History of Nursing in Pacific Canada

The Vancouver Medical Association Bulletin: July, 1943 Vancouver Medical Association Jul 31, 1943

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 the BUllMW
of the
^^pVANCOUVER     ■
MEDICAL ASSOCIATION
— Vol. XIX
JULY, 1943
No. 10
With Which Is Incorporated
Transactions of the
Victoria Medical Society
the
Vancouver General Hospital
and
St Paul's Hospital
In This Issue: WsA
Page
NEWS AND ^QfTV^^^^^^^^^^^^^^^^^^^^^^S^^7\:
•MEDICINE AND WAR—H. A; DESBRISAY^rl.pfe^^^^^fe-: ■ jpfrf
TEST FOR CANCER-^-Report by Dr. F. N. Robertsogr^^^^^fe^^^f286-
STAFF WORK IN THE V. G, HL—G. L. Hodgins, M.D^^^^^tt^^288'
SUBDURAL HAEMATOMA IN INFANCY-^J, W. Cluff, M.I^^^^^:2*9
ANNUAL MEETING
BRITISH COLUMBIA MEDICAL fl&SOCIATfo^
SEP^8 - S#1<W1943 OESTROFORM
Trade Mark
in follicular hormone deficiency
wgpa
The results of hypofunction of the ovarian follicle in the
female are characteristic; they vary according to the age at
which the signs of hypof unction first become manifest.
In early life the syndrome of delayed puberty resultsjin non-appearance of the seconda ry sex
characteristics, in genital infantilism and ^primary amenorrhea.
At a later age. Secondary amenor-
rhcea or oligomenorrhcea, dys-
menorrhcea, steri I ityy or functional
nervous disturbances may be en^
countered.
At. the time^||the^ienopause
ovarian hypofunctior^is physiologically normal, being a prelude
to-the cessation of ovulation and
ovarian activity^Durihg the period ofiadjustment the protean
symptomatology of the climacteric may include such associated
conditions as endocrine arthritis^
pruritus and kraurosis vulvae.
Such syndromes are indications for the use of Oestrofoi*nt§
which, being the natural oestrogenic hormone in standardised
form, produces a specific and immediate response.
Stocks of Oestroform are held by leading druggists throughout the Dominion,
and full particulars are obtainable from
ThI   BRITISH   DRUG^HOUSEi (CANADA)   LTD.
Toronto Canada
-oes/can/43: THE    VANCOUVER   MEDICAL   ASSOCIATION
B U|L L E T I N
Published Monthly under the Auspices of the Vancouver Medical Asociation
in the interests of the Medical Profession.
Offices: 203 Medical-Dental Building, Georgia Street, Vancouver, B.C.
EDITORIAL BOARD:
Dr. J. H. MacDermot
Dr. G. A. Davidson Dr. D. E. H. Cleveland
All communications to be addressed to the Editor at the above address.
Vol. XIX.
JULY, 1943
No. 10
OFFICERS, 1943-1944
Dr. A. E. Trites Dr. H. H. Pitts Dr. J. R. Neilson
President Vice-President Past President
Dr. Gordon Burke Dr. J. A. McLean
Hon. Treasurer Hon. Secretary
Additional Members of Executive: Dr. J. R. Davies, Dr. Frank Turnbull
TRUSTEES
Dr. F. Brodie Dr. J. A. Gillespie Dr. W. T. Lockhabt
Auditors: Messrs. Plommer, Whiting & Co.
SECTIONS   §
Clinical Section
Dr. J. W. Miller Chairman Dr. Keith Burwell.——Secretary
Eye, Ear, Nose and Throat
Dr. C. E. Davies Chairman Dr. Leith Webster Secretary
■V                         Pediatric Section
Dr. J. H. B. Grant Chairman Dr. John Piters- Secretary
STANDING COMMITTEES
Library:
Dr. F. J. Buller, Dr. D, E. H. Cleveland, Dr. J. R. Davies,
Dr. A. Bagnall, Dr. J. R. Neilson, Dr. S. E. C. Turvey
Publications:
Dr. J. H. MacDermot, Dr. D. E. H. Cleveland, Dr. G. A. Davidson
Summer School:
Dr. J. E. Harrison, Dr. G. A. Davidson, Dr. R. A. Gilchrist,
Dr. Howard Spohn, Dr. W. L. Graham, Dr. J. C. Thomas
Credentials:
Dr. D. E. H. Cleveland, Dr. E. A. Campbell, Dr. D. D. Freeze
V. O. N. Advisory Board:
Dr. L. W. MacNutt, Dr. G. E. Seldon, Dr. Isabel Day
Metropolitan Health Board Advisory Committee:
Dr. W. D. Patton, Dr. W. D. Kennedy, Dr. G. A. Lamont
Representative to B. C. Medical Association: Dr. J. R. Neilson
Sickness and Benevolent Fund: The President—The Trustees CIRCULATORY   SYSTEM
Mannitol Hexanitrate has a hypotensive effect lasting
from four to six hours. By dilating the smaller blood vessels
it reduces the strain on the circulatory system and plays an
important role in the prophylaxis of frequent anginal
attacks and in relief of high blood pressure.
For literature write:
36 Caledonia Ret.; Toronto: Ont.
ERrScoJiBB & Sons
of Canada, Ltd.
manufacturing chemists to the
medical  profession   since   1858 VANCOUVER HEALTH DEPARTMENT
STATISTICS—MAY, 1943
Total Population—Estimated        288,541
Japanese Population 1 Evacuated
Chinese Population—Estimated  5,541
Hindu  Population—Estimated    301
Rate per 1,000
Number       Population
Total deaths _  307                   12.5
Japanese deaths !  1 Population evacuated
Chinese deaths  17                   36.1
Deaths—residents only  269                  11.0
BIRTH REGISTRATIONS:
Male, 342; Female, 700 |    700 28.6
INFANTILE MORTALITY:                                          May, 1943 May 1942
Deaths under one year of age      22 24
Death rate—per 1,000 births —     31.4 44.9
Stillbirths (not included above) I        7 18
CASES OF COMMUNICABLE DISEASES REPORTED IN THE CITY
April, 1943 May, 1943 June 1-15,1943
Cases Deaths Cases Deaths Cases Deaths
Scarlet Fever 41           0 41           0 16           0
Diphtheria 1 10 0           0 0           0
Diphtheria Carrier      0           0 0          0 0           0
Chicken Pox 67           0 200           0 142           0
Measles    - 779           0 691          0 126          0
Rubella 11           0 14           0 3           0
Mumps _iL- 165           0 138           0 40           0
Whooping Cough 30           0 64           0 18           0
Typhoid Fever 0          0 0          0 0          0
Undulant Fever 0           0 0           0 0           0
Poliomyelitis !■   0           0 0           0 0           0
Tuberculosis 45         22 36           _ 31
Erysipelas 3           0 4          0 3           0
Meningococcus Meningitis       2           0 10 10
V.D. CASES REPORTED TO PROVINCIAL BOARD OF HEALTH
DIVISION OF VENEREAL DISEASE CONTROL
West North       Vane.   Hospitals &
Burnaby    Vane.   Richmond   Vane.      Clinic   Private Drs.   Totals
Gonorrhoea   (March) 1 0 1 1 77 35 115
Syphilis  (March) 0 1 0 7 28 50 86
HIGH   BLOOD   PRESSURE
BETTER RESULTS OBTAINED WITH
BIOGLAN
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 268 T
Phone MArine 5411
Res.: MArine 2988
&eat>Uce Qallap,
CANADIAN PHYSIOTHERAPY ASSOCIATION
GRADUATE McGILL UNIVERSITY SCHOOL
OF MASSAGE AND REMEDIAL GYMNASTICS
Electricity, including Short Wave
House Visits
417 Vancouver Block
Vancouver, B. C.
V
 \
IF ARTHRITIS and ECZEMA
ARE ALLERGIC   /
ETIOLOGICALLY
effective treatment suggests the use of
agents to correct mineral deficiency,
increase cellular activity, and secure
adequate elimination ef toxic watte.
LYXANTHINE ASTIER -^
orally given, supplies calcium, sulphur,
iodine, and lysidln bitartrate — an
effective solvent. Amelioration of,
symptoms and general functional improvement may be  expected.
Since the best evidence is clinical
evidence, write for literature and
sample.
L-15
Canadian Distributors
ROUGIER FRERES
350  Le Moyne   Street,   Montreal
Nmrn $c
t
2559 Cambie Street
Vancouver, B.C.
COLONIC AND PHYSIOTHERAPY CENTRE
Up-to-date Scientific Treatments
COLONIC  IRRIGATIONS, SHORTWAVE  DIATHERMY,  SINNEWAVE GALVINISM,
IONIZATION, ULTRA VIOLET RAY, STEAM BATHS AND SHOWERS
Medical and Swedish Massage
Physical Culture Exercises
STAFF OF GRADUATE NURSES
1119 Vancouver Block
Superintendent
E. M. LEONARD, R.N.
Post Graduate Mayo Bros.
MArine 3723
Vancouver, B.C. OLD!TUBERCULIN
FOR TUBERCULIN  TESTING  IN   HUMANS
Old Tuberculin is prepared by the Connaught Laboratories from a
human strain of tubercle bacillus grown on a protein-free synthetic
medium. A control test is unnecessary, since it has been demonstrated that the synthetic medium itself does not elicit a reaction
in the skin.
The Old Tuberculin prepared in these Laboratories is standardized
by intracutaneous testing in sensitized guinea pigs against the
International Old Tuberculin Standard adopted by the Health
Organization of the League of Nations.
THE  MANTOUX  TEST
The intracutaneous (Mantoux) test is the most
delicate of the skin tests for tuberculosis and is
recommended, using as an initial injection a dose of
0.01 mg. of Old Tuberculin.
For those who fail to react to the initial injection of
0.01 mg., the injection of 1.0 mg. is recommended.
An individual who fails to react to the injection of
1.0 mg. may be considered tuberculin-negative.
Old Tuberculin is supplied by the Connaught Laboratories in 1 cc.
rubber-stoppered vials in the following forms:
OLD TUBERCULIN  (1:10,000)
For intracutaneous (Mantoux) tests, using as an initial
test an injection of 0.01 mg. in 0.1 cc.
OLD TUBERCULIN  (1:100)
For testing only of persons who fail to  react to a
previous injection of 0.01 mg.
CONCENTRATED OLD TUBERCULIN (1000 mg. per cc.)
For distribution only to sanatoria and specialists hav-
in suitable facilities for making dilutions for intracutaneous testing or for other purposes.
CONNAUGHT   LABORATORIES
UNIVERSITY  OF   TORONTOjj
Toronto, Canada
DEPOT FOR BRITISH COLUMBIA
MACDONALD'S PRESCRIPTIONS LIMITED
MEDICAL-DENTAL BUILDING, VANCOUVER, B.C. (Mulotum
A Clean, Effective Treatment for All Types of Impetigo Contagiosa
Wyeth's ALULOTION (Ainmonicrted Mercury with Kaolin)
which combines the0 bactericidal action of ammoniated mercury
with, the drying effect of aluminum hydroxide and. kaolin is
effective in all types.
Clinical evidence has shown that ALULOTION (Ammoniated
Mercury with Kaolin) clears up impetigo contagiosa in less time
than older methods.1
1. 'Impetigo Contagiosa Treated with Ammoniated Mercury-Colloidal Kaolin
Lotion." A. G. Pratt. R. E. Imhoif. and K. B. Decker. J. M. Soc..{lew Jersey.
36:442 (July). 1939.
Supplied in 3 tl. oz. bottles.
John Wyeth & Brother (Canada) Limited
WALKERVILLE. ONTARIO We are grateful to Dr. F. N. Robertson of Vancouver for affording us an opportunity to publish his report to the Medical Staff of the Vancouver General Hospital on
the present status of the Robertson Test for cancer. A continued accuracy over the
years of its use, of 85%, means that this test has been definitely proven of value, and all
of us know of cases where it has been of very great assistance. We are very glad to see
that the Hospital (Vancouver General) has decided to continue the test on a charge basis.
This is as it should be. *      *      *      *
The air is full, and cloakroom conversations are charged, with the subject of hospital insurance, hospital expansions, etc. We were all surprised recently to see wide
newspaper publicity given to an alleged scheme of hospital insurance, which, according
to our newspaper friends, is to come into active operation at an early date. We understand that there are still a good many points to be cleared up—and as the whole matter
is still in a very fluid state, and still sub judice, so to speak, we shall not attempt to discuss it at this juncture, further than to say it looks decidedly like a long step in the right
direction. A few of the more obvious difficulties that will confront such a plan, leap
to one's mind—but we hope they will be found surmountable. If the increased hospital
accommodation that will certainly be needed, can be found, such a plan will meet a very
definite want, and will be of very great benefit to the community.
And that last sentence, with its conditional clause "if the increased hospital accommodation can be found" is really the text of what we wanted to say. Recently we have
read in the press of great new roads that are to be built after the war, and of the careful
plans that are being worked out towards that end. All to the good: B. C. needs roads,
and good ones, Heaven knows: and it is a statesmanlike project. But B. C. needs other
things too, just as badly as roads: perhaps even more urgently than we need roads. One
of these things is hospital extension. We need a great many more hospital beds in this
province—we need better accommodations for nurses—we need psychopathic wards—
we need provision made for the Medical School that is bound to come. From a remark
dropped by the Hon. Ian McKenzie, Minister of Health for Canada, plans are developing along these lines. We should like to see it stated that many millions of dollars are
being earmarked for this, a project that should rank high amongst the post-war reconstruction schemes that are even now being formulated.
And we confess that we should like to see a more coherent and orderly scheme of
hospital extension and hospital location for this province of ours. We should like to see
a definite policy adopted, which would survey carefully and accurately the needs of the
province in all its parts and would lay down definite lines, which could be followed consistently and in logical order. Our present haphazard way of building hospitals, and
choosing their sites, does not, in our opinion, meet all needs well—nor does it avoid overlapping and a marked imbalance. Why should we not have in B. C. a Hospitals Commission, as we have Workmen's Compensation Commissions, and Board of Education,
and Waterworks Commission, and so on: which would exercise a much-needed judgment
and control over the size and location and designs of hospitals, and work to a plan
which might look forward to the future, as well as merely meeting immediate needs.
Not only would it mean more efficiency, and more adequate adaptation of demand to
supply, but it would, we believe, save a great deal of public money. And there are
other advantages with which we cannot deal here. Hospitals have always been much
too local in their origin and growth—whereas they are an important and essential factor
in public health organisation and should be linked up with Public Health administration.
Clinics, teaching, training of nurses, social service workers, dietitians, mothers' aids and
so on: all these are just as important in one part of the province as another—but they
cannot be adequately provided for under our present individualistic, hit-or-miss methods.
Page 269 Vancouver Medical Association
THE   SUMMER   SCHOOL
The twenty-first Annual Summer School of the Vancouver Medical Association
was held at the Hotel Vancouver on June 22, 23, 24, 25.
The total registration this year set an all-time record at 400. Of this number, 76
were Army Medical Officers, 60 were Air Force Medical Officers, 20 were Naval Medical
Officers and 25 were hospital interns. The committee were pleased to be hosts to the
above men in the services. Our American neighbors numbered 19 this year, and five men
came from Alberta, one from Saskatchewan and one from Manitoba. It would seemi
that the Summer School has established a worth-while reputation in Western Canada.
The luncheon was very well attended on Tuesday noon. Our guest speaker, Dr.
Foster Kennedy, spoke on "De Propaganda Fide." Withj pleasing phrases and with his
Irish humour he stimulated the minds of his audience and established himself at once
as a very able and thoughtful speaker.
The programme was well received if the attendance be taken as an index of the
interest and appreciation of those present. The committee was fortunate in the choice
of speakers, all of whom were experienced teachers and lecturers. To the R.C.A.M.C. we
wish to extend our heartiest thanks for so generously providing us with three speakers.
Brigadier J. C. Meakins gave a medical clinic on Rheumatic Heart Disease as well as his
lectures. His close contact with Army medicine and his recent connection with McGill
Medical School were self evident. Lt.-Col. Adamson and Lt.-Col. Fahrni gave practical
help to both military and civil practitioners in their lectures and clinic.
Dr. Robertson used all methods of teaching possible without actual cases to make
his lecture-demonstrations varied and practical. There was much favourable comment
on his talks. <
Dr. Cantor came to us with a wealth of recent work for interpretation and clinical
application. During his visit he was also speaking to the B. C. Pharmacists, and we
were fortunate to share this speaker who was sponsored by J. Wyeth & Bros, for the
Pharmacists.
After listening to Df. Foster Kennedy at the luncheon meeting it was natural that
anyone would make a special effort to be present at his lectures. The large attendance
at all his lectures and his clinic in Neurology is proof of his teaching ability. A return
visit has been suggested by many.
Golf was played as usual Thursday afternoon at Point Grey Golf Club. In spite of
threatening weather there was a good turnout of competitors for the prizes. The visitors,
especially those from Edmonton, were winners of mjost of the booty.
Dr. Brien King came from Seattle to participate in the Round Table on, Thyroid
Disease. Again this form of informal discussion of a broad subject was highly successful.
The twenty-first Summer School is -over and no one will suggest that this fine
refresher course has not proven its right to franchise. The committee are to be congratulated on having appreciative audiences for interesting speakers. Medical men attend
Summer School each year and derive from it ready knowledge and mental stimulation.
Under the added stress of wartime conditions this is all the more desirable.
Among the out-of-down Doctors who attended the Summer School were:
Dr. J. A. Alton, Lamont, Alta.      Dr. I. B. Greene, Everson, Wn.  Dr. H. M. Page, Portland
Dr. George Hall, Victoria Dr. G. C. Paine, Penticton
Dr. D. P. Hanington, Ladysmith Dr. D. G. Perry, Ganges
Dr. C. M. Anderson, Spokane
Dr. W. S. Barclay, Sardis
Dr. M. R. Basted, Trail
Dr. D. Berman, Victoria
Dr. E. M. Bevis, Wenatchee
Dr. M. C. Bridgman, Oliver
Dr. R. B. Brummitt, Nelson
Dr. J. M. Burnett, Greenwood
Dr. F. M. Bryant, Victoria
Page 270
Dr. R. H. Irish, Tranquille
Dr. R. M. Jameson, Victoria
Dr. N. A. Johanson, Seattle
Dr. T. M. Jones, Victoria
Dr. Homer D. Dudley, Seattle
Dr. D. B. Leitch, Edmonton
Dr. C. Melgard, Seattle
Dr. G. A. C. Roberts, Chilliwack
Dr. A. O. Rose, Langley
Dr. E. S. Sarvis, Huntingdon
Dr. J. W. Schori, Bellevue
Dr. Ivan V. Shuler, Seattle
Dr. A. C. Sinclair, Victoria
Dr. L. E. Skinner, Tacoma NEWS    AND    NOTES
Surg.-Lieut. John W. Frost, R.G.N.V.R., son of Dr. and Mrs. Anson C. Frost, was
married recently in London.
Surgeon-Commander W. M, Paton is to be congratulated upon his recent promotion.
He is now stationed near Victoria.
The sympathy of the profession is extended to Dr. Gerald L. Burke in the loss of
his wife, who died on June 13 th.
Surg.-Lieut. D. M. Whitelaw, R.C.N.V.R., and Mrs. Whitelaw are congratulated on
the birth of a son.
Dr. C. C. Browne of Nanaimo has just returned from a ten-day cruise in his yacht
Ann, which was accompanied by the Vancouver yacht Benora. A very successful fishing trip netted them fifty lake trout.
Dr. S. W. Baker of Ladysmith has left for Rochester, where he will do post-graduate
study at the Mayo Clinic. He will also visit his relatives in Toronto. During Doctor
Baker's absence, Dr. D. P. Hanington, who formerly practised at Ladysmith, will serve
as locuM tenens.
Dr. H. H. Christie, Chief Medical Officer of the Department of National War Services, visited Vancouver. Doctor Christie is well known here, he having been a classmate of Drs. A. W. Hunter and C. E. Gillies, and he renewed acquaintances with his
contemporaries at McGill in those days. Doctor Christie spoke in the highest terms of
the splendid work done by the profession in examining the young men called up under
the N.R.M.A.
*      *      *      *
Dr. R. B. Brummitt of Nelson and Dr. M. R. Basted of Trail attended the Summer
School in Vancouver.
Dr. and Mrs. Frank Turnbull of Vancouver spent their vacation at Kelowna.
We regret to announce that Dr. D. M. Black of Kelowna has been forced through
illness to temporarily discontinue practice at that point.
Dr. C. H. Hankinson of Prince Rupert, Immediate Past President of the British
Columbia Medical Association and a member of General Council of the Canadian Medical Association, was unable to attend the meeting in Montreal because of the serious
illness of his wife. Dr. Hankinson has the sincere sympathy of the profession in this
Province.
Congratulations to Lieut.-Col. F. H. Stringer on his promotion and appointment as
Officer Commanding, Prince George Military Hospital.
We are glad to learn that Major Douglas R. Learoyd has gained his promotion.
Capt. E. J. Curtis has been moved to M.D. 3 with headquarters at Kingston. We
understand that he is to be promoted to the rank of Major in his new appointment as
District Hygiene Officer.
Page 271 Captains N. J. Ball, formerly of Oliver; R. R. M. Glasgow, formerly of Michel; F.
W. Grauer, recently filling a temporary appointment at Shaughnessy Hospital during
his convalescence from a recent illness; R. J. Macdonald, until recently Director of the
Health Unit at Prince Rupert; R. A. Wilson, Paediatrician of Vancouver; J. W. ClufJ;
J. W. Pickering, and H. G. Weaver, the last three being recent internes of the Vancouver
General Hospital, have proceeded to No. 22 Training Depot in Eastern Canada.
*
Lieut.-Col. S. G. Baldwin has just returned from Great Britain. Colonel Baldwin
left Canada as Officer Commanding No. 12 Field Ambulance. Latterly he has been
Officer Commanding a Canadian Casualty Clearing Station. Colonel Baldwin, after
three and a half years' service, is now returning to civil practice, and has opened an
office in the Medical-Dental Building in Vancouver, where he proposes to confine his
practice to Obstetrics and Gynaecology.
Colonel Baldwin was able to tell us somewhat of the doings of a large number of our
members who are Overseas:
•^ *!> *4> *t
Colonel La veil H. Leeson is A.D.M.S. of the 3rd Canadian Division. It is just possible that he may be among the Canadians at present in the Mediterranean.
Colonel J. F. (Jack) Haszard is now Officer Commanding No. 16 General Hospital.
Lieut.-Col. Murray McC. Baird is Chief of Medicine of No. 16.
Major Russell A. Palmer, Captains E. F. Christopherson, L. W. Bassett, formerly of
Victoria, R. D. Coddington, formerly of Ocean Falls, and Henry Scott of Vancouver,
are all on the medical side at No. 16 General Hospital.
* *       *       *
Lieut.-Col. W. Allan Fraser is Chief of Surgery at No. 16, and associated with him
are Majors G. W. C. Bissett, formerly of Duncan,  and Reg. J.  Wride,  formerly of
Princeton.
* «•       *       a-
Major H. H. (Hammy) Boucher is reported to be doing good work as Orthopaedic
Surgeon with No. 16.
Major H. R. L. (Chesty) Davis is very busy in a large Reinforcement area.
Major W. Lee Boulter is Senior Medical Officer to large Infantry Reinforcement
Depot.
Major Roy Huggard is attached as Surgeon Specialist to No. 16 General Hopital.
This hospital has now been moved from its former location and has taken over from a
Canadian hospital which now serves the Canadian invasion forces.
LIBRARY NOTES
RECENT ACCESSIONS TO LIBRARY—
Surgical Clinics of North America, Symposium on Traumatic Surgery, April, 1943.
Medical Clinics of North America, Symposium on Infectious and Tropical Diseases,
May, 1943.
Transactions of the American Ophthalmological Society, 1942.
Transactions of the American Proctologic Society, 1942.
Transactions of the American Association of Genito-Urinary Surgeons, 1942.
New and Non-Official Remedies, 1943.
Handbook of Medical Library Practice, 1942, Janet Doe,, Editor.
Acute Injuries of the Head, 1942, by G. F. Rowbotham.
Page 272 British Columbia Medical Association
1943 AIIUAL MEETING    |
VANCOUVER
September, 8-9-10
Three Full Days
LECTURES    -    CLINICS    - § DEMONSTRATIONS
Special Features
• PUBLIC HEALTH
• MILITARY MEDICINE
• ECONOMICS
• PUBLIC MEETING
• ANNUAL DINNER
• PREVENTIVE MEDICINE
• HEALTH INSURANCE
• INDUSTRIAL MEDICINE
• ANNUAL MEETINGS
• GOLF
Pleace Make Plans and Reservations Early
*•     *     *     *
BRITISH COLUMBIA MEDICAL ASSOCIATION
COMMITTEE ON THE STUDY OF ECONOMICS
Chairman: Dr. G. F. Strong
The following is quoted from the Minutes of the Proceedings and Evidence presented
to the Special Committee on Social Security now holding sessions in Ottawa. Dr. A. E.
Archer, Chairman of General Council, Canadian Medical Association, was introduced by
Dr. D. Sclater Lewis of Montreal, now President of the C.M.A., and made the following representation to the Committee:—
6.    DOCTORS ON ACTIVE SERVICE
At the present time, 3,100 of our Canadian doctors, or approximately 30% of our
total number, are on active military service. How many more will be required by His
Majesty's services we are unable to say, but certainly whatever the number is, they will
be provided. The great responsibility rests upon those of us who remain at home and
upon the country generally, to safeguard the interests of those doctors who considered
only the interests of all of us when they enlisted. These doctors have had comparatively
little opportunity of expressing their views with respect to this measure (Health Insurance) which will affect them so profoundly when they return home. We should see to
it that no action be taken under health insurance measures which would make it difficult
for the doctors in the armed services to resume their former practices, or, if recent
graduates, to establish practices. The draft measure proposed that all insured persons
shall be registered with the physician of their choice. It is foreseen that the setting
up of these lists or "panels" during the absence of so mny of our doctors might be distinctly unfair to those who are absent. Either the actual putting into operation of the
whole provincial measure should be deferred until the return of the absent medical men,
or those clauses in the provincial Act relating to registration and the placing of names
Page 273 on doctors' lists should remain non-operative, or operative only to the degree which
concerns the broad aspects of public health and preventive medicine rather than individual service.
We are aware that the perfecting and implementing in the provinces of a satisfactory
plan of health insurance will take considerable time. If, however, such a satisfactory
plan can be worked out at this time, should its operation be deferred until the post-war
period?
This is a very broad question which has engaged our most serious attention. With
more than 30% of our physicians now engaged in military service, it will be obvious
that the medical practitioners still in civilian life are carrying an increasingly heavy
burden. To ask that depleted number to undertake the institution of a health insurance
measure at this time, with its accelerated program, indeed might be asking too much.
On the other hand, it might be observed and indeed has been stated by some, that
the enactment of health insurance and its implementation in the provinces during the
war period might facilitate the transition to civilian life of the doctors who are now in
the armed services. Under any circumstances, however, provision would have to be most
carefully made in order that these doctors do not find themselves in a position of having
to fight for a place in the economy of the nation.
It has been said that if this scheme were operating we could say to these men who
are returning that wherever there was a population there would be an income.
It is our opinion that this whole measure should be carefully studied and that all
concerned should be sure that whatever plan be adopted be sound and in the best interests of all concerned. Whatever structure is erected may prove to be the framework for
health protection in this country for generations to come. Let us be sure that the
foundations are-carefully, firmly and wisely laid.
Finally, Mr. Chairman, we wish to say that the Canadian Medical Association desires
most earnestly to co-operate with constituted authority in every possible way in sound
planning for the future health services of Canada. We shall always welcome an opportunity to consult at any time with this Conunittee, or any committee of goveshment,
engaged in the consideration of this important subject.
Dr. Archer answered several questions, one of which is quoted below:—
Mr. Gershaw:    Yes.    My idea would be that doctors now on active service might
easily be fettered in medical practice.    It seems to me that if they come back and find
most of the arrangements signed up to doctors who are here now they will have more
difficulty in establishing a practice just as do recent graduates.
The Witness: Mr. Chairman, it is our thought that it is quite possible that it
may be found that the working out of these proposals may be so tedious that it may
not be possible to get the Arcts ready to operate until the end of th ewar, or it may be
deemed advisable to say that they would not operate until the end of the war; or if it
was thought to be advisable to implement them before the end of the war that these
clauses which require the registration of patients with a doctor, tying up the patient with
individual doctors, be made non-operative until the end of the war, except in so far as
it may be necessary to have them operate in order to implement preventive services..
You will see that if the practitioners are to be responsible for preventive services they
will have to know for whom they are responsible, and to that extent it may be necessary
to have people assigned to certain doctors.
THE MEYERS MEMORIAL
The Chairman of the Meyers Memorial Committee wishes to direct attention to the
Meyers Memorial award. The announcement published hereunder sets forth the particulars.   You are invited to submit a paper on this basis:
The Canadian Medical Association receives the sum of $100.00 a year from the
estate of the late Dr. Campbell D. Meyers of Toronto to provide an honorarium known
as the Meyers Memorial.
Page 274 The award is made in accordance with the instructions of the donor, which are:—
(1) That the award shall be made ". . . to such member or guest of the Canadian
or of one of the Provincial Medical Associations as shall write and read at the
annual meeting of any of the said Associations the best thesis or dissertation ..."
(2) That the subject shall be ". . . the study and treatment of those functional
neuroses which, if untreated, or not treated sufficiently early, might probably
terminate in insanity . . ."
". . . It is impossible to classify definitely the type of diseases referred to
above. I desire, however, to refer to those Functional Neuroses in which the
psychological symptoms form the essential part of the syndrome, and to that
type of Neurosis which develops in late adolescent or in adult life in a patient
of previous good mental and nervous history, especially strain caused by excessive grief, worry and allied conditions. . . ." "I desire to exclude from this thesis
the study of Mental Defectives, paranoia and similar conditions of mental disease due to hereditary or organic states. . . ."
(3) That the award shall be made :. . . by a Committee consisting of the President,
a physician and a neurologist. . . ."
Anyone wishing to submit a thesis is advised to confer in advance with the Chairman of the Meyers Memorial Committee (through the office of the Canadian Medical
Association) in order to make sure that his thesis will come within the terms of the
award.
The thesis must be in the hands of the Chairman of the Meyers Memorial Committee
on or before May 31st if it is to be considered for the award of that year and should be
forwarded to him at 184 College Street, Toronto. Any thesis received after May 31st
will be considered as being submitted for the following year.
CANADIAN MEDICAL ASSOCIATION MEETING
HELD IN MONTREAL, JUNE, 1943
The Annual Meeting of the Executive Committee of the Canadian Medical Association was held on June 12th and 13 th, and the meeting of General Council' was held
on the 14th and 15th. Dr. A. H. Spohn attended the meeting of the Executive.Committee and also the sessions of General Council. Dr. Spohn was elected member as from
British Columbia of the Executive Committee, and Dr. P. A. C. Cousland of Victoria,
first vice-president of the British Columbia Medical Association, was elected alternate
as from this Province. Dr. Cousland attended meetings of the Executive and also all
sessions of General Council, having travelled to Montreal for that purpose, he feeling
that the opportunity to attend the sessions of the Executive Committee would be invaluable to him should it be necessary for him to attend the Executive Committee later as
alternate and in case of Dr. Spohn's inability.
The next Annual Meeting of the C.M.A. will be held in Toronto. Dr. Harris
McPhedran was chosen as President-Elect. Dr. D. Sclater Lewis of Montreal at the
ceremonial session was installed as President of the Canadian Medical Association for this
year. Dr. T. H. Leggett of Ottawa, who has served for several years as Chairman of
General Council, has retired from this office, which he has filled so acceptably. Dr. A. E.
Archer of Lamont, Alberta, who has been so active during his presidency on behalf of
the profession in Canada, was unanimously chosen as the new chairman of General
Council.   Dr. F. S. Patch was re-elected to the office of Honorary Treasurer.
Dr. J. A. Gillespie of Vancouver had Senior Membership in the Canadian Medical
Association conferred upon him at this annual meeting.
Members from British Columbia who attended General Council included: Dr. F. M.
Auld of Nelson, Drs. E. W. Boak and P. A. C. Cousland of Victoria, Dr. A. H. Spohn
of Vancouver, Dr. P. L. Straith of Courtenay, Dr. Ethlyn Trapp of Vancouver and
Dr. M. W. Thomas.
Page 275 MEDICINE AND WAR
H. A. DesBrisay, M.D.
Read before the Vancouver Medical Association.
War has always played an important role in the development of medicine.
Even though war interferes with the steady medical research of peace-time, it calls
forth such urgent problems that of necessity medicine and surgery advance, side by side
with famine and pestilence and destruction.
Upon mobilization, a nation learns to its surprise and dismay that some 40% of its
potential fighting men are defective in some way (47% of the first three million men
called by the draft in the United States were rejected). Because of the revelation of so
many unfit, as well as the problem of caring for the actual casualties of war, war gives
great impetus to social reform and preventive medicine. (Following the last war Industrial Medicine developed as never before.) But, war destroys much that medicine has
attempted to build. The strong of mind and body are mustered against the foe, leaving
the physically and mentally inferior to reproduce, and inherit the land. (Those in the
low mental group reproduce themselves nearly four times as rapidly as do those of
higher mentality.)
At present over 40% of Canadian recruits (in this area at least) are rejected as
unfit, and 30% of the rejected are classed as, mentally and nervously defective.
The largest percentage of this neuro-psychiatric group are of central European
origin (surely a condemnation of our immigration system which allowed such poor stock
into the country).
War affects all medical men, personally and professionally, whether in the services
or not.
Social changes and reforms come with war, and the medical profession is being regimented here, much as in England. Medical men are used in the armed forces in the
proportion of nearly 5 to each 1000 men (picked, healthy men)u Civilians can get
along with one general practitioner to every two to three thousand of population, according to the official ruling. It is estimated that one-third of the physicians in this country,
as well as in the United States, will be required for the services, and this will embrace
two-thirds of those under the age of 45.
This is as it should be, for active warfare, and in preparation for battle. However,
we have in Canada some 65,000 Home Defence men (draftees) who do not volunteer
for overseas service. These men (many of them lacking "the will to do" and the spirit
of volunteers) are merely sitting in Canada, and must be housed, clothed, fed, paid
AND supplied with medical services, in the above proportion. Some three hundred
medical men are thus removed from civilian practice or needful military service to look
after these dead-heads.
After the war many of these conscripts will continue to be problems, and will, no
doubt, demand much from a grateful country that coddled them during the war.
However, for actual fighting men, the best medical care should be provided and
maintained. Without the constant salvage of sick and wounded, gigantic armies have
melted away. Thus, there has always been a medical service of some kind to meet the
needs of armies. Hippocrates alludes several times to the medical service in the field.
The Romans established a regular medical service before the First Century. Medical
attendants to armed forces, however, were for centuries merely tolerated, and were
looked upon as anomalies in the military scheme, before the medical service finally
became an integral part of the army as a whole.
During the 18 th Century the only sick on whom statistics were available were soldiers, sailors and prisoners. Thus the most important movements in preventive medicine,
in England and elsewhere, were initiated by naval and military surgeons.
Many of the great names in medicine and science have come from the ranks of military and naval surgeons—James Lind advised limejuice to prevent scurvy. (It took the
Admiralty 42 years to accept his advice.)
Darwin and Huxley were naval surgeons. Dover (of Dover's Powders) was surgeon
on a pirate ship.
Page 276 This war is to be one of annihilation or survival. Civilization cannot be preserved
without proper conservation of our fighting strength, for in the end it is the human
factor that wins or loses wars.
In earlier wars, disease was much more devastating than death-dealing missiles.
The Plague of 429 B.C. accelerated the fall of Athens. Greece was saved from the
Persian invasion in 492 B.C. by an epidemic. The Black Death forced the English army
to withdraw and sign an armistice (in 1348) after the Battle of Crecy. In almost every
European war, when the louse was still triumphant, typhus took enormous toll.
Napoleon's defeat in Russia was largely due to typhus, aided by typhoid and dysentery. It is stated by historians that if Napoleon had contented himself with occupying
Poland, and there organizing sanitation, his campaign might have succeeded, and thus
changed the whole course of history. But Bonaparte was in a hurry. He pressed on to
Moscow, carrying wagon-loads of infected soldiers (perhaps called lead swingers) into
that city. He left the desperately ill behind in towns and villages, and these infected
the new troops pressing on to Moscow.
In the South African War 65% of deaths were due to disease.
In the First World War less than 10% were due to disease.
Typhoid..—This has long been the scourge of armies. There were approximately
58,000 cases in the South African War and of these 8,000 died. Inoculation against
typhoid was not actually adopted until two years after the Boer war—salthough Sir
Almoth Wright had demonstrated its value two years before that war started. In the
last war there were 1,190 deaths from typhoid—in a British Army of some eight million.
Only 16 Oanadians died out of some 400 cases of the disease. In this war so far, it is
almost non-existent—3 cases to a million men.
Dysentery.—38,000 cases occurred in the Boer war, with 1,300 deaths.
In World War I dysentery took second place in importance. It was the chief cause
of the Gallipoli failure. One hundred and twenty thousand casualties were evacuated
from the Peninsula in five months of 1915, most of them due to this disease. The mortality, however, was not much over 5%.
A virulent Shiga type attacked the German army in Poland in 1939.
A medical officer recently returned from Libya tells, us that practically everyone out
there contracts dysentery (bacillary). House-flies apparently are responsible for the
spread of bacillary dysentery.
Nowadays we may expect better control of bacillary dysentery by anti-dysenteric
serum and sulphaguanidine. Recently succinyl sulphathiazole has been found to be as
effective as sulphaguanidine.
m—Cerebrospinal Meningitis.—In the Canadian Expeditionary Force in the last war,
the mortality from this disease was 55%—219 deaths in 399 cases. In the Canadian
Army overseas, 1939-1942, there have occurred some 40 to 50 cases per year, with a
mortality of less than 3%.
Of interest are 26 cases reported from No. 15 Canadian General Hospital.
Eleven of these cases on admission had meningococcic septicaemia, without involvement of the nervous system.   Only one of these developed meningitis under treatment.
Here it may be noted that the common use now of sulpha drugs in so many febrile
conditions may in some instances mask the symptoms, and prevent the recognition of
meningococcic septicaemia.
In England, patients with meningococcic infection are treated in the open wards,
as the disease is not considered directly contagious. No two cases have ever occurred
in the same barracks or quarters.
The practice of swabbing the throats of contacts has been discontinued.
Catarrhal Jaundice.—In the South African war this was common, over 5,600 cases
being reported in five months.
In the last war cases were numerous, many being considered of spirochetal origin.
In this war catarrhal jaundice has occurred in epidemic proportions in England, and
also in the German army in France and Belgium.    At one time in a Canadian hospital
Page 277 in England, 12% of medical admissions were cases of jaundice. It was thought that
these cases were due to a filtrable virus and one worker in London believed that he had
proven this. The condition is quite distinct from Weil's Disease. Punch-biopsies in
many cases of so-called catarrhal jaundice have shown a hepatitis to be present. The
incubation period is long,—up to a month or more. In young individuals the disease is
usually of short duration, but in older men the jaundice may persist for weeks or even
months.    Convalescent serum has been suggested as a form of treatment.
Influenza and Acute Respiratory Disease.—In the last war there were some 46,000
cases of influenza in the Canadian Expeditionary Force, with 776 deaths. In the U.S.
Army during 1917-18 influenza and pneumonia accounted for 75% of deaths from
disease. So far there have been no signs of an epidemic in this war, even with the
crowding of large numbers of people into air-raid shelters. (At one time in London
alone, 300,000 people spent their nights in these dormitories, 1,500-2,000 in one shelter
in Picadilly. Some, however, were more hygienically housed in shelters than in their
own homes.)
In view of the possibility i of an influenza epidemic again, the lessons learned in the
last conflict should be recalled. It will be remembered that operation for empyema in
these cases was at first accompanied by a mortality of from 30 to 90%. Only after the
introduction of repeated aspirations and the avoidance of an open pneumothorax was the
death rate cut to about 4%.,,
The use of the term influenza is very loose. Influenza is apparently due to a combination of viruses unspecified and largely unknown, so that there is no hope of diagnosing influenza as a clear-cut entity on our present information.
Tuberculosis.—In the last war 3,000 Canadian soldiers died of tuberculosis; 8,500
were perisioned for this disease. In the first 1 l/z years of this war, in the Canadian Army
overseas, there were only 114 cases—which included 31 cases of Idiopathic Pleurisy with
Effusion. Cases where the enlistment film was considered as reported negative in error
numbered only 6.
It is to be mentioned that tuberculosis has increased in England. There has been
reported in London, from 1938-42, an increase in pulmonary tuberculosis of 43% and
a death rate increase of 73%. (-Later figures have, however, shown a decline.)
Recently, Wilson of the London School of Hygiene and Tropical Medicine has
reported in the British Medical Journal that about 5 to 10% of farms in Great Britain
still send out milk containing tubercle bacilli (and incidentally, 20-40% B. abortus).
Rheumatic Disease.—It has been one's impression that rheumatic disease is much less
frequent in this war than in the last. True, conditions are much different, but it seems
evident that the excellent early work done on recruits by the Canadian Dental Corps
has beed a big factor in keeping the incidence down.
About 10% of cases returned to Canada as medically unfit have arthritis, but they
are mainly in the older age group.
Tetanus.—In pre-antitoxin days mortality from battle wounds was as high as 85%.
In the B.E.F. in France in 1914-18, in spite of the use of antitoxin, there were over
2,500 cases of tetanus—more than 1 to each 1,000 wounded—with 23% deaths.
In the present war, with troops inoculated with tetanus toxoid, there has not been
one case of tetanus develop in a man properly immunized—even in those coming back
from Dunkirk.
In the German-Polish campaign of 1939, 53.5% of the Polish wounded, who
developed tetanus, died. The Poles were unprepared, and not protected by inoculation
to any extent.
So much faith is placed in tetanus toxoid that in the Canadian Army antitoxin is
not given.
Gas Gangrene.—There has been surprisingly little gas gangrene reported during this
war. Some of the men returning from Dunkirk did develop the disease. The use of
sulphanilamide, and adequate early surgery, is the best safeguard. X-ray treatment may
be utilized.
Page 278 Streptococcic Infections.—These caused 70% of the fatal infection of wounds in
the British Army of 1914-18.
American soldiers today carry sulphathiazole powder for their own wounds.
Implantation of sulphanilamide powder into a wound gives a local concentration up
to 800 mgm. %. (When used in the peritoneal cavity, maximum blood-levels may be
reached in 15 minutes. It is advised that not over 5 gm. be used, as patients have died
of toxic hepatitis after implantation of 10 gm. of the drug in the peritoneal cavity.)
Trench Fever.—From 1915 to 1918, 15% of the admissions to hospitals in France
were for trench fever. This condition was unknown before the last war, died out soon
after the Armistice, has never recurred, and no one knows why.
Trench Nephritis.—There was none in the South African War, but in the last war
it occurred in epidemic proportions as a form of acute glomerular nephritis. Strangely
enough no East Indian troops in France developed the condition. The cause was never
discovered.    There has been none in this war.    Ordinary acute nephritis has been rare.
Trench Mouth.—As in the last war, trench mouth is very prevalent. Dietary
deficiencies no doubt contribute. It seems certain that vitamin deficiencies do play a
big part. From No, 5 Canadian General Hospital in England there were reported several
cases of malignant stomatitis with extreme prostration—cultures showed pneumococci—
but the condition did not respond to sulphapyridine. Repeated small blood transfusions
in these cases were considered life-saving.
Scabies.—Scabies is a problem not to be too lightly brushed away. In the last war
30% of medical casualties, it is estimated, were due to scabies and pediculosis—"The
Mite of Scabies versus the Might of Armies." Scabies is prevalent in England. It is the
source of much worry and labour to field medical units. Best results were obtained with
benzyl benzoate emulsion.
Various other less common diseases may occur.
Bubonic Plague.—This has been reported from East Africa. In Nairobi, 547 patients
were treated in hospital in the year 1941. Sulphapyridine acted almost as a specific in
the bubonic form, when given early and in adequate dosage.
Relapsing Fever was reported as occurring in the Tobruk garrison.
Malaria is common in the Pacific war zone.
Venereal Disease^—From 1914-1918 in the C.E.F. there were over 66,000 cases of
venereal disease. Of these, 18,500 were syphilis. At its peak the incidence of venereal
disease was 34 per 1,000.
In this war, up to a year ago, it was 28 per 1,000 (4 cases of gonorrhoea to 1 of
syphilis). The rate is increasing. One of the great difficulties with which the Medical
Service in England has to contend is the fact that there is no legal authority to search
out, and deal with, the sources of infection.
In the treatment of gonorrhoea, sulphathiazole is considered the drug of choice. In
a recent report of a group of cases treated with the various sulpha drugs in the U.S.
Army, it was stated that sulphanilamide cured 44%, sulphapyridine 86%, and sulphathiazole 98%.
The rapid five-day treatment of early syphilis has been tried out in a Canadian hospital in England (using mapharsen—1,200 mgm. in 5 or 6 days) with 81% successful
results reported.
An American medical officer reports that venereal disease is virtually unknown in
the Red Army and Air Force, because there is no prostitution in Russia. There is no
prostitution because there is no unemployment. The women all have work to do. For
"Idleness is the handmaiden of lechery and venereal disease."
Dyspepsia.—Here is one of the major problems of the present war. It is cited as the
single most prevalent type of disease among military patients. "The army still marches
on its stomach, even though, it travels in mechanized vehicles."
A great increase has occurred in peptic ulcer compared with the last war, but it has
also increased enormously in the past twenty years in civil life. (Better facilities for
diagnosis have no doubt to be considered.)
Page 279 Early in this war 60% of dyspepsias in the services in British hospitals were diagnosed as ulcer.—now about 40% or less. Over 20% of all men invalided to Canada
are labelled peptic ulcer.    In one group reported, 96% of the ulcers were duodenal.
Most cases had the condition before enlistment (90%), and some 70% recurred
within two months and the remainder within eight months.
Severe complications are less common than in civilian life.
Approximately 60% of dyspepsias fall into the functional or reflex type—and are
listed often as "Dyspepsias of Unknown Origin."
A small number of these are eventually shown to have ulcer.
Ryal regards gastric neurosis as often a preliminary state to ulcer.
Gastric neurosis may be thought of as D.A.S. (Disordered Action of the Stomach).
Comparable to the old Disordered Action of the Heart (D.A.H.).
Emotional tensions generated in this war are evidently appearing as psychosomatic
disorders.
One contributing factor to gastric neurosis and probably to aggravation of peptic
ulcer, may arise from prolonged tension present in men who are mobilized for war, but
who have little opportunity to carry off their emotions in combatant activity.
The German army is apparently facing the same problem with dyspeptics. The
reported stay "in German hospitals (67 days) is even longer than ours.
It has been reported by one German medical officer that during the Polish campaign,
German soldiers with peptic ulcer lost their symptoms, only to have them recur when
transferred to France as garrison troops. The importance of emotional reactions from
frustration and resentment has been suggested as engendering dyspepsia and reactivating
ulcer. Ff this be true, God knows the Canadian Army in England is entitled to a few
spepeicsailcers.
'•^&re?*too many*3nen>rbeing discharged from the army with duodenal ulcer?
It may be recalled that surgeons, and medical men claimed, in civilian practice, that
some 75% could be cured. Why then the note of despair about the treatment and cure
of ulcer in the services? Surely, from the large number of cases, some could %be salvaged by adequate treatment.
In Shaughnessy Hospital there are usually 35 to 50 indoor cases of gastro-intestinal
disease, of which about 75% have peptic ulcer, far the largest number being young men
from the active army.
The actual cause of peptic ulcer being still unknown, there is much controversy as
to the reason for the high incidence.
A combination of factors must be responsible—defects in diet, long periods between
meals, focal infection, mental strain and worry, familial tendency, excessive smoking, or
other toxins.
There is some evidence that hypoglycaemia occurs in patients with peptic ulcer at
the time of hunger pain and night pain. It is known that insulin will cause an increase
in gastric acids and pepsin. It has been suggested that hypoglycaemia may be produced
by disturbances of the hypothalamus, acting on a liver with impaired function, with
then a vagal reflex causing hypersecretion in the stomach, leading to ulceration. It is
known that vitamin deficiencies can cause liver damage.
It has been shown that superficial erosions develop in the gizzard of chicks fed on a
diet deficient in a fat-soluble factor (associated with vitamin K). With further changes
produced by cincophen, the erosions develop into ulcers closely resembling those seen in
man. The more deficient the diet, the more pronounced the ulcers. It is thought that
cincophen acts first on the liver.
A liver disturbance caused by some toxin, bacterial or chemical, such as industrial
poisons, alcohol, even sulpha drugs, tobacco, or allergins and vitamin deficiencies, must
be borne in mind.
Now, what of tobacco?
There has been a great increase in the use of tobacco between the two wars. It is
stated that over 2 mgm. of nicotine are absorbed in the smoking of one cigarette.
Page 280 (30 to 60 mgm. may produce fatal intoxication.) It has been found that in pronounced
smokers the cell content of the gastric joice is increased above normal in almost all cases
of gastritis, in 80% of gastric ulcer and in 53% of duodenal ulcer.
(The normal cell count ranges from 25 to 500 per cubic mm. with 10-40%
leukocytes. A true gastritis shows an increase of from 1000 to 3000 and up to 8000
with 40-80% leukocytes.)
Nicotine appears to be a specific toxin to at least the vegetative nervous system. By
many it is considered as at least an ^aggravating factor in peptic ulcer. Perhaps nicotine
acts indirectly through the liver and the nervous system, especially where a dietary
deficiency exists.
Nutrition.—Deficiency diseases, in past centuries, helped to vanquish the Crusaders.
Food was a decisive factor in World War I. Scurvy and beri-beri conquered the
British at Kut-el-Amara, in Iraq, in 1915. The defeat of the Italian Army at Caporetto
in 1917 has been attributed partly to the poor quality of the soldier's diet which had
been drastically reduced several months beforehand.
The final collapse of Germany in 1918 resulted in part from malnutrition in the
armed forces and civilian population.
During the Spanish Civil War a great incidence of deficiency states occurred after
18 to 20 months' siege. Starvation oedema became serious after two years. Scurvy was
slow to appear.
Good nutrition is a military necessity.
Even in the face of apparent plenty, food deficiencies occur in a civilian population.
It is estimated that some 15 % of the first million men called by the draft in the United
States had disabilities directly or indirectly due to nutritional faults.
On a proper daily diet the soldier usually has excellent physical efficiency and good
morale.   He resists infection and recuperates quickly from wounds.
The Canadian soldier overseas gets better food than does the civilian in Britain. He
certainly gets better rations than did his father, last time. He receives more meat and
cheese than the civilian, but he misses fresh milk, eggs, green vegetables and fruit.
For the civilian population of the British Isles proteins are of course the big problem
and the most expensive items. First-class proteins—meat and eggs—are scarce, so second-class proteins from cereals and vegetables must be used in abundance.
The British people are prepared, if necessary, to eat grass. The dried juice of one-
quarter of the available grass in the British Isles would supply 100 gm. of second-class
protein per day for the whole population.   Grass is also a good source of vitamin C.
Yeast is a good source of protein, and can be literally plucked out of the air, for
yeast can be grown on a synthetic medium made from nitrogen.
How are the British people getting along with the stringent rationing—on 1 shilling
and two-pence worth of meat per week, practically no eggs, very little milk and cheese,
and no imported fruits?   (Children under 5 years, of course, fare better.)
One's impression of the people in the large cities is that they are beginning to show
some of the effects of a war-time diet—many appear to look rather pale and lean.
A report of group examinations shows that the haemoglobin of older school children
is now lower than pre-war levels.
On the whole, however, the dietary in Great Britain is perhaps better than before the
war, especially for the poorer classes, because of th very regimentation imposed. People
have, perforce, to tend more to a vegetarian type of diet. The national wheat loaf contains extra vitamin Bl and also calcium carbonate.
Even in the United States about 12% of people show clinical deficiency of vitamin
A. About 40% of indigent clinic patients show a vitamin C deficiency; as do all
patients over 70 years of age.
A patient on the old strict ulcer diet becomes vitamin C deficient in about four days.
The diet for Canadian soldiers was said to contain 25 mgm. of vitamin C. This was
not allowing for the destructive effect of army cooking.
German soldiers, be it noted, receive 100 mgm. of crystalline vitamin C daily.
Page 2%l The Neuroses.—These, including gastric neuroses, are a tremendous item in war,
as shown by the large number of neuropsychiatric individuals rejected before enlistment,
and the still considerable number that do get into the services or devleop after induction.
In the First Great War over 340,000 men were discharged from the British Army
for -neuropsychiatric conditions—100,000 of them pensioned. In this war approximately 20% of men invalided to Canada are nervous or mental cases.
Of a group of cases seen t No. 1 Canadian Neurological Hospital, 79% had a
history of previous nervous instability. Fifty per cent were boarded to Category E;
20% of the remaining 50% were made E within a year.
Many of these men, at least in the early part of the war, were hurried over to
England, within a month of enlistment.
In the United States, from 1917-19, there were admitted to service mental hospitals
95,000 cases. Approximately 58% of those hospitalized in veterans' hospitals today are
neuropsychiatric cases and cost the United States Government almost one billion dollars
in 15 years.    Over two-fifths of U. S. pensioners are nervous or mental cases.
It is estimated that it costs $30,000 to care for one psychiatric patient from breakdown to death.
It is reported, that even in 1939, before the Americans came into this war, 3 out of
every 7 men discharged from service suffered from mental disease, and suicide ranked
second as a major cause of death.
In the present South Pacific war over 34% of the first American soldiers returned
to Australia were cases of disturbance of, or injury to, the nervous system. Most of
the anxiety state cases gave a history of previous nervousness or breakdowns.
In the last war, the large number of neuroses (one-third of the British unwounded
casualties) caught the medical services unprepared, without any agreed method of diagnosis or treatment.    The unhappy term "shell shock" was a costly misnomer.
A British commission finally recommended in 1939 that the term be dropped altogether.
Actual war neuroses have been few. It was anticipated that bombing would cause
mass panic and hysteria in the civil population. Nothing of the sort happened^ This
was first apparent in the Spanish war in Barcelona, and later in London and other large
British cities. This is felt to be chiefly because the population was prepared. Bombing
of England did not occur as soon as expected, and also because many peace-time neurotics
were too busy helping, by driving ambulances, working in the A.R.P. and auxiliary services, and feeling too important to complain of their previous symptoms. London neurotics have practically disappeared from outdoor clinics.
The British people appear more bored than worried about air-raids. Young children
have been much less affected than adults.
Proportionately, there have been more neuroses among service men than in civilians.
Until recently at least, the highest incidence of battle neuroses occurred in Norway
—where new men were subjected to the new terror of dive bombing. A large number
showed marked primary shock without being wounded. Nearly every patient was back
with his unit, however, within a few days. For die hard lessons of the last war were
utilized. In that war it was finally noted that the earlier such cases were treated, the
better the results—70% back to duty when held within 10 miles of the front, 40%
from the base, and 10% from England.
Among British troops in France in 1939 to 1940 there was very little battle neurosis
—for fight and flight happened close together. There were a few functional paralysis
of the arms, but none, be it noted, of the legs.
In the first Libyan campaign only 93 psychiatric cases developed and these all cleared
up within three weeks.
There are always many dullards and psychopathic personalities in the services. Frequently they are in trouble with the Sergeant-Ma j or and are often found in the guardroom. The army is not a social service agency, nor a haven of rest for misfits. In war,
it is far better to have a man who is physically sick than one who is neurotic.
Page 282 <Sew        » »..
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3se*s3  tsMWDii
ttB,
MEAD'S
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A product consisting of maltose
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Ingredi
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Magnes
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Magnes
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OF DILAXOL IN VARIOUS GASTRIC DISORDERS
ntative
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Enteritis
Gastric Ulcer
Adsorptive
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Normal
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Actively neutralizes
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Protective
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Insoluble—
Forms protective
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Very active—should
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No effect
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Neutralizes
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Non-
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No action
Mild laxative
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Laxative if excess
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Highly adsorptive
Slight laxative
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rrhoea
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180 However, something can be done with a certain number. The British Army boards
the dullards to category C and employs them in labour battalions where they are relatively happy and do good work. But units, hospitals and reserve units will probably
always be clogged with these charwomen, "the unsatisfactory sick/'
The Germans do not recognize war neurosis as sufficient reason to put a man out of
service, and they, too, use the neurotics in building roads, and trenches, but put them
where they are subject to all the dangers that other men must face.
It may be remarked that in the British Guards Regiments, it is "not done" to be
neurotic, and it is said that no case of neurosis has ever been sent into hospital from
"The Guards."
While most of the neurotics should never have been enlisted, many might be well
today, with high morale, had they but achieved battle. For morale is an awareness of
efficiency. High efficiency depends much on good health. Contentment engenders good
health. Efficiency to perform a task cannot be maintained at a high level, if men are
held back from performing that task. Discontent with waiting, boredom and frustration all interfere with morale, and contribute to, or even cause, ill health.
Rees states that all of us are potential neurotics and delinquents—"There but for the
Grace of God, go I."
Effort syndrome is a vexatious problem in this war, as it was in the last. It occurred
in the American Civil War, where it was described as "young soldier's heart." Forty-
four thousand from the last war were pensioned in Great Britain. Most cases of effort
syndrome are anxiety neurosis or have nervous system cause. • Some few are post-
infective, but these often show a mild depressive state. This condition of ill health is
not a specific disease in itself. Its pathogenesis is actually unknown. Symptoms and
signs, however, closely resemble those of fear rather than those of effort.
From cases reviewed at Hammersmith Hospital, London, two points are emphasized:
1. Severe mental or physical strain is of no more importance than rough conditions,
discipline, and fear of, and dislike for, army life.
2. A psychoneurotic state can nearly always be diagnosed in these cases.
When strenuous assault training was put into effect in England, a fair number of
men were sent into hospital with no specific disease—men of 3 5 to 40 years of age or
more—often previously alcoholic or of poor physique—who carried on with ordinary
training, but who were unable to keep up with the tempo of the toughening process.
Some were cases of mild effort syndrome and some showed signs of 'early cardiovascular
change.
The most common cause of death at ages 40 and above is still cardiovascular disease,
and the age incidence of coronary deaths appears to be lower year by year. The chronic
stress of flying is said eventually to induce a generalized and often rapid deterioration
of the cardiovascular and nervous systems. Alcohol and tobacco probably hasten the
process.
When one considers what battle training entails, and the strain of modern mechanized warfare, in which powers of endurance must be immense, one tends to agree with
the statement that this is a young man's war.
Air Raid Casualties.—Up until a year ago approximately 50,000 British civilians
had been killed by bombs and about the same number wounded. The casualties from
battle in World War I were in the proportion of one killed to four wonded. Now,
where bombing plays tne biggest part, the-proportion is about one killed to two wounded
and of the wounded 50% die soon after injury.
Although tremendous devastation has been caused in many cities by bombing, yet, if
looked upon in a cold analytical way bombing loses much of its terror. Most people
adopt a fatalistic attitude, and stay where they are when a raid is on.
It is estimated that to kill one man in an open field, 50 to 100 bombs are required.
A Short Reference to Blast and Its Effects.—When a bomb bursts, there is pushed
out a single pulsation of short duration, travelling faster than sound, followed by a
zone of rarefaction (the negative wave).   The force may vary from 100 pounds up to
Page 283 hundreds of tons per square inch. Even 10 pounds pressure per square inch against a
wall 10 x 20 feet is equivalent to a weight of 50 tons. However, the pressure effect
falls rapidly. Thus, of three men standing 6 feet apart, only two may be killed. In
one instance reported, a 50 kgm. bomb dropped into a room containing eight people.
Five only were killed, and the other three were back to work in three weeks' time.
One man in London, lying only 50 feet from a land mine when it exploded, was
lifted for a distance of two feet. His ear-drums were ruptured (apparently about 6
pounds pressure will rupture ear-drums) but he was conscious and in two weeks' time
was well.
If a person is unconscious from blast he usually does not recover.
Experiments with rabbits have shown that when they are anchored at different distances from a given explosion, certain events will occur:
At 10 feet (pressure 120 pounds to square inch) the animals disintegrate.
At 15 feet (pressure 60 pounds) all animals are dead, with bloody froth pouring
from nose and mouth.
At 20 feet—some are dead, some die later (up to 2 or 3 weeks).
At 25 feet, the rabbits live but show changes in various organs.
At 40 feet, they are unharmed.
At postrmortem the outstanding lesions are haemorrhages into the lungs, but also in
abdominal organs, and less often in the nervous system. The haemorrhages are due to
the impact of the blast wave on the body wall, and not to blast acting through the
respiratory passages. The chief effects are on the side exposed to the blast. This is
proven by encasing animals in sponge-rubber, which protects them from damage.
Post-mortem findings in humans killed by blast are similar to those of the experimental animals.
Where patients survive the blast-damage to the lungs, diapedesis of the red blood
cells from the capillaries occurs, and goes on for about 48 hours. These patients show
shock (often profound), dyspnoea for the first 2 or 3 days, and cyanosis, may have
chest pains, and blood-stained sputum. *
X-ray shows bilateral mottling which takes about 7 to 10 days to clear up.
Some of these chest cases show abdominal pain and rigidity. Some have had laparotomies done—with negative findings.    (Probably reflex vagus effect).
Heart damage may occur through trauma to the chest wall—especially in the young
adult. Experimentally it has been noted that in a heart sensitized by adrenalin, cardiac
irregularities and coronary spasm may develop.
In the strain of battle, where the vascular system is surcharged with adrenalin, slight
trauma to the chest wall may cause considerable cardiac disturbance. Vascular occlusion may develop several hours or several days later. Therefore, when cardiac irregularities appear soon after chest injuries, coronary occlusion must be considered.
Impact of the blast wave from depth charges, striking men in the water, causes
chiefly abdominal injuries, retroperitoneal haemorrhage or rupture of the intestine.
Air raid casualties are seldom caused by blast alone. A multitude of other events
complicate the picture—as bomb fragments, flying masonry, displacement and falls,
carbon monoxide, asphyxia and burns.
Because of the prevalence of lung damage from blast it may be fatal to give an
inhalation anaesthetic.
The crush syndrome is an arresting condition, occurring where a limb has been
pinned down under debris for hours. Plasma pours into the injured limb and progressive anuria develops. Mortality has been 100% in these cases treated in one London
hospital.
Shock in air raid casualties is usually present and may be divided into: (1) Primary
shock—where the nervous system alone is involved—a vaso-vagal phenomenon—but
where the blood volume is normal; (2) Secondary shock, in which the blood volume is
low—with falling blood pressure. Secondary shock may be superimposed on primary
shock.
Page 284 There are also other conditions associated with apparent shock, such as elderly
patients with hypertension, patients with carbon monoxide poisoning and patients with
coronary thrombosis.
According to Sharpey Shaffer the treatment of shocked casualties is of three types:—
1. The so called conservative surgical method (warmth, morphia, and rush in and
operate.
2. The hematological method, used by those with large supplies of fluids that they
wish to utilize.
3. The method of observation, by serial blood pressure readings, serial haemoglobin
readings, and serial postural response—with the giving of plasma and fluids as indicated.
This is known as the Continuous Interference Syndrome.
Burns.—The treatment of burns has called forth many remedies and produced much
controversy. Tannic acid, of course, is taboo on the face and extremities, but is
favoured by some for other parts. Continuous saline baths have produced excellent
results. Dyes of various sorts are used. Those used vary with the colour scheme
favoured by the surgeon.
Recently sulphadiazine triethanolamine, in ointment or spray, has been offered as the
treatment of choice.
So many remedies have been employed that a consultant to one of the large London
hospitals has said, "I really don't know what the treatment for burns is this week."
In the last war, the British medical service handled over eleven million sick and
wounded, and sent 90% back to duty. (The British Empire mobilized over eight and a
half million—of whom- nearly one million were killed, over two and a half million were
wounded, and over 270,000 were taken prisoner.)
The Canadian Medical Service, which first became a living and powerful force at
Ypres in 1915, cared for well above 500,000 (over 144,000 of these Canadian battle
casualties).
Battle casualties in the last war in France in the B.E.F. were: wounded, 37%; total
killed, wounded and prisoner, 56%. Canadian battle casualties were 34.5%—144,600
(of whom 56,638 were killed).
The medical officer does his killing by proxy—although he may be killed himself.
Seven hundred and forty-two British medical officers were killed or died of wounds in
the last war. (The only two men who ever won the Victoria Cross twice were medical
officers in the R.A.M.C.)
Thirty Canadian medical officers were killed, 99 were wounded. It is not generally
known that 21 Canadian nursing sisters were killed or died of wounds.
At Dieppe, several Canadian medical officers were killed or wounded.
A few words about Dieppe  (information obtained from Brigadier Sherwood Lett,
D.S.O., M.C., who was wounded in that battle).
Two medical officers accompanied each battalion. Extra stretcher-bearers from field
ambulances went ashore with the attacking troops. All wounded, if humanly possible,
were brought back to the beaches. The first-aid training that every officer and man of
the attacking force had received paid big dividends. Casualties from the beaches were
placed on landing craft first, and taken to several ships, which had been fitted as emergency floating hospitals. These were soon filled to over-flowing. The wounded were
back over the sixty miles of water, and carried by ambulance or ambulance train, and
admitted to various Canadian hospitals in England within 18 to 36 hours.
Incidentally, secrecy was good—so good, in fact, that hospitals did not know they
were to receive casualties until after the attack began.
Blood plasma undoubetdly saved many lives, as did sulpha drugs and early surgery.
Only one case of osteomyelitis developed. Of 8 8 severely wounded men admitted to
one hospital dnly 2 developed gas-gangrene, which was quickly controlled. The Brigadier was full of praise for the medical services, and remarked that if the standard set
at Dieppe, in efficiency and courage, be taken as an example of what the Canadian
Page 285 ~~l
Medical Service can provide, then the Canadian people may have the satisfaction of
knowing that their sons will always receive the finest medical care possible.
In conclusion, it is apparent in this war, as it affects the Canadian Army, that the
devastating diseases of former wars are almost non-existent, that tuberculosis, kidney
disease and rheumatic disease are relatively low in incidence. This has been accomplished
by preventive medicine, routine inoculation, routine chest X-rays, routine urinalysis and
routine dental care.
Apart from the casualties of battles yet to come, the chief problems that confront
the Canadian Medical Services are seen to be gastro-intestinal, neuropsychiatric and
venereal.
To practise medicine with the armed forces is not only a great adventure but a great
privilege, and War Medicine throws a challenge to the eager young medical man. As
a happy warrior against disease and death, he finds that satisfaction and comradeship,
born of common service and often of common misery and stark fear, that cannot be
found except in war.
The task of the Medical Service is "To preserve a man alive and fighting fit, in the
midst of chance and hostilities."
In the First World War, the Canadian Medical Service never once failed in this task.
In this World War it shall not fail.
V
ancouver
G
eneral
Hospital
REPORT MADE BY DR. F. N. ROBERTSON TO THE
MEDICAL BOARD OF THE VANCOUVER
GENERAL HOSPITAL
Mr. Chairman and Gentlemen:
I have asked for a few minutes of your time in order to render a final report upon
the test for cancer, which you have so kindly sponsored. In order to save time, no
description of the technique nor the test will be given, but just the statistical findings.
But before giving them it will be necessary to pick up the threads from my last report.
You will recollect that Dr. Dolman was asked to look into the technique and the
whole matter of the test. His criticism was that the test depended too much upon the
personal element and that two technicians might get different results. He also recommended that 100 tests be done where the technician never saw the patient nor the chart.
A variation of the test was made so that the personal element would not enter
into the results. This was presented to Dr. Dolman and met with his approval. This
new method is as follows: the urine was measured, not guessed at, for 60 c.c. This was
tested for calcium by Sulkowitch's reagent and lime water added to the urine till it
contained a normal amount of calcium. Blood to the amount of 4 cc. was taken from
the patient and the needle removed from the syringe. The glass tip was then placed
against the bottom of the enamel dish, and the blood laid under the urine, not forcibly
as before. The whole was left to stand for 20 minutes. Then the blood and urine were
carefully poured out and any excess remaining in the dish gently washed out with cold
water. Any blood clots in the dish were then decolourized by hydrogen peroxide and
gently washed again with cold water. A 5% aqueous solution of Carbol Fuchsin was
then added and any fibrin left in the dish would be vividly stained, which would be a
positive test.
Neither the technicians nor myself liked this method- as well as the original, as, in
pouring off the blood and urine, the normal blood clots were liable to cling to the clots
adherent to the dish and tear them off.   Thus the test was rendered of no value.   Also
Page 286 any chips or scratches in the enamel would stain with Carbol Fuchsin and were difficult
to distinguish from stained fibrin.   However, it met Dr. Dolman's requirements.
The next step was to get 100 patients. Dr. J. B. Harrison kindly consented to send
100 patients who were receiving X-ray therapy. These were just "the run of the mill"
cases, not all cancer patients. In order that the technician doing the tests should not see
the patients, we really required two technicians. In these war times it was found impossible to obtain two. However, the technician did the best she could under the circumstances. Dr. Harrison sent 72 patients and for 64 of these the technician was able to
find another technician in the Lab, not busy at the moment, who drew the blood for her.
These 64 patients were never seen by the technician. She only knew them by number and the reports she rendered were given by number and compared with the diagnosis
held in the X-ray Department. They also were tested by the new method as outlined
before. The number is not that required by Dr. Dolman, but his conditions have been
met in every other way.
Of these 64 cases, 2 had leukaemia, 1 had Hodgkin's disease and 4 have no final diagnosis. Thus only 57 cases are left to be reported on, and in this small series the test was
accurate in 50 cases or 87.7%. There were 41 Positive tests, 9 Negative tests, 2 Doubtful tests (which should have been repeated) and 5 False tests.
All this has been done to meet Dr. Dolman's criticism. Filling his requirements
for a test where the personal element does not interfere with the test, and where the
technician has no knowledge of the patient, the accuracy of the test, as stated, was
87.7%.
Now I would like to give you the results of the major portion of my work, which
will take much less time. This book contains the record of 1310 cases tested by 1729
tests.
From these 1310 cases must be taken 443 cases, as 260 had no final diagnosis, 73
were taking sulphonamides, 3 had dermatitis, 6 had Hodgkin's disease, 10 had sarcoma,
6 were abortions or Estopic pregnancies, 10 had leukaemia, 9 were technical errors and
there were 66 doubtful tests. Thus there is left a balance of 867 cases and in these
cases the test was correct 735 times—480 Positive tests and 245 Negative tests. This
gives an accuracy of 84.7%.
Of the 66 doubtful cases only 6 were repeated and these still remained doubtful. In
the 1729 tests done there were 104 doubtful reports. These were all repeated with
the following results 17 remained doubtful, 52 became positive, 13 became negative, or
a definite report could be given in 65 of the 104 cases.
The balance of the cases were as follows: 6 false positives, 2 false negatives, 1 leukaemia, 3 on sulpha drugs and 10 without a final diagnosis. In the series of 867 cases
there was agreement with the diagnosis in 735 cases. There were 93 false positives, 15
false negatives, and 66 doubtfuls.
The false positives are so many more than the false negatives and there are so many
doubtfuls that it rather suggests that the test is too sensitive. All doubtful tests should
be repeated.
Regarding the reports of weakly positive, moderately positive, strongly positive, etc.:
These terms were used at first and we felt the terms might have some relation to the
grade of malignancy or the extent of it. But experience has shown that there is no relation. However, the terms were continued, as they were found useful in writing up our
reports. As far as the clinician is concerned a "weakly positive" report is just as significant as a "strongly positive." In other words, the reports should be either positive,
negative or doubtful, and all doubtfuls should be repeated.
In conclusion, I would like to express my gratitude to the Staff for their assistance
in these experiments, and to sum up my own opinion of the results. I feel that it has
been definitely proved that a reaction between the blood and urine of a cancer patient
does take place. Also I think the test is of very definite value, when taken in conjunction with clinical findings. It may be impossible for the Lab. to carry on these tests as
before, but I do feel that the Lab. could set a charge for the test and do it upon request,
as is done at St. Paul's. The charge would limit the number of tests, yet the test could
be obtained when desired and in this way the technique could gradually be improved.
Page 287 STAFF MEDICAL WORK IN THE VANCOUVER GENERAL
HOSPITAL
G. L. Hodgins, M.D.
The members of the medical staff of The Vancouver General Hospital have thought
that the physicians of Vancouver might be interested in a record of the amount of work
done in the medical wards and in a comparison of the work done during each year of
the War. There is a tendency to regard this present era as one of general prosperity,
and therefore, one in which the staff medical work would be drastically curtailed. This
tendency is reflected in the reduced number of beds which have been allotted to staff
medicine, but the figures presented in the accompanying tables show that this is not
entirely the truth. The steady reduction in the total number of beds allotted to medicine since 1940 has been offset by the steady reduction in the number of days each
patient stays in the hospital. It is not due to any change in the type of case which is
seen, rather it is due to more rapid diagnosis, more intense work by the house physicians,
and more work done by the attending physicians. If the Provincial Government could
provide more room for infirmary cases, and if the City authorities could provide more
beds for convalescent patients, it would be possible to reduce the hospital days' stay very
appreciably. There are many days each month when there are as many as seven to eight
patients waiting to be transferred to convalescent homes or infirmary beds. At times,
there have been periods when patients had to wait two and three weeks before they could
be transferred out of the hospital and only because of lack of space.
In Table 1, we see the total number of male and female medical beds in The Vancouver General Hospital since 1940.    It will be seen that they have been reduced by 23
beds during this time.
Table 1.
Total Number of Staff Beds (Medical)
Male Female Total
1940 51 20 71
1941 45 20 65
1942 36 12 48
In Table 2, there is an outline of the total number of staff medical patients treated
each year and the average number of days which each have stayed in the hospital. Thus,
there have been 546 male patients in 1942 with an average stay in hospital of ten days.
Table 2.
"Staff" Medical Patients in Vancouver General Hospital
Male Female Total
1940      1941      1942 1940      1941      1942 1940      1941      1942
Total Number  Treated_______.   691        638        546 551        569       435 1242      1207       981
Average Stay in Hospital in Days_ 14.1       12.8 10 15.5       14.1       13.5 14.6       12.9       11.8
Table 3 is more illuminating insofar as it shows that the average number of patients
discharged has increased each year, which is an excellent sign, and also the death rate in
the hospital has steadily declined. Furthermore, the improvement in discharges and in
death rates has not been accomplished by transferring them from the hospital because
the number transferred per year has declined steadily also.
1940
Male
1941
Table 3.
1942
1940
Female
1941
1942
Patients
Discharged
Patients Died
Patients ^
Transferred— 348(52.2%)     275(44.4%)     258(47.2%)       229(42.9%)     211(39.1%)     157(36.1%)
178(26.7%)  193(31.1%)  168(31.0%)
140(21.0%)  152(24.5%)  107(19.6%)
240(45.3%)  257(47.6%)  224(51.5%)
63(11.8%)  72(13.3%)  41(9.4%)
666 620        533 532        540        422
As the physicians of Vancouver can readily understand, these 48 staff medical beds
must serve the population of Greater Vancouver as well as many cases sent from outside
Page 288 the city. Therefore, it is absolutely necessary that they be kept as beds for the treatment of acutely ill patients and as active beds for the rapid diagnosis of difficult medical
problems. It is impossible to be expected to use them for the aged people who need only
nursing care, for everyone who has had a "stroke," or for anyone who can get any care
at home whatsoever. The physicians of Vancouver have been very cooperative in this
regard, otherwise it would not be possible for a city of this size to be able to carry on
with so few medical beds.
(I would like to thank Mr. Fish of the Medical Records Department for his courtesy
in making the statistical survey.)
SUBDURAL HAEMATOMA IN INFANCY
J. W. Cluff, M.D.
{Senior Resident in Neurology, The Vancouver General Hospital)
Intracranial haemorrhage with the formation of a subdural haematoma is not an uncommon disease of infants, and it is one in which the diagnosis is so simple it should
never be overlooked.
Etiology
Formerly the condition was known as Pachymeningitis hemorrhagica interna, which
name expressed the belief that an inflammatory process was in question. Price goes so
far as to state that the condition is now considered to be invariably of traumatic origin.
Trotter was the first to point out that the lesion in reality was traumatic, but, due to
the minor nature of the trauma, and the long interval between injury and onset of symptoms, the injury is frequently forgotten or overlooked and the history does not reveal
the primary cause.
It occurs most frequently in undernourished infants, particularly those not breastfed.
Ingalls made a study of Vitamin C deficiency and its relation to subdural haematoma.
Rosenberg stated that he had never seen it occur in a healthy normally developed breastfed baby. Such factors as malnutrition and Vitamin C deficiency do appear to predispose to the disease. Sherwood, Rosenberg, Peet and Kahn all refer to the fact that the
greater proportion of cases occur in illegitimate children reared in institutions or foster
homes, who may well have a deficient diet but are also exposed to frequent trauma. The
modern concensus of opinion seems to favour trauma as the actual exciting mechanism
in all cases.
The increase in the incidence of the disease is comparable to the increase in the incidence of carcinoma. The frequency with which both conditions are found is in direct
relation to the intensity with which they are sought for. An increased effort toward diagnosis is rewarded by the increasingly favourable prognosis of treated cases.
Pathologic Physiology: The origin now undoubtedly appears to be haemorrhage into
the subdural space from rupture of the superior cerebral veins. These run from the
cerebral cortex to the dura or longitudinal sinus and have a short vertical course in the
subdural space. The line of force of the blow is usually in the anteroposterior or postero-
anterior diameter, since the falx cerebri protects this region from lateral trauma.
Following the original haemorrhage there is organization along the inner dural surface
with formation of very thin walled vessels and a vascular membrane is formed. Peet and
Kahn state that from these vessels there is continuous transudation producing the xanthochromic fluid. The membrane lining the outer surface of the arachnoid is less vascular
but is fibrous and inelastic and milky white in appearance at operation.
Possibly increased intracranial pressure compresses the venous drainage system, augmenting transudation by passive congestion. From time to time these thin walled vessels
in the inner dural membrane rupture; this accounts for lamination of the subdural membrane and frequent alterations in colour of fluid.
Clinical Features
First symptom noted is usually a gradual enlargement in the size of the head, frequently associated with convulsions.    The shape and size of the head resemble hydro-
WM Page 289 cephalus with bulging of fontanelles, but instead of a dull apathetic face one is struck by
the bright alert expression usually seen except in advanced cases, even though the eyeballs
are displaced downward.
General symptoms of increased intracranial pressure as headaches, changes in optic
fundi, vomiting, strange behaviour, irritability progressing to drowsiness, lethargy and
eventually coma are frequently found.
Various neurological signs may also appear, the most common being convulsions and
an internal strabismus, but one may also find flaccid or spastic paralysis, weakness, exaggerated reflexes and muscular incoordination in various limbs.
Diagnosis
Suspicion of the presence of subdural haematoma is aroused by any of the above findings. In some cases the only sign is gradually increasing size of the head. Confirmation
of diagnosis is a simple procedure. A subdural tap will reveal the typical blood stained
xanthochromic fluid if the haematoma is present.
Bilateral aspirations should be attempted whether fluid is found on the first side
tapped or not. In contrast to adults in whom only about fifty per cent of subdural
haematoma are bilateral, most series of cases reported in infants show the large majority
to be bilateral.
The aspiration is relatively safe and easy to do if certain precautions are observed:
1. Use aseptic precautions: shave and scrub scalp well.
2. Use sharp needle with short bevel and make entry at point of lateral angle of
anterior fontanel, pointing the needle in a lateral direction.
3. Force used to insert the needle must be under control. The needle should be
grasped near the tip with gloved fingers resting on scalp to prevent it from being pushed
into brain when dura is pierced.
As soon as the needle enters the dura, if present, the fluid usually appears and gushes
forth each time the baby cries. This fluid is always xanthochromic and bloody, with
elevated protein content, and if centrifuged the supernatant fluid usually shows a yellowish colouration.    These factors are important in distinguishing it from
1. Ventricle fluid in hydrocephalus. In this condition fluid is not usually encountered until needle has penetrated the dura one or two centimetres. The fluid is clear and
has a normal cell count. If red cells are present they are usually due to trauma of puncv
ture; centrifuging in such cases gives clear supernatant fluid.
2. Subarachnoid fluid. If more than a drop or two of clear fluid is obtained, the
possibility of an accumulation of a large amount of subarachnoid fluid following cortical
atrophy must be considered. Such fluid may be rendered bloody by trauma of the tap
but if centrifuged it will give a clear supernatant fluid.
If lumbar puncture is performed it may yield clear fluid, chemically normal or
xanthochromic or blood-stained fluid, and the possibility of subdural haematoma must be
remembered with any of these findings.
Treatment
This must of necessity be based on a comparison of the effects of the disease in
infants and adults. When infants and children are seen only occasionally in a group,
most of whom are adults, there is a tendency to treat all the same way regardless of age.
If infants and young children are considered as a separate group, one is more likely to
remember the factors requiring more radical treatment in this group.
According to Ingraham and Heyl these factors include:
1. The fact that the brain volume is doubled during the first three months of life
and redoubled during the next six months. In view of this fact a thin membrane of
inelastic tissue covering the brain should do considerable damage. Obviously the danger
from the constrictive effect on the circulation is greater than in a brain which has
reached full growth.
2. In addition to the constrictive effect of the inner membrane there is interference
with absorption of cerebro-spinal fluid because of   (a)   pressure tending to obliterate
Page 290 the subarachnoid space and (b) the inflammatory reaction to the presence of blood in the
subarachnoid and subdural spaces. Ingraham and Heyl believe that the removal of
bloody cerebro-spinal fluid will minimize this difficulty but that as long as a membrane
is present, absorption will be impaired with resultant tendency to increasing hydrocephalus.
In adults hydrocephalus secondary to subdural haematoma is uncommon whereas in
infancy it occurs in most cases.
3. In addition to the above two factors relative resistance of the infant and adult
brain is based on principles that as the functions of the cortex are in the process of being
developed there should be as little interference with circulation as possible. To accomplish this, membranes must in large parts be removed. While formerly leaning toward
conservatism the treatment has now become radical.
The only type of case that might recover spontaneously with repeated aspirations is
one with an outer membrane so thin as to be scarcely visible on the inner surface of the
dura and a great amount of fluid present. Rosenberg states that of cases treated this way
fifty per cent die in hospital of intercurrent infection. He followed fifteen out *of a
total of thirty cases who left hospital and found that four died, two were idiots, four
imbeciles, one severe neuropath, one stutterer, and two bed-wetters, one of whom had
optic atrophy.    Only two of the original thirty were normal.
Peet and Kahn reporting nine cases in 1932, of whom five died during or shortly
following radical surgery, felt that in spite of their mortality rate surgery was justified
in view of Rosenberg's findings.
They proposed examination of membranes through a trephine opening to determine
whether the condition might regress under conservative therapy or not. The burr holes
were so placed that they could be extended as osteoplastic flaps if membranes were in
evidence.
In reviewing their series they proposed the following operative procedure:
1. If haematoma is bilateral the space opposite the operative side is tapped before
commencing the operation. This procedure is to avoid subsequent pushing over of the
brain stem by pressure of fluid on the unoperated side when the intracranial pressure
commences to reach normal postoperatively.
They felt that three of their five deaths were due to this mechanism.
2. A moderate sized osteoplastic flap is then turned down in the frontoparietal
region, the dura is opened, meningeal vessels clipped and membrane removed. The milky
membrane is removed from the arachnoid and permits brain expansion. The wound is
closed without a decompression opening being left.
During operation, faculties are available for immediate transfusion.
Ingraham and Heyl in 1939 reported a series of eleven cases with only one death.
They propose a plan rendering radical management safe and giving (in their series at
least)  a low mortality rate.
1. Lumbar puncture. This is performed only in absence of evidence of markedly
increased intracranial pressure. About ten cubic centimetres (10 c.c.) of fluid are removed. If it is bloody, daily spinal taps are perfomed until it clears; if there is marked
increase of intracranial pressure, bilateral subdural taps are first perfomed.
2. Bilateral subdural tap. Not more than fifteen cubic centimetres (15 c.c.) are
removed from each space. If only a small quantity is obtained it may be examined for
protein and red cells. Each side is subsequently tapped on alternate days for seven to ten
days while improving the general condition of the patient. Vitamins, fluids, and transfusions are administered as indicated and infections such as pneumonia and otitis media,
which not infrequently occur as associated conditions, are controlled.
3. Bilateral trephine. After seven to ten days bilateral trephine is performed with
burr holes so placed that they can be included in bone flaps. The cavities are emptied
and examined for the presence of membranes and organized clots. If desired the cavities
may be filled with air and radiographs taken to determine the size of the space. If
membranes are present one must proceed and perform osteoplastic flaps and remove as
much of the membrane as can safely be reached through the operative opening. One side
at a time is operated, allowing a brief period of convalescence between.
Page 291
■ Report of Two Cases
Case 1: D. M. B., female, aged four and one-half months, admitted on February 12,
1942, to The Vancouver General Hospital under Dr. Isabel Day and referred to Dr.
Frank Turnbull, with a history of convulsions and vomiting. She was a second child of
normal term birth and had been breast-fed for three weeks, making satisfactory progress
except that she failed to gain weight as mother thought she should. One month previous
to admittance she had a convulsion. A doctor was called and diagnosed a feeding upset.
Three days prior to admittance she had another convulsion and had vomited frequently
from that time on. Examination revealed an emaciated child, dehydrated, head enlarged,
fontanel tense, eyes displaced downward, fundi clear. She continued vomiting and had
one convulsion in the hospital. Aspiration of the right subdural space a few days later
revealed fifteen cubic centimetres (15 c.c.) of amber fluid containing gross blood. This
was repeated three times in one week with improvement.
February 27, 1942: Under ether anaesthesia a right parietal bone flap was turned
down. The dura was opened and a thin but definite subdural membrane removed. The
brain expanded well and was closed without drainage. Postoperatively aspirations were
done for five days and increasing amounts of fluid ranging from thirty to fifty cubic
centimetres (30-50 c.c.) were obtained.
March 5, 1942: Trephine was performed just behind the bone flap margin under
local anaesthesia. Dura and membrane were opened; the outer membrane was removed
as much as possible and inner membrane incised allowing brain to expand. The space
was washed and the wound closed with drainage. Drainage was continued for one week;
then the wound healed and the child was discharged from hospital, apparently well.
April 23, 1942 (seven weeks later): The patient was readmitted with a history of
her head enlarging and being drowsy and irritable. The bone flap was reopened and the
inner surface of the dura found to be covered by a light granulation tissue. The subdural membrane was thin. The sac was washed out and the dura replaced and closed
with drainage.    She continued to improve and was discharged two weeks later.
August 25, 1942 (four months later) : The patient was readmitted. She had been
well until three days previously when she fell, bruising forehead and right eyelids. She
vomited all the following day and on the day of admission screamed, fainted and became
tense. Physical examination revealed bilateral retinal haemorrhages, the right optic nerve-
head swollen, internal strabismus and the eyes pushed down.
August 28, 1942: Under avertin and ether anaesthesia the bone flap was re-opened and
about eight cubic centimetres (8 c.c.) of loculated fluid and a moderately thick subdural membrane were found. The space was cleaned out and the dura excised, turned
inside out and sutured back in place. The wound was closed with drainage. Reports
say that she has continued to be well.
Case 2: L. T., male, aged five and one-half months, admitted to hospital on January
24, 1943, under Dr. J. W. Millar, referred to Dr. Frank Turnbull, with a history of
having had a block of wood fall one foot onto chest producing bruises. He became immediately unconscious and had a convulsion. Radiographs revealed no fracture of chest.
The child continued to be comatose and was tube-fed; he also had frequent minor twitch -
ings which were controlled by phenobarbital. Further questioning of foster parents
revealed that the child had been adopted at the age of about two months. He had
always been well and weighed eighteen and one-half pounds at the time of the injury.
One week before the injury he had fallen three feet from a table to the floor, bumping
his head with resultant ecchymoses to both cheeks and temples and bump over the occiput.   On admittance the central fontanel was tense and internal strabismus was present.
A few days later subdural spaces were aspirated and forty cubic centimetres (40 c.c.)
of bloody fluid were obtained from the left and two cubic centimetres (2 c.c.) from the
right. Aspirations of the left space were repeated as indicated. One week after admittance the child was lethargic, the fontanel tense, and internal strasbismus present; the
limbs moved very little voluntarily and were flaccid on passive movement.
February 1, 1943: Under ether anaesthesia the left space was aspirated and forty-five
cubic centimetres (45 c.c.) of bloody fluid obtained. A left parietal flap was turned
down and the dura was opened with a circular incision and removed.    A few pieces of
Page 292 membrane were removed from the surface of the subarachnoid membrane and the inner
surface of the dura. The dura was replaced and sutured inside out. The bone flap was
replaced and the scalp closed with drainage. At the conclusion of the operation a small
blood transfusion was given. The child made good progress and became conscious but
was drowsy most of the time. Aspirations were attempted postoperatively for about
one week but no fluid was obtained.
Approximately three weeks later the baby again became lethargic and irritable.
Aspiration of the left space yielded forty cubic centimetres (40 c.c.) of bloody fluid on
three occasions.
February 27, 1943: Under local anaesthesia, a burr hole was made in the right frontoparietal area. On opening the dura about forty cubic centimetres (40 c.c.) of blood
tinged brownish fluid exuded and a small organized clot was teased out. The former burr
hole on the left side was then re-opened. On opening the dura the brain was found to
be depressed one-half centimetre (J4 cm.), giving the impression that haematoma had
been bilateral but communicated and had drained through opening on the right. (One
other case that communicated was mentioned by Peet and Kahn.) The wounds were
closed, with drainage. That on the left drained very little but the right side drained
for a total period of nine days. The last two or three days the drainage was clear cerebrospinal fluid. The child made a good recovery, was discharged in three weeks, and is now
well.
Comment
Lumbar puncture was not performed in either of these cases. Though advocated by
Ingraham and Heyl, they admit that.it must not be done until after subdural aspiration
in the presence of markedly increased intracranail pressure. Certainly it seems safer to
remove fluid from above than from below and avoid the danger of pressure from above
pushing the brain down and compressing the brain stem at the incisura or foramen magnum. Aspiration is a simple procedure and may be repeated until the infant is prepared for operation.
These cases also illustrate how well infants tolerate cranial surgery when precautions
are taken. The first case had craniotomy performed on four occasions, the second on two.
Blood for transfusions is routinely taken the night before operation and is available
immediately if shock supervenes. In the absence of this complication the baby is given
a transfusion of ten cubic centimetres (10 c.c.) of whole blood for each pound of body
weight immediately following operation.
The dura was turned inside out because even after the memberane has been removed
the inner aspect of the dura is seen to be covered with delicate granulation tissue which
carries the vessels supplying the membrane. This tissue obviously would exude fluid if
replaced; by .inversion the non-vascular outer surface is placed next the arachnoid membrane.
Summary
1. Subdural haematoma is not an uncommon condition in infancy and is one which
is amenable to treatment and offers a good prognosis. Due to the simplicity of aspiration the diagnosis is easily made. In any child presenting progressive hydrocephalus,
especially if associated with convulsions, aspiration must be attempted to rule out subdural haematoma which can be cured.
2. Due to several factors the condition in infants and small children should be considered as a separate group and treated as such.
3. Radical treatment seems the most satisfactory method and offers the better
prognosis.
I wish to thank Dr. Frank Turnbull for his assistance in the preparation of this paper.
BIBLIOGRAPHY
A Textbook of the Practice of Medicine—Edited by F.  W*. Price—Sixth Edition   (1941)—Oxford University Press, London.
Peet, Max, and Kahn, Edgar: Journal of the American Medical Association,  (1932)  98: 1851-1856.
Rand, C W\: Archives of Surgery,  (1927)   14:1136.
Trotter W\: British Journal of Surgery,  (1914)  2:271.
Sherwood, David: American Journal of Diseases of Children, (1930)  39-981.
Ingraham, F. D., and Heyl, H. L.: Journal of the American Medical Association,  (1939)   112:198-204.
Rosenberg, O.: Quoted by Peet and Kahn as above.
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