History of Nursing in Pacific Canada

The Vancouver Medical Association Bulletin: August, 1931 Vancouver Medical Association Aug 31, 1931

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 Published monthly at Vancouver, B. C, by
McBeath-Campbell Ltd., 326 Pender Street West
Subscription, $1.50 per year. STRAND THEATRE  BLDG.
VAUGOIM^ CANADA
ANDERS'
EPHEDRINE COMPOUND
NASAL SPRAY   |j|
1% Ephedrine
Costs patient $1.00 per 02.
ANDERS'
ALL GLASS NEBULIZER
Costs patient $1.50
CHAS. H. ANDERS, Chemist
GORDON  M.  CLAY, Associate Chemist THE   VANCOUVER   MEDICAL   ASSOCIATION
BULLETIN
Published Monthly under the  Auspices of the Vancouver Medical Association in  the
Interests of the Medical Profession.
Offices:
203 Medical Dental Building, Georgia Street, Vancouver, B. C.
Editorial Board:
Dr. J. M. Pearson
Dr. J. H. MacDermot Dr. D. E. H. Cleveland
All communications to be addressed to the Editor at the abovi address.
Vol. VII.
AUGUST, 1931
No. 11
OFFICERS 1929-30
Dr. C. W. Prowd Dr. E. Murray Blair Dr. G. F. Strong
President Vice-President Past President
Dr. L. H. Appleby Dr. W. T. Lockhart
Hon. Secretary Hon. Treasurer
Additional Members of Executive:—Dr. A. C. Frost; Dr. W. L. Pedlow
Trustees
Dr. W. D. Brydone-Jack Dr. J. A. Gillespie Dr. J. M. Pearson
Auditors:   Messrs. Shaw, Salter & Plommer
SECTIONS
Clinical Section
Dr. J. E. Harrison  j Chairman
Dr. A. M. Agnew Secretary
Eye, Ear, Nose and Throat
Dr. N. E. MacDougall . | Chairman
Dr. J. A. Smith ; Secretary
Pediatric Section
Dr. C. A. Eggert  Chairman
Dr. S. S. Murray Secretary
STANDING COMMITTEES
Library
Dr. D. M. Meekison
Dr. W. H. Hatfield
Dr. C. H. Bastin
Dr. C. H. Vrooman
Dr. C. E. Brown
Dr. H. A. Spohn
'Dinner
Dr. J. E. Harrison
Dr. H. H. Pitt
Dr. N. McNeill
Rep. to B. C. Med. Assn.
Dr. H. H. Milburn
Orchestra
Dr. J. R. Davies
Dr. F. N. Robertson
Dr. J. A. Smith
Dr. J. E. Harrison
Publications
Dr. J. M. Pearson
Dr. J. H. MacDermot
Dr. D. E. H. Cleveland
Credentials
Dr. A. J. MacLachlan
Dr. A. Y. McNair
Dr. T. L. Butters
Sickness and Benevolent Fund
The President
Summer School
Dr. R. P. Kinsman
Dr. W. L. Graham
Dr. C. E. Brown
Dr. T. L. Butters
Dr. C. H. Vrooman
Dr. J. "W. Arbuckle
Hospitals
Dr. W. C. Walsh
Dr. F. W. Lees
Dr. A. W. Bagnall
Dr. F. J. Buller
V.O.N. Advisory Board
Dr. Isabel Day
Dr. H. H. Caple
Dr. G. O. Matthews
The Trustees 8.3
11.2
7.7
20.5
VANCOUVER HEALTH DEPARTMENT
STATISTICS, JUNE, 1931
Total   Population    (Estimated) 242,629
Asiatic   Population   (Estimated)    -       14,227
Rate per 1,000 of Population
Total   Deaths    !     166
Asiatic   Deaths .__       13
Deaths—Residents   only        153
Birth   Registrations        409
Female    194
Male        215
INFANTILE MORTALITY—
Deaths  under one year of  age          6
Death   Rate—Per   1,000   births    -        14.7
Stillbirths   (not  included  in  above)     8
CASES OF CONTAGIOUS DISEASES REPORTED IN CITY
Smallpox   	
Scarlet   Fever   	
Diphtheria   	
Chicken-pox        64
Measles      ■—	
Mumps      l	
Whooping-cough     	
Typhoid   Fever   	
Paratyphoid     	
Tuberculosis    	
Poliomyelitis    	
Meningitis    (Epidemic)    	
Erysipelas            11
Encephalitis   Lethargica   	
July
1st
May
1931 *
June
1931
to 15th
, 1931
Cases
Deaths
Cases
Deaths
Cases
Deaths
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0
95
0
27
0
2
0
12
0
2
0
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0
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as tablets, powder, solution or ointment. Write for literature.
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_J EDITOR'S PAGE
Dr. Rabinowitch in his address before the Vancouver Medical
Association recently, raised once more the vexed question of clinical
medicine and laboratory aids. Or foreshadowing, or perhaps embodying,
the attitude of current modernity, he introduces the term "Laboratory
Medicine" into the title of his paper. Thus he seems to make a bold
attempt to remove the shackles with which the laboratory has hitherto
thought itself hampered and to claim for it a distinct and permanent
place in the practice of medicine. Undoubtedly the laboratory has had
to justify itself. Its existence is infancy personified, compared with the
hoary antiquity which inherits from the dawn of recorded history, of
clinical medicine.
Think of the embattlemented, vested interests which have had
to be stormed, all in a period which may be spanned almost in the
lifetime of some now living. Is it to be wondered at that traces of
ancient prejudice still remain?
It is indeed at once a tribute to the accessibility of the medical
mind and to the worth of these laboratory methods that on the whole
so little is left. Much doubtless remains to be accomplished. In certain
countries and in certain parts of all countries these things are still
lightly regarded. But with the steadily increasing number of graduates
who have been trained in these methods from early medical youth, we
can see nothing but a speedy, complete acceptance of all that the
laboratory has to offer, especially in view of its evident appeal at once
to the person of the patient and to his purse.
There are drawbacks, of course, to this new form of medicine,
which is called laboratory medicine.
One is that the old cry of the reactionaries may become in time
an actuality, that clinical sense and clinical training with all that such
things mean of quickened observation, accumulated experience, cultivated memory and the power of deductive reasoning, may become submerged in the constant outflow of what are regarded as more accurate
and therefore more scientific methods. Such, of course, would seem to
be a calamity, for there are many holes and corners of the human body
and the human mind which are apparently inacessible to any but the
time honoured means of diagnosis. If that large class of patients, ailing
but not ill, who are crowding the establishments of the various cults
and still, though in lesser degree perhaps, fattening the bank accounts
of the nostrum purveyor, if these are ever to be successfully protected
and cared for, it must be by methods or amplification of methods which
had their origin in the time of Hippocrates.
A second complication following upon the heels of laboratory
medicine is expense. Gone are those happy days when all medical
knowledge was supposed to be centred in any one medical practitioner.
Unless from a surgeon, he sought and could seek, no assistance save from
another, whose riper years and grayer hairs might be supposed to have
enlarged his experience. No barium series then, no blood counts, no
glucose curves, no Widals, no Kahns.    The profession might have taken
Page 242 as its slogan the motto of our submarine commanders who do their stuff
"By God and by guess." Constitutions were doubtless more hardy,
those who had survived were fit and Providence watched over its own.
But think of the money saved. Now we make nothing of spending
a patient's income for a month before we tell him what is the matter
with him and what might be done about it.
This condition is we fear steadily driving the profession into the
hands of the State. The stupendous nature and amount of our own
discoveries and the resulting uneasiness of mind which will beset the
conscientious physician who fails to utilize them, are providing an increasing bill of costs which bids fair to make of medical diagnosis
a community problem.
So the tail of the serpent returns to its mouth and we are introduced
to another problem, can hirelings do the work of free men?
NEWS and NOTES
Dr. J. W. Ford has recently returned from a trip to Europe where
he has availed himself of the clinical facilities in Vienna and other
centres of medical learning.
Dr. G. A. Lawson of Port Alice has joined the resident staff of the
Vancouver General Hospital as senior interne in Obstetrics for a month's
Postgraduate course of clinical instruction. In his absence from Port Alice
his work is being cared for by D. R. Elder of Vancouver.
St. Paul's Hospital has made an important addition to its staff by
the appointment of five internes. Their names are as follows: Dr. Apple-
yard, London, Dr. Schwarzman, Edmonton, Dr. Beattie, London,
Dr. Stewart, Edmonton and Dr. Wilson, Edmonton.
Dr. C. W. Prowd and Dr. H. H. Macintosh have left for Europe
to attend the Third International (Radiological Congress in Paris). Later
Dr. Prowd intends going to Russia to study the Five Year Plan, which
appears to be misinterpreted in Canada. The general impression is, among
a large portion of the public, that this is something to do with an instalment system for settling doctors' bills. These travellers will leave
for home on October  15th,   (Stalin permitting).
Miss Archibald, formerly of the Training School at the Vancouver
General Hospital, has been appointed Matron of the Abbotsford Hospital.
The Vancouver General Hospital deficit is doing as well as can be
expected.
We are gratified to learn that Dr. Murray Blair is rising in the world.
Already recognized, he has now been appointed a Conductor of Eagles—
at the recent international gathering in Seattle of the Fraternity of
Eagles.
Page 243
■mm Vancouver has had further visits from Drs. Primrose and D. E.
Robertson of Toronto. The reception Committee induced both to deliver
addresses while here, reports of which will be found on another page.
Dr. J. H. MacDermot, acting editor of the Bulletin, has been enjoying the balmy breezes and salt seas of Savary Island. If this issue is
not up to its usual standard our readers will know the reason.
Building operations of the new wing of St. Paul's Hospital are expected to be completed by the end of August, but will not be occupied
for some time after that. The Laboratory and X-Ray Departments will be
found on the ground floor of the building, the top floor being devoted
to surgery entirely. 150 additional beds will thus be made available, 38
of which are in private rooms and the balance in wards of from three
to six beds, in cubicle style. Following completion of the new wing, it
is the intention to tear down the old original part of the Hospital with
a view to subsequently building upon the ground.
Dr. William Gordon Cumming, who practised here before the war,
has returned to Vancouver, and will limit his practice to anaesthesia.
The following books and journals are missing from the Library. Will
the members who have these please return them immediately:
Nephritis, Elwyn.
Pamphlets on the Cost of Medical Care.
Sex and Sex Worship, Wall.
American Jnl. Obst. & Gyn. for July 1930.
American Journal Medical Sciences Vol. 171.
American Journal of Surgery, March 1931.
Journal Tropical Med. & Hygiene, July 15, 1930.
Arch. Neurology & Psychiatry for March 1930.
Abt's Pediatrics, volume VI.
B. C. MEDICAL ASSOCIATION NOTES
The Annual Meeting of the B. C. Medical Association was held
in the Hotel Vancouver on June 23rd. There was an excellent attendance
and much business of importance was dealt with. Dr. G. Lyall Hodgins
presided. The following officers were elected. President, Dr. Thomas
McPherson, Victoria; President-Elect, Dr. W. J. Knox, Kelowna; Vice-
President, Dr. Douglas Corsan, Fernie; Hon. Secretary-Treasurer, Dr.
D. E. H. Cleveland, Vancouver. Members of Executive at large: Dr.
C. S. Williams, Trail; Dr. J. M. Fowler, Victoria; and Dr. G. W. Sinclair,
New Westminster.   Mr. C. J. Fletcher continues as Executive Secretary.
The Annual Dinner was held on June 23 rd, when our guests were
the members of the Council of the Canadian Medical Association. Dr.
Ward Woolner, of Ayr, Ontario, Past President of the Ontario Medical
Page 244 Association, was the guest of honour and gave a most interesting address
on "Medical Economics." The attendance was good, the dinner was
good, the speakers were good, and a good time was had by all. Dr.
Thomas McPherson, the new president of the Association, presided.
ADDRESSES AND CLINICS
On Thursday evening, July 9 th, Dr. John Stokes, Professor of
Dermatology and Syphilology at the University of Pennsylvania, addressed a well attended meeting of the Vancouver Medical Association in the
Auditorium, Medical Dental Building.
Professor Stokes took as his subject "Eczema in relation to the
asthma-hay fever-complex." He allocated eczema to the position of a
medical problem in dermatology. Dermatitis or eczema, which terms
are synonymous, is not a disease but a symptom-complex. The Germans
regard eczema as that form of dermatitis in which the epidermis exhibits
an intrinsic hypersensitivity to irritants. Dr. Stokes, while accepting this
as far as it goes, broadens it by giving greater attention to the background.
The type of eczema varies according to a definitely distinguished
group of predisposing factors; these various types can, in a great number
of cases, be distinguished by their distribution, as was illustrated by diagrammatic drawings; this in turn, to a large extent, gives definite indications or contraindications with regard to treatment, and finally is
of great assistance in prognosis. These type-determining factors, eight
in number, were described as follows: hereditary or familial disposition;
the ichthyotic factor; the seborrhoeic habitus; the pyogenic factor; the
mycotic factor; the metabolic factor; especially with regard to carbohydrates; the allergic (general or specific) and finally the neurogenic
factor. It was clearly indicated that these factors may commonly appear
in combinations. For instance, a combination of the seborrhoeic and
pyogenic are often present with a hereditary background; another combination frequently encountered was the ichthyotic-allergic factor. This
exposition was followed by a brief sketch of therapeutic indications.
With regard to allergic tests, Dr. Stokes, while not undervaluing the
protein skin tests, if performed by an expert (not a dermatologist, but an
expert working with asthma) pointed out that the "patch test" which
could be done in the physician's office, was of very high value.
Dr. Stokes' remarks were followed with intense interest and were
illustrated by a short series of lantern slides, illustrating some of the
points which he had made.
A vote of thanks was moved by Dr. Cleveland and seconded by
Dr. Nelles.
On July 14th the Association was privileged to hear Dr. D. E.
Robertson, Surgeon in Chief of the Hospital for Sick Children, Toronto,
give an excellent practical Clinic on the surgery of the sympathetic
nervous system. Dr. Robertson has been keenly interested in this subject
ever since Royle and Hunter of Australia brought out the results of
their interesting observations on lumbar sympathectomy. Dr. Robertson sketched briefly the history of surgery of the nervous
system and stressed three points originally made by Royle in speaking
for lumbar sympathectomy, (1) less spasticity (2) relief of constipation
(3) the limb becomes dry and warm. In discussing congenital spastics
the speaker said that most orthopaedists considered the operation to be
useless. He very strongly recommends it in these cases and he speaks from
a fairly wide experience. He definitely states that it improves the gait,
the limb becomes dry and warm and the patient has a much better
balance.  In his  own  words  "the  patient  can  untie  his  limbs  quickly
r position."
enough to take a new
Dr. Robertson next considered Hirschsprung's disease and does not
believe it to be congenital. He believes it starts with an enlargement
of the rectum and sigmoid and progresses hence to the caecum. John
Fraser, of Edinburgh, on the other hand, believes that it is due to a
sphincter spasm. Dr. Robertson recommends left ramisection and reports
some highly successful cases. The operation is always done by the Royle
technique, rather than the transperitoneal and gives his reason that the
transperitoneal operation is much more difficult. An important point is
to find the white ramus of the second lumbar, pick it up and strip down
from there to the third and fourth. The patients show marked and rapid
improvement. His observation in post operative ramisection patients
is that those who have been chronically constipated show vast and
rapid improvement. Dr. Harris, of Toronto, he reports, has been doing
ramisection in cases of anterior poliomyelitis. Through the increased
blood supply there has been a fairly marked growth take place in the
affected limb. Dr. Robertson does not think that this growth has proved
to be of very great practical value.
Another group of conditions in which surgery of the nervous system
is taking an important place is in vascular disease of the extremities.
He states that. Raynaud's disease, in his opinion, is extraordinarily rare.
He has had one quite typical case upon which he did a cervical sympathectomy. There was marked relief in the spasms and small patches of
gangrene in the tips of the fingers cleared up, but he believes that this
is recurring in this patient and although sympathectomy is the only thing
one can do as yet, it is inadequate for complete relief. The pathological
report, by the way, in this case, was "chronic inflammation." An interesting observation in Raynaud's disease is that vasomotor spasm occurs at
certain bands of temperature.
Buerger's disease offers a great field for sympathectomy and excellent relief is obtained following operation. It further enables one to
amputate with much greater ease and less risk. White finger requires
no surgical interference. Dr. Robertson has had no experience in ramisection for arthritis but he quotes M. S. Henderson as stating that a few
cases showed improvement.
He finally touched on cervical sympathectomy in the treatment of
angina pectoris . He discussed the various minor procedures but he himself
is in favour of the removal of the stellate ganglion after the technique
of Henry of Dublin-.   He can see a very great field in the relief of anginal
Page 246 pains by this procedure and believes, too, that lumbar sympathectomy
will be used a great deal in the relief of the pain of intermittent
claudication.
For an hour and a half a large group of men listened attentively to
Dr. Robertson and he received a most enthusiastic vote of thanks for
his clinic. Those who did not attend lost much practical and valuable
information.
Dr. Primrose, Dean of the Medical Faculty of the University of
Toronto, addressed a gathering of medical men in the Auditorium of the
Vancouver General Hospital on the morning of July 17th. Taking as his
subject the value of records, which theme he developed in relation to
the problem of cancer, Dr. Primrose said that clinical records had been
kept from the earliest days of medicine and much that we know of
procedure in those days is gained from these records. Ambrose Pare, who
used this form of history-taking very largely is responsible for the
aphorism, "I dressed him—God healed him." Erichsen, much later, called
attention to the tendency of wounds to heal. The modern development
of records is that of the follow-up system which, while difficult to carry
out, has resulted in important information. It is commonly the case
to name a five year period as representing the cures in cases of cancer
of the breast. It is impossible now to regard this as always correct. Dr.
Primrose cited a case of his own where for 12 years the patient remained
well and where there was then a subsequent recurrence on the original
site of operation. Another similar case, after a long period of time, where
during the operation there appeared to be no involvement of the glands,
developed secondary manifestations in the spine.
It is noteworthy to consider that changes are constantly going on
in the body tissues even in normal people, such as the occurrence of
adiposity. Fibrotic changes are also continuously and slowly taking place.
When we speak of the healing of T. B. lesions in the lung, that is
really a question of fibrotic change, and foreign bodies which find an
entrance into the body, may afterwards become encapsulated and under
suitable conditions slowly absorbed.
What, asked Dr. Primrose, do we mean by early cancer? He mentioned a case of his own which came to operation and on referring to
his notes, he found that two and a half years earlier he had seen the
same patient and had recorded the condition as probably one of cancer
at that time. What, he asked, had taken place? Was the early diagnosis
a correct one and if so had the cancer remained latent during that long
period of time?
He referred us to those cases of cancer of the bladder which occur
in Germany among the workers in aniline dyes. Cancers very commonly
developed in those circumstances and there are many histories of patients
who as long as twenty years after quitting the occupation had developed
a characteristic type of cancer in the bladder.
The late Dr. Archibald Leitch of the Cancer Institute of London
refers to the peculiar type of cancer which occurs in cotton spinners
Page 24/ connected with the use of mineral oil, which also takes, in many instances,
many years to develop.
Dr. Primrose referred to two cases of primary carcinoma of the
appendix in two sisters, both of whom were subject to T. B., one to
pulmonary tuberculosis, the other to tuberculosis of a fallopian tube. He
considered that there was some relation between the incidence of cancer
and tuberculosis and cited Sampson Handley's views with regard to the
dissemination of cancer cells by lymphatic permeation. Lymph stasis
occurs many years before. He noted also that while the death rate from
all forms of tuberculosis was a gradually diminishing quantity and that of
cancer a constantly increasing one, yet the combined death rate of cancer
and tuberculosis remained the same, showing that one may consider that
cancer has a long life history before it becomes evident to the clinician
and that the metamorphic changes in disease are very slow. Dr. Primrose
showed slides indicating the slowness of the changes which take place
in the tissues of the body. One of the slides showed a cystic tumour of a
finger, where he was very anxious to preserve the finger and opening the
shell of the cyst, he inserted a part of an ivory knitting kneedle pointed
at both ends to act as a splint for the remaining fragments. He showed
several slides at various periods showing the condition of the graft. At
the end of eight years the graft was obviously beginning to absorb and
twenty-one years after the original operation, absorption of the ivory
needle was almost complete.
He showed a plate of a woman sixty-three years of age who consulted
him with regard to a goitre and in the ordinary routine of such procedure the existence of a bullet was revealed in the neck. Meeting the
daughter of his patient he spoke of the occurrence and the daughter
begged him to say nothing about it to her mother, the bullet being the
evidence of a frustrated love affair which took place forty-five years
previously.
Another set of slides showed the slow absorbtion of bone implanted
to repair a defect in the skull and its gradual replacement by fibrous
tissue. When this fibrotic replacement was completed certain Jacksonian-
epileptic symptoms and severe headaches entirely disappeared.
An interesting series was that of the after history of a case of psoas
abscess. Dr. Primrose, forty years ago, in his early connection with the
Hospital for Sick Children, opened a psoas abscess anteriorly and posteriorly and dressed it with the solutions common in that day. After
three years stay in the hospital suppuration ceased and the wounds healed.
The patient was lost sight of until a drive was advertised to raise money
for some extension to the hospital. One morning a husky looking man
presented himself at the desk and said he had no money to give but
would be glad to show himself as one who had received very great
benefits from the treatment he had received in childhood. X-ray films
taken at this time showed the four lower lumbar vertebrae fused together
with apparently no signs of any cord compression so that the individual
had been able to lead a normal active life. We must conclude therefore,
that changes which take place in the body may occur very slowly and
Page  248 it is probable, as he had already said, that cases which are now spoken
of as early cancer are not really early, but that the initial process may
have been going on for many years.
Our views with regard to the recurrence of breast cancer after
operation have changed considerably of late years and Dr. Primrose
instanced the statistics of Dean Lewis in the Johns Hopkins Hospital
Bulletin showing that of those patients who have not fallen victims
to intercurrent complaints, less than ten per cent have been free from
recurrence. The late Dr. J. B. Murphy of Chicago was always extremely
pessimistic about the cure of cancer and it would appear that subsequent
developments had gone a considerable way to prove his views to be
correct.
A vote of thanks to Dr. Primrose for his excellent address was moved
by Dr. Seldon and carried unanimously. Dr. B. D. Gillies was in the chair.
PRACTICAL CONSIDERATIONS IN THE TREATMENT OF
DIABETES WITH HIGH CARBOHYDRATE LOW CALORIE DIETS
Dr. I. M. Rahinowitch
The purpose of this brief communication is to outline the present
plan of management and education of the diabetic at the clinic for
diabetes at the Montreal General Hospital. The relatively large experiences we have had with this form of treatment has brought to light
a number of practical difficulties on the part of both physician and
patient; and it is hardly necessary to state that successful management
of the diabetic depends upon a thorough understanding of the object in
view. Thus, only, can the doctor prescribe properly and the patient
cooperate intelligently.
As you are probably aware, we have, for some time, been using a
high carbohydrate-low calorie diet for the treatment of this disease.
A preliminary report (1), appeared in the Journal of the Canadian
Medical Association in October, 1930, and a more extensive report later
(2). May I here observe that though the change of treatment is radical,
it is rational; it is based upon experiment and has passed the experimental
stage; and were it not for our uniform experiences with hundreds of
diabetics, I would hesitate to advise its use in general practice.
With this form of treatment, the carbohydrate content of the diabetic's diet approaches that of the normal individual and, judging from
the clinical response, the lives of the diabetics are made happier. The
patients look better, feel better and can carry on their ordinary duties
which, in the final analysis, is the best test of the value of any form of
treatment. Diabetics, with this treatment, eat bread, cereals and the
vegetables of high carbohydrate content, such as potatoes, etc., in practically normal quantities, and either require no insulin, or use the same
amount as, or less than, with the older diets.
This diet still retains the principle of under-nutrition, but, as I
have stated on a former occasion, the term uhder-nutrition is not used in
Read at the Annual Meeting of the Canadian Medical Association at Vancouver, B.  C,
June   25th,   1931. the same sense as prior to the days of insulin. At that time under-nutrition
meant keeping the individual in a state incompatible with his ordinary-
duties. By under-nutrition I now mean keeping the individual's body
weight slightly below that which is normal for his height and age, but,
at the same time the total amount of food prescribed must meet the
requirements of the individual's ordinary activities. I cannot too greatly
stress the importance of the application of the principle of under-nutrition
in the use of these new diets; the patients must not be over-fed.
As stated before, a welcome and frequent result of this treatment,
from the patient's point of view, is that the amounts of insulin as ordinarily required with the older diets, not only do not have to be
increased, but they may actually be decreased. In our first studies, the
impression gained was that the average dosage of insulin required showed
a decrease, but the average values in our second, and larger, group of
cases, indicated no such change. However, the data were then not
strictly comparable. At that time, insulin dosages of patients, as on discharge from the hospital on the new diets, were compared with the
amounts required with the older diets immediately prior to change of
treatment. Many of these patients had been subjected to the older diets
for long periods of time—not only months but years—and, while on them,
were performing their ordinary duties. With such activity, as is well
known, insulin dosage tends to be reduced. It may here, therefore, be
observed that more recent data clearly indicate that insulin dosage may
be reduced with the new diets also after some time. In other w'ords,
insulin dosage may be decreased while the carbohydrate content of the
diet is greatly increased.
Let us now turn to practical considerations. I shall outline briefly
the routine procedure in our hospital, but confine my remarks to that
which is applicable to general practice. As I have often stated, the
mortality rate from diabetes cannot possibly be lowered unless the
physician in general practice can trust his patients successfully. Undoubtedly, results which may be regarded as theoretically ideal are obtained in hospital practice only; but, what may be regarded as "ideal",
from a theoretical point of view, is not necessarily the most practical
and, therefore, the most successful. Results obtained in hospital practice,
strikingly successful as they may be, cannot, because of the relatively
small number of patients treated, materially affect mortality data. It is
the average result obtained in general practice which largely influences
such data and it need hardly be observed that the majority of diabetics
cannot for practical reasons apply for hospital treatment, nor, as I hope
to demonstrate, need they do so.
When patients are first admitted, either into the Out-door clinic
or the wards, they are immediately supplied with a set of wood and
paper moulds which indicate the units of measurement of the various
food materials they are to receive. These include, as you will note, *
blocks of wood indicating the respective dimensions of the following :-
A practical demonstration was given here.
Page 250 One slice of bread weighing one ounce or 30 grams. The block
of wood is three and one-half inches square and one-half inch
thick.
One-half slice of bread weighing one-half ounce or 15 grams.
One portion of butter weighing one-third of an ounce or  10
grams. The block of wood is one inch square and one-half
inch thick.
One portion of meat or fish weighing one and one-half ounces
or 45 grams.
The paper moulds represent the respective dimensions of the following:-
A teaspoon the contents of eight of which are equal to*one
fluid ounce.
A dessertspoon the contents of four of which are equal to one
fluid ounce.
An apple, orange and grapefruit. The paper moulds show the
cross section areas of the cut surfaces of these fuits when
they have been divided into halves.
A banana and potato the carbohydrate content of each of which
is approximately equal to that of one ounce or one slice of
bread.
A soda biscuit of standard size the carbohydrate content of five
of which is approximately equal to that of one ounce or one
slice of bread.
A cup the capacity of which is eight fluid ounces.
The diet is firstly explained to the patient in terms of bread. As a
rule, the amounts allowed are more than the individual cares for. Under
these conditions, recourse may be had to a variety of substitutes, which
include cereals and the fruits and vegetables of high carbohydrate content,   (banana, potato, etc.).
Other than the bread and its substitutes the diet is essentially the
same in all cases. This simplifies matters for both patient and physician.
As stated before, the fat content of the diet must not only be low,
but, as we have found, must not be above a definite amount. This amount
is about 50 grams. In order to avoid the use of scales and calculations,
the patient must be given such clear instructions as will protect him
against exceeding this amount of fat, providing treatment is followed.
If the following six rules are adhered to, it is not possible to exceed the
amount allowed.
1. Cream is forbidden; milk is used as a substitute.
2. The amount of butter allowed at each meal must not be
greater than one portion, as represented by the wood
mould.
3. Fatty meats and fish of all kinds   (bacon,  salmon, etc.)
are forbidden.
4. One egg only is allowed in a day's diet because of its high
fat content.
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The total amount of lean meat or fish is limited to two
portions a day, each portion being equal to the size of the
wood mould.
The total daily allowance of milk is a little more than one-
half pint (about 12 ounces).
Because of the relatively large amounts of carbohydrates now allowed
with this diet, it is, as stated on a former occasion, unnecessary to separate
the so-called 5, 10 and 15 per cent vegetables and fruits; they may all be
included in one group; but patients must be warned to avoid the constant use of any one fruit or vegetable; these articles of diet should
be varied not only daily, but at the different meals. The Laws of
Probability then operate: if a so-called 10 or 15 per cent vegetable or
fruit is taken at one meal, a 5 per cent or less will be taken at the next.
After, and only after, the patient thoroughly understands these
general rules, the diet is outlined in detail and is as follows:
BREAKFAST:    One orange, or one apple, or one grapefruit.
One  egg,  prepared  in  any  form.   No  extra   butter  is
allowed for frying.
— slices of bread.
Tea or coffee, with one-half cup of milk.
LUNCH: Clear broth of any kind. (Remove fat).
One portion of lean meat or fish.
Two portions of vegetables from list allowed.
— slices of bread.
One portion of butter.
One portion of fruit from list allowed.
Tea or coffee with milk, as at breakfast.
DINNER: Same as.lunch, substituting the various meats, fish, fruits
vegetables and — slices of bread.
The number of slices of bread allowed is the only variable in the
diet and depends upon the caloric requirements of the individual.
Again, before proceeding to the teaching of substitutes for bread,
the warning is given that the use of any more bread or butter, or the
use of more meat, or meat which is not very lean, destroys the value
of the diet.
In order to demonstrate the use of substitutes for bread, let us
assume the individual is allowed twelve slices of bread a day. As a rule,
as stated, this amount is more than the individual cares for. The substitutes, as will be noted from the following list, consist of the cereals
and the various fruits and vegetables of highter carbohydrate content
(20 per cent or more).
Any one of the following may be substituted for one slice of bread:-
Two apples.
Two oranges.
Two grapefruit.
Three level dessertspoonsful cream of wheat.
Page 252 Three level   dessertspoonsful  of  any one of   the  following  flours:
Wheat, barley, buckwheat, corn, cornmeal, oat, rice.
Two level dessertspoonsful rice.
Four heaping dessertspoonsful oatmeal.
Two heaping dessertspoonsful dried beans.
Two heaping dessertspoonsful dried whole peas.
One cupful toasted cornflakes.
One banana.
One potato.
Five soda biscuits.
Four teaspoonsful jam or marmalade.
Three teaspoonsful sugar.
Any of the following may be substituted for one and one-half
slices of bread :-
One  shredded  wheat.
Macaroni—eight (8)  strips, each being 8 inches long.
When substitutions are used, the following must be emphasized:
The cereals must be measured uncooked in order to obtain uniform
quantities. After they have been measured they may be prepared as
usual, as the amount of salt, water and time of cooking do not alter
the values of their carbohydrate contents.
Teaspoons and dessertspoons must correspond in size to the paper
moulds and particular attention must be paid to the instructions with
regard to the use of level or heaping measurements. For example,
as the list shows, the oatmeal made from four heaping dessertspoonsful of
the dry represents the carbohydrate content of a slice of bread and, therefore, may be substituted for it. Three level dessertspoonsful of cream of
wheat are equal to a slice of bread. The carbohydrate content of four level
teaspoonsful of jam or marmalade is approximately equal to that of one
slice of bread.
One potato, or one banana, the size of each of which is shown by
the paper moulds, is equal to one slice of bread. Two apples, two oranges,
two grapefruits or five soda biscuits, the size of each of which is shown
by the paper moulds are equal to one slice of bread.
As an added precaution, not only do the diet sheets which the patients receive contain the above mentioned instructions, but each mould
bears a description of its value with respect to bread. These precautions
may appear at first sight to be unnecessary, but our experiences have
taught us otherwise and I emphasise them in order that you may avoid
the errors we encountered in our early treatment with this diet.
Not only may the diet be abused readily by the use of more fat
deliberately, but a number of innocent errors have been met with and
may here be dealt with. The fact must be emphasized repeatedly that
the amount of butter, shown by the mould, is not for each slice of bread,
but for the total meal and that the use of other fats, in addition to the
butter allowed, is equally harmful (bacon, drippings, olive oil, etc.) A
common error is the innocent ingestion of excess fat in the form of
Page broths.    It must be pointed out that when broth has been prepared it
must be thoroughly cooled before the fat is removed.
The substitution of jam and marmalade for bread is encouraged—
a heresy, from the point of view of the older treatment of diabetes.
Their use is encouraged particularly at breakfast, as it eliminates the use
of butter at this meal and allows a greater quantity at other meals, for
frying meats, etc.
Exceptionally intelligent patients only are taught to substitute
cream for butter. The fat content of one-third of a portion of butter is
equal to that of two dessertspoonsful of cream.
I have dealt with the above matters in detail, in order to emphasize
the harmful effects of fat. According to the prevalent conception of
diabetes, normal utilization of carbohydrates is essential for normal
metabolism of fat. The idea, however, that alteration of fat metabolism
may harmfully affect the carbohydrates has received relatively little consideration. That fat, per se, may be harmful, is suggested from the repeated observation that, unless its content was kept very low, it was
not possible to materially increase the carbohydrate content of diets without the use of large amounts of insulin. For example, when diets contain
a normal, or nearly normal, amount of fat (70 to 100 grams), individuals
who require no insulin with 50 grams of carbohydrate could not do without it if the diet was increased to 150 grams. If an attempt was made
to raise the carbohydrate content above 150 grams, enormous amounts
of insulin were required. In addition to this, there is other experimental
evidence. Because of this observation, the fat contents of our more recent
diets have been lowered still further; they range between 30 to 40 grams
a day only. However, as I have just shown, compared with low carbohydrate diets, low fat diets can be made quite attractive. I should, also,
like to emphasize the important fact that these diets should be given to
reliable patients only. If the temptation to increase the fat content of
the diet is followed, the patient is no more receiving treatment, as the diet
is rich in everything; such individuals may then require enormous amounts
of insulin. It is best, under these conditions, to let them follow the older,
but less attractive, diets.
If it is practicable, individuals are encouraged to eat at frequent
intervals rather than to consume all of the food allowed in the usual three
meals. Incidentally, this practice avoids hunger. For example, in the above
diet, instead of taking four slices of bread at breakfast, one may take three
slices and substitute two apples or two oranges for the remainder. One
of these may be taken in late morning and another between the noon and
the evening meals. If it has been the individual's custom to take some
nourishment before retiring, this practice can still be continued. For
example, if the diet allows four slices at the evening meal, three may be
taken and, before retiring, five soda biscuits may be substituted for the
remaining slice and taken with a cup of broth.
The disadvantage of this diet is that, because of the use of fruits
and vegetables of higher carbohydrate content and bread, etc., the cellu-
Page 254 lose intake is decreased. Because of this, constipation so commonly seen
in the past, becomes again an important consideration. As is well known,
with the older diets, this difficulty was fairly successfully overcome by
the use of bran muffins and the fruits and leafy vegetables of high cellulose content. However, our dietitian, Miss Ruth Park, has been successful
in preparing a fairly attractive bran wafer, the food value of which may
be disregarded from the practical point of view*. Two or three, or more,
of these may be taken a day. The following is the recipe for this wafer :-
BRAN CRACKERS
Bran (dry washed)  3 cupsful
India   Gum 3   tablespoonsful
Salt    1   teaspoonful
Saccharin  2 - % of a grain
Nutmeg or Cinnamon a pinch
Hot water to make a moist batter.
Spread one-third of an inch thick in shallow pans greased with mineral oil.
Bake 3 or 4 hours in a slow oven until crisp.
It is advisable not to give the entire amount of food allowed when the
patient is first seen, but to increase the amounts gradually as with the
older ladder diets. This may be done as follows:-
On the first day, the patient is given nothing but water, clear broth,
tea and coffee. The following day, the diet is given as outlined, without
the bread. The bread is then increased at the rate of one slice per day
until the limit has been reached, the total amount as stated before, depending upon the requirements of the individual. The determination of
the latter differs in no way from that made use of with former treatment. Judging from a fairly large experience with these diets with
patients attending the Out-door Clinic only, this procedure should be
applicable to general practice. Incidentally, by following this ladder form
of diet, it is possible, as with the older diets, to determine readily whether
the patients do, or do not, require insulin. Relatively few do, provided the
instructions are adhered to.
Finally, a brief observation may be made with regard to the theoretical aspects of this diet. The original basis for its use will be found in the
earlier reports (1.2.) and for purposes of brevity I shall not deal with
them here. The fact which I should like to emphasize here is that the
experiences with this diet are compatible with the prevalent conception
of the pathogenesis of diabetes. They, as stated, emphasize fats rather
than carbohydrates as the exciting agent in the train of signs and symptoms of this disease. Other experimental data which, because of the time
factor, cannot be discussed here, strengthen this view.
A word about insulin. As stated before, these patients, in time, are
able to take these diets with less insulin than required with the older
form of treatment. This was at first attributed to under-nutrition. Under-
* Grateful acknowledgment is due Miss Ruth Park and her Assistant,  Miss  Olive Snyder
for  their  cooperation. nutrition, undoubtedly, is an influencing factor. Our experiences, however,
clearly demonstrated that it, alone, does not account for the results. For
example, under-nutrition does not explain why an individual can tolerate
a diet of 250 grams carbohydrate, 50 grams fat and 75 grams protein
better than a diet of 50 grams carbohydrate, 150 grams fat and 50 grams
protein; these diets are identical with respect to their caloric values.
A newer theory as to the pathogenesis of diabetes has, therefore, been
formulated and is now being tested by experiment. From the point of
view of practice, however, we may, at present, be little concerned with
explanations of results. The important and incontestable fact of practical
importance is that these diets yield better results than those used formerly,
both from the clinical and laboratory point of view. We may here
observe that, the physical sciences have been witness to the fact, repeatedly, that a theory may form the basis of sound practice, though
subsequently, the theory itself may prove to be untenable. This applies
equally to the biological sciences to which medicine belongs and diabetes
is a striking example. Thus, the treatment of this disease by under-nutrition is based upon the principle of resting the tired islet cells of the
pancreas; the evidence, however, that under-nutrition rests the islet cells is
far from perfect. As a matter of fact, there is much to doubt whether
the disease is at all due to the islet cells, except in cases in which the destructive process is so diffuse as to correspond to complete removal of the
pancreas. This does not, however, alter the fact that the lives of the great
majority of diabetics were prolonged for a decade prior to the discovery
of insulin with treatment on the principle of under-nutrition and undernutrition is still the basis of sound practice. The great majority of patients do not require insulin, diet alone suffices.
In closing, may I again warn about the harmful effects of fat.
This warning cannot be repeated to patients too often, since, as stated
before, with the use of additional fat, the diet becomes treacherous as
the patient is no more receiving treatment; the diet is rich in everything—
carbohydrates, fat and protein. Under these conditions, the amounts of
insulin required may be enormous and such results tend to discredit the
diet. May I, also, again state that I should not have brought this diet
before a group of physicians in general practice and recommend its use
unless I had incontestable proof of its efficiency, provided it is properly
made use of.
REFERENCES:
1. Rabinowitch, I.M., J. Can. Med Assoc, vol. 23, p 489, 1930.
2. Rabinowitch, I.M., New Eng. J. Med., vol. 204, p 799  (April
16th), 1931.
BOOK REVIEW
It happens occasionally in the medical world that a book is published revealing the lingering wisdom of the period as distinct from the
knowledge which comes all too copiously. Of such, is the small volume by
Dr. Alvarez before us as we write, entitled "Nervous Indigestion." Of
Page 256 such, to an older generation though covering a wider field, was Lauder
Brunton's "Action of Medicines," and still earlier, Hilton's "Rest and
Pain." Many of the more general writings of Osier are of this order
and indeed this excellence pervades the monumental "Medicine" saving
and redeeming it from the aridity of the ordinary text book. This wisdom is the essence of a knowledge, not only of medicine but of human
nature; the art which uses but does not deify science; the Philosophy
dealing with underlying principles on which the practice of medicine
is or should be based.
Through the kindness of a colleague, who either recognizing our
deficiencies or realizing our interest in literary affairs, this book of
Alvarez fell into our hands a few days ago. We hasten to pass on the
good news. The book we think however, should be purchased, not
borrowed. It literally should be on every physician's desk and remain
within easy reach until at the end of a long and honourable life it falls
to pieces from overuse.
If any doctor wants a real treat let him read chapter 4 on "the
handling of the nervous patient." When he is not astonished and flattered
by finding his cherished though inchoate opinions clearly and charmingly
expounded, he will be amused at the review of the manners and methods
of his rival on the next floor or at worst or perhaps at best as more
stimulating, will decide that in this or that, his experience has differed
from that of Dr. Alvarez.
But and certainly if he has passed his medical youth, he will recognize
with delight the truth—the abundant realness of every sentence and
acknowledge the geniality, the shrewdness, the humour, the humanity,
with which each subject is examined.
The peculiarities, the whims, the aversions of that class of patients
which all of us for our sins meet only too often are here clearly set
forth.
Many of us have drifted into the acting belief that indigestion,
save in terms of ulcer, or cancer, or obstruction, or adhesions, or suchlike
demonstrable or suspected lesion, has ceased to exist except in the mind
of the sort of patient who refers to a "touch of liver." To such Dr.
Alvarez particularly addresses himself. Warning us not once or twice
and by no means neglecting any and every means of investigation which
may or might lead to the finding of such "organic" lesion, he realizes
and acknowledges that only too often the search is in vain.
"Every time that someone with cancer is told definitely that he is
only neurotic; every time that someone who needs only a little rest is
told definitely that he has cancer—serious injury is done not only to a
patient and to his physician but, unfortunately, also to the cause of
scientific medicine as a whole."
There is a disorder of function apart from a disturbance of structure
or, at any rate, of such structural changes as are at present recognizable.
Page Doubtless in the era of perfection all function will be found to depend for its proper operation upon intact constituents but now, seeing
as we do through a glass darkly, we may justly differentiate.
And as Dr. Stokes appeals to the methods of the mind-adjustor for
the relief of certain forms of eczema, so Dr. Alvarez appeals, not indeed
to the professed pyschiatrist, but to the general practitioner, to us all,
to recall (if we have forgotten) that not all forms of indigestion need
.short circuiting, or excision, or even a Sippy diet.
NOTES ON THE LIFE OF
DR. WILLIAM FRASER TOLMIE, 1812-1886.
The following is one of a number of extracts which, with Dr. A. S.
Monro's kind permission, we hope to publish from his Medical History
of British Columbia.
This history represents a large amount of labour and research, and
is very valuable in interest and importance.    (Editor's note.)
Dr. Tolmie was born in Inverness, Scotland, on the 3rd day of
February, 1812. He acquired his education in Glasgow, being graduated
from the University in 1832, in which year he crossed the Atlantic as
a surgeon in the service of the Hudson's Bay Company. He came to
Fort Vancouver on the "Columbia," a sailing vessel, by way of Cape
Horn, stopping at Honolulu and the Sandwich Islands, arriving at the
Fort in 1833. In his younger days, he was greatly interested in botany
and natural history, and he discovered many new plants and birds on
this coast, some of which were named in his honour. In 1833, while on
a botanizing trip, accompanied by two or three Indians, he made the
first attempt to scale Mt. Rainier, Washington, but owing to his holiday
coming to an end, he was unable to get to the summit. A peak of this
mountain is now called Tolmie Peak in his honour. In 1834 he was a
member of an expedition along the northwest coast as far as the Russian
boundary, now Alaska, establishing trading posts at various points for
the Hudson's Bay Company, and at this time also choosing the site of
Fort Simpson. About 183 5 he was the first white man to draw attention to the fact that coal was to be found on this coast.
In 1836 Dr. Tolmie returned to Fort Vancouver in the capacity of
.surgeon. In 1841 he visited his native land, returned to Canada the
following year, making the overland journey by way of Fort Garry
and other Hudson's Bay Company posts. Upon arriving at Fort Vancouver he was placed in charge of the Hudson's Bay Company posts on
Puget Sound, with headquarters at Fort Nisqually, which is now about
sixteen miles from Tacoma, Wash. He took a very prominent part in
the war of 1855 and 1856, and as he was quite familiar with a number
•of Indian languages, it was through his efforts and knowledge that peace
followed and the red men were pacified. In 1855 he was made chief
factor of the Hudson's Bay Company at Fort Nisqually, and after the
company gave up their possessory rights to American soil, he removed to
Victoria in 1859 and continued in its service, building at this time the
Page 258 first stone house erected in British Columbia, which is now occupied by
his descendants.
Dr. Tolmie remained in the service of the Hudson's Bay Company
and also as agent of the Puget Sound Company until 1870, when he
retired to his farm of eleven hundred acres, which he had purchased several years previously. He was very active in agricultural affairs and
did much to raise the standard and grade of cattle and horses, importing
thoroughbred stock. Dr. Tolmie also gained recognition as an ethnologist and historian, contributing valuable treatises and articles on the
history and languages of the West coast natives. He gave the vocabularies of a number of tribes to Dr. Scouler and George Gibbs, and these
have been published in contributions to American Ethnology. In 1884
he collaborated with Dr. G. M. Dawson in the publication of a nearly
complete series of short vocabularies of the principal languages spoken
in British Columbia. Today, the works of Dr. Tolmie stand as authority
in the history of the northwest and this province. All through his life
he was ever ready to contribute from his extensive store of knowledge
to anyone to whom it would be useful, and being at all times public-
spirited and progressive, his opinions were highly valued. He remained
intimate with Indian affairs until the time of his death, which occurred
on the 8th of December, 1886, when he had reached the age of 74 years.
In 1850 Dr. Tolmie was united in marriage to Miss Jane Work,
the eldest daughter of John Work, then chief factor of the Hudson's
Bay Company at Victoria. Mrs. Tolmie, who passed away on the 23 rd
of June, 1880, became the mother of seven sons and five daughters.
Simon Fraser Tolmie, the present Prime Minister of British Columbia
and an outstanding man of affairs in his native Province, is a son of
this distinguished pioneer physician.
Dr. Tolmie was a member of the local legislature for two terms, representing the Victoria district until 1878. The cause of public instruction always found in him a staunch supporter and ardent champion and
for many years he served as a member of the board of education. He
held many positions of trust and responsibility and was everywhere recognized as a valued and respected citizen. Generous and kind-hearted,
he is still remembered for his many acts of quiet charity and for his
loyalty and friendship.
AUSTRALIAN
ORANGES!
"GEMS O'
GOLD"
IS THE BRAND
This superior, well ripened fruit is
now here. Richer in flavor and richer
in juice—British-grown oranges of
finest quality! Phone us and we will
tell you your nearest dealer!
OPPENHEIMER BROS. WOODS LTD., Distributors—134 Abbott St.
Page  259 «"■
B. C. Clean Towel Supply Co., Ltd.
900 Richards Street
Vancouver, B. C.
"FOR BETTER SERVICE"
TOWEL AND CABINET SERVICE.
Doctors and Dentists Gowns supplied on monthly
contracts at reasonable prices.
PHONE DOUGLAS 156
Bay. 4234 L
MRS. KATE PEGRAM
C.A.M.R.G.
Medical and Surgical Message
Electricity Remedial Exercises
1645  11th AVENUE WEST
Vancouver,  B.   C.
Office Sey. 2855
Res. Doug. 4682Y
MISS BEATRICE GALLOP
C.   A.   M.   R.   G.
Graduate
McGill   University   School   of   Massage
and Remedial Exercises
419 VANCOUVER BLOCK
Vancouver,  B.   C
Remedial
Institute
Our work conducted under
supervision of trained instructors, endorsed by
members of medical profession.
Doctors close contact with
patient maintained by progress  charts for medical
reference
TRINITY 1550
Vancouver Atheneum
of Physical Culture
804 Pender St. W.
Office Doug. 908 Res.  Doug. 908
MISS A. E. MARKHAM
Chartered Masseuse,  England
Canadian   Association   of   Massage   and
Remedial   Gymnastics
924  BIRKS  BUILDING
Vancouver,  B.   C
Telephone Sey. 3334
MRS.  E.  M.  PARR
Chartered Society of Massage and Medical Gymnastics,  England
Canadian   Association   of   Massage   and
Remedial Gymnastics
430-431   BIRKS   BUILDING
Vancouver,  B.  C IffiiD.ONES'r.eH^^
' '* '
These are the matched clubs with which Bobby Jones retained the amateur golf championship,
IN GOLF, THE CLUB IS ADAPTED TO THE SHOT. IN INFANT
FEEDING, THE DIET MATERIAL IS ADAPTED TO THE
INDIVIDUAL REQUIREMENT OF THE INDIVIDUAL BABY.
IT IS possible to play over the entire
course with a single club and bring in
a fair score. But playing with only one
club is a handicap. The best scores are made
when the player carefully studies each shot,
determining in advance how he is going to
make it, then selects from his bag the particular club best adapted to execute that shot.
For many years, Mead Johnson & Company
have offered "matched clubs", so to speak,
best adapted to meet the individual requirements of the individual baby.
We believe this a more intelligent and helpful service than to attempt to make one "baby
food" to which the baby must be adapted.
Dextri-Maltose No. 1
(with 2% sodium chloride), for normal babies.
Dextri-Maltose No. 2
(plain, salt free), for salt
modifications by the physician. Dextri-Maltose
No. 3 (with 3% potassium
bicarbonate), for constipated babies. "Dextri-
Maltose With Vitamin B"
is now available for its
appetite-and - growth -
stimulating properties.
Mead's Powdered Non-
Curdling Lactic Acid
Milks, Nos. 1 and 2.
Mead's Alacta. Mead's
Powdered Whole Milk.
Mead's Powdered Protein
Milk (Non-Curdling).
Mead's Recolac. Mead's
Sobee. Mead's Powdered
Brewer's Yeast. Mead's
Cereal. Mead's Viosterol
in Oil 250 D. Mead's
10 D Cod Liver Oil Wii|
Viosterol. Mead's Standardized  Cod   Liver  Oil.
Mead Johnson & Co. of Canada, Ltd., Belleville, Ont.
S SPECIALISTS IN INFANT DIET MATERIALS AND PIONEERS IN VITAMIN  RESEARCH i 100% Whole Wheat Cereal
"Easy to Cook and Easy to Digest"
This Package Contains 3x/2 lbs.
Order From Your Merchant Today. Surgical Supplies Sterilizers
Surgical Dressings
Fisher & Burpe Ltd*
X-Ray and
Physiotherapy Apparatus
Phone Trinity 6253
536 SMYTHE STREET VANCOUVER, B. C.
=.-iaJtaaiC7^, I
em
ti rn inuMTtirf
__ "WHEAT.__
55    BRAN   5H5
-"*■   JIAX    ~~
Hm h*W Cifl^fc*
You can recommend Dina-Mite for your Patients.
Made from the full ripened grains all thoroughly cleaned
and washed, finely ground, rich in the vitamins and mineral salts.  Easily assimilated anti-acid.  The flax content a
tonic to the intestinal tract.
Your name and address forwarded to
The Dina-Mite Food Co. Limited
49  Broadway East Vancouver, B.  C
will bring you a free package. Nu-Kor Belt
Complete line of
surgical belts, fitted by expert
Corsetieres
For further
information  call
Sey.   725J
Office
445  Granville  St,
Vancouver,  B.  C
USE HOME PRODUCTS
The B. C. Pharmacal Co. Ltd. concentrates on hand filled
capsules. We believe the dosage is more accurate than in
those of the machine filled variety.
In this we. follow the lead of the original manufacturers
of these products, for our Mr. Carrick learnt this business in Glasgow in the very early days of the industry.
?1 'H -     Gfl0 IB^^flHl
At All Pharmacies
Located since 1913 in Vancouver at 329 Railway St. (Hatter & Pjarara, ^Etft,
Established 1893
VANCOUVER, B. C.
North Vancouver, B. C.
Powell River, B. C.
"CIBA"
Back in 1864, there appeared the rather inauspicious beginning
of what is today a great industry. It was in that year that
A. Clavel founded the laboratories which now are known as
"CIBA." From a vision to a successful realization is the
record of "CIBA'S" progress during these decades. An organization of international scope irrevocably dedicated to
precision in the scientific preparation of pharmaceutical products.
Of infinitely greater value than mere material success, is the
splendid reputation which "CIBA" has established by rendering a sincere service in the field of therapeutics. The seal
"CIBA" is a symbol of purity, effectiveness, reliability and
ethical merchandising.
CIBA COMPANY LIMITED
MONTREAL
Messrs.  Macdonalds  Prescriptions,  Ltd.      -      Vancouver,  B.  C,
Messrs. McGill & Orme, Ltd.      -      Victoria,  B.  C.
keep a full range of "CIBA" specialties. r-" ~H«©K
-iff"
■iSSsf-t-
NEW WING
Hollywood Sanitarium
j|       '; ..j     LIMITED        ,:   -\    ?ff|f
^or the treatment oj
Alcoholic, Nervous and Psychopathic Cases
Exclusively
Reference ~ "23. Q. cP&edical ^Association
For information apply to
Medical Superintendent, New Westminster, B. C.
or 515 Birks Building, Vancouver
Seymour 4183
Westminster 288
?«<3V

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