History of Nursing in Pacific Canada

The Vancouver Medical Association Bulletin: August, 1942 Vancouver Medical Association Aug 31, 1942

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 'A*'"
The BULLETIN
of the
I      IVANCOUVER
MEDICAL ASSOCIATION
-Vol. XVIII
AUGUST, 1942
No. 11-
Witb Which Is Incorporated
Transactions of the
Victoria Medical Society
the
Vancouver General Hospital
and
St Paul's Hospital
In This Issue:
Page
EXAMINATION OF RECRUITSj||~- —ft • — \^K^ %326
PROGRAMME SUMMER SCHOOL, ||lj|f   —"^^^^^^i 4lllllP30
BURNS AND THEIR TREATMENT!- J§_ |^__^.  333
DIET—PEPTIC ULCER PATIENTS—^- - J| IBr    34°
NEURO—CIRCULATORY ASTHENIA :j||. _jj|- |fc___ | 344
HYPOSPADIA.^ JSJ    . life — ^MPIS^^^B     348
VANCOUVER MEDICAL ASSOCIATION
||SUMMER SCHOOL
SEPTEMBER 15 H 8 Inc.
lis
S81
;4Hb r'l
%
L:- imI
i. j ;«
MHHM_£^>:-'-
The.Ori^nal Antcif id
PALATABLE ..... PROTECTIVE
DILAXOL E.B.S. has earned the approval of the
Medical Profession, because of its high efficacy in
control of gastric hyperacidity and the protection
tSfe affords against threatened breakdown of the
gastric wall.
Though alkaline in reaction, Dilaxol, unlike strong
alkalies, does not stimulate the secretion of excess
acid. Dilaxol neutralizes free acid and its acid-combining power is extremely high. It has prolonged action,
but does not interfere with digestive processes, nor
does it cause alkalosis.
Because of its colloidal nature, Dilaxol exerts a protective action on the mucous lining of the stomach,
thus preventing breakdown of the gastric wall.
It is indicated in the treatment of hyperacidity,
duodenitis, flatulence, functional dyspepsia, peptic
ulcer and nausea of pregnancy.
Each Fluid Ounce Contains:
Bismuth Subsalicylate r^^«^^|^K'-4 grains
Digestive Enzymes .^^^fe^p^<M 1 grain
Magnesium Trisilicate, Carbonate and Hydroxide combined . ^^Sfev^^^! • 75 grains
DOSE: One or two fluid drachms, in water.
Also supplied  in
_-_- IB POWDER FORM,
WHEN PRESCRIBING ^_^SSf__2!"
wm   .,    _ i g _ mm pensing packages.
Specify E.B.S. Preparonons^
JUST TO
BE  SUREI
DHilXOt
*<> pftmbvnea
5'ii!!'!!i'>!i!'i(!i'»i!!<!'!!'iH«i!!!'»ii!'ii!'<<'.
THItE. BI SHUTTLEWORTH CHEMICAL COMIMITED
TORONTO
MANUFACTURING   CHEMISTS
CANADA Ii BRITISH
THE    VANCOUVER    MEDICAL    A SSOCI AJTIjQN-
BULLETIN
Published Monthly under the Auspices of the Vancouver Medical Association
in the interests of the Medical Profession.
Offices: 203 Medical- Dental Building, Georgia Street, Vancouver, B. C.
EDITORIAL BOARD:
Db. J. H. MacDermot
Dr. G. A. Davidson Db. D. E. H. Cleveland
All communications to be addressed to the Editor at the above address.
Yn
Vol. XVTII
AUGUST, 1942
No. 11
OFFICERS, 15>41-1942
Db. J. R. Neilson Db. H. H. Pitts Db. C. McDiabmid
President Vice-President Past President
Db. Gobdon Bubke Db. A. E. Trites
Hon. Treasurer Hon. Secretary
Additional Members of Executive: Db. J. R. Davidson, Db. J. A. McLean
TRUSTEES
Db. F. Bbodie Db. J. A. Gillespie Db. W. T. Lockhart
Auditors: Messrs. Plommer, Whiting & Go.
SECTIONS
Clinical Section
Db. Ross Davidson Chairman Db. D. A. Steele Secretary
E}/c, Ear, Nose and Throat
Db. A. R. Anthony Chairman Db. C. E. Davies- Secretary
Pediatric Section
Db. G. O. Matthews Chairman Db. J. H. B. Gbant Secretary
STANDING COMMITTEES
Library:
Db. F. J. Bulleb, Db. D. E. H. Cleveland, Db. J. R. Davies,
Db. A. Bagnall, Db. A. B. Manson, Db. B. J. Habbison
Publications:
Db. J. H. MacDebmot, Db. D. E. H. Cleveland, Db. G. A. Davidson.
Summer School:
Db. H. H. Caple, Db. J. E. Habbison, Db. H. H. Hatfield,
Db. Howabd Spohn, Db. W. L. Graham, Db. J. C. Thomas
Credentials:
Db. A. W. Hunteb, Db. W. L. Pedlow, Db. A. T. Henby
V. O. N. Advisory Board:
Db. L. W. McNutt, Db. G. E. Seldon, Dr. Isabel Day.
Metropolitan Health Board Advisory Committee:
Db. W. D. Patton, Db. W. D. Kennedy, Db. G. A. Lamont.
Greater Vancouver Health League Representatives:
Db. R. A. Wilson, Db. Wallace Cobubn.
Representative to B. C. Medical Association: Db. C. McDiabmid.
Sickness and Benevolent Fund: The Pbesident—The Tbustees.
M
!&!$ ' u
SQUIBB amj^Z/uomnee^j^t
INDIVIDUALLY
0
0
0
THIAMINE
HYDROCHLORIDE
1, 3, 5 and 10 mg. Microcaps
RIBOFLAVIN
1  and 5 mg. Microcaps
PYRIDOXINE
HYDROCHLORIDE
1 and 10 mg. Microcaps
NICOTINAMIDE
50 mg. Microcaps
CALCIUM
PANTOTHENATE
10 mg. Microcaps
Vitamin b com?tf*
SYRUP
SYNTHEPLEX B
MICROCAPS
The five synthetic
factors of the B-
Complex in therapeutic quantities in
easy-to-swallow
microcaps.
VITAMIN B
COMPLEX SYRUP
An extract of the whole
natural B-Complex as
derived from rice bran,
enriched with thiamine
hydrochloride and
riboflavin.
COMPLEX
PRODUCTS
SQtHBB
WTAJB8 8 COMPUX
TABLETS
VITAMIN B
COMPLEX CAPSULES
Contains the whole
natural B-Complex as
derived from high
potency brewers' yeast,
fortified with five crystalline vitamins.
VITAMIN B
COMPLEX TABLETS
Made with a special B-
Complex extract of brewers' yeast fortified with
five crystalline vitamins.
Potent and Economical.
For literature write 36 Caledonia Road, Toronto, Canada.
ERiSqjJibb]„So$s of Canada,Ltd.
MANUFACTURING i#iMlSTS   TO   111E   MEDICAB PROFESSION   SINCE   1858 VANCOUVER     HEALTH     DEPARTMENT
STATISTICS—JUNE, 1942
Total Population—estimated	
Japanese Population—estimated	
Chinese Population—estimated	
Hindu Population—estimated	
Total deaths	
Japanese deaths
272,352
8,760
8,558
360
Number
_   276
7
Chinese deaths      19
Deaths—residents only 232
BIRTH REGISTRATIONS
Male, 304; Female, 282	
INFANTILE MORTALITY
Deaths under one year of age	
Death rate—per 1,000 births	
Stillbirths (not included in above).
__   586
June, 1942
_     14
__     23.9
13
Rate per 1,000
Population
12.3
9.3
26.4
10.4
26.2     .
June, 1941
8
15.2
11
CASES OF COMMUNICABLE DISEASES REPORTED IN THE CITY
May, 1942 June,
Cases   Deaths    Cases
July 1-15,1942
Cases   Deaths
Scarlet Fever  62
Diphtheria j  2
Diphtheria Carrier  0
Chicken Pox  83
Measles  21
Rubella  24
Mumps  582
Whooping Cough  95
Typhoid Fever  0
Undulant Fever  0
Poliomyelitis  0
Tuberculosis __=  50
Erysipelas  l .  0
Meningococcus Meningitis  0
Varicellaform Dermatitis  2
<IT
V. D. CASES REPORTED TO PROVINCIAL BOARD OF HEALTH,
DIVISION OF VENEREAL DISEASE CONTROL
Month of May, 1942
Syphilis	
Gonorrhoea	
Burnaby
West
Vancr.
Richmond
North
Vancr.
Vane.
Clinic
Hospitals &
Private Drs.
Totals
A DYNAMIC MENTAL AND PHYSICAL TONIC
INDICATED IN THESE DAYS OF STRESS
ii  A  »»
BIOGLAN "A
Another Product of the Bioglan Laboratories, Hertford, England
Phone MA. 4027
Stanley N. Bayne, Representative
1432 MEDICAL-DENTAL BUILDING
Descriptive Literature on Request
THE SCIENTIFIC HORMONE TREATMENT
Vancouver, B. C.
Page 324 SICCOLAM I {
A fat-free desiccant paste for the treatment
of inflammatory conditions of the skin
The introduction of Siccolam is the culmination of a long series of
investigations/ and its dermatological value has been confirmed
by extensive clinical trial. The conclusion has been reached (Brit.
Journ. Dermat. & Syph., June, 1941, p. 177) that f. . . technical
properties render this preparation superior to the many lotions, such as
calamine, zinc oxide lotion, etc., so commonly used . . . for the same indications.3
Advantages of Siccolam—
1 Active in all inflammatory dermatoses
2 Absolutely innocuous     No contra-indications
to its use
Effects immediate adsorption of fluid exudate
Causes rapid relief of inflammation and pruritus
Active in both acute and chronic conditions
Can be used in conditions in which the use of
fatty preparations is contra-indicated
Simple and cleanly in use       Dries rapidly
3
4
5
6
Stocks of Siccolam are held by leading druggists throughout the Dominion,
and full particulars are obtainable from:
THE BRITISH DRUG HOUSES (CANADA) LTD.
Toronto Canada
 Sic/Can/4 2 8 MEASLES
Modification
»«
Prevention
In 1939 there were 197 deaths from measles in Canada.
More than 95 per cent of these were in the age-group 0-5
years.
Human serum prepared from the blood of healthy adults
so as to involve a pooling from a large number of persons
may be used effectively either for modification or prevention
of measles. Modification is often preferable in that it reduces
to a minimum the illness and hazards associated with measles,
but does not interfere with the acquiring of the active and
lasting immunity which is conferred by an attack of the
disease. On the other hand, complete prevention of an attack
of measles is frequently desirable, and can be accomplished
provided that an ample quantity of serum is administered
within five days of exposure to the disease.
For use in modification or prevention of measles, pooled
human serum is available from the Connaught Laboratories in
a concentrated form. While the recommended dose of this
pooled and concentrated human serum for purposes of prevention is ordinarily 10 cc, the most usual dose is for
purposes of modification and amounts to 5 cc. The serum is
therefore supplied in 5-cc. vials. Prices and information
relating to it will be supplied gladly upon request.
%
W
CONNAUGHT LABORATORIES
UNIVERSITY   OF  TORONTO
Toronto
Canada
DEPOT FOR BRITISH COLUMBIA
MACDONALD'S PRESCRIPTIONS LIMITED
MEDICAL-DENTAL BUILDING, VANCOUVER, B.C. tir;
<,
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1
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i .f-t <
'nte
^/K£6e> ate, the &a4>onA-~
'Au
wkuweA
CtM*
'^ S-MA
%
%
Physicians will find that S-M-A* is
not a "compromise formula!* It is a
complete milk formula for infants
deprived of human milk.
Cows' milk fat is replaced with the
unique S-M-A fat for easy digestion
and adequate nutrition. It compares
physically, chemically and biologically with the fat in human milk.
The carbohydrates in S-M-A and
human milk are identical.
With the exception of vitamin C,
the vitamins essential to normal
growth and development (Bi, D,
and A) are included in adequate
proportion in S-M-A ready to feed.
Furthermore, iron (so difficult to provide for the bottle-fed infant) is
induded in S-M-A. When prepared
each quart provides 10 mg. iron and
ammonium citrate.
* * * * *
Excellent results with hundreds of
thousands of infants is reason enough
why S-M-A is the choice of a steadily
increasing number of physicians.
Try S-M-A. Results tell the true story
more .aptly than words and pictures.
nn
•S-M-A, a trade mark of S.M.A.—Biochemical
Division, John Wyeth & Brother (Canada)
Limited, for its brand of food especially prepared for infant feeding—derived from tuberculin tested cow's milk, the -fat of which is replaced by animal and vegetable fats, including
biologically tested cod liver oil; with the addition of milk sugar and potassium chloride;
altogether forming an antirachitic food. When
diluted according to directions, it is essentially
similar to human milk in percentages of protein,
fat, carbohydrate and ash. in chemical constants
of the fat and physical properties.
S.M.A.—Biochemical Division   -   John Wyeth & Brother (Canada) Limited
WALKERVILLE   -   ONTARIO Some time ago, thanks to the courtesy of the B. C. Pharmaceutical Association, and
after many months of work by a Committee of the B. C. Medical Association, headed
by Dr. C. H. Vrooman, the B. C. Formulary was distributed to all members of the
profession throughout British Columbia. This was a forward step, we felt at the time,
and now are more than ever convinced of the value of this excellent little publication.
It is a book that one uses constantly: apart entirely from the purely pharmaceutical
side of it, it has many sections which are most useful to us every day. The sections on
Diet, Toxicology, Treatments, Quarantine Tables, and last but not least, the Social
Service Section, all are genuinely helpful and constantly referred to.
The Committee, however, feels that the time has come when they should get, and
would heartily welcome, comments and criticisms from the practising profession of B. C.
They want to know several things. First, if the book is really of value. Secondly, in
what ways it might be made more useful to doctors. They would welcome any criticism
that would enable them, in a revised and improved edition, to enhance the value of this
Formulary.
Many of us may feel that perhaps the list of prescriptions is too small: that many
tested and proven formulae have been omitted. The Committee would gladly hear of
these. Their original plan, and it seems to us a thoroughly wise one, was to start on a
small scale, and leave plenty of room for growth and enlargement as they saw along
what lines these should take place. So the book in its present form represents rather a
beginning, perhaps a skeleton, of what it may ultimately become. So you are asked to
sit down and write to the Committee on Pharmacy of the B. C. Medical Association
(Dr. C. H. Vrooman, Chairman, Vancouver, B.C.) and make your suggestions. They
will be gladly received and given due consideration.
Then the question arises: Would it be a good plan to introduce other sections, or
improve on those already there? For instance, the sections on Diets, Treatment, and so
on are excellent now—but possibly they could be enlarged. Perhaps a section on military
medicine, A.R.P. methods of dealing with poisonous gases, etc., might be of great value,
especially now.
But this is not the place to make suggestions: these should come from the man in
practice.    So fall to, gentlemen, and let the chips fall where they may.
. i!;l;'
'IK
In this issue, we print a short appeal from Dr. Neil M. McNeill, Medical Advisor to
Division K, Dept. of War Services, for the examination of men called up by the Draft.
We are very glad to be of use here, and would urge our readers to give careful heed to
what Dr. McNeill says. Apart from the trouble and work that we can save ourselves,
in these busy days, when we are all overworked, we can save time and trouble for the
Registrar's office: and this is our plain duty.
As Dr. McNeill points out, the mistakes made are generally errors of omission. The
doctor is in a bit of a hurry, and does not check over the form after he has filled it out.
It is like writing exams: one should go over one's work after it is done, and check carefully such things as seeing that every question is dealt with, one's name is on the paper,
and so on. The staff in the Divisional Registrar's office cannot fill these answers out for
you—and the form must be sent back for completion. Often the man's signature is
missing, and he has left town, even the province, and cannot be got hold of. Or questions are missed altogether. So it behooves us to take a little more care with this matter.
Dr. McNeill deals very courteously with us, and we should do all we can to help him out.
Page 325 Vi - ■ ■
»h
&
It:.II
HI
In this issue too we publish a short contribution on Ulcer Diets from the Department of Dietetics of the Vancouver General Hospital (Miss Ethel Pipes, R.N., Director).
The work in this case was carried out mainly by Miss Eileen Dunn, R.N., of Miss Pipes'
staff, and we think everyone will be grateful to Miss Dunn for this simplification and
improvement of the already excellent system of diets now in use at the V.G.H.
We understand that this is only the beginning of a series of short articles on diet,
from the same source, and we shall look forward eagerly to others.
Talking of the Vancouver General Hospital, we owe an apology to the Publications
Committee of that institution, for not displaying greater care in the treatment of their
material, which they so generously contribute each month. Some papers have been published without reference to the fact that they are part of the Vancouver General Hospital Section of the Bulletin, and so have lost some of their force by being taken out
of their setting.
We can only plead, as a partly extenuating circumstance, the fact that we have been
too busy for our own good, and have let things escape our watchful eye, or our eye
which should have been watchful. We shall try to be more careful in future. We are
very grateful to the V.G.H. for excellent material, well prepared and valuable, we
should like to feel that they are given all the consideration they deserve.
Last, but far from least, we should like to make a reference to the forthcoming
Summer School of the Vancouver Medical Association. We feel that the latter body, and
its Committee on this subject, are to be especially congratulated this year on the courage
and enterprise they have shewn. Their published programme is amazingly good, and it
deserves our heartiest support. It also promises to us the fullest value for the effort and
money it will cost us.
But the Committee has had a very bad time. Speakers are being rationed now, like
tea and coffee, and several men on whom the Committee had counted have been devoured
by "the grim wolf" of war's necessities. So their troubles are by no means ended. However, we feel that they will overcome them—we sincerely hope so at least—and we look
forward to a very good Summer School in September.
EXAMINATION OF RECRUITS
The Department of National War Services would like to again express their
thanks to all medical examiners in British Columbia for their splendid cooperation in perfonning this very essential work.
It is suggested however, that in order to save the time of the staff in the
local office, who are greatly over-worked, that special care be taken by the
doctors when filling in medical forms.
The recruit must be stripped for exarnination.
It is necessary that the recruit sign the medical form.
Fill in all the blank spaces. Be sure to categorize each one, and in
one place only.
Write as plainly as possible.    The doctor must sign the form.
If the above details are attended to carefully, much needless trouble will
be avoided. When mistakes occur in the medical form it must be sent back
to the doctor, who may not at the time, have the proper address of the recruit,
and therefore be unable to contact him.
If more medical forms are required for this work, please telephone MArine
5748, or write the Department of National War Services (Medical), 525
Seymour Street, Vancouver, B. C.
NEIL M. McNEILL, M.D.,
Medical Advisor,
National War Services.
Page 326 "m
NEWS    AND    NOTES
Flight-Lieut. W. C. Gibson of Victoria is a recent registrant in British Columbia,
serving with the R.C.A.F. at Regina.
Dr. W. H. Sutherland, Jr., son of Dr. W. H. Sutherland, is a recent graduate from
McGill, and has registered in British Columbia.
Dr. J. W. Whitelaw, a recent graduate from McGill ,son of Dr. W. A. Whitelaw,
is entering the R.C.A.F. Medical Services.
Major Murray Baird, who left with No. 16 General Hospital, suffered an illness in
Great Britain and made a good recovery.
Lieut.-Col. W. S. Baird is Officer Commanding of Victoria Military Hospital, formerly known as Esquimalt Military Hospital.
Dr. Harry Baker, formerly of Salmon Arm, is now in the R.C.A.M.C.
Lieut.-Col. Sidney G. Baldwin, O.C. of No. 12 Field Ambulance, has been in Great
Britain for some time and will soon be joined by his unit.
Col. Walter Bapty, for many years in Victoria, is now at Borden Camp in charge
of the depot there.
Headquarters of M.D. No. 11 is now located in the Vancouver Barracks. Those
attached to the D.M.O.'s office include: Lieut.-Col. Wallace Wilson, D.M.O., Major W.
A. Clarke, Lieut.-Col. R. L. Mailer and Major J. D. Hunter in charge of Medical Boards,
Major T. Miller and Capt. E. J. Curtis in charge of Hygiene.
Recent entries to the R.C.A.M.C. include: Doctors I. C. C. Tchaperoff, H. E. Hamer,
S. A. McFetridge, K H. Wray-Johnston, A. N. Beattie, J. Moscovich, B. Meth and D.
W. Moffatt.
Major W. M. Carr, who has been overseas doing Radiology, has returned to M.D.
No. 11.
The Principal Medical Officer of the Western Air Command is Wing-Commander
S. G. Chalk with headquarters in Belmont House, Victoria.
lie
No. 16 General Hospital of British Columbia has arrived in Great Britain, and
according to newspaper reports and from letters received the personnel is in excellent
condition.
The roster of officers included: Colonel G. C. Kenning, O.C; Lieut.-Col. W. A.
Fraser, Major M. McC. Baird, Major G. W. C. Bissett, Major E. H. W. Elkington, Major
C. J. Kirk, Major H. B. MacEwen, Major P. H. Malcolmson, Major D. B. Roxburgh,
Major R. Scott-Moncrieff, Capt. L. W. Bassett, Capt. H. H. Boucher, Capt. E. F. Chris-
topherson, Capt. J. A. Ganshorn, Capt. W. C. Jeanes, Q.M., Capt. N. G. M. Lougheed,
Paymaster, Capt. W. C. Mooney, Capt. R. A. Palmer, Capt. L. L. Ptak, Capt, R. J.
Wride, Lieut. G. A. Aaronson, Pharmacist.
Page 327
lilifi Drs. J. McNichol and Gordon Burke actually brought back some sizeable trout from
their recent fishing expedition.
Dr. F. D. Sinclair of Cloverdale is taking a short vacation before the summer is over.
Dr. S. Cameron MacEwen of New Westminster is receiving congratulations on the
occasion of his marriage to Miss Marjory Baker.
*r *f *£■ *c
Dr. B. D. Gillies had a week's fishing near Kamloops, and it was good.
Major Stewart Wallace of Nanaimo called at the office.   He had been back to Kamloops for a short visit and had some good fishing.
TIRES
When doctors are making application for TIRE REPLACEMENTS,
it is necessary to state the MILEAGE IN PROFESSIONAL WORK for
which tires are required.
Sincere sympathy is passed to Dr. A. W. Bagnall in the loss of his wife on July 15th.
Dr. Belle Holland Wilson, widow of the late Dr. T. A. Wilson, and mother of Dr.
P. M. Wilson, died on June 22nd. The sympathy of the profession is extended to Dr.
P. M. Wilson in his bereavement.
The profession was saddened when the news of the fate of P.O. G. F. Strong was
received on July 26th, while serving with the Air Force. Dr. and Mrs. Strong have
received many expressions of condolence from the members of the profession.
Dr. G. B. Helem of Port Alberni is back at work and made a good recovery from
a brief illness.
Drs. N. H. Jones, W. C. Pitts, B. T. H. Marteinsson, all of Port Alberni, went to
Qualicum for a short holiday spell during the past month.
"if* *r *r *C
Capt. W. H. White had a short visit at his home in Penticton recently.
Dr. Wilfrid Laishley of Nelson has been on vacation.
Dr. and Mrs. William Leonard of Trail have been to Kaslo and report the fishing
as good.
Dr. and Mrs. D. J. M. Crawford and their daughter Kay have returned to Trail from
a visit at Medicine Hat.
Dr. R. J. Paine has been appointed resident physician in Stewart.
Dr. D. J. Millar of North Vancouver reports good fishing in the Cariboo.
Dr. Dorothy Miller is now a Medical Officer with the R.C.A.M.C.   She was formerly
of North Vancouver, and more recently had an office in the Birks Building.
Page 328 Dr. J. J. Gibson of Prince Rupert is recuperating at Lake Kathlyn near Smithers.
Dr. J. W. Vosburgh of Princeton visited on the Coast.
Dr. G. K. MacNaughton of Cumberland visited the office on his way home from
Montreal. Dr. and Mrs. MacNaughton attended the wadding of their daughter in
Montreal.
jr
Dr. B. J. Hallowes of Port Renfrew had a week in Vancouver.
Dr. H. E. Cannon of Abbotsford is away on a short vacation.
LIBRARY NOTES
RECENT ACCESSIONS TO LIBRARY:
Henry Phipps Institute, 29th Annual Report, 1940-1941.  (For the study, treatment
and prevention of tuberculosis.)
Acta Radiologica—Cancer of the Corpus of the Uterus.    (Collected papers from King
Gustaf V's Stockholm Jubilee Clinic, 1941.)
Therapeutics, or The Art of Healing, 1817—Gift of Mrs. Wallace Wilson.
Blood Grouping Technic, 1942, by Fritz Schiff and William C. Boyd.    Gift of Inter-
science Publishers.
Treatment in General Practice, 4th ed., 1942, by Harry Beckman.
Carcinoma and Other Malignant Lesions of the Stomach, 1942, by Waltman Walters,
H. K. Gray and J. T. Priestley.
Manual of Standard Practice of Plastic and Maxillofacial Surgery, 1942, Published by
National Research Council and Representatives of the Medical Department, U. S.
Army.
Surgical Clinics of North America, Symposium on Operative Technic, Lahey Clinic
Number, June, 1942.
Four Treatises by Theophrastus Von Hohenheim, Called Paracelsus. Trans, from Original
German.  Edited by Henry Sigerist.   (Nicholson Collection.)
Stitt's Diagnosis, Prevention and Treatment of Tropical Diseases, 6th ed., 1942, 2 vols.,
by Richard P. Strong.
War Gases, by Morris B. Jacobs, 1942. Gift of Interscience Publishers.
STATE JOURNALS
The sample index of one of the State Journals received in the Library for this month
is for June, 1942, of California and State Medicine—
Intravenous Anaesthesia in the Field. By Jonathan M. Rigdon (M.C.), U.S.A., Fort Ord.
War-Time Problems in Industrial Health.  By Carl M. Peterson, Chicago.
Hallucinations: Their Mechanism and Significance. By James a Cutting, Agnew.
Endocrine Therapy: Potential Abuses in Gynaecologic Disorders.   By C. F. Fluhmann,
San Francisco.
Sulfonamide Medication.  By Lowell A. Rantz, San Francisco.
Intestino-Vesical Fistula.   By Roger W. Barnes and Malcolm R. Hill, Los Angeles.
Page 3'29 Ul
i.*i
:
Ml
: m
Vancouver Medical Association
SUMMER   SCHOOL
Hotel Vancouver—September 15th to 18th Inc.
1942
SPEAKERS
Dr. Walter C. Alvarez,
Professor of Medicine, The Mayor Clinic, Rochester, Minn.
Dr. W. Fulton Gillespie,
Professor of Surgery, University of Alberta, Edmonton, Alta.
Dr. John W. Scott,
Assistant    Professor of Clinical Medicine, University of Alberta,
Edmonton, Alta.
Dr. Donald V. Trueblood,
F.A.C.S., Seattle, Wash.
PROGRAMME
Tuesday, September 15 th—
9:00 a.m.—Registration.
10:00 a.m.—Dr. Alvarez: "Flints in the Diagnosis of Indigestion."
11:00 a.m.—Dr. Gillespie: "Treatment of Varicose Veins and Ulcers."
12:30 p.m.—LUNCHEON—Guest Speaker:  Dr. A. E. Archer, President, Canadian
Medical Association.
8:00 p.m.—Dr. Trueblood.  To be announced.
9:00 p.m.—Dr. Scott: "The Haemorrhagic Blood Diseases."
Wednesday, September 16th.—
9:00 a.m.—Dr. Trueblood. To be announced.
11:00 a.m.—Dr. Gillespie: "Modern Principles in Wound Treatment."
11:00 a.m.—Dr. Alvarez: "Puzzling Types of Abdominal Pain."
2:30 p.m.—Medical Clinic—Vancouver General Hospital.
8:00 p.m. ( Round Table Discussion on Gastro-Duodenal Lesions.
9:00 p.m.j Chairman: Dr. W. L. Graham.
Thursday, September 17th—
9:00 p.m.—Dr. Gillespie: "Diagnosis and Treatment of Intestinal Obstruction."
10:00 a.m.—Dr. Scott: "The Diagnosis and Treatment of Chronic Arthritis."
11:00 a.m.—Dr. Alvarez: "What is the Matter with the Patient who is Always Sickly?"
Afternoon     GOLF TOURNAMENT and DINNER.
and Evening The Golf Tournament will be held jointly with the Annual Tournament of
the Vancouver Doctors.
Friday, September 18 th—
9:00 a.m.—Dr. Scott: "The Sulphonamide Drugs in General Practice."
10:00 a.m.—Dr. Trueblood.  To be announced.
11:00 a.m.—Dr. Gillespie: "The Surgery of Empyema Thoracis."
2:30 p.m.—Surgical Clinic—St. Paul's Hospital.
8:00 p.m.—Dr. Alvarez: "The Handling of the Nervous Patient."
9:00 p.m.—Dr. Scott: "The Iron Deficiency Ansmias."
Page 330 T«
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Vancouver Hotel,
where Summer School,
Vancouver Medical
Association, will be held
September 15-18 inclusive.
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SUMMER SCHOOL DATE
The Summer School was postponed to September this year so as not to conflict with
the Annual Meetings of the Canadian Medical Association and the British Columbia
Medical Association, which were held at Jasper in June.
CHANGES IN PROGRAMME
Although there have been" numerous alterations in the programme, necessitated by
prior claims of National Service, the Committee is confident nevertheless that the programme outlined above will be of interest to the medical profession and that it will
receive their usual enthusiastic support.
It is regretted that Lt. Colonel Warner, whose name appeared on the original announcement as one of the speakers, has found it impossible to be present.
FEE—CORRECTION
We wish to direct attention to the fact that the fee has been maintained at $5.00
this year, in place of $6.00 as previously announced.
GUEST SPEAKER AT LUNCHEON
The Committee is happy to announce that Dr. A. E. Archer, President of the Canadian Medical Association, will be Guest Speaker at the luncheon to be held on the first
day of the Summer School. This luncheon is being held under the auspices of the British
Columbia Division of the Canadian Medical Association. ;3^
Page 331 ROUND TABLE DISCUSSION
A Round Table Discussion will be held on Wednesday evening, September 16th.
The subject chosen this year is "Gastro-Duodenal Lesions." The Chairman is Dr. W. L.
Graham, who will welcome any questions the members wish to put before the meeting.
GOLF
This year we are holding the Summer School Golf Tournament with the Annual
Tournament of the Vancouver Doctors. A feature of the latter tournament is the Rams
Horn Golf Trophy, presented by Dr. Daniel McLellan, for the Aggregate Low Net
Score of any two out of three scheduled games each year. Members of the College of
Physicians and Surgeons resident on the Mainland of British Columbia, south of Powell
River and west of Hope, both towns included, are eligible to compete. Other prizes will
be open for competition to all who attend the Summer School. A dinner will conclude
the tournaments.
FILMS
A number of interesting motion picture films will be presented during the Sessions.
The time of presentation and titles of these films will be posted at the Information Desk
of the Summer School.
TELEPHONE SERVICE
Private telephone service to the Summer School suite in the Hotel will be available
as usual .
MEDICAL MEN ON ACTIVE SERVICE
The Committee wishes to extend to all members of the medical profession on active
service a cordial invitation to attend the Summer School Session. Complimentary tickets
will be issued on registration.
<ti\
The following is published for the information of the Profession.
Department of National Defence—Army
To: All Medical Officers, Military District No. 11.
SALE OF INSTRUMENTS
1. The following is an extract of letter received from D.G.M.S. H.Q.  1980-5-3
(Meds) dated 2nd July, 1942.
"1. It is understood that there are many Doctors who have joined the Army and
some whom you may know in civilian life who have instruments for sale and
it is possible that some of these instruments could be put to use in the Medical
Service.
2. Kindly ascertain if such is the case. If so, a list, giving the name of the
article and condition, description and catalogue number, should be forwarded
to this Headquarters and price asked.
3. While they are not urgently required at the moment, it is intended to compile
a list in this office of the instruments available from the sources mentioned
above to be used if the purchase of the same on the open market becomes
critical."
2. If you desire to take any action as outlined in Para. 2 quoted above, please send
in to this Headquarters all particulars as requested.
Please Note: This announcement for the purchase of instruments is equally applicable
to doctors in civil life.
Communications should be addressed to the Office of the D.M.O., M.D. No. 11,
Vancouver, B. C.
Page 332 %
BURNS AND THEIR TREATMENT
Dr. W. A. Farmer
Delivered at Summer School of Vancouver Medical Association, 1940.
I should first like to express my appreciation for this opportunity to address you. It
is an honour as well as a very great pleasure to be asked to come west for this purpose.
It is my only hope that you will find these lectures instructive and entertaining.
The first discourse is on burns and their treatment. A burn is a type of wound
caused by thermal heat, electrical heat, chemical action or by radiant energy. Tonight,
those caused by thermal heat only will be discussed. These are accidents, chiefly of
childhood, and since 1932 all such cases have come under my care at The Hospital for
Sick Children. They are subdivided into: Scalds due to contact with hot liquids or
steam, and fire burns due to exposure to flame or molten metals. While scalds may cover
large surface areas they are not likely to be so deeply destructive, due to rapid cooling
of the fluid and the insulating effect of subcutaneous <fat. The fire burns are apt to be
more circumscribed but deeper as the subcutaneous fat catches fire.
These are chiefly preventable accidents. The scalds are chiefly from hot tea, hot
coffee, or allowing the child to fall into a tub of hot water during the spring or fall
cleaning. The fire burns are chiefly from playing with matches, gasoline burns or conflagrations. Previous to the advent of the motor car, this was the commonest cause of
accidental death in childhood. Even until very recent years, in the lower age brackets
(1 to 5 years), it remained the leader. Public education has been slow. One has only
to see one bad burn to realize that an addition to the death list might be preferred to the
terrible morbidity with final disfigurement. The medical profession has a duty: To
make the community "burn conscious."
Any discussion of burns is most easily undertaken by describing the clinical course of
a burn of a moderate amount. This immediately raises the question of what is a moderate amount. Articles are read occasionally stating that many cases involving 50% or
more of the body surface, were treated by some special method with 100% recovery.
It is immediately apparent that the estimation of area involved has been wrong, as such
large burns rarely recover. An easy, quick and accurate way to judge the percent of
surface affected, is to know that the head makes up about 6%—the trunk with the neck
about 38%—an upper extremity 9% (both 18%)—a lower extremity with the buttock
19% (both 38%), or, giving more details, a hand or foot about 2^4%—a leg 6%—
a thigh 9'%—an arm with the forearm 6l/z%. It thus immediately becomes apparent
that in his enthusiasm an observer may not realize that, though the whole trunk is
involved, front, back and sides, it is still considerably less than 50%.
A burn of moderate degree is one which affects 5 to 10% of the surface.
The clinical stages through which a patient with such a burn may pass are listed for
sake of convenience as: (1) primary shock, (2) toxaemia (sometimes called secondary
shock), (3) sepsis, (4) repair and (5) contracture.
(1) Primary shock following burns is no different than that following other accidents. Despite tremendous effort in recent years the problem of shock defies solution.
The term is unscientifically vague but is used to indicate a clinical state following injury,
manifested by (1) a decrease in blood pressure from a disproportion between the blood
volume and vascular bed (absolute or relative) and (2) acute circulatory collapse, lowered metabolism, increased concentration of blood and anoxemia. The terms primary
and secondary have been used to classify shock according to the lapse of time between
receipt of the injury and the onset of symptoms. The former develops immediately, is
probably neurogenic in origin, there being a fall in blood pressure with no decrease in
blood volume. The latter appears in one to several hours and a decided reduction in
blood volume accompanies the fall in blood pressure. Primary shock with burns is
present only in severe cases.    It is treated by rest ensured by sedatives  (morphine),
Page 333
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warmth, and the administration of intravenous fluids. In moderate cases, whole blood
seems sufficient, but in severe cases concentrated serum is used. In Canada this is put
up only by Connaught Laboratories. By them, after the cells are removed the serum is
concentrated three times and put up in sealed glass vials. The serum is typed and given
to "like" recipients. Practically no patients now die in this stage. In severe cases this
may merge with that following, which is called the (2) stage of secondary shock and
toxxmia. They are discussed together since they are probably due to the same causes
and their symptoms overlap.
The shock begins in 1 to 5 hours, as mentioned above, but the toxxmia is rarely
recognizable before 6 to 8 hours and, in moderate burns, not until about 24 hours.
Toxaemia is recognized by certain clinical observations: (1) Temperature reaction.
In a moderate burn this is about 100-101°. In more severe cases it ascends to 105-107°
and up. Some of our highest temperature reactions have been recorded in burns. Over
a period of days it gradually drops toward normal with no very sharp swings. (2)
Drowsiness which may go to to coma and death in severe cases. Before coma one observes localized twitchings. (3) Vomiting. This becomes continuous in severe cases
and finally has the appearance of coffee grounds. This is due to .petechial haemorrhage
in the mucosa of the upper part of the gastro-intestinal tract. Gross ulceration (Curling's ulcers) is very rare. (4) The urine is scanty and contains albumin, casts and
maybe blood. (5) The pulse is rapid and in severe cases feeble, with low blood pressure
and poor peripheral circulation.
As most burns die in this stage there must be some attempt at understanding of the
mechanism of its production in order to treat intelligently. Unhappily, despite much
research work, all who might be considered competent observers do not agree. From
experimental work done in conjunction with cases at our hospital, there is little doubt
in our minds that the constitutional phenomena are, partly at least, due to toxic agents
absorbed from the burned area. The exact nature of the poison has never been proved.
It has not been isolated. Autopsies following death in this stage show degenerative
changes of a toxic nature in the liver, kidneys, adrenals, heart, etc.
There is a great shift in the body fluids in a severe burn and some explain the symptoms on this. There results a decreased blood volume and diminished cardiac output.
The blood is concentrated, the red cells are increased in number and the haemoglobin may
become very high (150%). The leukocytes are increased (20,000). Blood chlorides
are reduced greatly in severe cases by retention of sodium chloride in the tissues.
There is another conception that infection is the cause of toxaemia of burns. Aldrick
is one of the protagonists of this idea. For my own part, I do not subscribe at all to
this notion. Large superficial burns can heal under a coating of tan after passing
through a severe toxaemia, with infection as we recognize it clinically not being recognizable. On the other hand, infection may be severe in the late stage with none of the
signs of toxaemia as we identify them being present.
The treatment of burns changed radically in 1925 due to work of Davidson of
Detroit. It was thought that if the toxaemia were due to absorption of toxins from the
burned surface, some coagulating substance applied there might delay and lessen its
appearance. Tannic acid was used for this purpose. At our hospital a 10% solution
is in employment. It does not make much difference whether this is 15% or 5%. It
is sprayed on every 20 minutes until a good tan is attained in 16 to 24 hours. Since the
advent of tannic acid many other coagulating agents have been tried—chromic acid,
ferrous, ferric chloride solutions, silver nitrate, etc. When the ferric and ferrous chloride
solutions were first used, it was thought that something definitely better than tannic
acid had at last been found. A series was run at our hospital. The area tanned in about
one hour with a thin, pliable coating. However, there is the danger of iron pigments
in the skin, leaving one open to criticism and possible suit for malpractice, especially if
on the face. A number of our cases have such pigment and others have not. Just what
is the determining factor was not found.   The iron solutions were discontinued.
Page 334 \>v*t
A method of hurrying the tanning process is to swab the area first with 10% silver
nitrate and then spray-with 10% tannic acid. This was not original with us but has
been routine at our hospital for some time. A firm covering is obtained in 2 hours.
This form of treatment was devised to delay or lessen absorption from the affected surface. It was also pointed out that it might limit the loss of fluids from the burn area.
There is still some division of opinion as to its value in accompUshing these aims (e.g.
diminishing toxic absorption, cUrninishing greatly fluid loss), but everybody agrees that
it forms a coating which protects the exposed nerve endings and thus relieves pain,
that a moist wound is converted into a dry one even though the tannic acid may possibly
destroy a few injured epithelial cells, and that it simplifies the after care.
The tannic acid must be made up freshly or it deteriorates into gallic acid. We have
used solutions which have stood for 10 days without apparent change. In order to
limit infection many antiseptics have been added to the solution—bichloride of mercury,
acriflavine, hexylresorcinol, etc. We do not use these due to failure to observe any difference in those cases where they have been employed. Our statistics will be given later
but I should like to remark here that the improved, present-day prognosis, in the stage of
toxaemia, is probably as much due to attention to other details (especially fluid intake
and attempts to aid the cardiovascular system) as to tannic acid.
It should also be mentioned here that while the tannic acid method of treatment is
routine with us except for occasional groups of cases, used to test new methods when
thought deserving, it is not in universal use. Because some observers believe the stage of
toxaemia to be due to early infection (Aldrich) dyes having bacteriostatic and bactericidal powers are used. Thus a mixture of brilliant green and acri-violet is applied by
spraying. It has definite disadvantages in that it is hard on the hospital linen, the tan
produced is very thin, and exudate will leak through it.
Others have advised the use of hypertonic saline baths or compresses. Ointments
and paraffin dressings may be used in very small burns in adults where the question of
toxaemia does not arise.
So far, methods designed to reduce toxaemia have been described and the use of the
tannic acid and silver nitrate method advised. In this stage is should also be remembered that vomiting is a feature, that there is a great change in the composition of the
blood, and that in severe cases there is a fall in blood pressure and a failure of peripheral
circulation. Thus, when a severe case enters hospital it is treated for shock, if any,
then the area is cleansed with benzene if there has been any greasy preparation applied
previously. This is followed by washing gently with soap and water, followed by swabs
of 10% silver nitrate and 10% tannic acid spray. A continuous intravenous of glucose
and saline is started immediately. The glucose is thought of value because of degenerative liver changes due to toxaemia. A planned amount of fluid (depending on the
size of the child) is run in daily. The blood pressure haemoglobin, red blood count
and urinalysis are followed closely. Falls in blood pressure are considered serious and are
controlled by the use of pitressin and cortin. This latter is obtained from the Connaught
Laboratories and used in large doses intravenously through the already established continuous intravenous apparatus. This is looked upon as a very important part of the
treatment. Small transfusions or concentrated serum or both are also used in this stage
with quite apparent benefit. While there is red cell loss by petechial haemorrhages in this
stage, it is probably not great and the haemoglobin does not drop due to concentration of
the blood.
Concerning the prognosis: It depends chiefly on the area burned, but to some extent
on the depth and such factors as position involved, and the age of the child. Any burn
beyond 15% of the surface is very serious and anything beyond 30% carries almost
100% mortality. The infant stands burns less well than the older child. It is our
impression that burns on the anterior surface of the body are more serious.
This finishes the discussion of the stage of secondary shock and toxaemia, or, as it is
generally called, simply the stage of toxaemia.
Page 33 5
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(3) Stage of sepsis. In order to appreciate this there must be some discussion concerning the depth of burn. Dupuytren classified burns according to depth in the following way: (1) Erythema; (2) vesication: the blisters being in the epidermis; (3)
destruction of epidermis leaving small islands of epithelial cells at the tops of papillae;
(4) destruction of the dermis; (5) destruction of skin and subcutaneous tissues; (6)
charring.
Healing following the first two degrees is very fast. That following the 3rd degree
is rapid from the cells left at the tips of papillae. In the 4th degree if the destruction
leaves some of the epithelial cells in the dermis about hair follicles, sebaceous and sudoriferous glands, healing is also fairly rapid (as in a Thiersch graft—2 to 3 weeks). When
all the derma is lost and in the deeper degrees there must be of course healing by epi-
thelialization from the sides of an ulcer. The dead tissue separates from the living as in
any gangrenous process by a line of demarcation with granulation tissue made up of
loops of capillary vessels and fibroblasts. This is accompanied by exudate from the
surface and inevitably organisms become associated with this. Thus, if an area is tanned,
heading in the superficial degrees of _>urn may be so fast that when the tan separates
in 10 days to 3 weeks there is complete epithelialization. On the other hand, in deeper
varieties the tan and dead tissue slough leaving an ulcer. If during this process there
is clinically a swinging type of fever and a purulent discharge the patient may be stated
to have entered the stage of sepsis. The organism most commonly found is a haemolytic
streptococcus. This may be of the scarlet fever type so that surgical scarlet fever may
result (10% of old cases). This, all our patients are given 10 cc. of scarlet fever antitoxin on admission to hospital. In this stage they are put on sulphanilamide or dagenan
as a precautionary measure. A multiplicity of organisms of course may be present. The
patient may die in this stage due to a septicaemia. Wet antiseptic (not aseptic—Hygeol)
dressings are instituted and the tannic acid coating if present is removed as quickly as
possible. Some prefer to give an anaesthetic and tear it off. This is not our practice as
it is usually quite adherent and this leads to considerable bleeding from a large area.
(4) One now enters the stage of repair and (5) contracture. These go on together.
The repair is ordinarily thought to be complete when the surface is epithelialized. The
contracture goes on for years due to change of young fibrous tissue cells into old and the
deposition of more intercellular substance. This scar epithelium is not skin and should
not be confused with it. There is an absence of hair follicles, sebaceous and sudoriferous
glands. The papillae are not present. The epidermis is thin and set on a thick fibrous
tissue. It rubs off easily. It is very subject to trauma and infection. It cracks and
scabs and is itchy.   Some even complain of an intense discomfort in it.
This stage canbe hastened and helped by plastic surgery. No more will be said concerning this now.   The slides and moving pictures will be self-explanatory.
■ *
H
Page 336 British  Columbia  Medical  Association
(Canadian Medical Association, British Columbia Division)
President 1 Dr. A.  H Spohn, Vancouver
First Vice-President Dr. P A. C. Cousland, Victoria
Second Vice-President Dr. H. McGregor, Penticton
Honorary Secretary-Treasurer Dr. G. O. Matthews, Vancouver
Immediate Past President Dr. C. H. Hankinson, Prince Rupert
Executive Secretary Dr. M. W. Thomas, Vancouver
fir
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COMMITTEE ON INDUSTRIAL MEDICINE
Dr. A. W. Bagnall has accepted the Chairmanship of the Committee on Industrial
Medicine in the British Columbia Medical Association, British Columbia Division of the
Canadian Medical Association.
The Canadian Medical Association has set up a Standing Committee, of which Dr.
Bagnall will be the member from British Columbia. Dr. J. Grant Cunningham of
Toronto is Chairman of the Central Committee.
The duties of these committees are laid down in the Constitution and By-laws of
the Canadian Medical Association:
1. To define the objectives, scope and methods of Industrial Medicine.
2. To determine what medical services now exist in industry, what need exists and
what facilities in personnel are available to meet it.
3. To consider and suggest what qualifications and training, undegraduate and postgraduate, are necessary for the physician, nurse and first aid worker in industry.
4. To assist in keeping the medical profession informed of developments in this field
>with a view to improving industrial health.
Those responsible for production in War Industries are impressed by the need for
the introduction of Modern Medicine in the form of Industrial Medicine as a valuable
aid towards increased production, greater efficiency, lessened absenteeism, improved conditions of work, supervision of health of workers, guidance in personal hygiene, safety
measures to lessen illness and accidents, helpful advice regarding living conditions, checking on causes of time-loss, examinations and supervision of workers, recognition and
control of occupational diseases, prevention of infections in accidents and as a cause of
illness, checking industrial environment, ventilation, lighting, sanitation, hazards, plant
cafeterias, co-operate with worker's own doctor and in general keeping workers at work
in the jobs they are best fitted to fill.
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The medical officer doing Industrial Medicine will not interfere with the practising
physician and surgeon. In the course of his duty, he will discover occupational and
also non-occupational diseases, which will be referred to the practitioner of the worker's
own choice. Where a worker is found to have ans arrested Tuberculosis or any other
condition which would affect the-nature of his employment, it will be part of the duty
of the medical supervisor to place him in a safe position in the industry. The worker
discovered with active Tuberculosis would have to be dealt with, with due regard to his
own welfare and the safety of others.
Industrial Medicine, while primarily designed to increase production and efficiency
in a plant, can be very helpful to the worker and allow of the freest co-operation with
his own doctor.   Industrial Medicine is not therapeutic medicine.
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COMMITTEE ON THE STUDY OF CANCER
[ THE KING CAN DO NO WRONG
Every, little while a case of far advanced cancer is presented to a physician for the
first time and he, in his helplessness, asks why the patient did not come to see the doctor
sooner. The reply is so frequently one indicating a lack of knowledge about cancer and
the doctor cries for more lay education on subject relevant to cancer, intimating that,
if the patient came early, the doctor would do his part. But is the patient always to
blame and the doctor beyond reproach?
Recently, a fifty-one-year-old woman died in a British Columbia city hospital from
secondary manifestations of cancer of the breast. Her husband is wrathful at the medical
profession as a whole and blames it for the death of his wife, clauning that she did her
part but that the doctors failed to do theirs. Perhaps the criticism is unjustified. Let the
reader decide.
Mr. and Mrs. A. and their lovely sixteen-year-old daughter lived up the British
Columbia coast in a rather inaccessible spot where they carried on a small logging operation. Mr. A. worked hard and Mrs. A. did likewise, cooking for the men, helping with
the books, and giving wise counsel on business matters. The daughter worked hard, too,
for the success of the organization and altogether it was a very close-knit family. One
day, however, Mrs. A. found a lump in her breast and immediately a family council was
held. They all had read popular articles discussing the signs of early cancer of the breast
and, being intelligent people, they decided to consult a physician without delay. Plans
were made and the difficult and time-consuming and expensive trip was made to the
nearest city and a physician of good repute and standing was consulted. Imagine their
joy, the three being together there in the doctor's office, when they were told the lump
was of no consequence. They were all very happy and returned to their home elated.
Soon after their return home, Mrs. A. re-read some of the original health articles,
advising that all lumps in the breast were suspicious and most had to be removed for
positive diagnosis. Doubt clouded the happy skies and a family council again was called.
It was decided that, although the doctor who had consulted was probably right, Mrs.
A was so precious to them that they would take no chances and a second opinion would
do no harm. So the journey was repeated and another honourable member of the profession gave verbal reassurance. Again the relief was great, but a week or so after, another
opinion was sought, "just to be sure."  Again verbal assurance was given.
Several weeks went by and although they had been told three times that the lump
was of no consequence, fear of losing one of the members of this happy family of good
Canadian citizns made them take the journey to the city once more. This time, they
were prepared to insist on removal of the lump to reassure themselves, if not the doctor.
A doctor was selected with the aid of a business firm whom they could trust, and the
physician consulted. Excision of the tumour for immediate pathological study, to be
followed by radical amputation of the breast, if the lesion proved malignant, was advised
and carried out.   The lesion was malignant and the axillary glands showed involvement.
Now, three years later, Mrs. A. died of secondaries. Mr. A. and the daughter are
heartbroken and bitter against the medical profession, realizing full well that invaluable
time was lost by the doctors who did not know or did not trouble to take seriously the
maxim "Biopsy early and safe a life."
Reader, what would you think if she were a dearly beloved relative of yours? Could
this type of thing happen in your practice?
MEDICAL OFFICERS NOW SERVING WITH THE NAVY
Surgeon-Lieut. Commander F. P. McNamee, formerly Kamloops.
Surgeon-Lieut. Commander W. M. Paton, formerly Vancouver.
Surgeon-Lieut. W. S. Archibald, son of Dr. M. G. Archibald of Kamloops.
Surgeon-Lieut. H. G. Baker, formerly of Metropolitan Health Board, Vancouver.
Page 338 Surgeon-Lieut. R. E. Burns, of Trail, previously an interne at V.G.H.
Surgeon-Lieut. W. J. Elliot, son of Dr. Robert Elliot, Parksville.
Surgeon-Lieut. H. G. Farish, son of Dr. J. C. Farish, Vancouver.
Surgeon-Lieut. J. W. Frost, son of Dr. A. C. Frost, Vancouver.
Surgeon-Lieut. A. Marshall, formerly at Tranquille Sanatorium.
Sturgeon-Lieut. R. D. Millar (son of Dr. W. J. S. Millar), formerly in practice in
Vancouver.
Surgeon-Lieut. A. C. McCurrach, formerly of Kamloops.
Surgeon-Lieut. M. McRitchie, formerly of Fernie, now serving in Mediterranean.
Surgeon-Lieut. D. M. Whitelaw, son of Dr. W. A. Whitelaw, Vancouver.
Surgeon Lieut. E. W. Wylde, of New Westminster.
Others from British Columbia include:
Surgeon-Lieut. Commander H. R. Ruttan of Victoria.
Surgeon-Lieut. S. F. Blundell of Victoria.
Surgeon-Lieut. N. C. Olivers of Vancouver.
Surgeon-Lieut. W. D. Love of Penticton.
Dr. J. W. Arbuckle, son of Dr. J. W. Arbuckle of Vancouver, has recently graduated and is entering the Naval Services.
FRASER VALLEY MEDICAL SOCIETY
ANNUAL ELECTIONS
The Annual Dinner of the Fraser Valley Medical Society was held at the Westminster
Club on May 20th, 1942.
The members of the Society turned out in force, and in addition there were several
guests present: Dr. Roger Anderson of Seattle, the guest speaker; Captain Turner of the
Kent Regiment, Dr. J. R. Naden of Vancouver, Dr. Chambers of the local dental society
and Mr. Rick Foote, the well known pianist.
The Society was singularly fortunate in having Dr. Anderson as guest speaker. Dr.
Anderson gave a very excellent address on "Reduction and Treatment of Compound
Fractures." He also showed numerous slides, a motion picture, and numerous instruments for the reduction and fixation of fractures. These were all of his own design.
After the address by Dr. Anderson, a general discussion took place, led by Dr. Naden.
Dr. Bowles thanked Dr. Anderson on behalf of the Society.
Dr. Lawson, the singer of the Society, accompanied by Mr. Rick Foote at the piano,
sang numerous songs, to the. great enjoyment of everyone.
At a late hour the meeting adjourned.
The officers for the year 1942-43 were elected at a special meeting on June 8th.
The following were placed in office: President, Dr. R. E. Mitchell; Vice-President, Dr.
J. T. Lawson; Secretary-Treasurer, Dr. E. K. Hough.
JOURNAL OF C.M.A. FOR MEDICAL OFFICERS
The Canadian Medical Association has a special low rate to the Journal for
all Medical Officers on Active Service. The rate is $4.00, which entitles the
Officer to receive the Journal for one year.
This may be sent direct or to the office of the College of Physicians and
Surgeons of British Columbia, 203 Medical Dental Bldg., Vancouver, B.C. It
has been arranged that all membership fees as from British Columbia will be
received by the office and transmitted to the Canadian Medical Association.
Page 339 V
ancouver
G
enerai
Hospita
DEPARTMENT OF DIETETICS
Eileen J. M. Dunn, R.N.
The following diets are recently revised outlines of five of the therapeutic diets used
in the Vancouver General Hospital. In making the revision two important principles
were given emphasis: firstly, that a therapeutic diet should vary as little as possible from
the normal adequate diet, and secondly, that it should be sufficiently detailed and explicit
to be easily understood and adaptable to any income.
Verbal explanations accompany the printed instructions and the patient is encouraged to plan his diet using the family menu as a basis.
Diet for Patients with Peptic Ulcer
* First Week:
1st, 2nd and 3rd days:
Milk and cream—x/z cup every hour from
7 a.m. to 9 p.m. (Use half whole pasteurized milk and half table cream.)
4th, 5th, 6th and 7th days:
Milk and cream—l/z cup every hour from
7 a.m. to 9 p.m.
Well cooked cream of wheat—J4 cup at
8 a.m., 11 a.m., 2 p.m. and 6 p.m.
Second Week:
Breakfast:  Cream of wheat or strained
oatmeal—l/i cup, with milk or cream.
Sugar—if desired.
Milk—1 cup.
Weak milky tea—if desired.
Mid-Morning: Milk^-1 cup. Once, twice
or three times during the morning as
required.
Dinner: Cream of vegetable soup—l/z
cup (made with cooked strained (pureed) peas or string beans or potato or
carrot or tomato).
Crackers—2; OR dry white toast—1
slice, with butter.
Milk pudding—(Use custard, junket, rice,
tapioca, sago, or cornstarch pudding).
Milk—1 cup.
Mid-Afternoon: Milk—1 cup. Once,
twice or three times during the afternoon as required.
Page 340
Supper:  Poached egg—1,  on dry white
toast moistened with hot milk.
Well cooked strained  (pureed)  prunes
—1/2 cup; OR jelly—]/2 cup.
Evening: Milk—1 cup. Once, twice or
three times during the evening as required.
One cup should be taken just before retiring.
Notes:
1. The success of this diet depends upon
two principles:
(a) small frequent feedings;
(b) use   of   smooth   finely   divided,
non-irritating foods.
Milk should be taken at least once between meals, and as often as once
every hour, if necessary. A covered
glass of milk should be at the bedside
for use during the night,-if necessary.
2. To strain (puree) foods, cook until
tender, drain, then press through a
sieve until only tough fibres remain.
Use only the smooth portion that has
passed through the sieve.
3. NO smoking is permitted with this
diet.
Third Week:
15th, 16th, 17th and 18th days:
Breakfast—Cream of wheat or strained
oatmeal—J4 cup, with milk and sugar
if desired.
Poached egg—1, on dry white toast with
butter.
__L Milk—1 cup.
Weak milky tea—if desired.
Mid-Morning: Milk—1 to 2 cups, as required.
Dinner:   Cream   of   vegetable   soup^J/_
cup.
Mashed or baked potato with butter.
Crackers—2;  OR dry white toast with
butter.
Milk—1 cup.
Mid-Afternoon: Milk—1 to 2 cups, as required.
Supper: Poached egg—1.
Cooked strained (pureed) vegetable—J/_
cup (Use pureed peas or string beans or
carrots or young beets or squash or
marrow or parsnips).
Dry white toast—1 to 2 slices with butter.
Jello or strained (pureed) prunes or applesauce or canned pears or canned
peaches.
Milk—1 cup.
Arrowroots—if desired.
Before retiring: Milk—1 to 2 cups, as required.
19th, 20th and 21st days:
Breakfast: Same.
Mid-Morning: Same.
Dinner: Add: Flaked steamed whitefish in
milk sauce, OR
Boiled scraped beef pattie (with spoon
scrape raw beef and shape meat collected into a ball.  Cook without fat.)
Add: Strained (pureed) vegetable from
list allowed.
Mid-Afternoon: Same.
Supper: Egg—soft cooked in any form
without extra fat. (Use poached, coddled, scrambled, foamy omelette,
souffle, or cooked in shell).
Add: Potato—mashed or baked, if de-
sider.
Before retiring: Same.
Fourth Week:
Beverages: Milk, eggnogs, hot water with
cream or weak milky tea with cream,
malted milk, cocoa, milk shakes.
Avoid: Alcohol, coffee, strong tea, very
hot or very cold fluids, and carbonated
drinks.
Cereals: Cream of wheat, rolled oats or
fine oatmeal, cornflakes, puffed rice,
rice krispies, puffed wheat.
Breads:   Stale white bread,  white  toast,
rusks, or hard rolls, soda crackers, arrowroot biscuits, graham wafers.
Avoid: Muffins, hot biscuits and brown
breads, waffles, griddlecakes.
Soups: Milk and cream soups, made with
strained vegetables allowed.
Avoid: Canned soups and soups made
with meat stock.
Meats and Fish: Scraped beef, minced
lamb, beef and liver, chicken, sweetbreads, halibut, haddock, fine cod, or
tripe or oysters cooked in milk.
Avoid: Fried meats, fish, pork (except
liver), veal, tongue, salmon, smoked,
canned or salted meats and fish, shellfish, and meat loaf, sausages, bologna.
Vegetables: Potatoes in all forms except
fried. Strained (pureed) peas, string
beans, beets, carrots, parsnips, squash,
marrow. Take 2 vegetables plus potatoes daily. (Strained tomatoes may be
used only in soup.)
Avoid: Salads, and all vegetables not
included in the above list.
Fruits: Fruit juice, strained (pureed
prunes, strained applesauce, baked apple
without skin or seeds), canned peaches,
pears, apricots or white cherries, or
ripe bananas.
Avoid: All seedy fruits, grapefruit juice
and all raw fruits except orange juice,
bananas.
Desserts: Custard, junket, rice pudding,
sago, tapioca, bread pudding, cornstarch pudding, jello, strained fruits
folded into egg whites, vanilla ice
cream, sponge cake.
Avoid'. Pies, rich puddings, cakes and
fruit or nut cookies.
Eggs: In any form—except fried or hard
cooked.
Butter: Include generous amounts.
Honey and Jelly: May be used in moderation.
Avoid: Seasoned gravies, spices, relishes,
pickles, sauces, jams,  marmalade, and
Page 341 A'
H
.
cheese of all kinds except cottage cheese
and mild Canadian or American cheese.
Note:   Take  milk  with  meals,  between
meals and at bedtime.
Breakfast:
Fourth Week:
Sample Menu
Fruit juice or strained fruit—
from list allowed.
Cereal from list allowed with
milk or cream.
Soft cooked egg.
White toast with butter.
Milk—1 glass.
Weak milky tea.
10 a.m.:
Milk—1 glass.
Dinner:
Meat or fish from list allowed.
Strained vegetable.
Mashed potatoes.
White bread with butter.
Milk pudding.
Milk—1 glass.
p.m.
Supper:
Milk—1 glass.
Cream of vegetable soup.
Soft cooked egg or creamed whitefish
or cottage cheese or meat from
list allowed.
Strained vegetable.
Potato—if desired.
White bread with butter.
Strained fruit.
Milk—1 glass.
9 p.m.:
Milk—1 glass.
THE PREVENTION OF HEMORRHAGIC DISEASE
OF THE NEWBORN WITH VITAMIN K
G. O. Mathews, M.D.
1. It has been shown and confirmed repeatedly that haemorrhagic disease of the
newborn occurs because of an exaggeration of the hypo-thrombinemia, which normally
occurs to some extent in the first few days of life.
2. 2-Methyl-l 4-Naphthoquinone has been demonstrated to have remarkable
vitamin K activity and has been largely used by all workers. This is a synthetic preparation known as Vitamin K analogue and called Proklot by Lilly, Kavitan by Ayerst,
Synkamin by Parke, Davis & Company, and Klotogen by Abbott.
3. It has also been shown by all workers that vitamin K if given to mothers antepartum or to infants in their first few days of life, either orally, intramuscularly or intravenously, will increase the prothrombin level to normal or above normal. This is measurable directly by the prothrombin clotting time in seconds or minutes or as a percentage
of the adult normal. This valuable test is now done by micro-method using only a few
drops of blood.
4. Lawson and Hill give the following prothrombin times as the normal in infants:
Birth and for the first twelve hours—Prothrombin time 15-30 sees.
2-3 days—Prothrombin time 65-75 sees.
6-8 days returns to Prothrombin time 15-30 sees.
Anything above even 75 seconds is considered to indicate a potential bleeder.  Premature
babies show always a relatively higher prothrombin time and should all be considered
potential bleeders.
5. Lawson and Hill have shown that 20 c.c. of whole maternal blood given at birth
did not affect the normal curve, as given in 4.
6. One milligram vitamin K analogue given intramuscularly immediately after birth
in all cases kept prothrombin time level at 25 sees, or less continually to tenth day.
Page 342 7. Two milligrams given orally five to twelve hours before delivery kept babies'
prothrombin below 45, but 4 mgm. kept the prothrombin times below 25 in all cases
// given at least five hours before delivery.
8. In hemorrhagic disease cases, prothrombin times of as much as six to fourteen
minutes were decreased to fifteen to thirty seconds, within two to four hours, by 1 mgm.
vitamin K analogue orally.
9. Bile salts are unnecessary either to mother or baby, providing there is no biliary
obstruction, e.g. no jaundice.
10. Oral adrninistration gives much more rapid absorption than the intramuscular
route.   The intramuscular injection method gives a more prolonged action.
11. There are few difficulties in the oral adrninistration. With simple gelatin capsules for adults or for infants the drug may readily be dissolved in sesame oil or in
water-glucose, water or milk.  There is little if any nausea.
Conclusions: To prevent hemorrhagic disease in the newborn, vitamin K can be
given with the same effect directly to the infant at birth, or to the nursing mother before
and after delivery for six days. It should be given in small dosage to mothers for ten
days before delivery or one big dose at least five hours before delivery.
Suggestions for Routine:
Mothers: 1. One milligram orally to mothers for ten days prior to delivery, or at
least 4 mgm. orally given at least five hours before delivery, followed by 1 mgm. orally
for the first six days post-partum if baby is nursing.
Babies: Normal full-term seven pounds or more: 2. One milligram orally to babies
daily for six days or 5 mgm. intramuscularly to babies at birth (l/2 c.c. Kavitan intramuscularly) .
3. Prematures, or after abnormal labours, 1 mgm. orally for six days and 5 mgm.
at birth, or 5 mgm. intramuscularly at birth and 5 mgm. intramuscularly on third day.
These dosages are all higher than considered necessary but even extreme over-dosage
is quite harmless.
Hemorrhagic disease of the newborn is, like diphtheria and smallpox, now entirely
preventable. The routine use of vitamin K as indicated here will drop its incidence to
nil, and the tragedy of the normal baby at birth which, due to hemorrhagic disease in
its first week, is turned into an idiot and a charge on the state for life will be a thing
entirely of the past.
To overcome any possible confusion resulting from the difference in strength of the
many preparations I have given all dosages in milligrams. The more common trade
names, their makers and strength are as follows:
For Oral Use
Parke, Davis & Co Synkamin—1 capsule or 1 c.c. liquid 2 mgms.
Ayerst  Kavitan—1 capsule, 1 c.c. liquid 1 mgm.
Lilly Proklot—1 capsule, 1 c.c. liquid 1 mgm.
Proklot—1 tablet soluble 1 mgm.
Abbott Klotogen—1 capsule, 1 c.c. liquid 1 mgm.
For Intramuscular or Intravenous Use.
Parke, Davis & Co Synkamin—1 ampoule—1 c.c 1 mgm.
Lilly Proklot—1 ampoule—1 c.c 1 mgm.
Ayerst __Kavitan—1 ampoule—1 c.c. 10 mgm.
Page 343 I
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V.
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ii
.
NEURO-CIRCULATORY ASTHENIA
Geo. A. Davidson
The syndrome of Neuro-Circulatory Asthenia (Soldier's Irritable Heart, D.A.H.,
Effort Syndrome, etc.) was first described by DaCosta in 1871. White1 remarks that
"it is not established as yet primarily as a psychoneurosis although such is at least a
common complication. A cardiac or other neurosis may be present with none of the
evidence of neuro-circulatory asthenia which is clinically a symptom complex resulting
chiefly from fatigue and consisting of various combinations of palpitations, heartache,
dyspnoea (often sighing), faintness, easy fatigability, increased perspiration, tremor and
nervousness in whole or in part."
The three cases reported may not be regarded as typically neuro-circulatory asthenia
but they show definite evidence of disturbance of the cardiac rate with various other
combinations of symptoms.
I do not recall having seen a case that might fit into the classification of neurocirculatory asthenia in which evidence of anxiety and instabUity of the personality could
not be demonstrated.
In this group no particular stress is being placed on the psychiatric picture but each
case is described for its particular interest, and it will be noted that in no instance was
rest recommended but rather the patients were encouraged to exercise and in none were
symptoms aggravated. On the contrary the symptoms improved, and while this may
not have resulted from the exercise, it is felt that the exercise did tend to decrease the
tension and gave the patient something more to consider than his symptoms.
Lewis2 says: "These patients are unusually sensitive and among them is an excess of
abstainers from alcohol or inimoderate smoking." Culpin3 remarks that this suggests
(what is familiar to some of us) that cardiac symptoms tend to arise in the over-scrupulous, anxious men who in time of stress are liable to develop anxiety or obsessional
troubles rather than a simpler conversion hysteria.
Case I—H. G., Age 24.
This patient was under observation for almost two years. She was first seen in the
Outpatient Department on May 29, 1940, with the following complaints:
1. Loss of weight—25 pounds in six months.    2. Backache.    3. Anorexia.    4. Indigestion.    5. Constipation.    6. Lassitude.
Still later she complained of weakness, severe sweating, heat intolerance and backache. At that time the skin was moist, clammy and cold. There were marked tremors
to the outstretched fingers. The thyroid was slightly enlarged, the blood pressure 120/90.
She was unchanged at the time of discharge from the Outpatient Department.
She dated her trouble from June, 1939, at which time there was a broken-off love
affair of eighteen months' duration.
She was admitted as an in-patient on June 20, 1940, and remained for about five
weeks. She was readmitted September 12, 1940, and remained almost three months.
At that time she was sent to one of the city nursing homes jand has been seen in my
office or at the nursing home at intervals since. For the greater part of that time there
seemed to be little change in her condition.
She was twice presented to the Neuropsychiatric Ward Rounds and once to the General Ward Rounds but during most of this time her condition remained almost stationary; that is, she constantly ran a rapid pulse rate, her skin was cold, clammy and moist;
she perspired very freely and had many complaints.
Her weight varied from 90 to 99Y^. Her basal metabolism rate was done on several
occasions and was reported at different times as 16 above, 3 below, 25 above, 17 above.
The urine on occasions showed albumen. The sedimentation rate was 0/1. A galactose tolerance test was done which showed 26 mgm. galactose per 100 c.c. in 30 minutes
and 26 mgm. in 60 minutes.
Page 344 The blood cholesterol was 168 mgm. The chest x-ray was negative. The blood Kahn
was negative. The stool showed no parasites. The blood sugar was 90 mgm. per 100 c.c.
The blood calcium was 11.48 mgm. per 100 c.c. The blood chloride was 4.25 mgm.
per 100 c.c.
She continued to perspire very profusely and salivated profusely. She was tried on
thyroid at one time, and Lugol's solution at another time. Belladonna was used to control the salivation. It was the opinion of some that she might be suffering from a
chronic encephalitis.
She was tried on increasing exercises and stayed at these and performed them well
without too much variation in her pulse rate or in her general condition.
When seen in the office from December 30, 1941, on, the pulse continued to run
from 120 to 132.  The weight was usually around 95 pounds.   It was difficult to get the
blood pressure but it was somewhat low—106, with an indefinite diastolic reading.   This
was found to be so on several different occasions.   Her complaints continued to be
numerous.
On November 24, 1941, she visited my office and said that she had been working six hours daily for about one week. After a long period on relief she was earning
$15.00 per month with two meals per day. She liked the place. She still had complaints of being very tired, of having some backache, some headache, but her weight
had increased by a pound, and her pulse rate was 102. She was advised to continue work.
She was seen two months later, January 28, 1942, and was still working, although
she had various complaints. She liked her place quite well. Her weight had increased
to 112 pounds. The pulse rate for the first time in the two years that I had seen her
had now fallen to 72 and the blood pressure was recorded at 114/68. This was a gain
of 22 pounds from her lowest weight. Her skin was considerably warmer. Her palms
were dry for the first time on record and she looked very much better than at any time
that I had seen her.
Case II—M. W., Male, Age 21, Single.
This patient was first seen in March, 1937, at which time he had not worked for
about six months.   He did not live in the city so was not seen again for almost two years.
His complaints when first seen in 1937 were:
1. Heart—a sensation as if sticking, irregular, feels as if he will "pass out." This is
succeeded by palpitation which lasts about one minute. There is a.heavy, weakening
feeling following this.
2. Stomach—Gas on arising, belching every day in the morning. This lasts for two
hours but there is no pain associated.
The duration of these eomplaints had been two years.
The family history showed that the father had been alcoholic when the boy was young.
The mother was given to worrying a lot about the patient. There is one brother three
years is senior who is doing well in his work.
The personal history showed that he was a bed-wetter until six years of age. He
had always bitten his nails. He frequently expressed the opinion that he thought his
whole trouble was that he was too industrious and that he had worked too hard. He
smoked about fifteen cigarettes a day and at one time spent a lot of time "playing" the
race horses and actually at times expressed the opinion that his anxiety over the races
may have been related to his condition.
He had a poor daily routine. He got up about seven, had his breakfast, spent most
of the morning studying the racing lists, read a little and if the sun was shining he
would go out and sit in the sunf
His first job he held was helping a man with horses. He left because his mother
felt he was working too hard. He then started farming with his brother and worked
from 4 a.m. until dark.   His nervousness started at this time.   He did not like his work.
Physically he showed dilated pupils and moderate generalized tremors. The thyroid
was not enlarged.    Incidentally, he had been referred to consider thyroidectomy.
Page 345 His pulse rate was 140, 164 after exercise, and at the end of one minute 124, that
is, lower than the original rate.    His blood pressure was 164/84.
This was all at the time of the first examination in March, 1937. He then did nothing for two years at which time he came to Vancouver. In February, 1939, he complained of:
1. Gas in the stomach.
2. Difficulty in breathing.
3. Constipation with the taking of enemas every other day.
He had been from his original doctor to a chiropractor, and thence to another doctor. He admitted that he was in a rut and had got used to it. He suggested that the
trouble may have started with masturbation. He protested that the routine that he
was put on would not solve his problem. He voluntarily stated that he had to stand
on his own feet, that he believed that his parents had been babying him along. The
pulse rate on this occasion was 124.
He was seen every few days and complained that there was no use of his getting on
his feet as he had nothing for which to work. He admitted that he was loafing on his
father and made the significant remark "To tell you the truth, I pack more weight
around the house than my brother" (that is because of sickness).
He started doing some breathing exercises and some calisthenics. He began to eat
heavier food. His bowels moved naturally. He at this time expressed the opinion that
he was sensitive because one part of his chest was underdeveloped. Incidentally, his
brother of whom he was quite envious was described as being "barrel chested." The
patient remarked that his chest was robbing him of his courage.
At the end of the week from being up only four to five hours a day he was staying
up as long as eleven hours a day. He still talked of lacking "nerve force." During this
period his pulse was recorded- as being between 124 and 96, the blood pressure! 144/86.
At the end of two weeks he went to town twice in one day and began to talk of getting
work. At the end of three weeks he reported that he had walked seven and a half miles
that day and his pulse rate was 96. For the next couple of weeks he continued to walk
from six to seven miles daily and developed a noticeably better attitude.
The mother was written to and advised against continuing the overprotective attitude
that she had shown.
Four months after the boy's return home a letter was received from his mother in
which she talked of her son's return to normal and said that he ate and slept well. He
went to the golf club daily as a caddy and although he did not always get a job she said
that he met people and talked with them and she thought that this was doing him a
lot of good.
A letter was received on February 16, 1942, from his mother and she reported that
he is still somewhat nervous, uncertain about what he wants to do but said that he had
been in the army for one year. He had been sent to Debert but had not flbeen given
category A. As his company was leaving for England he demanded category A or complete exemption. He was then given category A but the day before sailing he went
A.W.L. for the second time. This was somewhere around Christmas time and the mother
has not seen or heard of the boy since. Certainly the history suggests an instability with
feelings of insecurity.
Case III—R. C, Male, Age 30, Single.
He had not worked for twenty-two months and for the past five years had gone to
bed each night at 9 o'clock.
The family history suggested that there was a mother fixation. The patient did not
get along well with his only sister or with his father.
His complaints were:
1. "The old pump," that is, "an odd feeling about the heart as if it were hanging
on a string."
2. "Use of bromides for years and years."
Page 346 ii!*?!
3. Exaggerated reflexes."
4. "Cold waves across the stomach."
.     Jumpy.
6.   "A feeling of something in the region of the appendix."
He was taking phenobarbital and as much as 9 grains of nembutal nightly.
He had had his thyroid removed five years ago, probably because of the tremors.
His heart rate was 92 to 100.   After ten toe-touches the rate returned to 90 in one
minute.
He blamed his condition on doing night work which he disliked and which produced
sleeplessness and tremors. He thought also that his sexual difficulty may have produced
considerable anxiety.
The personal history showed some interesting points. At the age of eight he was
nearly drowned and feared the water for long afterwards. At fourteen years he had to
have a seat in the school near the window to relieve "air insufficiency." At that time he
was panicky when in a crowd.
He was first seen in Victoria and in September, 1937, wrote a letter asking to come
over and wishing to make arrangements for a private room and insisting that he must
have absolute quietness after 10 p.m. He asked to be met at the freight deck to lessen
the distance that he had to walk so that it would be easier on "the old pump." He
pointed out that after I had seen him at his home he had had to remain in bed—strictly
in bed—for two days. At the moment of writing he said that he had been confined to
bed for two days because he "overdid it." However, he was getting up from five to
eight hours daily but resting in the middle of the period. "If I refuse to heed the warnings of my fool pump—a case of jitters will appear."
He was first seen in-August, 1937, and he came to Vancouver in October, 1937.
Possibly I was too abrupt in dealing with him for he did not remain long here and decided
that he would go home. However, he appeared to gain something from the change and
in December, 1937, he reported that he had definitely improved since returning home.
He was spending fourteen to fifteen hours continuously out of bed. He was visiting
the swimming pool. He had played badminton a few times and had been to a few
shows—the first in three years. He was last heard of in November, 1938. As far as
could be made out from his letter he appeared to be getting along satisfactorily. He
was written to a short time ago but so far there has been no response to that enquiry so
that an up-to-date report is not available.
1 ■Til'
w
Conclusions:
Three cases are presented in which cardiac signs or symptoms were the principal
complaint.
One of these showed a very marked change in symptoms and signs while the other
two showed a definite change in attitude with improvement in routine.
In this type of case it is felt that rest should not be stressed but rather that they
should be encouraged to lead a more active life.
REFERENCES:
1. White, PaulD.: J.A.M.A., Vol. 118, No. 4  (Jan. 24 1942), p. 270.
2. Lewis, T.: M. R. C. Special reports No.  8   (1918), quoted by Culpin in "The Neuroses in War,"
edited by Emanuel Miller (MacMillan 1940).
3. Culpin, Millais: ibid p.  52.
Page 347
..'-• ::i HYPOSPADIAS
L. R. Williams, M.D.
It is with trepidation that one brings to your attention apparently so small a matter
as hypospadias, yet it is of interest that for a good many years it has been a challenge
to the ingenuity and patience of the surgeon. Etiologically, it is still imperfectly understood, although it is an arrested development and a swing towards a hermaphroditic
manifestation likely associated with dysfunction of the glands of internal secretion, the
sex glands, the adrenal cortex and pituitary being most likely involved. There are malformations which frequently co-exist such as cryptorchidism, testicular atrophy, cleft
scrotum, etc.
Pathological Changes
In the male, with whom we are most concerned, hypospadias is limited to the anterior
urethra, the posterior urethra and sphincters being intact, and the anterior urethra being
arrested at almost any stage of its development. To be as simple as possible and not
too embroiled in embryology: the foetus at an early stage, approximately two months,
presents a phallus which is developed from the genital tubercle with a groove down its
midline, opening at its base into the uro-genital sinus. This is a primitive orifice which
becomes the urethral orifice. On the lateral surfaces of this groove and orifice are, first,
urethral folds and, still further laterally, labial scrotal eminences. The latter with farther
development grow caudally and later fuse in the midline to produce the scrotum. The
phallus increases in size and as it grows the aforementioned urethral folds, which bound
the primitive uro-genital opening, fuse from behind forwards, fonning the perineal
raphe and the raphe of the penis, and carry the primitive urethral orifice to the top of
the penis. Arrested development leaves this orifice somewhere down the shaft of the
penis and so produces the various types of hypospadias, named according to its site,
either glandar, penile, peno-scrotal, or perineal. That portion of the urethral folds
which does not fuse and represents the undeveloped part of the urethra partially atrophies
and is represented by a fibrous cord which causes a greater or lesser degree of approxi-;
mation of the glans to the hypospadiac meatus and produces the second deformity; that
is, ventral curvature or chordee. It is common knowledge that when the parts are
dissected free from this fibrous band, the penis can be fully extended. However, if this
is left to al late period, then secondary fore-shortening of the ventral surface of Buck's
fascia, covering the corpa cavernosa, takes place, and the correction of the curvature is
not so simple.
Thus, a problem is presented, the answer to which surgically is two-fold. First, the
correction of the ventral curvature. This is perhaps the most important for without this
correction marital relationships are not possible. Secondly, the construction of a new
urethra so that the urinary and seminal streams can be discharged at the tip of the
penis. The surgical answer to the latter, namely urethroplasty, is the one which has
received the most attention. The fact that most surgeons will admit to frequent partial
or complete failure and that they constantly change their technique, produces a feeling
that the question is far from solved. Further, the astonishing number of operations
proposed in the literature supports this feeling. The answer to the former is not so
complex and actually there is a tendency to neglect it and quite wrongly so, for the dual
function of the penis cannot be over-emphasized. I propose to deal briefly with the
common operations for both, show some illustrations to elucidate the technique and comment on the good points and faults of each. These illustrations can be found in the
bibliography appended.
Correction of Ventral Curvature
This should be done between the ages of two and three years. There are two main
operations which I would like to mention: the first is a simple ventral transverse incision
Page 348 in front of the hypospadiac orifice, undercutting the skin, dissecting free the fibrous
band and suturing the wound longitudinally. This is sufficient for mild curvature. Elaborations of the technique have been devised for the more severe defects but the more
suitable operation is that devised by Edmunds. This is a two-stage operation in which
the dorsal apron of the penis is utilized in the rearrangement of the skin to make up the
defect on the ventral surface. The first operation is the button-holing of the dorsal
apron so as to produce a roll graft with pedicles attached on either side of the glans.
The second stage, two weeks later, is as follows: First, bisect the graft, then slit each half
longitudinally, carrying the incision on either side so as to meet on the ventral surface of
the penis just beneath the glans, and carrying the incision in the midline down to the
hypospadiac orifice; the graft is spread open and the skin dissected up the ventral surface
of the penis exposing the fibrous band which is removed; then the graft and skin are
reconstructed on the ventral surface of the penis.
Urethroplasty
In regard to urethroplasty, which should be carried out between six and eight years,
I would like to mention four operations; three of which are local grafts, namely Thiersch-
Dupley, Bucknall and Ombredanne, and the fourth, an operation devised by Mclndoe,
which is a modification of the Nove Jusserand technique. As it is impossible to describe
these operations without illustrations, reference should be made to the bibliography for
details. I would like to mention, however, that the Mclndoe operation is one which is
done in two stages, using a free pedicle graft from the hair-free ventral aspect of the
forearm, introduced by a special trocar which can hold a gum elastic bougie around
which the graft is tied. When the graft is in place, the trocar is removed and the graft
lightly sutured in place. Continuous dilation by means of a bougie for a period of six
months is required to prevent contracture of the graft. If this is done, patency of the
lumen can be maintained, and at the end of this time, the new urethra can be joined to
the old hypospadiac meatus. This, combined with the Edmunds operation, produces a
normal appearing penis and the technique is much simpler than that of other operations.
Shortcomings of the Operations
1. Thiersch-Dupley: The technique is difficult and the incision is prone to break
down, resulting in fistule on the ventral surface which are difficult to cure, requiring
frequently many subsequent operations.
2. Bucknall and Ombredanne: These operations utilize local pedicle grafts from the
scrotal skin which is a hair-bearing skin and is very prone to produce hair on the newly
formed urethra, pre-disposing it to infection and stone formation.
3. Mclndoe: The shortcomings in this operation are the difficulty in cutting the
free graft and the length of time required for completion of the operation.
BIBLIOGRAPHY
Bucknall, R. T. H.: Hypospadias.   Lancet, vol. 2, 887-890, Sept., 1907.
Cabot, H.: Jour, of Urology, 33:400-407, April, 1935.
Mclndoe, A. H.: Surgical Treatment.   Amer. Jour of Surgery, 38:176-185, Oct., 1937.
Lowsley, O. S., and Br'agg, C. L.: Jour. Amer. Med. Assoc., 40:487, Feb., 1938.
Young, H H.: Plastic Surgery of Lower Genito-Urinary Tract.   Jour, of Urology, 35:417-480, 1936.
Lyle: Annals of Surgery, 98:513-519, Oct., 1933.
McRenna, C. M.: Surgical Correction.   Jour. Amer. Med. Assoc, 113:2138, Dec. 9, 1939.
Page 349 in
'it.
liffn
:v
IS ADMINISTRATION OF VITAMIN K TO THE NEWBORN
■ |     ;f OF CLINICAL VALUE? |fgf SH
Heyworth N. Sanford, M.D., Irene Shmigelsky, M.D., and
Josephine M. Chapin, M.D.
Chicago.
Abstract from Jour. AM.A., Vol. 118, No. 9, Feb. 28, 1942.
CONCLUSIONS: One thousand, six hundred and ninety-three newborn infants
were observed during the first ten days of life, over a period of two years. Vitamin K
was administered to 711 of these infants. In 606 plasma prothrombin determinations,
it was found that prothrombin content of the cord blood plasma of the normal infant
was similar to the prothrombin content of its mother's blood plasma. During the newborn period, the plasma prothrombin diminished during the first, second and third days
of life in descending proportions. It increased during the fourth, fifth and sixth days
of life and almost returned to cord value from the seventh day throughout the newborn
period. The value of plasma prothrombin could be increased above cord plasma prothrombin value by administration of vitamin K to the infant. The plasma prothrombin
of the mother and the cord plasma prothrombin of her infant were both increased above
normal values by the administration of vitamin K to the mother before the birth of her
child. The plasma prothrombin values of infants given vitamin K or given to their
mothers before delivery is well above that of normal infants throughout the newborn
period.
However, the administration of vitamin K did not affect the frequency of hemorrhagic manifestations. There were just as many conjunctival, vaginal, petechial, cerebral and umbilical hemorrhages, cases of melena and cephalematomas in one group as
in the other.  The percentage of mortality for the two groups was the same.
There were no hemorrhagic manifestations in either group in which the coagulation
time of the whole blood was increased over normal (five minutes). As judged by this
standard, our frequency of hemorrhagic disease of the newborn for the last ten years
has been one in twentv-five hundred.
SURGEONS' CONGRESS SCHEDULED FOR
CLEVELAND, NOVEMBER 17 TO 20     J|
The 1942 Clinical Congress of the American College of Surgeons, originally scheduled for October at the Stevens Hotel, Chicago, which was taken over August 1 by the
United States Army Air Corps, will be held in Cleveland, with headquarters at the Cleveland Public Auditorium, from November 17 to 20, according to an announcement from
the College headquarters in Chicago. The twenty-fifth annual Hospital Standardization
Conference sponsored by the College will be held simultaneously.
The programme of panel discussions, clinical conferences, scientific sessions, hospital
meetings, and medical motion picture exhibitions at headquarters, and operative clinics
and demonstrations in the local hospitals and Western Reserve University School of
Medicine, has been centered around the many medical and surgical problems arising out
of the prosecution of an all-out effort to win the war, emphasizing the needs of the
rapidly expanding medical services of the Army and Navy, and consideration of special
problems related to the increasing activities for civilian defense.
The programme of both meetings will begin with a Joint General Assembly on Tuesday morning, November 17, with addresses by Surgeon General James C. Magee of the
Page 3 50 Medical Corps, United States Army; Surgeon General Ross T. Mclntire of the Medical
Corps, United States Navy; Surgeon General Thomas Parran of the United States Public
Health Service; Lieutenant Colonel George Baehr, Chief Medical Officer of the United
States Office of Civilian Defense; Dr. Frank H. Lahey, Chairman, Directing Board,
Procurement and Assignment Services; Dr. Irvin Abell, Chairman of the Board of
Regents of the College and Chairman of the Health and Medical Comimittee of the
Federal Security Agency; and Dr. W. Edward Gallie of Toronto, President of the College. The surgeons general and Colonel Baehr will also speak at the Presidential Meeting
and Convocation the same evening.
The Forum on Fundamental Surgical Prbolems inaugurated at the 1941 Clinical
Congress will be repeated to give the younger men, representing various university departments of surgery, an opportunity to present the important results of their clinical and
experimental research work before a large surgical meeting. Heretofore these younger
men have seldom been able to present their original work and ideas, since many of them
have not yet qualified for membership in the principal surgical societies. The forum will
be held on three successive mornings.
The officers-elect of the College who will be inaugurated at the Presidential Meeting
and Convocation on November 17 are Dr. Irwin Abell of Louisville, President; Dr.
Leland S. McKittrick of Boston, First Vice-President; and Dr. F. Phinizy Calhoun of
Atlanta, Second Vice-President.
A large technical exhibition in which leading manufacturers of surgical instruments
and supplies, sutures, dressings, pharmaceuticals, operating room equipment, x-ray apparatus and hospital equipment of all kinds, as well as publishers of medical books, will
participate, will be a feature of the Clinical Congress as usual. It will be housed in the
exhibit hall of the Cleveland Public Auditorium.
BRINGING EUROPE BACK TO LIFE
Allies Notv at Work on Comprehensive Plan
by a Ke construction Expert
Today almost the whole of continental Europe is subject to a blockade which will
not be lifted till the Nazi power in Germany has been completely broken. This blockade is not only, or even mainly, directed to thedenial of foodstuffs to the enmy. Europe
is not, even in normal times, wholly self-supporting in food and since production in wartime is more incalculable than in peace, there remains the probability of grave—if only
local—shortages arising at or before the end of the war.
The blockaded area now includes the whole of Europe with the exception of Switzerland and the Iberian peninsula. Spain is in a precarious food position. The Scandinavian
countries and Holland have become potential candidates for relief instead of sources of
supplies. Greece, Norway and Belgium, three countries which in peace-time are importers of bulk foodstuffs and in the last war received at least minimum supplies from overseas, are now entirely dependent on German-controlled economy.
Estimates of the post-war needs of food and raw materials of Europe are now being
prepared by the Allies. The technical problems of agricultural relief, medical relief,
nutrition, inland transport and of supplies and shipping are under consideration. The
aim is that, by the time Europe or any part of it is free, a comprehensive plan of dealing
with the emergencies that will arise shall be agreed by all the Allied Governments. There
is no suggestion of taking arbitrary action on statistics prepared beforehand, but of
developing plans of a flexible character to meet the situation which is likely to arise. The
supply of foodstuffs will depend, perhaps, more on the course of the war outside Europe
and the possibility of placing stocks in positions where they can be drawn on at short
notice.
Page 351 :
I <h
Britain Will Go Shares With Europe
Reconstruction must synchronize with relief. It is important that, so far as possible,
relief should be initiated on sound dietary lines so as to make this foundation the basis
for an all-round improvement in European nutrition in the years to come. A well fed
Europe will be a peaceful Europe. This result will not depend merely on a realization
of the need for improvement or in dietary education. It depends, not only for the
industrial workers but to some extent also for the rural population, on such an increase
in spending power as will permit the purchase of something more than the cheapest type
of bulk foodstuffs.
Relief is both a political and an economic concern since adequate feeding, the prevention of epidemics, the return of people to their homes, the re-stocking of farms and
the provision of productive employment are indispensable foundations for a stable political regime in Europe.
The state of Europe after this war may be so critical as to prompt the people of the
better-off countries willingly to forego for some months the freedom of purchase which
they enjoyed before the war and to demand a continuance of rationing of at least some
of the vital food supplies. The contribution of the United Kingdom can be as effective
in refraining from consumption as by donating supplies. We have been told that stocks
of food will be in Britain at the end of the war and quantities of food will be on their
way there, as they have been, thanks to the Allied Navies, so regularly throughout this
war. May we not expect to find repeated the generous action which, on the day the
last Armistice was signed, prompted the Governments to divert cargoes of food to
northern and southern Europe to meet acute feeding difficulties and to transfer immediately consumable war stocks to black areas on the Continent?
\m
S
Europe's Harvest Well Depend on America's New Ships
Europe will need raw materials as well as food at a very early point after the end of
the war: cotton and wool for clothing, hides and leather for boots, copper for electrical
power and light, and timber for rebuilding the houses in the devastated areas. Shipping
therefore cannot at the end of the war be devoted solely to the carriage of foodstuffs
but must also bring essential raw materials so that men can get back to work once more
and make good the deficiencies of food, wearing apparel and dwellings. The construction
of refrigerated tonnage will become an urgent problem to enable imports of meat, butter
and fruit to be resumed as rapidly as possible. Europe will be expecting supplies of
coffee, cocoa, rice and tropical fruits. Coffee has become a necessity on the Continent.
The Germans' effort to find a satisfactory brown, wet and hot substitute from acorns
and barley, or anything else which when roasted will give the right degree of color^js
proof of this. We in Great Britain consume as much cocoa as the whole of the rest ca.
Europe. A surplus of cocoa is piling up in West Africa and after the war, when shipping
is available, Britain and the Continent will have cocoa in plenty. Rice is a Far Eastern
staple article of diet and the provision of European needs will be affected if the Far
Eastern war finishes after the European war. Oilseeds and copra which go into the
making of margarine will also not be easy to import from the Far East while the Japanese
war continues. We may therefore expect to see an increased production of African palm
products.    The Continent will need these vegetable fats.
Feeding stuffs are necessary to build up the livestock population and maize is one of
the most important of them. There are large supplies but maize is bulky to ship and
ships may be scarce. The hope of. increasing European supplies of maize and of oil cake,
so important to the dairy industry in countries such as Denmark and Holland, rests on
the development of the vast shipping programme which the United States has in hand.
Fertilizers are of course essential to increased production of food in Europe. There will
be a large demand in Europe after the war for potash and phosphates provided before the
Page 352
fll war by France.    Nitrogenous manures will not, with the change-over of European
industry from war to peace, be a problem.
Each Country to be Rationed for First Year of Peace
One of the subsidiary aims of relief in 1919 was the firm estabUshment of a number
of new or reconstructed national states. It seems unlikely that this motive will play an
important part in the future. The movement in Central and South-eastern Europe is
towards regional agreements, of which the first have been the Polish-Czech and the
Greek-Yugoslav agreements. The possibility of wider understanding is being discussed
today by Allied statesmen. The exact form which such agreements may take or the
areas which they will ultimately cover is unknown, but the mere existence of larger
economic units will considerably simplify the problems of relief. Many difficulties bearing on questions of transport, currency and the balancing of surplus and deficiency areas
will be greatly relieved, as will certain minority and potential refugee problems.
There can probably be no immediate reversion at the end of the war to a free economy, and the Allied nations will need to plan a policy to take the place of the Nazi New
Order in Europe. If this seems to be far from the sphere of post-war feeding in Europe,
and of relief, it must; be remembered that, for the first years after the war, or perhaps
longer, it will be for the Inter-Allied relief authorities to decide the quantities not only
of foodstuffs but of raw materials, agricultural requirements and capital goods entering
each country.
Poltical planning on a regional scale should be accompanied by economic planning.
Industrially it should be possible to aim at preserving and extending those branches of
manufacture which are adapted to each region's natural resources, including labor resources, its home consumption or payment for its necessary imports. Agriculturally a
similar plan might be followed with the special aim of raising the nutritional standards
in Europe.
The object of a relief organization, when it has completed the work it has been set
up to do, is to give fuller opportunities for reconstructive effort. If the Allied relief
organization whose planning has now begun can, in its fuller international development,
not only prevent the immediate suffering of the after-war years but leave a foundation
on which the constructive agents can build, its main purpose will have been fulfilled.
Page 353 «A WORKING CURE FOR ATHLETE'S FOOT"
<:i
i'i
w
The Reader's Digest for May, 1942, by means of an encircling paper bandage, specially features an article with the above title. Just what is meant by a "working cure"
is not explained. The ambiguity of the term does not commend it to the thoughtful.
In the December 6th, 1941, number of the Journal of the American Medical Association,
under the "Clinical Notes" section, there appeared a brief article by Edward Francis,
M.D., Medical Director (Retired) U.S. Public Health Service, entitled "Phenol-Camphor
for 'Athlete's Foot'." Paul de Kruif, the bacteriologist, who makes a good thing out of
popularizing medical subjects for the public, has highlighted and dramatized Dr. Francis*
modest three hundred words, expanding it into an article of some thirteen hundred words
which purports to put into the hands of "everyman-his-own-doctor" a simple working
cure for mycotic dermatitis of the feet. The popular name, "athlete's foot," incidentally, is the brain-child of a writer of advertisement copy for a patent medicine manufacturer, being of a kind with such terms as "B.O.," "Halitosis," etc.
The "working cure" described is simply the application several times daily of a mixture of equal parts of phenol and camphor. The dangers of its application to moist
surfaces are mentioned, but any physician knows that the average man likes to feel he
is getting action for his money, and disregards petty precautions, so that if he burns his
toe with pure dissociated phenol he frequently will regard the macerated, burning skin
as a demand for more vigorous use of the remedy. "If a little is good, more's better.
Dermatologists and others interested may therefore expect to encounter phenol burns and
even gangrene in increasing numbers for a time, as a result of the bacteriologist de Kruif's
activities in the field of popular clinical medicine.
A few of de Kruif's remarks are as enlightening as they are amusing. He states that
there is a "bewildering array of twenty-six different salves, unguents and lotions"
(italics are ours) that have been tried by skin doctors, which are efficacious only in mild
cases. Our impression is that a zero might follow the above numerals without exaggeration or materially altering the significance of this statement. He says that "X-rays
sometimes dried up the condition for a few days" followed by recurrence when "the
X-ray, used again, began to burn. For it took fifty times more X-ray to kill the parasite than it took to hurt human skin." Every dermatologist knows that X-rays are
occasionally a useful adjunct to treatment of the disease, but are never solely relied upon
to effect a cure; and X-rays have not been shown to have any such definite fungicidal
activity, as de Kruif implies. Lewis and Hopper1 state, "In our hands rcentgen rays and
radium have had little action as lethal agents, although some observers have reported
inhibitory action on certain fungi,' and Dodge2 confines his remarks in this connection
to stating that, "Neidhart (1924) reports lethal action of X-rays and radium iA
Sporotrichum and Ectotrichophyton Gypsum." Neither of these organisms are imp_^
cated in "Athlete's Foot."
The article closes on this illuminating comment, "A permanent cure for athlete's
■ foot ... has never been found.    The disease may recur when you expose yourself to
fungus again."   That should be remembered by the surgeon when he is tempted to regard
a fractured humerus successfully re-united as "permanently cured."    It cannot be, for
if suitable violence is again properly applied the arm will again be broken.
1. Lewis, George M., M.D., and Hopper, Mary E., M.S.    An Introduction to Medical Mycology, p. 8,
Chicago: The Year Book Publishers, Inc. 1939..
2. Dodge, Carroll William, Ph.D.    Medical Mycology, p.  39.    St. Louis: The C. V. Mosby Company,
1935.
Page 354

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