History of Nursing in Pacific Canada

The Vancouver Medical Association Bulletin: March, 1926 Vancouver Medical Association Mar 31, 1926

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 $*<
THE VANCOUVER MEDICAL
ASSOCIATION
|; BULLETIN
Published monthly at Vancouver, B. C.
^Mental ^ygiene^
c&hyroid HDisease^
Surgery in IDiabetes
MARCH, 1926
*«
Published by
(fMc^eath Spedding (Limited, ^Vancouver, 63$. Q. ™»-^®e
as^-
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Page Two THE   VANCOUVER   MEDICAL   ASSOCIATION
BULLETIN
Published Monthly under the Auspices of the Vancouver Medical Association
in the Interests of the Medical Profession.
Offices:
529-30-31 Birks Building, 718 Granville St., Vancouver, B. C.
Editorial Board:
Dr. J. M. Pearson
Dr. J. H. MacDermot Dr. Stanley Paulin
All communications to be addressed to the Editor at the above address.
VOL. 2.
MARCH 1st, 1926
No. 6
OFFICERS, 1925-26
Dr. J. A. Gillespie
President
Dr.
A. w. Hunter
Past P
resident
Vice-President
DR.  H.  H.
Milburn
Secretary
Treasurer
Dr. G. H.
Clement                   Dr. A. B. Schinbein
TRUSTEES
Dr.
W. F. Coy
Dr. W. B. Burnett                Dr. J.
M. Pearson
Representative to B
C. Medical Association                       Auditor
DR.  A. J.
MacLachlan                      Dr. A. C.
SECTIONS
Clinical Section
Frost
Dr.
W.  L.  Pedlow
.......
Chairman
Dr.
F. N. Robertson
.         .         .
Secretary
Phy
biological and Pathological Section
Dr.
G. F. Strong
.
Chairman
Dr.
C. H. Bastin -
.
Secretary
Ey<
?, Ear, Nose and Throat Section
Dr.
Colin Graham
-
Chairman
Dr.
E. H. Saunders
Genito-Urinary Section
Secretary
Dr.
G. S. Gordon
.......
Chairman
Dr.
J. A. E. Campbell	
Secretary
Physiotherapy Section
Dr.
H. A. Barrett
.......
Chairman
Dr.
H. R. Ross
.
Secretary
COMMITTEES
Library Committee
Dr. Wallace Wilson
Dr. A. W. Bagnall
Dr. W. D. Keith
Dr. W. F. McKay
Orchestra  Committee
Dr. F. N. Robertson
Dr. J. A. Smith
Dr. l. Macmillan
Dr. A. M. Warner
Dinner Committee
Dr. g. F. Strong
Dr. w. a. Dobson
Dr. L. H. Appleby
Credit  Bureau  Committee
Dr. Lachlan Macmillan
Dr. D.. G. Perry
Dr. G. A. Lamont
Credentials Committee
Dr. Lyall Hodgins
Dr. R. Crosby
Dr. J. A. Sutherland
Summer School Committee
Dr. G. S. Gordon
Dr. Murray Blair
Dr. W. D. Keith
Dr. G. F. Strong
Dr. H. R. Storrs
Dr. R. Crosby VANCOUVER MEDICAL ASSOCIATION.
Founded  1898. Incorporated  1906.
Programme of the 28th Annual Session
GENERAL MEETINGS will be held on the first Tuesday of the month
at 8 p.m.
CLINICAL MEETINGS will be held on the third Tuesday of the month
at 8 p.m.
Place of Meeting will appear on Agenda.
General Meetings will conform to the following order:—
8.00  p.m.-—Business as per Agenda.
9.00  p.m.—Paper of Evening.
1925.
OCTOBER  6th-
OCTOBER  20th—
NOVEMBER  3rd—
NOVEMBER   17th-
DECEMBER   1st—
General Meeting.
Presidential  Address:     DR.  J.   A.  GILLESPIE.
"The Progress and Future of Medicine."
Clinical Meeting.
General Meeting.
Paper:     DR.  HlBBERT WlNSLOW HlLL.
"The Part Played by  the  Laboratory in  Clinical
Medicine."
Clinical Meeting.
General Meeting.
Paper: DRS. WALLACE WILSON and LYALL HODGINS
"Intravenous Therapy."
DECEMBER   15 th—      Clinical Meeting.
1926.
JANUARY   5 th—
JANUARY  19th—
FEBRUARY 2nd—
FEBRUARY   16th—
MARCH 2nd—
MARCH   16 th—
APRIL  6 th—
APRIL 20th—
General Meeting.
Paper:     DR.  G. F. STRONG.
"Cardiac   Pain."
Clinical Meeting.
General Meeting.
Papers:     Dr. J. TATE MASON, of the Mason Clinic,
Seattle.
"Surgical Treatment of Thyroid Diseases."
Dr. LESTER J. PALMER, of the Mason Clinic.
"Some Phases of the Diabetic Situation."
DR. MASON will probably give a Clinic at the V.G.H.
on the morning of Feb. 2nd.
Clinical Meeting.
General Meeting.
The OSLER LECTURE.    DR. E. D. CARDER.
Clinical Meeting.
General Meeting.
Urological Evening.    DRS.  B.  H.  CHAMPION, G. H.
Clement, G. S. Gordon, and A. W. Hunter,
on
"Problems in Urological Diseases."
ANNUAL MEETING.
■ Page Four 'iiniiiiuiiiuiiiuiintiiiniiiuiiiiiiiii!
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in 11111111111111111 r 1111 r 11111
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As a result Victor air'cooled and water'
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VICTOR X-RAY CORPORATION
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Authoritative papers on uU
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charge on request. They con'
stitute a textboo\ on the
subject. EDITOR'S PAGE.
Between the theory and the practice of medicine there is a
gulf fixed. In places this is wide, in others not so wide, but
always visible, perhaps less so to those dealing with what ought
to be than to those realizing what is.
On one side of the gulf science promulgates her achievements,
on the other art haltingly applies these with much else.
To diminish the width of this gulf, even ultimately to fill
it in, is the ardent wish and constant endeavour of all interested
in the prevention and treatment of disease.
Perhaps in limiting the definition of science in medicine, we
do ourselves injustice. If science be regarded as knowledge susceptible to proof by experiment, the field is narrowed and the
practical application of science is difficult. But if we regard science
also as knowledge acquired by observation, or based on reasoning,
then most of our medical information is scientific in nature.
Where knowledge fails, probabilities must take its place with
reason and experience as guides. Highly developed and apparently
instinctive, this method becomes intuition, the possession of the
few and most gifted.
In the present state of medical development a mind too rigidly encompassed by the forms of experimental science is handicapped.
The light of science must be followed as it burns brightly
and illumines the path; when this light grows dim or disappears
the mender of the 'maimed must nevertheless push on. Scientist by nature and by inclination, empirical by force of circumstances and in the meantime; when the sick are clamouring for
relief, much may be done even when experimental direction is
lacking.    Even the exploratory laparatomy has its uses.
We would call our readers' attention to the fact that at the
next regular meeting of the Association Dr. E. D. Carder will
deliver the Osier Lecture for 1926. This lecture is one of the outstanding events of our year's programme—and it has a worthy
exponent in Dr. Carder. His subject is "The Thymus." Interest in this hitherto somewhat obscure gland has been especially
aroused in our city during the last year or so by a series of unfortunate anaesthetic deaths, and we congratulate the speaker on his
most timely choice of subject.
The meeting will take the form of a dinner at the University
Club (Robson and Howe Streets). This dinner is informal, will
begin at 7 p.m. sharp, and tickets will be $1.50 each. Those
who find that they cannot attend the dinner will be ablje to come
afterwards, in time for the lecture and regular business proceedings. Dr. H. E. Young, and Dr. G. Wace, of Victoria, will be
guests of the Association for the evening.
Page Six NEWS AND NOTES.
The regular monthly meeting of the Association was held in
the Auditorium, Tenth and Willow Streets, on Tuesday, February
2nd, the President, Dr. J. A. Gillespie, in the chair. The
members present had the pleasure of hearing papers by Dr. J.
Tate Mason and Dr. L. J. Palmer, of Seattle. Dr. Tate Mason
spoke on "The Surgery of Thyroid Diseases," and Dr. Palmer
took up the subject of "Surgery in Diabetes Mellitus." Both papers are published in this issue.
The clinical meeting of the Association was held at Shaughnessy Hospital on the 16th instant, under the auspices of the medical staff of that institution. Dr. W. L. Pedlow was in the chair,
and there was a good attendance. Dr. P. W. Barker showed an
interesting case of blood dyscrasia associated with tuberculosis appearing as the result of exposure to the fumes of "dope" used in
aeroplane manufacture. A series of gastric cases was commented
on by Dr. Schinbein, particularly illustrating the occasional unsatisfactory results occurring after gastroenterostomy. One very
temarkable case exhibited a series of three ulcers, the original one
in the duodenum, which perforated, followed by one in the jejunum, which also perforated, and later by one at the gastro-jejunal
junction. At the present time the anastomosis has been
separated,. the stomach closed up, and the man is in comparatively good health. A case of partial gastrectomy was also shown
in which the blood picture had very closely resembled that of
pernicious anaemia, for which disease treatment had been instituted for some considerable time prior to the development of symptoms pointing to involvement of the stomach. Considerable discussion took place on these cases, and it was the general opinion
that Dr. Schinbein had done good service in drawing the attention of the members to this form of undesirable complication in
apparently simple cases. Dr. Wallace Wilson briefly discussed
two cases of exophthalmic goitre which, having been operated on
and remaining well for some time, subsequently developed new
symptoms.
At the close of the session, coffee was served by the nursing
staff, presided over by Miss Matheson, and an enjoyable half-
hour of social intercourse closed the evening.
VANCOUVER GENERAL HOSPITAL LABORATORIES
H. W. Hill, M.D., D.P.H., L.M.C.C, Director.
Lobar pneumonia is distinctly rare in B. C. Broncho, or
lobular pneumonia, in striking contrast, is so common that the
death rate from "pneumonia" (undistinguished as to type) is
about as high here as it is in general elsewhere (see records of federal vital statistics of Canada).    Hence it is evident that our total pneumonia deaths must be made up of little lobar and much
broncho or lobular, while elsewhere the total pneumonia deaths
are made up of much lobar and little broncho-or lobular.
In view of our greatly preponderant type being broncho-or
lobular forming a very serious fraction of our total morbidity and
mortality, the Laboratories will welcome from the physicians of
British Columbia sputum, blood culture material, empyxma material, etc., from broncho-or lobular pneumonia cases, with the
hope that the specific pneumonia organism or organisms operating
in B. C. may be determined and dealt with.
The "News and Notes" column of this journal for February,
1926, page 8, notes the development of tetanus from the use of
bunion pads in the dressing of vaccination wounds.
This note forms a good text for reiterating strenuously the
advice to use no dressing at all (unless to satisfy the patient, on
the other arm!)  in vaccinations against smallpox.
If the Canadian or "puncture" (acupuncture) method of
vaccination be followed, dressings of any kind, always a menace,
become wholly unnecessary and therefore inexcusable from the
standpoint of the best technique.
The principles involved are very simple. Vaccination results
in modified localized smallpox pustules, which, if only left alone,
remain as firm, intact and unbreakable as those of the ordinary
generalized smallpox. This firmness, intactness and unbreakable-
ness of smallpox pustules is so characteristic as to constitute one
of the best diagnostic features of the disease. But these features
depend only in part on the factor of the deep seated character of
the pustule which gives to it its characteristic thick epithelial roof.
The other factor is the free evaporation always accorded the pustules of smallpox, since no one presumes to bunion-pad or celluloid-cup or otherwise maltreat them. If the modified, localized
smallpox pustules of vaccination are similarly left free to evaporate, they remain similarly firm and intact. If, however, they are
bandaged, strapped, or otherwise "cribbed, cabined and confined,"
so that the moisture of the sweat and of the pustular contents is
prevented from escaping, very naturally the otherwise thick, strong
and efficiently protective epithelial roof macerates, weakens and
breaks, leaving a wet ulcerous base open to any infection that may
present itself.
Once a patient is vaccinated, the best possible treatment of
the lesion is to leave it alone, and leave it alone—and keep on
leaving it alone.
Only those who can conscientiously persuade themselves that
they would bandage a smallpox patient from head to foot, can
logically persuade themselves that they should bandage a vaccinated arm.
Page Eight Modern vaccination protects completely as a rule for at least
seven years, generally longer. Even when the protection given by
a "take" has decreased to the point where smallpox can be contracted, any smallpox which is contracted runs a very mild course.
This is true of smallpox in patients successfully vaccinated as much
as 30 to 40 years previously. In Detroit and in Windsor (1924)
no one successfully vaccinated ten years previously contracted the
disease, even from the malignant hemorrhagic types then existing
there.
It is probable, although the evidence is difficult to accumulate, that annual revaccination, following the first take, would
maintain immunity without a second take, for an average lifetime. The Puncture method is in itself so harmless that revaccination loses all its terrors.     (See footnote.)
* ♦ ♦
CITY HEALTH DEPARTMENT.
Vancouver, B. C.
STATISTICS — JANUARY, 1926
Total   Population    (estimated)        128,366
Asiatic   Population    (estimated)     „      10,100
Rate Per 1000 of
Population per Annum
Total   Deaths         131 12.0
Asiatic Deaths        19 22.1
Deaths   (Residents only)           99 9.1
Total Births—Male,     134
Female,   116  ___:____     250 22.9
Stillbirths—not included in above          15
INFANTILE MORTALITY—
Deaths under one year of age         13
Death Rate per   1000   Births       52.0
CASES OF  INFECTIOUS  DISEASES  REPORTED.
December
Cases Deaths
Smallpox           0 0
Scarlet   Fever        28 0
Diphtheria         31 2
Chicken   Pox         20 0
Measles           0 0
Mumps        101 0
Erysipelas           2 0
Tuberculosis    1      11 10
Whooping Cough         5 0
Typhoid  Fever          3 1
January,  1926
Cases
2
10
20
8
10
19
2
18
2
1
Cases from Outside City—included in above:
Diphtheria.        8          8 5
Smallpox            0          0 1
Scarlet   Fever           8          0 4
Typhoid Fever         10 1
Deaths
0
0
1
0
0
0
0
9
0
0
1
0
0
0
February  1st to
15th,   1926
Cases Deaths
*The Puncture method of vaccination is described in the Canadian Medical
Association Journal, March. 1916, and in Kolmer's "Infection and Immunity,"
1920 edition (unfortunately in the latter with a suggestion to dress it, which
will be omitted in future editions) . It was made official by the Canadian Public Health Association. Montreal meeting, June, 1925. (Public Health Journal,
June,   1925, page 287.)
Page Nine SURGERY OF THYROID DISEASES.
Abstract of an Address given before the Vancouver Medical Association by Dr. J. Tate Mason, of Seattle, Feb. 2, 1926.
Dr. Tate Mason opened his remarks on the subject of goitre
with a short discussion on the means of diagnosis and treatment.
It was estimated, said the lecturer, that some 65 per cent, of the
children in Seattle showed evidence of thyroid gland enlargement.
In many of these cases, where the use of iodine is indicated, it had
occurred to him that, owing to the pressure of the colloid material
in the acini of the gland, the actual cell secreting surface might be
diminished. In the adolescent type of goitre it had been the experience in his clinic that the judicious use of dessicated thyroid
was a valuable addition to the iodine used for therapeutic purposes.
Dr. Mason classified the various forms of goitre for clinical
purposes as follows:—
1. adolescent.
2. Colloid.
3. Adenomata-toxic and Non-toxic
4. Exophthalmic.
In colloid goitres the cells of the acini were flattened. In
this type there is no disturbance of function and no special treatment is required. It had been observed that in these glands small
cysts would form which might become confluent, forming larger
cysts, and thus induce the characteristic examples of cystic goitre.
The adenomata which are found in goitre are simply encapsulated masses of tissue with thyroid characteristics which, for the
most part, are non-toxic in character. Concerning those that are
toxic, opinions differ as to the causation. It may be disordered
function produced by pressure of the tumour mass on the surrounding thyroid tissue, or, on the other hand, the adenomata
themselves may be the source of the toxic material. These adenomatous goitres are slow in developing, having a duration of
from 10 to 15 years. The use of iodine has generally been considered as contra-indicated in this form of goitre, but of late, in
Dr. Mason's experience, this conclusion has seemed, perhaps, unwarranted. His attention was first drawn to the matter by a case
where he had to deal with a goitre which was hyperplastic on one
side and had an adenomatous involvement on the other. Knowing the general opinion as to the inadvisability of administering
iodine in cases of adenomata, they had proceeded with the exhibition of the drug very cautiously. Much to their surprise, not
only was a valuable effect produced on the hyperplastic area of the
gland, but the adenomata seemed to be considerably reduced in size
and the toxic symptoms were favourably affected. Since then they
have been inclined to use iodine on all toxic adenomata, and with
careful administration their experience has lately been that these
cases respond almost equally well to the use of the drug as does the
toxic type.
Page Ten A good deal has been written upon the condition of the
heart in toxic goitre. Dr. Mason said his experience had led him
to discontinue the routine use of digitalis in these conditions as not
necessary, and having possibly harmful effects. Of course, where
the heart condition definitely calls for the use of digitalis, as in any
other case, it would be administered.
The last form of goitre discussed was the exophthalmic. Dr.
Mason said this form ran a typical course, which he illustrated in a
graphic manner by lantern slides thrown on the screen. There
was a time when the symptoms were mild and hard to recognize.
This was followed for a period of two to three months by a
gradual increase in the severity of the symptoms. By the eighth
month the symptoms had reached a peak when the patient was
quite ill, with metabolic rate raised, pulse rapid, tremor severe and
exophthalmos characteristic. Following this peak and under favourable circumstances, a 'descent took place, so that by the end of
the first year something approaching the normal metabolic rate
might be expected. As a rule during the second year there was an
exacerbation of symptoms not so severe. The subsequent course
is one of chronicity, and is really a reproach on the guidance of the
case, and should never be allowed to occur if the patient can be
persuaded to have a previous operation.
Dr. Mason showed slides illustrating various microscopic examinations of glands which he had made. One of a very toxic
gland taken from a patient during the ligation of one superior
thyroid artery, showed a very characteristic appearance of overacting cell hyperplasia. Following this ligation, under the
administration of Lugol's solution, an amelioration of symptoms had occurred so that a removal of the gland became possible.
The next slide which the lecturer showed exhibited the profound
alteration which had taken place in the gland during the interval,
showing the large element of colloid material now present and the
flattening out, as if through pressure, of the epithelial lining of
the acini.
Slides were also shown indicating the changes which took
place in normal dogs after the administration of iodine, pieces of
the gland having been taken and sectioned before and after this
procedure.
Dr. Mason mentioned that in normal people after the administration of Lugol's solution, iodine was found to be present in
the sputum within ten minutes, whereas in patients with derangement of the thyroid function a time up to 26 minutes might elapse
before the iodine was detected. It is the practice in their clinic,
when administering iodine, to test the sputum from time to time
to observe the length of interval which elapses.
Dr. Mason thought there was a very close connection between
all the different types of goitre which he had presented, and that
in places where the simple goitres of the adolescent or colloid type
were mostly found, there also were the toxic forms in abundance. It was his opinion that, if by the administration of iodine or other
methods, some means of controlling the formation of the simpler
types could be found, that a solution of the problem of dealing
with the toxic forms would be accomplished.
Dr. Mason then showed in detail, by means of lantern slides,
his method of removal of the gland. He used a small transverse
incision placed in one of the creases of the neck. This incision
was drawn back by means of special retractors, and the underlying
platysma was split vertically over the whole length of the incision. On exposure of the gland, it was grasped by a special
forceps, which he illustrated. The central suspensory ligament of
the isthmus was found and divided, and following this the lateral
ligament on one or other side. This procedure made available the
superior pole of the gland, which was then ligated, allowing the
goitre to be rolled out through the incision, where the necessary
portions were removed. He found that his tendency was to leave
rather more of the gland than formerly. Drainage was instituted
in every case, as it was found impossible otherwise to guard against
collection of serum. The drainage material was brought out
through the centre of the incision, as giving the most direct route
to the surface. No muscles were cut during the operation, and
following the closure of the platysma the skin incision was fastened together with clips.
In answer to a question, Dr. Mason said that in dealing with
toxic adenomata, every endeavour was made to remove all the
adenomatous tissue present, and a complete exploration of the
gland was made for that purpose.
COMMUNITY MENTAL HEALTH PROBLEMS.
By H. C. Steeves, B.A., M.D., CM.. Medical Superintendent,
Provincial Mental Hospitals, Essondale, B. C.
In the last century the science of medicine in all its branches
has made rapid and important strides in combatting and overcoming disease. This progress has been apparent in all departments
of the healing art, but perhaps the interest of the profession as a
whole has been focussed on the somatic diseases, leaving the large
and important field of mental diseases to an entirely too small
group of workers. There has, however, been a great movement
forward in this field (though much indeed remains), and it is
with the hope of eliciting still further interest and greater cooperation that I attempt to draw attention to a few facts, and
offer a few suggestions which may be of interest to the profession at large, and thus reflect to the good of the mental health of
the people.
As a basis of fact on which to formulate conclusions, I must
quote statistics, but will endeavour to be as concise as is practical
for clearness.    Statistics are not often interesting, but I must use
Page Twelve them to give a clear insight into the question in so far as the data
in hand make this possible. My available data refer only to the
major psychoses, or those cases which have been committed to the
Mental Hospital under the requirements of the law. When this
fact is considered, and the cases of the psychoneruroses, psychas-
thenias, psychopathic inferiorities, to say nothing of the higher
grades of feeble-mindedness (which all physicians can readily recall) are borne in mind, I am sure one must be impressed with the
magnitude of the field, and the necessity for a serious study of
conditions in order that this department of public health and welfare may not be neglected.
During the fifty years in which British Columbia has made
an organized effort to care for and treat the major psychoses, some
9000 cases have been dealt with, and the records of these cases
(fragmentary in the early ones) are on file at the hospital. From
this number there has been a gradual accumulation of chronic
cases until, at the end of the last fiscal year, March 31, 1925, there
were resident in the hospital 1884 patients, or .32% of the total
population of the province.
For my purpose, I will use the statistical data of the last
fiscal year, which will give a clear view, and not be too cumberr
some nor confusing. During this period, 461 new patients were
admitted to the hospital, and, as it is a matter of very considerable importance in connection with the immigration problems of
a new country, I wish to draw attention to the nativity of these
cases:—
Canadian   155 33.6%
Other parts of the British Empire  179 38.8%
Oriental  j  20 4.3%
All other countries   107 23.3%
You will see that only one-third of our new patients last
year were born in Canada, and I may add that, of the others, some
37 had not resided in Canada the five years required to obtain
Canadian domicile. These people had to be cared for here and
returned to their own country at our expense at a cost of not
less than $20,000 (if indeed this would cover it). Many of these
cases could have been prevented from entering the country had the
Department of Immigration been provided with the facilities it
requires in its work, and a considerable saving to general community health would have been effected. The physicians who
come in daily contact with the public will fully realize the serious
drain on community hygiene due to the inefficient and mentally
defective who never reach hospital, and of whom there is no official cognizance. I feel that every effort should be made to add
to the population, but, at the same time, the people so added must
be strong and healthy in mind as well as body, in order that a
virile, intelligent race of Canadians may result. The physician
has a splendid opportunity for study and teaching in this field of
public health, and it behooves him to do so at every opportunity.
Page Thirteen A study of the diagnosis of cases admitted provides valuable
information as well as much food for thought. It is well known
and, at the present time, seems an incontrovertible fact, that heredity plays an extremely important part in mental disease; if
this be so, it would seem that our avenue of approach to this illness (as in bodily illness) is along the line of prevention. The
psychopathic person should be advised and guided along those
channels of life which will present the least mental strain and
fatigue. He should be educated as to his own limitations and the
sources of danger to his mental health, as well as to his responsibilities to posterity. Let us see what was the actual incidence of
mental illness as illustrating the importance of heredity.
(1) Where the heredity factor predominates:
Manic Depressive Psychosis   28.2   %
Dementia Praecox Psychosis   22.12%
Paranoia     7.3   %
Epilepsy, with Psychosis   4.7   %
Idiot and Imbecile   9.0   %
71.32%
(2) Where the heredity factor is less evident:
Syphilis (General Paresis, etc.)   6.0   %
Old Age   (Senile Psychosis)     7.1   %
Psychosis following physical illness   11.9   %
Miscellaneous   3.68%
28.68%
Thus we see that over 70% of the major psychoses are developed from a personal equation poorly endowed by heredity to
withstand the strains of life to which it is subjected. The resulting serious illness develops an illness which, unhappily, too frequently ends in the partial or complete disability of the patient,
and thus a grave economic loss to the community is sustained, to
say nothing of the actual cost of the future care and treatment of
the patient.
The physician, in the course of his work and through his
influence in the community, can do much to avert these catastro-
phies if he is alive to the mental calibre and stability of his patients, and he should use his influence at every opportunity in
ordle;r that the mental, as well as the physical hygiene of
the community may be improved. The physician is not infrequently asked by his patients if there is any reason why they
should not marry. I believe this subject should be given serious
study and a very carefully considered opinion rendered, having
quite as much, if not more, regard for the mental and nervous
health as for the physical health of the contracting parties. Such
persons suffering from a marked kidney lesion would be cause for
serious consideration, why not equally serious consideration in the
case of the highly neurotic with probably actual psychosis in the
Page  Fourteen genealogical tree? If such people do marry, they should be advised of their responsibilities to posterity, and the question of
sterilization be seriously considered. In the case of the epileptic
and the feeble-minded, I am convinced that marriage should be
prohibited until sterilization is carried out.
The results of treatment of mental diseases are often discouraging in the extreme, but much can be done to improve these
results, and more will be done as time goes on and mental trouble
is recognized as a disease, and not a visitation of evil spirits to be
hidden from the world.
The Mental Hospital discharged 305 patients in the last
fiscal year, and of this number 113, or 37.3%, showed a duration
of mental illness of less than two months before receiving hospital
care, and 63, or 20.6%, were discharged recovered from their
psychoses. Does this not suggest that the case developing mental
illness should be hospitalized as early as possible.''
I believe that the case developing mental illness should be
hospitalized at the very earliest possible moment. The patient is
thus removed from the environment which in many cases had
much to do with precipitating the illness (and where too often
there is little or no understanding of the illness developing) to a
proper environment where surroundings, associates and methods
of dealing with the problem are entirely different. In the new
environment the patient can develop confidence and co-operation,
knowing that an honest effort to study, understand and correct
his troubles is being made.
The facilities for carrying this out are not at present available, and I believe the profession as a body should urge that these
be provided. The mental hospitals, as at present constituted, have
not sufficient room, and tradition and the law prevent patients
from coming sufficiently early to derive the maximum benefit and
while there is still at least a partial ability to understand and cooperate in treatment.
A psychopathic hospital, centrally located to the needs of
the population and as freely accessible for the admission of patients as any general hospital, under the direction of physicians
trained in psychiatry and staffed by nurses trained in the care of
the mentally ill, seems to me a pressing need, and one which must
be provided if the best results are to be hoped for in salvaging
these unhappy victims from an illness for which they are in no
sense responsible. The patient could then be hospitalized before
the illness progresses so far that insight and the road to co-operation are lost. Thus the patient's chances of recovery, or at least
readjustment to such a degree that he does not become an economic
loss, and too often an economic burden, are greatly enhanced.
The need is very great, and I trust some definite and positive action will be taken in this direction in the near future.
The economic side of mental illness is an important one
indeed, and costs the community probably more in money, pov-
Page Fifteen erty and suffering than physical illness. When we say that it
cost British Columbia $600,000 to maintain her mentally ill last
year, we do not take into account the loss to the community of
these people as producers, the monies required to assist the dependents, nor the future community loss owing to lack of education of those children who must leave school to earn a livelihood for themselves, as well as assist the younger members of the
family because the parent has broken down and become insane.
The field is large, and it is important that the physician,
as the guardian and adviser in matters of public health, should
not overlook this great and important problem of mental hygiene
in his pursuit of physical ills, for mental and physical ailments are
often found to travel hand in hand.
LIBRARY NOTES.
(The Library is situated in 529-531, Birks Building, Granville Street, Vancouver. Librarian: Miss Ftrmtn. Hours 10
fo 1, 2 to 6.)
Recent Accessions to the Library.
Eyesight Conservation Survey.     Hammum & Henry.     1925.
Medical Clinics of North America.    September,   1925.
Harvey Society Lectures  (1923-24).     1925.
Clinical Lectures on Surgery in Egypt.    Dr. R. V. Dolbey.   1924.
International Clinics for 1925.
The Liver in Relation to Chronic Abdominal Infection.    Heyd.
U. S. Medical History of the War.   Vol. XV Statistics.   1925.
Medical Clinics of North America.    November,  1925.
The Medical Follies.    Dr. Morris Fishbein.   1925.
Alcohol in Medical Practice.    C. C. Weeks.    1925.
Diseases of Nose, Throat and Ear.    Ballenger.   5th edition.   1925.
General Bacteriology.    E. O. Jordan.    8th edition.    1925.
Epidemiology and Public Health.    Vaughan.    Vols. 1 and 2.
Coll. Reprints, Dept. Exp. Surgery, Bellevue Hospitals.    Vol. IV.
Annual Report of Surgeon General, U. S. A.    1925.
Hippocrates.    Translation by W. H. S. Jones.    2 volumes.
Minor Surgery.    Lionel Fifield.    1925.
Extra Pharmacopoeia   (British).    Martindale & Westcott.
Newer Knowledge of Nutrition.    E. V. McCollum.    3rd edition.
Fractures and Dislocations.    Wilson & Cochrane.     1925.
Medical Clinics of North America.    January, 1926.
Surgical Clinics of North America.  St. Louis number.   Oct., 1925.
Transactions of the American Otological Society.     1925.
Manipulative Surgery.    Timbrell Fisher.     1925.
Blood Chemistry,    de Wesselow.
Lectures on Dyspepsia.    Robt. Hutchison.     1925.
Diseases of the Heart.    4th edition.   Sir James Mackenzie.   1925.
Page Sixteen Will the member who borrowed the November, 1924, issue
of the American Journal of Medical Sciences return it to the
Library, as this issue is out of print and cannot be replaced.
ABSTRACTS.
C. LUNDSGAARD and G. A. HOLBOLL, Journal of Biological
Chemistry, September,  1925.
Though the special journals like the Journal of Biological
Chemistry are designed primarily for the specialist, the other
members of the profession, by reading the summaries, can often
glean very practical points, without wading through the chemical
and mathematical formulas in the body of such articles. The
non-specialist, reading the summaries at the end of a series of
articles by C. Lundsgaard and G. A. Holboll, in the September
issue of the Journal of Biological Chemistry, will note a further
step toward the solution of underlying principles controlling the
inter-action of glucose and insulin, which, after all, it must be
remembered, is physiological and therefore of general applicability
in all diseases. Diabetes mellitus is but the end result of a disturbance in this relationship. Winter and Smith have claimed
that, besides the ordinary forms of alpha and beta glucose, in
which glucose is commonly found, there occurs in the body a
gamma form. If such a gamma form of glucose were to exist
in the body, it would be expected, for chemical reasons, that such
a form would be much more active than the other two forms and
so much more readily oxidized in the body. Lundsgaard and
Holboll chose rather the non-committal term "New Glucose" to
account for their results, but in the main their results bear out the
ideas of Winter and Smith, that insulin produces its results by
converting a relatively inactive form of relatively active glucose
into a much more active form. Thus in diabetes we have, as a final
result, the patient with possibly several times the normal amount
of sugar in his blood. Like the sailor in the open boat dying of
thirst 'midst plenty of water, the diabetic is dying for lack of
active sugar 'midst a surplus of inactive sugar.
—R. E. Coleman.
British Journal of Surgery.
July, 1925.
In recent years the study of morbid anatomy has been overshadowed by the advance of bacteriology, and by many it has
been considered that morbid histology has offered its all, and that
the field was an exhausted one. The British Journal of Surgery,
in its July issue, makes an effort to stimulate an active interest
in specimens obtained from the operating and autopsy rooms,
feeling that it is very much in the interests of practical surgery
that such a step should be taken. They are issuing, as a means-
to this end, a supplement to their Journal of about twenty pages,
Page  Seventeen profusely and well illustrated from specimens in the Hunterian
Museum in London. The supplement to the July and October
issues has to do with neoplastic diseases of bone, and is well
worthy of study. It is their hope that the study of these plates
and descriptions may so awaken the interest of the readers that
they will be prompted to a more careful and frequent examination
of specimens in their own museums and laboratories. A worthy
object indeed.
LECOUNT AND Guy.     (Journal American Medical Association,
Dec. 26,  1925.)
This is a study of thirty cases of spontaneous intra cerebral
haemorrhage admitted to hospital, and coming to autopsy, with
special reference to the differential diagnosis between apoplexy
and uraemia. They found that blood pressure readings were deceptive, systolic pressures as high as 225 being obtained in apoplexy.
They lay great stress upon an estimation of the nitrogen
retention in the blood, no case of apoplexy showing values nearly
so high as in uraemic coma.
The presence of blood in the spinal fluid, in apoplexy (except in deep-seated haemorrhages, where its appearance may be
delayed), and the great increase in the nitrogenous elements in
the blood in uraemia, are the most important factor in the differential diagnosis. —C. H. B.
BOOK REVIEW
GENERAL BACTERIOLOGY. E. O. Jordan, Professor of Bacteriology in the University of Chicago and Rush Medical School.
Eighth Edition, 1924, revised. 752 pages. W. B. Saunders
Co.    London and Philadelphia.     $5.00.
The eighth edition of this standard work is the outgrowth
of lectures given to Chicago University students by Prof. Jordan
over many years. It is one of our very best bacteriologies dealing with medicine, the most important field of applied bacteriology.
Eight chapters are devoted to general bacteriology, including the latest and best of bacteriological technique and nomenclature, the relationships of bacteria to disease in animals and
man, and an outline of immunology. Twenty-two chapters deal
with specific bacteria or bacterial groups, pathogenic to man; a
chapter each deals with pathogenic blastomycetes, hyphomycetes,
protozoa and filterable viruses, while the bacteriology of milk,
of soils, of the arts and industries, of air and water, and of plant
diseases have also a chapter each. A very useful appendix gives
•the present status of our knowledge on diseases of unknown
origin.
Page Eighteen The information given is extensive, concise, authoritative,
up-to-date, and easy to read. The index of writers quoted constitutes a very complete bibliography of the subject. For the
practitioner, as well as the student of bacteriology, few books on
this subject will prove more generally useful.
B. C. MEDICAL ASSOCIATION NEWS.
Considerable work on the part of the Publicity and Educational Committee of the B. C. Medical Association, and the cooperation of a number of members who had been asked to assist,
enabled us to commence publishing health articles in ten B. C.
newspapers on Feb. 1st. Already we have sufficient articles on
hand to publish daily for three months. It is hoped also that
weekly radio health talks will start on the first of March.
In January the Executive Secretary, Mr. Fletcher, paid his
annual visit to Vancouver Island, where he saw the medical men
in the main centres. These calls of our Executive Secretary are
greatly appreciated by the members, as it gives them an opportunity not only to pay their fees, which 95% of the profession in
this locality did on this occasion, but also to take up, through
him, any matter that is perplexing them, in which the various
committees of the B. C. Medical Association can be of service.
Thus many matters referable to the relation of the medical man
to the W. C. B. are handed over to our Industrial Service Committee to be dealt with, generally with results which are satisfactory to all concerned.
The next regular meeting of the full Executive will be held
some time in March. It is planned that this meeting shall coincide with the visit of some speakers from the East, who are coming out in connection with the Extra Mural Post Graduate educational scheme of the C. M. A. A luncheon of the B. C. Medical
Association will be held, at which it is expected that Dr. Forrest
Leeder, of Victoria, will be the speaker. Dr. Leeder's capacities
as a public speaker are well known, and we are sure that the
knowledge that he is to speak will in itself be a drawing card
for many who have already heard some of his delightful and
witty addresses.
This mention of Dr. Leeder reminds us that he is the President of the Canadian Medical Association for this year, and we
would again urge all our members to make their arrangements
with a view to taking in the meeting at Victoria, in June. Full
particulars as to programme, speakers, etc., will be given as soon
as they can be obtained, and it is hoped to have these for an early
number of the BULLETIN.
Recent happenings in the police court have brought forcibly
to the attention of the medical profession certain changes that
have been made in the-Narcotic and Drugs Act of Canada.    We
Page Nineteen had hoped to have copies of this Act by this date, that we might
publish certain sections which are of the greatest importance to
every practitioner, but have, unfortunately, been unable to secure
these in time. However, we may note the following: Under
the Act, as recently amended, it is unlawful for a medical man to
prescribe any narcotic or drug to anyone who is an addict, whether
these prescriptions be in writing or whether the drug be administered by the physician himself.
Victoria is at present full of C. M. A. matters, and is to be
congratulated on its immense natural advantages for such a meeting. The Empress Hotel will be the headquarters of the meeting, and no better place could possibly be chosen. For those few
of our number who play golf, it may be of interest to note that
there are five golf courses in Victoria. We are also urged to bring
bathing suits, fishing rods, and tennis rackets. We are informed
that there are no mosquitoes. More cannot be said, except that
we are also urged to bring our motor cars along, as there are
many beautiful drives.
SURGERY IN PRESENCE  OF DIABETES MELLITUS.
Lester J. Palmer, M.D., Seattle.
Read before the February meeting of the Vancouver
Medical Association.
Five years ago this subject was so surrounded by gloom and
pessimism that few surgeons or internists cared to discuss it. Formerly many patients with diabetes mellitus, having surgical lesions,
were allowed to die without any attempt at operative interference.
This is no longer the case. To-day the situation has changed entirely. Although surgery performed upon diabetic patients is not
attended by the lowest mortality, the death rate compares favourably with that among surgical cases generally. What has brought
about this improvement? Certainly it would have been impossible without insulin. However, insulin alone has not given the
surgeon this greater sense of security in regard to operations upon
diabetic patients. Modern advances made in nutritional studies,
a better understanding of these principles and of the chemistry of
the disease by more thoroughly trained internists, better co-operation between surgeons and internists, better surgical technique in
this special branch of surgery, less harmful anaesthetics, earlier
operation, better hospital facilities, including laboratory and dietetic service—all these have combined to lower the mortality of
operations upon patients having diabetes mellitus.
Thus Allen recently has said: "America has reversed the old
European rule that surgery on patients with diabetes mellitus
should be avoided as far as possible." Wilder and Adams (1)
state that a previous surgical mortality of 7 per cent, at the Mayo
Clinic has been reduced to 1.2 per cent, during the past two years.
Page Twenty MMH
This percentage is based on 327 operations performed upon 251
patients. Foster (2) reports a drop of surgical mortality from
40 per cent, during the decade preceding the advent of insulin to
12 per cent, during the first year of its use.
Wonderful as this improvement has been, there is a limit to
the reduction of surgical mortality among diabetic patients. The
risk in this class of patients will always be somewhat higher than
the general average. Joslin (3) has given us the reason why this
must be so. He has shown by various series of collected cases that
51 per cent, of the cases of diabetes occur during the sixth and
seventh decades of life. It is even more true that we are called
upon to subject diabetic patients to surgery many times more often
during these two decades than at any other age. The wear and
tear of life have at this age left their mark in varying degrees upon
the vital organs, particularly upon the cardiovascular and renal
systems. Diabetes has caused these changes to ble, more
profound than they would otherwise have been. Jones (4) reminds us that "We must therefore compare the results of surgery
in these cases with a group, 51 per cent, of whom average 60 years
old and in whom there is a high percentage of damaged circulatory
systems and kidneys."
Bauman (5) has given a classification of the surgical conditions occurring in the presence of diabetes which is complete and
satisfactory: First, those more or less characteristic of the disease,
that is, carbuncle and gangrene; and, second, those which are purely accidental or coincidental. The second group may be subdivided into conditions that require immediate operation and those
for which operation may be deferred.
Carbuncle may be considered alone. The surgical treatment
may not be deferred. Excision is probably a better procedure
than crucial incision. Control of the diabetes must be established
as soon as possible to insure healing.
Gangrene may be superficial or deep, limited or extensive.
Two types occur: First, that type in which infection is largely
absent and circulatory disturbance predominates; second, that
type in which infection is very active and extensive. In the first
type, particularly if superficial or limited in extent, exact control
of the diabetes may result in healing or demarcation and separation
of the affected, part. If extensive or extending, prompt amputation is indicated. The site for amputation is governed by the site
of election, rate of progression of the advancing margin, and the
condition of the circulation. Radiograms of the part, extending
well above the lesion, and the quality of pulsation in the arteries
both give valuable information. In the second type of gangrene,
when infection is active and extensive, immediate amputation is
imperative to save life. In that case, the control of the diabetes
must be established by the internist coincident with the surgical
interference by measures to be outlined later.
In the second group of surgical conditions occurring in the
presence of diabetes, that is, those which are accidental or coincidental, there are two classes of cases, as mentioned above:   those
Page Twenty-one in which surgical intervention cannot be deferred without danger,
and those in which intervention may be deferred with safety. In
the first class the indications, for operation, at least as to time, are
the same in the presence of diabetes as in its absence. Control of
the diabetes and safeguarding of the patient against complications
which may be precipitated by surgery, must be handled by the
internist, just as in the cases where immediate amputation is imperative.
In the second class of these cases, namely, those in which
operation can be deferred, control of the diabetes should be established before operation. The time required for establishment of
this control should not exceed a few days. Examples of conditions which may be classed in this group are: Cholecystectomy
for chronic gall-bladder disease or gallstones, thyroidectomy,
herniotomy, nephrectomy, or prostatectomy.
At this point we may discuss the indications for or permissibility of this type of surgery in the presence of diabetes. In gen--
eral it may be stated that with the modern equipment for controlling the diabetes, all other things being equal, no greater mortality should accompany this type of major surgery on diabetic
patients than on non-diabetic patients. However, some major
surgery of this type may be meddlesome when performed upon
diabetic patients, whereas-it would not be considered so upon non-
diabetic patients. In the opinion of the writer, examples of such
surgery would be thyroidectomy for colloid goitre or non-toxic
adenomata of the thyroid when done for cosmetic reasons, nephrectomy for silent calculus, or.nephropexies, prostatectomy in patients without retention, gastroenterostomy for peptic ulcer without obstruction or perforation. I desire not to be misunderstood.
The meaning intended is that surgery of this major type, falling
in the group where surgery may be deferred, must be absolutely
indicated as the only or best method of treating the condition and
must give promise of a high degree of relief from the condition for
which it is performed, or of a definite improvement in or arrest
of loss of tolerance.
One or two conditions may be made the subject of special
comment. There is some difference of opinion as to just what
should be done about chronic gall-bladder infection. Some believe that there is no greater incidence of gall-bladder disease among
diabetic patients than among patients in general. Others believe
there is a much higher incidence of this condition among diabetics.
Some believe that any degree of chronic cholecystitis, active or
quiescent, will cause progressive loss of tolerance in the diabetic.
In this connection Wilder recently reports 82 deaths among 2500
patients having diabetes. Fifty-one autopsies were done. Thirty-
three per cent, of the autopsied cases showed gallstones. Our attitude upon this particular phase of the subject has been as follows:
First, that there is a frequent incidence of cholecystitis among diabetics, possibly .greater than among our patients in general; second, that any sourc of infection, acute or chronic, present in the
diabetic patient tends to cause progressive loss of tolerance or at
Page Twenty-ttoo least to prevent a gain, both varying in degree in different patients.
For this reason all sources of infection are corrected if possible.
But the risk involved in removing a gall-bladder as a source of
chronic infection is much greater than that involved in removing
abscessed teeth as a source of infection. We have also believed
that a quiescent gall-bladder infection is probably entirely latent
as far as the pancreas is concerned, and for this reason we have
done cholecystectomy only in those cases where activity of the infection was positively present, or repeated colics were occurring.
The second condition deserving special comment is thyroid
disease. Fitz was able to collect only 18 cases of proven exophthalmic goitre and diabetes. Toxic adenoma is much more common. Several internists who give special attention to diabetes
believe that correction of a hyperthyroidism always sharply improves sugar tolerance in the diabetic. We have done but one
thyroidectomy for hyperthyroidism, but in this patient there was
marked improvement in the psychic and nervous condition
and four months after operation a moderate improvement
in tolerance. One case of typical exophthalmic goitre and proven
diabetes received iodine for the hyperthyroidism. The insulin required was necessarily lowered early in the management to an
amount very small compared to what would usually be required
by a case of that apparent severity. The question arises as to
whether or not there is any interrelation between the thyroid and
the pancreas, both internal secretory organs, or if the improvement in tolerance noted by various observers is not the same as
might be found after any procedure which improves the general
health of the diabetic patient.
Just what measures constitute the best medical support of
the patient during emergency surgical operations, or the best control and preparation of the patient for deferable surgical procedures, should be briefly outlined. As to emergency operations,
measures employed vary, naturally, according to the blood and
urine findings, the clinical condition of the patient, and the duration of the surgical condition. When infection of any kind is
present in such degree as to cause a constitutional reaction, the essential effect is an increase in the severity of the diabetes; this results in lowered tissue resistance, permitting progression of the
infection, which again further augments the diabetes. Thus a
vicious circle is established. Dehydration, if present, must be corrected by the introduction of fluids by any or all possible methods. If acidosis is present, as evidenced by the presence of ketone
bodies in the urine and lowered alkali reserve, sufficient insulin
must be given before, during and after operation to reduce or at
least prevent an increase in the degree of this condition. Some
authorities believe that, regardless of the amount of glucose available in the blood, the quantity of insulin necessary to combat the
acidosis should be buffered by administration of glucose, usually
one gram for each unit. These authorities advise the routine intravenous administration of 500 cc. of a 5 per cent, solution of
glucose containing 25 units of insulin.    Joslin is authority for
Page  I'wenty-three the statement that he has not been able to bring himself to giving
sugar as such to a diabetic, particularly in the face of marked
hyperglycemia and glycosuria. If a high blood sugar content exists, and it can be determined, using an inlying catheter, that sugar
remains present in the urine, or if the blood sugar remains high,
it probably is unnecessary to buffer the insulin given. If the blood
sugar content is relatively low and little or no sugar is present in
the urine, glucose must be given to buffer the insulin required to
promote oxidation of the ketone bodies present and being produced. Except in rare instances, however, this glucose may be
given as orange juice or oatmeal gruel by mouth. The policy
just outlined has been followed by us, and it has not yet been
necessary for us to buffer even quite large amounts of insulin with
glucose given intravenously. It may occasionally be necessary to
give glucose solution per rectum when the nature of the surgical
procedure prohibits or vomiting prevents the taking of liquids by
mouth for any considerable period of time. In rather rare instances even intravenous administration of glucose must be resorted to when surgical procedure or diarrhoea, in addition to the
foregoing, prevents using the rectum as a port of entry. Unless
these contraindications exist, orange juice and oatmeal gruel, given
freely by mouth, usually supply sufficient glucose for buffer purposes. Foster suggests the use of milk during this primary crucial
period.
After most laparotomies, unless vomiting is present, these
three liquids are not contraindicated in frequently repeated tea-
spoonful quantities.
When a day or two's delay is permissible for preparing the
diabetic for operation, glycemia should be reduced to at least 200
mg. per 100 cc. and the alkali reserve raised to at least 50 volumes
per cent. Too great a restriction of carbohydrate intake should
not be made, particularly in the presence of infection or in elderly
diabetics, because of the danger of depleting the glycogen stores,
but rather more insulin should be given to remove ketone bodies,
lower the glucose content of the blood, and increase glycogen reserve. Protein intake also should not be less than the usual, but
fat intake should be reduced to a very small amount. During
immediate postoperative days these patients are handled in a manner similar to that employed following emergency surgical intervention, although as a rule they are much less of a responsibility.
As soon as vomiting or diarrhoea ceases, if either is present, and
as soon as the surgical condition will permit, these patients are
placed successively upon soft, semi-solid, and finally solid food.
Protein intake is at all times kept at about the usual amount. In
general, carbohydrate intake is maintained high and cared for
with the necessary amount of insulin, and normal amounts of fat
are added to the diet list.
Few remarks need be made about the choice of anaesthetic.
Chloroform should never be used. Ether should be avoided if
possible. Nitrous oxide and oxygen alone, or combined with
local anaesthesia, used either by infiltration or preferably as nerve
Page Twenty-four blocking, is very satisfactory. Spinal anaesthesia is probably the
safest anaesthetic from the standpoint of the diabetes. Ethylene
also is entirely satisfactory.
To summarize: Emergency surgery can be safely done in the
presence of diabetes.
Surgery for the relief of chronic conditions, the effect of
which is unfavourable upon the diabetes, may be safely done, and
is indicated.
There is no justification for surgery which is not so indicated.
Finally, the following factors are essential in maintaining a
low mortality: Early diagnosis; early decision to operate; proper
metabolic preparation of the patient if time permits, if not, proper metabolic support during the emergency; relief of dehydration
and circulatory support; proper selection of the anaesthetic; a competent surgeon experienced in diabetic surgery; short operation;
competent nursing; competent metabolic after-care.
(1) Wilder, R. M.,  and Adams,  S. F.:  Present Status of Diabetic Patient as
Surgical Risk.     Wisconsin M. J.,   1924, Vol.  22, P. 557.
(2) Foster, Nellis B.;  Some Surgical Aspects of Diabetes.    J. A. M. A. 84:
572.  1925.
(3) Joslin, E. P.; Treatment of Diabetes Mellitus.    Philadelphia.   J. B. Lip-
pincott  Company.    1923.
(4) Jones, Daniel Fiske et at; Abdominal Surgery in Diabetes.    J. A. M. A.
85:   809   (Sept.   12),   1925.
(5) Bauman, Louis; Diabetes in Surgical Patients, with Especial Reference to
Insulin.    Surg. Gyn. and Obst. 41: 272   (Sept.,  1925). THE UNIVERSAL CAR
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VANCOUVER, B.C.
crfqn
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Page Twenty-iix The Basis of all Artificial
Infant Feeding
The basis of infant feeding is human milk, and
the principle involved in the artificial feeding of normal infants is the imitation of human milk.
Cows' milk is the basic material used in practically all artificial feedings. It is modified one way
or another to make it better suited to the infant's
digestion, and to have more or less the same proportions of food elements as human milk.
Pediatrists say that fresh cow's milk is, therefore, a logical diet for normal infants, provided that
it is diluted with water to reduce its fat and protein
contents and that a suitable sugar is added to the
mixture to give it approximately the same percentage
of carbohydrate as in human milk.
Mead's Dextri-Maltose
is a special sugar to be added to diluted milk, which
has been found to be more easily assimilated by infants and less likely to produce diarrhoea than cane
sugar or milk sugar.
DEXTRI-MALTOSE is advertised only to
the profession in order that the physician may control each case and be the sole judge of the proper
formula to suit the needs of the individual baby.
On request, a Mead's Feeding Calculator, showing usual formulas for normal infants suggested by
the results of pediatrists, will be supplied to physicians, together with samples of Dextri-Maltose.
Mead, Johnson & Company
OF CANADA, LTD.
BELLEVILLE, ONT.
Page Twenty-seven B. Q Pharmacal Co. Ltd.
329 Railway Street,
VANCOUVER.
Manufacturers of Hand-made Filled Soluble
Elastic Capsules.
Specimen  Formulae:
No. 60— No. 61 —
Blaud Pill, 10 gr. Blaud Pill, 10 gr.
Arsenious Acid, 1/50 gr.      Arsenious Acid 1/50 gr.
Ext. Nux Vomica, j gr. Ext. Nux Vomica, J gr.
Phenolpthallin, | gr. Phenolpthallin, § gr.
Special Formulae Made on a Few Hours' Notice.
Price Lists and Formulae on
Application.
PRESCRIPTIONS
filled exactly as written
Phones: Seymour 1050-1051
Day and Night Service
Qeorgia Pharmacy Ltd.
Qeorgia arid Qranville Sts.
Vancouver, B. C.
Page Twenty-eight Frost Pharmacy LtcL
Gordon Frost
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Prescriptions a Specialty
o+j>
TWELFTH AVE, AT GRANVILLE
Phones:
Bay. 540 Bay. 1720
Say it with Flowers
Cut Flowers, Potted Plants, Bulbs,  Trees,  Shrubs,
Roots,   Wedding  Bouquets.
Florists'  Supplies and Funeral Designs a specialty.
Three Stores to Serve You:
48 Hastings St. E. Phones Sey. 988 and 672
665 Granville St. Phones Sey. 9513 and 1391
151 Hastings St. W. Phone Sey. 1370
Brown Bros. & Co. Ltd.
VANCOUVER, B. C. SPECIAL OFFER
Doctors* Bags
Of Exceptional Value
Manufactured in England
Solid Cowhide Leather
Hand'sewn and rivetted frames
Adjustable bottle loops and pocket
Orders will be filled in sequence
We have a stock on hand and another shipment coming
Special price during run of this advertisement:
isiPlfiS   W*BSsM. wi 16 inch      I      $12.00
CLUB STYLE   -   18inch    .    \l3M
A saving of about 25%
B. C. Stevens Co. Ltd.
730 Richards Street Vancouver
The OipI Drug
Co., Ltd.
J{\\ prescriptions dispensed
by qualified Druggists.
y"ou can depend on the Ou?l
"for ^Accuracy, and despatch.
VJe deliuer free of charge.
5 Stores, cenlrally located.    We
would appreciate a call while
in our territory.
Ambulance
Service
TELEPHONE
Fair. 58 & 59
^Aount Pleasant
Undertaking Co.   Ltd.
R. F. Harrison    W. E. Reynolds
Cor. Kingsuiay and Main
Page Thirty H. A. BARRETT, M.D.
TELEPHONE SEY. 4144
Practice  limited  to   Physiotherapy.
Quartz   Lamps,   water   and   air-cooled;   High   Frequency,
Galvanic Static and Wave Currents; Massage, etc.
Special   facilities   for   surgical   diathermy -(electro-coagulation) .
Hydrosine  bath  for  weight  reduction—by  artificial  exercise of muscular tissue—not a dehydrating process.
Electrolysis for hyertrichosis, e'tc.
Ionization for otorrhoea.     A. R. Friel's method.
Authorized   by   the   Workmen's   Compensation   Board   to
treat their cases.
Trained assistants only.
Hours  9  a.m.  to   6  p.m.,  including Saturday.     Evenings
by appointment.
Address:    Court House Block, 812 ROBSON STREET
. LABORATORY
1200 Fifteenth Avenue West
Telephone Bayview 268
OFFICE
206 Vancouver, Block
Telephone Seymour 2996
Private Clinical Laboratory
Service
We are prepared to undertake all the work usually
done in a well equipped Clinical Laboratory. Blood
Chemistry, Wasserman Tests, Vaccines, etc.
C. S. McKEE, M. B.
MISS M. M. McKEE
Page Thirty-one ■•■• MC*l-=
=«@s§-
Hollywood Sanitarium
LIMITED
tyor the treatment of
Alcoholic, Nervous and Psychopathic Cases
Exclusively
Reference ~ <23. Q. (Medical Association
For information apply to
Medical Superintendent, New Westminster, B. C.
or 515 Birks Building, Vancouver
Seymour 4183
Westminster 2{
«rf©K
■OSSv
Page Thirty-two

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