· pdf filet he c an adian medic al mo nthly vol . i v., n o. 4 toronto, c an ada apr i l, 1...

Cserfa S

a,

TORONTO , APRIL 1920

PUBLISHED UNDER THE DIRECTION 0 1:

THE FOLLOWING BOARD OF ED lTORS

Dr. H . E . ALEXANDER (Sask atoon, Sask . )Dr. E . W. ALLIN (E dmonton, Alta .)Dr. E . B . ALPORT (Regina , Sask . )Dr. ALLEN BAINE S (Toronto , Ont . )Dr. A . T . BOND (O ttawa , Ont . )Dr. G . STEWART CAMERON , (Peterboro , Ont . )Dr. JAME S COTTON (Toronto, Ont .)Dr. W. W. CH IPMAN (Montrea l, Que.)Dr. MURDOCK CH ISH OLM (Halifax, N .S . )Dr. GORDON G . COPELAND (Toronto , Ont . )Dr. ANDREW CROLL (Sas katoon, Sask .)Dr. HERBERT K. DETWE ILER (Toronto , Ont . )Dr. GEO. E .

“

EAKINS (Port Arthur, Ont . )Dr. T. S . FARNCOMB (Trenton, Ont . )Dr. ALEXANDER PORIN (E dm onton , Al ta . )Dr. F . J . R. FORSTER (Stratford , Ont . )Dr. WILLIAM GOLDIE (Toronto , On t . )Dr. PERRY G. GOLDSMITH (Toronto , Ont .)Dr. D . W. GRAHAM (Swif t Current, Sask .)Dr. C . P . H IGGINS (Victoria , B C .)Dr. E . E . KELLS (Regina , Sask . )

Dr. T. C . ROUTLEY, 70 Bond

THIRTY - FIV E CENTS THE COPY

APRIL , 1920

H AY FEV E R

2 mm tun

c a n b e preven ted

C lin ic a l resu lts, cover ing m o re tha n ca ses , a ttest the va lu e”

o f

Po llen Ant ig en . During the pa st five yea rs , from 19 15 to 1919 in

elusive , Po llen Antigen ha s a ffo rded re lief from hay fever by c o n ferr

ing an avera ge pro tec tio n o f

Trea tm en t shou ld be c omm enc ed six w eeks befo re the u sua l o n set o fthe a tta ck o f hay fever.

Further informa tion on request .

L E D E R L E A NT IT O X IN L A B O R A TO R IE S

5 1 1 Fi f th Avenu e 464 St . C a th erine S tN EW Y ORK MONTREAL Wes t 265 Po r tage Avenu e

W INN IPEG

THREE DOLLARS THE YEAR

DrDr.DrDr.Dr.NE IL J. MacLEAN (Winn ipeg, Man .)

R. J. MANION (Fort Wil l iam , Ont . )FRED . W. MARLOW (Toronto , Ont . )J. D . McGUIGAN (Charlott etown,G . A . McLARTY (Toronto , Ont .)NE IL M cNEIL (Prince Rupert, B .C .)JOHN P . MORTON (H ami lton, Ont . )J. HEURNER MULLIN (H amilton, Ont . )GORDON W. MYLKS (K ingston, Ont .)EDW. B . OLIVER (Fort Wi lli am , Ont . )

W. E . SCOTT - MONCRIEFF (V ictoria , B.C . )E . R . SECORD (Brantford , Ont . )J. SINCLAIR TAIT (S t . John’s , Nfld .)

B. P . WATSON (Toronto , Ont . )ERNE ST WILLIAM S (London , Ont .)

W. J . KN OX (Kelowna , B .C . )H . I. KIN SEY (Toronto , Ont . )F . B. LEEDER (Victoria , B.C .)WM . H . MACDONALD (M ed ic ine H a t , Alta .)E . O . MacDONALD (New Aberdeen, N .S .)

Toronto , Ont . , Ed itoria l Secreta ry

“ (Dist inc t ly Ca nad ian"

(COPY R IGNT )

is laying a fo unda tion o f robust hea lth for thousands o f Ca na dia nCh ildren. There

is no food a t once so enioyable and nourish ing a s this delic ious Ca na dian Cocoa .

I T IS G E N E R A L LY AGR E E D T HA T

THE MOST SAT I S FAC TORY MEA NSOF EXH I B I T I NG PHOS PHOR

'

US I S BY

NATURAL FOODS R IC H IN PHOSPHATIDES.

Ova ltine the T o nic Food

Beverage, is made from ripe

barleyma l t , creamym i lk and

fresh eggs— a ll ri ch in assi

m il'

able organ i c pho sphorusbodies—by a special pro cess

o f extractio n a nd co ncentra

tion which presents these

principles in'

undim inished

activity and in a form which

ensures prompt and complete

abso rptio n .

Ovaltine is a great help in

tho se cases where it is essen

t ial to arrest t issue was te and

to counter- balance ex cessivelo ss o f pho sphorus such as

cert a in n eu ras t hen ic a nd

generaldebilitated co nditio ns ,

pu lmo nary tubercu lo sis, etc.

Ovaltine”

_

is_

characterised

by being o f definite thera

peu tieva lue, bybeing convenient and palatable, and bybeing reaso nable in price.

SUPPL IED BY ALL DRUGGISTS. SPEC IALLYLOW PR IC ES ARE QUOTED TO HOSP ITALSAND KINDRED INST ITUT IONS ON D IRECTAPP L ICAT ION TO TORONTO OFFIC E .

A .WANDER LTD. , LONDON , Eng.

W o rk s : King s L ang ley , E ng .

TORON TO 27 FRON T ST . EAST ,

Hay FeverMem oranda

E l S TPa t ients whose hay fever develops in late

w March ,

'

April, or beg inn ing of May,shou ld

be trea ted w ith po l lens of early f loweringtrees.

L S TPat ients whose hay fever develops in the

ate 131 1112 Ype la t terpart of May, or during June, shou ld betested w ith the pollens Of the ch ief grasses,such as orchard grass, t im othy,

red top—

and

certain early f lowering weeds.

ArlcO- Po llen Ex trac tsFor Cutaneous Tests and Treatment cover early and late spring, also summer and autumn.

Litera ture and List o f Po llens on Request

T H E A R L IN GTON C H EM IC A L COM PAN YYONKERS. NEW YORK

Canadian Branch : R. L. GIBSON, 88 Wellington St West , Toronto

A STANDARD EXTRACT OF MALT

SURPASSES ALL OTHER EXTRACTS'

OF MALT IN NUTRITIV EAND DIASTASIC (STARCH CONV ERTING) EFFICIENCY . IT IS THE

BASIS OF A NUMBER OF LOGICAL COMBINATIONS WITHAPPROV ED REMEDIES .

FOR SALE BY ALL DRUGGISTSM a ter- e

g gs,“ SAM P LE O N A P P L IC AT IO NP e p a in a nd H a n c re a t in e

T h e Ma l t i n e C Oh o e . Iro n . Q u in . a n d S try c h .

M a lto—Y e rb in e To ro n to

ism ctant and orant

THE PROVEN GERMICIDE THAT LEAVES NOODOR"

A powerfu l germ ic ide tha t k i l ls a ll

Obnox iou s odo rs in a few m oments

Of’

specia l benef i t in the s ick - ro om

w h ere t h e speed y re c ove ry o f

pa t ients is Ofparam ount impo rtance

S E N D FO R L IT ER ATUR E

MCCRIMMon‘

s

FLUID

Mo st u sefu l in c a ses o f Infec t ion ,

D i scharg ing Sinu ses, lndo lent U lcers,

U l cera t i o n in M a l igna n t D i sea ses

and Stom at i t is

A chem ic a l a n a lys i s o f McCrimm o n's Flu id gave

the fo l low in g resu ltsThe Flu id c o n ta in s n o free a c id , o n ly the s l ightesttra c e be ing fo und in respon se to the m o st del ic a tetests . It show s a prepo ndera nce Of Z inc , a nd c o n

s iderable q ua n t it i es o f so d ium , a lum in ium , a nd

po ta ss ium , a sm a l l am o unt o f lead a nd s l i ght tra c eso f i ro n , c a lc ium , m agnes ium a nd m agan ese. These

m eta ls are presen t in the fo rm o f sa lts o f wh ichch lo rides are the l a rgest in q ua nt i ty , w ith c o n s iderable su lpha tes a nd som e bo ra tes and n itra tes .

So ld through the

Profess ion Only

1007 Starch and SugarFree

w i l l please your DIABETIC pa t ient s immensely.

You can , w i th safety,

i

ba se a l ibera l d iet o n the

Sugar Free Soluable Protein

(24hours from fresh who lemilk to drypro teinpowder)

TRANC E, bu t true, tha t fresh m ilk pro te in prepared the Diapro tein way

bakes a va riety o f del ic iou s breads , m uffins , cook ies , a nd o ther pa la table and

ea s i ly d iges ted d ishes . En t ire ly free from s tarch a nd suga r, it fully sa t isfiesthe bread hunger a nd pa s try appetite o f a lm o s t every d iabe tic pa t ient

bu i ld ing s trength rapid ly while produc ing no sugar"

MENTS . Your druggis t c a n procure it , or o rder d irec t fo r your pa tients from

THE D IAPROTEIN COMPANY5 6 EAS T RANDOLPH S TREET

fl P luriglandularPrepara tion

of Proven Va lue

(ll Ho rm o to ne is a c om bina t io n o f tho se ho rm o nes , o r

in terna l sec ret io ns w hich c o opera te in m a in ta in ing thedynam ic fo rce O f the o rga n i sm .

(11 Ho rm o to ne ha s a‘

m a rkedly s tim u la t ing e ffect o n

m etabo lism a nd o x ida tio n a nd c a u ses a n increa se in

m enta l; nervo u s a nd m uscu la r act ivity . It is a to n ic O fra re q ua lity .

INDICA TIONS Neuras thenia and a ll a s thenic conditions impo tence ,

prema ture s enility and the debilities of old age ; mens trua l d isorders andc lima cteric dis turbances ; chronic ca rdia c ca ses with hypotens ion, circula

tory s tas is and cold extremities conva les cent a nd pos t - febrile weaknes s .

HormotoneWithout Post Pituitarysho u ld be used instead O f the regu la r fo rm u la in men t a sthen ia a sso c ia ted w ith high blo o d pressure .

Dosage : One or two tablets three times daily before meals.

l"Horm o tone is pu t up forphys icians;

prescript ions in bo tt les Of 100,

two and a ha lf gra in tablets .

The s e pro d u cts c a n be o bta ined from yo ur reg u lar d ea ler“o r the fo llo w i ng

LYMANS LIMITED, MONTREAL and TORONTO

NATIONAL DRUG a CHEMICAL co . (All Bran ches)

Canadian Agency; Lymans Ltd Montreal

C . W. CARNRICK COMPANY NEW YORK. N Y .

(Patented)

Katherine L. Storm , M.D. , 1540 Diamond St Phila . , Pa .

Order Blank w ith Directions forMea suring

Sh ip to

If thi s is a d u pl i ca te , ple a s e sta te Ord er No . g iven o n yo u r la st b i llMateri a l En c lo s ed is

THE STORM BINDER AND ABDOMINAL SUPPORTERTAKE SNUG MEASUREMENTS OVER SKIN

C irc u m feren c e a t A

Fro m the m a teria ls o f w h icho u r be lts a re m a de . w e a ls om a ke a la c ed legg in g fro mg a rter to a n k le . a ls o a sto c king s im i la r to the legg ing ,exc ept tha t it ha s the ha l ffo ot a dd iti o na l . Thes e Le gSu pporters a re firm a ndd u ra b le , g ivi ng a n eve n

sm o oth , c o m pre s s i o n. s tro ngto w ear, c o o l a nd a bs o rbent.w ith n o ne o f the d i s c o m fortsa tte nd i ng ru bber e la stic .

Price o f one Legging, c otton ,

Linen Mesh ,

Price o f one Stock ing w ith ha lfIo o t . cotton . LinenMesh ,

Fo r exten s io n upo n theth i gh write fo r

e stim a tes .

Every S to rm SuppKATHERINE L. S

THE STORM LEG SUPPORTER(See Fo lder, Page 27)

(Take snug mea surements) I to K

L to MNo te H c irc u m fere nc e is be low the

a n k le .

TERMS—Prepa id w ith order, or C .0 .D. and Charges

. . to p to bo tto m E .

An extra c i rc u m fere n ce a t X 2 i n c he s a bo ve thw a i st is re q u ired in s u ppo rters fo r g a ll s to ne .

l iver a n

sto m a c h o pera ti o n s a nd fo rSpe c i a l H i gh Kid ney Be lts(No te extra c ha rge ) . Sta tew hether fo r m a n , w o m a n ,

c h i ld o r i n fa nt a nd fo r w ha tpu rpo s e be lt is w orn . Sta ted a te o f a dva nc e fo r pre gn a n cy be lts . Lo c a te in

c is io n . tu m o r o r hern i a byt he exa ct m ea s urem e ntfrom m ed ia n l i ne a nd a ls olo ca te it o n c u t . The m orein fo rm a tio n g ive n , the be tte r th e re s u lts .

LOESER’S INTRAV ENOUS SOLUTIONS

T h ese sterile stab le s olut ions a re intend ed for intraveno us inject ion exc lus ively.

I RON AN D ARS EN I -CE a ch aum poule, 5 c .c . , c o nta ins 64 m ill igram s

( 1 gra in ) o f Iron C a c odyla te .

6 ampoules per box

A pos itive remedy in a l l cond itio ns where Iron a ndArsenic are ind icated . such a s Anem ia , Chlorosis , Tuberculosis , Ma la ria a nd Pellagra , etc . , increas ing bloodcount a nd he moglob in i ndex, recuperative power a ndres istance to bacterial invasion.

A R S EN I C A N D ME RC U RY 2 Gm .

E a c h a'mpoule, 5 c .c . , c onta in s 2. gm . ( 3 1

gra ins ) S od ium D imethy lars ena te (C a co dylate) U.S .F . a nd 5 m il-Iigramm es gra in )Merc ury Iod ide U .S .F .

6 ampou les ( a nd o ne tolera nce d ose

a d ded ) in box

This methyl compound of arsenic ha s come into almostuniversal use for Syph il is . On account of lack of tox

icity, an aggress ive routine can be carried on. The

s imple technique and absence of reactions make .i t mostdes irable for the regular practitioner. Th is large dose

g ives more uni form results both as to hea ling manifesta t ions and negative Wassermanns .

SOD I UM SA L I CY LAT EE a c h am ipo u le ,

~5 c .c c onta ins 1

granlns ) S o d ium S a l icyla te U .S .F .

6 ampo ules Per box

For Tonsil itis. Acute Arthritis and streptococc i i ntee ‘

tio ns. Antipyretic , Analges ic .

ME RCURY OXYCYAN I D EE a ch ampo ule, 5 c .c . , c onta ins 8 m ill igram s

(V3 gra in ) M erc ury Oxycya n id e.

6 ampoules per box

For Syph il is , Mercury Oxycyanide has come into greatm and , particularly - for intra venous use. as . it is less

apt to irritate the veins than "

a ny other salt o f Mercuryand has proved an effi c ient anti - syph ilitic .

SOD IUM IOD I DEE a c h ampoule , 20 c .c . , cont a lns 2 gm . ( 3 1

gra in s ) S od ium Iod id e , U .S .F .

6 ampoules per box

Indicated in Asthma , Bronch itis , Pneum onia , Acute.and Ch ronic Nephribis . Syph ilis. Go itre. Tuberculos is.rthritis , etc . ( See l iterature on Iod ides. )

SA L I C Y LAT E AN D IOD I D EE a ch ampoule, 20 c .c ., conta ins 1 gm . ( 15

gra ins ) S od ium Iod ide a nd S o d i um S a licylate U .S .F .

6 ampo ules per box

For Acute a nd Chronic Art hritis, a ll strepto cocc i infactions . Influenza .

H EXAMETH Y L ENAMIN E5 c .c. c onta in gm . of H examet hylenam lne

U .S .P .

6 ampou‘les per box

Toxem ias , Cys titis, Pyel itis, Bronchitis, Pneumonia .

H EXAMET H Y LENAM I N E A N D SOD I UMIOD I D E

20 c .c . conta in H examethylenam ine gm . ,

So d ium Iod o de 1 gm

6 ampoules per box

Toxem ias , Cystitis. Pyel itis, Bronch itis , Pneumonia .

QU I’N IN E o nHYD ROC H LOR II

D E .5

E ac h ampoule , 5 c .c . , conta ins .5 gm . (7V2

gra ins ) Qu in ine D i h yd ro c h loride U .S .P .

6 ampoules in box

For malaria.

T ech n ic : D o no t d ilute th is so lution . Brea k a mpo u le, draw into a ll - gla s s syring e a nd a tt a ch a 23 to 25 ga uge h yponeed le. U se to urniq uet or h ave t h e pa t ient gra sp th e a rm w ith h is - free h a nd unt il t he veins a t t h e b end o f t h e elbows ta nd ou t prom inent ly : ru n t h e need le into th e ve in q u ick ly . B lood usua lly c om es ba c k into syring e b a c k o f need le o r

c a n be drawn b’a c lc to b e c erta in th a t need le is in t h e ve in : relea se pres s ure, th en inject s lowly .

S E N D FOR SOLUT ION S , LIT E RAT URE~ AN D R E P R INTS .

NEW YORK INTR AV ENOUS LABOR ATORY1 10 EAST 2 3 D STREET NEW YORK CITY

Producing Eth ica l Intravenous So lutions fo r the Medic al Pro fession Exclus ively.

For correcting intes tina l d isorders

in infants a nd children

ProteinMilkPowder (its; l llell(C.M.P.) is not soldby

lo- lZ ST. PATRlCK STREET

drugglsls,hul |sobtalnableTORONTO

l dl t fl 3 2 Jam e s Avenu e Ea s t 8 | Pri nce Wi ll i am Stre et

0“ Y rec mm“3 WINNIPEG ST. JOHN. N.B.

IOSte . So ph ie La n eWe sell it d irect to hospita ls and MONTREALphys ic ians , or to mother.on thepresentation oi an order froma physician . though we wouldmuch rather the phys ic ian procured it h im self .No directions foruse are

printedonthelabelsolhaiit cannot beusedwithoutthe advice of a doctor.

Feeding tests co nduc ted a t the Ho spita l fo r

Sick Children , To ronto , have dem onstra ted

the va lue o f Pro tein Milk Pow derThese tests , c overing m a ny m onths , have

show n its e ffec tiveness a s a c o rrec tive fo od

for infa nts in ca ses o f ferm en ta tive dia rrhoea ,

infec tuo u s dia rrhoea , and the prelim ina ry c orrec tive s tages o f m a ra sm us ; and a lso a s a n ad

junet to brea st - feeding in ca ses o f dyspeps ia .

Older children su ffering from chronic intes

tima l indigestion have show n m arked im

provem en t where Pro tein Milk Pow der ha sbeen used . Foradults it m ay be used where

bu tterm ilk is ordinarily prescribed .

Pro tein Milk Powder is the resu lt

o f exha ustive resea rch and tests which prove

beyond doubt its uniform effec tiveness whenused in pla ce of the liq uid pro tein m ilk so

difficult to prepa re by labora to ry m e

'

thods .

Pam phlets a nd direc tions W i ll be gladly sen t

to a ny interested physic ian . Write to o ur

neares t o ffice .

https://www.forgottenbooks.com/join

T he

C an ad ian Med ic al Mo n th ly

V OL . IV .,N o . 4 TORONTO, C ANADA APR IL , 1 920

ED ITOR IAL

THE ROCKEFE LLER FOUNDATIONMuch in teres t cen t res a round the v i s i t o f Mr . Geo rge V in cen t and Dr . Pea rse

to Cana da a t t h i s t im e in connec t ion w i t h the a c t iv i t ies o f the Ro ckefel lerFounda t ion in it s rela t ion to the a dvan cem en t o f Cana dian m ed i c ine.

Po ss i b ly no th ing in the pa s t decade ha s helped so m a ter ia l ly to a rou se in teres t in the anna l s o f m edi ca l pu rsui t s in Cana da a s the announcem en t a sho r t t im e

ago t ha t is to be devoted by the Ro c kefel ler Founda t ion t o the

advancem en t o f med ic ine in t h is coun t ry .

Th ere is no t the sm a l les t doub t t ha t the pa r t p layed by the m edi ca l p ro iess ion in Cana da in the w o r l d w a r in no sm a l l m anner con t r ibu ted to our beingrecogn i zed a s w o r thy o f pa r t i c i pa t ion in the Ro ckefel ler Fund , and the Cana

dian A rm y Medi ca l Co rp s aga in ha s rea son to be p roud o f a reco rd w h i ch ha sadded one fu r t her no ta b le t r ibu te to it s g lo r ious ca reer .

No announcem en t is a s yet fo r t h com ing as to how the m unificen t g ran t is tobe expended . Mr. Vincen t and Dr . Pea rse in v is i t ing the va r ious m ed i ca l cen t resin Cana da ,

w i l l undoub ted ly be gu ided by the counsel and a dv i ce'

a ffo rded themlo ca l l y ; w h i le, on the o ther hand , the exper ience and know ledge o f t hese em inen td i rec to rs w i l l be la rgely a fa c to r in determ in ing the u l t im a te u t i l i za t ion o f the

funds t o be spen t in t h is coun t ry .

I t is ea rnes t ly hoped tha t p rov is ionmay be m a de fo r the ca r ry ing ou t o f a

defin i te p lan w h i ch w i l l be o f pa r t i cu la r in teres t to genera l p ra c t i t ioners and

c i t i zens , nam ely , the m a king po ss ib le o f pos t—g ra dua te cou rses being ta ken to thedo c to r ra t her t han h is hav ing to g i ve uph is w o rk am ong h is pa t ien t s for the purpose o i a t tending di s tan t po s t -

g ra dua te cen t res .

There cou ld be no saner expend i tu re o f medica l funds , or m o re w isel y spen tpa r t o f the Ro ckefel ler g ran t t han t ha t w h i ch w ou l d keep the ou t ly ing pro fes

C)

CD

TH E CANADIAN MEDICAL MONTHLY

s io n p ro per ly in fo rm ed o f a ll a dva nces in s c ien t i fi c m ed ic ine and t hough t bym eans

o f sy s tem a t i c po s t -

g ra dua te lec tu re cou rses being ca r r ied on a t va r ious cen t resth roughou t the coun t ry ,

conven ien t ly a va i la b le to the m en w ho find i t a ha rdship,

‘

and in m anv ins tances an im poss i b i l i ty , to get aw ay for the pu rpo se o f

b rush ing up.

The a ca dem i c cen t res shou l d be s ta ffed by w el l pa id fu l l—t im e tea chers ,w ho se pa r t ia l du ty i t w ou l d be to sp rea d t hei r labou rs o ver defin i te d is t r i c t sw hereby the genera l p ra c t i t ioner cou l d sit a t the feet o f a ppo in ted lea rn ing and

s t i l l ca r ry on h is avo ca t ion . The advan tages o f such a p lan to the p ro fess ionand the pub l i c is m an i fo l d . Ins tea d o f ret rog ress ion in our own ranks we w ou l dfind s t im u lu s for keener in teres t and w o rking know ledge, w h i le the pub l i c w homw e serve w ou ld co r responding ly benefi t .

MED ICAL FEES

Du r ing the pa s t five yea rs the co s t o f l iv ing ha s inc rea sed nea r ly 100 percen t . . and w i t h p r i ces o f a ll comm odi t ies ever so a r ing , the end is not yet . An

ana ly s is o f the s i tua t ion sugges t s a“ v ic iou s ci rc le”— t ru l y no m isnomer , w hen

the fa c t s a re p roper ly w eighed and co r rela ted . The em p loyee,in o rder to l ive ,

requ i res in c rea s ing em o lum en ts for his serv i ces . The em p loyer , fo rced to paym o re,

co r responding ly inc rea ses the p r i ce o f his p ro du c t . And t hus , con t inua l l yupw a rd c l im b s the cos t co lum n

,the net resu l t being t ha t tw o do l la rs to - day onlv

does the w o rk o f one do l la r five vea rs ago .

Therefo re, i f X equa l s the incom e requ i red to live'

on in 1914, 2X equa l s theincom e requ i red for the necess i t ies o f to - dav.

I f X incom e is a s adequa te to—day a s in 1914, the reci p ien t w a s e i t her a

profi teer befo re the w a r, or is l iv ing in a foo l ’s pa ra dise t o - day.

Wh a t ha s a ll t h is to do w i t h m ed ica l fees ? Pla in l y t h is , t ha t the p ro fess ionrequ i res jus t doub le the am oun t to—day t ha t t hey received fo r a l i ke serv i ce fiveyea rs ago .

Many a ru ra l p ra c t i t ioner a few yea rs ago recei ved tw en ty—five bushel s o f

oa t s o r a ton o f hay in paym en t for his serv i ces to h is fa rm er pa t ien t . Whenga so l ine d isp la ced the do c to r

’

s nag . ca sh . in equ i va len t , to o k the p la ce o f o a t s ,bu t a t the t hen p r i ce o f oa t s . The fa rm er to—day get s doub le the p r i ce for h isoa t s , bu t s t i l l con s i ders he shou l d pav the do c to r

’

s fee com pu ted on the old pr i ceso f ru ra l p rodu ce . Y et the m an on the land is fa r bet ter a b le to pay to—day, on

t o - day’s ba s is , than ever befo re inthe his torv o f Cana da .

S im i la r com pa r ison s m igh t be m ade a s to the po in t o f view o f the dw el lers inc i t ies and tow ns .

Wha t a c t ion ha s been taken by the p ro fess ion genera l ly ? On l y spo ra di c ,i so la ted and ind iv idua l , t o sav the m o s t . Here is a v i ta l p ro b lem dem and ingo rgan i zed a c t ion bv lo ca l g roup s , coun tv so c iet ies and p rov inc ia l a s so c ia t ions .


The pub l i c ha s lea rned the neces s i t y for inc rea sed co s t s in every a ng le o f exis tence, and the p ro fess ion ow es a du ty to i t sel f to see to i t t ha t thei r ser vi ces a re

cons idered w o r t hy. o f inc rea sed rem unera t ion in com pa r i son w i t h any o t hernecess i ty in l i fe.

WERE WE PROF ITEERS F IV E YEARS AGO, OR ARE WE FOOLS

TO—DAY p

GOVERNMENT OWNERSH IP\Vhether or no t w e bel ieve in Governmen t ow nersh ip o f ra i lw ays i t m a kes

no difference. Cana da owns a t ranscon t inen ta l sy s tem o f ra i lwa y s f rom sea t o

sea , w i t h b ranch l ines and feeders , to the exten t o f

m i les in a ll, rea ch ing any p la ce you w ish tov is i t .

Our inves tm en t in t hese roa ds to da team oun t s to m any m i l l ions , and our in teres t to be provided annua l l y w i l l be a very la rge sum . So , a s w e

sa i d,w het her w e l i ke i t o r no t , we ha ve pu t our goo d

m oney in to the p ro jec t , and the sy s tem is ou rs jus ta s m u ch so a s a do c to r’s m o to r ca r is h is .

There canno t be any c r i t i c i sm aga ins t our governm en t—ow ned road s so long a s they a re m anaged in the sam e effic ien t m annera s a t p resen t

,and so w e do no t o ffer go vernm en t serv i ce w i t h an a po logy . On

the con t ra ry , the objec t o f t h is edi to r ia l is to u rge t ra vel over our own ra i l s forthe p lea su re o f i t .

The Ma r i t im e Prov inces , connec ted by the o ld In ter - Co lon ia l w i t h Mon trea l and the Wes t , have had t hei r a dm i rers in pa in t and p ro se and ver se,

and

many a do c to r ha s a t one t im e or a no t her t ra vel led t h rough t ha t in teres t ing pa r to f o l der Ca nada . The go vernm en t roa ds to theWes t , how ever , a re m uch new erand less w el l—know n

,ha b i t indu c ing m any to con t inue us ing the

“ fi rs t com er” intheWes t . Now is the t im e w hen a Cana dian shou l d beg in to use h is. ow n ca r and

cea se h i r ing a taxi every t ime he travels .

The Med ica l Conven t ion to be hel d in V ancouver in June o ffers us an a dm i tab le Oppo r tun i ty to get som e o f our m oney ba ck by gi v ing the governm en t roa dour fa res and hel p ing to pay o ff som e prm crpa l and in teres t . There is no rea sonwhy anyone should be ph i lan t h ro p i c in the m a t ter

, or cons i der the a ffa i r o f a

t r ip m any pa t ron i z ing way. Jus t a s good serv i ce can be had fo r . t he m oney a s on

a non—governm en t - owned road ,in fa c t by June

,pa ssengers w i l l get qu i cker ser

vi ce to Vancouver than by any o t her road , and w i l l go t h rough a pa r t o f them agn ifi cen t Wes t m o s t o f t hem ha ve never seen befo re. Com fo r tab le s leep ingand observa t ion ca rs , wel l equ ipped d in ing ca rs w i t h excel len t serv i ce. and a goodroadbed , a ll condu ce to a m o s t p lea san t ho l i day on the ra i l .

But the t h ing p r inc i pa l l y to rem em ber is t ha t s ince i t is ou rs let ’s use i t andspend our t ra vel l ing m oney on our own possess ion .

p ou own a

Motor Cor

do you always

Hire a Taxi ?

SIR V ICTOR HORSL EY , C .B . ,F .R


SIR VICTOR HORSLEY

C .B . ,

PERRY G . GOLDSM ITH , C .E .E .

Co lonel , Canad ian A rm y M ed ica l Co rps .

To ron to , Ont .

Am ong the m a ny g rea t E ng l ishm en w ho se l ives have been g i ven to the hea ling o f the s i ck and the bet term en t Of m ank ind by thei r q u iet

-

yet tho rough and.

pa instak ing inves t iga t ions , few ha ve a t ta ined the s c ien t i fi c em inence rea ched bySir Vic to r Ho rs ley . Tha t he shou l d ta ke a lea d ing pa r t in the Su rg i ca l Coun c i l so f the Roya l A rmy Med i ca l Co rp s is a s i t sho u l d be,

a nd t ha t he shou l d die inM esopo tam ia a t the heigh t o f his ca reer , serv ing the s i ck and w ounded , is a s hem igh t have w ished .

Vic to r Ho rs lev w a s bo rn on Ap r i l 14th , 18 57, the sam e day t ha t P r incessBea t r i ce wa s bo rn , and theQueen ,

who had a k ind ly rega rd for the fam i ly ,no t ing

theco inc i dence, sen t w o rd tha t she w i shed him to be nam ed a f ter hersel f“

. H is

fa t her,a Roya l Aca dem i c ian ,

w as known for his book en t i t led the “

Reco l lec t ionsOf a Roya l Academ i c ian ,

”and h is pa in t ing ,

“

Ren t Day a t Ha ddon Ha l l .” To h im

a l so fel l the unusua l honou r o f ha v ing one o f his canva ses hung in the Na t iona lGa l lery W h i le he w a s s t i l l l i v ing . Vic to r’s ea r ly l i fewas t herefo re spen t in an

a r t is t i c a tm osphere, and t h is m ay ha ve had no sm a l l bea r ing on h is sk i l l in ca reful and a ccu ra te ob serva t ion and h is freeand a ccu ra te draw ing s . In Decem ber ,1873 , he lef t C ranb rook Schoo l , in Ken t , and m a t r i cu la ted a t

'

the Un ivers i t y o f

London in the fo l low ing yea r . Du r ing his sub sequen t s tudies for h is p rel im ina ryscien t ifi c exam ina t ion he cam e under the eye o f Sir Ol iver Lo dge, and on pa s sing his exam ina t ion in 1875 , he w a s aw a rded the co l lege geld -m eda l forAna tom y .

H is next th ree yea rs w ere g iven to the s tudy o f anatom y and phy' sio logyunder su ch m a s ters a s E l l is , Thane, Bu rden - Sanderson and Sha fer . He pa ssedhis qua l i fy ing exam ina t ion for the Roya l Co l lege o f Su rgeons in 1880,a t the age

Of tw en t y —t h ree. Am ong his fel low—s tuden t s he w a s no ted for h is ha rd w o rk ando r ig ina l i dea s . In the S tuden t s’ M edi ca l So c iety Of 1876- 1877 he rea d a pa peron the

“

Term ina t ion o f Muscu la r F i b res , and a no te on the“

S t ruc tu re Of In terver teb ra l Discs .

”H e w a s elec ted hea d o f the Stu-den t s’ Medi ca l So c iet y and

aw a rded a p ri ze o f five pounds for h is w o rk . A t exam ina t ions ,— and he pro

tes ted s t rong ly aga ins t thei r va lue,

~ he wa s f requen t l y am ong. the m eda l is t s .

-'

In 1880 he w a s a sso c ia ted w i t h M r . F . W . Mo t t in the studvo f ba c ter io log y .

and thei r w o rk a ppea red in the Jou rna l Of Phys io logy in a pa per en t i t led .

“

On the

Exi s tence o f Ba c ter ia and Thei r An teceden t s in Hea l t hy T i ssues .

”These tw o

70 THE CANADIAN MEDICAL MONTHLY

s tuden t s , w ho a f terw a rds ga ined su ch h igh di s t inc t ion ,w ere a l rea dy in 1880

do ing ba c ter io log i ca l w o rk fa r in a dvance Of t hei r con tem po ra r ies . Befo re hew a s qua l ified to pra c t i ce he wa s tea ch ing , exper im en t ing and pub l ish ing Ob servat ions in phys io logy and ba c ter io logy . Where w i l l one find a m edica l s tuden t nowwho , a s Ho rs ley did , spen t pa r t o f his ho l idays w o rk ing ou t som e deta ils in the

m i c roscop i c - s t ruc tu re o f the sa l i va ry g lands o f the g reen w oodpecker ?

H e w a s a s t rong - w i l led , ha rd - th inking young m an, and defended his Op in ions

ea rnes t l y and so good - na tu red ly tha t w here lesser m en w ou l d have lo s t influencehe g a ined i t . H e denounced w ine and toba cco ,

even in his s tuden t days , for hefound h is ab i l i ty to s tudy

-

m a ter ia l l y lessened by even very m odera te use o f t hem .

For his devo t ion to ba c ter io logy ,w h i ch then w a s a new sc ience fu l l o f la rge and

am a z ing su rp r ises , s tuden t s ca l led h im the Germ ; o ther nam es less o f ten usedw ere the Pro fesso r and the '

V u lture, the la t ter for his in s i s tence on pos t mortems,

w h i le in m o re recen t t im es he w a s ca l led A r ch iba l d A l l r igh t , for his inv inc ib leop t im ism .

H is fi rs t ho sp i ta l a ppo in tm en t a f ter pa ss ing h is fina l m embersh ip exam inat ion in 1880, w a s a s house su rgeon to Mr . John Ma rsha l l , Pro fes so r Of C l in i ca lSu rgery a t Un ivers i ty Co l lege. Du r ing t h i s per iod he w as keen l y in teres ted inthe s tudy Of

'

t he b ra in , and in o rder to a r r ive a t som e defin i te conc lus ions , undertook a long ser ies o f exper im en t s on h is own b ra in . H e a naes t het i zed h im sel f,0 1

go t a f r iend to do so , som e fi f ty t im es in a ll, dev is ing w ays of reco rd ing and

s igna l l ing his. exper iences . In 188 1 he took the deg ree Of Ba chelo r o f Medic ineand B a chelo r o f Su rgery o f the Un ivers i ty o f London . The go ld m eda l in Sur

gery w a s aw a rded h im and a l so a un i vers i ty scho la rsh ip . Th ree yea rs la ter hebecam e a Fel low o f the Roya l Co l lege o f Su rgeons .

The next six y ea rs w ere yea rs o f very ha rd w o rk and had m uch to do w i t hh is fu tu re success . H e w a s on ly twen ty - seven yea rs o f age, yet w o rk ing w i t hSha fer he w a s con t r ibu t ing sc ien t i fi c a r t i c les dea l ing w i t h pa t ho log i ca l cond it ions o f the nervous sys tem . In th is per io d he became Pro fesso r Super in tenden to f the B rown Ins t i tu t ion . H e wa s s ingu la r ly wel l fi t ted for the pos t . I t ga vehim a labo ra to ry o f h is own and the di rec t ion o f the inves t iga t ions o f a numbero f ca pab le young m en who w ere g la d to recogn i ze his a t ta inm en t s . I t a l sob rough t h im m o re in touch w i t h govern ing bod ies , su ch a s the Lo ca l Governm en t Boa rd , A rmy Veter ina ry Depa r tm en t , Roya l Ag r i cu l tura l So c iet y and the

Roya l So c iety for ea ch o f w h i ch he ca r r ied ou t spec ia l inves t iga t ions . It w a s

a t th i s inst i tu t ion t ha t Ho rs ley did m o s t o f his w o rk on the thy ro i d g land and

rab ies a s w e l l a s a g rea t dea l o f his inves t iga t ions on thelo ca l i za t ion o f the funct ion in the b ra in . Wh i le Sir Fel ix Sem on w a s the fi rs t to a sser t defin i tel y tha tc ret in ism , myxodem a and ca chexia s t rum i p r iva w ere c lo sely a l l ied w i t h and due

to ab sence or degenera t ion o f the t hy ro i d g land , i t w a s la rgel y due to Hors ley ’s

exper im en ta l wo rk on monkeys t ha t defin i te t hough ta rdy p roo f w a s b rough tfo rw a rd .

TH E CANADIAN MED ICAL MONTHLY

In 1894, and o n l y t h i r ty—seven yea rs o f age,w e find h im in Ca vendi sh Squa re

engaged in consu l t ing w o rk , and t ho ugh a c t ively em p loyed w i t h h is p r iva te p raet i ce and ho spi ta l a ppo in tm en t s

,he found t im e

,by w o rk ing long a f ter o t hers

w ou l d have res ted , t o con t inue his seien t ifi c inves t iga t ions , w h i ch he ca r r ied ou t

in a labo ra to ry in his own house. In t h is yea r he w a s aw a rded one o f the go l dm eda l s o f the Roya l So c iety fo r h is “ inves t iga t ions rela t ing to the phys io logy o f

the nervou s sy s tem and Of the thy ro id g land and to t hei r a pp l i ca t ion in the t rea tm en t o f d i sea se.

”Though he had been m any t im es honou red by s c ien t ifi c so c ie

t ies , bo t h in B ri ta in and the Con t inen t , t here is no aw a rd mo re h igh ly t hough t o ft han th is one.

In 1902 he recei ved the honou r Of kn igh thood and t ook a very leading pa r tin the m edi ca l po l i t i cs o f Grea t B r i ta in . When fi f ty y ea rs o f age he res igned h isa ppo in tm en t a t Un i vers i ty Co l lege Hosp i ta l and the p ro fesso rsh ip o f C l in i ca lSu rgery o f Un ivers i ty Co l lege. One who had held bo t h the cha i r o f pa t ho logya nd su rgery a t a un i vers i ty co u l d ha rd ly d ives t h im sel f o f a ll

,

un i vers i ty connect ions a t so com pa ra t ive young an age. Though no t a c t i vel y engaged in ho sp i ta ltea ch ing he. m a in ta ined a room in the co l lege in w h i ch he ca r r ied ou t many

exper im en t s , and w here he w a s m u ch sough t for by the m any pos t -

g ra dua tes tuden t s who cam e t o London .

H e com p leted tw en t y yea rs o f serv i ce a t Queen’

s Squa re, a nd a t his v i s i t toTo ron to in 1906, in a pa per read a t the

‘B r i t ish Medi ca l A sso c ia t ion ,he summ ed

up a ll he had lea rned in t ha t t im e. Though h is ch ief d iscover ies 1n phys io logya nd su rgery w e1 e in the w onder fu l yea rs betw een 1884 and 1900, he con t inued tocon t r ibu te to 0 111 sc ien t i fi c know ledge a s la te a s the beg inn ing o f the w a r

, eveni f he w a s po ss i b l y a ll too a c t ively engaged in po l i t i ca l and so c ia l ques t ions .

H is v is i t to To ron to w i l l be rem em bered by m any . The Un i vers i ty Of

To ron to confer red upon him the deg ree o f Do c to r o f Law s . H is s t rong a dvo ca cyo f to ta l ab s t inence from a l coho l i c d r ink w a s so un i versa l l y known t ha t he w a s

a sked , w i t h S im s VVOOdhead , to a ddress the On ta r io B ranch Of the Dom in ionTem perance A l l iance .

One who had m ade such a g rea t s tudy o f so c ia l condi t ions in E ng land , preven t ive m edi c ine and m edi ca l po l i t i cs w a s su re to be sough t ou t for pa rliamen

ta ry honou rs . The L ibera l Asso c ia t ion Of the Un i vers i ty o f London nom ina tedhim in 1910, bu t he w a s defea ted by Sir Ph i l i p Magnu s . H is s t rong a dvo ca cy fo rthe vo tes for w om en w h i ch he hel d p robab ly cau sed his ret i rem en t from the

po l i t i ca l con tes t in the Ha 1 bo ro Div i s ion Of Lei ces tersh i re. Though he fa i led t oen ter Pa r l iam en t , had he l ived a l i t t le longer he p roba b ly w ou l d have done so

, a s

j us t befo re h is dea th he w a s the a ccep ted nom inee for Hudders fiel d .

The sphe1 e o f p1 o fess iona l po l i t i cs ha d a n a b so rb ing in teres t for his a c t iveb ra in . The a dm in i s t ra t i ve a ffa i rs o f his p ro fess ion ,

it s p la ce in the s o c ia l sy s tem .

and it s influen ce on the m ind o f the commun i ty w ere Of un fa i l ing in teres t to h im .

They exer ci sed h is des i re to im p rove “condi t ions and the rew a rd s Of genera lp ra c t i ce, the educa t ion and exam ina t ion o f s tuden t s

, the pena l t ies fo r w rong

THE CANADIAN MEDICAL MONTH LY \I

CD

do ing , the p ro tec t ion o f hono u ra b le m en f rom s lander and b la ckm a i l , the protec t ion o f the pub l i c f rom qua ckery ,

the tea ch ing o f tem perance and hyg iene, andthe reg i s t ra t ion o f nu rses and m i dw i ves .

”

H is wo rk for the B ri t i sh M edi ca l Asso c ia t ion over m any yea rs ha s had m uchto do w i t h the p resen t h igh s ta nding a nd au t ho r i ta t ive po s i t ion t h is o rga n i za t ionha s in a ll ques t ions dea l ing w i t h the m edi ca l s i de o f B r i t ish l i fe.

H is a dvo ca cy o f to ta l a b s t inence w a s so fier ce a nd so ha rsh , a nd o f tenunjus t w a s his c r i t i c i sm o f t ho se w ho di ffered f rom h im t ha t he m a de m an y

enem ies , even am ong l i fe—long f r iends . Never t heless , Ho rs ley by h is yea rs o f

edu ca t i ve w o rk a long tem perance l ines ha s done a g rea t dea l to d i rec t a t ten t ionto the dem o ra l i za t ion w h i ch ha s ta ken p la ce am ong m any o f the w o rking c la ssesow ing to t hei r excess i ve indu lgence in a l coho l i c d r ink . H is h igh pos i t ion in the

Sc ien t ifi c and M ed ica l Coun c i l s o f_

t he Em p i re gave to h is a dvo ca cy o f tem perance g rea t p rom inence and recogn i t ion . Any cause w a s the s t ronger for Ho rsley’

s suppo r t . When a ppo in ted t o any comm i t tee dea l ing w i t h im po r tan t quest iOns , he pu t a ll his s t reng t h in to the w o r k , and w a s im pa t ien t and somet im es

ungenerou s to t ho se who d id no t show the am o unt o f en t hus ia sm he cons i deredthe cause dem anded . Th is is p robab ly the rea son he w a s cons idered by som e a s

ha rd to get a long w i t h a t comm i t tee m eet ings .

The rum issue to the t roo ps a ffo rded him an Objec t fo r a t ta ck , w h i ch he ca r

r ied out w i t h his a ccus tom ed v igo r and un relen t ing zea l .The w ar found h im eager to ta ke his pa r t , a s his

'

tw o sons had a l rea dy done .

Though hono red by m any o f the'

scien t ific so c iet ies in Germ any , and in t im a telya sso cia ted w i t h m os t o f her lea ding phy s io log is t s and su rgeons , Ho rs ley didno t hes i ta te a m omen t to pub l i c ly exp ress his loa t h ing and d isgus t

i

o f the b ru ta land disgus t ing a c t ions o f the Germ an a rm y . When a house su rgeon he d r i l ledw i t h the A r t is t s’ R ifles , and t hough connec ted w i t h va r ious m i l i ta ry o rga n i zat ions a ll h is l i fe

,he,

l i ke m any o ther a b le and energet i c su rgeons , w a s ta rd i lypla ced ,

_

and bad ly so a t fi rs t . H is ea r ly exper im en t s o f the effec t o f bu l let w ounds0 11 the b ra in and o ther o rga n s w a s u t i l i zed by theWa r Office w hen he w a s a skedto repo r t on the r ifle and revo lver ammun i t ion i ssued to the t roops . Th is wa sdone t o refu te the Germ an a sser t ion t ha t the B r i t i sh w ere supp l ied w i t h dumdum bu l lets . For his w o rk he

'

received the t hanks o f Lo rd Ki t chener .

E a r ly in 1915 he w a s a ppo in ted in cha rge o f the Su rg i ca l D 1y 1s 1on o f the l t

Genera l Ho sp i ta l for servi ce in F rance . Wh i le t h i s ho sp i ta l w a s being o rga nized , he w a s a c t ively engaged a t Sir Hen ry and La dy No rm an

’

s ho sp i ta l a tVVim ereux . In May o f 1915 the l t Genera l Ho sp i ta l w a s o rdered to Egyp t , andHo rs ley a ccompan ied h is un i t . H e w a s soOn a ppo in ted Consu l tan t in Su rgery tothe Medi ter ranean Exped i t iona ry Fo rce,

w i t h the fu l l rank o f Co lonel . H e w a s

unspa r ing in h is c r i t i c i sm o f a ll t h ings la cking for the com fo r t a nd w el l - being o f

the s i ck and w ounded . InEgyp t he m a de m any enem ies , by exp ress ing ,w i t h a ll

t ha t con tem p t for any th ing t ha t w a s no t t ho rough , his v iew s o f m u ch t ha t w a s

fau l ty in the a r rangem en t s fo r the fi rs t rush o f w o unded from Ga l l i po l i and the


a dm in i s t ra t ion a t Ca i ro . An am us ing exper ience o ccu r red here. A 11 Egyp t ianm edi ca l officer had a num ber o f severe hea d ca ses under h is ca re, rega rd ing them anagem en t o f wh i ch he des i red a dv i ce. H e teleg ra phed the a dm in i s t ra t ion to

send a b ra in specia l is t , and Sir V i c to r Ho rs ley w a s sen t a t once. H e saw the

ca ses and a dvi sed a s to t rea tm en t . The Egyp t ian no t know ing the nam e or fam e

o f his consu l tan t w a s no t sa t isfied tha t one o f suffic ien t p rom inence w a s sen t ,beca use he wa s an

”

Old m an and on l y a m ajo r . H e d id no t know he w a s beinga ss is ted by p robab ly the g rea tes t b ra in su rgeon in the wo r ld .

H e v is i t ed Ga l l i po l i and w a s in g rea t dem and by the su rgeons to a s s is t inthe t rea tm en t o f hea d w ounds . H e inspec ted nea r ly every ho sp i ta l and fiel dam bu lance,

ta lked and lec tu red to the m edi ca l offi cers r igh t up to the t renches .

E veryw here he w a s ha i led w i t h del igh t , for he did every th ing he cou ld to

encou rage the m edi ca l officers and hel p t hem in th ei r d iffi cu l t ies , for he recogn ized the g rea t d i fference exper ienced by m en who w ere a ccus tom ed to be

rega rded a s som ebody in t hei r own sm a l l w ay, sudden l y find ing t hem sel vesa tom s o f one big m a ch ine.

H e. w as subsequen t ly t rans fer red to Ind ia and Meso po tam ia , w here hedied o f hea t s t roke on Ju l y 16, 1916, a t the age o f 59. Wh i le he wa s Consu l t ingSu rgeon w i th the fo rces in the Fa r E a s t t here w a s l i t t le su rgery to em p loy h ist ime, but he w o rked long and la te to get a ll the m ed ica l a r rangem en t s on a bet terfoo t ing .

B ra very m ay show i t sel f in m any fo rm s . Sudden im pu l se,w i t h con tem p t

for immedia te and inevi tab le dea th , is no t any m o re rea l t han the b ra very shown

by Sir V i c to r Ho rs ley in vo lun teer ing for serv i ce in Mesopo tam ia . Aga ins t thea dv i ce o f t ho se know ing bet ter t han he the dangers o f a cam pa ign in the hea to f E a s tern coun t r ies , and the pr iva t ions and ha rdsh i ps to be encoun tered

,he

w en t to the E a s t know ing tha t he m igh t d ie t here. H e sa i d to Lady Ho rs leyjus t befo re he lef t Egyp t : Don’t w o r ry a bou t m e ; I don’t m a t ter ; I can’t l ivefo rever ; it ’s the young t ha t m a t ter.

”

To reco rd som e o f the even t s in the ca reer o f Sir Victo r Ho rs ley is no t diffi

cu l t a s I have s im p ly v iew ed them th rough the eyes o f S tephen Paget’s book

on Sir Victo r Ho rs ley .

”To do jus t i ce to h is m a rvel lous a ch ievem en t s in the

rea lm o f sc ien t ifi c m edi c ine, and to va lue t hem from the s tandpo in t o f the benefi the ha s g iven suffer ing hum an i ty , is a farm o re difficu l t ta sk .

The p rob lem s o f the su rgery o f the b ra in and nervous sys tem have no t yet

a ll been so l ved . Grea t a s ha s been the p rog ress in recen t yea rs , the fu ture wou l dseem da rk indeed had

’

Sir V ic to r Ho rs ley no t l i ved .

In the sun - baked p la ins o f Ama ra h the ea r t h ha s em b ra ced fo r a ll t ime the

rem a ins o f th i s g rea t m an . The w inds t ha t sh i f t the sands to and fro o ver hisg rave mus t ca r ry to a ll land s an inspi ra t ion and exho rta t ion to even t hose ‘

yet

unbo rn t ha t am ong l i fe’s g rea tes t t rea su res is no t the a m a ss ing o f w ea l t h or

po s i t ion ,bu t the know ledge t ha t one ha s con t r i bu ted somet h ing to the sum to ta l

o f t h ings tha t m ake for the a l lev ia t ion o f hum an su ff er ing and the am el io ra t iono f the condi t ions o f l i fe am ong the m a sses .

THE CANADIAN MEDICAL MONTHLY

ILEO CAECAL REGURGITAT ION SYMPTOM COMPLEX

W I LL IAM GOLDIE, M .B To ron to .

The fun c t ion ing o f the severa l port ions o f the ga s t ro—in tes t ina l t ra c t is a s

y et no t fu l l y unders tood ,hen ce w e have no c lea r concep t ion o f the co r rela t ion

and the in tera c t ion o f the d ifferen t port ion s o f the sy s tem ,nor do w e fu l ly

a pp rec ia te how defec t s in a sso c ia t ed o rgans , o r a ppa ren t ly una sso c ia ted o rgans ,in terfere w i t h the func t ion ing o f the va rious po r t ions o f the t ra c t .

Therefo re, in the s tudy o f ga s t ro in tes t ina l ca ses the conc lus ion is soon

rea ched t ha t t here are a rem a rka b ly sm a l l num ber o f ca ses w h ich can be rea d i lyc la ss i fied under the hea dings o f the w el l known d iso rders .

So o f ten do the sam e sym p tom com p lexes a r ise f rom di fferen t cau ses , or

com b ina t ion o f ca uses , and so of ten do va r iab le sym p tom s a r ise f rom the sam e

ca use or com b ina t ion o f causes , t ha t i t is necessa ry to under ta ke a p ro longedand repea ted ana l ys i s o f the h i s to ry ,

and to repea t a ll the known tes ts and examina t ions befo re a sepa ra t ion in to rough g roups can be a ccom p l ished , or the fewca ses be c la ss i fied a s due to defin i te ca uses .

In rough ly g roup ing ca ses i t is necessa ry tha t t here be som e comm on fa c to r ,o r fa c to rs , such a s a sym p tom g roup , a defin i te t im e rela t ion to the func t ioncyc le, a con s ta n t func t ion fau l t a s revea led by tes t o r X—Ray exam ina t ion ,

— or a

cons tan t c l in i ca l finding .

The objec t o f t h i s comm un i ca t ion is t o reco rd one o f t hese g roups w h i chha ve cer ta in comm on sym p tom com p lexes , a comm on func t ion fau l t , w i t h a dis

t inct ive t ime o c cu r rence o f the p r inc i pa l sym p tom s .

The sym p tom g roup s cons is ted o f t h ree d iv is ions , ea ch va ry ing in in tens i t yor sever i ty , but a lwa ys recogn i za b le

0

( 1 ) Di s t ress in the low er abdom en ,m os t m a rked in the lower r igh t qua d

ran t , va ry ing f rom unea se, heav iness , d ragg ing a che, sense o f bu rn ing ,deep

so reness , to a c tua l pa in o f va ry ing sever i ty .

(2) Ind ifference to food , lo ss o f a ppet i te, dis ta s te, nausea ,— to vom i t ing .

(3 ) Hea v iness , la ss i tude, t i redness , pa l lo r to pa t chy p igmen ta t ion , etc .

the so - ca l led au to in toxica t ion .

The t im e o f o ccurrence is even m o re dis t inc t ive than the sym p tom s,for i t is

on aw a ken ing and befo reb rea kfas t tha t the d is t ress and the ga s t r i c sym p tom s

a re m o s t ev iden t . Dur ing the fo renoon the sym p tom s lessen or di sa ppea r , bu trecu r a f ter s leep next m o rn ing or in the a f ternoon i f the pa t ien t indu lges in a

nap. In the ea r ly ca ses t here seem to be a t ta cks o f va r ia b le leng t h ,w i t h in ter

va l s o f a ppa ren t ly no rm a l hea l t h , bu t in the m o re advan ced ca ses t here is con

t inuou s discom fo r t and i l l—hea l t h , w i t h per iods o f m a rked exa cerba t ion .

76 TH E CANADIAN MEDICAL MONTHLY

In a ll bu t the m o s t severe ca ses t here o ccu r in terva ls in wh ich the pa t ien tra pid ly im p roves ; a ll d is t ress and ga s t r i c sym p tom s disa ppea r , and genera lhea l t h is so m u ch bet ter t ha t the pa t ien t is hopef u l o f perm anen t rel ief . Thesein terva l s co r respond defin i tely to per iods w hen the pa t ien t is f ree f rom nervou stens ion , and ha v ing m u ch ou t ~ doo r exerc i se, or w hen the pa t ien t is ta k ing frequen t ly in the day sm a l l do ses o f laxa t i ves . Very soon a f ter the pa t ien t retu rnsto the usua l rou t ine Of l i fe the sym p tom s recu r w i t h the sam e con t inu i ty and the

sam e exa cerba t ions .

The sym p tom s in these ca ses c lo sel y resem b le t ho se a sso c ia ted w i t h o rgan i ci lea l s ta s is , bu t the t im e o f o ccu r rence is di ff eren t . In the ca se o f o rgan i c i lea ls ta s is the pa t ien t com p la ins o f no dis t ress un t i l a f ter the m id—day m ea l . I f thesecond m ea l is delayed un t i l the evening , or un t i l the term ina l i leum is f ree o f

the con ten t f rom the p rev ious m ea l , there is no com p la in t o f di s t res s .

Bu t in the p resen t ser ies the t im e o f o ccu r rence is in the ea r ly m o rn ing w henthe i leum shou l d be em p ty , and in none o f t hese ca ses w a s t here ga s t r i c dela ywh i ch wou l d a ccoun t for an i lea l con ten t in the m o rn ing . Th is being so

, t henthe sym ptom s t ha t w e a sso c ia te w i t h o rgan i c i lea l s ta s i s a re due to som e o t herfa c to r, o r t here is in t h is ser ies a s ta s is or a ' regu rg i ta t ion o ccu r r ing du r ing s leep :Bu t the s ta te o f s leep canno t o f i t sel f p ro du ce su ch an i lea l s ta s is w i t h sym p tom s ,

or a ll o rgan i c i lea l s ta s is ca ses w ou l d have an exa cerba t ion o f sym p tom s on

aw aken ing .

In the l i tera tu re concern ing incom petency o f the i leo caeca l va lve, I cou l dno t find t ha t no te had been m a de o f th is t im e fa c to r .

Wh i le engaged in ana l ys ing t hese h i s to r ies , I w a s fo r tuna te to have com e

under m y ob serva t ion a ser ies o f t h i r teen ca ses w h i ch ga ve the above comm on

fa c to rs , and i t w a s poss ib le t o ca r ry the inves t iga t ion fu r t her by the use o f

ba r ium enema ta,and i t wa s found tha t a ll bu t one ca se showed ext rem e g ra des

o f incom peten cy o f the i leo caeca l va lve, w i t h regu rg i ta t ion fa r ba ck up the sm a l lin tes t ine.

In tw o ca ses the regu rg i ta t ion w en t a s fa r upa s the junc t ion o f the jejunuma nd the duodenum .

F rom the X—Ray exam ina t ions no o t her comm on func t ion fau lt cou l d bedem ons t ra ted .

The X - Ray inves tiga t ion is no t com p lete, a s i t ha s no t been determ inedhow long the sm a l l“ in tes t ine reta ins the ba r ium enem a , nor ha s i t been determ ined in a ll cases tha t the caeca' l con ten t s f rom a m ixed ba r ium m ea l taken inthe even ing are to be found in the i leum in the m o rn ing .

In th ree ca ses t h is inves t iga t ion ha s been ca r r ied out : a heavy m ixed m ea lw i t h bu t term i l k , a nd ba r ium w a s g iven a t 10 pm . The fo l low ing m o rn ing fluoros cop i c exam ina t ion wa s s ta r ted a t a m . and repea t ed every hou r dur ing the

da y . In one ca se, a t a m . t here wa s 3 0 per cen t . o f the ba r 1um m the i leum :

a t ha l f an hou r a f ter b rea kfa s t , t here w a s 10 per cen t . ; a t there w a s

betw een 15 per cen t . and 20 per cen t . ; a t t here w a s 10 per cen t a t


15 per cen t . ; a t ha l f an hou r a f ter lun ch ,the ba r ium had lef t the i leum and

did no t retu rn . In the o t her tw o ca ses the per cen tages and t im e w ere so nea r lythe sam e tha t the deta i l need no t be re—s ta ted .

The one o f the t h i r teen ca ses w h ich fa i led to show incompeten t:y is w el lw o r t h no t ing ,

a s the sym p tom s w ere t ho se o f an ea r ly ca se,w i t h tw o d is t inc t

per iods o f exa cerba t ion , o ccu r r ing in a young m a r r ied w om an o f tw en ty - t h ree.

She w a s m ens t rua t ing a t the t im e o f exam ina t ion , and had no t m issed a per iod .

Bu t ins tea d o f incom petency o f the i leo—czeca l va l ve being found i t w a s d iscov

ered t ha t she w a s fu l l t h ree m on t h s p regnan t

Wh i le i t is po s s ib le by m ea ns o f the sym p tom g roup s and the d is t in c t ivet im e o f o ccu r ren ce to sepa ra te a g roup o f ca ses w h ich have a defin i te func t ionfau l t o f incom petency o f the i leo - czeca l sph in c ter w i t h regu rg i ta t ion , i t m u s t no tbe in fer red tha t incom petency o f t h is sph in c ter w i t h regurg i ta t ion g i ves r iseto a ll the sym p tom s

,fo r i t ha s been dem ons t ra ted tha t t h is func t ion fa u l t o ccu rs

in m o re or less deg ree in a bou t one ou t o f s ix ga s t ro—in tes t ina l ca ses . Mere s ta s i so r regu rg i ta t ion canno t be the so le ca u se o f the d i s tu rban ces t ha t o ccu r in t h i s

g roup o f ca ses .

Regu rg i ta t ion f rom the s tom a ch in to the oeso phagus in its s l igh tes t fo rmcan a lm o s t be rega rded a s no rm a l , yet in som e ca ses w here i t is modera te t hereis m u ch d i s t ress and di scom fo r t .

_

In t h i s in s tance the o r ig in o f the sym p tom s

depends less upon the regu rg i tat io n t han upon the t im e o f it s o ccu r rence and the

s tage t ha t d iges t ion ha s rea ched in the s tom a ch .

I t m ay w el l be t ha t a s im i la r influence is a c t ing in t h is g roup , o r t ha t thefa c to rs w h i ch p ro du ce the cha ra c ter i s t i c g roup p i c tu re a l so p roduce the incom

petency and determ ine the t im e o f regu rg i ta t ion .

The i leo - caeca l va l ve is essen t ia l l y a sph inc ter a t the term ina l i leum , underthe s t im u la to ry cont ro l o f the sym pa t het i c and the inh ib i to ry con t ro l o f thevagu s .

Its a c t ion a s a sph inc ter ha s been w el l dem ons t ra ted in a ca se reco rded bySho 1 t , w here the sph inc ter con t ra c ted fi rm l y w hen the s tom a ch and i leum w ereem p ty , and relaxed w hen t hese po r t ion s o f the t ra c t w ere a c t ive ; bu t the o t herfa c to rs t ha t influence its a c t ion can on ly be su rm ised .

The sph inc ter is a i ded in m any ca ses by the m echan i ca l va l ve a c t ion o f a

p ro jec t ion o f themu cous m em b rane o f the i leum and the caecum in to the lumen o f

the caecum , fo rm ing a tw o - flap va l ve, suppo r ted by a p ro jec t ing ledge o f m ucousm emb rane extending ho r i zon ta l l y fa r a round the in ter io r “

o f the caecum .

Th i s m echan i ca l fea tu re is no t a lw ays p resen t , and the sph inc ter t hen must

bea r the b run t o f the ext ra caeca l p ressu res .

The sph inc ter m igh t be relaxed by d isea se, in terference w i t h it s innerva t ion ,

or by influences , phys i ca l or chem i ca l , exi s t ing in the ceecum and the a scendingco lon .


Opera t i ve in terference m us t be di rec ted to rep la c ing the defec t ive sph inc terby a m echan i ca l va l ve, and i t w ou l d a ppea r f rom the l i tera tu re t ha t the resu l t so f the techn i que in use a t p resen t are no t sa t isfa c to ry .

I f the o pera t i ve m ea su res cou l d p rov ide a perm anen t mechan i ca l va l ve, yett here w ou l d rem am the defec ts

,

w h i ch b rough t a bou t incom petency o f the

sph inc ter , and those fa c t o rs o t her t han the regu rg i ta t ion w h i ch p roduced the

sym p tom s .

On l y two o f m y ca ses have undergone opera t ion for the fo rma t ion o f a

m echan i ca l va l ve.

In one the incom petency and regu rg i ta t ion wa s over com e, w i t h com p leterel ief o f a ll the sym p tom s , w 1th a ga in in w eigh t f rom eigh ty—six pounds to one

hundred and tw en ty—eigh t pounds , but laxa t ives a re necessa ryIn the o ther the in com pet ency and regu rg i ta t ion recu r red w i t h in six w eeks .

and though the pa t ien t c la im s som e im p rovem en t he does no t feel w el l,nor ha s

he ga ined w eigh tNone o f the o t her ten ca ses in w h ich in com petence and regurg i ta t ion o f

m a rked deg ree w a s dem ons t ra ted ,nor any o f the p resum p t ive ca ses belong ing

t o the sam e g roup repo r t s a perm anen t cu re by a dher ing to m edi ca l t rea tm en t ,bu t a ll have ob ta ined m o re o r less rel ief .

The m edica l t rea tm en t ha s cons i s ted o f sm a l l doses o f sa l ine, ta ken t h ree o r

fou r t im es a day, an enem a ea ch n igh t , m eans to rel ieve the nervou s tens ion , and

regu la r phys i ca l exerc ise.

REPORT OF A CASE OF STEEL IN THE LARNYX

By F . ALLPORT and B . W ILSON .

Jo '

ur. A MA Vo l . / 2 , N o . 1 8 , May 3 rd , 1 91 9. Pa t ient Ma le,Age 40 .

Seven teen days befo re being seen by the a u t ho rs the pa t ien t w a s s t ru ck by a

sm a l l f ragm en t o f s teel . The w ound , w h i ch w a s jus t below the po in t o f the ch in ,

w a s su tu red , and the m an resum ed h is w o rk . S ince the a cc iden t he sa id he cou l dno t ta l k a bove a w h isper

,a nd w hen exam ined by the a u t ho rs , a hoa rse, rough

wh i sper pers is ted . A s l igh t p rom inence, som ew ha t con i ca l in shape, w a s founda t the lef t low er a spec t o f the t hyro i d ca r t i lage . I t w a s adheren t to . the o verlying skin , so l id to the tou ch and m o ved w i t h the la rynx .

La ryngo sc0pic exam ina t ion revea led imm ob i l i ty Of the lef t vo ca l cho rd ,

w i t h m odera te la ryngea l inflamm a t ion . X - Ray exam ina t ion d is c lo sed a fo reignbody one and a qua r ter inches in leng t h extending an teropo steriorlv and a ppa ren t ly th rough the left

'

thyro id ca r t i lage.

The p iece o f s t eel w a s rem oved under lo ca l a naes t hes ia . A t the end o f a

w eek the no rm a l vo i ce had retu rned .

The au tho rs’ exp lana t ion o f the pa ra lys is o f the vo ca l cho rd is t ha t in som e

w a y the fo reign body w a s ab le to imm ob i l i ze the vo ca l cho rd w i t hou t havinga c tua l ly penet ra ted the la ry nx . PERRY GOLDSM ITH .


disa ppea r , a nd by puberty m a y be non - exi s ten t,thus sugges t ing t ha t t hey a re

rudim en ta ry o rga ns , and i t is cer ta in ly pro ba b le t ha t t hey p lay bu t a rela t i velyun im po r tan t lym pha t i c ro le.

Of w ha t va lue a re the fau c ia l tons i l s ? Am ong o t her theo r ies a dvanced thefo l low ing a re the m o s t in fa vou r :

H om opo iet ic Theo ry— To p rodu ce lym pho cy tes for the b lood,in comm on

w i t h the o ther lym pho i d nodu les o f the body . Many o f t hese lym pho cy tes produced by the fa u cia l tons i l s pa ss di rec t l y in to the pha rynx , bu t w ha t p ropo r t ionin t o the regu la r lym ph s t ream ha s no t been a scer ta ined . Th i s t heo ry m a y be sa i dto have som e undoub ted h i s to log i c ba s i s .

In terna l Sec ret ion Theo ry— Ma s in i a t t r i bu ted. to the fau c ia l tons i l s a funct ion s im i la r t o t ha t o f the sup ra - rena l g land s , .beca use t here a s a r i se o f b loodp ressu re fo l low ing the inj ec t ion o f tons i l ext ra c t in to dogs . F rom the c l in i ca lpo in t o f v iew ,

w hen w e t h ink o f the good resu l ts fo l low ing fauc ia l tons i l rem ova lin m any ‘

o f our pa t ien t s , w e a re fo rced to con s i der t h is t heo ry un tena b le.

Pro t ec t ion Theo ry—Ba sed upon the w el l unders tood a c t ion o f a ll lym pha t i cg lands in dela y ing the sprea d o f ba c ter ia l in fec t ion s . In t h is connec t ion I canno t do bet ter t han quo te Sir St . C la i r Thom pson ,

w ho say s :'

It w ou l d a ppea rrea sona b le to rega rd the va r iou s ton s i l s o f VV a ldeyer

’

s R ing a s o rgans fo r

defen ce o f'

t he resp i ra to ry and diges t i ve t ra c t s du r ing the ea r ly yea rs o f ch i l dhoo d . The ages in w h i ch they a re m o s t in ev idence,

t hei r s i tua t ion ,t hei r struc

tu re,the recognizd em ig ra t ion o f lym pho cy tes t h rough t hei r ep i t hel ium , thei r

frequen t en la rgem en t w i t h an infec t ious p ro cess , the f requency w i t h w h i ch,

w hen t hei r res i s tan ce is o vercom e,t hey a ppea r to be the s ta r t ing po in t s o f infec

t ion ,t hei r la s t ing hyper t ro phy a f ter p ro longed o r repea ted in fec t ions , experi

m en ta l observa t ions wh i ch show t ha t t hey serve a s po r t s o f en t ry for in fec t ion ,

and t hei r no rm a l invo lu t ion a t puber ty ,a ppea r to confi rm t h is v iew .

”They

fo rm . a s o t hers pu t i t ,“

a fi rs t l ine o f defence.

”

In suppo r t o f t h i s t heo ry I m igh t fu r t her c i te Go erke,w ho bel ieves t ha t

there is no t on l y a s t ream o f cel lu la r elem en t s f rom the ton s i l la r pa ren chym a

t h rough the c ryp t s , bu t a cons tan t flow o f flu i d th rough the in ter s t i ces o f the

ep i thel ium ,w h i ch p reven t s the en t rance o f o rgan ism s .

Th is t heo ry ha s m any foes a swel l a s f r iends,bu t i t is needfu l to rem em ber

t ha t even i f i t be co r rec t , w e mus t ha ve a hea l t hy tons i l a s a fi rs t l ine o f defence,

and in a ddi t ion t ha t the body fo rces w h i ch con t ro l the supp ly o f the s t ream s o f

lymph and flu i d mus t be in fu l l w o rk ing o rder . The tons i ls p lu s t hese fo rcesm u s t be equa l to the ta s k o f defea t ing the onset o f the ba c ter ia f rom t he t h roa t .On t h i s po in t i t is in t eres t ing to no te the w o rds o f Jona t han W r igh t a s quo tedby Phi l l i ps : My exper ience seem s to fu rn i sh conc lus i ve ev idence t ha tunder no rm a l condi t ions. ba c ter ia do no t penet ra te the epi thel ia l layer o f the

( fau cia l ) tons i l in suffi c ien t num bers , a t lea s t , to set up di sea se. Y et w e knowf rom c l in i ca l exper ience t ha t nerve sho ck f rom f ra c tu res , heem o rrhage. na sa lopera t ions , u r i c a ci d , sudden co l d , etc . , p roduce sys tem i c change by w h i ch


in fec t ion is m o re easy a nd m o re dangerous . I bel ieve t ha t the m echan i sm causing su r fa ce in fec t ion is a chem ico—phys i ca l change set up by im pu l ses ca r r ieda long the sym pa t het i c nerves . Th is p roduces a n a l tera t ion in the su r fa ce tens ionexis t ing no rm a l ly between the ba c ter ia l den i zen of the tons i l la r cryp t and the

ep i t hel ium w h i ch l ines i t . By v i r tue o f t h is change the l i v ing pa t hogen i c agen ten ters the sys tem .

”

Imm un i ty Theo ry— By w h i ch the c ryp t s a re rega rded a s cu l tu re tubes inw h i ch o rgan ism s a re cu l t i va ted , and toxines genera ted , t o be a b so rbed in do sesjus t la rge enough to p rodu ce suffi c ien t a n t i - bo dies t o imm un i ze the ow ner .

I f t h is be t rue, the rem ova l o f the fa u c ia l tons i ls in the ch i l d befo re he ha sa cqu i red the needfu l supp ly o f an t i—bodies , w ou l d p redi spo se to infec t ion .

E xtens ive s tudy upon the effec t s of tons i l lec tom ies in ch i ld ren , hav ing rega rd t ot hei r suscep t ib i l i ty o r o t herw i se to a cu te infec t ions , su ch a s . diph t her ia , sca rla

t ina,m ea s les , et c . ,

w o u l d be o f g rea t va lue in dea l ing w i t h t h is p rob lem ,and I

am su re the s ta ff o f the Hosp i ta l for S i ck Ch i l d ren w i l l recogn i ze t hei r respons ibilit ies in condu c t ing su ch a resea r ch .

Fu r t her,i f t h is t heo ry w ere correct , the to ta l rem ova l o f the ch i l d ’

s tons i lw ou l d be a c r im e, a nd the so le need for a tons i l lo tomy w ou l d be t ha t the s i zeo f the fau c ia l tons i l in ter fered w i t h p roper b rea t h ing or speech , or w a s undoub tedly disea sed .

The d ivers i t y o f v iew a s to the t rue fun c t ion o f the fau c ia l tons i l ha s ledto som e m os t ext rem e u t terancesand p ra c t i ces .

The la te Dr . Ba l lenger , o f Ch icago , to ld m e persona l ly t ha t he wou l d en t i rel yrem ove the tons i l s in ch i l d ren ,

m ak ing no excep t ion a s to the age o f the ch i l d .

H e bel ieved tha t the deepes t pa r ts o f the c ryp ts w ere the m o s t dangerous , and ,

therefo re,t ha t i f rem ova l w ere needfu l a t a ll, i t m u s t be com p lete. How ever

,

Dr . Ba l lenger a f terw a rds m od ified h is v iew s , and s ta ted in h is 1908 edi t ion t ha t“ i t m ay be s t i l l ques t ioned w het her i t is good p ra c t i ce to rem ove the tons i ls inthe w ho lesa le m anner w h i ch is now in vogue. The func t ion o f the ( fau c ia l )tons i ls in a ch i l d

,and in an a du l t , is s t i l l an o pen ques t ion . The la s t

.

w o rd con

cern ing the t rea tm en t o f t he tons i l canno t be spoken un t i l its exa c t func t ion ises tab l ished .

Meanw h i le w e find Per ry a dv is ing the rem ova l o f the fau c ia l ton s i l s in allch i l d ren o f fou r yea rs o f age, a s a prophy la c t i c m ea su re, fo r soo t h . Such tea ching is a s m i sch ievous a s i t is fa l se.

Th i s b r ings m e to the ques t ion o f ' t he even ing ,w h i ch is :When is the p res

ence o f a fau c ia l tons i l a m ena ce to it s ow ner ?l s t . Or ra t her by w ay o f a fu r t her p rem ise, I w ish to p ro tes t aga ins t the

term en la rged tons i l , .a term upon the l i ps o f every s choo l nu rse, and o f m any o f

the m ed i ca l p ro fess ion , and a s a d i rec t.

resu l t , o f the pub l i c .

Coo l i dge and Ga r land w eighed the fau c ia l tons i ls from a long series o f ton

sillectom ies in - ch i ldren ,w i t h the resu l t t ha t t hey show ed an a s ton ish ing uni

fo rm i ty in w eigh t , betw een 40 and 50 g ra ins . Tho se p ronounced en la rged befo re

8 2 TH E CANADIAN MEDICAL MONTHLY

Opera t ion w ere found a c tua l ly to weigh less t han t ho se w h ich w ere bu r ied ou t o fs igh t . The p rom inen t tons i l w a s a c tua l l y sm a l ler t han its m a te

,w h i ch had no t

a t t ra c ted a t ten t ion .

Prom inence, and hy per t rophy or en la rgemen t , a re no t synonym ous term s ,

no r any ind i ca t ion for opera t ion . The rela t i ve dep th o f the s inus in w h i ch the

tons i l l ies is so lel y respons ib le for it s p rom inence o r o therw ise.

2nd . Tons i l s , by t hei r p ro jec t ion in to the pha rynx,m ay in ter fere w i t h the

b rea t h cu r ren t , m ay p reven t p ro per phona t ion by c logg ing the m ovem en ts o f thepa la te,

m ay drag upon the leva to r and tenso r m usc les o f the pa la te, and so a ffec tthe pha ryngea l end o f the eus ta ch ian tube, and indu ce dea fness . These w ou l dbe leg i t im a te rea sons for t hei r redu c t ion in s i ze, i r respec t ive o f the ques t ion a s to

whet her o r no t t hey w ere in t hem sel ves d isea sed .

3 rd . Wha tever v iew o f the func t ion o f the fau c ia l ton s i l a ppea ls to the

la ryngo log is t as the m os t rea sonab le, t here 15 no differen ce o f op in ion am ong

the c ra f t a s to the fa c t t ha t once a tons i l becom es disea sed such func t ion isla rgel y or com p letel y a bo l ished , and dec is ion a s to the p roper m et ho d o f dea l ingw i t h the s i tua t ion is ca l led for, bu t here aga in w e find sha rp d ifferences o f op inion w hen w e a sk w ha t cons t i tu tes a d isea sed tons i l .

A h is to ry o f an a t ta ck o f qu insy m ay be cons i dered a s determ in ing defin i telythe p resence o f d isea se. Su ch a t ta cks w i l l recu r w i t hou t ques t ion un less theton s i l be rem oved .

Recu r ren t a t ta cks o f ton s i l i t i s a l so fo rm a defin i te indi ca t ion fo r rem ova l ,and I am o f o p in ion t ha t the p resence o f pu ru len t sec ret ion in the c ryp t s is a s

defin i te.

The p resence of en la rged cerv i ca l g lands is l i kew i se a good and p roper reason fo r o pera t ion

,beca use w e know t ha t d i rec t infec t ion ha s o ccu r red f rom the

tons i l s t h rough such g lands. Tuber cu lous g lands in the neck ha ve been d i rec t l yt ra ced to the fauc ia l tons i ls . I f w e ha ve a s ing le ca se o f tuber cu lo s is in a fam i l y ,

the tons i l s o f the o ther inha b i tan t s o f the house shou l d be exam ined , and i f anydoub t exi s t s , t hei r tons i ls shou l d a t on ce be rem oved . L i kew i se the ch i ld ren o f

pa ren t s w i t h a h is to ry o f cerv i ca l a den i t i s shou ld lo se t hei r tons i l s .

There is an undoub ted connec t ion betw een rheum a t ism a nd the fauc ia l tons il

,and every la ryngo log is t ha s reco rd s o f ca ses w here tons i l lec tom ies have been

per fo rm ed w i t h m o s t b r i l l ian t resu l ts , no t on l y in rheum a t i c t h roa ts , but in a cu terheum a t ism , and rheum a to i d a r t h r i t is . I am conv inced , how ever , t ha t ea r l ierrem ova l o f the tons i l s in t ho se w ho suffer f rom w ha t m ay,

for la ck o f a bet terterm ,

be ca l led growmg pa ins ,”w ou l d be w ise. E a r ly opera t ion in a ll pa t ien t s

w ho su ffer f rom any ind i ca t ion o f rheum a t i sm shou l d be the ru le, and I w ou l dno t hes i ta te to do a tons i l lec tomy a t the beg inn ing o f an a t ta ck o f a cu te rheum a t i c fever .

Aga in the connec t ion o f Neph r i t is w i t h the fauc ia l tons i l ha s been p ra c t i ca l l yp roven , su ffi c ien t ly so ,

a t lea s t , to m ake i t goo d p ra c t i ce to ca refu l l y and repea tedly exam ine the u r ine in a ll a t ta cks o f tons i l i t i s . and to rem ove the fa u c ia l tons i l s w here the kidney s a re a t ta cked .

THE CANADIAN MEDICAL MONTHLY 8 3

Where t here is E a r Di sea se, ei t her the dea fness refer red to befo re, or Suppura t ion o f a ch ron i c va r iety , the fau c ia l tons i l s shou l d be sea rched a s a po ss ib lecause o f fa i lu re to respond to t rea tm en t .

Ch ron i c ga s t r i t is , and lo ss o f a ppet i te fo r b rea kfa s t , ha s been found to a r isef rom the cons tan t sw a l low ing o f the m a sses o f ba c ter ia - la den deb r i s shed f romthe fa ucia l tons i l c ryp t s . In su ch ca ses t hese t i ssues shou ld be sea rched .

The f requency w i t h w h i ch the fauc ia l tons i l s a re found to be respons ib le fora ff ec t ions o f the eye is w el l b rough t ou t in a recen t a r t i c le by B el l in theupon w ha t he term s the t h ree T’

s— s tand ing for teet h , t ons i l s and in tes t ina ltoxa em ia . E xam ina t ion o f the tons i l s shou ld never be neg lec ted by the oph tha l

m ic su rgeon , and some a t lea s t o f h is obs t ina te ca ses w i l l be c lea red up w henthose fau c ia l tons i l s w h i ch a re d isea sed a re rem oved .

Ano t her reference is o f in teres t— the po ss ib i l i ty o f the tons i l c ryp t s beingthe b reed ing g round for the hem o l y t i c s t rep to co cci , w h i ch a ppea red to have

mu ch to do w i t h the ou t b reak o f b roncho—pneumon ia among the Am er i can cam psla s t yea r .

There is s t i l l a la rge a rm y o f fauc ia l tons i l s w h i ch lie ou t in No Man’s La nd .

.ls t . Tho se w here m a sses o f deb r is are concea led in the c ryp ts . Thesem a sses shou ld be exam ined and a reco rd m ade o f the ba c ter ia p resen t . We do

no t know y et how to es t im a te the va lue o f such an exam ina t ion , o r how to d i rec tour t rea tm en t in a cco rdance w i t h the findings , bu t w here our oph tha lm o log i cconfreres have succeeded , w e ha ve a r igh t to hope t ha t w e too sha l l y et be a b leto d i rec t our t rea tm en t a cco rd ing to the cha ra c ter o f t hese ba c ter ia .

2nd . Tho se w here som e o f the c ryp ts a re unab le to d is cha rge t hei r deb r i sf reel y on a ccount o f t hei r m ou t h s being covered by the p l i ca , or by the junc t iono f the p i l la rs in the sup ra tons i l la r a rea . Su ch c ry p t s a re fa r m o re l i kel y to be

the. sou r ce o f ab so rp t ion t han t ho se w h ich ,by being f reel y open ,

a re led to d is

g o rge t hei r con ten t s by the perpetua l squeez ing to w h i ch the fauc ia l tons i l s a re

subjec ted by the m o t ions o f sw a l low ing .

3 rd . Tho se w here the p i l lars a re a dheren t shou l d receive c lose ob serva t ion ,

because the po in t s o f a dhes ion m ay p reven t f ree pa la te m ovem en t , o r m a y con

t ra c t the m ou t h s o f the. c ry p t s and lea d to reten t ion and ab so rp t ion “

.

4th . Those w h i ch fa i l to a t rophy a t puber ty . Ky le s ta tes t ha t t h is fa i lu ret o a t ro phy is due t o som e pa t ho log i ca l cond i t ion o f the tons i l Or its su r round ings truc turesf

’

No t h ing ha s been sa id a s to the Indi ca t ions aga ins t Tons i l lec tom y , bu t m uch ,

I t rus t , m ay ha ve been rea d betw een m y p rev ious l ines . The opera t ion ha s a ppa ren t ly “ pa ssed beyond the sphere o f t ho se seem ing ly m o s t com peten t t o judge o f

it s necess i ty , and t h rough techn i ca l exper ien ces bes t qua l ified to per fo rm the

o pera t ion ,

”and , t herefo re, I mus t add yet ano ther w o rd .

The d iag ram taken f rom S t . C la i r Thom pson show s t ha t the fau c ia l tons i l sa re on ly two o f the s ix o r m o re po r t ions o f lVa lder

’s R ing , a nd the sea r ch for

the fo cus o f infec t ion m us t no t on ly em b ra ce a ll o f the r ing (o t her pa r t s o f w h ich


a re p ro ven m o re suscep t ib le a s in fec t ive t ra c t s t han the fau c ia l tons i l s) , - bu t the

teet h , the gum s , the no se and a ccesso ry s inuses,the ea r and m a s to i d cel l s , the

ga l l - b la dder , a ppendix , and the sem ina l ves i c les , befo re the fauc ia l tons i l s , un lessdefin i tel y d isea sed , shou l d be t rea ted a s the sca pegoa t , w h i ch in the Heb rewd ispensa t ion ,

a f ter hav ing received the s ins o f the na t ion upon its '

head ,wa s persona lly conduc ted in to the deser t and t here lo s t to s igh t for ever . A s has beenwel l sa i d , the tons il opera t ion is f requen t ly an indi ca t ion o f la ck o f m en ta l effo r t .In comm on w i t h my co l leagues I f requen t ly see ca ses w here the sca pegoa t ha sfa i led to ca r ry aw ay the s ins .

The s ta tus lym pha t i cus m ay be a legi t im a te rea son for avo i d ing o pera t ion ,

bu t I am conv in ced t ha t heem ophylia is no t , When p roper p recau t ions a re

ob served , un less the haem ophylia be o f the pu re va r iety .

Fo rtieth Annu a l Meeting

On tario Medica l Asso cia tion

Toron to , May 25 th, 25 th, 27th and 28 th, 1920

A cco rd ing to the prel im ina ry progra mm e now a nnounced by the Comm i ttee in

cha rge , the fo rt ieth a nnua l m eet ing o f the Onta r io Med ica l A sso c i a t i on . wh ich is t o be

held in To ronto dur ing the da tes o f May 25th , 26th , 27th , and 28 th ,1920, b ids fa i r to excel

in po int o f interes t a nd instruc t ion prev iou s ga ther ings o f the A sso c ia t ion .

Dur ing the pa st two month s the m em bers o f the Programm e Comm i t tee have beena ss iduou s ly endeavo r ing to secu re the co - Opera t io n bo th a t hom e and from abro ad , o f Ou t

sta nd ing m embers o f the pro fess ion to ta ke part in the sc ient i fic programm e.

In referr ing to the l i st o f speakers and the i r subjects , elsewhere t o be found in o ur

co lum ns , it w i l l be read i ly recogn i zed tha t an ex cept iona l ly w el l ba lanced programm e is

a s sured .

Now tha t the m ed i ca l pro fess ion is la rgely rehab i l i ta ted fo l low ing"

the past five yearso f grea t ly depleted ranks a t hom e, the Onta r io Med i ca l Asso c ia t ion w i l l undo ubtedly havea m o s t enthu s ia st ic and representa t ive ga ther ing a t it s Fo rt ieth Annua l Meet ing .

SECTION OF OBSTETR ICS AND GYNAECOLOGY

Prelim inary Anno uncem en t fo r Fo rt ieth Annua l Meet ing

DR . TH os . S . CULLE N, Ba l t im o re, Pro f. o f D i str ibu t ion o f Adenomyom a ta conta in ingGynaeco logy,

Johns H opk ins . Uter ine M ‘

uco sa .

DR . B . P . WATSON,To ronto . Induct i on o f Labo u r .

DR . E . K . CULLE N , Detro i t . T i t le t o be anno unced .

DR . W . W . LAILEY,To ronto . Complem ent F i xa t ion Test (in gono rrhoea

in fem a le) .

DR . G. G. COPELAND, To ronto . The Va lue o f Rec ta l E xam ina t ions in Obs te

t rics .

D R . C . J . CURR IE,To ronto . Po st Pa rtum Tempera tures .


THE STRANGE CASE OF DR . BISHOPHUGH S . EAYRS.

No t a ll them arty rs a re g lo r i fied in Foxe’s Book o f Ma r ty rs " Any m edi ca l m an

w ho ha s seen the Am er i can new spa per repo r t s of wha t w e m ay refer to a s“

The

B ishop Ca se” du r ing the la s t tw o w eeks o f Feb rua ry and up to t h is w r i t ing , m us thave been in teres ted , and no t a l i t t le pu z z led , a s to the w o rking s o f Am er i canlaw

The B i shop Ca se cen t res round the fa c t o f a do c to r w ho held a very c lea rand defined conv i c t ion on a m a t ter o f m ed ica l t rea tm en t o f an i l l ; w het her t h isi l l is w ho l ly phys i ca l or w het her i t is pa r t ly phys i ca l , pa r t lym en ta l and pa r t lym o ra l , has h i t her to been a ma t ter o f op in ion . H e ba cked up h is conv i c t ion bycer ta in a c t ion in p ra c t i ce. As a resu l t he is a r ra igned for v io la t ing the very lawthe exis ten ce o f w h i ch on the s ta tu te book he is m o s t anxious to a pp ro ve, and

m o s t u rgen t to ins i s t t ha t i t be app l ied w i t h unm i t iga ted r igo r , t o the end t ha t apub l i c ev i l be dim in ished and fina l ly sw ep t aw ay .

I cu l l the fo l low ing f rom the Am er i can “ Med ica l Reco rd .

“ I t s ta tes the

ca se : “

E rnes t S . B ishop , o f N ew Yo rk C i ty ,w a s a r ra igned befo re Federa l Judge

Hough on Feb rua ry 10, and held in ba i l , cha rged w i t h v io la t ing the H ar

r ison Drug Law . The indi c tm en t cha rges the defendan t w i t h p resc r ib ing m or

ph ine, hero in and co ca ine in excess i ve am oun t s , and con t ra ry to the leg i t ima t ep ra c t i ce o f m ed i c ine, to hab i tua l users o f na rco t i c d rugs . IV hen a r ra igned thedefendan t p lea ded “

no t gu ilty,

”

and w a s relea sed on ba i l pend ing t r ia l . Of cou rse,no one w ho know s Dr . B ishop can for a m om en t bel i eve t ha t h is o ffending w a s

o t her t han t echn i ca l , and the t r ia l , w hen i t com es o ff , w i l l w i t hou t doub t m a ket h is c lea r to the du l les t orm o s t p rejudi ced m ind . The cha rge is , how ever , a veryser ious one, and Dr . B i shop ’s f r iends w i l l sym pa th i ze w i t h him in h is t roub le, and

w i sh for h im a Speedy t r ia l and t r ium phan t a cqu i t ta l .”Th is s t ra igh t fo rw a rd and seem ing l y suffi c ien t s ta tem en t m igh t delude any

body who do es no t know the fa ct s . These a re the fa c t s . F or a num ber o f y ea rsDr . E rnes t R . B i shop ha s p ioneered in the inves t iga t ion o f the inc rea s ing ly ser ious evi l o f Op ia te d rug a dd ic t ion . H e began w here m o s t phys i c ian s beg inunha pp i ly ,

few o f t hem seem to p rog ress— secu re in the bel ief t ha t the a dd ic tw a s

“

a degenera te,a dep ra ved w ret ch unw o r thy o f hel p , in cu rab le and hope

less .

” “

L i ke o t hers ,” says Dr . B ishop,.

I p la ced the b lam e"

on the a ddi c t s’ suppo sed w eakness o f w i l l and la ck o f determ ina t ion to get r id o f t hei r m a la dy .

”

Thi s w a s the ba s is on w h i ch D r . B ishop w a s w o rk ing in h is ea r ly da y s a s

res iden t phys i c ian to the A l coho l i c and Pr i son Wa rds a t the Bel levue Ho spi ta l .As he confesses , he fa i led m iserab ly in his w o rk . H e changed h is g round l i t t leby l i t t le—

‘

the s to ry is too long to tel l here— and a dop ted the v iew t ha t d rug


a ddi c t ion is a disease. Yea rs o f p ra c t i ce have s t reng t hened t ha t op in ion, and

Dr . B ishop ha s reso lu tely p lea ded tha t the p rob lem o f drug a ddi c t ion mus t bet rea ted svmptom a t ica lly ; h is exper ience disp roves the t heo ry t ha t addi c t ion isa v i ce, a ha b i t , a tendency , or t ha t a ddi c t s a re “ do pe fiends ,” “ dope hab i tues ,

”or

“

m erel y v i c iou s . It does p rove t ha t the drug addi c t is a c tua l ly di sea sed .

BLAZ ING A TRAIL .

I t 5 very ev iden t t o tho se who ha ve fo l low ed the cou rse o f even t s in New

Yo rk S ta te tha t such a t heo ry a s Dr . B isho p p ropounded ha d no t on l y the

m is fo r tune o f it s novel ty , bu t the fu r t her l ia b i l i ty —from h is s tandpo in t— tha t i tm a de enem ies . H e w a s bound to t read on a num ber o f m os t im po r tan t co rns "Why f rom thefi rs t have lea ding l igh t s am ongs t Am er i can m edi cos tu rned a co l dshou l der to Dr . B ishop’s advo ca cy o f t h is newer t heo ry o f the so l v ing o f the drugaddi c t ion p rob lem ? Why ha s he been badgered in sea son and ou t o f sea son by

th rea t s f rom h igh p la ces to get h im” i f he pers i s ted in flou t ing the com fo r tab le

view t ha t d rug addi c t ion w a s a necessa ry m o ra l ev i l and jus t t ha t ? And

why fina l l y , is he hau led up a s a c r im ina l w ho ha s o ffended aga ins t the law o f

his coun t ry ?

The answ ers to t hese ques t ions tou ch a po in t o f m edi ca l et h i cs . I t is known

t ha t m a ny phys i c ians h igh up in t hei r p ro fess ion in the Un i ted S ta tes a re finan

cia lly in t eres ted in “

s ty l i sh san i t a r ia '

w h i ch exis t to t rea t dope fiends and

ext ra c t eno rmous fees for fake m in is t ra t ions and pretended'

cures . I t is known

tha t D r . B ishop’s ins i s tence t hat d rug a ddi c t ion w a s a disea se and t ha t t herefo rei t m us t be t rea ted a long t ho se pa t ho log i ca l l ines fo l low ed in a ll ca ses w heredisea se is p roven ,

set h im up,f rom the fi rs t , a s the m an w ho w a s to ta ke up the

cudgel s aga ins t qua cks and cha r la tans m a squera d ing a s cons cien t ious m edi ca lp ra c t i t ioners . I t is fu r ther known to t ho se who have the p r iv i lege o f Dr .

B ishop’s persona l f r iendsh ip tha t he is cou rageous to a fau l t , and dogged and

ru t h less in the ba cking upo f his conv i c t ion ,no m a t ter how ce leb ra ted the hea ds

t ha t , a s a resu l t o f h is cam pa ign ing , fa l l in to the ba sket .Dr . B ishop , bel iev ing t ha t d rug a ddi c t ion is a d isea se

,ha s t rea ted i t a s a

disea se. To cure sm a l l pox the p ract i t ioner inj ec t s the very germ o f sm a l l pox .

To cu re typho i d the do c to r uses typho i d ba c i l l i serum . To cu re the opia te d rugaddi c t , Dr . B i shop , hav ing p roven by h is ow n ea r l ier fa i lu res the fa l la cy o f cu reby m ere w i l l—pow er , con t inues the addi c t a s long a s he deem s i t necessa ry in the

usage o f the very d rug w h i ch ha s disea sed him . H is enem ies sei ze on the on lyveh ic le by wh i ch t hey can ,

a s t hey th ink , ca r ry him - to p ro fess iona l ext inc t ion ,

and secu re his a r ra ignm en t for v io la t ing the Ha r r ison Dru O'

Ac t , cha rg ing t ha the p rov ides d rugs

“

in exces s ive am oun t s and con t ra ry to the leg i t im a te pract i ce .

”The m a t t er w ou l d be ludi c rou s w ere it s i ssue no t so po r ten tous f rom the

s tandpo in t o f the pub l i c good .

The hea r ing shou l d be in teres t ing . Tha tQ

it w i l l v indi ca te Dr . B i sho p’s v iewOf the d rug a ddi c t ion m ena ce is no t to be doub ted ; i t shou l d do m o re t han tha t .

8 8 TH E CANADIAN MEDICAL MONTH LY

these t rea tm en t s , he show ed , w h i le o t hers lo s t t hei r eyes igh t a nd' hea r ing .

pa r t i cu la r ly v i c t im s w ho subm i t ted to the hyocine cu re, used in severa l New

Yo rk C i ty and S ta te ins t i tu t ions .

The S ta te Na rco t i c Law ,w h i ch D r . B isho p w a s ins t rum en ta l in enac t ing ,

ha s been a dead let ter . Som e po ten t influence a t A lbany ha s p reven ted the

a pp rop r ia t ion necessa ry for it s opera t ion . All the depa r tm en t get s is abou tenough t o pay the s a la r ies o f it s o ffic ia l s . No m oney is p rovi ded for "resea rchwo rk , the one fa c to r w h i ch w a s to con t r ibu te tow a rd a so lu t ion o f the p rob lemo f drug a dd i c t ion .

Dem ands have been m ade on the Leg is la tu re for abo l i t ion o f t h i s depa r tm en t . Cha i rm an Wh i tney ,

who w a s p la ced in cha rge w hen i t w a s c rea ted,w a s

ous ted ; and o ffic ia l s w ere pu t in o ffice who w ere ho s t i le to the o r ig ina l hum an ita r ian a im s

‘

o f the s ta tu te. A t p resen t the depa r tm en t is w o rk ing v i r tua l ly a s

an a djunc t to the New Yo rk C i ty Hea l t h Depa r tm en t,w h ich Dr . B isho p ha s no t

hes i ta ted to c r i t i c i ze.

I t is to be hoped tha t the hea r ing o f the B ishop ca se no t on l y b r ings ou t the

fa c t o f B ishop’s sp lend id reco rd , bu t the jus t a s im po r tan t fa c t a s to who a re the

men anxious to defea t the practica l working ant of his disease theory, and why.

I t is sa i d t ha t m o re t han one m edi co w ho bea rs an hono red m em bersh ip in the

Am er i can Med i ca l A sso cia tion w ou l d lo se a very excel len t incom e w ere the

qua ck a sy lum s for d rug a ddi c t ion to be sw ep t away . I t is sa id'

tha t severa lleading Am er i can do c to rs w ou ld lo se t hei r lau rels (and even “ t hei r p ra c t i ces )w ere t hei r connec t ion w i t h cer ta in fake pa ten t m edic ines for suppo sed cu re o f

drug a ddi c t ion to be d isclo sed .

F rom our s tandpo in t a s Cana d ians , and f rom the pa r t i cu la r s tandpo in t o fthe p ro fess iona l rea der o f the Canadian Medica l .l /onthly, the B ishop ca se is m o s tim po r tan t . The p rob lem o f d rug a dd i c t ion in Canada is jus t a s g rea t and jus t a sp ress ing a s i t is in the Un i ted S ta tes . It s ra p id p rog ress is , unhapp i ly , one o f

the unfo r tuna te by—produ-ct s o f the g rea t w ar. Appa ren t ly a s l i t t le is beingdone on th is s i de o f the bo rder a s the o t her to com ba t t h is m ena ce. Indeed

,w e

a re even w o rse o ff t han our Sou t hern neighbo r , for here w e have no vo i ce c ry ingin the w i l derness . Our flo ck is w i t hou t its B isho p " The fi rs t requ is ite is t ha tour m edi ca l m en becom e a l i ve to the g ra ve S i tua t ion ; t ha t d rug a ddic t ion is theev i l i t is and b ids fa i r s tea di ly to g row . The B i sho p ca se shou l d be w a t cheda t every po in t by a ll Cana dian m edi ca l men . Such an in teres t taken in the ca sem igh t w el l s t im u la te a rgum en t a nd d is cuss ion a s to the r igh t or

'

w rong a pp ro a chto the w ho le drug addic t ion ques t ion . Hab i t or disea se ; w h i ch is i t ? Once t h isis determ ined , diagnos is and t rea tmen t w i l l doub t less undergo rev i s ion .

And , a s a c lo s ing t hough t , w here does the new ly - c rea ted Depa r tmen t o f

Federa l Hea l t h s tand ? Wha t v iew does i t ho l d a s to the m ena ce o f d rug a ddic

t ion ?Wha t is i t do ing ?

Any th ing ?No th ing ?

THE CANADIAN MEDICAL MONTHLY 89

CZESAREAN SECTION’“

INDICAT IONS AND L IM ITAT IONS

B . P . WATSON ,M .D .

, Ch .B .,

Pro fesso r o f Obs tet r i cs and Gynaeco logy ,Un i vers i ty o f To ron to .

I ha ve recen t ly m ade a rev iew Of our ho sp i ta l s ta t is t i cs on Cmsa rean Sec t ion .

Th is rev iew fu l ly bea rs ou t the v iew s I have hel d for som e t im e, in comm on w i t ha g rea t m any ob s tet r i c ians , t ha t the opera t ion is being under ta ken by m any

opera to rs m uch too l igh t ly , on in suffi c ien t indi ca t ion s and w i t hou t due rega rd t oposs i b le a f ter resu l t s . Th i s is largel y due to the com pa ra t ive ea se o f the a c tua lopera t ion

,to the m o re or less d rama t i c na tu re o f it, and espec ia l ly to the

eno rm ou s num ber o f reco rds in the - m ed i ca l l i tera tu re o f the la s t few yea rs o f

i so la ted ca ses w here the o pera t ion ha s been under ta ken for t h is or t ha t comp l i ca t ion o f p regnancy or la bo r , and a lw ays , o f cou rse, w i t h per fec t su ccessthe fa i lu res sel dom ha ve the l igh t o f pub l i c i t y shed upon t hem . Now ,

in judg ingo f the rea l va lue o f any m etho d o f t rea tm en t w e m us t d i scoun t a l toget her t hesei so la ted ca ses and ba se our con c lus ions on la rge ser ies o f ca ses , com pa r ing the

resu l ts in such w i t h t ho se ob ta ined by o t her m et hods . Th is w i l l g i ve us som e

so r t o f s tanda rd to gu i de us in our genera l po l i cy ,and w hen w e com e to t rea t the

ind ivi dua l ca se w e sha l l know w ha t so r t o f a cha n ce wea re g iv ing our pa t ien t ,and w ha t so r t o f r isk w e a re subjec t ing her to .

The i dea l w e a im a t a s ob s t et r i c ians is t o hel p b r ing in to the w o r ld a hea l t hy ,

undam aged , l iv ing ba by , and to res to re to a c t i v i t y a s qu i ck ly a s poss ib le a hea l t hym o ther , ca pab le o f fu r t her ch i l d—bea r ing , and no t l i kel y to develop any phys i ca ld isab i l i ty la ter .

Let i t be g ran ted a t once t ha t , w ere w e con cerned on l y W i t h the sa fety o f

the ch i ld , Caesa rean Sec t ion wou l d be the i dea l m et ho d o f del i very in a ll ca ses .

We w ou l d no t a lw ays get a l i v ing ba by , for such com p l i ca t ions a s p la cen tap rev ia . a cc iden ta l haem o r rhage and toxaem ia m ay resu l t in the dea t h o f the ch i l din u tero , even befo re the onset o f labo r , but a pa r t f rom t heset here is no theoret ica l rea son why a l i v ing ch i l d shou ld no t a lw ays be ob ta ined . (See ta b le. )

A s rega rds the second pa r t o f our idea l , Caesa rean Sec t ion does no t ho l d thesam e p la ce. E ven w hen done under the very bes t o f condi t ions i t is s t i l l a t tendedby an imm edia te m a terna l m o r ta l i ty fa r in excess o f t ha t fo l low ing na tu ra l

“

cad trio”? f/lc A cademy of Mcdi i-uc. Toronto .


del i very . When i t is under taken fo r any pa r t i cu la r com p l i ca t ion i t t herefo rebehooves us to sa t is fy ou rsel ves t ha t w e are g iv ing the mo t her a bet ter chan ce o fl i fe by i t t han by any o ther m eans

, and i f the chances are a bou t even ,t hen the

g rea ter sa fety o f thel

ch ild shou ld tu rn the sca le in favo r o f Caesa rean Sec t ion .

Bu t w e mus t ta ke o t her t h ings in to cons i dera t ion bes ides t h i s p r im a ry o pera t ionm o r ta l i ty . We mus t cons i der w hether the Opera t ion is go ing to resu l t in the

p reven t ion o f fu r t her ch i ld - bea r ing , or, i f fu r t her p regnanc ies shou ld o ccu r ,w het her i t is go ing

’

to add to the r i sk o f these. Now,w hen Caesa rean Sec t ion is

under taken under cer ta in condi t ions— espec ia l ly a f t er p ro longed a t tem p t s a t

vag ina l del i very , or vag ina l m an i pu la t ions no t ab so lu tely a sep t i ca l l y conduc tedthe on l y sa fe t h ing to do is to fo l low the opera t ion by an imm edia te bys terectom y , w i t h con sequen t s ter i l i t y . Tha t a spec t o f the ca se shou l d recei ve veryca refu l cons idera t ion befo re any dec i s ion is a r r ived a t .

When the u terus is lef t in s i tu and a sub sequen t p regnanc y o ccu rs ,can the

w om a n pa ss th rough a no rm a l labo r w i t h no ext ra r i sk ? Th i s is a m os t per t inen tques t ion in . ca ses w here the opera t ion is con tem p la ted for such condi t ions a s

p la cen ta p raev ia , ec lam p s ia , etc .,condi t ions w h ich are no t l i kel y to recu r in fur

t her p regnan cies . Now ,w h i le I do no t ho l d w i t h the di c tum ,

“

Once a Czesarean

a lw ay s a Caesa rean ,

”w e canno t get aw ay f rom the fa c t t ha t t here is a danger

o f rup tu re o f the u terus t h rough the sca r in sub sequen t la bo r . I ha ve del i veredth ree pa t ien t s in the la s t tw o yea rs w ho had had Czesa rean Sec t ions per fo rm edby o t her o pera to rs . All t h ree had per fec t l y no rm a l labo r s and puerper ia . Rongy

(“

Am er i can Jou rna l o f Ob s tet r i cs ,” lxxiv . , p . 954) finds f rom a sea r ch o f the

l i tera tu re t ha t rup tu re o f the s ca r o ccu rs in 3% o f su ch ca ses , and t ha t t h is a cc iden t is a t tended by a m o r ta l i t y o f So t ha t , to the imm edia te opera t i vem o r ta li ty o f Caesa rean Sec t ion under taken for cond i t ions o ther t han ob s t ruc t ionin the pa ssages, we m u s t add a fu r t her to cover the sub sequen t h i s tory o f

t hese pa t ien t s . Rongy bel ieves tha t in 7570 o f ca ses the d ic tum ,

“

Once a Caesa rean a lw ay s a Caesa rean ,

” ho l ds . W i t h g rea ter ca re in su tu r ing the w ound and

ab sence o f infec t ion t here is no doub t tha t t h i s percen tage ough t to be g rea t lylow ered .

Keeping the fo rego ing con s idera t ion s befo re us , let u s now t ry to a r r ive a t

som e genera l conc lus ion rega rding the a dvi sab i l i ty o f the opera t ion in the di fferen t condi t ions forw h i ch i t ha s been a dvo cated . In ea ch c la s s o f ca se w e m us ttry to keep befo re u s c ons tan t ly the p roba b le imm ed ia te and u l t im a te resu l t a srega rds the m o t her , the ch i l d ,

and the po s s ib le ch i l d ren tha t m ay com e la ter .

The va r iou s condi t ions w h i ch o f la te y ea rs ha ve been rega rded a s jus t i fy ingCeesa rean Sect ion by d i fferen t opera t o rs w i l l be taken up. These m ay be tabul a t ed a s fo l low s :

1 . Con t ra c t ed or defo rm ed pel v is , im ped ing the pa ssage o f the l i v ing ch i ld .


2. Tum o rs o f the pel v is o r so f t pa r t s , im ped ing the pa ssage o f the l iv ing

ch i l d .

3 . Cond i t ions o f the so f t pa r t s . su ch a s c i ca t r i ces , resu l t ing f rom fo rm erlabors or opera t ions , and uny iel d ing condi t ion , such a s is m et w i t h in elder ly

p r im i pa rae, a ll o f w h i ch m ay obs t ruc t the pa ssage o f the ch i l d .

4.Disp la cem en t s o f the u terus , su ch a s fo l low ven t ra l fixa t ion ,

and w h ich

a l ter the axis o f the u terus .

5 .Ma lp resen ta t ions and m a l po s i t ions o f the ch i l d ,

such a s t ransverse,b reech , b row ,

fa ce, o cc i p i to po s ter io r , etc .

6.Haem o r rhage f rom the no rm a l ly s i tua ted pla cen ta and f rom p la cen ta

przevia .

7 . E c lam p t i c toxaem ia .

8 . Heart and lung cond i t ion s o f the m o t her l ikel y to be severel y agg rava tedby the s t ress o f labo r .

( 1 ) CON TRACTED OR DEFORMED PELV I S.

Th is ha s been the m o s t f requen t indi ca t ion up to the p resen t t im e,and is

l i kely to rem a in so for a long t im e t o come. When the conjuga ta vera is less t ha ncm . the ind i ca t ion is ab so lu te. No fu l l term ch i ld

,l iv ing o r dea d , cou l d be

bo rn t h rough su ch an in let . The on ly w ay in w h i ch the l i fe o f the m o t her can besaved is by Caesa rean Sec t ion . W i t h a conjuga ta vera betw een cm . and 9 cm .

the p roper m o de o f del ivery in the va s t m a j o r i ty o f ca ses w i l l be by Czesa rean ,

bu t t here a re bo rder—l ine ca ses w i t h a conjuga te a round 9 cm ., and betw een t ha t

and 10 cm .,w here very ca refu l ob serva t ion is ca l led for to dec ide the p roper pro ~

cedure to a dop t . I am so r ry to ha ve to m en t ion figu res in t h i s connec t ion ,for

a f ter a ll i t is no t a ques t ion o f the a c tua l s i ze o f the pel v is, bu t o f the rela t ive

s i ze o f the pelv is and the foeta l hea d , and the dec i s ion m ay be m a defor or aga ins tCaesa rean

‘

Sec t ion ,no t by the s i ze o f the diam eters o f the pelvis , ~bu t by tho se o f

the foeta l head . Accu ra te pelv im et ry shou l d never be neg lec ted , and w here w e

find t ha t t here is som e deg ree o f con t ra c t ion or defo rm i ty we shou l d ta ke t ha ta s a w a rn ing t ha t w e ha ve to keep ca refu l w a t ch on the pa t ien t du r ing the la s ttw o m on t hs o f p regnancy . Tha t w a t ch invo l ves exam ina t ion s a t f requen t in ter:va l s to determ ine the po ss ib i l i ty o f fi t t ing the hea d in to the pel v i c b r im . In t ho sebo rder—l ine ca ses you canno t m a ke up you r m ind (a t , say, t he s ix t h m on t h ) t ha tt hey mus t be del i vered by Caesa rean Sec t ion . F requen t exam ina t ions by a bdom ina l pa l pa t ion and by the Muel ler - Ker r p ro cedu re m us t be m ade ; only by t ha tm eans w i l l one be a b le to dec ide w het her the bes t chan ce for them o t her and ch i l dis a ffo rded by the indu c t ion o f p rem a tu re labo r , by na tu ra l del i very a t term , or

by Caesa rean Sec t ion .


CAE SAREAN SECT ION

*95 Opera t ions by 13 Opera to rs .

Tota l m a terna l m o r ta l i ty , to ta l foeta l m o r ta l i ty,

Ind ica t ions

C o n tra c ted pelv i sE c lamps iaAn tepa rtuin Hem .

Hea rt a nd lung d i sea se .

E lderly Pr im ipa ra .

Ma lpresenta t ions .

U ter ine fibro id .

Ma lfo rmed u terus .

Acu te Append ic i t is .

Adhes io ns . .

R uptured u terus

These include all the Cwsarean operat ions perf orm ed in the Toronto Genera l H ospita l by members of theObstetrica l S taff 111 the Publ ic and Private Wards and by doctors no t members of t he Sta ff in the PrivateWards .

When the pub l i c ha s been educa ted rega rd ing the im po r tance o f m ed ica lca re du r ing p regnancy , a nd w hen w e, a s a p ro fess ion , a re p repa red to g ive

a dequa te superv is ion such a s I ha ve m en t ioned , a very la rge num ber o f w om en

w ho now undergo i t w i l l be spa red the Caesa rean opera t ion and be del i vered o f

hea l t hy ch i l d ren w i t h a m in im um o f t ra uma to t hem sel ves by induc t ion o f labo rbefo re or nea r term . I t m us t a lw ays be rem em bered t ha t i t is t hese bo rder - l ineca ses w h i ch supp ly the la rge m o r ta l i ty

~f rom the Caesa rean opera t ion . In the

ab sence o f pel v i c m ea su rem en t and o f es t im a t ion o f rela t i ve s i ze o f the hea d tothe pel v is , t hey a re a l low ed to go

'

in to la bo r a t or a f ter term . The labo r d rags on ,

a t tem p t s m ay be m ade to del iver by fo r ceps , and w hen t hese fa i l recou rse isha d to Caesa rean Sec t ion . Under such cond i t ion s the opera t ion is a t tended byvery h igh m o r ta l i ty— va ry ing f rom 10% to The on ly w ay in w h i ch them o r ta l i ty can be lessened is by fo l low ing the sec t ion by hy s terec tom y . In defin

itely in fec ted ca ses t h is is the on l y sa fe p ro cedu re, and in doub t fu l l y in fec tedones i t m ay f requen t ly ha ve to be done,

and t ha t , o f cou rse,is the end o f the

pa t ien t ’s ch i l d—bea r ing . In the t rea tm en t o f t ho se bo rder - l ine ca ses , i f t hey a re

a l low ed to go in to labo r , every po ss ib le a sep t i c p recau t ion ough t to be taken.

In terna l exam ina t ions are sel dom necessa ry , a nd when needed shou l d be m a de

TH E CANADIAN MEDICAL MONTHLY 93

by rec tum . Di la ta t ion o f the cerv ix is o ften s low,and m u s t be a l low ed to com

plete i t sel f na tu ra l l y , the pa t ien t being ca r r ied a long by m o rph ine - hyo sc inena rco s is . When the second s tage is en tered upon p len t y o f t im e m u s t be g i venfor the head to engage and to be m ou l ded t h rough the pelv i s . When one

’

s m indis m a de up to be conserva t ive in such ca ses , one m u s t be ra d ica l in one

’

s con

serva t ism . To a t tem p t to del i ver such a head by the h igh fo rcep s opera t ion is tocou r t d isa s ter . The ch i l d , w hen del i vered , w i l l a lm o s t cer ta in l y be dea d , and them o t her is being exposed to a r i sk no t less t han t ha t f rom Caesa rean Sec t ion donea t the t im e o f elec t ion . I f the head fa i l s to m ou ld th rough and every a sep t i cp recau t ion ha s been observed and the ch i ld is s t i l l a l ive

, Czesa rean Sec t ion m ay

be done w i t h s l igh t ly g rea ter r isk than i f i t had been done befo re or a t the onseto f la bo r . On the o t her hand , i f at tem p t s have been m a de a t del i very under c i rcum s tances w h i ch make i t l i kel y t ha t in fec t ion ha s o ccu r red , t here IS a cho i ce o f

tw o p ro cedu res,

— Czesa reanSec t ion ,fo l low ed by hys terec tom y , or c ran io tomy .

In su ch ca ses I shou l d choo se the la t ter in a p r im i pa rous pa t ien t , even i f the ch i l dw ere a live, so a s t o p reserve the po ss i b i l i ty o f fu r t her ch i l d—bea r ing under m o refa vo rab le cond i t ions . Pubio tonjy ha s a p la ce in su ch ca ses , a l t hough the r i sk o f

t ha t o pera t ion is a lso g rea t ly in c rea sed by the p rev ious in ter ference.

To sum up, in con t ra c t ions o f the pel v i s w i t h the conjuga ta vera belowcm .

, a lw ays do a Caesa rean Sec t ion befo re, or a t the on set o f labo r . W i t h con

t ra c t ions o f low er deg ree , es t im a te the rela t ive s i ze o f the hea d to the pelv i s , andi f t here is m a rked dispa r i ty ,

per fo rm Caesa rean Sec t ion a t the t im e o f elec t ion .

“ 7hen w a t ch ing the pa t ien t in the la s t tw o m on th s o f p regnancy induce labo rbefo re such a dispa r i t y is ev iden t . In the condu c t o f a ll su ch labo rs ob serve thes t r i c tes t a sep t i c p recau t ions , hav ing befo re -

you a lw ays the po ss ib i l i ty t ha t a

Caesa rea n Sec t ion m ay be requ i red. In the ab sence o f su ch p recau t ions fa i lu reto del i ver w i l l usua l l y indi ca te c ran io tom y ,

a s the r i sk of pub io tom y even is too

g rea t .The s ta t i s t i cs quo ted by B eck , f rom the Long Is land Hosp i ta l , B rookly n

V . 79, p . show the d i fferen ce in m o r ta l i ty o f Caesa rean Sec t ion in

ca ses hand led ou t s i de and ins i de the ho sp i ta l . In 19 ca ses w h i ch had been hand ledou t s i de, the mo r ta l i ty w a s in 18 ca ses w h i ch had been hand led en t i relyin s i de . the m o r ta l i t y w a s a l i t t le over These figu res are a very fa i r index tow ha t is ha ppen ing a ll over the coun t ry , and to my m ind jus t i fy a c ran io tom y

opera t ion in cer ta in ca ses , even w hen the ch i l d is a l ive. In the To ron to Genera lHosp i ta l , in the la s t s ix y ea rs , 50 Caesa rean Sec t ions ha ve been per fo rm ed forva r ious deg rees o f con t ra c t ed pel v is , and our to ta l m o r ta l i ty ha s been :m a terna l ,

and foeta l , (See t a b le. ) One o f the m a terna l dea t h s w a s in a ca sew here the opera t ion w a s done a f tera t tem p t s a t fo r ceps del i very had fa i led .

(2 ) TUM o-

URS OF TH E PELV IS OR SOFT PARTS, IM PEDIN G TH E PASSAGE OF TH E L IV

ING CH ILD .

The tum ou rs w h i ch m o s t f requen t ly ob s t ru ct the pa ssage o f the ch i l d a re

in ters t i t ia l fibro ids , g row ing f rom the low er u ter ine segm en t o r cerv ix, or pedum


cula ted tum ou rs , g row ing f rom the body o f the u terus ; ova r ian tum ou rs , especia l ly dermo ids, wh i ch a lways have a tendency to fa l l down in to the Pou ch o f

Doug la s , p robab ly ow ing to t hei r w eigh t . In such ca ses w here the tum ou r canno t be

'

pu shed up abo ve the p resen t ing pa r t , the p roper p ro cedu re is to per fo rma Caesa rean Sec t ion and t hen remove the tum ou r . In the ca se o f fibro ids t h isw i l l nea r ly a lw ays invo l ve the rem ova l o f the body o f the u terus a s wel l . I t issel dom poss i b le to do a m y om ec tomy in such ca ses . Th is , how ever , m ay be donein som e ca ses du r ing p regnancy . I t is sel dom a dv isa b le to a t tem p t the rem ova lo f the ova r ian tum ou rs t h rough the po s ter io r fo rn ix . There have been su ccessfu lca ses , but the r i sk o f m eet ing w i t h . a dhes ions and o f ha v ing extens ivehaemo r rhage f rom the s l ipp ing o f the ped ic le,

du r ing the sub sequen t labo r isg rea ter t han tha t o f the abdom ina l opera t ion .

(3 ) CON DIT ION S OF TH E SOFT PARTS, SUCH As C I CATR I CES RE SULT IN G FROMFORMER LABORs OR OPERAT ION S

,AND AN UN Y IELDING CONDIT ION , SUCH AS Is

MET WITH IN E LDERLY PR IM IPARAE—ALL OF WH ICH MAY OBSTRUCT TH E

PASSAGE OF TH E CH ILD .

Under t h is head ing w e m ay c la ss such condi t ions a s c i ca t r i sa t ion o f the

cerv ix fo l low ing la cera t ion repa i r or am pu ta t ion . Persona l l y,I have never fel t

m y sel f ca l led upon t o perfo rm the opera t ion for t hese cond i t ions . Recen t ly Iconfined a pa t ien t who had had a very extens ive la cera t ion w i t h her fi rs t ch i ld ,the del ivery had been an ins t rum en ta l one, and the ch i ld w a s bo rn dea d . The

cervix w a s deep ly to rn , and in the p ro cess o f hea l ing had become adheren t tovag ina l vau l t , w i t h the fo rm a t ion o f a g rea t dea l o f sca r t issue. She w a s del ivered by Caesa rean Sec t ion by ano t her opera to r t h ree yea rs la ter . She consu l tedm e rega rding the poss i b i l i ty o f ha v ing a ch i l d by no rm a l del i very , and I to l dher I t hough t she cou l d . She w en t t h rough the fi rs t s tage very ea s i ly and ga veb i r t h to a hea l t hy n ine—pound ch i ld in sp i te o f the p resen ta t ion being a b reechone. A f ter am pu ta t ion o f

'

the cerv ix t here m ay be d iffi cu l ty in the fi rs t s tage,

bu t so far I have no t m et w i t h i t .

In t h i s g roup o f ca ses w e inc lude the el der ly p r im i pa ra . I confess to hav ingper fo rm ed Caesa rean Sec t ion on tw o w om en

, bo t h o ver fo r ty yea rs o f age, and

p regnan t for the fi rs t t im e,the o l des t being 43 . We a ll know o f p r im ipa rous

pa t ien t s o f t ha t age com ing th rough no rm a l labo r com pa ra t ively ea s i l y , but t hereis a cer ta in ty pe w here a t rophy and sh r ink ing o f the vag ina l w a l l and cerv ix ha sbegun , and w here the musc le a c t ion o f the u terus is p resum ab ly feeb le. The

l i kel i hood o f su ch a pa t ien t becom ing p regnan t aga in is sm a l l ; i t is t herefo reim po r tan t t ha t the ch i l d shou l d be l iv ing and hea l t hy . Under the bes t o f cond itions del i very by the vag ina w ou l d a lw ays be d ifficu l t and ins t rum en ta l , w i t hposs ib le inju ry t o the ch i l d and cons i dera b le la cera t ion of the m o t her . The bes tresu l t in such a ca se w i l l undoub ted ly be go t by Caesa rean Sec t ion ,

per fo rm ed a t

the t im e o f elec t ion .


cri t i ca l ly in to the subjec t w e do no t find t ha t i t m a kes such a very good show ing .

The a verage m a terna l m o r ta l i ty in a ll types of ca ses o f p la cen ta p raev ia t rea tedo therw ise t han by Caesa rean Sec t ion is from 5 to w h i l s t the foeta l m o r ta l i t yranges f rom 45 to a cco rd ing a s the t rea tm en t ha s been

,by bag o r by ver

s ion . In a co llec ted‘

series o f ca ses t rea ted by Caesa rean Sec t ion the m a terna lm o r ta l i t y w a s In the To ron to Genera l Ho sp i ta l the m o r ta l i ty w a s 1 1% in

a ser ies o f n ine ca ses o pera ted on by s ix d i fferen t o pera to r s . The foeta l m o r ta l i tyw a s In a la rger ser ies o f ca ses the foeta l m o r ta l i ty w ou l d undoub ted ly bebet ter than t ha t , bu t i t w i l l a lw ays be com pa ra t i vely h igh for the g rea t m ajo rl ty

o f ch i l d ren are p rem a tu re. Probab ly on l y a bou t 32% o f the pa t ien t s w e t rea t forp la cen ta przevia a re a t term . A cco rd ing to the bes t ava i lab le s ta t is t i cs , then ,

Caesa rean Sec t ion cou l d be u rged a s a rou t ine t rea tm en t o f a ll types o f p la cen tap raevia on ly on the p lea t ha t i t w ou l d save a few m o re ch i l d ren . Ba lance aga ins tt ha t the s l ight ly h igher m a terna l m o r ta l i ty and the d isab i l i ty a s rega rds fu tu rech i l d—bea r ing w h i ch the o pera t ion en ta i ls , and I t h ink w e m u s t conc lude t ha t thea rgumen t is no t conc lus i ve.

On the o ther hand , w e m us t con cede t ha t Caesa rean Sec t ion is the very bes ta va i la b le m eans o f t rea tm en t in cer ta in ca ses . The indica t ions a re very w el lsumm a r i zed by Bea ch l xxv i . , p . 57 ) a s fo l low s :

I . E l der l y p r im i pa rae w i t h p la cen ta praev ia o f any type, and t h i s p robab ly theon ly chance o f having a ch i ld .

2 . Cen t ra l p la cen ta przey ia in prim ipa rze.

3 . Cen t ra l p la cen ta p raev ia in m u l t i pa ra w i t h no l iv ing ch i l d .

4. Pla cen ta p raev ia w i t h con t ra c ted pelv is .

5 . Pla cen ta p raev ia w i t h a very rig i d cerv ix ( very ra re) .

Tha t is perha p s an u l t ra - conserva t i ve s ta tem en t o f the indi ca t ions , but inm a in i t is a good one. There is no ques t ion bu t t ha t Caesa rean Sec t ion is p robab l y the ea s ies t m et hod o f t rea tm en t for th e o pera to r , bu t t ha t is no a rgum en ti f m o re a rduous and m ore diffi cu l t p ro cedu res , su ch a s tam ponna de, the u se o f

hydro s ta t i c bags , or B raxton H i cks ’ vers ion g ive s l igh t ly bet ter immedia tem a terna l resu l t s in the a verage ca se.

In a very la rge num ber o f p la cen ta p raev ia ca ses t here ha s been a good dea lo f vag ina l m an i pula t ion befo re the pa t ien t en ters the ho sp i ta l , and t ha t unquest ionably con t r ibu tes to the h igh m o r ta l i ty fo l low ing Caesa rean . In ca ses con

sidered su i tab le for the o pera t ion t here shou l d be a m in im um o f hand l ing , and the

o pera t ion shou l d be under taken a t the ea r l ies t po ss i b le t im e a f ter the diagno s isha s been m ade and the ch i l d cons i dered v iab le. In som e o f the ca ses w herehzem o rrhage pers i s t s a f ter the rem ova l o f t he p la cen ta , hys terec tom y m ay be

requ i red .

(7) E CLAM PT IC TOXAEM IA .

In discuss ing Caesarean Sec t ion for ec lam ps ia w e are a t once led in to the

con t rover sy o f o pera t i ve versu s conserva t i ve t rea tm en t . In no o ther cond i t ion

N"


in ob s tet r i cs do w e find tw o s cho o l s so d iam et r i ca l ly o ppo sed t o ea ch o t her a s

rega rds t rea tm en t . The o ne ho l d s t ha t no o pera t i ve t rea tm en t is ca l led for o t hert han m edium or low fo rceps o r b reech ext ra c t ion , a nd the o ther

,tha t no m a t ter

w ha t the s tage o f p regnancy o r la bo r, the u terus m us t be em p t ied by som e m ea n s

o r o ther . Bo t h b r ing fo rwa rd m a sses o f s ta t is t i cs to upho l d t hei r a rgum en t s .

We canno t hel p t h inking t ha t w i t h such d ivergen t v iew s the t ru t h m ay lie som e

w here betw een . So fa r a s recen t s ta t i s t i cs go t ho se a dvo ca t ing con serva t i vet rea tm en t undoub ted ly ha ve the bet ter o f the a rgum en t . Ro ss McPherson

lxxv i i,p . 58 ) s ta tes tha t the m a terna l m o r ta l i t y o f eclam ps ia in the

S loane Ma tern i ty under s t r i c t l y conserva t i ve t rea tm en t w a s l4.5% , a nd in

recen t ca ses i t ha s been redu ced to 12% m a terna l and 3470 foeta l . Z ink e ha d a

m a t erna l m o r ta l i ty o f l 3 .3% ,Bu ffa lo Genera l Hosp i ta l Tw eedy in Dub l in

and S t ragono ff , who ha s p roba b ly done m o re t han anyone to s tanda rdi zeconserva t i ve t rea tm en t , Aga ins t t ho se figu res p la ce t ho se rela t ing t o the

resu l t s a f ter C esa rean Sec t ion . Peterson,in 500 co l lec ted ca ses t rea ted by

Caesa rean ,found a ma terna l m o r ta l i ty o f Da v is ,

in 1 1 ca ses , Kel

l i t z,in 28 ca ses ,

In the To ron to Genera l Ho sp i ta l , in 17 opera t ions byeigh t o pera to rs , (See tab le. )

E ven g ran t ing tha t m o s t o f the Czesa rean Sec t ions w ere done in very severeca ses , w h i ch w ou l d ha ve died under any fo rm o f t reatm en t

,t hese figu res m us t

m ake us pause and cons i der very'

ca refully w het her the opera t ion ha s any p la cea t a ll in the t rea tm en t o f ec lam p s ia . I confess t ha t in the a cu te fu lm ina t ingtype,

w i t h no p rod rom a l sym p tom s , o t her t han perha ps a cu te epiga s t r i c pa in ,

I am inc l ined to per fo rm the o pera t ion i f the pa t ien t is a p r im i pa ra and no t in

la bo r , o r in a very ea r ly s tage o f labo r . I have done so in tw o ca ses in the'

la s t

t h ree yea rs ; bo t h ch i l d ren su rv ived , bu t one m o t her d ied . In the o t her ca ses Ifeel tha t in the fu tu re I m u s t g i ve conserva t i ve t rea tm en t a fa i r chance. Up tothe p resen t I feel tha t '

w e have no t ca r r ied ou t the deta i l s w i t h suffic ien t ca re, and

perha ps som e o f you m ay. fee l the sam e. The essen t ia l s o f the t rea tm en t inb r ief a re -M o rph ia gr. M,

to s ta r t w i t h ,and t hen gr. M ea ch hou r un t i l the

resp i ra t ions fa l l to 8 per m inu te ,f ree ga s t r i c lavage, a dm in is t ra t ion of ca s to r

o il , f ree co lon i c i r r iga t ion w i t h soda b i ca rb ., and g luco se w i t h a bso lu t e qu iet

ness and da rknes s in the room . W i t h the recen t resu l t s o f t h i s t rea tm en t befo reus I t h ink w e m us t a dm i t t ha t Czesa rean Sec t ion , or o t her f o rm s o f fo rc ib ledel i very ,

is no t ju s t ified in the va s t m a jo r i ty o f ca ses , and so fa r a s I am con

cerned i t w i l l be reserved for the type o f fu lm inat ing case I m en t ioned .

(8 ) H EART AN D LUN G CON DIT ION S L IKELY To BE AGGRAV ATED BY TH E STRESS OF

LABOR .

Rega rd ing t hese com p l i ca t ions , l i t t le need be sa i d . The ques t ion o f Caesa rean Sec t ion versu s na tu ra l del ivery m us t be answ ered a cco rding to the effec t o fthe d i sea se on the genera l nu t r i t ion and res i s tance o f the pa t ien t . There a re

r isk s by ei t her m et hod , and too o f ten i t is on l y a cho i ce betw een tw o evi l s . Dur


ing the pa s t yea r in the To ron to Genera l Ho sp i ta l t h ree pa t ien t s w ere opera tedon , one w i t h bad va l vu la r d isea se o f the hea r t , and one w i t h a dvanced pu lm ona rytubercu los i s d ied .

In my p resen ta t ion o f the subj ec t I hope y ou do no t cons ider m e too con

dem na to ry o f the opera t ion . I do no t in tend to be. I t is an opera t ion w h i ch ,

when under taken under p roper condi t ions and for a dequa te indi ca t ions , is one

o f the m o st sa t is fa c to ry in su rgery , sa y ing , a s i t so o f ten does , two l ives w h i chw ou l d o therw ise be sa cr ifi ced , or g ra vely im per i l led . Bu t do no t a l low i t tofa l l in to d is repu te by a sking f rom i t m o re t han i t can g i ve.

REPORT OF A CASE OF SEPTIC S INUS THROMBOS IS, WITHOUTINVOLVEMENT OF THE MASTOIDBy ST . JUL IEN R . DE CARADEU C ,

M .D .

Jo ur. V o l . 72,N o . 1 8

,May 3 rd , 1 919.

The au t ho r repo r t s a ca se Of b i la tera l m i dd le ea r inflamm a t ion du r ing an

a t ta ck o f influenza . Myringo tom y w a s ea r ly reso r ted to , and bo r i c a c i d i r r igat ion ca r r ied ou t every tw o hou rs . The a ppa ren t cou rse o f the au ra l inflamm a t ionw a s no t unu sua l . Th ree w eeks fo l low ing the in i t ia l ea ra che bo t h cana l s w ered ry and the drum head a lm o s t no rm a l . A few days l a ter the pa t ien t com p la inedo f pa in On the lef t s ide o f the fa ce,

and a l i t t le la ter ha d a defin i te ch i l l w i t h a

r ise o f tem pera tu re to severe hea da che a nd a p ro fuse sw ea t , w h i te b loodcount po lym o rphonu c lea r and a po s i t i ve b lood cu l tu re o f s treph to

co ccus hzem o lvt icus .

There w a s no m a s to i d tenderness a t a ny t im e,no r were t here any s ign s on

au ra l exam ina t ion t ha t sugges ted a ny m a s to i d invo l vem en t . Genera l exam inat ion fa i led to discover any cause fo r the pa t ien t

’

s cond i t ion . Though the b loodcu l tu res becam e nega t ive, opera t ion on the m a s to i d w a s dec ided upon . (No no teis m a de a s to w h i ch ear w a s o pera ted upon , o r on w ha t g rounds one w a s selec t ~

ed . ) The m a s to i d cel l s w ere no rm a l , and t here w a s no pu s in the an t rum . The

s inus w a s expo sed , bu t t here did no t a ppea r t o be any d isea se ill i t . so the du rao f the tem p ro - Spheno ida l lobe w a s expo sed and found no rm a l . Fu r t her exam ~

ina t ion o f the la tera l s inus w a s then ca r r ied ou t , and on in c i s ion t h i ck pus exudedand con t inued a s f rom an a b scess. The jugu la r w a s t hen resec ted in the neck .

A cu l tu re o f the pu s f rom the s inus show ed a pu re grow t h o f s t rep to co ccushaem o lyt ic is .

“

Recovery w a s uneven t fu l .(Thi s is ev iden t ly a ca se w here the in fec t ion t o the la tera l s inu s w a s con

veyed by sm a l l veins" f rom the m a s to i d w h i ch . a t the heigh t o f the m i dd le ea r

inflamm a t ion ,w a s a l so invo l ved .

Bo t h the an t ra l m uco sa and the tym pan i t i c m u co sa w ere a ble to o vercom e

the in fec t ion w i t hou t a ny a c tua l des t ru c t ion o f bone. a nd the d isea se in t heseca vi t ies w a s cu red . Th is , how ever , did no t o ccu r in the comm un i ca t ing veins and

the l a tera l s inus w here an ab scess recu r red . )PERRY GOLDSM ITH .

TH E CANADIAN MEDICAL MONTHLY 99

VACC lNATlo'

N

C . K. WH ITELOCK , M .D ., Sa ska toon , Sa sk .

The lo ca l i zed ou t b reaks o f sm a l l pox m I a l ious pa l ts o f the coun try b l ingto m ind thewo l k o f E dwa rd Jenner

, the discovele l o f va cc ina t ion . A s tudy o f

h is w o rk and a ca l eful cons i dera t ion o f the h istOIy o f t h is disea se w ou l d g ivefood for t hough t to an t i va ccina t ion is t s , w ho se ag i ta t ions a l e g i ven a ce l ta in

p rom inence in the new s o f the day.

E dw a rd Jenner wa s bo rn a t B erkeley ,Glouces tersh i re, E ng lan d , on May

17t h , 1749. On com p let ion o f s choo l l i fe he w a s a pp ren t i ced to a lo ca l su rgeon .

In 1770 he w en t to London to becom e a pup i l o f tha t g rea t su rgeon and ana tomist , John Hun ter . In 1773 he took up p ra c t i se a t B erkeley . H e died o f a po p lexyin London in 1823 .

E a r ly in his ca reer he began to no t i ce the phenom ena o f cow pox, a d isea secomm on in ru ra l Eng land a t t ha t t im e. I t w a s a po pu la r bel ief am ong the

pea san t ry t ha t a person w ho had had an a t ta ck o f cow pox w a s t herea f ter sa fef rom the in fec t ion o f sm a l l pox. I t is sa i d t ha t a young g i r l consu l ted Jennera bou t som et h ing or o t her , and du r ing the in terv iew m a de the rem a rk t ha t shecou l d no t ta ke sm a l l pox, because she had a l rea dy had cow pox . Th i s rem a rkm a de a la s t ing im p ress ion on Jenner ’s m ind . H e m a de his fi rs t exper im en t inva cc ina t ion abou t 1796. In tha t yea r he ino cu la ted a boy w i t h cow pox , and uponh is recovery w i t h sm a l l pox . The boy d id no t take the la t ter d i sea se.

The recep t ion by the m edi ca l p ro fess ion o f the pub l i ca t ion o f Jenner’sexper im en t s and t hei r resu l t s w a s ext rem el y d isco u rag ing . Oppo s i t ion to h is

t heo ry ha s never com p letel y d ied aw ay , and is s t i l l a c t ive,in sp i te o f the l igh t

th rown upon the subjec t by the exper ience o f yea rs .

F rom t im e imm em o r ia l C i r ca ss ian w om en ha ve infec ted t hei r ch i l d ren w i t hsm a l lpox , by m ak ing an inc is ion in the a rm and in t roduc ing a

‘pu s tu le taken f romano ther ca se. I t m ay ha ve been m o re o r less o f a bus iness p ropo s i t ion w i t h t hem .

I t is w el l known t ha t the.

C i r ca ss ians w ere poo r , a nd t ha t thei r da ugh ter s w erebeau t i fu l . They fu rn i shed the annua l c rop o f beau t y for the ha rem s o f Tu rk ishSu l tans and nob les . They w ere w el l ins t ru c ted in a ll art s and dev i ces w h i chm igh t en ter ta in t hei r in tended m a s ters . Occa s iona l l y i t happened t ha t a f teryea rs o f ca re and t ra in ing the va lua b le p iece o f hum an m er chandi se w ou l d bem ade va lueless by an a t ta ck o f sm a l l pox ; for no person w ou ld buy a s lave d isfigu red by th is d isea se. Consequen t ly ,

i f the beau ty o f tw o or t h ree gi r l s w a s

t hu s m a r red the fam i ly m igh t be ru ined fi nanc ia l ly . S ince a t ra ding na t ion


a lw a y s w a t ches ca refu l ly it s Own in teres t s,and s ince one o f the ch ief a r t i c les o f

m erchand i se in C i rca ss ia w a s w om en,t herefo re i t behoo ved them t o find som e

w ay o f p reven t ing the des t ruc t ion o f the va lue o f su ch m erchandiseb y d isea se.

BY Observa t ion and exper ien ce t ha t no person ever had severe sm a l l pox tw i ce,they found tha t the - p rodu c t ion of a r t i fi c ia l sm a l l pox ,

by the m eans desc r ibeda bove, gave the des i red p ro tec t ion . Consequen t ly ,

w hen sm a l l pox had lef t thecoun t ry the inha b i tan t s w ere g rea t ly w o r r ied , for. t hey had no sou rce o f supp lyo f in fec t ious m a ter ia l o t her t han ca ses w h i ch o ccu r red .

I t ha s been sa i d tha t the C i r ca ss ians bo r row ed t h i s cus tom f rom the an c ien tA rab ia ns . No defin i te in fo rm a t ion is ava i lab le. The Tu rks so on Cop ied i t , a ndino cu la ted thei r ch i ld ren soon a f ter t hey w ere w eaned . The Ch inese ha ve pra ct ised ino cu la t ion fo r cen tu r ies ; bu t i t is done t h rough the no se ins tea d o f byinc i s ion , the dr ied sca b s being in t rodu ced a f ter the m anner o f t a k ing snuff . I trem a ined fo r Jenner to pu t the p ra c t i se on a sc ien t i fi c ba s i s . Th i s is a ll h i s to r i ca l ,a nd m o re o r less d ry and un in teres t ing ; bu t w ha t I am t ry ing to Show is

,t ha t

the a n c ien t peop les ha d m o re sense,appa ren t ly , t han w e w ho l i ve in t h i s en l igh t

ened age.

Jenner 5 Ob serva t ions led him to th ink tha t the g rea se,a d isea se o f the heel s

o f the ho rse, and cow pox w ere i den t i ca l . We know . o f cou rse,t ha t th is is in co r

rec t . fo r i t ha s s ince been disp roved . Th is does no t a ffec t the m a in cons idera t ion ,

and h is con c lus ion t ha t cow pox a ff o rd s p ro tec t ion aga ins t sm a l l pox ho l ds good .

H ow ever , he ob served tha t an ou tb reak o f the g rea se w a s u sua l l y fo l low ed byan ou t b rea k o f cow pox , and conc luded tha t the na tu re o f the

.

infec t ion w a s the

sam e in bo th ca ses . Ca relessness on the pa r t o f the a t tendan t s w a s the m eans

by w h i ch the infec t ion w a s sp rea d . The m i l k ing w a s done by the fa rm ha nds ,a nd i f one o f t hese w ho w a s a t tending a ho r se w i t h the g rea se shou ld hel p w i t hthe m i l k ing ,

he sp rea d the d isea se f rom the ho rse to the cow . F rom the cow i tw a s sp rea d to the hum an v i c t im s . The d isea se a ppea red on the n i pp les o f the

cow , and ha s been des c r ibed a s being in the fo rm o f i r regu la r pus tu les o f a pa l i shb lue co lo r , or som ew ha t a ppro a ch ing to the l i v id , and su r rounded by an erys i pela tous inflamm a t ion . These pu s tu les f requen t ly degenera ted in to phagadenic

u l cers un less t rea ted , and w ere very t roub lesom e . The indi spo s i t ion in ter feredw i t h the sec ret ion o f m i l k ,

w h i ch w a s les sened . The dom es t i cs , being in fec tedfrom the cow s

,pus tu les appea red on the hands and w r i s t s , p ro ceed ing qu i ck l y

to suppu ra t ion and u l cera t ion ,a f ter fi rs t a ssum ing the a ppea ran ce o f ves i ca t ion

p rodu ced by a bu rn . Ab so rp t ion o ccu r red ,and tum o rs a ppea red in the axi l lae .

Sy s tem i c sym p tom s w ere p roduced , a s ch i l l s , fever,

"

inc rea sed pu l s e ra te. la s s itude,

pa ins in the l im b s and lo ins , vom i t ing . Heada che w a s comm on . and o cca

s iona lly del i r ium . These sym p tom s la s ted a few da y s and t hen g ra dua l l y sub

s ided .

A few h is t o r ies o f Jenner ’s ca ses a re quo ted in suppo r t o f h is content lon .

“

Ca se I . Jo seph Merret , now an underga'rdener to the E a r l o f Berkeley .

TH E CANADIAN MEDICAL MONTH LY 10 1

l ived a s a servan t to a fa rm er nea r t h i s p la ce, in the yea r 1770,a nd o cca s iona l l y

a s s i s ted in m i l k ing h is m a s ter’s cow s . Severa l ho rses belong ing to the fa rmbegan to ha ve so re heel s , w h i ch Merret f requen t l y a t tended . The cow s soon

becam e a ffl i c ted w i t h cow pox , and soon a f ter severa l so res a ppea red on h is

hands . Sw el l ing and s t i ffness in ea ch axi l la fo l low ed, a nd he w a s so m uch ind is

po sed for severa l days a s to p reven t his fo l low ing o rd ina ry em p loym en t . Prev ious to the a ppea rance o f t h i s di s tem per am ong the cow s t here w a s no f resh cow

b ro ugh t in t o the fa rm ,nor any servan t em p loyed w ho wa s a ffec ted w i t h the

cowpox . In 1795 , a genera l ino cu la t ion ta king p la ce here, Merret w a s ino cu la tedw i t h his fam i l y , so t ha t a per iod o f tw en ty - five yea rs had ela psed s ince his ha v ingthe cow pox . How ever , t hough va r io lous m a t ter w a s repea ted ly in ser t ed in to hisa rm s , I found i t im p ra c t i ca b le to in fec t him w i t h i t ; an efflo rescence on ly , ta k ingon an erys ipela tou s look a bou t the cen t re, a ppearing on the s k in nea r thepun c tu red pa r t s .

Du r ing the w ho le t im e h is fam i l y had the sm a l l pox , one o f

w hom had i t very fu l l , he rem a ined in the house w i t h t hem ,bu t recei ved no

inju ry f rom the expo su re t o the in fec t ion .

”

“

Ca se I I . Sa rah Po r t lo ck , o f '

th is p la ce,w a s in fec ted w i t h the cow pox w hen

a servan t a t a fa rm er’s in the neighbo rhood , tw en t y - seven yea rs ago . In 1792,

conceiv ing hersel f from t h is c i r cum s tance secu re f rom the in fec t ion o f the sm a l l

pox , she nu rsed one o f her own ch i l d ren w ho had a cc iden ta l ly caught the di sea se,

bu t no indispo s i t ion ensued . Du r ing the t im e she rem a ined in the infec ted roomva r io lou s m a t ter w a s inser ted in to bo t h her a rm s

,bu t w i t hou t any fu r t her effec t

t han in the p receding ca se.

”

“

Ca se I I I . John Ph i l l i ps , a t radesm an o f t h is town,had the cow pox a t so

ea r ly a per io d a s n ine yea rs o f age. A t the age o f s ixt y—tw o I ino cu la ted h im ,

and w a s very ca refu l in selec t ing m a t ter in the m o s t a c t i ve s ta te. I t w a s ta kenf rom the a rm o f a boy jus t befo re the comm encem en t o f the erup t ive fever

,a nd

ins tan t ly inser ted . An efflorescence a ppea red wh i ch on the fou r t h day w a s

extens i ve, and som e deg ree o f pa in and s t i ffnes s w a s fel t a bou t the sho u l der :bu t on the fi f t h day t hese sym p tom s began to d i sa ppea r , and in a day or tw o

w en t en t i rely o ff w i t hou t p ro duc ing any effec t on the sys tem .

Ca se IX . A l t hough cow pox sh iel ds the cons t i tu t ion from sm a l lpox, andsm a l l pox is a p ro tect ion aga ins t its ow n fu tu re po i son , yet it a ppea rs t ha t thehum an. bo dy is aga in a nd aga in suscep t i b le to the infec t ious m a t ter o f the cow

pox . a s the fo l low ing h i s to ry w i l l Show : W i l l iam Sm i t h , o f Pyr ton ,in t h i s

pa r ish , con t ra c ted the d i sea se w hen he l i ved w i t h a neighbo r ing fa rm er in'

t heyea r 1780. One o f the ho rses belong ing to the fa rm ha d so re heel s , and i t fel l tothe lo t o f Sm i t h to d res s him . By t hese m ea n s the in fec t ion v\ a s ca r r ied to the

cow s . and from the cow s i t w a s comm un i ca ted to Sm i t h . On one o f h is ha ndsthere w ere severa l u l cera ted so res , and he w a s a ffec ted w i t h the sym p tom s

befo re desc r ibed . In the y ea r 1791 the cowpox b ro k e ou t at ano t her fa rm ; w herehe w a s t hen a s. a servan t , a nd he becam e a ff ec ted w i t h i t a second t im e. In the

y ear 1794 he w a s so unfo r tuna te a s to ca t ch‘ i t aga in . The - di sea se w a s equa l ly


a s severe the second and t h i rd t im e a s i t w a s on the fi r s t . In the sp r ing o f the

vea r 1795 he w a s tw i ce ino cu la t ed , bu t no a ffec t ion o f the sy s tem cou l d be produced by the va r io lous m a t ter

, and he ha s s ince a sso c ia ted w i t h t ho se w ho hadthe sm a l lpox in its mos t con tag ious s ta te w i t hou t feel ing any effec t s from i t .

.

Ca se XV I I . The m o re a ccu ra tel y to ob serve the p rog res s o f the infec t ion ,

I selec ted a hea l thy boy a bou t eigh t y ea rs o ld for the pu rpo se o f ino cu la t ion fo rthe cow pox . The m a t ter w a s taken f rom a so re on the hand o f a da i ry m a i d ,who w a s in fec ted by her m a s ter’

s cow s,and w a s inser ted on the 14t h o f May,

1796, in to the a rm s o f the boy by m eans o f tw o super fi c ia l inci s ions , ba rely penetra t ing the cu t is , ea ch abou t ha l f an inch long . On the seven th day he com

p la ined o f unea s iness in the axi l la , and on the nin t h day he w a s a l i t t le ch i l ly ,lo s t

h is a ppet i te and had a s l igh t hea da che. Du r ing the w ho le o f the day he w a s

percep t ib ly indisposed and spen t the n igh t w i t h som e deg ree o f res t lessness , bu ton the fo l low ing day he w a s per fec t ly w el l . The a ppea ran ce o f the inc is ions int hei r p rog ress to a s ta te o f m a tu ra t ion w a s m u ch the sam e a s w hen p roducedin a s im i la r manner by va r io lous m a t ter. The on l y d i fference w h i ch I perceivedw a s in the s ta te of the l im p id flu i d a r is ing f rom the a c t ion o f the v i rus , w h i cha ssum ed a da rker hue, and in t ha t o f the efflorescence sp rea ding round the

in ci s ions , w h ich had a m o re erys i pela tous look t han w e comm on l y per cei ve w henva r io lous m a t ter ha s been m ade use o f in the sam e m anner ; bu t the w ho le diedaw ay , leav ing on the ino cu la ted pa r ts s cab s and sub sequen t escha rs , w i t hou tg iving m e or my pa t ien t the lea s t t roub le.

”

‘

In o rder to a scer ta in w het her the bov a f ter feel ing so s l igh t an a ffec t ion o f

the sys tem f rom the cow pox v i rus w a s secu re f rom the con tag ion o f the sm a l lpox ,

he w a s ino cu la ted the l st o f Ju l y fo l low ing w i t h va r io lou s m a t ter imm edi

a tely taken f rom a pus tu le. S l igh t punc tu res and inc is ions w ere m a de on bo t hhis a rm s , and the m a t ter ca refu l l y inser ted

,but no disea se fo l low ed . The sam e

a ppea rances w ere ob servab le on the a rm a s w e comm onl y see w hen a pa t ien t ha shad va r io lous m a t ter a pp l ied , a f ter ha v ing ei t her the cow pox or sm a l lpox . Sev

era l m on t hs a f terw a rds he w a s aga in ino cu la ted w i t h va r io lous m a t ter , bu t nosens i b le effec t wa s produced on the cons t i tu t ion .

”

A l though I p resum e i t m ay be unnecessa ry to p roduce fu r t her tes t im ony insuppo r t o f my a sser t ion tha t the cow pox p ro tec t s the hum an cons t i tu t ion f romthe infec t ion of the sm a l l pox , yet i t a ffo rds m e cons i derab le sa t is fa c t ion to say

tha t Lo rd Somm ervi l le, the Pres iden t o f the Boa rd o f Ag r i cu l tu re, to w hom t h ispa per wa s shown by Sir Jo seph Banks , ha s found upon inqu i ry t ha t the s ta tem en t s w ere confi rm ed by the concu r r ing tes t im ony o f Mr . Do l land , a surgeon

who res i des in a da i ry coun t ry , rem o te f rom t h is in w h ich t hese observa t ionsw ere m ade. W i t h respec t to the o pin ion a dduced tha t the sou r ce o f the infec

t ion is a pecu l ia r mo rb i d m a t ter a r i s ing in the ho rse, a l t hough I ha ve no t beenab le to p rove i t by a c tua l exper im en t s conduc ted under my own eye, yet the

ev idence addu ced a ppea rs sufficient t o es tab l i sh i t .


from 1893 to 1897 . Of t h is num ber,Rus s ia a lone lo s t Du r ing the

F ranco—Prus s ian Wa r a ll the m en o f the Germ an a rm y had been va cc ina teda ga ins t sm a l l pox . The F rench a rmy w a s no t so pro tec ted . The fo rm er lo s t on lya few hundreds f rom t h is d isea se. The la t ter lo s t som ew here a bou t m en .

In the Grea t -

'V a r ju s t c lo sed the B r i t i sh a rm y , inc lud ing the m en f rom t he

co lo n ies and g rea t dom in io ns . ere va cc ina ted aga ins t sm a l l pox ,w i t h the resu l t

t ha t the di sea se w a s a lm o s t unknown

The exper ien ce o f y ea rs show s convinc ing p ro o f o f the d iff erence in m or

b id ity and m o r ta l i ty ,betw een the va cc ina ted and tho se,no t so pro tec ted . I t ha s

been shown t ha t in t hou sands o f ca ses o f sm a l l pox o ccu r r ing the w o r l d over them o r ta l i ty am ong the unva cc ina ted is f rom five to s ixteen t im es a s g rea t a s

am ong the va cc ina ted .

V a cc ina t ion in t im es pa s t m ea n t a p ro cedure to es ta b l i sh p ro tec t ion aga ins tinfec t ion by sm a l l pox . Now i t a pp l ies to the p rodu c t ion o f immun i ty aga ins t

pneumom a,typho id fever , tetanu s , and severa l o t her d isea ses .

Mo s t o f u s can rem em ber the a lm o s t un i versa l p reva len ce o f typho i d fever .

It is no t long s in ce th i s w a s one o f the'

m o s t w i desp rea d and fa ta l d isea ses w i t hwh ich w e ha d to dea l . I t h ink i t w a s Os ler w ho sa i d ,

“Wherever m en a re con

grega ted toget her w i t hou t m a king a dequa te p rovis ion for the d ispo sa l o f thei rexc reta , typho i d w i l l o ccu r .

”Th is is t rue, espec ia l ly in a rm ies

,w here the san i

ta ry a r rangem en t s ca nno t , t h rough fo rce o f c i rcum s tan ces, be a s ela bo ra te a s

m a y be necessa ry . Su rely any t h ing w h i ch w ou l d p reven t t h is disea se w o u l d beo f ines t im a b le benefi t . We ha ve su ch p ro tec t ion in typho id va cc ine. In the

So u th A fr i can Wa r the B r i t ish a rm y w a s a pp roxim a tely m en . The

dea th s f rom typho i d a lone num bered som e o r m o re. In the Wo r l d Wa r

ju s t over, the Cana dian A rm y Co rp s w a s a pp roxim a tely ha l f a m i l l ion s t rong .

The dea th s f rom typho i d w ere few, and the num ber o f ca ses w a s a bou t 300. The

Ca na d ia ns w ere va cc ina ted aga ins t t ypho id ,w h i le in the So u t h A f r i ca n cam

pa ign no su ch p ro tec t ion w a s fu rn ished .

A s ea r ly a s 1807 va cc ina t ion w a s m a de com pu l so ry in Ba va r ia, and s ince

tha t .t im e m o s t E u ropean Go vernm en t s ha ve com pel led the p ra c t i se, or, a t lea s t .

encou raged i t . The resu l t is t ha t sm a l l pox ha s cea sed to be the scou rge i t w a s

befo re Jenner ’s di scovery . Som e am ong u s have, a ppa ren t l y ,no t a r r ived a t tha t

s tage o f en l igh t enm en t and in tel l igen ce w here w e can a pp rec ia te the im po r tanceo f va cc ina t ion . Why w i l l peop le, suppo sed ly in tel l igen t and en l igh tened , dis

rega rd the evidence o f cen tu r ies o f exper ience, and b l ind l y subm i t t hem sel ves t o

po s s ib le ann ih i la t ion ? Is i t igno rance, supers t i t ion, or jus t p la in cussedness ?

Sm a l l pox is a m o s t loa th som e disea se,leav ing it s v i c t im s w ho recover

,di sfigu red .

som e b l inded ,som e c r ippled in o t her w a y s , o r w i t h som e deb i l ity the cu re o f

w h ich is doub t fu l . I t 1s t rue tha t t here a re som e ins ta nces o f person s w ho ha y ebeen va cc ina ted a nd i e—va cc ina ted a nd have la ter becom e in fec ted w i t h the

d i sea se, but they a re very few I t 15 a lso t rue t ha t t here a 1 e ins tan ces o f perso nsw ho ha ve had sm a l l pox and con t 1 a c ted the di sea se a second t im e a t a la ter pe1 iod


in l i fe . Th is does no t a ffec t the fa c t t ha t in a va s t m a j o r i ty o f ca ses the pro tect io n a ffo rded by vacc ina t ion is a b so lu te. In my op in ion va cc ina t ion ough t to bem a de com pu l so ry by law . I f w e do no t va cc ina te, w ha t o t her p ro tec t ion ha vew e ; o r w ha t m eans o f s tam ping ou t t h i s s cou rge ? There a re none so b l ind a s

t ho se w ho w i l l no t see.

Onta rio Medica l Asso cia tio n

SECT ION or MEDlC lNE

Prelimina ry Announcemen t for Fo rt ieth Annua l Mee t ing

To ro n to , May 25 , 26, 2 7 , 28 , 1920

D R . E . C . ROSENOW Mayo Fo unda t io n , R o ch

es ter .

D R . A . GEORGE , A s st . Instruc to r , Dept . o fRoentgeno logy , Tu f t’s Co l lege Med i ca lScho o l , Bo s ton .

DR . CHAS . F . MART IN,Pro f. o f C l in i ca l Med i

c ine,

-McGill Un ivers i ty.

DR . J . W . CRANE ,Dept . o f Pha rm a co logy,

W'

es tern Un ivers i ty,Lo ndon .

DR . A . H . CA ULF IELD , C l in i c ian t o Dept . o f

Med ic ine , To ro nto Un ivers i ty,

and

DR . G. E . R ICHARDS , Rad io log i st , To ron toGenera l Ho spi ta l .

DR . J . G. F ITZ GERALD,Pro f. o f Hyg iene, Uni

vers i ty o f To ro n to .

DR . GEORGE P IR IE, A s so c . A t tend ing Phys i

ei an , H o sp. for S i ck Ch i ldren , To ro nto .

DR . JABEZ H . E LL IOTT , Phys i c ian Ches t C linic

,St . M i cha el’s Ho sp ; A ss t . Phys i c ia n

Ches t C l in ic , H o sp. fo r S ick Ch i ldren ,

To ro nto .

DR . NORM A N B . Gv, C l in i c ian to Dept . o f

Med i c ine To ro nto Un ivers i ty.

DR . J . E . K IDD,Londo n , Ont .

DR . W . R . CAM PBELL , C l in i c i a n to Dept . o f

Med i c ine, To ronto Un ivers i ty .

DR . E . A .

'MORGAN,A sso c . A t tend i ng Phys i

c ian ,H o sp. fo r S ick Ch i ld ren , To ronto .

DR . N . M . KE ITH , C l in i c ian to Dept . o f Med ic ine

, To ronto Un ivers i ty .

DR . G. A . DAV IS,To ro nto .

DR . D . K I NG SM ITH . Dept . o f Derm a to logy,

To ron to Genera l H o spi ta l ,and

DR . E MERSON TRow,Ass t . in C l i n i c o f D is

ea ses o f Sk in . To ronto Genera l H o spi ta l .a nd

DR . H . A . D I CK SON, C l in ica l A ss t , Dept .

Sk in,To ronto Genera l H OSpit

-a l.

DR . C . H . ROBSON,Anzes thet is t , H o sp. fo r

S i ck Ch i ldren , To ronto .

DR . R . D . DEFR IE S , Dept . o f Hyg iene. Uni

vers i ty o f To ronto .

Stud i es 0 11 Influenza .

X - Ray a s a n Aid in the Interpreta t ion o f

Symptom s referable to the B i l ia ry Sy s

t em .

P sych ia t ry,from the s ta ndpo int o f the Gen

era l Prac t i t ioner .

D ietet i c Trea tm en t o f Infec t io ns .

A Compa r i so n betw een the in terpreta t io nOf the find ings "in Chron i c Pu lm ona ryLes ions by C l in i ca l and Stereo - Roen tgeno

g raph i c exam ina t ion .

Ana lys i s o f D iph ther i a Dea ths in Onta r io .

Vom i t ing and Co ns t ipa t ion in Infancy.

Pregnancy a Mena ce to the Tubercu la rMo ther .

C l in i c a l S ide O f Empyem a in Influenza .

A c ido s i s in Influenza Pneum on ia .

Rena l Func t iona l Tes ts fo r the Genera lPra c t i t ioner .

D i a rrhoea in Infancy (Genera l m a nagem enta nd trea tm ent ) .

The Trea tm ent o f Rena l D i sea se in rega rdto the New er Func t io na l Tests .Interva l Methods O f Feed i ng .

Presenta t ion o f som e interest ing ca ses OfD i sea ses o f the Sk in .

Intra tra chea l Anaesthes ia (w i th exh ib i t io no f appa ra tus ) .

Vi ab i l i ty o f the Va cc ine Vi rus .


THE TREATMENT OF ECLAMPSIA

Ob serva t ions . Met hods a nd Resu l t s in Som e F i f ty - t h ree Consecu t i ve Ca ses ,W i t h Mo r ta l i ty .

GORDON G . COPELAN D, B .A . , MB .

Ass is tan t Ob s t et r i ca l Su rgeon , Obs tet r i c ian in Cha rge o f Ma tern i t y Depa r tm en tTo ron to Wes tern Hosp i ta l .

E clam p s ia ,the cu lm ina t ing even t in cer ta in toxaem ia s o f p regnancy , is one

o f the m os t ser ious d isea ses f rom w h i ch the ch i l d - bea r ing w om an can suffer .

Cons ider ing the coun t ry a s a w ho le, the ma terna l m o r ta l i ty ranges f rom 20

per cen t . to 30 per cen t . a cco rd ing t o the m o s t recen t textbooks su ch a s C rag in ,

DeLee a nd Shea res . The feta l m o r ta l i ty is p robab ly over 50 per cen t . Th isa ppa l l ing dea th ra te is , to a very la rge exten t , unnecessa ry and p reven tab le.

Ca refu l and f requen t an tena ta l exam ina t ions o f the b lood p ressu re, the u r ine,

and the prog ress ive h is to ry and inspec t ion o f the p regnan t w om an g ive us veryrel iab le da ta , ea s i ly ob ta ined , a s to w hether a toxaem

'

ia is p resen t and a l sow hether i t is p rog ress ing , and hence w a rn o f th rea ten ing convu l s ions . Usua l lyfor w eeks befo re t h i s d isa s ter o ccu rs , the w a rn ing s igna l s are di sp layed to t ho sewho look for t hem . E c lam ps ia sel dom com es from a c lea r sky , bu t ra t her fla shesou t from the da rk s to rm—c loud ba ckg round o f a r i s ing toxaem ia .

Prena ta l ca re,hones t ly conduc ted , and by tha t I m ean the fu l l inves t iga t iono f the w om an , her b lood p ressu re, and a u r ine ana l y s i s

,the ski l fu l ques t ion ing

a s to the amoun t o f u r ine pa ssed , the cha ra c ter o f the bow el m ovem en ts , thep resence o f hea da ches , eye sym p tom s , edem a ,

pa in ,b rea t h lessness , e tc . , the

detec t ion and rem ova l o f fo c i o f in fec t ion a s in o ra l sep s i s , the necessa ryd ieta ry changes , and o t her deta i ls sugges ted by the w om an

’s a ppea rance,

or

h i s to ry , or a s a resu l t o f fa c t s b rough t ou t upon exam ina t ion , and the modifica

t ion o f her hab i t s o f l i fe a s m ay seem indi ca ted a s ges ta t ion a dvances , w i t h m o ref requen t exam ina t ions and change o f t rea tm en t shou ld these seem a dv isab le,

and the timely temmfna -tion of pregnancy shou ld trea tment fail, a re m et hods w h i ch .

i f ca r r ied ou t fa i t h fu l ly and sc ien t ifi ca l ly by the do c to r,and s incerely co - opera tedin by the pa t ien t , w i l l a lmo s t a lw ays p reven t ec lam ps ia .

Tha t I am ab le to tel l you o f over fi fty consecu t ive ca ses persona l ly t rea tedin the la s t five yea rs , no t to m en t ion m any o thers I have seen but no t t rea ted ,is a m a t ter o f s incere reg ret to m e,

for i t show s on the one hand how very ca re

*Reari. before the Section on. Gynaeco logy and Obstet-rice. The Canad ian Medica l Assoc iat ion Meet ing , Quebec,June, 1919.

TH E CANADIAN MEDICAL MONTH LY 107

less som e m edi ca l m en have been , and , 0 11 the o t her hand,how igno ran t and

foo l ish m any w om en s t i l l a re. To ha ve saved over 95 per cen t . o f t hese wom en ,

a ll o f w hom w ere ser ious ca ses , m any o f t hem despera te indeed , g ives m e causefor t hankfu lness , bu t the g rea t p i ty o f i t is t ha t su ch a la rge num ber o f w om en

shou l d ever ha ve rea ched such a ter r ib le s ta te. I feel m o ra l ly certa in'

tha t had Ihad t hese w om en under my ca re f rom ea r ly in p regnan cy and had t hey fo l low edmy a dvi ce, p ra c t i ca l ly a ll w ou l d ha ve es ca ped the t ragedy ,

and m a ny ba b ies cou l dha ve been saved . Fo r the m o s t pa r t , the m et hods I u se a re a ll m o re or less‘

genera l l y em p loyed by m odern ob s tet r i c ians , though perha ps no t in jus t thesame o rder and exc lu s i veness a s I ha ve w o rked w i t h . I have com b ined in to myOwn flexib le sy s tem ,

t hose p ro cedu res w h i ch seem ed to m e to be the m o s trea sona b le, essen t ia l and s im p le f rom am ong the severa l excel len t m et hods o f

t rea tm en t w h i ch I have persona l l y s tud ied and seen u sed in the S loaneWom an’s

Ho sp i ta l , New Yo rk ; The Ro tunda Ho sp i ta l , Dub l in ; and va r ious o t her ho sp i ta l sin Cana da the U . S . A . , London , Gla sgow , and the Con t inen t .

F rom persona l conversa t ion w i t h the s ta ffs o f the To ron to Genera l H os

p i ta l a nd the Mon t rea l Ma tern i ty , and o t hers , a s w el l a s the resu l t s o f my own

c l in i c in the To ron to Wes tern Hosp i ta l , I feel i t to be the consensus o f op in iont ha t ec lam p s ia ha rd ly ever develo ps am ong the c l in i c pa t ien t s w ho com e ea r lya nd fa i t h fu l l y to t hese p rena ta l c l in i cs . And the

"

m ethods w e use a re so s im pl eand ea sy t ha t any p ra c t i t ioner can dup l i ca te t hem .

The g i r l s o f our coun t ry shou l d be taugh t in the sen io r g ra des o f a ll schoo l sthe fundam en ta l fa c ts o f hea lth ‘

law s w h i ch govern t hei r ow n bod ies . The S ta tet ha t fails to im pa r t such v i ta l know ledgeha s fa i led to g ive ins t ru c t ion neces

sa ry for the p reserva t ion o f l i fe i t sel f .TH E CAUSAT ION OF ECLAMPSIA .

The essen t ia l and cons tan t fa c to r in the ca usa t ion o f ec lam ps ia is the p regnancy i t sel f . As ide f rom t h is , In V iew o f the exis t ing con fus ion o f t heo r ies con

cern ing t h is d isea se, I can g ive you no exa c t and fina l w o rd a s to its et io logy , bu tt here are severa l observa t ion s w h i ch a re no t genera l ly known

,w h i ch neverthe

less seem to ha ve some bea r ing on t h is subjec t .1 . As the food supp ly p rog ress i vel y d im in i shed du r ing the w a r, and the

ca rbohyd ra te consum p t ion w a s rela t i vel y inc rea sed, ow ing to the s ca r c i ty and

h igh co s t o f an im a l fa t s , espec ia l l y bu t ter and ma rga r ine, a s w el l a s m ea t s ,the f requency o f ec lam ps ia w a s bo t h a c tua l ly and rela t ively dec rea sed . In - the

la s t tw o y ea rs o f the w a r, w hen food here in Canada w a s so expens ive, and s ca r cea l so , I saw on ly abou t ha l f as m any ca ses o f ec lam ps ia a s in the p reced ing tw o

y ea rs . Th i s ob serva t ion w a s no ted to a s t r ik ing exten t in No rw ay and Ger

m any du r ing the sam e per iod , s ta rva t ion being very c lose. F rom t hese observat ions i t w ou ld seem rea sona b le to conc lude t ha t a t lea s t one im po r tan t fa c to r inthe causa t ion o f ec lam ps ia is a d i s tu rbance o f m eta bo l i sm concerned w i t h food .

A l though I had g ra sped t h i s i dea independen t ly , and , on em p i r i c grounds la rgely ,

108 TH E CANADIAN MEDICAL MONTH LY

had t rea ted my pa t ien t s , show ing the toxaem ia s o f p regnancy , w i t h a h igh ca rboh y d ra te d iet , fo r the la s t five o r m o re yea rs , yet i t w a s no t un t i l Dun can and

H a rd ing , o f M on t rea l , b rough t ou t t hei r w o rk on pern i c ious vom i t ing in p regnancy , and its rela t ion to the d is tu rbance o f ba lance betw een fa t and ca rbohyd ra te metabo l ism t ha t I had suffic ien t sc ien t i fi c ba s is for my ow n bel iefs ,a s i de f rom resu l t s . On the o t her hand ,

I w a s w el l aw a re o f the fa c t tha t a nexc lus ive p ro tein diet w i l l o f ten ca use a neph r i t is

,and had u sed w i t h success a

l ibera l ca rbohy d ra te d iet , f ree, fo r a ll pra c t i ca l pu rpo ses , f rom pu r in s . The suc

cess t ha t Duncan and Ha rd ing have had in t rea t ing the ea r ly t oxaem ia s o f p regnancy by a h igh ca rbohyd ra te d iet , I have, t o som e exten t . pa ra l leled in the

toxeem ia s Of the la s t m on t h s o f ges ta t ion ,though here the p rob lem is m o re com ~

p l i ca ted by su ch fa c to rs a s p ressu re and infec t ion . Du r ing t hese la s t tw o yea rswom en w o rked ha rder and t hus w ere in bet ter cond i t ion .

2 . P recipita ting Factors in E clampsia . There are p rec ip i ta t ing fa c to rs w h i ch ,a dded to p r im a ry and pre

—exis t ing m eta bo l i c changes , espec ia l l y in the l iver andk idney s , ca use a fu r t her and overw helm ing b rea kdown o f the o rgans invo l ved ,

a nd so a ffec t d is tan t o rgan s l i ke the b ra in,t ha t convu l s ions or com a , o r bo th ,

resu l t . Ch ief o f t hese p rec ip i ta t ing ca uses s tand s infec tion . I ha ve m a deca refu l no te in the last fou r y ea rs o f the co nd i t ion o f the teet h and t h roa t , a ndI have repea ted ly dem ons t ra ted tha t o ra l seps i s w a s the v i s ib le and p roba b lesou rce o f infec t ion in nea r ly 75% o f my ec lam p t i c ca ses . Th is v iew po in t is a l sosha red by Mo sher , o f S t . Lou is , and Ta l bo t , o f VV orches ter, Ma ss . I bel ieve t ha ti t is bet ter to a t tem p t the rem ova l o f fo c i o f in fec t ion du r ing thepregna ncy , pro

vided t h i s can be under ta ken w i t hou t undue r isk , a s i t u sua l ly can ,cons i der ing

tha t the danger to the m o t her and fetus is g rea ter in m any ca ses by the con t inuan ce o f the po ison ing than w ou l d resu l t f rom carefu l and w el l cons idered o perat ive t rea tm en t . Cer ta in ly the l iver , kidneys a nd hea r t a re fa r bet ter a b le to s tandthe necessa ry s t ra in poss i b ly resu l t ing f rom ea r ly t rea tm en t

,because t hey a re

then m o re o r l es s in ta c t , t han t hey w o u l d be fo rced to s tand a s a resu l t o f cont inned po ison ing p lus the m etabo l i c changes due to the p regnancy i tse l f . I fin fec ted t eet h a re rem oved du r ing p regnancy I bel ieve tha t the chance o f absorp

t ion o f toxins or ba c t er ia f rom the raw a rea s may be g rea t ly m in im i zed i f thecavi ty is a t once sw abbed ou t w i t h , say, Di - ch lo ram ine- T , in ch lo rco sane. a nd

t ha t no t too extens ive o pera t ing is done a t one s i t t ing .

On the. o ther hand ,

‘I ha ve Of ten ob served the fa c t . w el l know n , t ha t one

a t ta ck o f ec lam p s ia seem s to con fer an imm un i ty a ga ins t sub sequen t a t ta c k s .

and t h i s in sp i te o f the fa c t t ha t obv ious sou rces o f infec t ion ha ve no t beenrem o ved m ea n t im e . Ta l bo t ’s theo ry ,

in teres t ing ,a nd fo r the m a j o r pa r t I t h ink

co r rec t . fa i l s to exp la in th is phenom enon .

Aga in . i t is su rp r i s ing how som e w om en w i t h very obvious sep tic fo c i seemuna ffec ted by them du r ing p regnancy . Th i s w ou l d seem to indi ca te t ha t thebo dy had a cqu i red a cer ta in imm un i ty aga in s t t hese o rga n i sm s . o r t ha t the g rea tfi l ters , the liver and kidney s . ha d had such a sp lendid reserve fo rce tha t t hey w ere


a b le to dea l w i t h t hese ba c ter ia and t hei r toxin s . I f , how ever , the genera l res i s ta nce is b ro ken dow n by som e s t rong infec t ion , such a s influen za , then t hese fo c io f in fec t ion. can and do o verw helm the o rgans o f el im ina t ion w ho se reserve is

gone. Thus I ha ve seen ec lam p s ia develo p in m u l t i pa ra: w ho ha d pa ssed severa l

pregnan c ies sa fe ly . In s evera l , influenza seem ed to be the fa c to r to b rea k downthe res i s ta n ce w h i ch had h i ther to been effec t ive aga ins t sep t i c fo c i .

Pro phyla c t i c innocu la t ion s aga in s t the comm on resp i ra to ry com p l i ca t ions o finfluenza I have em p loyed in my p regnan cy ca ses w i t h a ppa ren t ly very goodsu ccess w hen com pa red w i t h s im i la r ca ses no t so pro tec ted .

Wh i le a t t h is pa r t o f the di s cu ss ion o f the influence o f infec t ion s i t m igh t beo f som e in teres t to m en t ion the fa c t t ha t t h reeca ses o f s ter i l i ty o f f rom t h ree tofive yea rs ’ du ra t ion

,a f ter rem ova l o f ba d ly d i sea sed tons i l s a nd t eet h ,

and the

a dm in is t ra t ion o f au togenous va cc ines a ll becam e p regnan t w i t h in tw o o r t h reem on t h s a f ter the rem ova l o f the sep tic fo c i . I bel ieve a di rec t rela t ionshi p exis tedbetw een the infec t ion and the s ter i l i t y .

3 . Wh i le cons ider ing the ca u ses o f ec lam p s ia ,I w i sh to o ffer a sugges t ion .

I t m ay on ly ha ve been a co inc i dence, bu t I ha ve know n o f ec lam p s ia develo p ingin success i ve w i ves o f the same hu sba nd . Migh t th i s m ea n t ha t he had pa ssed0 11 an in fec t ion ,

no t venerea l , to w h i ch the w i ves w ere pa r t i cu la r ly sus cep t ib le ?Or m igh t i t be po s s i b le t ha t the p la cen ta l and fe ta l t i ssue and t i ssue flu i ds ha

'

d

dom ina n t pa terna l cha ra c ter is t i cs jus t a s dis t inc t i ve a s t ho se w h i ch a re vi s ib le,

su ch a s ha i r , eyes , fea tu res , etc . , and tha t t hese p la cen ta l p rodu c t s w ere an tagonis t ic to the m a terna l '

t issues, t ha t is , w ere o f oppo s ing b lo od g roup s o r incom

pa t i b le b loods ? I f t h is w ere so ,a nd i t is a rea sona b le hypo thes i s in m y op in ion ,

i t w ou ld no t be ha rd to concei ve t ha t the m o t her cou ld becom e sens i t i zed aga ins tthe incom pa t i b le pa terna l cons t i tuen t s in the p ro du c t s o f concep t ion . Anaphy

laxi s or p ro tein sho ck m igh t thu s be p rodu ced . I have considered t h i s po ss ib i l i tyfor severa l yea rs , and ha ve hoped to ha ve tes ted the b lood o f husband a nd w i feto a scer ta in w het her t hey belonged t o the sam e o r incom pa t ib le b lood g roups int hose ca ses w here ec lam p s ia develo ped , bu t ha ve la c ked the oppo r tun i ty . Othersw i t h g rea ter fa c i l i t ies m igh t a t ta ck th i s p rob lem . I f it - w ere Show n t ha t theb lo ods o f hu sba nd a nd w i fe w ere in com pa t i b le in ec lam p s ia

,t h is fa c to r m igh t

t hen a ssum e a very la rge ro le in the causa t ion o f the di sea se,and m eans m igh t

be fo und to desens i t i ze the m o t her , po ss ib ly by smal l inj ec t ions o f the hu sband’sb loo d . A defin i te p rophyla c t i c p ro cedu re m igh t t hus be evo l ved . I do no t w i sh ,

how ever , t o a t ta ch undue im po r tance to any one s ing le fa c to r , for I bel ieve t ha tthe p rob lem is m uch too com p l i ca ted to be di spo sed o f by one o r tw o fa c to rs .

CLASSES OF CASES .

In my ow n ser ies a bou t 90% w ere p r i’m i pa rae, bu t la rge ser ies Show t h is propo r t ion to be ra t her h igh w hen the w ho le coun t ry is cons i dered . Po s t—pa r tumconvu l s ions on l y o ccu r red th ree t im es

,The m a jo r i ty o f ca ses developed

ec lam ps ia a t abou t fu l l term . The fi t s s ta r ted u sua l ly befo re labo r comm enced ,bu t la bo r f requen t ly fo l low ed sho r t ly a f ter , Spon ta neou s ly . o r el se i t was induced .

1 10 THE CANADIAN MEDICAL MONTHLY

A sm a l l num ber o f w om en developed convu l s ions in the m i dd le t h i rd Of p regnan cy . I had one ca se develop a s ea r ly a s 3% m on t hs .

Rough ly g rouped , the ca ses ha ve fa l len in to tw o m a in types , the l iver ork idney t y pe, depending on w h i ch o rgan w a s the m o re a ffec ted .

Liver Type. Th is “

w a s cha ra c ter i zed by jaundi ce,low b lood p ressu re ( the

hea r t ha s no t com pensa ted Ow ing to the in tens i ty o f the t oxaem ia ) , abdom ina l o rep iga s t r i c pa in ,

vom i t ing a nd com a . Convu l s ions m ay or m ay no t be p resen t .These ca ses a re ra ther m o re dangerous t han the kidney type, and respond to

t rea tm en t poo r ly .

Kidney Type. Th is is cha ra c ter i zed by hea da ches,

fla shes befo re the eyes ,

epiga s t r i c pa in , edem a, h igh b lood p ressu re, a l bumen and ca s ts in the u r ine,

severe. convu ls ions . Th i s type respond s a s a ru le qu i te w el l t o the fo l low ingt rea tm en t .

M ix ed Type. Th i s ha s sym p tom s and s ign s comm on t o bo t h the above. and

in addi t ion m ay have o t her o rgans , such a s the b ra in o r hea r t , spec ia l lydam aged .

PREV ENT IV E TREATMENT .

Th i s Shou l d be the m a in di rec t ion o f our a t ta ck on the w ho le ec lam ps iaprob lem . Wom en shou l d no t rea ch the s tage o f convu l s ion s o r com a i fthe do c to r do es hones t m odern w o rk a nd the pa t ien t co - opera tes fa i t hfu l ly w i t h him . Th is m eans superv is ion t h roughou t p regnancy . When a

toxaem ia o f p regnancy is detec ted , p rom p t m ea su res Shou l d be under ta ken to

reduce the s t ra in on the o rgans o f el im ina t ion , the l i ver’

and k i dneys . I ha veSpoken a bo u t the im po r tan ce o f rem ov ing sep t i c fo c i . The bowel s shou l d be kep tm o ving f ree ly ; m agnes ium su l pha te is one o f the bes t sa l t s . A t lea s t one qua r to f w a ter shou l d be ta ken per day,

and the to ta l flu i d in take and ou t pu t ca refu l l ym ea su red . I f edem a is presen t in the hands and fa ce

,t ha t is , a toxi c edem a ,

tab lesa l t shou l d be res t r i c ted . A pu r in scan t d iet I cons ider very im po r tan t in the preec lam p t i c t oxaem ia s , a s a l so in t ho se recover ing f rom eclam p s ia . F resh f ru i t s ,su ch a s lem ons , o ranges and g ra pe f ru i t , a re va luab le,

a s the c i t r i c a cid they con

ta in hel p s redu ce the v isco s i ty o f the b lood ,w h i ch is h igh in m any o f these ca ses .

111 the s l igh ter ca ses , a l ibera l pu r in scan t d iet m a y b e g 1ven w i t h a dvan tage .

F resh a ir and deep b rea t h ing a re va lua b le. Modera t e exerc i se in the f resh a ir is

excel len t . Ch i l l ing and w et feet shou l d be avo i ded . A sudden change to co l dw ea ther , un less ca refu l l y gua rded aga ins t , m ay p rec i p i ta te an a t ta ck o f eclamp

s ia . Modera tely ho t ba t hs rel ieve the k idneys o f the s tra in'

o f g et t ing r id o f the

o rd ina ry w a s te sa l t s . The w om an shou l d get in to a w a rm bed fo r an hou r or so

fo l low ing a ho t ba t h ,w hen i t is taken a t o ther than bed t im e . Mu ch res t in bed

w i t h p len t y o f co ver ing s to m a in ta in the skin a t the sw ea t ing po in t , and lo t s o f

f resh a ir is va luab le, espec ia l l y so i f the a bo ve m ea su res a re no t suffic ien t . Da i lyexam ina t ions o f the b lo od p res su re and u r ine , in clud ing the 24—hou r ou t pu t ,Shou l d be m a de. If the co ndit ion do es no t improve the wom an shou ld be pla ced

in a ho spita l under observa t ion and trea tm en t , i f a t a ll po ss ib le. I f she is far


TH E TREATMENT OF ECLAMPSI A.

Convu l s ions ha ve o ccu r red . Wha t sha l l w e do ? Tha t a ll depends on c i rcum s ta n ces . The v i ta l fa c to rs w h ich m u s t be qu i ck ly cons i dered a re t hese : Is

the fetus a l ive ? IS i t v ia b le ? Is la bo r in p rog res s ? Is the w om an a prim ipa ree?

IS the b i r t h cana l norm a l ? IS the cervix d i la ted or di la ta b le ? Is the do c to r onesk i l led in o b s tet r i ca l su rgery ? Is a Ski l led Spec ia l i s t a va i la b le ? Are ho sp i ta lfa c i l i t ies ob ta inab le ?

I sha l l t ry to Show yo u w ha t can be done in a goo d ho sp i ta l , and I sha l l g i vey o u m y own pro cedu res , con s ider ing the a bo ve ques t ion s in som e deta i l .

ANTEPARTUM CONVUL'

SIONS .

Bef o re Via bility .

Here on l y the l i fe o f the m o t her shou l d be cons i dered,s ince the fetus is

ei t her a l rea dy dea d or dying , o r w i l l a lm o s t'

surely'

die i f the d isea se p rog resses .

1 . Give ha lf a grain of m orphia by hypo . Try t hu s to con t ro l convu l s ions , andi f poss ib le p reven t t hem . Get the pa t ien t in to a hospi ta l i f a t a ll po ss i b le w i thou tundue r i sk . Preven t the w om an do ing hersel f inju ry by gen t ly res t ra in ing her,a nd p la c ing som e c lean so f t objec t betw een her teet h to p reven t her b i t ing hertongue. A c lean handkerch ief ro l led up; a ny rea d i ly a va i lab le c lean objec t w h i chp la ced betw een the teet h w i l l p reven t t hem c lo s ing , a nd w h i ch w i l l no t b reak thet eeth t hem sel ves , w i l l serve . I f the w om an fro th s a t the m ou t h ,

turn the hea ddow n o ver the s ide o f the bed so a s to m in im i ze the cha nces o f her a sp i ra t ing the

f ro t h a nd m ucus w i t h the a ccom panying danger o f an a spi ra t ion pneum on ia .

D o no t give chloroform to con t ro l the convu l s ions,a s t h i s anaes t het i c cau ses

dam age to the l i ver and k idney s s im i la r to t ha t done by the ecl am ps ia i t sel f .2 . Fresh A ir and Oxygen . Give p len ty Of f resh a ir

,and oxygen i f a va i lab le.

Give suffi cien t oxygen to c lea r up the cy ano s is . Keep the pa t ien t w a rm .

3 . In ters titia l Injectimi s . Give an in ters t i t ia l ( subcu taneous ) injec t ion o f

s ter i le phys io log i ca l sa l ine, f rom 500 to c . c . , under the b rea s t s , and m ak ingsu re t ha t t h is S im p le p ro cedu re is done in an a sep t i c m anner . I m en t ion the

s teri le sa l ine fi rs t,a s i t is nea r ly a lw ays a va i lab le a nd is good t rea tm en t . W ha t

is d is t in c t ly bet ter is a m et ho d w h i ch I bel ieve I w a s the fi r s t to em p loy in the

fo l low ing p ro po r t ions , and fo r the spec ia l t rea tm en t o f ec lam ps ia ,a da p t ing to

t h is di sea se a p ro cedu re a dvo ca ted som e yea rs ago by Thom p son Wa l ker fo r therel ief o f the a cu te anu r ia o ccur r ing in neph r i t i s . I t is the in ters t i t ia l injec t ion o f

a s t er i le 20% to 25% g lucose so lu t ion in sa l ine or w a ter , depending 0 11 cer ta infa c to r s to be m en t ioned la ter . Tw o hundred and fi f ty g ram s o f pu re g luco seshou l d be bo i led for ten m inu tes w i t h no rm a l sa l ine so lu t ion , c . c . , a nd coo ledto b lo od hea t , and injec ted under the b rea s t s w i t h a sep t i c p recau t ions . Th i sso lu t ion is the m os t pow er fu l sa fe s t im u lan t o f the kidney s w e have, a nd i t a l sosupp l ies imm edia tel y a va i lab le food to a s t ra ined , toxi c and s ta rved hea r t , a s

w el l a s pro tec t ing the l i ver , w h i ch is tem po ra r i ly di sa b led , and in a ddi t ion is a

very s t rong sa fegua rd aga ins t sep s i s . I t causes a m a rked leu co cy to s i s . In com

TH E CANADIAN MEDICAL MONTHLY 1 1 3

1110 11 w i t h s im p le sa l ine i t a l so di lu tes the toxins c i r cu la t ing in t he sys tem , and

renders the bloo d less l ia b le to a bno rm a l c lo t t ing . A 11 in ters t i t ia l shou l d be g ivenin p reference to an in t ra venous inj ec t ion ,

a s the techn i c o f in ters t i t ia l injec t ion isea s ier to per fo rm a nd less dangerou s , for i t is f requen t ly ha rd to find su i ta b leveins in w om en ,

the hea r t ca n rea d i l y be em ba r ra s sed by a sudden inc rea se inthe b lood vo lum e , a nd w o rs t o f a ll, and a very rea l da nger , shou l d a convu l s ions ta r t w hen the need le is in the vein ,

m uch dam age m igh t resu l t f rom w ound ingthe a r tery o r nerve. On the o t her hand ,

the g lu co se so lu t ion is a b so rbed in a

s im i la r w ay to the sa l ine,and en ters the c i rcu la t ion g ra dua l l y and does no t

em ba r ra ss the hea r t . I t redu ces the b lood p ressu re i f i t is abno rm a l ly h igh ,and

ra i ses i t i f i t is very low .

4. V cnesec tion or o'eni/mnctare is good in fa ll—blooded 1 00 71 1611 . I t rem oves a

cer ta in am oun t o f c i rcu la t ing t oxin ,and redu ces the .b lood p ressu re. I t is no t a

good th ing ,.how ever, in low b lood p ressu res , and m us t be u sed w i t h judgm en t ,

fo r the w om a n s t i l l ha s to lo se an unknown am oun t o f b lood at del i very . Usua l ly10 to 20 ounces (300 c . c . to 600 c . c . ) m ay be w i t hd rawn w i t h g rea t a dvan tage.

The la rger am oun t is na tu ra l l y fo r big w om en . I t is bet ter,a s a ru le, to w a i t

un t i l the in ters t i t ia l ha s been g i ven and a bso rbed before ta king the b loo d , a s i t ist hen less l i kely to c lo t . I ha ve a t tem p ted to rem ove b lood f rom the a rm s o f

ec lam p t i c w om en,and no t on l y d id I fa i l to ob t a inmo re t han a - few d rop s o f

b la ck ,ta r ry b lood , bu t have had the w ho le an tecub i ta l fo ssa t h rom bo se . La ter ,

w hen the b loo d w a s d i lu ted by sa l ine o r g luco se so lu t ion , the b lood ran ea s i ly .

5 . Empty the u terus under aseptic conditions w ith. a min.imam of shock and

traum a .

F i rs t m et hod , hyd ro s ta t i c d i la ta t ion ,u s ing V oo rhees ’ ba g s . o r t h i s pro

cedure,fo l lowed by m anua l di la ta t ion and del i very .

I f the cerv ix is no t so f t enough to be d i la ted ea s i ly under an anaes t het i c to a

s i ze su ffic ien t to del i ver the fetu s a t one s i t t ing ,then i t m a y be d ig i ta l l y o r

instrum en t ly d i la ted to the S i ze Of the index finger , and t hen inser t the la rges ts i zed V oo rhees’ bag w h i ch w i l l go in ,

usua l l y No . 3 ; fi l l t h is bag w 1th s ter i lew a ter o r wea k an t i sep t i c so lu t ion , t ie and apply

‘

tra c t ion o f tw o o r t h ree pounds .

I t is f requen t ly po ss i b le to do t h is w i t hou t any furthei' seda t ive'

than the m o r

ph ia , bu t i f an anaes t het i c is necessa ry , t hen n i t rous oxide—oxy gen , o r et heroxy gen ,

is the bes t to use.

When the bag com es ou t , a s i t do es in a few hou rs a s a ru le, the cerv ix m ay

t hen be o pen enough for del i very , bu t shou l d fu r t her d i la t ion be necessa ry,it

m ay t hen be po ss i b le to fin ish di la ta t ion m anua l ly w i t hout la cera t ing the cerv ix .

Som et imes , how ever , the cerv ix canno t be m anua l l y di la ted w i t hou t danger o ftea r ing ,

and t hen w e ha ve to cons ider the ca se. I f. the w om an is do ing w el l,hav

ing goo d la bo r pa ins , a nd i t‘

i s fel t t ha t in a few hou rs She w i l l del i ver hersel f , i tis bes t to g ive na tu re a chance. Occa s iona l l y the pa ins s to p a s so on a s the fi rs tbag com es ou t . Ano t her la rger bag m ay t hen be inser ted under a sep t i c preca u ~

t ions , t ra c t ion a pp l ied , ah d the ca se w a t ched . I f the w om an is do ing w el l she


m ay del i ver hersel f . Wh en the bag com es ou t , i f the pa ins subs i de, the fetusm ay t hen be ext ra c ted by fo rceps , or vers ion and b reech ext ra c t ion , a s m ay seem

bes t in the ind iv idua l ca se. Shou l d the fetus be dea d , per fo ra t ion m ay be doneand thus sa ve va luab le t im e and unnecessa ry di la ta t ion . Jus t here I m igh t m en

t ion tha t i t w ou l d be w el l to g i ve F4 g ra in o f m o rph ia w i t h in som e two hou rs o f

the fi rs t in jec t ion shou l d the w om an show fu r t her - s igns o f a pp roa ch ing con

vulsions

Second method :V ag ina l Caesa rean Sec t ion , or vag ina l hys tero tom y . Occas iona lly the. cerv ix w i l l be found long and r ig i d , ca r t i lag inous in fa c t . Here t hereis S l igh t hope o f the less ra di ca l m ethods a ccom p l ish ing a sa t is fa c to ry d i la ta t ionin a sa fe t im e. Aga in , the cerv ix m ay adm i t No . 1 , or ra rely No . 2

, bag , and a f tersevera l hou rs’t ra c t ion no suffic ien t fu r t her en la rgem en t o f the cerv ix ha so ccu r red , or the condi t ion o f the w om an m ay becom e w o rse and dem a nd speed"eva cua t ion o f the u terus .

When any o f t hese condi t ions 18 p resen t the bes t w ay t o em p ty the u terusis a vag ina l Caesa rean sec t ion . Th i s opera t ion proper ly done is ra p id , ha s veryl i t t le sho ck , does very s l igh t dam age, and in com peten t hands is very sa t isfac

to ry . I t may be used to a dvan tage up to the eigh t h m on t h , p rov ided no ser iouspel v i c con t ra c t ion exis ts . A f ter t ha t t im e

,a bdom ina l Caesa rean sec t ion is pre

ferable, and in my ow n hands is very m u ch fa s ter .I ha ve m odified the c lass i ca l vag ina l Czesarean sec t ion , m aking i t m uch sim

pler. The m od ifi ca t ion w a s o r ig ina l w i t h m e, and I ha ve em p loyed i t w i t h verysa t is fa c to ry resu l t s som e seven t im es . La tely

,how ever , in speaking w i t h Pro f .

B . P . Wa t son , I found tha t he em p loyed a som ew ha t s im i la r techn i c .

Vag ina l Caesa reansec t ion a s I do i t is a s fo l low s : The o pera t ing fiel d is m a dea s s ter i le a s po ss ib le a f ter the pa t ien t is under the anaes t het i c . S ter i le dra pes a rep la ced ,

and the per ineum ret ra c ted w i t h a w eigh ted specu lum The

b la dder is ca t heter i zed , and the cerv ix d raw n down a s fa r a s necessa ry, or a s is

po ss ib le w i t hou t inju ry . Tena cu la a re p la ced On the an ter io r l ip , and the cerv ixSp l i t upwa rds in the m i d l ine to w i t h in a ha l f an inch o f the b ladder , or to the

ho rizon ta l pa r t o f the inver ted l o f the Ol der Opera t ion . Th is produces cu t sur

fa ces l ike tw o t r iang les , v‘

vith the a p i ces towa rd the opera to r and the ba ses jo ined .

The s ter i le g loved finger is p la ced in the cen ter o f the ba se o f the cut and gen t lyins inua ted , caus ing a separa t ion betw een the tw o layers o f the cerv ix . The

ba se o f the cervix is t hus d iv ided in to the upper and an ter io r vag ina l layer , w h ichis con t inued up to the b ladder and a low er po s ter io r layer o f the cerv ix wh i chm erges in to the low eru ter ine segm en t . The b la dder is ro l led and s t r i pped aw a y

from the cerv ix to bo t h s i des , a s'

w el l a s upw a rds . I usua l l y p la ce s ter i le gauzea round the index finger in do ing t h i s . An anter io r ret ra c to r is t hen inser ted ,and the vag ina l layer o f the cerv ix and the b ladder are ret ra c ted and p ro tec ted .

The cerv ix is t hen cu t upw a rds w i t h s c isso rs un t i l enough room is ga ined to

a l low the fetu s to be ext ra c ted . I f the fetu s is sm a l l t h i s a n terio r vag ina lhy s tero tomy is suffic ien t , bu t i f the ch i l d sho u l d be v ia b le, one canno t u sua l ly cu t


high enough to g ive room and a t the sam e t im e keep the inc is ion w i t h in con t ro la b le d is tance. Shou l d t h is be the ca se, the pos ter io r l i p o f the cerv ix m ay be dea l tw i t h in a s im i la r m anner , ta k ing ca re to avo i d inju r ing the rec tum . The m em

b ranes a re t hen rup tu red i f t h is ha s no t been done or o ccu r red spon taneou s l y .

The fetus is t hen ex t ra c ted w i t h fo rceps or by the b reech , a cco rd ing to the

indi ca t ions p resen t . The a f terb i r t h is rem oved , and ca re shou l d be ta ken les t theuterus be pushed ins i de out . I t hen c lose the low er u ter ine segm en t and cerv ixby a runn ing su tu re o f ch rom i c ca tgu t , No . 2 , and the vag ina l layer by a runn ingsu tu re o f ch rom i c ca tgu t , No . 1 . A t the top, and aga in ha l f w ay down the cu t ,

I take a deep b i te in to the cervix , a s th is un i tes the two layers and p reven t s a

hema toma .I f the po s ter io r hys tero tom y ha s been done i t is w el l to repa i r the

po s ter io r inc is ion fi rs t .

The sooner the w oman can be del ivered a f ter the fi rs t convu ls ion , the

m o re l i kely w i l l she recover , and fu r t her convu l s ions be p reven ted , w h i le i f thefetus is viab le, th e qu i cker i t is go t ou t w i t hou t inj u ry , the bet ter it s chancesw h i ch a re no t good .

To the coun t ry do c to r , unab le to get his pa t ien t to a ho sp i ta l , and w i t hina dequa te hel p , I w ou l d a dv i se the m o rph ia to be g iven in la rge doses ; g i ve a n

in ters t i t ia l , u s ing s t erile sa l ine, i f g luco se is no t ava i la b le ; la ter b leed the pa t ien ti f the b lood p res su re is h igh and she ha s lo t s o f b lood . Then under p roper an t isep t i c and a sep t i c precau t ions , punc tu re the m em b ranes , pa ck the cerv ix and

vag ina w i t h s ter i le gau ze, soaked w i t h g lycer ine and a w ea k an t isep t i c . Wa t chthe ca se, and i f la bo r does no t ensue sho r t ly , w hen the cerv ix is wel l so f tened , i tm a y be ca refu l ly d i la ted ,

and ta ke suffi c ien t t im e a t t h is s tage to a vo i d lacerat ions (o f ten from ha l f an hou r to an hou r Shou l d be spen t ) . Wh i le w a i t ing forthe cerv ix to so f ten , ho t pa cks , to the lo ins espec ia l ly , and i f th e sk in is ho t a nddry and the b loo d p ressu re h igh a genera l ho t pa ck ma y do cons iderab le good .

H o t pa cks Shou l d no t , a s a ru le, be g i ven to w om en w i t h low b lood p ressu res , a sthe pa ck Soon causes exhaus t ion . I f for som e good rea son the cerv ix is no t

packed , the co lon m ay be flushed o f ten w i t h ho t wa ter , and here the temperatu re shou ld nOt be above 1 15 Fa h r . Tw o oun ces o f m ag . su lph . m a y be g i ven bym ou t h i f the pa t ien t can sw a l low , o r m ay be g i ven by a s tomach tube. The

s toma ch m ay be w a shed ou t , bu t the good to be der ived from t h is p ro cedu re isvery s l igh t and shou ld no t rep la ce the o t her m ea su res sugges ted . Som e m en lay

g rea t s t ress on s tom a ch w a sh ing , bu t I bel ieve i t serves to exc i te and dis tu rb thewOm an: To the m an w ho m us t do som et h ing i t is m u ch sa fer t han tinkering w i t hthe gen i ta l cana l . Of ten , indeed ,

the Stom a ch ha s been a lm o s t em p ty for days .

The l iver and k idneys have been fa i l ing , the b loo d p ressu re f requen t ly changed ,

edem a p resen t , y et let a convu l s ion o ccu r , a cco rd ing to som e, the s tom a ch m us t

be w a shed out a t a ll co s t s , the la s t m ea l taken ha s sudden ly a cqu i red m ys ter iousand po isonous p roper t ies and m us t be go t ou t . Pu rga t ion does good ,

u sed w i t hcomm on Sense. The ec lam p s ia po ison , or po isons , how ever , a re p roba b ly co l lo idin na tu re, and very un l i kely t o be pu rged o r sw ea ted ou t o f the sy s tem . Let us


unders tand jus t w ha t va lue cer ta in m ea su res po ssess . Pu rga t ion in m odera t ionrel ieves the kidneys f rom the s t ra in o f e l im ina t ing m u ch o f the w a s te p roduc t sw h ich m igh t o t herw i se be a b so rbed . I t can do cons idera b le good , bu t pushed toan ext rem e exhaus ts the pa t ien t . Sw ea t ing does som e good by remov ing manywa s te sa l ts , and a ho t pa ck i f the Skin is ho t and dry m ay di la te the superfi c ia lvessels , and espec ia l ly h o t pa cks over the k i dneys m ay reflex ly relax the spa smo f the rena l vessel s . B lood p ressu re is t hu s Of ten tem po ra r i ly low ered . Bu t i fa t the sam e t im e w a ter is no t go t in to the sys tem ,

t hen the va r ious body flu i dsa re concen t ra ted , a nd the toxins p roduc ing the convu l s ions a re in tens ified

,and

mo reha rm t han good is the resu l t . Rem em ber a lw a y s to rep la ce the w a ter lo s tt h rough s k in and bow el s . The cerv ix ha v ing t hen been ca refu l ly d i la t ed , and Ila y s t ress on t h i s po in t , for a ccou chem en t fo rce i t is no t on ly dep lo rab le in it sresu l t s in m any ca ses

,bu t unnecessa ry , the fetus shou l d be del i vered . S ince

ec lam p t i c w om en a re m o re l ia b le to becom e sep t ic , ow ing to a low ered res i s tance ,

and m u ch in ter ference, the g i v ing o f the g luco se ha s pa r t i cu la r va lue in com ba ting t h is lowered res is tance. A f ter in ter feren ce ha s o ccu r red , a bou t 40 g ra ins o f

hexam ine a re d isso l ved in a bou t a qua r t ‘

o f w a ter, o

r lem ona de, and g iven in the

next 24 hou rs . Th is ha s seem ed to m e to have ha d a fa vo ra b le effec t . E spec ia l lyin the coun t ry a figh t for lo t s o f f resh a ir m ay ha ve to be m a de. As a ru le theha rd - w o rk ing fa rm er’s w i fe ha s bet ter res is ta nce t han her c i ty s i s ter , and w i t hequa l l y good t rea tm en t shou l d reco ver fa s ter .

After Viability—Ba by Living .

1 . Cervix E asily D ila table. S im i la r m ethods to t ho se a dvised a bo ve shou l d beem p loyed , w i t h , how ever , t h i s excep t ion

, give little m orphia un t i l the ba by isdel i vered , o t herw i se i f the ba by is under the influence o f m o rph ia i t m ay be

im po ss i b le to resusc i ta te i t . In t hese ca ses the pa t ien t m a y be pu t under ga s andoxygen a nzesthes ia w i t h ether sequence, a s t h i s a dds g rea t ly to the relaxa t ion o f

the cerv ix ; ether oxygen‘

is a l so very good . The in ters t i t ia l m ay be g i ven w h i ledi la t ing the cerv ix . Pu sh the oxygen . Rem em ber the ba by is toxi c and can i l lw ith s tand rough hand l ing . Ta ke g rea t ca re, t herefo re, w hen del i ver ing to u se

gen t le t ra c t ion , a l low ing a res t f rom com p ress ion every m inu te and g iv ingoxy gen f reel y to the m o t her , or i f a b reech ext ra c t ion is to be done , flood them o t her w i t h oxygen jus t befo re del i ver ing the t ho rax and head ,

us ing the

m et hods I des c r ibed in the Jo u rna l o f the Cana d ian Medi ca l Asso c ia t ion , May,

1917. The fetus is t hen m uch bet ter a b le to w i t h s tand necessa ry and unavo id

ab le b i r th head com p ress ion t han o t herw i se. Let the wom an b leed a m odera team oun t i f she ha s i t to Spa re.

2 . Cervix no t eas ily dila table— Baby in good condition— Case no t urgen t. Givem o rph ia ,

an in ters t i t ia l , inser t la rges t po s s i b le V oo rhees’bag . t ie and a pp l y t ra ct ion . I f the b lood pressu re is no t very h igh , t ha t is , under 160 mm . o f H g , sm a l ldo ses o f pi tu i ta ry ext ra c t m ay be ca u t iou s ly g i ven i f pa ins a re no t set up by thebags . In a few hou rs w e have rea ched the s tage o f an ea s i l y d i la tab le cerv ix .

THE CANADIAN MEDICAL MONTHLY 1 1 7

\V e m a y t hen p ro ceed a s under the a bove hea d ing ,Cerv ix E a s i l y Di la ta b le, i f

ha s te is neces sa ry ; bu t i f the ca se is do ing w el l , la bo r p ro ceed ing sa t i s fa c to r i ly ,

w e m a y l ea ve m a t ters t o na tu re,being rea dy to a ss i s t her i f neces sa ry . B lood

p res su re rea dings shou l d be f requen t , a nd superv i s ion con s ta n t . L i s ten to the

feta l hea r t s' ounds f requen t ly .

3 . Cervix rigid and no t likely to dila te qu it /sly w ith bags o r m a nua lly.

a . Fetus no t be y ond the eigh th m on t h and rela t i vel y sm a l l com pa red to the

b i r t h cana l . Here vag ina l Ceesa rean sec t ion , a s desc r ibed a bo ve , perfo rm ed by a

goo d su rgeon ,under goo d co nd i t ion s , is perha p s the bes t m et hod . Mo rph ia

shou ld be w i t hh el d un t i l the baby is ext ra c ted . The in ters t i t ia l shou l d be g i ven .

B leeding is u sua l l y f ree here, and is genera l ly an a dvan tage.

b . Fetus in the 9th m on t h and rela t ivelv la rge , o r a con t ra c ted pel v i s ,o r a

com p lete p la cen ta p raev ia , o r huge edem a o f the vu l va,is com p l i ca t ing the

ec lam p s ia .

Here a n a bdom ina l Caesa rean sec t ion g i ves bo t h pa t ien t s the bes t chance , i fi t is w el l done. Give oxygen . M o rph ia shou l d be w i t hheld unt i l the baby isrem oved . The in ters t i t ia l shou l d beg iven w h i le the o pera t ing room a nd su rg i ca lteam is g et t ing readv. Speed w i t h sa fety can be a t ta ined in t h i s opera t ion .

I ha ve per fo rm ed s evera l com p lete a bdom ina l Caesa rean sec t ions and had a

d ress ing a pp l ied in less t han fi f teen m inu tesI f an ob s tet r i ca l spec ia l is t is a va i la b le, one ca pab le o f g ivmg the w om an

and baby every po ss ib le chance, i t is jus t a s m u ch the pa t ien t ’s r igh t to ha vethe bes t ski l l a va i la b le,

especia llv. s in ce in the hands o f the p ro fes s ion a s a w ho le.

the m o r ta l i ty is so ter r i fi c in ec lam ps ia , a s i t is a pa t ien t ’s r igh t to ha ve a

ski l led su rgeon for an a cu te a ppendi c i t i s . In the la t ter ca se. the m odern genera lp ra c t i t ioner rea l i zes his ow n l im i ta t ions and the publ i c al so rea l i ze t hem . Theyknow he la cks the sk i l l and exper ien ce to do a s w el l on the a verage a s a sk i l ledsu rgeon can do ,

and yet the genera l p ra c t i t io ner too o f ten t h ink s i f it be a n

ob s tet r i ca l ca se he is qu i te com peten t t o hand le i t . The t im e m us t soon com e,

how ever . w hen the pub l i c w i l l w ake up to the fa c t tha t the dea t h s due to ch i ldb i r t h a re no t on l y the second la rges t ca use o f dea t h in the ch i l dbea r ing per iod .

bu t a re for the m o s t pa r t p reven tab le w hen the bes t ski l l a va i lab le in ob s tet r i c sis gi ven . Bu t I w ou l d no t for a m om en t d i spa rage the rea l ly excel len t w o rkdone by m any coun t ry do c to rs w o rk ing under hea vy hand i ca ps , do ing the bes tt hey can under a dverse cond i t ion s , bu t God speed the day w hen p regna n t w om en

w i l l ha ve the fa vo ra b le condi t ions and sk i l l w h i ch w il l “

ensu re t hem and t hei rba bies a sa fe b i r t h . Tho sefa vo ra b le cond i t ions and t ha t a dequa t e ski l l can beob ta ined . Wha t I do condemn

, how ever , is the ca reless , igno ran t a nd dirtv w o r kdo ne by g enera l p ra c t i t ioners . w i t h ho sp i ta l s a nd ski l led hel p a ll a ro und t hem .

Wh i le mv m et hods a re,in m y op in ion , the bes t , and have in inv hands g i ven

resu l t s second to none anyw here, yet s low er methods ha ve gi ven fai r ly go o dresu l t s on the w ho le,

and perhaps a s good as cou ld be hoped for w hen the do c to rw o rk s under cond i t ion s les s t han the bes t .

1 1 8 THE CANADIAN MEDICAL MONTHLY

Tho se m ethods w h ich m ay be a pp l ied in the coun t ry , are, m o rph ia ,in ter

s t it ia ls o f sa l ine o r g luco se, venesec t ion w here indi ca ted , punc tu r ing the m em

b ranes , f resh a ir, m odera te pu rga t ion ,ho t pa cks when h igh b lood p ressure is

‘

p resen t , a sep t i c pa c k ing o f the cerv ix , or di la ta t ion by hydro s ta t i c bags, m anua ld i la ta t ion

,and ext ra c t ion by fo rcep s or b reech . E t her can be g i ven in the coun

t ry, and shou l d be used in

.

p reference to ch lo ro fo rm i f po ss i b le. Lumbarpuncture

ha s been fa vo rab ly spoken o f , and I shou l d use i t i f convu l s ions pers is ted a f terthe o t her m et hods I have ou t l ined .

Shou ld the ch i l d be dead or dying , the s low er m ethods a re to be p refer reda s a ru le. Shou l d the m o t her need hu r r ied em p ty ing o f the u terus a f ter thedea t h o f the ch i ld , perfora t ion m ay wel l be done shou l d the cerv ix be too sm a l lto ex t ra c t the ch i ld a t once. Grea t ca re is necessa ry to avo i d la cera t ing the

vag ina w i t h the sha rp edges o f the per fo ra ted sku l l . Here the Copeland so l i db laded fo rceps , or to a less exten t , the Tu cker - McLean so l i d b laded fo r ceps , w i l la id m a ter ia l l y in p ro tec t ing the m a terna l so f t pa r t s .

Wh i le the em p ty ing o f the u terus is the bes t s ingle fa c to r in t rea t ingec lam p s ia ,

i t is no t in i tsel f inva r iab ly ‘

cu ra t ive. Nor w hen the w om an is deliv

ered is the danger over , for t here rem a ins the dam age done to the l iver , kidneysand o t her o rgans , and she is no t ou t o f danger for severa l w eeks .

POST PARTUM CONV ULSIONSThese shou ld be t rea ted a cco rd ing to the genera l t rea tm en t ou t l ined a bove.

Mo rph ia in la rge do ses , ,

an in ters t i t ia l‘

o f sa l ine or g luco se ; b lood m ay be

rem oved i f t ha t los t du r ing labo r is sma l l , and p let ho ra s t i l l exis ts .I f the

convu ls ions con t inue, lumba r punc tu re m ay be perfo rm ed . Oxygen shou ld beg i ven i f a va i la b le, and f resh a ir in any ca se. I f the b lood p ressu re is h igh , andthe skin d ry , a ho t pa ck m ay do good , bu t shou l d no t be g i ven un less wa ter isgo t in to the t issues , to rep la ce the loss t h rough the sk in . I f the pu lse is weak ,

how ever , do no t g ive a com p lete ho t pa ck , bu t jus t ho t s tupes to the lo ins . H o t

co lon i c flushes m ay be g iven .

After Trea tmen t . For severa l day s fo l low ing the convu l s ions, an ounce o f

Mag . Su l ph . in the m o rn ing shou l d be g i ven un less the b lood p ressu re is verylow . In t h i s even t , I t h ink ho t co lon i c flush ings a re bet ter . The food shou ldcons is t for severa l days m a in ly o f m i l k , and g luco se lem onade (one ounce o f

g lucose, the ju i ce o f a w ho le lemon in a la rge g la ss o f wa ter ) shou ld be g ivensevera l t imes a day. No ha rm w i l l com e in m os t ca ses f rom the ea r ly ca refu lca rbohyd ra te diet . I f the pa t ien t can be cons tan t ly wa t ched , for there is dangero f a toxi c insan i ty fora t im e, she shou ld be p la ced ou t in the f resh a ir in the sun

,

wel l w ra pped and kep t w a rm , and m uch good w i l l resu l t . I t h ink a good i ronton i c is very va luab le.

The baby shou ld no t be p la ced a t the b reas t for severa l days a f ter the la s tconvu ls ion ; the b rea s t s shou l d be pum ped , how ever

, every eigh t hou rs . Therea son fo r t h is is tha t the m o ther m igh t develop a toxi c insan i ty

, and inju re thebaby , or her m i l k m igh t p rove toxi c .


On the way t o see her in consu l ta t ion w i t h her phys iciaa ho had been t ry inge l im ina t ion and pu rga t ion and sw ea t ing ,

he rela ted the a bo ve condi t ions and Ia dvi sed rem oving her a t once to the ho sp i ta l and em p ty ing the u terus on the

s t reng th o f t hese s igns and sym p tom s a lone. On exam in ing the lady,she w en t

t o ta l ly b l ind befo re our ey es . I a t once ga ve her ha l f a g ra in o f m o rph ia hypoderm ica llv and took her a t once to the ho sp i ta l and in t roduced a V oo rhees ’

bag ,

and sho r t ly a f terw a rd delivered her under ga s and oxygen . Bo th m o t her and

baby did wel l . The b l indness c lea red in tw o days . H a d I dela y ed un t i l cony u l ~

s ions o ccu r red , a s t hey w ou l d ha ve done w i t hou t doub t , in a m a t ter o f mm u tes

very p roba b ly , bo t h pa t ien t s m igh t ha ve been lo s t . I am now convinced,in spi te

o f p revio u s op in ion s , t ha t the convu l s ion s a re dangero u s a nd do m uch dam age .

Som e o f you m ay t h in k my m et ho ds a re ra di ca l , tha t I am a su rgeon a nd

t herefo re l i ke opera t ing ; w hy no t lea ve t h ings to kind ly na tu re,who on l y k i l l s

a bou t 25 per cen t . o f the w om en ? My jus t i fi ca t ion is a to t a l o f t h ree w om en

lo s t , a g ro ss m o r ta l i ty o f per cen t . A s one o f t hese w om en had a ch ron i cneph r i t is p receding her second a t ta ck o f ec lam ps ia ,

a nd w a s s low l y reco ver inga ppa ren t l y ,

f rom a hem i p leg ia and the effec t s o f the second a t ta ck , a nd had beend is cha rged. s o fa r a s the ec l am p s ia w a s concerned , bu t had died sudden ly a m on t hl a ter a ppa ren t l y o f a haem o r rhage in to the b ra in , t h i s ca se m igh t fa i r l y be

a t t r ibu ted t o the ch ron i c neph r i t is and h igh b lood p ressu re ra t her t ha n to the

ec lamps ia d i rec t ly ,t hough undoub ted ly the ec lam p s ia had a p ro found effec t .

Th is g i ves a co r rected m a terna l m o r ta l i ty o f per cen t . in the 53 ca ses o f

ec lam ps ia . The feta l m o r ta l i ty ,I reg ret to say, I w a s unab le t o redu ce below

50 per cen t . .because,

in m a ny ca ses ,the bab ies w ere a l ready dea d w i t h in the

m o ther w hen I fi rs t saw the“ca se, or because o f prem a tu r i ty and toxaem ia . Onlv

tw o o f the cja ses'

wh ich had'

conVu lsions w ere seen befo re the fi t s had a l read 1o ccu r red .

"

One o f t hese W i l fu l ly p reven ted m e render ing effec t i ve t rea tm en twhen I w i shed ,

therefo re,I do no t ho l d m y sel f respon s i b le for in fer io r resu l t s :

t he o t her w om an w a s recogn i zed t o be t h rea tened 1 1 i t h convu l s ions w hen fi rs tseen ,

bu t a l though she w a s g i ven imm edia t e t rea tm en t a convu l s io n o ccu r redbefore the t rea tm en t w a s effec t ive.

Brief deta i l s o f w om en who died m igh t be o f in t eres t '

o nce . The w om a n . a young prima pa rze . w a s

a t fu l l term . She w a s seen fo r the fi rst t im e in consu l ta t i on , hav ing ha d twelve '

co untedco nvu l s i ons

,and an unknown number prev i ous t o being fo und in com a on the k i tchen flo o r

by her husband when he returned home at noon . H erblo o d pressure vyas 190 m m . o f H

sys to l i c “

"A c'

a theter w i thdrew on’

ly’

abo u t tw o ounces'

o f da rk ur ine wh i ch w a s lo aded w it -hb lo o d ca sts and went so l id on bo i l ings E dem a w a s o n ly present in the conj11n

_,c t ivae wh i ch

w ere m odera tely j aund iced a lso . Mo rphia a nd ho t pa cks had been g iven w i tho u t benefi t .by her phys i c ian She was no t in labo r a nd the so ft pa rt s were und i la ted . There was a

t i ta n i c Spa sm o f the u terus . bu t the feta l hea r t“ to nes w ere stro ng . I to ld the husband and

th e a ttend ing do c tor tha t the w oman had ve1 y l i t t le hope o f recovery, a nd tha t'

the o nl ycha nce for the baby and

"

the bes t "f‘

o r 5the m other was an imm ed i a te ad m inal Czesare‘

an

sec t ion ,wh i ch I '

d id under ga s and o xygen . I s aved the baby,a nd she is a l ivet o - dav. I bel ieve .

THE CANADIAN MEDICAL MONTHLY 12 1

On open ing the a bdom en ,t he per i toneum bu lged o u t befo re i nc i s ing , a nd a s so o n a s opened ,

a la rge quant i ty o f turb id flu id gu shed ou t ; a spo nta neo u s per i to n i t i s w a s present . The

w om a n appa rent ly recovered from t he sho ck o f the opera t io n,wh i ch w a s s l igh t , bu t she ha d

severa l mo re co nvu l s ions . She w a s g iven an inters t i t ia l o f g luco se and in the fi rs t 24hours a fter the opera t io n had 40 o unces o f ur ine rem oved by ca theter . She rem a ined in

com a ,and a t the end o f the firs t day she developed pa ra lys i s o f the r igh t s ide . The

blo od pressu re w a s reduced cons i derably,bu t a t the end o f 30 ho urs she appa rent ly had a

cerebra l haem o rrhage a nd d ied suddenly . On ly a pa rt ia l po s t—m o rtem w a s perm i tted . The

per i to n i t i s had progressed further and w a s genera l . The l iver had degenera ted so a s t o

present no no rm a l a rea to the eye . The abdom ina l a nd u ter ine w o und s w ere 1n go od co nd it io n . The a reas o f inject io n o f the g luco se inters t i t i a l under the brea sts show ed no gro s sinjury. The k idneys w ere co nges ted , bu t show ed a la rge a rea o f pa renchym a . The kidney shad responded w el l to the interst i t i a l . H appi ly I saved o ne l ife where tw o seem ed doom ed .

V ag ina l Czeca rea n sec t ion w a s done s ix t im es in t h i s ser ies,tw i ce in one

w om a n,w ho sub sequen t ly d ied o f ch ron i c neph r i t is . A ll m o t hers reco vered

f rom the vag ina l Caesa rean sec t ioii . There w ere only tw o v iab le l iv ing ba b iesin t hese vag ina l Caesarean sec t ion ca ses ; one bo rn a l i ve a t seven m on t h s died ina few hou rs o f ec lam p s ia po i son ing ,

the o t her su rv i ved . One v iable ch i l d w a s

dea d w hen I opera ted . H ad I been f ree to opera te w hen I des i red . I m igh t h a vesa ved i t . The m o ther in t h i s ca se very na r row ly esca ped w i t h her l i fe. My

a naes t het is t expec ted her to d ie on the ta b le . I s tayed up w i t h her a ll n igh t .

Indeed , m u ch o f my success I con s i der ha s been due t o the fa c t tha t I ha veju s t devo ted a ll my t im e a nd been p resen t to persona l l y g i ve the pa t ien t thebenefi t o f a w i de exper ience . Many ca ses needed spec ia l d rugs o r t rea tm en t tom eet specia l indi ca t ions . I have g i ven you genera l p r in ci p les o f t rea tm en tspec ia l em ergenc ies w i l l ha ve to be t rea ted a s t hey a rise . Much o f the m os tva lua b le a sset s w e po ssess , our persona l exper ience and judgm en t , unfo rtun

a tely . w e canno t pa ss on to o t hers . Mo s t o f t hese ca ses o f ec lam p s ia ha ve beencha r i ty pa t ien t s , bu t I ha ve t r ied to g ive to th e po o rest the bes t t rea tm en tpo ss i b le. I have no t m en t ioned the a dvi sa b i l i ty o f q u iet a nd iso la t ion ,

beca u sem o s t o f m y ca ses had to be t rea ted in a no i sy w a rd , no o t her p la ce being a va i la bl e. I ha y e no t found the fi t s to ha ve been p rec ip i ta ted by the noise

,t hough

I do t h ink the w om an does bet ter i f she can ha ve qu iet .

a t the beg inning o f thes i x th month . Ro u t ine exam ina t ion d i sc lo sed a sys to l i c blo o d pressu reo f 200 mm . o f H g . In spi te o f th i s fa c t , she lo o ked w el l

, sa id she fel t wel l . w i th the except iono f heada ches . Sl igh t edem a o f the feet w a s present . The w ea ther w a s very ho t a t the t im e

a nd she w a s dr ink ing w a ter f reely a nd t he sk i n w a s a c t ive . The u r inew a s no rm a l . I '

a t tempted to t ide her a long unt i l v i ab i l i ty a nd keeping her under clo se observa t i o n . A'

pur in

scant d i et wa s g iven , flu ids fo rced , and she w a s m i ld ly purged .

She‘ began to improve . The

blo o d pressure fel l , a nd the heada ches left . Then the w ea ther sudden ly turned qu i te co ld .

and a t once her u r ine becam e lo aded w i th a lbum en and ca st s and the b lo o d pressu re ro se .I w i shed her to a l low m e to induce labo r a t once, bu t she refused .

I then d id the nex t bes tth ing , sent her to bed , pla ced her .o n . a milk d i et , fo rced flu ids and purged her w i th Mag .

Su lph . da i ly. H ow ever, she did no t improve, and I. threa tened to w i thdraw from the ca se i fshe d id no t a t once go to a ho spi ta l and a l low m e t o induce labo r. \Vhen she rea ched t he


ho spi ta l she aga in refused to let m e induce labo r , and begged m e to t ry s t i l l further med ica ltrea tm ent . I fina l ly refused to have anyth ing further to do w i th the ca se, and then she

consented to a l low m e to do wha t I knew was bes t for her. I a rranged for the opera t ingro om ‘

a t 4 pm . A t 2 pm . she had a convu l s ion, I wa s info rm ed over the telephone. Io rdered ha l f a gra in o f m o rph ia per hypo a t once, and w i th in an hour I d i la ted the cerv i xt o the si ze o f one finger and inserted a No . I ‘V o ohees

’bag wh i le she wa s under the gas and

oxygen . I then appl ied tract ion . Severa l hours pa ssed ,a no ther convu l s ion o ccurred , and

the cerv i x w a s no t so ften ing no r d i la t ing sa t i sfa c to r i ly eno ugh . I t hen had the wom an g ivenga s and o xygen , and did an an ter i o r and po s ter i o r hystero tomy as I have descr ibed aboveunder Vag ina l Czesa rean sect ion . The fetu s wa s ex tra c ted w i th fo rceps and l ived severa lho urs , dying o f ec lampt ic po i son ing .

At the t im e o f opera t ing the b lood pressure w a s 260 mm . o f Hg . An inters t i t ia l o fg luco se sa l ine wa s g iven . Severa l days a fter, the blood pressure sudden ly ro se aga in and

I w i thdrew s i x teen o unces o f blood w i th very grea t benefi t . She m ade a s low, pa rt ia l recov

ery, bu t a ch ron i c nephr i t i s rema ined . Th i s I trea ted fo r severa l m onths w i th som e success ,

the ur ine fina l ly show ing j us t atra ce o f a lbum en and the blood pres sure 160. I w a rned heraga ins t further pregnanc ies unt i l I shou ld tel l her i t w a s safe. She d i sappea red . Mo rethan a year a fter th i s , on enter ing my w a i t ing ro om I found a w om an in a heap on the flo o r .

She w a s unconsc ious . Her face w as flushed , she had a h igh tens ion pu lse,there wa s some

fro th a t the m outh . I did no t recogn i ze the w oman, bu t placed her on a couch,loo sened

her c lo thes , and gave o xygen . She began to com e a ro und . I exam ined her purse, found a

gas b i l l w i th her nam e on i t , and i t w a s th i s sam e w om a n on w hom I had opera ted a yea ror so prev ious ly fo r ec lamps ia . I summ oned her husband

,who w a s a po l icem an

, got an

ambu la nce and rushed her t o the ho spi ta l . I found from her hu sband tha t she was threea nd a ha l f m onth s pregnant . , Under ga s and o xygen , I perfo rm ed an anter io r vag ina lhy stero tomy ( the second t im e on the sam e w om an , a rare event for any surgeon ) . To my

surpr i se, I had no d ifficu l ty a s a resu l t o f the fo rmer opera t ion . I empt ied the u terus w i thou tany trouble, gave an inters t i t ia l . H er b lood pressure wa s over 260 mm . o f Hg . The ur inewas lo aded w i th blood ca s ts and free b lood , and went so l id on bo i l ing . A s to rmy conva l

escence ensued . She w a s gradua l ly improv ing , when a t the end o f a w eek she had a sudden

pa ra lys i s o f the r igh t s ide develop. She w a s very much bec louded m enta l ly. She had

severa l syncopa l a t tack s , became pu lseless a t the w r i s t . I had 20 m in im s o f pure etherin jec ted into the perica rd ium, and she ra l l ied . One n igh t she was unconscious

, the pulse,wh ich had been above 200 mm . o f Hg ,

fel l , and cou ld no t be detec ted a t the w rist . I gaveintraveno u s ly by hypo . o f a gra in o f Merck ’s D ig i ta l in wh i ch I had bro ugh t fromE ng land w i th me severa l yea rs prev ious ly. W i th in five m inutes the pu l se returned , and

becam e fu l l,regu la r and s trong ,

and rem a ined so . She gradua l ly improved ,though the

neph r i t i s wa s s t i l l very ser iou s . After a m onth , I d i scha rged her from the ho spi ta l wa rd ,

a s i t seem ed tha t a s low recovery from the hem ipleg ia w a s befo re her. Abou t five weeksafter the opera t ion I had seen her a t m idn igh t , and she seem ed improved , a t 2 a .m . , wh i leta l k ing to her nurse, who was giv ing her a g la ss o f m i lk , she s topped in the m idd le o f a

sentence her eyes s ta red and d i la ted suddenly and she s topped brea th ing . I was telephonedto a t once and sugges ted o xygen and a rt i fic ia l respira t ion, and a hypoderm ic o f ether intothe hea rt . Adrena l in was a lso g iven and campho r - in o il. The hea rt respo nded wel l forabou t t en m inu tes bu t she never brea thed aga in . The hea rt then s low ly gave ou t a nd she

w a s dead befo re I cou ld rea ch her. E v ident ly a hzem o rrhage had suddenly o ccurred into the

respi ra to ry center . Th i s ca se I g ive a t som e length becau se o f the severa l interes t ingdeta i ls . I do no t feel tha t i t. shou ld be inc luded in my m o rta l i ty resu l ts, as i t wa s no t a d i rectand immed ia te resu l t o f the ec lamps ia , bu t wa s probab ly due t o the pre- ex i s t ing and cont inu


ing chron ic neph r i t is and h igh blo od pressure, though undoubtedly the ec lamptic a ttack didhave a pro found effect .

The th i rd and la st w om an t o d ie, Mrs . M .

,No . 47 in th i s ser ies , w a s brough t into the

ho spi ta l in com a,a l terna t ing w i th co nvu l s ion s . She had recent ly had influenza . She w as

very edem a to us . She w a s a m u l t ipa ra and had had no rm a l labo rs prev io us ly. She had a cu teedem a o f the lungs , and fro thy m ucou s bubbled from her m ou th . She w a s hav ing s tronglabo r pa ins . I gave her a qua rter o f a gra in o f m o rph ia a nd lo t s o f o xygen and b led her,as her blood pres sure w a s 190 mm . o f Hg . I progno sed her speedy dea th . She del iveredherself in abou t three hours . She did no t respond to any trea tm en t . ‘

A t the reques t o f herfam i ly, I a sked Pro fesso r B . P . Wa tson t o see her w i th m e, ask ing h im to com e qu ick ly ifhe w ished t o see her a l ive H e agreed w i th a ll my t rea tm ent , a nd confirmed my progno s i s .

She d ied w i th in twenty m inu tes . Th i s ca se was do om ed from the t ime fi rs t seen .

A fa ta l ou t com e w a s t hus p rognosed , bo th ca ses being p ronoun ced hopelessw hen fi rs t seen ; bo t h bab ies l ived,

how ever . A fa ta l i ssue w a s p rognosed a s

very p robab le in the ca se o f Mrs . B

All o f the w om en who had any chance w ere saved .

My t rea tm en t ha s becom e m o re s im p le a s I ha ve bet ter unders tood the

ba s i c p r inc i p les invo lved . I tend to in terfere and use m o re ra d i ca l m et hods t hanfo rm er ly ; on l y , however , i f t hey a re ind ica ted . The m et hods I have sugges tedare no t the on l y goo d ones , bu t in my hands have g iven you the resu l t s m en

t ioned . One shou l d keep an open m ind on t h is subjec t,and be w i l l ing to change,

i f the change 13 ba sed on rea son , and g i ves much bet ter resu l ts . I have t r ied tov isua l i ze to m ysel f the p roba b le pa t ho log i ca l cond i t ions in ea ch ca se

,and t rea t

ea ch ca se on its own m er i t s , ra t her t han by a r ig i d sys tem . The convu l s ion is,

a f ter a l l , on ly a ter r ib le inc iden t . The dam age to the so l i d o rgans ha s beenp rog ress ing a long t im e, and even a f ter del ivery and the disa ppea rance o f the

convu l s ions , thewoman is s t i l l in a dangerous condi t ion and needs ca refu l superv is ion .

Rem em ber t h is fina l l y , t ha t the g rea tes t good to the g rea tes t num ber o f

w om en and ba b ies w i l l no t . be a ch ieved by tho se o f us w ho a re spec ia l is t s and

rescue wom en f rom despera te condi t ions by b r i l l ian t w o rk , bu t-

by the ca refu l,

cons i s ten t , and in tel l igen t supervis ion and t rea tm en t o f the women t h roughou tthe w ho le na t ion by the genera l p ra c t i t ioner , who shou l d no t on l y be a conscien

t ious do c to r to t hose al rea dy i l l , bu t shou ld be an a c t ive p ro pagand is t in his comm un i ty in a ll m easu res lea ding to inc rea sed hea l t h ,

sa fety‘

and happ iness o f the

peo p le. I f this paper sha l l ha ve helped some do c to r save som e poor w oman and

baby ,i t sha l l no t have been in va in .

E very wom an and ba by deserves a sa fe b i r t h .

SUMMARY or TREATMENT

Let m e aga in u rge the g rea t im po r tance o f p reven t ion . Ca refu l and

f requen t superv is ion ,her p rog ress ive h is to ry and a ppea rance a s ges ta t ion

advances , and the f requen t inves t iga t ion o f the b lood p ressu re and u r ine, w i l lfu rn i sh rel iab le gu i des a s to fu r t her t rea tm en t . I f ca refu l el im ina t ion o f rem ov

124 THE CANADIAN MEDICAL MONTH LY

a b le. fo c i o f in fec t ion , and o t her sou rces o f s t ra in on the o rgans o f el im ina t ion ,

a diet h igh in ca rbohyd ra tes and low in pu r in bodies , a dequa te exerc i se,a bun ~

dan ce o f f resh a ir a nd deep b rea th ing , f ree skin a c t ion encou raged by ho t ba t h s ,fo l low ed by res t in a w a rm bed ,

suffic ien t res t , fo rced flu id s a nd m o dera tepu rga t ion ,

espec ia l l y w i t h m ag . su l ph .,and la s t ly bv hypoderm o c l y s i s w i t h sa l ine

g lu co se so lu t io n ,i f a ll t hese m ea su res fa i l to a r res t the fu r t her p rog ress o f the

di sea se,t hen do n o t dela y fu r ther , bu t t erm ina t e the p regnan cy w i t h a

‘

m inim um

o f dam age. Get the w om a n in to a ho spi ta l i f po s s i b le .

If com ~uls ions or coma have occurred , o r i f t hey seem imm edia tel y impendinO

'

.

l s t . .

‘lf orpli ia in la rge do ses shou l d be g i ven , suffic ien t to con t ro l the convu l

s ions . I f th e fa c i l i t ies a va i la b le and sk i l l o f the su rgeon w a r ran t i t , and on l yt hen , the pa t ien t shou l d be p la ced under ga s oxygen p referab ly , o r et her oxygena t o nce and w ha t ever o pera t i ve p ro cedu res a re a dv isab le p ro ceeded w i t h , lea v ingthe m o rph ia un t i l the ch i l d is de l i vered . I f the ch i ld is dea d o r no t v iab le

, g i vethe m o rph ia. .

2nd . . F resh. a ir. a nd oxygen i f a va i lab le .

3 rd . Keepwarm .

4th . Preven t pa t ien t b i t ing tongue, tu rn 0 11 s ide to p reven t a spi ra t ion o f

f ro t hy m u cu s and danger o f inha la t ion pneum on ia .

5 t h . In ters titia l injection o f 25 per cen t . g luco se in phys io log i ca l sa l ine, to

be f resh l y s ter i l i zed by bo i l ing ten m inu tes , and g i ven under the b rea s ts a t b loodhea t under a sep t i c p reca u t ion s . Give f rom 500 c . c . to c .c . I f g lu co se is no tava i lab l e. g i ve s im p le sa l ine in a s im i la r m anner . The g luco se o r sa line im av be

repea ted in 24 hou rs i f a dv i sab le. In t ra venous injec t ions 111 ec lam ps ia a re

da ngero u s.

6th . V enesec tion . I f the b lood pres su re is h igh and the w om an fu l l b looded .

the w i t hd raw a l o f f rom 5 to 20 oun ces o f b lood a sep t i ca l ly a f terthe in ters t i t ia lha s been a b so rbed is o f ten o f m a rked benefit. I t w i t hd raw s som e c i rcu la t ingpo ison and redu ces the b lood p ressu re . I t is ina dvi sa b le in low b lood p ressu reso r m a rked anaem ia.

7th . H o t packs . These a re o f on l y s l igh t va lue. They shou l d on l y be useda s t em po ra ry m ea su res w h i le o t her m o re va lua b le p ro cedu res are being p repa redo r a re in prog ress . I f the b lood p res su re is h igh and the skin no t sw ea t ing ,

t heydo som e good . They shou l d no t be used in low blood p ressures . bu t m a y be

rep l a ced by ho t s tupes to the lo ins . The flu i d lo s t t h rough the sk in sho u l d berepla ced by in ters t i t ia ls , rec ta l d ri ps , o r by m ou th .

8 t h . Empty the u terus .

‘

Th i s is the m os t va luable o f a ll the m ea su res u sed .

Met hods a nd indi ca t ions : Co r rec t anaes thet i c and a seps i s and an t i seps is to beused in a ll fo llow ing : a bove m ea su res to p recede o r a ccom pany .

TH E CANADIAN MEDICAL MONTH LY 12.V1

.4. [ fetus N o t V iable, Cond it ion N o t Urgent .

(a ) Cervix dila table,

Inser t la rges t s i ze V oo rhees’ bag , a pp ly t ra c t ion .

-

"

hen bag com es ou t , the u terus m ay t hen be em p t ied a t once in som e ca ses , o rsu f fic ien t fu r t her d i la ta t ion m ay be done m anua l ly i f cerv ix is so f t . . I f no t , inser tano t her bag . Keep up the m o rph ia .

(b ) Cervix no t dila ta ble. Pa ck w i t h s ter i le g ly cer ine w i t h iod ine, o f l% ,

0 11 s ter i le gau ze. Wa i t t i l l cerv ix is so f t , i f pa t ien t’

s cond i t ion w i l l jus t i fy delay .

B . Fetus N o t V iable, But Condition Urgen t .

(a ) Cervix dila table. Ca refu l m anua l d i la ta t ion and ext ra c t ion o f u ter inecon ten ts .

( b ) Cervix no t dila table. Vag ina l Caesa rean sec t ion . See a bove fo r deta i l s .

C . Fetus V iable and Living , Cond ition N o t Urgent .

( a l Cervix dila table. Rup ture o f m em b ranes , hyd ro s ta t i c d i la ta t ion o f

cerv ix , sm a l l do ses o f pi tu i ta ry ext ra c t la ter , i f la b'

o r does no t resu l t w i t hou t i t .Del ivery m a y t hen o ccu r spon taneou s l y , o r be a ss i s ted a cco rd ing to the condit ions a r is ing .

( b ) Cervix no t dila table,condition urgen t .

( 1 ) Before the ninth m on th ,no pel v i c con t ra c t ion p resen t . Vag ina l

Czesa rean sec t ion , fo rceps o r b reech ext ra c t ion .

(2) N in th mon th onwards , or in p resence o f effec t ive pel v i c con t ra c t ion ,

la rge edem a o f vu lva , cen t ra l p la cen ta p raev ia , o r obs t ruc t ing objec t in a va i la b le b i r t h cana l : Abdom ina l Caesa rean Sec t ion . No vag ina l exam ina t ions .

Oxygen f reel y ,m o rph ia a f ter ch i l d is rem o ved .

D . Fetus V iable,Bu t D ead .

( a ) Cervix dila table.

~ Hyd ro s ta t i c d i la ta t ion ,fo r cep s or b reech ext ra c t ion .

per fo ra t ion o cca s iona l ly a dvi sa b le.

(b ) Cervix no t dila table. I f ca se is u rgen t , Abdom ina l Caesa rean sec t ion ,

o t herw i se pa ck ing ,hyd ro s ta t i c d i la ta t ion ,

fo rceps or b reech ext ra c t ion i f la bo ris no t effic ien t .A fter Trea tmen t .

Mag . su l ph . m ay be g i ven ea ch m orn ing fo r severa l days a f ter del ivery .

Fo rce the flu i ds ; m i l k ,bu t term i l k , lem ona de, g lu cose lem ona de, toa s t and jam

m ay be g i ven . I f k idneys a re no t a c t ive,ho t s tupes to the lo ins , and ho t co lon i c

flu sh ing s . A good i ron t on i c does good . Lo t s o f f resh a ir. Gra dua l l y inc rea sed iet to fu l l pu r in scan t d iet . Go ba ck to p ro teins s low ly .

Vera t rum veride, p i lo ca rp ine‘

,cro tan o il

,a re a ll po isons w h i ch do a very

ques t iona b le am oun t o f go od and o f ten ha rm ; They a re qu i te unnecessa ry .

Acouchem en t fo rce is ba d, s tom a ch w a sh ings do l i t t le i f any good , and p redi spo se to fu r ther convu l s ion s . Lum ba r punc tu re is a rea sonab le p ro cedu re. Iw ou l d u se i t i f the a bo ve m ea su res fa i led to s to p the convu l s ion s .


RESULTSIn th is ser ies t here w ere 53 consecu t i ve ca ses o f ec lam ps ia . Fo r ty - s ix o f the

w omen . had convu ls ions . The sevenwho did no t have convu l s ions w ere ver1

ser io us ly dam aged and the onset o f fi t s w a s a m a t ter o f a few m inu tes or hou rsa t m o s t . Tw o w omen d ied a s a di rec t resu l t o f the ec lam ps ia , a m o r ta l i ty o f

per cen t . These ca ses were hopeless f rom the t im e fi rs t seen, bu t bo t h thei r

bab ies w ere saved . Nea r l y a ll t hese w om en had had severa l convu l s ion s w henfi rs t seen

,and in m any the fetus w a s a l ready dead

.

No w om an died who hadany chance w hen firs t seen .

The feta l m o r ta l i ty w a s a pp roxim a tely 50 per cen t . P reven t i ve t rea tm en t ,obvious ly . cou ld no t have been a ppl ied . In t h i s la rge ser ies , no t one w om an

w en t sep t i c , g rea t ca re in techn i c being t hus abundan t ly rewa rded .

Du r ing t hese five yea rs , 11 0 p r iva te pa t ien t , nor t hose in my pre—na ta l cl in i ca t the Wes tern Ho sp i ta l , developed ec lam ps ia ,

w i t h the two no ted excep t ions ,t hough many ca ses o f pre - ec lam pt i c toxaem ia o ccu r red .

Purin Scan t D iet .

Acu te s tage : Mi l k ,bu t term i l k ,

m i l k cus ta rd,lem onade w i t h la rge quan t i t ies

o f suga r , p referab ly g luco se ; o ranges , g ra pe f ru i t ju i ce,ice c ream .

Pre and pos t—ec lam p t i c toxzem ia s : The above, p lus m i l k soups m ade f rom “

vegetab les , po ta toes , celery,tom a to es . etc . No m ea t s to ck .

B read and bu t ter , toa s t , jam s , m a rm a lade, honey .

Eggs , m i lk and egg p repa ra t ions .

Vegetables : Po ta toes , Sp ina ch , ca bbage, let tuce, sweet po ta toes , etc .

“

Cerea l s : Ma ca ron i , spaghet t i , co rns ta rch p repa ra tions , tap io ca , r i ce, sago .

F ru i t s : Oranges , lem ons , g rape f ru i t , and p ra c t i ca l ly a ll the f resh f ru i t s insea son . One shou ld a l so s tudy the quest ion o f d iges tability ; for exam p le, ha rdpea rs and g reen p lum s are bet ter no t ta ken raw .

Desser t s may be m ade f rom com b ina t ions o f the abo ve.

N .B .

—The m any ca se h i s to r ies and cha r t s p resen ted w hen th is pa per w a s

read are no t shown here,spa ce fo rb idd ing .


A NEW TREATMENT FOR OZ ENA AND ATROPH IC RH lNITlS.

Pa t ien t s su ffer ing f rom a t rophy o f the na sa l m u co us m em b ra ne,a sso c ia ted

w i t h fou l pu s and c rus t fo rm a t ion,ha ve had l i t t le in the w ay o f permanen t

benefi t o ffered them . Pers is ten t dou ch ing and the sub sequen t a pp l i ca t ion o f

va r iou s pigm en t s com pr ise the genera l run o f t rea tm en t . A s t hey becom e o l derthe di sea se fo r tuna tely is g rea t ly am el io ra t ed : bu t t im e,

no t t rea tm en t , is the

g rea tes t fa c to r . The finding o f som e s inus invo l vem en t , a s w a s ins i s ted upon byGriinw a ld ,

ha s no t by any m eans been un i ver sa l l y a ccom p l i shed .

T . H . Bem a ris and C . H . Hay ton ha ve reported i n the Roya l So c iety o f

Med icine Pro ceed ings , V o l. XII, No . 9,Aug . , 1919, a m ethod o f t rea tm en t ba sed

on an a l tera t ion in com po s i t ion and rea c t ion o f the sub s t ra ta on w h i ch the

ba c ter ia l ferm en t s a re a c t ing . The t rea tm en t,w h i ch cons i s t s in a copiou s

a pp l i ca t ion o f g lycer ine o r g lu co se,o r bo t h toget her . to the infec ted a rea o f the

na sa l cav i t ies , is di rec ted p r im a r i ly aga ins t the foeto r o f the disea se. Th i s foeto r ,i t is a ssum ed , is due to the des t ru c t ion o f p ro tein bodies by ba c ter ia l t ryp t i cferm en t s

,resu l t ing in thefo rm a t ion o f va r iou s s t inking end - p roduc t s o f p ro tein

d iges t ion . Th is a c t ion is a t t r i bu ted to the ba c i l lus o f Perez , w h i ch can be i so la tedin m o s t severe ca ses o f o zena , and g i ves the cha ra c ter i s t i c foeto r in it s cu l tu res .

Usua l ly in a ddi t ion to va r io us o ther ba c ter ia , the s ta phy lo co ccus a l bus is found .

The a im o f the t rea tm en t is to explo i t the a c t iv i t ies o f su ch no rm a l ly foundo rgan i sm to the det r im en t o f the obnoxio u s ba c i l lus o f Perez . Exper im en t sshow t ha t w hen th i s ba c i l lus is g rown in b ro t h ,

toget her w i t h the s ta phy lo co ccu s ,i t rea di ly m a in ta ins it s po s i t ion in the cu l tu re ; bu t i f g lu co se is p resen t in the

flu i d m edium , the ca rbo hy d ra te is ferm en ted by the co cei , w i t h the p roduc t ion o f

a c id i t y , and the ba c i l lus o f Perez is ra pid ly ki l led o u t . By a l ter ing the subs t ra tain com po s i t ion and rea c t ion , w e get an inh ib i t ion o f tho se p ro cesses o f ferm en tat ion w h i ch p roduce the factor. I t is t hus seen t ha t t h is s im p le and effec t ivem et hod is ba sed upon a . s tudy o f the cha ra c ter o f the flo ra o f the no se.

The au tho rs do no t c la im t ha t t here is res to ra t ion o f long s ta nding s truc

tu ra l changes in the t issue, bu t Hay ton ha s exhib i ted ca ses befo re the La ryngolog i ca l Sec t ion o f the Roya l So c iet y o f Medi c ine in w h i ch the dis t ress ingfea tu res o f the com p la in t , foeto r , hea da ches and c ru s t s , ha ve been very m a rked lydim in i shed . These ca ses w ere a ll o f o ld s tand ing and had for m any y ea rs t r ieda ll the known rem ed ies for the di sea se.

Dou ch ing the no se is no t recomm ended fo r the fo l low ing rea sons : ( 1 ) I ttends t o sp rea d the in fec t ion to o ther pa r t s o f the no se and t h roa t , (2 ) i t w a shesaw ay the ha rm less flo ra and the norm a l p ro tec t ive sec ret ions and expo ses them ucous m emb rane to o t her infec t ions and ca ta r rha l condi t ions . The m et hodo f a pp l i ca t ion is a s fo l low s C rus t s a re a s fa r a s po ss i b le rem oved and the en t i rena sa l m u cou s m em b rane is b ru shed w i t h co t ton w oo l a pp l i ca to rs soa ked in a

m ix tu re o f pu re g lycer ine w i t h the‘

addi t ion o f 25% l i qu i d g lu co se. S evera la pp l i ca t ions are m ade da i ly , a t fi rs t by the su rgeon and sub sequen t ly by the


pa t ien t h im sel f . F rom t im e to t im e the flo ra o f the no se is exam ined to no t ethe cu l tu ra l p ro per t ies o f the ba c t er ia p resen t and t o determ ine whet her or 11 0

they a re the s t ra in to ferm en t them ed ia supp l ied . In som e ca ses w hen a Sprayor iriiga t ion 1s requ 1red , a m ix tu re o f the tw o sub s tan ces ha s been used in a

100 ? a queous so lu t ion .

The h is t o r ies o f t en ca ses , extending over a per iod o f tw o y ea r s , is g i ven .

The fcet or o f a ll th e ca ses d i sa ppea red a nd the g reen ish c ru s t s w ere rep la cedby m u co i d sec ret ion s .

PERRY GOLDSM ITH .

On ta rio Medic a l Asso a citio n

SECT ION OF SURGERYPrelim ina ry Anno uncem en t fo r Fo rtieth Annua l Meeting

To ron to , May 25 , 26, 2 7 , 28 , 1 920

DR . GEORGE D . STEWA RT,Pro f . o f Su rgery,

Un ivers i ty a nd Bel levue H o sp. Med i ca lCo l lege, New Yo rk .

DR . N . PERCY,A sso c . P ro f . o f C l in ica l

Su rgery,Un ivers i ty o f I l l ino i s , Ch i cago .

DR . EDWARD B . ARCH IBALD Lec tu rer in C l in ica l Surgery,

McGill Un ivers i ty. Mon t rea l .DR .

~ JAME S MASSON,Ma y o C l in i c

,Ro chester , Subj ec t to be a nno unced .

M inn .

DR . E M ERSON HODGI N S,London

, Ont .

DR . SCOTT,To ro nto .

DR . JOHN R . PARRY , H am i lto n .

DR . S . M . H AY, To ronto .

DR . E . STA NLEY RYERSON , To ronto .

DR . D . E . MU NDELL . lxm g s to n .

DR . H . H ARR IS,To ronto .

D R . ROSCOE GRA HAM,To ro nto .

DR . ED . D . ROBERTSON,To ro n to .

DR . ROBERT MCCOM R,To ro nto .

The Ga s tr i c Hyperm o t i l i ty asso c ia ted w i thD i sea ses o f t he Ga l l Bladder . Duodenum

a nd Append i x .

Techn ique o f t he T ra ns fus io n o f

Blo o d and it s va lue in a sso c ia t io n w i thsurg i ca l pro cedu res in the trea tm en t o f

pern i c io u s and o ther anzem ia s .

I’a ncrea t it is .

Tum o urs o f the Bra in .

Fra c tures o f the Sku l l ( the i r D iagno s i s a nd

Trea tm ent ) .

Surg ic a l Trea tm ent o f Empyem a .

D i agno s i s o f som e Com m o n Acu te Abdom ina l Co nd i t ion s .

Rela t io n o f Pa tho log ica l Co nd i t ions o f t he

Ga l l Bla dder t o Trea tm ent .Tendo n Transpla nta t i o n .

Co nd i t io n s s im u la t ing Ga str i c UlcerS ign i fi canc e o f Pa in in the r igh t I l i a c Fo ssae.

Trea tm ent o f Unun i ted Fra c ture s .

Per inea l Pro s ta tec tom y .

uotations fromDoctors :N o . 1

To m en tion the hygro scopic a c

tio n o f glycerine to a nyone who

ha s the slightest k now ledge o f

chem istry , is unnecessa ry . Bu t to be

able‘

to ha rness'

this a c tio n and

utilize it a s a the rapeu tic agent o f

grea t po tency , is w o rthy o f no te .

we have such a com bina t ion ; and

it ha s s to od the test o fm any yea rs .

lt ha s show n tha t , in prope r m ix

ture w ith a su itable ba se , the a c

know ledged o sm o tic pow e r o f

glycerine m ay be grea tly in tens i

hed ; tha t through this a c t io n

co ngestio n in a ll tissues m ay be

reduced , thus re lieving pa in from

disten tio n and a c ting a s a s ti

mu la u t to no rm a l c ircu la tio n , a nd

ha stening reso lu t io n .

heDenverChem ical Mfg. Co .

MONTREAL

TO - DAY’S WORLD PROBLEM IN

DISEASE PREV ENTION

Ac t ing upon the reques t o f the Counc i l o fNa t iona l Defen ce o f the Un i ted S ta tes ,

Dr .

John H . S to kes . Derm a to log is t and Syph ilorg rapher to the Ma vo C l in i c o f Ro ches ter ,under took to w r i te a non - techn i ca l d iscuss ion o f syph i l is and gono r rhoea ,

w h i ch he ha sbeen p lea sed to pub l ish in boo k fo rm underthe t i t le “

T o—day’

s Wo r l d P rob lem in Disea sePreven t ion .

”

Tha t Dr . S tokes w a s am p ly qua l ified to

edi t such a d is cuss ion ,ha s been m an i fes t l y

dem ons t ra t ed by the c lea r,fo r cefu l and

t ho rough m anner in w h ich the subj ec t m a t terha s been t rea ted .

Rea l i z ing the va lue o f th i s book to the

m edi ca l pro fes s io n , the Prov inc ia l Boa rd o f

Hea l t h o f On ta r io m ade a r rangem en ts w i t hthe au t ho r for the supp ly o f a l im i ted num

ber o f co p ies fo r di s t r ibu t ion to p ra c t i t ionersin the Province. I t is to be hoped tha t th i sillmn ina t ing con t r ibu t ion on a m o s t v i ta l andna t iona l subjec t m ay be w i del y d issem ina tedand read .

Herew i t h is a ppended the in t roduc to rycha p ter to the book from the pen o f Dr . John

S . McCulloug h , Ch ief Officer o f Hea l t hfo r the Provin ce o f On ta r io :Prev iou s to the Wa r, the p rob lem o f the

con t ro l o f syph i l is and gonorrhoea had

received l i t t le a t ten t ion in Canada . No pa r to f Canada had any leg i s la t ion bea r ing on th issubjec t . Condi t ion s in the a rm y fo cussedpubl i c a t ten t ion upon the ques t ion , and t herew a s som e di scuss ion in the p ress a s to

w het her o r no t the so l d iers sen t o versea sw ere being sufficien t lv p ro tec ted aga in s t thevenerea l ev i l . I t so on becam e a ppa ren t tha tthe m ea su res o f con t ro l a dop ted in the a rm y

were o f g rea ter va lue t han t ho se in eff ec tam ong the c i v i l po pu la t ion . En l is tm en t sshow ed tha t th ere w a s m o re venerea l d i sea sein the c iv i l popu l a t ion than in the a rm y . In

Sep tem ber , 1916. o u t o f nea r l y Cana

d ian t roop s in Grea t B ri ta in there w ere 960venerea l d i sea se ca ses . Du r ing the m on t h o f

Sep tem ber . 1918 . of Cana dians in

Grea t B r i ta in there w ere bu t 750 ca ses . a

redu c t io n in t he a dm i ss ions du r ing t h is in terva l o i The ev idence o f eff ec t ive mea s

u res u sed in the a rm y , the repo r t o f the

Svdenham Roya l Comm is s ion in E ng land ,

and the effo r t s o f an Hono ra ry Adviso ryComm i t tee in M i l i ta ry D is t r i c t No . 2 and o f

the To ron to Academ v o f Medi c ine influencedthe On ta r io Governm en t t o a ppo in t

.

a Ro y a lC omm iss ion o f Inves t iga t ion in 1917 . The

resu l t o f the repo r t o f t h is Comm i ss ion w a s

tha t in the sess ion o f 1918 the Governm en tpa ssed the V enerea l D i sea ses Preven t ionA c t , the ea r l ies t leg is la t ion o f the kind inCanada . In the summ er o f 1917 the Com

m it tee refer red t o , a sso c ia ted w i t h the Provincia l Boa rd o f Hea l t h o f On ta r io ,

had takenupw i t h the Dom in ion Governm en t the quest ion o f i ssu ing a l i cense to the Bo a rd to produce an a rsphenam ine p rodu c t under the

a r Mea su res A c t,in o rder to redu ce to rea

sonab le p ropo r t ions the co s t o f t h is rem edv.

The m edi ca l p ro fess ion o f Cana da is aw a reo f the successfu l effo r t s o f the Boa rd in providing supp l ies o f d iph ther ia an t i toxin and

o t her b io log i ca l p rodu c t s used in the p revent ion and t rea tm en t o f cer ta in o f the o t hercomm un i cab le di sea ses and o f the verv lo w

p ri ces a t w h i ch t hese a re secu red . I t w a s

hoped t ha t a som ew ha t s im i la r resu l t m igh tbe a t ta ined in reference to the rem edy u sedin syph i l i s . A f ter a p ro longed eff o r t t h i sl i cen se ha s been p rom i sed the B oa rd and

s tep s a re being taken t o p rodu ce an a rs

phenam ine p rodu c t a t rea sonab le co s t .

t he a ss i s tan ce of the pub l i c hea l t h offi cer s of

the o ther p ro vin ces o f Canada and o f so c ia lw o rkers in teres ted in the ques t ion o f venerea l di sea se, p ressu re w a s b rough t by the

B oa r d to bea r on the Dom in ion Governm en tto g i ve financ ia l a id to the Prov inces in the

ca re o f venerea l ca ses . and a t the recen t sess ion o f Pa r l iam en t the sum o f $200 000 w a s

vo ted for t h i s pu rpo se. Th i s m oney is to be

di s t r ibu ted to the Pro vinces in p ro po r t ion topopu la t ion on cond i t ion t ha t an equa l am oun tis vo ted bv the severa l P rov inces . On tar ioha s ag reed to p ro v ide the requ i s i te funds ,and t hese a dded to our p ro po r t ion o f the

Dom in ion g ran t w i l l a ff o rd a cons idera b le

66GerrardStreet East

11 Non - Poisonous , Unirrita ting

Antiseptic So/ution

Op era t ive o r a c c i d en t alwounds hea l ra p i d ly undera L i ster ine dres s ing, a s it s

a ct ion does n ot in t erferew i t h the n a t u ra l repa ra

t i ve p ro cesses .

The freedom cf L is t er inefrom po ss i b i l i t y of po i sono u s eff ec t i s a d i s t i n c tadvan t age, and espec i a l lyso w hen the prepa ra t ion isp rescr i bed for em p loym en t

LAMBERTPHARMACALCOMPANYSt. Louis, Mo , U.S.A.

Toronto, Ont.

Agreea b le and s a t i sfa ct o rya l i ke t o the Phys i c ian , Su r

geon , Nurse and Pa t ien t .

L i s t er ineha s a w i de field o fu sefu lnes s , and it s unva rying qua l i t y a s su res l i ke re

su lt s under l i ke cond i t i on s .

As a w a sh a nd dressingfor w o unds

3 a deodoriz ing ,a n t isept ic

lo t ion

As a ga rgle ,spra y or do u che

As a m ou th - w a sh - den trifice

ECOGNlTlON o f Ho rlicl-c'

s

Ma l tedMi lk ha s been growing fo r o ver a third o f a cen tu ry .

It res ts upo n qual ity tha t comb ine s o rigin a l i ty,

un ifo rm i tya nd dependabi l i ty.

u l ly Ho rl ick'

s

req u i remen tso f the phys i cian and needs o f

the pa tien t is.

shown by the

un iversa l a c cord w i th w hich itis prescribed .

POST—INFLUENZ AL DYSPEPS IA

Sample a nd Printed Ma tterprepa id to the Pro f es s io n

Horl ic'

k’

s Malted Mi lk C0

Racine,Wis. Slough , Bucks , Eng.

Montrea l , Can.

sum w i t h wh i ch to es tab l i sh cl in i cs for the

ca re o f venerea l ca ses . S teps ha ve a l readybeen ta ken by the Boa rd t o inaugura te th i sw o rk . In add i t ion, a s t rong Na t iona l Counc i l

,s im i la r to the one es tab l i shed in E ng land ,

ha s been fo rm ed fo r the pu rpo se o f ca r ry ingon edu ca t iona l and o t her usefu l p ropaganda .

The Boa rd is o f the opin ion tha t in the

cu r ta i lm en t o f the venerea l ev i l a s t rong edu

ca t iona l cam pa ign is necessa ry ,and in t h is

connec t ion the booklet here p resen ted to them edica l p ro fess ion o f On ta r io seem s a va lua b le one. Th i s vo lum e w a s w r i t ten by Dr .John H . S tokes

,Derm a to log i s t and Syph i lo

grapher . to the Mayo C l in i c o f Ro ches ter ,Minneso ta , a t the reques t o f the Counc i l o fNa t iona l Defence o f the Un i ted St a tes

, dur

ing the la te w a r. I t ha s been pub l ished bythe Un i ted Sta tes Pub l i c Hea l th Serv i ce . and

by them and the S ta te Boa rds o f Hea l t h o f

the va r iou s S ta tes ha s been di s t r ibu ted to

phy s i c ian s and to pub l i c Sp i r i ted lavm en .

Dr . Stokes ha s con sen ted t o a l low the pub l ica t ion o f the vo lum e in a l im i ted edi t ion bythe Pro v in cia l Boa rd o f H ea l t h o f On ta r io .

I t w i l l be di s t r i bu ted bv the Boa rd to the

Mem bers o f the m edi ca l p ro fess ion in

On ta r io . I des i re to exp ress the Boa rd’sco rd ia l a pp rec ia t ion o f Dr . S tokes’ con tribut ion to o ur educa t iona l cam pa ign .

A cco rd ing t o G . D eusch (Med . Kl in i k , November16th . the la st epidem i c o f i nfluenza a t Ro s

to ck w a s fo l low ed bv a num ber o f ca ses o f dyspep

s ia w h i ch la sted severa l m o nth s . No ne o f the

pa t i en t s ha d su ffered from auv ga st r i c tro ublebefo re the i r a tta ch o f i nfluenza . The dy speps ia is

a t tr ibu ted bv Deu sch t o a hyperaesthes i a o f the

m u co u s m em bra nes o f the s to m a ch due t o dam a ge

t o the sen so ry nerve end ings bv the influenza to x in .

D i stu rba nces o f th e m o to r func t io n o f the s tom a ch

appea red t o be fa i rly uncomm o n ; o n the o ther ha nd,

m o s t o f the ca ses show ed secreto rv d i sturba ncesd im inu t i o n o r complete ab sence o f a c id i ty w a s the

pr inc ipa l find ing , being '

probab ly due t o a tox i cinvo lvem ent o f the vagu s .

THE DIFFICULTIES OF TREATMENT

OF GONORRHCEA

The t rea tm en t o f gono r rhoea bea r s the

ea rm a rks unfo r tuna tely fam i l ia r in m o ret han one fi el d o f m ed ica l p ra c t i ce, in t ha tm any m et hods and a hos t o f rem ed ies m ean

doub t fu l g round . N ea rlv every exper t in the

m anagem en t o f the d isea se ha s h is own

pecu l ia r w ay o f go ing a bou t i t . Genera lp r inc ip les are recogn i zed , to be su re bu t t heyla ck spec i fi c i ty , a s w e say. Tha t is, no one

o r tw o rem ed ies or m et ho ds ca n be cer ta ino f p rodu c ing resu l ts in the o verw helm ingp ropo r t ion o f pa t ien t s , a s is the ca se

,for

exam p le,in syph i l is . No epo ch - m a king

a ch ievem en t s in the t rea tm en t o f gono r rhoeaseem to have been reco rded in recen t yea rs

,

a l t hough on the w ho le t here ha s been a per

s i s ten t im p ro vem en t in m et hod s and resu l t s .

The g row ing a pp recia t ion o f the im po r tanceo f the m i c ro scope in the con t ro l o f t rea tm en tis a s igna l a dvance. A t t im es i t seem s a s i ft he ra t her so rd id pecu l ia r i t ies o f the d i sea se,

the di ffi cu l t y o f get t ing the pa t ien t ’s co

o pera t ion w hen it is so v i ta l to a success fu li s sue. the la ck o f the spec ta cu la r , th e tendency to ob s t ina cy and ch ron i c i ty , a nd the

b ri l l ia n t t r ium ph s in the rela ted fi el d o f

sy ph i l i s had,in an indefin i te w a y , deflec t ed

in teres t from a fiel d in w h i ch com pen sa t ion sa re few a nd the la bo r o f ten o u t o f p ropo rt ion t o the rew a rds . Y et no t h ing is b ecom ingm o re a ppa ren t t han t ha t in tel l igen t t rea tm en t o f a gono rrhcea is an essen t ia l to it scu re, a nd shou ld be a dequa tel y p ro vided fo rin the in teres t o f the pub l i c hea l t h a lone, to

say no th ing o f the pa t ien t h im sel f . I t res tsw i t h the fu tu re t o dev i se m eans to b r inghom e the im po r tance o f a dequa te ca re o f

gono r rhoea a nd a m o re p ress ing sen se o f

respons i b i l i ty in rega rd to i t . fi rs t to the publ i c . and t hen perha p s to the m edi ca l pro fess ion — JOH N H . STOKES . in To - da v ’

s

P rob lem inDi sea se Preven t ion .

The Idea l Tonic a nd Recons truc ta n t

CompoundPla in , o r w i th

C reo so te a nd Gu a ia co l

OdorlessTastelessC ONTAINS

The resu l tan t product obta ined by the

a ction o f the fres h d iges t ive fermen ts

pancrea s , ox ga l l , spleen , o n

C o d Liver Oil— 2 5 %

Malt Ex trac t

Hypopho sph ites C o(GLYC ER IN E BA SE )

Ex t . Cherry , Eu c a lyptus

Yerba San t a an d A rom a t ics

N O SUGAR

S ig .

i

I Tablespoo n/h i 4 to 6 t imes a day

TheWaterbury Chemical Co .

of Canada , Limited

D0 8 EIOIII CS Toronto New York

Pres cribed by Phys ic ia ns in a il parts o/ the Wo rld

Pri ces Effective Ja nua ry 1920

Runabout

Touring

Coupe— fully equipped

Sedan— fully equipped

Chassis

One- Ton Truck Chassis

Prices a re f .o .b. Ford,Ont .

,a nd do no t include

E lectric Sta rt ing and L ight ing Equ ipment is sup

pl ied on Sed an and Coupe at prices quo ted .

Runabou t and Tou ring th i s equ ipment is opt iona l

a t an add i t iona l co st o f $100.00, exc lu s ive o fW arT ax

Ford Mo tor Company of Canada Lim i tedFORD ON TAR IO

Prices E ffective Ja nua ry 1920

Runabout

Touring

Coupe— fully equipped

Sedan— fully equipped

Chassis

One- Ton Truck Chassis

Prices a re f .0 .b. Ford,Ont .

,a nd do no t include Wa r Tax

E lectric Start ing and L ight ing Equ ipment is sup

pl ied on Sed an and Coupe‘

a t prices quo ted .

Runabou t and Tou ring th i s equ ipment is opt iona l

a t an add i t iona l co st o f $100.00, exc lu s ive o fW arT ax

Ford Mo tor Company of Canada Limi tedFORD ON TAR IO

e yc

lant 1pp1ng

CANADA

ALL WEATHER TREAD

The Goodyear Tire Rubber Co .

’

of Canada , Limited

All Wea ther Tires a re

All- Wheel Tires

T the wo rld , wherever a

co nveyan ce is cu shio ned o n pneum a t i ct i res , there yo u w i l l find the imprin t o f the

All-Wea ther Trea d . It m ay be the n a rrow pa th o f

the b icyc le , the bro a d er tra i l o f the m o to rcyc lethe a u tom ob i le— o r the unm i sta kable tra c k o f a

g ia nt truck . Bu t a lw ays the sto ry it tel l s is the

sam e— m o re m o to r i sts r ide o n Go o dyea r Tires tha n

o n a ny o ther bra nd .

Olds MotorWorks of CanadaLIMITED

OSHAWA , ON TAR IO

T EACH success ive automob i le show in the past ,the Old smob i le has set t he pa ce I t ha s set a

s ta ndard o f exce l len ce many m anufac turers find d iflicul tto fo llow .

Aga in, a t t he present: autom obi le show the Oldsmob i leexh ib it sets thepa ce. The w ide va rieties o f styles in both the“

s ix"

a nd“eight” m odels , the q ua l ity tha t ha s establ is hed a ninterna tiona l reputa t ion d uring twenty—two years o f superior

a utom ob i le manu fa cturing a nd the a ttra ctive prices w i llco nvinc e a nyone who ma kes search ing comparisons that Aga inOldsmobile Sets the P a ce.

McLa ughlin Ma ster S ix Coupe. K- S ix -46

See the N ew McLaugh lin Mo dels a t

the neares t McLaugh lin Show Ro om s

The C lo sed Ca r is grow ing in fa vo r am o ngmen who ha ve used C a rs fo r severa l yea rs .

A lways com fo rta ble in a ll extremes o f c l im a te.

the C o upe is the idea l ca r where a l im itedpa s senger ca rrying capa c ity is needed .

Fo r bus ines s a nd pro fes s iona l needs o r for

s o c ia l o r pa t rio t ic d u ties the Mc La ughlinMa s ter S ix C o upe is the c h o i c e o f the“

Mo to r Wis e .

McLAUGHLlN MOTOR C AR CO . LlMlTEDosm wx. ONT.

BRANCHES IN LEADING CITIES . DEALERS EVERW HERE .

Wheeler’s Handbo o k o f Med ic ine —Jack.

Fif th E di tion , 5 5 2 pa ges , excellen t d ia g ra m s , bou nd in c lothBv WM . R . JACK

,E .SC . , M.D .

,Phys ic i an t o t he G la sgow Roya l lnfi rma ry:

Lec turer in C l in ica l Med ic ine in th e Un ivers i ty , Glasgow .

A Manu al o f‘

Midw ifery .—Eden.

F if th E d it ion . 1 91 9, 747 pa ges , with 5 pla tes a nd'

3 69 i llu s tra tions in the tex tbo a -a d in. cloth

By THOMAS WATTS E DE N , M .D .,C .M . , E d in . , Lond . ,

E d in . , MajorObs tetr ic Phys i c i an and Lec tu rer o n M idw i fery and Gynaeco logy , Ch a r ing

C ro s s H ospi ta l ; Consu l t ing Phys i c ian t o Queen Cha rlo t tes Ly ing - in H o spi ta l ; Surgeonto In - Pa t ients , Chel sea H o spi ta l fo r Wom en .

D iseases o f the Sk in .— Sequeira .

Third E d it ion , 1 91 9, 644 pa ges , with 5 2 pla tes in co lo r a nd 25 7 ta rt fiigu res ,

bou nd in clothBy JAME S H . SEQUE I RA , M.D .

,London ; London ; E ng

' Phys i c ia nt o the Skin Departmen t a nd Lec turer o n Derma to logy a t the London H o spi ta l ; in

ch a rge o f Queen A lexandra ’

s Depart men t fo r L igh t Trea tmen t ; Cons u l tan t fo r D i sea seso f Skin to M i l i ta ry H o spi ta ls in London ,

et c . , et c .

On Fac ial . N eura lgia and It s Treatm en t .—Hutchison.

l'V'ith E spec ia l Reference to the Surgery of the F if th Nerve, a nd the Ga s seria n Ga ng lion

.21 6‘

pa ges , with i llus tra tions a nd d ia gra m s ,1 91 9 , boun d i n cloth

BV J. HUTCH ISON , Surgeon t o t he London H ospi ta l ; E xam iner in Surgerya nd la te H un ter i a n Pro fessor a t the Roya l Co l lege o f Surgeon s .

T he Urethro scope in the D iagno sis and Trea tmen t o f

Urethrit is .

—Lumb.

A Con tribut ion to Urethros copy . Illus tra ted by 40 o rig ina l il lus tra tio ns , 1 91 9,

Bv MAJOR N . P . L . L UMB , Au tho r o f Sys tema t i c Trea tmen to f Gono rrh tna .

The Macmillan Company of Canada ,Limited

S t . Ma rtin’

s House 70 Bond S treet, Toronto

X - R ay Observat io ns fo r Fo reign Bo d ies and their

Lo calisat ion . Gage.

1 91 9, excellen t i llu s tra tions a nd d ia g ram s ,bound in clo th

By CAPTAIN H AROLD C . GAGE , O.I.P . Con su l t ing Rad iographer to the Amer icanRed C ro ss H o spi ta l , Pa r i s ; Rad iograph er in Ch a rge M i l i ta ry H o spi tal , V .R . 76, R is

Orang i s , and complem en ta ry h ospi tals .

T he Pitu it ary . Bell1 91 9, 3 48 pa ges , 1 90 illu stra tion s a nd dia grams

By W. BLAIR BE LL , B .S .,M .D . London , etc . Gynaeco log i c a l Surgeon Roya l Infi rm a ry ,

L iverpo o l ; Lec turer in C l in ica l Gynaeco logy in the Un ivers i ty o f L iverpoo l , etc .

Physio lo gic al Princ iples in Treatmen t . Brown.

1 920 , Fou rth E d itio n , 408 pa ges

By W . LANGDON BROWN , M.A. ,M .D . , C a n tab . , As s i s ta n t Phys i c i an to S t .

Ba rth o lomew’

s H ospi ta l a nd Ph ys i c i a n t o th e Met ropo l i ta n H o spi ta l , et c .

Fo o d and Princ iples o f D ietet ic s . Hutchison.

Fourth E di tion , Thi rd Impress ion , 1 91 9, 61 7 pa ges , with pla tes a n d d ia gram s

By ROBE RT HUTCH ISON , M.D . E d in . ; F .R .C .P Phys ic ia n to the London H o spi ta l '

Ph ys ic ia n in charge o f o u t -

pa t ient s to th e H o spi ta l fo r s ick ch i ldren , Grea t Orm ond

Street , et c .

Sanita t io n for Public Health N urses . H ill.1 91 9, 21 1 pa ges

By H IBBE RT WINSLOW H ILL , M .E ., M .D . ,

D .P .H L a te D i rector , D iv i s i on o f E pidem i

o logy,M inneso ta ; S ta te Boa rd o f H ea l th and la ter , D i rec tor, In s t i tu te o f Pub l i c

H ea l th ; M .O .H . o f Londo n,On ta r io , and Pro fessor of Pub l i c Hea l th ,

WesternUn ivers i ty,

et c .

Papers o n Psych o - Analysis . Jones .

R evis ed a n d en la rged ed it ion ,1 91 8 , 71 5 pa ges

By E RNE ST JONE S , M.D . ,London ; P res i den t o f the London Psycho—Ana lys i s

Soc iety ; la te Assoc i a te P ro fes so r o f P sych ia try a t t he U n ivers i ty o f Toron to .

The Macmillan Company of Canada , Limited

S t. Ma rtin’

s House 70 Bond S treet, Toronto

tho ugh primarily a symptom. wi ll, if allowed tocontinue. soon depress or d isturb every functiono f the body

The prompt rel ie f o f pa in. therefore, is a lwaysimperative. and to accomplish th is

GEO . C . C OOK 8 CO . IN C Su c c es s o rs

W RTII l IVlNG

fl P lea s a nt a nd Effec tive Aperient

NE o f the m o st e ffic ient Ape rients fo r c lean ing the

C a stro intestina l t ra c t is Abbey 3 E ffervescen t Sa lt .

lt is a lso a c onven ien t a nd pa la table prescriptio n for

Heada ches due to diso rders o f the stom a ch or liver,wh ile its diuretic a c tio n is o ften helpfu l in trea ting c a ses o f

Kidney Congestion whe re there is a m a rked increa se in thea ccum ula t ion o f Urid Ac id .

The Abbey Effervescent Salt Company Montreal

has no superior. Pa in. no matter how severe orwhere located , is quick ly co ntro lled and withnone o f the drawbacks o f the Opiates or theo ther narcotic drugs.

The every day experience of thousands o f physicians has shown conclus ively that no otheranodyne is so satis factory in its effect. and atthe same t ime so free from d isagreeable or

harm ful action.

The use o f Phena lg in means the rel ief o f pa inpromptly. sa fety and sat is factorily w itho ut

upsetting the stomach . suppress ing the secret ions. o r creating a h abit. N o specia l blank o rreco rds required fo r its use.

Well has it been te ed by those who use it inpreference to any o t erana lgesic “

the logica lsupplanter o f Opium.

"

Samples on req uestETNA CHEMICALC0.

5 9 Bank S treetNew York

1"“l l“.l"mt?

it ever 1111 El" X [710

M u lfo rd B ra n d

For the Preventi on and Trea tment of Rose Coldsand Spring Hay Fever

H a y F ever Sprin g P o l len Extra c t , M a l fo rd B ra n d

cons ists oi'

the protein obta ined from the po l lens of timothy, rye,

red - top and severa l other grasses— the cause of so - ca l led Rose- Co ldsor Spring or SummerHay Fever d isso lved in physio logica l sa l inesolution and accurately standardized.

Th e P o l len E x tra c t m ay be used W i tho ut pre l im inaryd iagno s t ic tes ts , where t hese are rio t feas ib le, Spring H ay

Fever be ing caused mo st ly by the po l len from gra sses .

H a y F ever S prin g P o l len E x t ra c t is furnished as fo l lowsN o . O—In pac kages of four ster ile syringes , A, B, C , D strengthN o . 4— 11) 20- mil vials, each mil strength of Syripge DN o . 9—In 5 - mi1 u u u

N o . l l —S ingle syringe, gstre‘

ngt’n

N O . 1 2

N o . 1 4 F

Syringe A conta ins mg. po llen prote in n itrogenB Ct

0 . (X)6( C U

CD

E

F

F o r Im m u n iz a t io n a n d T re a tm en t o f H a y F ever, f irs t d o s e

( S y r in ge A ) s h o u ld be given a t l ea s t 3 0 da y s befo re . expec ted

a t t a c k , fo llowed by B, C and D at five- day intervals . Syringe D strengthHay Fever Po llen Extract should be used at week ly interva ls during the entireperiod of accustomed attack or until '

immunity is established .

H. K. MULFORD CO., Philadelphia , U. S. A.

Manu fa c turing and Biologica l Chem ists

F u l l l ite r - t u re w i ll b e m a i l edu po n re q u e s t

‘V L I JO X'

D “7

0 0 “ T o r o n t o . G e n e r a l A ge n t f o r C a n a d a

(ABBOTT)

Dakin’s

Powerfu l An t isept ic

u s non -

po isonous . eflic ient and conven ien t c i m ic ide i s

rapid ly repla c ing such dangero us agen ts a s b ichloride o f

m ercury , carbo l ic a c id and o ther prepara t io n s o f th is c la ss

For the trea tm en t o f comm on wound s . injuries and c arbunc l es ,

a s a spray to the no se,in pyorrhea and denta l surgery, a s a

vagina l do uche and a s a s imple conven ien t remedy for the

trea tm en t o f venerea l d i sea se,in fa ct , fo r a ll purpo ses , where

an an t i septic is requ ired , CHLORA Z E NE m eets the ind icat ion s m o st adm irably .

F or pro tec tion in sist on the trade- m a rk A bbo tt .

” Th is

trade - m ark in sures puri ty and streng th .

Spec ify a lso Abbo tt’

s D ich loram ine - T,Ch lorco sane

,Halazone

B arbita l, (form erly V erona l) and P ro c a ine (form erly h oro

ca ine), and o ther Abbo tt m ade Medic ina t Pro duc ts .

L itera ture on Reques t.

THE ABBOTT LABORATORIESHOME OFFICE AND“

LABOTATORIES CHICAGO, DEPT. 75 :

W. LLOYD WOOD, Agent , 64- 66Gerrard St Toronto

And for your particu'ar convenience, all theWho lesa leDistributing DrugHouses in Canada .

DIFFICULT INFANT FEEDING CASES

To carry the little Pa tient thru this critica l period req uires a

susta ining , sa tisfying and easily digested nourishm ent— why

experim ent w ith variou s feeding m ixtures— Prescribe

which m eets a ll the req u irem ents o f m odified m ilk, w ith the

added advantages o f assured cleanliness , dependibility and

uniform compo sition .

“

Ea g le Brand is m ade from richest

m ilk, from h ea lthy cow s— highest grade refined sugar added

to insure the keeping q ua lities— c ondensed in definite pro

portions— gua ran teeing a standardized finished produc t a t

a ll sea sons o f the year.

We shall be pleased to send

S amples , Ana lys is a nd

literature on request.

BORDEN M ILK COMPANY , L IM ITEDMon trea l V ancouver

· pdf filet he c an adian medic al mo nthly vol . i v., n o. 4 toronto, c an ada apr i l, 1...

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