History of Nursing in Pacific Canada

The Vancouver Medical Association Bulletin: March, 1941 Vancouver Medical Association Mar 31, 1941

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 «sra&3 t
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3RIT1S1
Tlhe BULLE
of the
VANCOUVER
MEDICAL ASSOCIATION
Vol. XVII.
MARCH, 1941
No. 6-
With Which Is Incorporated
Transactions of the
Victoria Medical Society
the
Vancouver General Hospital
and
StMPaul's Hospital
In This Issue:
NEWS AND NOTES-_» J|-;. || _	
ELECTION OF MEMBERS, COUNCIL OF PHYSICIANS
III AND SURGEONS _^L—j^^„ JS^'lf	
CANADIAN MEDICAL ADVISORY COMMITTEE-J|§LJ||
TEST FOR CANCER—Dr. F. N. Robertson, JjB,* -■—	
CLINICAL IMPORTANCE OF VENOUS PRESSURE-—
Dr. J. A. McCaffreyjM  j	
DEVELOPMENT IN PAEDIATRICS—d||Grover F. Powers-
ETHICS AND ECONOMICS OF DRUG MANUFACTURING.
Page
§§48
1 150
_ 152
.  155
| 159
pH 62
. 174
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Don't fight fever
Made in
Canada
Remove the cause!
Fever is Nature's reaction to disease.
By combating inflammation and corv
gestion, Antiphlogistine helps to remove
the cause of the fever.
SAMPLE AND LITERATURE ON
REQUEST
INFLAMMATION'S ANTIDOTE
THE DENVER CHEMICAL MANUFACTURING COMPANY
153 Lagauchetiere St. W.    fH •      Si      Montreal THE     VANCOUVER    MEDICAL     ASSOCIATION
BULLETIN
Published Monthly under the Auspices of the Vancouver Medical Association
in the interests of the Medical Profession.
Offices: 203 Medical- Dental Building, Georgia Street, Vancouver, B. C.
EDITORIAL BOARD:
Db. J. H. MacDermot
Dr. G. A. Davidson Dr. D. E. H. Cleveland
All communications to be addressed to the Editor at the above address.
Vol. XVII.
MARCH, 1941
No. 6
OFFICERS, 1940-1941
Dr. D. F. Busteed Dr. W. M. Paton Dr. A. M. Agnew'
President Vice-President Past President
Dr. W. T. Lockhart Dr. R. A. Palmer
Hon. Treasurer Hon. Secretary
Additional Members of Executive: Dr. C. McDiarmid, Dr. L. W. McNutt.
TRUSTEES
Dr. F. Brodie Dr. J. A. Gillespie Dr. F. W. Lees
Auditors: Messrs. Plommer, Whiting & Co.
SECTIONS
Clinical Section
Dr. Karl Haig Chairman Dr. Ross Davidson Secretary
Eye, Ear, Nose and Throat
Dr. J. A. McLean Chairman Dr. A. R. Anthony Secretary
Pediatric Section
Dr. R. P. Kinsman.'. Chairman Dr. G. O. Matthews Secretary
STANDING COMMITTEES   §
Library:
Dr. F. J. Buller, Dr. D. E. H. Cleveland, Dr. J. R. Davies,
Dr. W. A. Bagnall, Dr. T. H. Lennie, Dr. J. E. Walker.
Publications:
Dr. J. H. MacDermot, Dr. D. E. H. Cleveland, Dr. G. A. Davidson.
Summer School:
Dr. H. H. Caple, Dr. W. W. Simpson, Dr. Karl Haig, Dr. J. E. Harrison,
Dr. H. H. Hatfield, Dr. Howard Spohn.
Credentials:
Dr. A. W. Hunter, Dr. W. T. Ewing, Dr. A. E. Trites.
V. 0. N. Advisory Board:
Dr. E. Riggs, Dr. W. C. Walsh, Dr. R. E. McKechnie II.
Metropolitan Health Board Advisory Committee:
Dr. H. Spohn, Dr. F. J. Buller, Dr. W. T. Ewing.
Greater Vancouver Health League Representatives:
Dr. G. O. Matthews, Dr. M. W. Simpson.
Representative to B. C. Medical Association: Dr. A. M. Agnew.
Sickness and Benevolent Fund: The President—The Trustees.
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EVER
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FEED
nit;
SMA
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—A SPECIAL PRODUCT—
For  premature and  undernourished infants."
Protein S.M.A. (acidulated)
is a modified form of S.M.A.,
intended to meet the special
nutritional needs of the premature and undernourished
infant and for infants re-,
quiring a high protein intake.
Protein S.M.A. (acidulated)
is similar to both casein milk
and lactic acid milk, but presents additional nutritional
elements lacking in both.
When you prescribe S.M.A. for the bottle-fed infant you give
an easily digested fat, a protein that provides the amino acids
essential for adequate nutrition and growth and lactose, a
physiological carbohydrate, in correct proportion to the nutritional requirements of the normal full-term infant.
In addition, when prepared according to the usual dilution for
feeding, each quart of S.M.A. contains:
9400 international units vitamin A activity
250 international units vitamin Bi
600 international units vitamin D
10 mg. Iron
S.M.A. provides easily digested fat and protein of full biological value in correct proportion to the nutritional requirements of the normal full term infant. Therefore, the only
carbohydrate in S.M.A. is Lactose. . . .
Normal infants relish S.M.A. . . . digest it easily and thrive
on it.
*S.M.A., a trade mark of S.M.A.-Biochemical Division, John
Wyeth & Brother (Canada) Limited, for its brand of food
especially prepared for infant feeding—derived from tuberculin-tested cow's milk the fat of which is replaced by animal
and vegetable fats, including biologically tested cod liver
oil; with the addition of milk sugar and potassium chloride;
altogether forming an antirachitic food. When diluted according to directions, it is essentially similar to human milk
in percentages of protein, fat, carbohydrate and ash, in
chemical constants of the fat and physical properties.
S.M.A.—Biochemical Division—JOHN WYETH & BROTHER (Canada) LIMITED, Walkerville VANCOUVER     HEALTH     DEPARTMENT
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STATISTICS—JANUARY, 1941
Total population—estimated  — - -     272,352
Japanese population—estimated            8,769
Chinese population—estimated         8,558
Hindu  population—estimated    360
Rate per 1,000
Number
Total deaths   366
Japanese deaths  3
Chinese deaths  20
Deaths—residents only     331
Population
15.8
4.0
27.5
14.3
BIRTH REGISTRATIONS:
Male, 234; Female, 237 -    471 20.4
INFANTILE MORTALITY:                                           Jan., 1941 Jan., 1940
Deaths under one year of age      19 9
Death rate—per 1,000 births      40.3 23.2
Stillbirths (not included in above)      14 10
CASES OF COMMUNICABLE DISEASES REPORTED IN THE CITY
December, 1940    January, 1941 Feb. 1-15,1941
Scarlet Fever 	
Diphtheria 	
Chicken Pox 	
Measles         t42
Rubella   	
Mumps 	
Whooping Cough  1 1	
Typhoid  Fever 1	
Undulant Fever 	
Poliomyelitis 	
Tuberculosis     	
Erysipelas	
Meningococcus Meningitis   _
Paratyphoid  Fever	
tses
Deaths
Cases
21
0
19
0
0
0
82
0
134
42
0
1171
17
0
115
3
0
0
2
0
0
0
0
1
0
0
1
0
0
0
36
11
1
0
1
5
0
6
0
0
0
Deaths
0
0
0
• 0
0
0
0
0
0
0
19
0
o
o
0
Cases
6
0
65
895
175
6
3
0
0
0
1
3
0
Deaths
0
0
0
0
0
0
0
0
0
0
0
0
V. D. CASES REPORTED TO PROVINCIAL BOARD OF HEALTH,
DIVISION OF VENEREAL DISEASE CONTROL
West North        Vane.   Hospitals &
Syphilis 	
Gonorrhoea
Burnaby
Vancr.
Richmond
Vancr.
Clinic   Private Drs.
Totals
0
0
1
1
20               16
38
0
0
2
0
64               20
86
i BIOGLAN!
THE SCIENTIFIC HORMONE TREATMENT
Bioglan products differ in that they are derived from original material."
A Product of the Bioglan Laboratories, Hertford, England.
Represented by
STANLEY   N.   BAYNE
«
Phone: MAr.402?
1432 Medical-Dental Bldg.
Descriptive Literature on Request
Vancouver, B. C.
Page 144 m
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CALCIUM A
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VITAMIN A
3500 International Units
VITAMIN D
350 International Units
DIBASIC
CALCIUM PHOSPHATE
560 mg. (8.6 grains)
in each capsule
"Calcium A" with its substantially increased content of
calcium, phosphorus and Vitamin A will be found more
effective than ever as a calcium-cod liver oil dietary supplement. Three capsules daily furnish approximately 400 mg.
of calcium and 300 mg. of phosphorus as well as concentrated cod liver oil having the Vitamin A and D value of
at least three teaspoonfuls of cod liver oil,  B.P.
Supplied   in    original    boxes    of   40    and    100    capsules
iHRfeMcKEHNl alHAHRISiiLIMIT'Ei
Biological G+td PUa/mtaceuUcGl GUemtitl
MONTREAL
PRESCRIBE CANADIAN MADE PRODUCTS
HELP WIN THE WAR
92'
CANADA
BUY WAR SAVINGS CERTIFICATES VANCOUVER MEDICAL ASSOCIATION
Founded 1898 . • . Incorporated 1906
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
8:00 p.m. Place of meeting will appear on the Agenda.
General meetings will conform to the following order:
8:00 p.m.—Business as per Agenda.
9:00 p.m.—Paper of the evening.
Programme of the 43rd Annual Session
February 18—CLINICAL MEETING.
Programme of the 43rd Annual Session (Spring Session)
March    4—SPECIAL LECTURE.
Dr. Henrik Dam of Copenhagen.
March 12—OSLER LECTURE.
Dr. G. F. Strong.
March 18—CLINICAL MEETING.
April    1—GENERAL MEETING.
Symposium on Cancer—Conducted by Department of Cancer Control of the
Canadian Medical Association.
April 15—CLINICAL MEETING.
April 22—ANNUAL MEETING.
BDI* i
MEMBERS of THE GUILD
of PRESCRIPTION OPTICIANS of AMERICA
Always Maintain the
Ethical  "Principles  of
the Medical Profession
Guilder aft Opticians
430 Birks Bid?.        Phone Sey. 9000
Vancouver, Canada.
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11 IP
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FOR THERAPY
Average adult dose, 4 grams (about 60 grains) Sulpha th.ia.zole
Squibb initially, followed by 1 gram (15 grains) q. 4 h.
For infants and young children, 1 grain per pound of body
weight initially, followed by \i grain per pound of body
weight every six hours.
FOR CONVALESCENCE
Navitol Malt Compound 2 tsp. T.I.D.
SULPHATHIAZOLE SQUIBB §
The Thiazole Analogue of Sulphapyradine chief advantages appear to be:
(1) Less tendency to cause serious (3) Less conjugation after absorption,
nausea or provoke vomiting. (4) Less tendency for urinary
(2) More uniform absorption. complications.
Supplied in 7.7 grain (0.5Gm.) Tablets in bottles 0/ 50, 100, 500 and 1000.
NAVITOL MALT COMPOUND
A useful dietary adjunct containing Liver Extract, Calcium,
Phosphorus and Vitamins A, Bi, D and the B-Complex.
Supplied in %, 1 and 2 lb. bottles.
%.
^ For literature, address 86 Caledonia Road, Toronto
eVRiSojjibb & Sons of Canada, Ltd.
MANUFACTURING   CHEMISTS   TO   THE   MEDICAL   PROFESSION   SINCE   1858 At a recent meeting of the Vancouver Medical Association, the question of the
Summer School came up, whether in this present year of our Lord it were wise or politic
to hold a Summer School, or whether we should intermit this institution of ours for a
period. There are arguments pro and con, no doubt: and we can understand that many
might quite honestly and sincerely feel that the objections outweigh the advantage to
be gained. But we think the Association decided wisely when they gave the go-ahead
signal. An enterprise like the Summer School, gradually and laboriously built up over
the years, has acquired a momentum and instituted traditions and techniques which
might easily be lost—and it would be a serious loss. It is not only the fact that good
mien and able speakers come here to address us—that would be merely our own gain.
But it is Vancouver's contribution to the scientific resources available to men practising
medicine in British Columbia. At present, and up till now, it has been our main contribution, affording a forum where men from all parts of B. C. may meet and together
refresh and stimulate their keenness and interest in the latest and newest work. And so,
as long as we can do so without prejudice to other, perhaps more urgent, necessities
arising out of the present world situation, we feel that we are doing a national service,
even though it be a small one, by maintaining and improving this community effort.
There are, however, one or other aspects of this matter, of Postgraduate Courses,
Summer Schools, B. C. Medical meetings, with which we should like to deal for a minute or so.
First, about the social side of these meetings. Many of us journeyed to Nelson last
Septmeber, and we learnt there some lessons. We saw certain things done which we
might well copy: a whole section of the medical profession, our hosts, putting their
whole energy into securing that we were not only received cordially, but that we were
given a welcome which warmed all our hearts, and that we were given everything they
had: as, in private life, we might entertain our friends. And we had a rather unpleasant
feeling that we in Vancouver have been very remiss in this regard. Our visitors, at
Summer School or whatnot, are "strangers within our gates," not, as in Nelson, honoured
and welcome guests and friends. They are left to fend for themselves. A golf game
and a Dinner are arranged. If they like) to play, well and good—if they care to come
to the Dinner, well and good—but there is little or no trouble taken to see that they
have a pleasant, even a delightful visit, and that they take away, as we took away, very
happy memories of a most enjoyable visit.
This is a pity—but it can be remedied, and we suggest to the Vancouver Medical
Association, as well as the B. C. Medical Association, that it be remedied, and that suitable steps be taken to this end. We are really glad, delighted even, to see these fellows
from other towns, and other lands, and we should show it abundantly and enthusiastically, and convince them of the fact.
The other aspect is this. Why could not Vancouver itself put on a Schiool, a Postgraduate Week, a Clinical Instruction Programme, anything you like? We have two
excellent and well-staffed hospitals, with clinical and pathological material and resources
equal to many big teaching hospitals. For many years, the staffs of the two big hospitals
have been organized to give clinical demonstrations, discussions, lectures, etc. We have,
too, the B. C. Cancer Institute, where work is being done that would be of value to all
medical men to see and learn from. There is the Chest Diseases Division of the Provincial Board of Health, with its wealth of records and graphic displays, and the Venereal
Diseases Division could give an admirable contribution to the programme. We have
abundant resources here for teaching and postgraduate work, and we should begin to
Page 145
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use them. It would take us some time, some years, perhaps, to organise thoroughly for
adequate teaching purposes, if for instance a Medical School were to be added to the
University facilities of B. C: so that the sooner we begin to mobilise our resources, the
better. Meantime, we shall be making use of material which is at present largely going
to waste.
Why could not the various Staffs get together, and put on a really good show? It
could be done without charge to anyone, and as regards the worth-whileness of it, one
has only to read some of the work published by these Hospitals and Clinics to recognise
that they would have not the slightest difficulty in arranging a programme of real excellence, which would attract men as does the Summer School or the Annual B. C. Medical
programme. We commend this idea to the two Hospital Staffs: and we are sure they
would get support in large numbers, not only from local practitioners, but from all
parts of the Province.
The Editor of the Bulletin is at present peering cautiously out from the doghouse
into which he has recently retired: and he desires! to make an explanation, and perhaps
utter an apology, for an act for which he takes full responsibility.
In the last two issues of the Bulletin has appeared, in two instalments, a condensed account, reprinted from the Coronet, a small vest-pocket magazine many men
will know, of a book written by Anton Hertzler, author of The Horse and Buggy Doctor. Many men, and they are men whose judgment we sincerely respect, have taken
serious exception to our publication of this, as being much below the standard of the
Bulletin: and as having in it stuff that, to put it mildly, may leave a bad taste in
the mouth.
Well, we acknowledge the corn. Our only excuse is that we meant it purely "In
Lighter Vein." The man writes rather wittily and humorously, and we felt it might
amuse and divert. The Bulletin is written for medical men, and is not generally
published, and so we felt that this might be tolerated: not, be it said, that we would
admit for a second that what might not be good enough for a lay gentleman would be
good enough for a medical ditto. But it is written by a doctor, and we need not feel,
we think, that it was written to offend.
But we think now that its publication was perhaps a mistake, and we beg our
readers' pardon.—Frankly, we do not think much, and never did think much, of
Hertzler: whom we have always regarded as a bit of a bore—and excused for his boasting,
on.the ground that he is too old to know better. But he has a ready and sometimes an
amusing pen—and we thought it might pass muster for that reason.
May we say that we are, in spite of our discomfiture and remorse, secretly rather
proud that the Bulletin's honour and dignity mean so much to its readers; that they
regard it is an error and a wrong thing to lower the standard which they feel it has
attained. May we say, too, that we are grateful to those who have, so frankly, yet with
a kindness and consideration which we hardly deserved, spoken to us about this. We
shall always welcome, and pay due respect to, such criticism and censorship. The rebuke
has been, in all cases, a kindly one, the act of a friend—as the Biblical essayist has it,
"Rebuke a friend: it may be that he said it not, and if he said it, that he will not say
it again."  We assure our friends that we will not say it again.
W
The Bulletin has been asked by the Executive of the Vancouver Medical Association to call its readers' attention to certain considerations with regard to some of Vancouver's newest guests: those unfortunate people who have had to leave their homes in
Great Britain.
1. A few of these, women and children, are at present in the city, and will be here
for the duration of the war. We imagine that our remarks will apply to the case of
others in other towns and places in British Columbia.
Page 146
EM- 2. Certain very serious problems arise out of their present condition, since many of
them are without funds. As we all know, they were not allowed to bring money and
cannot have money sent to them from England or Scotland. They are not eligible for
relief from Provincial or municipal funds.
3. The Children's Section of the Co-ordinating Council has undertaken through
various social agencies to care for these families. The Family Welfare Bureau has the
largest share of this work in Vancouver. Private individuals have donated a small trust
fund for this purpose. No doubt, when the war is over, many of the families will be
able to reimburse anyone who has advanced them money: all will want to do what they
can—but meanwhile, this must not be reckoned with.
4. The question of medical care has arisen, and has been brought to the attention of
the Medical Associations of British Columbia—in this case the Vancouver Medical Association.
5. The Executive of this body has met the Family Welfare Bureau and others concerned: has discussed the matter with them, and has given assurances that medical care
will be gladly and freely given to these people in the same way as it is given to others
in similar unfortunate financial circumstances.
6. All members of the V. M. A. are urged to give to any such case to which they
may be called their most lenient and considerate attention.
7. The Family Welfare Bureau will be glad to help in ascertaining the financial
status of any of these families on request.
The Bulletin heartily commends these points to the careful consideration of its
readers.   It feels that the Executive has handled this situation in quite the right way:
and it is up to each one of us to justify their confidence in our generosity and willingness to do all in our power to mitigate for these people who have done so much for us
their.physical and mental distress and suffering.
LIBRARY NOTES
NEW BOOKS RECEIVED IN LIBRARY
Transactions of the American Opthalmological Society, vol. 38, 1940.
Fractures and Other Bone and Joint Injuries, 2nd ed. 1940, by R. Watson-Jones.
1940 Year Book of General Surgery, edited by Evarts A. Graham.
Diseases of the Nervous System, 2nd 2d., 1940, by W. Russell Brain.
Manual of Clinical Chemistry, 1941, by Miriam Reiner.
MISSING BOOKS
The following books have been borrowed from the Library without being recorded.
It is urgently requested that they be returned at once:
Dietetics for the Clinician, 2nd ed., by M. A. Bridges.
Newer Knowledge of Nutrition, 4th ed., 1929, by E. V. McCollum.
1937 Year Book of General Medicine.
Statistical Survey of 3000 Autopsies.   Stanford University.
Surgery, Gynaecology & Obstetrics, vol. 63, 1936.
American Journal of Surgery, vol. 44, 1939.
Endocrinology, May and July, 1940, numbers.
Archives of Surgery, February, 1940.
Journal of Infectious Diseases, Nov.-Dec, 1939, number.
WANTED—By Record Office, V. G. H.
Surgery, Gynaecology & Obstetrics, June, 1940, number.
Page 147 t. 5 t S
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NEWS    AND    NOTES
Capt. J. A. Wright visited Vancouver while on leave from his Regiment stationed in
Nova Scotia.
The profession extends sympathy to Dr. O. S. Large of Vancouver on the death of
his mother.
We announce the arrival of four sons to members of the profession—Dr. Lincoln
Cromwell of Victoria, Dr. F. J. Hebb of Vancouver, Dr. P. Ragona of Vancouver and
Dr. J. D. Stenstrom of Vancouver.
Doctors H. H. Boucher and D. M. Meekison of Vancouver have returned from
Phoenix, Arizona.
Dr. S. P. Findlay of Fraser Lake is receiving congratulations on his marriage to Miss
Audrey Chamberlain in Vancouver on February 19th.
Dr. D. M. Black of Kelowna is extended the sympathy of the profession in the loss
of his father on February 19th in Vancouver.
Dr. G. R. Barrett, formerly of Pioneer and more recently on the staff of the Vancouver General Hospital, has joined Dr. R. B. Shaw of Nelson, thus permitting Dr. B.
L. Dunham to join the R.C.A.M.C. Doctor Dunham's departure for service in the
R.C.A.M.C. was the occasion of a dinner in his honour given by the Nelson Medical
Society when a presentation of a wrist watch was made.
Dr. A. G. Macdonald is now associated with Doctors E. R. Hicks and G. K. Mac-
Naughton at Cumberland.
Dr. T. J. Agnew, formerly of Peace River, Alberta, is now associated with Doctors
P. L. Straith and H. A. L. Mooney at Courtenay.
Dr. J. Bain Thorn of Trail was in Vancouver recently.
Dr. Arnold Francis of New Denver participated in the bonspiel at Nelson.
Both Doctors Stewart Wallace and J. A. Ireland of Kamloops are absent on war service, the latter now located in England. Dr. G. D. Oliver, who has been associated with
Doctor Irving, has now joined the R.C.A.M.C. and is located in Victoria. Dr. H. Ostry
is now in Kamloops assisting Doctor Irving. Doctors Grafton and Coltart are the other
members of that group.
Capt. W. M. G. Wilson and wife visited Kamloops and renewed old acquaintances.
Captain Wilson was on sick leave. He was formerly associated with Doctors Burris and
Archibald in the practice there. Dr. Willoughby is still carrying on, and Dr. McNamee
is now with the Naval Medical Services.
sS» *^ *^ s£
Dr. W. H. White of Penticton had a two weeks holiday at the coast.
Page 148 We are glad to hear that Dr. George C. Paine of Penticton has completely recovered
the use of a seriously fractured arm.
The programme of the April 1st meeting of the Vancouver Medical Association will
take the form of a Symposium on Cancer. The speakers will include Drs. H. H. Murphy,
Thomas McPherson and G. F. Amyot of Victoria, and Doctors H. H. Milburn, Wallace
Wilson, T. H. Lennie, C. W. Prowd, A. B. Schinbein, H. H. Pitts, A. Y. McNair, F. A.
Turnbull and L. H. Appleby.
.
WILLIAM Y. CORRY
Obiit February 16th, 1941
It is very difficult to write about a man one has known so well, and of
whom one has been so fond, in any objective way—and anything one says
must perforce be coloured by this personal bias. But few, we think, will disagree with anything we may say about this man who, of all the men one met
in medical practice, most consistently and most adequately filled the requirements and attained the standards of what constitutes a "good doctor."
William Corry had only one idea in his head at all times, to respond to any
call that was made on him, with everything he had. A knowledge of him
extending over thirty years, fails to shew a single instance on his part of refusal
to answer a call, whether it were from a patient who needed him, or another
medical man who sought his advice and help. He had one unfailing answer to
all such calls, given in that quiet reassuring voice of his, "I'll be there." And
he always was, very much, there.
He was a general practitioner all his life, from the time he graduated till
two weeks before his death—and he was in there fighting our ancient enemy
every minute of that time. In his early days he picked out one of the hardest,
bleakest, most uninviting battlefields he could find, the mid-northwest of the
United States, and here he learned his business, in the teeth of blizzard and cold
and hardship. And he learned here self-reliance, quickness of hand and eye,
resourcefulness, and a tempered and seasoned judgment, which lasted him all
his life. Few men had better clinical judgment, few men a readier hand—and
withit all, he never over-estimated his own abilities, or undertook work for
which he did not feel he was fitted.
All these things brought their reward to him—not in money, for he was
a perfectly incompetent person financially, but in the utter trust and confidence of one of the biggest practices any man ever had in Vancouver. At his
funeral one could not but notice the long lines of elderly men and women who
had been his patients, and so his friends, for many, many years—for his patients
stayed by this man who had so loyally stood by them.
Personally, he was one of the dearest men that ever lived—courteous always,
considerate of others, possessed of a true wit, and of a kindly humour, he was
always a welcome addition to any gathering, large or small. He loved his
fellows, and was happy with his own kind. Deeply religious in his outlook on
life, he did his full share as a good citizen, and his standards of conduct were
very high, and in a long life, he never lowered them.
Some time before his death he received the degree of P.G.F. (Prince of
Good Fellows) from the Vancouver Medical Association, and this was one of
the highlights of his life—but to those who knew him, no title could better
describe him.
One could go on forever; but to those who knew him, no praise or eulogy
is necessary—he is with the past now, but we shall never forget him, nor cease
to miss his kindly, cheery presence.
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Page 149
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College of Physicians and Surgeons
President Dr. L. H. Appleby, Vancouver
Vice-President Dr.  W\ A. Clarke, New Westminster
Treasurer Dr.   W\  E.  Ainley
Members of the Council—Dr. J. Bain Thom, Trail; Dr. Thomas McPherson, Victoria; Dr.
Gordon C. Kenning, Victoria; Dr. Osborne Morris, Vernon.
Registrar Dr.  A.  J.  McLachlan
Executive Secretary Dr. M W*. Thomas
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ELECTION OF MEMBERS OF COUNCIL
Election now on—polls close 10:00 a.m. on April 7th.
In three of the five Medical Electoral Districts of British Columbia, voting for
councillors is now well under way.
In Districts No. 2 and 4 Doctors W. A. Clarke of New Westminster and Osborne
Morris of Vernon are the only nominees in their respective districts.
In District No. 1, which extends from Victoria to Atlin, three candidates are in
the field: Doctors F. M. Bryant, Thomas McPherson and J. H. Moore, all of Victoria.
The present councillors in that district are Lt.-Col. G. C. Kenning, who is now the
D.M.O., M.D. No. 11, with headquarters in Victoria, and Dr. Thomas McPherson, who
has accepted nomination for re-election.
In District No. 3, which includes Vancouver, the North Shore and close outlying
points on the lower coastal mainland, five candidates have been placed in nomination:—
Doctors A. M. Agnew, L. H. Appleby, H. H. Milburn, J. R. Neilson and Wallace
Wilson. The two councillors serving now are Doctors W. E. Ainley and L. H. Appleby,
both of Vancouver. Dr. W. E. Ainley is retiring from Council after six years of service,
which is recognized by all as an outstandingly fine contribution. Doctor Appleby has
accepted nomination for re-election.
In District No. 5, which might be described as that of the two Kootenays, Dr. F. M.
Auld of Nelson and Dr. F. W. Green of Cranbrook are the two candidates, one of whom
will be elected.
In the case of District No. 3, Vancouver, and District No. 1, two councillors will be
elected. The one receiving the larger number of votes will serve for four years—the
other for a period of two years. Recent changes in the Medical Act provide that councillors will serve for terms of two years or four years and allow for a certain continuity
of service among its members. In District No. 4 (Okanagan and Central B. C.) and 5
(the Kootenays) the councillors will serve for four years. In District No. 2 (New
Westminster area) councillor will serve for two years.
The rules regarding the election of members of Council provide that a proclamation
of election shall be broadcast by mail on the 14th of January in the year in which the
election is being held. At that time nomination papers are distributed which may be
returned to the office of the Registrar at any time before 10:00 a.m. on February 15th.
Ballot forms are then prepared and sent out to all members on the 2nd day of March.
These are to be returned properly marked before 10:00 a.m. on the first Monday in April,
which falls, this year, on April 7th. Scrutineers properly appointed will meet at 10.00
a.m. on April 7th and count the votes. New councillors will take their seats on the first
Monday in May—the date of the Annual Meeting of the Council.
The various documents distributed to the members have all impressed the fact
that outstanding dues must be paid before the member is eligible to vote. There has
been some misunderstanding with regard to 1941 dues. The regulations provide that the
1941 fees are due and payable on January 1st, and that the member to be in good
standing must have paid them.
Page 150
m^ A very widespread interest is being shown by the members of the College of Physicians
and Surgeons in this election and, while no public meetings are held, yet it possesses
many of the thrills to be found in governmental contests. Because of this considerable
display of enthusiasm on behalf of various candidates in Districts 1, 3 and 5, where
voting is taking place, the need for assuring eligibility by payment of dues is emphasized
and thus any disappointment by the voters should be avoided.
PLEASE NOTE:    1941  dues must be paid before the member is eligible to vote.
Dr. F. W. Green of Cranbrook has requested that he be permitted to withdraw his
name in deference to Dr. F. M. Auld of Nelson.
British I Columbia  Medical | Association
(Canadian Medical Association, British Columbia Division)
President .Dr. Murray Blair, Vancouver
First Vice-President Dr. C. H. Hankinson, Prince Rupert
Second Vice-President _Dr. A. H. Spohn, Vancouver
Honorary Secretary-Treasurer. Dr. Walter M. Paton, Vancouver
Immediate Past President Dr. F. M. Auld, Nelson
Executive Secretary i Dr. M. W. Thomas, Vancouver
BRITISH COLUMBIA MEDICAL ASSOCIATION
Committee on Maternal Welfare
THE VALUE OF ADEQUATE PRE-NATAL CARE
It may appear superfluous to draw to the attention of those members of the medical
profession who are concerned with Obstetrics, the fact that prenatal care is an essential
part of the conduct of pregnancy. It is, however, a lamentable fact that this care is
sometimes inadequate or even lacking entirely.
Through the medium of lay magazines, our patients are able to read well written
articles on the subject, and will rightly be critical of the doctor whose methods are
slipshod.
Our duty is clear cut. When we assume responsibility for the care of an expectant
mother we first must ascertain, by means of a complete physical examination, whether
any defect or disease exists which will increase the risk of pregnancy and labour. Such
existing pathological conditions must be corrected if possible, or so treated as to minimize exacerbations.
A recently enacted law provides for the taking of a "routine blood test." Obviously
a Wasserman is implied, and while this law is not enforced yet the blood Wasserman
should be taken if possible. Blood haemoglobin tests are important, and existing anaemia
should be combatted by suitable iron therapy.
The taking of pelvic measurements is fundamental, and a knowledge of the relationship of the foetal size to pelvic size, coupled with the presentation and position of the
foetus, is obtained by careful examination and is essential in arriving at a preconceived
plan of delivery.
At monthly, or if warranted shorter intervals throughout pregnancy the blood
pressure readings and urinalysis must be recorded routinely if we are to succeed in combatting one of the major causes of maternal death, namely, toxaemia.
A suitable diet should be advised whereby the essential vitamins and minerals are
included or added.   Weight gain, if excessive, should be restricted.
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Not of least importance is the gaining of the patient's confidence, so that the expectant mother approaches labour with a calm and co-operative mind.
Seventy-two per cent of the fatalities among mothers are due to sepsis, toxaemia and
haemorrhage, and all these are considered to be amenable to skilled medical care. Let us
strive that our part in the reduction of this calamity will be adequate at all times.
THE WAR
The following items arising in recent meetings of the Canadian Medical Advisory
Committee are published for the information of members of the Association:
Foreign Exchange Control Board
By invitation, the Committee conferred with the Foreign Exchange Control Board
at which conference the Committee stated that the medical profession of Canada is
qualified to provide adequate medical care for its people, thus making it unnecessary for
Canadians to proceed outside of Canada for treatment. Your Committee was asked to
provide a letter to be sent to every medical practitioner in Canada, setting forth the
position which has been taken.   This has been done.
The attention of the Committee was directed to a form of medical certificate issued
by the Foreign Exchange Control Board, applicable to Canadian citizens who desire to
go to the United States either for medical treatment or for reasons of health. In studying
the form, the Committee felt that many of the questions requiring answers by the
examining Doctor might be deleted or separated to a second form, and so recommended.
The form is being restudied by the Board.
CO-OPERATION  WITH  THE AlR FORCE
The Committee interviewed the Honourable Mr. Power, Minister of Defence for Air,
who accepted our offer of co-operation and subsequently, Group Captain Ryan, Senior
Medical Officer in the Service, advised the respective P.M.O.'s in Canada to co-operate
fully with the Advisory Committee of the C.M.A. in respect to the selection of medical
personnel for the Air Force.
CO-OPERATION  WITH  THE  NAVY
The Committee interviewed the Honourable Angus MacDonald, Minister of National
Defence for Navy, offering the full co-operation of the Association in the selection of
medical officers as required. Mr. MacDonald assured the committee that in the further
selection of medical officers for the Navy, this Association will be consulted in matters
which would properly come under our review.
It may be regarded as a matter of gratification that the Association has now formally and officially been recognized by the three Departments of National Defence, to
act in an advisory capacity coming within our scope and functions.
Enlisting of Interns
It is the Committee's understanding that the various services look favourably upon
a recent medical graduate completing a year of junior internship before enlistment.
Accordingly, enlistment of junior interns in the services will not be encouraged. There
always remains, however, the matter of choice on the part of the individual, and the
Committee is not in a position to guarantee that enlistment by junior interns will not
take place.
Recruiting of Interns and Medical Students for Military Training
The Committee was assured by Major-General LaFleche, Associate Deputy Minister
of the Department of National War Services, that every consideration would be given
interns and medical students in the selection of a time for their military training which
would interfere as little as possible with their hospital and university obligations. As
far as possible, the period* of one year's internship will not be disturbed so long as the
Page 152 ^
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I prospective trainee can take the training within twelve months of the date of proclama-
1 tion calling out his age group. Notification to this effect has been sent to hospitals and
I medical schools throughout Canada.
The following additional information was given to the Committee by Major-General
| LaFleche:
(1) Categorization of prospective trainees by original medical examiners was reason-
i ably satisfactory but could be improved.   The attention of the profession is redirected
to the instructions sent to them. In this connection, Major-General LaFleche provided
j the Committee with a letter to be published in our Journal and in Provincial Bulletins,
\ the publication of which was approved by the Committee.
(2) Statistics re Rejections due to physical unfitness are not yet ready for release
\ but it may be stated that the percentage is lower than might have been anticipated.
When the break-down of statistics is available for publication, full particulars will be
| supplied the Committee.
(3) Medical Advisers have been selected and appointed by the Department of
I National War Services in the various Military Districts, part of whose duties will be
! to examine all medical certificates of trainees, with particular reference to rejections.
I An agreement was entered into between your Committee and Major-General LaFleche
by which the C.M.A. co-operating through its Divisions and the respective Colleges of
Physicians and Surgeons would undertake to nominate Medical Boards (three members
to a Board—a physician, a surgeon, and an Eye, Ear, Nose and Throat specialist) for
the purpose of re-exarnining recruits who were rejected at the first medical examination.
On the nomination of the C.M.A. the Boards will be appointed by the Minister, in the
areas and to the number required, as set forth by the Minister. Each member of a Board
will be paid $10 a day or $5 for part of a day, together with travelling expenses where
such are necessary when the Board is asked to proceed from its base. It is suggested
that these Boards might be recruited from, senior members of the profession who are less
likely to be called upon for active military service due to age or some physical disability.
Journals to First Canadian Division Medical Society in England
The members of the first Canadian Division Medical Society in England will be glad
to receive current Medical Journals and Year Books. If any of our members can spare
copies of these publications, they will be performing a real piece of service by mailing
them to the First Canadian Division Medical Society, Canadian Army Overseas.
Military and Civil Medical Needs
It is recommended to all the Divisions that in the matter of enlistment of medical
personnel for war services, a careful watch be kept to provide a balance between military
and civilian needs as related to medical practitioners.
Journals to Military Hospitals in Canada
It has been decided that the Canadian Medical Association Journal will be sent, with
the compliments of the Association, to the Military Hospitals in Canada of 2 5 0 beds and
over, the list of such ot be provided by the D.G.M.S.
It has been suggested that Medical Societies and members of the Association who
are in possession of Journals which they do not require for permanent keep, forward
them to hospital units and medical personnel in military service, where they will be
very much appreciated.
Industrial Medicine
Some time ago, the Committee had under consideration a proposal for the establishment of a Committee on Industrial Medicine, and the General Secretary was instructed
to secure more detailed information on the proposal. The following suggestions were
submitted:
1. That the attention of the Dominion Government, perhaps through the Minister
of Munitions and Supply, be drawn to the contribution to the war effort which can be
made by the medical profession through the practice of preventive medicine in war
Page 153 ,1'
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industry.  This involved the employment by industry of physicians mainly on a retainer
basis for work within the factory.
2. That an alternative might take the form of representation to Provincial Governments to pass regulations requiring employment by employers in war industry, of
physicians and nurses necessary for the maintenance of health. Such a measure is in
effect in Great Britain. Expand the post-graduate training facilities of the Association
to include industrial medicine, using short intensive courses in industrial centres to
prepare physicians to meet the demand.
3. That a Committee on Industrial Medicine be appointed to consider and eventually
to define the objectives and scope of industrial medicine; to consider the qualifications
and training for industrial physicians and industrial nurses; and to make a survey of
present personnel and training facilities.
It was the feeling of the committee that this matter was of sufficient importance to
be studied by a Comniittee set up for the purpose; and it was agreed that Dr. J. G.
Cunningham of Toronto and Dr. Vance Ward of Montreal be appointed a Committee
with power to add, to study the question of Industrial Medicine and report back to the
Executive Committee.
Central Medical War Committee of the B.M.A.
The Committee had before it a letter from the Central Medical War Committee of
Great Britain requesting that 100 medical officers be recruited in Canada by the C.M.A.
for the R.A.M.C.  The military authorities at Ottawa were conversant with the request.
In order that the committee might consider this request thoroughly, it had available
a list (in the various age groups) of unmarried men who had already signified their
willingness to proceed overseas; a list of those who had already joined one of the services; and an indication from the three military services as to the number of medical
men who might be required during the course of the next twelve months. It was the
unanimous opinion of the committee that every endeavour should be made to secure for
the R.A.M.C. at least 100 men as had been requested. The following procedure was
agreed upon:
That the Divisions be acquainted with the request from the Central Medical War
Committee of Great Britain by sending them a copy of the letter together with information re pay and allowances.
That there be sent to each Division information already available as to enlistments
within the Division of unmarried men thirty years of age and under; that the Divisions
be asked to check the enlistments against their records, noting the men not over thirty
years of age, unmarried, who have volunteered to serve in any capacity overseas; and
that inquiry be made of these man to ascertain if they would be willing to serve in
the R.A.M.C.
If it is ascertained in such inquiry that a man has married since completing his registration card, this information should be noted in the Divisional Records and communicated to the General Secretary.
It is hoped that it will not be necessary to disturb interns serving their first year in
hospital, nor that local medical services will be disrupted unduly.
That the Divisions be asked to take immediate action to ascertain the number of
men not over 30 years of age and unmarried, who are licensed to practise and who, in
the opinion of the Division, are eligible to be recommended to the Canadian Medical
Association for appointment in the R.A.M.C. according to the requirements herein
specified.
All nominations from a Division are to be submitted to the General Secretary of the
C.M.A., who will arrange through the D.G.M.S. to have the candidates medically examined and documented to ascertain their fitness for service.
To secure at least 100 officers for the R.A.M.C. it seems wise to the Committee to
ask for upwards of 125 nominations.
The General Secretary was authorized to carry out the arrangements discussed and
agreed upon, as outlined herein.
Page 154
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eneral
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FURTHER WORK ON TEST FOR CANCER
By Dr. F. N. Robertson, Medical Staff.
[It is with great pleasure that the Bulletin publishes a further report by Dr. F. N.
Robertson, of the Vancouver General Hospital Staff, on his work in endeavouring to
find a reliable and simple test for cancer. Our readers will not have forgotten his preliminary article, published in July, 1940: and we think they will agree that the subjoined report constitutes a notable advance in this work. It is yet much too soon, and
Dr. Robertson would be the first to admit it, to accept the test as final or authoritative
—but reading this report, nothing the overwhelmingly large percentage of accurate
tests, and the meticulous care with which the author has checked his results, together
with the scrupulous honesty of its presentation, one cannot but feel that, in the language of the street, he "has got something there." Certainly, he has gone a long way
past his original beginnings, and has, in our humble opinion, amply justified further
research. It is to be hoped that this work will be put in hand in other centres, and
checked and re-checked, and that some what may, in the way of proof or disproof, this
thing will be thoroughly and most rigidly investigated. Meantime we earnestly congratulate Dr. Robertson on his enterprise and ingenuity, and wish him every success.—Ed.]
Hfl
For a number of years I have held the idea that urine from a cancer patient would
contain something' different from normal urine. Hoping to find some reaction which
would indicate the presence of cancer, I have tried numerous reagents and chemicals
and have even done a lot of experiments on the surface tension of urine, but got nowhere
with it.
Other medical men did not seem to agree with me and thought that cancer tissue
would be broken down and excreted like any other protein. It was not until the
Aschheim-Zondek Test came in that I really felt encouraged to believe that the urine
from a cancer patient really might be different.
Although the idea was original as far as I was concerned, yet others had thought of
it also. For instance, Erlasser and Wallace published a paper claiming to be able to diagnose the presence of cancer by injecting. urine into pregnant rabbits. If the urine was
obtained from a cancer patient the rabbit would abort in about five days.
Dr. Arthur Ham of the University of Toronto has been working along the same
line. He has not yet published his findings, but in personal communication with him
I gather that he has not been able to confirm Erlasser and Wallace's findings.
About 1939 while washing out a blood counting pipette which had contained blood
from a cancer patient I noted a peculiar action of the blood in water. I inadvertently
laid a drop of blood on the surface of the water and there was a peculiar brown, oily
stain on the surface of the water which lasted a few seconds. The drop of blood sank
to the bottom with a smoky trail and formed a peculiar clot. My own blood did not
behave in this manner. The thought came to me that if cancer blood behaves this way
in water, what would it do in "cancer urine"? I tried this test ckver and over and in
various ways until I felt sure there was something real in my results.
In the July, 1940, issue of the V. M. A. Bulletin, you no doubt read a short account of these findings and the technique to be used. This technique has been improved
so as to be more simple, more accurate and quicker. Up to this time no records of tests
were kept but tests were merely done to see if the blood clotted or not. Tonight I wish
to report the results of about 134 cases of these tests.   For the benefit of any who did
Page 155 t!
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not see the article, the technique then used was to have four pus basins. Two of these
contained 2 ozs. or more of urine from a cancer patient and two of them held a similar
amount of urine from a person not suspected of having cancer. From both patients
about 10 c.c. of blood were taken. The "cancer blood" was injected beneath the surface
of the urine, 5 c.c. into his own urine and 5 c.c. into the non-cancerous urine. Similarly blood from the non-cancerous patient was injected—5 c.c. into his own urine and
5 c.c. into the cancerous urine. The basins were then gently agitated every few minutes.
After about 45 minutes the cancer blood in the cancer urine formed a small clot which
clung to the bottom of the dish. The non-cancerous blood in the non-cancerous urine
formed no clot, or else a jelly-like clot—non-adherent. The other two basins occasionally
showed clots, but so seldom that I think it of no consequence and have discontinued
their use.
Of these 134 reported tests 64 are on non-cancerous patients. You may wonder why
so many have been included. This is done because it is just as important to prove that
non-cancerous blood does not clot as to prove cancerous blood does clot.
These controls were taken from patients of both sexes and all ages from first to
seventh decade and who had the following ailments:
Pleurisy with effusion (1)
Injuries (4)
Hernia (1)
Ischio-Rectal Abscess (3)
Rheumatism (4)
Lung Abscess (2)
Pneumonia (3)
Undiagnosed conditions  (5)
Dilated Stomach (1)
Peptic Ulcer (6)
Appendicitis (3)
Bronchiectasis (1)
Burns (3)
Insanity (2)
Tuberculosis (1)
Arthritis (1)
Post-Operative Cystocele
Cirrhosis of liver
Fractured skull
Varicose ulcer
Diabetes (5)
Silicosis (2)
Toxic Goitre (1)
Hodgkin's Disease (1)
Catarrhal Jaundice (1)
Lymphosarcoma (1)
Pregnancy (3)
Normals (3)
Anaemia with Deficient Vitamins
Decompensated heart (1).
In all these cases there was no clotting of blood whereas in 36 cases of known cancer
there was definite clotting.
Cirrhosis of liver (1)
Varicose ulcer  (1)
Post-operative Cystocele (1)
Fractured skull (1)
Of these 36 cancer cases:
8 were carcinoma of the stomach by X-ray and clinical findings but who are still
alive;
3 were proved carcinoma of the stomach by operation;
2 were proved carcinoma of the stomach by autopsy;
2 were carcinoma of the prostate—one is still alive and the other was proved by
autopsy;
2 were carcinoma of the rectum—one was proved by proctoscopic examination,
the other by autopsy;
1 carcinoma of the sigmoid, proved by operation;
1 in the hepatic flexure as proved by X-ray and clinically, the other by biopsy
and autopsy;
2 were in the neck, one proved by X-ray and clinically and the other by biopsy
and autopsy;
5 were in the lung. Three were proved by autopsy and 2 by X-ray who are
still alive;
3 were in the ovaries but no autopsies were allowed, cancer cells were found w
the abdominal fluid;
Page 156 2 were in the vagina, proved by autopsy;
4 were in the pelvis—one proved by autopsy and one by biopsy;
2 are still alive but clinically there is no doubt about the condition.
Two cases of cancer of the sigmoid who had been operated upon, one six weeks and
the other five years before when the growth was thought to be entirely removed, were
both negative to the test.
To this list of positive tests I would like to add 18 other cases. These cases were
suspected cancer cases either clinically or by X-ray in which the test was negative. The
test was correct in all cases are proved by autopsy or recovery.
1. A suspected cancer of the lung at autopsy was an abscess.
2. A suspected cancerous condition recovered and left hospital.
3. A suspected cancer of the stomach at autopsy was an ulcer.
4. A suspected cancer of the stomach recovered and left the hospital.
5. A suspected cancer of the stomach at autopsy was an ulcer.
6. A suspected cancer of the lung at autopsy was bronchiectasis.
7. A suspected cancer of the stomach recovered.
8. A suspscted cancer of the stomach at autopsy was an ulcer.
9. A suspected cancer of the fiver at autopsy was cirrhosis.
10. A suspected cancer of the bowel recovered.
11. A suspected cancer of the stomach had uraemia.
12. A suspected cancer of the lungs= by-X-ray only suspected^2 negative tests-—dkdu:
but no autopsy-.;^-   *$&»&<
13. A suspected cancer-of. the lungs at'/autop&yshaik'Silico«fs^^^?w^'e«^^^s^i
14. A suspected cancer of the liver at autopsy had toxic liver from gold.
15. A suspected hypernephroma recovered and left the hospital.
16. A suspected cancer of the stomach at autopsy had a heart condition.
18. A suspected lymphadenoma cleared up and left the hospital.
17. A suspected cancer of the liver at autopsy had Diabetes and Arteriosclerosis.
You will see now that blood from a cancer patient clots in his own urine and that
in many other diseases the blood does not clot. Still one must not jump to conclusions.
In other words, does it always work or what is the percentage of accuracy? So far you
have only seen the good side—now let's face the failures.
The following cases gave a false positive test:
1. A suspected cancer of the lung gave a positive test but at autopsy it was tuberculosis. This test was left standing 35 minutes without agitation and a clot
formed.  This was an error in technique.
2. A case of Thrombocytopenia gave a positive test. He had many transfusions
and may have received some early cancerous blood, or it may be a peculiarity of
this disease, or he may have had an early cancer.
3. A suspected cancer of the sigmoid gave a positive test. Two tests were being
carried out at the same time and the urines might have been mixed. A re-check
gave a negative test (another error in technique).
4. A control who had dermatitis gave a positive test. He was not suspected of
cancer but was in the cancer age. He has no symptoms yet. This skin condition
may give a positive test.
5. A suspected duodenal ulcer by X-ray.   Two tests positive, moved away and lost
sight of.  This may not be a false positive but cannot be proved.
6. A suspected cancer of the bowel gave a positive test but at autopsy it was Hodg-
kin's disease.
7. A suspected cancer of the liver was positive but also had Hodgkin's disease.
Query: Is Hodgkin's Disease to be considered as a malignancy?
Page 157
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Now for the False Negatives: There are 7 of such:
1. A cancer of the rectum gavel a negative test with two tests. The urine had so
much sediment that it was unsatisfactory. It should have been filtered. (An
error in technique.)
2. A cancer of the stomach gave a negative test. This is the urine that was mixed
and gave a false positive. (An error in technique.)
3. A cancer of the stomach, proved by exploratory laparotomy, gave 4 negative
tests. This case caused me to change my technique. I felt this case should have
been positive and that there must be a cause for the blood not clotting. I suspected a lack of calcium and added lime water to the urine and got a strongly
positive reaction in about ten minutes.
4. A cancer of the stomach by X-ray was negative but on the addition of lime
water was positive.
5. Another cancer of the stomach was negative but positive with lime water.
6. Still another cancer of the stomach was negative and again positive when lime
water was added.
7. A Lymphosarcoma gave a negative test. This is the only sarcoma tried and this
test may be useless in sarcomas.
Now to summarize all tins:
64 tests on non-cancerous patients were negative.
36 tests on cancerous patients were positive.
18 tests on suspected cancer patients were negative and proved so.
2 were post operative cases showing negative tests where there had been total
removal.
7 cases gave a false ositive test:
2 were due to errors in technique.
2 were Hodgkin's disease.
1 was thrombocytopenia with transfusions.
1 has been lost sight of and not so proved.
1 was a control in the cancer age.
7 cases gave a false negative test:
2 were errors in technique.
1 was Lymphosarcoma.
4 gave a negative test but were positive on the addition of lime water.
This brings me to where I wish to explain the change in technique. Two or more
ounces of urine are placed in a basin and a dram or more of lime water added. 5 c.c. of
blood are drawn from the patient and the needle is dipped below the surface of the
urine to the bottom of the dish; the blood is then squirted forcibly against the bottom
in one spot. The dish is then left standing 2 or 3 minutes and the blood slowly travels
along the bottom. After this 2 or 3 minutes rest the mixture is gently swished from
end to end of the dish. If a small clot forms and does not wash off the test is positive.
The clot is usually definitely formed in 10 minutes or less. Just a word of warning
regarding the urine. The concentrated or early morning urine is best. If there is a
sediment it should be filtered. The patient should not be taking any of the Sulphanila-
mides. Tests are better done before X-ray or radium treatment. After treatments are
started the clots may be very small and overlooked.
Enough work has not been done yet to make any definite statements. No epithelio-
mata have been tested nor cancer in enough organs, e.g., there are no tests on cancer of
the breast. No idea can yet be given of how early in the disease this reaction occurs, nor
how soon it disappears after removal or destruction of the growth.
However, enough work has been done to make me feel that a test for the presence of
cancer can be found, if not by this technique then by something very similar, and that
some day this test will be of real value. More than this: If the cause of the clotting can
be isolated—is it not within reason to hope an antidote may be found and thus lead to a
cure for this disease?
Page 158 NOTICE
CLINICAL-PATHOLOGICAL CONFERENCE
VANCOUVER GENERAL HOSPITAL
Members of the visiting and attending staffs of other hospitals in the city and
i visitors from out of town are cordially invited to attend these meetings. They are held
| each Wednesday for one hour, starting at 9 a.m., in the Chemistry Building.
An average of fifteen to twenty autopsies are conducted each week at the General
Hospital. From these cases two or three are chosen which had presented difficulties in
diagnosis, and about which good records are available. A copy of the pertinent data
from the records is available for everyone attending the conference. The differential
diagnosis is first considered on the basis of available clinical evidence.
This is followed by a presentation of the gross and microscopic autopsy specimens
by Dr. H. Pitts and his assistants.
m
*
CLINICAL IMPORTANCE OF VENOUS PRESSURE
J. A. McCaffrey, M.D.
Senior Resident n Medicine, Vancouver General Hospital
Venous blood pressure is not a new subject. It has been studied by many investigators, but the conclusions have been of interest chiefly to physiologists and cardiologists.
Arterial pressure determinations are of interest to everyone. Therefore it is only fair to
expect that information gained from venous pressure determinations would be useful as a
diagnostic aid in many disease entities.
Physiology
There are six fundamental factors which affect the peripheral venous pressure.   These
are
1. The contraction of the left ventricle, or the "vis a tergo" of the heart.
2. The intrathoracic pressure, which is always negative except on very forceful
expiration. Normally, it is -80 mm. of water on inspiration and -30 mm. of water on
expiration.
This negative pressure has a suction pump effect on the venous blood.
3. The massaging effect of muscles. Veins are very thin walled. Any pressure
from without will readily affect the pressure within. Thus in violent exercise venous
pressure will tend to incraese, at rest it will decrease.
4. Hydrostatic level. This comes into play when the individual is in the erect
posture. Therefore, above the level of the heart gravity will aid the return of the blood;
below this level gravity will oppose the return of the blood.
5. Action of the right side of the heart. If the blood is not removed at once from
the right auricle, there will be a "damming back" of the blood into the graet veins, thus
causing an increase in venous blood prsesure.
6. Amount of blood in the veins. The more blood there is in the vein, the greater
the pressure will be, provided the calibre of the vessel remains the same. The calibre
of the lumina of the veins, and the number of venules patent at one time, are under
control of the vaso-constructor and vaso-dilator nerves.
Not all these factors necessarily affect the venous pressure simultaneously. If the
patient is at rest, the massaging effect of the muscles is absent. If the patient is in the
supine position the effect of gravity on the venous side will be the same above the level
of the heart as below. Then only the vis a tergo of the heart, the amount of blood in
the veins, the action of the right heart and the sub-atmospheric pressure in the thorax,
directly affects the venous pressure.
Page 159 if-.
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Measurement of Venous Pressure
Clinically venous pressure may be determined in three different ways:
1. At the bedside, by noting the level at which the veins collapse. This method
was originally introduced by Gaertner and should always be done in the course of a
general physical examination. Normally the veins should collapse at the level of the
right auricle. Evans states that with the patient in the supine opsition, the level of the
right auricle is the mid-axillary line. The other levels frequently given are five centimeters (5 cms.) posterior to the fourth costo-manubrial junction and ten centimetres
(10 cms.) anterior to the skin of the back. The veins of the arm are used. The arm
is lifted passively, and the level at which the veins collapse is noted. If the veins do not
collapse until the arm is anterior to the level of the right auricle, there is an increase in
the venous blood pressure. Also the veins of the neck are never distended in a normal
unclothed person, standing in the erect posture. If the venous blood pressure is increased,
these veins will stand out like cords.
2. Indirect method. An instrument has been devised by Hooker and Eyster for
the indirect measurement of venous blood pressure. It is essentially an instrument with
which one can collapse a peripheral vein, and can note the amount of pressure needed to
bring about this collapse.
3. Direct method. The direct method was first introduced by Moritz and Von
Tabora. This consists of .introducing a large bore needle, attached to a water manometer
into the anti-cubital vein, and noting the level to which the blood will rise in the manometer. There are various modifications of this apparatus, but we have here a very simple
form. It is an 18-gauge needle attached to a two-way Kaufman syringe. The side
arm of the syringe is attached to a water manometer by means of a piece of rubber
tubing. The inside of the apparatus is washed with sodium citrate, in order to prevent
clotting of the column of blood. The patient is placed in the supine position ,with the
arm to be used slightly abducted and on a support so that it is at the level of the right
auricle. A venipuncture is then done ,the plunger of the syringe is drawn back past
the side arm, and the level to which the blood rises in the manometer is noted. A reading
is satisfactory if reached ten to fifteen seconds after the venipuncture. One must avoid
making the patient too apprehensive or causing abnormal trauma to the vein, which will
give spasm of the vein. An element of error is also caused by the capillarity of the
manometer, and comparing a column of blood to a column of water. This error is
small, but constant; therefore, negligible. One must avoid too much abduction of the
arm, coughing, or straining.
The normal venous blood pressure by this method is from 40 to 120 mm. of water.
Discussion of Various Methods
The indirect method requires a great deal of skill and is only useful in a very limited
number of patients. Figures vary as much as four hundred per cent (400%); so for
general purposes its use is not advocated. Thus we have the clinical method to choose
from. The question arises as to whether the direct method will give more information
than the clinical method. In his work on Static Venous Pressure, Starr states that his
experience with several methods has left him with a high regard for the rough accuracy
of the Gaertner method, if carefully performed. When patients were extremely dyspnceic
his results were often too high with the Gaertner technique. In these days, when the
majority of patients have a venipuncture in order to obtain blood for one of the
innumerable laboratory tests, it would seem but a short procedure to attach a manometer
to the needle; then one would have an accurate, scientific numerical record of the venous
pressure.
Practical Significance of Venous Pressure
Increase in venous blood pressure occurs in
1. Cardiac failure
2. Localized obstruction to the vein.
Page 160 It was Starling who first stated that the output of the normal heart is determined
by the venous load put upon it. It was Eyster who first defined cardiac failure as "that
condition in which the venous pressure exceeds the range within which the heart is
capable of responding, by increased work, to increased venous load." In cardiac failure,
whether it is left heart failure, or right heart failure, there is always an abnormally high
venous pressure. Many of the signs of cardiac failure, such as an enlarged liver or
oedema of the ankles, are partly the signs of a venous hypertension. Therefore venous
pressure readings would be of value in a case of impending cardiac failure, in that therapeutic measures could be instituted before the clinical signs of failure occur. This would
be of special value in pregnancy complicated with heart disease.
In the days before Dagenan was used, one of the commonest complications of
pneumonia was cardiac failure, and its signs were often obscured by the signs of respiratory embarrassment. Here a rising venous pressure would prognosticate a failing heart.
Many advocated following the venous rather than the arterial blood pressure.
In a dyspnceic patient the venous pressure estimation will aid in determining whether
the dyspnoea is pulmonary or cardiac in origin. There is no rise in venous blood pressure
in pulmonary conditions.
In the treatment of a cardiac patient, the venous pressure should be followed. Records
of repeated estimations of venous blood pressure are valuable in offering a prognosis.
If, after treatment has been instituted, the venous blood pressure continues to rise, the
prognosis is grave, whereas if it fails the prognosis is good.
A rise in venous blood pressure does not occur in moderate pneumothorax, but only
when the pneumothorax is so large as to cause circulatory embarrassment. Indeed, some
writers have gone so far as to advise that venous blood pressure be done as a guide to
pneumothorax control.
Venous pressure may be elevated due to localized obstruction to the venous return.
An aneurysm may or may not press on the veins in the superior mediastinum. It may
obstruct the veins to one arm and not to the other. The same holds true of masses that
occur in the mediastinum.
Chronic constrictive pericarditis at times raises the general venous pressure.
Venous pressure is low in cases of shock and syncope. In cases of shock, as the
patients improve, the venous blood pressure rises. Much of the treatment of shock is an
attempt to elevate the venous blood pressure. Mayerson and Burch state that the development of syncope in people standing in the upright position is due primarily to a
diminished venous return, which leads secondarily to vasomotor failure.
The significance of venous hypotension is not fully determined as yet, but its presence
in shock, syncope, and in some cases of neurocirculatory asthenia, would lead one to
believe that it is clinically important.
Summary
1. A review of the physiology of venous pressure has been given.
2. The methods for the measurement of venous blood pressure have been briefly
described.
3. Some clinical entities in which venous hypertension and hypotension are found
have been given.
REFERENCES
White: Amer. Jour, of Physiology, 69 ,410, 1924.
White, and Moore: Amer. Jour, of Physiology, 73, 63 6, 1925.
Boas: Mechanism of Peripheral Stasis in Myocardial Insufficiency.
Owens: Studies in Venous Pressure, Jour, of Laboratory and Clinical Medicine.
Eyster, and Middleton: Archives of Internal Medicine, 34, 228, 1924.
Hooker: Amer. Jour, of Physiology, 40, 43,  1916.
Clark: A Study of the Diagnostic and Prognostic Significance of Venous Pressure Observations in Cardiac
Disease—Archives of Internal Medicine,  16:587, 1915.
Evans: Venous Pressure—New England Jour, of Medicine, 207: 934,  1932.
Wartman: Amer. Jour, of Medicinal Science, 190: 464, 193 5.
Griffith, Chamberlain, Kitchell: Amer. Jour- of Medical Science,  187, 642,  1934.
Page 161
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DEVELOPMENTS IN PEDIATRICS IN THE PAST
QUARTER CENTURY*
Grover F. Powers, M.D.
Professor of Pediatrics
Yale University School of Medicine.
Reprinted from The Yale Journal of Biology and Medicine, Vol. 12, No. 1, October, 1939.
I venture the opinion that in the past twenty-five years paediatrics, both in knowledge
and in practice, has made as marked progress as have any of the older services of the
Johns Hopkins Hospital in the half century now being celebrated. Without making any
attempt to prove this assertion, I should like to assemble certain pertinent facts, most of
which could be demonstrated easily from data in the Harriet Lane Home, the clinic
which led in this country to the establishment of paediatrics on a scientific basis. At the
outset, I wish to make it clear that I have most profound respect for what had been
done in the field of child care in the prevention and treatment of the diseases of childhood prior to the period which has elapsed since the opening of the harriet Lane Home.
But the events of the past quarter century-}" have been thrilling and dramatic, and in
their unfolding my entire medical experience has been lived. Since I was a member of
the first class taught in the Harriet Lane Home, one of its staff for eight years following
graduation, and associated with its present eminent director for six more years while he
was at Yale, I must ask pardon if the presentation is somewhat personal and is based
largely on hospital practice.
So many facts are available in discussing development in paediatrics in the past
quarter-century that one must of necessary assemble his remarks about a few major
subjects. What I have to say, therefore, will be grouped under eight topics: Supportive
Therapy, Infant Feeding and Nutrition, Infectious Diseases, The Newborn, Emotional
Disturbances, Mental Deficiency, Preventive Paediatrics, and the Future of Paediatrics.
Supportive Therapy.
An outstanding advance in the paediatrics of today over that of twenty-five years
ago is in the development of what I shall call supportive therapy—procedures which
might be termed physiological treatment since they are directed toward correcting
physiological disturbances rather than to eliminating causes of disease. I refer particularly to the use of parenteral fluids such as blood, blood serum, and normal salt, special
electrolyte, and glucose solutions. Now, as never before, we realize that a baby can
tolerate tremendous physical trauma, but he cannot endure fluid and salt deficits without
exhibiting the train of serious symptoms we associate with the terms dehydration, electrolyte imbalance, and shock.
In those earlier days we gave fluids subcutaneously and rectally. At Dr. Howland's
suggestion I began (very timidly at first) to inject normal salt solution into the peritoneal cavity. When acidosis was demonstrated in certain patients with severe diarrhoea
we gave, quite logically it was thought, solutions of bicarbonate of soda intravenously;
the only result seemed to be that the Kussmaul breathing disappeared. As many patients
died as under previous therapy. The administration of salvarsan into the longitudinal
sinus, or, rarely, into a scalp vein was regarded as a matter of such major progress that
I recall one entire clinic hour given over to a class demonstration of the procedure. The
drawing of blood according to the ingenious method devised by Dr. Blackf an was almost
a major operation. A nurse held the child, in an upright position usually, and the doctor
made an incision with a scalpel in the interscapular region; over the bleeding wound a
suction cup with attached test-tube Was applied. If an insufficient amount of blood
flowed from one stab, it was enlarged or another made.
How changed is all of this today!   Most of us would not permit puncture of the
* From the Department of Paediatrics, Yale University School of Medicine. Read at the exercises in
commemoration of the Fiftieth Anniversary of the opening of the Johns Hopkins Hospital, May 4, 1939.
tThe period under consideration is actually twenty-seven years; the Harriet Lane Home was opened
in 1912.
Page 162 longitudinal sinus or of the peritoneum for the purposes indicates. With modern
syringes,' needles and skill, venipuncture excites no interest or comment even when performed dn the tiniest baby; the procedure permits bacteriological, serological, and
chemical examinations of the blood to be made as readily on infants as on adults.
But, of course, requisite technical procedures are inevitably evolved when definite
therapeutic requirements are appreciated, and these come only with an understanding of
the disturbances in physiological processes brought about by disease. This understanding
was lacking twenty-five years ago. We had then most of the therapeutic tools which
we have now—salt, glucose, and alkali solutions—but we could not use them effectively
because of our fragmentary knowledge of function and our limited quantitative data.
We now administer normal salt, glucose, and specially devised electrolyte solutions with
little hesitation or hindrance in appropriately studied cases because we know fairly well
just what, qualitatively and quantitatively, will restore physiological processes to their
normal state. It does not, of course, follow that once rectified the correct status can
always be maintained in the presence of certain disease processes or that there may not
have been injury1 so severe as to cause death.
During my residence in the Harriet Lane Home we were just learning of the prac-
itcal importance of blood groups; in all that period I doubt if I saw a dozen transfusions,
although personally I was always eager to try this method of treatment. These early
transfusions were direct and were carried out with almost as much surgical preparation
as now accompanies a brain operation. Today, with blood typing and cross-matching
perfected, and with understanding of the proper method of preparing rubber tubing,
blood transfusions by the citrate method may be carried out simply and freely; they are
seldom followed by reactions of any moment when the procedure is carried out according to available knowledge of technical details.
Consider some outstanding indications for transfusion in a modern children's clinic;
Malnutrition; shock as seen in dehydration, ketosis, operations, and burns; bleeding, as
seen in haemorrhagic disease of the newborn, in purpura, and in haemophilia; low haemoglobin or red blood cell content, as seen in premature babies, nutritional deficiencies, and
other anaemias; infectious diseases," for supportive purposes and for immunological reactions as well; and protein replacement, as in nephrosis and nutritional oedema.
Again, consider the value of supportive therapy in surgical operations. Operations
on babies with harelip, cleft palate, intussusception, pyloric stenosis, empyema, or appendicitis were, twenty-five years ago, grave matters. Now, with parenteral fluids at our
easy command, the operative mortality in all of these procedures is slight indeed. Dr.
Ernest Gordon, in reviewing the cases of intussusception in the New Haven Hospital,
points out that in twenty-five cases with minimal supportive therapy the postoperative
mortality was thirty-two per cent, whereas with intensive supportive therapy the mor-
taltiy in sixteen later cases was only six per Cent'.
In this connection, consider also the change in the treatment of hypertrophic stenosis
of the pylorus. The old regime, often carried on for months, was lavage, gavage with
human milk, and refeeding if all were vomited. Surgical treatment was rarely employed.
The first operation I saw for this condition was a long procedure in which gastroenterostomy was performed, and the infant, already terribly malnourished, nearly died of
shock. Today, such patients are usually not allowed to get emaciated; they are given
supportive therapy and the simple Fredet-Rammstedt operation is performed promptly.
Skilled operators can accomplish this quickly and the baby is entirely well in a short
time; the mortality is very low.
Infant Feeding and Nutrition.
We now pass to another area of paediatric practice where unbelievably great changes
have taken place in twenty-five years—the domain of infant feeding and nutrition.
Not only has there been tremendous reduction in feeding difficulties and in nutritional
disorders, but I believe improved nutritional status, along with other factors, has had
a share in the progressive lowering of the mortality rates of scarlet fever, measles, whooping cough, and other infectious diseases.   Twenty-five years ago the paediatrician was
Page 163
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defined frequently as the "baby feeder"; certified milk and mixtures compounded in
many instances of skimmed milk, whey, and cream according to percentage computation
adjusted to meet supposed indications in the baby, constituted the physician's chief stock
in trade! His activities in preventive paediatrics were linked with "milk stations," "diet
kitchens," and "babies milk fund associations." His other medical duties chiefly called
him to battle with "summer complaint"—an engagement in which he was all too frequently defeated; his weapons were tea, barley water, protein milk, floating hospitals,
and seaside or country sanatoria!*
How changed is all of this today! More facts, discovered in biochemical laboratories
and applied by scientifically trained physicians, have established infant feeding on a really
sound basis. Vomiting is a less frequently observed symptom and while malnutrition is
still seen, the terms balance disturbance, infantile atrophy, athrepsia, decomposition, and
dystrophy are disappearing from paediatric nomenclature in many localities. We do not
split hairs over slight changes in amounts of protein, carbohydrate, and fat, nor argue
much about the relative values of casein and whey proteins. To many of us, discussions
over the relative merits of lactose, cane sugar, corn syrup, dextri-maltose, and barley or
oat gruel are boring. Malt soup and butter-flour mixtures are pretty well consigned to
oblivion and even protein milk is looked at askance in present-day simplified infant
feeding.
The lowering of digestive function and tolerance for food during an infection is a
condition more clearly recognized now than it was a few decades back. We know that
the most frequent causes of vomiting in the past were unmodified milk protein and too
much fluid bulk, not often too much fat, sugar, or casein. Due in large measure to the
outstanding work of Joseph Brennemann, we definitely recognize the importance of
protein modification, and while this can be accomplished in a great variety of very dissimilar ways no one of them is better or easier than is simple cooking—a procedure
accomplished by boiling, drying, or evaporating, often followed by canning. We recognize the caloric intake is variable from feeding to feeding, and in total amount can be
l\W
* Dr. W. T. Howard Jr., when Assistant Commissioner of Health, prepared a fascinating report on
"Public Health Administration and the Natural History of Disease in Baltimore, Maryland, 1797-1920."
The following quotation is of interest:
"The medical profession has always insisted upon the importance of breast-feeding over the second
summer if possible, and when this was impracticable upon the use of the best cow's milk procurable and
properly modified. For both prevention and cure, removal of babies to the country was standard advice
to mothers who could afford it. As early as 1870, "William T. Howard, Sr., taught that babies weaned
after April 1 rarely if ever escaped cholera infantum during the succeeding summer if kept in the city.
While the public dispensaries and those connected with various hospitals had special services for children's
diseases, the first organized paediatric clinic to undertake in a truly scientific manner the prevention and
cure of infantile diarrhoea was that established in 1889 under the charge of Dr. William D. Booker, at
the dispensary of the Johns Hopkins Hospital. Work on similar lines was soon undertaken at the Robert
Garrett Hospital under the direction of Dr. Walter B. Piatt, and at the Nursery and Children's Hospital
by Drs. Friedenwald and Ruhrah. By 1900 the tretament of this disease had greatly improved at all the
dispensaries with children's clinics. Booker was responsible for introducing the practice of pasteurization
of milk for babies about 1892, the modification of cow's milk on scientific principles for infant feeding
about 1895, and persuading Mr. Samual M. Shoemaker to establish a Walker«Gordon milk laboratory to
supply pure milk, both modified and whole, in 1900.
"The Thomas Wilson Sanatorium, the first endowed philanthropic institution in the city to contribute in a large way to the decrease in the death-rate from cholera infantum, opened its summer home
in the country for babies ill with this disease in 1884. This institution has ever since favourably affected
the official death-rate from cholera infantum, not only be preventing deaths among its patients, but by
the fact that many children died there whose deaths would otherwise have occurred in the city. In addition to its other beneficent services and hardly of less importance, it afforded Booker, as dirdctor from
1884 to 1898, the necessary opportunity to pursue the studies and to gain the experience on which his
qualification for leadership were based. On Booker's pioneer work all real advances in the control of
cholera infantum in Baltimore have been based. In 1904 the sanatorium established four milk stations in
the city to provide good milk and nursing care for the babies. Milk modified in a number of simple mixtures by the Walker-Gordon laboratory was dispensed. By 1912 the Babies Milk Fund Association, which
was organized in 1904 to operate these milk stations, substituted for the distribution of modified milk the
practice of teaching mothers to modify milk in their homes. In addition a number of welfare clinics were
established for the oversight of babies and the instruction of mothers in their feeding and general care."
Page 164 estimated fairly accurately, but in the long run, the intake is pretty largely determined
by the child's appetite. We recognize that of the total caloric intake ten to twenty per
cent should be in protein, about sixty per cent in carbohydrate and the remainder in fat.
And furthermore, if water is added to a milk mixture we do so for the sake of the
child's water requirements and not for the sole purpose of making the food more easily
digestible.
One recalls here the subject of rumination which used to be a vexing and not uncommon disorder in infants; it is seldom seen today. We thought it largely a neurosis. In
part that was certainly true, but since neuroses are not diminishing and the use of large,
dilute milk mixtures is, I am inclined to think that while the latter did not cause rumination they made it possible. In retrospect, treatment of this disorder in those early days
is amusing. In addition to dietary measures and evil-tasting drugs, mechanical devices
were advocated; Kanner summarizes them as follows: "So-called rumination caps; plugging of the nostrils with wax or cotton; fixation of the child, compelling him to lie on
his abdomen; blocking the passage from the cardia through the insertion into the
esophagus of an inflatable fish-bladder balloon ofter each meal."
In the early years of this quaretr century, human milk was a sine qua non of even
reasonable success in infant feeding; children's hospitals and the homes of the well-to-do
had their wet-nurses, and human milk dairies had great vogue. But the importance of
human milk is no longer dominant in infant feeding from a nutritional point of view.
It is no longer true of the paediatrician that, as Oliver Wendell Holmes said, "We are
willing to give Liebig's artificial milk when we cannot do better but we watch the child
anxiously whose wet nurse is a chemist's pipkin." It is true, as it always has been, that
human milk is "easily assimilated, cheap, clean and convenient" (in the words of the
Children's Bureau booklet); for these reasons and another to be discussed later breast
feeding should be energteically fostered; but it is also true that science has met in large
measure the challenge of producing a nutritionally acceptable substitute for human milk.
A quarter of a century ago the market was glutted, as it is today, with various baby
foods; the difference is that most of these foods today are not just carbohydrate concoctions but preparations which, while unnecessary, can be used to prepare a balanced
diet for the child. Canned foods, such as evaporated or dried milk, are very useful in
many ways. I well recall the anxiety one Harriet Lane Home family had as to how to
secure the baby's milk and keep it refrigerated during a transcontinental journey. How
easily that problem can be met today!
And now, what of our old bete noire, "summer complaint," "cholera infantum,"
and that ilk! (Table 1.) Paediatrics has made forward strides here also. Few speak
today with fear and trembling of the baby's "second summer." In the first place, that
ancient enemy "ileocolitis" is established in nosology as bacillary dysentery, to be prevented with the same hygienic and sanitary weapons directed against infected food,
fingers, and flies as are effectively used against typhoid fever. Pasteurization of milk—
rare twenty-five years ago, but now common practice by statute in many urban communities,—boiling of milk mixtures and sterilization of utensils, screening of windows,
and proper sanitary facilities have reduced the incidence of this disease wherever the
measures enumerated have been carried out. I believe the highest incidence of dysentery
is now in the very poor rural districts. When I was a student in Baltimore, unrefriger-
ated raw milk was commonly sold in open containers over the counters of tiny grocery
stores; the pasteurization ordinance was enacted in 1917 (Warthen). This and future
generations of students and physicians can never adequately appreciate the valiant campaign waged during the past fifty years by physicians, nurses, philanthropists, and public
health officials to make safe milk available for everyone in our cities.
We next pass to developments in respect to non-infectious diarrhoea in babies, perhaps the most dreaded and prevalent of all children's diseases since the urbanization of
population began. This malady is not now common in private practice in many cities or
in infant welfare clinics; indeed there are whole communities where the morbidity is
negligible.   The death rate has gone steadily downward until in some places it is now
Page 165
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Table 1
dlarrhcea in children under two years of age in baltimore.
Rate of death per 100,000 living inhabitants under 2 years of age, calculated on estimated
population under 2 years or on census count.
Diarrhoea
Population under 2 years of age
Year under 2 years Deaths Rate
1850     12472 407 3263
I860  12742 544 4269
1870    —. 14544 617 4242
1880     16227 618 3808
1890    '  18762 646 3443
1900    ; .  20220 759 3754
1910     19851 543 2735
1920 li  28902 640 2214
1925       26029 279 1070
1930       23908 139 584
1935    ,  21756 101 463
This table is baSed upon figures presented by William T. Howard Jr. in Public
Health Administration and the Natural History of Disease in Baltimore, Maryland,
1797-1920, supplemented by data for the years 1925 to 193 5 provided by W. T. Fales.   .
Table 2
Deaths under 1 Year from Diarrhoea per 1000 Live Births in Connecticut
1916   23.1 1929 u_  7.
1923   8.6
1924   8.1
1925   8.3
1926   7.4
1927   5.8
1928   3.5
1934    3.6
193 5    1.2
1936    1.9
'i *
Compiled from the Connecticut Health Bulletin.
practically nil. (Table 2.) That is indeed a paediatric and public health triumph in
which mitigation of poverty and ignorance shares the honours. Many factors, of course,
have been operative in bringing this situation to pass, notably, improved infant feeding,
better nutrition, good nursing, and intelligent medical care guided by the results of
brilliant clinical and laboratory studies. These have demonstrated that the symptoms
are due largely to fluid loss, electrolyte imbalance, and vascular and circulatory failure.
The contributions to this field from the Harriet Lane Home by Gamble, Marriott,
Howland, and Higgins, together with the investigations of Schloss in New York and,
later, of Marriott and Hartmann in St. Louis, and of Darrow and Shohl in New Haven
are outstanding. In my interne days the treatment of these dreaded patients consisted
of parenteral salt solution, sodium bicarbonate by mouth or by vein, and protein milk
or buttermilk. Not only was it not realized that the symptoms were due, in the last
analysis, to fluid and salt deficits in the tissues, but the diarrhoea was supposed to be
largely a local conditions in the gut, caused by the wrong food and could be cured, it
was hoped, by some good food if only one could find out what it was! The albumin
milk of Finklestein was as satisfactory an answer as was ever given. Today, therapy
consists essentially in discouraging further fluid loss by putting the gastro-intestinal
tract at rest (nothing by mouth), by fluid and electrolyte replacement, and by special
anti-shock treatment; no procedure, in this latter respect, is as effective as is blood
transfusion. When body and intestinal tract are restored to a near normal condition
the patient can be fed (at first in small quantities), and the food need not differ from
Page 166
i ' that which would be given under ordinary circumstances. If oral intake of food must
be in abeyance for several days we are now in a position to use parenterally organic
substances other than glucose, namely, vitamins and amino acids.
The vitamin chapter in the science of nutrition and in paediatric practice is likewise
brilliant. Many of the most important studies on rickets, tetany, xerophthalmia, and
scurvy have been made in paediatric clinics. Here again, the Harriet Lane Home was in
the forefront and continues its leadership; one has but to mention the names of Park,
Howland, McCollum, Simmons, Marriott, Shipley, and Kramer. Up to ten or fifteen
years ago, the majority of admissions to any non-contagious children's ward were due
either to diarrhoea or to the results of vitamin D deficiency—rickets, pneumonia secondary to thoracic deformities, and convulsions due to rachitic tetany. Now, all of these
last three disorders are preventable, not by one method of administering vitamin D but
by a dozen or more! It seems unbelievable that when, on my first day in the Harriet
Lane Dispensary I inquired concerning a row of bottles of "cod-liver oil and phosphorus"
in the drug room, I was told that some physicians used that medicine in the treatment
of rickets and I was free to prescribe it since it was harmless, but really the stuff had
little value! And today, because of the almost universal use of this same evil-smelling
fish oil and its allies and associates, rickets, instead of being well-nigh ubiquitous in temperate climates, is so rare clinically that in many communities one can hardly find a
patient upon whom one can demonstrate signs of the disease to incredulous students!
And where are the dozens of babies with frank convulsions, and the other dozens who
had fits the moment they had a degree of fever or cut a tooth)—the cases of active and
of latent tetany? Such spasmophilia is seen rarely now; and with it has vanished, among
other things, the fine art of doing electrical reactions!
In discussing rickets, it is fitting that we pay richly merited tribute to the vital part
which roentgenology has played in the study of this disease. Indeed, the increasing value
of this technic in the investigation of a large number of children's diseases can hardly be
exaggerated; where we used x-ray study once twenty-five years ago we use it ten, twenty,
or more times today!
One need not labour the discussion of nutrition further on this occasion with a prolonged discussion of the other vitamins and their role in paediatric practice. The thrilling
story of the vitamins is being again vitalized by new developments in respect to chemical
isolation and to quantitative determinations of these substances in the human body. And
so much of this amazing vitamin story in a short quarter century!
I shall conclude reference to nutrition by mere mention of the discoveries concerning
liver and iron in the treatment of certain anaemias. With modern diet one does not see
the nutritional anaemias so numerous in our clinics a few short years ago, in particular,
that known as von Jaksch's anaemia.
Infectious Diseases.
It is during recent years that the Schick test was developed and immunization against
diphtheria extensively carried out; and both morbidity and mortality from the disease
have approached the vanishing point in many communities. In these localities intubation
is now a lost art and diphtheritic myocarditis almost unknown.
Measles—that bogey-man of children's hospitals—may now be temporarily averted
or postponed until a more favorable time in babies and delicate or ill children by the
use of convalescent measles serum. However, this procedure has probably influenced
but slightly the fatality rate, the trend of which has been downward for some years.
Scarlet fever, whooping cough (Table 3), and tuberculosis continue the downward
trend in mortality rates that was already in progress. Tuberculous meningitis, which
caused over one-half of the deaths from tuberculosis in white children, has dropped
among those insured by the Metropolitan Life Insurance Company in the age-group one
to four from fifty per hundred thousand in the first five years of the quarter century
(1911-1915) to ten in the last five (1931-1935).  Scrofula and phlyctenular conjuncti-
Page 167
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vitis are now very uncommon childhood forms of tuberculosis in many communities
where these manifestations of the disease were formerly often seen. In these same communities, tuberculous peritonitis and calcified abdominal glands are seldom observed.
The widespread use of diagnostic tests for syphilis has led to earlier and more effective
treatment of parents, and consequently one sees much less congenital lues now than in
the past.
With the introduction of sulfanilamide, erysipelas and other streptococcal diseases
are being conquered in a striking manner as are gonorrhceal ophthalmia and meningococcal meningitis by the same drug.
Serum and sulf apyridine therapy will doubtless make significant inroads against pneumonia mortality. The bronchopneumonias which I so commonly saw in my early years
of paediatric experience are less frequent today, probably because malnutrition is less
frequent and supportive treatment more effective in children with measles and whooping
cough, the most important infections preceding this form of pneumonitis.
In respect to poliomyelitis, no preventive or curative measures have been developed,
but Trask, Poul, and associates have reopened the question of epidemiology. We now
know that the non-paralytic is the most common form of the disease. We know that
the virus, of which there are several strains, may enter the body by way of the skin as
well as through the mucous membranes, and is present in faeces. Monkeys can be
infected by feeding them with virus-containing food.
Table 3
Death Rates from Whooping Cough in Connecticut
Rates per  100,000  Population
Five-year Averages
1875-1879      8.3
1880-1884  12.2
1885-1889   11.3
1905-1909
1890-1894   13.6
1895-1899   14.2
1900-1904   15.4
    13.7
1909   -
1910 . - —
Annual Rates Since
 .... 13.0
   ... 14.0
1909
1924
1925
1^11
.     15.7
1926
1912  	
1913      _
  10.8
  .   8.3
1927
1928
1914 _ 	
1915 —	
   12.2
  .12.0
1929
1930
1916 . 	
1917  	
1918      	
...  ... .  12.5
 -  8.3
...    19.8
1931
1932
1933
1919
   4.0
1934
1920  	
    15.6
1935
1921 .. —   ..
    9.6
1936
1922	
■5.7
1937
1923 .
9.0
1938
5.2
7.3
6.1
2.5
6.3
2.6
2.0
2.7
2.7
1.6
1.0
1.2
1.7
1.5
.7
The data incorporated in this table were supplied by W"m. C Welling.
"Ward infections" in the sense of upper respiratory inflammation with otitis media
were a continuous source of annoyance and alarm in hospital practice. There is definitely less of this now, owing, in part, to better isolation technic, but more probably,
again, to the better nutritional status of ward patients in many localities.
In discussing infectious diseases, one should conclude with the reminder that their
courses have been changing and their mortality rates steadily dropping over a long
period of years—possibly three centuries, for example, in the case of scarlet fever. No
complete explanation of these changes in the natural history of these disaeses is available.
One can say no kind word, however, for rheumatic infections, which continue a black
scourge to childhood.
Page 168 The Newborn.
The experience of the past twenty-five years has shown ever increasing interest in
clinical studies as well as in investigations of the physiology and pathology of babies
during the first month of life. During the period from 1915 to 1935 there was no
change in mortality trend for the first day of life, but for the first month of life the
trend is downward (ten fewer deaths per thousand live births), although less sharply
than that of the mortality curve for the first year of life (forty fewer deaths per
thousand live births).
Improved care and feeding and the wise use of supportive therapy have reduced the
death rate among premature babies. The use of air-conditioned rooms for the premature
baby has stimulated investigations of the value of this type of environment, but concomitant progress in care and feeding has made differential credit difficult to place.
Progress has been made in understanding the anaemias of the newborn, and improvement has been made in their treatment. Erysipelas of the newborn, a disease formerly
with an eighty to ninety per cent mortality, can be cured now by the use of sulfanilamide. Septicaemia in newborn infants may be diagnosed readily because blood cultures
can be taken easily.
So far as I am aware, there have been no developments in obstetrics during the past
several decades which have contributed significantly toward lowering infant morbidity
and mortality. The increase in stature of certain selected groups of women and the
possible reduction in frequency of rachitic pelves might be contributing to a diminution
in the number of difficult deliveries; but we have no means of making an appraisal of
that situation at this time. There has been a marked rise in the use of sedation and
anaesthesia in childbirth and the amount of asphyxia probably has been increased thereby.
Possibly the increased number of caesarean sections may have reduced slightly the incidence of birth injuries, but very probably at the same time it has favoured an-increase
in the number of premature births. X-ray pelvimetry is an additional help in the selection of cases in which caesarean section is necessary and in rejection of those in which it
is not required.
At this point it may be appropriate to mention a matter which gives me concern—
the interrelated responsibilities of obstetrician and paediatrician in the handling of
mother and baby during the neonatal period. Many obstetricians turn over to the
paediatrician the care of the newborn baby. I approve heartily of this procedure, but I am
sure it is not entirely satisfactory at this time, owing to the fact that many paediatricians
do not utilize the obstetrician's special knowledge of and relationship to the mother at
this critical time. He very naturally has the special confidence of the mother of the
baby he has just brought into the world. On the other hand, especially with primiparae,
the paediatrician too often comes into the situation almost a stranger. And yet, just at
this time the adjustment between mother and new baby—one of the most delicate and
critical either will ever have to face—has to be made. This adjustment cries out for
complete co-operation and understanding between the two physicians and for a unified
programme as to the management and maternal nursing. Unfortunately, far too often,
the obstetrician is pushed aside in a cavalier manner and his close relationship of trust
and confidence with the mother is completely ignored. From this faux pas arises, I
believe, many emotional disorders in both mothers and babies, and many regrettable
failures in maternal nursing.
Behaviour Problems.
Emotional disturbances in children have always been numerous; very probably such
maladies have been most frequent after great social, religious, or kindred mass upheavals;
the Children's Crusades and the pilgrimages to shrines with which we associate chorea
major, the original St. Vitus dance, are examples. Today we recognize these emotional
disorders as such and do not attribute them to occult influences of one kind or another.
However, these disturbances seem to be more frequent today than in my earlier medical
experience; this may well be the case, for while we diagnose these maladies more accurately and ferret them out from among camouflaging physical symptoms, it is certainly
Page 169
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true that in modern life there is ample basis for increased incidence of emotional confusion. Life for children, as for adults, has been getting more complex and tense in the
period under review. Our world experienced a horrible war and the post-war exhilaration of supposed prosperity. Then came the depression with, for many people, an utter
collapse of material, social, and spiritual values; and now we are embarked upon another
cycle of war, fear, and insecurity into which vicious nationalism and racial discrimination have been injected. These matters disturb us; they cannot but disturb our children,
even the babies!
Moreover, certain developments in paediatrics itself have had malignant influence
upon the emotional life of children.   I can only mention some of them briefly.
In the first place, progress in knowledge of nutrition and the practice of infant
feeding has made it possible to rear babies successfully from a purely physical standpoint
without maternal nursing. It is my strong conviction that this has been a very mixed
blessing. The obvious and pressing incentive to nursing having.been eliminated, many
mothers, with the sanction and even encouragement of their paediatricians, make no
e:ort to suckle their babies. I believe that maternal nursing may have just as great
importance in the normal unfolding of the emotional life of the child as human milk
itself had in the physical development of the baby twenty-five years ago. Furthermore,
maternal nursing, or at least the earnest desire to fulfil that function, is of vital importance in developing the normal relationship between mother and child. It is, of course,
an unfortunate fact that some mothers through no fault of their own (or of their
physician's)  can not nurse their babies.
Moreover, we have laid great stress on mensuration in our studies of growth and
development, and upon regularity in carrying out various procedures in infant care. We
measure caloric requirements, weight, length, circumferences, muscular function, intelligence and social quotients; we note order in ossification and dentition; we feed "by the
clock" in fixed amounts; we demland habit training in elimination almost from birth.
We try to force conformity, and moulding to conventional patterns of physical, social,
racial, and intellectual development. The data required are often of great scientific
importance and of much value in practice, but only when used as guides to the physician
in his efforts to achieve fully his own inherent potentialities for growth and not as bases
of comparison in trying to inflict the developmental standards of others upon the
individual.
Rules and regulations likewise have their proper place as rough guides against too
flagrant a departure from the ordinary routines of life and conduct. But insistence upon
fixed procedures without wide latitude for individual variation has brought upon many
children emotional disorders which have manifested themselves in a variety of "body
protests" (as Dr. Esther Richards calls them) and of other displays of neurotic behaviour. Our strict therapy has often fostered some of the very disorders we are trying
to prevent. The following quotation from the admirable book by Dr. and Mrs. C. A.
Aldrich—Babies are Human Beings—is illustrative of the point I wish to make.
"This frequent insistence that children should be denied gratification is undoubtedly
due to the prevalence of spoiled children. Every doctor has the opportunity of knowing
many such youngsters, but I have never seen one who was spoiled because his parents
consistently planned his life to meet his basic needs. In my experience most spoiled
children are those who, as babies, have been denied essential gratifications in a mistaken
attempt to fit them into a rigid regime. Warmth, cuddling, freedom of action and
pleasant associations with food and sleep have been pushed out of the way to make room
for a technic. The lack of these things is so keenly felt that by the time babyhood is
past, such children have learned their own efficient technic of whining and tantrums
as a means of getting their desires. In this way is fostered the belligerent, fussy, unpleasant personality of the typical spoiled child, who insists on undue attention because
he has missed this fundamental experience. A satisfied baby does not need to develop
these methods of wresting his comforts from an unresponsive world. It is axiomatic
that satisfied people never start a revolution."
Page 170 One should, at least, call attention to emotional disorclers which develop in certain
intelligent children because of difficulties in language acquisition at the symbolic level
a definite neurological basis with which lack of unilateral cerebral dominance may be
linked. The flash system of teaching reading does not seem suitable for such children,
and should be supplanted by the old phonetic methods.
And finally, I wish to emphasize the fact, more clearly seen today than it was even
a few years ago, that in cases of emotional disturbance in children, it is toward educators and parents more than toward the children themselves that therapy must be
directed if it is to be successful.
;!: :
Mental Deficiency.
By our advancement in the control of disease we have saved many lives and in many
instances we ask ourselves if it would not have been better for the world if the child
had died. Are we not saving many who are feeble-minded, emotionally unbalanced,
diabetic, cretinous, crippled, or otherwise apparently hopelessly handicapped or afflicted?
Are we not preventing the beneficent operation of the law of the survival of the fittest?
My own answer is that the same procedures which save the unfit save the fit and that
science must continuously seek new truth and effective means of its application, let the
results be what they may. Fielding Garrison said: "A high infant mortality means
sacrifice of the unfortunate rather than the unfit who must be eUminated by birth,
not death." We paediatricians have paid much attention to preventing elimination by
death; to contribute studies, interest, and support toward the promotion of "elimination
by birth" may be increasingly one of our functions in the future.
Granted that preventive paediatrics is bringing about an increase in the number of
survivals among the feeble-minded and other subnormal children, these patients have
always been with us and have constituted a very large portion of the paediatrician's
clientele. The subject is drab and distasteful and has received far too little thought,
interest, and support. As a result, we are reaping the fruits of inadequate concern in
retardation of educational programmes, antisocial conduct, and crime in our communities, and serious behaviour problems among the relatives of the defectives as well as in
the patients themselves. Our machinery for diagnosis—especially as to intelligence and
social ratings, and encephalography—has advanced in the past decades, but prevention
and effective care and training have not kept pace. The paediatrician usually is the first
to diagnose these children and he must concern himself in the future with the genetic
and eugenic aspects of the matter, looking, in the long view, to prevention of those
cases due to faulty germ plasm. He must concern himself, on the one hand, with
adequate and properly equipped institutions furnishing custodial care for idiots and
imbeciles, and on the other, with training facilities for the higher types whereby they
may be given occupational technics to the end that they may be useful members of their
communities and not continue as helpless and sometimes vicious parasites on society.
Such institutions should be vital centres of research in educational, psychological, and
medical fields. Recent chemical studies have opened up a vista of the possibilities for
this technic of investigation.
And lastly, the paediatrician must interest himself in the public school as regards
this subject. He has had much to say about school health from the physical side; in
the future he must have something to say about the emotional and educational problems
which arise from the presence there of subnormal children. They are a serious handicap
to normal children and themselves present behaviour problems when attempts are made
to force upon them an educational mould which they are not equipped to fit.
How large the problem of mental deficiency is no one can say, but from a survey
of the situation during the past three years I have been forced to the conclusion that
with its widespread ramifications the matter is one of major paediatric and educational
importance.
Page 171
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Preventive Pediatrics.
It is appropriate to call attention to the leadership in preventive medicine and public
health which paediatrics has furnished. Again Johns Hopkins has been outstanding
through the work of Dr. J. H. Mason Knox Jr. and before him that of Dr.
W. D. Booker. The whole infant welfare movement has been in the forefront of public
health activities and their fruition came to a large extent in the field of paediatrics itself
(See Tables 1, 2, 4, and 5.) This preventive work had many ramifications, but it
centered largely about maternal and infant welfare conferences, "summer round-ups,"
school examinations, milk stations, public health nursing, infant feeding, nutrition and
vitamin studies, campaigns for clean milk, vaccination, tuberculin testing (starting
with the vonPirquet test), diphtheria prevention, rickets elimination, and typhoid and
dysentery control.
Table 4
Average Annual Infant Mortality Rate—Baltimore
1884-1886 296*
1889-1891 283*
1894-1896      302*
1899-1901 298*
1904-1906 269*
1909-1911 _   207*
Drop in rate of 69
* Recorded Infant Mortality Rate.
■f" Calculated Rate Based on Correction for Incomplete Birth Registration
1909-1911   _: .	
1914-1916  	
1919-1921   	
1924-1926  jS	
1929-1931   	
1934-1936  	
Drop in rate of 84
Table 5
Infant Mortality—Connecticut
*»:.
1885 158
1890 146
1895 151
1900 171
1905 136
1910 | 127
Drop in rate of 31
1910  127
1915   - I  107
1920    92
1925  73
1930  56
193 5  43
Drop in rate of 84
Compiled from the Connecticut Health Bulletin.
Many of the activities in preventive paediatrics were sponsored and developed by
individuals and by special groups, both small and large. Such, for example, was The
American Association for the Study and Prevention of Infant Mortality organized at
Yale University in 1909. The sponsors included obstetricians as well as paediatricians,
sociologists, and philanthropists. The launching of this association was, as Dr. Van
Ingen says, "the first concerted movement for the prevention of infant mortality and
the protection of child health" and "was the only organization devoted exclusively to
the health of the child. Other national organizations touched the problem casually.
Today every one of the great national health organizations specializing in various phases
of health work realizes that the child is the keystone of Preventive Measures."
In 1918 this fine organization, reflecting the broadening interests of paediatrics,
became the American Child Hygeine Association and in 1923 merged with the American Child Health Association, a group which in 1935 dissolved because of lack of funds
and also because a special soctiey was no longer vitally needed. For educational work
had greatly broadened, and special studies had been extended; more and more of these
activities were undertaken by official groups—municipal, state, and Federal—and by
regular medical and public health organizations. Thus, the first city division of child
hygiene was established in New York in 1908, the first state division in New York in
1914, and the United States Children's Bureau in 1912. Today, most cities and states
have bureaus of child hygiene, and the functions of the Children's Bureau are vastly
extended with its health activities under the leadership of Drs. Eliot and Dunham.
Page 172
'■I >;•. The Future of Pediatrics.
As the vitalizing medical discipline for research concerning growth and development
of children and the diseases, both mental and physical, which are characteristic of childhood, paediatrics has certainly amply justified its existence. And since all medical problems of childhood are by no means solved, departments of paediatrics in medical schools
and children's services in hospitals will continue their functions of investigation, of
teaching, and of the care of children.
But what of the future of the paediatrician? Has he fulfilled the physician's ideal
of self-elimination by doing his work so effectively that there is no longer need of him?
"With infant feeding simplified, diarrhoea and rickets under control, and many infectious
diseases modified or almost eliminated, cannot the general practitioner without special
preparation give all the medical care required for both child and adult?
If management of infant feeding and the treatment of rickets and diarrhoea are the
principal activities upon which the need for the paediatrician is based, then I think
quite possibly he may be eliminated from the medicine of the future. But it is my conviction that the particular diseases, disorders, and adjustments which the paediatrician
is called upon to treat do not constitute justification for his function; his raison d'etre
arises from the distinctive human being who has these ills—the child. Those who are
expert in ministering to adults are rarely by interest, training, or temperament adept in
handling the problems of childhood. The paediatrician in the past, largely because of the
nature of the ills of his patient—those maladies now so largely under control—has been
more narrow in his interests than he must be in the future if he is to cope adequately
with the disorders of the child of our and future generations—a human being upon
whom at the time in his life of vast physical, intellectual, and emotional growth and
development, impinge the forces of a confused, complex, and unstable world. To minister to the child at this time should be the responsibility of a physician specially interested in children and understandingly aware of their peculiar physical, mental, and
emotional characteristics in sickness and in health. This knowledge and the technics
necessary to use it are acquired only by living and working with children and by studying
them, as well as the diseases to whichf they are specially susceptible. This, of course, is
not the sort of training required of an internist or psychiatrist or psychologist or educator or nurse—those workers whose contributions the paediatrician must often integrate
and interpret in the actual treatment of his patient.
These statements are not based on criticism, nor are they theorizing; they express a
conviction, growing from observation of the way persons trained in various disciplines
deal with children. The paediatrician who knows children from birth through puberty
and, indeed, throughout adolescence, and whose concept of his responsibilities has broadened to include emotional and social reactions, is the person who can give the child the
professional care and advice he needs in sickness and in health as he travels the irregular
and confusing path of growth and unfolding personality. And because of the intimate
relationship of the paediatrician to the family and to the community through the children, and because of his special interest and training in preventive medicine, he has
become in many instances quite logically the family health counsellor and one of the
most active leaders in community health responsibilities.
For assistance in obtaining statistical data I wish to thank Elizabeth C. Tandy, Sc.D., Consultant on
Infant and Maternal Mortality and Stillbirth Statistics, United States Children's Bureau; John H. Watkins,
Ph.D., Assistant Professor of Public Health, Yale University School of Medicine; William C. "Welling,
Director of the Bureau of Vital Statistics, Connecticut State Department of Health; and W. Thurber
Fales, Sc.D., Director of the Bureau of Vital Statistics, Baltimore City Health Department.
NOTICE
Doctors treating patients on relief will please take notice that chronic cases
which apply for relief, month after month, should be referred to the Outpatients' Department, Vancouver General Hospital.
Medical Relief funds are inadequate to permit payment of fees in such cases.
w
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Victoria  Medical  Society
Officers, 1939-40.
President
Vice-President
Honorary Secretary
Honorary Treasurer
Dr. A. B. Nash
Dr. D. M. Bahxie
Dr. O. C. Lucas
Dr. P. A. Cousland
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ETHICS AND ECONOMICS OF DRUG MANUFACTURING
By Tom Moffat Matheson
I appreciate very much the courtesy extended to me by your association in inviting
me to present this paper to you. I justify my prompt acceptance of this privilege by the
fact that quite different views from mine are currently being expressed to medical
groups. It has been suggested, for example, that our present method of manufacturing
and distributing pharmaceuticals has become anti-social in at least some of its aspects.
Well, it might be accepted that drug manufacturers have not yet quite reached their
apotheosis—that quite a number of things need correcting. My point is that some of
the cures suggested would either kill the patient outright or render him a permanent
invalid.
I might, in fact, have entitled this paper "What is RIGHT about Pharmaceutical
Manufacturing" except that the very word "right" has an old-fashioned ring about it.
Certainly among the higher intellectuals, among the PhJD.s in debunking, it would have
placed me among such dull fellows as people who still believe in democracy, people who
do not believe that the profit-motive is necessarily anti-social, people who so expose then-
aesthetic nudity as to admitting readily a liking for Gilbert and Sullivan.
So, here am I about to commit the rankest of heresies in the eyes of the left-wing
sociologists and economists—I am going to point out some of the things that I think
are good about business as we now conduct it. I am going to suggest that all humani-
tarianism, all social sense and all ethics are not the exclusive prerogative of short-haired
women and long-haired men.
Probably the fairest approach to this belief of mine would be to list some of the
most frequently expressed complaints about the pharmaceutical manufacturers and
examine these complaints separately.   Here they are:
1. Money is wasted on advertising, on sampling, on detail work.   Cost to the
public is thus increased.
2. Duplication of products is wasteful, cuts down the druggist's profit.
3. Fanciful, invented names tend to obscure the true nature of a product and
confuse the physician.
4. Doctors are naive fellows who can be taken in by any slick detail man.
5. Drug manufacturers are just in business for profit.
Quite a crime-sheet with which to be paraded before the Colonel.
The first complaint, with regard to the cost of advertising, is an interesting one.
Briefly the facts might be stated as these: advertising increases demand, decreases the
problems of distribution, identifies the product with its maker, and actually lowers the
cost to the consumer. All of these effects are socially desirable. The idea that the
Canadian Pacific Railway could sell better transportation cheaper if it ceased to advertise
is hardly tenable in face of the evident facts. It would be difficult to contend seriously
that Heinz could make and sell better beans at a lower price if they saved the advertising
Page 174 costs. Yet some groups ask us seriously to believe just that. We have only to look at
the modern method of selling the old B. P. emplastrums to realize that what is now sold
at twenty-five or thirty-five cents to the public, and on which the druggist makes a
satisfactory profit, to see that modern methods of manufacturing and distribution have
decreased costs in this case enormously. Yet the large manufacturers of plasters today
are among the world's largest advertisers. Just how important it is to identify a product
with a maker's name is well exhibited by a list of a few of the great commerial names
in the English-speaking world: Cunard Line, Lea and Perrins, Parke, Davis & Co., Rolls-
Royce, Macy's. These names are known to us through advertising; they represent goods
or services to sell to the public. They represent honest pride in craft. The socially
desirable results of a good name are tremendous and the methods that bring their identification about should not be hastily discarded for problematic benefits which exist, for
all the pragmatic evidence to the contrary, solely in the minds of theorists.
Some years ago such a complete monopoly as the British Post Office found the necessity for advertising. And in Soviet Russia, according to the New York Times of some
time past, they had successfully produced peaches for canning in the Black Sea area, but
before this operation became practical in its complete sense the Soviet found that they
had to create a demand for peaches, and toward that end they had handsome lithographed labels designed for their cans. Witout this advertising the chain of events from
manufacturer to consumer was not fulfilled, and even the Soviet state was unable to
find a better solution to the problem than that which we in the democracies have been
using more or less automatically for generations.
Actually this saving of costs is not all that it appears on the surface. For example,
both retail druggists and doctors frequently find convenience of location or attractive
premises are desirable, and it would be very difficult to maintain that this situation could
be changed easily for the common good.
Detailing physicians is merely one form of advertising. If it increases costs one of
two things happens: the detail man gets fired because his cost of doing business is
increasing faster than the net revenue—or the firm goes into bankruptcy. Some theorists
would have us believe that selling prices were figures picked out of thin air, modified
only by the ignorance or avarice of the vendor. Well, the desire for profit might well
tell, and does tell, the intelligent pharmaceutical manufacturer that he had better heed
some more realistic facts than this Alice in Wonderland type of expert. He had better
remember, for example, that he has competitors trying constantly and energetically to
beat him in price, elegance and convenience, as well as efficacy. And even if he were
successful in creating something after the nature of a domestic monopoly he would still
have, in this particular business at least, foreign competition, at least in normal times.
He had better remember, too, that more people have one dollar to spend on drugs than
five dollars. So his intelligence will tell him to make haste to become more efficient, lower
costs, fulfil the requirements of his market, that he may make a profit. All of which,
I contend, is socially desirable.
The matter of duplication is, of course, merely the problem of competition. Without
it we must sacrifice the valuable prerogative of consumer's choice, and it is well to
remember that duplication is not a special problem of pharmaceutical manufacturing
but, of course, exists throughout our economy. I like the privilege of being able to say
the Crosse & Blackwell's pickles please me, or that Smith's Drug Store have always
treated me well and thus shall have my business. And most physicians evidently appreciate the privilege they enjoy in being able to say that they find that the Jones Pharmaceutical Company conform to their standards of ethics, efficiency and convenience and
thus shall be patronized, or that Black and Company are unreliable and are to be avoided.
Over a period of years the result of this consumer's choice will be that only the manufacturers who do conform to their market requirements have survived. Which is as it
should be. Where, if it were possible, physicians were limited to prescribing from a
pharmacopoeia, it would merely mean that they had exchanged this prerogative of choice
to the cemented opinion of a bureau.  However, from my observations of similar efforts
Page 175
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to guide the prescribing of doctors in a single direction, such a plan would be approximately as effective as King Canute. Recently the Chicago Daily News used a very apt
phrase to describe the difference in effect between bureaus and the free, open, competitive markets. They said, "God save us from an Anonymous Marketplace." I remember
a letter written to the British Medical Journal a year or so ago, which I cannot quote
verbatim, but the writer thoroughly conveyed his scorn for the supposed economy
enforced upon him by panel practice under which he was at liberty to prescribe a few
hundred gallons of useless medicine over a period of years, and thus satisfy the bureaucrats of his integrity. Under this heading I mentioned druggists' profits, and I would
merely like to say in passing that statistics available readily suggest that the average
druggists works much too cheaply and should have considerably more return for his
professional services. This, however, is a separate problem.
The complaint about fanciful names has some justification. There can be no more
complaint about a pharmaceutical manufacturer identifying his product than there can
about a physician using his own name rather than—say—diploma number 914. But
every reputable manufacturer should make every effort to describe the exact nature of
his product clearly upon his labels. This, of course, is not always possible when a new
chemical is discovered, as in the case of Prontylin. Some time after this discovery the
leading manufacturers agreed on the general term Sulphanilamide and merely prefixed
this description with a brand name. To choose a product of a respected competitor as
an illustration I would suggest that a product could be labelled "Burroughs Wellcome
'Emfpirin'—brand of Acid Acetylsalicylic," without working a hardship on physician,
druggist, or patient. And this method of labelling is becoming the vogue because the
market demands it.
After fourteen years' experience calling on a great number of doctors throughout
Canada, as well as some in England and the United States, I do not believe for one
moment that doctors are less competent to conduct their own professional business than
other highly-trained groups. Mind you I have all too frequently been exasperated because
they did not see eye to eye with me, and I am busily trying to correct that astigmatism.
But, more seriously, it is very questionable whether anything will separate the pharmaceutical wheat from the chaff more thoroughly or more quickly than the aggregate of
individual opinions of thousands of physicians in private practise. I know of few
products that have remained in use by doctors over a period of years that do not have
very good reasons for their existence. Although I do know of relatively useless products
that have been forced into use by bureaus. In the British Medical Journal for February
24, 1934, N. Mutch, M.D., F.R.C.P., pharmacologist of London University, expresses
this opinion: "Sale under brand name has much to be said in its favour. The quality of
even B.P. products sold by large firms under their brand name is often maintained by
systematic tests of a far more discriminating nature than those laid down in the Pharmacopoeia." Dr. Mutch then lists several examples such as charcoal, medicinal paraffin,
ergot, etc. Yet under British panel practice physicians were required to use the minimum
standards of these drugs.
It is hardly necessary to corroborate the charge that pharmaceutical manufacturers
are in business for profit. But that this is in itself anti-social might well be denied. It is
fair to say that never before in the history of the world have so many good, efficient,
therapeutic agents been so easily available at such low cost. We have become so accustomed to accepting a great number of essential services that we tend to disregard the
efficiency and complexity of the system that makes them available. When a doctor can
go into a drug store in Victoria or Hazelton or even Cheltenham today and buy a tube
of quarter grain morphine tablets with the guarantee of a maker's name on the label for
a cost of something like fifty or sixty cents, then I say that something tremendous has
been accomplished, and I would a great deal rather see the name of Parke, Davis &
Company or British Drug Houses on that label than I would the hammer and sickle of
the Soviet Union. In England today the pharmaceutical manufacturers are fulfilling a
gigantic task very ably.   They are supplying exports of good repute to obtain vitally
Page 176
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necessary credits, they are supplying drugs for the navy and army and air force with
tremendous efficiency. In times of peace they build great organizations selling in the
markets of the world, through advertising and for profit. Now they are able to turn
this efficiency to the ends of the present task. Canada, too, is building just such organizations and the good name of at least one of our Canadian pharmaceutical manufacturers is carrying their products into United States markets. Some day we might be
glad of this aggressive Canadian profit-seeking. The Canadian firm I refer to is Ayerst,
McKenna and Harrison. I know one British manufacturer who keeps as a credo for
profit-making an apt quotation on his desk: "Dead flies cause the ointment of the
apothecary to send forth a stinking savour; so doth a little folly him that is in reput-
tation for wisdom and honour."
Now I think it is time that I started to forego the pleasures of self-praise in which
I seem to have been indulging. I have purposely made this paper what to me seems rather
short and abrupt—and what I hope to you seems not too long—so that I might have
you invest me with a hair-shirt in the form of round-table discussion. I would like to
add one statement: I have not asked the manufacturers whose names I have mentioned
whether or not they wanted to be included in these remarks and I'have failed to mention
the names of many excellent manufacturers for the sake of brevity: the ideas I have
expressed, the errors and omissions are all mine and no blame should be attached either
to my principals or competitors.
I desire, gentlemen, to express again my sincere appreciation for this opportunity to
indulge what amounts to a hobby before you.
11
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.
ARTHRITIS and ECZEMA
of endogenous origin
claimed to be allergic, may be
favored or induced by calcium
and sulphur deficiency, impaired
cell action, and imperfect elimination of toxic waste.
LYXANTHINE ASTIER
administered per os, brings about
improved cell nutrition and activity, increased elimination, resulting symptom relief, and general functional improvement.
Since the best evidence is clinical
Ividence/write for literature and
sample.
L-17
Canadian^&stribuiBf^M
ROUGIER FRERES
350  Le Moyne   Street,  Montreal
Ntttttt   &
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2559 Cambie Street
ancouver
,B.C.
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flfoount pleasant mnbertaking Co. Xtb.
KINGSWAY at 11th AVE. Telephone FAirmont 0058 VANCOUVER, B. C.
R. F. HARRISON W. E. REYNOLDS
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38?
13 th Ave. and Heather St.
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Exclusive Ambulance Service
FAirmont 0080
PRIVATE AMBULANCES AND INVALID COACHES
WE SPECIALIZE IN AMBULANCE SERVICE  ONLY
J. H. CREL.LIN
W. K BERTRAND

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