History of Nursing in Pacific Canada

The Vancouver Medical Association Bulletin: December, 1936 Vancouver Medical Association 1936

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 \
The BULLETIN
OF THE
VANCOUVER MEDICAlf
ASSOCIATION
Vol. XIII.
DECEMBER,  1936
No. 3
In This Issue:
CANCER OF THE CERVIX
THE RELIEF OF PAIN IN LABOUR
iRISOR SARDONICUS
I BULKETTS
(With Cascara and Bile Salts)
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BULKETTS POSSESS ENORMOUS BULK
PRODUCING PROPERTIES AND BEING
PROCESSED WITH CASCARA AND
BILE SALTS PRODUCE BULK WITH
MOTILITY.
WE WILL BE PLEASED TO PROVIDE
ORIGINAL CONTAINERS FOR TRIAL
ON REQUEST.
Western Wholesale Drug
(1928) Limited
456 BROADWAY WEST
VANCOUVER   -   BRITISH COLUMBIA
(Or at all Vancouver Drug Co. Stores) THE     VANCOUVER     MEDICAL     ASSOCIATION
BULLETIN
Published ^Monthly under the nAuspices of the Vancouver ^Medical ^Association in the
interests of the ^Medical Profession.
Offices:
203 Medical Dental Building, Georgia Street, Vancouver, B. C.
Editorial Board:
Dr. J. H. MacDermot
Dr. M. McC. Baird Dr. D. E. H. Cleveland
All communications to be addressed to the Editor at the above address
Vol. XIII.
DECEMBER,  193 6
No.
OFFICERS  1936-1937
Dr. W. T. Ewing Dr. G. H. Clement Dr. C. H. Vrooman
President Vice-President Past President
Dr. Lavell H. Leeson Dr. W. T. Lockhart
Hon. Secretary Hon. Treasurer
Additional Members of Executive—Dr. A. M. Agnew, Dr. J. R. Neilson
TRUSTEES:
Dr. F. Brodie Dr. J. A. Gillespie Dr. F. P. Patterson
Auditors: Messrs. Shaw, Salter & Plommer.
SECTIONS
Ctinical Section
Dr. Roy Huggard Chairman     Dr. Russell Palmer Secretary
Eye, Ear, Nose and Throat
Dr. L. H. Leeson Chairmjan      Dr. S. G. Elliot Secretary
Pediatric Section
Dr. G. A. Lamont Chairman     Dr. J. R. Davies Secretary
Cancer Section
Dr. B. J. Harrison Chairman     Dr. Roy Huggard Secretary
STANDING COMMITTEES
Library
Dr. A. W. Bagnall
Dr. H. A. Rawlings
Dr. W. D. Keith
Dr. S. Paulin
Dr. W. F. Emmons
Dr. Roy Huggard
Publications
Dr. J. H. MacDermot
Dr. Murray Baird
Dr. D. E. H. Cleveland
V. O. N. Advisory Board
Dr. I. T. Day
Dr. W. A. Dobson
Dr. G. A. Lamont
Dinner
Dr. A. Lowrie
Dr. A. E. Trites
Dr. J. G. McKay
Summer School
Dr. J. W. Arbuckle
Dr. J. E. Walker
Dr. H. A. DesBrisay
Dr. H. R. Mustard
Dr. A. C. Frost
Dr. J. R. Naden
Credentials
Dr. A. B. Schinbein
Dr. H. A. DesBrisay
Dr. J. R. Naden
Rep. to B. C. Medical Assn.
Dr. Wallace Wilson
Sickness and Benevolent Fund—The President—The Trustees Prevention of Diphtheria
DIPHTHERIA TOXOID
The Connaught Laboratories have been preparing Diphtheria Toxoid continuously since 1924. During this
period private physicians and health departments have
been using the product for inirnunization against diphtheria with most gratifying results.
Diphtheria Toxoid is prepared according to the methods
devised by Ramon of the Pasteur Institute, Paris. It is
non-toxic and contains no serum.
In twelve years the Connaught Laboratories have supplied
sufficient Diphtheria Toxoid for the active immunization
of 3,000,000 persons. No untoward results have been
reported in Canada following its administration during
this extended period of use.
The efficacy of Diphtheria Toxoid in preventing diphtheria
is thoroughly established. In a number of Canadian cities
where a large proportion of the children have been immunized, the incidence of diphtheria has been reduced to
exceedingly low figures.
Diphtheria is still a serious menace. In 193 5 there were
1,995 cases of the disease reported in Canada, among
which were 263 deaths. Such a morbidity and mortality
can be controlled only by private and public endeavour
in achieving wide-spread immunization.
Diphtheria Toxoid (Anatoxine-Ramon) is available in 1-person,
6-person and 12-person packages. Information and prices
relating to this product will be supplied gladly upon request.
CONNAUGHT 1 LABORATORIES
UNIVERSITY OF TORONTO
TORONTO 5      •      CANADA
Depot for British Columbia
Macdonald's Prescriptions Limited
MEDICAL-DENTAL BUILDING, VANCOUVER, B. C. VANCOUVER HEALTH DEPARTMENT
STATISTICS—OCTOBER,
Total Population—estimated	
Japanese Population—estimated	
Chinese   Population—estimated	
Hindu  Population—estimated	
1936
247,5 58
8,055
7,895
320
Number
Total  deaths   ,     211
Japanese deaths        12
Chinese   deaths    i         6
Deaths—Residents only  i     183
BIRTH REGISTRATIONS—
Male, 156; Female, 157     313
INFANTILE MORTALITY— October,
1936
Deaths under one year of age  5
Death   rate—per   1,000   births        16.0
Stillbirths (not included in above)         7
Rate per 1,000
Population
10.1
17.6
9.8
8.7
14.9
October,
1935
7
22.1
7
CASES OF COMMUNICABLE DISEASES REPORTED IN CITY
September, 1936
Cases Deaths
Smallpox      0 0
Scarlet   Fever     23 0
Diphtheria        0 0
Chicken Pox      7 0
Measles   __.     2 0
Rubella       1 0
Mumps     14 0
Whooping Cough      2 0
Typhoid Fever      1 0
Undulant Fever      0 0
Poliomyelitis        2 0
Tuberculosis   3 5 12
Meningitis   (Epidemic)        0 0
Erysipelas        5 0
Encephalitis Lethargica      0 0
Paratyphoid Fever      0 0
October, 1936
Cases    Deaths
Nov. 1st to
15th,1936
Cases    Deaths
0
38
0
39
176
2
44
4
1
0
6
19
0
10
0
0
0
0
0
0
1
0
0
0
0
0
2
11
0
0
0
0
0
30
0
39
224
2
45
1
1
0
1
16
1
7
0
0
0
0
0
0
0
0
0
0
0
0
1
1
0
0
0
Bioglan Hormone Treatment
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Its use is being attended with better than ordinary results.
Descriptive literature on request.
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References: "Ask the Doctor who has used it."
Page 43 u
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Elixir Gabail
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The sedative dose is 2 teaspoons-
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daily: as a hypnotic, a table-
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For complimentary sample,
write to Anglo-French Drug
Co., 3 54 St. Catherine St. East,
Montreal.
SAMPLE ON REQUEST
ELIXIR GABAIL
(BROMO-VALERIAN ATE) VANCOUVER  MEDICAL  ASSOCIATION
Founded 1898
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Programme of the 39 th Annual Session
GENERAL MEETINGS will be held on the first Tuesday of the month
at 8 p.m.
CLINICAL MEETINGS will be held on the third Tuesday of the month
at 8 p.m.
Place of meeting will appear on the Agenda.
General Meetings will conform to the following order:
8:00 p.m.—Business as per Agenda.
9:00 p.m.—Papers of the evening.
1936. ...-.-.
October 6th—GENERAL MEETING.
Dr. W. H. Hatfield: "Programme of the Tuberculosis Division of
the Provincial Board of Health."
Dr. A. B. Schinbein and
Dr. W. Elliott Harrison: "Surgical Treatment of Pulmonary Tuberculosis."
October 20th—CLINICAL MEETING.
November 3rd—GENERAL MEETING.
Dr. E. J. Curtis and
Dr. H. Lavell Leeson: "Respiratory Infections of Childhood."
November 17th—CLINICAL MEETING.
December 1st—GENERAL MEETING.
Dr. C. W. Prowd and
Dr. A. Y. McNair: "Tumours of the Large Bowel."
1937
January 5 th—GENERAL MEETING.
Dr. R. Huggard: "Some Physiological Concepts of the Stomach and
Duodenum."
Dr. J. E. Walker: "Physiology of the Stomach."
Discussion opened by Dr. H. A. DesBrisay.
January 19th—CLINICAL MEETING. &"
February 2nd—GENERAL MEETING.
Dr. T. McPherson and
Dr. J. D. Balfour: "Obstruction of the Small Bowel."
Discussion opened by Dr. L. H. Appleby.
February 16th—CLINICAL MEETING. ft
March 2nd—OSLER LECTURE. §
March 16th—CLINICAL MEETING. §
April 6th—GENERAL MEETING. 1
Dr. Walter Turnbull and Staff: Symposium on
"Pelvic Conditions."
April 20th—CLINICAL MEETING. |
Page 46 EDITOR'S PAGE
The visit to Vancouver of Dr. Walter Schiller, of the Wertheim Clinic
of Vienna, was a very important one, and we believe should be recognised
as such, and steps taken to translate it into constructive action. We wish
that every member of the profession could have heard this address. In
another part of the Bulletin will be found notes of the address, as full and
accurate as we could obtain, but this secondhand presentation is not to be
compared with the original.
Why Dr. Schiller should be going on his way so unobtrusively and
almost secretively is one of the mysteries of life. Here is a very eminent
scientist who for fifteen years has been gradually building up a solid structure of facts and statistics, of new techniques and most important methods
of diagnosis of cancer. He claims, and it would seem with ample documentation and demonstrable proof, to have discovered a method of diagnosis of
carcinoma of the cervix at such an early stage that 70 out" of 100 of them
would go undiscovered and undiscoverable by any of our present methods,
and the other 3 0 only give a faint hint of their presence. Yet his method of
discovery is simple, cheap, painless, foolproof and accurate, and will shew
carcinoma at a time when suitable treatment gives 96 to 98% of five-year
cures.
But it is almost by accident that we hear of his) arrival—and there is no
hint anywhere in the public press of the message he brings. Yet if he were
lecturing on a new sort of bran mash the daily consumption of which is
guaranteed to make a man at 80 a veritable Apollo (besides adding considerably to the bank account of its discoverer), the Hotel Vancouver
Ballroom would have been inadequate to hold the crowds. Such is greatness!
Omitting altogether the cases that come for treatment of cancer, and
merely examining routinely every woman that came to the Wertheim
Clinic, for whatever cause, the doctors examining found 1 in 30 of these
women to have carcinoma of the cervix, detected by the method Schiller
describes. These women (51 out of 1500 from 1928 to 1931) were treated
and 49 of them are now alive and without signs of carcinoma after five full
years.
The best results previously in cancer of the cervix are 25 to 3 0 % five-
year cures. These women had no signs of cancer of the cervix: no discharge,
no erosion, no enlargement; at least 70% looked like normal cervices.
The point Schiller makes, and the fact that is of such vital concern, is
that this great improvement in results has only been secured, and can only
be secured, by making the diagnosis early, before "invasion" has taken place,
that is, before the growth has passed the basement membrane.
Another discovery of his, of immense importance, is that the initial
stages of cancer of the cervix are slow and prolonged) and almost inert; that
for periods of months to years the tiny initial growth remains almost motionless; that during this stage there is in 70% of cases no method of inspection
by the naked eye that will lead one even to suspect cancer; though to the
alert and expert observer the other 30% will give rise to a strong suspicion
of cancer.
"During this initial stage we have time—but never again. During this
stage we can study the growth, make a biopsy of it, identify it, and cure it
in 97 to 98% of cases.
This gives the greatest hope yet offered for a solution of the problem of
Page 47 cervical cancer, and may, of course, lead to great discoveries of a similar
nature in other types of cancer.
But—there is a but—only on one condition is this discovery of any real
value. We must remember that in these 51 cases there was nothing to suggest
cancer. They were found in the routine examination, not of suspects, not of
selected cases, not of women who thought they might have cancer, but of
every woman, young and old, who presented herself at the Clinic, for whatever cause.
What does this mean to us? It means this, that we must examine as a
routine, and by Schiller's or some similar method, every woman who comes
to our office or clinics; and when we do this, we shall find, as they have done
in Vienna, that we get carcinoma early, while it can be cured.
It means that hope of dealing with the cancer problem will rest with
the general practitioner of medicine, through whose hands 8 5 % or more of
patients first pass. It is important that we should have radium available,
adequate radiation facilities, cancer institutes for handling cases. These
things are all necessary, but they can only deal with known and established
cases of cancer. They cannot possibly detect cancer in its early stages to any
appreciable extent. They can only deal with the cases whose mortality rate
is 75%, and they cannot, as Schiller pointed out, do muchHo lessen this
mortality.
It means, then, that we must educate ourselves, our own men, to look for
cancer, not to wait for it to appear. We must learn this simple technique,
and we must apply it in every case we possibly can. We cannot hope for the
perfection of coverage that they have in Vienna, where people do exactly as
their doctor tells them; but we can do our part, and we must; and our part
is to examine everyone we possibly can.
Then it means that we can tell the public of what their part in this
must be. We must alter our method of approach to the public in this matter
of cancer.
For years we have been preaching to the public: "Go to your doctor
whenever you feel a suspicious lump, or have an irregular or unusual or
suspicious discharge of any kind from any orifice."
We can see now that this was not nearly enough.
First, because this is the very time people will not go to their doctor;
they are afraid the lump or discharge will turn out to be cancer, and more
humano, they dread the knowledge more than they do the danger of cancer.
Carefully compiled statistics shew that the average time that elapses between the time a woman notices a lump in her breast, and the time she seeks
advice, is several months, sometimes a<year or more.
Secondly, by the time a lump or a discharge appears, we have recognisable cancer, if it is cancer, and the mortality, by the best methods, surgery
or irradiation, is 75% or more; and as Dr. Schiller pointed out, only by
finding cancer before it is recognisable, to put things in rather an Irish
fashion, can we hope to arrive at a real solution of this problem.
So we must find a better way:'and that is by the periodic physical examination, thoroughly carried out, and carried out at regular intervals. People
will have no fear of this, and will gladly agree to thorough, careful examinations, biopsies of small, easily and painlessly obtained specimens, and treatment that may be necessary. This way we shall solve the problem of one type
of cancer at least, and one which constitutes 20% of all cancers. And
success in this, and the periodic examination, will lead to the discovery, early,
of other types of cancer.
Page 48 This means education of our own members, education of the public,
education of governments in the line of providing means of thorough
periodic examinations. And when we have these things, we shall meet our
ancient foe with some hope of victory.
We suggest to the B. C. Medical Association that it does something to
ensure that this visit o Dr. Schiller's will bear fruit. It would be a crime to
allow it to meet the fate of the seed that fell on stony ground, and the winds
blew it away, and the birds devoured it. We may not reach perfection in a
day, but we must make a start, and the time to begin is now.
We regret that Dr. Curtis' paper on "Factors Regulating Nutrition and
Growth in Infants" is delayed till next month. This was part of a symposium, the other part of which, contributed by Dr. Lavell Leeson, has
most unfortunately been mislaid. Dr. Leeson's contribution is quite essential to the balance of the presentation, and he has kindly agreed to give it
to us again: so that it will be published later.—Ed.
NEWS AND NOTES
A most interesting meeting of the Eye, Ear, Nose and Throat Section
was held in the Hotel Georgia on Wednesday, October 21st. An election of
officers for the coming season was held, Dr. Lavell H. Leeson being elected
Chairman of the Section and Dr. S. Graham Elliott Secretary.
Dr. A. B. Schinbein has returned from a trip to the Eastern States,
during which he attended the meeting of the Arnerican College of Surgeons
at Philadelphia.
Dr. Lyon H. Appleby and Dr. Wildred L. Graham were initiated into
the fellowship of the American College of Surgeons at the recent meeting
of the College at Philadelphia.
%_*_,*!_._!_
*r »t* »r *r
Dr. H. H. Milburn is in Eastern Canada, and will be away for some
months. He is a member of the Executive Committee of the Canadian
Medical Association and attended the meeting of the Committee at Ottawa
in October.
._•       .j-       *       >_•
Dr. A. L. Lynch has left or California and will be away for a month.
Dr. D. M. Meekison has returned from a trip to Southern California.
ANNUAL DINNER
The Annual Dinner of the Vancouver Medical Association will be held
on December 4th in the Hotel Vancouver. Tickets may be obtained from
members of the (_-ommitt.ee or from the Library.
RECENT ADDITIONS TO THE LIBRARY
C. F. Geschickter and M. A. Copeland—Tumjours of Bone, 2nd ed.   1936.
Oxford System of Medicine: Volume 7—"Psychiatry for Practitioners."
Edward .Kaufman—Pathology, 3 vols.  Trans, from the German.   1929.
Thos. Lewis—Vascular Disorders of the Limbs.  1936.
Page 49 BOOK REVIEW
FROM A SURGEON'S JOURNAL by Dr. Harvey Cushing.
A volume which has come to our Library through the generosity of
Dr. F. J. Nicholson, whose fund is so helpful in broadening the scope of our
members' reading, is Dr. Harvey Cushing's "From a Surgeon's Journal."
It is unusual for anyone to keep a diary nowadays, and particularly
unusual that a great surgeon who was right in the thick of things on the
Western front—with the American Ambulance in 1915, with the B.E.F.
in 1917, and then finally with the A.E.F. when they came into the picture
—should find time and inclination and energy enough to write down daily,
or almost daily, the happenings of those strenuous days.
Probably the most interesting records to us as Canadians are the intimate
touches and contacts Dr. Cushing makes with outstanding personalities in
the British and Canadain Army Medical Corps.
Nobody could peruse the pages of this diary without feeling that a
world war, with its death and mutilation of humans by the wholesale, surely
can never happen again.—W. D. Keith, M.D.
CANCER OF THE CERVIX
Address before the Vancouver Medical Association on Nov. 17, 1936, by
Dr. Walter Schiller
of the Westheim Clinic, Vienna, Austria.
The Vancouver Medical Association was particularly fortunate in having
Dr. Schiller as its guest speaker. Dr. Schiller was in Vancouver en route
through Canada and the U.S.A., in both of which countries he is in process
of delivering a course of lectures on the subject of "Cancer of the Cervix":
its early diagnosis, and the results to be attained thereby. His record of work
in this matter goes back 15 years or more, during which time he has been
patiently working out, with most meticulous care, a plan by which carcinoma may be detected years before it become evident to our ordinary clinical
methods of examination. His work deserves, nay needs, to be written clearly
and in large characters, and his technique mastered and used by every general practitioner. A careful perusal of even the imperfect notes attached
hereto will shew the tremendous significance of the work of Dr. Schiller, and
the greatness of his contribution to the cause of humanity in its battle against
that last enemy, cancer.
Dr. Schiller was introduced by Dr. W. F. Ewing, the President of the
Vancouver Medical Association. He has a very full and long record of distinguished service in medical fields. He is now specialising in gynaecological
pathology, and has arrived at this after years of work, during which he has
been by turns physiologist, biochemist, pathologist, internist, and gynaecologist.
Dr. Schiller said, inter alia:
One of the most important and urgent problems confronting us today
is carcinoma. This is for two reasons: (1) the morbidity of it, and its incidence, are increasing from year to year; (2) the mortality of carcinoma, in
spite of all efforts, of improved knowledge, of theories of causation, of better
clinical methods of estimation, and of practical medicine and clinical research, is not decreasing.
Cancer falls into two main groups, and one intermediate group.
The first group is the one in which, for the past 10 to 15 years, we have
Page 30 made no progress—carcinoma of internal organs: i.e., invisible cancer, e.g.,
cancer of stomach, bowel, etc.
The second is that including visible carcinomata, especially of the skin.
Here we have been much more fortunate, and >our results are much better.
The intermediate group is that in which the carcinoma is midway
between visible and invisible. (This is sometimes termed orificial cancer.)
This group comprises carcinoma of the tongue, gums, cervix, etc. Of this
cancer of the cervix is by far the most frequent and important. It is midway
between visible and invisible. In the words of Dr. Schiller, "It is visible—
if we observe it—if we observe it in time: if we examine.3'
The incidence of cancer of the cervix is very high; varies somewhat
according to locality. In Europe, it is surpassed only by breast cancer; in
Canada and the U.S.A., only by cancer of the stomach.
Cancer of the cervix amounts, roughly, to 20% of all cancers.
Ffteen years ago Schiller started to collect statistics, in order to get a
reliable idea as to the results we are getting, and may expect to get. These
figures vary somewhat in different countries, but not too widely. He collected figures from all countries, and found the following: Among 100
patients shewing all degrees of carcinomatous involvement when they first
come for examination, 50 are lost before they enter the clinic or hospital.
Only in 5 0 % is there any chance for recovery or a reasonable prolongation
of life; the rest can only be given relief.
Of the 5 0 that have some chance, irradiation or surgery will give a 5 -year
cure in not more than 2 5; on the average, the other 2 5 are hopeless, on the
criterion of the 5-year period.
So of four women with cancer, we lose three and save one. The mortality is 75%. This varies somewhat in different countries, as high a rate of
cure as 30-31% being sometmes obtained. These variations (and this is
important) are not dependent on the skill of the surgeon, the amount of
radium, or the equipment of the radiologist.
The only point is how early the patient consults the surgeon or radiologist—how early the presence of carcinoma is realised.
If we ask the question: "What can be done to improve these results?"
Not much is to be expected from surgery. Wertheim's or Schauta's operations do not admit of any great improvement or extension: in fact they do
not admit of any.| They have about reached the limit of perfectibility or
extent. Improvements have been suggested by which the Schauta operation
is made even more thorough than originally, but this makes it too complicated and difficult for any but the most expert surgeon.
There is the same limitation imposed on irradiation and, the results that
it gives; it cannot be carried much further than has already been done;
increase in the amount of radium available, etc., will give little or no improvement in our statistics.
If, then, neither surgery nor irradiation can go any further, what
remains? How can be hope for victory in our battle against cancer?
Only early diagnosis. We must find ways of diagnosing cancer, earlier
and earlier.
Schiller put these questions to himself 15 years ago: "How far is it possible to go in early diagnosis?" "What do we mean by early diagnosis, or
diagnosis of an early carcinoma?" "What is early carcinoma, its criteria,
its signs?"
Size. The size of the carcinoma is no, criterion of earliness or lateness.
He found that a carcinoma of 2 to 3 mm. in diameter might remain this
Page 51 size for months, even up to 3 years, with apparently little or no growth;
then it might rapidly grow to 10 mm. and proceed to grow steadily. So a
2 to 3 mm. patch might be a month old or three years old—might give us
months of margin, or a few days only.
It is the rate of growth in the early stages of size that is so important.
Carcinoma grows very slowly at first; the growth curve is very gradual.
(Dr. Schiller observed a series from the very first appearance of carcinomatous cytological changes.) Then the curve rises more and more rapidly.
This slow growth gives us a marvellous opportunity for early diagnosis,
and it is in this stage that we must make our diagnosis; it is on the diagnosis
in this stage that we must base our hopes for success in tackling the problem
of carcinoma.
Schiller found that as a pathologist he must recast his conception of what
constitutes carcinoma.
Virchow, that great master of pathology, has dominated this field for
a generation and still does, so that we still tend to think in terms of his
definition of carcinoma.
To him the diagnosis of carcinoma or malignancy turns on the presence
or absence of invasion: i.e., the breaking through the basement membrane
by the diseased cells.
So we have waited for invasion before admitting the diagnosis of malignancy.
Schiller asked himself, "Does carcinoma invade at its very first beginning, or can it only be recognised by invasion?"
This makes a tremendous difference in our relation to the problem.
Is there a possibility of recognising carcinoma before invasion?
In what way, and by what bridges, are normal epithelium and carcinomatous tissue connected with each other ?
Where we have recognizable lesions of the cervix, we find that in 9 5 %
of all the cases we have: (1) an invasion carcinoma with ulceration of the
surface layers; (2) normal epithelial tissue; and (3) between these two a
zone occupied neither by obvious, invading carcinomatous tissue, nor by
normal tissue. This is called the zone of demarcation.
In 5% there is no ulceration, but we find tissue that in every other
characteristic is indistinguishable from carcinoma. We have, cytologically,
carcinoma—irregular cells, cells with mitotic figures, etc. Cytologically
this tissue is carcinoma. In this group we have invasion, cytological change,
and no ulceration.
Hence we cannot base our diagnosis on ulceration alone.
Must we then base our diagnosis on invasion alone? or on cytological
similarity where there is no invasion?
Virchow says there must be invasion. Schiller says that cytology alone
is enough, and is more important, for early diagnosis, than invasion, since
invasion may occur later on, and the cytological change comes first, sometimes many months sooner.
This is the first time that a pathologist has opposed Virchow in this
regard.
We have a cervix shewing changes. These changes may include erosion,
invasion, and cytological change, or invasion and cytological change, or
cytological change alone—as shewn on microscopical examination of a
biopsy specimen.
The earliness of the cancer depends upon which of these conditions are
present.
Page 52 Schiller describes a cancer as early, which is too small to be discovered
by the naked eye, and.can only be identified upon section.
But how, then, are we to recognise it? With our present methods, only
by chance could we discover such an early carcinoma, or even suspect its
presence.
Schiller has made a systematic study of thousands of cervices, of all
sorts, of which many hundreds were apparently normal as regards the possibility of cancer. He has examined a series, of 3000 slides, cutting in eight
directions from the centre.
He has found three different types. (In this we are considering small
cancers, which may or may not be recognisable by naked-eye inspection, but
are not grossly evident.)
The first group shews, starting from the os, a small carcinomatous
growth, shewing ulceration and invasion; next to this the expansion zone,
shewing cytological changes; next, normal epithelium. No great progress is
made here—this is a small cancer, obvious to the eye, and only requiring
careful inspection.
Next group shews a small cancer with invasion, but no ulceration; next
the expansion zone as above, then normal epithelium. Examining this patient
with the naked eye we find no ulceration—but a smooth surface. However,
biopsy (suggested by methods to be described later) reveals invasion, and
cytological change. We must do better than this, since we have not been
early enough to avoid invasion, and the danger of metastases is very great.
There is a yet earlier type. Here a biopsy reveals no ulceration, no invasion, merely a cytological change in the small area of the cervix, with
normal tissue adjacent to it.
This is not visible to the naked eye, and is the earliest type of all, consisting only of carcinomatous transformation of the surface.
What about the terminology of this? We must, if we admit cytology as
the test of cancer, describe this as cancer, even if invasion and ulceration are
not present.
The name usually given to this is the precancerous stage—based on
Virchow's ruling that invasion is a sine qua non for diagnosis of cancer.
Schiller opposes very strongly the use of the term "precancerous"—it
is not accurate as all scientific terms should be.
Some pathologists use the term for lesions which may, others for lesions
which must, become carcinomatous. In the first use of the word, the field is
far too large; in the second, far too sm_.ll—We miss changes of diagnosis
and cure. It is far better to call the third group "carcinoma." It has also been
defined as carcinoma in utu, and, better as Schiller thinks, as preinvasive
carcinoma.
Now we have got to a point where we can perhaps make progress, by
studying these cases before invasion; we have made "one earlier step towards
early diagnosis."
But we must accept this as an axiom, that the very first, initial, stage
of carcinoma is perfectly identical with advanced carcinoma, as regards
cytological change.
Cancer does not develop on an erosion or previous lesion, but in surface
cells; and is characterised by the cytological changes ascribed to carcinoma.
Examining a specimen, we find a sharp cut between the normal epithelium and the cancerous tissue. Carcinoma spreads faster in the basal tissue,
so the line of demarcation is oblique, and the base is wider than the surface.
Dr. Schiller shewed a great many slides exhibiting these points. In these
Page 53 slides one saw: (1) Normal epithelium. This was squamous-celled on the
surface. Below this was a layer of large empty-looking cells. Below these,
prickle-cells, the usual connective-tissue cells, and a basement membrane.
(2) Where there was carcinoma with erosion and invasion, these were
seen quite plainly, groups of cells breaking through the basement membrane. The large cells above mentioned were not seen, and many irregular,
oversized, degenerate, mitotic cells were seen.
A zone between was seen, with cytological changes as above, with a
sharp oblique edge, and no large empty cells.
Some slides shewed a picture like the zone described, with no erosion and
no invasion. These are the third group described by Dr. Schiller. These
would appear grossly normal, with a smooth, unbroken surface, and would
not excite the least suspicion. Yet they are cancer.
How are we to make clinical use of these observations? How make
visible these invisible carcinomata?
As the result of the examination of a great many cervices of this type,
Dr. Schiller came to some conclusions.
In about 30% of these cases there are some differences recognisable by
the naked eye.
The field of the initial carcinoma differs from the surrounding field:
(1) it is slightly elevated; (2) this elevated area is not shiny, as is normal
cervix, but some what dull; (3) the normal pinkish colour of the underlying tissue, which shews clearly through the translucent normal epithelium,
is not there. The patch looks white.
So we have an elevated, duller, paler, "white spot," otherwise known as
"leukoplakia."
Leukoplakia is a description, not a diagnosis, as we say fever, jaundice,
etc., meaning symptoms, not disease entities. Leukoplakia is the optical
appearance of many pathological conditions of the epithelium, not only of
cancer. This is the first thing to remember about leukoplakia.
What about the other 70% ? How can we make these visible?
Schiller tried, first, staining with dyes. This did not succeed, though he
tried some 200 different dyes.
Finally, he came to a clue, and followed it: In the slides of normal tissue
as shewn, there were, as has been said, large cells which look empty; using a
special stain we discover they are filled with glycogen; not quite identical
with the glycogen of liver or muscle, which is soluble in water.
This glycogen is quite insoluble in water, and—the important point—
is disappears in carcinoma. So its absence is diagnostic of something wrong.
How can we make this glycogen visible?
(1) By use of alkaline carmine (Best). This is ideal for histological
examination of dead cells, but is unfit for living tissues, since it contains
ammonia which macerates the epithelium.
(2) By iodine. If normal tissue is exposed to iodine, the glycogen
absorbs the iodine. We cannot, however, use alcoholic solutions, as the alcohol precipitates the albumin of surface cells. We must use a water solution,
as follows: pure iodine, 1 gm.; pot. iodide, 2 gm.; water, 300 cc. This has
ten times the dilution of Lugol's solution. It is a highly diluted solution and
this is best for three reasons: (1) some patients have an idiosyncrasy to
iodine, and a 5% solution is dangerous; (2) using stronger solutions, we do
not get the fine differences—with the weak solution the stain is much
sharper and most distinct; (3) it is much cheaper and can be used in bulk.
Page 54 It takes from 40 to 60 seconds to stand. The normal glycogen-containing
cervical epithelium stains evenly and continuously to a deep brown.
Abnormal tissue does not take the stain.
If part of the epithelium remains unstained, this does not ipso facto
prove carcinoma to be present: it merely means that this part is suspicious.
Is may be carcinoma, or it may be something else.
So—a brown stain is specific for normality; a white stain is not specific,
but calls for biopsy and microscopical examination.
It may be: (1) Cancer. There is generally a sharply defined and demarcated white spot, with no transitional zones. The spot is so placed, usually,
that the central core corresponds with the external os. (2) Comification or
hyperkeratosis. Keratinised tissue never contains glycogen.
We find keratinisation (a) in syphilis (syphilitic leukoplakia), e.g., in
gumma. In thousands of slides examined over fifteen years Schiller found
only three syphilitic leukoplakias, (b) As a protective tissue, protecting
underlying tissue against dry air; e.g., physiologically in the skin, and
pathologically, in ectropion of the eyelids, in prolapse, where the vaginal
mucous membrane is exposed to the air, undergoes cornification and loses
glycogen.
There are transitional zones in these types. Further, the leucoplakia of
cancer remains unchanged for many months or years; that of prolapse
changes from day to day and week to week, "like white clouds passing over
the brown sky of the cervix."
(c) There is a small group, found in young women whose Wassermann
is negative, of hyperkeratoses, with no other pathology. It corresponds to
cancer in naked-eye appearance—it is sharply defined, but histologically it
is normal, except for absence of glycogen. These are accidental or congenital
conditions.
Now, we have recognised a pathological condition which may be cancer,
or syphilis, or protective leukoplakia (prolapse), or accidental.
Some men advise a Sturmdorff or use of radium. This is either too much
or, as regards a Sturmdorff, not enough. Too much if no cancer is present:
unnecessarily mutilating and destructive; not enough (the Sturmdorff) if
cancer is present: because the zone of demarcation does not stain with iodine
and extends an unknown distance, and we may not include it all in a
Sturmdorff.
Nor is there any case on record where hyperkeratosis or other non-
malignant leukoplakias have become cancer. If there were, we must not run
the risk. But Schiller kept very careful records up to six years, in one case
making 11 biopsies in five years, of a hyperkeratosis, with no signs of change.
These are local abnormalities, no more and no less—they do not need
surgery or radium, but should be kept under very careful observation, no
more, but no less.
Sometimes there is traumatic loss of glycogen-staining, e.g., from injury
from the speculum, but with experience we can recognise this.
If in 100 cases examined we find 25 with suspected white spots, 10 can
be ruled out by naked-eye examination, as due to prolapse, hyperkeratosis or
trauma. The other 15 must be examined, and we will probably find three
malignancies. If we only find one in one hundired the work is more than
worth while.
As to the percentage found, the more people we examine, the smaller
the percentage; but the more we examine, the better the work we are doing.
•Page 55 If a man does complete work, i.e., if he examines fully every patient, he will
not find more than 3%, generally 1 to 2%.
Cases should all be painted before any operation is done, as we may pick
up clues. The third phase (without erosion or invasion) lasts many months,
sometimes years. Schiller has had cases lasting more than five years. So we
have a long time available for the discovery of early carcinoma; and if we
examine a woman twice a year, even once a year, we shall find early carcinoma.
The method is not painful, is not expensive, not difficult; but to be of
value, must be carried out as a routine in every case, not merely in selected
cases.
Cancer incidence as regards age is coming to be sooner and sooner; is
shifting, as regards the cervix, to younger women. There is only one safe
rule—examine routinely all women once or twice a year.
Since 1928 Schiller has discovered in the women coming to the Wertheim clinic (not for cancer, but for other examinations) that one in thirty
of all cases shews cancer.
Up to 1931 (to allow for five-year period 1931-1936) he examined
1500 women, and got 51 cases, of cancer smaller than 10 mm. in size.
These were treated, and 49 are alive today, nearly 98% five-year cures.
One of these was of type III, but died of metastases. There was no
ulceration, no invasion. This case is not called carcinoma by older pathologists, but precancerous. This is a very important case, for it might have
been saved by radium.
By propaganda and organisation we may get hold of more and more
women for a yearly or six-monthly examination and so increase our 25%
five-year cures to 96% or better.
In the discussion afterwards, Dr. Schiller brought out several points.
(1) The technique of biopsy. With a small sharp spoon, one edge is
lifted and the whole piece peels out (especially if malignant); if hyperkeratosis, it separates and some difficulty.
Neither alcohol nor formalin must be used for fixation, for technical
reasons of difficulty in handling such a tiny speck of tissue. He uses: absolute alcohol 6, chloroform 3, glacial acetic acid 1, which has a very low
specific gravity, so that tissue sinks to the bottom and cannot be lost.
Dr. Schiller spoke of the colposcope. This is' theoretically and scientifically a very valuable instrument—as an adjunct to> the naked eye—but practically is of little value; it is too cumbersome, too slow, and too expensive.
It is better to paint 50 women unnecessarily than take any chance of
missing one.
Radium, in Dr. Schiller's opinion, is the treatment of choice in any
woman under 50. Sturmdorff's operation is useless, as we may miss extensions of the disease. Only hysterectomy is any good: this should be done
after 5 0—but radium at all other times. He quoted two cases which had
had children following treatment of the cervix for cancer by radium.
Radium has a selective action on cancer cells, and so will reach cells that
surgery of the cervix might miss. Of course, there are carcinomata resistant
to radiation, but the typical cervical cancer is usually radio-sensitive. These
remarks do not apply to cancer of the body of the uterus.
Page 56 THE RELIEF OF PAIN IN LABOUR
By Dr. J. McF. Bergland
This question of pain in labour is one of the most important that
obstetricians have to face.
The public has come to the point where they say to us, "You have
for years removed pain as an adjunct to surgery—and it is a matter of
course that a surgical operation should be painless. You say that,, by so
doing, you add to the safety as well as thei comfort of the patient. Why
should it not be just as important and necessary, ast well as beneficial, to
relieve labour of its pain?"
The truth is that the problems are very different. Surgical anaesthesia
is simple; there are not so many factors involved. In surgery we are
dealing with pathological processes. Anaesthesia renders their treatment
easier and safer; it does not hinder in any way any of the procedures
necessary.
But in labour we are dealing with a physiological process, and with
a rhythm of contractions. It is most important not to interfere with
these, or hinder them in any way. This constitutes at! once an obstacle in
the way of anaesthesia used superficially.
Then there is the unborn child! as a complication. We must not injure
or kill this; and unfortunately, many analgesicsi and anaesthetics not only
interfere with labour, but also seriously threaten or injure the child.
History.—Sir James Simpson was the first accoucheur to use anything to alleviate the pains of labour. Ninety years ago he first used
chloroform. He at once met with opposition, chiefly from the clergy, of
whom the bishops were particularly vocal. They objected strongly to his
interference with the doom which an outraged Creator was reported to
have pronounced on Eve—that in future labour should always be a
matter of grief and pain.
His memoirs show that he carried on a long and humorous correspondence with many of them.
Possibly, sucr is the innate snobbishness of mankind, anaesthesia would
have been longer of acceptance if it had not been that Queen Victoria,
who was due to have a baby, insisted, in defiance of all ecclesiastical
authority, in having Dr. Simpson to give her chloroform. So this process
became known as the Queen's anaesthesia, or as the French still call it,
ancesthesie a la reine.
Simpson's method of administering chloroform was practically identical with ours,, as regards labour. He reserved it for late in the second
stage: the head must be in sight, the cervix fully dilated, and the mjem-
branes ruptured. This accords exactly with our practice.
Chloroform has several excellent points in its favor. It gives the
completest relaxation of the perineum, and is followed by fewer perineal
tears for this reason. In the doses ordinarily used, it has no effect on the
child. It is quick, positive, convenient to carry and give, and is economical.
But it is a tricky anaesthetic. It needs the full attention of the anaesthetist; when disaster strikes with chloroform, it does so quickly and
heavily, and with very little if any warning. Further, it inhibits pains
quickly.
It presents also definite threats to the heart, and secondarily to the
liver: a most important by-effect.
Page 57 Many men, however, still use it.
Ether.—The effect of this is slower; it is more irritating and nauseating; patients often do not like it. It is, however, eminently safe, and does
not have as markedly inhibiting an effect on labour as does chloroform.
The first stage pains are especially disagreeable and discouraging,,
hence there has long been a demand for something to alleviate these, and
many techniques have been devised.
The first major step was "twilight sleep," which was developed in
Freiburg in Germany by Gauss and his colleagues in 1902.
It has never become popular in United States or Canada, and its supporters say it has never been given a fair trial. This may be true, but
German clinics have all discarded it, and every clinic in the U.S.A. that
has tried it has discarded it. (This is also true of Canada.—Ed.)
In 1914, Gauss came over to America, read papers, and was the
originator of a tremendous propaganda. The magazines, e.g., Red Book,
Cosmopolitan, were all full of it, and the popular demand for it practically forced a good many clinics to try it once more. But the method
is cumbersome, expensive, difficult to apply properly. It requires special
rooms, many extra nurses, special methods of excluding noise, etc.
Worse still, it is very dangerous to the child.
So it was given up again, and has never again won any place over here.
In 1914 such men as Webster, Polak, etc., began the use of nitrous
oxide and oxygen, with or without ether. It turned out to be very successful and useful. It has many advantages. It is pleasant to take, can be
administered to herself by the patient, can be used during most of the
first stage, and all of the second stage, and is safe. So it fulfils nearly all
the theoretical requirements for a satisfactory obstetrical anaesthetic.
By removing the fear of pain with its inhibiting effect on uterine contractions, it actually shortens labour.
Some fcetal deaths have been caused through excess of N20, but
this is rare.
We can use it as an analgesic], or as an anaesthetic, deepening the effect
very markedly by adding ether, to the point of surgical anaesthesia if this
is needed.
The patient recovers quickly, and is free from nausea.
This anaesthetic has stood the test of time. This, to Dr. Bergland, is
a very important consideration. New anaesthetics and analgesics come
and go; "they have their day and cease to be", and he would warn us
against going off at half-cock over new methods. Each must be tried, not
in hundreds, but in thousands of labours, and results, both to mother and
child, honestly and accurately recorded and evaluated.
So nitrous oxide and oxygen fulfils yet another requirement, in that it
has been used for many years with success. It has disadvantages: the gas is
expensive; the apparatus cumbersome, and the administration requires an
anaesthetist, in the deeper stage of anaesthesia, who is an expert. But these
disadvantages are not insuperable. Expense is not really prohibitive here; the
apparatus has been greatly simplified, and made lighter and easily portable.
As far as the expertise necessary is concerned, we provide experts for sur-
cigal anaesthesia as a matter of course, why not for labour? Explain the
matter to the patient; she will readily agree to the not overwhelming extra
expense.
On the whole, therefore, in Dr. Bergland's opinion, this is the best
method.
Page 58 The truth is that more and more people are demanding relief. They
want to have babies without pain; they expect us to perform miracles.
Bergland utters a warning in this matter. We must as a profession deal
frankly with our patients, and tell them quite frankly that labour cannot
safely be made painless; that pain can be safely reduced to an easily bearable
degree of severity—but no further; that the drugs are dangerous not only
to the child, but to the mother herself. These; drugs are powerful, and if
used every day, in every case, will cause disaster.
Irving of Boston has for some years been using the barbiturates, and
this has spread quite widely over the country. They must be used in conjunction with heroin or morphine or some similar drug.
Perhaps the safest combination is nembutal and scopolamin.
(Our readers may remember the address) on this by Conn of Edmonton
before the B. C. Medical at Kamloops a year ago.—Ed.)
Bergland does not like scopolamin; it is too uncertain in its action, and
there is very often an individual idiosyncrasy.
Irving uses huge doses of nembutal, upj to 12 grains and more.
Heroin.—This has long been used at Johns Hopkins, where it is preferred to morphine. It is used in conjunction with small doses of nembutal.
In using it it is important to get the confidence and co-operation of the
patient, and the time at which it is given is important. It certainly causes
some delay in the breathing of the baby, and this has added to our burdens
as obstetricians.
(Our experience of heroin in Vancouver is such as to confirm entirely
Dr. Bergland's opinion of its advantages.—Ed.)
Other methods in use are the use of ether, quinine and oil by rectum,
and of mag. sulph. intravenously. Bergland thinks very little of these
methods of obstetrical analgesia and anaesthesia. They prolong labour and
we have to use forceps more often.
Spinal anaesthesia, local anaesthesia of the cervix, etc., have been tried,
too, but are of no value from a routine point of view. Paraldehyde is now
being widely used, and apart from the fact that the babies' ward reeks of it
for days after, it is safe and has a distinct field of usefulness.
Even Christian Science, hypnotism and other methods of suggestion
have been tried. These leave no bad effects, but require special technical
abilities, and a suggestibility in the patient which is rather rare.
RISOR SARDONICUS
Contributed by Dr. M. W. Thomas
Secretary of The College of Physicians and Surgeons of B. C.
The story retailed here might be given the title of (rThe Inquest on
MacEwen's Flats." The details were supplied to your Secretary by Dr. R.
B. White of Penticton while we were passing through that area en route to
Oliver. Dr. R. B. White is affectionately and appreciatively known to all
men who practised in British Columbia in the nineties, and in the earlier
years of this century. In Penticton, where Dr. White has practised for many
years, he is deservedly the widely-respected Dean of Medicine. He has been
honoured by his colleagues in the whole area, known as District No. 4,
which extends far to the North and to the boundary in the South, having
been elected to serve on the Council of the College during several years.
Dr. White left McGill in 1896 a very young man and after practising
along the north shore of Lake Superior for a few months came to B. C. and
Page 59 prepared to set up practice at Fairview, about twenty-five miles south of
what is now the city of Penticton. Full of timidity and inexperience, he took
up office in the shack occupied by "Doc" McLeod, an undergraduate with
about two years of training and known to Dr. White in student days. There
were no other houses vacant in this wildly new district. McLeod was the
"Doc" in Fairview, having come in when Dr. Boyce, notw of Kelowna, left.
"Doc" McLeod welcomed Dr. White and promised to move away and
not interfere with the finished product who had just arrived. McLeod was
as rough as the times and the district. He was not very dependable but did
the best he knew for the people who were unfortunate enough to require his
services.
In those early days there were both rough living and rough houses. In
Fairview the hotel was operated by Hughie Cameron, whose boiled-shirt open
at the neck added an air of respectability to the bar of the hostelry which
was known as "The Bucket of Blood." Hughie's brother, Dugald Cameron,
known as the assistant manager, was in charge of the adjoining room, the
floor of which, bedded down with hay and straw, provided a snake-room
and a repository, or better still a depository, for those who were too sodden
to sit or stand to imbibe further. Dugald's rest-room was mildly referred to
as "The Ram-Pasture." On one occasion when Dr. White sought Dugald
for information about a patient he asked Hugh as to his whereabouts and
was told by the drink-for-drink bartender that Dugald was "in there
keepin' order among them damned bastards in the Ram Pasture." Hugh
complained constantly that Dugald was untidy in his habits and dress in
that he never laced his boots, but his slovenliness permitted easy removal
when his diurnal drinking overcame him and helped when his nocturnal
nursing duties made him put them on again.
One must know "The Ram Pasture" to picture, the "Coroner's Jury."
Another character must meet the reader and his introduction may be as rude
and terrifying as Dr. White's first meeting with Jim McCaig, a bad-man
with two guns, from across the border. He was bluff, boisterous and boasting
—possessed a two-notch butt on his favourite pistol. He was known to the
new doctor by reputation, and when McCaig appeared at the office seeking
"Doc" McLeod, two days after the arrival of Dr. White, the latter told
McCaig that the "Doc" was not in. McCaig, however, was not so easily
disposed of and challenged the young doctor, "Aren't you the new 'Doc'?"
Dr. White was trapped and admitted his identity. I may say that Dr. White
has overcome his youthful timidity and many of his experiences show him
to have possessed great fortitude and courage, enduring all the hardships of
a medical practice on horseback with hundreds of miles of trails to cover.
McCaig gruffly ordered the youthful doctor to "look at this thing on
my neck." Dr. White says his heart sank—it was one of the real carbuncles
—and he was certain that all his abdominal viscera would be perforated if
he hurt this virulent patient. However, we find him selecting a large, fairly
sharp scalpel and before incising the carbuncle with no local anaesthetic
available, warning McCaig that he might hurt him. The patient snarled at
him, "Go ahead, I can stand pain." The crucial incision was made with no
untoward gun action by McCaig, but to Dr. White's surprise he slipped off
the chair with a thud and the carbuncle was cleaned up with no other narcosis than that provided by the syncope. The dressing applied, the doctor
was apprehensive of reactions subsequent to recovery of consciousness. He
grasped the two legs of the comatose McCaig and dragged him through the
rear door to the shelter of the woodshed and to fresh air and recovery out-
Pa^ 60 side the office. Upon awakening the bad man moved about and the doctor,
hearing him, was fearful lest his patient seek revenge. His heart stopped
when a loud knock announced a farewell visit. Dr. White opened the door
carefully and with caution. McCaig asked what had happened, and on being
assured that it was only a faint, told Dr. White that he had never had that
happen before. He paid the doctor and went away, and Dr. White was grateful that he had. Some months later, McCaig was found dead in his shack
and by his side was an empty vial labelled "strychnine." Dr. White was
called and notified the Coroner, Dr. Osborne Morris of Vernon, who ordered
that an inquest be held on a stated date, the hour being indefinite, in that
he would travel southward down Okanagan Lake by the boat which usually
arrived at the Penticton landing, twenty-two miles from the shack, at any
hour between 4 in the afternoon and 12 midnight. The day having been set
for the arrival of the Coroner, the police constable proceeded to empanel a
jury, and as many of the scattered population were difficult to summon, his
chief readily available source of supply of jurors proved to be the Ram
Pasture down at Hugh Cameron's. The personnel were pushed into a wagon
for transport, a box for the corpse occupying most of the space but providing extra seats. A half-case of whiskey completed the necessary equipment
and with some considerable ceremonial arising out of the important duty
to be performed the wagon load of jurors moved away from "The Bucket
of Blood." Even the horses seemed to sense the serious nature of this
procession. The police having the convening of the court well in hand, it
was Dr. White's privilege and pleasure to meet the Coroner, Dr. Osborne
Morris, who was travelling from Vernon by boat, arriving on this particular
day at 10:30 p.m. at the Penticton, Landing, whence he must be transported to MacEwen's Flats. Horseback was not a pastime with Dr. Morris,
but that appeared to be the best mode of travel, so Dr. White trailed along
to the boat-landing a high-horse, which was to carry the Coroner. At 10:30
p.m. promptly, on a dirty wet night, the Coroner disembarked and mounted
his charger to jog over the twenty-two miles of road and trail. Dr. White
had prepared for the arduous ride and had secreted a bottle of brandy in his
saddle-bag. This he presented to the Coroner in event of the need of medical
comforts. The journey was uneventful, but it was early in the next day
when the two medicos reached the scene of the fatality and the court was
ready to proceed with the inquest into the cause of death of one Jim McCaig.
As the body had not been discovered until several days had elapsed, the
house-of-death was deemed unfit as a Hall of Justice and after conferring
with the foreman of the jury, Mr. Reginald Pennington, it was decided to
convert the barn into a courtroom.
A lantern was tied to a rafter and provided a cUmmed illumination
through the smoky chimney glass, with long shadows adding to the eerieness
of a bat-infested spaciousness, the long fingers of escaping light pointing
suspiciously at the whitened faces of the frightened jurors. The stall seemed
suited to the court and the Coroner was seated on one box and placed his
paper on a packing-case on which two candles were flickering. His back
being towards the jury he was unable to see al! that happened in that grotesque courtroom. Dr. White had a seat of greater vantage just inside the
bar, or rather stall, and he was able to see many never-to-be-forgotten incidents of that (to him) memorable inquest. The rail, which was made of a
barked tree, marked the edge of the hay-mow and was smooth from age and
wear. This provided a bench or perch for the jurors, and now the story
develops. The half-case of whiskey was not all consumed, but sufficiently
Page 61 to make that perch precarious for even a contortionist. The constable arranged the jurors on the pole, which was smooth and slippery enough to
test the most agile acrobat. The foreman, Reginald Pennington, accepted it
as his duty to keep them poised. Pennington was an Englishman, a son of
an Old Country judge, and inherently conscious of a strange respect for the
decorum of a court.
The court proceeded with solemnity, the Coroner writing copiously in
the stall, unmindful of the efforts at strict observance of the proprieties by
the good and true from the Ram Pasture. The perilous position of the jurors
on that pole required constant attention from Pennington and the Constable. Overcome by thirst one juror would reach back into the mow and
produce a bottle which was passed along the perch, all of which made it
increasingly difficult for Reginald to keep his jury seated. First one and then
another would get off centre and his efforts to save himself would often
endanger the poise of all, as they were projected to their knees on the barn
floor. Pennington pushed them back, only to find that the next topple took
all or part of his row back into the hay. Dr. White was in a sad position,
as he must preserve the dignity of the principal witness. There were swallows
swooping down and hens perched on the rafters. Pennington insisted on hats
being removed and heads bared. Next to the foreman sat a bald-headed juror,
and over him there must have been a hen, for all too frequently Reginald
used a wisp of hay to wipe the bald pate clean only to find that the hen was
still there somewhere on a rafter above. The Court directed the jury, the
verdict was given, and the jury having been thanked and discharged, the
Court adjourned. The Coroner produced the brandy and addressing himself
to the jurors expressed regret that they had had such a long and tiresome
night of jury duty and invited them to drink from his bottle. Dr. Morris
had misplaced his sympathy. There was none left for the doctors.
The box for the corpse was brought and all that remained of Jim McCaig
was lifted into it. The Englishman, Reginald Pennington, was an aesthetic
type and disliked intensely having to view, much less handle, dead bodies.
There appeared to be a very considerable stubbornness in the nature of this
particular corpse and one upper Hmb persistently refused to allow the lid
on. Pennington finally in exasperation pressed the arm down with a vicious
foot. The arm snapped as the foreman scolded the corpse, "Get your damned
arm in there, McCaig! The next time you commit suicide don't take
strychnine."
The box lid secured, the rude coffin was lifted to the wagon and the constable and Reginald hoisted the jurymen on to the box for the drive homewards and a last ride with Jim McCaig.
Dr. White saw Dr. Morris safely down the trail toward Penticton Landing and at daybreak bade him rrbon voyage."
COLLEGE OF PHYSICIANS AND SURGEONS
OF BRITISH COLUMBIA        I
Following extracts from the Statutes of the Province are published
for the information of members.
AN ACT RESPECTING MASTER AND SERVANT.
Master and Servant Act, R.S. 1911, c 154, s. 1.
Medical Attendance.
Deduction from wages for medical attendance.
12.   Where thirty or more workmen or servants employed in, on, or about
Page 62 any work or undertaking by a master, request, in writing, such master
to deduct from the wages a sum to provide for medical attendance,
it shall be the duty of the master to give immediate effect to such
request; the amount of such sum shall be determined by the workmen
or servants and the medical practitioner selected. R.S. 1911, c. 154,
s. 12.
Selection of medical practitioners.
13. (1) Before making the request referred to in section 12, a duly qualified medical practitioner or practitioners shall be selected by such workmen or servants, either present in person or represented by proxy, at
a special meeting of such workmen or servants called for that purpose.
A certificate in writing setting out the amount of the sums to be
deducted under the provisions of section 12, and the name of the medical practitioner selected, signed by the chairman and secretary of the
meeting and by the medical practitioner, shall be furnished to the
master along with the request.
( 2 ) The workmen or servants may at any time by like resolution alter
the name of the medical practitioner, upon giving one month's notice
to the master by a like certificate amended in accordance with the
resolution and signed by the chairman and secretary of the meeting at
which the resolution is passed and by the new medical practitioner
selected.
(3 ) It shall be the duty of the master to pay all sums so deducted to
the medical practitioner named in the then current certificate or certificates, and, except as provided in the "Workmen's Compensation
Act," no other sums shall be deducted from the wages of a workman
or servant by a master for medical attendance.   1915, c. 42, s. 2.
Penalties.
14. A master who refuses to comply with the last two preceding sections
or uses any influence or intimidation in the selection of a medical practitioner as aforesaid, shall be liable to a penalty of fifty dollars for each
offence, to be recovered on complaint of any person under the provisions of the "Summary Convictions Act." R.S. 1911, c. 153, s. 14.
Medical attendance fund.
15. Where a master deducts from the wages of his workmen or servants
any sum to provide a fund for paying for medical attendance upon
such workmen or servants, it shall be the| duty of the master to keep
a separate account of all moneys so deducted, and also showing in detail
to whom the moneys have been paid and for what purpose expended,
and a committee appointed by a majority of such workmen or servants
shall have the right at any time to inspect and audit the accounts. A
statement of the account, verified by statutory declaration, shall be
filed with the Provincial Secretary on the first of January and the first
of July in each year, and any person who contributes to the medical
fund shall, upon application to the Provincial Secretary, be supplied
with a copy of such statement upon the payment of twenty-five cents.
1915, c. 42, s. 3.
Disposal of fund where work closed down.
16. Where the majority of the workmen engaged by a master through any
cause whatever cease to work for more than one month for the master,
and any money contributed to the medical fund by the workmen is
Pave 63 held by the master, it shall upon request in writing, signed by a majority
who contributed to the fund, be handed over to the workmen or committee appointed by them, and shall be divided pro rata among all
persons contributing to same.   1915, c. 42,, s. 4.
Penalty for contravention of s. 15 or 16.
17. (1) A master who refuses to allow the committee to inspect and audit
said account, or who pays out any moneys therefrom to a person not
approved as aforesaid, shall be liable, on summary conviction, to a fine
of fifty dollars.
(2) Every master who neglects to pay out the said fund or any portion thereof to, or withholds or attempts to withhold the said fund or
any portion .thereof from, the medical practitioner to whom the same
is payable under this Act shall be liable, on summary conviction, to a
fine of fifty dollars. R.S. 1911, c. 153, s. 17; 1915, c. 42, s. 5.
Interpretation of word "master."
18. The expression "master" in the last six preceding sections shall include
a body of persons, corporate or unincorporate. R.S. 1911, c. 153, s. 18.
AN ACT RESPECTING CORONERS
R.S.B.C. 1924, Chapter 49, amended 1928-1929 (consolidated
July 1st, 1929).
Section 8.(1) Every legally qualified medical practitioner who was last
in attendance during the last illness or on the death of any person who dies
from other than natural causes shall, within twenty-four hours after having
notice or knowledge of the death of such person, notify in writing the
Coroner within whose jurisdiction the 'death occurs that such person has
died from other than natural causes.
(2) Every legally qualified medical practitioner who in contravention
of this section neglects or fails to notify any Coroner respecting the death
of any person shall be liable, on summary conviction, to a penalty of not less
than one hundred dollars and not more than two hundred and fifty dollars.
Section 21. (2) Where a person duly summoned to give evidence at an
inquest does not, after being openly called three times, appear to such summons, or, appearing, refuses without lawful excuse to answer a question put
to him, the Coroner may impose on such person a fine not exceeding ten
dollars.
Section 24. Where, upon the summoning or holding of any Coroner's
inquest, the Coroner finds that the deceased was attended during his last
illness, or at his death, by any legally qualified medical practitioner, the
Coroner may issue his order for the attendance of such practitioner as a
witness at the inquest.
Section 26 provides that a majority of jurymen may require Coroner
to summon a second medjcal witness.
Section 27. The written request of a jury for a second medical witness,
referred to in the last preceding section, shall be attached by the Coroner to
the certificate given by him for the payment of such medical witness.
Section 28. Where any legally qualified practitioner has attended in
obedience to any such order as aforesaid, he shall receive for his attendance
the fees set out in the Fourth Schedule, and the Coroner shall in each case
certify as to the correctness! of the amount claimed.
Section 29. Where any Coroner's order issued in pursuance of the pro-
Page 64 visions of this Act for the attendance of any medical practitioner at an
inquest, or for the attendance of such medical practitioner at an inquest
and the making or assisting in making a post-mortem examination, has been
personally served on, or, if not personally served on, has been received by,
the medical practitioner, or has been left at his residence or office in sufficient
time for him to have obeyed the order, and he has not obeyed the same, he
shall, upon information laid by the Coroner who held the inquest in the order
referred to, or by one of the jurors who sat on! the inquest, be liable, on
summary conviction, to a penalty of not less than twenty dollars and not
more than one hundred dollars: Provided that if, upon hearing what is
alleged by the medical practitioner, the Justice hearing the case considers
that such disobedience was caused by circumstances amounting to a reasonable excuse therefor, it shall be lawful for the Justice to dismiss the information upon such terms as to costs or otherwise as may seem just.
SECOND SCHEDULE
(Schedule 6)
For every inquiry by a Coroner, when inquest deemed necessary, $10.00
for each day necessarily spent in going to, conducting, and returning
from the inquiry.
For every inquest held by a Coroner, including precept to summon jury,
empanelling jury, summons to witness, information on examination of
witness, taking every recognizance, inquisition, and return, and every
warrant and commitment, $15.00 for each day necessarily spent in
going to, attending at, and returning from the inquest, but no additional
fee shall be allowed if the inquest is held at the same time and place over
more than one dead body.
For travelling expenses, the actual sum paid, as shown by receipts to be
attached to vouchers, if so required, for accommodation and meals and
for railway or stage fare or for reasonable livery charges.
For stenographer, if employed by Coroner, for transcript of evidence, 10
cents per folio of 100 words and such allowance for attendance as may
be proper in each case.
Where the time spent by a Coroner on any day does not extend beyond one-
half of the day, the fee for that day under the first two paragraphs of
this Schedule shall be reduced to $5.00 and $7.50 respectively, but the
total fee for any one inquiry shall not be less than $10.00, nor less than
$15.00 for any one inquest; and in allowing fees demanded in any case
under this Schedule regard shall be had to the fact whether or not the
time claimed to have been spent was necessarily so spent for the purposes
of the inquiry or inquest. R.S. 1924, c. 49, Second Sch.; 1929, c. 17, s. 2.
FOURTH SCHEDULE
(Section 28)
Medical Practitioners' Fees
For each day necessarily spent in attending at the inquest or inquiry
as a witness $ 7.00
For making post-mortem examination without dissection of the body
or analysis of the contents of the stomach or intestines, including
one day's attendance at inquest  15.00
Page 65 For making post-mortem examination involving dissection of the
body, without analysis of the contents of the stomach or intestines, including one day's attendance at inquest  25.00
For each day necessarily spent in attending the inquest in connection
with a post-mortem examination, subsequent to the first day     7.00
For each day necessarily spent in going to and returning from the
inquest, inquiry, or post-mortem examination _._    7.00
For travelling expenses, the actual sum paid, as shown by receipts to
be attached to vouchers, if so required, for accommodations and
meals and for railway or stage fare or for reasonable livery charges.
R.S. 1924, c. 29, Fourth Sch.; 1929, c. 17, s. 3.
|     MUNICIPAL ACT
R.S.B.C. 1924, Chapter 179, Part XXII, Section 464.
"Duty of Municipalities to provide for Poor and Destitute."
"It shall be the duty of every city and district municipality, whether
created under any general Act for the time being in force or any special
Act, to make suitable provision for its poor and destitute."
Chapter 183. An Act to provide for the Incorporation of
Village Municipalities.
Section 25. Poor.
Where the revenue either for the current year or for the last preceding
year from taxes on land and improvements exceeds five thousand dollars, it
shall be the duty of the municipality to make suitable provision for the poor
and destitute within the municipality.   1929, c. 48, s. 5.
Note: Provincial Relief applies in certain Village Municipalities.
JusfeJ
i36L»
PETROLAGAR MISCIBILITY
'       I      ASSURES EFFECTIVENESS
To a half-glass of water add a tablespoon of Petrolagar and
stir. The miscibility of the Petrolagar emulsion is thus
easily demonstrated. Such miscibility increases the effectiveness of the 65% pure mineral oil contained in Petrolagar
for the treatment of constipation.
PETROLAGAR  LABORATORIES  OF  CANADA,  LTD.
WALKERVILLE   ::   MONTREAL
Page 66 COCOMALT
'AMERICAN^ —AND —
Massnn L ll IMPORTANT FACTS ABOUT IRON
ConunUiee.
jmEoodd^
Iron, recognized as an important and necessary ingredient of the diet, is lacking* or
deficient in the majority of foods.
One ounce of Cocomalt (the amount used to
mix one glass or cup) contains 5 milligrams
of available Iron.
The Iron in Cocomalt is combined in an organic compound. Biological tests prove it
to be easily assimilable.
Three glasses or cups of Cocomalt a day
supply 15 milligrams of available Iron—the
amount of Iron recognized as the normal
daily nutritional requirement.
Used regularly, as a delicious mealtime or
in-between mealtime beverage, Cocomalt is
a simple palatable way of adding the necessary Iron to the diet in an
easily assimilated form.
(SAMPLES SENT TO ANYONE ON REQUEST)
WESTERN CANADA AGENTS:
SCOTT-BATHGATE CO., LTD.
WINNIPEG      ::      VANCOUVER
(ocomalt
k _ur__f_
ADELICIOUS FOOD DRlNlCte«J
CHOCOLATE FLAVOR        Hgi£
„._..-■'•   V/iO
„____-•   wy.
«__»,
(Hljris-tmag (Imtmg; ^Mmm
Telephone Seymour 6606 now, in order that our
representative may show you samples of our beautifully lithographed Christmas Letterpaper, Cards and
Envelopes.
THESE ARE DECIDEDLY
SUPERIOR   IN   QUALITY
It is very important to make your selection early.
You are under no obligation, and we are confident
you will be delighted.
ROY WRIGLEY
TED
300 West Pender Street, Vancouver, B. C.
_5m "pORDEN'S ST. CHARLES MILK is effectively prescribed for infants that are
not breast fed, because it is easier to digest than milk in its ordinary form.
It is also successfully used in feeding premature babies, and those with weak
digestions.
Borden's St. Charles Milk is pure, safe, whole milk, produced on selected farms
and guarded by the most rigid tests jin all the dairy industry. Sixty per cent, of
the natural water is removed, and the milk is thoroughly sterilized. No sugar is
added, so the carbohydrate content of each feeding formula can be regulated.
When you add the words "Borden's St. Charles" to your evaporated milk infant
feeding formulae you are assuring the purity, quality and effectiveness of your
prescription. No feeding formulae are given to the laity. We will gladly supply
physicians with Simplified Formulary and full information. Write to the Borden
Company, Limited, Yardley House, Toronto.
The Vitamin D content of Borden's St.
Charles Milk is increased by direct irradiation with ultra violet rays under
Canadian Patents Nos. 291,138 and
306,562. Licensed by the Wisconsin
Alumni   Research   Foundation.
AJOK&fVS  IRRADIATED EVAPORATED
ST.CHARLES MILK
&&**%!
■'Hiar_a|-|iijii,
"IAD. HiWa.dSl.a.D
ST.CHARlcc
**•      .        BRAND J?_»
imilk m
Wi?
^^
HH
O
_g_
-??___-
m
IHsr
Me also needs
INTERNAL EXERCISE
With millions of men, golf, riding
and other forms of exercise are a daily
ritual. Yet these same men eat meals
that fail to give their systems proper
exercise, meals that may lead to constipation due to insufficient "bulk."
Fruits, vegetables and bran are the
Lest sources of "bulk." But experiments have indicated that, with some
individuals, the "bulk" in fruits and
vegetables is largely broken down in
the intestines. So bran is often more
effective.
Kellogg's All-Bran is an excel-
on
lent source of gentle "bulk." Scien
tific tests show that it is safe and
effective. Within the body, this
"bulk" absorbs moisture, and forms
a soft mass. Gently this exercises and
strengthens intestinal muscles, and
cleanses the system.
This natural laxative food may be
served as a cereal with milk or cream,
or cooked into
appetizing
recipes. It is
sold by all grocers. Made by
Kellogg in
London, Ont.
It§il i| i^fli^^pil <^^^fi|^^
co r re c riliiKsM- PAMlii!
I TALIPES EQUINOVARUS.
(a)   Congenital  talipes  equinovarus,   (b)
Acquired (paralytic) talipes equino varus.
Doctors...
We can fit your patients with
Made-to-Measure and
Corrective Shoes
I
Subject to your Prescription and
Recommendation
34 YEARS' EXPERIENCE IN LAST MAKING AND
CUSTOM SHOE-BUILDING
<Pi
LESLIE,
<P<
aXL±
51 WEST HASTINGS ST., VANCOUVER, B. C. HAP
el^!>pm_i__i 11
(Standardised Vitamins A, Bx B2 and D)
RADIO-MALT provides a valuable safeguard against
attacks of invading organisms during epidemics of coughs,
colds, influenza, tonsillitis and other infections which
attack the patient whose resistance is lowered through
special stress, strain or other conditions of lowered vitality
resulting from depleted reserves.
The value of RADIO-MALT is attributable to its accurately-standardised and balanced content of Vitamins A,
B1? B2 and D.
Stocks are held by leading druggists throughout
the Dominion, and full particulars are
obtainable from
The BRITISH DRUG HOUSES (Canada) Ltd.
Terminal Warehouse Toronto 2, Ont.
Ill
c^wvwv-x<^;>y^o^-<*^^,^^^*■!
S*K
M
Pi
S[M-*»*Xv-V-yWMiS-jW£M|_
iWWWXWW
RM/Can/3612
S^^^^$!!SS§^^S^^S?!®is*;
:::_W¥ft«ft__
536 13 th Avenue West
Fairmont 80
Exclusive Ambulance Service
FAIRMONT 80
ALL ATTENDANTS QUALIFIED IN FIRST AID
"St. John's Ambulance Association"
WE SPECIALIZE IN AMBULANCE SERVICE ONLY
R. J. Campbell
J. H. Crellin
W. L. Bertrand COLONIC IRRIGATION INSTITUTE
Superintendent—E. M. LEONARD, R.N., Post Graduate, Mayo Bros.
Treatment Room, showing the Irrigation Table.
REALIZING the need for a properly equipped centre where those suffering
from constipation, worms, indigestion, etc., could be assured of modern
scientific colonic irrigation and internal medication, E. M. Leonard, R.N., has
fitted out operating rooms with the most up-to-date scientific equipment. Here
the patient will receive every attention, and proper thorough treatment under
the care of a fully trained nursing staff, at a moderate charge.
Individual   Treatment $ 2.50
Entire Course  10.00
Medication (if necessary) $1 to $3 extra
This treatment is beneficial in cases such as constipation, indigestion, acidity,
rheumatism, arthritis, worms, diverticulosis, colitis, acne, and any condition
which may have originated in the intestinal tract. To ensure comfort, convenience and thoroughness in these treatments, call at the Colonic Irrigation
Institute, either in Vancouver or Victoria, B.C. Registered nurses always at
your service.
631 Birks Bldg.     Phone Sey. 2443.     Vancouver, B. C.
506-7 CAMPBULL BLDG.
Phone Empire 2721
VICTORIA, B. C. A PRESCRIPTION SERVICE . . .
Conducted in accord with the ethics of the Medical
Profession and maintained to the standard suggested by
our slogan:
Pharmaceutical Excellence
AAcOill 6 Grmo
LIMITED V-'
FORT STREET (opp. Times)      Phone Garden 1196     VICTORIA, B. C.
Ntutn Sc ®Ij0m00tt
2559 Cambie Street
Vancouver, B. C
A new type of bismuth salts has recently appeared in the field of therapeutics: the oil-soluble salts for intramuscular injection. These constitute
a class of products which are rapidly absorbed due to the fact that the
bismuth derivative dissolves immediately in the lipoids and does not have
to be transformed in situ.
Ever anxious to meet all the requirements of the Medical Profession, we
are now offering, under the trade name of NEOCARDYL, a compound
representative of this new form of liposoluble bismuth.
"POULENC"
Ampoules of 1.5 cc. equivalent to 0.075 Gm. of bismuth metal.
Boxes of 12, 50 and 100 ampoules; bottles of 30 cc.
LABORATORY POULENC FRERES
OF CANADA LIMITED    |
Distributors: ROUGIER FRERES, MONTREAL Dial "Ciba"
Dial calms excited, irritated nerves, and for such occasions as nervous insomnia, mental and traumatic agitation, pre-operative restlessness, etc., it will fulfil all the
requirements of a good hypnotic.
Cibalgine "Ciba"
Cibalgine represents a non-narcotic analgesic and antipyretic worthy of the physician's confidence. It is indicated in the treatment of pain of every description, febrile
manifestations, nervous excitement, insomnia due to
pain, dysmenorrhoea, etc.
CIBA COMPANY LIMITED
MONTREAL
flfoount pleasant Xftnoertalnno Co. %tb.
KINGSWAY at 11th AVE. Telephone Fairmont 58 VANCOUVER, B. C.
1 R. F. HARRISON W. R. REYNOLDS STEVENS' SAFETY PACKAGE
STERILE GAUZE
is a handy, convenient, clean commodity for the bag or the office.  Supplied
in one yard, five yards and twenty-five yard packages.
ESTAEfLISHED  NEARLY A
,CENTURY.*
B. C. STEVENS CO.
Phone Seymour 698
73 0 Richards St., Vancouver, B. C.
BOWELL|& SON
DISTINCTIVE FUNERAL
SERVICE    f
Phone 993
66 SIXTH STREET
NEW WESTMINSTER, B. C.
|___£S:W?v$:x::.£&^
Breaks the vicious Circle of perverted
menstrual function incases of amenorrhea,
tardy periods (ifiipn-physiologicalpand dysmenorrhea. Affords remarkalpie symptomatic
relief by stimulating the innervation of the
uterus and  stabilizing the;|tprie^)f its
musculatfire: Controls the uterO-byarian
circulation and thereby encourages a
i   normal menstrual;cycl^•■gj^^S §|t
* I ♦ MARTIN H. SMITH COMPANY
__ ISO lAFAVITTt STRUT. NEW YORK, N. T.
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* HiUis season
eftkeyea*
when Bronchitis, Pneumonia, Influenza and
other acute infectious fevers are rife, the
use of Antiphlogistine is a helpful ally in
combating these conditions.
Promoting the action of the skin and lessening the tension in the chest, Antiphlogistine
serves to relieve the pain, loosen the
cough and shorten the duration of the
acute symptoms.
Its timely application may help to prevent
or to overcome pulmonary congestion and
lessenthe danger of complicating secondary
lobar pneumonia and bronco-pneumonia.
Sample on request
ANTIPHLOGISTIN E
TOE DENVER CHEMICAL MFG. COMPANY
153 Lagauchetiere St. W., Montreal
MADE IN CANADA 'smoke arising from the fossile coal
11 very fit not only for producing
sbui glsMMr- supporting the rickets'
—William Farter, 1773
HE RELATION of atmospheric pollution to rickets is not a moden
discovery for as far back as the seventeenth century shrewd observers sus
pected the relationship. Perhaps at no time in history was there a moti
graphic demonstration of this alliance than in England of that day
William Harvey, describing London in 1657, spoke of "the smoki
engendered by the general use of sulphureous coal as fuel, whereby thi
air is at all times rendered heavy, but much more so inthe autumn thai
at any other season."1
Rickets became so prevalent in this period that on the continent it wa
known as "the English disease," because, Rutherfurd points out, "Englanc
was the pioneer in the commercial exploitation of coal, and so passe.
first under the smoke pall that cut off the sunlight from city children."
At this Season of the Year
OLEUM PERCOMORPHUM       *        £      j
is more reliable than the sun J|
Ever since the industrial era began, smoke has been a menace to citi
children. Literally hundreds of tons of dust fall annually over each squat!
mile of the larger urban centers, according to a recent survey by the U. S
Public Health Service.2 Fortunately, winter sunlight need no longer b
depended upon to prevent rickets. A few drops of Oleum Percomorphum
at a cost of less than one cent a day, furnish ample vitamin D — ii
measured and controlled dosage. At no additional cost, at least 7,00
units of vitamin A are also furnished. Oleum Percomorphum makes j
possible to prescribe natural vitamins A and D in 1/100 the dose c
U.S.P. cod liver oil, and in the same ratio as the latter. Each gram c
Oleum Percomorphum offers not less than 60,000 vitamin A units anj
8,500 D units (U.S.P).
JBrit. J Child. Dis. 33:40, Jan.-Mar. 1936
2U. S. Public Health Bulletin No. Z
MEAD JOHNSON & CO. OF CANADA, Ltd., Belleville, On
Please enclose professional card when requesting samples of Mead Johnson products to cooperate in preventing their reaching unauthorized person NEWjs
Preparedness
—a policy we have practised—3 0 years in
Vancouver.
At Your Service
ITEMS IN STOCK:
Abbott's Syrup Amdelate
Winthrop's Evicyl Tablets
Chovanol Tablets
Stamyl Tablets
Kahlenberg Bichloracetic Acid
B. D. H. Anahaemin
Mandelix
—   24 Hours a Day
OPEN
ALL
NIGHT
rSEY*IOSO
WiNMl
NIOMT
GEORGIA PHARMACY
U I M  I T E O
SEYMOUR
1050
W.OIOROIA
STRUT
(Hunter $c %mtm CflL
Established It93
VANCOUVER, B. C.
North Vancouver, B. C.    Powell River, B. C.
PUBLISHED  MONTHLY   AT  VANCOUVER.   B. C.   BY  ROY WRIOLEY  LTD.,   300  WEST  PENDER  STREET Hollywood Sanitarium
Limited
For the treatment of
Alcoholic, Nervous and Psychopathic Cases
Exclusively
Reference—B. C. Medical Association
For information apply to
Medical Superintendent, New Westminster, B. C.
or 515 Birks Building, Vancouver
Seymour 4183
Westminster 288
&3S_3^_3^§-_^^_^^§___^^_^SS

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