"CONTENTdm"@en . "http://resolve.library.ubc.ca/cgi-bin/catsearch?bid=1179642"@en . "History of Nursing in Pacific Canada"@en . "Vancouver Medical Association"@en . "1947-08"@en . "2015-01-29"@en . "1947-08"@en . "https://open.library.ubc.ca/collections/vma/items/1.0214436/source.json"@en . "image/jpeg"@en . " i gas j* jai\n\u00E2\u0096\u00A0\u00C2\u00BBi\nThe \u00E2\u0080\u00A2 .\nBULLET!\ngNPrnHl\n>-\nof the ...\nVANCOUVER\nMJfE D l|D AL\nASSOCIATION\nWith Which Is Incorporated\nTransactions of the\nVICTORIA MEDICAL SOCIETY\nthe\nVANCOUVER GENERAL HOSPITAL\nand\nST. PAUL'S HOSPITAL\nIn This Issue:\nPage\nHISTORY OF THE V.M.A. || jT - \u00C2\u00A7 290\nCHIROPODY-\u00E2\u0080\u0094AN AUXILIARY TO MEDICAL PRACTICE\n\u00E2\u0080\u0094B. J. H. MacDermot, M.D \u00E2\u0096\u00A0&\u00E2\u0096\u00A0 ;|j||fe|l^29\u00C2\u00A3\nSYMPOSIUM\u00E2\u0080\u0094By Clement A. Smith, M.D.\nThe Cause of Abdominal Pain in Infants and Children 302\nPhysiological Peculiarities of Newborn Infants 307\nDiseases of the Newborn:\nAsphyxia, Atelectasis, Erythroblastosis , 311\nDiarrhea, Prematurity -ftp; 316\nNEWS AND NOTES-..., __j\u00C2\u00A3i 223\nin*'\nVOL. XXIII. NO. 11\nAUGUST, 1947 NEW\nr-I\nI K\n1 !'L\n\u00E2\u0080\u00A2Kii;\n\u00C2\u00BB\nAPPROACH TO THE TREATMENT OF\nTINEA PEDIS\nf/ft/?/etes foot)\nwmm\n A\n=\u00C2\u00BB'\u00E2\u0080\u00A2,. \u00E2\u0096\u00A0 eniora\nPenioral (Buffered Penicillin Wyeth) reaches the\npatient Laboratory-Fresh. It is protected three\nways against moisture, arch enemy of penicillin.\nf\nMEANS\n*\**M *tt\n\\nW^\n'\"VKttlttllAl\nWttmi KMKiUIN .\n\u00E2\u0080\u00A2 Vial is sealed air-tight until opening.\n\u00E2\u0080\u00A2 Desiccant absorbs moisture after vial is opened.\n\u00E2\u0080\u00A2 Blue indicator turns pink when excessive moisture threatens full potency of the penicillin.\n\u00E2\u0080\u00A2 Added protection \u00E2\u0080\u0094expiration date on every vial.\nEach vial contains an average\nday's prescription\n25,000 International Unit\ntablets\u00E2\u0080\u0094Vials of 12\n50,000 International Unit\ntablets \u00E2\u0080\u0094 Vials of 8\n100,000 International Unit\ntablets \u00E2\u0080\u0094 Vials of 8\nWfaM\nRegistered Trade Mark\nFor assured\nPotency \u00E2\u0080\u0094\nWrite PENIORAL\non your\nPenicillin 1$\nJOHN WYETH & BROTHER (CANADA) LIMITED\nWALKERVILLE - ONTARIO VANCOUVER MEDICAL ASSOCIATION\nFounded 1898; Incorporated 1906.\nPROGRAMME FOR THE FIFTIETH ANNUAL SESSION\nOctober 7 GENERAL MEETING\u00E2\u0080\u0094\"The Treatment of Peptic Ulcer.\"\nDr. A. H. Gordon, Montreal.\nOctober 21 CLINICAL MEETING\u00E2\u0080\u0094Vancouver General Hospital.\nNovember 4 GENERAL MEETING\u00E2\u0080\u0094\"Sympocium on Peripheral Vascular Disease.\"\nDr. Rocke Robertson and associates.\nNovember 18 CLINICAL MEETING\u00E2\u0080\u0094St. Paul's Hospital.\nDecember 2 GENERAL MEETING\u00E2\u0080\u0094\"Symposium on Pre-frontal Leucotomy.\"\nDr. Frank Turnbull\nDr. Allan Davidson\nDr. R. Whitman.\nDecember 16 CLINICAL MEETING\u00E2\u0080\u0094Shaughnessy Hospital.\nBreaks the vicious circle of perverted\nmenstrual function in cases of amenorrhea,\ntardy periods (non-physiological) and dysmenorrhea. Affords remarkable symptomatic\nrelief by stimulating the innervation of the\nuterus and stabilizing the tone of its\nmusculature. Controls the utero-ovarian\nt circulation and thereby encourages a J\ntk normal menstrual cycle.\nI \u00C2\u00AB MARTIN H. SMITH COMPANY\nW. ' ISO MMYtm SI (HI. NIW VOMC, N. T.\nFull formula and descriptive\nliterature an request\nDosage: l to 2 capsules\n3 or 4 times daily. Supplied\nin packages of 20*\nEthical protective mark MHS\nembossed on inside of each\ncapsule, viable only when capsule is cut in half at seam.\n*t\ni1'' m\n1'.9\nm\nw\nPage Two Hundred and Eighty-six 11 '-I.\ny\ni V\nSpecify..\nSODIUM\nVIALS {for aqueous solution)\nThe presence of a buffer (4 to 5.% sodium citrate) makes\nSquibb Crystalline Penicillin G Sodium considerably more stable\nin solution than unbuffered solutions of crystalline penicillin\nG sodium.\nIn diaphragm-capped vials of 100,000 and 200,000 units.\nOIL AND WAX\nSquibb Crystalline Penicillin G Sodium in Oil and Wax has\nimproved physical characteristics permitting easier adminis-\n/tration . . . and provides prolonged-action penicillin in double-\ncell cartridges. One cell contains 300,000 units of penicillin\nin refined peanut oil with 4.8% bleached beeswax. The other\ncell contains sterile aspirating test solution to guard against\naccidental intravenous injection.\n300,000 units in 1 cc. double-cell cartridges in B-D* disposable syringes, or for use with B-D* permanent syringe.\nAlso in 10 cc. vials, 300,000 units per cc*\nTABLETS li\ .Jj,\nSquibb Tablets Crystalline Penicillin G Sodium (Buffered) are\nindividually and hermetically sealed in aluminum foil to protect\nthem from penicillin-destroying moisture. For high oral dosage.\n50,000 units per tablet, boxes of 12 and 100.\n100,000 units per tablet, boxes of 12 and 100.\nAll these dosage forms of Squibb Crystalline Penicillin G\nSodium may be stored at room temperature. Refrigeration\nof aqueous solution is necessary.\n*T. M. Reg. Becton, Dickinson & Co.\nCRYSTALLINE PENICILLIN G SODIUM\nFor Literature write\nE. R. SQUIBB. & SONS OF CANADA LIMITED\n36-48 CALEDONIA ROAD TORONTO\nN\n\u00E2\u0096\u00A0.*! VANCOUVER HEALTH DEPARTMENT\nStatistics\u00E2\u0080\u0094June, 1947\nTotal deaths 271\nChinese deaths 13\nDeaths, residents only 237\nBIRTH REGISTRATIONS:\nMale 389\nFemale : 392\n781\n28.0\nINFANT MORTALITY: June, 1947 June, 1946\nDeaths under 1 year of age 20 27\nDeath rate per 1000 live births \u00E2\u0096\u00A0 25.6 38.7\nStillbirths (not included above) ^__ 14 4\nCASES OF COMMUNICABLE DISEASE REPORTED IN THE CITY\n<*r\nMay, 1947\nCases Deaths\nScarlet Fever . 11\nDiphtheria ) j 3\nDiphtheria Carrier : \u00E2\u0096\u00A0 \u00E2\u0096\u00A0 : 0\nChicken Pox . 64\nMeasles 87\nRubella 2\nMumps 175\nWhooping Cough 107\nTyphoid Fever h j I 0\nTyphoid Fever Carrier 0\nUndulant Fever 0\nPoliomyelitis 2\nTuberculosis 47\nErysipelas 2\nMeningococcus (Meningitis) 0\nInfectious Jaundice 1\nSalmonellosis 4\nSalmonellosis (Carrier) . 0\nDysentery , 1 0\nDysentery (Carriers) _ . 0\nTetanus 0\nSyphilis j 93\nGonorrhoea 238\nCancer (Reportable):\nResident j 98\nN on-Resident 32\nJune, 1947\nCases Deaths\nJuly, 1947\nCases Deaths\n\u00E2\u0096\u00A0\u00C2\u00AB\n\u00C2\u00B1i\nPage 287 4 m\nu i ,;\u00E2\u0080\u00A2\u00E2\u0080\u00A2\n\u00C2\u00BB\u00E2\u0080\u00A2 v\n\u00E2\u0096\u00A0**',. w:\nH\n?i\n':\u00E2\u0096\u00A0*\n*'\u00E2\u0080\u00A2:'\ni*\n* !\nCRYSTALLINE PENICILLIN G\nIt has been widely established that Penicilln G is a highly effective\ntherapeutic agent. The crystalline form of Penicillin G prepared and\nsupplied by the Connaught Medical ^^ __5_^\nResearch Laboratories is highly purified. Because of this high degree of\npurity, pain on injection is seldom\nreported and local reactions are\nreduced to a minimum. Crystalline\nPenicillin G is heat-stable, and in the\ndried form can be safely stored at\nroom temperature for at least three\nyears.\nPHOTOMICROGRAPH\nOF PENICILLIN CRYSTALS\nHOW SUPPLIED\nCRYSTALLINE PENICILLIN G IN VIALS\nHighly purified Crystalline Potassium Penicillin G is supplied by the Laboratories in sealed rubber-\nstoppered vials of 100,000, 200,000, 300,000 and 500,000 International Units. No refrigeration it\nrequired.\nCRYSTALLINE PENICILLIN IN OIL AND WAX (ROMANSKY FORMULA)\nA heat-stable and conveniently administered form of Crystalline Sodium Penicillin G in peanut oil\nand beeswax is available in 1-cc. cartridges for use with B-D* disposable plastic syringes, or as replacements with B-D* metal cartridge syringes. Each 1-cc. cartridge contains 300,000 International Units of\nCrystalline Sodium Penicillin G.\n* T.M. Reg. Becton, Dickinson & Co.\nCRYSTALLINE PENICILLIN G IN TABLETS FOR ORAL USE\nBuffered tablets of Crystalline Sodium Penicillin G are distributed by the Laboratories in tubes of\n12. Two strengths are supplied, 50,000 and 100,000 International Units per tablet. No refrigeration is\nrequired.\nCONNAUGHT MEDICAL RESEARCH LABORATORIES\nUniversity of Toronto Toronto 4, Canada\nDEPOT FOR BRITISH COLUMBIA\nMACDONALD'S PRESCRIPTIONS LIMITED\nMEDICAL-DENTAL BUILDING, VANCOUVER, B.C.\n<4 *lke ZdUafiH Paaa\nIt is very gratifying to read in the papers of the recent action of the Alberta Medical\nAssociation at their Annual Meeting, which has just been held, with reference to a\nscheme of prepaid medical care, to apply to all residents of the Province of Alberta. Of\ncourse, newspaper accounts are necessarily very sketchy, and it is too early to make any\nvery extensive comment on the matter, but it would appear that the scheme is intended\nto apply to any individual that wishes to take advantage of its provisions, and not to be\nlimited to groups. If this is so, and our colleagues in Alberta can put a good scheme\ninto effect, soundly financed, on terms that are equitable to the medical man, and not\nmerely generous to the beneficiary, as most government-proposed schemes seem to be, a\nvery great step will have been taken in the direction of a practical system of health\ninsurance that will have a chance to become permanent, and that will satisfy the desiderata that our profession has always insisted, in Canada at any rate, must be met adequately, if we are to feel free to accept it.\nIt is unfortunate that the financial problems of health insurance have always presented differing aspects, according to whether the person who examines them is on the\nmedical side or on the side of the patient, or shall we say the public, who ultimately\nhave to pay the bills. This is, we think, because the premises are not clear or at least,\nthe two sides seem to be working from different angles. We are accused of being ungenerous, greedy, even grasping\u00E2\u0080\u0094it is popularly supposed, and many people, even on the\nfloor of the Legislature, have said so categorically, that we are disingenious in our\nopposition to the schemes of Health Insurance that have hitherto been brought forward,\nand notably to the B. C. Health Insurance Act, and that we object merely because we\ndo not get enough money. Our good faith, our sense of public responsibility, even our\nstanding as good citizens, are impugned.\nThis is, as we have said before in these columns, at least partly our own fault\u00E2\u0080\u0094in\nthat we have never presented our side of tht case at all adequately to those who are\nentitled to know the whole truth about this controversy\u00E2\u0080\u0094viz., the public. We have\nsat supinely by and allowed all these things to be said, and have allowed the other side\nto give their views unchallenged and unchecked. But, apart from this, we should let\nthe public know more clearly why we have always resisted the suggestions that have so\nfar been made by governmental bodies seeking to inaugurate Health Insurance. It is\ntrue that we should be scandalously underpaid, by any standards\u00E2\u0080\u0094but this is not the\nonly, not even the main evil, though it is naturally very important, too. The real\nobjection to all the schemes proposed and this applies too, to the schemes now in force\nin Great Britain and elsewhere, is that it would mean an instant and a dangerous lowering\nof all the standards of medical work that we feel must be maintained and even raised\nhigher. It would mean a denying to the so-called beneficiary\u00E2\u0080\u0094victim might be a better\nword\u00E2\u0080\u0094of certain drugs and treatments that we think are necessary, simply on the\nground that they would be too costly\u00E2\u0080\u0094it would mean cheap work, cheaply done\u00E2\u0080\u0094it\nwould remove from medical practice what, under our so-called democracy, every other\ncitizen can claim, the right of free enterprise\u00E2\u0080\u0094the initiative that leads to good work.\nNo provision is made for prevention of disease, for research, in fact, any politically\ninspired scheme of Health Insurance as we see it at least, is doomed to split on the two\nrocks of penury and political expediency. So it is good to see Alberta medical men\ntaking things into their own hands, and working out a scheme that will conform with\nthe laws of supply and demand, and with ordinary economic considerations. We, in\nB. C., of course, have the M.S.A., and as far as it goes, and this applies for the other\nPage 288\ni\"W.\nif.*\nSI\n'I-'. '\n'Si\n*&\nCl\u00C2\u00A33\nm\nij- i\nit*\nM , H\napproved plans in the province, it is a model of what a Health Insurance plan can and\nshould be\u00E2\u0080\u0094but unfortunately, so far, it has not been possible to open it to all classes\nof the community. We believe that steps in this direction are to be taken as soon as it\ncan be done, and we hope that day will come quickly.\nWe shall all watch the developments in Alberta with the greatest interest, and we\nwish them the success that their courage and public spirit deserve.\nm\nK i\nLIBRARY NOTES\nHOURS\u00E2\u0080\u0094\nEvening hours in the Library will be resumed on October 1st, when the Library\nwill remain open until 9:30 o'clock three nights a week (Mondays, Wednesdays and\nFridays). On alternate days (Tuesdays and Thursdays) hours will be 9:00 to 5:00\ndaily, and 9:00 to 1:00 on Saturdays.\nRECENT ACCESSIONS TO LIBRARY\u00E2\u0080\u0094\nMedical Clinics of North America, Symposium on Blood Transfusion and Rh Factor,\nMayo Clinic Number, July, 1947.\nActa Medica Scandinavica, Symposia\u00E2\u0080\u0094\nNo. 175 Hypertension. Hemodynamic factors and retinal changes in hypertensive\ndiseases.\nNo. 176 Plasma Protein. The normal plasma protein values and their relative\nvariations.\nNo. 177\u00E2\u0080\u0094Peroral and Intravenous Galactose Tests. A comparative study of their\nsignificance in different conditions.\nNo. 178 Diabetes Mellitus in Bergen, 1925-1941. A study of morbidity, mortality, causes of death and complications.\nNo. 179 On the distribution of the morbidity of epidemic diseases with regard\nto age.\nNo. 180 A new method for staining tubercle bacilli, applicable also to the microorganisms of leprosy and other acid-fast germs.\nNo. 181 Tuberculosis Incipiens. Further studies of the initial stage of chronic\npulmonary tuberculosis.\nNo. 182 Methanol. Poisoning, its clinical course, pathogenesis and treatment.\nNo. 183 Acidosis\u00E2\u0080\u0094Clinical aspects and treatment with isotonic sodium bicarbonate solution.\nNo. 184 Hypometabolism. A clinical study of 308 consecutive cases.\nNo. 185 The quantitative nature of renal research and other concluding remarks.\nLECTURES IN MEDICINE AND SURGERY\nSHAUGHNESSY HOSPITAL\nWith reference to a programme of lectures in Medicine and Surgery, repeated this year by the Staff and others of Shaughnessy Hospital, it has now\nbeen decided to admit any members of the profession resident in Vancouver,\nwho are in good standing.\nLectures will be given in the Auditorium, Old Building, on Mondays and\nWednesdays, from September 29 at 7:30 p.m., unless otherwise notified.\nF. C. BELL, M.D.,\nSuperintendent.\nPage 289 Vancouver Medical Association\nPresident\t\nVice-President\t\nHonorary Treasurer-\nHonorary Secretary-\nEditor\t\n Dr. H. A. DesBrisay\n Dr. G. A. Davidson\n Dr. Gordon Burke\n-Dr. Gordon C. Johnston\n Dr. J. H. MacDermot\nHISTORY OF THE VANCOUVER MEDICAL ASSOCIATION\n(Continued)\nTHE CITY HOSPITALS\nNote: I wish to acknowledge my indebtedness to Mr. F. J. Fish, in charge of\nthe Office of Records at the Vancouver General Hospital, for his assistance in\ncompiling the following material relating to the City Hospitals. He unreservedly made available all his comprehensive records pertaining to these Institutions throughout the earlier years. Without his assistance the following\nstory could not have been told. G. E. Kidd.\nIt was in 1886\" that Vancouver first had a hospital of its own. During that year the\ncity took over the small building on Powell Street, which had served the C.P.R. as a\ndressing station during the years of the construction of the Coastal section of the Road.\nAfter steel had been laid into Vancouver the Company's local hospital was given over\nto the city. The railroad had used the building for treatment of minor cases only, and\nas a clearing station for the more serious ones before transfer to Yale where a central\nhospital was located.\nWhile still under the control of the C.P.R., the Powell Street building had given\nemergency treatment to Vancouver's citizens as needed, but all cases requiring hospitalization went to New Westminster. As late as February of 1887 we find a record of a\nbill of charges from the Royal City Hospital to Vancouver's City Council.\nThe small hospital was located on Powell Street near where the sugar refinery now\nstands. The late Dr. A. M. Robertson described it as: \"A little one and one-half story\nbuilding with two rooms upstairs and two down. The front room on the ground floor\nwas the dining room, on the table of which necessary operations were performed. In a\ncorner were several shelves on which the doctors kept their kits and medicines. The\nstaff consisted of one man, a Welshman named Hughes. He acted as nurse, cook and\ngeneral handyman. He slept in a bunk in the kitchen and was none too clean. The\nsecond room on the ground floor contained four beds, and ine one of the rooms upstairs\nthere were two more. The hospital had a wide verandah, in front of which passed the\ndirt road from Hastings to Gastown. There were usually two or three patients, but\nsometimes all the beds were occupied. The main C.P.R. hospital was in Yale, to which\nall more serious cases were transferred.\"\nThe building having, through the efforts of the above-mentioned Hughes, escaped\nthe great fire of 1886, was taken over by Vancouver, and became known as the City\nHospital. There are on record a few references to it under its new name. In September,\n1886, Owen Hughes was appointed Steward of the hospital, with a salary of $25.00 a\nmonth. Under the date of January, 1887, we have reference to the payment of $6.00\nto W. Ashford for delivery of milk, and on the same date tenders were asked for to\nsupply five cords of wood, stovewood length. In March of 1888 we have an item asking\nPage 290\nI.'},\n\"It\"\n;?\nft;*1\n.\u00E2\u0096\u00A0..Jl\n\u00E2\u0096\u00A0'\nIi'' it'll!\nf \u00E2\u0096\u00A0;\u00E2\u0080\u00A2\u00E2\u0080\u00A2.;\nIT'* n\n9i\nj\n1!'\n.\n\u00C2\u00BB\u00E2\u0080\u00A2!\n\u00E2\u0080\u00A2\nm\nDr. Lefevre to pay over to the City treasury all monies he had collected from the hospital. Finally on November 23, 1888, it was agreed at a meeting of the Board of Health\nthat: \"The old City Hospital is now no longer needed, and that the C.P.R. Commissioner be notified to this effect.\"\nMeanwhile it had been generally recognized, that the city urgently required a new\nand larger hospital. The population of Vancouver in 1886 was only 1000, but during\n1887 it reached the 5000 mark. Arranging for such an institution was the duty of\nthe Board of Health. Accordingly this body, in September, 1886, asked the Provincial\nGovernment to apportion a sum of money towards the erection of a hospital building,\nwhile the city itself was requtsted to supply beds and general furnishings for the same.\nThe Government apparently took no action, so the Council was asked to shoulder the\nentire cost. In August of 1887 invitations went out for the submission of plans and\nspecifications for a hospital which would eventually, cost $20,000, the estimates for the\nfirst unit, to be erected at once, being $4,000. Property owners were invited to provide\na suitable site, but failed to respond, so a special committee selected a location on Beatty\nStreet, Lots 1 to 10, Block 38. This property, which faces on Pender Street, was purchased fro mthe C.P.R.\nHere in 1888 was erected the two-storey frame building which is still standing, but\nfarther south on Beatty Street, which it now faces. It has had a colourful history. It\nserved first as a general hospital, then an isolation hospital. The first seeds of the University of British Columbia were planted here. Still later it served as an old people's\nhome. For the past two decades it has been used as headquarters for the city's labour\norganizations\u00E2\u0080\u0094address 529 Beatty Street.\nExtracts from the pages of the Vancouver News Advertiser, published during the\nsummer of 1888, give us a picture of the progress of the erection and equipping of the\nbuilding.\nJune 22, 1888.\n\"Last summer, Dr. Edmunds, a celebrated English physician, who has been for many\nyears connected with London hospitals, while on a visit to Vancouver was asked to give\nto the City Council his opinion on the kind of a hospital best adapted to the wants of the\ncity. Acting on his suggestions, the architect, Mr. A. E. McCartney, designed a building which stands before the citizens of Vancouver as a hospital of which they may well\nbe proud. The building is two stories with a basement, in height, and stands on the side\nof a hill, the main entrance facing Pender Street, which is approached by a broad flight\nof steps. To the left, on entering, is an emergency room for the treatment of accidents\nrequiring immediate attention, and to the right are the dispensary and nurses' room.\nThe main ward is a fine spacious room, which will accommodate sixteen beds. It will be\nheated by stoves, and lighted by electricity.\n\"The second floor comprises two private wards, a nurses' room, and a large ward\nsimilar to that on the first floor. The windows here open onto a balcony, from which a\nmagnificent view of the city and inlet may be obtained. The recreation grounds are also\nvisible, and it will be a great source of amusement to the convalescent patients to watch,\nthe different games carried on there.\n\"The basement contains the kitchen, store rooms, laundry and necessary offices. The\nkitchen is connected with the wards by speaking tubes. There is apparently no dumb\nwaiter nor elevator to convey the food from the kitchen to upstairs. The extension to\nthe building contains the water closets and bathrooms, which are entirely distinct and\napart from the main building.\n\"The building as it at present stands is only one-third of what it ultimately will be,\ntwo other wings of similar size being provided for in the plans, connected by means of\nenclosed galleries. The present building, however, is expected to be sufficient for some\ntime to come. Its total cost alone will be in the neighborhood of $7,000 or $8,000.\"\nThat everyone was not completely satisfied with the new building is indicated by the\nfollowing letter to the News Advertiser from a Vancouver practitioner, Dr. G. F. Bod-\nPage 291\nrfMk ington. His letter is dated September 7, 1888, and reads as follows: \"Sirs,\u00E2\u0080\u0094I have not\nyet been inside the new City Hospital, but the outside is a sufficient illustration of the\nmischief of doing without the aid of experts. Anyone can now see that a great mistake\nhas been made in the mode of access to the building. The front entrance is reached by\na steep staircase of 17 steps. Added to this there is a jump of more than three feet from\nthe lowest step to the level of the sidewalk. To abolish this jump three or four more\nsteps will be needed, so that there must ultimately be 20 steps or more between the sidewalk and the front door of the hospital. Fancy a patient with fractured ribs or a broken\nthigh, or any other agonizing injury, jerked and jolted up these twenty steps in a sort\nof tortuous Jacob's ladder which he must mount painfully before entering the haven of\nrest and recovery above. I cannot conceive that such a mistake as this would have been\nperpetrated had there been a Medical Board in office during construction who would have\nbrought the fierce blaze of combined criticism to bear upon the work as it proceeded.\"\nThe new hospital was opened on September 22, 1888, and the News Advertiser reported on the event as follows: \"A visit to the hospital yesterday afternoon showed that\nthe work of moving the patients from their old quarters had been successfully carried\nout and the poor sufferers already looked better for the change. The lower ward is the\nonly one in use at present, and it presented a cheerful and homelike appearance. Bright\nfires were burning in the stoves, the beds with their snowy coverlets looked the embodiment of rest; the Matron, Mrs. Roberts, and her assistant, Miss Crickmay, in high, white\nlinen caps and the regulation nurses' costumes looked the personification of Sir Walter\nScott's ideal, while bunches of autumnal blooms scattered here and there added beauty\nand charm to the scene.\n\"There is accommodation for 16 beds in each ward, the upstairs ward to be for\nwomen and downstairs for men, and three in private wards. The operating room is\nfitted with portable electric lights for use in surgical operations.\n\"The matron, Mrs. Roberts, is an acquisition to any hospital, having had a thorough\ntraining in leading London hospitals, and subsequently a large and extensive experience\nas Matron and Nurse in Egypt and Australia. The Medical Board, which will have\ncharge of the hospital, was elected by the City Council, and consists of Doctors Bell-\nIrving, Langis, Lefevre, McGuigan and Robertson.\n\"In connection with the hospital it might be mentioned that contributions of flowers\nand old linen will be thankfully received by the matron.\"\nHereafter all affairs pertaining to the institution were administered by the Board\nof Health acting in conjunction with two members of the Hospital Medical Staff. This\nbody was known as the Health Committee of the City Council, and continued to function until the incorporation of the Vancouver General Hospital in 1902, at which time\nit gave place to a Board of Directors appointed by the Provincial Government.\nThe selection of the Medical Staff gave rise to some difficulties. In 1887 there were\nnine registered physicians practising in Vancouver. These were Doctors Bell-Irving,\nLefevre, Robertson, McGuigan, Langis, Bodington, Beckingsale, Stevenson and McAlpine.\nAbout the time that the building of a new hospital was first mooted, a Vancouver\nMedical Society was organized; probably, but without certainty, for the sole purpose of\ndealing with the selection of a staff for the institution. Dr. Bodington was President.\nThis latter was evidently a man of very decided opinions which he did not hesitate to\nexpress most forcibly. Major Matthews, the City Archivist, states that he was an\nEnglishman whose father, also a Physician, had won some recognition in the Old\nCountry as being among the first to advocate the treatment of pulmonary tuberculosis\nby the fresh air and rest method. The younger man later moved to New Westminster,\nand was for some years before his death, Superintendent of the Provincial Mental Hospital. Since we have no means of deciding between the rights and wrongs of this\nremote dispute, quotations bearing on it from contemporary newspapers, will be given.\nFrom the Daily World, October 12, 1888.\nPage 292\n.&\n#!\nr' *i\n.'*\nlit I\n%% 1\nI\na\n\"A move was made in 1887 to replace the old hospital east of Hastings sawmill.\nThis summer, Dr. Bodington, President of the Vancouver Medical Society, made suggestions regarding the future management of the hospital. They were thrown out by\nthe City Council. On July 31, a delegation from the Medical Society came before the\nCouncil. Their suggestions were held over for future consideration.\n\"Meanwhile, Dr. Robertson, through the Chairman of the Board of Health, had been\nvirtually appointed by the City Council to act as Medical Officer in sole control of the\nhospital, at a salary of $1000 a year. It is evident that a great deal of wire pulling of\none kind or another had brought this about, and the other registered Medical Men found\nthemselves out in the cold. The Council reconsidered the matter, and the Medical\nSociety was asked to draw up a scheme for the future management of the hospital. It\nproposed that a staff of nine doctors, eventually reduced to five, should be in control;\nseach to be on duty, in rotation, for one week. The Medical Staff was to constitute the\nMedical Board, this Board to depute two members to act with the Board of Health for\ndeliberating and explanatory purposes.\n\"The plan for placing Dr. Robertson in charge was dropped and that of the Medical\nSociety adopted. The Council then appointed five members to the Hospital Staff, viz.,\nDoctors Bell-Irving, Lefevre, McGuigan, Robertson and Langis. Just why, has not come\nout. There were wheels within wheels in the arrangement. An indignation meeting has\nbeen arranged.\"\nReporting on this meeting the Daily World continues: \"Capt. Mellon was in the\nchair. It was resolved that: 'This meeting is of the opinion that the recent election of\nthe Medical Staff for the new hospital was informal, irregular and void, and calls upon\nthe City Council to proceed with a new election forthwith. A great injustice has been\ndone.' Dr. Bodington was asked to address the meeting. He reviewed the formation\nof the Medical Society of Vancouver. A letter from it to the Board of Health regarding the Medical Staff had been ignored, as was a deputation of its members. Said Dr.\nBodington: 'Five names came before the City Council, and that body should be ashamed\nof the way in which these appointments were passed by them. The whole thing had\nbeen pre-arranged. The City Council was pulled by the nose in a way I have never seen\nin any city elsewhere. Why should the Chairman of the Board of Health act like this?\nWas it professional jealousy, or national jealousy? Was it national hatred? The election was cooked beforehand, and sprung on the Council. No cliques should be allowed.\nThe Council should be sheared of certain members not fit to hold office.'\n\"The resolution was passed unanimously. Dr. Beckingsale spoke, as also did Dr.\nStevenson, who suggested that perhaps the Council had chosen for the staff those doctors\nwho had most time on their hands.\"\nAs time went on other members were added to the hospital staff. In 1890 we find\nthe names of Doctors Johnson, Wilson and Beckingsale on the list. In 1891 Doctors\nThomas and Herbert were added. Members took turns on duty, each for a period of\none week. There are sugestions of neglect of these duties, since in 1892 we find a\nrecord of one, George Gagen, complaining to the Council that patients were being\nneglected by the staff. The matron was instructed to notify staff members two days\nbefore they were due to come on their weekly term of duty. At the same time the\nChairman of the Board of Health was empowered to examine into the condition of all\npatients, and to take any steps which, he considered necessary for their disposal.\nThe first suggestion that a house-surgeon be appointed to duty in the hospital, precipitated a small riot among the members of the staff. In the minutes of a staff meeting\nheld in April, 1896 we find the following startling resolution: \"We the undersigned, t*he\nMedical Board of the City Hospital, have been informed by the Chairman of the Board\nof Health that the services of the Medical Board be dispensed with and that a house-\nsurgeon be employed. We who have given service for seven years should have been consulted before such radical step was taken. We hereby tender our resignations.\" The\nresolution was signed by Doctors Bell-Irving, Wilson, McCuigan, Robertson, Langis,\nPage 293 Poole, Weld, Tunstall and Thomas. It was forwarded to the Mayor and to the morning\npaper for publication.\nThe story of the episode is confused, but it would seem that an advertisement had\nappeared in a city newspaper asking that appliations be made for the position of house-\nsurgeon to the city hospital. In reply to the Board's letter of resignation the city clerk\nsent a hasty denial that the Board of Health had in any way been responsible for the\nplacing of the notice in the paper; at the same time stating that such an appointment\nof a house-man would in no way affect the status of the hospital staff or of existing\narrangements, and asking that the staff continue as heretofore. In view of this explanation the resignation of the Board was withdrawn.\nIt does not appear just who was responsible for the advertising for a house-man, nor\ndoes it seem that any immediate replies were forthcoming. It is not until two years\nlater, in 1898, that we have a reference to application for the position having been\nreceived from Doctors Bentley and McEwen. Dr. Bentley, at least, was attached to the\nhospital staff in 1898, and in records covering the following year we find Dr. McEwen\nreferred to as House-surgeon and Hospital Superintendent. He held this position until\nJuly, 1904, when he resigned and was succeeded by Dr. A. M. Robertson. The latter\nis variously referred to as Resident Medical Officer and as Medical Superintendent. In\nFebruary of 1906 Dr. Robertson asked for an assistant resident house-surgeon. Pending\nappointment of a permanent man, a part-time local practitioner was given the position\nat a stated salary. It was not until 1909 that the Medical Superintendent was made a\npermanent, full-time official of the institution, who was also chief executive of the hospital. He was henceforth known as General Superintendent.\nThe first nursing staff of the new hospital on Beatty Street was constituted as follows:\nMatron, Mrs. Roberts; Assistant Matron, Miss Bessie Crickmay; Nurses: Miss Agnes\nCrickmay, Mrs. Birks; Night Nurse, Mr. G. D. Day; Porter; Cook. The matron held\na responsible position and her duties were many. She acted as hospital superintendent.\nBesides managing her nursing staff, she supervised the hospital grounds, collected fees\nfrom the paying patients, and purchased all supplies; although such purchases had first\nto have the approval of either the Chairman of the Board of Health, or of the Mayor.\nOnce when a dead Chinaman was inadvertently left in the morgue for five days, it became the duty of the matron to see that it did not occur again. At first each druggist\nwas given an equal share in the supplying of drugs to the hospital. Beginning with\nF. E. McCartney, they took turns, each covering a period of one month. In 1889 the\nmatron was instructed to purchase drugs from the best druggists, giving each a fair\nshare of patronage. The next year, 1890, we find a six months' contract for the supply\nof drugs being given to H. HcDowell & Co. For the sake of economy, all drugs, insofar\nas possible, were to be purchased in concentrated form, and it was a duty of members\nof the medical staff to assist in making up stock solutions. In 1890 we find a letter\nfrom the City Clerk complaining that the staff members were writing prescriptions\ninstead of making use of the stocks on hand. We note too, a purchase of three gallons\nof whiskey from the Hudson's Bay Company, at a cost of $8.50.\nFrom the first there appears to have been minor troubles with the nursing staff.\nWithin a month of the opening of the hospital we have a recorded meeting of the Staff:\n\"To consider charges against the Matron.\" Her resignation was asked for. Miss Bessie\nCrickmay succeeded her and held the position for one year. In August of 1899 the\nentire nursing staff, including the matron, was dismissed for unstated reasons, and newspaper advertisements inserted calling for applicants to fill their places. These specified\nthat: \"The Matron must be a person of middle age.\" The new Matron was Miss Swan\nand she had as a staff Nurses Alcock and Woodward. This staff was soon afterwards\naugmented by a housekeeper, a night porter, a woman cook, and two assistants, the latter\nat a salary of ten dollars a month. The night porter was appointed Steward, with a five\ndollar increase in his twenty dollar salary. His additional duties consisted of collecting\n#!\nH* fldi\n>\u00C2\u00AB\n\u00C2\u00BB>\n'}\u00E2\u0096\u00A0%\nPage 294 I 'i & t\n,\H\n'\u00E2\u0096\u00A0t\n\u00E2\u0096\u00A0#'\u00E2\u0096\u00A0\nfees from private patients. We note that about this time the day porter asked that he\nmight have every fourth Sunday off. This was granted.\nMatron Swan resigned in January, 1892, but reconsidered and remained in office\nuntil May of 1893. As an appreciation of her services she was given an embossed\naddress. She was succeeded by Miss Jean Macfie. The latter was in turn followed by\nMiss Margaret Clendenning, who held the position until 1904. At this time we have\nan item in the Board minutes felicitating her on her recent marriage to J. B. Hart. In\n1902 there had been another flareup of trouble with the nursing staff. It appears that\nMatron Clendenning had been severely rebuked by the Mayor for some unstated action\nof hers in connection with one, Mrs. Topley, probably a patient in the hospital. The\nnursing staff was greatly incensed and threatened to resign in a body. On the persuasion\nof the Assistant Matron they reconsidered, but let it be clearly understood that if anything more was said to their Matron, they would leave the wards at once.\nThe Beatty Street hospital began modestly with a men's ward of ten beds. Besides\nthe main building there were on the grounds a morgue and a small isolation hospital. In\n1890 the City Solicitor advised that to avoid legal action the morgue must be moved. It\nwas placed nearer to Pender Street. A year later it was resolved: \"In future the morgue\nwill be connected with the City water works and sewers.\"\nMiss Agnes Crickmay has left a statement describing conditions during those early\nyears: \"In 1888 my sister Bessie succeeded Mrs. Roberts as Matron, and I was a nurse\nunder her. There was another day nurse and a male night nurse. There were ten or\ntwelve beds in the only furnished ward, which was on the main floor. Another ward\nupstairs, intended for women, was never finished, although an occasional woman was\nnursed there. We had water and electric light in abundance. There were three bedrooms upstairs, for the staff, and a small sitting room. The kitchen and store-room were\nin the basement. We had a Chinaman for cook. There was much typhoid and much\nsurgery. Many cases were beyond description, and much of the C.P.R. work was left\nto the nurses to do, as the doctors had little time at their disposal.\"\nFrom another source we learn: \"There was a queer little operating room, primitive in\nthe extreme. Water was boiled in a wash boiler, and a fish kettle was used for sterilizing\nthe instruments.\" In October of 1888 we find a resolution by the Medical Staff to the\neffect that whenever an operation was slated to be performed, all members should be\nnotified so that they might attend.\nFinancing the institution through those early years was a problem. Rates for private\ncases were $10.00 a week. C.P.R. patients got a special rate of $5.00. Marine cases were\ncharged 90 cents a day, but the Health Committee insisted that a doctor to attend them\nshould be supplied by the shipping companies. A city man was appointed to the post at\na salary of $400.00 a year. The most severe economy was practised by all concerned.\nIn 1889, the Matron, Miss Crickmay, offered to reduce her meagre staff to lessen expenses.\nThis was approved by the Board. We find her asking for 60 feet of hose and being given\n50. Dr. Lefevre ordered chicken diet for one of his patients. The request, coming\nbefore the Board, was laid over. Presented again, it was again refused. As noted before,\nthe Matron was responsible for the collection of fees. As late as 1892 we find her being\nurged to make more strenuous efforts to collect from paying patients. Later on, the male\nnight nurse was appointed Steward and given the task of collecting these fees. In 1893\nthe City Council was asked to place a bookkeeper in the hospital to look after accounts.\nThe city was growing rapidly. By 1890 it had reached the 12,000 mark, and a ten-\nbed hospital, for men only, was quite inadequate to serve such a population.1 Plans for\naugmenting the ward accommodation included dividing the upper floors into a women's\nand a fever ward. Tenders were called for this, and in June of 1889 a contract was let\nto J. G. Garvin, the cost to be $190.00. It seems never to have been carried out.\nPressure was brought to bear on the City Council from various sources. In January,\n1890, we find on record a letter from Mrs. E. Salsbury, President of the Ladies' Aid to\nthe hospital asking for increased accommodation, including space for children. The sum\nPage 295 of $1000 was placed in the estimates for that purpose. In August of the same year the\nletter from the Ladies' Aid was repeated, and careful consideration promised by the\nBoard. The following month a request came from the Secretary-treasurer of the Hospital Committee, signed by Mrs. Annie E. Webster, asking that the Council found a\nseparate institution to be known as a \"Women's and Children's Hospital.\" This was\nreferred to the incoming Council.\nThe new Council placed in its estimates two items of considerable size. One for\n$6000 for a new hospital wing, and a second for $2000 for the erection of a Women's\nand Children's hospital. In consideration of the last appropriation it was resolved:\n\"That the chairman of this Board be at all times one of the Board of the said hospital.\"\nConstruction of the new wing got under way at once. While it is spoken of as a wing,\nit was in reality a detached building, joined to the other by a closed-in passageway. By-\nthe spring of 1892 it was completed and beds installed in the wards, ready for occupation. Plans for a Women's and Children's hospital seem to have fallen through, since\nnothing more is heard of such a separate institution being built.\nCHIROPODY\u00E2\u0080\u0094AN AUXILIARY TO MEDICAL PRACTICE\nBy Dr. J. H. McDermot\nThe healing art, as we know it today under the name of the Practice of Medicine, is\na very complex structure, more or less homogeneous in the main, with all its parts interlocking to a very high degree of efficiency. Medicine and surgery, the two main divisions, are almost completely interlocked; and the specialties, gynaecology, obstetrics,\neye, ear, nose and throat, and so on, are all firmly knit with them and with each other,\nthrough a uniform underlying aggregation of principles and laws, based upon a uniformity of teaching in the basic sciences of chemistry, anatomy, physiology, pathology\nand bacteriology, therapeutics, and all the rest of it. True, at times, and from time to\ntime, we are challenged by other schools of thought, which seek to interpret the causes\nof disease, and to build on their interpretations methods of treatment which are wholly,\nor in the major part, unacceptable to our theories and understanding, and which often\nseem bizarre or even harmful to us. The only test of these, in reality, is the old test\nsuggested by Gamaliel, in the Acts of the Apostles, the test of time and experience. If\nthey have in them any truth, this truth will in time justify itself\u00E2\u0080\u0094and since in the main\nwe (that is, the medical profession) are honest seekers after truth, in time we adopt\nthem and turn them to our own use, and profit by them. As we read the history of\nmedicine, we find that this is the case in such matters as vaccination, the circulation of\nthe blood, Pasteur's theory of disease, based on his discovery of germs, and so on. As we\ngo further back in history and view the struggles between the Galenists and those who\nsought a scientific basis for medicine, we see that this struggle between the \"orthodox\"\nmedical profession, and those who challenged it, was not always decided in favour of\nthe orthodoxists. But, to the honour and credit, and profit too, of the medical profession, we find that each of these, at the time, revolutionary ideas, was studied and weighed,\nand ultimately accepted and digested, to become part of the framework of the medical\nstructure. Where there has been no element of truth in the pretender's thesis, no scientific\nbasis for his claims, sooner or later these have failed of acceptance, not only by the\nmedical profession, whose opposition was often misinterpreted by laymen as a purely\ninterested refusal to accept the new methods and theories, but by the public itself, which\ncame gradually to see that there was no virtue in the claims put forward by those who\nmade them. Countless false doctrines have come and gone\u00E2\u0080\u0094each generation sees a new\none\u00E2\u0080\u0094some of them have done us a lot of good, by forcing us to face the issues involved,\nand clarify our own position. Others, like homeopathy and osteopathy, have gradually\nPage 296\n&\nrti\niSii\nir\nW,-\n'ljfi\n'\nWl\nttf\nfi\n-''\" \"\u00E2\u0080\u00A2<(\nI .\nw\n; ii Ui\ni,\n\"Chiropody is a practice ancillary\u00E2\u0080\u0094a hand maiden\u00E2\u0080\u0094to medical practice in a\nlimited field. . . . General opinion seems to be that chiropody fairly well satisfies a\ngap that the (medical) profession has failed to fill.\"\n\u00E2\u0080\u0094A.M.A. Judicial Council.\nExcerpt from a Statement by The San Francisco County Medical Society:\n\"The profession of chiropody ... is that branch of medicine which cares for the\nneeds of the human foot in health and disease. This includes the diagnosis, prevention and treament of the ailments of the foot. Treatment constitutes mtdical,\nmechanical and minor surgical procedures.\n\"As with medicine and dentistry the educational requirements of chiropody have\nadvanced with the years. . . . Today he scholastic requirements embrace three years1\nof intensive . . . classroom, laboratory and clinical instruction. . . .\"\n\"Following successful graduation . . . the student is invested with the degree\u00E2\u0080\u0094\nD.S.C.\u00E2\u0080\u0094Doctor of Surgical Chiropody.\"\n-r-Publications Committee.\nGranted the truth of all that has been written as to the educational qualifications\nof the chiropodist, and the justice of his claim to a place in the structure of the healing\nart, one may ask \"What has this to do with us?\"\nA great deal.\nAs it was said above, the medical practitioner is not qualified, either by training or\nthe exigencies of his practice, to treat diseases of the foot as they should be treated. An\ninteresting confirmation of this fact is seen in the experience of the armed forces of the\ncountry, which enlisted the services of the chiropodist, and provided for their members\nregular and systematic chiropodial service. It is true that the best service, such as could\nonly be given by fully trained chiropodists was not always available\u00E2\u0080\u0094but the need was\nrecognized nevertheless.\nExcerpt from a Statement by A. S. Moscarella, M.D., Orthopaedic Surgeon, Spring\nValley, New York:\n\"I believe that the present-day chiropodist is well trained in the work required of\nhim ... in the national defense set-up of the country.\"\nExcerpt from a Statement by Edward Schaffer, Lt. Col., Medical Corps, Oklahoma\nCity, Oklahoma:\n\"I have had occasion in the past several years to refer patients of mine with . . .\nailments of the feet ... to chiropodists.\"\n\"This type of professional service is not to be confused with chiropractors but is\nactually recognized by physicians and surgeons as an important branch of medicine.\"\nExcerpt from a Statement by Edward T. Fischer, M.D., Capt. Medical Dept. Detachment, 192nd Field Artillery, Danbury, Conn.:\n\"Chiropody as a definite part of the medical care administered to the members\nof the Army and Navy is necessarv-\"\nThere are a great many opportunities in civilian medical practice for the chiropodist,\nand we need only mention a few. Many of the great hospitals of the United States and\nCanada have, attached to their outpatient departments, a chiropody service. The chiropodist's work is especially important in diabetic clinics, in metabolic clinics, in orthopaedic cases and so on.\nWe quote from Eliot P. Joslin, M.D., of Harvard University, whose words are deserving of our close attention.\n\"I think the work done by chiropodists, particularly for diabetic patients in hospitals, is invaluable. ... I heartily favour the association of chiropodists with doctors\nand surgeons in the hospitals of the country.\"\nPage 299 Again\u00E2\u0080\u0094\nExcerpt from a Statement by H. Gray, M.D., and W. E. Close, D.S.C., San Francisco, California.\n\". . . as a result of chiropodial vigilance ... at the Cedars of Lebanon Hospital\nin Los Angeles . . . the incidence rate was wonderfully reduced: for hospitalization\nfrom diabetic gangrene to eighteen per cent . . . and from amputations to twenty-\nseven per cent of the (prior) rate. . . .\"\n\u00E2\u0080\u0094Medical Record, Oecember 17, 1941.\nExcerpt from a Statement by K. Hammond Mish, M.D., Garfield Hospital, Washington, D.C.\n\"I have witnessed the tremendous help that the chiropody service has been to\nour patients and I do not believe that a diabetic clinic can be satisfactorily conducted without similar connections.\"\nTextbook: Foot and Ankle (1940; Lea and Febiger).\nAuthor: Phillip Lewin, M.D., F.A.C.S., Northewestern University Medical School.\nStatement:\n\"A diabetic person should have his . . . foot defects treated by an orthopaedic\nsurgeon or a competent chiropodist.\" (Page 493.)\nNor is this all. Every industrial surgeon knows the importance, in his hospidal practice, of prophylaxis as regards the feet, in the case of men who have been bedridden for\nmany days or even weeks. The postpartum patient suffers, far too often, from foot dis-\nabilies following pregnancy, and antepartum patients very frequently need the care and\nadvice that only a trained chiropodist can give. The nurse in training would benefit\ngreatly by sympathetic and intelligent care of her feet. We all remember lectures given\nby medical officers of the Navy and Army, during one Summer School, showing the\ntremendous amount of trouble that was caused in soldiers, sailors, nursing sisters, and\nso on, by disabilities arising from foot deformities and improper shoes.\nAll these things lead one to feel that every general hospital should possess, as one of\nits most important services, a department of chiropody, as it does a department of dentistry. This department's services should be available to its staff, to its patients both in\nand out, and to the public at large.\nAuthor: Dudley J. Morton, M.D., Columbia University.\nTextbook: The Human Foot (1935: Columbia University Press).\nStatement:\n\"Since chiropodists are so extensively involved in the treatment of these (foot)\ndisorders their relation toward the broader problem as an agency for public benefit\nis obvious. ...\" (Page 229.)\nExcerpt from a Joint Statement by Physicians of Cooper Hospital, Camden, New\nJersey.\n\"Chiropody is a necessity, and an important branch of the medical profession.\"\nRobert Cooper, M.D.; E. E. Manser, M.D.; Arthur D. Sewall, M.D.; Geo. H.\nGarrison, M.D.; K. N. E. Haines, M.D.; Henrik W. Lorke, M.D.; W. D.\nKunliz, M.D.\nAnd, too, the practitioner of medicine would do well to realize the importance of,\nand necessity for, the chiropodist's service, both to his patients and himself. The evil\neffects of diseases of the foot have only recently come to be realized by orthopaedic\nsurgeons and by the general practitioner\u00E2\u0080\u0094but there is a vast total of suffering and disability, a great loss of working efficiency and of time, a long fist of evil consequences,\nbackaches, postural defects, arthritis and so on, directly due to diseases and disabilities\nof the feet. These can only be treated by painstaking, meticulouls, detailed care, by\nproper shoes, by adequate supportive measures, by local therapy\u00E2\u0080\u0094and of all these things\nPage 300\n*r.\n*'\n:*\ntf\n#!\nh* i\nHi Ml\n1;!\n1\n'ft\nIR\n>\nwe, as a profession, know little or nothing. The medical profession as a whole has completely failed to realize the importance of healthy, painless feet to the human animal, in\nhis work and play, and the crippling and disability that accompany painful and unhealthy feet; the mental and nervous distress, the limitation of capacity to lead a useful\nlife and do a full day's work\u00E2\u0080\u0094to take part in sports\u00E2\u0080\u0094to be, in short, physically fit.\nThere is practically no teaching in medical schools devoted to the foot\u00E2\u0080\u0094no teaching as\nregards the matter of shoes, and the evils that arise from improperly-fitted footwear.\nThe study of geriatrics would benefit greatly from this knowledge\u00E2\u0080\u0094the old suffer greatly\nfrom their feet, and get little or no recognition of the fact from medical men. Even\nmore important is the care of the feet in children, in adolescents, in women, in industrial\nlife, and so on.\nThe physician treating a diabetic or tabetic, or the neurologist treating cases with\nsensory disturbances and lessened sensory reception; the orthopaedist treating injured\nfeet, arthritides, and so on; the medical men who has an elderly patient suffering from\npainful and deformed feet, corns, callouses, and the like\u00E2\u0080\u0094all these would benefit greatly,\nas would too their patients, by a free interplay of consultation and co-operation in treatment.\nYet it has been left for the chiropodist to bring this to our attention. We might\nwell add to our summer school and other similar programmes, a talk from a qualified\nchiropodist on the care of the feet.\nAs one looks through the literature, one is struck by the entire absence of any reference to the work of chiropodists. Even leading books dealing exclusively with diseases\nof the foot, make no mention of this, and deal chiefly with the work of the orthopaedic\nsurgeon. Books on paediatrics, obstetrics, say little or nothing about prophylaxis and\npreventive care of the feet. Steiglitz, in his work on Geriatrics, says nothing whatever\nabout the disabilities of the feet that especially bese old age.\nThere is no conflict here between the work of the orthopaedist and that of the\nchiropodist.\nExcerpt from a Statement by R. R. Goldenberg, M.D., Orthopedic Surgeon, New\nYork, New York.\n\". . . the profession of chiropody does not in any way encroach or interfere with\nmy practice of orthopaedic surgery.\"\nExcerpt from a Statement by H. V. Krutz, M.D., Orthopedic Surgeon, Nyak, New\nYork.\n\"The scope of the chiropodist . . . (does not) . . . overlap with the activities of\nthe orthopedic surgeon.\"\nNeither can or does do the work that the other is qualified to undertake\u00E2\u0080\u0094no chiropodist would undertake any form of major surgery, treat fractures or wounds of the feet\u00E2\u0080\u0094\nhis work lies along the line of detailed, continuous, day by day care, the fitting of proper\nfootwear, the study of which occupies a large part of his training, supportive and corrective measures, physiotherapy, the care of the nails, of calluses, and so on. This is\nwork that the orthopaedist cannot undertake; and yet it is as important as the major\nprocedures, if full efficiency of the foot is to be recovered.\nWe might well formally recognize, as the British.Medical Association has done, the\nprofession of chiropody as a special branch of the organized profession of medicine, of\nwhich it is quite fully qualified to be a branch in good standing.\nPage 301 THE CAUSES OF ABDOMINAL PAIN IN INFANTS\nAND CHILDREN\nClement A. SmIth, M.D.\n(Summer School, Vancouver Medical Association, June 1947)\nFOREWORD |\nWe think that all our readers will be well repaid for a careful study of the following\npapers' delivered at the recent Summer School of the Vancouver Medical Association by\nDr. Clement A. Smith of the Department of Pediatrics, Harvard University, Boston,\nMass.\nDr. Smith described himself as a sort of liaison officer between the Pediatric Department and the Obstetrical Department of Harvard, thus including all the work, done\nat the famous Boston Lying-in Hospital and the next door Children's Hospital.\nHe has made, and is here reporting, a very careful survey of the new-born child and\nthe various troubles met with in these very young children in sickness and in health.\nThe papers dealing with the presently popular Erythoblastosis, with prematurity and\nespecially with the treatment of diarrhoed diseases in the young infant should help many\nin the care of these conditions.\nDr. Smith was a real favourite with those attending the Summer School and we are\nglad indeed to publish his papers for the benefit of the much larger number of our\nreaders who were unable to attend our summer meetings.\nThe Paediatric Section of the Association feels that we were very fortunate in having\nDr. Smith make the long journey from Boston to present his views to the medical profession in British Columbia.\n*'4\nLet me begin by saying that abdominal pain is an exceedingly common admission\nticket to the doctor or clinic, and that even under concentrated diagnostic effort about\nhalf the cases will not be explained to the absolute satisfaction of the critically-minded\npediatrician.\nIt will be best to discuss this undiagnosable group first. These are the children whose\ndiscomfort is always more frequent than prolonged, whose pain is almost always described by them as right at the umbilicus, who seldom or never cry or double up with the\npain, are seldom nauseated and almost never vomit, rarely lie down for more than a few\nminutes, and to see whom one is seldom called to the home at night. And they go on\ncomplaining of pains which, I think, are really quite honest complaints. Physical examination usually reveals little, yet the thoughtful doctor is often troubled by questions\nin his own mind concerning the state of the appendix or some other abdominal organ,\nand the intelligent parent is understandably still more often plagued by the same worry.\nCertainly the parent wants the pain stopped.\nMany of us acquire a theory for explaining these children's troubles. Some lay the\ncondition to the door of allergy, some to constipation, some to improper diet or habits\nof eating. None of these explanations has seemed entirely satisfactory to me. Abdominal pain demonstrably due to allergy has been very rare in our experience. Constipation\nas a logical cause of pain bothers me because I have seen so many constipated children\nwho were quite happy and untroubled by it. About dietary habits, I am not quite so\nsure. My own theory, and I have no real proof for it, is that children and adults both\nsuffer their occasional digestive gripes and pangs, but that children, being less reticent\nand more concerned with matters of the moment than adults, tend to talk more about\nthese discomforts. If such remarks prove successful as \"attention-getting mechanisms\"\nthey will usually be repeated. Again, I have no means of establishing the truth of this\nconception. If, however, one can avoid the big mistake of mis-diagnosing pain from\nPage 302\nLi*\n*'\n*tfi\nn- *\ni* ft* fe?\nI'\nI\n)|\n\u00C2\u00BB\u00E2\u0080\u00A2(\ntl\n1\na serious organic cause, he can bear to make a little mistake in theorizing about the numerous complaints upon an inconsequential basis.\nOur first job, then, is usually to rule out those cases\u00E2\u0080\u0094roughly, perhaps, half\u00E2\u0080\u0094in\nwhich more exhaustive investigation is, to say the least, an inefficient waste of time and\nmoney, and discuss the residue which suggest to us in some way that something is really\nwrong, and in whom our job is to find out what that something is. We might as well\nget appendicitis out of the way first. The slides, which I have borrowed from Dr.\nGross, are based on a series of 506 patients treated in five and a half years and studied\nby Scott and Ware. Obviously acute appendicitis is, in our region, common in children.\nYou will note from Table 1 that 23 patients were between 1 and 2 years old, so that it\nis obviously not rare in infants. Perforation, which occurs earlier the younger the\npatient, had occurred in all but one of these infants.\nThe younger the patient, the more difficult will be the diagnosis. Pain, which is\nimpressive more by its persistence than its severity, is really the one constant symptom\nor sign. Fever is not striking in the unruptured case and was absent in nearly 20 per\ncent of these. Vomiting is common. In this series, it had occurred in 83 per cent. The\nunhappy and irritable little child with appendicitis will localize his pain poorly and will\nbe completely confused\u00E2\u0080\u0094as will his physician\u00E2\u0080\u0094by questions involving such things as\nrebound tenderness. However, one side of his belly (almost always the right) will be\nfound the site of more discomfort than the other. The rectal palpation of a small and\nfrightened child is often limited in diagnostic value, but here it really helps in two ways\n\u00E2\u0080\u0094by demonstration of unmistakable localized tenderness on the right side, and by the\nsense of resistance offered to bringing the hand on the skin of the right abdomen toward\nthe finger in the rectum. The white blood count is not a very strong diagnostic support\n(Table 2), almost one child in ten having a count of less than 10,000.\nTreatment cannot be discussed here, but two aspects of it are important. Delay is\ndangerous. Seven of the eight deaths in this series occurred when operation was delayed\nmore than 36 hours after symptoms began (Tables 3 and 4). Second, I believe that a\nproperly serious appreciation of the mildness of symptoms will lead to the occasional\nremoval of a normal appendix. Better that this should happen than that a child die\nbecaues his symptoms were not taken sufficiently seriously.\nThe commonest conditions which masquerade as acute appendicitis in children are\nthe abdominal pains associated with throat and ear infections, the pneumonias with abdominal pain, and the not too uncommon instances in which such pain is a manifestation\nof rheumatic fever. All of these are conditions marked by fever and tendency to\nelevated white blood cell count. Those associated with throat infections are far the\nmost common sources of confusion in my part of the country. The tenderness and pain\nmay be localized to the right side, as to any other part of the abdomen. Rectal tenderness is, however, very unusual in mesenteric adenitis. A complete examination, including the ears as well as the throat, is, of course, helpful, but it must be remembered that\nappendicitis may occur in the presence of tonsillitis, and the demonstration of a throat\nor ear infection does not remove an inflamed appendix from the list of diagnostic possibilities. A useful hint is often given by a higher temperature in the abdominal pain of a\nthroat infection than would be expected in that of an acute appendix. In conclusion,\nit must be admitted that the most expert diagnosicians occasionally open a young child's\nabdomen for appendicitis only to find a more or less normal appendix and, usually, fairly\nobvious swelling of the mesenteric glands. Pneumonia is less difficult, especially if one\nthinks of it, watches for a hint of the characteristic shallow and grunting respiration,\nand takes a chest roentgenogram on suspicion\u00E2\u0080\u0094-even though careful percussion and aus-\ncultutation have given negative results.\nThe abdominal pain of rheumatic fever is to us most difficult of all, because its great\ncharacteristic is that it is not characteristic. There is usually, however, less nausea and\nvomiting than in appendicitis, and if one dares to wait, the response to salicylates may be\ndiagnostic. If a history of an earlier cycle of rheumatic symptoms is obtainable, one's\nPage 303 troubles are perhaps easier. But if, among the multiple manifestations of the rheumatic\nstate, abdominal pain happens by chance to be the overture, then the best surgeon may\nbe lured into operating, and need feel no shame if the appendix is normal and joint or\ncardiac manifestations appear a few days or weeks later.\nHaving dealt at some length upon these not uncommon simulators of appendicitis,\nI should just like to mention that infectious mononucleosis and infectious hepatitis may\nsometimes afford confusion, and that children are occasionally seen with primary peritonitis. Then let us consider that other common surgical emergency of the pediatric\nabdomen, intussusception.\nHere, though the diagnosis of intussusception is much simpler, the possibility of its\npresence seems often to be forgotten\u00E2\u0080\u0094perhaps because it is so strikingly limited to a\nnarrow age range of infancy. The usual patient is a male infant of 6 to 12 months,\ncharacteristically attacked by obvious and sudden pain at a time when his physical condition seems better than average. The pain tends to rise and fall in intensity. Either\nvomiting, or blood in the rectum, is almost always present\u00E2\u0080\u0094and usually both. The mass,\nusually along the course of the colon, may require sedation with a barbiturate for its\ndefinite palpation and the use of a sedative for this purpose is a rewarding maneuver.\nOur surgeons seldom use a barium enema, and are in general not fond of the procedure,\nsince it will not reveal the occasional ileo-ileal intussusception. Like everyone else's\nstatistics, those of Dr. Gross's department point to the tremendous value of early diagnostic and prompt operative reduction (pushing, not pulling the bowel back ino place).\nMortality at the Children's Hospital has been nil when operation is performed within 24\nhours after onset, and rises sharply to 30-40 per cent if more than 48 hours elapse before\noperation.\nThere are now to be considered the group of conditions which give rise to recurrent\npain like the functional group, only more definite and severe. These are the children in\nwhom absence of fever, of rectal or abdominal tenderness, and of elevated white count,\nintusssusception-like mass, or blood per rectum make one quite sure he is not dealing\nwith an appendix or its imitators, or with an intussusception. Yet the pain seems to\nbe too marked to be on the basis of simple digestive discomfort, dietary indiscretion, or\nconstipation. Often a careful history will elicit that the chilld has had a good deal of\nit before. Equally commonly, after one has reassured the parents and been cheered to\nfind the pain gone by the next day, the child will later appear at one's office (or someone else's) with the same complaint. In an adult one would think of gall bladder, gastric\nor duodenal wall as the site of the trouble. We have found ulcer to be extremely rare\nand gall bladder disease even more so in our child patients.\nIn these situations we have learned to start by studying the urinary tract before\nstudying the bowel. The best investment of everyone's time, and the patient's (or the\nhospital's) money is a series of intravenous pyelograms. The most frequent diagnosis\narrived at by this maneuver is a recurrent or low grade' hydronephrosis consequent upon\npressure of an aberrant renal vessel upon the ureter. This is a nice diagnosis to make\nbecause one can promise a future free of pain by operating and dividing the vessel, as\none can also perform a useful service in preventive medicine by the same maneuver.\nNow and then, anomalies such as reduplications of portions of the urinary tract are discovered by pyelography in children with painful abdomens, but these conditions more\ncommonly result in urinary infections than in pain. And, in passing, simple acute or\nchronic pyelonephritis has not in our experience been very often so painful as to call\nattention to itself on that score or to suggest appendicitis. The child witjh acute pyelonephritis is usually a more generally sick individual than the one with an inflamed\nappendix, and has a higher white cell count and more fever. Thus, convulsions are\nextremely common at the onset of pelonephritis, but very uncommon in appendicitis.\nIn returning to the urinary tract as a source of diagnosis in children with stubbornly\nrecurrent abdominal pain, I should like to add a few more remarks. One is that we\nfind every now and then the most important pathology in the survey film taken before\n#!\nPage 304 ti.\nM\nthe diodrast is introduced, since renal or ureteral calculi are occasionally encountered.\nSecondly, we insist on a routine skin sensitivity test before subjecting a child to diodrast\ninjection. If a wheal or other sensitivity manifestations are encountered and pyelography seems really indicated, it should be done from below. Finally, our surgical staff\nhas found it a wise measure to do pyelography on any child whose abdomen is to be\nexplored for a suspected but undiagnosed disease process. The reason is that the usual\nlaparotomy incision allows a fairly complete estimate of the status of most organs, but\nnot of the kidneys and upper urinary tract. It would be embarrassing to discover after\nthe laparotomy that the symptoms came from that part of the body which, though nearby, could not be explored.\nGastrointestinal x-rays rarely help to diagnose abdominal pains in children and\nbarium enemas seldom do. The reason for this is that most of the reduplications, mal-\nrotations, and other congenital anomalities which one may hope to demonstrate by these\ntechniques are so much more frequently marked by vomiting than by pain. Moreover,\nmany quite important anomalies, such as those improper mesenteric attachments which\nallow the intermittent wandering of the bowel into unfavorable positions, are frequently\nnot discernible by barium and require exploration (after careful weighing of other possibilities) for their discovery.\nI have no idea what your situation regarding the consumption of raw milk from\nuntested cows is in this part of the continent, but when that was common in our part\u00E2\u0080\u0094\nnot long ago\u00E2\u0080\u0094we saw a number of children with pain associated in some way with\ncalcified abdominal glands. These children had a rural background as a rule, gave a positive tuberculin test, and showed the calcified mass or masses on x-ray. About half of\nthem had a good deal of pain, and after a period of some months' observation, we sometimes had the glands removed\u00E2\u0080\u0094with relief of the pain.\nI have left until nearly the end the question of intestinal parasites.. These have a\nregional distribution, so that you may not have to think about them here. We see the\npinworm, Oxyuris vermicularis, extremely commonly, the tapeworm and the round\nworm only two or three times a year. My own clinical impression is that none of them\nis\u00E2\u0080\u0094with us\u00E2\u0080\u0094to be very seriously thought of as a cause of significant abdominal symptoms. It is true that in a few of the appendices removed by our surgeons, oxyuris has\nbeen found. However, when one considers that random surveys of all children brought\nto our medical clinic with whatever conditions have discovered pinworms in one out of\nthree, the significance of a small percentage of appendices containing these parasites is\npretty questionable.\nIn summarizing, i,t is obvious that many conditions have been left out\u00E2\u0080\u0094such as the\ncolics of infants, the relation of Meckel's diverticula to abdominal complaints, and the\npains associated with certain cases of purpura and\u00E2\u0080\u0094in regions where the Negro population is large\u00E2\u0080\u0094the very confusing crises occcurring in Sickle-cell anemia. These, and\nothers, have been omitted to allow concentration largely upon common conditions which\nmay on the one hand be the source of over-investigation, or on the other be dangerous\nthrough neglect of taking them sufficiently seriously. Let me conclude by repeating\nthen that one need not be ashamed to be unable to label with exactness the cause of\nperhaps half of the abdominal pangs of children if he avoids the mis-diagnosis or too-late\ndiagnosis of the other half. In this latter group, he should keep the thought of appendicitis before him, and try to sort out the distinctions between that and the pains of\nthroat infections, pneumonia, and rheumatic fever. He should never consider obvious\nand severe pain in the abdomen of an infant properly dealt with until he has satisfied\nhis own conscience on the matter of intussusception. An in his handling of recurrent\nabdominal pain in which the symptoms are more than transient in character he should\nlearn to trust the roentgenological study of the urinary tract as his best diagnostic tool.\nPage 3 05 TABLLE 1\nRELATION BETWEEN TYPE OF APPENDICITIS AND AGE\nAge\nIB\nYears\n0\u00E2\u0080\u0094\n1\n1\u00E2\u0080\u0094\n2\n2\t\n4\n6\n6\u00E2\u0080\u0094\n12\n12\u00E2\u0080\u0094\n16\nAcute Unruptured\number of\nAge in\nCases\nYears\n1\n0\u00E2\u0080\u0094 1\n0\n1\u00E2\u0080\u0094 2\n15\n2\u00E2\u0080\u0094 4\n37\nA\u00E2\u0080\u0094 6\n195\n6\u00E2\u0080\u009412\n24\n12\u00E2\u0080\u009416\nAcute Ruptured\nNumber of\nCases\n0\n22\n59\n42\n109\n2\nData from: Scott, H. William, Jr., and Ware, Paul F., Acute Appendicitis in Childhood, Arch. Surg., 1945,\n50, 258-268.\nTABLE 2\nRANGE OF LEUKOCYTE COUNT\nAcute\nUnruptured,\nNumber of\nLeukocytes per Cu. Mm. Cases\nUnder 10,000 25\n10,000-15,000 86\n15,000-20,000 89\n20,000-30,000 50\nOver 30,000 \ 2\n(Scott and Ware, loc cit.)\nAcute\nRuptured,\nNumber of\nCases\n17\n59\n61\n82\n19\nm\nDuration of Symptoms\n0 to 12 hours\t\n12 to 24 hours. \t\n24 to 3 6 hours\t\n36 to 48 hours\t\n2 to 3 days\t\n3 to 4 days\t\n4 to 5 days\t\n5 days and over\t\n(Scott and Ware, loc cit.)\nTABLE 3\n[ OF SYMPTOMS\nAND TYPE\nOF\nAPPENDICITIS\nAppedicitis\nAppend\nicitis\nPer Cent\nJnruptured\nRuptu\nred\nPerforation\nAcute\nAcute\nIncidence of\n67\n2\n3\n116\n36\n23\n28\n28\n50\n24\n43\n64\n11\n19\n63\n14\n34\n70\n5\n11\n70\n7\n61\n90\n#\u00E2\u0080\u00A2\nTABLE 4\nDURATION OF SYMPTOMS IN RELATION TO MORTALITY\nDuration of Symutoms Before Operation\n9 to 12 hours\t\n12 to 24 hours\t\n24 to 36 hours = ,\t\n36 to 48 hours\t\n2 to 3 days\t\n3 to 4 days \t\n4 to 5 -days jj\t\n5 days and over :._\n(Scott and Ware, loc cit.)\nCases\n69\n152\n56\n67\n30\n48\n16\n68\nDeaths\n0\n1\n0\n1\n2\n1\n$\u00C2\u00A3.$\n2\nMortality,\nPercentage\n0.00\n0.65\n0.00\n1.49\n6.66\n2.08\n6.25\n2.94\nPage 306 i ! \u00C2\u00BB\nPHYSIOLOGICAL PECULIARITIES OF NEWBORN INFANTS\n(L\nr.\nClement A. Smith, M.D.\nRead before the Summer School of the Vancouver Medical Association,\nJune, 1947.\nInfant mortality statistics from my part of the United States show that in the last\n40 years the death rate during the first year per 1000 live births has fallen from about\n1445 to 30. Almost all of the saving has been effected in deaths occurring after the\nnewborn period, and thus that period has become the frontier of pediatrics.\nBecause the little patients with whom we deal at this age are fundamentally different\nin various physiological ways from those seen later in life, I am devoting this first period\nto a somewhat rambling discussion of certain of their outstanding characteristics. The\nchild is not a little man, nor is the newborn merely a very small child. Among the differences are certain obvious ones of delicacy and fragility which count as serious disadvantages, hampering us in our attempts to help the newborn. However, I think it\ncan be shown that in other ways there are interesting physiological advantages possessed\nby the newborn infant but denied to older patients. Sometimes we need to be reminded\nof these.\nWithout stretching the facts, I believe the situation may be best suggested by a simple\ndiagram. (Slide shown here.) This smaller circle is a rough diagrammatic concept of\nthe physiological status of our usual child or adult patient, indeed of ourselves as living\norganisms. We exist normally at or near the exact center of a rather narrowly limited\nphysiological field. Scores of ingenious devices have been arranged by Nature to keep us\nat that equilibrium point which Cannon called \"homeostasis.\" I would stress the fact,\nthen, that this field of physiological range in whose carefully guarded center we exist is\nof comparatively narrow compass; that its walls are strong and high, and that we stay\nalmost exactly in its center when well and alter but little from that point even when ill.\nBy contrast, the newly-born human or animal organism is, I think, the occupant of\na wider circle of physiological range. The barrier separating conditions which are\ntolerable from those which are intolerable for his existence encloses more territory. It is\nnot so strong a barrier as that of the adult, as indicated by its more fragile outline in\nthe diagram, and (and this is important) the newborn is less often to be found at its\nexact center. I should like to mention some simple examples of this state of affairs,\nthen to dwell at greater length upon some others, and, in conclusion, to suggest certain\napplications of these observations to our every-day dealings with newborn patients.\nThe infant at birth (and all these things are even mort true of the premature infant)\nhas little of the adult's ability to deal wih body temperature alterations. Injudiciously\ncover him with blankets and his temperature may jump to 104\u00C2\u00B0 or more; subject him to\nexposure and it may fall below 90\u00C2\u00B0. But, while neither of these experiences is in any\nway good for him, he will usually survive them with less evidence of affront than will a\nshocked adult whose temperature has not been distorted half as much. And, in passing,\nwe do not expect to find that even under normal room temperature conditions the thermometer will demonstrate the infant's temperature at exactly the 98.6 level where the\nadult's is held.\nThe blood sugar of the newborn is not uncommonly as low as 40 mgm. per cent\nduring the first day of life in perfectly normal babies. Not only is it often not immediately and correctly righted from this point by physiologcal adjustment\u00E2\u0080\u0094as would\noccur in ourselves\u00E2\u0080\u0094but while it is at this low level the newborn baby does not seem\nparticularly embarrassed by the circumstances. An older child might well be in hypoglycemic shock with a blood sugar of 40. Again, I am not saying that it does the\ninfant any good to have this hypoglycemia. What is to be stressed is that Nature has\nequipped him so that such a level is physiologically tolerable, whereas it could not be so\neasily tolerable by an older individual.\nPage 307 As to acid-base balance and its regulation by the kidneys and lungs, we have less\ndata for the newborn subject. But we do know that the pH of his blood is not so exactly\nfixed at 7.4-7.5, as with the adult, and if it wanders down to 7.2 or so, he gives less\nevidence of trying to put it right by hyperpnea than he would in later life. Moreover,\nwhile a pH of less than 7 is supposedly too much acidosis for the human organism to\nsurvive, in laboratory investigation I have at least once found an infant whose blood at\nbirth showed a pH of 6.69, and who lived through it. The experience did not benefit\nthe baby. The point is that neither did it demolish him. These, ten, are a few simple\nexamples of the wider range of tolerable physiological situations within which the newborn subjects stray.\nNow let us scrutinize a few of these peculiarities more closely. Respiration, when\nconceived in its ultimate function of bringing sufficient oxygen to the tissues, is a\nmatter of prime significance in the newborn. What do we know about its fundamentals? One thing we know from experimental animals is that the newborn has a\nrelatively wide tolerance to lack of oxygen. It is apparent from Table 1 that newborn\nanimals possess means of continuing to live during periods of oxygen lack long after an\nolder animal would have succumbed.\nAs to the human infant's performance, we have, of course, no experimental data.\nYet we have some impressions based upon the persistence of heart beat for many minutes without breathing. Most of us have worked over a newborn infant for five or ten\nminutes or even more to induce respiration\u00E2\u0080\u0094and often been successful. An infant\nwhose blood oxygen we happened to be following took no breath at all for 14 minutes\nafter birth and then began to breathe, which he has continued to do successfully since.\nThis, I think, is beyond the record to be expected from an adult.\nThe newborn then does have more latitude in regard to bearing anoxia than does the\nolder organism. Let me say again that this is not necessarily good for him in all instances.\nIt has been, however, an extremely fortunate circumstance for the human race as a\nwhole, even though it is occasionally the cause of persistence of life in damaged individuals.\nNot only is this wider latitude of tolerable anoxia present right at birth, it appears\nto linger for some days or weeks thereafter, during which time, as in our crude diagram\nshown earlier, these small patients do not exist at the exactly balanced center of the\nbroad area of allowable oxygen economy. Close observation will show that in the newborn period babies do not usually breathe regularly and smoothly, but at times slow,\nvery often their rhythm has a Cheyne-Stokes-like periodicity, sometimes they seem to\nforget to breathe at all. Only gradually do the nice adjustments of respiration to which\nwe are accustomed supervene.\nIt will not be possible to build up a detailed explanation of why the newborn subject\ncan exist over such a wide range of respiratory possibilities nor why he seems to wander\nso much at random through the range. I should only like to point out a few of the\nfactors concerned.\nOne, about which we shall probably hear much more in years to come, is the so-\ncalled \"anaerobic metabolism\" characterizing the period. In some way, and I shall mention it, the fetus and his successor, the newborn infant, seem to have their fundamental\ntissue metabolism of glucose breakdown adjusted to produce more organic acids and less\nC02 than later in life. Another factor is the excess of hemoglobin accumulated during\nthe final fetal months. Not only is the newborn endowed with an excessive amount of\nhemoglobin. His hemoglobin is qualitatively a different protein from that of the adults\nwith whom we usually deal, its differences being such as would contribute to efficiency\nunder circumstances of oxygen lack. This is shown in three slides indicating that the\nembryonic or immature creature has a hemoglobin which takes up oxygen under circumstances at which the usual adult hemoglobin would have to relinquish it.\nBefore we leave the subject of respiratory peculiarities in neonatal patients, I would\nlike to mention two circumstances of a purely circulatory nature which suggests a tem-\nPage308\n!\u00E2\u0080\u00A2\nIK\n\u00E2\u0096\u00A0wi\n\\ni* I\nI\nM\nf\nporarily advantageous state of affairs in the newborn patient. One is that the heart at\nbirth has just been relieved of the work of pumping about a third of the blood volume\nthrough about 80 cm. of umbilical cord and placental vessels. Consequently, during\nthe first two weeks after birth, the heart grows less rapidly than until then. The other\nis the remarkable adjustability of the infant in the face of a varying blood loss left\nbehind in these vessels when the cord is clamped at birth. Look at two newborn babies,\none of whom has had the umbilical cord tied immediately upon delivery, whereas the\nother has been allowed to retrieve his placental blood by the obstetrician's waiting until\npulsation ceases before clamping the cord. The former will have given up about as\nmuch as a 2.5 liter blood loss would be in an adult. And yet you would be unable\u00E2\u0080\u0094at\nleast I am unable\u00E2\u0080\u0094to tell the deprived baby from the other by anything short of careful blood studies, so great are the powers of circulatory adjustment at this time.\nNow let us examine excretory physiology for physiological peculiarities. The kidneys\nhave been shown by certain workers (notably McCance and his colleagues) to be somewhat less adequate in performing their jobs during neonatal life than later\u00E2\u0080\u0094as is quite\nunderstandable when one recalls that they have had little or no practice, excretion\nhaving been taken care of by the placenta. Yet, seen from certain angles, the kidneys\ndo not do so badly under newborn circumstances, and what is more to the point, the\ninfant seems at this period able to withstand the effects of his relatively impaired renal\nperformance.\nThomson's figures on the urine of normal newborn infants were obtained with an\naverage fluid intake of about 100 cm. during the first two days of life, in contrast to\nour infants who get no fluid during these days. Thomson's data, as shown in the next\ntwo slides, are interesting. Note not only the respectably high specific gravity achieved,\nbut also the degree of variation. Note also the very wide range of urine output soon after\nbirth. Certain infants passed no urine over 24-hour periods (I do not mean to imply\nthat their kidneys made no urine) others passed from 60 to 80 cc. Imagine yourself\nfaced with a group of supposedly healthy adults, some of whom pass no urine in 24\nhours, while others get rid of a liter and a half during the same period. . You would have\nconsiderable respect for organisms able to tolerate such a wide degree of excretory\nlatitude.\nHere are two slides of material from work in progress in our laboratory on one\naspect of renal function in premature and full-term infants. It will be seen that when\nit comes to the job of making a little water go a long way by excreting a concentrated\nurine, even the premature infant's kidney does fairly well.\nLet us look for just a minute at matters of nutrition. Until the time of birth, the\ngastro-intestinal tract is one of the few vital parts of the body which has done no work\nat all. Two weeks later, the average infant is taking at least 2J4 ounces of milk per\npound per 24 hours. If I took 2l/z ounces of milk per pound per 24 hours, I should\nhave to digest 450 ounces, or about 14 quarts of milk. Every 4 hours around the clock,\nmy alimentary canal would have to handle nearly 2 x/z quarts of milk. Even with a good\nmany years of practice, I doubt if it could be done. This is, of course, an oversimplification. A more significant point is that infants, when born, are in a position to go a\ncouple of days, at least, without any water, and a good deal longer without any calories,\nand still come up to the mark of meeting their relatively tremendous digestive responsibilities a few days later.\nI am aware that you may take all I have been saying in exactly the wrong way. I\ndo not mean to imply that newborn infants are so excessively rugged that we should\ndeprive them of oxygen, water, and other requirements of life. What I do wish to\nsuggest is that they are physiologically different creatures from those we deal with in\nlater years, and that their differences are here and there of a sort which are singularly\nuseful to them, and to us in helping them survive. (Indeed, it is likely that without\nthese adaptabilities few of them would have survived before we were around to help\nthem.) I also wish to stress the fact that, since they do not exist in the exact center\nPage 309 of a limited circle of physiological possibilities, well-meaning attempts to get an infant\nfrom a borderline situation to a more satisfactory one may push him beyond the point\nof our aim. Thus, a few extra blankets or a heat lamp applied to a small and chilly\ninfant may raise his temperature not to 98.6 but to 1042. One may, at times, administer\nextra fluid to a somewhat dehydrated infant, only to rapidly overshoot the mark and\nproduce severe edema.\nI have used this first lecture period to discuss these matters not merely because they\nseem to me interesting but because we often feel they are overlooked to the detriment\nof the baby. This is more apt to be true in the case of the premature than the full-term\ninfant, but it is observed in both. For example, we see in our Children's Hospital many\nmore premature and other newborns brought to us in trouble because they have been\nfed too early and too much than too little and too late. Much better that a baby should\nbe unfed and hungry at four days of age, even though considerably under birth weight,\n\u00E2\u0099\u00A6\u00E2\u0096\u00A0han that he should be vomiting from over-feeding with food he neither wanted nor\n\u00E2\u0080\u00A2needed. We often see mild edema made worse because the kidneys have put out little\nfluid and someone has become over-anxious and inserted some salt solution under the\nskin where merely waiting would have served. We used to see obstetrical house officers\npounding infants who did not breathe at once on emergence from the birth canal, whereas\nmerely leaving the infant undisturbed in a warm oxygen tent might be sufficient and\nsafer. And we often see hurried activity of all sorts confusing the diagnosis, where time\ncould better be spared for quiet consideration of symptoms.\nIt is, then, our feeling that infants are as often\u00E2\u0080\u0094perhaps more often\u00E2\u0080\u0094overtreattd\nthan undertreated. What is it that constiutes the line between masterly inactivity and\ncriminal negligence; between watchful expectancy and dangerous procrastination? Actually, it is what is implied in the words \"masterly\" and \"watchful.\" If we do master\nthe physiological distinctions of these infants and if we are really \"watchful\" in their\ncase, we shall be neither dangerous nor criminal in our dealings with them.\nTABLE 1\n(Data of Snyder and Webster)\nIt*\nits-\nit\n,4P\nPM\nSURVIVAL TIME IN PURE NITROGEN AT VARIOUS AGES\nAge Rabbits Dogs\nAt birth 31 min. 31 min.\n1 day 27 25\n4 days 13 17\n7 days 9 14\nAdult j 1.5 3\nGuinea Pigs\n6 min.\n4.5\n3.5\n3\n3\nf\u00C2\u00BB' *i\nFOR-SALE\u00E2\u0080\u0094In Yorkton, Saskatchewan, Eye, Ear, Nose and Throat\nSpecialty practice with two complete Ritter Chairs with Units and\nGreen Retractor Heads and all complete equipment. Exceptional opportunity for any Eye, Ear, Nose and Throat man. Yorkton serves an area\nof approximately one hundred thousand people. For further information write to Mrs. R. E. Whitteker, Box 730, Yorkton, Sask.\nr\nPage 310 m\n}i\nm\nn\n#\n\u00C2\u00BBi\n'It'\nDISEASES OF THE NEWBORN:\nASPHYXIA, ATELECTASIS, ERYTHROBLASTOSIS\nClement A. Smith, M.D.\nIn a very simple way, it is possible to divide the problems which arise out of the\nbirth process and affect the infant into two major groups\u00E2\u0080\u0094those of mechanical obstetrics and those of physiological obstetrics. Emphasis is increasingly shifting from the\nmechanical to the physiological aspect. This is borne out by two sets of data to be shown\non slides (Tables land 2).\nThese figures teach us that our obstetricians have got the answer to all but an almost\nirreducible minimum of the mechanical problems. No trauma, but anoxia (or asphyxia),\nnow leads the fist of easily attacked causes of fatal loss. That is why I thought we\nshould begin with the general subject of respiratory difficulties.\nIn doing so, it might be helpful to sketch out the present status of information on\nhow the baby normally begins to breathe at birth. The facts about this matter seem to\nbe pretty well cleared up, largely by the work of Barcroft. Just before his death, he\npointed out that there were two main types of respiratory movement observable both\nin the fetus and in the newborn infant or animal. One of these is rhythmical, it has a\nvery definite inspiratory component, and a very definite expiratory component, and it\noccurs in response to all sorts of superficial stimuli. In the human infant there may be\ncrying instead of this sort of respiratory movement, particularly if the stimulus is excessive. In the animal fetus, if the mother's abdomen is opened under spinal or local anesthetic, this type of movement is elicited with increasing ease as term approaches. Near\nterm, simply bringing a hypodermic needle near the nose of a quiesscent sheep fetus\nand gently directing a current of amniotic fluid at its face will start such movements.\nThey seem to be the sign of an intact respiratory center\u00E2\u0080\u0094actually of an integrated series\nof intact respiratory centers.\nOn the other hand, the fetus is capable of an entirely different type of respiratory\nperformance, as it the newborn subject also. This is essentially an instantaneous gasp,\nwith only an inspiratory component. It is entirely irregular in timing. It is never\nproduced by peripheral stimulation nor punctuated by crying. Characteristically it may\nbe best produced experimentally by opening a pregnant animal at term under deep general anesthesia and then pinching the umbilical cord leading to a fetus. In about a\nminute, the fetus will begin to gasp in this way. This inefficient, irregular gasping has\nbeen seen by all of us in certain infants at birth, indeed, in dying patients at any age.\nAs Barcroft has pointed out, the gasps are exactly like those produced by cyanide and\nindeed they have the same meaning\u00E2\u0080\u0094a poisoned or dying respiratory center.\nSometimes this poisoning in the newborn infant is from too much anesthetics, more\noften too little oxygen, as in placenta previa, pressure on the cord, etc., often a combination of the two. Sometimes, it means damage from intra-cranial bleeding. The\none thing most useful in curing it is an increase in the amount of oxygen reaching the\nbrain. Now, fortunately for the human race, if these irregular gasps continue long\nenough, especially if extra oxygen is provided, they may bring enough of it to the blood\nand thence to the brain so as to induce the more normal type of rhythmical response.\nAs Barcroft puts it, \"The last gasps of the dying fetus may open the door to life for\nthe infant.\" If this does not happen, the irregular breaths or gasps peter out, and the\nbaby dies.\nIn summarizing then, perfectly normal, natural delivery, with cord and placenta\nintact, will Usually produce an infant whose rhythmical, efficient respiration starts right\noff\u00E2\u0080\u0094apparently from cutaneous stimuli. Delivery which is abnormal\u00E2\u0080\u0094in numerous possible ways\u00E2\u0080\u0094may result in an infant with an entirely different respiratory performance,\nbut which is often capable of being transformed into the other, by skilful handling.\nBetween these lies a whole spectrum of possible gradations.\nPage 3 11 Among the ways in which the nervous control of breathing can be damaged at birth\nare: too much pre-anesthetic medication; too much anesthesia; too little oxygen with\nthe anesthetic; premature separation or placenta previa; compression of the cord; trauma\nto the brain; or an enfeebled control of respiration, as in prematures. I would just like\nto discuss our own feelings about the narcosis-anesthesia problem, and our treatment of\nthese babies, with a word as to their ultimate course.\nWe believe that pre-anesthetic medication and inhalation anesthesia offer more good\nthan harm. We do not believe that any drug introduced into the mother's circulation\nand capable of producing real analgesia or even amnesia will not slow up the onset of\nrespiration in some\u00E2\u0080\u0094perhaps one-third\u00E2\u0080\u0094of the babies. We thought demerol was going\nto be such a drug, but, with more experience, have more or less given it up and gone\nback to mixtures of nembutal and scopolamine, potentiated, oddly enough, with a small\namount of amorphine. Our obstetricians usually deliver the baby under ether, given\nby machine, so that oxygen can be added. They have pretty well given up cyclopropane, and regard nitrous oxide mixtures as potentially, if not actually, hazardous. Spinal\nanesthesia is not regarded as safe enough for a routine, and the feeling about caudal\nanesthesia is still more strong.\nThe best pre-anesthetic medication is the one with which the user has had the greatest experience, though I'm not sure if morphine comes under that rule. The best delivery anesthetic is also the one most f amiliar to its user, though we would disallow caudal\nunder that rule, and might not allow spinal or nitrous oxide either. The best medication\nan anesthetic for delivering a premature is no medication or anesthetic at all.\nNow, let us suppose we have\u00E2\u0080\u0094as we do have from time to time\u00E2\u0080\u0094an asphyxiated,\nor, as we should say, an anoxic baby to work with. He may not be breathing at all, or\nhe may be gasping irregularly\u00E2\u0080\u0094the diagnostic implications are the same. It will do\nlittle or no good to apply cutaneous stimulation\u00E2\u0080\u0094his respiratory state indicates that he\nwill not respond. We should secure a reasonably open airway by posture and suction\n(though in our clinics we have not encouraged laryngoscopy) and then we should inflate\nthe lungs with oxygen in some simple manner. After trying many machines, we always\ncome back to a home-made modification of that devised by Kreisleman. Our feeling is\nthat rupture of the lung is not a very likely possibility, and that often one has to use\n, considerably more force than that advised by makers of resuscitating devices\u00E2\u0080\u0094up to 3 5\nor 40 cm. H20 (26-30 mm. Hg) for the first expansions. The need for this has been\nshown by experiments in our clinic\u00E2\u0080\u0094as has been the safety of such pressures. We have\nalways felt that oxygen works better than C02 and oxygen, but there is not time to go\ninto that argument. There is almost no modern testimony now available in favor of\ndrugs as respiratory stimulants, and we certainly can add none. There is certain testimony suggesting they may do harm. Once breathing improves, it goes without saying\nthat warmth, watchfulness, and an oxygen tent will be required for hours\u00E2\u0080\u0094sometimes\nfor days.\nHow many infants who have been subjected to severe anoxia at or before birth?\nwill later show permanent central nervous system damage is a matter upon which wc\nneed information, as asphyxiated infants who developed normally are missed by this\nmethod. It seems clear that tragic sequelae do occasionally occur, but we are as yet in\nno position to condemn the whole practice of obstetrical anesthesia and analgesia because of them. What we should do is to strive to accumulate scientifically sound data\nabout the whole problem, and to improve our use of drugs in obstetrics, and our alertness and skill in dealing with their occasional consequences.\nBefore leaving the subject of respiratory difficulties in the newborn, I should like\nto say a word about atelectasis. Every baby at birth has completely atelectatic lungs.\nX-rays of normal-appearing infants at 10 days of age have shown that, in perhaps 20\nper cent of them, some parts of the lungs have not expanded (i.e. some atelectasis is\npresent). Atelectasis is thus a relative matter. If a serious degree persists, it is not a\ndisease condition in itself so much as a sign that something is fundamentally wrong in\nPage 312\n!\n'U\nI\nIf j\nMl\nil\n!, /;\nm\nu\n\u00E2\u0080\u00A2 ;\nI'.\n'\u00E2\u0096\u00A0>}\nKi\nCause of Death\nAnoxia\t\nPrimary prematurity\t\nCongenital malformation \t\nBirth trauma\t\nInfections\t\nErythroblastosis .\t\nHemorrhagic disease \t\nSyphilis \t\nMaceration and maternal toxemia-\nMaceration, no toxemia\t\nUnknown, not macerated\t\nMiscellaneous \t\nTotal mortality \\u00E2\u0080\u0094j\t\nMortality, over 1,000 Gm\t\nTotal cases .\t\nStillbirths\t\nNeonatal deaths\t\nDuration of study\t\nNew York Lying-in\nand Sloane Hospital\nfor Women\n19.8 per cent\n18.5\nChicago Lying-in\nHospital\n1935-1940\nml\nTABLE 2\nINCIDENCE OF TRAUMATIC AND ASPHYXIAL HEMORRHAGE\n1931-1935 Compared with 1941-45 (Boston Lying-in Hospital)\nSubjects Post-mortem Examinations\nNumber Per cent showing:\nA. Traumatic B. Asphyxial\nHemorrhage Hemorrhage\nPremature stillborn 1931-35 42 9.5 7.2\n1941-45\". 52 7.8 13.5\nPremature liveborn 1931-35 63 35.0 9.5\n1941-45 89 20.2 12.4\nTerm stillborn 1931-35 54 24.0 7.4\n1941-45 84 10.1 11.4\nTerm liveborn 1931-35 60 50.0 10.0\n1941-45 103 22.5 18.4\nMortality (Combined neonatal deaths and stillbirths of viable fetuses):\n1931-3 5 \u00E2\u0080\u0094 5.05 per cent\n1941-45 \u00E2\u0080\u0094 3.65 per cent\nPage 315 DISEASES OF THE NEWBORN:\n1 DIARRHEA, PREMATURITY\nClement A. Smith, M.D.\nIt is clear from experience and the literature that since about 1938 an increasing\nnumber of epidemics of diarrhea have occurred among young infants, particularly in\nobstetrical nurseries. It is difficult to describe this as a disease entity because the descriptive term \"Epidemic Diarrhea of the Newborn\" has undoubtedly served as a waste-\nbasket into which conditions of varying etiology have been tossed. We can, however,\nsort three major groups of conditions out of this wastebasket.\nThe first of these includes tht outbreaks caused by a demonstrable micro-organism,\nsuch as a strain of salmonella;, a staphylococcus, or even a dysentery bacillus. These\nare usually febrile infections with a fulminant onset, and represent the easiest type of\nepidemic to bring under control. A second group consists of diarrheal disease occurring\nconcomitantly in both adult and infant members of a community. The adults have a\nmild disease presumably of virus etiology and usually labelled grippe, or \"intestinal flu.\"\nThough most severe in younger infants, these attacks are not spectacularly dangerous,\nand are usually manageable mainly on a basis of simple epidemiology and therapy. Finally, there are the outbreaks in which no organism is demonstrated, no adults are usually\ninvolved, and the disease passes mysteriously and often fatally from one small infant\nto another. At least two viruses appear to have been isolated from such epidemics\u00E2\u0080\u0094one\nby Light and Hodes, the other by Buddingh and Dodd. How consistently these same\nviruses will reappear in other epidemics remains to be seen.\nIs this a new disease? The situation seems to me analogous with the position of infectious hepatitis during the last war: There, a relatively mild and infrequent disturbance\nof peace-time became, through the unusual circumstances of overcrowded troop conditions, an epidemiological problem of great importance and a serious and sometimes\nfatal disease. The unusual circumstance which has created the diarrhea problem among\nnewborns may well be the recent great increase in hospital as compared to home deliveries?\u00E2\u0080\u0094an increase with which the available number of beds and nurses has not kept pace.\nTherefore, this may well have been an occasional disease of the past which new circumstances have brought into great prominence.\nOur pediatricians seldom encounter these conditions in the home care of infants\nunless the baby was recently sent home from an obstetrical or infants' hospital where\ncases occurred. It is, on the other hand, an important problem of pediatrics in hospitals,\neither obstetrical ones or hospitals like ours for infants\u00E2\u0080\u0094which act as the vortex of a\nfunnel collecting sick babies from the newborn nurseries over a large community.\nSince the condition is ill-defined, only a very general symptomatology can be given.\nIn epidemics of the first sort, due to specific bacterial infection, fever is common; if\nstaphylococci are causative agents, pustular skin rashes may occur. Otherwise, watery\nstools, vomiting, more or less distension, dehydration and acidosis (often more marked\nthan hyperpnea indicates) make up the picture. Blood count, blood cultures stool cultures, etc., are not revealing unless one is fortunate enough to be dealing whlh a specific\nmicro-organism. Spread to nearby infants is so characteristic that, as Clifford has said,\ntwo cases equal an epidemic. The infectiousness and seriousness of the condition can\nnever be predicted from the first case, so that even one case must be very seriously\nregarded.\nAs to the mechanism of spread, all that can be said is that indirect fecal-oral contact\nsuch as may happen from poor technique, overcrowding, insufficient attendants, and\nimproper food handling, appears to be more important than air-borne contamination or\n\u00E2\u0080\u0094in most epidemics\u00E2\u0080\u0094than immune adult carriers. Soap and water cleanliness, individualization of supplies, autoclaving or steam sterilization of formulae in the bottle with\nnipple (covered) attached, all seem to be more useful interrupters of spread than are\nmasks and sterilization of air.\nJ\\n\u00C2\u00AB*j'i\nI\ni\u00C2\u00AB\nPage 316 ?fi\nm\nn/\n\u00E2\u0096\u00A0\u00E2\u0096\u00A0*\nv:\nt\u00C2\u00AB\nThe relationship of breast-nursing to resistance is unsettled, but certainly for many\nobvious reasons this type of feeding increases the safety of infants, if not actually protecting them.\nIn the recently published statistics of Rubenstein from 19 Massachusetts epidemics,\nthe disease was acquired by 50 per cent of premature infants and by 20 per cent of full-\nterm infants exposed. The same study showed an average case fatality rate of 53 per\ncent for premature infants and 25 per cent for full-term ones. In several epidemics all\npremature infants who were infected have died, as well as nearly half the infected full-\nterm infants.\nNo specific preventive or therapeutic results have been noted from transfusion of\nblood or plasma, injection of gamma globulin, or the use of sulfonamides, penicillin, or\nstreptomycin.\nHow, then, should an epidemic of diarrhea or an individual case be managed? The\nkey procedure for stopping an epidemic are (1) absolute isolation of infected patients,\n(2) prompt recognition and declaration of the situation rather than attempts to minimize or conceal it, (3) delegation of responsibility to one staff physician, (4) stool\ncultures, which may later be abandoned if no significant organisms appear, (5) critical\nstudy of techniques of food preparation and nursing care, and (6) readiness to close for\ncomplete cleaning any ward in which cases persist in appearing in spite of the foregoing measures.\nIn the individual infant, therapy must be one of replacement of electrolyte, water,\nand other losses. At present, we are trying a modification of the routine recently advocated by Darrow and others, which introduces potassium in relatively high concentration\nto replace loss of intracellular electrolyte. \"Darrow's solution,\" made as follows, has\nthe chemical structure indicated:\nK\nKC1\n\u00E2\u0080\u0094 2\ngm.\nNaCl\n\u00E2\u0080\u0094 3 gm\nMolar sodium lactate\n\u00E2\u0080\u0094 40 cc.\nWater\n\u00E2\u0080\u0094 710 cc.\nNa\nCI\nLactate\n\u00E2\u0080\u0094 35 mM./L\n\u00E2\u0080\u0094 122 mM./L.\n\u00E2\u0080\u0094 104 mM./L.\n\u00E2\u0080\u0094 53 mM./L.\nThe routine therapy at present on trial in our own wards is carried out as follows:\nFirst day Nothing by mouth.\nBy I. V. drip \u00E2\u0080\u0094 10 cc. matched blood per lb.\n\u00E2\u0080\u0094 10 cc. M/6 Na lactate or NaHC03 per lb.\n\u00E2\u0080\u0094 40 cc. 10 per cent glucose solution per lb.\n\u00E2\u0080\u0094 40 cc. Darrow's solution per lb.\n\u00E2\u0080\u0094100 cc. per lb.\nA (if vomiting, distended, or especially weak):\n\u00E2\u0080\u0094 55 cc. 10 per cent glucose.\n\u00E2\u0080\u0094 30 cc. (l/z Darrow's solution % 5 per cent glucose).\n\u00E2\u0080\u0094 85 cc. per lb.\nor B (if able to eat) :\n\u00E2\u0080\u0094 20 cc. Darrow's solution with\n\u00E2\u0080\u0094 60 cc. 5 per cent glucose solution.\n\u00E2\u0080\u0094 80 cc. per lb.\nThird day. Continue A or B above.\nFourth or Fifth day. Begin orally, 5 or 10 calories per lb. of dilute skim milk, with\nwater to make 75 cc. per lb. To this is added 1 gm. to 2 gm. of KC1 daily, depending\non the size of the infant and dividing among the feeds. Calories are increased very\nslowly, so that most infants are still receiving less than 50 calories per pound by 10 or\neven 14 days after treatment was begun. One cc. of crude liver extract is given intramuscularly every day from the first, and chemotherapy only on definite indications.\nPage 317\n(up to)\nTotal\nBy S. C. clysis\nSecond day.\nBy I. V. drip\nBy S. C. clysis\nTotal\nTotal\nBv mouth We have not yet been strikingly impressed with the results of this treatment, and I\nintroduce it here merely because Dr. Darrow and his colleagues, for whom we have\ngreat respect, have introduced it to us. Our mortality is perhaps 10 per cent at present,\nbut the slow and interrupted progress the infants make, with many set-backs requiring\nre-starting treatment has been a very impressive feature of the problem. Certainly we\nhope as fervently for means of preventing this condition as for methods of curing it.\nPrematurity\nSince prematurity, although occurring only in about 3 per cent of all deliveries, is\ndirectly or indirectly responsible for 50 per cent of neonatal deaths, we will conclude\nwith some very brief remarks about the care of such infants. Our diagnosis is purely\nby weight, as we consider any baby of less than 5 lbs. to be premature. At the Lying-in\nHospital, where babies are brought directly from the delivery room to the air-conditioned\nspecial nursery, their mortality is about as follows:\nBirth weight 1\u00E2\u0080\u00945 lb. about 30 per cent\n1\u00E2\u0080\u00942 lb. \" 95\n2\u00E2\u0080\u00943 lb. \"66\n3_4 lb. \" 25\n4\u00E2\u0080\u00945 lb. \" 2-5\nIn the Premature Nursery at the Children's Hospital, to which babies are brought\nfrom a few hours to a day or two old, our death rate is almost 50 per cent rather than\n30 per cent, although almost exactly the same techniques are used. The main difference\nis that infants admitted to the latter nursery may have been skilfully delivered and less\nprotected from trauma and infection than the ones born at the Lying-in Hospital.\nPremature infants present a list of specialized problems. First is that of respiration.\nAs factors preventing or relieving this problem, we believe the following are especially\nimportant: (1) the most normal delivery possible; (2) no analgesia or general anesthesia,\n(3) oxygen for days or even weeks after birth, (4) careful observation with gentle\nsuction of mucus and occasional superficial stimulation if needed (by an experienced\nnurse), and (5) delay of 24 to 48 hours or longer in instituting feeding (see below).\nFor the temperature problem, stability is more important than an arbitrary level of\n98.6\u00C2\u00B0. A steady temperature of 93\u00C2\u00B0 or even less is preferable to one fluctuating widely\nabout 98\u00C2\u00B0 or 99\u00C2\u00B0. Temperatures should be taken by axilla. A constant environment,\nboth as to temperature and humidity ,can be supplied by an air-conditioned room or by\none of the incubators devised by Dr. C. C. Chappie of Philadelphia, which have the\ngreat advantage of providing the infant with his own individual amosphere which is not\nbreathed by the nurses, doctors, and other infants. Of less expensive incubators not\nproviding conditioned outdoor air, the Armstrong type is a good one.\nThe nutrition problem is approached by us from the attitude that fluid and food\nare not urgent requirements during the first two or three days, and that each feeding\nis a time of potential accident to the respiratory tract. Therefore, the more precarious\nthe baby's condition, the longer do we delay the first feeding, delays of four days being\nnot unusual. The gavage feedings are given at two- or three-hour intervals for twO-\nto three-pound babies, at four-hour intervals for larger ones. Conventionally, we begin\nwith 5 or 10 per cent lactose or glucose in water, in increasing amounts of 1, 2, 3, and\n4 drams for the smaller, and 2, 4, 6, and 8 drams for the larger infants. At the 4- or 8-\ndram level, the solution is replaced one or two drams at a time by breast milk. Later\nincreases are gradually made so that by 10 to 14 days of age the infant is getting his\nmaximum of 65 calories per pound, if in good condition.\nThough we still use breast milk, Levine and Gordon have brought considerable evidence to show that modified milks with more protein, carbohydrate, and minerals, and\nless water and fat may be better utilized by the premature (not full-term) infant.\nLevine's best results have been obtained with the following mixture:\nPage 318\nfa' *| ' I ii'.\n:K i?S n\nSi it i\nHalf-skimmed milk powder (\"Alacta\") \u00E2\u0080\u0094 1 tbsp./lb.\nCarbohydrate (Dextri-maltose or Karo) \u00E2\u0080\u0094 5 gm./lb.\nWater to 2l/4 oz./lb.\nMakes 55 cals./lb.\nBeside the basic diet, the premature has obviously increased need for accessory food\nsubstances, which we introduce by the end of the second week as:\nAscorbic Acid 50 mg./day\nVitamin D 1,000 to 4,000 U./day\nVitamin A 2,500 to 5,000 U./day\nSupplied in a non-oil vehicle such as propylene glycoll in\n\"Vi-penta.\" This will also provide adequate Vitamin B\ncomplex.\n(Vitamin K \u00E2\u0080\u0094 2.5 mgm. at birth.)\nIt is our supposition also that, although the infant may at first be physiologically\nunable to manufacture hemoglobin, provision of 20 to 40 drops daily of elixir of ferrous\nsulfate from the third week onward will provide available iron at such time as he may\nacquire this ability.\nFinally, one constantly faces an infection problem. Reducing to a minimum the\nhuman contacts of a premature infant is the major requirement. Separation of prematures and their nurses from others, especially from sick infants, is almost equally important. Education of the profession toward immediate admission of such infants at\nbirth to a central premature station is extremely worthwhile. It may well be that half\nthe advantage of an air-conditioned premature nursery to a community is actually that\nisolation and separate staffing provide or contribute to the provision of these desirable\nprophylactic measures against infection.\nm.\n\u00E2\u0080\u00A2 \m\nE\ni*\nt*\n'\u00C2\u00AB* l\nNOTICE\nLocum Tenens, Assistantships, Partnerships, Locations for Practice, Etc.\nAll doctors who are available for locum tenens, assistantships, etc., are requested to\nforward the particulars to the Executive Secretary of the College of Physicians and\nurgeons, Room 203, Medical Dental Building, Vancouver.\nDoctors now established in practice who are looking for suitable partners or assistants\nare similarly requested to forward particulars to the Executive Secretary.\nMany enquiries are received each week from doctors in the Province, and outside it,\nfor information regarding openings available.\nEvery effort will be made to comply with individual wishes and requirements and to\narrange for suitably qualified men to meet each other so that private matters re finance,\netc., can be discussed.\nW\nPage 3 19 British Columbia Medical Association\n(Canadian Medical Association, Britsih Columbia Division)\nPresident Dr. Lavell H. Leeson\nPresident-elect '. Dr. Frank Bryant\nVice-President Dr. W~. Laishley\nHonorary Secretary-Treasurer . Dr. J. C. Thomas\nImmediate Past President '. Dr. Ethlyn Trapp\nREPORT OF REPRESENTATIVE ON EXECUTIVE\nI COMMITTEE, C.M.A. |\nTo: The President, Officers and Members of the\nBritish Columbia Medical Association.\nAs your representative on the Executive of the Canadian Medical Association for\nthe term 1946-47, I beg to report as follows:\nI ATTENDANCE AT MEETINGS\nI attended two meetings of the Executive Committee in Ottawa, one in October,\n1946, and the other in March of this year. I also attended a meeting in Winnipeg in\nJune of his year. It so happened that the National President was also from British\nColumbia, in the person of Dr. Wallace Wilson. The British Columbia doctors were\nfurther represented at the June session in Winnipeg by Dr. Ethlyn Trapp, President,\nand Dr. F. L. Whitehead, our new executive secretary, who sat in as observers.\n2. SUMMARY OF PROCEEDINGS\nThis summary will be boiled down to bare essentials, as there is much other important\nbusiness to consider at this meeting and I do not wish to take up too much time.\n(a) Medical Care of Veterans.\nAs you know, a D.V.A. schedule of fees has finally been worked out and sent to\nall doctors. While it might casually appear that D.V.A. work has pretty well petered\nout as far as civilian doctors are concerned, it should be remembered that should work\nbecome more scarce and incomes less, this activity might easily become of renewed\nimportance.\n(b) Income Tax\nIt has long been felt that doctors have been unfairly discriminated against in the\nmatter of income tax. I shall not go into details but a strong committee has been quite\nactive in this regard and finally have reached the responsible cabinet ministers. They\nhave achieved some definite reforms and the promise of serious consideration of other\npoints.\nTo date the chief accomplishments are:\n(1) Motor car depreciation has been raised from $1750 to $2500.00.\n(2) Mileage has been raised from 4J4c to 7c per mile beginning January 1, 1947.\nA committee was appointed to pursue further the question of deductions for attend\nance at post-graduate courses, medical conventions, etc.\n(c) Economics\nDuring the past year Dr. G. F. Strong has been chairman of the Dominion Committee on Economics. The main problem has been to meet the insistent demand for Prepaid\nMedical Plans. A meeting of the executive officers of these plans and representatives\nfrom the various provinces was arranged to precede the June meeting in Winnipeg. This\nPage 320\n-*\n\ fa' tft\n*\nm\u00C2\u00BBi\nHi 1 r\nIf\n\v.\nfour-day conference proved highly instructive as well as bringing into relief the strengths\nand weaknesses of the various schemes. As a result of this meeting, and its recommendations, a Committee on Prepaid Medical Plans was formed and is headed by Dr. Lavell\nLeeson of Vancouver. This committee is to consider especially the wisdom or possibility\nof forming a Dominion-wide body, and if advisable, to suggest ways and means of putting such a scheme on a workable basis. Endeavours to correlate the activities of plans\nof voluntary prepaid medical care have indicated that a schedule of medical fees applicable throughout Canada would be desirable. Although the elaboration of tariffs has\nhitherto been a provincial responsibility the C.M.A. is now consulting the Divisions to\ndetermine their wishes in this matter.\n(d) Publicity\nThe opinion was expressed that while proponents of all sorts of schemes for giving\nso-called free medical services to the public were given plentiful and not always accurate\npublicity, the medical men were keeping too quiet and perhaps failing in their duty in,\nfirst crystallizing their own opinion, and second, in educating the public and keeping it\ninformed as to the stand of organized medicine on these important matters. A subcommittee of the executive was appointed to act in the interim and bring in recommendations as to our future course.\n(e) General Practitioners\nDr. W. A. Wilson has been very active in devising ways and means of maintaining\nand reviving the status of the General Practitioner and you will hear more of this later.\n(f) World Health\nAs you no doubt know, two new world organizations have been set up\u00E2\u0080\u0094one Lay,,\nthe other Professional. The lay Organization is the World Health Organization and\nthe medical one is the World Medical Association. Canada has played a leading part in\nthis, largely due to the ability of our General Secretary, Dr. T. C. Routley, who is occupying posts in both.\n(g) Group Life Insurance\nA sub-committee of the Dominion Executive spent considerable time looking into\nthe possibility and advisability of making arrangements for a group life insurance\nscheme, which could be participated in by any member of the association. It was\ndecided that up to the present no plan had been put forward which merited acceptance.\n(h) Rheumatism\nConsideration was given to the question of giving leadership to certain lay bodies\nwhich have been very active in Canada, especially in British Columbia. This matter is\nstill under consideration.\n(i) Radio Interference\nEvery doctor in Canada has been notified that he must discontinue or shield all short\nwave apparatus before December 31, 1947. In wndov^.\nfBll\nAYERST, McKENNA & HARRISON LIMITED\nBiological and Pharmaceutical Chemists \u00E2\u0080\u00A2 MONTREAL flDount Peasant TElnoertalunQ Co. %tb.\nKINGS WAY at 11th AVE.\nTelephone FAirmont 0058\nW. E. REYNOLDS\nVANCOUVER, B. C.\n\u00C2\u00AB\nEXCLUSIVE flfl.BULfll.CE\nI #' SERVICE\nVANCOUVER: 13th Avenue and Heather Street fflir. 0080\nNEW WESTMINSTER: 814 London Street ||UJ. 60\nWe Specialize in Ambulance Service Only\nJ. H. GRELLIN W. L. BERTRAND\nmi 1\ni\n\u00E2\u0080\u00A2\u00C2\u00BB\u00C2\u00BB:\nAS THE SIGNATURE OF\nc\nPIONEER\nOF THE\nOF\n. .. also known and described as Digitaline Nativelle in the\nU.S.P-XIII (Official April 1947). In the year 1868 Digitaline\n(Digitoxin) was first isolated by Claude Adolphe Nativelle\nand has been used since that date, as it is today by world\nrenowned clinicians such as: Basil-Parsons-Smith, James Orr,\nHarry Gold, S. A. Levine, Sir James MacKenzie and many\nother authorities in the field of digitalis therapy.\nDIGITALINE NATIVELLE\nThe Digitoxin Original as the Name it Bears.\nCANADIAN DISTRIBUTORS\nROUGIER FRERES\n350 LE MOYNE STREET - - MONTREAL, P.Q.\nStrictly Ethical Preparations. DIAGNOSTIC\nCERTAINTY\nte KELEKET KXP-100 Combination Unit\nThis compact, space-saving unit provides diagnostic certainty for\nyou and absolute assurance for your patients. A room as small\nas 8 by 10^ feet is adequate for this complete radiographic and\nfluoroscopic installation.\nThe Multicron Control performs instantly and automatically, essential operations normally performed by hand.\nAmple x-ray energy plus a three-position tilt table, make this combination the answer to all your radiographic and fluoroscopic needs.\nFor further information on Keleket KXP-100\nCombination Unit write this company\nfor Catalog 86444.\n\u00C2\u00AB\u00C2\u00AB'(\n-\u00E2\u0082\u00ACK\ni*\n261 Davenport Rd. - Toronto 5\nL7EBEC \u00E2\u0080\u00A2 MONTREAL \u00E2\u0080\u00A2 WINNIPEG \u00E2\u0080\u00A2 EDMONTON \u00E2\u0080\u00A2 CALGARY \u00E2\u0080\u00A2 VANCOUVER n\nIIENCE AT THE SERVICE OF MLE D I C ! N E\nI The other factors\nare important, too\nThe superior results obtained from natural vitamin B-complex therapy, are due\nto the combined effect of many components, some well known and others as yet\nunidentified.\nThe increasing preference for natural vitamin B-complex therapy parallels the\ngrowing concept that B-vitamin deficiencies are usually multiple.\nB-PLEX Wyeth is an aqueous extract Of rice bran\u00E2\u0080\u0094one of nature's richest sources\nof the B-Complex\u00E2\u0080\u0094Biologically Balanced1 by the addition of crystalline B Factors.\nB-PLEX supplies thiamine hydrochloride, riboflavin and niacin in the ratio of\n1:2:10' PLUS adequate amounts of pyridoxine, pantothenate acid PLUS the unidentified factors naturally present in rice bran extract.\n'The evaluation of Preparations of the vitamin B-\nComplez. C.M.A.J. May, 1942.\n'Council on Pharmacy and Chemistry and Council on\nFoods and Nutrition. J.A.M.A. 119-12-948.\nTrade Mark Reg. in Canada\nJOHN WYETH & BROTHER (CANADA) LIMITED \u00E2\u0080\u00A2 WALKERVILLE, ONTARIO IT,\nriv\n\u00E2\u0096\u00A0\"\u00E2\u0096\u00A0':\nHi\nme\n^Btfi^jrriirte is released i^|i||^c patients\n^hk symp&matil relief affor<^Kll^ BENADRYL\nJprochfafijd'e isj prompt. Clinfdal investigations\nounffy^dver lave shown this antihistaminic\n** %i 11L\"% \u00E2\u0080\u00A2 ; I\nWpgeW is ulpfuYirtJhe symptomatic management of\n^ipf|ia, d\u00C2\u00A7|itatf \aermatitis, erythema multiforme,\nwvi Ifnsitis^^h, .Vasomotor rhinitis, hay fever,\n "Periodicals"@en . "W1 .VA625"@en . "W1_VA625_1947_08"@en . "10.14288/1.0214436"@en . "English"@en . "Vancouver : University of British Columbia Library"@en . "Vancouver, B.C. : McBeath Spedding Limited"@en . "Images provided for research and reference use only. Permission to publish, copy, or otherwise use these images must be obtained from the Digitization Centre: http://digitize.library.ubc.ca/"@en . "Original Format: University of British Columbia. Library. Woodward Library Memorial Room. W1 .VA625"@en . "Medicine--Periodicals"@en . "The Vancouver Medical Association Bulletin: August, 1947"@en . "Text"@en . ""@en .