History of Nursing in Pacific Canada

The Vancouver Medical Association Bulletin: April, 1943 Vancouver Medical Association Apr 30, 1943

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 8*
^1898,
^0<
The BU||LHi»i
of the
VANCOUVER
MEDICAL ASSOCIATION
Vol. XIX.
APRIL 1943
No. 7 -m
With Which Is Incorporated
Transactions of the
Victoria Medical Society
the
Vancouver General Hospital
and
StMPaul's Hospital
In This Issue:*
Page
SPECIAL NOTICE RE GOVERNMENT LIQUOR ACT
GOVERNING PRESCRIPTIONS^- _^^^^m. ^^^ —-^^P19l
REVIEW OF CASES OF CARCINOMA OF THE BODY OF THE UTERUS 192
THE FEAR OF THE SKIN (The Osier iMture^^^^^^^ :£-. 196
A REVIEW OF CAESAREAN SECTIONS IN THE
VANCOUVER GENERAL HOSPITAL, ^^tV^^ff^   •r^^^^^^m^nfj
ERYTHROBLASTOSIS FOETALIS AND ITS RELATIONSHIP
TO THE Rh FACTOR W^^^^S^&S^^^^^   -WJ"  #?Spsi21i
J|   ^SUMMER SCHOOL
Tlie Annual Summer School of the Vancouver Medical
Association will be held at the
HOTEL VANCOUVER, JUNE^2nd toi6th, Inclusive CALCIUM
GLUCONATE.
While many mineral
elements have a single
physiological function,
such as iodine and iron,
calcium is required for
several unrelated pro-
cesses, e.g., the clotting of
blood, activation of trypsin, promotion of muscle
contractility, prevention
of tetany, skeletal building and repair, and during
pregnancy and lactation.
In many of our common
foods the calcium content
is small in relation to
bodily needs, making
necessary an additional
supply of calcium in conditions of disease. Calcium
metabolism is most active
in the presence of adequate amounts of vitamin
D, as supplied in Cal-
glucol "D" E.B.S,
Calglucof "D"EJB.S. supplies calcium combined
with vitamin D for oral
administration in a form
which is well absorbed
and is used in the following conditions to supple-
mint dietary calcium"
%   In pregnant and lactating
|*|| womenWand   injSrapidly
growing children.
2 To raise the level of blood
fg§|calcium in tetany.
Each tablet
contain*'*'*!
% In nervous hyperirritabiliBf due to calcium deficiency an^pn
nervous spasm of the gastro-intestinal tract and nervous
twitchings of skeletal muscles, which may also be due to
calcium deficiency.
A To temporarily raise the blood calcium level, to shorten the
coagulation period before and after surgical and dental
operations.
C In asthma and hay fever, in which conditions it has been
claimed that a calcium deficiency exists in a large percentage
of cases. B^
£ To diminish inflammation and particularly to decrease plef,
v effusion and oedema by decreasing the permeability of Ihe
capillaries. ■
"7 In the treatment of respiratory diseases which it influences by
relaxing bronchial spasm ana by decreasing secretion of the
mucosa of the respiratory tract. |^^^
To relieve skin rashes, urticaria, as in hives, allergic and
drug rashes and eczema. Bi
O To decrease pain in dysmenorrhea and in cases of intractable
pain, as i$ cancer.
8
10
In the treatment of cases of poisoning in which a disturbance
of calcium metabolism is involved—as in lead poisoning,
poisoning with carbon tetrachloride, chloroform and similar
chlorinated hydrocarbons, oxalic acid poisoning and to
counteract the systemic effect of magnesium.
CALGLUCOLflllE.B.SlclNoui
available for oral use. in bottles of 100, 500,
and 1,000 compressed tablets No. 149A.
For intramuscular injection, Calglucol in a 10%
solution, is supplied in boxes of six ampoules of
10 cc. each. No. A-31V In this form it is of value
in  serum   sickness,  urticaria,  spasmodic^ and
infantile convulsions, and eclampsia.
jfj^It is also prophylactic against milk fever.
Oedema of children suffering from nephrosis has
 K been successfully treated with Calglucol ampoules.
Injection of Calglucol E.B.S. is not recommended during a course of treatment with Digitalis.
THE E. B. SHUTTLEWORTH CHEMICAL CO. LIMITED
TORONTO
MANUFACTURING   CHEMISTS
CANADA
H
on your
prescrlptior >4S
mimi
MAY 12 1943
THE    VANCOUVER    MEDICAL    A5SOCI
BULLETI
Published Monthly under the Auspices of the Vancouver Medical Association
in the interests of the Medical Profession.
Offices: 203 Medical- Dental Building, Georgia Street, Vancouver, B. C.
EDITORIAL BOARD:
Db. J. H. MacDermot
Db. G. A. Davidson Db. D. E. H. Cleveland
All communications to be addressed to the Editor at the above address.
•XHSUHR
Vol. XIX
APRIL, 1943
No. 7
OFFICERS, 1942-1943
Db. J. R. Neilson Db. H. H. Pitts Db. G. McDiabmid
President Vice-President Past President
Db. Gobdon Bubke Db. A. E. Tbites
Hon. Treasurer Hon. Secretary
Additional Members of Executive: Db. Wilfbid Gbaham, Db. J. A. McLean
TRUSTEES
Db. F. Brodie Db. J. A. Gillespie Db. W. T. Lookhabt
Auditors: Messrs. Plommer, Whiting & Co.
SECTIONS
Clinical Section
Db. D. A. Steele Chairman Db. J. W. Millab Secretary
Eye, Ear, Nose and Throat
Db. A. R. Anthony Chairman Db. C. E. Davies Secretary
Pcediatric Section
Db. J. H. B. Gbant Chairman Db. John Pitebs Secretary
STANDING COMMITTEES
Library:
Db. F. J. Bulleb, Db. D. E. H. Cleveland, Db. J. R. Davies,
Db. A. Bagnall, Db. A. B. Manson, Db. B. J. Harrison
Publications:
Dr. J. H. MacDermot, Dr. D. E. H. Cleveland, Dr. G. A. Davidson.
Summer School:
Dr. J. E. Harbison, Db. G. A. Davidson, Db. R. A. Gilchbist
Db. Howabd Spohn, Db. W. L. Gbaham, Db. J. C. Thomas
Credentials:
Db. A. W. Hunteb, Db. W. L. Pedlow, Db. A. T. Henby
V. 0. N. Advisory Board:
Db. L. W. McNutt, Db. G. E. Seldon, Db. Isabel Day.
Metropolitan Health Board Advisory Committee:
Db. W. D. Patton, Db. W. D. Kennedy, Db. G. A. Lamont.
Greater Vancouver Health League Representatives:
Db. R. A. Wilson, Db. Wallace Cobubn.
Representative to B. C. Medical Association: Db. C. McDiabmid.
Sickness and Benevolent Fund: The Pbesident—The Tbustees.       fev «SgSSSgS^§S^SS^§^^
I
1
HI
*<HBS vU53iy tASttl*     }
| Fsrrous S«»»t«
ra^sai^Si&SesSj
FERROUS IRON has been shown in numerous
clinical reports to be effective in smaller
dosage than other forms of iron and to have
fewer undesirable side-effects. Included in the
number of hematinics available under the Squibb
label are three which supply iron in ferrous form.
To meet the needs of individual patients and
preferences of physicians one of these products
supplies iron alone; another iron and Bi; a third,
iron, Bt, and liver.
TABLETS   FERROUS   SULFATE   EXSICCATED   SQUIBB
For use where iron alone is indicated. Supplied
in 3-grain enteric-coated tablets in bottles of 100
and 1000. Three grains exsiccated ferrous sulfate
supplies as much iron (approx. 60 mg.) as 5 grains
of ordinary U. S. P. ferrous sulfate.
CAPSULES   FERROUS   SULFATE  WITH   Bi   SQUIBB
For prevention and treatment of secondary
anemia, especially in patients with anorexia due
to vitamin Bi deficiency. Each capsule contains 3
grains of ferrous sulfate exsiccated and 1 mg. of
thiamine hydrochloride (333 U. S. P. XI units of
vitamin Bi). Supplied in bottles of 100 and
1000 capsules.
CAPSULES   HEBULON*
For prophylaxis and treatment of secondary
anemia and as a nutritive adjunct during pregnancy, convalescence and general undernutrition.
Each small, easy-to-swallow gelatin capsule contains 2 grains exsiccated ferrous sulfate (approx.
40 mg. of iron), 50 U. S. P. XI units of vitamin
Bi; and liver extract (derived from 16 Gm. fresh
liver) containing appreciable amounts of certain
vitamin B complex factors including riboflavin
and filtrate factors. Supplied in bottles of 100,
500 and 1000 capsules.
♦"Hebulon" is a trade-mark of E. R. Squibb 8b Sons.
For literature write 36  Caledonia Road, Toronto, Canada
E-RiSoyiBB &. Sons
I of Canada. Ltd.
MANUFACTURING CHEMISTS
TO   THE  MEDICAL   PROFESSION   SINCE   1838 VANCOUVER HEALTH DEPARTMENT
STATISTICS—FEBRUARY, 1943
Total population—estimated   .      271,597
Japanese  population   k  " "l_Evacuated
Chinese population—estimated :  8,767
Hindu  population—estimated     367
Rate per 1,000
Number       Population
Total deaths     312 14.1
Japanese  deaths  — _ Population evacuated
Chinese deaths  -. _      14 32.9
Deaths—residents only  ] ....   280 12.6
BIRTH REGISTRATIONS:
Male,  318;   Female,  289    607 27.4
INFANTILE  MORTALITY: Feb., 1943 Feb., 1942
Deaths under one year of age      22 17
Death rate—per 1,000 births      36.2 31.4
Stillbirths (not included in above)        8 8
CASES OF COMMUNICABLE DISEASES REPORTED IN THE CITY
January, 1943 February, 1943 Mar. 1-15. 1943
Cases Deaths Cases Deaths Cases Deaths
Scarlet Fever     64           0 49           0 16           0
Diphtheria       0           0 0           0               0           0
Diphtheria Carrier       0           0 0           0              0           0
Chicken Pox      66           0 84           0 39           0
Measles       11           0 133           0 286           0
Rubella  I      10 6-0              4           0
Mumps   257           0 235           0 110           0
Whooping Cough  £     31           0 30           0 14           0
Typhoid Fever       0           0 0           0               0           0
Undulant Fever       0           0 0           0              0           0
Poliomyelitis  H      0           0 0           0               0           0
Tuberculosis      47         12 45         12 10
Erysipelas  &j      10 2           0               10
Meningococcus Meningitis      3           1 6           0               2           0
V.D. CASES REPORTED TO PROVINCIAL BOARD OF HEALTH
DIVISION OF VENEREAL DISEASE CONTROL
West North       Vane.    Hospitals &
Burnaby    Vane.   Richmond   Vane.      Clinic   Private Drs.   Totals
Syphilis I Figures for January and February not yet available.
Gonorrhoea )
Phone MArine 5411
Res.: MArine 2988
/Zeafiuce QcUlOfi
CANADIAN PHYSIOTHERAPY ASSOCIATION
GRADUATE McGILL UNIVERSITY SCHOOL
OF MASSAGE AND REMEDIAL GYMNASTICS
Electricity, including Short Wave
House Visits
417 Vancouver Block
Vancouver, B. C.
Page 185 Purified Liver Extract
IN THE TREATMENT OF PERNICIOUS ANAEMIA
THE BEST therapeutic measure at present available is the
intramuscular injection of a potent, concentrated, and
purified liver extract. The concentrated extract prepared by
the Connaught Laboratories has the following advantages:—
ASSURED POTENCY
Each lot is tested clinically
for  therapeutic  activity
SMALL DOSAGE
In most cases initial treatment with one cc.
per week is sufficient—for maintenance, one cc.
at less frequent intervals is generally adequate.
PURITY
The extract is a clear, light
brown solution, containing less
than   100  mg.   solids   per cc.
PURIFIED LIVER EXTRACT (HIGHLY CONCENTRATED)
is supplied by the Connaught Laboratories in Four-cc. Rubber-
Stoppered Vials.
CONNAUGHT   LABORATORIES
UNIVERSITY  OF   TORONTO
Toronto, Canada
DEPOT FOR BRITISH COLUMBIA
MACDONALD'S PRESCRIPTIONS LIMITED
MEDICAL-DENTAL BUILDING, VANCOUVER, B.C.
I VANCOUVER MEDICAL ASSOCIATION
FOUNDED  1898    ::    INCORPORATED  1906
Programme of the Forty-fifth Annual Session    (Spring Session)
GENERAL MEETINGS will be held on the first Tuesday of the month at 8:00 p.m.
CLINICAL MEETINGS will be held on the third Tuesday of the month at 8:00 p.m.
These meetings  are  to  be  amalgamated  with  the  clinical  staff meetings of  thr
various hospitals for the coming year. Place of meeting will appear on the agenda
General meetings will conform to the following order:
8:00 p.m.—Business as per Agenda.
9:00 p.m.—Paper of the evening.
1943
May 4th—ANNUAL MEETING.
8:00 p.m.—Business Meeting and Elections.
9:00 p.m.—Address by Dr. P. A. McLennan: "MEMORIES."
SUMMER SCHOOL
June 22 nd to 25 th, incl.
The Summer School Committee is happy to announce that the following well-known
medical men will be among those participating in the School Session in June:
Dr. Foster Kennedy, Professor of Clinical Neurology, Cornell University Medical
College, New York, N.Y.
Dr. Edwin M. Robertson, Department of Obstetrics and Gynaecology, Faculty of
Medicine, Queen's University, Kingston, Ont.
Dr. Max M. Cantor, Asst. Professor of Biochemistry, University of Alberta, Edmonton, Alta.
MArine 6735
C.S.M.M.G.
805, 718 Granville Street
GP.A.
AflU Ada S. ManJzJixwi
wishes to inform the Medical Profession that she has resumed her
Physio-Therapy practice at 805 Birks Building.
Short Wave Remedial Exercises
Massage
|HIGH   BLOOD   PRESSURE
BETTER RESULTS OBTAINED WITH
BIOGLAN1
Another Product of the Bioglan Laboratories, Hertford, England
Phone MA. 4027
Stanley N. Bayne, Representative
1432 MEDICAL-DENTAL BUILDING
Descriptive Literature on Request
THE SCIENTIFIC HORMONE TREATMENT
Vancouver, B. C.
Page 186 ANAHiSMIN B.D.H.
for economy in Pernicious Anaemia Treatment
There is no more economical or effective liver treatment than by
the use of Anahaemin B.D.H. Small doses at comparatively long
intervals produce maximum responses both in the treatment of
pernicious anaemia cases in relapse and in the maintenance of
satisfactory blood counts over long periods.
Further, the high degree of purification of Anahaemin B.D.H. has
resulted in the reduction of the content of haempoietically inert
reaction-producing proteins to a minimum, while the concentration
of the haempoietic principle itself is such that great activity is
contained in small volume. The comfort of the patient is therefore
ensured by reason of the smallness of each dose and the long
intervals between injections.
Stocks of Anahamin B.D.H. are held by leading druggists throughout
the Dominion, and full particulars are obtainable from
THE BRITISH DRUG HOUSES (CANADA) LTD.
Toronto Canada
•An/Can/434 EDITOR'S PAGE
This is the Osier number of the Bulletin, and it is with great pleasure that we publish the Osier Lecture of Dr. E. H. Cleveland. Our readers will, we know, share this
pleasure with us. Not only is the subject-matter of the paper worthy of perpetuation
in permanent form—but the delightful style and pleasant, easy writing of which Dr.
Cleveland is a master, will make the reading of his paper what the hearing of it was, an
intellectual treat. We need scarcely add that the advice given by its author is worthy of
our keenest attention.
The medical profession of this province has been much disturbed recently, and rightly
so, by the action of governmental authorities,with respect to old-age pensioners. For
quite a while, we saw reports in the daily press to the effect that these persons were to
receive free medical attention in addition to the living allowance they now have. This
seemed praiseworthy and even generous. But while the motive may have been sound,
the execution of the scheme was not so good. Without any formal consultation of the
medical profession, or any attempt to obtain their views on the matter, the Government
went ahead and informed each of these pesioners, by a circular letter, that from now
on they could go to the doctor of their choice and obtain free medical treatment. A
card was given each of them, which the doctor was to sign, signifying thereby his willingness to assume the care of the pensioner.
This was, as we have said, very generous of the government—but, after all, it is easy
to be generous with other people's time and money—and we of the medical profession
rather resent this action. The basis of payment has not yet, we understand, been
formally stated: we question if- any decision has been made at all: and in any case, our
opinion was not asked, as a profession, nor our permission obtained, before our services
were so generously given away. As far as we can make out, the general idea is to use the
relief rate as a basis.
There are several points here to be considered, apart from the serious objection raised
above, that we have not consented to any plan. First, the relief rate, as well as the whole
plan of medical assistance given to patients on relief, should not and must not be used
as a standard for treatment of such groups as old-age pensioners. Relief assistance was
a temporary expedient, and we hope it will disappear. Old-age pensioners and mothers'
pensioners will probably always exist, and a permanent policy should be worked out for
their care. And it should be worked out by full conference and consultation between
the parties concerned. The organized medical profession through its duly constituted
Concil and Economic Committees, should be the ones to review this whole question and
decide on what would constitute a fair scheme, and no individual doctor should agree
to assume this work until this is done.
Secondly, the relief medical scheme is a very poor one indeed. It gives a poor, inadequate service—and we would think it disgraceful that such a medical service should be
all that can be given to old-age pensioners. These people are old, often ill, often helpless. They require a lot of care: and an adequate, efficient scheme, including hospitalization, should be worked out for them. Anything less than this would be quite
inadequate.
Lastly, we are concerned for the reason that if this is to be the attitude of governmental authorities towards pensioners, the indigent, etc., then there is grave reason for us
to consider what sort of place in a health insurance scheme, which we now see in the
near future, is to be assigned to these unfortunates. As a profession, we have again
and again formulated our ideas as to how they should be taken care of and this miserable,
half-baked scheme is certainly a long way from what we feel is right. We hope our
leaders will take cognizance of all thfs, and that they will take a definite and firm stand
in the matter. We urge all medical men not to act as individuals, but to refer all such
schemes and suggestions to their regularly constituted representatives.
Page 187 NEWS    AND    NOTES
Col. Gordon C. Kenning, after three years and eight months of service, his last
appointment being Officer Comanding No. 16 General Hospital, has received discharge
from the R.C.A.M.C. and is returning to civilian practice in Victoria. Dr. Kenning
has the well wishes of the profession in opening the office which was finally closed when
his four associates all entered the Services. He has secured his former office at 625 Fort
Street.
Recent promotions are those of Major A. B. Manson and Squadron Leader E. T. W.
Nash.
Congratulations are extended to Dr. and Mrs. R. H. Irish of Tranquille on the birth
of a son on March 20th; to Dr. and Mrs. R. W. Garner of Port Alberni on the birth of
a daughter on March 26th; to Dr. and Mrs. D. E. Starr of Vancouver on the birth of i
daughter on April 3rd; and to Capt. and Mrs. Donald W. Moffatt on the birth of a
daughter on April 10th.
The sympathy of the profession is extended to Dr. M. W. Thomas, Executive Secretary of the College of Physicians and Surgeons, on the death of his father, Mr. J. E.
Thomas, in Victoria.
Lieut. Nursing Sister Edith M. Kergin was awarded the Royal Red Cross. She is the
daughter of Dr. L. W. Kergin of Prince Rupert. She is now Mrs. Randolph Mutrie,
having married Capt. Mutrie, R.C.A.M.C., of No. 15 General Hospital.
Three doctors who have returned to practice following war service: Dr. T. C.
Harold, formerly of Ladysmith, who served as Flight Lieut, with the R.C.A.F., has
opened an office in the Medical-Dental Building, Vancouver. Dr. Harry Baker, formerly
of Salmon Arm, who served as Medical Officer with the R.C.A.M.C, has taken up practice in the Birks Building, and will confine himself to children's diseases. Dr. W. McK.
McCallum, formerly Medical Officer with the R.C.A.M.C., Pacific Command, has returned to practice in the office formerly occupied by Major Kenneth Craig and latterly
by Capt. A. N. Beattie.
*S* .*T *f *r
Dr. Joseph Olivier, formerly of Creston and more recently in Alberta, has returned
to the Province, and is now reported to have moved to White Rock.
«-       *       *      *
Dr. H. A. Macdonald, who was at Surf Inlet, is now at Woodfibre.
Dr. J. A. Street, until recently at Woodfibre, has joined the staff of the Workmen's
Comensation Board.
Dr. L. W. Kergin of Prince Rupert was in Vancouver in March and called at the
office.   Dr. R. Geddes Large was also in Vancouver recently.
»? •? *r »r
We are glad to report that Dr. F. W. Green convalesced very satisfactorily following his recent operation. He was able to attend the sessions of the Legislature, of which
he is the member from Cranbrook area.
»». »». *;►, »»,
Dr. G. P. Dunne of Vancouver has returned from New York, where he studied
caudal anaesthesia.
Page 188 SUMMER SCHOOL CLINICS
VANCOUVER MEDICAL ASSOCIATION
June 22nd to 25th, 1943, inch
HOTEL VANCOUVER, SALON "A"
SPEAKERS:
Lieut.-Colonel J. D. Adamson, R.C.A.M.C, Consultant in Medicine.
Dr. Max M.  Cantor, Asst. Professor of Biochemistry,  University of
Alberta.
Lieut.-Colonel G. S. Fahrni, R.C.A.M.C., Consultant in Surgery.
Dr. Foster Kennedy, Professor of Clinical Neurology, Cornell University Medical College.
Brigadier J. C Meakins, R.C.A.M.C, Deputy Director General of Medical Services.
Dr. Edwin M. Robertson, Department of Obstetrics and Gynaecology,
Queen's University, Faculty of Medicine.
ELECTIONS TO COUNCIL—COLLEGE OF PHYSICIANS & SURGEONS
The following results of elections of members to Council are announced:
District No.  1—Dr. F. M. Bryant, Victoria.
District No. 2—Dr. G. S. Purvis, New Westminster.
District No. 3—Dr. H. H. Milburn, Vancouver.
Dr. F. A. Olacke of Ashcroft was in Vancouver recently, applying for appointment
as Medical Officer with the R.C.A.M.C
Dr. Donald Williams is now occupying an important post at Ottawa as Lieut.-Col.
D. H. Williams, R.CA.M.C He is the Chief Venereal Disease Control Officer for the
Army. Steps are being taken to amalgamate this work with that of the Department of
Pensions and National Health so that the work among the Forces and the civilian population will be co-ordinated.
j;- * si-        *
Dr. W. A. Drummond of Salmon Arm has been in the East doing post-graduate
study during the past month.
*^ s** »S» sS*
Capt. C. G. G. Maclean visited the office when in Vancouver recently.
sj. «- * *
Dr. R.- W. Garner and Dr. B. T. H. Marteinsson of Port Alberni were in Vancouver
recently and called at the office.
We are glad to report that Dr. W. F. Drysdale of Nanaimo is rapidly recovering
following his recent indisposition.
Page 189 LIBRARY NOTES
RECENT ACCESSIONS TO LIBRARY
Medical Clinics of North America, Symposium on Office Gynaecology, Chicago Number,
January, 1943.
Spray Painting Hazards, 1939, by Jakob Jakobsen (Copenhagen).
Surgical Clinics of North America, Symposium on Gynaecology and Obstetrics, Chicago
Number, February, 1943.
Diseases of the Heart, 3rd ed., 1943, by Sir Thomas Lewis.
Pain, 1943, by Sir Thomas Lewis.
Clinical Haematology, 1942, by Maxwell M. Wintrobe.
Banting as an Artist, 1943, by A. Y. Jackson (Complimentary copy, kindness of the
Art Committee of Hart House).
COMMITTEE ON INDUSTRIAL MEDICINE
Dr. A. W. Bagnall,
Chairman,
Committee on Industrial Medicine,
B. C. Medical Association,
925 West Georgia Street,
Vancouver, B. C.
Dear Doctor Bagnall:
Because of the urgent need for speed in the prpoduction of the weapons of
war, it is important that industrial workers return to their jobs as soon as
reasonably safe after injury or illness.
The family physician is in a position to influence the date of the worker's
return to the job. I believe that a letter to the profession, from your committee, asking their co-operation, would be most effective.
Justification for this request for aid from an already overworked profession,
is the present need for preventing unnecessary loss of time.
Yours very truly,
WARTIME MERCHANT SHIPPING LIMITED,
W. G. Saunders, M.D., D.PH.,
Director of Industrial Health.
Page 190 College of Physicians and Surgeons
President—. Dr. W. A. Clarke, New Westminster
Vice-President Dr. F. M. Bryant, Victoria
Treasurer . Dr. H. H. Milburn, Vancouver
Members of Council—Dr. F. M. Auld, Nelson  (District No. 5); Dr. F. M. Bryant, Victoria
(District No.  1); Dr.  W. A. Clarke, New Westminster   (District No.  2);  Dr. Thomas
McPherson, Victoria (District No.  1); Dr. H. H. Milburn, Vancouver  (District No. 3);
Dr. Osborne Morris, Vernon  (District No. 4); Dr. Wallace Wilson. Vancouver  (District
No. 3).
Registrar Dr. A. J. McLachlan, Vancouver
Executive Secretary ! Dr. M. W. Thomas, Vancouver
SPECIAL NOTICE
Extracts from Government Liquor Act Governing Prescriptions
For your information I quote hereunder sub-sections from Section 2, and
Sections 21 and 22 of the "Government Liquor Act":
"Druggist" means a member of The Pharmaceutical Association of the Province
of British Columbia who holds a valid licence under the "Pharmacy Act"
and is lawfully and regularly engaged in carrying on the business of a
pharmaceutical chemist:
"Physician" means a member of the College of Physicians and Surgeons of
British Columbia who is registered under the "Medical Act" and who is
lawfully and regularly engaged in the practice of his profession:
"Prescription" means a memorandum signed by a physician, and given by him
to a patient for the obtaining of liquor pursuant to this Act for use for
medicinal purposes:
Sec. 21. Any druggist may keep for sale and may sell for strictly medicinal
purposes liquor purchased by him under special permit pursuant to this
Act, but no sale of liquor shall be made by a druggist except upon a bona-
fide prescription signed by a physician, and no more than one sale and one
delivery shall be made on any one prescription. R.S. 1924, c. 146, s. 21;
1931, c. 36, s. 5.
Sec. 22. (1) Any physician "who deems liquor necessary for the health of a
patient of his whom he has seen or visited professionally may give to the
patient a prescription therefor signed by the physician, or the physician may
administer the liquor to the patient, for "which purpose the physician shall
administer liquor purchased by him under special permit pursuant to this
Act, and may charge for the liquor so admlinistered; but no prescription
shall be given nor shall liquor be administered by a physician except to
bona-fide patients in cases of actual need, and when in the judgment of the
physician the use of liquor as medicine in the quantity prescribed or administered is necessary.
(2) Every physician who gives any prescription or administers any liquor
in evasion or violation of this Act, or -who gives to or writes for any person
a prescription for or including liquor for. the purpose of enabling or assisting any person to evade any of the probisions of this Act, or for the purpose
of enabling or assisting any person to obtain liquor as a beverage, or to be
sold or disposed of in any manner in violation of the provisions of this Act,
shall be guilty of an offence against this Act. R.S. 1924, c. 146, s. 22;
1937, c. 27, s. 4.
A. J. MacLACHLAN, M.D.,
Registrar.
Page 191 THE ANNUAL MEETING OF
THE HONORARY ATTENDING STAFF
THE BRITISH COLUMBIA CANCER INSTITUTE
The Annual Meeting of the Honorary Attending Staff of the B. C. Cancer Institute
was held Monday, February 15, 1943, at 8 p.m. This meeting is called annually to
review the work of the past year, for election of officers, for the setting forth of policies
and a programme for the coming year and for the discussion of prepared papers on
chosen clinical subjects.
The Medical Superintendent reported that 348 patients had been admitted to the
Institute in 1942, had been seen in consultation with the Honorary Attending Staff and
had received the recommended treatment. The location of the malignancies were as
follows: Breast, 29; female genital organs, 39; oral cavity, 48; upper air passages, 8;
alimentary tract, 17; male genital organs, 6; urinary organs, 1; skin, 66; thyroid, 1;
salivary gland, 1; branchial cleft, 1; and other malignancies, Hodgkin's, 2; myelogenous
leukaemia, 1; lymphosarcoma, 1; malignant tumour of eyeball, 1.
Dr. Trapp, the acting Medical Superintendent during Dr. Evan's absence overseas,
emphasized the necessity for the growth and development of the cancer unit to serve
the growing needs of a population whose second greatest cause of death is cancer. The
Richards Memorandum, recently prepared at the request of the Canadian Medical Association and envisaging a centralization of cancer work, was recommended for careful
thought and study. It might well be made a goal, in expanding to meet increased
demands. Britain has continued to meet her cancer problem throughout the war. The
British Empire Cancer Campaign reports that it is able to make the proud boast that
since the war began, it has been possible to subsidize to the fullest extent every research
centre associated with the Campaign. The All-Union Library of Moscow has recently
written to the British Empire Cancer Campaign, urgently asking for all the latest dati
on the cancer problem. Dr. Trapp found much for inspiration in these progressive tendencies elsewhere, and saw little justification in making the war a reason for the curtailment of essential activities in the field of cancer.
Two research problems had been continued during the year, namely, the investigation of pain in relation to cancer under the direction of Dr. Frank Turnbull and the
Robertson Cancer Test. It is hoped that the former investigation can be carried on in
spite of shortage of facilities imposed by war conditions. Dr. Robertson's promising
experiment must be abandoned temporarily, he stated, as a qualified technician is not
available.
Dr. T. H. Lennie was re-elected President of the Honorary Attending Staff. Dr. H.
H. Caple was elected Secretary.
Dr. Frank A. Turnbull presented a paper of great clinical interest, namely, a consideration of the "Indications for Cordotomy" in the relief of intractable pain such as
is encountered in late incurable uterine cancer,. To get satisfactory results, Dr. Turn-
bull stated that the cordotomy should be performed while the general condition of the
patient is reasonably good and before the patient has become demoralized by the use of
morphine.   It is possible that Dr. Turnbull may publish this paper at a later date.
Dr. Margaret Hardie presented a review of "Cases of Cancer of the Body of the
Uterus," which is published below.
REVIEW OF CASES OF CARCINOMA OF THE
BODY OF THE UTERUS
Dr. Margaret Hardie
This review concerns itself with a study of 72 cases of carcinoma of the body of
the uterus, of which 33 are cases treated through the Institute, 11 are from records of
Dr. Trapp's private practice, 5 are OPD cases treated in hospital and not referred to the
Page 192
mm Institute, and the remaining 23 are those treated privately at the Vancouver General
Hospital by various doctors. The review includes all cases from these sources for the
years 1939-1942 inclusive, with a histological diagnosis of carcinoma of the corpus. In
addition, the records of these years show 2 malignancies of the corpus uteri of a sarcomatous nature, which are not included in this study.
Statistics re age, relation to menopause, parity, social status, family history, symptomatology, clinical extent of disease are computed from the information contained in
the histories of all the cases.
Following these observations, an attempt will be made to analyze the cases of the
Institute, of private practice, of the OPD from the point of view of treatment received.
Age.—The youngest was 37, the oldest was 78. The average was 59.2 years. Eighty
per cent of the patients were between 50-70 years of age.
Relation to Menopause.—In 53 cases only was the age of menopause recorded. The
average age of onset of menopause in these cases was 49.3 years. If we consider the
average age of the menopause in normal women to be 47 years, these figures suggest
that the menopause is a little later in patients developing corporeal carcinoma.
Family History.—The majority of the histories did not give the requisite information. Of 3 3 case histories making reference to family histories 13 were positive, 2 0 were
negative; i.e., 39.5% positive and 60.5% negative. It is not suggested that statistics
based on such a small number are of any value.
Parity.—It is generally considered that evidence is against child-bearing as an
etiological factor in fundal carcinoma. Our figures seem to refute this opinion, as 8 3 %
of the women had borne children.
Social Status.—Sixty-eight per cent of these women were private cases—i.e., private
patients of various doctors, or Institute cases in receipt of more than minimal income.
This finding confirms an apparently old observation with respect to carcinoma of the
fundus, though investigators seem to be at a loss to explain it. It would be interesting
to have comparable figures on carcinoma of the cervix in our community, as the same
investigators claim that, in contrast, the preponderance of patients with cervical cancer
are staff or charity cases.
Symptomatology.—TTie most usual symptom was bleeding—intermittent or continuous. Sometimes the bleeding was associated with a thin discharge—sometimes the
latter was the only symptom. There were 3 patients with long standing symptoms.
Mrs. H. had had bleeding for 20 years. It is interesting to note that she was a 1939
patient, aged 70, who received radiation treatment and is still living. Two others had
blood-stained discharge for 7-8 years. They both received radiation treatment but
died within a few months after admission and autopsy in both cases revealed widespread
metastases. The average duration of symptoms of patients in this review was 17.1
months before seeking medical advice.
Pain as a symptom occurred in 22 cases or 31% Usually the pain was low in the
abdomen to either side; occasionally in the back. Compared with findings in other
clinics 31% is a high figure. Healy and Brown suggest that the symptom of pain
indicates an extension of the growth beyond the uterus which cannot be recognized
clinically.
Examination—Extent of Disease.—The majority of patients appeared to be overweight and to maintain their weight. Mrs. W. on first examination weighed 178 pounds.
She died one year later from disease, weighing 173 pounds. The average weight of the
30 whose weight was recorded was 164 pounds. Eleven others were described as "obese"
in their histories.
The most constant finding on pelvic examination was enlargement of the body—
varying from a slight enlargement to a 5 x/z-inch canal. Of 50 cases reporting, 84%
showed enlargement, 16% showed no enlargement.
Cervical polyp was present in 17 cases or 23.6%. In 10 of the 17 cases the polyp
had undergone malignant degeneration. In 6 cases the malignancy was confined to
the polyp.
Page 19'3 Fibroids were present in 20.8% of the cases but only occasionally were these recognizable clinically. In the majority of cases the diagnosis of fibroids was made post-oper-
atively—from which fact we must conclude that the actual co-existence of fibroids is
much greater than 20.8%. In 2 of the 15 cases the fibroids had undergone malignant
degeneration (sarcomatous).
On admission examination 3 cases were found to have secondary deposits in the
vagina.
Diagnosis.—All cases in the review have diagnosis based on histological findings
either of the curettings or of the uterus post-operatively. No attempt has been made
to grade the pathology.
Investigators whose reports I have studied in preparation of this review seem to agree
that for surgical treatment the grade of cancer has some relation to the prognosis,
namely, the less differentiated the cell, the worse the result; whereas with radium treatment, the cure rate does not drop significantly as the grade of malignancy increases.
Our records did not permit an investigation from the point of view.
Analysis of Institute Cases
Boyd states that less than 10% of uterine cancer is of the body. The Institute figures for the 1939-42 interval show 130 cases of cancer of the cervix and 33 cases or
20% of cancer of the body.
Of these 33 treated through the Institute, 26 were treated radiologically alone.
Five were referred, following their surgical treatment elsewhere, for radiation of subsequent vaginal metastases (in 2 cases) and for radiation of extension of disease beyond
the uterus found at the time of operation (in 3 cases); 2 others received surgical treatment, on consultation with the gynaecologists, following their radiation treatment. Of
the 26 receiving radiation treatment alone, 7 were considered technically inoperable because of clinical evidence of extension beyond the uterus, and 15 were considered
inoperable on account of previous handicaps, hypertension, obesity, auricular fibrillation,
angina, diabetes.    The average weight of patients referred to the Institute was 173 lbs.
The treatment given this group of 26 patients treated radiologically is the treatment devised by Heyman and known as "The Stockholm Treatment." It consists in
packing the uterine cavity on two occasions, three weeks apart, with irradiators of equal
size in the form of small capsules containing 10 mgm. each of radium. With this method
both cornu and the fundus, even in the case of grossly enlarged uteri, as well as the
collus uteri, are in close relationship with the radium and receive the emanations equally.
The mechanical difficulties are few, as each capsule has a wire string attached and a
number tagged to it. No. 1 is inserted first into one cornu and so on. An attempt is
made to pack not less than 10 capsules, i.e., 100 mgm., and not more than 20 into the
uterine cavity. The last capsule is left within the os of the cervical canal to keep the
canal patent and facilitate removal following treatment. The time for removal is calculated so that the uterus will have received 1500 - 2000 mgm. hours at each operation.
In addition bakelite irradiators are packed into the vagina with the purpose of preventing vaginal metastases. Sodium pentothal is the anaesthetic of election. The patient is
in hospital 3 to 5 days only with each insertion. Two to three weeks following the last
treatment the patient receives deep x-ray therapy to the pelvis.
If hysterectomy is to be subsequently performed, it should be done approximately
six weeks to two months following radiation treatment for best results. This is no
longer done routinely in the Stockholm Clinic, but only if symptoms reappear.
For statistical purposes, the Institute cases and those receiving the Stockholm treatment privately, can be considered as one group—a group of 44 cases. Of these, 76.7%
are still living.
Analysis of Cases Receiving Treatment Privately
Twenty-three cases comprise this group—of which 16 cases were treated by hysterectomy alone. In two cases after laparotomy revealed widespread extension, radio therapy
was resorted to.   Of two cases who receive radiation treatment alone, one was clinically
Page 194 ^■i^^^H
inoperable and died from a heart condition before her treatment was completed. Two
received a preliminary radium treatment followed by hysterectomy and one patient had
no treatment.
The observation one might make from this short analysis is that the gynaecologist
overwhelmingly prefers surgery in the treatment of fundal cancer where the case is
clinically and technically operable.
Radium insertion in the foregoing cases was by a single irradiator in the form of a
segmented tube.
The 5 O.P.D. cases received similar surgical and radiation treatment, namely: Two
received surgery followed by radiation (in one case to extension discovered at operation,
in another case to metastases developing two years later); two received radium followed
by x-ray therapy; 1 received radium followed by surgery.
These two groups, private practice and O.P.D., which have received similar treatment, total 27 patients (without the patient who was too advanced for treatment).
Seventy per cent of these patients are still living.
Obviously there are results which are desirable to have but impossible to obtain from
this review.
1. No 5-year survival rates are possible for any group, clinically operable, technically operable or inoperable—as our earliest record is for December, 1938.
2. No reliable comparison can be made between surgery and radiotherapy as treatments, because we have no 5-year survival rates, because of the small number of cases
available for study, and because irradiation is so often reserved for those cases which are
inoperable. ^|
From the literature it appears that the cure rate in operative treatment of operable
cases of corpus cancer is 55% or less. Heyman, on account of results which he has
obtained, considers his method of packing the uterus with radium, combined with
hysterectomy in case of failure, as the method of choice. He has increased his survival
rates by this method 25-30% in the case of clinically operable cancer. This figure
suggests a 60% or better 5-year survival rate for selected cases. Confirmatory results
based on at least 100 cases are not yet available. He expresses gratification at the increasing number of operable cases being referred to him for radiotherapy but emphasizes
that the present lack of satisfactory statistics make a reliable comparison of surgical
and radiological results impossible.
REFERENCES:
1. The  Radiumhemmet  Experience  with   Radiotherapy   in  Cancer  Corpus  Uteri by J.  Heyman.  Acta
Radiologica, Vol. XXII.
2. Cancer of the Body of the Uterus—H. H. Fouracre Barns in Journal of Obstetrics & Gynecology of
British Empire, July, 1942.
3. Adenocarcinoma of Uterine Fundus—Dan. Morton, University of California—American Journal of
Roentgenology, Vol. 41, May, 1939.
4. Experiences  with   Radiation  Therapy  Alone  in  Cancer   Curpus   Uteri—Healy   &  Brown,   Memorial
Hospital, in The American Journal of Roentgenology, Vol. 41, May, 1939.
5. Cancer of the Uterus—Elizabeth Hurdon, C.B.E., M.D., Oxford University Press, London.
PATON LIBRARY FUND
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Draeseke, G. C.
Page 195 THE FEAR OF THE SKIN
Mr. President, Ladies and Gentlemen-.
It is customary at this time for the speaker to express his sensibility and
appreciation of the distinction you have conferred upon him. In conforming
to this custom I make no perfunctory gesture. Of all honours most prized
are they which are bestowed by one's own friends. Such an honour is that of
delivering the Osier Lecture before the Vancouver Medical Association, and it
is recognized moreover as one of the highest gifts of that body. I thank you
and I will try to deserve your kindness.
The title I have chosen for my subject may have a strange sound in your
ears, and introduces a curious conjunction of ideas. I hope to shonv you that
it is a reasonable one.
It has been said of old The Fear of the Lord is the Beginning of Wisdom.
But
THE FEAR OF SKIN
is Unwisdom; it is Panic, and Panic is Folly.
D. E. H. Cleveland, M.D.
Read at the Annual Osier Dinner of the Vancouver Medical Association, March 2, 1943.
Sir William Osier, the great physician whose name we honour tonight, probably
owed his commanding position among his contemporaries and his rank in medical history to the fact that he brought Pathology into the perspective of the working medical
man. He established the indispensable relationship between the pathological laboratory
and the bedside. Before Osier's time the pathologist was a being apart from the multitude. His interest in human bodies appeared to begin where that of others left off.
Over his autopsy-table, pickle-jars, microscope and slides the pathologist took apart the
wreckage, classified the fragments and got an intimate and detailed view of what an
ex-patient had become. Sometimes he was able to deduce more or less accurately the
chain of events which had led to the dissolution before him. But he dealt in high and
mighty mysteries and an air of detachment clung about him. He and his concerns were
foreign territory which the fighting men in the line of battle against death dared not
invade. They feared discomfiture would attend them there, and faced this danger by
turning their backs to it. That he. could help them, and help them to help their
unbeliefs, he had not demonstrated and they had not suspected.
Osier, whose earliest beginnings were characterized by a divinely-inspired curiosity,
invaded this forbidding domain and made himself master of it. Then he threw down
the barriers between it and clinical medicine, showed that they were artificial, and that
pathology and medicine were actually co-extensive. The establishment of the intimate
relations which must exist between pathology and clinical medicine was Osier's supreme
achievement.
In very modest emulation of this work of Osier's I have taken as my task an attempt
to breach the walls which appear to separate Dermatology from Medicine.
Dermatology is a field in the domain of Clinical Medicine, but it should not be a
walled enclosure. One cannot claim full competence as a clinician if dermatology is to
him a terra incognita, and a dermatologist who is not well-informed and adequately
trained in clinical medicine is no dermatologist.    He is a mere "spotter of spots."
Too often the medical man who finds himself faced with a dermatologic problem
does one of two things. Either he declares at once that he knows nothing whatever
about the skin, admitting helplessness, or he takes comfort in saying that there is nothing
to it anyway. This is rank defeatism. With more courage than judgment he shuts his
eyes and walks on in the hope that when he looks again the spectre will have vanished.
If it does not he tells himself, perhaps, that if he but ignores it or placates it with gentle
looks it will by-and-by go away peaceably.    "Skin diseases all get well sooner or later;
Page 196 try some calamine on it." Or still with tight-shut eyes he throws things at the horrible
apparition: mercury, zinc oxide, tar, sulphur, something placed in his hand by the last
detail-man who called. All are chosen at random and hurled with random aim. Then
he tries turning "rays" on it. Any kind of rays will do. After all, isn't a gun a gun,
whether it is a Flit-gun or 16-inch naval ordnance? If you have not one handy, someone nearby has, and since you are uncertain whether you are shooting at butterflies or
bombers the only thing that matters is the impressiveness of the performance.
I am reminded of Lewis Carroll's "Hunting of the Snark."
They sought it with thhnbles, they sought it with care;
They pursued it with forks and hope;
They threatened its life with a railway share;
They charmed it with smiles and soap.
But why all this bewilderment and panic, this supine acceptance of defeat, this purposeless cavorting? It is dictated by fear. With any other ordinary medical problem
the doctor of ordinary ability does not lose his balance and "play such fantastic tricks
before high heaven, as make the angels weep." Carefully and methodically symptoms
and signs are observed. They are classified and interpreted in the light of the fundamental branches of knowledge in which he has been schooled. Then he constructs a
working hypothesis or provisional diagnosis which will permit him to institute some
rational treatment. Why should such an exception be made in the case of a skin disease, in which futile fumbling is the usual procedure in contrast to the sane and ordered
one with other conditions?
You may disagree with me: may think that "fear" is too strong a term to use here.
To me it seems logical but not harsh. Failure in rational procedure before an obstacle,
or in unfamiliar surroundings—in short, losing one's head—betrays fear. This calls not
for castigation but for encouragement and restoration of confidence.
Of what is the fear born? Of apprehension of embarrassment, nakedness before the
enemy, discomfiture, loss of dignity; fear of the unknown, of walking in unfamiliar
ground, unlighted and full of pitfalls both imaginary and real.
But skin is not an unfamiliar object. It has no peculiar sanctity. It should evoke
in us neither awe nor a brash familiarity like that of Tomlinson, who "patted his God
on the head that men might call him brave." It is the first organ to come under our
inspection when we examine a patient. But, is it customary to regard it as an organ?
Thoughtlessly it is passed over as a mere integument, a garment only slightly more intimate than the last of those shed by the patient. True, certain impressions are gathered
in passing: its approximate colour and temperature, degree of moisture, and, very
roughly, any gross departure from its customary appearance. But these are such things
as might be observed by any casual passer-by. They include such pathological features
as bruises and other discolorations, excoriations, blisters, warty or other growths, prominent vessels, ulcers and scars. In eruptive fevers, the colour, pattern, distribution and
intrinsic details of the individual lesions composing the rash are fairly familiar to all,
and observed with some intelligent appreciation.
But here we stop. The skin still is not regarded as an organ as are the liver and
heart. It is still but an outward covering which shows marks of external violence, a
background for certain excrescences, or occasionally a mirror reflecting some inward
disturbances of body or mind. The skin is all of these things; but it is more. It is an
organ, one of the vital organs, the largest organ of the body and possessed of a number
of remarkable properties, not the least significant being the unique one of constantly
exhibiting its physiological and pathological processes in full view of the observer. It
must never be forgotten that the pathological changes which occur in the skin are those
of general pathology. Like the other organs it has its blood and lymph circulation, its
motor and sensory innervation, and performs its functions of excretion, secretion and
growth in the light of day.
The approach to the skin, then, must be made as to any other organ. It is partly
because this absolutely necessary viewpoint has been ignored that the average man finds
Page 197 himself frustrated when the skin misbehaves and thrusts itself upon his notice. This
approach predicates as intimate a knowledge of the histology and physiology of the
skin as we have of any other organ in the body.
The various agencies, organic and inorganic, physical or biological, which injure the
skin or alter its functions, may act directly from without or within. From outside,
impinging upon its surface, and with varying degrees of penetration, actinic rays, heat
or cold, physical violence, chemical irritants or micro-organisms, may produce effects
which are almost entirely localized in the skin. Penetrating to greater depths they may
produce effects in remote parts of the body. The circulating fluids of the body may
bring to the skin noxious substances, including micro-organisms or their products, which
have gained entrance through the various body orifices, including the ostia of skin-
glands themselves or through damaged epidermis. They also bring substances formed
within the body. With this in view one must not lose sight of the important factor
furnished by the inherent predispositions of the skin which vary in different individuals,
often indicated characteristically by complexion, race, sex and hereditary characters not
so readily apparent.
Allergy is such a large subject that a mere mention of it can be made here. Allergy
has been defined recently as an altered capacity to react, and not necessarily a hypersensitivity, to various inorganic and organic substances. Before a tissue reacts to a
substance in such a manner that it becomes a matter of clinical interest it must by
previous exposure have become sensitized to that substance. At that time of original
contact no visible alteration in behaviour took place, but when a subsequent exposure,
occurs a reaction takes place which is a distinct departure from the normal. The skin
is not the only organ which exhibits allergic reaction, .neither are the bronchi nor the
upper respiratory passages the only other ones. The skin, however, as we have remarked
and shall again recur to, is the most accessible organ for study in health and disease, and
it is readily apparent therefore why the earliest and greatest amount of investigation of
allergic phenomena has been done, indeed the foundations of the science of allergy were
laid, by dermatologists. Allergens reach the skin from without or are brought to it
from within by the circulation. Three different principal sites of attack or "shock
tissues" are recognized: the cells of the epidermis, the corium, and the blood-vessels of
the sub-cutis. The phenomena produced vary with some correspondence to the shock-
tissue involved, but not to an absolutely pathognomonic degree. Allergic disturbances
of the skin, by themselves, as accompaniments of infection, or complicated by superadded infection account for a very large proportion of the skin-complaints for which
patients seek help.
The popular tendency has been to minimize or neglect the significance of external
and locally acting agencies in the production of skin disease, and to exaggerate the part
played by internal causation. Unlike the popular crime-mysteries the most fascinating
skin problems are furnished by the "outside job." Even allergic diseases, except in early
infancy, are more often due to external causes. Banal infections with pyogenic microorganisms, while fairly familiar to all, are external in origin. Substances encountered in
the domestic and occupational environment, especially with the rapid multiplication of
synthetic compounds, not only in industry but in articles of personal use or household
use, account for a constantly increasing number of allergens producing contact dermatitis, or contact eczema, or dermatitis venenata. The latter term includes a proportionately smjaller number of skin inflammations produced by substances which are primary
cutaneous irritants, such as dehydrating and defatting agents. An acquaintance with
these facts, an alert attitude toward their implications and an ability to recognize in
most cases evidence pointing to this sort of trouble should not be the attribute of any
one group of doctors, but should be acquired and cultivated by all.
If we add to local infections with bacteria and fungi, contact dermatitis, animal
parasites and physical agencies we have included about all of the locally acting external
causes of skin disease. Bacterial infections are commonly recognized but often ill-
treated, and fungi are perhaps invoked as the cause of eruptions more frequently than
Page 198 T
is justified.   Contact dermatitis is least commonly suspected although often well-signed.
Popular belief, either shared or acquiesced in far too readily by professional people,
is that skin diseases are preponderatingly of internal origin. The idea seems to be that
"poisons" are formed in the body, usually from "improper foods," and retained because
of "improper elimination" by the bowel. These poisons must find an outlet somewhere,
•being denied the only one which the public is interested in, and therefore "break out"
through the skin. The quacks and nostrum-vendors, always ready to foster any error
by which they can profit, have been extremely active in promoting this doctrine. The
doctor who treats all skin diseases as one, orders a diet (meat and carbohydrates are the
most popular bugbears), prescribes a brisk cathartic to "cool the blood" and a tonic
mixture to "purify the blood," is certain of success—of a sort. Nothing goes down so
well with the patient as being told solemnly that what he believes is so.
It is not to be denied that many skin diseases are of internal origin. Ingesta and
inhalants give rise to eczematous and urticarial eruptions. Toxins of microbic infections, and occasionally the microbes themselves, cause eruption. Nearly all the drugs
which we use, whether orally or parenterally, are capable of producing reactions in the
skin of susceptible persons. Some types of ingesta or by-products of deranged metabolism
while producing no visible effects increase the susceptibility of the skin to external
attack. Dietary deficiencies, among which the avitaminoses are attracting an excessive
amount of attention' at present, also produce characteristic cutaneous symptoms.
"Nerves," using the word in its popular acceptance, do not cause skin disease; disturbances of emotional equilibrium may give rise to transient vascular and secretory
phenomena. But certain diseases of the nervous system cause characteristic skin lesions.
The cutaneous manifestations of the systemic diseases, with the exception of the various
neoplastic diseases of generalized type, will be found included in one or another of the
above categories. The extrusion of "poisons" from the interior of the body onto the
surface is not a commonplace occurrence, and does not account for the greater amount
of skin disease.
It must be obvious that a thorough knowledge of general medicine, with some
experience in its practice, and particularly of general pathology, is indispensable to the
scientific dermatologist. Coupled with this it seems reasonable to assert with equal
emphasis that a good general knowledge of cutaneous structure, physiology and sym-
tomatology should be required of the scientific practitioner in the general field of
medicine.
While the skin offers an inestimable advantage in the fact that while its pathological
changes are only those df general pathology, no other organ offers such opportunity for
the study of pathological processes during life and the correlation with symptomatology
as does the skin. But it is precisely from this unique character of the skin that there
arises the Fear of Skin. While we may admire the extent, the accessibility and the
facilities offered for the observation of the effects of local and systemic therapy, the
patient, who may be said to have an inside angle on the skin, uses these features for our
discomfiture.
The doctor treating the skin has to work out in the open. The patient usually is
not feeling very sick or disabled, but he is very uncomfortable in both mind and body
and he is alert to what is going on, sometimes appearing to be unreasonably apprehensive.
Yet he considers that since he has "only some skin trouble" nothing should be easier or
accomplished more quickly than its cure. The internist and the surgeon share some of
that divinity that does hedge a king. They work their mysteries behind the merciful
veil of the skin, and who may question them or distinguish true from false? The patient
cannot see beyond the veil. He can see what is going on upon his skin, but he cannot
bend a critical eye upon his lung or liver. He has an objective attitude towards his skin,
he can see the results of therapy; he wants results and can see if he is not getting them.
The skin cannot be set aside to cool like a sick heart. Give your patient a draught or
a pill to swallow, and it is usually a case of "out of sight, out of mind." Your medicine may smash through all the laws of chemical and physiological compatibilities and
Page 199 be as ill devised for its purpose as possible, and how often will the patient know? A
remedy for the skin is another matter. It must be correctly compounded, cannot contravene the laws of chemical compatibility, and it must produce gratifying results with
little delay. In spite of the best thought of the prescriber and the utmost skill of the
pharmacist it yet may contain an ingredient which is poison to the skin of one individual. About one percent of all skins are intolerant to the familiar and useful white
precipitate; another percentage will react with violence to resorcin; the synthetic sedatives, analgesics and anaesthetics are responsible for numerous cases of dermatitis which
the dermatologist encounters. Surgeons are familiar with the frequency with which the
adhesive constituent of plaster strappings sets up severe inflammation. Even such commonly used ingredients of ointments as zinc oxide and lanolin are sometimes not tolerated. Again, a remedy may meet all the requriements and provoke no undue bodily
reactions, but if due regard is not had to aesthetic considerations, or sufficiently detailed
instructions are not imparted to the patient or the attendants, it may be a failure. No
young lady will thank you for messing up her hair with a zinc oxide ointment for the
scalp or blackening her face with a mixture of white precipitate and sulphur; and a
patient who tries to rub Lassal's paste into the skin as he would a cream will not excuse
your failure to tell him how it should be used.
But these considerations should not inspire the modern physician with fear and aversion towards meddling with the skin. After all, dermatology as a field of special interest
and study had its origins with men like any of us, in very many respects not so well
equipped. An examination of the history of this development should furnish encouragement today. Those whom we regard as dermatological pioneers did not deliberately
launch themselves upon such a career. They simply thought of the body as a whole,
with no ideas of any areas being supersanct, or inhibitions regarding such areas. They
were physicians, surgeons, anatomists and other who found themselves increasingly
attracted by problems relating to the skin until it mastered them, and today we call
them masters of dermatology. Not until a little more than fifty years ago were the
greatest contributors to this branch of knowledge dermatologists in the modern sense.
Pusey accounts for the increasing interest in the study of skin diseases in early modern
Europe by the interest in syphilis, the differentiation of which from other skin diseases
was beginning to be recognized.
The first evidences of the infectious nature of disease were furnished by study of
the skin. Avenzoar, one of the greatest of Moorish physicians in 12th century Spain,
recognized the itch-mite, although he failed to prove its etiological role in scabies. Early
in the 14th century Guy de Chauliac, physician to the popes at Avignon, whose name
is a renowned one in mediaeval surgery, established that scabies was a contagious disease.
Ambroise Pare, the great surgeon, also recognized the parasite in the 16th century. But
it remained for Bonomo in Italy in 1687 to demonstrate that this parasite was the cause
of the disease. His brochure describing his discovery, monumental in its significance,
for the first time demonstrated that a living parasite was the cause of a disease, and thus
opposed a mighty weight against the humoral theory of disease.   .
This demonstration that disease could be caused by an infection with living organisms led further investigations of disease along new paths. Micro-organisms were eventually discovered and demonstrated as causes of diseases. But this next stage was delayed
for 150 years until in the early part of the 19th century two Italian savants discovered
that muscardine, a contagious disease of silkworms, was due to a fungus. Four years
later Schonlein of Berlin, stimulated by this discovery, demonstrated that favus, a contagious disease of the scalp, was also caused by a fungus. In succession other workers
discovered other micro-organisms which were shown to cause various diseases of men
and animals, and thus the sciences of bacteriology and mycology were established.
Investigations by Scandinavian, German and Viennese scientists into other skin diseases
such as lupus vulgaris greatly advanced the knowledge of the cause and nature of infectious disease in general. Study of lupus erythematosus, erythema nodosum, erythema
induratum, erythema multiforme and the purpuras led to the recognition that they
Page 200   j|J •were only cutaneous manifestations of systemic diseases. In some of these the nature of
the infectious agent is as yet unknown. While knowledge of these diseases is growing
it is commonly forgotten that this knowledge had its origins in the study of the skin.
This is also true of sarcoid and lymphoblastic erythrodermias, pellagra and the other
avitaminoses, many of which were familiar to and objects of intensive study by dermatologists for years before they attracted the notice of workers in other fields.
The dermatologist of today may justly take pride in claiming that his field of interest
is the skin and all contained therein, for these pioneer contributors to dermatologic
knowledge were men of such broad interests as all of us would like to be. They saw
the body as a whole, not as an aggregation of watertight compartments carrying on
independent existences under tutelary deities called specialists. With its accessibility
they found the skin the ideal testing-ground for their theories of physiology, pathology,
pharmacology and therapy.
Jean Astruc is sometimes regarded as the founder of modern dermatology, for he
not only made a special study of the histology of the skin but first indicated the pathology of certain affections in the light of that knowledge. The importance of this conception to medical study in any field cannot be exaggerated. The character of the man
who made it his contribution to the science of dermatology is noteworthy. He was
professor of anatomy at Toulouse and relinquished that chair in 1717 to accept that of
medicine at Montpellier. Later he was physician to the king of Poland, and then regius
professor of medicine at Paris under Louis XV. We may note that such was his scholarship that it transcended the bounds of medicine, and he even won fame as a Biblical
critic.
The first name prominent in British dermatology is that of Daniel Turner. He was
contemporary with Astruc but his contributions are of much less moment. The first
medical degree given in English-speaking America was an honorary one, bestowed upon
himjn recognition of his studies of the skin by Yale University in 1723.
The important subject of Industrial Medicine was first presented to the world in
1700 when Ramazzini, professor of medicine at Modena and later at Padua, published
an accurate and trustworthy account of the skin diseases which occur in a large variety
of occupations. This man was an associate of Malpighi and Morgagni and shared the
wide enthusiasms and scientific viewpoint of both. That some diseases were associated
with certain kinds of work was no new thing: Shakespeare had no doubt a good reason
when in the "Midsummer Night's Dream" he named his weaver Bottom*. But it was
Ramazzini who first investigated the occupational skin diseases and studied the precise
manner in which they were brought about. Until Prosser White's work dealing with
the Industrial Diseases of the Skin appeared in England in the twentieth century no
other great study of the subject had appeared comparable to that of Ramazzini.
Robert Willan is generally accepted as the founder of English dermatology. Although
he is identified almost wholly with dermatology, the importance of his work and its
significance to all medical endeavour cannot be confined within its bounds. He was
especially interested in public health through his concern with smallpox. William
Heberden, Sr., had demonstrated nearly half a century earlier that smallpox and chicken-
pox were distinct diseases with no immunological relationships. Willan elaborated upon
this and was one of the most powerful supporters of Jenner. In quoting Willan's
treatise on vaccination Jenner freely acknowledged its authority. Willan was a pioneer
in the bedside method of teaching, to which such of his pupils as Bright and Addison
give tribute.
In the nineteenth century, although we find dermatology keeping pace in its development with science in general, more of the great names associated with its advance are
of those who were primarily dermatologists. But they still continued to contribute to
the progress of general medicine. Among them we find Rayer, who first demonstrated
that glanders was a contagious disease and distinguished it from tuberculosis, with which
it had hitherto been confused.    This piece of bacteriological research, utilizing animal
*Ischial bursitis, in former times commonly called "weaver's bottom," analgous with the terms "miner's
elbow" and "house-maid's knee" for olecranon and pre-patellar bursitis respectively. fage 201 experimentation, is of the greatest historical significance. Rayer's monumental three-
volume Treatise on Diseases of the Kidney also is a classic in early clinico-pathologic
studies. He was the predecessor of Fournier and his school in his demonstration that
syphilis was of major significance in the consideration of organic disease. It was in fact
a systemic disease, linked as inseparably on the one hand with general medicine as it was
to dermatology on the other. Other dermatologists made similar contributions to the
general field when they identified certain skin diseases as the outward, exponents of
clinical syndromes which had not hitherto been recognized.
In the first half of the 19th century the improvement of technical facilities made it
possible for a great number of independent investigators to further the knowledge of
the histopathology of the skin. Many of them are known by name to most of us, such
as Meissner, Pacini and Purkinje.
Although the contagious nature of certain skin diseases had long been recognized,
and in one instance already mentioned a living cause found for contagious disease, it was
a long jump from organized metazoa such as itch-mites to microscopic parasites consisting of a single, or at most very few but slightly differentiated cells. When Schonlein
demonstrated a low-grade fungus/ as the cause of favus he also demonstrated how in the
skin both the disease and the affected organ can be observed in all their interactions
without removing either from its normal environment. Schonlein's command of the
field of medicine is evident from his original description of rheumatic purpura, his
adoption as routine procedure in clinical examinations of urinalysis and hematology, and
placing the microscope in its present position as a clinical aid. It was he also who introduced from France the use of auscultation and percussion in physical examination.
The name of Ferdinand Hebra owes its inseparable association with 18th century
dermatology to a curious situation. In 1842 when Hebra joined the staff of the Allge-
meines Krankenhaus in Vienna he was posted as assistant physician in Skoda's chest
clinic. Hebra, as a disciple of the great Bohemian pathologist, Rokitansky, founder of
the Viennese school of pathological anatomy, applied his master's methods to the study
of skin diseases. At the same time he profited greatly by his training as a clinician
under Skoda. The combination was irresistible. Two fundamental ideas for which we
are indebted to Hebra are: the one previously mentioned, that the pathological changes
which occur in the skin are those of general pathology, and, there are diseases specifically
limited to the skin. In stressing the importance of local causes in the etiology of many
skin diseases Hebra properly counterbalanced the tendency of the French school which
had been regarding most skin diseases as evidence of constitutional dyscrasias. It is to
Hebra that we owe the increasing recognition of dermatology as one of the most important fields of medical knowledge, large enough to demand the full time and attention of
those working in it. Hebra succeeded Rokitansky as President of the Viennese Academy
of Science, and attained the pinnacle of Austrian medical honours when he became
President of the Royal Society of Physicians of Vienna.
Contrasted to him is Virchow, known to the world at large as a pure pathologist,
who published a large number of studies in cutaneous pathology, including pemphigus,
diseases of the nails, warts, xanthoma and cutaneous tuberculosis. Other works of his
in the general field of dermatology are almost unknown, and seemingly out of character
—such for instance as his investigations which he published On Disinfectant Soaps.
In the closing half of the last century we find an anatomist who, in spite of the
prejudice against medical specialism in the England of his time, attained fame as a
dermatologist. This was Sir Erasmus Wilson. He was one of the first medical writers
on medical subjects for the lay reader. It is probably by this means that he became
credited with being the founder of the cult of the daily tub observed faithfully by the
traditional Englishman. Before Wilson's time the Bath was an Order of Chivalry.
After him the bath became the order of the day for what Kipling calls all proper and
right-minded men. The popular English bath-soap labelled with an adjectival derivative of his Christian name is a perpetual testimonial to the popularity of his teachings.*
Beside this honour he was also knighted and became President of the Royal College of
Surgeons.   His interests and enthusiasms were varied and widely diversified; witness the
*This is not an advertisement published or displayed by the Vancouver Medical Association, for Erasmic
Soap.
Page 202 chair of Pathology at Aberdeen University,  and  Cleopatra's  Needle on  the Thames
Embankment, both of which were set up by him..
Following in his tradition was another surgeon who attained eminence as a dermatologist and syphilologist in the person of Sir Jonathan Hutchinson. His association
with clinical medicine via syphilis is too well known to be dwelt upon here. Other
individual contributors to the advance of British dermatology, whose names are more
familiarly known in other connections, are Sir James Paget and Addison. The latter
not only gave his name to the disease in which he was the first to associate the characteristic asthenia and cutaneous pigmentation with suprarenal disease, but he also described morphcea, sometimes known as Addison's keloid, a circumscribed form of scleroderma.
Osier's familiarity with the skin and his interest in the association of its symptoms
with diseases of other organs is apparent throughout his writings. To him, as it should
be to all his disciples, the skin was but an organ like others, yet one which would well
repay the keenest scrutiny which he could bring to bear upon it, in the light which it
could throw on the problems of disease. Osier's name appears in dermatological literature, especially as the original describer of a type of haemorrhagic telangiectasia which
perpetuates his name. This list of contributors to dermatology, most of whom were not.
in the ordinary sense, or exclusively, skin specialists, may be closed by that of Albert
Neisser. The world does not remember him as a dermatologist, for although his greatest
work was in dermatology and syphilology, his name is best known in connection with
gonorrhoea . However, we find Osier writing from Vienna in 1908, describing Neisser
lecturing on the Pathology and Therapy of Syphilis at the Congress of Internal Medicine. Osier spoke of "splendid address delivered without notes, in a good clear voice,
and the subject matter arranged in a most orderly manner."
Not only have many workers in other fields contributed much to the sum of dermatological knowledge, and dermatological discoveries have found wide application in
establishing the relationship of apparently dissociated symptoms in systemic diseases, and
in the science of immunology, but the history of physical therapy also brings out some
interesting facts for our notice. Beside the work of Finsen in ultra-violet therapy, first
scientifically and successfully applied in a skin disease, the first therapeutic application
of roentgen rays was also found in the treatment of a skin disease. On the American
continent it was a dermatologist, William Allan Pusey, who first used roentgen rays as a
therapeutic agent. Again, only two years after the Curies discovered radium, two German scientists, Walkhoff and Giesel, announced that the new substance had certain
physiological effects. Pierre Curie exposed himself personally to a test of this assertion.
In his report to the Academy in Paris he gives in minute detail the clinical history of
this first reaction to unfiltered radium as observed on his own skin. He also described
an analogous reaction to filtered radium' when the substance was enclosed in a metal box
which was applied to the skin of Marie Curie. He also accurately described the chronic
radiodermatitis which developed after frequent exposures of the unprotected hands in
the course of other researches. These observations quickly led to therapeutic investigations,
which first met with success in a case of skin cancer. Thus did radiotherapy with all
its far-reaching modern developments find its first home in the field of dermatology.
Where internists, surgeons, pathologists and others have led in times gone by you of
today should not hesitate to follow. The field for clinical observation, study nd experimental research in the ward, the consulting-room and the laboratory, is just as freely
open as ever it was.
What then? Must all become dermatologists? God forbid! But all can be students
of the skin; indeed all must be who would practise medicine scientifically. We must use
here as elsewhere our ordinary powers of close observation, of induction and also deduction, with the background of knowledge which we all share. Our powers of observation
will sharpen with use. But, as Osier (I think it was) said, "I can forgive you for not
seeing, but I cannot forgive you for not looking."
If dermatologists have on occasion appeared to pose as the appointed priests of high
and mighty mysteries, do not allow yourselves ta be overawed.    The skin is no more
Page 203 mysterious than the heart. If the nomenclature appears to be excessively cumbersome
and complicated I would ask you to remember this: More distinct nosological entities
are comprised in a list of the diseases of the skin than of any other organ or system of
organs in the body; nearly all the terms which appear to come under your indictment
are descriptive, and based upon or borrowed from anatomy or pathology; thus each
dermatological name means something definite, and is a clue to the nature of the condition described, and in this respect at least is far superior to the much more difficult and
complicated names in the Linnaean system of classifying plants and animals.
My observations and arguments are not to be construed as a criticism of my non-
dermatological colleagues for their failure to appreciate the superior beauties of dermatology, and dermatologists. Rather have I been pleading for an abandonment of their
attitude of alarm and feeling of hopelessness when confronted by skin problems. All
have to live with as well as within the skin. Without claim to special knowledge or
experience as dermatologists you may approach disorders of the skin in the same spirit of
confidence that you have in other clinical situations. Apply the same principles in
examination, and in reasoning out your difficulties and applying your remedies. It is
doubtful if there is any condition in which common-sense is more useful; where rational
rather than empiric therapy is more readily rewarded. A retentive and photographic
memory is of help, but no more here than elsewhere. Names matter little in most cases,
as Shakespeare long ago observed. It is the nature of what is going on that you must
understand and appreciate. Scabies by any other name would itch as much. You may
make a diagnosis and cure your patient without ever knowing the book-name of his
disease.
Stokes has said, "The disposition to avoid a section headed 'Principles' and to thumb
the pages of a presentation until one reaches the routine prescriptions . . . which it is
fondly imagined will give the desired 'practical knowledge of treatment' ... is one of
the most serious mistakes . . . that can be imagined It is an inescapable fact that
the chief defect 'in our management of . . . disease today . . . lies in the attempts to
apply formulae without any conception of the objectives (one) wishes to attain and
with little or no notion of the action and purposes of the drugs he is using." This
statement has general application in medicine and surgery but is especially apt in connection with dermatology.
For all, the primary lesions of the skin, the macule, the papule, the vesicle, the bulla,
the pustule, the nodule and wheal, should be as familiar and as readily recognized as
bronchial breathing, the rhonchus, tympany, murmurs and friction-rubs, or the crepitus
of fracture. It is far easier to know them, I assure you. It is also easier to interpret
their significance and to recognize the secondary lesions to which they give rise, the
excoriation, the fissure, the scale, the crust, the ulcer, the cicatrix and the atrophy.
Mastery of only this much puts in your hand the key to dermatological diagnosis. Search
for and identify these primary and secondary lesions in every case that you see. Link
them together rationally with the subjective symptoms, the history, signs and objective
evidences of other sorts obtained in your clinical and laboratory investigations of the
rest of the body, and while you may not be able to name the disease, at least you have
some insight into what is taking place, and your remedial measures will have a basis in
intelligence.
I would recommend that everyone perfect himself in the technique of simple procedures such as tlisinterring the itchmite or her eggs from a scabies burrow, examining
scales and hairs for mycelia and spores of fungi, and making patch-tests. These are all
easy to do. There is not one of you who does not daily carry out much more difficult
and complicated diagnostic procedures, and ones in which the ever-fallible personal equation is operating in much higher proportion. Negative findings are not conclusive;
positive ones often are. Your assurance will grow as you turn up more and more positive tests, and uncertainty grows less. Remember the old hunter's adage: "You will
often mistake a stump for a bear, but not often take a bear for a stump."
Having touched upon diagnosis merely, there remains to say a few words about
treatment. There are not many diseases for which we have specific remedies. Most of
our therapy, in the first approach at least, is symptomatic.    Here as elsewhere a few
Page 204 drugs intelligently used outweigh in value many times a multitude used without thought
and knowledge of their properties.
In 1817 Sir Walter Scott hurled a shaft as envenomed as any of Byron's, whom he
was imitating, at the medical men of his day, with his lines
Physicians . . . sage, ware, and tried,
As e'er scrawl'd jargon in a darkened room.
We would like to consider, in our prescription writing, that this misses the modern
physician.    Let us see that we do not offer it a fair target.
It is not enough to know merely when to use your mercury or your sulphur, zinc
oxide, calamine or tars. The selection of the proper vehicle and the precise manner of
the use of the remedy is of the greatest importance. A little thought and employment
of common-sense are all that is necessary in most cases. An area of red, hot, weeping
dermatitis thickly smeared with a greasy ointment, which inhibits nature's efforts by
preventing radiation of heat and damming back secretions, impresses one not so much
of ignorance as of sheer thoughtlessness. A skin dry nearly to the point of cracking
will not be helped by a drying astringent lotion. (Would you try to restore pliability
to the leather of a pair of old dried-out boots with whitewash or varnish?) Rubbing
a greasy preparation containing stimulant remedies into a pustular eruption or into the
axillary or genito-crural lesions will not make the patient love you.
Remember that calamine lotion, which always seems to be the most popular in the
role of "any old port in a (dermatologic) storm," is slightly astringent, drying in its
effects, forms an impermeable crust when mixed with secretions, is of negligible antiseptic value, and although of itself it has very slight antipruritic value it forms an
excellent vehicle for skin sedatives when its other properties do not happen to render it
objectionable in a given situation. Edematous or exudative, hot and itchy, stages of
dermatitis are usually rendered most comfortable by compresses wet—not merely damp—
with mildly astringent watery solutions. Ointments or salves should contain little or
no insoluble material and are used as emollients, or when we want to effect some penetration of an active remedy. The addition to such fatty bases of insoluble powders in
varying quantities makes them into pastes of more or less stiff consistency for protective
purposes. They may at the same time serve as vehicles for sedatives or stimulants but
it is useless to try to rub them in. They should be spread on with a spatula, best of
all spread on lint to make a plaster. These are given only as a few examples of what we
mean by Principles, which, as Stokes has pointed out, are infinitely more important than
prescriptions.
As for diet, unless your patient is one who must be impressed by a certain amount
of mumbo-jumbo, it is best not to interfere without a sound reason. There is no sense,
as I see it, in adding to a patient's discomforts and inconveniences, by needless restrictions. Restrictions are only justified when material benefit to the patient can confidently be expected.
Rest, however, is a factor in treatment commonly neglected, and admittedly difficult
to secure in most cases of skin disease. It is one form of restriction which is almost
always well justified. Rest, local and general, is just as important, and for the same
reasons, as in any other class of disease. Local rest is often neglected in cases where
general rest may be or may not be necessary. A boil on the upper extremity, for instance,
will recover more quickly if the limb is immobilized, even if the patient goes about.
Immobilization of the muscles of the face is of vital importance in a boil or other acute
deep-seated infection about the nose and mouth.
In conclusion, let me repeat that I am not expecting to turn my audience into
dermatologists en masse, but I do want to make a breach in the wall that appears so
formidable, which separates the skin and its disorders from the same consideration and
confident approach that you employ in dealing with the other ills that beset the body.
Having thus made the assault on the insubstantial and the immaterial, I leave youl
[Without attempting a bibliography I wish to make special acknowledgement, among
a number of authors consulted, of "The History of Dermatology" by the late Wm.
Allen Pusey, (Chas. C. Thomas, Springfield and Baltimore, 1933), from which I have
drawn extensive references.]
Page 205 V
ancouver
G
enera
Hospital
A REVIEW OF CAESAREAN SECTIONS IN THE
1; VANCOUVER GENERAL HOSPITAL, 1941
Geo. H. McKee, M.D.
Senior Resident in Gynaecology and Obstetrics, The Vancouver General Hospital.
In presenting this paper on Caesarean Sections performed in The Vancouver General
Hospital during 1941, it is our purpose not only to review these cases, but to examine
the statistics and to compare them with results obtained in other hospitals, and to present
some of the current views regarding the various conditions relating to Caesarean Section.
The Vancouver General Hospital is one of the largest open hospitals on the continent.
The Maternity Building has a bed capacity of 130. There are about 150 doctors—both
general practitioners and obstetrical specialists—who attend cases in this wing.
Restrictions placed on the performance of Caesarean Section in this hospital are governed by By-law No. 108 of the Hospital Constitution. This reads as follows: "Before
a Caesarean Section shall be undertaken in this hospital, the approval of the General
Superintendent or one of his assistants shall be obtained. Failing this, a consultation on
tlv case snail be had between the physician about to perform the operation and some
senior member of the Attending Staff in the Department of Obstetrics and Gynaecology.
A record of such approval or consultation shall be made and signed by the General
Superintendent, Assistant Superintendent or the physician and the consultant and filed
with the case record. The Anaesthetist shall not commence the administration of any
anaesthetic until this By-law has been complied with."
The sections performed during the year under review were done in the majority of
cases by members of the obstetrical staff of this hospital, and by other obstetricians in
the city, but also in some cases by general surgeons.
Incidence.—In 1941, there were a total of 2771 cases delivered in The Vancouver
General Hospital, and of these, 112 were by section. This is an incidence of 4.04% or
roughly 1 in every 25 cases is a Caesarean Section (actually 1 in 24.7). During the years
1933 to 1941 inclusive, the incidence varied from 2.5% to 4.2%v Comparing this
with other institutions, we find that at the Chicago Lying-in Hospital in 1931-1934 it
was 5.6%; at the Royal Victoria Hospital (Maternity), Montreal, from 1936 to 1938
it was 3.3,% and in 1941, 3.86%; at the Burnside Hospital in Toronto in 1929 it was
5.78% and in 1937 it was 1.9%. Weaver in the Canadian Medical Association Journal
quotes Harris, "3% of all women delivered in hospital have their babies by the abdominal
route; this represents about 1% of all deliveries."
The question arises, "Is our incidence too high?" I do not intend to answer that
question. There appears to be a general rise in the incidence of Caesarean Sections, and
our own institution shares this characteristic. Many hospitals have made a conscientious
attempt to reduce their incidence and have been successful by insisting on a consultation
with a Staff Obstetrician.
Indications.—Before operation is performed in this hospital, a consent form must
be signed by the Superintendent or Assistant Superintendent of the Hospital. On this
form must be given the indication for operation. Table I shows the indications as contained in these forms.
Table I.
INDICATIONS FOR CAESAREAN SECTIONS, V.G.H., 1941
I.    Anomalies of the bony pelvis:
A.    Contracted pelvis—
a.    with previous section 13
b.    without previous section.
32
Page 206 c.    with other complications—
fibroids  1
mitral stenosis  1
' prolonged labour  1
toxic neuritis  1
previous vaginal plastic operation ,  1
B. Funnel type—
a. with previous section  2
b. without previous section  g
C. Male type  1
D. Other types of pelves—
a. with previous section—
deformity  (polio)    1
b. without previous section—
deformity  1
deformity   (congenital hip)  1
bony exostosis of sacrum !  1
E. Pelvic dystocia—
elderly primipara with non-engagement ;  1
F. Disproportion—
a. with previous section t  1
b. without previous section  6
II.    Anomalies of pelvic organs:
bicornuate uterus, cervix and vagina  1
placenta praevia .  4
ovarian cyst .  2
fibroids   % I . 'JssKl
III. Toxaemias:
a. with previous section  2
b. without previous section  7
IV. Previous sections   (as only indication)  8
V.    Diseases not related to pregnancy:
pulmonary tuberculosis -  1
cardiovascular disease .  1
arthritis of spine  (painful pregnancy) ! 'ill 1
rheumatoid arthritis :  1
VI.    Abnormal presentations:
face presentation  1
breech—unengaged twins  1
VII.    Previous intra-uterine death of foetus:
without extra-uterine complications  2
previous ectopic, and stillbirth  1
VIII.    Elective   for   sterilization »-  1
IX.    Foetal distress  j = .   1
73
11
112
The original indication for Caesarean Section was an absolute disproportion. As the
operation has become safer with improved operative technique and antiseptics, the range
of indications has increased tremendously as can be seen by the preceding table. Many
indications are now accepted if the patient is individualized and the case has received
full consideration of good obstetrical judgment.
Cosgrove and Norton of Jersey City advise that section should only be undertaken
"'with the concurrence of at least two physicians, one of whom should be, if possible,
an obstetrician of acknowledged competence and experience."
From the above summary we see that 73 out of a total of 112 cases were for what
briefly may be termed disproportion. Sixteen of the 73 cases designated as disproportion
were given a test of labour ranging from 2 to 80 hours.
Page 207 Previous section alone, or in combination with other indications, was given in 30
cases—these include of course several which were noted previously under disproportion.
There were 8 cases where previous section alone was the indication. The summary in
Table II gives the reasons for previous section.
Table II.
INDICATIONS FOR PREVIOUS SECTIONS.
1. Contracted pelvis   (all types) '{ 16
2. Toxaemias i : 2
Placenta  previa	
Fibroids	
Bicornuate uterus	
Large baby  ;!	
Previous stillbirths :	
7.    Impacted  foetus	
9.    Undesignated 4
30
I am not able to say how many cases there have been in this hospital where a baby
has been born by the vaginal route after a previous Caesarean section. Weaver states
that "a trial labour under careful supervision is permissible where the indications for the
original section are absent and the post-operative course had been normal, particularly
if the previous section had been a low one."
In the series under discussion, there were 8 cases where previous section was given as
the sole indication; in the other 22 cases the original indication was still present. Previous sections then were responsible for 7.1% of the operations; Weaver shows a variation from different reports of 6.5% to 27%.
Placenta praevia was the indication in 4 cases. A report of 2117 cases of placenta
praevia delivered mainly by the vaginal route shows a maternal mortality of 9.68% and
a fcetal mortality of 50%. In another series of 262 cases treated chiefly by Caesarean
section the maternal mortality was only 1.78%. Bill advodcates Caesarean section
probably with transfusion as the treatment of choice in partial or complete placenta
praevia.
Toxaemias were given as indication in 9 cases. There is considerable controversy as
to the advisability of section in toxaemias. The type of toxaemia and its severity determine to a large degree whether section should be done or not. "In 1936, 89 women
died in Canada following Caesarean section and of these, 19 were under the classification
of puerperal albuminuria and eclampsia."
In his article, Weaver sums up the indications for operation: "Heart disease,
eclampsia, abruptio placentae, and most medical conditions complicating pregnancy are
usually best handled by conservative obstetrical means. More careful study and increased judgment will lessen the number of Caesarean sections for disproportion. Placenta
praevia and chronic nephritis should be treated more radically."
Type of Operation
A brief review of the types of operations performed may be in order. The earliest
sections performed were the classical sections. A high mortality rate from this type of
.operation in cases infected from long labour or mishandling led to a search for a safer
technique. Porro originated the operation named after him, which was actually an
eventration of the uterus, delivery of the baby, and amputation at the junction of the
body and the neck of the uterus. The peritoneum was sutured around the cervix and
the stump exposed in the abdominal wound. Later the technique was improved when
the stump was peritonealized and returned to the pelvis. Thirty years ago extra-peritoneal approach to the uterus was devised and the outcome are the procedures termed
the Latzko and Waters operations. Soon after this the classical operation was modified
somewhat by a new technique by which the uterine incision was made into the lower
uterine segment after mobilization of the bladder.
Cosgrove and Norton, in reviewing the subject, say that trans-peritoneal section is
used when time of operation is elective as far as duration of labour is concerned.  Where
Page 208 there has been a test of labour and there is risk of increasing infection a Porro or extraperitoneal section must be done. For a trans-peritoneal section they set down as conditions—complete lack of contamination; freedom from clinical evidence of infection;
total labour not in excess of 24 hours; membranes not ruptured for more than 8 to 12
hours. They say it is immaterial whether the trans-peritoneal section is a classical or
low segment operation, but believe that the convalescence in low operation is smoother
and there is less risk of future rupture of the scar.
Table III shows the types of operations performed here in 1941.
Table III.
TYPES OF CAESAREAN SECTIONS PERFORMED IN V.G.H., 1941.
Classical        47
Low segment   (vertical)     42
Low segment   (transverse)     23
112
In 14 cases the membranes had been ruptured for times varying from 2 to 80 hours.
In all cases the trans-peritoneal route was used. At the time of operation 39 patients
were sterilized.
Morbidity.—When considering the type of operation and the conditions set forth jfor
each type we shall also note the maternal morbiidty.
Type of operation Cases Morbidity % Morbidity
Classical         47 17 36.2
Low segment         65 26 40.0
In our review we note a total of 43 cases of morbiity or an incidence of 38.4%
morbidity. In the classical operation totalling 47 cases morbidity was 17 or 36.2%; in
65 low segment operations it was 26 or 40%. This seems high, but in the article mentioned above, the authors quote a series of 68 classical sections with a morbidity of
44.1%, and 637 low segment operations with a morbidity of 49.3%. These cases were
in the majority elective cases, that is, less than 9 hours in labour with membranes ruptured.
Mortality.—Following discussion of morbidity, we should mention maternal and
fcetal mortality. In 1941, out of 112 sections there was not a maternal death. There
were 4 fcetal deaths of which two were stillbirth. Of the 2 stillbirths one was an
anencephalic and the second showed evidence of distress ante-partum, which incidentally
was the indication for section. Cosgrove and Norton publish the following figures of
maternal mortality. In classical section in 68 cases mortality was 10.3%; they point
out however that the type of operation was used only with reference to the condition
of the mother and to shorten the time of operation. In low segment operation, out of
637 cases mortality was 0.471%. Noting fcetal mortality, in classical operation it was
19.12%, but consideration was also given to conditions under which operation was done.
In low segment operation a total of 8.32% consisting almost equally of stillbirths and
neonatal deaths.
Anaesthetics.—The type of anaesthetic used in Caesarean section in The Vancouver
General Hospital varied, with the use of ether in the majority of cases.
Table IV.
ANAESTHETICS USED IN VANCOUVER GENERAL HOSPITAL
Ethyl Chloride and Ether.  50
Avertin   and  Ether  2 5
Ether     18
Spinal     14
Gas      2
Local  i—  2
Gas and Ether   1
112
Heard, of St. Michael's Hospital, Toronto, in an article in Surgery, Gynecology and
Obstetrics, appears to favour spinal anaesthesia. He points out that the use of an anaesthetic should not endanger the baby, and its safety demands the avoidance of ether.   In
Page 209 his summary he states, "for if this article is not to be interpreted as an argument for
spinal anaesthesia, it is at least a condemnation of ether."
Dr. Marshall, of the Liverpool Maternity Hospital, in his book on Caesarean Section,
reviews the use of anaesthetics and admits that ether is used more widely in Caesarean
Sections than any other anaesthetic. His main argument against its use is that it may
cause uterine atony and haemorrhage; but also notes its effect on metabolism, its toxic
effect on the liver and kidneys, and on the fcetus. He says of spinal anaesthesia that
uterine haemorrhage and atony are absent, there is no toxic effect on kidneys and liver,
and the fcetus is spared the depressing action of a general anaesthetic, but against this is
the peculiar susceptibility to spinal anaesthesia of the pregnant woman. The conclusion
he draws is: "Any obstetrician who sets out to perform a large series of Caesarean Sections under spinal anaesthesia must be prepared to face a possible mortality of not less
than 1% due to this cause alone." There are of course other contra-indications often
found in the pregnant woman, to the use of spinal anaesthetic. Marshall, in common
with De Lee of Chicago, favours the use of local anaesthesia. Quoting from his book,
"Ether should be reserved for certain cases of great urgency, and spinal anaesthesia for
a few patients in whom considerable technical difficulties can be foreseen. Otherwise
local anaesthesia should be much more widely employed in this operation."
Before concluding this paper, I would like to mention one more item. Up to the
present it has been felt that the information regarding Caesarean Sections performed in
this hospital has been inadequate. The Head of the Department of Obstetrics and
Gynaecology, Dr. Blair, in co-operation with Mr. Fish, the Director of Records, has
outlined a new form to be used on the chart of each patient subjected to section. This
form contains all the essential information regarding the operation and is to be used in
place of the usual operative record. The American College of Surgeons is attempting to
have Hospital Records standardized on this continent; to this end this form has been
submitted to them for their approval. After a year's trial, a report will be made on the
success of this form, including changes thought necessary to make it satisfactory for
more generalized use.
Conclusion.—A review of the Caesarean Sections performed in The Vancouver General Hospital during 1941, numbering 112, has been presented. A summary of the
indications, the type of operation, morbidity, and anaesthetics used, is given. This paper
is not intended to be a criticism of work done nor does it pretend to set forth as ideal
any technique of surgery or anaesthesia, but merely to present in some fashion a resume
of the Caesarean Sections performed in a large open hospital.
REFERENCES:
Weaver: Canadian Medical Association Journal, 40:25?-264, March, 1939.
Cosgrove and Norton: Journal of the American Medical Association, 118:201-204, January 17, 1942.
Heard: Surgery, Gynaecology and Obstetrics, 70:657-661, March,  1940.
Marshall, C. Mcintosh: Caesarean Section, Lower Segment Operation;   1st Ed., Bristol: John Wright and
Sons Ltd., 1939.
CHINESE DIETS
H. S. D. Garven, B.Sc, M.D.
(Abstract of a paper given at the Staff Clinical Meeting of The Vancouver General Hospital
on February 23, 1943.)
The diet of the peasant farming population—the great mass of the people—of North
China and Manchuria offers a marked contrast to that of the population of South China.
The former is a sorghum or tall millet growing area and rice and noodles are very little
used. Dairy products, baked bread, white potatoes and beef are conspicuous by their
absence.   Little or no rice is used.
The millet, roughly ground or in whole grains, boiled to the consistency of porridge,
is the staple. This is supplemented with green vegetables, fresh or pickled—mainly
Chinese cabbage—a few root vegetables, some sweet potatoes, soya bean products—bean
curd, bean sprouts, bean oil—with occasionally a little pork, a little wheat flour, eggs,
Page 210 peanuts, local fruits in season, especially the various types of melon.
The diet is poor in variety; usually sufficient in calorific value; excessive in carbohydrate; and high in fibre, resulting in a low coefficient digestibility. Proteins are low
and of poor biological value, being mainly vegetable in origin. Fats are also low and
nearly all of vegetable origin. Vitamins B and C are usually ample but A and D
are poor.
In the towns the diet is much more varied with a large number of vegetables, more
meat and more wheat flour.
A description of a typical Chinese feast of thirty-odd courses such as might be served
on some official occasion or family celebration was also given.
ERYTHROBLASTOSIS FCETALIS AND ITS RELATIONSHIP
TO THE Rh FACTOR
By Alfred Howard Spohn, M.B., F.R.C.P.,
Peter Howard Spohn, M.D.
St. Paul's Hospital.
Studies on the cause of transfusion accidents associated with pregnancy established
the importance of the concept of iso-immunization of the mother by blood factors in the
fcetus transmitted from the father. With this theory in mind, a recent possible cause
of erythroblastosis fcetalis is reported and also a brief discussion of the more recent work
on the Rh factor and its relationship to this condition.
Because of no available specific serum, and because of lack of co-operation from the
mother, we have been handicapped in fully establishing this now accepted theory in this
particular case. However, the clinical findings are of sufficient interest to warrant
discussion.
A.—Presentation of the Case.
This baby was a full-term infant, the second child of a mother who had been previously married to another husband. Her first child was a normal baby with a healthy
development up to the present age of 2J4 years.
The second child, a male, was born with multiple haemorrhagic spots which covered
the entire body from the scalp to the toes, and varied in size from 1 mm. to 5 mm. in
diameter. The spots were hard to the touch and gave the sensation and appearance of
lesions that had been present for some time previous to birth. The spots were of a dark
purplish hue, and were so numerous that a hurried first glance gave the false impression
of a dusky skin. The attending obstetrician, Dr. Anson Frost, reported that at birth
there was a large amount of icteritic amniotic fluid, and that the infant was covered
with a deeply stained yellow slime. The child weighed 6 lbs. and had the scrawny
appearance of a poorly nourished new-born. However, the respirations and heart action
were normal. At birth, conjunctivae were yellow in colour and remained so until the
third week of life. The liver was slightly enlarged, and during the first weeek of life,
there was a small amount of bright red blood on the diapers after the child had micturated. The urine was also bile-stained. The anterior fontanelle was small and admitted
only the tip of the index finger, and by the time the child was 2 months old, the fontanelle was closed and the cranial bones were overlapping. The child was given
30 cc. of blood subcutaneously from the mother shortly after birth and also 1 cc. Kavi-
tan. There was no apparent reaction from the mother's blood. On the second and third
days 25 cc. of blood from another source were given subcutaneously and subsequently
Page 211 several injections of blood plasma were given subcutaneously.    The spleen was palpable
after the first week of life.   The mother had a negative Kahn.
This case presents an infant born with numerous haemorrhagic spots, and a blood
picture resembling erythroblastosis fcetalis. The closed fontanelle, the lack of development in the size of the infant's head, and the twitchings occurring during the second
month of life indicate probable cerebral haemorrhages associated with subcutaneous
haemorrhages.
It has been noted in other cases that there may be degeneration of cerebral tissue due
to the action of excessive bile on the sensitive brain tissue. It has been recommended at
the Hospital for Sick Children in Toronto that calcium gluconate be given intravenously
in such cases to prevent an excessive amount of bilirubin settling out in the brain tissue.
The prognosis in this particular case is still uncertain, although the child's general
condition at three months of age was satisfactory except for the closed fontanelle and
small head.
Laboratory Reports
3/12/42—W.B.C.: 14,600, 40% Polys., 53% Lymphs, 6% Mono., 1% Eosin.; R.B.C.:
5.5 mill. Haem.: 105%. Platelets: 60,000; bleeding time, 3 min., clotting
time 3 l/z min. General remarks: Numerous immature white cells. Several nucleated
red cells.    Clotted blood shows definite bile stained serum.
6/1/43—W.B.C.: 8,100, 35% Polys, 56% Lymphs; 9% Mono. R.B.C.: 5.1 miH.
Haem.: 103%. Platelets: 56,870. General remarks: Numerous nucleated reds
with some megaloblasts.  Polychromatophilia.
15/2/43—W.B.C.: 9200, 32% Polys, 58% Lymphs, 8% Mono, 2% Eosin. R.B.C.:
3.3 Mill. Haem.: 59%. Colour index: .90. General remarks: Moderate Poikilocy-
tosis.    Marked Polychromatophilia.    Occasional megaloblast seen.
23/2/43—W.B.C., 11,750. RB.C: 4.2 Mill. Haem.: 67%. General remarks: Plasma
injections during previous week.
1/3/43—W.B.C.: 8900, 17% Polys, 72% Lymphs, 5% Mono., 2% Baso., 4% Eosin.
R.BC: 3.4 Mill.    Haem.: 68%.    General remarks: Some variation in size and shape of
red cells.    Nucleated red cells present.    Some Polychromatophilia.
20/3/43—W.B.C.: 7600, 33% Poly, 60% Lymphs, 4% Mono., 3% Eosin.    R.B.C.:
4.2 Mill.    Haem.: 66%.   General remarks: Some variation in sie and shape of red cells.
B.—Discussion of the Rh factor and its Relationship to Erythroblastosis Fcetalis.
In 1940, Landsteiner and Weiner showed that the blood cells of human beings fell
into two separate groups other than those previously recognized. This was determined
when human cells were incubated with rabbit sera to which the cells of the Rhesus
monkey had been added until the rabbit produced an agglutinin for the monkey cells.
The two groups were designated rh negative and Rh positive according to whether they
possessed an agglutinogen that reacted with the agglutinin of the monkey's blood. It is
estimated that 15% of individuals are found to lack an agglutinogen, being therefore
rh negative, and 85% possess the agglutinogen and are Rh positive.
In 1939, Levine and Stetson reported the case of a woman who was delivered of a
stillborn fcetus, and after birth was transfused with her husband's blood. Both the
donor and the recipient were Group O, but during the transfusion the wife went into
severe shock which was followed by haematuria. She was then cross-agglutinated with
104 Group 0 donors and found to be compatible with only 21 of these. This work led
to the theory that the father of the fcetus possessed an agglutinogen which the mother
lacked, and which was transmitted as a dominant Mendelian gene from the father. In
a manner not yet explained, there appears to be, in these cases, a leakage of fcetal blood
into the maternal blood stream. The explanation is that as the mother lacked the
agglutinogen possessed by her fcetus, an aitibody was formed against this type of blood,
and when she was transfused with her husband's blood she went into shock.
These developments led to an explanation of the pathogenesis of (1) hydrops fcetalis,
(2) icterus gravis neonatorum and (3 ) haemolytic anaemia of the newborn.   All of these
Page 212 conditions are now considered as entities associated with erythroblastosis fcetalis. The
same theory is also used to explain the occurrences of numerous miscarriages, stillbirths,
and macerated foetuses which are associated with mothers who have produced an infant
suffering from erythroblastosis fcetalis.
If a man who is Rh positive mates with an rh negative woman, he passes on the Rh
agglutinogen to some or all of his children. The fcetal blood may or may not escape
into the maternal blood stream. If it does the mother manufactures an antibody against
the baby's Rh positive blood. This antibody appears to be capable of diffusing back
through the placenta, and destroys the fed blood cells of the fcetal circulation. The
fcetus responds by manufacturing more red blood cells to compensate for the destruction It is because of this defensive regeneration of cells by the fcetus, that the typical
blood picture of erythroblasts and other forms of nucleated red blood cells is found. The
haemolytic anaemia and the diminution of platelets it brought about by the destructive
action of the maternal antibodies. The prognosis of the fcetus balances between the
severity of this process of destruction, and the ability of the fcetal blood-forming organs
to regenerate new cells. In a given case, miscarriage may result, or the fcetus may go
to term and be born as a stillbirth, or it may survive as has the presented case, and
simulate one of the various syndromes of erythroblastosis fcetalis.
In considering what may happen in subsequent pregnancies, it should be remembered
that the antibodies in the maternal blood supply gradually disappear. On becoming
pregnant again the same history may follow, as is seen in cases with repeated miscarriages or stillbirths. This, however, does not necessarily occur, because being an inherited
condition, the fcetus receives genes from each parent. If the Rh factor is inherited from
one or both parents, the fcetus is an Rh Rh with both parents being Rh positive, or an
Rh rh if one parent is Rh positive and one rh negative. In either case, the fcetus is Rh
positive. If one parent is Rh rh and the other rh rh, there is a possibility of the fcetus
being rh rh, i.e., rh negative, and no incompatibility would follow. Thus a mother
who has had a baby with erythroblastosis may have normal children providing the
father is Rh positive.
Conclusions
From this brief discussion, it may be concluded:
A. That 85% of humans are Rh positive, and 15% are rh negative.
B. That in giving a transfusion to a pregnant woman or one who has just terminated her pregnancy, plasma is indicated rather than whole blood. If whole blood is
given, the father should never be used as a donor unless it is possible to test for the Rh
factor.
C. That a complete obstetrical history is of great importance before giving a
woman a transfusion. A detailed history must be obtained especially with reference to
miscarriages.
D. That the Rh factor plays a definite part in the pathogenesis of erythroblastosis
fcetalis, and may also be associated with cases of repeated miscarriages, stillbirths and
macerated foetuses.
COLONIC AND PHYSIOTHERAPY CENTRE
Up-to-date Scientific Treatments
COLONIC IRRIGATIONS, SHORTWAVE  DIATHERMY,  SINNEWAVE GALVINISM,
IONIZATION, ULTRA VIOLET RAY, STEAM BATHS AND SHOWERS
Medical and Swedish Massage
Physical Culture Exercises
STAFF OF GRADUATE NURSES
1119 Vancouver Block
Superintendent
E. M. LEONARD, R.N.
Post Graduate Mayo Bros.
MArine 3723
Vancouver, B.C.
Page 213 1930 Tisda11- F- F- Drake, T. G. H., and
Brown, A.: A new cereal mixture containing vitamins and mineral elements. Am.
J. Dis. Child. 40:791-799, Oct. 1930.
IGrtl Tisdall j F. F.: Dietary factors and
L*JX health, Soc. Tr., Am. J. Dis. Child.
42:1490, Dec. 1931.
\Q~XJ, Summerfeldt, P.: The value of an in-
creased supply of vitamin Bi and iron
in the diet of children, Am. J. Dis. Child.
43:284-290.. Feb. 1932. • Morse.J. L.: Fads
and fancies in present day pediatrics, Pennsylvania M. J. 35:280-285, Feb. 1932. Hen-
ricke, S. G.: The vitamin B complex: Its role
in infant feeding in the light of our present
knowledge. Northwest Med. 31:165-169,
April 1932. Langhorst, H. F.: Vitamins:
Their role in the prevention and treatment of
disease. M. J. & Rec. 135:326-329, April 6,
1932. Crimm, P. D.: Dietary of Childhood
Tuberculosis: Cereal as a source of added
mineral and vitamin elements; preliminary
report, J. Indiana M. A. 25:205-206, May
1932. Troutt, L.: Quality studies of therapeutic diets: I. The ulcer diet; a committee
report, J. Am. Dietet. A. 8:25-32, May 1932.
Summerfeldt, P., Tisdall, F. F.. and Brown,
A.: The curative effects of cereals and biscuits on experimental anaemias, Canad.
M.A.J. 26:666-669, June 1932. Sneed, W.:
Ununited and delayed union of fractures,
Kentucky M. J. 30:363-370, July 1932.
Silverman, A. C.: Celiac disease. New York
State J. Med. 32:1055-1061, Sept. 15, 1932.
von Meysenbug, L.: Infant feeding with
especial reference to some of its problems
during the first year, Texas State J. Med.
28:543-547, Dec. 1932.
1933 Wampler, F. J., and Forbes. J. C.: Cal-
cium and phosphorus metabolism in a
case of celiac disease. South. M. J. 26:555-
558, June 1933. Brown, A., and Tisdall,
F. F.: The role of minerals and vitamins in
growth and resistance to infection, Brit. M.
J. 1:55-57, Jan. 14, 1933; Effect of vitamins
Orleans M. & S. J. 87:738*743. May 1935.
Tarr. E. M., and McNeile. O.: Relation of
vitamin B deficiency to metabolic disturbances during pregnancy and lactation. Am.
J. Obst. & Gynec. 29:811-818, June 1935.-
Blatt, M. L., and Schapiro, I. E.: Influence
of a special cereal mixture on infant development. Am. J. Dis. Child. 50:324-336, Aug.
1935. Coward, N. B.: Infant feeding.
Nova Scotia M. Bull. 14:525-532. Oct. 1935.
Tisdall, F. F.: Inadequacy of present dietary
standards.-Tr. Sect. Pediat.. A.M.A.. 1935:
Canad. M. A. J. 33:624-628, Dec. 1935.
Marriott, W. McK.: Infant Nutrition, second
edition, C. V. Mosby Co., St. Louis, 1935, p.
202. Summerfeldt, P.: Iron and its availability in foods, Tr. Sect. Pediat., A.M.A.
1935. pp. 214-220.
1936 Dafoe' A- Rv Further history of the
care and feeding of the Dionne quintuplets, Canad. M. A. J. 34:26-32, Jan. 1936.
' Conn, L. C, Vant. J. R., and Malone, M. M.:
Some aspects of maternal nutrition. Surg.,
Gynec. & Obst. 62:377-383, Feb. 15. 1936.
Ross, J. R., and Summerfeldt, P.: Haemoglobin of normal children and certain factors
influencing its formation, Canad. M. A. J.
34:155-15X, Feb. 1936. Smyth, F. S.: Allergic diseases, J.  Pediat.  8:500-515.   April
1936. Lemmon, J. R.: Problems of the crying infant. Southwestern Med. 20:248-250,
July 1936. Rice, C. V.: The success of treating
celiac disease from a standpoint of vitamin
deficiency. Arch. Pediat. 53:626-629, Sept.
1936. Smith, C. H.: Management of" nutritional anemia in infancy, M. Clin. North
America 20:933-950, Nov. 1936. Strong.
R. A., editor: Nutritional anemia of infants,
Orleans Parish M. Soc. Bull., pp. 6-9, Nov.
9, 1936. Jeans, P. C: Specific factors in
nutrition. Round Table discussion, J. Pediat.
9:693-698. Nov. 1936. Young, J. G.:
Meeting the requirements for proper nutrition in infancy, Texas State J. Med. 32:531-
533, Dec. 1936.
1Q17 Stearns. G., and Stinger, D.: Iron re-
tention in infancy, J. Nutrition 13:127-
ner, B., and Gruehl, H. L.: Anaphylactogenic
.properties of certain cereal foods and bread-
stuffs: Am. J. Dis. Child. 57:739-758. April
1939. Monypenny, D.: Early introduction
of solid foods in the infant diet. Soc. Tr., Am.
J. Dis. Child. 58:1144-1145. Nov. 1939. Brown,
A., and Tisdall, F. F. Common Procedures in
the practice of paediatrics, third edition, McClelland & Stewart. Ltd., Toronto. 1939. pp.
77-79.
1940 McDougal. L. L.. Jr.r Feeding a nor-
^ mal infant, Mississippi Doctor 17:437-
442, Jan. 1940. Monypenny, D.: The early
introduction of solid foods in the infant diet,
Canad. M. A. J. 42:137-140, Feb. 1940.
Robinson, E. C.: A study of two hundred and
forty breast-fed and artificially fed infants in
the St. Louis area, Am. J. Dis. Child. 58:816-
827. April 1940. Ratner. B.: Round Table
discussion on food allergy. J. Pediat. 16:653-
672, May 1940. Rosenbaum. I.. Jr.: The
management of the allergic child, Kentucky
M. J. 38:199-203, May 1940. Barondes. R.
de R.: Report of a case of pellagroid, M. Rec.
151:376-380. June 5, 1940. Brown. A.:
The fourth Blackader lecture on a decade of
paediatric progress, Canad. M. A. J. 43:305-
313. Oct. 1940. Drueck. C. J.. Vitamin
therapy in colon and rectal disease, Illinois
M. J. 78:337-341. Oct. 1940. Swift. F. L.:
Infant feeding, Lackawanna Co. M. Soc.
Reporter. 33:16-18, Nov. 1940. B.ogert.
L. J., and Porter, M. T.: Dietetics Simplified.
ed. 2, Macmillan Co.. New York, 1940. p.
181. Davison. W. C: The Compleat Pediatrician, third edition, Duke University Press,
Durham, N. C. 1940. No. 216. Hawley,
E. E.. and Ma'urer-Mast, E. E.: The Fundamentals of Nutrition. C. C. Thomas, Springfield. 111.. 1940. pp. 296. 456. Kugel-
mass. I. N.: The Newer Nutrition in Pediatric
Practice. J. B. Lippincott Co., Philadelphia.
1940. p. 372. Leaman, W. G., Jr.: Management of the Cardiac Patient, J. B. Lippincott Co.. Phila.. 1940. p. 549. Paterson.
D., in Index of Treatment, edited by R.
Hutchison, ed. 12, revised, Williams & Wilkins
Co., Baltimore, 1940, p. 491.     Thomas. G.
SCIENTIFIC   BACKGROUND
Mead's Cereal was introduced in 1930, and Pablum in 1932, by
Mead Johnson & Company. Since then, the growing literature
indicates early recognition and continued acceptance of these
products and the important pioneer principles they represent*
and the inorganic elements on growth and
resistance to disease in children, Ann. Int.
Med. 7:342-352; Sept. 1933. Crimm, P. D..
Raphael, I. J., and Schnute, L. F.: Diet of.
tuberculous and non-tuberculous children:
Effect of increased supply of vitamin B concentrate and minerals, Am. J. Dis. Child.
46:751-;756, Oct. 1933. Smith, A. D.: Consideration of various infants' foods. Pacific
Coast J. Homeop. 44:463-465. Sept.-Dec. 1933.
1 Q34 Somers, R., Rotton, G. C, and Rown-
~ tree, J. I.: Possibilities of improving
dental structures, Soc. Tr., Bull. King Co. M.
Soc. 13:6, Jan. 15, 1934. Blatt, M. L.:
Development of infants on a diet of a special
cereal mixture, Soc. Tr., Am. J. Dis. Child.
47:918, April 1934. Rice, C. V.: Anemia of
infancy and early childhood, J. Oklahoma
M. A. 27:125-129. April 1934. Hawk. W.
A.: A few of the commoner feeding problems
in infancy. Univ. Toronto M. J. 11:218-229,
May 1934. Ross, J. R., and Burrill, L. M.:
The effect of cooking on the digestibility of
cereals, J. Pediat. 4:654-659, May 1934._
Rice, C. V.: Sauerkraut juicefor the acidification of evaporated milk in infant feeding.
Arch. Pediat. 51:390-395. June 1934. Eder.
H. L.: Iron therapy: A routine procedure
during infancy. Arch. Pediat. 51:701-713,
Nov. 1934. Lynch, H. D.: Fundamentals
of infant feeding, J. Indiana M. A. 27:571-
574. Dec. 1934. Chaney. M. S., and Ahl-
born, M.: Nutrition, Houghton Mifflin Co.,
Boston, 1934, p. 323.
1QT. e Bailey, C. W.: Anemia in infants and
X-7JJ young children, J. South Carolina M.
A. 31:54-58, March 1935. Kugelmass, I;
N.: The recent advances _ in treatment _ of
nutritional disturbances in infancy and'childhood, M. Comment 17:5-13, March 1, 1935.
Ross, J. R-, and Summerfeldt, P.: Value of
increased supply of vitamin Bi and iron in
the diet of children: Paper II, Am. J. Dis.
Child. 49:1185-1188. May 1935. \ von Meysenbug, L.: Breast feeding with especial
reference  to  some  of   its   problems.   New
■ 141, Feb. 1937. Strong, R. A.: Nutritional
anemia, Mississippi Doctor 15:13-16, Aug.
.1937. Smith, C. H.: Prevention and treatment of nutritional anemia in infancy. Preventive Med. 7:115-124. Aug. 1937. Saxl.
N. T.: Pediatrics, in Dietetics for the Clinician, edited by M. A. Bridges, third edition.
Lea & Febiger, Philadelphia, 1937, pp. 637-
639. Boyd, J. D.; Nutrition of the Infant
and Child, National Medical Book Co., Inc.,
New York, 1937, p. 110. Brennemann, J.:
Practice of Pediatrics, W. F. Prior Co., Inc.,
Hagerstown. Md., 1937, Vol. 1. Ch. 25. p. 19.
Griffith. J. P. C, and Mitchell. A. G.: The
Diseases of Infants and Children, second
edition, W. B. Saunders Co.. Philadelphia,
1937, pp. 106, 111. Saxl. N. T.: Pediatric
Dietetics. Lea & Febiger, Philadelphia, 1937,
pp. 131-133.
1938 Hoffman, S. J., Greenhill, J. P., and
Lundeen, E. C: A premature infant
weighing 735 grams and surviving, J.A.M.A.
110:283-285, Jan. 22, 1938. Krasnow, F.:
Nutritional influence on teeth. Am. J. Pub.
Health 28:325-333, March 1938. Ratner, B.:
Round Table discussion on asthma and hay
fever in children, J. Pediat. 12:399-413,
March 1938. Ratner, B.: Panel discussion
on the role of allergy in pediatric practice,
J. Pediat. 13:582-604, Oct. 1938. Snelling.
C. E.: Nutritional anaemia. Bull. Acad. Med.
Toronto 12:710, Oct. 1938. Dauphinee.
J. A.: The iron requirement in normal nutrition,   Canad.   M.A.J.   39:483-486,   Nov.
1938. Summerfeldt. P.. and Ross. J. R.:
Value of an increased supply of vitamin Bi
and iron in the diet of children. Paper III,
Am. J. Dis. Child. 56:985-988. Nov. 1938.
Tisdall, F. F., and Drake. T. G. H.: The
'utilization of calcium, J. Nutrition 16:613-
620, Dec. 1938. Drake. T. G. H.: Introduction of solid foods into the diets of children, Canad. M. A. J. 39:578-580, Dec. 1938.
1939 Strong,  R. A.:_ The most frequent
.         causes of vomiting in infancy, Texas
State J. Med. 34:665-676, Feb. 1939.     Rat-
L: Dietary of Health and Disease, ed. 3, revised. Lea & Febiger, Phila., 1940, pp. 171.
1 Q41 Gipson, A. C: The role of allergy in
~ pediatric practice, J. M. A. Alabama
10:272-274. Feb. 1941. Ross. J. R.. Monypenny, D., and Jackson, S. H.: II. The effect
of cooking on the digestibility of cereals. J.
Pediat. lS:395-398, March 1941. Kennedy.
A. S., Snider, O., Hazen, J. S., and McLean.
C: The dietary management of intestinal
tuberculosis. Canad. M. A. J. 44:380-385,
April 1941. McAlpine, K. L.: Management of the nutritional anaemia of infancy,
Canad. M. A. J. 44:386-390. April 1941.
Patek, A. J.. Jr.. and Post. J.: Treatment of
cirrhosis of the liver by a nutritious diet and
supplements rich in vitamin B complex, J.
Clin. Investigation 20:481-505, Sept. 1941.
Bercovitz, Z., and Johnson, H. J.: Ulcerative
Colitis, in Dietetics for the Clinician, by M.
A. Bridges, fourth edition, revised. Lea &
Febiger, Phila.. 1941. p. 295. Bridges. M.
A.: Dietetics for the Clinician, fourth edition,
•revised. Lea & Febiger, Phila., 1941, pp. 727,1
751, 809. Griffith, J. P. C., and Mitchell.*?
A. G.: Textbook of Pediatrics, ed. 3, revised,^
W. B. Saunders Co.. Phila., 1941, pp. 87, 91.
Rowe, A. H.: Elimination Diets and the
Patient's Allergies,  Lea &  Febiger,  Phila.,
1941, p. 230. Twiss. J. R.: Gall-bladder
Disease, in Dietetics for the Clinician, by
M. A. Bridges, fourth edition, revised. Lea &
Febiger, Phila., 1941, p. 401.
1QA7. Gleich, M.: The premature infant.
x^^" Part II. Arch. Pediat. 59:99-135. Feb.
1942. Part IV. Arch. Pediat. 59:241-263.
April  1942.       Brown,   A.,  and   Robertson,
E. C: Factors to be considered in the construction of the diet of the older child. J.
Kansas M. Soc. 43:237-244. June 1942. Por- ;
ter, L., and Carter, W. E.: Management of the
Sick Infant and Child, ed. 6, C. V. Mosby Co.,
St. Louis, 1942. p. 125. Proudfit, F. T.;
Nutrition and Diet Therapy, ed. 8, Macmillan
Co.. New York. 1942, p. 515. WiUard. J.
H.: Digestive Diseases in General Practice,
F. A. Davis Co.. Phila., 1942. p. 147.
J \ Vehicle that Stimulates Appetite
©
I5iux>tt lXwuk U/u£w!a (b.A.
WYETH'S BEWON ELIXIR serves as
an excellent solvent and vehicle for
many medicaments. Compatible with
most drugs, BEWON. ELIXIR contains
18% alcohol and is slightly acid in
reaction.
Standardized to contain 500 Interna*
tional Units o! Vitamin Bx (thiamin
chloride) per fluid ounce, BEWON
ELIXIR stimulates the appetite and is
indicated in Vitamin B, deficiencies.
Supplied in 16 II. oz. and 160 il. oz. bottles.
John Wyeth & Brother (Canada) Ltd.
WALKERVILLE, ONT. /
.... Promise
... Proof
Zephiran Chloride is a mixture
of high molecular alkyl-dimethyl-
benzyl-ammonium chlorides. It
contains no phenol, no iodine, no
mercury, or other metals.
In addition to effectiveness as a
germicide, Zephiran Chloride
offers new important plus properties;
•k Rapidity of Action
ir Detergent Properties
it Penetration Power
* Non-Injurious Effect
Upon Tissues, in Proper
Dilutions
• Wide Field of Application
it Economy in Use
BtchkI <rf Se«iyt'Tr»o8«m«Hn Cfeior«fe
CHLORIDE
NON-MERCURIAL GERMICIDE
In the early stages of its development
Zephiran Chloride gave promise of certain desirable properties which had always
been lacking in bacteriotogically potent
germicides'. ^^^^^^^B
Between promise and proof, however,,
the road is bard and long. Through re*
search and clinical work, Zephiran
Chloride has given convincing proof that
certain plus, properties, also essential in
preoperative skin antisepsis, can exist
with germicidal effectiveness.
■In-recognition of the proved ability of
Zephiran Chloride tomeet today'scritical
needs with new advantages, the Council
on Pharmacy and ti&emistry has granted
the Seal of Acceptance^!© it.
bod* More Peontefec
m Conodo
CHLORIDE
Germicide for surgery and obstetrics ...
Skin ... Mucous Membranes... Infected Wounds • UROLOGY
... Bladder irrigation and Lavage • EYE, EAR, NOSE AND
THROAT o STERILE STORAGE OF INSTRUMENTS.
(®)   ALBA   PHARMACEUTICAL   DIVISION
*—y Winthrop Chemical Company, Inc. §1
Professional Service Office SUCCESSOR Adbnlnlrtrufion and Laboratories
1010 St. Catherine St. W. 1019 Elliott Street West
MONTREAL, P.Q. WINDSOR, ONT. BEMINAL   BEMlNALl BEMINALl BEMINAL   BEMINAll BEMINAL
$
Wm
GyetAt
mm
vSaSS
«F!WI
S3S
t^tftjfj
^
£f@s
fo<£eaa^
The problem of selecting the most suitable agent for B complex therapy can readily
be solved by reference to the Ayerst group of "Beminal" preparations. The variety
in form and vitamin content which these products afford facilitates the choice of a
preparation to meet the requirements of each patient. "Beminal" Tablets and "Beminal"
Concentrate for oral administration and "Beminal" Injectable for parenteral use are
indicated where high dose levels are required. "Beminal" Compound, "Beminal"
Liquid and "Beminal" Granules, given by mouth, are recommended for the milder
forms of B complex deficiency. Literature on request. AYERST, McKENNA & HARRISON
LIMITED, Biological and Pharmaceutical Chemists, MONTREAL, CANADA.
129
wmm
ft" COMPLEX
SBiaeedd UTS RHYTHMIC TIMING that counts ... in
bowel function too.
Agarol follows this principle closely: its exceptionally stable emulsion of pure medicinal mineral oil
softens and lubricates the intestinal contents. At the
same time, it furnishes gentle peristaltic stimulation,
which follows from the even diffusion of pure,
white phenolphthalein throughout the emulsion. The
result is rhythmic timing, and easy and comfortable
evacuation.
A complimentary trial supply of Agarol will be sent
promptly if you will please write to our Department
of Professional Service.
WILLIAM R. WARNER & CO., LTD., 727 KING ST. WEST, TORONTO, ONT. FOR INFANTS and
FOR CHILDREN
t\
IPIk
5   -    -
i
sUfi
il
Ml
wk
WfAMIN
URISDOL in Propylene Glycol makes ration is simple, convenient and easy
it possible to secure the benefits to use, and relatively little is required
obtainable from combining vitamin D for prophylaxis and treatment of
with the daily milk ration. This prepa- rickets—only two drops daily.
DRISDOL IN PROPYLENE GLYCOL
DOES NOT FLOAT ON MILK    •    DOES NOT ADHERE TO BOTTLE
DOES NOT HAVE A FISHY TASTE    •    DOES NOT HAVE A FISHY ODOR
Drisdol in Propylene Glycol—10,000 International units per Gram—is available in bottles containing 5 cc. and 50 cc. A special dropper delivering 250 International vitamin D units per drop is
supplied with each bottle.
DRISDOL
Reg. U. S. Pat. Off. & Canada
IN   PROPYLENE   GLYCOL
Brand of Crystalline Vitamin D from ergosterol
WINTHROP CHEMICAL COMPANY, INC.
Pharmaceuticals of merit for the physician
General Office: WINDSOR, ONTARIO
Professional Service Office: Dominion Square Building, Montreal, Que.
WINTHROP
WINTHROP
^^S^ss^+^'-aW
^■Awsawttsafl-xv* fl&ount pleasant XHnbertaklnQ Co. %tb.
KINGSWAY at 11th AVE. Telephone FAirmont 0058 VANCOUVER, B. C
R. F. HARRISON W. E. REYNOLDS
13 th Ave. and Heather St.
Exclusive  Ambulance  Service
FAirmont 0080
PRIVATE AMBULANCES AND INVALID COACHES
WE SPECIALIZE  IN  AMBULANCE SERVICE  ONLY
J. H. CRELLIN
W. L. BERTRAND URINE-SUGAR   TESTING   BECOMES
A MATTER   OF   SECONDS  WITH...
I    CLINITEST
The New Tablet Method
S drops urine
plus
10 drops water
Drop in tablet
Allow for reaction
and compare with
color scale
DEPENDABLE RESULTS—Clinitest Tablet Method is
based on same chemical principles involved in Benedict's test
•.. except ... no external heating required, and active
ingredients for test contained in a single tablet. Indicates sugar
at 0%, H%, V2%, H%91% and 2% plus.     |p^     §
A PRACTICAL ECONOMY—Complete set (with tablets
for 50 tests). Retails to the
patient for $2.00. Tablet Refill
(for 75 tests)—$2.00.
Write for full descriptive
literature.
Clinitest Urine-Sugar Test and
Clinitest Tablet Refill are available through your surgical supply
house or prescription pharmacy.
EFFERVESCENT   PRODUCTS   INC
Sole Canadian Distributors
FRED.    J.    WHITLOW   &   CO.,    LTD.,     187    DUFFERIN    STREET,    TORONTO SKKSSSIffiSSfclSSiSS
to
1
H
Breaks the vicious circle of perverted
• menstrual function in cases of amenorrhea,
tardy periods (non-physiological) and dysmenorrhea. Affords remarkable symptomatic
relief by stimulating the innervation of the
uterus and  stabilizing the tone of its
musculature. Controls the utero-ovarian
circulation and thereby encourages a
normal menstrual cycle.
*^W | MARTIN H. SMITH COMPANY   j4
fev. •        150 IAFATHTI ST*UT. NEW YORK. N. T. , J
full formula and descriptive
literature on request
Dosage:   l to 2 capsules
3 or 4 times daily.   Supplied
in packages of 20.
Ethical protective mark MHS
embossed on inside of each
capsule, visible only when capsule  is  cut  in  half  at  seam.
Jlead CoMd. Checked
WITH 3 DROPS IN EACH NOSTRIL . . .
PRIVINE"Ciba"
(1:1000 solution of 2— (naphthyl—1-methyl)-imidazoline hydrochloride)
NASAL   DROPS
Clinical investigations on Privine Nasal Drops have proved that
they are excellently suited for the treatment of all forms of nasopharyngeal affections. In head colds, a few moments after the
instillation of 3 drops of Privine in each nostril, the headache and
sensation of heaviness in the head disappear, while the nasal respiration becomes easier, the watering of the eyes stops, the voice regains
its normal tone and the sense of smell is restored.
ISSUED:
In bottles of Vi ounce with dropper, and bottles of 4 ounces.
CIBA COMPANY LTD.
Montreal \
IF ARTHRITIS and ECZEMA
ARE ALLERGIC
ETIOLOCICALLY
effective treatment suggests the use of
agents to correct mineral deficiency,
increase cellular activity, and secure
adequate  elimination  ef toxic watte.
LYXANTHINE ASTIER -~(
orally given, supplies calcium, sulphur,
iodine, and lysidln bitartrate — an
effective solvent. Amelioration of
symptoms and general functional improvement  may   be  expected.
Since the best evidence is clinical
evidence, write for literature and
sample.
L-15
Canadian Distributors
ROUGIER FRERES
350  Le Moyne   Street,  Montreal
J
t
2559 Cambie Street
Vancouver, B.C.
Results of Extensive
Studies of Research
on the Use of Bran |
X-ray of barium
meal in the colon
where   laxative
effect is primarily
exerted.  Observations indicate that
KELLOGG'S
ALL-BRAN does
not interfere with
normal digestive
processes in the
stomach or small
intestines.
ES^JI             Br    jfl
R
.ECENTLY reported developments
in research as to the mode of laxative operation of ALL-BRAN added to unrestricted and
uncontrolled diets are of considerable interest. Evaluations by the use of measuring
methods that have been found consistently
reliable indicate that:
• When bran is added to the diet a desirable
change takes place in the waste material—
it becomes bulkier and softer.1
• Bran exerts its laxative effect primarily
in the colon; it does not interfere with normal processes of digestion in the stomach or
small intestine.2
• Bran has little effect on the emptying
time of the colon when this emptying time
is as it should be. But among subjects with
a delayed emptying time, bran has a distinct
accelerating effect.2
• It is not necessary to control rigidly the
quantity of bran eaten, as 2 ounces (double
the usual cereal serving) eaten daily does
not result in a corresponding increase in
laxation.3
• Bran eaten every day for an extended
period of time has no adverse effects on normal intestines; its continued use does not
lessen or increase its laxative effect.3
1 "Mode of Action of Bran,'' Journal of Laboratory
and Clinical Medicine, August, 1941.
2 "Roentgen Study of Intestinal Motility as Influenced by Bran," The Journal of the American
Medical Association, February 3, 1940.
3 "Effect of Long-Continued Consumption of
Bran by Normal Men," Journal of American
Dietetic Association, April, 1942.
• Any or all of these reports are available.
Requests for reprints relative to the action of
KELLOGG'S ALL-BRAN should be made to
KELLOGG COMPANY OF CANADA LIMITED, London, Ont. tflTTXIltTIIlErillllllllllllltlllllTlIIIllIIIllllIIlllIlIIIllITIIIIIIIIIIITIIIHIITillllirillTITIIlIIIlIII] IIIIlIIIIIlIillilllllllllTIIIlIIIIIIIfrilillllllllilTIEIIIIfllllllllllllliilllllllllJIIirilflllirillHIIIillL
It gives a girl Glamour,
| • t when she EATS
her milk too
JLf glamour starts with the soundly constructed feeding formula that the physi-
sian prescribes in infancy, it continues
with a well-balanced diet, adequately
supplied with nourishing milk solids.
And those solids—as many parents fail
to realize—do not have to be obtained
from milk consumed as a beverage.
In these days of rising food costs, the
physician will often be justified in
pointing out the economy, as well as the
nutritive value, of Irradiated Carnation
Milk—and the special usefulness of this
high-quality evaporated milk in the
preparation of milk-rich dishes that
find favor with children. It may often
be employed undiluted, to double the
milk solids in every serving. In a 1:1
(whole-milk) dilution, it meets all ordinary cooking requirements and is
wholesome and palatable for drinking.
. . . Carnation Co. Limited, Toronto,
IRRADIATED
Carnation
'FROM  CONTENTED COWS"
Milk
A Canadian Product We're Ready, Doctori
Everyone has difficulties these days in
the performance of duty—pharmacies
included. But very few prescriptions
from the medical profession come to us
that^e cannot dispense efficiently and
with no lost time.
Phone
MArine 4161
\^&fa^.JUhd*4^
GEORGIA PHARMACY
l.   I   M   I   T   I
<&wtfrr & 2f amta Slto
ESTABLISHED 1893
VANCOUVER, B. C.
North Vancouver, B. C.
Powell River, B. C. (So. Imttttro *c
New Westminster, B. C.
For f At? treatment of
NEUROPSYCHIATRIC
DISORDERS
Reference—B. C. Medical Association
For information apply to
Medical Superintendent, New Westminster, B. C,
or 721 Medical-Dental Building, Vancouver, B. C.
PAcific 7823
Westminster 288
27

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