAL REPORT OF g  159
MEDICAL COUNCIL OF CANADA—R. S. Thornton  128
MEDICINE IN THE KLONDYKE—Alfred Thompson  193
MEETINGS, GENERAL  27, 71, 84 145
NEPHRITIS IN CHILDREN, DIAGNOSIS AND PROGNOSIS OF—C. A. Aldrich 213
NEPHRITIS IN CHILDREN, TREATMENT OF—C. A. Aldrich  215
OBESITY—/. E. Walker      230
PEDIATRICS, POINTS IN TREATMENT OF SOME COMMON CONDITIONS
—C. A. Aldrich  218
PEDLOW, W. L.—"Remarks of Retiring President"  147
PETERSKY, Dr. S.—Obituary .  10 5
PNEUMOCOCCIC INFECTION—H. A. DesBrisay  130
PROCTER, DR. A. P.—Obituary  226
PROGRAMME,   193 3-193 4 j  2
RELIEF, MEDICAL    29, 67
REVIEWS .  9, 10, 12, 107, 126 186
SMITH, LEE—"Notes on the Treatment of Gonorrhoea! Urethritis"  189
SPECIAL  MEETINGS  73
STAPHYLOCOCCAL PROBLEMS—C. E. Dolman  207
STILLBIRTH   PROBLEM   IN   RELATION   TO   IODINE   INSUFFICIENCY—
W. N. Kemp |  52
SUMMER   SCHOOL    167, 203
SUTHERLAND, J. A.—"Internal Prolapse of Rectal Mucosa"  187
SYPHILIS, THE MACRO-MICRO FLOCCULATION TEST FOR—F. Smith  11
THOMPSON, A.—"Medicine in the Klondyke"  193
THORNTON, R. S.—"Medical Council of Canada"  128
WALKER, J. E.—"Ancemia"  {conclusion)  15
"Obesity"   230 jjipfffpf
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