History of Nursing in Pacific Canada

The Vancouver Medical Association Bulletin: January, 1937 Vancouver Medical Association Jan 31, 1937

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 77.elBULLETIN
OF THE
VANCOUVER MEDICAL
ASSOCIATION
VoLXIH.
JANUARY, 1937
In This Issue:
SOME FACTORS REGULATING NUTRITION
. PH-...        AND GROWTH pi
With Special Reference to the Gastro-intestinal and
Respiratory Tracts
THE RELATION OF MASTOID INFECTION TO
CASTRO-ENTERITIS IN INFANTS       |1
NEWS AND NOTES BULKETTS
(With Cascara and Bile Salts)
. . FOR . .
Chronic  Habitual
Constipation               |
BULKLETTS POSSESS ENORMOUS BULK    fj
PRODUCING PROPERTIES AND BEING
PROCESSED    WITH   CASCARA    AND
BILE   SALTS  PRODUCE   BULK  WITH
MOTILITY.
WE WILL BE PLEASED TO PROVIDE
ORIGINAL CONTAINERS FOR TRIAL
ON REQUEST.
Western Wholesale Drug
(1928) Limited
456 BROADWAY WEST
VANCOUVER   -   BRITISH COLUMBIA
•
(Or at all Vancouver Drug Co. Stores)
I 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. XIII.
JANUARY, 1937
No. 4
N
OFFICERS  1936-1937
Dr. W. T. Ewing Dr. G. H. Clement Dr. C. H. Vrooman
President Vice-President Past President
Dr. Lavell H. Leeson Dr. W. T. Lockhart
Hon. Secretary Hon. Treasurer
Additional Members of Executive—Dr. A. M. Agnew, Dr. J. R. Neilson
TRUSTEES:
Dr. F. Brodie Dr. J. A. Gillespie Dr. F. P. Patterson
Auditors: Messrs. Shaw, Salter & Plommer.
SECTIONS
Clinical Section
Dr. Roy Huggard Chairman     Dr. Russell Palmer Secretary
Eye, Ear, Mose and Throat
Dr. L. H. Leeson Chairman     Dr. S. G. Elliot Secretary
Pediatric Section
Dr. G. A. Lamont Chairman     Dr. J. R. Davies Secretary
Cancer Section
Dr. B. J. Harrison Chairman     Dr. Roy Huggard Secretary
STANDING COMMITTEES
Library
Dr. A. W. Bagnall
Dr. H. A. Rawlings
Dr. W. D. Keith
Dr. S. Paulin
Dr. W. F. Emmons
Dr. Roy Huggard
Publications
Dr. J. H. MacDermot
Dr. Murray Baird
Dr. D. E. H. Cleveland
V. O. N. Advisory Board
Dr. I. T. Day
Dr. W. A. Dobson
Dr. G. A. Lamont
Dinner
Dr. A. Lowrie
Dr. A. E. Trites
Dr. J. G. McKay
Summer School
Dr. J. W. Arbuckle
Dr. J. E. Walker
Dr. H. A. DesBrisay
Dr. H. R. Mustard
Dr. A. C. Frost
Dr. J. R. Naden
Credentials
Dr. A. B. Schinbein
Dr. H. A. DesBrisay
Dr. J. R. Naden
Rep. to B. C. Medical Assn.
Dr. Wallace Wilson
Sickness and Benevolent Fund—The President—The Trustees Meningococcus Meningitis
This form of meningitis is distinguished from other acute
infections of the meninges by the presence of the meningococcus in the cerebro-spinal fluid. During the five-
year period 1930-34, deaths in Canada from meningococcus meningitis totalled 851, of which 80 per cent
occurred in children.
Jochmann and Flexner independently demonstrated, in 1906, the
efficacy of anti-meningococcus serum for treatment of meningococcus
meningitis. In the intervening thirty years the clinical value .of such
serum has been established.
During the years of the Great War the Connaught Laboratories cooperated in clinical and laboratory studies of meningococcus meningitis occurring among soldiers. Many of the strains of meningococci
isolated from these cases were utilized in the preparation of serum.
Similar studies have been continued, and the anti-meningococcus
serum prepared in the Connaught Laboratories has been maintained at
high levels of potency. Extensive clinical experience has demonstrated
the therapeutic value of this polyvalent serum.
Anti-Meningococcus Serum is available in 20 cc. vial-packages and
in 20 cc. intraspinal outfit-packages. Information and prices
relating to  this product will  be supplied gladly upon request.
CONNAUGHT LABORATORIES
UNIVERSITY OF TORONTO
TORONTO 5      •      CANADA
Depot for British Columbia
MACDONALD'S PRESCRIPTIONS LIMITED
MEDICAL-DENTAL BUILDING, VANCOUVER, B. C. VANCOUVER HEALTH DEPARTMENT
STATISTICS-
Total Population—estimated	
Japanese Population—estimated	
Chinese  Population—estimated	
Hindu  Population—estimated	
-NOVEMBER, 1936.
247,558
8,055
7,895
320
Number
Total   deaths .     L     222
Japanese deaths  8
Chinese deaths   .         8
Deaths—Residents only     192
BIRTH REGISTRATIONS—
Male, 141; Female, 139-
280
INFANTILE MORTALITY— Nov., 193 6
Deaths under one year o£ age       15
Death rate—per 1000 births       50.4
Stillbirths (not included in above)        10
Rate per 1,000
Population
10.9
12.1
12.4
9.5
13.8
Nov., 1935
14
52.6
9
CASES OF COMMUNICABLE DISEASES REPORTED IN CITY
October, 1936
Cases     Deaths
Smallpox   0 0
Scarlet Fever  3 8 0
Diphtheria     0 0
Chicken Pox  39 0
Measles     176 1
Rubella   2 0
Mumps    44 0
Whooping Cough  4 0
Typhoid Fever  1 0
Undulant Fever  0 0
Poliomyelitis    6 2
Tuberculosis   19 11
Meningitis   (Epidemic)  0 0
Erysipelas   , -  10 0
Encephalitis Lethargica  0 0
Paratyphoid Fever  0 0
November, 1936
Cases    Deaths
December 1st
to 15th, 1936
Cases    Deaths
0
46
0
60
796
6
113
1
3
0
1
36
1
16
0
0
0
0
0
0
0
0
0
0
0
0
0
11
1
0
0
0
0
14
0
54
920
5
98
0
0
0
0
19
0
5
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
Bioglan Hormone Treatment
A SCIENTIFIC BIOLOGICAL
PLURI-GLANDULAR REMEDY
Its use is being attended with better than ordinary results.
Descriptive literature on request.
MADE IN ENGLAND  BY
THE BOWSHER LABORATORIES LTD.
Biological and Research
Ponsoourne Manor, Hertford, England.
Rep., S. N. BAYNE
1432 Medical Dental Building'       Phone Sey. 4239       Vancouver, B. C.
References: "Ask the Doctor who has used it."
Page 67 ii
Yes,
^_
M
M
DOCTOR,
THIS SEDATIVE
Tastes
GOOD"
Yet it contains VALERIAN!
BY a special process Gabail
Laboratories have removed
all objectionable taste and odor.
You know the value of Valerian
for hysteria and conditions of
nervous instability. Scott (Potter's Therapeutics, 15th ed.,
1931) says: "It is a valuable
remedy in all forms of hysteria
and various forms of 'nervousness/ especially in young and
delicate women."
Elixir Gabail
(Bromoi - Valerianate) contains odorless, tasteless valerian
reinforced by Strontium
Bromide and % grain of
Chloral Hydrate per teaspoonful. A remarkably good sedative and hypnotic for nervous
women.
The sedative dose is 2 teaspoons-
ful to a tablespoonful 3 times
daily: as a hypnotic, a table-
spoonful shortly before retiring, repeated if required.
For complimentary sample,
write to Anglo-French Drug
Co., 3 54 St. Catherine St. East,
Montreal.
SAMPLE ON REQUEST
ELIXIR GABAIL
(BROMO- VALERIAN ATE)       11 VANCOUVER MEDICAL ASSOCIATION
Founded 1898
Incorporated 1906
Programme of the 39 th 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 the Agenda.
General Meetings will conform to the following order:
8:00 p.m.—Business as per Agenda.
9:00 p.m.—Papers of the evening.
1936.
October 6*th--GENERAL MEETING.
Dr. W. H. Hatfield: "Programme of the Tuberculosis Division of
the Provincial Board of Health."
Dr. A. B. Schinbein and
Dr. W. Elliott Harrison: "Surgical Treatment of Pulmonary Tuberculosis."
October 20th—CLINICAL MEETING.
November 3rd—GENERAL MEETING.
Dr. E. J. Curtis and
Dr. H. Lavell Leeson: "Respiratory Infections of Childhood."
November 17th—CLINICAL MEETING.
December 1st—GENERAL MEETING.
Dr. C. W. Prowd and
Dr. A. Y. McNair: "Tumours of the Large Bowel."
1937
January 5 th—GENERAL MEETING.
Dr. R. Huggard: "Some Physiological Concepts of the Stomach and
Duodenum."
Dr. J. E. Walker: "Physiology of the Stomach."
Discussion opened by Dr. H. A. DesBrisay.
January 19th—CLINICAL MEETING.
February 2nd—GENERAL MEETING.
Dr. T. McPherson and
Dr. J. D. Balfour: "Obstruction of the Small Bowel."
Discussion opened by Dr. L. H. Appleby.
February 1 6th—CLINICAL MEETING.
March 2nd—OSLER LECTURE.
March 16th—CLINICAL MEETING.
April 6th—GENERAL MEETING.
Dr. Walter Turnbull and Staff: Symposium on
"Pelvic Conditions."
April 20th—CLINICAL MEETING.
Page 68 EDITOR'S PAGE
By the time this number of the Bulletin reaches our readers, it will be
rather late for Christmas wishes—the turkey and the plum pudding will
have died—but we shall be just in time to wish you a very Happy and
Prosperous New Year.
As a profession, 1937 bids fair to be for us a very significant and interesting year. We shall have some bigi problems to tackle, some big decisions
to make, some big dangers to face. What can we wish to our fellows for
the New Year?
We shall wish them courage: the first and most necessary gift; and in
wishing it, we know already that they have it. But it will be a courage
based on other gifts that we wish for them. Loyalty, for example, to each
other and to our common cause. Loyalty to our patients and the public,
who depend on us for the very best that is in us—whose present and future
well being are in our hands to make or mar. A loyalty that will not allow
us to give anything less than the very best that is in us—a courage that will
not allow us to be bullied or cajoled or threatened into betrayal of our trust.
A loyalty to each other that will not allow our own selfish desires, our own
immediate needs, to be the deciding motive of what we do.
Leadership, too, we wish to our profession. It is there—and it is up to
each one of us.to follow it loyally and generously. Clear vision and statesmanship are necessary now more than they have ever been: generosity and
unselfishness, the wider view that not only sees the immediate necessities of
the case, but can also envisage the future, and build for permanence and
stability.
The past year has been one of progress and consolidation—we are
stronger, better knit than we have ever been. Our union must grow and
become firmer. It can only do so if our objects are worthy, and our aims
high. We believe that this is the case, and that it is with all the omens favourable, and all signals set fair, that we enter a New Year, of construction and
growth, which will mean, not only to us but to the community at large,
a Happy New Year.
HAVE YOU PAID YOUR DUES?
Members are reminded, that delinquents will be posted in the
library on the first day of January, according to
Bylaw Number 6, Section 1.
NEWS AND NOTES
The following men were elected to membership in the Vancouver
Medical Association at the regular general meeting on November 3rd: Drs.
R. K. Brynildsen, K. J. Haig, E. S. James, Douglas Telford. Dr. T. A. Lane
Connold of the Columbia Coast Mission was made an Associate member.
Dr. G. S. Gordon, accompanied by Mrs. Gordon, has left for New
Zealand, where they will spend the winter months. Dr. Gordon reports that
the trout fishing in New Zealand is always excellent.
Page 69 Dr. and Mrs. Lyon Appleby are receiving congratulations on the birth
of a daughter.
nT *T #8" *r
Dr. W. J. Knox of Kelowna paid another of his brief but none-the-less
enjoyable visits to the Coast—enjoyed also by his many friends in Vancouver
and Victoria.
*       #       #       *
Dr. F. M. Auld of Nelson spent a fortnight in Vancouver and Victoria.
While in Vancouver, Dr. Auld attended the meeting of the Board of Directors of the B. C. Medical Association, representing the West Kootenay
Medical Society, of which he is President.
*r ^r *c *r
Congratulations are being passed to Dr. J. S. Daly and Mrs. Daly of
Trail on the birth of a daughter.
»P *T •«• *-*
Dr. Gordon A. Lawson of Port Alice is spending six weeks visiting in
Alberta. He will spend Christmas and New Year's with relatives.
^L »li *_, _(_
*_* »r »r *r
Dr. H. A. Whillans of Victoria is doing locum tenens for Dr. Lawson
of Port Alice during his absence.
*_ *_ *■_ _t-
*r •*■ ir *s*
Dr. Gordon E. Wride of Hedley, who is associated with his brother, Dr.
R. J. Wride of Princeton, is leaving for post-graduate study in Eastern
centres.
a-      *      *      *
Dr. J. S. Burris of Kamloops is in the East pursuing special work in
thoracic surgery and will be away for at least six weeks.
*_. _t 4L _!_
*_* •_• *_* •_•
Dr. James Murison of Powell River will spend a Christmas and New
Year's vacation on the Prairies.
»_ *_   I »_. *_
Dr. F. V. Agnew of Smithers visited Vancouver recently and called at
the office of the College. We are always pleased to see our friends from the
North.
*^ '     S5» A *_■
Dr. K. F. Brandon has been appointed an assistant to Dr. Mcintosh at
the Metropolitan Health Centre, in Vancouver.
$*■ »*• 5^ 5_»
Dr. G. L. Watson is now assisting Dr. W. A. Moffatt in Vancouver.
>.•       -I-       -f       -<-
Dr. Kritzwiser, formerly on the C.P.S.S. Empress of Canada, has gone to
Premier to relieve Dr. W. S. Kergin.
Dr. Paul Phillips has gone to Hedley to assist Dr. R. J. Wride for several
months, during the absence of Dr. A. E. Wride.
?S» *j» 5J» •sr
Dr. E. H. W. Elkington has moved from Duncan to Victoria.
Dr. G. W. Leroux is now in Fernie, where he will assist Dr. G. A. E.
Kelman.
#       *       *       *
Dr. G. E. Darby of Bella Bella is now in England, where he is doing
Page 70 post-graduate work. Dr. and Mrs. Darby sailed for England via the Panama
Canal, and will be gone some months.
Dr. L. S. Ghipperfield is now practising in Coquitlam.
The Upper Island Medical Society met at the Qualicum Beach Hotel
on Tuesday, November 10, 1936.
After an excellent dinner, several papers were read.
Dr. T. McPherson gave a paper on "Obstruction of the Small Bowel."
This paper was discussed by Drs. Higgs, Hilton and Thomas.
Dr. Norman Hall gave a paper on "Carcinoma in the First Three
Decades of Life." This paper was supplemented by appropriate lantern slides.
Dr. M. W. Thomas talked on aims of the B. C. Medical Association,
functions of the Secretary, and on Health Insurance.
Officers for the ensuing year were elected: Dr. C. T. Hilton was made
president, Dr. G. K. McNaughton vice-president, Dr. W. D. Higgs secretary-treasurer, and R. W. Garner reporter.
Dr. Norman Hall was appointed as society representative to the Cancer
Committee, and Dr. G. A. B. Hall is to continue as the society representative
to the Council.
The attendance was the best in the history of the society: Doctors G. A.
B. Hall, Norman Hall, L. Giouanda, A. H. Meneely, C. C. Brown, D. Emery
and S. L. Williams represented Nanaimo; Dr. N. B. Hall, Campbell River;
Dr. G. K. McNaughton, Cumberland; Drs. P. L. Straith, J. McKee and
L. A. Briggs, Courtenay; Dr. C. Davidson, Qualicum Beach; and Drs. C.
T. Hilton, W. D. Higgs and R. W. Garner, the Albernis. Also present were
Drs. T. McPherson, B. J. Thomas and B. Hallows.
The fees to the society are to be one dollar per year and it was agreed
that the society meet at least twice a year.
We also wish to report that Dr. and Mrs. D. Emery are the proud
parents of a girl born in September of this year. t»   w Cakiter.
SOME FACTORS REGULATING NUTRITION
I      AND GROWTH
With Special Reference to the Gastro-intestinal and
Respiratory Tracts,
E. Johnston Curtis, M.D., Vancouver.
Paediatrics has been defined as that branch of medicine which has as its
purpose the making of a better next generation. The particular training for
a paediatrician is that of a specially trained internist. His practice involves
the mechanisms of the body as a whole. No other specialty is so filled with
responsibilities and relationships. He is not a regional specialist.
Infancy and childhood constitute that period of life where there is
found rapid mental and physical growth. It is the period where growth
influences predominate. Growth and development are dependent upon the
nutrition of a particular tissue or the tissues as a whjole. Therefore it may
be asked what are the factors which influence nutrition.
There are many factors which influence nutrition and growth. Important
as some may be, I feel, not only from my own personal experience and training, but from the experience of others, that parenteral infection, as distinct
Read before Vancouver Medical Association, November 3, 1936.
Page 71 from enteral, plays a dominant role. Too, I wish to point out throughout
this paper that many things which physicians call a disease are merely symptoms. I know no one here has used the term "intestinal flu" for influenza.
The disease entering by the upper respiratory tract shows manifestations and
symptoms elsewhere. The diarrhoea and intestinal upset often seen is not
intestinal influenza, but is the result of the influenzal organism in the tissues
elsewhere. Upset cellular and intercellular exchanges occur; water balance
is upset by physio-chemical and irnniunological reactions. The diarrhoea and
local nutritional disturbance are really due to disease in parts remote.
A similar condition is seen in the infant or young child with boils. The
diarrhoea and loss of weight or marasmus in the infant is a symptom—there
is no boil in the intestinal tract.
In order to clarify factors which influence nutrition and growth, I have
arbitrarily takeni the base line of an equilateral triangle, and divided it into
equal parts. All early life and its future development are primarily dependent
upon "heredity" and "environmental influence"; these I have placed on the
base line. The apex represents the ultimate result of these normal basic
factors for nutrition and physical growth. Within the triangle, the alimentary tract is depicted as a circle which touches all its sides. (Here Dr .Curtis
shewed a diagram containing these points described.—Ed.)
I have placed within the two equal triangles, at the base, the endocrine
and prenatal influences. This is because they are so closely related to the
basic factors producing normal nutrition and growth.
In the third angle is depicted the influences of organic functions, particularly those pertaining to cellular and intercellular exchanges, or metabolic changes.
One may let his imagination range a little further. Consider the thickened inner circle as depicting the nervous, vascular and lymphatic systems,
respectively transporting nervous impulses or the products of digestion or
of elimination.
The alimentary tract is closely affected by the various influences of
heredity and environment (prenatal and glandular) factors. This triangle
depicts the influence that any or all of these factors may have on the gastrointestinal tract and subsequent nutrition.
Hereditary Factors
Many mental and physical characteristics are inherited, such as race,
colour, form, temperament, intellectual ability, disease resistance.
All affect nutrition and growth. For example, the nasal sinuses of the
offspring follow closely the conformation and life history of the sinuses of
the parent whom he most resembles. Similarly with the development of the
dental arches, and 80 per cent of allergic manifestations in children are
hereditary. It has been suggested that gingivitis is a local allergic response.
The chronic and periodic diarrhoeas are frequently caused by allergic foods—
colic and mucous colitis are often explainable on an allergic basis. Spastic
constipation, indigestion, when not on an organic basis, may be due to an
allergic cause. Cyclic vomiting, eczema, urticaria are often allergic.
Many show the effects of sensitivity upon the gastro-intestinal tract
and we blame the food, while in reality the hereditary trait or taint is to
blame. Such conditions as Cooley's erythroblastic ansemia, familial haemolytic anaemia, haemophilias, are other hereditary conditions which affect
nutrition, and growth. Each of these will at times have an effect upon the
gastro-intestinal tract. Secondary infection will often be superimposed upon
this already sickly individual followed by further malnutrition.
Page 72 Environment
Environment has a moulding effect upon the product of hereditary influence. A favourable environment will help nutrition and growth. Climate,
clothing, habitat and food are important environmental factors influencing
the race or the individual's nutrition and growth. Such factors affect the
mental attitude or responses. The mental attitude toward food is determined
not only by hereditary influence but by environment. For example, the child
forced to eat soon finds that the parent is making it the centre of attraction.
With each meal and the increasing concern of the parent the child refuses
more food.
Nor is it only the upset mental reactions and its being a psychological
problem that occur: the child often shows signs of gastro-intestinal upset
and malnutrition. There has been some capitalization of the fears of such
parents in this respect.
Many have come to think of food in terms of Diet, not Dinner. The
taking of food, which should be a joyous affair, has become a perilous and
risky venture with all kinds of chances of a technical mistake. The layman
(maybe some doctors) worries too much about food elements in the normal
individual. Are we to blame the food taken in such instances when a gastrointestinal upset or malnutrition occurs?
Food
In many instances human mothers have become biologically unsound
more in the quantity than in the quality of their milk. Cow's milk must
be canned or pasteurized, destroying many vitamins, and it does not contain
other elements, such as iron, to any appreciable amount. More often do we
find gastro-intestinal and nutritional upsets from defects of food in quantity rather than quality in the nursing child or the artificially fed. Omission
of vitamins in the infant diet is unlikely, with all the present day drug-house
propaganda. There is a greater danger of hypervitaminosis. It is interesting
that certain foods in excess are more deleterious than others. Oatmeal in
excess is a decalcifying food in spite of cod liver oil. In this country* like
excesses occur only among the poor; the average diet, however, has plenty
of sins of commission and not omission.
Omissions occur among those affected by diet cranks. Of course, frank
omissions or commissions of diet may upset the gastro-intestinal tract, but
they are less likely today. Food today is clean—there is not even the green
apple episode.
The human race did not spend a hundred thousand years acquiring a
selective appetite for nothing. Infants and children have been allowed to
select their own foods—foods which are good for them. They have thrived,
with none of the psychological and gastro-intestinal symptoms induced by
the diet-conscious parent.
Any disturbance in the above hereditary and environmental factors will
often result in poor nutrition and growth. When malnutrition occurs in
any tissue, infection, and more especially parenteral infection, will set in.
Prenatal
Because of the aforementioned biologically unsound mother we are faced
with the problem of prenatal influences upon the foetus. Too many things
happen to the unborn child. The care of the child should begin with the care
of the mother, during or even before her pregnancy.
The tooth buds are formed in the early months of pregnancy. Should a
calcium deficiency exist the teeth will rapidly decay in early childhood.
Page 73 Fcetal rickets is now a recognized entity. Contagious and infectious conditions during foetal growth are responsible for conditions in post-natal life.
For example, the first symptoms of a syphilitic baby from an untreated
syphilitic mother are in most instances referable to the gastro-intestinal tract
and nutrition. Otosclerosis is now considered to result from food deficiencies,
toxaemias, and infections in the pregnant women. Vascular and endocrine
states should be cited.
Endocrines
There is a link with the endocrines. At no period of post-natal life do
endocrines play so important a part. The link is in every direction, influencing nutrition and growth.
It is not an uncommon finding to have a gastro-intestinal upset associated with thyroid dysfunction. One of the common signs of thyroid gland
overdosage is a diarrhoea or nutritional disturbance. One commonly sees the
thyroid influenced by remote infections. The fat boy with undescended testicles has an unbalanced nutrition and growth. The pituitary gland in such
an instance is at fault.
Infections
We now describe a circle about the whole triangle. This should depict
the influence of parenteral infection upon all factors and upon nutrition.
This is distinct from enteral infection, which refers only to the gastrointestinal tract.
The respiratory tract is taken as an example, because a large proportion
of diseases enter by the respiratory tract, and constitute a large proportion
of our work. Not infrequently are these reflected in the gastro-intestinal
tract with resulting malnutrition. There are some physiological facts which
one must necessarily review in order to appreciate the widespread effects.
At birth the respiratory mechanism undergoes a most sudden change as
compared to the more gradual evolution in other organs. The new environment has a profound effect upon the lurigs. This may account to some extent
for the liability to, respiratory infections in childhood.
The respiratory tract performs a considerable function in heat mechanism. The bronchial tree is relatively larger in the child and is therefore
more susceptible to changes in temperature and humidity. This relatively
larger bronchial tree bears the brunt of droplet infection from the upper
respiratory tract. Often, as the result of a paranasal sinusitis, bronchitis,
fibrosis and bronchiectasis occur. The latter is a much more common condition than is generally supposed, and affects nutrition and growth in no
small way. The bronchial tree being larger, there must necessarily exist a
larger dead air space in contrast to the relatively less alveolar air space. Such
relatively lessened alveolar air is responsible for the more rapid respirations
of infancy, during normal and abnormal states.
Most pneumonias of infancy are associated with the bronchial tree, and
are secondary to extension from above. Pneumonias of later childhood are
more adult in type for the above stated reasons. Often such parenteral infections are ushered in by gastro-intestinal upsets. Where pulmonary conditions
have become chronic (example: chronic bronchitis, pneumonia), the digestive capacity is definitely limited. Nutrition and growth are affected in no
small way by such infections.
What of the defensive and protective mechanisms of the respiratory
tract?
There is a ring of lymphatics interspersed with nodes or glands in the
upper tract, the former being the first line of defense, and the latter the
Page 74 second. It is regrettable that at times these defensive and protective nodes
must be removed. It is never wise to remove them unless chronicity has set
in, yet chronicity will set in, much earlier than is sometimes realized.
The status of this mechanism is dependent upon the quantity and quality
of products, bacterial or otherwise, which travel through and from the
system to almost any remote tissue or organ; for example: lungs, pleura,
mediastinum, heart, peritoneum, joints, bones and kidneys.
One can recall that frequently the intestinal tract is upset in the course
of any of the above affections. The disadvantage to this system is a marked
tendency to chronicity even during an early acute infection. Not infrequently such chronicity results in affections remote from the respiratory
tract, noted above.
There is, too, the lymphatic mechanism of the lower respiratory tract;
the bronchial tree, the bronchial glands, peribronchial and hilar gland, the
lymphatic channels of the lung parenchyma and pleura, all intimately
related and connected in devious manner with the upper respiratory tract.
Similar conflicts and dangers lurk in this more hidden lymphatic system. The
acute and chronic affections are more often associated with simple pyogenic
organisms, yet the acid-fast organism is not unconunon. Primary infections
of the lungs are not so frequent, but are generally caused by infections
entering or beginning in the parts above.
Exanthemata and other infectious diseases all enter by the upper respiratory tract, often ushered in by a gastro-intestinal upset. So often they leave
sequelae elsewhere: in the heart, kidney or lungs.
Atelectasis, bronchiectasis, hare lip and cleft palate, congenital laryngeal
obstructions and tumours are due to prematurity or lack of local normal
growth. Then bacterial and fungous invasions occur even more rapidly than
in normal tissues, and soon chronicity sets in.
Immunity and its development plays a considerable part in such infections—it is comparatively slow to develop in the child.
All parenteral infections find reflections in remote parts and organs
which ultimately result in inadequate cellular and intercellular exchange of
the products of digestion. The inadequate interchanges mean poor nutrition,
and are therefore not directly related to the gastro-intestinal tract. So any
component part or symptom, such as diarrhoea or vomiting or malnutrition,
is not necessarily and primarily a gastro-intestinal tract upset.
There exists no characteristic pathology in the gastro-intestinal tract
of infants dying with nutritional, diarrhceal or vomiting disorders. This
would indicate that factors other than gastro-intestinal are operative. I
eliminate, of course, in this discussion the specific dysenteries (typhoid, etc.).
This is the phase of pediatrics that has been most perplexing, and its
study has gone on for over fifty years. There came a bacteriological era, an
era of high fat and low fat studies. Every food element as the cause of
nutritional disturbances in the intestinal tract has been studied and blamed.
Nobody has given a satisfactory reason for these discrepancies until within
the last ten years. There was no realization that disturbances in the gastrointestinal tract and the subsequent nutritional defect could be reflections
from parts remote; there is no essential difference between the diarrhoea of
parenteral or enteral origin.
There are features common to all gastro-intestinal upsets of non-specific
disease, i.e., excessive bacterial growth in the upper gastro-intestinal tract.
Normally this activity is inhibited by acid. When for any reason conditions are altered in the stomach or small intestine so that bacterial growth
Page 75 is not inhibited, or when excessive bacteria are ingested by mouth, or the
amount of food is in excess of digestive or absorptive capacity, bacterial
growth becomes vigourous in the stomach, duodenum and the ileum. When
every precaution has been taken to avoid contaminated food there must be
a different explanation.
When organisms migrate upward from the colon, the withdrawal of
food results in them remaining in their normal habitat, the colon.
When gastric secretion is decreased, or when such acid is neutralized by
food or alkaline mucous, the stomach or duodenal contents do not then
inhibit bacterial growth. Under such conditions one can appreciate why fermentation takes place.
A decreased acidity by lessened secretion or neutralization may result
from numerous causes:
1. Prematurity or malnourishment.
2. Excessive external temperature.
3. Hyperpyrexia, infections, upset water balance.
4. High buffer foods, mlk, fermentable foods.
5. Irritations; infection, bacterial or otherwise  (of pharynx or oesophagus) .
Of all the above factors which are associated with gastro-intestinal
upsets or nutritional failure, infection is the predominant one, especially of
the upper respiratory tract, rhinopharyngitis, tonsillitis, sinusitis, otitis
media, mastoiditis. The severity of the disturbance is closely associated with
the type of organism. There is much neutralizating effect of the upper
gastro-intestinal tract by the excessive alkaline mucus formed in such conditions. It would seem necessary to correct the primary cause—infection.
Such does not seem reasonable where the nutritional disturbance has
continued long after the acute upper respiratory infection has subsided. We
therefore again refer to the marked tendency to chronicity in the lymphatic
ring—to the type of organism or to the toxins elaborated. The latter has a
known effect upon osmosis or cellular andj intercellular exchanges. A relationship to water balance is seen in the claim that there is a loss of proto-
nucleins in the secretions) of the nasal passages. This: loss of protonucleins is
excessive in upper respiratory infections and becomes manifest in a disturbance of water balance. There is in this some evidence of the association of
upper respiratory infections and nephroses. Evidence accumulates that
respiratory tract infections have effects remote from the local lesion, and,
too, that disturbances of the alimentary tract are not necessarily primary
factors in a nutritional disturbance.
Yet there are disturbances that are primarily related to the gastrointestinal tract that are errors of commission and omission. If such have
been present for any length of time the nutritional condition is further
impaired by infection of tissues somewhat devitalized, and the slow development of immunity. Such infections are soon chronic—and are generally
related to the conditions noted above, in the respiratory tract. Middle ear
infection with resultant mastoid antrum involvement is more common than
is generally admitted. However, it is felt that in this type there has been
aspiration through the large Eustachian tube into the middle ear, of
materials vomited by the child.
Whether the gastro-intestinal upset is primary or secondary; whether
the nutritional disturbance resulting from infection is primary or secondary,
correction of all abnormal conditions is necessary. Whatever the factors
may be, elimination of infection is as essential as correction of the gastric
Page 76 acidity. Correction or aid to intercellular and cellular exchanges by the
advantageous use of parenteral and enteral fluids is often helpful.
There is so often a vicious circle which must be broken or corrected in
two places in order to produce adequate nutrition for future growth and
development.
To illustrate that the battle front in this life period has shifted from the
digestive tract to the parenteral tract the following should be noted.
Infants' Hospital Statistics
From 1927 to October, 1936, there were 4000 infants admitted to the
Vancouver General Hospital (Infants' department) under 2 years of age.
Three hundred and twenty of them (8 % ) were diagnosed as otitis media.
Ninety-eight of them, or 30%, were admitted with the following diagnoses:
malnutrition, intestinal intoxication, diarrhoea, diarrhoea and vomiting,
feeding cases, infectious diarrhoea, or admitted for diet regulation. Seventeen,
or 5.6%, of these shewed suppurative otitis media and eventually had a
mastoidectomy.
In these 17 cases of otitis media operated upon for mastoiditis the following conditions were also present: 3 with periosteal abscess; 1 with acro-
dynia; 1 with atelectasis; 2 with pyelitis; 1 pneumonia; 1 eczema; 1 haemi-
plegia; 1 burns; 6 other conditions classified under malnutrition and gastrointestinal upset. Another 3 cases were found at post-mortem to have mastoid
infection with a suppurative otitis media. These 3 showed gastro-intestinal
upsets and malnutrition during life.
There are recorded 46 other mastoidectomies or antrotomies. These cases
showed no sign of suppurative otitis media. Among those without a suppu-
ratve otitis media but who came later to mastoidectomy, we find the following conditions: 1 with tetany; 1 septicaemia (died); 1 meningitis (died);
1 facial paralysis; 1 TB adenitis; 1 hypothyroid; 1 rhinopharyngitis; 3 bronchitis; 4 pneumonia; 2 acrodynia; 27 others had conditions stated to be
malnutrition and (or) gastro-intestinal upsets. It is this last group of which
you are to hear more. There were 3 more cases of this type which died following operation.
There were 5 mastoid infections which did not come to operation—
4 of them had gastro-intestinal upsets and the other an ulcerative coltis.
They were found at post-mortem.
There is a total of 71 known mastoid infections in 371 known ear infections, or 19%. Thus 371, or 9.3%, of the 4000 admissions had an otitis or
mastoiditis or 1.7% had a mastoidectomy.
Summary
(1927 to October, 1936)
4000 admissions 2 years of age and under.
9.3% or 371 cases of otitis or mastoiditis
30% of them were admitted for malnutrition intestinal intoxication,
diarrhoea and vomiting, diarrhoea, diet regulation, infectious diarrhoea.
Incidence: 1.5% or 63 mastoidectomies or antrotomies.
Mastoiditis
(Summary 71 cases)
Mastodectomy or Antrotomy—57: 16 with suppurative otitis media, 41
without suppurative otitis media (27 of these had only a nutritional and
G-I upset): well.
Mastoidectomy or antrotomy—6:  1 with suppurative otitis media, died
Page 77 atelectasis; 5 without suppurative otitis media, died:  1 septicaemia, 1
meningitis, 3 malnutrition and G-I upset (moribund) : died.
No operation—8: 3 with suppurative otitis media, malnutrition and G-I
upset; 5 without suppurative otitis media, malnutrition: 4 malnutrition
and G-I upset, 1 ulcerative colitis: ddzd.
Why should a paediatrician presume to discuss a subject that might seem
to belong to a regional specialist?
The answer is evident in this schematic representation. Brennemann has
written: "The paediatrician as a rule sees the patients (because of some upset
or for the underlying throat infection) before the ear is involved. If he is
a good doctor he has long ago found his otoscope as indispensable as his
stethoscope, and in some cases even more so. By examining all ears in as
routine a fashion as he does a chest, he becomes familiar with the normal
and abnormal. Finally he is in a position that the otologist cannot occupy—
that of being able to size up the whole clinical setting of which the otitis
or tonsillitis may be either a major or minor part. On the other hand, the
otologist has a technical knowledge and skill the practitioner does not often
possess. The practitioner must acquire the ability and have the knowledge
to examine and to evaluate with reasonable accuracy (even) an ordinary
otitis media."
It is the observation of keen experienced practitioners that the most
frequent difficulty in diagnosis is not the lack of careful examination nor
failure to analyse the signs and symptoms to a lesser degree, but the fact
that the correct cause of the condition or conditions does not happen to
occur to them. In correct diagnosis of all conditions affecting nutrition and
growth an intimate acquaintance with pathologic and biochemical variations
is at times more important even than the examination of the patient. Such
variations affecting nutrition are not so often primarily in the gastro-intestinal tract. The battle front has shifted to the upper respiratory tract.
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Taylor, H.—Trans. A.M.A., Laryn., Otol. & Rhinol., sec. xx, Jan .10-14, 193 5, pp. 48.
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Wells, H. G.—Science of Life.
THE RELATION OF MASTOID INFECTION TO
%     GASTRO-ENTERITIS IN INFANTS
By Dr. L. H. Leeson
Vancouver
Were it not for the fact that the subject already discussed is of a contentious nature, I would not venture to give this account of the work I
have been doing, and which I fully1 believe has a distinct bearing upon some
illnesses of children which we meet under the age of two years.
For the past four years I have had an opportunity of seeing staff cases
at the Infants' Hospital. Some of these cases were of a peculiar type, in that
the predominating disease appeared to be an intestinal infection. These cases
fall into the category of mastoidal infection associated with intestinal disturbances, or intestinal infection associated with mastoiditis.
During this period 21 cases have been operated on in the Infants' Hospital, with one mortality. These cases are usually admitted with the outstanding signs of intestinal infection. There is no seasonal period which
might have an influence upon the progress of the disease. It has been said
that these cases may be categorized as "summer complaint." I do not think
there is sufficient evidence to warrant a classification of "summer complaint"
with that of a mastoidal infection. This statement is controversial, and I
realize that such remarks may raise a storm of protest. This position I am
not prepared to defend, as any remarks relative to the subject are founded
on the records which have come to hand, and have been studied from the
above 21 cases alone. Much has been written, and much more will be written,
which is certain to blast the subject wide open, and when all is said and done
we shall no doubt be in the same position as tonight. I think we should only
accept those cases as a separate and individual entity, in which there is no
text book picture of etiology, signs and symptoms which can be accepted,
nor can they be given as a means by which we arrive at a conclusion as to
whether cases, as a rule, should be operated on or not.
The fact is definitely established that mastoiditis is present in certain
gastro-intestinal disturbances in infants, but there appears to be much to
be discussed in the standardization of our ideas regarding the selection of
time for operation and the preoperative and postoperative treatment. There
can hardly be another condition where individual attention and decision are
more necessary, but there are certain procedures which we have found must
Read before Vancouver Medical Association Nov. 3, 1936.
Page 79 be followed to obtain uniformly good results. The diagnosis is often difficult
and cannot intelligently be made except by the greatest co-operation with
the paediatrician.
Carmack reports that x-ray is of decided value in all his cases. In the
cases in this hospital we have not found this so. In the matter of diagnosis
there must be an elimination or confirmation of all other conditions,
mechanical or infectious, which would produce trouble of this kind, such
as chest, heart, urinary or primary gastro-intestinal disturbances, and, just
as important, there must be demonstrable evidence of disease before surgical
intervention is justifiable. This latter statement is in itself necessary for the
fullest appreciation of a scientific diagnosis. However, I must confess that
there are times when the signs of actual mastoidal infection are lacking, and
then it is only by a process of elimination, as above, that our attention is
guided towards possibly the only remaining field where infection may be
enclosed in tissues which do not readily rid themselves of the infection. It
appears that the appearance of the drum membrane is not always a safe
indication of the extent of the disease inside. It has been our observation
that few, if any, of these infants with marked gastro-intestinal disturbances
have a normal drum membrane, especially where there is considerable dehydration. If the drum is intact it usually presents a grey lustreless appearance
with some or all of the normal membrane marks obliterated. If there is a
bulging of the upper posterior portion of the membrane it is a valuable aid,
but in a few cases drum incision has revealed a djry air space in the middle
ear, while at operation it was found the mastoid space was filled with pus
which did not escape through the aditus. In these cases drainage must have
continued through the Eustachian tube. Bulging indications over the mastoid
area externally have been notably absent.
The selection of time of operation on these babies is of major importance.
Most unsatisfactory results are in cases in which operation has been done
during the height of acute bowel inflammation, frequent stools, high temperature, marked toxaemia and dehydration, regardless of preoperative
preparation. It is, therefore, better and in fact imperative to wait until the
intestinal storm passes or subsides, as there is thus less shock and febrile
reaction after mastoid surgery in infants. Preoperative attention has been
directed towards restoring body fluids to as near a normal state as possible.
Salines, intravenously and subcutaneously, are used, and a blood transfusion
is indicated where the haemoglobin is under 70% or the red cell count under
four million.
Carmack gives as his impressions: First—Mastoiditis may occur coinci-
dentally with an acute respiratory and gastro-intestinal infection, and may
become an important factor in the outcome of the case, while in others the
mastoid may become involved and remain as a focus of infection producing
gastro-intestinal signs of a toxic nature, or subsequent intestinal infection.
Second—Surgical intervention cannot be decided intelligently without close
co-operation between the paediatrician, the roentgenologist and the otolaryngologist; no mastoid should be opened without clinical evidence of disease
in the mastoid space. Third—That all infants with marked or continued
gastro-intestinal disturbances should have careful ear examinations, and if
signs of disease are found, early and free drum incision should be made. If
the mastoid is involved, and satisfactory improvement is not obtained by
air drainage, the mastoid operation is indicated. Fourth—That operation,
except in the occasional case, should not be attempted during the acute
gastro-intestinal phase.
Helwig and Dixon had 57 cases of mastoid in children under one year
Page 80 of age. Their conclusions are that in the fatal illnesses of infants ear infection
is a common event. Enteritis too frequently antedates the ear infection for
one to assume that the latter is primary. Their mortality of about 40% is
much higher than is reported in the clinics of Toronto and St. Louis.
Dick and Williams (1929) reported that in an epidemic of enteritis,
characterized by diarrhoea, loss of weight, regurgitation, fever, otitis media
and mastoiditis, the epidemic was not due to air-borne infection, but was of
intestinal origin. The Morgan dysentery bacillus found in these cases was
highly pathogenic. These authors believe that this was an epidemic of
enteritis associated with mastoiditis, and caused by primary intestinal infection in which the Morgan dysentery bacillus was found.
Lierle and Potter studied the mortality rate in infants where the cause
has been diagnosed as acute mastoiditis, with the idea of determining as far
as possible the factors entering into their deaths. This exclusive study of
these cases brought to light the following observations: it was found there
were two types of cases, those in which there was mastoiditis without
diarrhoea, and second, those in which it was accompanied by diarrhoea.
When there is a definite sinusitis accompanying the mastoid infection improvement may not take place following the operation of antrotomy until
the sinuses as well have been treated. In the great majority of instances
diarrhoea and weight-loss ceased as soon as adequate drainage was established.
With the exception of an occasional epidemic, mastoiditis with marked
diarrhoea occurs chiefly during the fall, winter and spring months when
upper respiratory infection is most prevalent. We have not found this so
in Vancouver, since, as before mentioned, it did not occur in any special
season. Mastoiditis in infants is vastly different in symptoms, course and
indicated treatment from that in the adult.
The mortality rate in infants with mastoiditis and diarrhoea is higher
than those having mastoiditis without diarrhoea, and requires particularly
close observation and unusual treatment. An early diagnosis is essential and
operative measures consist in rapid operation with little trauma.
The term "mastoiditis" in a child under one year of age is misleading.
From examination of mastoid processes in children at this age there is very
little, if any, pneumatization of the bony structure. What is present is the
antrum, and is really part of the tympanic cavity, or the antrum tympani-
cum. Antrum infection exists, and probably invariably exists in connection
with any acute otitis media in an infant, because the two spaces, tympanicum
and antrum, communicate by a wide opening.
Hickey in 1931 reported four cases in which there was a mastoiditis
associated with nutritional disorders in infancy.
Conclusive evidence is still lacking that ear infection is the cause of
acute intestinal intoxication. Also serious otologic infection will be present
in infants without grave nutritional disabilities. As stated, otologists should
operate in the presence of definite indications of ear pathology, and not
merely on suspicion nor at the unsupported request of others.
W. H. Johnston reports from observers in every section of this country
and Europe, and with few exceptions the impression has been that the
so-called gastro-intestinal syndrome in infants does exist. The most important findings, he says, are in the ear drum and canal. Those most often
recorded are drab or grey drum with the loss of normal lustre.
In the cases seen in the Vancouver Infants' Hospital the signs which are
usually found in acute mastoiditis, or a chronic mastoiditis, were lacking.
These cases presented a normal drum, which may have had a slight lack of
lustre. The impression I gained, after repeated examinations of these drums,
Page 81 was that there was an apparent change in colour of the mucosa of the middle
ear. The colour was not that of the normal pinkish mucosa, but there appeared to be a cyanotic colour, which as I say could only be found after
repeated examinations.
Loebell has stated that in the absence of acute middle ear infection, and
where a diagnosis has been made of a probable mastoiditis of a non-acute
type, where it is possible that some toxic material is being thrown into the
intestinal tract, this same appearance of the drum and middle ear mucosa
exists. When the diagnosis has been made, surgical treatment should be
instituted as rapidly as possible.
Our treatment in this hospital begins with giving sufficient sedatives to
have the patient drowsy before the operation. A l/z % solution of novocain
and saline, with l/z min. of adrenalin,to the drachm of solution, is injected
over the mastoid area. It is not necessary to give this procedure in detail,
but one must be sure that the sensory branches of the superior, posterior
and inferior auricular nerves are blocked. It is possible to do a subperiosteal
injection so that the periosteum over the region of the antrum, and as far
forward as the bony canal, is lifted. An incision is made from the temporal
ridge downwards to the exact tip of the mastoid, with the lower end of the
incision curving backwards towards the occiput. The reason for the lower
end of the incision being placed in this manner is that,the styloid process in
an infant of this age is not developed, and it is possible that the facial nerve
may be anterior. The mastoid cavity is uncovered and the antrum cleaned
out. For 24 hours after the operation gauze wicks are left in the antrum and
in the ear canal. The gauze is left in the ear canal for three to four days.
This is for the purpose of allowing the posterior canal wall to become firmly
attached to the bony wall. At the end of 24 hours the gauze is removed from
the mastoid wound and antrum, and each day, until the wound is closed,
a drop or two of acetone mercurochrome is placed therein. There are no
dressings; a sterile towel is placed under the head and pinned to the shoulders
of the baby's gown, the hands are tied to the side of the crib, and the baby
lies comfortably. It has been found that leaving the mastoid area uncovered,
with no dressings or bandages, provides better drainage and is less uncomfortable, as the skin does not perspire and develop a heat rash or pustules
under the bandages and dressings. In from two to three weeks the mastoid
cavity usually heals, and the drum has also healed. With the exception of
one case which terminated fatally, due to excessive dehydration and possibly
a lack of necessary preoperative treatment, which at that time was not done
routinely, the other cases have responded well to this treatment. Fever has
been notably absent, or if present runs its course in two or three days. Food
is easily taken and retained, usually immediately after the operation or
within a few hours. The baby gains in weight, and the facial expression
changes from that of the pinched wan type to the normal.
Marantz, in Vienna, while doing post-graduate work, was amazed by
the amount of surgical mastoiditis which had not been discovered during
life. In a series of 11 cases observed in the Cumberland Hospital,, Brooklyn,
there were no exceptional signs of mastoiditis, though two showed perforation of the cortex at operation, vomiting, loss of weight, prostration,
dehydration, and some fever. They appeared quite toxic and pale. Ear
involvement is not suspected unless the ears are examined, when a slight
discharge may be seen, but more often the drum membranes are intact.
In this series x-ray was of slight assistance. In most cases extensive necrosis
was found at operation; all cases were bilateral. In all cases a thick ©edematous
mucous membrane lined the mastoid cells with pus in the antrum and cells.
Page 82 The author stresses the importance of routine ear examinations on all infants
with gastro-intestinal disturbances, with early operation before these infants
have become too toxic.
Clark H. Hall (1936) says: "Most of the cases are admitted to the
hospital for the treatment of a subacute or chronic diarrhoea primarily.
Usually there is a history of poor feeding associated with poor hygiene and
home conditions. Many of the cases give no history of symptoms pointing
to involvement of the middle ear or mastoid." He quotes certain authorities
who have dealt with this problem and have at different times committed
themselves as to their views. "As regards the subject of treatment: It is
sometimes difficult to convince the otologist that there is a mastoid infection
and to get him to carry out the rather simple surgical procedure indicated.
The operation is done under local anaesthesia and consists of an antrotomy.
Extensive cleaning out of the mastoid should be avoided as these patients
are in poor general condition and are poor risks for extensive surgical work.
If the simple antrotomy is done it takes very little time and there is little if
any post-operative shock. As the general condition of the patient is very
important, usually several blood transfusions are needed.
"Recovery, if it takes place, is not as a rule rapid in these cases and may
be a matter of weeks. Very often there are many ups and downs. Every
infant with this condition should be given the benefit of the doubt and
operated on. There is very little chance of recovery if the mastoid is not
drained."
The particular case cited by Dr. Curtis of the baby with pyelo-nephrosis
was a case which had been under observation, so far as the ears were concerned, for a considerable time. Numerous consultations had been held for
the purpose of establishing the presence or absence of a focus of infection,
which was probably aggravating the already existing kidney condition. In
this case the drum membranes, at a cursory examination, might have passed
as normal, but as before mentioned after repeated examinations it was felt
that these drums did not present the normal appearance as seen in cases with
the absence of a middle ear or mastoid infection. The normal colour of the
middle ear mucosa was absent, and peculiar that in the mastoid which
showed the greatest change in middle ear mucosa colour there appeared to
be less involvement of the mastoid area than on the opposite side.
Dean and Marriott of St. Louis for some years stressed the importance
of masked mastoiditis. It is felt in some quarters that their work appeared
to be that of enthusiasts, and it was also felt that the means did not justify
the end in that in the height of their enthusiasm their clinic operated on
many cases in which there seemed to be insufficient grounds for a surgical
procedure. In a recent conversation with Dr. Dean I had the opportunity
to discuss this type of case of the masked mastoid infection. He told me
that they were still of the opinion that these cases did exist, and that as a
result of the occult infection in the mastoid region intestinal disturbances
resulted or accompanied the infection in the upper area. I reviewed this
series of cases with him, and he felt that the procedure had been justified,
but that with continued practise it might be possible to find other cases
presenting infection or disturbances of other organs or areas which had not
been relieved by ordinary treatments, and which might have shown some
mastoidal infection.
This paper is not given for the purpose of reporting a certain limited
number of cases of intestinal infection which have by a mastoid operation
recovered, but rather that our attention may more specifically point to an
overflow of infection from some area which necessarily does not show the
Page 83 usual signs of mastoid disease. There are some who "W_.ll be of the opinion
that more stress should be placed on the use for diagnosis, or aid in diagnosis,
of x-ray. It is possible that our interpretation of x-ray of an infant of this
age, without the clinical picture, needs to be improved. We have found in
the earlier cases in which x-rays were taken that the interpretation was not
in keeping with the clinical picture, nor with the disease as found in the
area operated on. I feel that these few cases will bring to mind possibly
other cases in a medical practitioner's work which might have fallen into
the above classification. I am not an enthusiast. It is only after repeated
examinations, by the laboratory, by the otoscope, and by clinical examination, that we find ourselves in the position to operate on these children.
*_* •_* *_• **•
Subsequent discussion of this paper by various men brought out these
main facts:
(1) All babies with gastro-enteritis should have a careful examination
of the ears done, as upper respiratory infection is frequently the fons et origo
mali.
(2) Typical, or what have hitherto been regarded as typical, signs may
be lacking. The changes in the drum may be merely lack of lustre, or change
of colour, and incision may reveal no pus. This does not preclude mastoiditis.
Repeated examinations may be necessary.
( 3 )  X-ray is of relatively little value in making the diagnosis.
(4) The decision whether or not to operate frequently demands courage
on the part of the operator, in the absence of many signs hitherto held
essential.
( 5 ) Operation must not be delayed, but should not be done at the height
of the intestinal storm. Water, glucose, etc., must be given.
(6) Operation must be confined to the minimum necessary, and should
be done quickly and with a minimum of trauma.
B. C. MEDICAL ASSOCIATION
Message from the President
To the Members of the B. C. Medical Association:
Elsewhere there are to be found brief notes as to the progress of the
various Committees of the B. C. Medical Association. It is the feeling of
your Executive Committee that it is wise to keep the members of our profession throughout the Province informed as to our activities. The most
important progress we can report is that we now have an accredited representative on the Executive Committee of the Canadian Medical Association.
We believe that the contact so established will do much to secure a better
co-operation between the Provincial association and the Dominion body.
We are particularly fortunate in having as our first representative our
immediate Past-President, Dr. Harry Milburn, a man who has devoted himself whole-heartedly to the task of furthering the best interests of the profession. He has recently returned from a meeting in Ottawa and we feel
satisfied that the ultimate results will be abundantly satisfactory.
On behalf of your Officers and Directors, permit me to extend to each
and every one of you the very sincerest wishes for a prosperous and happy
New Year.
G. F. Strong, M.D., President,
British Columbia Medical Association.
Page 84 B. C. MEDICAL ASSOCIATION
Report of Committee on Pharmacy
The (Committee on Pharmacy has been busily engaged during the past
few months with a study of the codeine situation in the Province of British
Columbia. As is well known, the activities of municipal and provincial
police together with the splendid work of the Royal Canadian Mounted
Police has so limited the opium supply to addicts that these unfortunates
have been forced to turn to codeine as a substitute.
It should be made plain that codeine is an addictable drug, known and
proved to be such through observation of its use in this Province. When
Canadian authorities made this statement at Geneva they were ridiculed by
representatives of European countries. Men over there who had spent a
lifetime in this work had never seen codeine addiction. In this country,
however, it is a known fact.
In the years 1933 and 1934 the consumption of codeine increased in a
most alarming manner, until the first six months January to June, 193 5,
showed a consumption of 2221 ounces. Early in that year the Federal Narcotic Division at Ottawa under the Department of Pensions and National
Health advised the various Provincial Governments that legislation should
be instituted liniiting the sale of codeine to doctors' prescriptions. Not all
the Provinces complied in the request, although some did. Among them
were the three western Provinces, Saskatchewan, Alberta and British Columbia. As a result of that legislation the reduction in the consumption of
codeine in this Province has been really remarkable. The actual figures are
available from Ottawa and are given below.
The figures represent a comparison of codeine consumption in this Province from January to June, 193 5, as compared with January to June, 1936.
Jan. -June, 193 5 Jan.-June, 1936
British Columbia  2221 oz. 380 grs. 274 oz. 241 grs.
From the standpoint of per capita consumption the population of this
Province is given as 694,000, which is 6.70% of the population of the
Dominion. It could be assumed, therefore, that this Province might consume 6.70% of the total consumption of the Dominion of Canada. The
following comparison of figures based on the percentage consumption in this
Province should, then, be of interest. The percentage of codeine consumption over the same periods as above are as follows:
Consumption
Population Percentage
Percentage Jan.-June, 193 5
British Columbia     6.70 22.19
It is apparent from the above that whereas in the first six months of
1935 this Province consumed more than three times its quota of codeine on
a percentage basis, that in the first six months of 1936 it consumed actually
less codeine than it might be expected to use per capita in the Province.
Similar figures for each of the Provinces of the Dominion are available
for comparison. It would seem, however, that such a comparison would serve
no good purpose here. Suffice it to say that those Provinces which have
enacted similar legislation to that passed in British Columbia have had a
similar decrease in codeine consumption. Those Provinces which have failed
to enact that legislation have either the same or an increased consumption
of codeine.
In October of this year your Committee was privileged to meet and discuss this situation with Col. C. H. L. Sharman, Chief of the Narcotic
Page 85
Consumption
Percentage
Jan.-June, 1936
5.74 Division under the Department of Pensions and National Health. It became
immediately apparent to us that Col. Sharman and his Department had the
matter of the sale and consumption of narcotics well in hand in this Province and in all Provinces. It is the feeling of your Committee that the codeine
situation in our Province is now under control and in good hands.
Murray Blair, M.D., Chairman,
Committee on Pharmacy, B. C. Medical Association.
B. C. MEDICAL ASSOCIATION
A meeting of the Board of Directors of the B. C. Medical Association
was held on December 9th. Those present included the President, Dr. G. F.
Strong, Doctors L. H. Appleby, E. Murray Blair, D. E. H. Cleveland, Colin
Graham, D. M. Meekison, H. H. Milburn, A. B. Schinbein, W. S. Turnbull,
C. H. Vrooman, J. R. Naden and M. W. Thomas, all of Vancouver; Dr. H.
Carson Graham of North Vancouver, Dr. F. R. G. Langston of New
Westminster, Dr. F. M. Auld of Nelson, Dr. G. A. B. Hall of Nanaimo and
Dr. W. Allan Fraser of Victoria.
Dr. H. H. Milburn reported to the meeting on his attendance at the
recent meeting of the Executive of the Canadian Medical Association in
Ottawa. Those present felt that in Dr. Milburn the membership possesses
a real friend at court—one who has an intimate insight into our needs and
ready to work, study, and if needed strongly support the profession in the
higher Councils. A resolution was passed expressing appreciation and thanking Dr. Milburn for splendid work.
The Committee on Cancer reported plans for education and study
throughout the province.
The Committee on the Study of Economics was able to report progress
in that a group of twenty men were studying and reporting on various
phases of medical practice and economics.
The Committee on Medical Education, of which Dr. M. Meekison is
Chairman, announced that it was functioning, and had been in contact
with the Medical Schools of Canada, and that it had on file information
concerning the requirements, and Internship requirements, which should
be invaluable to those who were contemplating or entering upon a medical
education.
COLLEGE OF PHYSICIANS AND SURGEONS
I OF BRITISH COLUMBIA
The Health Insurance Committee of the College of Physicians and Surgeons is a strong committee and we wish to assure you that it is very active,
always alert, in full possession of all the facts—imbued by a desire to serve,
impelled with the knowledge that the profession, whom it represents, is
upholding it with expressions of confidence and ready to support is best
endeavour.
Dr. Thomas McPherson, President of the College of Physicians and
Surgeons, is the Chairman of the Health Insurance Committee and Dr.
Wallace Wilson of Vancouver is Vice-Chairman. It would be invidious to
select any one member of the Committee for mention, but the profession
must be grateful to this group and Christmastide provides an opportunity
for freedom of compliment and demonstration of appreciation.
The Health Insurance Committee is in contact continuously with the
Health Insurance Commission and by frequent conferences has made a
Page 86 contribution to the profession's cause, and we hope has been helpful to the
Commission in its task of attempting to make the Health Insurance Act
meet even partially its plan and purpose with the limited funds available.
The President of the College has stated, and this may be repeated for the
information of every member, that no final action will be taken without
consultation with the whole profession. The New Year, we trust, will bring
increasingly better times—happiness in life and work and a solution of some
problems which confront the profession. Let us support the Council of the
College in its insistence that the Government implement its promises to
relieve the profession financially in the burden of providing a medical service to the indigent.
COLLEGE OF PHYSICIANS AND SURGEONS
OF BRITISH COLUMBIA
Following extracts from the Statutes are published for the
information of members.
AN ACT RELATING TO MENTAL HOSPITALS.
Chapter 158. General Provisions.
45. Judges, Registrars, District of Deputy Registrars, or Stipendiary
Magistrates, or Police Magistrates, or Justices of the Peace, who sign the
order, or any persons who sign the statement, or duly qualified medical
practitioners who sign the medical certificates under any section of this Act,
shall not be liable to any civil proceedings on the ground of want of jurisdiction, or on any other ground, if they have acted in good faith and with
reasonable care; and if any such proceedings are commenced, they may be
stayed upon summary application to the Supreme Court or to a Judge thereof
upon such terms as to costs and otherwise as) the Court or Judge may think
fit, if the Court or Judge is satisfied that no reasonable ground exists for
alleging want of good faith or reasonable care; and no action shall be brought
against such Judge, Registrar, District Registrar, Deputy Registrar, Stipendiary or Police Magistrate, Justice of the Peace, or duly qualified practitioner,
except within twelve months next after the release of the party bringing the
act, and any such action shall be laid or brought in the County where the
cause of action arose, and not elsewhere. R.S. 1911, c. 11, s. 45; 1912, c.
13, s. 14. 	
X-RAY TREATMENT FOR HYPERTRICHOSIS
Greenbaum and Tumen (J.A.M.A. 107: 1297; Oct. 17, 1936), report
that recently in Philadelphia a concern known as Cosmique Laboratories,
has been treating hypertrichosis with a new X-ray "system," said to employ
specially filtered X-rays It is recalled that in the past a number of patients
with untoward skin complications have been treated in various parts of the
United States, which has resulted from another X-ray "system" which was
known as the "Tricho." This concern, whose operations were widespread
in large cities throughout the country, appears to have folded its tents, due
undoubtedly to the action of dermatological societies and state medical
associations which were successful in several states in prevailing upon state
legislatures to pass laws banning it; also like the late unlamented Koremlu
Cream (Thallium acetate 7%), it was considerably hampered by the publicity resulting from damage suits.
In a case seen by the authors which had been treated by the new X-ray
"system," deep effects had occurred on the salivary glands and oral mucous
Page 87 membrane, resulting in severe symptoms of dryness and some atrophy of
the lingual mucosa.
Our readers should be reminded that there is nothing in a name, and
we have had for some years in Vancouver a concern treating a very large
number of women for hypertrichosis of the face, and claiming that by the
use of a filter of secret composition said to be the invention of a "doctor in
Paris," all harmful consequences are obviated. This concern operated and
advertised for some years under the name of the Marton Dermic Laboratories. In the well-known book, "Ten Million Guinea-Pigs," the Marton
Laboratories, operating in various parts of the United States, were referred
to in terms not eulogistic. It may have been only a coincidence that within
a very short time after the publication of this book the name "Marton" was
replaced by "Arnold."
"Absolute Accuracy"
In filling the eye physician's prescription, nothing short
of absolute precision will satisfy us.
We take a pride in maintaining
Guild standards to the utmost.
OPTICAL CO. LTD.
Dispensing Opticians
430 Birks Bldg., Vancouver, B. C.
AMERICAN
MEDICAL
ASSN.
Committee.
onfbodA^
COCOMALT
— AND —
IMPORTANT FACTS ABOUT IRON
(ocomalt
A DELICIOUS FOOD DRlNK^S
CHOCOLATE FLAVOR      ,V%4
* ___» C_M.«UM—-_, _•* —
<u_<t_._____Vni-a'
Iron, recognized as an important and accessary ingredient of the diet, is lacking or
deficient in the majority of foods.
One ounce of Cocomalt (the amount used to
mix one glass or cup) contains 5 milligrams
of available Iron.
The Iron in Cocomalt is combined in an organic compound. Biological tests prove it
to be easily assimilable.
Three glasses or cups of Cocomalt a day
supply 15 milligrams of available Iron—the
amount of Iron recognized as the normal
daily nutritional requirement.
Used regularly, as a delicious mealtime or
in-between mealtime beverage, Cocomalt is
a simple palatable way of adding the necessary Iron to the diet in an
easily assimilated form.
(SAMPLES SENT TO ANYONE ON REQUEST)
WESTERN CANADA AGENTS:
SCOTT-BATHGATE CO., LTD.
WINNIPEG      ::      VANCOUVER
Page 88 YEAR
»»»»»»»»»»»»»»»»»»»»»»»»»»»»» • «««««««««««««««««««««««««««««
In 1930, when Emmenin was first announced by Dr. J. B. Collip as an orally-
active water-soluble hormone of the placenta, little was known of the chemical
nature of placental oestrogenic substances or of the important part they
ere now known to play in endocrinology.
Over six years have elapsed—striking progress has been made in the study
of endocrine substances—yet the early description of Emmenin is as sound
to-day as it was in 1930. Emmenin enjoys a prestige that only a truly successful
clinical background can create, and the evidence of this clinical background
is found in an extensive bibliography.*
The original claims for Emmenin in the treatment of disturbances associated
with menstruation have been amply confirmed. In symptoms of the menopause,
in menstrual migraine and dysmenorrhoea, Emmenin may be relied on to
produce a high percentage of satisfactory results and the simplicity of
administration permits extended treatment without inconvenience or excessive
cost to the patient.
* Copy on  request
»»»»»»»»»»»»»»»»»»»»»»»»»»»»» • «««««««««««««««««««««««««««««
EMM
vl/a ter-soluble
MENOPAUSAL DISTURBANCES
FOR
DYSMENORRHOEA
Kyrally-active
MENSTRUAL MIGRAINE
(bmmenin is now offered in liquid form (original four ounce bottles) and in
tablet form (bottles of42 tablets J at substantially reduced prices.
AYERST,  McKENNA & HARRISON,  LIMITED
Biological and Pharmaceutical Chemists
MONTREAL CANADA
609 K             ■     ____■&                                         B            9         ___p
.mK'           __B    ____&I!p-        __■                           ___BT'                      ____^s_
Hal                         H£                                                            _____            ____tv         J
H&|'      £9            Hej£ ■      _BE                                          __£              ____M'       __.
_-_-_K^               v^B                                                      flH                                                                         C__i%i               ___.                                  _____&               ____
li__i If    ■.l_---J----_i I # 1I.-M
_■_______!                                                                            _»■'•'___ 8__B        ■____■_
(a) Bilateral weakfoot in a boy fourteen years old (apparently
congenital).  Note the  marked  distension of the veins  which is
typical  in  pronounced  cases  on  weight bearing,   (b)   The  same
patient being taught to assume, by muscular effort, the correct
foot posture. If he can train himself to assume at all times on
weightbearing this—to him a new foot attitude—so that it becomes habitual in time, little else will be needed for a cure.
Doctors...
We can fit your patients with
Made-to-Measure and
Corrective Shoes
Subject to your Prescription and
Recommendation
34 YEARS' EXPERIENCE IN LAST MAKING AND
M               CUSTOM SHOE-BUILDING     \
51 WEST HASTINGS ST., VANCOUVER, B. C. dd. f 1d.13
(meta-amino-para-hydroxy-phenylarsine oxide hydrochloride)
A   REFINEMENT   OF   THE   ARSENICAL THERAPY  OF  SYPHILIS
OVER HALF-A-MILLION
INJECTIONS HAVE BEEN
ADMINISTERED WITHOUT
ANY   SERIOUS   ACCIDENT
Mapharsen has been accepted by the Council on Pharmacy and
Chemistry of the American Medical Association.
PARKE, DAVIS & COMPANY   •   WALKERVILLE,  ONTARIO An X-Ray Power Plant
About the Size of Your Hat
YET   SURPRISINGLY   EFFICIENT
FOR OFFICE AND PORTABLE WORK
w
HEN both, the high-voltage transformer and x-ray tube are
immersed in oil and sealed within the same container, you
have a unit which in bulk seems exceedingly small when compared to the
amount of x-ray energy it delivers. But that's the result of complete oil-
immersion, also the reason for its shockproof operation.
Hundreds of physicians have found this G-E Model "F" Office-Portable
X-Ray Unit to be just what they had long wanted—a small unit to be set
on the desk, ready for service by simply plugging in to the nearest electrical outlet when a simple radiograph or fluoroscopic examination is
desired. In the management of fracture cases especially, the location of
foreign bodies, or for emergency service in the patient's home, these
users find it practically indispensable—a convenience both to themselves
and their patients.
It's highly probable that you are skeptical of the ability of such a small
x-ray unit to serve a worthwhile purpose. If so, then do as most present
users of this unit did—ask us to put it through its paces—right in your
own office, and without any obligations.
GENERAL ELECTRIC X-RAY CORPORATION
2012    JACKSON    BLVD.
CHICAGO,    ILL.,   U.
A. ANNOUNCEMENT OF IMPORTANT CHANGES IN
B. D. H.
GONAN
SEX HORMONE  PREPARATIONS
Potency Increased and Prices Considerably Reduced
The gonadotropic substance isolated from the urine
of pregnancy, issued in ampoules of dry powder containing 100 and 500 rat units per ampoule, together
with ampoules of sterile distilled water for use as a
solvent.
OESTROFORM
One international benzoate unit
equals approximately 5 international units.
PROGESTIN B.D.H.
The ovarian follicular hormone, issued for injection
as solutions of an ester in oil, in ampoules containing
1000, 20,000 and 50,000 international benzoate units
per ampoule (1 cc). For oral use, Oestroform is
issued in tablets containing 1000 and 10,000 international units per tablet, and for vaginal administration in pessaries of two sizes (adults and children) each having an activity of 1000 international
units of free hormone.
The hormone of the corpus luteum issued in ampoules containing 1 and 2 international units per cc
Stocks are held by leading druggists throughout
the Dominion, and full particulars are
obtainable from
The BRITISH DRUG HOUSES (Canada) Ltd.
Terminal Warehouse Toronto 2, Ont.
Hor/Can/371
A
i_li_$5$s§i
AMMMMAWN4KJ
^-'-frLyMtffMqF&OTftw1™???!. ???... iff?.
aSss
sii
SB
11
~W~_^-<~v>^_*«~v_>~-*\     SS
ii&&&S£___
536 13 th Avenue West
Fairmont 80
Exclusive Ambulance
Service
|                      FAIRMONT 80
ALL ATTENDANTS QUALIFIED IN FIRST AID
"St. John's Ambulance Association"
WE SPECIALIZE IN AMBULANCE SERVICE ONLY
R. J. Campbell                         J. H. Crellin
w\ L. Bertrand COLONIC IRRIGATION INSTITUTE
Superintendent—E. M. LEONARD, B.N., Post Graduate, Mayo Bros.
Treatment Room, showing the Irrigation Table.
REALIZING the need for a properly equipped centre where those suffering
from constipation, worms, indigestion, etc., could be assured of modern
scientific colonic irrigation and internal medication, E. M. Leonard, R.N., has
fitted out operating rooms with the most up-to-date scientific equipment. Here
the patient will receive every attention, and proper thorough treatment under
the care of a fully trained nursing staff, at a moderate charge.
Individual   Treatment $ 2.50
Entire Course  10.00
Medication (if necessary) $1 to $3 extra
This treatment is beneficial in cases such as constipation, indigestion, acidity,
rheumatism, arthritis, worms, diverticulosis, colitis, acne, and any condition
which may have originated in the intestinal tract. To ensure comfort, convenience and thoroughness in these treatments, call at the Colonic Irrigation
Institute, either in Vancouver or Victoria, B.C. Registered nurses always at
your service.
631 Birks Bldg.     Phone Sey. 2443.     Vancouver, B. C.
506-7 CAMPBELL BLDG. Phone Empire 2721 VICTORIA, B. C. A PRESCRIPTION SERVICE ...
Conducted in accord with the ethics of the Medical
Profession and maintained to the standard suggested by
our slogan:
Pharmaceutical Excellence
McGill 6 Ormr,
LIMITED v-'
FORT STREET (opp. Times)      Phone Garden 1196     VICTORIA, B. C
Nmut $c StytftttBtftt
2559 Cambie Street
ancouver
; B. C.
The hypnotic with analgesic properties
WILL PROCURE A QUIET AND
RECUPERATIVE SLEEP
All forms of insomnia are amenable to SONERYL.
DOSE: 1 or 2 tablets half an hour before retiring.
% tablet is sufficient in light insomnia.X
LABORATORY POULENC FRERES
OF CANADA LIMITED
Distributors: ROUGIER FRERES, MONTREAL Dial "Ciba"
Dial calms excited, irritated nerves, and for such occasions as nervous insomnia, mental and traumatic agitation, pre-operative restlessness, etc., it will fulfil all the
requirements of a good hypnotic.
Cibalgine "Ciba"
Cibalgine represents a non-narcotic analgesic and antipyretic worthy of the physician's confidence. It is indicated in the treatment of pain of every description, febrile
manifestations, nervous excitement, insomnia due to
pain, dysmenorrhoea, etc.
CIBA COMPANY LIMITED
MONTREAL
flfoount pleasant TnnbertakinG Go. Xto.
KINGSWAY at 11th AVE. Telephone Fairmont 58 VANCOUVER, B. C.
R. P. HARRISON W. R. REYNOLDS STEVENS' SAFETY PACKAGE
STERILE GAUZE
is a handy, convenient, clean commodity for the bag or the office. Supplied
in one yard, five yards and twenty-five yard packages.
ESTABLISHED  NEARLY A
B. C. STEVENS CO.
Phone Seymour 698
730 Richards St., Vancouver, B. C.
BOWELL & SON
DISTINCTIVE FUNERAL
SERVICE I     I
Phone 993
66 SIXTH STREET
NEW WESTMINSTER, B. C.
^^>^^^0^0^X^^^^^
______88feS8lS--&ft^
Breaks the vicious circle of perverted
menstrual function in cases of amenorrhea,
tardy period$ (non-physiological) and dysmenorrhea. Affords remarkable symptomatic
relief by stimulating the innervation of the
uterus and  stabilizing the||one ojgit's
musculature. Controls the utero-ovarian
circulation and thereby encouriiges a |||
normal menstrual cyde^|f|^^
• MARTIN H. SMITH COMPANY
__ ISO LAfATITII STRUT, NIW TOIK, N. T.
1
ii
Full formula and descriptive
literature on request
Dosage:   l to 2 capsules
3 or 4 times daily.   Supplied
in packages of 20.
Ethical protective mark MHS
embossed on inside of each
capsule, visible only when capsule  is cut in half at seam.
^^^^_^S^^^^^^^^^^^^S^^K^^^^^»rSw^4^IS*4S^^^^8_^^^iS^^SS5^ MM
Pneu
onia
INFLUENZA so frequently leads on to complications.
Broncho-pneumonia, Pneumonia and even Pulmonary
Tuberculosis, may follow in the wake of this most treacherous disease.
The early application of Antiphlogistine, at the onset of an
attack of influenza, assists in promoting early resolution of
the disease process, tending thereby to safeguard, the patient
against the onset of secondary complications.
lip
Broncho-pneumonia    Pneumonia
When these conditions supervene, they may be considerably
mitigated by the application to the front and back of the
chest of
iinniiH^KTiftE.
MADE IN CANADA
Sample on request
The Denver Chemical Mfg. Co.
153 Lagauchetiere St. W.,
MONTREAL nvXftitittfiiil&^-f^ !§
How Much Sun ^k
Does thelnfant f
Really Get +
Not very much: (1) When
the baby is bundled to protect against weather or (2)
when shaded to protect
against glare or (3) when
the sun does not shine for
days at a time. Oleum
Percomorphum offers protection against rickets
365% days in the year, in
measurable potency and in
controllable dosage. Use
the sun, too*
We are hopeful that by the medical profession's continued whole-hearted acceptance of Oleum
Percomorphum, liquid and capsules (also Mead's Cod Liver Oil Fortified With Percomorph
Liver Oil), it will be possible for us to make the patient's "vitamin nickel" stretch still further.
Mead Johnson & Company of Canada, Ltd., Belleville, Ont., does not advertise to the public* In Appreciation
AS the last few days of the old year quickly slip into the
| past, we pause in the daily routine and glance backwards over the years—back to 1908—-28 years ago. In those
early days, we set a high standard. We needed (as we do
today) and received (as we do today) the confidence and
encouragement of the Medical Profession.
Your loyalty has been our incentive; we pledge the continuance of our standards—and we thank you.
Bapptj JS>m f *ar
fSEY'lOSO
OWN Alt
NIOHT
GEORGIA PHARMACY
i_ I M
W. OEOROIA
STRUT
<£mttt $c Ijatma Utt
Established 1893
VANCOUVER, B. C.
North Vancouver, B. C.    Powell River, B. C.
published Monthly at Vancouver, B. C. by ROY WRIGLEY LTD., 300 West Pender Street S-_3g-_3S--3£-g^^
Hollywood Sanitarium
Limited
For the treatment of
Alcoholic, Nervous and Psychopathic Cases
Exclusively
Reference—B. C. Medical Association
For information apply to
Medical Superintendent, New Westminster, B. C.
or 515 Birks Building, Vancouver
Seymour 4183
Westminster 288
S_^_^S^.^SS_^S_SS5§__^^5S-^--S

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