History of Nursing in Pacific Canada

The Vancouver Medical Association Bulletin: February, 1935 Vancouver Medical Association Feb 28, 1935

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 The BULLETIN
OF THE
VANCOUVER MEDICAL
I ASSOCIATION
Vol. XI.
FEBRUARY,  193 5
No. 5
In This Issue:
RELATION OF THE RETINA TO CARDIO-VASCULAR
AND RENAL DISEASES
MATERNITY RELIEF
THE MEDICAL PROLETARIAT VANASPRA made from the
finest quality Acetylsalicylic Acid so compressed as to insure immediate disintegration
in the stomach.
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VANASPRA  5-GRAIN PLAIN.
VANASPRA COMPOUND No. 203.
VANASPRA COMPOUND No. 303 with
CODEINE.
M
We commend VANASPRA to the profession
as of the highest standard at less than half
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u jj<
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Western Wholesale Drug
Limited
456 Broadway West
Vancouver, B. C. THE     VANCOUVER     MEDICAL     ASSOCIATION
BULLETIN
'Published ^Monthly under the ^Auspices of the Vancouver Medical ^Association in the
Interests of the ^Medical 'Profession.
Offices:
203 Medical Dental Building, Georgia Street, Vancouver, B. C.
Editorial Board:
Dr. J. H. MacDermot
Dr. M. McC. Baird Dr. D. E. H. Cleveland
All communications to be addressed to the Editor at the above address
Vol. XI. FEBRUARY, 193 5 No. 5
OFFICERS   1934-193 5
Dr. A. C. Frost Dr. C. H. Vrooman Dr. W. L. Pedlow
President Vice-President Past President
Dr. W. T. Ewing Dr. W. T. Lockhart
Hon. Secretary Hon. Treasurer
Additional Members of Executive:—Dr. H. H. McIntosh, Dr. L. H. Appleby
TRUSTEES
Dr. W. D. Brydone-Jack Dr. J. A. Gillespie Dr. F. Brodie
Auditors: Messrs. Shaw, Salter & Plommer
SECTIONS
Clinical Section
Dr. W. L. Graham ._.   -      Chairman
Dr. J. R. Neilson *. Secretary
Eye, Ear, Nose and Throat
Dr. E. E. Day     —   Chairman
Dr. H. R. Mustard Secretary
Paediatric Section
Dr. G. A. Lamont     Chairman
Dr. J. R. Davies .'.       Secretary
Cancer Section
Dr. A. B. Schinbein          Chairman
Dr. J. W. Thomson    Secretary
STANDING COMMITTEES
Library Summer School
Dr. W. D. Keith Publications Dr. H. A. DesBrisay
Dr. C H. Bastin Dr  t h MacDermot Dr. H. R. Mustard
Dr. A. W Bagnall Dr Jd £ R Cleveland °r. J^ W. Thomson
Dr. G E^ Kidd Dr Murray Baird Dr. C. E. Brown
Dr. W. K. Burwell D.R. J. E. Walker
Dr. C. A. Ryan Dr. J. W. Arbuckle
Credentials Hospitals
n    , w. '"ner °r. r- a- Simpson Dr t h Lennie
?" 1 w TH°MSON Dr. J. T. Wall Dr q r Covernto>
KR' w r r"8 DR- D- M- MnirKISON Dr. H. H. Milburn
Dr. W. G. Gunn Dr> s Paulin
V. O. N. Advisory Board
Dr. I. Day ReP- to B- C- Metl'ca^ Assn.
Dr. H. H. Boucher Dr. Wallace Wilson
Dr. W. S. Baird
Sickness and Benevolent Fund — The President — The Trustees
111 [I .• I J
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MILK...
and the Family Diet
DURING the past few years the decrease in the
demand for milk has been less than for many
other kinds of food. At the same time the milk
dealer is interested in knowing how such decreases
may be reduced or prevented.
There is also the larger question as to why the use
of milk has not increased more. Just at present milk
problems are receiving unusual study in New York
State and an article in Health News for October
29th treated this matter in a helpful way.
MILK IS AN ECONOMICAL  FOOD
"The value of milk in growth and repair, in fortifying bodily
resistance, and in providing energy is well known to health -workers.
"The standard of one quart of milk a day in the diet of children
and of one pint of milk in that of adults is familiar to all school
children and to all adults -who have any contact with health literature.
"Why, then, does the-actual consumption of milk fall far short of
these standards?
"One reason is that, while the nutritive value of milk has been
widely taught, its economic value has not been given sufficient
emphasis.
"Milk gives high return for its cost; in other words, it is an
inexpensive food.
"Its purchase is economically justified for every member of the
family. If only one food could be provided, that one food should
be milk.
"Had this fact been more generally known, the consumption of
milk would not have decreased so materially during the depression."
ASSOCIATED DAIRIES
LIMITED
DISTRIBUTING
RICH—SAFE—CLEAN—MILK
Fairmont 1000
service phones:
North 122     New Westminster 1445
Mf VANCOUVER HEALTH DEPARTMENT
STATISTICS—DECEMBER, 1934
Total Population (Estimated)...
Japanese Population   (Estimated).
Chinese Population  (Estimated)...
Hindu Population  (Estimated)	
243,711
7,866
8,315
251
Total Deaths  	
Japanese Deaths- —
Chinese  Deaths	
Deaths—Residents  only
Birth Registrations—
Male, 127: Female,
125.
Number
197
4
9
187
252
Rate per 1,000
Population
9.5
6.0
12.7
9.0
12.2
INFANTILE MORTALITY—
Deaths under one year of age	
Death rate—per  1,000  births	
Stillbirths (not included in above).
December,
1934
8
3 1.7
3
December,
1933
9
37.5
3
CASES OF COMMUNICABLE DISEASES REPORTED IN THE CITY
January 1st
to 1 5th, 1935
Cases     Deaths
November, 1934
Cases     Deaths
December, 1934
Cases     Deaths
Smallpox     0
Scarlet   Fever    ~       3 8
Diphtheria    -  2
Chicken Pox  -      65
Measles       0
Rubelhi          0
Mumps            43
Whooping-cough     ~~ -       24
1
0
0
        59.
  0
0
0
  0
Typhoid Fever (non-res.).
Uudulant Fever__ —
Poliomyelitis   (non-res.) .
Tuberculosis  	
Meningitis    (epidemic) —
Erysipelas    	
Encephalitis Lethargica—
Paratyphoid    -
0
0
0
0
0
0
0
0
0
0
0
16
0
0
0
0
0
47
5
99
2
0
27
13
1
0
1
47
0
i  3
0
0
0
0
1
0
0
0
0
0
0
.0
0
7
0
0
0
0
0
26
0
36
0
2
3
30
0
0
0
18
1
0
0
0
RUM
S. BOWELL & SON
DISTINCTIVE  FUNERAL
SERVICE
Phone 993
66 SIXTH STREET
NEW WESTMINSTER, B. C.
Page 91 m\
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PUBLIC HEALTH
BIOLOGICAL PRODUCTS
Diphtheria Antitoxin
Diphtheria Toxin for Schick Test
Diphtheria Toxoid  (Anatoxine-Ramon)
Scarlet Fever Antitoxin
Scarlet Fever Toxin for Dick Test
Scarlet Fever Toxin
Tetanus Antitoxin
Anti-Meningitis Serum
Anti-Pneumococcic Serum  (Type 1)
Anti-Anthrax Serum
Normal Horse Serum
Smallpox Vaccine
Typhoid Vaccine
Typhoid-Paratyphoid Vaccine
Pertussis Vaccine
Rabies Vaccine   (Semple Method)
INSULIN
Price List Upon Request
Connaught Laboratories
University of Toronto
TORONTO 5 - CANADA
Depot for British Columbia
Macdonald's Prescriptions Limited
Medical-Dental Building, Vancouver, B. C. VANCOUVER  MEDICAL ASSOCIATION
Founded   1S1>8     ::     Incorporated   1906
Programme of the 3 7th Annual Session
GENERAL MEETINGS will bo held on the first Tuesday of the month
at 8 p.m.
CLINICAL MEETINGS will beheld on the third Tuesday of the month
at 8 p.m.
Place of meeting will appear on Agenda.
General meetings will conform to the following order:
8:00 p.m.—Business as per Agenda.
9:00 p.m.—Paper of the evening.
1934.
October 2nd—GENERAL MEETING.
Dr. G. F. Amyot: "Infection, Its Spread and Control."
Discussion: Dr. E. D. Carder
Dr. H. A. Spohn.
October 16th—CLINICAL MEETING.
November 6th—GENERAL MEETING.
Dr. C. E. Brown: "Some Secretory Disturbances of the Stomach."
Discussion:  Dr. H. A. DesBrisay.
Dr.  A. Y. M< Nair.
November 20th—CLINICAL MEETING.
December 4th—GENERAL MEETING.
Dr. A. B. Schinbein: "Tumours of the Breast."
Discussion:  Dr. J. J. Mason
Dr. B. J.  Harrison
Dr.  H. H. Pitts.
December 18th—CLINICAL MEETING.
1935.
January 8th—GENERAL MEETING.
Dr. W. E. Ainley: "The Relation of the Retina to Cardio-Vascular
and Renal Disease."
Discussion:   Dr.  W.   D.  K	
Dr. Wallace Wilson.
January 22nd—CLINICAL MEETING.
February  5th—GENERAL MEETING.
Dr. Murray Blair: "Physiological Observations in Obstetrics."
Discussion:  Dr.  \\".  S.  Baird.
February  19th—CLINICAL MEETING.
March 5th—GENERAL MEETING.
The Osler Li c i lre—Dr. Wallace Wilson.
March   19th—CLINICAL MEETING.
April 2nd—GENERAL MEETING.
Dr. F. W. Emmons: "The Surgery of the Presacral Nerve."
Discussion:   Dr.   I    J.  MaSON
Dr. F. Turnbull.
April   16th—CLINICAL MEETING.
April  23rd—ANNUAL MEETING.
Page 92 I
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TO RELIEVE HEADACHES, OCULAR and AUDITORY
TROUBLES DUE TO HIGH BLOOD PRESSURE
VISCUM ALBUM—HEPATIC—PANCREATIC EXTRACTS
In bottles of 50 and 500 tablets.
Obtainable from. B.  C. Drug's Limited, Vancouver; Georgia Pharmacy, Vancouver;
McGill & Onne, Victoria.
ANGLO-FRENCH DRUG CO., MONTREAL EDITOR'S PAGE
This year marks an anniversary which we feel needs, as it deserves, our
comments and consideration. Fifty years ago, a very well-known practitioner of Vancouver began active practice. We refer to Dr. William D.
Brydone-Jack. Everyone known "B-J" as he is affectionately called—
and everyone likes and respects him deeply.
Dr. Brydone-Jack is one of the institutions of medicine in Vancouver,
and our earnest hope is that he will long remain with us, active and at work,
as he is at present. To those of us who have known him for many years, he
is more than an institution. A parish pump can be that—but it is a dull
piece of furniture—but Dr. Brydone-Jack is a standard. He stands for the
best in the general practice of medicine, and, perhaps influenced to some
degree by our own occupation, but we hope not entirely, we feel that there
can be few activities of the human race which afford greater opportunities
for positive good, and are a severer test of character than this. To minister
through many years, to the mind and body warped and buffeted by disease,
to be the guide, counsellor and friend of hundreds, nay, thousands of
people of all types and ages and circumstances in life, and to emerge from
it serene and calm, with a store of wise kindliness, is a great achievement.
Many might live the tale of years, but not many can shew a bigger, or
as big, a meed of work and accomplishment. "Such men maintain the
fabric of the world.  ..."
Dr. Brydone-Jack, too, has lived a generous life, especially to his fellow-
practitioners. Their problems have been his problems—and his store of
accumulated experience, tempered and made effectual by an inherent
shrewdness and sagacity, has been freely at the dosposal of those who, on
many occasions, have sought his advice. We speak from personal experience, and have seen, more than once, where the practical wisdom of the man
has been able to avert a hasty and ill-considered action, and to find a way,
honourable but safe, out of some dilemma.
The man himself, all who really know, must regard with affection as
well as esteem and respect. Not a talkative man, somewhat slow and
deliberate of speech, he has the control and poise of the self-contained man:
who does not spend his all in every effort, but is always well within himself.
Such a man does not wear his heart on his sleeve, but as one gets to know
him, one learns of greater depths and capacities.
It is fitting, we think, that these things should be said; and our only
hesitation in saying them is lest the subject of them may, in his modesty,
feel at all uncomfortable or embarrassed at this exposure of his true and
inward self. But after all, we have been extremely reserved, not to say
conservative, in our estimate, and we cannot but rejoice that our comrade
and friend is so well and so much with, and of us; and we desire, with his
multitudinous friends of Vancouver and elsewhere, to wish him "many
happy returns." ...       .,
Dr., Grant Fleming, professor of hygiene at McGill, has accepted the
position of Secretary to the Health Insurance Committee of the B. C.
College of Physicians and Surgeons. He will be here for some months, and
will represent us in our negotiations with the Government, and contribute
his experience and knowledge to our cause.
We are extremely fortunate in having secured Dr. Fleming's services.
He is deeply interested in Health Insurance, and is an authority on the
Page 93
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matter, having been secretary of the Committee on Economics of the
Canadian Medical Association, which studied this whole subject last year,
and brought in a very full report, published in the June 1933 issue of the
C. M. A. Journal.
He is a prominent man in public health and preventive medicine, and
so links us with this half of medicine. Further, he is a completely disinterested party, and so is free. He is associated with the national organisation,
and so can link up the provincial with the national.
And lastly, he is a very capable organiser and a hard worker. So we
welcome him to B. C. most heartily, and urge all members of the profession to get behind him, and give him their support.
NEWS AND NOTES
All those in Vancouver who are attending maternity relief cases are
asked to read carefully the letter received from Mr. W. R. Bone, City Relief
Officer, a copy of which appears below. The manner in which these cases
have been reported in many instances is most unsatisfactory.
Copy of Letter from City Relief Department
Gentlemen:
Attention Maternity Relief Section.
I have been authorized by the Provincial Government on their behalf
to give to relief maternity cases extra assistance to the extent of $5.00 per
month after the fifth month of pregnancy, namely, the final four months.
In order to be able to give this relief, it will be necessary to have in
future an official certificate in duplicate from the doctor in attendance. I
would suggest that on the A Form, a statement be included to the effect
that you have in your possession a certificate from the doctor in attendance
stating that he has been retained to attend the relief maternity case.
I wish to call your attention to the fact that in the past a great percentage of forms A and B have been submitted at the same time. This, you can
readily see, will defeat the purposes of the above mentioned arrangement.
I would, therefore, ask you kindly to call the attention of the medical
practitioner in Vancouver to the fact that it will be necessary for him to
notify you immediately he is engaged by the relief maternity case.
Thanking you for your co-operation,
I am, yours truly,
(Sgd.)   W. R. Bone, Relief Officer.
We regret to announce the unheralded passing of Dr. C. H. West of
Mayne Island, who died in his sleep on the eve of a projected holiday trip to
the British Isles, on January 13 th.
Dr. F. J. Nicholson is holidaying in Hawaii. We willingly accede to his
request to be exempted from responsibility for whatever happens while
he is there.
Dr. D. M. Meekison left on January 12th to attend a meeting in New
York on January 14th. Although weather conditions compelled him to
forsake the air at Cleveland, Ohio, on January 13 th, he was able to reach
New York by rail the following morning. He reports an extremely success-
Page 94 ful and interesting meeting of the American Academy of Orthopaedic
Surgery and in spite of flying conditions at this time of year the air trip
was most enjoyable. His return trip, accomplished in three days, was much
more disturbed, as he was able to fly only as far as Chicago before he was
"grounded" till he reached North Platte, Nebraska, whence he again went
aloft for the remainder of the trip to Seattle.
RELATION OF THE RETINA TO CARDIOVASCULAR AND RENAL DISEASES
By Dr. W. E. Ainley
It is with a good deal of diffidence that I appear before you tonight.
Any subject dealing more or less with such a specialized subject as
ophthalmology is difficult to present in such a manner that it will be
interesting and of value to the general practitioner.
I have done the best I could in this respect, and can only hope my effort
will be successful.
There has been a new trend of thought during the past few years along
the lines on which I will speak, a trend which seems to become more and
more consolidated and confirmed as time goes on, so that I feel justified in
presenting this subject to you.
While I do not mention many specific names in my paper, the opinions
expressed are the result of much study and reading and some experience
and have the weight of considerable authority behind them.
Someone in one of the earlier meetings expressed the regret that his
paper did not seem controversial enough or stimulate enough criticism.
I submit that this subject is exceedingly controversial and I hope that it
will stimulate criticism.
I am depending on my seconders, Dr. Keith and Dr. Wallace Wilson, to
take a share of the burden of entertainment off my shoulders, for I do
not feel competent to put on a one-man show.
The invention of the ophthalmoscope by Helmholtz in 18 51 was one
of the epoch-making events in medicine. At that time he predicted its
usefulness in the following words:
"I do not doubt, judging from what can be seen of the state of the healthy retina, that
it will be possible to discern all its diseased conditions so far as these would admit of a
diagnosis by the sense of light. Distention or varicosity of the retinal vessels will be easily
perceptible. Exudates in the retinal substance or between the retina and choroid will be seen
precisely as in the cornea. I believe also that turbidity of the vitreous will be determined
with greatly increased ease and certainty. In brief, I do not consider it an overstrained
expectation that all the morbid changes of the retina or the vitreous that have been found
in the dead subject will admit of recognition in the living eye, an expectation that appears
to promise the greatest progress in the hitherto incomplete pathology of the organ."
And he might have added progress in the pathology "of the whole body"
and still not have overstrained expectation.
When one realizes that in studying the condition of the retinal vessels
one is gaining information regarding the entire vascular system, and observing plainly pictured before his eyes what is going on throughout every
organ in the body in some degree, one cannot help wondering why more
physicians do not make the use of the electric ophthalmoscope a routine
practice.
My object, then, in coming before you is briefly to review the recent
work done in an endeavor to correlate the modern concepts of cardio-
Given before a meeting of the Vancouver Medical Association, on January 8th, 193 5.
Page 9 J vascular and renal disease with the retinal changes which may be observed
with the ophthalmoscope, and to form some definite and concrete picture
of what this relationship is. The whole subject has been rather confused
and is only now beginning to emerge from the nebulous stage, being still
hampered by many old ideas and terms.
First, then, let us clear up some of the misconceptions and misnomers
that exist so that we may proceed with clear minds to construct on a sound
basis.
First the term retinitis. In the majority of instances in which this is
used the condition is not a retinitis, in that it is not an inflammatory process, but rather one of degeneration. The term implies a condition which
is non-existent.
Again, many of the so called exudates, which are so frequently referred
to in diseases of the retina, are not exudates. True exudates are rare in the
retina. My conception of an exudate is that it is the product of an active
inflammatory process, and most of the so-called retinal exudates would be
better termed transudates and simply white "spots," and are so termed by
some. The latter consist of localized degenerative processes incident upon
circulatory disturbances, causing loss of retinal transparency and so appearing white. However, it is necessary at times to let these terms pass until
some universally accepted reformation takes place.
Perhaps the most significant misconception was the failure to distinguish
between arterial sclerosis and arteriolar sclerosis. And here it is necessary to
explain the peculiar structure of the retinal arteries. The central retinal
artery and its first and second division must strictly be termed arteries on
account of their size, and the smaller branches than these, namely, those
fine vessels seen about the macular area and in the periphery of the fundus,
are strictly arterioles: but the histological structure of the arteries here
resembles that of the arterioles in the thinness of their walls and the absence
or great thinness of their muscular coat. So that it is perhaps not stretching
matters beyond what is legitimate to speak of the pathological changes in
all the retinal vessels as arteriolar changes, and in general when I speak of
retinal arteriolar sclerosis it will be in this sense.
The distinction between arterial sclerosis and arteriolar sclerosis is an
important one, for they are two vastly different things.
In the past the arteriolar sclerosis of the fundus had been included in the
general picture of arterio-sclerosis, and it was not till the two conditions
were differentiated that any advance could be made in the problem before
us. Since that time, however, the way has been opened for new ideas in our
conception of cardio-vascular and renal disease, and it has been, I think,
chiefly through the opportunity offered by the retina for the study of
vascular conditions by the ophthalmoscope that the advance has been made.
In arterio-sclerotic heart disease the patient is usually over sixty, the
palpable arteries usually infiltrated, the blood pressure, which has never been
high, is normal or low, and the heart is not enlarged. Pathologically the
changes are confined to the arteries and there is no marked involvement of
the arterioles.
In essential hypertension or hypertensive cardio-vascular disesae, increased blood pressure is a marked clinical sign. The disease has its beeinnine
often in early life and becomes manifest in the fifties. The systolic blood
pressure is above 150 and the diastolic above 100, and the heart is enlarged
to the left. It is a disease of the arterioles and the arteriolar changes are
found through all organs of the body.  Sclerotic changes may also be found
Page 96
SS in the larger arteries, but this bears no relation to the disease essential hypertension, contrary to the old idea that increased blood pressure was always
present in arterio-sclerosis.
In the fundus in arterio-sclerotic heart disease the choroidal vessels are
chiefly involved showing sclerosis,  the optic disc is pale,  there are no
hemorrhages,  transudates or white spots,  no compression  of
veins
by
arteries, no irregularity of lumen or increased light reflex. In other words,
no signs of arteriolar sclerosis. Should essential hypertension develop in
such a case then the characteristic signs will appear.
The fundus changes  in essential hypertension are also  characteristic
and are those of retinal arteriolar sclerosis, of which I will speak more fully.
Retinal sclerosis may be divided into two classes:
First—Simple arteriolar sclerosis.
Second—The so-called arteriolar sclerotic retinitis or retinopathy.
The classical signs of simple arteriolar sclerosis are:
1. Indentation of veins by arterioles at their crossings.
2. Irregularity of lumen of arterioles.
3. So-called copper wire arterioles.
4. Tortuosity of arterioles.
As the disease progresses, we come, generally after some years, to the
more advanced second form of arteriolar sclerotic retinopathy which is
further characterized by the appearance of transudates, cedema, haemorrhages and white spots of degeneration. These latter characteristics of
retinitis as will be shown may, however, appear without an accompanying
sclerosis.
I would like here to say a few words concerning the pathology and
significance of these signs. The sclerotic process involves both the intima
and the media of the vessels. In the intima there is a proliferation of the
endothelium with fatty and hyaline degeneration occurring at first in an
irregular manner and so causing the irregularity of lumen spoken of. In the
media there is a hyperplasia of connective tissue first occurring irregularly
and which, becoming more uniform, finally causes a general thickening of
the vessel wall with diminished transparency, so that the light reflex is
much broader, producing eventually the so-called copper wire arterioles.
This hyperplasia naturally does not occur only in the circumference of the
vessel, but also longitudinally, hence we get a lengthening of the vessel
between two given points, which results in an increase of tortuosity.
The indentation of the veins by the arteries Is self explanatory.
These signs, it will be seen, are all those of sclerosis, and I would point
out here for future reference that the process is one which results in a
strengthening of the vessel wall and not a weakening, and that a weakening
which may result in hemorrhages will only occur in the later or atheromatous stages of sclerosis.
The further signs which occur in the so-called retinitis are not the result
of a purely sclerotic process. Transudates, cedema and haemorrhage are more
reasonably to be attributed to an impairment of the endothelium of the
capillaries by which a diapedesis becomes possible, the impairment being
the result of some toxin carried by the blood. The white spots are the result
of fatty and hyaline degeneration, which causes a loss of transparency of the
retinal tissue and hence the white appearance. It is a similar process to that
which takes place in the intima of the vessels.
Some of the first work done in the differentiation of these two diseases,
arterial sclerosis and arteriolar sclerosis, was by O'Hare and Walker of
M
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Page 97 lit
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Boston and reported in 1924. They were led to their investigation by finding
that in a case of advanced sclerosis of the radial artery they found normal
retinal vessels, and this they considered accidental, but later, finding the
same condition in another case, they then discovered that both had normal
blood pressure. They had previously recognized the fact that marked arteriosclerosis could be accompanied by normal blood pressure, but were not aware
of any published observation on the retinal vessels in such cases. Foster
Moore of London had stated that increased tension was the rule when retinal
arterio-sclerosis was present. They therefore started observations in the
hope that they could throw some light on the relation between arteriosclerosis and hypertension. Their observations on the peripheral arteries
were confined to the radial, brachial and temporal. In their examination of
the retinal vessels they confined themselves to two signs in determining
sclerosis which they considered absolute, namely, compression of the veins
by arteries and irregularity of lumen. They included also, as more advanced
signs of the disease, beading and obliteration of the blood column through
increased opacity of the vessel walls. Other signs they considered as too
much dependent on the personal equation.
They investigated three groups of patients:
1. Those with peripheral arterio-sclerosis with normal blood pressure.
This group showed no cases with retinal sclerosis. It also showed there was
no relation between peripheral arterio-sclerosis and the blood pressure.
2. Those with peripheral arterio-sclerosis and increased blood pressure.
In 98' ( of these cases there was retinal arteriolar sclerosis, but no relation
between the degrees of peripheral sclerosis and retinal sclerosis. The cases
with most marked peripheral sclerosis had doubtful retinal involvement and
vice versa. Neither was there any relation between the degree of retinal
sclerosis and the height of the blood pressure. This latter may appear odd,
if we assume that arteriolar sclerosis alone is the cause of rise in blood pressure, but it must be evident that the blood pressure, varying as it does from
day to day and hour to hour, could not be dependent entirely on such a
constant single factor as the sclerosis of the arterioles. The more variable
factors entering into control of the blood pressure must here be taken into
account, namely, the vaso-constrictor and dilator mechanism and the heart
action.
Mr. Batty Shaw of London, carrying on similar investigations, found
a constant association between cardiac hypertrophy and hypertension, but
that the tension varied within wide limits from a little above normal to
the highest. He was puzzled to know how this variation could occur if the
blood pressure were dependent wholly on such a constant factor as arteriolar
sclerosis, and he came to the conclusion that there could be no such single
dependence, and could explain the variability only by supposing the presence
of a variable amount of toxin in the blood, which, besides being at least
partly responsible for the hypertension, through its action on the vaso-motor
system, could also explain the changes in the inner and middle coats of the
arterioles causing the sclerosis. So that O'Hare and Walker and Shaw were
all of necessity carried a step beyond arteriolar sclerosis to a toxaemia which
may be a cause of both the hypertension and the sclerosis.
3. O'Hare and Walker found in their investigation a third group of
sixteen cases which seemed contradictory to the previous two groups,
namely, cases with peripheral arterio-sclerosis, retinal arteriolar sclerosis and
low blood pressure, but it was found that in each of these cases they had
previously had high blood pressure.
Page 98 These facts brought out in O'Hare and Walker's investigation show the
clinical distinction between arterio-sclerosis confined to the peripheral
arteries and sclerosis of the arterioles. They prove that there is little relation
between peripheral sclerosis and increased tension, but a very marked relation between arteriolar sclerosis and increased tension.
All authorities agree that visible sclerosis of the retinal arterioles, if not
due to disease of the optic nerve, retina or choroid, is practically always
evidence of hypertensive disease, whether or not the blood pressure is high
at the time of examination.
The arteriolar sclerosis, once started, does not undergo resolution. The
sclerotic changes remain or advance. The haemorrhages, transudates and
spots may disappear, but are usually replaced by fresh lesions and generally
some evidence of their previous presence can be found. The persistence of
these changes is important in the diagnosis of the condition known as
"hypertensive disease without hypertension." In this condition we have the
picture of retinal arteriolar sclerosis associated with normal blood pressure
(the third group investigated by O'Hare and Walker). This would seem
an anomaly, for it is known that sclerosis of the retinal arterioles indicates
a similar condition in all the arterioles of the body to some degree, and,
broadly speaking, this indicates the necessity of a mechanical compensation
by means of an increase in the blood pressure and cardiac hypertrophy in
order to keep up the nutrition of the body, through a system of vessels
which have lost their elasticity. The logical assumption, therefore, is that
in these cases of arteriolar sclerosis with normal blood pressure there has
existed at some time the necessary compensation of high blood pressure
which has later broken down through subsequent or consequent myocardial
weakening and loss of vascular tone, in which case we would find the signs
of myocardial degeneration. Investigation has shown that this is practically
always the case. It seems also probable that a toxaemia of unknown origin
may be a factor in these cases, and that the diminution or disappearance of
the toxaemia which has been the cause of vasospasm and increased pressure
may result in a fall of the pressure, leaving behind the visible picture of
sclerosis in the retina on which the name "hypertensive disease without
hypertension" is based.
In hypertensive persons the onset of myocardial failure, uraemia, or
coronary occlusion will cause permanent lowering of the blood pressure, and
if such a case is examined the cause of cardiac hypertrophy may be obscure,
but the finding of the hypertensive type of fundus will reveal the explanation. Until these points were cleared up these apparently anomalous cases
may well have accounted for the confusion in the attempt to correlate the
retinal picture with associated clinical states.
These cases of benign hypertension which we have been discussing die
of cardio-vascular disease (cardiac failure, coronary thrombosis or cerebral
lesion).
Malignant hypertensive neuro-retinitis is of much more serious significance. It may occur in childhood or be engrafted on essential hypertension.
Sclerosis of the retinal arterioles may or may not be present, but it is usually
present. Where malignant hypertension occurs in the young, or in the
hypertension of pregnancy, or in acute glomerular nephritis, sclerosis is not
present, evidence that it is dependent on some toxic cause.
The distinguishing characteristic is an cedema of the optic disc which
in most cases is marked by a swelling of about 2 dioptres, but may be as
high as 8. This, apart from the vaso motor narrowing of the arterioles, may
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be the first sign of the condition, although it is usually first seen when other
signs of retinitis are present.
Keith and Wagener of Rochester, in a study of 81 cases of malignant
hypertension, report that many of them were up and about and did not
complain of severe discomfort. Fifty per cent of them reported visual disturbance, which seemed to depend on the extent and locality of the retinal
cedema. Retinitis was present in every case but one, and varied from mild,
with slight swelling of the disc and few spots and haemorrhages, to severe
with 6 dioptres of swelling of the disc, extensive cedema of retina and many
haemorrhages and spots. The retinal condition ends in secondary atrophy
of the nerve and blindness, if the patient lives long enough. The termination, however, is rapidly fatal, and out of the 81 cases only five lived two
years. The average duration after diagnosis was eight months.
Carmady and O'Hare, however, do not agree with Keith and Wagener
and others that malignant hypertension can be distinguished from glomerular nephritis by the fundus picture.
We have, then, I think, demonstrated the distinction that must be
drawn between arterio-sclerosis and arteriolar sclerosis and the association
of the latter with hypertension. It has also been shown that arteriolar
sclerosis in itself cannot account for all the phenomena either in hypertension or in the retinitis so often associated with it.
O'Hare and Walker and Batty Shaw were forced to the conclusion that
the variability of tension was not compatible wih the assumption that a
constant factor like sclerosis could be the sole factor and assumed the
presence of a pressor substance acting on the vaso-motor system through
the blood. The occurrence of hypertension in such non-sclerotic but highly
toxic diseases as eclampsia, toxaemia of pregnancy and some cases of nephritis,
must also be borne in mind. Nor can the characteristic signs of retinitis,
namely cedema, exudates and haemorrhages, be attributable to sclerosis alone.
As I took pains to point out previously, the sclerotic process is one which
strengthens the vessel walls, and therefore, except only in the very late
stages, would not account for retinal haemorrhages. Where retinal
haemorrhages have disappeared by absorption no break in the vessel wall has
been found, and it is more reasonable to assume that the haemorrhages are
due to a diapedesis through the smaller capillary walls, the endothelium of
which has been damaged by toxic agents in the blood stream. In other
words, they are similar to the petechia; found in malignant endocarditis and
other infectious disorders. It has been shown experimentally that the
injection of bacterial toxins into the blood will produce intimal changes
favoring diapedesis. Retinal haemorrhages are also seen in pernicious anaemia,
chlorosis, erythraemia and secondary anaemias in which sclerosis does not
occur. We may then, I think, assume what may be called a pre-sclerotic
toxaemia as an essential factor in the picture of hypertension and arteriolar
sclerosis.
The close relationship of nephritis to the condition we have been considering is evidenced by the term albuminuric retinitis. It is a relationship
which, however, stands much in need of clarification. There seems no doubt
that in the light of recent knowledge the term albuminuric retinitis is not
warranted, as it has no distinctive retinal picture which may not occur in
general arteriolar sclerosis. The term albuminuric retinitis at any rate has
been entirely abandoned in favour of renal retinitis by those who think there
is a distinctive retinal picture associated with renal disease, for albuminuria
may exist quite apart from kidney disease. Foster Moore of London is strong
Page 100 in his opinion that there is a type of retinitis peculiar to nephritis. He says
that a fundus which shows numerous cotton wool patches, i.e., fluffy patches
of fibrinous exudate, swelling of the optic disc and cedema with perhaps
detachment implies a different type of disease from that implied by purely
vascular changes with flame-shaped hemorrhages, little cedema, discrete
small white spots and no cotton wool patches. The first indicating the
predominance of the renal and toxic element and the latter the sclerotic. It
would seem that in these extreme cases a distinction might be made, but
there are many cases seen between these two in which we could not diagnose
nephritis with the ophthalmoscope. The work of other investigators, and
especially of Carmady and O'Hare, which I will cite later, seem to refute
this contention of Moore. In the last analysis it does not seem to me a matter
of great importance. Any fundus showing a picture or retinitis beyond an
arteriolar sclerosis calls for an examination of blood urea, urea concentration
in the urine and fixity of specific gravity.
Ellis of London has done some interesting work along this line. He
investigated 20 cases with retinitis as to their renal function. All, with the
exception of one, had high blood pressure. Nine of his cases showed markedly defective renal function and eleven did not. He showed that the renal
group was not merely an end stage in certain of the retinitis cases, for those
in the renal group showed an average age 13 years younger than the purely
retinitis group. While most early observers considered the retinal lesions
as due to renal insufficiency, the fact is that retinitis frequently occurs with
normal renal function.
Out of the 20 cases of retinitis studied by Ellis, as I have said, only nine
showed renal insufficiency, and this type lived only a very short time and
died usually of uraemi.a
Carmady and O'Hare of Boston have recently published some very
interesting observations in this connection, having attacked the problem
from a new angle.
They selected from material in their renal clinic 32 cases of chronic
glomerular nephritis which showed no retinal lesion or only the minimal
sign of arteriolar sclerosis at the time of the first observation. These cases
were continuously and frequently observed till death, which was due to
uraemia.
Their idea was that this type of case would give accurate information as
to the development and course of the retinopathies accompanying primary
glomerular nephritis.
Of the entire 32 cases, only 2 failed to show fundus changes before
death. Five did not progress beyond arteriolar sclerosis. Eleven were classed
as arterio sclerotic retinopathy, and fourteen were of the so-called renal
type of retinopathy, which, as I have said, Foster Moore claims to be typical
of nephritis.
This very high percentage of retinitis developing in nephritis is much
in excess of most findings, which usually give 50% or under, and is probably due to the fact that other observers did not make the same frequent
and continuous observations till death. Foster Moore found that in 20
cases of uraemia (the final stage of nephritis) only one failed to show retinal
changes, thus bearing out the above findings.
The eleven cases that developed arterio sclerotic retinopathy and progressed no further convinced them that this picture was not confined to the
purely hypertensive type of case, in other words, arterio-sclerotoic retinopathy occurred almost as frequently in nephritis as did the so-called renal
Page 101
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retinopathy. They also found that, based on nitrogen retention and secondary anaemia, one group was no more and no less toxic than the other.
Their findings caused them to doubt the wisdom of trying to divide
cases of retinitis into renal and non-renal. They decided that there is no
distinctive type of retinal lesion in nephritis but that the retinopathies
under consideration are only variations of the same pathological process
having its origin in the pre-renal toxaemia, being thus in agreement with
such authorities as Batty Shaw, Friedenwald, Duke Elder and Altnow.
Hypertension was the most common factor preceding or accompanying
retinal changes, being observed in 13 of 19 cases before any retinal changes
were found. Also arteriolar sclerosis was seen before the appearance of other
forms of retinopathy in all but 2 cases, in which they were discovered simultaneously, and these were so rapidly progressive that the same sequence
would probably have been found had more frequent examination been made.
Here we have a plain progression of events from initial hypertension
through arteriolar sclerosis to advanced retinopathy. They found that the
expectation of life after the appearance of advanced lesions was six months.
In a series of cases of chronic glomerular nephritis studied by Fishberg
and Oppenheimer, half of those which showed retinitis were of the malignant
hypertensive type, many of which showed necrosis of the renal arterioles
at autopsy, thus showing the highly toxic condition present where a combination of retinitis and nephritis exists.
Altnow in his investigations found that swelling of the optic disc,
haemorrhages and retinal cedema were more common in cases of hypertension
with chronic nephritis than in those without nephritis, indicating, as one
would expect, a greater toxic element in the former than the latter. It is
his opinion that the retinitis of both chronic nephritis and essential hypertension have a common underlying cause in vascular changes and that the
picture is altered as the toxic element varies, and so predominant may the
toxic element be that we sometimes find in acute nephritis a marked
retinitis in which the retinal vessels are normal. In other words, the toxins
are so virulent that the retinal tissue is damaged before there has been time
to effect a sclerosis of the vessels.
And so we have the toxin forced upon our attention as the fundamental
cause in the fundus picture associated with nephritis as we did in that associated with essential hypertension.
If we accept the view which seems now almost universal that the
nephritis and the retinitis are both due to some common underlying toxaemia
the position seems clear. The case exhibiting both nephritis and retinitis
will have a much more serious prognosis than the one with retinitis only,
for in the latter the kidney, functioning normally, gets rid of the toxins.
Practically this is found to be true. The case of retinitis with nephritis
seldom lives more than a few months. The retinitis case also has a worse
prognosis than the purely arteriolar sclerotic case. Sclerosis may be said to
be the index of chronicity, retinitis the index of toxicity.
It is important to note in this connection that in Ellis' cases of retinitis
only 5 0',; showed nephritis, while in Carmady and O'Hare's cases of chronic
nephritis 7i(/i showed retinitis.
The conclusion from this seems to be that chronic nephritis, which so
frequently develops a retinitis, indicates a much graver toxaemia than does
a retinitis which not nearly so often develops a nephritis, for evidently the
delicate retina may be affected by a degree of toxaemia which is insufficient
to disturb kidney function.
Page 102 With regard to diabetic retinitis I will say little beyond stating that for
all practical purposes it does not exist as a separate entity. Retinitis is never
seen in young diabetics, in whom the disease is found in its most virulent
form. In diabetics past middle life, if a retinitis is present, it is practically
always associated with defective renal function and hypertension, and it is
probable that they play the leading part in the retinitis.
In conclusion, I wish to bring to your attention certain established
observations.
Many observers have reported vasospasm of the retinal arterioles as the
earliest sign in hypertension. Moreover, in such cases the arterioles in other
parts of the body have shown early sclerosis to be present on biopsy.
Arteriolar sclerosis has been observed to precede the appearance of more
advanced retinopathies in practically all cases, with the exception of highly
toxic cases in which, as I have shown, the damage may be done to the retina
before there has been time to cause sclerosis.
Vasospasm has been demonstrated photographically in the retina in
eclampsia with hypertension, both the spasm and hypertension disappearing
after delivery.
Here we have a purely toxic cause of vasospasm and hypertension and a
most interesting finding.
I pointed out earlier in this paper the necessity recognized by many
observers of accepting the presence of toxaemia acting on the vasomotor
system to account for the variability of blood pressure in hypertension associated with arteriolar sclerosis.
Volhard has advanced the theory that the retinal lesions in arteriolar
sclerosis are due to an anaemia, and consequent interference with nutrition,
caused by vasospasm which is part of a systemic vasospasm.
I therefore leave you with the following proposition as the sequence of
events in the diseases under discussion.
A pre-renal and pre-sclerotic toxaemia of unknown origin resulting first
in vasospasm and hypertension and possibly nephritis, the vasospasm causing
anaemia of the retina, which, by interference with nutrition, results in
sclerosis. Retinitis, if it develops, may do so at any stage in this chain of
events, as it is independent of the sclerotic process, but dependent on the
virulence of the toxaemia.
I would also suggest that it is in the endeavour to solve the riddle of the
toxemia that most advance will be made in the study of hypertension and
nephritis.
m
THE  MEDICAL  PROLETARIAT
By "One of Them"
[We are glad to publish the paper "The Medical Proletariat" by Dr. Harold
Dyer, of North Vancouver. Those who heard this paper enjoyed it so thoroughly
that we feel it should be given to a wider circle of readers. As it was, some sixty
men turned out on one of the worst nights of the year to hear it, and felt that it
was more than worth the effort.
Dr. Dyer writes with a witty pen. Like Bernard Shaw in the Doctor's
Dilemma, he obtains some of his effect by exaggeration, if not exactly caricature.
Perhaps one's view in this regard depends upon whether one looks through the plain
glass spectacles of a general practitioner, or the more expensive and scientific lenses
of an eye-specialist who has fitted himself for glasses. At any rate the specialists,
as far as one in the back rows could see, took their medciine like men, and if they
did not exactly smack their lips, at least they made no complaint.
Given before the Vancouver Medical Association January 1 J, 193 5.
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Nor, we think, was this attitude of theirs merely that of a feeling of superiority.   One remembers many acts of specialists which more than atone for the sins
of commission or omission ascribed to them by the speaker.  Many and many a time
when in one's extremity as a general practitioner, dealing with some poverty-
stricken wretch who could not pay any fee, and whose pennilessness made one hesitate to infringe on the time of the specialist, the latter has cheerfully and unsparingly, and with no question of fee at all, given of his best, and helped one out of a
predicament that without his help would have been perhaps calamitous.   And we
cannot do without the competent and conscientious specialist, and these abound.
One is reminded of the lines, not, perhaps, quite accurately quoted:
"God and the doctor, all men adore
In time of trouble, and not before.
The trouble over, they're ill requited—
God is forgot, and the doctor slighted.
And so, when we are in need of him, the specialist is our greatest friend. We must,
we feel, think of this angle of the situation; and we feel sure that Dr. Dyer would
be the first to agree with this.
But there is much truth in what he says: and undoubtedly specialism has been
overdone, and by some few exploited. The remedy is yet to seek and find; ourselves
we cannot but think that specialists should be, so to speak, graduates from the
university of general practice, and should have to pass their practical tests as well
as their theoretical examinations in that school. Further, let us not forget that if
the specialist is sometimes "a good man gone wrong," the general practitioner himself is at least partly to blame for the way things have gone. And, too, we cannot
turn back the clock. There is a reason, and a positive reason, for the growth of
specialism, or it would not have lasted long; and we must not too long lament the
"tempora acta."
But such a paper as Dr. Dyer's, and the thought it has provoked, cannot but
do much good. We add our sincere congratulations, and our personal thanks for a
delightful evening. The paper was discussed by several men, including many men
in special practice, and Dr. Dyer was warmly congratulated by a large number.
—Ed.]
The position of the general practitioner in his professional dealings with
the general public and also with the specialist members of his own profession is becoming more unsatisfactory and ill defined every year.
Medical and surgical specialists have recently arrogated to themselves
that mental attitude of supreme aloofness so well described by Kipling in
the first verse of "The Wage-slaves":
"Oh glorious are the guarded heights
Where guardian souls abide,
Self-exiled from our gross delights,
Above, beyond, outside—
An ampler arc their spirit swings—
Commands a juster view,
We have their word for all these things,
Nor doubt their word is true."
The general public has been almost persuaded to take them at their own
valuation, as described in the above lines. The general practitioner, with
more knowledge of the facts, considers that the word "but" should be
substituted for the word "nor" in the last line. It is quite important in
the "interests of suffering humanity that there should be no large section of
the medical profession shouldering heavy responsibilities during its daily
work and knowing that it is regarded with increasing indifference or contempt by a public imperfectly acquainted with all the facts of a complicated situation.
In recent years the members of the proletariat, that is the great mass of
the population who do the essential, monotonous daily work of the nation,.
Page 104 have been lightened of their burden and their pecuniary rewards have been
increased till they can no longer claim the sole distinction of being classed
either as the "working class" or the "suffering poor."
In the little known social sphere of the medical profession the wheel of
time has brought round an exactly opposite state of affairs.
A new class has arisen within the profession, claiming social, intellectual,
and technical superiority to those practitioners who are still trying to carry
on the work of fighting disease, relieving suffering and doing useful work
for a moderate reward, which will keep them and their family in comfort,
and inflict a minimum of financial anxiety and loss on their patients.
This new medical aristocracy which has arisen can also claim to have
acquired all the vices of the "nouveau riche" with none of the virtues of
the old aristocracy. The specialists have learned well from the methods of
the governing classes of previous centuries. By devious routes and under
the altruistic guise of working for the profession, they have seized the reins
of power. This they have done by getting themselves elected as the heads
and administrators of the medical societies, from the Olympian heights of
which they dictate to the toiling practitioners the code of ethics which must
be followed. For any breach of these favoured class laws they sit in judgment on their victim and penalize him as far as they consider they can safely
go. Here let me state that no grievance against any individual specialist
has caused these opinions and experiences to be put forward, but rather the
need to expose the handicaps and difficulties of the general practitioner and
to demonstrate that he is often the equal and not necessarily the inferior of
his confrere, the specialist.
The specialist has been well described as the man who knows more and
more about less and less. In the great cities the general practitioner tends
to become a mere emergency ration, medical or surgical, for those of its
inhabitants who have any social ambitions. Not to have had a specialist
during a long illness, or to perform an operation, however trivial, or to give
his official approval of a death, is now coming to suggest that the family's
management of the affair has not been quite orthodox.
The practitioner who knows all the circumstances of a family in which
sickness has the misfortune to occur is in a dubious position. Often he
thinks that perhaps he is not doing the best for his patient and that possibly
other methods might hasten recovery. He knows, however, that the shortening of the illness by a few days or weeks can perhaps be purchased at too
high a price. Obviously little Jimmie or Mary would be safer in hospital
with an obscure illness where special nurses and numerous diagnostic
procedures may achieve a sensational cure. He also knows, however, that
for every dollar spent on Jimmie or Mary, father, mother and the other
children will have to go short of some of the necessities of life.
If improvement is delayed, the pressure of well meaning but irresponsible
friends will prevail, and a specialist will appear on the scene. His mind
deals only with the higher issues of life and death and is untrammelled by
petty financial considerations. The invalid is removed to hospital. There
he is bandied about from one scientific expert to another. Sometimes he
dies, but more often he goes home, cured of his disease but doomed to years
of penury, if the hospital and all its experts succeed in getting what they
consider their reasonable fees.
In the course of the year's work the family doctor runs up against a
mixed assortment of the ills that human flesh is heir to.   Sometimes he can
Page /Of rll!#
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carry on with a clear conscience, knowing that he can do as much or more
good for his patient as anyone else could do. Sometimes, and especially in
large cities and their outskirts, his right line of action becomes increasingly
difficult for him to decide on. Most people will do their duty but often the
chief difficulty is to decide what is one's duty. This difficulty has been much
increased by the greed of some of the specialists, and by the autocratic
regulations laid down by the members of the medical councils, nominally
for the protection of the public but practically for the financial advantage
of the specialist caste. This has been done by laying down the dictum that
it is unethical for the toiling practitioner to obtain any share of the rewards
of operative work which he has passed over to the specialist. Apparently it
is considered as quite likely that the practitioner may advise his patients to
undergo unnecessary operations for the sake of his share of the surgeon's
fee, but it is unthinkable that the surgeon should commit the same breach
of trust for the full fee. This is the reason why all practitioners try to do
their own surgery, sometimes to the detriment of their patients and sometimes not. After all, the practitioner must live and keep his family. If he
does no operating, the friends of his rivals say that he is no good and too
much of an old woman to operate, or has not the nerve for surgery, and his
practice ceases to exist. Also he has the galling experience of finding that
people who have been in debt to him for years and who have made use of
him for all their troubles will disgorge a large fee to a surgeon for one or
two hours of spectacular intestinal plumbing or other skilled technical
work, and leave his own equally responsible but less dramatic efforts unrewarded.
Possibly the general practitioner will soon be found only in the rural
districts. In the cities all minor illnesses, emergencies and infectious diseases will be dealt with by nurses, first aid stations, and public health officials.
The city general practitioner will take on the duties of a medical shop walker
and direct those of the public who are ignorant of the seat of the trouble
into the specialist department dealing with that portion of their anatomy
requiring attention.
Just as this crude endeavour to put the difficulties of the practitioner
before the public was nearing completion, an expert legal opinion on the
ethical relations of the patient, the practitioner and the specialist was
received from a patient's husband. It was received free of cost and unasked
for under the following typical circumstances.
A lady was referred by her family doctor to an eye specialist. Her
symptoms and age suggested eye-strain as being a likely cause of her troubles.
The eye-specialist, true to form, prescribed glasses for her, but without
waiting for the result of their use advised her to seek further advice from
another specialist, without any communication or information to the
patient's doctor without whose advice he would not have seen her. The
lady's husband, whose intellectual ability can be judged by the following
letter, supplied a definition of the ideal relations which should exist between
the three parties previously named. These relations are almost universally
ignored by the specialists who, with a few notable exceptions, have one
standard of ethics in dealing with one another and a totally different standard
in their dealings with the practitioner.  The letter is as follows:
Dear Doctor E.:—
At your suggestion my wife on Saturday last consulted and was examined by an oculist,
Dr. Y.; I look upon him as a specialist. He has prescribed some glasses; I was not present at
the examination but I gather from my wife's remarks that Dr. Y. seemed to think, if he did
Page 106 not actually express, that there was some underlying condition of which the eye trouble and
other afflictions from which my wife suffers were the expression. In fact, I think he definitely said that what was really desirable was a thorough examination. I am a little cynical
I admit, and inclined to ask "desirable for whom?" Now I find myself confronted with
the baffling problem of medical etiquette; I look upon it as a legal problem, i.e., you as our
solicitor keep us out of trouble, but when we get into a snarl, the solicitor protects himself
and I hope, by us, by submitting the situation to counsel—or a specialist. Counsel studies the
matter and returns his considered opinion, which goes. If it is wrong and the client complains, the solicitor waves the written opinion of counsel in his face, saying in effect "This
lets me out."
Assuming that the general relationship between the general practitioner and the
specialist is somewhat as above—isn't it possible or even eminently proper for you to ascertain from Dr. Y. as specialist what he thought of my wife's h-ealth as evidenced by her
general appearance and the particular state of her eyes—and if an examination was necessary
what kind of thing he would be disposed to look for first?
My wife, as you are aware, is a somewhat impetuous little person and is now talking of a
Dr. K., who is, I believe, a specialist in women's ills. But I certainly look on you as our
general practitioner and I look on a general practitioner as far wiser than a specialist—if
less costly. The general practitioner sees things as a whole, the specialist only sees an eye or
a tonsil which he itches to disturb.
The purpose of this letter is to find out how to act. I am not anxious to be smothered
with doctors' bills, for, as so many others, I am very dilapidated financially at the present
time and getting worse momentarily and swiftly, so if you can enlighten us as to the best
course to pursue we should be very much obliged and endeavour to abide by your suggestions.
Yours truly,
The Gynaecologist
The specialist in diseases of women is considered by most of the proletariat as the arch-villain of all his caste.
To be a success in any work, one must be an enthusiast and unusually
interested in the one particular subject. Any man who can choose the
pelvic diseases of women and their multitudinous minor ailments as the
most attractive field of his profession must have either an abnormal or a
good business mind.
Presumably pity for suffering wives and mothers and a worthy impulse
to mitigate the results of hasty or imperfect work of themselves or other
practitioners first leads them into this specialty. But the "cares of this
world and the deceitfulness of riches" soon choke the good seed. The worn-
out mothers of big families are not the patients to whom the gynaecologist
devotes most of his intellectual and manual dexterity. He soon finds that
the wealthy, childless, or one-child woman is the material out of which he
can build an easy reputation and extract an easy fortune. The doting or
thoroughly disillusioned husbands of such wives are easy marks, willing
and able to disgorge a big fee for any operation, which will perhaps restore
the invalid fretful wife to health or at any rate to a reasonable frame of
mind.
Young women, especially unmarried women, take little interest in their
own insides. Women of over thirty take little interest in anything else,
whether their own or those of somebody else. All obscure illnesses are
attributed by idle women to "ovarian" or "womb" trouble.
The gynaecologist therefore quite legitimately gets the first dip in the
lucky bag of the not very strong, well-to-do, unoccupied woman. Given
one or two successes among women of the fashionable world and his fame
spreads like a prairie fire, in the hen conventions and female uplift societies
of a big city. These women are mostly blessed with prosperous husbands
and take a pride in the money they cost such husbands. To have had a
more expensive operation than their social rival is a triumph too good to be
kept to themselves.   The gynaecologist in achieving success is gradually
Page 107
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forced into a line of action which would have demoralized the Apostle Paul
himself.
His patients expect of him expensive operations, which will rid them,
not only of any disabling disease, but of any inconveniences which handicap
their enjoyment of a social career. His fees, extortionate in proportion to
the work done, are squeezed out of a doting or henpecked husband by a
species of blackmail.  What fond husband can deny his wife the services of
the great Dr.  for her first baby even if he never takes a case for
less than $100.00? If there is any complication the husband can never
reproach himself nor be reproached, nor can the wife ever feel that poor
father's economical instincts were the cause of all her subsequent troubles.
Woe betide the husband who chooses a G. P. and a bill of $3 5.00 or $50.00
for the great event, if everything does not go quite right with the mother
or baby. Any mishap will be broadcasted by the specialist's lady friends
and nurses, and the dangers of getting an ordinary doctor to deal with such
cases will not be minimized by excessive accuracy at the next big tea of the
season. The busy husband of a childless or invalid wife has no defence when
the wife brings home the price laid down for restoring her to her place in
the whirl of society life to which she is entitled, and to which her husband
ought to be overjoyed at the prospect of her return. Quite probably he
really considers the price worth it for his own efficiency and peace of mind,
if the promised change in his wife's mental and physical health results from
the treatment. The gynaecologist is not entirely to blame for his extortionate
charges, nor for the extensive propaganda concerning his attainments. The
fashionable middle-aged patients who are at the same time the financial
bedrock of his practice and also act as his self-appointed advertising agents
require not only service but show. His office and nurse must be up-to-date
and blatantly efficient. His motorcar must be no cheap 4-cylinder runabout,
nor his clothes of a ready-made pattern. In fact, he is compelled to cut a
dash if he is to impress the ladies. He must also be a clever man, with a
knowledge of the psychology of the female mind not vouchsafed to most
men. Any man who possesses such a combination of attainments is certainly
an unusual type and can fairly claim to be a specialist. He is not, however,
always possessed of the virtue of tact, and perhaps because of his dealing so
much with women loses his understanding of the personalities of other men.
He does not add to his medical friends, when he recounts, after he has
finished an operation, the tale of his morning's work, which probably
amounts to considerably more than the monthly receipts of the G. P. who
has referred the case to him and who has perhaps been allowed to assist him
at the operation and carry on the after-treatment for 10% of the specialist's
fee for two hours work. To have the privilege of watching an obstetric
expert at his work in an up-to-date hospital is an object lesson in efficiency
and organisation. The patient reposes on a specially constructed altar known
as the obstetric table in a special room known as the "case room," sparsely
clad in a minimum of sterile drapery. At her head stands the anaesthetic
specialist, gowned in the robes of his high office. Grouped around are the
lesser acolytes, the nurses, also arrayed in vestments suitable for such a
momentous occasion. The obstetric specialist, as the great high priest,
supervises and controls the event which has been carried on by the female
of the species unaided for very many centuries with considerable success.
After an extensive investigation into the dangers of childbirth from a
series of a million births during a period of 10 years in Great Britain (Denning)  from 1920-1929 inclusive, an interesting fact was demonstrated.
Page 108 It was found that, even allowing for the bad cases going to hospital and
other complicating factors, the safest place for a woman to be confined was
in the woman's own home in some of the poorer parts of Birmingham,
attended by midwives or general practitioners. When the relative pomp
and ceremony, the relative costs and the relative success of the two systems
are compared—as the French would say, "Cest a rire."
The Genito-Urinary Specialist
The man who takes up G. U. work is generally of a quite different type
to those last described. In spite of his title he is chiefly a man's specialist,
as all the female work coming under the first half of his hyphenated name
is appropriated by the previous expert, and only a little of the work coming
under the classification of urinary troubles escapes the fine mesh of the
same individual. In fact, except for his double-barrelled name, he has no
claim to be numbered among the medical "upper ten" and would be quite
content to be treated even as other men. He need not necessarily be an
intellectual giant, though he sometimes is, but must have more than the
usual allowance of shrewd common sense and worldly wisdom tempered
with a leaven of charity in judging other men's weaknesses. Men of all
ages and social classes go to him to help them out of the troubles into which
their own indiscretions have usually, but not always, been the cause.
This medical aristocrat, in spite of his intimate acquaintance with the
more secluded areas of his fellow man's anatomy, does not usually acquire
the superior attitude of his fellow expert of the female specialty. His
patients come to him generally with real troubles, about which, whatever
their cause, they desire a minimum of publicity. Males after the age of 30
are much more secretive and reticent about their defects between the navel
and the knee than are their sisters. The genito-urinary expert has to give
his patients results which will enable them to carry on their daily work and
so enable them to reimburse him. The family doctor gladly deflects one
type of patients away from his own house or office owing to the extra worry
to himself and the extra risks to himself and his other patients. These people
who have often been compelled to suffer in silence rejoice at being able
to unburden their souls to the G. U. man, who learns to listen with or
without comments as he judges advisable or not, according to each individual patient's temperament. The G. U. man is generally a cheery but
cynical soul, with no trust in the word of man or woman but very tolerant
of human weaknesses. He is in the enviable position of being able to get
his money from a certain proportion of his daily round of patients without
much delay. The man who owes a bill to the G. U. man has no wish for the
details of his case to be blazoned forth in the Small Debts court. The urinary
expert deals with disabilities which, when they arise, require effective relief
urgently. He is therefore generally a thoroughly well trained type of
specialist intellectually and technically. He depends on his manual dexterity to attract and hold his clientele, and not much on the social or personal qualities which outweigh all other assets in the equipment of some
of the higher grade specialisms.
The Eye, Ear, Nose and Throat Specialist
If the gynaecologist is considered by the toiling G. P. as the arch-fiend
of the specialist caste, those of the above specialism or any one of its subdivisions generally give good cause toJ be considered as the arch-robbers of
the profession.
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Among them is a varied assortment of brilliant intellects, skillful
technicians and financial geniuses. Those who concentrate on diseases of
the eye are compelled by the essential functions of the eye to get results if
they are to keep their patients. Anyone with painful eyes or defective
vision knows whether his eyes are less painful or if he can see better after
the eye specialist has finished with him, and no amount of blarney can
convince him against the evidence of his own eyes. Also many eye conditions are secondary to disorders of other parts of the body, and the eye
man cannot limit his knowledge to that of eye diseases alone if he is to
achieve success. But, like all his specialist confreres, he is strongly imbued
with the spirit of class-consciousness and never misses the chance of helping
his fellow aristocrats at the expense of the family doctor. Having once sent
his patient for help with an obscure eye condition to the specialist, whether
or not the practitioner sees the patient again for any disorder of health, and
how soon, depends on the financial standing of the latter. Should he be able
to pay his way he will be deflected to the office of a fellow expert for whatever anatomical area shows signs of requiring treatment during the treatment of the eye condition. Should he fail to come through with the necessary payments or show early symptoms of poor financial health, he will
probably be referred back to his family doctor for treatment for his general
health.
A typical case was that of a little child who was sent to an eye specialist
with an obscure eye condition following pleurisy. The child's parents were
fairly well off, so the tonsils and adenoids were removed by the specialist
himself. No improvement following, the child passed into the hands of
bacterial experts and had T.B. tests, blood examinations, Wassermans and
anti-T. B. injections. Meanwhile the knee had become swollen, which called
for the services of a bone expert. Later the heart came under suspicion
and the child was referred to a heart specialist who went through all the
elaborate ritual of his kind. Finally, as funds became depleted, the child
returned to him who sent her. This man, looking at the sad, little nervous
wreck, sent her to the seaside to lie on the beach for the rest of the summer,
from which she returned after ten weeks in robust health.
After some years of special work one's vision may become so restricted
that one is unable to see the wood for the trees. To the doctor who is
accustomed to the early morning call of the asthmatic, the diagnosis and
early treatment of that condition seems fairly obvious. Yet it was my
experience to have a friend suffering with terrible suffocating attacks at
night for which he was treated by a famous throat specialist for a considerable time. He took a great interest in the sufferer, and painted his
throat assiduously at regular intervals for many months. Ultimately a local
doctor was called up in the early hours of a winter's morning, to find him
surrounded by atomisers, etc., and, as his wife had stated, apparently in
danger of speedy dissolution. The specialist had considered that he lived
too far away to be able to get to him in time to help him. A hypodermic of
adrenalin restored him to comfort in a few minutes, and the specialist's
comment when told of the speedy cure next day was that "Of course there
was a good deal of asthma about the case." Another unfortunate incident
for both parties was that of a man referred for an eye condition who was
found by the specialist to have nose and throat defects which should have
troubled him for the past forty years. As the man had never been ill during
this time he hesitated to part with these defects. However, on his next visit
J>age 110 to the office, under the pretence of examining his nose and eye, the expert
punched a hole in his nasal septum without his knowledge or consent. The
patient as a result returned to his "family doctor" to carry on till his
recovery, without risking any more destruction of innocuous tissue at
enormous expense. Deafness can be roughly divided into two chief classes,
the type which can be cured with an ear syringe, and that which cannot be
cured at all. If the patient does not suffer from the first type, the aural
specialist often feels that he must buoy up the hopes of such a patient by
unremitting attempts to achieve the impossible. Owing to the scale of
fees set by specialists and their effective business methods of extracting
them, the otologist seems to have little difficulty in convincing himself that
his cheering but useless consultations and treatments are beneficial to all
parties concerned. This complacent view of the situation is not so easily
recognised by the family doctor, who knows that often the cost of the
cheery office interview with the great ear doctor means the denial of some
luxury or even necessity to the unfortunate family of the deaf man or
woman.
However, criticism of this branch of the aristocracy is much moderated by the memory of the many acts of kindness from past and present
members whose skill and help have enabled the present writer to carry on
through many years and varieties of practice with varying success.
The X-Ray Specialist
In this ultra-modern brand of medical men we have a real specialist, who
is generally a real help to his fellow men, both patients and doctors. The
struggling members of the medical proletariat and the wealthy members
of the medical aristocracy can both seek and obtain the same help in their
difficulties, without loss of prestige, and without loss of their patients, as
the genuine x-ray specialist has no further interest in the patient or his
treatment after the latter has left his office. When a patient starts for the
specialist zone, either on his own initiative or on the advice of his family
doctor, he is remarkably lucky if the trip does not end in an extended tour
to many different varieties of medical and surgical experts. He reaches
home certainly a poorer man if no wiser, but generally thoroughly rattled
and quite uncertain which of his organs is the most urgently in need of
repair. The x-ray man, however, generally plays the game with the patient
and with his doctor who sent him, whatever is the financial standing of
either. This high standard of professional ethics is perhaps easier to maintain than in other specialisms. The x-ray picture does not lie, and if the
x-ray man is expert and experienced he knows what the picture means.
There is nothing to be gained and everything to be lost by magnifying or
minimising the state of affairs shown in the picture.
Medical men themselves tend to leave the interpretation of the plates
more and more to the x-ray expert. To be able to get the most information
from the plate the x-ray man must be well read and a thoroughly up-to-date
pathologist, knowing all the diseases whose presence will show enough
changes from the normal in an x-ray picture to justify a positive or tentative diagnosis of any one disease or its total exclusion.
Other requisites are necessary before a doctor can take up this ideal
branch of the profession. Firstly he must be a capitalist. To start his
office with equipment which will enable him to do effective work, even
without any competition necessitating unnecessary frills, calls for an outlay
of $10,000.   He has current expenses of films, special office arrangements
Page 111
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and skilled nursing help, which mean a large monthly outlay. He must have
the confidence of the medical profession and must have orderly methodical
business habits. Hundreds, then thousands, then tens of thousands of plates
must be numbered and recorded; for on his records depends the history of
every case he deals with. The law courts may suddenly demand and expect
accurate information from his records and plates, loag after the other details
of a case involving thousands of dollars are lost in the obscurity of passing
years.
The great dangers to which those engaged in this work were exposed
are now so well understood that there is little risk if proper precautions
are methodically observed. The x-ray man's opinion is in a class by itself.
There is no disputing what is depicted on the plate. The typewritten report,
to which there is no "come-back," has no respect for the specialist, the
junior interne or the practitioner. When we come to x-ray treatments,
deep therapy and radium therapy, we find a tendency among some of this
caste to become contaminated with the financial greed of so many of their
fellow aristocracy. But the malignant character of much of the disease so
treated generally deters all but the most incorrigible optimists or unscrupulous money seekers from inducing sufferers to submit to useless long-drawn
agony at enormous expense, which they can seldom afford. Altogether the
x-ray man can be numbered among the most desirable or the least objectionable of the specialist caste, whichever the reader considers the most
suitable descriptive term to use.
The "Lab." Man or Bacteriologist
This scientist occupies the same exalted position among his fellow
medicos as the x-ray man, only even more so. He deals in occult mysteries,
which, though seldom tangible or comprehensible except to the higher-
grade intellects of the profession, are at least not mere shadows as are the
x-ray man's stock-in-trade. The bacteriologist is also a man absolutely
detached from personal relations with his patients. Often he does not even
meet them face to face and, whether he does or not regards them merely
as a profitable source of blood, germs or other material for his culture tubes
and microscope slides. He is therefore welcomed by the practitioner as a
specialist who can be trusted not to raid his preserves after having been
given an introduction to his patients. His reports come back in figures and
statements, which are uninfluenced by any personality complex, and which
are at least definite even if they do not always unravel the mystery of an
obscure illness. Being individuals of scholastic, cultured, orderly and highly
specialised attainments, they tend to adopt a somewhat didactic attitude
towards the practitioner groping vainly in the dark. But this assumption of
superiority is cheerfully accepted by the practitioner, since he knows that
the greatest financial magnates in the specialist caste have to experience the
same feeling of infinite nothingness when they receive help from the shrine
of the microscopic or the metabolic expert.
The Paediatrician or Children's Specialist
This is a comparatively modern product of specialism. The breed has,
however, multiplied like locusts, especially on this continent, and threatens
to consume all medical practice among those under 10 years of age in the
big cities. Like many other pests they were started to serve a useful purpose
and have now become a blight instead of a blessing. The pxdiatrician himself or herself "is a kind of a b y harumphrodite, doctor and nursemaid
Page 112 too." They start younger than most specialists and with a minimum of
practical knowledge, but bristling with scientific data. Most of them,
having qualified, avoid the demoralising contact of general practice, and pass
directly into a resident appointment in a children's hospital, in a big city.
Here, in the enervating atmosphere of pretty nurses, invalid babies and
sick children, they acquire that conceit of themselves which is such a
valuable asset in dealing with the young mothers of their future patients.
From the hospital they pass on to the city of their choice, and have to consider how to advertise their own ability to deal with the ailing baby or
child better than the family doctor. They are lucky in having their way
made smooth for them by the "pursuit of health" craze of which Dr.
Hutchison made such a sacrilegious jest at the Winnipeg Medical Convention of 1930.
Some of the more quarrelsome type achieve notoriety by setting up a
milk scare, and stampeding the mothers into a loss of confidence in the milk
supply on which the babes of the city have thrived well in the past. This
having been achieved through the local papers, the grateful mothers naturally gravitate to the expert whose efforts have saved their babes from the
dangerous fluid on which they were thriving in ignorance. Another and
quite as effective a short cut to practice is via the well baby clinic. Here
the doting mothers of all classes bring their well babies to see if they can be
made any better, and to compare them with the other rival mothers' inferior babes.
Welfare nurses specially trained to detect minor defects do not fail to
point out the need of expert advice from the baby specialist in attendance.
The diet and general management of the baby since birth are discussed with
that infallible intuition and profound knowledge of mothercraft only
possessed by young paediatricians and childless women. Only a very small
proportion of the mothers can leave the clinic without a feeling of bitter
resentment against their own family doctor, for having failed to detect
the many deficiencies in their apparently healthy infants. And last but not
least, the young paediatrician has the busy obstetrician, who is too big a
man to deal with the baby while he is looking after the mother. The obstetrician, if he can help it, has no intention of letting the mother drift back
to her own doctor, who may possibly recapture his patient. To prevent such
an undesirable possibility occurring through the infant's shortcomings, he
pilots the baby into the paediatric expert's care. These two can be relied on
to blow each other's trumpets quite ethically and much more effectively
than their own. *
To those of us who are accustomed to dealing with children but are now
outside the charmed circle, the outstanding features of the specialty are
two. Firstly, the rapid changes in the diets and treatments laid down as
essential to the continued well being and even the existence of the infant.
Secondly, the still more wonderful way that babies have grown up to maturity for many thousands of years in spite of a universally faulty diet and
a total absence of "mother culture" till the last 20 years.
The children's specialist is, as a rule, a real enthusiast in his work and
anxious to do the best that can be done for his patients. Young children—
unless one has a real liking for them—have an unpleasant faculty of detecting any antipathy in those who are dealing with them. Two important
factors hinder the perfect judgment and absolute infallibility of most of the
modern children's specialists. Firstly, having had no experience of general
practice, and very often having only one or no children of their own, they
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have little practical knowledge of the alarming symptoms which can appear
in very young children from trivial causes. All symptoms to them suggest
those of children who were in hospitals under their care with serious illnesses, and they tend to rush all the children they see into hospital, often
for minor ailments, to the unnecessary mental anguish and financial loss of
the parents. The rapid recovery from a trivial complaint in a hospital has
more eclat and is more expensive than a day in bed at home on quarter
rations, and the modern parent seems to be in agreement with the paediatrician as to which is the more satisfactory procedure. Secondly and equally
important is the fact that the specialist sitting in his office with his trained
nurse and the juvenile waiting rooms outside only sees the sick child for a
few minutes under abnormal conditions. He knows nothing about the home
life of the baby, where the bottles are kept, what the bedrooms are like, how
many other children there are and how the sick child reacts to the other
members of the family.
Children have such a tenacious hold of life that they will often recover
from the most extraordinary therapeutic procedures. To the general public
it always seems so difficult for the doctor to diagnose the baby's ailments,
because the poor little mite cannot help by telling him anything about his
arches and pains. If the child under 10 cannot give the doctor much reliable
information it will at least not try to mislead him with inaccurate data.
The paediatrician does not have to sift out the true from the false in the
history of a sick or injured man who intends to take a holiday on Workmen's Compensation pay or on a Health Insurance policy if it can be
wangled. Nor does he have to take into account the tangled skein of
domestic troubles, as when a woman seeks her doctor hoping that he may
order a change of air or some pleasant way out of her home troubles.
The successful pxdiatrician is the one who keeps in his mind the essential fact that on his successful management of the child's mother more than
on his skill in the management of the sick child depends the volume of
his practice.
To succeed with the mothers he must be in the fashion. Fortunately the
insides of the majority of babies are as well able to withstand the changes
of fashions in diets as are the outsides of their mothers to adapt themselves
to the drastic changes in the fashions in dress. In our short lives we have
witnessed five systems of feeding laid down by the pxdiatric dietitians as
essential to the wellbeing of infants, and have also witnessed the survival of
equal proportions of those who have been fed according to the rules and
those whose parents have consistently disregarded them.
First there was the slashing attack on raw milk, when it was urged that
it was as barbarous a custom to feed babies on raw milk as it was to feed
adults on raw meat. Next came the citrated milk craze, when all the dyspeptic troubles of infancy were laid on the curds and proteids of milk. Then
arose a new school who talked of mysterious H-ions and babies were fed on
lactic acid milk or milk turned sour by any old acid. After a brief spell of
mingled success and failure this was replaced by an outburst of powdered
milks, in which the water having been driven out of the milk at great
expense and the dried remains tinned, it was restored to its former consistency with hot water and fed to the infant as a new diet. After a short
term of these in popular use, vitamins were suddenly sprung on a mixed
crowd of mothers, nurses and social welfare workers, and the babies initiated
into a mixed diet which requires the undivided efforts of one person during
a  16-hour day to carry out effectively.   Tomato juice, oranges, spinach,
Page 114
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irradiated food stuffs and dextro-rotary sugars are combined to make up a
diet which will prevent rickets and produce the race of super-children which
has long been hoped for.
Whatever the cause, the death rate in infancy has been much reduced,
probably partly owing to the increased care in the keeping of food clean and
partly or chiefly owing to the enormous reduction of flies with the replacement of horses by motors, and the careful watch over dairies by public
health officials.
Meanwhile, among the "best people" a new problem has replaced one
which was almost universal in the big families of previous generations. The
parents are faced with the pet child who won't eat and cannot be induced
to eat, and who is proving a much greater difficulty to cope with by both
parents and pxdiatricians than was the child who would not stop eating to
the parents and doctors of a previous generation.
The Orthopaedic Specialist
This is the specialist who deals in injuries and diseases of bones and
joints, and includes in his clientele all deformities of the limbs whether congenital or acquired. For reasons best known to themselves, the bone specialists' field of action ceases abruptly with the first cervical vertebra. Any
fracture, injury, disease or deformity of the skull bones is considered to be
the domain of the general surgeon or of a brand of surgeons who limit themselves to "cranial surgery." The bone specialist is a valuable asset to the
community, both the medical fraternity and the laity. It is essential that to
he an exclusive bone specialist he must be located in a big city with large
industrial works to supply the accidents which form the groundwork of
his practice. To every general practitioner a bad fracture or severe injury
to a joint is a source of anxiety for months after its occurrence. If all goes
well, no credit is given to him for his treatment. If anything goes wrong,
the patient and his entire circle of acquaintances lay the blame on the doctor
without any consideration or knowledge of the many complicating factors
which may have influenced the final result. It is in these cases that the bone
specialist is to the family doctor a tower of strength and a very present help
in trouble. To attain a position where the profession recognize him as
"master of his craft," it is necessary for him to be a man of unusual mental
ability and much manual dexterity, to enable him to foresee and overcome
difficulties and complications as they arise, and to possess a personality which
can quickly detect and overawe all schemers and neurotics. Mose "bone-
men" get the reputation of being tough, cold-blooded individuals, absolutely
indifferent to other people's pain, and of the type described by Tennyson in
his somewhat mawkish poem, "The Children's Hospital":
"Our doctor had called in another, I never had seen him before,
But he sent a chill to my heart when I saw him come in at the door,
Fresh from the surgery schools of France and of other lands,
Harsh red hair, big voice, big chest, big merciless hands.
This is not surprising when one considers how much of the work they do
necessitates the ignoring of their patients' pain when dealing with the fragments of broken bones out of position which must be rectified, or joints
which must be moved after long periods of stiffness. Another reason for
their callous or truculent mannerism is the frequency with which they have
to contend with an increasing type of men and women, who, having met
with a motor or industrial accident, are determined to prolong the period of
disability and conpensation to the last limit. These people the bone-specialist
Page 11 J I, ?
has to browbeat into a state of mind which realizes the fact and acknowledges it, that they are not so helpless as- they would like to be.
That long column of joints, the spine, each with its possibilities of
injury or disease, is always somewhat of a closed or at any rate a forgotten
book to most men in general practice. It is often astonishing to find what
relief a good bone specialist can give to the victims of chronic diseases of the
spine, and those suffering from the well meaning efforts of various healing
cults.
The orthopxdic specialist is one of the few among the medical fraternity
whose successes and failures are open to inspection by the public. The mistakes and omissions in the treatment of most of the internal organs of the
body have usually one of two results—either the condition of the patient
remains in statu quo or he dies, and he and his doctor and his treatment are
soon forgotten except by the nearest relatives. It is not so with the mistakes
of the bone man. When, after prolonged treatments and many operations
for fractures or deformities, the individual returns to his daily life with a
deformed and useless limb, there is no device which can hide from the public
for the rest of the patient's life that Dr. — "made a hash of the limb,"'
even if it was quite unavoidable. The abdominal and brain specialists bury
their mistakes. The mistakes of the bone specialists spend the rest of their
lives walking about, hugging their deformities and holding forth to all they
meet of the terrible sufferings they endured from their surgeon and the
still more distressing result he left them with.
The orthopxdic surgeon to make a success of his work must be good,
for one bad result will be more potent for evil to his reputation than a
hundred perfect results will be for good.
A thoroughly capable, fearless and honest bone specialist is a blessing
alike to his fellow men, whether doctors, patients, workmen or employers,
and a terror and stumbling block to all grafters, malingerers and neurotics.
The Future of the General Practitioner
The resources and organisation of the forces opposed to the interests of
the general practitioner are such that a justifiable gloom and "inferiority
complex" are permeating the ranks of the "army of the doomed." Among
those qualifying every year, an increasing proportion avoid general practice
and steer into the comparatively smooth waters of public health or specialism. Already in the States and to a less extent in Canada the rural districts
find it more and more difficult to get and keep resident medical aid. The
speed of motors not being enough to obviate the scarcity of doctors, the
aeroplane is now benig used to speed up the supply of medical and surgical
aid for rural emergencies. Meanwhile the supply of medical men, mostly
specialists, becomes more and more concentrated in the cities.
A solution of the problem would be that after a somewhat shorter course
of four years education and training along the present lines, a qualifying
examination of rather lower standard than the present "final" should be
passed. After this another two years should be compulsorily spent on intensive training for the various specialisms. Included in these courses should
be a special training in every variety of emergency work, which is really the
present specialism of the general practitioner. After this last two years the
doctor should be licensed to practice along whatever line he is trained for.
Only as an emergency specialist with equal years of training can the general
practitioner hope to be recognized as the intellectual equal of other
specialists.
Page 116 The income of a man practising in the country should be graded to
raise it at least to the level of that earned by the average city doctor. State
medicine with all payments made by the State for general practice work is
probably inevitable if any graduates are going to continue to take up general
practice, under present conditions, as their life work.
The rich could go to fashionable experts, teachers of medical schools
and owners of big private clinics. The poor could go to government specialists who could be appointed by examination or elected from their own
medical associations. These latter would probably draw a higher salary or
■scale of fees than others, but many medical men would be quite prepared
to carry on the work of a consultant in a big city rather than endure the
incessant demands of general practice even if the financial rewards were
the same.
Some such method seems the most simple and effective way to ensure
the survival of the general practitioner species.
It is already obvious both to the public and to the profession that no
individual can ever hope to become an expert at every branch of the profession. It is foolish that a man who intends to become a surgeon should waste
his time in the details of food supplies, drainage, or water supply, or that a
mental specialist should be compelled to know the treatment of infantile
diarrhoea.
But the man, woman, or child who suffers from the common ills of
humanity wants the nearest medical man and the first that he calls to find
out with a minimum of delay what is the matter and give relief instantly.
This the general practitioner has been doing effectively in most cases up to
recent times.
Familiarity breeds contempt and the public has ceased to look on the
promptness and efficiency of the service as worth the price paid for it.
If the city public no longer has need for the general practitioner, the
supply will soon cease to be renewed. The group system of multiple specialists will probably be the solution of the question of by whom is the sick
person going to be ultimately treated. This can only be possible in a big
enough centre of population to supply material for the various specialists in
the group. In the rural districts all emergency work and all chronic cases
must be treated by the emergency expert, i.e., the man who has had two
years intensive training for rural work. The work beyond his sphere and
that which can wait, must be dealt with by travelling teams from the big
cities or be forwarded to the cities.
In the minds of many people at the present time, there are some doubts
as to the benefit of many of the startling results of medical and surgical
advances. Is the old man or woman really benefitted by having the date of
death postponed by some operation heroically endured and still more
heroically paid for by the savings of a life time; with a few more years of
life, crippled bodily and financially, to be endured as the result of its success? In the battle of life in this work-a-day world the general practitioner
still plays the part of the regimental medical officer in war time. He is the
one who is dealing with those who are doing the world's work whether young
or old. Without his help, the number of those falling out of the struggle
for existence would be more numerous than they are now. Even if he
cannot cure, it is at least something to be able to help or encourage a combatant to carry on.
To those of a passing generation, who were brought up to believe that
the essential thing in life was to carry on and do the day's work until they
Page 117
m
—^- It
tli
broke down, the present-day health propaganda and education is more of a
menace than a safeguard, more a force for evil than for good. From a boy's
earliest school days the insidious and demoralising campaign of "safety first"
is instilled into him. To endure sickness and pain, yet still carry on whether
it be work or play, is no longer considered to show the virtue of endurance,
but rather the stigma of ignorance. Our up-to-date health crusaders, in
their frantic efforts to attain physical perfection for the nation and to forestall all prejudicial influences in their bodily health, are succeeding in sapping the spiritual stamina of the nation. This, with the development of an
introspective neurotic mentality, they are achieving in direct proportion
to the vigour and success of their teaching. Fortunately there are still some
large families of boys, and some boarding schools and training centres for
young men where these new doctrines of old women, male and female, find
a very stony soil to thrive on.
If state medicine is to be the solution of all future health problems, both
for the state and the individual, then both the public and the medical
profession will have to realize that the men who act as the first line of
defence are not going to act as "hewers of wood, and drawers of water" for
a class of individuals of their own intellectual standard. The specialists will
ultimately realize that, when by their cupidity and selfishness the general
practitioner has been squeezed out of existence, the work now being done
by the latter was as important to the public as their own.
Supply is ultimately fixed by the demand. When the present demand by
the public for the services of specialists more and more limited in their
scope, has been fully met, the value set on their services will drop in proportion.
Then will come again the demand for someone who can relieve bodily
disabilities whatever their cause or location, with a minimum of time and
expense. However urgent the need, a supply of men with general training
and fitted to deal quickly and effectively with any sudden illness or accident, cannot be increased at short notice. It is easier to train men quickly
for any specialty than for the much wider demands of general practice.
People have become obsessed with the idea that the specialist equipped to
deal with the disorders of a circumscribed area of the body is necessarily
superior to the practitioner who must have a thorough knowledge of the
whole body.
The difference between the family doctor and the specialist in their
handling of the sick is a psychological one. The family doctor was often
a spiritual and moral help in sickness and trouble. In this materialist age
people want something tangible for their money. The non-assessable value
of the ability to strengthen the morale of the family and the invalid which
some of the old practitioners possessed is not shared by the specialist. The
latter has no interest in his patient other than a financial one, unless it be a
scientific one in occasional instances. The practitioner himself certainly
cannot assess the value of his own moral help in terms of dollars and cents.
This being so, the public have ceased to recognize that it exists.
This last chapter may appear to be a somewhat fulsome glorification of
the practitioner. He has, however, had to endure so much derogatory
criticism that a little flattery will equalize matters.
I will close this swan song of a type of men now almost obsolete—as I
began—with lines of Kipling:
Page 118
tfl'liffffftll
H5- mrmm
If you can keep your head when all about yoti
Are losing theirs and blaming it on you;
If you can trust yourself when all men doubt you,
Yet make allowance for their doubting too;
If yon can bear to hear the truth you've spoken
Twisted by knaves to make a trap for fools . . .
Yours is the earth and every thing that's in it,
And what is more, you'll be a real practitioner, my son.
"Absolute Accuracy"
In filling the eye physician's prescription, nothing short
of absolute precision will satisfy us.
We take a pride in maintaining
Guild standards to the utmost.
OPTICAL CO. LTD.
Dispensing Opticians
631  Birks Bldg., Vancouver, B.C.
■1
For maximum efficiency give Petrolagar
in divided doses several
times each day after
meals.
Petrolagar is the original Council-accepted
emulsion of liquid
petrolatum (65% by
volume) and agar-
agar.
Samples free on request.
PETROLAGAR   LABORATORIES   OF
CANADA, Ltd.
364 Argyle Road
Walkerville, Ontario
Petrolagar  !
for CONSTIPATION
Distinctive
PRINTING
CARDS
STATIONERY
that really are nicer
AND COST YOU
NO MORE
ROY
WR1GLEY
Limited
300 WEST
PENDER STREET
VANCOUVER, B. C.
>!l
Ii  I
Page 119 I
I*
Mi'
\"1 ■
Relieve Your Patient
Suffering from Bronchial Irritation—
PRESCRIBE .
MISTURA TUSSI
FORMULA:
Each fluid ounce represents:
Marrubium vulgare   24 grains
Diamorphine Hydro-
chlor. 1/6 grain
Ammonii Carbonas 10 grains
Ammonii Chloridum 10 grains
Liquor Scillae 120 minims
SyrupusTolutanus 120 minims
Dose: One to two fluid drachms
HABTZ
A palatable stimulating expectorant and an effective cough
sedative which relieves bronchial irritation but does not
lock up the secretions. Particularly useful in hard, dry coughs
with scanty expectoration.
Clinical. Sample on Bequest
The J. F. HARTZ CO. Limited
TORONTO
Physicians'
Supplies
MONTREAL
The J. T. Hartz
Gentlemen: Pi
Co.,
ease
Limited, Toronto, Canada.
send clinical sample MIS1URA
TUSSI
Hartz.
V.
Dr	
Street  : „.   City.
Coramine "Ciba
jy
A non-toxic circulatory and respiratory stimulant for oral,  hypodermic,  intravenous  and
intracardiac administration.
Improves the pulse and blood pressure, reinforces the contractions of the myocardium.
Very wide margin of safety (1-15 cc.)
AMPOULES LIQUID
CIBA COMPANY LIMITED
MONTREAL
Page 120 SULFARSENOBENZOL
—   BILLON
A SUPERIOR BRAND OF SULPHARSPHENAMINE
For painless subcutaneous treatment of syphilis
Perfectly tolerated, SULFARSENOBENZOL is particularly indicated
for treating children or whenever the intravenous method
is not practicable.
Offered in gradual dosages of from 0.005 Gm. to 0.96 Gm.
LABORATORY POULENC FRERES
OF CANADA LIMITED
Tor literature and samples, apply to
Canadian Distributors:
ROUGIER FRERES,  3 50 Le Moyne Street, MONTREAL
A PRESCRIPTION SERVICE . . .
Conducted in accord with the ethics of the Medical
Profession and maintained to the standard suggested by
our slogan:
Pharmaceutical Excellence
I MCG!  ftCVmr,
l_l MITEO v—y
FORT STREET (opp. Times)      Phone Garden 1196      VICTORIA, B. C.
STEVENS' SAFETY PACKAGE
STERILE GAUZE
is a handy, convenient, clean commodity for the bag or the office.  Supplied
in one yard, five yards and twenty-five yard packages.
B. C. STEVENS CO.
Phone Seymour 698
73 0 Richards St., Vancouver, B. C.
'-"
M V
UilitlVH56&
ft
1
KB
ANTIPHLOGISTINE
in Bronchitis
Broncho-pneumonia
UNLIKE THE OLD-FASHIONED bacteriogenic
poultices, which cooled quickly and required constant changing, Antiphlogistine, in addition to
supplying prolonged moist heat, may be left in situ
for more than 12 hours.
in Bronchial Irritation
following measles, scarlet fever, tracheo bronchial
lymphadenitis, it is recommended that an Antiphlogistine dressing be applied over the upper chest,
posteriorly and anteriorly.
For alleviating the pain, lessening the sense of
tight feeling, loosening the cough and bringing
relief from the congestion, Antiphlogistine is of
definite value.
The Denver Chemical Mfg. Co.
153 Lagauchetiere Street W.
MONTREAL
Made in Canada The Evidence is Accumulating
In the common cold, infhrafiza, in fact,
in every rispiratory disellfe, evidence
ll ^      . ■   ill
is   accumulating   that   alHlization   is
definitely illeful.   And thilpvidence in
favor of Allk-Zane for acidoks is equally
convincing!I Alka-Zane, is Itbrth trying.
■hhhmhhhhhwhw?
Alka-Zane is a granular, effervescent salt, composed of sodium, potassium, magnesium and
calcium phosphates, carbonates and citrates.
Average dose: one teaspoonful in a glass of
water. Supplied in IK, 4 and 8 ounce bottles.
Literature and trial supplies
gladly sent  to physicians.
WILLIAM R. WARNER & CO., LTD., 727 King Street, West, Toronto, Ontario w-
ill
is
j'
ii'
ii"
■
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'ml   '
m
I*
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1*
If,.
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Ill I
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I
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Hutttt & (FltnmBim
2559 Cambie Street
V
ancouver
, B. C.
Portable   X-Ray Work   Now   Possible
IN THE HOME
A Convenience to All Doctors.    Totally Efficient and Shock Proof
For full details, phone or -write
W. C. ECCLES
X-Ray Department, St. Paul's Hospital, Vancouver, B. C.
REST HAVEN ' ■
A Medical Institution for the restoration of health,
situated eighteen miles from Victoria, overlooking the
Gulf of Georgia.
Modern facilities for the treatment of all classes of
patients with the exception of those suffering from
mental or contagious diseases. Hydrotherapy, electrotherapy, massage, and diet, under medical supervision.
Physicians referring patients or convalescents for
treatment are requested to send such reports and suggestions as may assist in their treatment.
REST HAVEN SANITARIUM
and HOSPITAL
SIDNEY, B. C. AT THE RIGHT HAND
OF THE DOCTOR
—stands the Georgia Pharmacy . . . filling
his prescriptions just as they should be filled
. . . with drugs that measure up to highest
standards of purity and in the exact quantities
ordered . . . day and night—at the right
hand of the Doctor.
fSEYIOSO
f OHM All
NIGHT
OPEN
ALL
NIGHT
GEORGIA PHARMACY
W. GEORGIA
STRE E T
SEYMOUR
1050
li H
R. F. Harrison
W. R. Reynolds
iWamtt pleasant
Ihtttcriakhm Co.
iCtmiteb
Telephone Fairmont 58
KINGS WAY at 11th AVENUE
VANCOUVER, B. C. naifa
Ri"
*
ii
nil'
i .ii
* if
\m
CONTROLLED
Cereal Cookery
If you instruct ten differ
cereal thus and so," there
HoME-COOKED cereal is seldom a
uniform product... because of many uncontrolled factors. The cook, for instance, rarely measures the cereal and
the liquid accurately. Nor does she
time the cooking carefully. Even if she
does, the intensity of the heat varies. Further, the degree of evaporation differs.
Even the type of utensil is a factor.
Cooking cereal in a double boiler is likely
to cause a surface "skin" to form that is
even less digestible than raw starch,
Carman  el  al find  from  digestibility
ent mothers, "Cook baby's
will be ten different results.
studies in vitro of breakfast cereals. They
also report that single-boiler cooking for
more than 15 minutes actually "decreases digestibility because of the formation of lumps produced by too rapid
evaporation of water." This clumping is
unavoidable without a condenser and
with ordinary household utensils.
Pablum*, in contrast, is manufactured
by a patented process  and precision
methods which insure a thoroughly cooked and uniform cereal. This is substantiated by in vitro studies of Ross and
Burrill, which show that the
starch of Pablum without additional cooking is more rapidly
digested than that of oatmeal,
farina,   cornmeal,   or   whole
wheat cooked  4  hours in a
double boiler.
Left—Two    double-jacket    cookers _ inf
which Pablum is steam-cooked under rigid1
control. Live steam of uniform pressure and
temperature flows into the cookers and displaces air above the cereal thus preventing!
oxidation and affording protection to vitamins  and flavor.  A  unique  paddle-knife]
constantly agitates the mixture so that a
fresh surface is constantly presented to the
steam. Note three gauges used in control-3
ling cooking: (A) gauges maintaining uni-a
form steam pressure in tops of cookers; (B)
gauges regulating steam pressure in surrounding jackets; (C) thermometers for con-
trol of temperature (control of steam pressure
and of temperature are both essential), %
Right—One of many drum
dryers used in the manufacture of Pablum. After the cereal mixture is steam-cooked
it is dropped between revolving steam-heated rollers
which roll and dry it in a
uniform layer of material.
Gauge (D) is used as a check
on the steam pressure within
the drums. Distance between them is maintained
within thousandths of an
inch by means of a micrometer plate (E).
*Pablum (Mead's Cereal pre-cooked)
is a palatable cereal enriched with
vitamin and mineral containing foods,
consisting of wheatmea], oatmeal,
wheat embryo, alfalfa leaf, beef bone,
brewers' yeast and sodium chloride.
Patent pending.
Please enclose professional card to Mead Johnson & Co. of Canada, Ltd., Belleville, Ont., when requesting samples of
Mead products to cooperate in preventing their reaching unauthorized persons.
, r i 5 3 6 13 th Avenue West
Fairmont 80
Exclusive
Ambulance
FAIRMONT 80
Service
ALL ATTENDANTS QUALIFIED IN FIRST AID
"St.
John's Ambulance Association"
WE SPECIALIZE IN AMBULANCE SERVICE ONLY
R. J. Campbell
J. H. Crellin
W. L. Bertrand
<ft?ttt?r $c If atma Eft
Established 1893
VANCOUVER, B. C.
North Vancouver, B. C.    Powell River, B. C.
W.iw. fJ I
JIM I
it firi
?*!<
Published Monthly at Vancouver, B. C by ROY WRIGLEY LTD., SOO West Pender Street f^S^^^S&l^^^&^^S^^^S^^&^&S^(
Hollywood Sanitarium
Limited
For the treatment of
Alcoholic, Nervous and Psychopathic Cases
Exclusively
Reference—B. C. Medical Association
For information apply to
Medical Superintendent, New Westminster, B. C.
or 515 Birks Building, Vancouver
Seymour 4183
Westminster 288
^^^SSS^SSSSSSSS^S^SSS^S^

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