History of Nursing in Pacific Canada

The Vancouver Medical Association Bulletin: June, 1937 Vancouver Medical Association Jun 30, 1937

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 77.e|BULLETIN
OF THE
vancouver medical
association!
Vol. XIII
JUNE,  1937
In This Issue:
PELVIC CONDITIONS
REPORT FROM GYNAECOLOGICAL DIVISION,
VANCOUVER GENERAL  HOSPITAL
NEWS and NOTES BULKETTS
(With Cascara and Bile Salts)
. . FOR . .
Chronic Habitual
Constipation
BULKETTS POSSESS ENORMOUS BULK
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)
_■__■
mm 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. MacDeemot
Dr. M. McC. Baird Dr. D. E. H. Cleveland
All communications to be addressed to the Editor' at the above address
Vol. XIII.
JUNE, 1937
OFFICERS  1937-1938
Dr. G. H. Clement Dr. Lavell H. Leeson Dr. W. T. Ewing
President Vice-President Past President
Dr. W. T. Lockhart Dr. A. M. Agnew
Hon. Treasurer Hon. Secretary
Additional Members of Executive—Dr. J. R. Neilson, Dr. J. P. Bilodeau.
TRUSTEES:
Dr. F. Brodie Dr. J. A. Gillespie Dr. F. P. Patterson
Historian: Dr. W. D. Keith
||i Auditors: Messrs. Shaw, Salter & Plommeb.
Library
Dr. S. Paulin
Dr. W. F. Emmons
Dr. R. Huggard
Db. A. W. Bagnall
Dr. H. A. Rawlings
Dr. R. Palmer
Publications
Dr. J. H. MacDermot
Dr. D. E. H. Cleveland
Dr. Murray Baird
V. 0. N. Advisory Board
Dr. I. Day
Dr. G. A. Lamont
Dr. Keith Burwell
SECTIONS
Clinical Section
Dr. R. Palmer Chairman    Dr. W. W. Simpson Secretary
Eye, Ear, Nose and Throat
Dr. L. H. Leeson..: Chairman     Dr. S. G. Elliott Secretary
Pwdiatrie j Section
Dr. G. A. Lamont Chairman    Dr. J. R. Davies . Secretary
Cancer Section
Dr. B. J. Harrison Chairman    Dr. Roy Huggard Secretary
STANDING COMMITTEES
Dinner
Dr. G. F. Strong
Dr. R. Huggard
Dr. D. D. Freeze
Summer School
Dr. A. C. Frost
Dr. R. Mustard
Dr. J. R. Naden
Db. H. A. DesBrisay
Dr. A. B. Schinbein
Dr. A. Y. McNair
Credentials
Dr. A. B. Schinbein
Dr. D. M. Meekison
Dr. F. J. Buller
Metropolitan Health Board
Advisory Committee
Dr. W. T. Ewing
Dr. H. A. Spohn
Dr. F. J. Buller
Representative to B. C. Medical Association—Db. Neil McDougall.
Sickness and Benevolent Fund—The Pbesident—The Tbustees Protection Against Typhoid
Typhoid and Typhoid-Paratyphoid Vaccines
Although not epidemic in Canada, typhoid and paratyphoid infections remain a serious menace—particularly
in rural and unorganized areas. This is borne out by the
fact that during the years 1931-1935 there were reported,
in the Dominion, 12,073 cases and 1,616 deaths due to
these infections.
The preventive values of typhoid vaccine and typhoid-
paratyphoid vaccine have been well established by military and civil experience. In order to ensure that these
values be maximum, it is essential that the vaccines be
prepared in accordance with the findings of recent laboratory studies concerning strains, cultural conditions and
dosage. This essential is observed in production of the
vaccines which are available from the Connaught
.Laboratories.
Residents of areas where danger of typhoid exists and
any one planning vacations or travel should have their
attention directed to the protection afforded by vaccination.
Information and prices relating to Typhoid Vaccine and to
Typhoid-Varatyphoid Vaccine 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 253,!363
Japanese Population—estimated _. . j ±     8,522
Chinese Population—estimated . -    ^..:- 7,765
Hindu Population—estimated _ .         352
Number
Total deaths .    253
Japanese deaths      11
Chinese- deaths      12
Deaths—residents only    217
BIRTH REGISTRATIONS—
Male, 157; Female, 158
INFANTILE MORTALITY—
Deaths under one year of age -        7
Death rate—per 1,000 births .      22.2
Stillbirths (not included in above)        6
CASES OF COMMUNICABLE DISEASES REPORTED IN THE CITY
March, 1937
Cases Deaths
Smallpox      0 0
Scarlet Fever    23
Diphtheria        0
Chicken Pox    36
Measles  ..  108
Rubella  .      0
Mumps    93
Whooping Cough    10
Typhoid Fever      1
Undulant Fever      1
Poliomyelitis t .      0
Tuberculosis    31
Meningitis (Epidemic)      0
Erysipelas .      9
MEMBERS of THE GUILD
of PRESCRIPTION OPTICIANS of AMERICA
Always Maintain the
Ethical   "Principles   of
the Medical Profession
Guildcraft Opticians
430 Birks Bldg*.       Phone Sey. 9000
Vancouver, Canada.
Page 176 OF HYPERTENSIVE
HEADACHES
RELIEVED
FOR rapid, efficient and safe relief of high
blood pressure and its associated symptoms, you can rely on Hypotensyl.
This is a synergistic combination of dependable hypotensive agents—Viscum album ( Au-
ropean mistletoe) and hepatic and insulin-free
pancreatic extracts. It hastens recovery and
wins your patient's confidence.
Viscum album has proven remarkably effective for relief of hypertension (O'Hare and
Hoyt 1928, Barrow 1930 and Danzer 1934).
Frequently Hypotensyl effects a reduction of
20 to 30 mm. Hg. in 12 hours. Headaches and
dizziness vanish and reduction is sustained.
Excellent results are obtained in cases of essential hypertension or benign hyperpiesia.
Hypotensyl is also efficacious in treatment of
high blood pressure accompanying pregnancy
or due to fibrotic kidney. The benefit obtained
from careful control of diet, as well as mental
and physical rest, is accentuated by Hypotensyl.
The usual dose is 3 to 6 tablets daily, one-
half hour before meals. Best results are
obtained when treatment is given in courses
lasting two to three weeks, with a week's
interval between, upplied in bottles of 50
and 500 tablets.
HYPOTENSYL
The Anglo-French  Drug Company
354 St. Catherine Street East Montreal, Quebec EDITOR'S PAGE :j|
By the time this number of the Bulletij. appears, the Provincial election
will be over, and we shall have had our fates settled for us for the next few
years. All we can do, beyond casting our individual vote, is hope that all the
candidates we want to see elected will have been successful.
The plebiscite on Health Insurance will also have been endorsed or
rejected. It may be perhaps captious to say that it reminds one rather of the
Delphic oracles of old, which might be interpreted in any way the hearer
saw fit, or according to his wishes. It is one of those not infrequent questions
that are rather difficult to answer with a categorical "yes" or "no": and does
not, we feel, bind anyone to anything. Perhaps this is as well—we confess to
a profound dislike and distrust of all plebiscites and referendums. They are,
in our very humble opinion, an evasion of the responsibility that the elected
member of Parliament should assume with his return to office. As we understand it, the fundamental idea underlying our method of popular government
is that the delegates elected are given time and opportunity to study dispassionately and in the light of the fullest access to facts, any question that
affects the public welfare, and are then competent to judge what is best to
be done, without prejudice. The voter has no such time or opportunity, and
has not access to enough of the facts to enable him to form a considered
opinion. Hence he can only vote according to his emotions or prejudices or
individual desires, and he is generally carried along on the wave of popular
feeling engendered by the various factors of the situation. One has seen this
so. often in other plebiscites, and it would seem to some extent to be opportunism rather than statesmanship that dictates the resort to this expedient.
Nobody questions the need for a Health Insurance measure, nobody denies
that the times are out of joint, medically speaking, and that some Hamlet is
needed to put them right—and it is only a question of how much we as a
community are prepared to pay. There are other factors to which we have
made reference before, but they all, more or less, are resolvable into terms
of cost. It is so with all kinds of insurance after all: you buy so much according to your purse and requirements; no magic exists that will alter this
principle.
*      *      #      *
We are glad to publish in this number a symposium of papers read before
the Vancouver Medical Association by members of the Gynaecological and
Obstetrical Staff of the Vancouver General Hospital. This is what staffs are
for, amongst other things, and we particularly applaud the analysis by one
of the speakers of the work done in the Hospital. The Staff at the Hospital
is doing excellent work all the, time, not only in this, but in other divisions,
and they can greatly enhance the value and permanency of their work by
just such reports as these. The rest of the profession can share, as we are
sure the §taff would want them to share, in the lessons learned from the
huge amount of valuable clinical material with which the Staff works. By
all means let us have more of this.
NEWS AND NOTES
The Vancouver Medical Association will be well represented at the meeting
of the Canadian Medical Association in Ottawa in June. Dr. H. H. Milburn,
who is on the Council, will of course attend. Dr. H. A. Spohn will give a
paper at the Pediatric Section on "The Physiology of the Central Nervous
System in regard to Paediatrics." Dr. D. H. Cleveland will speak on "Roentgen
and Ultra Violet Radiation in Dermatology," and Dr, A. W. Bagnall will give
Page 111 a paper on "Why Not a Status in Canada for Gold Therapy in Arthritis?*!
Other members of the British Columbia contingent will be Drs. G. H.
Clement, Wallace Wilson and G. F. Strong.
* *      #     *
Dr. R. A. Seymour, a native son of Vancouver, has taken over the position
of first assistant to the Superintendent of the Vancouver General Hospital.
Dr. Seymour, who was formerly in New Toronto Hospital for the Ontario.
Medical Society, is replacing Dr. H. S. Stalker, who left recently to take up
duties at Tranquille Sanatorium. Dr. Seymour was with the Vancouver General Hospital from 1921 until 1931. He was born in this city and attended
High School here. He graduated from the University of Toronto.
* *     •     *
Word has just been received from London, England, that Dr. Reginald
Wilson of this city has passed his examination for membership in the Royal
College of Physicians. Dr. Wilson is a son of a pioneer family of Vancouver.
He is at present a house physician in Great Ormond Street Hospital, London,
for sick children.
* ♦     ♦      *
Dr. S. A. Bell of Vacouver was married on May 5th to Miss Mary Thompson, a graduate of the Royal Jubilee Hospital in Victoria. Dr. Bell is in'
practice in Vancouver.
* ♦     *     *
Dr. and Mrs. John G. MacArthur of Prince George are the recipients of
congratulatory messages from many friends on the birth of a son (John
Ferrier) on May 8th. We wish to offer the congratulations and best wishes
of the whole provincial profession to this popular couple.
Dr. V. B. Goresky has entered practice at Castlegar in the offices of Dr.
L. N. Beckwith, who has now opened offices in Trail.
Dr. L. C. Steindel has been assisting Dr. F. D. Sinclair of Cloverdale
during the past month.
* *     *     *
Dr. H. A. Whillans has left for the North and will be associated with Dr.
Leonard B. Wrinch in the practice at Hazelton. We regret to report the
serious illness of Dr. Gordon E. Stanley, assistant to Dr. Wrinch. He is
confined to hospital at Hazelton. We wish him a speedy return to health.
* *      *     *
Dr. B. H. Cragg has taken up practice in New Westminster, and will be
associated with Dr. A. W. Bowles, the eye, ear, nose and throat specialist
Jj! -f. Jj. 3{C
Dr. G. B. Henderson of Creston, B. C, called to visit us returning from
Arizona, where he has been recuperating. He has improved and is now home
in Creston, where Dr. J. V. Murray, his partner, with the assistance of Dr.
G. R. F. Elliot, has been carrying on.
...      *
Dr. C. T. Hilton of Port Alberni, President of the Upper Island Medical
Association, called at the offices to discuss medical services as applied to the
needs of the logging industry.
* *      .      *
Dr. R. S. Woodsworth has been doing locum tenens for Dr. Herbert
McGregor of Penticton during the latter's absence on post-graduate study.
* *     *     •
Dr. W. R. S. Groves of West Vancouver and Miss Hazel Dick, R.N., a
graduate from the Vancouver General Hospital, were married on May 1st.
On their return from a month's visit at Lake Louise they will reside in West
Vancouver. They have the best wishes of the whole profession.
.       .      *     *
We extend congratulations to Dr. and Mrs. S. E. Turvey on the birth of
a daughter.
Page 178 Results of the University examinations shew the following doctors graduated from among the students from British Columbia:
From Queen's University:—Doctors: C. J. Austin, Fernie; W. J. Elliot,
Parksville; R. R. Laird, Oliver; W. M. S. Lauder, Vancouver.
University of Toronto:—Doctors: Arthur Bagnall, Vancouver; W. J.
Elliot, New Westminster; A. B. Jung, Vancouver; A. B. Sinclair, Victoria.
McGill University:—Doctors: Charles E. Battle, Vancouver; Hugo
Emanuele, Vancouver ; Bruce Bryson, New Westminster; M. Fong Law, New
Westminster; Gordon S. Rothwell, New Westminster; James W. Wilson,
New Westminster; Jack S. McCannel, Victoria; Herbert B. McGregor, Penticton.
Dr. James~W. Wilson is the son of Dr. George T. Wilson of New Westminster; Dr. Arthur W. Bagnall is the son of Dr. A. W. Bagnall of Vancouver; Dr. Herbert B. McGregor is the son of Dr. Herbert McGregor of
Penticton, and the name Rothwell in New Westminster has been associated
in medicine through the late Dr. Rothwell for many years.
We wish to share the satisfaction that must come to our doctor friends
in this their >sons' achievements.
DR. W. CHIPMAN
OBIIT MARCH 29, 1937
_**
IT is with deep regret that we note the passing of a man who, while
perhaps not very well known to many of his confreres, yet enjoyed
the esteem and affection of many of us who knew him rather better.
The chronological history of Dr. Chipman's life has been recorded
elsewhere, and we need not recapitulate it. He had a very full and active
life, and was one of the best-equipped surgeons. He had had a long
postgraduate training in Europe, and was extremely competent, as the
operating-room authorities of St. Paul's Hospital, where he did most of
his work, will testify.
Dr. Chipman had practised in the Yukon for many years before
coming to Vancouver, and his clieiitele included many of the people from
that land of the far north. His reputation there lived on long after he
left, and any Yukoner in need of medical or surgical care usually made
for Dr. Chipman's office. He had in his makeup the characteristics of
bluntness and downrightness which appeal to the type of man who finds
the rugged conditions of the northern countries to his taste: and they
liked and trusted him.
When his end came, he met it in full awareness of its coming, with
courage and a return to the faith of his childhood: and made a good
ending.
§    I LIBRARY NOTES |
WILLIAM SYDNEY THAYER, By Edith Reid.
Those of our profession who wish to envisage medicine under an ideal
leader should take a couple of hours to peruse the biography of the late
Professor William Sydney Thayer as given to us by Edith Gittings Reid.
The author, steeped in the Osier Tradition by her short biography of
that great physician and stimulated by the urge of the late Dr. William
H. Welch, has produced a book about Dr. Thayer, his beginnings, his teaching, his scholarship and the rigid honesty of the man's intellect which leaves
the reader with a vivid memory of a real leader in our profession.
Many years ago, when I was in Baltimore for a number of months, I
enjoyed following Dr. Thayer at the bedside and was greatly impressed with
his gifts as a clinician and teacher. He was, as his biographer states, always
Page 179 immaculately dressed, but he was no less particular in the thoroughness of
his clinical investigation and the use of the finest English to impress his
points.
This brief biography gives us a delightful and intimate glimpse into the
life and character of one of the outstanding medical teachers of his day.
—W. D. K.
IMPORTANT NOTICE
APPOINTMENTS and CONTRACTS
Members of the College of Physicians and Surgeons of
British Columbia ARE REQUESTED NOT TO
APPLY for any APPOINTMENT or enter into
negotiation with reference to any CONTRACT
without having first communicated with either or
both:—
DR. A. J. MACLACHLAN,
Registrar
COLLEGE OF PHYSICIANS & SURGEONS OF B. C.
or/and
DR. M. W. THOMAS
Executive Secretary
COLLEGE OF PHYSICIANS & SURGEONS OF B. C.
NORTH VANCOUVER MEDICAL ASSOCIATION
MUNICIPAL RELIEF MEDICAL SERVICES
The North Vancouver Medical Association, which is composed of all
doctors practising in North and West Vancouver, held its regular monthly
meeting in the North Vancouver General Hospital on May 11th. The President, Dr. J. W. Lang of West Vancouver, acted as chairman.
Much business was dealt with, the principal being that of Relief Medical
Services in both West and North Vancouver. Dr. Thomas attended the
meeting at the request of the Executive Committee and placed much data
before the members. Committees dealing with this phase of practice are now
negotiating to secure the $600.00 for each of the 11 doctors which should be
the pro rata share obtainable from this minimum fund which may be made
available on action of the Corporations on the North Shore. The Governmental grant of 33 cents per case per month is contingent upon the contributions of a like or larger amount by the Corporations. Many Corporations
have made their share larger in consideration of the services which are rendered to the poor of the community by their doctors. It was explained that the
Relief Administrator recognizes as "cases" "heads of families" (municipal
and transient and provincial) and "single individuals" (men and women).
The whole relief population is thus covered, and while these partial payments
are not deemed adequate they represent recognition and partly cover the
service and transportation costs.
Page 180 Attention
SPECIAL NOTICE RE SUMMER SCHOOL
LECTURES     I
It has been necessary to rearrange the order of the lectures to
be delivered by Dr. Donald Trueblood at Summer School and the
title of one lecture has been altered. Dr. Trueblood's lectures will,
therefore, be as follows:
Tuesday, June 22, 10 a.m.—Conditions of the breast, other than
cancer.
Wednesday, June 23, 11 a.m.—Intraoral tumours.
Thursday, June 24, 9 a.m.—Tumours of the Uterus.
Friday, May 25, 2:30 p.m.—Clinic—Skin Lesions.
Friday, May 25, 8 p.m.—Surgical treatment of carcinoma of the
breast.
i SUMMER SCHOOL NOTES
The Summer School Committee is delighted to announce that Dr. William Boyd of Winnipeg has consented to give the address at the luncheon
to be held in the Spanish Grill of the Hotel Vancouver on Tuesday, June 22nd.
Dr. Norman Kemp will have charge of the Golf Tournament to be held
on Thursday, June 24th. The tournament will be held at the Jericho Golf
and Country Club and it is hoped that there will be a good list of competitors. Registration for this may be made at the desk outside the Oval
Room at any time when the Summer School is in session. Dr. Kemp states
that he can secure clubs for anyone who may not have brought their own.
SOME GYNECOLOGICAL SEQUELAE OF
UNCOMPLICATED DELIVERY
WITH THE ASSOCIATED ENDOCRINE DYSFUNCTION
AND THERAPY
By Dr. W. L. Boulter, Vancouver.
Read before Vancouver Medical Association, April, 1937.
Mr. Chairman, ladies and gentlemen:
It is always difficult to know just what subject to choose in presenting
a short paper insofar as. gynaecology is concerned. While there are enough
problems, and some of them pretty sticky too, tonight I shall attempt to
keep clear of the more contentious, serious and common gynaecological
conditions. One's selection here is limited, for the most part, to a review of
work done in centres where better facilities are present for research and
investigation of new problems. However, it is to be hoped that you will be
interested to some extent in the subject chosen.
In reviewing any series of natural deliveries without complications,
where records are kept, we find that many* mothers suffer from a number of
minor gynaecological complaints which restrict their activities and, from
an economic point, may prove very embarrassing to the family budget.
Several of the more common will here be reviewed.
Before discussing some of these problems, it will probably be better if
Page 181 we take a short time to refresh ourselves insofar as the endocrine situation
is concerned with these problems. As you recall, Dr. Schiller, in his recent
lectures here, showed us that the pituitary, ovary and uterus function in
a definite way insofar as the activities of these three organs are concerned;
that is, that the ovary acts as the intermediate organ and must be present
for the endocrines- of the anterior pituitary to produce their effects insofar
as the normal functioning of the uterus is concerned.
We find that from the anterior pituitary body we get hormones which
were given the names, at first, of Prolan "A" and Prolan "B". To avoid any
misunderstanding, for the purpose of this paper, we shall refer to them as
Pituitary "A" and Pituitary "B". The "A" stimulates ovulation with the
production of follicular hormone, while "B" stimulates luteinization. A
third hormone produced by the anterior pituitary has been called Prolactin.
This causes the onset and continuation of milk secretion after the breast has!
first been developed by oestrin.
Antuitrin (Antuitrin-S,. the T$" standing for sex) is the sum of
Pituitary "A" and "B".
Pituitary "A" starts follicular reopening and incites granulosa cells to
produce oestrin, which in turn induces the growth phase of the endometrium. After full development of the follicle, ovulation occurs and a
corpus luteum is developed from the ruptured Graafian follicle. The action
of Pituitary "B" luteinizes the granulosa cells and incites them to produce
the corpus luteum hormone which, in conjunction with oestrin, causes the
premenstrual or secretory phase of the endometrium.
The amount of follicular hormone increases rather steadily through
the cycle, reaching its highest peak just before menstruation. Oestrin inhibits
the production of the gonadotropic hormone of the anterior pituitary.
Consequently, as the level of oestrin rises in the blood, there is a corresponding decrease in secretion of Pituitary "A" and "B". When this decrease
becomes so marked that it is insufficient to maintain the corpus luteum, the
latter undergoes retrogression. This results in a cessation of oestrin production. The sudden withdrawal of oestrin causes a breaking down of the
built up endometrium, resulting in a flow of blood and debris (menstruation). The absence of oestrin in the blood now removes the inhibition of
the anterior pituitary, allowing the basophilic cells to produce the gonadotropic hormone again. This stimulates a new follicle to develop, initiating
a new cycle.
When pregnancy occurs, the hypophyseal suppression persists, and the
cycle activity is held in abeyance throughout gestation period. The corpus
luteum continues to enlarge and its hormone, together with oestrin, prepares the endometrium for reception and embedding of the fertilized ovum.
THE PHYSIOLOGIC ACTIONS OF THE FOLLICULAR HORMONE   (OESTRIN,
THEELIN, PROGYNON or PROGYNON "B", EMMENIN, AMNIOTIN, ETC.)
1. Promotes development of secondary sex characteristics.
2. Promotes growth and vascularization of the uterus and controls the growth phase of
the endometrium.
3. Produces oestrus in normal or castrated, mature or immature, mice.
4. Inhibits the production of the gonadotropic hormone of the anterior lobe of-the
pituitary gland, by causing agranulation of the basophilic cells.
5. Withdrawal of the follicular hormone is thought to be the factor causing the onset of
menstruation.
6. Contractions of the Uterine and tubal musculatures are stimulated by oestrin. It also
sensitizes the uterine muscle to the action of pituitrin.
7. It inhibits the action of progestin on uterine and tubal muscle.
8. Corner and Allen produced uterine bleeding in castrated monkeys. The endontetrtut*
Page 182 12.
13.
showed no premenstrual changes. They later used theelin injections followed by progestin and produced menstrual-like bleeding with progestational changes in the endometrium.
9.   In monkeys and in human beings, excessive doses of theelin have haused hyperplasia of
the endometrium.
10. It causes a marked elongation of the milk ducts of the mammary gland and an
increase in the number of primary buds in the alveoli. The epithelium covering the
nipple is also thickened.
11. It inhibits lactation by its inhibitory influences on the lactating hormone of the
anterior lobe of the pituitary, and also by its local action on the breast. Both actions
are present during pregnancy, where there is marked breast development and preparation for lactation but no lactation until withdrawal of theelin after the delivery of
the placenta. Oestrin may be a factor in the etiology of breast carcinoma.
Prolonged administration combined with chronic trauma causes atypical growth of
the cervical epithelium in monkeys. Oestrin may be a factor in the etiology of cervical
carcinoma.
Oestrin passes through the placenta into the foetal circulation and affects the genital
organs of the foetus. The occasional finding of secreting breasts and uterine bleeding
in the newborn is attributed to the sudden withdrawal of the maternal oestrin at birth.
A test for prediction of sex is based on the placental permeability to the male and
female hormones.
14. Werner, and later Kaufmann, caused uterine bleeding in human castrates by huge
injection of oestrin, but curettage showed no premenstrual changes. Kaufmann gave
from three to ten million international units over a period of months to five patients
with primary amenorrhcea, some with uteri smaller than a hazelnut. In these women
he succeeded in causing the uteri to increase to normal size. Some of the patients had
short periods of bleeding. Warner used theelin. Kaufmann used a dihydro compound
(progynon B).
15. Kaufmann succeeded in causing a typical "swiss-cheese" hyperplasia in a human castrate by using huge unit doses. Oestrin may be a factor in the etiology of adenocarcinoma of the fundus.
16. Kaufmann caused the formation of a premenstrual-like endometrium, in a human
castrate, by using oestrin and proluton (progestin). This is discussed under the corpus
luteum hormone.
17. Werner attempted to cause lactation in human castrates by giving theelin, corporin
and prolactin in the proper sequence. He was unable to obtain lactation, although
some of the women had marked enlargement of the breasts and felt as though they
were about to lactate.
18. Oestrin is responsible for the series of changes in the organism which tend to facilitate
coitus and fecundation and to create a special state of libido, varying in degree
according to the species.
19. Birch reported good results in haemophilia, but the work of Chew et al., and also that
of Brem and Leopold, raise serious doubts of its efficacy.
THE PHYSIOLOGIC ACTIONS OF THE CORPUS LUTEUM HORMONE
(PROGESTIN, CORPORIN, RELAXIN, PROLUTEIN, ETC.)
1. Together with oestrin it controls the secretory or premenstrual phase of the endometrium and prepares it for the reception and embedding of the fertilized ovum.
2. It is essential for the conservation of early pregnancy before the placental progestin is
present. The anabolic phase of the corpus luteum lasts during the first three or four
months of pregnancy, after which time the placenta supplies the progestin.
3. It has been shown independently by Loeb, Papanicolau, and Macht that it inhibits
ovulation. It is thought by some that this action is an indirect one accomplished
through inhibition of the anterior pituitary gland. Moore states that the direct evidence
of the action on the pituitary gland is lacking.
4. It inhibits the contraction of the uterine muscle and maintains it in the state' of comparative quiescence during pregnancy. It also inhibits tubal contractions, being antagonistic in its action to oestrin and pituitrin in both tubal and uterine effects.
J. Corner and Allen have produced a premenstrual-like endometrium in castrated monkeys by using oestrin and progestin in the proper sequence.
-. It stimulates the development of the mammary gland beyond the degree secured by
oestrin.
7. According to C. V. S. Smith it helps maintain oestrin balance by promoting oestrin
secretion by the kidney.
Page 183 \ 8. Seitz claims that corpus luteum extract shortens the coagulation time of the blood.
9. Demonstration of the effect of the corpus luteum hormone on the human endometrium
in the castrate resisted all efforts until Kaufmann's work in 1932. He succeeded in
producing a premenstrual-like endometrium in a human castrate by using in their
proper sequence oestrin and the corpus luteum hormone. In forty cases of secondary
amenorrhcea he produced menstrual-like bleeding by the same means.
10. Inhibiting effect in menstruation. Removal at operation in the premenstrual phase
causes precipitate menstruation. Persistent corpora lutea in cows prevent ovulation
and cause sterility. Oestrus and ovulation can be prevented experimentally by injection
of corpus luteum extract. Therefore, while antagonistic, when used in the proper time
relation they are synergistic in promoting normal ovulation and menstruation. Two
types of cyclic uterine bleeding, one in which ovulation takes place and a corpus luteum
is formed, and one in which ovulation does not occur. With the latter type there are
no premenstrual changes in the endometrium.
The evolution of the corpus luteum depends on whether pregnancy
occurs or not, and is divided into two stages. Stage 1 is the anabolic stage.
Duration in woman lasts for twelve days in the corpus luteum of involution,
and three to four months in the corpus luteum of pregnancy. Stage 2 is the
catabolic stage—the stage of regression which, in pregnancy, lasts until,
delivery. Where pregnancy occurs, this hormone, progestin, causes certain
changes which affect the normal rhythm and function of the normal menstrual rhythm. Menstruation stops and the endometrium is changed so that
the fertilized ovum is received in a richly vascularized and quiet endometrium.
Progestin has been extracted from the human placenta. Whether it is
secreted or only stored is not known.
Summary.
Folliculin (oestrin hormone). It is produced by the ovary {inter alia)
in the follicle growth. It controls oestrus and stimulates proliferation and
ovulation, and prepares the uterus for menstruation.
Progestin, produced by the ovary (the corpus luteum). It influences'
the myometrium, causing paralysis and allowing embedding of the ovum
at rest, in the endometrium, which also has become thickened and more
vascular. The corpus luteum does not prepare for menstruation, but for
pregnancy.
Pituitrin (post pituitary lobe secretion). Stimulates the myometrium,
causing contractions; opposed by lutein or progestin.
Antuitrin-S. This is the anterior pituitary-like substance and is found
in large quantities in the urine of pregnant women (and prepared commercially very often from the urine of the pregnant mare). It contains both
Prolan "A" and "B" and, since this is the case, it can often be tried in place
of Progestin, since it is much cheaper, and will often produce enough Prolan
"B" stimulation of the corpus luteum to give the required results.
jgr i.—CONTINUOUS HAEMORRHAGE.
Where the placenta and membranes have come away intact and there
has been no evidence of sepsis, one is not alarmed at a moderate amount of
uterine bleeding, when the patient gets up for the first time, which usually
stops within a few days. One of the more important forms of continuous
haemorrhage usually starts about two weeks after delivery and may persist
for many weeks, and while the total amount of blood lost may not be
particularly severe, yet it is discouraging to the mother, weakening her
both physically and psychologically as well as being a contributory factor
in the development of puerperal anaemia.
While the etiology of this form of continuous uterine bleeding is not
Page 184 completely cleared up, we do know that there is no relation to uterine infection or to misplacement. Clinically this type of case is most frequently seen
where lactation is discontinued for some reason or excuse, and particularly
when lactation is deficient.
Again it also seems to be definitely established that after prolonged
labours resulting from uterine inertia, patients show a well marked tendency
to suffer from this type of continuous uterine bleeding. These cases should
be regarded as being caused by defective involution of the decidua and endometrium of the uterus. At other times the bleeding is due to a condition
exactly comparable to metropathia haemorrhagica, and shows all the characteristic appearance of this disease. Uterine bleeding of this same type is not
uncommon after miscarriage, and the same two pathological forms can be
recognized, although with abortion cases it is common to find relics of
chorionic villi attached to the thrombi which are dislodged from the uterus.
Treatment: Method of Controlling the Bleeding
This is probably the most important consideration both from the doctor's
and the patient's point of view.
First of all it is true that the bleeding will stop spontaneously in due
course. Just when, however, it is impossible to say, and this waiting is
usually very tiresome to all concerned. The patient is advised to lie down as
much as possible and she is given ergot and iron medication. This treatment
is not very satisfactory and bleeding very often persists in spite of it.
Secondly: Theoretically the administration of either mammary extract
or the corpus luteum hormone "Progestin" would be advisable. The results
from mammary extract are disputed, while Progestin gives very good results.
The only fly in the ointment is the expense associated with this latter,
which makes its use prohibitive in many instances.
Third: Curettage, Results are excellent and almost always the
haemorrhage stops immediately. Objections are separation of mother and
baby, and secondly, the risk of infection. It is true that this risk is almost
negligible after normal delivery, but in case of abortion more trouble may
be experienced.
II.—POLYMENORRHEA
A very cornmon gynaecological complaint; about 15% of hospital
gynaecological patients suffer from this condition in many clinics. This
condition usually follows childbirth. The etiology is probably related to
an endocrinal disturbance. While it is often regarded as being caused by a
persistence of the increased function of the anterior lobe of the pituitary
gland, so that ovulation occurs more frequently than normal, still there
seems to be no direct evidence to support this hypothesis. Symptomatology
is usually more frequent periods than before, persisting for a longer time
and with an increase in the blood lost. While this condition rarely leads to
a severe secondary anaemia, yet it does put a strain on the blood reproducing
system, and also there is the inconvenience of frequent and profuse menstruation. This condition of affairs may persist for several years following
childbirth but eventually the normal rhythm for each person is re-established. There is no evidence that post-partum polymenorrhcea is influenced
by lactation. The administration of ergot and iron seems to have little, if
any, effect on the frequency of the periods. The amount of blood lost is
reduced if the patient stays in bed and takes ergot by mouth.
Curettage rarely does any good nor is there any reason on theoretical
Page 185 grounds why it should, as this seems to be caused by an endocrinal disturbance.
"Progestin" given in large doses gives, in some cases, good results. The
condition is quite liable to recur when the treatment is discontinued.
Small doses of x-ray or radium are of very questionable value—both as to
results and also because of the risk that a child born of a subsequent pregnancy will be malformed. Again, even if the patient becomes pregnant
again, the condition almost always recurs during the next puerperium.
Mammary gland extracts are advised by some authorities. Others maintain that when the symptoms develop in association with a retroflexed
uterus, the polymenorrhcea resolves after the uterus has been replaced, if
necessary by suspension. If polymenorrhcea and retroflexion are found associated, however, the two conditions are coincident.
The condition tends to clear up if the patient's general health is improved. Fatigue must be avoided and, where possible, the patient should be
encouraged to He up during one or two periods. Attention should be paid
to nutrition and large doses of iron taken daily for at least a month. No
alcoholic drinks.
Antuitrin-S therapy. In those cases where the use of Progestin is indicated, it is sometimes possible (where expense cannot be tolerated or for
other reasons) to substitute Antuitrin-S. The suggested dosage of Antuitrin-S is 50 to 200 units daily for about two weeks. If it is desired to
continue the treatment, one hundred units three times a week may be given',
with rest periods between series of injections. Recently Novak and Hurd
reported their results from the use of Antuitrin-S in 51 cases of functional
uterine bleeding. Many of these were of the recurrent type and some had
had previous curettments. Bleeding was checked in 44 of the 51 cases of
the series, often with astonishing rapidity. The authors state that of 29
cases in which they used strongly luteinizing preparations they were able to
check the haemorrhage in 27. In 14 of the cases the bleeding stopped after
a single injection, and in 12 after two injections. In cases in which the
preparations used were not so strongly luteinizing, results, although not so
spectacular, were nevertheless satisfactory. They believe there is ample
clinical evidence to justify thir belief that the use of Antuitrin-S in such
cases will, in most instances, entirely supplant the other measures; e.g.,
curettage, etc. After cases of functional uterine bleeding have been brought
under control, it is advisable to continue injections of Antuitrin-S for
several months, the injections to be given during the week or ten days
immediately preceding each expected menstruation. Dosage for this purpose
is at least 300 R.U., divided into 2 or 3 injections.
Progestin (B.D.H.), $9.75 for two, 2 cc. rabbit units (6 two units
$16.90).
Prolutein (European rabbit unit), $4.65 for five 1 cc. ampoules.
Leucorrhcea and Vaginal Discharge
The normal vaginal secretion and histological characteristics of the
vaginal m.m. vary at different ages and are controlled by the activities of
the endocrine system.
(1) At birth, there is a creamy white secretion, often plentiful _o
amount and acid in reaction, present in the vagina. Sterile at birth but within
a week usually invaded with Doderlein's bacillus. From the seventh month
of intrauterine life the m.m. is thick and composed of many layered stratified squamous epithelium, in the cells of which much glycogen can be
demonstrated. Also during the latter months of pregnancy oestrin is pro-
Page 186 duced in the mother by the Graafian follicle and by the placenta and is
present in considerable amount in her blood, amniotic fluid, colostrum and
urine. The fcetus is therefore richly supplied with oestrin which at birth
is cut off and oestrin is gradually excreted. Two of the disturbances of the
neo-natal period, namely engorgement of the breasts and the occurrence of
a blood-stained vaginal discharge, are explained respectively by the stimulation by and sudden withdrawal of the oestrin in the infant's blood. Pari
passu with the marked diminution of oestrin from the infant's blood, the
vaginal epith. and discharge gradually change to that seen in the second
phase of life.
(2) During infancy and up to puberty the vaginal discharge is scanty
in amount, contains epithelial debris and W.C.B., and is much less acid in
reaction. With this rise in pH, the flora of the vagina consists of a number
of micro-organisms, including in some cases Doderlein's bacillus. During
this period of life the vaginal mucous membrane usually is thin, atrophic,
and its cells do not contain glycogen.
(3) At puberty and preceding the onset of menstruation a change again
occurs in the pH of the secretion, in the flora of the vagina, and in the
amount of glycogen present in its epithelial cells. During the period of
reproductive life the amount of oestrin in the blood increases, the discharge
becomes abundant, with a whitish appearance like curdled milk and strongly
acid in reaction. Discharge contains Doderlein's bacillus plus plus or even
in pure culture (a high acidity is inimical to all organisms except those of
the bacillus vag. group). This type of discharge does not change until the
menopause unless intercourse or operative interference occurs, in which case
the flora is likely to become a mixed one. If definite infection is presnt,
Doderlein's bacillus tend to disappear and the pH becomes more alkaline.
In this third period (reproductive life) the vaginal mucous membrane is
again thick, many-layered, sometimes keratinized, and rich in glycogen.
During the early months of pregnancy the vaginal flora may be mixed, containing few Doderlein bacillus. In the later months, associated with the
increased concentration of oestrin in the maternal blood, Doderlein's bacillus
tend to reappear in preponderating numbers or even in pure culture. The
cells of the thick, congested, pregnant vaginal mucous membrane are rich in
glycogen and the vaginal discharge becomes highly acid in reaction. (Intercourse, of course, interferes with this picture. Labour and delivery also
cause a change in the picture, as we have several factors, such as trauma,
bloody discharge, perhaps the introduction of some or many organisms, as
well as the diminution in the amount of oestrin in the blood. The trauma
may affect the cervix, vaginal wialls and/or the introitus. The damage to
the cervix, if extensive, will often necessitate some form of corrective
treatment to restore the normal anatomical relations; otherwise a discharge
may persist for years.)
(4) With the onset of a menopause, vaginal changes again occur. The
discharge reverts to the type found in childhood, e.g., scanty in amount,
more fluid, less highly acid,' and the flora increased in variety.
The establishment of a relationship between the production of oestrin
by the ovary and the deposition of glycogen in the cells of the vaginal
mucous membrane has opened up a valuable line of treatment in those nonpregnant patients in whom the vaginal flora is at fault or where the amount
of discharge is abnormal. The presence of glycogen leads to the production
of lactic acid in the vaginal discharge, and lactic acid is inimical to organisms other than Doderlein's bacillus. By increasing the production of glyco-
Page 187 gen, e.g., by injecting either oestrin or one of the anterior pituitary-like
hormones, which stimulate the ovary to produce oestrin, it is hoped that the
vaginal flora or mucous membrane or both will be restorred to a normal
condition. Acid douches or other medicaments likely to increase the acidity
of the vaginal content may also be used.
Endocrine dysfunction with an excess of oestrin in the blood may lead
to an increased vaginal discharge, highly acid (pH 4.2 to 4.7), thick, creamy,
containing only Doderlein's bacilli, and non-irritating. Here, Prolan
(A.P.L.) or Antuitrin-C containing the controlling hormone of the anterior
pituitary gland, should be tried.
>"'     III.—VAGINAL DISCHARGE '•
A very common symptom after normal delivery, and sometimes hard
to explain to the patient satisfactorily. Discharges as a result of puerperal
infection or Neisserian origin are not included in this paper. The two
common forms which are after a natural delivery are the ones to be discussed.
(a) Vaginal leucorrhcea caused by a mild vaginitis.
(b) Development of a glandular erosion of the cervix.
(a)  Vaginal Leucorrhceic Type
Here we have an irritating, thin, yellowish, muco-purulent discharge,
often associated with soreness of the vulva and perhaps with pruritus. The
vaginal vaults are reddened and inflamed and the discharge is easily seen in
any folds, as well as in the cul de sac, on inserting a speculum. In severe
cases, when trichomonas vaginalis can be detected, the discharge is yellowish
or even blood-tinged, and much more profuse and irritating. Vaginal
leucorrhcea of type A occurring post-partum is extremely common. The
worse cases are seen when the vaginal orifice is patulous as a result of a
perineal tear and there is some degree of prolapse of the vaginal walls. This
las led to claims that it is thus easy for extraneous microbes to attack the
vaginal walls and produce a low-grade vaginitis. Occasionally, however,
the condition arises following caesarean section, so that some other factor
must be present. Hormonal influences have been brought forward to explain
the leucorrhcea, it being claimed that there is an oestrin deficiency winch
renders the vaginal epithelium more disposed to transudation and less
restraint to infection.
Treatment.—A simple treatment—vaginal douches of lactic acid (60
minims to a pint of warm water) and run in slowly.
Devegan tablets are useful and should be inserted after the evening
douche (more often if necessary).
The patient's general condition should be improved, and the administration of oestrin usually accelerates the improvement; e.g., emmenin, 20
units t.i.d., one hour a.c. ex aqua.
(b) Glandular Erosion of the Cervix—Post-Partum
The pathology here is quite different. The discharge comes from a
glandular erosion of the cervix and a profuse secretion of clear mucous from
the cervical canal can be seen on inspecting the cervix. Here there is no
question of infection of the cervical canal. The discharge is not purulent
but consists of a clear mucous and the erosion is glandular and papillary in
type. Etiology is unknown, but it is believed that an increased circulation of
oestrin is the predisposing cause, leading to an undue proliferation of the
mucous membrane both of the body of the uterus and the cervical canal.
Treatment.—Those usually used, such as cautery, antiseptics, electrotherapy and diathermy, generally prove very unsatisfactory, and theoretic- I
Page 188 ally there is very little reason to see why any of these should be very successful. The condition always clears up spontaneously in due course, although,
again, many months may elapse before the condition of the vaginal portion
of the cervix returns to normal. In the meantime, the mucous discharge
canbe irrigated away with an alkaline douche. Particular attention should
be paid to building up the patient's general health, for this type of discharge
seems to develop particularly in patients who are anaemic and asthenic.
Promising results have followed from the use of progestin hormone,
although, due to the expense, not very many have been so treated.
Totem Pole Golf Tournament Medical-Dental Cup
Appreciating the attendance and support from the medical and dental
professions at their Annual Totem Pole Golf Tournament held at Jasper
Park, the Canadian National Railways, through W. G. Connolly, City
Passenger Agent at Vancouver, have put up a cup for annual
competition for our respective members only.
Those who have designs on the famed Totem Pole Trophy
will not be barred from competition, as our own event will
be carried out concurrently with the qualifying round on
the Monday morning. Our competition is to be decided on
medal play for eighteen holes on handicap basis.
The dates for the tournament this year have been announced, opening Sunday, September 5th, until
September 11th, and the special rate for the week
includes train fare, lower berth in each direction,
golf, meals and room with bath at the Lodge;
everything, in fact, except meals on the train.
All members of our professions, registered
members at the Lodge, will participate, and as it
has been through Mr. Connolly's efforts that this cup has been put up, he is
anxious to have one of the Vancouver entry bring it to Vancouver for the
first year, therefore he is expecting a good representation. He would also
welcome any suggestions for an appropriate name for the cup.
OSTEO-ARTHRITIS FERVENS
Dr. H. E. L. Langis commenced practice in Vancouver in 1884, his arrival
antedating by two years the great fire which razed the infant city in 1886.
Like many of his medical confreres he considered his equipment incomplete without a thermometer, a stethoscope, a Higginson, a whip catheter
and—most important of all—a human skeleton. Dr. Langis was lacking
skeleton and as its possession was vital he set himself to secure this bony
adjunct to his armamentarium. He enlisted the help of the druggist, McCartney, over whose store was located the doctor's surgery, and, having knowledge
of the whereabouts on Deadman's Island of the body of a Swede who had
"suicided himself" two years before, they proceeded to disinter the remains.
The spooky business of exhumation finished, they lifted their osseous burden
into a boat and to the back room of the drug store to be cleaned up and
prepared for articulation. The skeleton was placed in the cupboard and Dr.
Langis tells startling stories of the indiscretions of inquisitive persons who
peeked into that curtained corner of his office.
When the fire wiped out the city, Dr. Langis' office was completely
destroyed. Those who cleared away the debris were much impressed by the
burned skeleton on this piece of ground at the corner of Abbott and Water
Streets. This disclosure told its own story. A man confined to his bed had
been unable to save himself and had perished. One on-looker suggested that
it was quite apparent that he was ill and bed-ridden. "Why, look at him. He
could not possibly get off his bed. Look at the condition he was in. He was
Page 189 in bad shape; his bed must have been burned under him. Why, look at his
joints. They surely must have been badly diseased; they're all fastened
together with wires."
*     *      *      *
A SEAGULL VISITS THE DOCTOR      |
In the late afternoon of a balmy day the doctor was finishing a cigarette
as he cleared his desk for a quick getaway when he heard footsteps on the
window ledge behind him. The visitor was a full-grown gull and he appeared
to want something. Could it be that he needed medicine? Possibly he sought
the services of a specialist. There was evidence of rhinorrhcea. There had
been a nose specialist on that floor or just below. The bird seemed strangely
friendly and unafraid. The doctor tossed the cigarette stub on to the sill. The
gull snipped off the lighted end and swallowed the butt greedily. The doctor
wondered if he were really hungry. What could he give him? Searching his
medicine cabinet for samples he found some Anusol suppositories. These
proved delectable diet for his bird friend. Then Iodobesin was tried out successfully and Hypotensyl seemed satisfying, as were the Luminal tablets.
Then succulent Haemolytic capsules were followed by Yeast. The doctor^
wondered and feared the consequences, so hastened to pass out Caroid and
Bile Salts. The bird stayed long enough to leave a testimonial to the efficacy
of the latter treatment and the skill of his physician.
SOME SEQUELAE OF NORMAL LABOUR
By De. J. T. Wall, Vancouver.
Read before Vancouver Medical Association, April, 1937.
Before considering the effect of normal labour on the supporting structures of the female pelvis it is well to recall some of the anatomy.
The bladder, vagina, uterus and rectum are suspended by the levator ani
on each side, with the recto-vesical fascia on its upper and the anal or ischiorectal fascia on its lower surfaces. Above this muscle and fascia is the looser
elastic and connective tissue forming the base of the broad ligaments through
which the blood vessels and nerves pass to the uterus from the pelvic wail.
This also gives considerable support to the uterus and vagina. The levator
muscle on each side takes origin from the fascia lining the wall of the pelvis
along the white line, from the pubes anteriorly, and from the sacrum and
coccyx posteriorly, and pass downward and inwards to meet in the mid-line
to support the vagina, uterus and rectum. Some of the fibres interlace behind
the anus, some under the perineal curve of the rectum and some pass into
the perineal body. The levator ani muscles pull the perineum upward and
forward after the depression induced by parturition, defalcation or urination,
and can be voluntarily exercised. Thickened parts of the supplementary fascia
above the upper fascial covering serve special functions. The pubo-cervical
fascia extends from the back of the pubes to the cervix. It acts as the anterior
support of the cervix and also as a shelf for the base of the bladder. The
utero-sacral ligaments extend from the cervix to the sacrum, and by keeping
the lower part of the cervix well to the back of the pelvis, tends to keep the
fundus forward. In this forward position of the uterus, the intra-abdominal
pressure presses the anterior against the posterior vagina wall, and by this
means the pressure is distributed over the whole pelvic floor instead of pressing the uterus against the vaginal opening. The uterus is not fixed in any
one position but is held within certain limits by the pelvic floor, sacro-uterine
ligaments, broad ligaments, round ligaments and the normal tone and fullness
of the pelvic tissue.
During childbirth practically all primiparae and many multiparae suffer
from injuries to the parturient canal. These are generally considered normal.
A dilating cervix stretches and may tear the cervical attachments. During
the second stage of labour the vagina practically lines the true pelvis, which
Page 190 means that the bladder must be displaced anteriorly. Such a displacement
may tear or over-stretch its lateral attachments and support. Some relaxation
and descensus of the anterior vaginal and urethral wall is the result.
Laceration of the perineal body also occurs in most pjrimiparae. A tear
involving the perineum only does not do much damage to the pelvic floor.
Usually, however, the tear extends up the vagina, and involves the levator
muscles and fascia. Usually the muscle suffers less than the fascia. When
the perineum is torn, the transverse perineal muscles of each side, arising
from the tuber ischii, cause the vulva to be permanently open. This invites
infection, causing vaginal and cervical catarrh.
Variations in the elasticity of the perineum, connective tissue and fascia
exist. An inefficient pelvic floor may be destroyed even by an easy labour. Old
primiparae are more apt to be permanently damaged. A narrow pubic arch
prevents the head from occupying the space under the sub-pelvic ligament,
forces the head back towards the coccyx, and thus tears or overstretches the
perineum and levator with its fascia. Sometimes the deeper structures are
damaged while the skin is intact. At times, a well directed episiotomy may
prevent the dragging of the supportive structures from the pubis or serious
damage to the vagina, perineum or anal sphincter. The injury to the tissues
by the episiotomy is more apparent than the overstretching and tearing, and
can be more accurately repaired. This does not mean to imply that the free use
of episiotomy can replace natural dilatation of the perineum, but rather it
should be practised as less likely to do harm when overstretching and tearing
If the pubo-cervical strands of the fascia are torn off the cervix, the
bladder slides down, and overstretching of the vagina and parametrium
allows the cervix to come nearer to the vaginal outlet. At other times the
utero-sacral ligaments suffer traction injury, the fundus falls backwards
and prolapse more readily takes place.
Acquired retroversion is a common result of labour, in fact, it is so common
that many doctors look upon it as a normal position. While many patients
with retroversion, and especially those with congenital retroversion, do not
have symptoms, and there has been some question whether uncomplicated
retroversion causes any symptoms, retroversion noted soon after labour
should be corrected, when this can readily be done. By doing this, sub-involution and the tendency to prolapse with pelvic discomfort and backache can
often be prevented. Retroversion is less frequent where postural exercises
have been done after confinements, and where adequate periods of rest have
been taken during the puerperium.
Needless to say, all the visible lacerations of the normal labour should
be immediately repaired. Unfortunately, some subcutaneous tears of muscles
and fascia and some overstretching of these parts cannot be immediately
dealt with. On the other hand, a great many ill effects following the normal
labour can be prevented if we remember that involution of the uterus takes
eight weeks, and of the arteries and supporting connective tissue, twelve
weeks.
We occasionally see a patient whose uterus was in anterior position at
six weeks have retroversion later. Also, we frequently see patients at the
fourth to sixth week examination who have a retroversion and suffer from
pain in back and a general tired feeling, who immediately start to improve
when the retrodisplacement is corrected, and corrective exercises and tonics
given.
Many patients who have not had instrumental or operative delivery
later develop bladder symptoms or symptoms of prolapse. Instrumental
delivery is not the all important factor in producing birth canal injury.
There way be persistent relaxation through sub-involution and lack of tone,
even though there has been immediate repair and perfect healing of the
laceration. Invalidism following pelvic floor damage may not appear for
many years. Relaxation is progressive. If the supports of the uterus and
vagina are stretched, the tendency is to retroversion and prolapse of the
Page 191 uterus, and to anterior and posterior colpocele. Overstretching of the birth
canal by repeated, even normal, pregnancies is a common factor.
To lessen the likelihood of post-partum disabilities certain routine precautionary measures should be taken. The bladder should not be allowed to,
become distended during labour or during early puerperium. Premature
bearing down, before the parts are dilated, tends to drag the supporting
structures from the side wall of the pelvis. Overloading of the rectum, with j
its resultant straining, should of course be avoided, especially in the early
days post-partum. Involution of the markedly enlarged vagina and pelvic^
floor as well as of the uterus must be favored as much as possible by avoidance <
of pelvic congestion. If this involution process is not completed, there remains
an atonic relaxed condition. From the second day, sitting posture and at
least twice a day lying on the face for up to an hour promote drainage from
the uterus and vagina, and help involution. Special leg and abdominal exercises are started on the third or fourth day to improve the local muscular
and general tone, and on about the sixth to eighth day the patient starts the
knee-chest position for two to ten minutes twice a day. The buttocks should
be pulled widely apart to allow the air to balloon the vagina. This position,
tends to keep the heavy uterus forward and to improve the circulation about
it. After the patient gets up, frequent periods of recumbent rest relieves the
pressure and strain on the involuting structures, and lessens the relaxation.
If the uterus is found to be retrodisplaced at the post-partum examination
it is replaced when it can be readily done. Prolonged attempts at replacement
may lead to trauma and even to adhesions. If replacement cannot be done by
bimanual manipulation, the patient is put into the knee-chest position and
the post-vaginal wall is retracted by the Sims speculum until the cervix is
grasped by a tenaculum forceps. The cervix is pulled on while the finger in
the rectum presses the fundus out of the posterior position, and the cervix,!
is then pushed backwards into the hollow of the sacrum. It may be held there
for about eight weeks with a pessary. Sometimes, though, when replacement
to the anterior position cannot be readily accomplished, it is later found to
have assumed this position after patient has daily used the knee-chest
position, the monkey-walk, the mule kick or other exercises.
By some it is believed that many of the post-partum sequelae are due to
lack of quickly resuming routine activities. They think that results might be
better if the woman did as do the pregnant Eskimo on the trek, or the pregnant Indian on the trail. However, it seems that less misery results if we
follow the authorities who teach that the pelvic support was not built for
the upright position, and insist on prolonged rest with postural exercises.
REPORT FROM STAFF (GYNECOLOGICAL
DIVISION)  OF VANCOUVER GENERAL
I HOSPITAL
By Db. W. K. Burwell
Read before Vancouver Medical Association, April, 1937
The purpose of this paper is to give you an idea or a survey of the work
which is done on the indoor service of the Obstetrical Section at the Vancouver General Hospital. You will persistently say to yourselves, and I trust
you will not cause me embarrassment by saying it aloud, "But where are
the actual figures? What are the statistics?" And there is just criticism from
this angle. The truth of the matter is that I have not had time to prepare
such a paper for presentation to you. Statistical papers tend to be a little
dry, they are hard to grasp, they need digestion; in addition, they are not
always what they are supposed to be, they can be interpreted this way and
that way, depending on the bias of the physician, on what one wishes to prove
or disprove: and too frequently they are not borne out by fact and cannot be
duplicated in other centres.
Page 192
mm And so this paper does not aim at such heights, but rather is it a general
survey of impressions gained, lessons learned, errors made; it is an attempt
to carry hindsight into the realm of foresight, so that we may not make the
same mistakes again, so that we may do better obstetrics.
One word further in this preamble. What I may say does in no wise reflect
the considered opinion of the entire staff, or even of one member of the staff.
Just as often twelve good jurymen cannot see eye to eye, so do obstetricians
differ in their opinions. Obstetrically, diagnosis is a comparatively easy
thing, but on the other hand there may be a wide diversity of opinion as to
how to handle any given problem, and both camps may be right; it is for
this reason that I repeat again that the staff of which I am a member may
be far from endorsing any impressions or theories which I may present.
Now and again, I wish to interpolate a word or two about the work on the
private service, and I may even take the liberty of making a comparison here
and there with that of the staff service. At first I had hoped to mention more
along this line, but again I found lack of time and difficulty in making just
statements, and in addition, I am not sure that it is exactly propitious at
this time.
This r_sum_ of the work of indoor staff service is based on the records
of the years 1934,1935, 1936. During this period there were 1,726 admissions
to the hospital; incidentally, there were 3,776 patients admitted to the private
side. Comparatively speaking, there were many more women admitted in
false labour to the staff service, which is rather what one would expect, and
would certainly be the case if health insurance came into force. If one does
not have to pay for one's hospitalization, there is a strong tendency to run to
the hospital whenever pains of any kind make their presence felt, especially
during the last month of pregnancy; whereas, if each day spent in the
hospital increases the expense account to the patient, there is a greater
readiness to remain at home until labour is definitely established. Such is the
conclusion that one would form.
The induction of labour makes room for another comparison. It is interesting that such procedures are more successful on the private than on the
staff service. Staff work in obstetrics in any hospital is definitely more conservative than that on the private side; one may not hesitate to let the
patient return home after one or two unsuccessful inductions of labour where
no obstetrical abnormality is present beyond the fact that the patient is at
term; whereas, when one is dealing with a private patient in similar circumstances, there is a real urge to make it truly successful, to get it over with.
Patients are not much impressed with the idea, of going home and coming
back, and, as a result, the doctor gets the blame; it is rather poor advertising.
In my opinion, induction of labour should be done for very definite reasons,
and rarely does a patient need to be "induced" just because she is at term.
Those of you who believe in postmaturity will find ample ground to quarrel
with me here; indeed, the Chief and I frequently have a friendly difference
of opinion in this matter. Not uncommon is it for a woman to suffer two
unsuccessful medical inductions, occasionally three. Rupture of the membranes for induction has during this last two or three years become a very
popular procedure and is not infrequently done on the service. It is eminently
successful,—the closer to term the earlier will labour set in, the duration is
lessened, delivery seems no more complicated. It should rarely be done when
the head is floating, the breech presenting, or in abnormal presentations, for
fear of prolapsus of the cord. It is extremely useful when one is anxious to
terminate the pregnancy because of some pre-natal complication. The fear
of dry labour seems to have greatly lessened these last years.
The routine for medical induction of labour is as follows: 6 a.m., castor
oil oz. iss; 8 a.m., quinine gr. v; 9 a.m., quinine gr. v; 10 a.m., quinine gr. v,
infundin M. iii; 11 a.m., infundin M. iii; 11:30 a.m., infundin M. iii; and
after this infundin v every half hour for 4 doses. Of course, this medication
is discontinued with the onset of labour.
Page 193 Not often do we rupture the membranes before giving the patient at least
one medical induction. Bougies seem to have lost their usefulness, certainly
their popularity; the Voorhees bag is indeed a very valuable method and
usually a certain one, yet one is always a little nervous during the time it is
in position lest when the bag is expelled a prolapsus of the cord or foetal
member may take place. Just as in every obstetrical procedure there is a
certain amount of risk, so with the bag.
The Pre-natal Clinic is a great institution. Each year its efficiency and
value are increasing, and with this there is a smaller incidence of patients
with pre-natal complications admitted to the hospital. Money should be spent
lavishly on this Clinic, nothing should be denied it, since not only does it
prevent the patient from developing serious complications, but it also saves
the hospital much, in that relatively few require to be admitted for pre-natal
complications. Rarely does an' interne see an eclamptic patient, and in fact, a
resident may be with us a year and not witness a single case of eclampsia.
That speaks well for any pre-natal clinic. During these three years, we had
16 patients admitted because of hypertension per se. Such cases always do
well; one often wonders if it would not be advisable to have a bed or two
adjoining the clinic where they might rest for three or four hours and then
have their blood pressure checked, most of,them would be definitely lowered
after rest and quiet, certainly not all would require admission. Hypertension
alone is rarely a sufficient indication to send the patient to the hospital; I
believe a sudden increase in weight is definitely a more serious omen. We
have the odd case of essential hypertension, the systolic pressure, despite all
efforts, remaining anywhere from 150 to 180; and yet the patient feels well.
Provided the diastolic pressure does not remain above 100, drastic measures
are not undertaken. Here, as elsewhere, essential hypertension is not well
understood.
We had 36 admissions for pre-eclampsia,—a combination of two or more
of the following signs and symptoms: (a) Subjectively—headache, dizziness,
ringing in the ears, blurring of vision, specks before the eyes, etc.; (b)
Objectively—hypertension, rapidly increasing weight,. albuminuria, cedema
of the face or extremities, etc. None of these patients proceeded to the
eclamptic stage. The treatment is simple: bed rest, salt-free low-protein
diet, a little mag. sulph. each morning, daily analysis of the urine, daily
reading of blood pressure, etc. If they are close to term we induce labour,
provided the condition is cleared up, otherwise they return to their homes
with definite instructions as to rest, diet, etc. to follow, and report to the
clinic thereafter weekly or bi-weekly.
There have been in all 4 cases of eclampsia, 2 ante-partum and 2 postpartum. I believe this is remarkable. It hardly keeps one in practice, and,
as I have already said, the internes feel that they are being gypped; they go
out into private practice without seeing a single case of eclampsia. These
cases all responded well to treatment and made uneventful recoveries. They
are studied from every angle—urine (analysis, intake and output), blood
chemistry, eye grounds, etc. Too much emphasis cannot be laid on examination of the eye grounds, both in the convulsive and non-convulsive condition;
one must certainly be guided as much by the advice of the ophthalmologist
as by the laboratory tests. We do not care for these patients by any set rule;-
they are treated individually by the Strogonoff or modified Strogonoff technique. Their delivery is made as painless and as short as possible, and with
the minimum amount of interference. Following their discharge from the
hospital, not only do they return to the post-partum clinic, but they are also
referred to the medical clinic for regular periodic examination.
Nephritic cases are, of course, in a class by themselves. We had ten of
them. Here the obstetrician and internist go hand in hand; of the two, I
think the latter has the greater worry and responsibility. As compared to
other complications, the outlook for these patients before, and especially
after delivery, is extremely serious. They are the playground of the bio-
Page 194 chemist; to the internist he is the mechanic. It is not possible to more than
mention this complication—its symptoms, its diagnosis, its treatment, is
ground for many papers. The problem of continuing or interrupting the
pregnancy depends on the severity of the renal damage and the stage of the
pregnancy; and still later on we are confronted with the advisability or not
of sterilizing the patient.
Pernicious vomiting does not give us much worry—eleven cases in all.
They responded well to treatment of almost any kind; the adrenal cortex
popularized by Dr. Kemp certainly has a place. In these cases there is always
a strong psychological factor. The interruption of pregnancy because of this
condition is becoming more and more infrequent.
Pyelitis of pregnancy is a not infrequent complication, occurring on 36
occasions; 13 as a prenatal manifestation and 23 after delivery. Regarding
their cure, water seems still to be the big factor and probably will always so
remain. Posture does not seem to influence them much. Potassium citrate
with a little tincture of hyoscyamus continues to be the popular remedy.
Pyridium and serenium have a place; the latter is more popular with us.
There is little doubt concerning the efficacy of the ketogenic diet; however,
there is more than a little trouble in persuading the patient to take it; they
prefer the disease. The therapeutic value of mandelic acid is beyond doubt;
it has everything in its favour except the cost factor. Now. and again the
ureters will have to be catheterized and the pelvis drained.
A word or two on venereal disease* as a complication of pregnancy. Our
experience both on the outdoor and indoor service is that it is not nearly so
frequent as a certain morning journal would lead us to believe. Scabies, in
a way, gives us much more trouble; indeed, a senior member of the staff
suggested that it form the subject of a daily editorial, but perhaps not with
a breakfast number. The patients certainly complain more about their scabies
than they do about any venereal complication. We do not treat lues or
gonorrhoea in the ante-partum clinic. This is left entirely to the Government.
Those with gonorrhoea are delivered in the emergency case room and then
returned to Ward "W", whereas the luetic ones, although delivered in a
similar case room, are returned to the maternity floor, where they may or
may not be isolated, depending on the lesion. These cases all return to the
Government clinic for further observation or treatment.
May I rapidly run over rarer interesting complications. We are not
bothered much with mastitis. Bandl's Ring occurred in two cases; I regret
that in one of them the uterus was ruptured during delivery, following which
a hysterectomy was performed and the patient made an uneventful recovery.
A very rare thing to see is a prolapsus of the rectum following delivery. Third
degree lacerations are not so serious as formerly considered; if properly
repaired they heal well and with excellent functional results. We had one
case of ischiorectal abscess. Post-partum haemorrhage occurred four times,
one with a fatal termination. I shall mention this case later. Retained placenta
occurred in six patients; we did not have a single case of placenta accreta.
There were no cases of embolism.
Normal delivery took place in 1253 out of 1519 confinements; the remaining 266 were delivered as follows: low forceps 129, mid forceps 27, version 20,
caesarean section 45 and breech 45. Most of the low forceps were done for the
benefit of the interne on the service. They are always done under supervision
of the resident or a member of the staff. My own feeling is that more patients
might be delivered by prophylactic low forceps; it wouldn't hurt the patient
and it would be a great help to the interne who is soon to embark in private
practice. In this day and age, it is regrettable that the young physician should
attempt his first forceps delivery on a private patient without having previous
experience in their application or without one of experience standing by.
Personally, I prefer to deliver the primipara with prophylactic low forceps
and median episiotomy. In this way the woman avoids the severest pains,
labour is a little shortened, and the perineum is left in better shape. Most
Page 195 patients delivered with mid-forceps fell into the group of persistent occiput
posterior, where the head was manually rotated and forceps applied. There
were no cases of high forceps on the service over the last three years. It is
of-interest to note that instrumental deliveries are far more common on the
private than on the staff side.
Ca. serean sections were done 45 times. There were no deaths in this group.
The low flap and classical operations were done about an equal number of
times. I personally prefer the former operation provided the patient has been
in labour a few hours; I would not choose it as an elective operation unless
the patient was allowed two or three hours of labour, because in such cases
the lower uterine segment is not thinned out. It is indeed the operation of
choice where the patient has been in labour some hours with or without
membranes ruptured and where one or more vaginal examinations have taken
place. The Latzko operation has untold advantages in probable infected
cases; it is a pity that it is beset with such technical difficulties.
Cesarean section is a very simple operation, it is a glamorous procedure,
but the operation itself is no criterion of one's obstetrical ability. The better
the obstetrician the fewer the caesareans; there is hardly an exception to
this rule.
And what were these sections done for? They fall loosely into four groups:
1. Haemorrhage—(a) Placenta Previa, of which we had 10 cases. Nearly
all Previa cases, whether central or marginal, are now delivered by
this procedure. Time I think will.change this view with regard to many
of the marginal ones; here is one of the places where the nicety of
obstetrical judgment and ability will enter.
(b) Concealed haemorrhage must be cared for in this way. Cases
of partial separation of the placenta may or may not be attended to
in a like manner.
2. Previous Caesarean Section—The dictum "once a caesarean always a
caesarean" is not said with such force as in former years. However,
we follow this rule in our clinic.
3. Sterilization.—There are many cases which for one reason or another
we wish to sterilize; for example, tuberculosis, cardiac disease, mental
deficiency, or multiplicity of pregnancy, when we combine the operation. In this way the patient has but one anaesthetic and her stay in the
hospital is materially diminished. Please be assured that this procedure
is far from being a universal rule. My own opinion is that where possible it is better to deliver the patient by the vaginal route and do the
sterilization a few days later.
4. In this last group fall such cases as justominor and deformed pelvis,
tumours obstructing the passage of the child, the decompensated heart,
etc. It is surprising how infrequent are such cases.
Concerning Version.—In going hurriedly over our list of 20 such cases,
the following facts became very evident:
1.  Version and Extraction is a major performance.
Much of its success depends on the excellency and depth of the anaesthetic. Not often does a relaxed uterus rupture.
It is an extremely dangerous procedure for the child when rotation
and forceps have been attempted and failed.
The incidence of stillbirth is very high.
Maturity, and post-maturity if there be such a condition, need give
one less worry as to the outcome for the child than prematurity.
Premature children stand version badly.
Yet versions must occasionally be done, face presentations will make their
appearance, prolapsed cords do occur, shoulder presentations will pop up now
and again, and occasionally the persistent occiput posterior may need to be
dealt with in this manner. Here I might say that it probably requires more
skill to rotate and deliver a P.O.P. than do a version.
Breech presentation and delivery occurred 45 times. A word concerning
Page 196
2.
3.
5. forceps on the after-coming head. Pfeiffer forceps are undoubtedly the best,
yet the others will serve well. If the head cannot be delivered easily it is far
safer to apply forceps. In the primipara at least, an episiotomy ought to be
done. Cephalohaematoma is not an uncommon sequela; fortunately it is of
no particular importance.
There were six maternal deaths on the service during these three years.
Before mentioning their cause I would point out that during this same period
there were 44 stillborn children and 24 infant deaths. I regret that I cannot
elaborate on these cases; it takes much time for a careful analysis of each
one; they are food for much thought; in spots, just criticism.
The cause of the maternal mortality as determined by post-mortem
examination was as follows:
1. Uterine inertia, the patient dying three hours after normal delivery
from post-partum haemorrhage.
2. Haemorrhage and shock from rupture of the uterus in a case where
previous section had been done.
3. Cardiac disease—the patient delivered herself of a 7 months' foetus.
4. Lobar pneumonia.
5. Peritonitis and bilateral pleurisy. Although this patient had a periappendiceal abscess which had been drained, there was no evidence
at autopsy of any acute inffammatory process in the appendix.
6. Brain tumour—this was a glioblastoma situated in the right occipital
lobe with secondary haemorrhage. Symptoms developed suddenly on
the ninth post-partum day with death occurring about 18 hours later.
And so with this brief enumeration of the maternal mortality my story
is ended. It reminds jne of a yard engine shunting the cars back and forth
but carrying none of them to their ultimate destination. The paper is by no
means a finished product, it was not intended to be so; but rather to let you
know simply what we are doing, together with the odd impression gained.
I am indeed grateful to Dr. Turnbull and his* staff for letting me present it to
you; you have been patient during its presentation; it is always helpful to us
if you give your opinion tonight and from time to time as the work proceeds.
HOW TO CONDUCT A MEDICAL PRACTICE (DE LUXE)
Our friend Dr. W. A. Richardson, who graduated from Toronto in 1886
and was registered in this province in 1888, has during several years carried
on his practice at Campbell River on Vancouver Island. He may be found in
a very comfortable office and apartment over the general store just next to
the beach, where the doctor's boat landing is very handy.
On special afternoons, when the salmon are on, there is always a fortuitous lull in office practice, and Dr. Richardson puts out to sea for a spell
of fishing. If anyone turns up he may wave the flag from the waiting room
and the doctor comes in.
On one particular day the salmon were taking well and each time the
doctor caught a fish the flag was seen. This was repeated three times. What
a life! One doctor has solved a serious problem—how not to let pleasure
interfere with practice. Could not some similar arrangement be made in
other centres, especially in Vancouver, where the offices seem so far from
the great outdoors?
Page 197 MANDELIX
(Elixir of Ammonium Mandelate B.D.H.)
In Urinary Tract Infections
IN the report (Proceedings of the Royal Society of Medicine, February,
1937, p. 501) on a discussion on urinary antiseptics in which the "surprisingly good results" which follow the administration of mandelic acid in
the treatment of B. coli infections are commented upon, it is stated of
mandelic acid preparations that ". . . ammonium mandelate in the form of
an elixir seems to be the most suitable, and less likely to require the addition
of another urinary acidifler."
An elixir of ammonium mandelate in a highly palatable form is presented in
Mandelix, which contains in two fluid drachms the equivalent of a full
therapeutic dose of mandelic acid; its administration provides a dependable
alternative method to that of sodium mandelate and ammonium chloride.
Stocks of Mandelix 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.
Mndx/Can/376
OVOL'S
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Codeine  Phosphate     V_ gr.
OvoL "APC"      I
Acetylsalicylic  Acid...  8% grs.
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Caffeine   Citrate  «__.    V% gr.
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Caffeine   Citrate...__, .    % gr.
Codeine   Phosphate......     % gr.
No packages for laity demand. In bottles of 100 and 500 Tablets only.
Request literature and samples from our Vancouver Branch,
2051 Stephens Street.
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r     SAFE NEW MILK
every day! ...
• BECAUSE , their  doctor  advised  the  family to  take
along a good supply of KLIM Powdered Whole Milk,
Not a milk substitute, KLIM is pasteurized- Cows' milk
in dry powder form with only the water removed. Simply
replace the water and you have fresh-tasting milk of high
quality. KLIM is the safest form in which whole milk can
be transported and is equal to obtaining milk a few hours
after milking time.
KLIM stays fresh indefinitely in its vacuum-sealed container — keeps for long periods without refrigeration even
after the container is opened. >^v
As for the babies on holiday with the rest of the family,
KLIM is ideal for them. You can successfully recommend'
this safe whole milk to traveling mothers. Put the family
on KLIM when they go away and rest assured that they
are using a medically approved and controlled* product
and not milk of questionable purity.
"Spell It Backwards" DIARRHEA
"the commonest ailment  of I
infants in the summer months9]
(HOLT AND McINTOSH: HOLT'S DISEASES OP INFANCY AND CHILDHOOD. 1933)
One of the outstanding features of DJEXTRI-MALTOSE b
that it is almost unanimously preferred as the carbohydral
in the management of infantile diarrhea*
nseness, ^nrhohvdrates; ■ • • Avf^nn^ , gS.-Oi	
6.
*n diarrhea   "r~    _
<* without tro?bS»_!.i,csl
discussion
He
diets
%aW%™%*
"Dextri-maltose is a very excel-
lent carbohydrate.. It is made up
of maltose, a disaccharide which
in turn is broken up into two
molecules of glucose—a sugar that
is not as readily fermentable as
levulose and galactose—and dextrin, a partially hydrolyzed starch.
Because of the dextrin, there is
less fermentation and we can therefore give larger amounts of this
carbohydrate without fear of any
tendency of fermentative diarrhea."—A. Capper: Fads and fads
*"  infant ■r""r,;""—i____l______
iiM
and
conti
b.jI
rhea^i «**<*y*»t? O
gffi ;»„<»? young,   intend
In cases of diarrhea, Tor the
first day or so no sugar should
be added to the milk. If the bowel
movements improve carbony^
drates may be added. This shou
be the one that is most easilj
assimilated, so jk__iI_-S_i^__
the carbohydrate of cnoice. -
W H. McCaslan: Summer dtar-
^in infante and^un^chtld
ing theTeachiig _fnhTLb? adde
__£_
_.__j_% ^«w.w_r diar
most easuy as_£.*-ded sh°uK
SERIOUSNESS
OF DIARRHEA
There is a widespread opinion that,
thanks to improved sanitation, in*
fantile diarrhea is no longer of se*
rious aspect. But Holt and Mcintosh declare that diarrhea "is still
a problem of the foremost importance, producing a number of
deaths each year...." Because dehydration is so often an insidious
development even in mild cases,
prompt and effective treatment is
vital. Little states (Canad. Med.
A. J. 13:803, 1923), "There are
cases on record where death has
taken place within 24 hours of the
time of onset of the first symptoms."
il win inn ls
'i-.-e is there-
easi
-Maltose  is  WJ    ilk sugar,
)rbed than cane f       hydr
ni^pSS^deficient *
(\y of sugar-''        uses diar*
Whenchagnge Se Com J
me can change^
Mead s -SgSgS-^ ab«
doses ts ^'fo^to castor If
and so superior w^
sugar- ^tfbe better tha
seems not toJg°B>   QadsW
tor   sugar- •-«•    j  jn^m
William tit***™   7A
don!"**8'**'11,
■__^^WfTMe
laxatT.^"...*.,   have a defini«
whpn   5  *.«_tency.  whichl
when  earned   to   excess, can
severe intestinal irritation.'
i he more complex carbobs
tvnw* of which dextrin Si
do not have this laxative effect"
dlarr^ffdl"Tg   the   treatment
mo_t   __V fIn °ur experience,!
most   satisfactory  carbo hydra.
mIlt°Ut,I_? us? }? Mead's d«b
MS. No. _,•»-__?. R. fix,
^jnmer Complaints," South*
i/ ifi
'The condition in whirh Hextn-maltoseis partic
in acute attacks of vomiting, diarrhea and fever. It
covery is more rapid and recurrence less likely to take place if de_
t.ri-maltose is substituted for milk sugaror cane sugar when thes
havebeenused. and the subsequent gain in weight is more rapid.
"In brief. I think it safe to say that pediatmians are relying les
implicitly on milk sugar, but are inclined to sp it the sugar .elemenl
giving cane sugar a place of value, and dextrimaltose a decidedl
prominent place, particularly in acute and difficult.cases. —IV. L
Hoskins: Present tendencies in infant feeding. lndtanapolts M. J
July. 1914-          ,„
evaporated mi.k form,, =! ftt to-S whole ««*'
one and one*a_f toi™'Zhlch W.U W1* abou.
every pound o'body w^-h."^8 of _'hole ™«c to
should finally Lvr^o^h.Ll1,?0]1^- T-it also.
of lactose may cause _
centage of sugar be required it is better to repua
it by dextri-maltose. such as Mead's Nos. 1 and *
where the maltose is only slightly in excess of tl
dextrins, thus diminishing the possibility of -
cessive fermentation."—W. J. Pearson: Commo*
Practices in infant feeding, Post-Graduate Mtd. J.
6:38. 1930; abst. Brit. J. Child. Dis. t8:16Pltt,
Apr it*June, 1931.
amounting
Strong: Su
ally have the ^itionoTJ^rnalt^,
seven per cent. —-R   A~[
" jn/pney and early
to five t
o. •__....»»--
\childhoocLArrl-.
mrner diarrheas t
V*&din*      t "« . _T> j
"S nSK?^)^8 *Wve on) and"_£.! -111 yU^ar ^ K
it wa?nlP«°mp,,shes th« Purnoi  Fn,gh ,n PT<>te,n- Calciumc,
Just as DEXTRI-MALTOSE is a carbohydrate modifier of choice, so is CASEC (calcium case
ate) an accepted protein modifier. Casec is of special value for (1) colic and loose green stools
breast-fed infants, (2) fermentative diarrhea in bottle-fed infants, (3) prematures, (4) mar*1
 mus, (5) celiac disease.  MEAD JOHNSON & CO., EVANSfVI____B, HffP., U.S.A.
When requesting samples of Dextri-Maltose, please enclose professional card to cooperate in preventing t
reaching unauthorized persons.
. Points to GEORGIA
PHARMACY Service:
1. Open Day and Night
2e Absolute Accuracy
3e New Phone: Sey. 2263
Prescription
Specialists
GEORGIA PHARMACY
MIXED
W.OIOI.OIA
<&mt?x $c if antra ffitl-
Established 189}
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__3SS%2_^^
Hollywood Sanitarium
Limited
for the treatment of
Alcoholic, Nervous and Psychopathic Cases
Exclusively m
Reference—B. C. Medical Association
For information apply to
Medical Superintendent, New Westminster, B. C.
or 515 Birks Building, Vancouver
Seymour 4183
Westminster 288

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