History of Nursing in Pacific Canada

The Vancouver Medical Association Bulletin: July, 1935 Vancouver Medical Association Jul 31, 1935

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 The BULLETIN^
OF THE
VANCOUVER M0KCAL//
ASSOCIATION^
ri
Vol. XI.
JULY, 1935
No. 10
In This Issue:
SUMMER SCHOOL
PHYSIOLOGICAL OBSERVATIONS
IN THE PUERPERIUM
NEWS and NOTES I i m
WVl
I fill
I it I \f
ll t»
FINEST QUALITY
Halibut Liver
Oil
Biologically tested, imported from Great
Britain. Guaranteed to contain at least
50,000 International Vitamin A Units per
gram.
This fine produce is unsurpassed and is at
your disposal for prescription either in bulk
or collapsible capsules at approximately half
the price of other similar products.
Capsules containing 3 minims (equivalent in
Vitamin A content to 4 teaspoonsf ul of Cod
Liver Oil) 50 in box for $1.00.
Obtainable at all
VANCOUVER DRUG CO.  STORES
Western Wholesale Drug Co.
(1928) Limited
456 BROADWAY WEST
VANCOUVER   -   BRITISH COLUMBIA THE     VANCOUVER     MEDICAL     ASSOCIATION
BULLETIN
"Published Cilonthly under the ^Auspices of the Vancouver ^Medical ^Association in the
interests of the Medical "Profession.
Offices:
203 Medical Dental Building, Georgia Street, Vancouver, B. C.
Editorial Board:
Dr. J. H. MacDermot
Dr. M. McC. Baird Dr. D. E. H. Cleveland
All communications to be addressed to the Editor at the above address
Vol. XI. JULY,  193 5  No.  10
OFFICERS   193 5-193 6
Dr. C. H. Vrooman Dr. W. T. Ewing Dr. A. C. Frost
President Vice-President Past President
Dr. G. H. Clement Dr. W. T. Lockhart
Hon. Secretary Hon. Treasurer
Additional Members of Executive—Dr. T. R. B. Nelles, Dr. F. N. Robertson
TRUSTEES
Dr. W. D. Brydone-Jack Dr. J. A. Gillespie Dr. F. Brodie
Auditors: Messrs. Shaw, Salter & Plommer
SECTIONS
Clinical Section
Dr. J. R. Neilson _.   — — -    Chairman
Dr. Roy Huggard    —■ Secretary
Eye, Ear, Nose and Throat
Dr. E. E. Day               Chairman
Dr. H. R. Mustard   — - - ~~ — Secretary
Paediatric Section
Dr. G. A. Lamont..        Chairman
Dr. J. R. Davies    .—       Secretary
Cancer Section
Dr. J. W. Thomson         Chairman
Dr. Roy Huggard _ —   -   —  Secretary
STANDING COMMITTEES
Library Summer School
Dr. G. E. Kidd Dinner *-*R. H. A. DesBrisay
Dr. W. K. Burwell _     . , Dr. H. R. Mustard
r,,   ~   .   t, Dr. Lavell Leeson ^.     t w, -r
Dr. C. A. Ryan ~     . ^ , T Dr. J. V. Thomson
■r.    -an t-> v Dr.   . h. Harrison „    ^~ t~ r>
Dr. W. D. Ke;th _    J.   T Dr. C. E. Brown
tn    11   l   t> L)r. A. Lowrie -,-.     T r w,
Dr. H. A. Rawlings Dr. J. E. Walker
Dr. A. W. Bagnall Dr. J. W. Arbuckle
Publications Credentials
Dr. J. H. MacDermot Dr. H. A. Spohn
Dr. Murray Baird Dr. J. W. Thomson
Dr. D. E. H. Cleveland Dr. W. L. Graham
V. O. N. Advisory Board
Dr. I. T. Day R-cP- /o B- C. Medical Assn.
Dr. W. H. Hatfield Dr. W. C. Walsh
Dr. A. B. Schixbein
Sickness and Benevolent Fund — The President — The Trustees n
ii  n j'
fu-
I li'kM
IM
III
PUBLIC HEALTH
BIOLOGICAL PRODUCTS
Diphtheria Antitoxin
Diphtheria Toxin for Schick Test
Diphtheria Toxoid  (Anatoxine-Ramon)
Scarlet Fever Antitoxin
Scarlet Fever Toxin for Dick Test
Scarlet Fever Toxin
Tetanus Antitoxin
Anti-Meningitis Serum
Anti-Pneumococcic Serum   (Type 1)
Anti-Anthrax Serum
Normal Horse Serum
Smallpox Vaccine
Typhoid Vaccine
Typhoid-Paratyphoid Vaccine
Pertussis Vaccine
Rabies Vaccine   (Semple Method)
INSULIN
Price List Upon Request
Connaught Laboratories
University of Toronto
TORONTO 5 - CANADA
Depot for British Columbia
Macdonald's Prescriptions Limited
Medical-Dental Building, Vancouver, B. C. VANCOUVER HEALTH DEPARTMENT
STATISTICS—MAY, 193 5
Total Population (Estimated)	
Japanese Population (Estimated]
Chinese Population (Estimated).
Hindu Population  (Estimated)...
Total Deaths  	
Japanese Deaths  	
Chinese  Deaths 	
Deaths—Residents  only 	
Birth Registrations—
Male,  159;  Female,  161.
INFANTILE MORTALITY—
Deaths under one year of age	
Death rate—per  1,000  births	
Stillbirths  (not included in above).
Number
225
4
15
195
320
May,
1935
6
18.8
3
Rate
Pop
244,329
8,037
7,803
276
per 1,000
ulation
10.8
5.8
22.6
9.4
15.4
May,
1934
9
28.6
11
CASES OF COMMUNICABLE DISEASES REPORTED IN THE CITY
June 1st
April, 1935
Cases     Deaths
0
Smallpox     ~ 0
Scarlet   Fever  52 0
Diphtheria    5 3
Chicken  Pox    74 0
Measles        60 0
Rubella  —   5 0
Mumps        28 0
Whooping-cough     47 0
Typhoid Fever    0 0
Undulant Fever   0 0
Poliomyelitis       0 0
Tuberculosis       3 8 12
Meningitis   ^Epidemic)     0 0
Erysipelas       1 0
Encephalitis Lethargies   0 0
Paratyphoid       0 0
Ma)
Cases
0
49
0
201
237
3
26
61
1
0
0
59
0
1
0
0
, 1935
Deaths
0
0
0
0
0
0
0
0
0
0
0
12
0
0
0
0
to 15th, 1935
Cases     Deaths
0
23
1
120
136
4
6
34
3
0
0
17
0
1
0
0
BIOGLAN "H
«u»
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»
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blood pressure,  early arterio-sclerosis  (not due to renal disease).
Formula:   Each  1 cc. Ampoule contains
Pancreas—25 grammes of the fresh hypotensive principle;
Anterior Lobe Pituitary—2 grammes of fresh substance;
. Embryonin—2 grammes of fresh substance.
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References:
Vancouver, B. C.
Ask the Doctor who has used it."
Page 212 Jl If
t    H   1
For the rest of your natural life
I sentence you to the hypodermic needle!
THIS is the verdict feared by every diabetic. It is the sentence which the
physician should avoid wherever possible.
For proper indications and in emergencies, there is of course no complete
substitute for insulin. But many diabetics thrive on oral treatment with
Pancrepatine, which contains the hormone of pancreas and liver ACTIVE
BY MOUTH.
Pancrepatine spares insulin and never causes hypoglycemic shock. It spares
the patient the discomfort of the hypodermic needle. It reduces urinary
sugar—frequently clears it up entirely. Also controls polydipsia and polyuria.
Prescribe 2 to 4 globules of Pancrepatine t.i.d. Supplied in bottles of 100
hormone-active globules protected against ferment action.
PANCREPATINE ]
ORAL TREATMENT FOR  DIABETES
Obtainable from B. C. Drug's Limited, Vancouver; Georgia Pharmacy, Vancouver; McGill & Orme, Victoria.
ANGLO-FRENCH DRUG CO., MONTREAL EDITOR'S PAGE
! ■)   n
And so ends another Summer School of the Vancouver Medical Association. The standard reached by this annual function is now accepted as a
high one; it would be superfluous to say that this was a good Summer School.
It is now some years since the type of School that has become so popular here
was more or less standardised into its present form, and we cannot but feel
that from our point of view it could hardly be improved upon.
But what a vast deal of work it represents: six men, each a leader in his
subject, giving at least four papers each in the four days of the meeting.
One sometimes wonders just what it is that makes such men, nearly every
one of whom has had a full and busy winter and spring of university work
and must be at the saturation point as regards teaching and talking and
demonstrating, so willing and even eager to come here, to what is in reality
a small School, and give so freely, so ungrudgingly, and with such gusto, of
their very best.
It is not, of course, a financial question. We could not hope to secure
such men on any such basis; and the list, year after year, shews uniformly
outstanding men, men who have a long record of original work behind them
—men who, their energies directed along commercial or industrial lines,
could command any figure they chose to name.
Nor is it merely a "busman's holiday" for them. They come, many of
them, from great distances, simply for the purpose of this School, and they
come with their lectures prepared and polished to the last word and phrase—
with carefully thought out series of slides and films—in fact, with a real
contribution to medical knowledge. One is struck, again and again, listening to these men, with the thoroughness and comprehensiveness of their
papers—there is nothing condescending, nothing slipshod or careless about
one single lecture. One might be listening to papers prepared for some big
national convention.
We think it is due to two or three causes. The first is the natural human
instinct which leads us to do our job as well as we can: to do with all our
might whatever our hand finds to do. The man who has done good work
all "his life cannot do slovenly or poor work: as the real musician simply
cannot make himself play out of tune. We read, in the accounts of the
Greek temples, that even the part of the columns that was buried underground was carved as exquisitely and as accurately as the parts that shewed;
for the men who did it were artists and craftsmen, and there is nothing finer
in man than this instinctive, creative spirit of doing one's uttermost, "be
life's set prize what it will." In saying this we do not decry the Vancouver
Summer School, which we personally think is a thing well worthy of any
man's best effort, but a second-rate man might think otherwise.
Again, there is that wonderful tradition of our profession that makes
every man in it not only willing, but eager to share his finds with every
other brother of the craft. It is a tradition that has placed our profession
hors concours, and one cannot think of a case, since the days of the Cham-
berlens, where there has been any departure from this rule by any medical
man of standing who has made any discovery; though at one time a certain
tendency to capitalise a great discovery was shewn- in the case of a great
German medical scientist.
We must all be very grateful to these men.   Perhaps they find their
Page  213
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reward in other ways; in fact, their main reward, their real reward, does not
lie even in our gratitude, though that must mean something to them.
The background, too, was excellent, the machinery all ran silently,
smoothly: or did we say silently? We suggest a silence zone to be established, and maintained, if necessary, by strong men, for a distance of twenty
feet in every direction from the convention hall in future, that those who
came to pray may not remain to curse because they could not hear.
And what of the Committee, who worked so hard and engineered the
whole meeting so well? They, too, have their reward—and they deserve it—
in a big registration, 194 to be exact, and big meetings, and the keen interest
of everyone concerned. We must thank them, too, and congratulate them
on thier work, and hope for an equally good Committee next year.
One regret we have—and that is the impossibility of hearing all the
lectures. One would not willingly have missed one of them: the exigencies
of practice made us miss many. Perhaps (it is merely a suggestion) next year
the Vancouver Summer School might be held in Victoria, or New Westminster, then we could all go over there and spend our whole day at the
School in peace. There are, we admit, certain lions in the path and perhaps
it is not a practical suggestion—but it seems a pity that we cannot attend a
School in our home town without all these interruptions.
NEWS AND NOTES
Dr. F. Emmons and Mrs. Emmons are to be congratulated on the recent
safe arrival of a daughter; both doing well.
Dr. George Clement returned from Atlantic City Thursday morning
last, in good time to play golf in the afternoon. That's just what one would
expect of George. He reports a very successful meeting. Among those who
have not yet returned at the time of writing are Dr. Carl Eaton, Dr. Spohn
and others.
Dr. H. H. Milburn and family motored East at the beginning of the
month, and will be absent for some time.
Drs. Lavell Leeson and H. A. Desbrisay have gone down to Camp Lewis
in Washington to spend a week under canvas with the troops there. Whether
they have gone to give or receive instruction does not yet appear—but
probably a bit of each.  Dr. Boulter was another member of the party.
It was delightful to see Dr. W. A. Clarke, of New Westminster, at the
Summer School. He is feeling much better, but is not yet quite fit for work.
Dr. H. H. Caple left for Europe, with Mrs. Caple, recently. They will
be gone for about a year.
Dr. R. E. McKechnie is again to be congratulated as the recipient of
marked honour. This time it the conferring on him of the order of Companion of the Order of the British Empire, as one of the King's Jubilee
honours.  No one better deserves it.
Page 214
■mi Dr. B. J. Harrison, too, Director of Radiology at the V. G. H., receives
acknowledgment of some excellent work he has done in the methods of
localization, by the award at Atlantic City of the Order of Merit, conferred
[by the American Medical Association.
Dr. D. E. H. Cleveland has just returned from Atlantic City, where he
read a paper before the Dermatological Section of the Conference.
The B. C. Medical Association has just completed two postgraduate
tours. One team went to the Kootenays, composed of Dr. Lyall Hodgins
[and Dr. L. H. Appleby.
Dr. Appleby took occasion to speak to the various meetings on Council
j activities—while he gave lectures on Head Injuries and Peritonitis.
Dr. Hodgins spoke on Diabetes and Anasmias.
They report a most successful tour.
The other tour took in Prince Rupert district, and the team consisted
i of Dr. Murray Baird and Dr. Taylor Henry.
Dr. Baird spoke on Ansemia and Treatment of Infection; while Dr.
i Henry spoke on Tumours of the Neck, and some conditions of the Large
Bowel and Rectum.
ii}
THE   193 5   SUMMER  SCHOOL
The Summer School of the Vancouver Medical Association, which has
just been concluded, was a very successful one, coming well up to former
standards. The Chairman of the Committee, Dr. J. W. Thomson, and his
Secretary, Dr. J. E. Walker, are especially to be congratulated. Everything
worked with perfect smoothness, and everyone present seems to have been
well satisfied with everything.
One hundred and ninety-four men registered. Of these, twenty were
from points in the United States, chiefly Washington and Oregon, twenty-
eight from points in B. C. outside Vancouver, leaving one hundred and
forty-six Vancouver members. We feel that this is a very good showing.
And those attending all got good value for their time and money. There
was something for everyone—a great deal for everyone, really; and the
speakers deserve our special thanks in that their papers were all related to
general practice and its problems. Occasionally, one of them would soar into
levels where the average medical man began to shew signs of dyspncet and
general distress—but as a rule their addresses were thoroughly practical and
helpful.
We all rejoiced to have our old friend, Dr. Chas. Hunter of Winnipeg,
with us once more, and his four addresses were all worthy of him. It is hoped
that we shall be able to give these at some length in future numbers of the
Bulletin. It is regretted that we cannot give all the asides and amplifications with which Dr. Hunter embellishes his lectures, and which add so
much to the pleasure with which one listens.
Dr. William Dock, too, of San Francisco, lived
notices."   His talks were thoroughly good and very
occasionally rather theoretical.   This, however, added to their stimulating
effect.
Dr. Steindler's addresses on orthopxdic subjects were excellent, and displayed a very wide knowledge of his subject.  A little difficult to hear, on
Page 215
up to his "advance
interesting, even if
Jl 1
account of a rather low voice, he was yet extremely worth hearing—and
his illustrations by slides were excellent.
Dr. Perry McCullagh, of Cleveland, we regard as one of ourselves.  He I
has grown very greatly, in an atmosphere in which only the best can survive,
and listening to him, one was impressed by the immense amount of work
that is being done in the field of endocrinology today.
Dr. Verne Hunt, of Los Angeles, gave several interesting and valuable
talks on modern surgery, while Dr. John Budd, also of Los Angeles, dwelt
on the pathologist's point of view of disease, though he linked this up
with the clinician's side continually. He is a coming man, is Dr. Budd, and
we shall hear from him again.
Much enjoyed at the meeting were the films supplied through the courtesy of Messrs. Davis & Geek of New York, and a film showing three days'
work in the Fracture Clinic of the Royal Infirmary, Bristol, England. This
atter picture, showing the use of the Cellona surgical dressing, is the property of Mr. K. H. Priddie, F.R.C.S., of Bristol, and was loaned to the Vancouver Medical Association by Mr. Wisby of the Smith & Mathews Company, Montreal.
ATLANTIC CITY CONVENTION
The Atlantic City meeting was a grand gesture—a noble experiment.
Lately returned from the "other side of the line," such grandiloquent epigrams emanate from us as ether wafts from a patient coming down from
the O. R.
As a medical meeting something might be said by way of criticism. In
spite of the marvellous organization which was reflected in the smoothness
with which the various intricacies of its mechanism fitted and moved, there
was something overwhelming about it. One may be quite at home repairing
a radio set at one's own work-bench and feel excusably embarrassed if
invited to utilize all the resources of the Westinghouse laboratories.
Three hundred members of the C. M. A. and several thousand members
of the A. M. A. distributed among a dozen large hotels and a few acres of
auditorium flooring (these figures are hearsay and unofficial) do not make
for concentration. While the general meetings and sectional meetings were
well attended and much valuable work was presented and discussed, and
the scientific exhibit was as instructive as it was impressive, one could never
avoid the conclusion that the great value of the meeting lay in its international character. Canadian representation on the programmes of the
eneral meetings and sectional meetings was very generous. The address by
Dr. J. C. Meakins of Montreal on "The Breath of Life" was much eulogized.
Dr. B. J. Harrison brought honour to Vancouver by receiving First Class
Award of Merit for his demonstration of a new method of orientation
applicable to the body and the x-ray beam.
We cannot pass this opportunity of mentioning what most of us have
had occasion to experience at various times in the warm-hearted and whole-
souled hospitality which American hosts excel in displaying. We flatter ourselves—sundry kinks marking the sites of old knots in the lion's tail notwithstanding—that on no occasion is this accomplishment so well displayed
nor with such gusto as when the recipients of hospitality are Britishers.
Some of the highlights of the social and fraternal character of the
meeting centre about the dinner at the Traymore Hotel on the night of
June 10th, at which the Council of the C. M. A. were the guests of the
Page 216 —
House of Delegates of the A. M. A. There was an air not of national but of
college rivalry about it when in various sections of the large room "Yale
Boola" vied with "Old Nassau" and both were drowned by "Anchors
A weigh." With creditable feeling the Canadians gamely struggled with
three verses and as many versions of "O Canada," and received more respect-
, ful attention and applause than they deserved. Everyone sang and stamped
: to "Dixie"—as everyone in the English-speaking world not born south of
i the Mason and Dixon line does; but the musical climax was "Alouette"
\a le vrai Canadien, led inimitably by Dr. Guerin-Lajoie of Montreal. The
| address which was delivered by Senator James Hamilton Lewis, chairman of
I the Senate Committee on Foreign Relations, was a piece of moving eloquence
j and of such evident sincerity that one might excusably feel that the bonds
• of British-American friendship had been made stronger than ever.
To go further in description and comment without entering into involved detail is impossible.  This does not pretend to be a complete account
! of the convention.
In concluding, our readers will be interested in knowing that the next
jC. M. A. convention will be held in Victoria, the president-elect being Dr.
Hermann Robertson, and that B. C. was well represented at Atlantic City
by a number of members of the profession in the province, including Dr.
Hermann Robertson of Victoria, Dr. W. J. Knox of Kelowna, Dr. J. H.
[Hamilton of Revelstoke, Dr. F. D. Sinclair of Cloverdale, and Drs. G. H.
Clement, H. H. Milburn, B. J. Harrison, H. Spohn, G. F. Amyot and
D. E. H. Cleveland of Vancouver.
MEDICAL RELIEF
COPY OF ARTICLE BEING SUBMITTED FOR PUBLICATION IN
THE CANADIAN MEDICAL ASSOCIATION JOURNAL
By Dr. E. S. Moorhead
Operation of Winnipeg Relief Plan
In view of the interest throughout the Dominion on the question of
j Federal or Provincial Health Insurance, the following record of the opera-
[ tions of the Winnipeg Relief Plan, for a period of one. year, will probably
j prove to be of extreme value.
When the Winnipeg plan was adopted, the only figures available led us
to express the view that a relief medical service could be provided on a modi-
jfied scale of fees) for $1.75 per head per annum. The marked discrepancy
between theory and fact suggests the scale of fees submitted in the various
j Provincial Health Insurance Plans may also be very wide of the mark, and
j the profession must be warned about entering on a course which will prove
jlto be detrimental, in its present form, to their interests.
This report is submitted in the hope that every doctor who is interested
I will study and analyse it before endorsing or even accepting terms about
which he knows little. It is believed that it is the only report of its kind
I available in the Dominion and possibly in the North American continent.
The figures for an additional ten thousand relief cases in the suburbs of
Winnipeg do not materially alter the picture.
Page 217 ^
;1
ill
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(Vi-
H
SUMMARY OF MEDICAL CHARGES FOR SERVICES TO PATIENTS ON RELIEF
FROM MARCH 1, 1934, TO FEBRUARY 28, 193 5   (12 MONTHS)
Average month over
a 12-month period
Calls-
House      15,987
Office   22,265
Hospital
Operations—
Major   —
Minor   ....
T. and A.
Fractures
Maternity—
Hospital   	
House   	
Sundries—
Special   Exams..
X-rays 	
Anaesthetics   ...
Dental 	
Consultations   .
8,065
519
900
727
33
702
137
243
193
234
1
266
23,992.75
22,448.25
5,185.70
20,533.00
7,580.73
10,852.50
671.66
6,994.75
2,600.00
1,198.50
1,677.33
825.58
1.25
792.00
Percentage
50
37
1,332
1,855
672
43
75
61
59
11
20
16
20
$1,999.40
1,870.69
432.14
1,711.08
631.73
904.38
55.97
582.90
216.67
99.88
139.77
68.80
.10
66.00
Gross   Total  $104,647.00 $8,720.58
Net Total — -- 93,890.89 7,824.24
Number Doctors Rendered Accounts        2,590 216
Net Average Cost per Doctor      36.25
Cases Reported  Hospitalized        2,029 169
Average Number of People on Relief per Month  ._   34,040
Average Gross Cost per Person for 12 Months       $3.07
Average Net Cost per Person for 12 Months         $2.76
After reading the above figures there are many points to be considered.
The percentages show what a large proportion of treatment is provided by
the general practitioner, which is interesting in view of the fact that the
patient is entitled to choose his doctor.
The scale of fees is as follows:
All major surgery, which includes a reasonable amount of post-operative
care, $2 5.00. Tonsillectomy, $15.00. Confinements in Hospital, S 10,00;
in home, $20.00; both to include ante- and post-natal care in a normal case.
House calls, $1.5 0. Office calls, $1.00. Eye, Ear, Nose and Throat specialists get a somewhat higher fee for office consultations, but a certain list of
minor operations and treatments may have to be performed at this consultation. Hospital visits are 50 cents, but only one visit every second day is
paid for, unless the patient is shown to be suffering from an acute and serious
ailment. Consultations are $3.00 and x-ray work is done on an agreed
schedule.
It is not claimed that these fees are remunerative. There are several
factors which reduce the cost to the City. Two whole-time and two part-
time doctors, employees of the City, treat relief cases; the salaries of these
medical officers are not included in the summary. The difference between
the gross and net totals is due to the fact that, with few exceptions, no
doctor is paid more than $100.00 in one month, though his earnings may
be considerably above this figure.  The City undertakes all administration.
Before the gross total is reached, all bills submitted are taxed. Vs»ts to
note progress, or for minor treatments, either of which could have been done
Page 218 I by a visiting nurse, are refused. If the number of visits appears to be excessive, the medical referee, a City official, reduces them, and the practitioner
I may submit his case for redress to a Medical Board.
All emergencies can be treated without written authority from the
j Medical Referee.   Chronic cases requiring surgical or prolonged and some-
i times expensive treatment are frequently referred to the Medical Advisory
Board for an opinion as to necessity for treatment or likelihood of benefit.
For reasons of economy, tonsillectomies in adults and refractions are rarely
j authorized.
It will be seen that all these restrictions are intended to reduce the cost
of supplying medical service to the unemployed on relief. The service is
complete insofar as relief of pain, protection of life and prevention of disability or death, are concerned: but the reader must ask himself, would
people under a Health Insurance scheme be satisfied with such a modified
service.
An efficient but restricted service should have cost the City of Winnipeg
$3.07 per head per annum.  If the patient, under a Health Insurance plan,
accepted all the treatments recommended by his doctor and insisted on the
employment of the modern aids to diagnosis and treatments, it seems certain
I that the cost would be very much higher than the estimates frequently put
I forward, that is, if the doctor is to receive a reasonable remuneration.
PHYSIOLOGICAL OBSERVATIONS IN THE
PUERPERIUM*
Dr. E. Murray Blair
It is my intention tonight to digress somewhat from the usual diet of
this association and offer a paper based chiefly on physiological and obstetric
observations. In doing so I well realize that the paper may prove a disappointment to a good many, in that the usual clinical description, diagnosis
and treatment "will be conspicuous by their absence.   I also realize that the
j clinician who delves in the field of physiology is of necessity on foreign soil
j and any conclusions based on such observations are probably not only value -
| less but foolhardy.
I shall confine the discussion to those observations which are an every-
i day occurrence to those who visit the pregnant patient during her puer-
I perium.
Involution. I believe that no one can palpate the fundus of the uterus
each day post partum while it is still palpable, without being filled with
I wonder at the vagaries of that organ.   It lies sometimes on the right side of
| the abdomen, sometimes on the left.   It sometimes presents its left cornu
i anteriorly, or it may present the right cornu, all seemingly without rhyme
or reason.   We have checked these positions with the positions which the
foetus adopted while in utero and are satisfied that the one holds no relation
to the other. We find that the anterior surface of the uterus faces the right
i groin three times in four.  The descent of the fundus post partum showed
a wide range of variations without any accompanying clinical change that
we could find.   We have records of the fundus at the umbilicus ten days
post partum, and of others that we could not find on abdominal palpation
four days post partum.   We have observed patients with a variety of sys-
*Presented before the Vancouver Medical Association February 5th, 193 5.
Page 219 i J
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temic diseases, such as pyelitis, pneumonia, anaemia, intrauterine infections
and generalized septicemia, tuberculosis, pre-eclamptic toxsemia, eclampsia
and chronic nephritis. We have carefully measured and graphed the descent
of the uterus in these cases, and in most patients it seemed apparent that the
infection had little if any effect on the involution. We have observed and
graphed the involution in cases that have undergone the marked uterine
trauma of cesarean section and are satisfied that in the majority of cases
involution is little if at all disturbed.
Finally I want to report the autopsy findings of three maternal deaths
during the year, each at least attributable to the delivery.
No. 72617 S, V.G.H., cesarean section, marked febrile course, died on the
7th day post partum.  The fundus was found at the umbilicus.
No. 87010 S, V.G.H., ruptured uterus, cesarean section, marked febrile
course, died on the 7th day post partum. Autopsy findings, egneral plastic
peritonitis with ileus.   Fundus the size of two fists.
No. 87039, V.G.H., sharp painless hemorrhage at about full term. Caesarean
section, followed by marked febrile course, death on the 13th day. Autopsy findings, general peritonitis, purulent metritis, multiple mural abscesses in the uterus.
Uterus the size of one fist.
In the first case there was apparently little involution. In the last two,
despite a most acute intercurrent infection causing death, the phenomenon
of involution seemingly went serenely on. Such observations are surelv of
interest and worthy of our thought and consideration.
I have been making some attempt to observe the involution of the uterus
a little more carefully during the past two or three years. An attempt has
been made to ascribe some degree of accuracy to our observations by means
of repeated measurements. The work has kept sustained the interest of the
housemen in the apparently normal parturient patient. It has kept the young
doctor in close physical touch with the patient throughout, and has seemed
to add a distinct interest to his work generally. It has supplied us with a
mass of data which we think is of some interest.
A few simple rules were devised to assist in the accuracy of these observations. The patients were kept from becoming constipated by means of
the generous exhibition of liquid petrolatum, and all were "panned" at a
certain time each morning in order that the bladder might be emptied
immediately before measurements were taken. We had the same houseman
carry out the measurements each morning as far as it was practical. The
measurements were taken with calipers from the superior edge of the
symphysis to the top of the fundus. While the actual measurements may
not be very accurate, yet repeated measurements done each day in the same
manner by the same individual will show a relative accuracy in the degree
of change from day to day. Each case was graphed from the second day
post partum until the uterus could not be palpated or the patient discharged.
The experiment was carried out routinely on each parturient patient and
this in a rather large and active obstetrical service gave us opportunities to
observe all types and conditions. We have 245 such graphs.
By a purely arbitrary ruling the first and eighth day measurements were
joined and the angle so formed with the perpendicular was measured. I have
termed this the angle of descent.
Our first experiment attempted to find if any later treatment affected
the progress of involution and if so to what extent. The following procedure
was instituted. Taking each patient in rotation 24 hours after she came
down from the case room, the first was given an ice bag applied continuously
to the fundus; the second a tablet of ergot, quinine and strychnine, three
Page 220 times a day; the third nothing. Ninety cases were so observed, showing 30
graphs in each of the above groups. The results were, we thought, of distinct
interest in that the graphs of all three groups were essentially the same.
While the angle of descent varied in the individual case, the average angle
in each group was practically the name. In other words, nothing seemingly
was gained by the use of an ice bag or ergot, quinine and strychnine post
part mi/ from the standpoint of involution. Indeed, the nursing observation
was that the exhibition of ergot, quinine and strychnine increased after-
pains and general discomfort very appreciably. The continuous application
of an ice bag to the abdomen is added labour that is apparently without
reward as regards involution.
We find that the height of the fundus 24 hours post partum is, generally
speaking, in a direct ratio with the weight of the baby. The larger the baby
the higher the fundus.
36% of our series weighed over 8 lbs.
10' ( weighed less than 6 lbs.
54/f weighed between 6 and 8 lbs.
The interesting observation was that the angle of descent was the same
within reasonable limits in those cases with babies weighing over 6 lbs.
In those cases where the babies weighed less than 6 lbs., practically all
of them being premature, the fundus took almost as long to reach the
symphysis, but having a much shorter distance to go, the angle of descent
was decidedly greater.
There were three cases of babies Weighing 10 lbs. or over, the largest
13 lbs. 8 oz. In each case the fundus has not reached the symphysis in ten
days.
Two cases of twins were observed and graphed, and here too the fundus
was distinctly slow in its involution. In these few cases I think it is suggestive that overstretching of the uterine muscles may cause delayed involution.
It should be pointed out that the angle of descent was somewhat
increased but the fundus had a greater distance to descend in the same period
of observation.
Prolonged Labour. Among the ninety-two cases most recently
graphed there were thirteen labours of more than 24 hours duration. It was
interesting that apparently neither, the weight of the baby, the age of the
mother, the degree of parity, or the laxity of abdominal musculature, all
of which were carefully noted, seemed to have any particular bearing upon
cases. Four of these long labours were premature. The impression was
again gained that the fundus of the premature baby displays prolonged
involution.
There were ten patients graphed whose temperature placed them in the
uterine morbidity class. The definition of morbidity in this hospital is a
temperature reaching 1003 on two successive 24-hour periods, not including
the first twenty-four hours. From this group we have excluded those morbidities which werei apparently due to any other cause than uterine infection. In five of these ten the angle of descent was distinctly increased; in
the other'five there was a normal angle.
As has already been said, systemic diseases played little if any part in the
progress of involution as far as could be observed. Cesarean section with
its gross trauma to uterine musculature both by incision and handling,
together with added anesthetic and peritoneal shock, have influenced post
partum involution only mildly if at all.
Page 221
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The presence of intramural fibromyomata have been observed only four
times in cases that could be graphed. In one of these with a large fibroid in
the posterior wall of the lower uterine segment there was apparently a very-
definite delay in involution. In the other three the fundus was barely
palpable at the symphysis ten days post par htm.
We have graphed six cases of anemia, i.e., Hgb. 65% and under and
down as low as 42 % and there seemed little if any change in the rapidity
of involution.
Finally the autopsy findings already described, presenting as they do, in
one case in particular, about all the inter-, intra- and extra-uterine infection
that one could conceive of with practically complete involution when death
intervened on the 13 th day, was enough to make me look further afield for
an explanation of this phenomenon. I know that every text book
on obstetrics describes intrauterine infection as a common cause of delayed
involution; this I am in no position to refute, but in my own limited observations I can only say that it has been by no means a constant finding.
In the post-partum clinic where patients are seen six weeks after delivery,
delayed involution in its more prolonged state can best be studied. My
experience in post partum examination there is limited. There are those here
much better qualified to discuss this phase of the work because of a wider
experience. My own idea is that retroposition, marked cervical lacerations and cellular inflammation about the uterus are conducive to delayed
involution.
In order intelligently to understand something of this itneresting phenomenon it would seem necessary to study not so much involution per se,
but rather the whole question of uterine contractions and those factors
which directly or indirectly bear upon such contractions. I assume that
uterine contractions have an important bearing on involution as well as
labour.
Before doing so I am reminded of an old dictum to the effect that "In
order to hope to understand function, the first requisite is a knowledge of
structure." I shall discuss briefly the oreenant uterus under two headings,
the muscle and the nerve supply, and each purely from the standpoint of
function.
Muscle. It seems advisable to discuss uterine musculature as having
two coats:
1. An outer or longitudinal coat, covering the fundus, the lower segment and the cervix, and comprising about one-tenth of the musculature of the uterus.
2. A circular layer, by far the more extensive. It carries most of the
circulation, supports the decidua and the gestation and makes up
about nine-tenths of the uterus.
Myogenic Innervation. Purkinje in 1839 demonstrated special systems of muscle fibres in the heart and non-pregnant uterus. Not until 1929
were his observations on the uterus confirmed by Hofbauer. The latter
describes in detail a distinct conducting system situated in the longitudinal
muscle layer. He has shown by experiment that the longitudinal layer contracts much more markedly in response to stimuli than the underlying layer
of the uterus. The longitudinal layer responded to small abounts of pituitary
extract much more markedly than the circular layer. At cesarean section
the stimulus of the incision caused a more marked retraction of the superficial layer than that lying in a deeper plane.
Hofbauer's conclusion is interesting: "I am inclined to assume that a
Page 222
m\
m. specialized system of the human uterus may represent an analogue of the
His Bundle in the heart."
Many interesting experiments have been carried out to show that the
uterus is not dependent upon its nervous attachments for either contractility
or tonicity. It has been noted by many observers that the uterus, severed
from all its attachments, undergoes rhythmic contractions if kept moist at
body temperature. It must then be accepted that the theory of myogenic
systols and diastole of hollow smooth muscle is a factor which must not be
lost sight of.
Nervous Innervation. The nervous innervation of the uterus follows very closely the innervation of any smooth muscle organ in the body.
In all instances the autonomic nervous system primarily governs their
activity. Indeed the nervous control and regulation of all vital functions
in the body are carried out by the autonomic nervous system. It should also
be made plain at the outset that though there is no proven direct relation
between the central nervous system and the autonomic nervous system,
yet the one is in no sense functionally independent of the other. It is not my
intent to discuss in detail the autonomic nervous system which has indeed
been attracting the attention of the medical world for the last several years.
It does seem reasonable, however, that if we are going to discuss involution
we must consider the nervous innervation of the uterus as a primary factor
and that innervation as far as is known is wholly autonomic.
In 1871 Sir James Simpson found that parturition was normal in sows
from which he had removed the dorsal and lumbar cord with the interesting
exception that the last foetus of the litter in each case was undelivered.
Routh reports more than one observation on the course of labour in women
suffering from paraplegia, and in more modern times the profession is well
aware that parturition progresses quite normally with complete intra-thecal
anesthesia. We may then assume that the central nervous system is in all
probability not a factor in the uterine contractions of labor and the puer-
perium.
The autonomic nervous system is divided into a sympathetic and parasympathetic system. For our purpose it will not be necessary to delve too
deeply into the origins of these two systems. It will be necessary, however,
to remember the following facts:
(1) There is a sympathetic and parasympathetic innervation to every
plain or smooth muscle organ in the body.
(2) The actions of these two innervations on the one organ are exactly
opposed.
(3) The actions of the two are in general antagonistic to each other.
These facts obtain in the sympathetic innervation of the eye, heart,
stomach, intestine, uterus, bladder, and to some extent the blood
vessels.
(4) It is generally accepted that the sympathetic nervous system supplies the innervation to the circular muscle coat of the uterus and
the parasympathetic system to the longitudinal coat.
It will be simpler to follow the automatic innervation of the uterus by
means of diagrams, one showing the sympathetic innervation and the other
the parasympathetic innervation.
Sympathetic Innervation. This system is described beginning at the
solar plexus at the first lumbar vertebra. From thence downward are the
intermesenteric nerves, the superior, middle and inferior hypogastric plex-
Page 223
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uses. From the superior hypogastric plexus down, the sympathetic chain
bifurcates to form the presacral nerves. The inferior hypogastric plexuses
are then two in number, situated on either side of the mid-line, and are here
joined, as will be shown later, by the parasympathetic system. Together they
enter the uterus via the utero-sacral fold.
Parasympathetic Innervation. This system apparently has its origin within the spinal cord. The nerves proceed through the second, third,
and sometimes the fourth sacral foramina in conjunction with and as part
of the sacral nerves similarly numbered. They pass forward to join with the
sympathetic chain at the inferior hypogastric plexuses. They used to be
known as the "Nervi Erigentes."
As has already been pointed out, the sympathetic nerves are motor to the
circular muscle coat of the uterus and the parasympathetic or "Nervi Erigentes" are motor to the longitudinal coat. As was also pointed out, these
nerves are antagonistic one to the other. In other words, local paralysis of
the lumbar cord affecting the parasympathetic, whether permanently by
trauma or temporarily by spinal narcosis, produces marked contractions of
the circular muscle fibres of the uterus owing to uncontrolled sympathetic
impulses. The expulsive power is largely lost owing to paralysis of the innervation of the longitudinal fibres.
One can readily see the clinical importance of these physiological findings if true:
(1) That in spinal anesthesia in cesarean section the uterus should be
found in a state of extreme contraction. The inhibitory fibres to
the sympathetic chain, the "Nervi Erigentes," have been paralysed
by intra-thecal medication, hence the extreme contraction of circular fibres.
(2) In spinal anesthesia for normal delivery, the nervous innervation
of the longitudinal or expulsive coat is lost, hence though labour
may go on and doubtless does go on normally to the end of the
first stage, the expulsive power of the uterus should be in great
degree lost. Beckwith Whitehouse of Birmingham says that this is
his observation and experience both in cesarean sections and normal
deliveries with spinal anesthesia.
Having discussed uterine structure from the standpoint of musculature
and nervous innervation, we should now be in a position to discuss those
factors which bear upon uterine contractions. They consist in great part,
I believe, of the sex hormones.
I approach a discussion of the sex hormones with some misgivings.
During the past six years the literature has been filled with articles about
their action in almost every field of medicine. Despite the fact that the
whole matter is still in a state of flux, the commercial drug houses have
apparently the situation well in hand and are on the highway to another
bonanza. We have passed through the Barbiturate Era, the iniquitous
Vitamin Era, and are now as a profession playing the same unsavoury part as
a medium whereby commercialism is exploiting the public in the field of the
female sex hormones. We all realize that these hormones will play an important and permanent part as therapeutic agents in the gynecology and
obstetrics of the future and indeed in every branch of medicine, but I feel
that we shall deal with this intelligently only through a knowledge of basU
physiologic study.
The factors which bear upon the contraction of uterine muscle, as far
Page 224 as I am able to gather, are cestrin, progestin, prolan, inf undibulin, adrenalin,
acetyl-cholin, calcium and magnesium.
Oestrin is the hormone of the follicle of the ovary; it is also formed in
the corpus luteum, the placenta, and is found in the amniotic fluid. It is
also found in such foods as potatoes, sugar beets, yeast, rice and wheat.
Its functions are:
(1) It directly controls uterine growth, both in the non-pregnant and
pregnant uterus.
(2) It increases sensitivity of the uterus to pituitrin.
(3) It initiates the secretion of pituitrin and so indirectly increases the
activity of uterine muscle.
Oestrin gradually increases in amount during pregnancy until it is
found in greatest quantity in the circulation at the beginning of labour. It
rapidly diminishes during the puerperiurn and has disappeared at about ten
days post partum. It has a direct relation to pituitary activity. In rats its
injection will invariably produce abortion. In humans great quantities
would be necessary and such experimentation has not been successful. Its
principal sources for commercial production are the urine of pregnancy of
women and mares.
Progestin is the hormone of the corpus luteum and is not found, as far
as I know, elsewhere in either the animal or vegetable kingdom. It is extremely unstable and has never been produced commercially.
Its functions are:
(1) It prepares the endometrium for the reception of the fertilized
ovum.
(2) It apparently supervises the nourishment of the foetus during the
first three months of intrauterine life.
(3) It inhibits uterine activity and is, generally, an antagonist to cestro-
genic activity.
Progestin appears just before implantation, increases in quantity in early
pregnancy, then gradually decreases until at labour it has almost, if not
entirely, disappeared from the circulation. In early pregnancy progestin, the
inhibitor of uterine activity, is the dominating factor, but gradually cestrin
overcomes it until at labour the latter is the dominating factor.
Prolan. It has long been known that hormonal activity of the ovaries
is dependent on the anterior pituitary. The ovary itself is apparently a
passive factor and is activated to produce its own hormones (cestrin and
progestin) by the anterior pituitary. Much has been said about two hormones formed in the anterior pituitary, Prolan A to activate the follicle and
Prolan B to activate the corpus luteum. The two have not been satisfactorily separated, and there are those that doubt that they exist as two distinct entities. For our purpose we will discuss only the hormone of the
anterior pituitarv, proland.
Were we dependent upon anterior pituitary glands for the hormones
it would not be a commercial product as progestin is not, but in 1928
Zondek found a substance in the urine of early pregnancy which very closely
resembled it. Collip and others later found the same thing in the placenta.
The resulting commercial product1 is called anterior-pituitary-like (APL).
Page 225
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Zondek's findings became the well known test for pregnancy, the Aschheim-
Zondek Test. Prolan is found in quantity only in the early months of pregnancy.  Its action on the uterus is to inhibit activity.
Infundibulin. Hormone of the posterior pituitary is a normal constituent of the body. There is ample evidence that it is secreted in large
amounts toward the end of pregnancy. It may be the most important single
factor in initiating labor and involution. Its gradual increase is apparently
directly attributable to the corresponding increase in cestrin. The question
of the action of pituitary on the pregnant uterus is well known as an activator of muscle contractions, and it is now believed by many that it only
acts in the presence of cestrin. The degree of activity is directly dependent
upon the amount of cestrin present in the circulation.
Suprarenal. There is reason to believe that there is increased activity
of the suprarenals during pregnancy. Adrenalin is believed clinically to
inhibit expulsive contractions in labor. A full hypodermic administration
during labor has been shown to inhibit all contractions for as long as twelve
minutes. Williams Text Book (1930) advises the injection of five minims
of adrenalin to control the excessively violent contractions of the uterus
in labour. Other authors advise the use in eliminating the so called Bandl's
Ring. I have used the drug for such a purpose a number of times and so I
think have many of you. It has been accepted for many years that stimuli
carried by the sympathetic fibres of the autonomic nervous system will
activate the smooth muscle which they innervate only in the presence of
adrenalin.
Acetyl-Cholin. In 1931 Dale was able to isolate a substance called
acetyl-cholin, which he has proved performs precisely the same duties for
the parasympathetic nerves as adrenalin does for the sympathetic nerves;
in other words, the stimuli carried by the parasympathetic fibres of the
autonomic nervous system will activate the smooth muscles which the innervate only in the presence of acetyl-cholin.
Each branch of the autonomic nervous system is dependent, then, for
its function upon the presence of its chemical transmitter. It is an interesting and I think significant fact that acetyl-cholin is found, according to Sir
Henry Dale, in the spleen and in only one other tissue, the human placenta.
Calcium. Much has been written of late concerning the exhibition of
calcium salts in late pregnancy. The supposed depletion of maternal calcium by the growing foetus will not be discussed here. It has been shown
fairly conclusively that an optimum of calcium content in the blood is
necessary for an optimum of uterine motility, and that any amount below
that lessens uterine contractions, and indeed may be a factor in uterine
inertia and subinvolution.
Magnesium. Magnesium salts are apparently directly opposed to calcium salts in their reaction to uterine motility. Magnesium salts tend to
inhibit uterine contractions.
In summing up the interaction of these various factors, all of which may
and most of which probably do have a direct relation to uterine involution,
it seems fair to offer the following:
Page  226 (1) An increase of progestin in the circulation above normal might well
cause a slowing up of involution.
(2) A too rapid decrease of cestrin content, while in itself having no
direct action on the uterus, would nevertheless call out a smaller
quantity of pituitrin and decrease the sensitivity of uterine muscle
to the action of pituitrin, thus delaying involution.
( 3) An increase in prolan would be an inhibiting factor to normal involution. Although the anterior-pituitary-like hormone decreases
in the urine as pregnancy progresses, it is still found in some degree
in the circulation during the puerperium. An anterior-pituitary-
like substance is also present in the placenta, as Collip has shown.
In the same manner it can be argued that the varying presence of in-
fundibulin, adrenalin, acetyl-cholin, calcium and magnesium all enter into
the mechanism of uterine involution.
I am unable to relate these factors to the uterine innervations which we
have discussed earlier in the paper. Two thoughts might well come to one's
mind:
(1) How do these hormones circulating in the blood stream act upon
the muscle fibres? Haxe they a myogenic or a neurogenic action,
or both?
(2) What factors, if any, play upon the autonomic nervous system,
causing it to stimulate the organs which it innervates?
It is my feeling that the factors above described act upon the uterine
muscles through the medium of its autonomic nervous system. Is it any
wonder, then, that our experiments on involution bore such little fruit? Is
it not reasonable that the phenomenon of involution goes on according to
the hormone balance in the circulation, with its resulting reaction on the
autonomic innervation? Is it not reasonable that this innervation is only to
a minor degree influenced by systemic disease or even local infections?
Strangely enough I have found nothing very definite concerning autonomic stimulation, and so it is pure presumption on my part to offer this
postulate, that the chief and perhaps onlv innervation of the uterus is
autonomic in origin and that the factors which play upon its autonomic
mechanism are hormonal in character.
Il
BIBLIOGRAPHY
Whitehouse and Featherstone—Journal Obstetrics and Gynaecology British Empire, 1923,
xxx.
Hofbauer—Journal American Medical Association, 1929, xcii.
Davis—Journal Obstetrics and Gynecology British Empire, 1933, vol. xi.
Bourne and Bell—Journal Obstetrics and Gynecology British Empire, 1933, vol. xl, 423.
Dale—British Medical Journal, 1934, vol. i, 83 5.
Allan—Medical Journal of Australia, August, 1934, No. 7.
Frank—Journal American Medical Association, 1934, vol. 103, No. 6.
Council of Pharm. and Chem.—Journal American Medical Association, vol. c, No. 7.
Kuntz—The Autonomic Nervous System, 2nd edition, 1934,
Bell, Darnow and JefTcoate—Journal Obstetrics and Gynecology British Empire, 1933, vol.
xl, 541.
Page 227 Ill
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HISTORIC BASEBALL "LINE-UP"
We present in this number a picture of a group of our members taken
twenty-five years ago, with an accompanying letter from Mr. Leslie Henderson, of the Georgia Pharmacy. Mr. Henderson was inspired to send this
along by a note in the "Twenty Years Ago Today" column of the Vancouver Daily Province of June 20, 193 5.
Of those in the picture, only Dr. J. H. Carson is absent from our number. The others are all alive and well, and we have no doubt could give a
good account of themselves today in a baseball game. The mystic letters
C. B. of C. appearing on the sweaters of some of them, are there because
they were borrowed from a Bank of Commerce team, and have no medical
significance. It is delightful to see the carefree expression on these faces,
the expression of happy youth.
"No fear have they of ills to come
Or thoughts beyond today." . . .
i it 11111 ■ 1111111 in 11 ii i
GEORGIA PHARMACY Limited
777 West Georgia Street
Vancouver, B. C.
Dr. J. H. MacDermot,
92 5 West Georgia St.,
Vancouver, B. C.
Dear Doctor:
Having read in last night's Province, under the "Twenty Years Ago"
column, a reference to the Medical Baseball Team of twenty years ago, and
having had a picture of the team for many years, I thought you might be
interested in same in regard to the Medical Bulletin.
Should any of the members of the team care to have a complimentary
copy of the picture, I have a negative and will be very glad to send them
one upon request.
Yours very truly,
Leslie G. Henderson.
Page 228 PRESENT  STATUS  OF PROSTATECTOMY
Notes from Address by Dr. Verne Hunt
There would seem, said the speaker, to be some doubt about the value of
prostatectomy at the present day. As one of the older generation of surgeons he felt that we should not lightly discard the general principles which
have guided us in the past in the treatment of enlarged prostate.
Modern methods have been introduced and popularized; to some extent
advertised. Dr. Hunt felt that there had been a rather overwhelming degree
of propaganda, and in his mind there was room for some doubt about certain
things in connection with these.
We must not, he felt, be swept off our feet by the newer methods, which
have been adopted mainly by a younger generation of urologists, who perhaps have not had the experience and knowledge of past methods which have
been the lot of former surgeons. They may perhaps lack perspective for
this reason, to some extent. The speaker made it plain that he was not trying
to discourage these methods, when rightly used by competent men.
History. The speaker briefly reviewed the history of the evolution of
Prostatic Surgery.
First, there was the pre-surgical era, or rather the era before asepsis
made surgery at all possible, when the surgery of the prostate was very crude,
removal was seldom if ever practised, and merely some form of incision, as
by lithotomy, was practised.
Prostatic surgery developed from lithotomy, and at first was done by the
perineal route.
The early surgical era from 1885-1895 was coincident with Listerism.
The first prostatectomy was done by Billroth in 18 87 (perineal route)
for carcinoma.
In 1889, Watson operated for hypertrophy. The perineal operation was
popularised by Goodfellow of San Francisco, but Bellfield in Chicago did
the first suprapubic prostatectomy in 1887.
In 1890, the world's entire literature showed only 133 cases where the
prostate had been removed, all being done for complete obstruction; 68%
of these had voluntary micturition afterwards, and the mortality was only
10%, though higher by the suprapubic than by the perineal route.
Other methods were tried: e.g., bilateral castration, ligation of afferent
vessels, etc.  None of these were effective.
The method of operation was chiefly nibbling and no complete enucleation was tried till Fuller, in 1900, introduced this.
Freyer did much, as we all know, to make the operation a sane one and
to bring the profession back to prostatectomy, but it was left for Hugh
Young in 1903 to provide a method of open and accurate visualisation by
adequate exposure through the perineum, and this was a noteworthy contribution to this work.
Later Judd and Thomson-Walker introduced a light into the bladder
for suprapubic removal.
Gradually the suprapubic method became the method of choice, though
as regards results and mortality there was little to choose between the two
routes.
Transurethral removal. In one way this is nothing new. One hundred
years ago (1834) Guthrie first operated with a catheter and concealed
blade; in 1836 Mercier devised another instrument.
Page 229
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McKee in 1873 reported a transurethral operation.
Young (1909) found certain types of small glands and those with contractures of neck (the so-called "bar"). He devised an instrument known
as "Young's punch."
In 1918 and 1926 other instruments were introduced.
Then came the modern operation, preceded by the Davis resection.
Unfortunately, in Dr. Hunt's opinion, Davis (of Carolina), who was
extremely enthusiastic about this method, spoke of it as a minor surgical
procedure. Most emphatically, Dr. Hunt said, it is not a minor procedure.
With this report of Dr. Davis, a great deal of enthusiasm was engendered,
and an intensive campaign by instrument-makers started.
"I know that the transurethral method, properly and capably done, in
skilled hands, is an excellent operation."
But its ease of operation and results in skilled hands have led to its adoption by men who are not skilled, and so to results which would not have
occurred in the right hands.
It is not a procedure which a man merely skilled in cystoscopy can safely
undertake; nor can it be used in every case.
Indications. Dr. Hunt took the stand that whatever procedure is
adopted, we must have definite indications, and follow these closely, otherwise we court disaster.
(1) Prostatic age. Few men under 60 have true prostatic obstruction.
More than 50% of men over 50 have some enlargement of prostatic tissue.
There must be obstruction to the urinary output. This is a fundamental
Equal to the
H      Famous Spas of Europe
Many physicians, after visiting leading spas in Europe, find,
the waters at Harrison Hot Springs are more highly mineralized. Bad Nauheim is particularly comparable with Harrison,
as to location and. elevation. For heart, nervous and rheumatic cases, the treatments at Harrison are found particularly  beneficial.    Specific  in
formation    w i 11
given.
tladh
Relax and Revitalize
at the
SPA of CANADA
HARRISON HOT SPRINGS HOTEL
HARRISON, BRITISH COLUMBIA
Page 23 0 indication, irrespective of the size of the gland. As long as the patient is
emptying his bladder, operation is not called for.
(2) Very few men less than 60 years old require removal of any part
of gland on account of retention or difficulty in emptying bladder.
The average age is 63 years plus. Many men are doing transurethral
resections in patients under 60, for what they call prophylactic reasons, to
prevent trouble. Hunt does not subscribe to this. He needs definite indications for what is a major, and not a minor, surgical procedure.
The indications, to his mind, are exactly the same for transurethral as for
any other type of prostatectomy.
Alcock of Iowa has, he thinks, the best list of indications, based on
honestly collected and honestly interpreted statistical material.
We must not emphasize success and ignore failures. We must expect
that results will not be good in every case, and we must admit and record
our poor results. The integrity of the surgeon, his experience and skill are
the test as regards results.
Many complications may arise, and just as many, and the same complications, by the one method as by the other.
When definite indications are observed, and skill is adequate, mortality
may be less than 5 c/c, but can go up to 15 or 20%.
Dr. Hunt shewed slides which shewed the importance of age as a factor
in the results.
The causes of death: in 150 cases, 28% were due to pyelonephritis, 15 %
to sepsis, and 15 % to bronchopneumonia, a total of 5 8 % due to infection.
Uraemia caused only 6 Vzc/c and haemorrhage 3 J/2%.
"Delightfully
Palatable"
Your patients will cooperate willingly
when delightfully palatable Petrolagar is
prescribed in the treatment of constipation. May we suggest that you taste
Petrolagar and note the pleasant flavor.
Petrolagar is a mechanical emulsion of
liquid petrolatum (65% by volume)
and agar-agar.
Samples free on request
Petrolagar Laboratories of Canada, Ltd.
364 Argyle Road
Walkerville, Ontario
Petrolaqar
FDR CONSTIPATION
NOW PREPARED IN 5 TYPES
Distinctive
PRINTING
CARDS
STATIONERY
that really are nicer
AND COST YOU
NO MORE
ROY
WRIGLEY
Limited
300 WEST
PENDER STREET
VANCOUVER, B. C.
Page 231 Gold Sodium Thiosulphate
For  INTRAVENOUS
administration.
■   GOLD THERAPY
Of PULMONARY TUBERCULOSIS,
CHRONIC ARTHRITIS,
LUPUS ERYTHEMATOSUS,
—IS BEST REALIZED BY—
CRISALBINE      MYOCHRYSINE
Sodium   Aurothiomalate
For  INTRAMUSCULAR
administration.
PRODUCTS OF
LABORATORY POULENC FRERES
OF CANADA LIMITED
Complete  bibliography  and  detailed  literature upon request  to  the
Canadian Distributors:   ROUGIER FRERES,  MONTREAL
A PRESCRIPTION SERVICE . . .
Conducted in accord with the ethics of the Medical
Profession and maintained to the standard suggested by
our slogan:
Pharmaceutical Excellence
I  McGill 6 Ormo
LIMITED V*—'
FORT STREET (opp. Times)      Phone Garden 1196      VICTORIA, B. C.
STEVENS' SAFETY PACKAGE
STERILE GAUZE
is a handy, convenient, clean commodity for the bag or the office.  Supplied
in one yard, five yards and twenty-five yard packages.
B. C. STEVENS CO.
Phone Seymour 698
73 0 Richards St., Vancouver, B. C. «sd&&i
/
Your patients may enjoy ixdlGvyfyf
All-Bran in many delicious ways
In setting up a diet for a
patient, variety has strong psychological value. New dishes
maintain interest and stimulate
appetite. Where the diet permits "bulk," Kellogg's All-Bran
is doubly convenient.
This natural laxative food
may be served as a cereal with
milk or cream, or cooked into
appetizing muffins, breads,
waffles, etc. Made finer, softer,
more palatable, it blends better
with .other ingredients in the
recipe. All-Bran may also be
taken in orange juice, sprinkled
in soups, over salads or other
cereals.
Kellogg's All-Bran supplies
gentle "bulk" to aid regular
habits. Within the body, this
"bulk" absorbs moisture, and
forms a soft mass. Gently, this
sweeps out the intestinal wastes.
All-Bran also furnishes vitamin B and iron, an important
element of the blood.
Except with those few individuals who suffer from diseased
or highly sensitive intestines,
where "bulk" in any form is
contraindicated, you may safely
recommend Kellogg's All-
Bran. Sold by all grocers in the
red-and-green package. Made by
Kellogg in London, Ontario. Milk Problems
TUBERCULOSIS
PERHAPS the earliest health problem recognized as closely
connected with the milk supply was that of tuberculosis.
The certified milk movement was largely directed toward this
menace. A little later pasteurization came in as a protection
and the time and temperature of pasteurization has been fixed
at a point where all germs of tuberculosis, which may have
found their way into the milk, will be destroyed with certainty.
This organism was selected as a test object because it proved to
be more heat resistant than the germs causing other milk borne
diseases. Accordingly, proper pasteurization of milk makes it
safe from all forms of disease-producing germs.
SUMMER COMPLAINT
At about the same time raw milk was recognized as an
avenue through which tuberculosis might be carried; it was also
noted that it had a close connection with the frequency of
diarrheal disturbances among the smaller children.
Perhaps the most gratifying result of pasteurization, from
the standpoint of the pediatrician, has been the almost complete
disappearance during the hot months of diarrheal outbreaks,
such as was experienced in the days of the universal use of raw
milk. It is now known that these severe diarrheas of small
children are due to a variety of organisms which find their way
into the milk and are destroyed by pasteurization along with the
other disease producers.
ASSOCIATED DAIRIES
LIMITED
DISTRIBUTING
RICH—SAFE—CLEAN—MILK
service phones:
Fairmont 1000     North 122     New Westminster 1445 'i 11111111111111 n 1111111111111111111 r 11
Supplied in bottles containing 6,
10 and 16 ounces. The average
dose is one tablespoonful.
WILLIAM R. WARNER & CO.
Ltd.
727 King St., West, Toronto, Ont.
I 1 I I I I ! I 1 I I T I 1 ! 1 1 I t I I 1 1 I I 1 I I 1 I I 1 t I I I I 1 1 t t I 1 1 1 I M 1 I
URS FREELY
A good emulsion should pour
freely. Agarol does. Il is a mineral oil and agar-agar emulsion
with phenolphthalein that mixes
thoroughly A\ilh the intestinal
contents, supplies unabsorb-
able moisture, lubricates the
tract and gently stimulates peristalsis. And, of course, it may
be added to water, milk, or
to any other liquid. Agarol is
emulsified to such exceptional
fineness that it >\ ill not be broken down in any dilution.
Agarol is palatable without artificial flavoring, because highly purified ingredients impart no taste
that needs disguising. It contains
no sugar, alkali or alcohol—suitable for any age period, under any
condition, for the relief of acute
constipation and in the treatment
of habitual constipation. ... Trial
supply .gladly sent on request. ' 1 'O RELIEVE inflammation, swelling and
pain, and to promote the absorption of the
exudates and infiltrations in cases of sprains, dislocations and synovitis, the application of moist
heat is a valuable aid to the treatment.
Antiphlogistine dressings are an efficient metl.rd
of applying prolonged moist heat and they are
a safe and rational therapeutic measure for the
treatment of inflammations and congestions.
Sample and Literature
On Request.
The Denver Chemical Mfg. Co.
153 Lagauchetiere Street W.
MONTREAL
ANTIPHLOGISTINE
For DISLOCATIONS
SPRAINS SYNOVITIS
Made in Canada Clinical data indicates a reduction in mortality as compared with the mortality after
administration of antimeningococcic serum
dNow  commercially  available
Meningococcus
Antitoxin
• i
a
n
P. D.  & CO.
Accepted for N. N. R-. by the Council on Pharmacy anti
Chemistry of the American Medical Association.
Meningococcus Antitoxin, P. D. & Co. (Bio. 168), is
supplied in containers with diaphragm stopper at each
end, each container holding approximately 30 cc.
and representing at least 10,000 units.
Literature on request.
PARKE,  DAVIS   &   CO.,  Walkerville,  Ontario
I.1      f
la1;
SI '■'.    I
■i !r
at
•M
)X, N
>M
tf
• ! 11 wt
lUfc
IH
«li!
$
I-
1 I
fli^
•w   *r>   'U'   'V
"Absolute Accuracy,,
In filling the eye physician's prescription, nothing short
of absolute precision will satisfy us.
We take a pride in maintaining
Guild standards to the utmost.
OPTICAL CO. LTD.
Dispensing Opticians
631  Birks Bldg., Vancouver, B.C.
Nutttt $c ®l|omBon
2559 Cambie Street
ancouver
, B. C.
REST  HAVEN
A Medical Institution for the restoration of health, situated eighteen
miles from Victoria, overlooking the Gulf of Georgia.
Modern facilities for the treatment of all classes of patients with the
exception of those suffering from mental or contagious diseases. Hydrotherapy, electrotherapy, massage, and diet, under medical supervision.
Physicians referring patients or convalescents for treatment are requested
to send such reports and suggestions as may assist in their treatment.
REST HAVEN SANITARIUM and HOSPITAL
SIDNEY, B. C.
S. BOWELL & SON
DISTINCTIVE  FUNERAL
SERVICE
Phone 993
66 SIXTH STREET
NEW WESTMINSTER, B. C. i A
Nupercainal "Ciba"
A Non-Narcotic Analgesic Ointment
for the relief of pain or itching in affections of
the mucous membranes or skin.
Nupercainal has been found to be highly effective to secure
prompt and prolonged relief from discomfort in:
SUNBURN - BURNS - HAEMORRHOIDS - DRY
ECZEMA - ULCERS - DECUBITUS - PRURITUS ANI
and VULVAE - ANAL FISSURES, Etc.
Issued in one ounce tubes with a rectal applicator.
CIBA COMPANY LIMITED
MONTREAL
i.'  r
::U
.■*., |*
i%
i   t
?! 1
flftount BMeasant Ulttbertaking Co. %to.
KINGSWAY at 11th AVE. Telephone Fairmont 5 8 VANCOUVER, B. C.
R. F. HARRISON W. R. REYNOLDS H
j I lit
! II
ff'
ifi'
till
HI
For bland diet therapy, ffj
especially ULCER cases -
PABLUM
FAR too often the bland diet prescribed for gastric ulcer, colitis, and similar
gastro-intestinal disorders is a deficient diet. An analysis made by Troutt of
ulcer diets used by 6 leading hospitals in different sections of the country
showed them to be "well below the Sherman standard of 15 milligrams" in
iron and low in the water-soluble vitamins.1 "Vitamin B would appear to be
represented at a maintenance level in most cases," writes Troutt, "but the
possible relation of vitamin B to gastro-intestinal function and appetite should
make one pause before accepting a low standard."
how in Fiber — High in Iron
Pablum is the only food rich in a wide variety of the accessory food
factors that can be fed over long periods of time without danger of
gastro-intestinal irritation. Its fiber content is only 0.9%. Yet Pablum contains 37 times more iron than farina and is an excellent
source ( + 4- +) of vitamins B and G, in which farina is deficient.
Supplying %Y% mgms. iron per ounce, Pablum is 8 times richer than
spinach in iron.
Rich in Vitamin B
The high vitamin B content of Pablum assumes new importance in
lirrht of recent laboratory studies showing that avitaminosis B
predisposes to certain gastro-intestinal disorders. Apropos or this,
Cowgill says, "Gastric ulcer is another disorder which can conceivably be related to vitamin B deficiency. Insofar as the treatment of this condition usually involves a marked restriction of diet
the occurrence of at least a moderate shortage of this vitamin is by
no means unlikely. Obviously the length of the period of dietary
restriction is an important determining factor. Dalldorf and Kellogg
0-931) observed in rats subsisting on carefully controlled diets that
the incidence of gastric ulcer was greatly increased in vitamin B
deficiency. Observations of this type merit serious consideration.
Requiring no further cooking, Pablum is especially valuable during the heal' j
ing stage of ulcer when the patient is back at work but still requires frequent j
meals. Pablum can be prepared quickly and conveniently at the office or
shop simply by adding milk or cream and salt and sugar to taste. Pablum has
the added advantage that it can be prepared in many varied ways—in mufnns»
mush, puddings, junket, etc. Further, Pablum is so thoroughly cooked that its
cereal-starch has been shown to be more quickly digested than that of farif1^
oatmeal, cornmeal, or whole wheat cooked four hours in a double boiler,
(studies in vitro by Ross and Burrill).
mgm. re
perlOOGm.
PABLUM
30 mom.
o
- JO
— 10
Farina
1     0.8 mgm.
o
Although Pablum has a
low f.ber content it is 37
times richer than farina
in iron and in calcium, 4
times richer in phosphorus, and iyi times richer in copper.
Pablum consists of wheatmeal, oatmeal, cornmeal, wheat embryo, alfalfa, yeast, beef bone, iron salt and sodium chlorM-
1-2 Bibliography on request.
MEAD JOHNSON & CO. OF CANADA, Ltd., BellevilleJjnt. |
Please enclose professional card when requesting samp'es of Mead Johnson products to cooperate in preventing their reaching unauthorized l*r
J IT GIVES YOU
A SENSE of SECURITY
Sooner or later it happens to most of us ... an
urgent need of medicine or sickroom necessities.
It gives you a sense of security to know that you
can call Seymour 1050 any hour of the day or night
and get what you require.
Phone Georgia Pharmacy Day or Night.
for 25 Years Specialists in Prescriptions
PSEYIOSO
'               OMNAU.
 MIOHT
OPEN
ALL
NIGHT
GEORGIA PHARMACY
LIMITED
SEYMOUR
1050
W. GEORGIA ,
STREE T
ii S
(ftntter $c if atma l&ifc
Established 1893
VANCOUVER, B. C.
North Vancouver, B. C.    Powell River, B. C.
Published monthly at Vancouver, B. C, by ROY WRIOL.EY ltd., 300 west Pender Street ?^^&^^9^S^^^^m^^^^S^S^^S^^S&(
III
I K!
Hollywood Sanitarium
Limited
For the treatment of
Alcoholic, Nervous and Psychopathic Cases
Exclusively
Reference—B. C. Medical Association
For information apply to
Medical Superintendent, New Westminster, B. C.
or 515 Birks Building, Vancouver
Seymour 4183
Westminster 288
S5SSS5SSSSSSSSS^5S5SSS5SSS

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