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The Vancouver Medical Association Bulletin: December, 1943 Vancouver Medical Association 1943

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Full Text

 The BULL EM
of the
MEDICAL ASSOCIATION
Vol. XX.
DECEMBER* 1943
With Which Is Incorporated
Transactions of the
Vi c tori a Me die at Society
the
Vancouver General Hospital
and
St. Paul's Hospital
Special .Iff
"MilitaryjjMedicihe
.If Edition IADIOSTOLEUM
TRADE MARX
(Vitamins A and D)
The advantages of administering oils containing adequate doses of
Vitamins A and D in small bulk are being increasingly realised.
Radiostoleur^was the original preparation of this type and was
employedftj^many of the early investigations ^tto the precise
functions, doses, etc., of Vitamins A and D. Since that ^inemhas
been used extensively if|rmany parts of the world in the ordinary
routine of clinical practice.
Under® the ^disturbed ^conditions bf|j|?iving now prevailing
Radiostoleum assumes a new importance in that it provides a most
economical and convenient means of augmenting the dietary intake
of Vitamins A and D which is probably below the normal daily
requirement while body needs may actually be increased considerably.
Radiostoleum liquid may be given to infants, either undiluted from
a Spoon or mixed with a bottle feed. For young children also this
is the most convenient form for administration since the dose can
be shaken up in milk or added to puddings £>r cereals. Older|ihil-
dren and adults may prefer Radiostoleum capsules as the medium
for taking prophylactic doses although larger therapeutic doses may
be taken most convenienti^ln the form of Radiostoleum liquid.
Stocks of Radiostoleum are held by. leading druggists throughout
the Dominion, and full particulars are obtainable from
THE    BRITISH    DRUGpHOUSES    (CANADA)    LTD.
Toronto Canada
-Rstm/Can/4312 THE   VANCOUVER   MEDICAL   ASSOCm^^l1
BULLETPN'
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. XX.
DECEMBER, 1943
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
Son. 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. Lockhart
Auditors: Messrs. Plommer, Whiting & Co.
SECTIONS
Clinical Section
Db. J. W. Miller Chairman Dr. Keith Burwell Secretary
Eye, Ear, Nose and Throat
Dr. C. E. Davies Chairman Dr. Leith Webster Secretary
Pediatric Section
Dr. J. H. B. Grant Chairman Dr. John Piters Secretary
STANDING COMMITTEES
Library:
Dr. A. Bagnall, Chairman; Dr. F. J. Buller, Dr. D. E. H. Cleveland,
Dr. J. R. Davies, Dr. J. R. Neilson, Dr. S. E. C. Turvey
|||gi Publications:
Dr. J. H. MacDermot, Chairman; Dr. D. E. H. Cleveland,
Dr. G. A. Davidson
Summer School:
Dr. J. C. Thomas, Chairman; Dr. J. E. Harrison, Dr. G. A. Davidson,
Dr. R. A. Gilchrist, Dr. Howard Spohn, Dr. W. L. Graham
Credentials:
Dr. D. E. H. Cleveland, Chairman; 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 SOP IBB casij$//^cm
INDIVIDUALLY
THIAMINE
sj    HYDROCHLORIDE
X/       1,3,5 and 10 mg. Mlcrocaps
RIBOFLAVIN
1  and 5 mg. Mlcrocaps
PYRIDOXINE
HYDROCHLORIDE
1 and 10 mg. Mlcrocaps
NICOTINAMIDE
50 mg. Mlcrocaps
CALCIUM
PANTOTHENATE
10 mg. Mlcrocaps
^   SCttJIBBjli
W*MIN B C0«rl«
SYSUP
VITAMIN B
COMPLEX SYRUP
An extract of the whole
natural B-Complex as
derived from rice bran,
enriched with thiamine
hydrochloride and
riboflavin.
&
COMPLEX
PRODUCTS
VITAMIN B
COMPLEX CAPSULES
Contains the whole
natural B-Complex as
derived from high
potency brewers' yeast,
fortified with five crystalline vitamins.
VITAMIN B
COMPLEX TABLETS
Made with a special B-
Complex extract of brewers' yeast fortified with
five crystalline vitamins.
Potent and Economical.
For literature write 36 Caledonia Road, Toronto, Canada.
E-R:SQ!JiBBt& Sons of Canada, Ltd.
MANUFACTURING   CHEMISTS   TO   THE   MEDICAL   PROFESSION   SINCE   1858 VANCOUVER HEALTH DEPARTMENT
STATISTICS—SEPTEMBER, 1943
Total   Population—Estimated
Japanese  Population
Chinese   Population—Estimated
Hindu  Population j	
288,541
Evacuated
5,541
301
Number
Total deaths   246
Japanese deaths  _
Chinese  deaths  15
Deaths—residents  only  204
BIRTH REGISTRATIONS:
Male,  292;   Female,   289     581
INFANT MORTALITY: Sept., 1943
Deaths under one year of age       13
Death rate—per 1,000 births       22.4
Stillbirths  (not included above)         9
Rate per 1,000
Population
10.4
Population evacuated
32.9
8.6
24.5
Sept., 1942
13
22.6
16
CASES OF COMMUNICABLE DISEASES REPORTED IN THE CITY
August, 1943
Cases
Scarlet Fever i :  19
Diphtheria  0
Diphtheria Carrier  0
Chicken Pox !  18
Measles !  7
Rubella  1
Mumps  18
•Whooping  Cough  17
Typhoid  Fever  0
Undulant   Fever > .-_ 0
Poliomyelitis ■— 0
Tuberculosis J l  37
Erysipelas :  1
Meningococcus  Meningitis   j  1
Paratyphoid Fever \  0
Deaths
0
0
0
0
0
0
0
1
0
0
0
?3
0
0
0
September, 1943
Cases      Deaths
Oct. 1-15, 1943
Cases      Deaths
23
0
0
34
7
>l"
21
17
0
0
2
37
1
0
0
0
0
0
0
0
0
0
1
0
0
0
13
0
0
0
28
0
0
33
5
2
8
7
0
0
0
22
3
1
1
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
V. D. CASES REPORTED TO PROVINCIAL BOARD OF HEALTH
DIVISION OF VENEREAL DISEASE CONTROL
Burnaby
Syphilis   (Sept.)         0
Gonorrhoea  (Sept.)     0
West
Vane.
l
o
Richmond
o
o
North
Vane.
l
o
Vane.
Clinic
21
37
Hospitals &
Private Drs.
33
32
Totals
56
69
BIOG LAN-A
The most effective * therapy for waning mental and physical energy,
deficient concentration and memory, reduced resistance to infection,
muscular weakness and debility, neurasthenia and premature senility.
The efficacy of this very potent endocrine tonic has been confirmed by
the clinical evidence of many thousands of cases treated during
1932-1943.
Stanley N. Bayne, Representative
Phone MA. 4027 1432 MEDICAL-DENTAL BUILDING Vancouver, B. C.
Descriptive Literature on Request
THE SCIENTIFIC HORMONE TREATMENT
Page Fifty-six .>;.*:»':<!•,:■!-.'
\s=
m^s
£
WAR CONDITIONS
ARE LIMITING
SUPPLIES OF
w
m
V
ACETYL SALICYLIC ACID
compounds
with codeine
■^
%<.
Owing to the allocation of acetyl salicylic
acid and codeine, supplies of Ayerst preparations containing these substances have necessarily been curtailed. Every effort is being
made, however, to maintain an equitable
distribution of quantities available and thus
ensure that the majority of prescriptions for
A.S.A. Compounds with Codeine'will be filled.
AYERST. McKENNA & HARR^H^OJMITED      •      Biological and J^fjfl§P^'"■! Ch»rai«t»
MONTREA1 VANCOUVER     MEDICAL     ASSOCIATION
FOUNDED 1898    ::    INCORPORATED 1906
PROGRAMME OF THE FORTY-SIXTH ANNUAL SESSION
(SPRING SESSION)
GENERAL MEETINGS will be held on the first Tuesday of the month at 8:00 p.m.
CLINICAL MEETINGS will be held on the third Tuesday of the month at 8:00 p.m.
These meetings are to be amalgamated with the clinical staff meetings of the various
hospitals for the coming year.   Place of meeting will appear on the agenda.
General meetings will conform to the following order:
8:00 p.m.    Business as per Agenda.
9:00 p.m.    Paper of the evening.
January 18—COMBINED CLINICAL MEETING and STAFF MEETING at
VANCOUVER GENERAL HOSPITAL.
February    1—GENERAL MEETING:
Dr. Murray Meekison—"The Treatment of Fractures on the Orthopaedic Service of the Royal Air Force."
February 15--COMBINED CLINCAL MEETING and STAFF MEETING at
ST. PAUL'S HOSPITAL.
March   7—GENERAL MEETING:
QSLER LECTURE—Dr. T. H. Lennie.
March 21—COMBINED CLINICAL MEETING and STAFF MEETING at
VANCOUVER GENERAL HOSPITAL.
April   4—GENERAL MEETING:
Dr. J. R. Davies—To be announced.
April 18—COMBINED CLINICAL MEETING and STAFF MEETING at
ST. PAUL'S HOSPITAL.
13 th Ave. and Heather St.
Exclusive Ambulance  Service
FAirmont 0080
PRIVATE AMBULANCES AND INVALID COACHES
WE SPECIAUZE IN AMBULANCE SERVICE  ONLY
J. H. CREL.LIN
W.   L.  BERTRAND
Page Fifty-seven EPINEPHRINE  PREPARATIONS
EPINEPHRINE is the name specified by the regulations under
the Food and Drugs Act of Canada for the pressor principle
of the adrenal gland and is employed to raise blood pressure,
as a heart stimulant and in the treatment of bronchial asthma.
EPINEPHRINE is prepared in the
Connaught Lao oratories as a pure
crystalline compound from beef
adrenal glands. Each lot is assayed
for potency in terms of the
Government standard and is tested
for stability.
THREE preparations are made from the crystalline product
in the Connaught Laboratories:—
1. EPINEPHRINE HYDROCHLORIDE (1:1000). Issued as
a sterile solution in 30-cc. rubber-stoppered vials, to be given
by injection.
2. EPINEPHRINE HYDROCHLORIDE INHALANT (1:100).
Distributed in special dropper bottles containing 6-cc. Used
as an inhalant in the treatment of bronchial asthma.
3. EPINEPHRINE IN OIL (1:500). Supplied for injection as
a suspension of Epinephrine in oil in 20-cc. rubber-stoppered
vials.    For use when a prolonged effect is desired.
CONNAUGHT LABORATORIES
University of Toronto    Toronto, Canada
DEPOT FOR BRITISH COLUMBIA
MACDONALD'S PRESCRIPTIONS LIMITED
MEDICAL-DENTAL BUILDING, VANCOUVER, B.C. THE   EDITOR'S   PAGE
In this number of the Bulletin, which we have called the "Military Medicine"
number, we are publishing several articles written by men in the Medical Units of the
Canadian Forces. We are highly honoured in being allowed to do so. The Ottawa
authorities gave their consent to the publication of the articles, and we have been greatly
helped by Col. Wallace Wilson, C.M.O., Pacific Command, who has taken a great
interest in the idea of a special number of this nature. We had hoped for a "Foreword"
by him, but he is extremely busy, and cannot spare the time. However, we are very fortunate in being able to display, on the next page, an aerogram from our old friend and
erstwhile fellow-editor, Murray Baird, whose letter to us is so welcome and so heartwarming.
We assure Major Baird, and all our friends overseas, that it is with a sense of privilege that we send them copies of our Journal. If it is nothing else, it is a voice from
home, and bears .with it our sincerest admiration for the work they are doing, and
affection for them personally.    We hope they like this number.
Each one of the articles published is, we think, well worth reading. Perhaps the most
significant, however, is the historical review of Lieut.-Col. J. F. Cummins, dealing with
the Medical Services of 1885. We read this, and then turn to a book "The Miracles of
Military Medicine" written by one Albert Q. Maisel, a layman. Consider his opening
paragraph:
"This is a war of new weapons, far more accurate, far more pervasive, far more deadly than any that
have ever been used before. In hundreds of books and thousands of articles, in every paper, and over
every radio, the power of these weapons has been broadcast and ballyhooed. . . . B^it there is another
kind of new weapon that may play just as important a part in winning this war: a type of weapon that
Is little discussed and less well-known than any of our new planes and tanks. These are our new medical
weapons, the weapons that save lives.
"To a very substantial degree, the new tools of medicine and surgery have already gone far to counterbalance the greater destructive power of our modern war weapons. It is these new drugs, devices and
techniques which maintain the fighting strength of our troops at a higher level than ever before. These
weapons are vital to the maintenance of morale. ... In the final reckoning, these weapons will be
responsible for the fact that tens and hundreds of thousands of men, who would have died in any previous
war, won't die in this case."
War is organised destruction, and the loss of life, daily and hourly, is a grim necessity. With all our hearts, as a nation, we believe in the righteousness of this war, and
have given and will give our best to its prosecution and final winning. But it has its
constructive side, too. Out of it will come, as we firmly believe, peace and security,
freedom for men to grow and develop—out of it too will come more and better
knowledge of the laws of science. And preeminent among these will be the advances in
medicine. And these advances are being made by such men as those who have contributed these articles to us, men from Britain and Canada and Russia and the United
States: advances which are epoch-making—like the Trueta-Orr technique, or the
advances in burn therapy, and so on, and so on. So we salute these men, and ask them
to accept from us this humble tribute to their work, when we dedicate this number of
the Bulletin, with all our gratitude and admiration, to the Royal Canadian Army
Medical Corps, and all its men working with the forces of His Canadian Majesty, in
the air, on the sea, or on land.
NEW YEAR'S GREETING
The Publications Board of the Bulletin extends to all its readers heartiest
greetings and best wishes for the New Year.
Page Fifty-eight A NEW YEAR'S MESSAGE FROM THE PRESIDENT OF
THE VANCOUVER MEDICAL ASSOCIATION
At the beginning of the New Year, and at this critical period of the world conflict,
I believe we should give some earnest thought to the welfare of our fellow members
who are serving overseas with the Armed Forces. Some of these men have already
returned to practice, and undoubtedly many more will return during the next two years.
Let us see to it that we extend to these men, many of whom have made great personal
and professional sacrifices to serve their country, a genuine welcome home, as well as
practical assistance if necessary.
Wishing all members of the profession a Happy and Prosperous New Year.
A. E. Trites, President.
#
*
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V#u
Qirisfrwas Giredliwgs !§4
KNOCK'S HAHE
AND ADQftfSS.
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4M$L.
Page Fifty-nine LIBRARY NOTES
RECENT ACCESSIONS TO LIBRARY—
Surgical Clinics of North America, Symposium on Surgical Technique, October, 1943
Nelson Loose Leaf Renewal Pages, as follows:
Malaria, by Charles F. Craig.
Schistosomiasis, by Richard P. Strong.
Simmonds* Disease, by Sidney C. Werner.
Anorexia Nervosa, by Sidney C. Werner.
Pulmonary Edema, by Dickinson W. Richards, Jr.
Abnormal Mechanisms of the Heart, by William J. Kerr and F. L. Chamberlain
General Paralysis, by C. Macfie Campbell.
Psychiatric Disorders, by Leland E. Hinslie.
BOOK REVIEW
PSYCHOSOMATIC MEDICINE: Weiss and English, W. B. Saunders Co., 1943.
This recent acquisition to the library is well worth reading. Medical literature in
recent years has tended to stress the relationship of the emotions in disease and this work
by the Professor of Clinical Medicine and the Professor of Psychiatry of the Temple
University Medical School, Philadelphia, gives a clear presentation of this relationship.
The authors state that Psychosomatic Medicine is concerned with a vast number of
sick people who are not "out of their minds" and yet who do not have any bodily disease
to account for their illness. This group orthodox medicine has neglected, having contented itself with the study of the organism as a physiological mechanism, impressed by
the blood chemistry, electrocardiography and other methods of investigation, but unimpressed by and, indeed often holding in contempt the psychological background of the
patient, which was not considered so scientific  as  the  results of laboratory studies.
It is estimated that about one-third of the patients who consult a physician fall into
the functional group, while another third who consult a physician have symptoms that
are in part dependent upon emotional factors, even though organic findings are present.
The authors stress the point that the diagnosis of "functional" illness must be established not simply by the exclusion of organic disease, but on its own characteristics as
well.
In adults, domestic problems and professional and business relationships play a large
part in functional illness. In young, unmarried people, family relationships, choice of a
career, and often religious and sexual problems are important topics for discussion.
In discussing anxiety the authors clearly point out that it has two components, (a)
Psychic, and (b) Somatic (physiological). It is the latter that takes the patient to the
physician as a rule. It may be rapid heart action, rapid or embarrassed respiration,
flushing and perspiration, or a disturbance of the gastro-intestinal tract.
After discussing chapters on Psychosomatic Medicine, Personality Development and
Psychopathology, the text follows the customary procedure of discussing diseases under
systems and an up-to-date review of current medical views is given and the relationship,
if any, that emotional problems bear to that disease.
The popular style of giving numerous case histories including the life situation of
the individual is followed. Some may feel that these case records are too numerous and
for the man well acquainted with the subject this criticism is probably just. Also, one
feels that there is a tendency to over-emphasize symbolism in the case records. However, it was the intention of the authors to present their viewpoint for the average
reader and not the specialist, and it is felt that they have done this well. On the whole
the book is clearly written and easy to follow.
G. A. D.
Page Sixty CORRESPONDENCE
Letter received from Capt. W. H. (Bill) White:
Dear Doctor Thomas:
Just a note to wish a Merry Christmas and Happy New Year to all my friends in
B. C. and to you and the staff in the office.
I am in the land of sunshine, oranges, lemons, nuts, donkeys, flies and mosquitoes.
Jack McCannel of Victoria is in the same unit, the others being Easterners. Colonel
Haszard of Kimberley brought the boys overseas (8th Field Ambulance) and they
swear by him. We are moderately busy on routine work, but tropical diseases do show
up. Medical units do well for billets and are good scrougers too, so we lack nothing.
At present we are in a luxury hotel with a perfect view of the Mediterranean and are
sun bathing and swimming as often as time allows. I'd like to give you a bottle of the
. local wine.  I'm sure one bottle would be enough!
I have seen no B.C. men for some time, but Lloyd Bassett and Fred Bonnell are
nearby, likewise Hank Scott and Major John Ganshorn. I hear from Dad regularly and
enjoy his letters and am glad to hear he is hard at it again, though I know he can look
after himself.
I hope this finds you in good health and the usual good spirits. Don't forget to keep
sending the Bulletin.
Bill White.
Letter received from Capt. F. L. Skinner:
Dear Doctor Thomas:
One of your Vancouver Medical Bulletins was just delivered to me, and I feel
inspired to write to wish all of you in Vancouver a Very Merry Christmas and a Most
Happy and Prosperous New Year.   May 1944 see all of us return to the fold.
The Canadians are continuing to do their job. We are slowly but steadily pushing
Jerry northward, but you will know all about the fighting from the newspapers.
John Poole is now with the 2nd Canadian Field Dressing Station and seems to be
liking it there. Johnny Coleman is still 2 i/c of the 5 th Field Ambulance. I haven't
seen many other of the B. C. fellows recently. Rocke Robertson is in charge of one of
our two field surgical units. He has just been made co-consultant in surgery to the
division.
I have just been moved from the 48th Highlanders after 10J4 months to this Field
Ambulance. I was made Consultant in Medicine to the Division about six weeks ago,
and it was inconvenient for me to be with a unit, so I was transferred.
I met Collison, who is with the 5th Canadian Casualty Station. Hadn't known him
before as he joined the army early in '40.
Just wanted to thank you for the Bulletin. It is very welcome. A touch of
home.    Keep them coming.
All the best to you all.
Sincerely,
F. L. Skinner.
PROVINCIAL BOARD OF HEALTH
DIVISION OF VENEREAL DISEASE CONTROL
Since publishing information in the Bulletin of September, we are now informed
that laboratories of the Royal Inland Hospital at Kamloops and the Prince Rupert General Hospital at Prince Rupert have the necessary equipment and technicians to carry
out darkfield examinations. It will therefore be satisfactory for doctors in the vicinity
of those towns to send in specimens and obtain reports from those laboratries.
D. E. H. Cleveland, M.D.,
Acting Director, Venereal Disease Control.
Page Sixty-one SOME ASPECTS OF AIR RAID CASUALTY SURGERY
Capt. F. W. Grauer
R.C.A.M.C.
The surgery of air raid casualties is essentially traumatic surgery in its broadest application. One or all systems in the body may be injured directly or indirectly in a variety
of ways. In recent years much has been learned in the proving ground of raided areas in
the matter of applied surgery, with a wealth of new materials, and under conditions permitting earnest possible hospitalization. The principles of surgery have not changed,
but many notable alterations in application of these principles have now reached the
accepted stage, at least for the present.
The following is an attempt to outline progress and present-day practices in wound
surgery as it relates to air raid casualties. This is undertaken on a background experience
with over 1000 hospital admissions of this nature and in recognition that to many the
contents will be repetitious and incomplete.
Shock progress hinged on the development of plasma and serum therapy and the
discovery that two distinct types of shock occur depending on whether whole blood or
predominantly blood plasma is lost from the circulating medium of the body. This is
manifested by haemodilution and haemoconcentration respectively, and may be recognized
and followed by the hematocrit, haemoglobinometer or by blood specific gravity determination.
The shock of trauma, apart from crush-syndrome and burns, is associated with the
loss of effective circulating whole blood. This may be due to the direct loss of blood
from the body, to internal haemorrhage, including haematoma, and to capillary dilatation.
Where blood has actually left the vascular tree compensatory haemodilution occurs along
with other physiological events peculiar to haemorrhage. The earlier work on traumatic
shock indicated that haemoconcentration was the underlying pathology, but it is now
known that haemoconcentration is only a transitory phase, which is short, and passes
over to haemodilution as soon as compensatory mechanisms come.into play. It is clear
then that the substitute of choice in open or hidden bleeding, including fractures, is
whole blood prefaced by a small preliminary saline given intravenously. There are, of
course, times when plasma or serum have to be used when whole blood is not available.
This works quite well in that the volume and osmotic balance of the circulating medium
is restored. The patient is then relieved of shock but retains an anaemia which is higb'v
unlikely to prove fatal and can be dealt with in due course.
Haemoconcentration occurs notably in two conditions of trauma, crush-syndrome
and burns. In both of these the common factor is plasma loss from the circulating
medium. Crush-syndrome may occur where an individual has been trapped under a
sagging weight. Apparently a gradual, heavy and persistent pressure, as of a settling
timber across the upper thighs, has the effect of rupturing lymphatics and causing a
dilator paralysis of blood capillaries without rupturing many. This permits an internal
pooling of the fluid portion of blood in the interstices. Oliguria and haematuria usually
follow upon a static renal circulation and may persist under treatment. The latter consists of plasma or serum transfusion containing physiological amounts of protein. Failing this, an intravenous saline or glucose saline is useful. In persistent cases, an intravenous sodium sulphate drip provides a forceful renal stimulant through its sulphate ion.
Here, as in all shock cases, it is important to keep a urinary output chart.
Page Sixty-two Burn management has undergone a terrific evolutionary development during which
all previously known methods were again given a trial. Carron oil, ferric chloride, eucalyptus, zinc oxide, benzoin, dyes and many others were in turn found inferior to properly applied tannic acid and silver nitrate which was standard treatment in 1939. The
latter fell into disfavour because of too frequent infection beneath the eschar and
because of its constricting effects on digits with circumferential burns. Then, too, it
was finally admitted that one could not tell initially the true depth of a burn. Cases in
which tan was used on deeper burns where no epithelial islets remained simply never
epithelialized.
The problem, then, was one of infection control and recognition of the indication
for epithelial replacement by skin grafting. Sulfathiazole in the form of emulsion proved
the solution. Provided that adequate preHminary cutaneous toilet is carried out, the
sulfonamide dressing certainly keeps bacterial activity at a low ebb. The dressing need
not be disturbed more than every 5 to 7 days. This prevents exposure to outside organisms and rests the affected parts, which do much better with additional splintage. In
a matter of two weeks, visible evidence of granulation tissue formation appears where
epithelial islets are lacking. In order to prevent ultimate scar contracture, this is the
time to skin graft and always with the member in full extension where the denuded
area is on a flexor surface, and vice-versa.
An important advance in burn treatment has been the pressure dressing. There is
an enormous loss of protein-rich fluid in blisters and subsequent ooze from burned areas.
This loss contributes to burn shock and is responsible for haemoconcentration. The very
low hydrostatic pressure in capillaries and lymphatics is readily offset by a firm bandage
placed over padding applied outside the sulfonamide dressing. Further loss of fluid and
protein is thus prevented. This measure, in combination with early plasma or serum
transfusions, as indicated by haemoconcentration readings and fluid balance control chart,
has vastly increased the survival rate in extensive burns.
Saline and glucose solutions hold an important place in treatment of the injured. In
extreme shock, with vascular collapse, a half litre of saline as a preliminary frequently
opens the way for a freer flow of the more viscid substitutes. They are useful in maintaining caloric intake with glucose where feeding is hampered and in maintaining fluid
balance once shock is controlled. There is ample post mortem evidence to condemn the
excessive use of these solutions as the sole means of combating shock. Marked pulmonary oedema is almost uniformly found where this has occurred. One litre of physiological saline solution contains 9 gm. of salt, which is far above the normal daily
requirement. It is obvious that amounts above this are bound to favor water retention
except in those with vomiting and consequent loss of chlorides. When used, control
measures for developing oedema should be maintained by keeping a fluid intake and
output chart, frequent chest auscultation and by twice daily testing for urine chlorides.
A rational method of management is to use .45% NaCl where amounts exceeding 1500
cc. are given daily. Glucose may be used in combination as indicated, and by the same
token urinary sugar should be tested for to avoid running in glucose solution faster than
it can be assimilated. Finally, in shock management, saline and glucose solutions are
no longer regarded as blood substitutes because they have not the sustained osmotic
effect of solutions containing larger molecules. They may, however, be useful adjuncts
in treating the injured, and be of some value where blood substitutes are unavailable.
The majority of bomb casualties have somatic wounds from penetrating foreign
bodies. Visceral lesions will not be discussed. Bomb splinters predominate, and may
show as a single entrance wound with a buried missile, or as an entrance and exit wound
where the missile has carried through. Exit wounds may be some distance from, and are
usually larger than, entrance wounds. A wide variety of foreign bodies may be driven
in by blast, including glass, metal bits, clothing, chinaware, wads of mattress or pillow
stuffing, chips of wood, dirt and gravel. Many of these are not opaque to the Roentgen
ray and therefore a negative X-ray film does not exclude foreign body. Some are literally
tattooed with fine gravel over large areas.   Other wounds result from falling building
Page Sixty-three materials and sheer blast effects.    These may be associated with lacerations or internal
injury.
It is desirable to remove foreign bodies, as they frequently interfere with healing,
may cause sinus formation, or carry anaerobic infection. They may later give rise to
deep scar contracture with pain, or be associated with a nerve lesion, or cause arteriovenous aneurysm. However, relatively superficial small multiple foreign bodies have been
found to be comparatively harmless if left in situ. They either extrude themselves or
the tracts heal. The choice lies between leaving them, or spending valuable time at a
tedious non-life-or-lirnb-saving procedure which may well be spent at other more important work under raid conditions.
Bomb splinter wounds are often associated with fracture or shattering of bone.
Joint, nerve and vascular lesions occur less frequently. A minute entrance wound may
be associated with a serious internal injury. As always, a thorough and complete examination should be carried out. It is not uncommon to find other less obvious injuries,
such as a compression vertebral or pelvic fracture. Hidden internal muscle laceration
out of all proportion to size of entrance wound may be found, and is due to high-
velocity revolving fragments reproducing the effects of a small explosion. This type
on recognition should be left open with loose packing, as any attempt at excision would
not fall far short of amputation. They do well with rest in plaster and bacteriological
control measures of ATS, AGS and sulfonamides.
Massive tissue loss presents a problem in management. It occurs as a result of missiles striking the body surface as a tangent. High velocity fragments grazing the skin
surface frequently cause late necrosis for some distance around the apparent area of
injury. The skin and subcutaneous tissues sequestrate, leaving a large indolent ulcer.
In these cases the method popularized by Trueta has proved invaluable in combination
with later skin grafting.
Large flaps of full thickness skin may be raised and peeled down a limb by falling
building material. These flaps usually undergo ischaemic necrosis along their free borders. Primary suture under tension usually fails. Skin under tension soon breaks down,
circulation is impaired, avascular gangrene is frequent, distal oedema is common and
sutures often cut out. Primary skin grafting on muscle or fascia seldom takes, and if
it does, gives a poor functional result. After a thorough skin preparation and cleansing
of all exposed surfaces with saline, followed by a 1:4000 flavine solution, the skin edges
are excised all around and deeper soiling is excised. The wound is then dried with sterile
gauze and sulfonamide powder is dusted evenly on all surfaces. An occasional stay suture
is placed and the whole then managed as a pedicled skin graft. Granulating areas are
later covered with split skin or pinch grafts.
Where a limb is shattered beyond repair, and will obviously come to amputation, and
where the patient, for reason of shock or transport, will not receive operative treatment
for a period of time exceeding 10 or 12 hours, a narrow rubber tourniquet applied at
the upper edge of the wound tight enough to occlude arterial circulation is an effective
and useful measure. It is disconcertingly true that even under full treatment some individuals do not recover from shock for periods of 24 to 48 hours, and some not at all.
Although academically controversial, experience has shown this measure to be of considerable aid in recovery and prophylaxis. Oozing, with consequent loss of plasma,
tissue fluid and whole blood, is arrested. Absorption from the traumatized area is prevented. Infection spread is barred, which may be of importance in an incipient virulent
anaerobic infection. The tourniquet in no way interferes with amputation, and may
be a decisive factor in choosing a flap amputation in contrast with one of the guillotine
types, where a patient has had to wait many hours.
In temperate climates all wounds may be dealt with in one of three ways. A wound
may be excised in its entirety and primarily sutured; it may be excised and packed with
a view to secondary suture, subsequent events permitting; or more commonly it may
receive debridement with or without packing and be left to heal by secondary intention.
The choice depends on several factors, most important of which are the time lapse,
Page Sixty-four degree of contamination, multiplicity of minute deep foreign bodies, association of
fracture with or without overlying soft tissue loss, and depth of wound tract or extent
of muscle injury.
Most casualties are covered with dust. Time is well spent on preoperative skin
preparation. Gross dirt may be removed with spirits of soap and washing. Shaving the
skin for some distance around the wound is routine for obvious reasons. A fat solvent
such as ether or acetone not only removes sebum but, owing to low surface tension,
reaches the depths of hair follicles and destroys bacteria. Finally, an alcoholic pigment
serves to outline the prepared area. Preliminary wound probing will reveal the direction
of the tract where there is no exit wound. This indicates the direction for incisional
enlargement where the tract is oblique.
Excision aims to remove the tract intact in the form of a flattened funnel, leaving
only healthy untraumatized and uninfected tissue. In limbs, the wound is excised in an
ellipse whose long axis is parallel with the long axis of the limb. If a wound lies at right
angles to the long axis its extremities should be tailed upwards and downwards if enlarging of the wound is necessary. The reasons for this are that fewer cutaneous trunk
nerves are cut, less impediment to lymph flow is created and better exposure of muscle
planes is gained. In muscle excision, cross cutting is to be avoided if possible. The
excision can be carried out layer by layer, skin, fascia, then muscle and foreign body.
Haemorrhage is controlled by artery forceps on the vessel alone, so that muscle is not
crushed. Alternately, a bloodless field may be used. Larger vessels have to be tied with
fine plain catgut cut short without redundant vessel distal to the ligature. Smaller
vessels can be twisted into stasis. As little catgut as possible is used and no deep sutures
are placed. Bandaging is relied upon for the occlusion of dead space. The skin is closed
in one layer with interrupted full thickness everting sutures of silkworm gut. In the
absence of fracture, a small drain may be placed at its dependent end for 3 days to allow
any blood to escape. Finally the skin is again painted and dressed with a pressure bandage with absorbent cotton left protruding from the ends to prevent congestion, and
the limb is kept elevated.
More often it will be found expedient to dry the excised wound with gauze and dust
its interior with a sulfonamide powder. The sulfonamides were never meant to replace
a proper excision and suture, but to offer additional security when carefully used. In
debridement, however, they are relied upon to inhibit bacterial growth as potential
infection is left in the wound with a pabulum of some injured tissue or blood. The sulfonamides have special requirements for sterilization by autoclave, as their activity is
destroyed by ordinary routine standards. The practice of using a common container
from case to case is entirely unsound. Individual 5 gm. paper containers exclude contamination. It is quite safe to use up to 10 or 15 gm. in the average adult. Sulfanilamide is most soluble in wounds and gives the greatest tissue penetration ,and concentration. Sulfathiazole is slowly soluble and therefore longer acting. It has the disadvantage of caking and should not be used in compound skull fractures or around
nerve sutures. Sulfanilamide is the drug of choice in primary excision and suture.
Equal parts of sulfanilamide and sulfathiazole in debrided wounds provide an immediate
and sustained bacteriostatic action.
Where the wound is through and through, the same funnelling excision is used at
both entrance and exit wounds and these meet somewhere about the middle. The older
pull-through of gauze soaked in antiseptic solution is definitely out, because it completely
fails to remove the pabulum upon which bacteria flourish. In the case of compound fractures the same procedure is followed. When the fracture site is exposed, bone fragments,
which have become detached from periosteum, should be removed. Fragments with no
blood supply, in this type of wound, are a menace and may later behave as foreign bodies
or sequestra. Soiled bone is best removed by chisel or rongeur. Liberally applied sulfonamides in no way interfere with union. A carefully excised wound done early, say
within 6 to 8 hours of injury, can be confidently sutured. Where soft tissue loss or
time lapse prevent this, the wound may be loosely packed with sterile vaseline gauze
Page Sixty-Five over the sulfonamide and the limb placed in unpadded plaster of paris. Debridement is
not enough in compound fractures or joint wounds, as this almost invariably leads to
suppuration.
Very often a nerve trunk will be found in the wall of a wound tract and should be
anticipated according to the affected region. The excision has to be modified where
nerves are concerned, so that one may end up with an excised wound with a nerve
running through it. The question of nerve suture has to be individualized. In principle
a primary suture is indicated where wound excision is undertaken early, and one is satisfied that septic material has been thoroughly removed, and where the nerve in question
is not lacerated to a jellied pulp. Nerve haematomas should be evacuated. Loss of
nerve substance, or complicated wounds, indicate secondary suture. It is quite safe to
apply sulfanilamide powder in the region of nerves.
Joint wounds vary from a penetrating small fragment to complete destruction.
Excision is carried out from skin to synovial membrane inclusive, being particularly
careful to keep instruments outside the wound tract and changing them if soiled. Fragments impacted in bone or joint surfaces are removed with a surrounding thin layer of
bone by sharp curette, the size of which should match that requiring removal. Following this, the joint may be flushed out with sterile warm saline using catheter and syringe.
Residual fluid is sucked out and the joint interior and wound walls are dusted with
sulfanilamide powder. Early wounds should always be closed after excision. If insufficient tissue is available to close the aperature, a flap of fascia lata may be rotated down
on a hinge and sutured in place. Skin may be advanced over this or in some instances
moved with the fascial flap. In complete joint destruction, excision of the joint is carried out and the limb immobilized in the position of choice. Arthroplasty may be considered at a later date.
Rest and posture, though having long known virtues, have until recently not received the attention they deserve. In wounds and fractures, as in infections, the vicious
cycle of movement, spasm, and pain has met defeat in the judicious and dexterous use of
plaster of paris splintage. The names of Orr and Trueta are associated with this advance.
In open or large wounds excision is carried out in the manner previously described, with
the same careful antiseptic and aseptic precautions. After bleeding is arrested, the raw
surfaces are dusted thoroughly with sulfonamide powder and sheets of sterile vaseline-
impregnated gauze applied flush with the raw surface, overlapping the skin 1 or 2 inches.
The residual cavity is loosely packed with vaseline gauze to slightly above skin level.
The whole limb is then immobilized in unpadded, unlined plaster of paris casing, in a
manner preventing motion of the proximal and distal joints. In the arm this means a
plaster jacket; in the thigh, a spica. Pressure points and surfaces away from the wound
area may be padded and lined. Plaster and dressing changes are carried out as indicated,
usually each 4 to 6 weeks, under strictly aseptic precautions. The affected area is thoroughly cleansed of inspissated material and redressed as outlined. Most of us at some
time have read Hilton's book on Rest and Pain. This scheme is a modern version of
Hilton's principles.
Where ligation of trunk arteries and veins has been done, post-operative posturing,
to take gravitational weight off the area containing the collateral blood supply, may
make the difference between limb survival and gangrene. For example, femoral ligation
in Scarpa's triangle calls for gluteal anastomotic blood supply. Pressure from sitting or
recumbency impedes this collateral circulation. This type of case benefits by lateral and
prone posture which permits a freer collateral flow. Injured limbs in plaster, while in
bed, should always be kept elevated. They are at rest and consequently have no means
of combating gravitational congestion which may lead to more serious consequences.
Page Sixty-six BLOOD GROUPING
Major T. R. E. Morgan
R.C.A.M.C.
The relative merits of transfusion of the whole blood and plasma and the indications
for each are well known and require no repetition. It has been decided that blood
grouping of all members of combat units will be of undoubted value to transfusion
units working in the field. Knowledge of the wounded soldier's blood group and the
ease of securing donors of a similar group is obviously a great time-saver. Donor selection and cross agglutination can, therefore, be performed within the shortest possible
time and with the minimum of equipment.
Transfusion without preliminary cross matching of bloods is not recommended
except in cases of extreme urgency where the additional few minutes' delay would possibly place the soldier's life in jeopardy. It is, however, expected that the situation will
not infrequently occur in which rapid transfusion will be a life saving measure. In
these instances the recipient and donor should be of the same group rather than using
a group O donor. The giving of a second transfusion without cross matching is definitely not condoned except under rare and grave battle conditions.
It is at once obvious that the first consideration in blood grouping is accuracy,
rather than rapidity of performance of the test. A mistake in grouping or the recording
of the type on the soldier's identification disc may lose a life rather than save one.
The decision to blood group a large number of troops presented the problem of
establishing a simple rapid accurate method of performing this task. While it was necessary to cause a rninimum of dislocation of the training schedule it was firmly decided
that there should be no compromise between accuracy and speed. The routine microscope slide technique was adapted to an assembly line principle and it was found that
three technicians plus clerical help could perform the test at the rate of from eighty to
one hundred per hour. It was unnecessary, therefore, for any company to miss more
than two hours' training.
By this method each member of the group has a simple routine task to perform and
each important step is double checked. In a previously reported series of blood groupings
it was found possible for two technicians to do approximately forty groupings per hour.
The advantages of more than doubling this rate by increase of only one technician are
obvious.
Personnel required consists of the following:
(a) One well trained and experienced medical officer or laboratory technician who
can direct the work and is cognisant of the various sources of error.
(b) One trained technician who has had experience in blood grouping and understands its basic principles.
(c) One semi-skilled technician to take blood and perform initial cell-sera mixing.
(d) Four intelligent co-operative clerical personnel obtained from unit being grouped
or from convalescent patients.
Equipment
Materials required are as follows:
Typing serum A approx. 3.5 cc per 100 groupings.
Typing serum B approx. 3.5 cc per 100 groupings.
Glass microscope slides.
Glass marking pencil.
Automatic blood lancet.
Alcohol.
Absorbent cotton.
Wooden applicator sticks.
Page Sixty-seven Paper slips approx. 3x4 inches.
Microscope and lamp.
Identification disc stamping equipment.
Division of Work
The laboratory or barrack room is set up as illustrated on diagram which is schematic
and may be modified to suit various local conditions.
I. Soldier is first seen at Statidn No. I where a clerk writes his number, rank, name
and initials on a small piece of paper of approximately 3x4 inches. He then carries the
slip of paper to station No. IV.
II. At station No. II a clerk removes soldier's M.F.M.'s 1 or 2 or M.F.M. 103 from
envelope and in section No. 3 of M.F.M.'s 1 or 2, or corresponding section of M.F.M.
103, inserts the date followed by the words Blood Group. Identification discs are secured
from soldier and placed in document envelope. Forms are returned to their envelope
and transferred in small piles to Station No. VII.
UJ. At station No. Ill the glass microscope slides are prepared. The operator may
be any intelligent unit member, convalescent patient or R.C.A.M.C. personnel who can
be entrusted with a simple routine task. Using a glass pencil a slide is marked as indicated and two drops of each of the testing sera are placed as shown. Several slides may
be prepared at one time but since the serum dries rather quickly no more than six to
eight slides should be prepared in advance. A prepared glass slide is placed on the man's
paper sKp and is passed to station No. TV.
N.B.—Except when being examined each slide remains on its own slip of paper
during the entire test.  Only one slide is ever picked up by any one technician at any
time.
•
IV. A technician at station No. IV swabs a finger with alcohol and after it is dried
obtains blood using the automatic lancet. With first one and then the other end of an
applicator stick a very small amount of blood is picked up. Then the blood on the one
end is mixed with the A serum and on the other end with B serum and the applicator is
discarded.  Applicator sticks broken in half serve equally well and are more economical.
The correct amount of blood is just enough to product a light pink shade when
mixed with the serum. Mixing of blood and serum with a medium which is cheap and
may be discarded, is very rapid and prevents the possibility of mixing A and B sera when
a wire loop, pipette, glass rod or other instrument is used.
The slide on its paper is passed to the next technician.
V. After standing for a period of from five to ten minutes the slide is picked up
by a technician at station No. V. It is agitated to again mix cells and serum. A preliminary reading of the grouping is made and recorded on the paper slip. The slide is
then passed to the next technician.
VI. At station No. VI the slide, after it has stood a further ten minutes, is again
picked up and agitated and the gross grouping result compared with that previously
noted. The slide is then examined microscopically as a final check and is discarded into
a bowl of water.
Those slide preparations requiring change of group reading are seen by technician at
No. V and agreement reached before final group is allotted. The slips of paper are
passed to the next member of the unit at No. VII.
VLT. The previously prepared soldier's documents (II) are completed by clerk at
station VII, by the addition of the letters O. A. B. or AB following the words Blood
Group.  The result is checked by the M.O. in charge and the document is initialled.
Page Sixty-eight The clerk then takes documents and paper slips to a wooden block, a butcher's
cutting block is excellent, where the identification tags are stamped by the words Blood
Group beneath which is stamped the correct type. Once again the result is checked by
comparing the group letter with that recorded on the paper slip. The completed document envelope, with its enclosed identification tags, is returned to the unit, and the paper
slips are taken for record purposes.
Discussion
While there are other methods of blood grouping which are thought to be without
possibility of error it was decided that none of these would be practical for our purpose.
The method described above is simply an adaptation of a technique which is well known
to all trained Canadian technicians and is used routinely in most large Canadian hospitals. Other techniques require a longer time to perform, large amounts of glassware,
etc., which are now unavailable, and a larger, more highly skilled technical staff.
It is not within the scope of this article to discuss the various factors which produce
erroneous results for it is considered that the medical officer in charge of this work will
be acquainted with these problems.
Summary
A simple rapid adaptation of a standard technique is described by means of which
eighty to one hundred blood groupings may be performed and recorded per hour.
The method provides maximum accuracy and speed and a minimum dislocation of
training schedule.
VIEW-BOX FOR OBSERVING FOOT IMPRINTS
Mat. S. A. McFetridge
R.C.A.M.C.
One of the most difficult problems in the Army is the evaluation of foot complaints.
Paintful foot is the most common disability, and it is estimated that fifteen per cent of
all Army disabilities are due to foot trouble. This is readily understood because modern
civilian life does not require that men stand or walk to any great extent, and the
majority of men in civilian life have never done the amount of walking required by the
Army.
There are many different methods of viewing and recording the imprints of the
feet. There is a simple method of wetting the sole of the foot and having the patient
leave a wet imprint on a smooth surface. There is a similar method of using powder
to obtain the imprint. Another quick way is to take a large piece of plate glass and,
press it against the sole of the foot, with the patient in a prone position, and thug
observe the points of impact. Freiberg's method is to paint the sole of the foot with
ferric chloride and have tannic acid on the recording paper. Prussian blue is formed
and this gives the imprint. At the Shaughnessy Military Hospital in. Vancouver, imprints of the feet are recorded on paper by using printers' ink on the sole of the foot.
These imprints have the advantage of being a permanent record and can be filed with
the patient's documents.
At the Little Mountain Induction Centre in Vancouver, we at first used a box platform set up three or four steps from the floor level, so that close inspection of the foot
could be made, and water imprints taken if necessary. These water imprints were messy
and required too much time. We now use the same box platform, but the patient stands
on a square of porthole glass approximately 14 x 16 in. and 1% in. thick.  There is an
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Page Seventy aperture in the platform and this glass is over it. Electric lights are placed under the
feet. Another hole is cut in the side of the box, and a mirror, at about an eighteen degree
angle, is fixed so that one can look into the mirror and see the patient's imprints on the
porthole glass, as he stands on the platform. We thought this was an original idea but
on looking through Lewin's book on the Foot and Ankle, we note that he has described
the same thing and recommends its use. Lieut.-Col. P. A. H. King had some difficulty in
procuring the porthole glass. This glass must be very strong to prevent accidental
breaking and serious injuries resulting.
The advantages of this direct vision of the soles of the feet with the patient standing
are, of course, obvious. The view-box is easy to use, is quick, and it enables you to see
the natural imprints of the soles of the feet of the patient standing on the platform.
Very little experience is necessary with this apparatus before one feels confident in using
it. We have included a few pictures of the more common types of foot conditions met
with at the Induction Centre. These are just to illustrate what a clear and precise image
may be obtained.
Page Seventy-one THE ORGANIZATION OF THE MEDICAL SERVCES IN
THE NORTH WEST CAMPAIGN OF 1885
By Ldeut.-Colonel J. F. Cummins, C.M.S.C.
Historical Section (G.S.)
When the Rebellion broke out in March, 1885, and orders were issued for the mobilization of an expeditionary force, there existed in the Canadian Militia no trace of a
medical staff, nor was there any proper stock of medical supplies in hand. Arrangements
for treating the sick were always regimental, although several units might sometimes
attend the same camp. The only medical personnel were the Regimental Surgeons and
medical supplies were chiefly represented by stale and ill-assorted medicines and some
minor surgical instruments contained in the field panniers supplied to those units which
trained at camp. Consistently, as each annual training came round these had been reported upon in scathing terms by the Regimental Surgeons; yet year after year the same
panniers were sent to camp with insufficient surgical appliances and with the remains
of medicines unused in previous years. It became the custom for the surgeons to pur
chase supplies of medicines on their own responsibility after arrival in camp, when
deficiencies had been ascertained, and in at least some cases they were unable to obtain
a refund of their expenditure.
There were no hospital cots, nor even boards on trestles, and patients in camp hospitals had to lie on the bare ground like other troops, with one blanket and a greatcoat
(if such were in possession, which was not always) as mattress and covering. In the
chilly nights of the fall or early summer this was a positive hardship, and dangerous to
health when the ground was damp. Although a certain number of waterproof sheets
were in stock, these were not available save under exceptional circumstances, and recommendations from medical officers for their use remained unheeded until camps had been
flooded by heavy storms. There was no aspect of the Militia organization, which at this
time had sunk extremely low, that so reflected upon the administration at Ottawa.
On a portion of the Militia being organized for the North West campaign only three
Regimental Surgeons accompanied their units in the field, and volunteer surgeons replaced the permanent surgeons in other regiments. None of these substitutes had any
knowledge of military procedure or discipline and some are stated by the Surgeon-General to have been "very inefficient and from their want of discipline and ignorance of
military law, were very difficult to control, and gave no adequate return for the large
amount of money expended upon them for transport, pay and rations. . . . Without an
exception they were all very scantily provided with medicines, instruments and dressings necessary for the campaign. . . . Many of the surgeons coming up with their Corps
were entirely, or almost entirely, destitute of the commonest instruments and appliances
required in every day work."*
The rebellious Provisional Government of the North. West was set up under Riel on
the 17th March and a few days later the unfortunate affair at Duck Lake had made a
punitive expedition inevitable. On the 26th March orders for mobilization were issued.
By the 1st April the G.O.C. had reached Winnipeg and was already moving western
*Report of the Surgeon General dated 13 May, '86, p. 77.
Report of the Deputy Surgeon-General dated 10 May, '86, p. 104.
Report of the Purveyor-General dated 11 May, '86, p. 121. %H
"In a profession, whose sole reason for existence is the relief or prevention of suffering, it would be
strange if these reflections applied generally. They did not. There were Regimental Surgeons, both permanent and temporary, who worked at all times with a single eye to the good of the service and whose
devotion to duty under fire, as well as in the calmer atmosphere of the hospitals, was beyond all praise.
Among survivors of the campaign still living,' there are those, for instance, who speak in terms of affectionate admiration of Brigade Surgeon F. W. Strange of the Infantry School Corps, and Surgeon J. W".
Lesslie of the Queen's Own Rifles. At Cut Knife Hill these two officers attended to the wounded, both
on the field and in the wagon laager, throughout the action, with that complete detachment from all
thought of danger which is characteristic of the devoted service to which they belonged. And what is
said of Surgeons Strange and Lesslie is applicable also to other surgeons who were present at Fish Creek,
Batoche and Frenchman's Butte."
Page Seventy-two troops to his adyanced base at Qu'Appelle, while five or six regiments from the East
were on the march westward. On this date (the 1st April) the Minister decided to form
a Medical Service, and on the same day Mr. Darby Bergin, M.D., M.P., of Cornwall,
Ontario, was offered and accepted the position of Chief Medical Officer with authority
to organize a-Medical Staff Corps and to take complete charge of all medical arrangements for the campaign. The grounds upon which the Minister based his choice are
not known, but, if results be the criterion, no happier selection could have been made.
Dr. Bergin, a deeply religious Irishman whose simple faith is disclosed even in his official
reports, combined with his medical qualifications the invaluable experience of eight years
as a company officer and sixteen years in command of a combatant unit, the 59th Stor-
mont Battalion of Infantry which he had organized. The knowledge of military admin-
ministration and of the necessity of proper discipline, thus acquired, was of inestimable
service to him in his new sphere. At the same time his academic qualifications were
viewed so highly by the other members of his profession that when the call to military
duty came in 1885 he was filling his second term as President of the Council of the
College of Physicians and Surgeons.
Surgeon-General Bergin, as he shortly became, realized fully the task that was before
him.   He says, in a report dated 13 th May, 1886:
"I was not blind to the difficulties of the situation. There was no fixed Departmental Medical Staff, no Field Hospital or Ambulance Service, no organized Corps of
Nurses, no fixed method of recognizing such societies as the St. John's Hospital Aid
Society, the Red Cross, and other similar charitable associations.
"Added to these the hurried levy, the necessarily scant equipment of many of the
men consequent upon this, the severity of the weather, the difficulties of transport,
exposure of the troops to the frost and snow in open cars, the long distances to be
traversed through the gaps between the finished and unfinished portions of the railway,
the difficulties of communication, the distance between the city (Ottawa), the base of
supply, and the field of operations, the Major-General Commanding having already left
Winnipeg for the front with a portion of the troops—all conspired to render the task
one of unusual difficulty. Five or six regiments and two batteries, comprising the
Ontario and Quebec and Nova Scotia contingents, were already on the march and were
provided, with, some of them at least, but very meagre or ill-regulated medical supplies
and very few medical comforts."
Of all services the Medical Service comes under the most pitiless storm of criticism
in the event of failure on a campaign. There was no failure in 18 8 5. The Medical. Service was a masterpiece of rapid improvisation calculated on the requirements of 6000
men for a six months' campaign. Dr. Bergin acted with the most extraordinary celerity.
As a first step he proceeded to select his staff, the principal members of which were
Dr. T. G. Roddick of Montreal, as Deputy Surgeon-General, and Senator the Hon.
Michael Sullivan, M.D., Professor of Surgery at the Royal College of Surgeons, Kingston,
as Purveyor-General.
Deputy Surgeon-General Roddick, "one of the most distinguished Canadian surgeons, young, full of vigour, of powerful physique, knowing no fatigue, a first-class
horseman,"* was to be the representative of the Surgeon-General at the front. He
reported at Ottawa on the 4th April, conferred with Dr. Bergin, assisted in the organization of field hospitals and, armed with a memorandum of instructions from the
Surgeon-General, had left for the front with the personnel of No. 1 Field Hospital by
the 7th April. By this date, so rapidly were things moving, Major-General Middleton
was nearing the Touchwood Hills, on his march with the main column to Batoche.
The Purveyor-General reported also on the 4th April but remained longer at Ottawa
perfecting arrangements at this end. He was, however, at Winnipeg by the 14th April.t
On leaving Ottawa, he, too, received from the Surgeon-General a memorandum of
*Report of the Surgeon-General, p. 74.    Dr. Roddick later was knighted.
■fReport of the Surgeon-General, p. 74.
Page Seventy-three instructions^ as to his duties, which comprised, among other responsibilities, charge of
hospital marquees, buildings and surroundings at his headquarters; charge of all stores,
instruments, drugs and medicines and responsibility for their issue with due regard to
proper economy, and the care and distribution of medical comforts. Though it extends
to 55 clauses the memorandum is a model of conciseness. So far as a layman may presume to judge, the function of a Purveyor-General are covered in a most complete manner. No detail which tends to efficient working is too small to be provided for. That
it proved to be a thoroughly workable scheme may be judged by the report of th
Purveyor-General on the conclusion of the campaign, although inevitably there were
.suggestions for improvement in the light of experience.
It was decided by the Surgeon-General to form two Field Hospitals. Their establishments appear to have varied slightly in one or two respects. The following was the
strength of No. 2 Field Hospital:
1 Surgeon-Major (in command)
6 Surgeons
18 Dressers
1 Apothecary
6 Orderlies
1 Cook.
These Field Hospitals were so organized that each might be automatically divided
into four equal parts of 50 beds (200 beds in all per Hospital) so that sections might be
detached as required to accompany different columns.
Although on the day following his appointment the Surgeon-General had framed
regulations for their engagement and their duties, the circumstances at the start made
it uncertain where Nurses could best be employed, and it was only when the Deputy
Surgeon-General had been able to survey the situation on the spot that arrangements
were made for the despatch of three Nurses from Winnipeg, three other Nurses from
t Toronto, and four Sisters of St. John the Divine under the Lady Superior, also from
Toronto, to the Field Hospital at Saskatoon and the Base Hospital at Moose Jaw.
Despite the unhurried speed with which arrangements were being made the staffs of
the Field Hospitals were picked with the greatest care. The selection of Surgeon-Majors
and Surgeons was made by the Surgeon-General himself. The choice of dressers and
orderlies was confided to the Professor of Surgery at McGill University for one Field
Hospital and to the Surgeon of the Toronto General Hospital for the other Field Hospital. Very many applications were received from volunteers for the positions, but these
two seats of medical learning were selected because during the last year or two some
attention had been given there to ambulance work, classes having been formed at both
places for the instruction of medical students in First Aid and Stretcher Drill. The two
gentlemen named were requested by Surgeon-General Bergin to make selections from the
graduate classes and the third and second year students who had the necessary knowledge
of First Aid and Stretcher Drill. But the selections were evidently made from even
higher grades, for the roll of No. 1 Field Hospital includes four fully qualified medical
doctors who took service as dressers.
As an instance of Dr. Bergin's keen understanding of the necessity for strict discipline and order in a military medical service, he shrewdly refused to countenance the
offer of these volunteers to serve without pay. "It was manifest to me," he says, "that
the Hospitals, to be of real benefit to the sick and to the wounded, must be under the
most perfect discipline, and experience teaches that when men are employed in any service which is voluntary, and to which no pay is attached, they feel under very little
restraint, and are not inclined to practice the virtue of obedience, beyond what it may
please them at the moment to observe."*
$The date of arrival given in Dr. Sullivan's own report is 9th April, but he was admittedly writing
from memory a year later.   From other sources it is clear that the date should be either 13 th or 14th April.
*Report of the Surgeon-General, p. 74.
Page Seventy-four In addition a Red Cross Corps was organized at Toronto by the Grand Trunk Railway, the personnel consisting "almost without exception of young medical men, gradu-
aies in medicine and surgery."*
After a week's intensive instruction in First Aid and Stretcher Drill the Corps
(which was splendidly equipped by the citizens of Toronto), under command of Dr.
Nattrass, left for the West. They arrived at Winnipeg on the 21st April and were
immediately despatched to Battleford* arriving there in time to render invaluable aid in
caring for those wounded in the fight at Cut Knife Hill.
But the personnel of Field Hospitals cannot carry on their work without tools to do
it with, and the equipment of these hospitals was a problem. Previous to Dr. Bergin's
appointment, an officer (Surgeon-Major Douglas, V.C.) had been engaged by the Department to make purchases of medical equipment, etc. He was out of touch with
Ottawa when the Surgeon-General assumed his duties on the 1st of April, making purchases in various cities. Such purchases as he made, it would seem, were in some cases
in appropriate and inadequate, and made at extravagant prices."]"
In anticipation of having to make extensive purchases, Dr. Bergin had immediately
on commencing work appointed two purchasing agents at New York and Montreal
respectively. But it was not until the 4th April that he was able to confer with Dr.
Douglas and ascertain exactly what stores had already been purchased or contracted for
and until he knew this it was impossible to place his own requirements. Having seen
Dr. Douglas on the 4th April, on the night 4th/5th April Surgeon-General Bergin drew
up a scale of "hospital supplies, furniture, utensils, hospital clothing, bedding, medical
and surgical appliances, instruments and medical comforts," to meet the requirements
of Field Hospitals and Regimental Surgeons in the Field. The list, which is appended
to his report, covers a multitude of requirements of every description.^: The following
morning copies were dispatched to the purchasing agents at New York and Montreal
with information as to what remained to be purchased and "with instructions to procure
and forward all the Winnipeg by express train without an hour's delay." Whenever
possible purchases were to be made at Montreal. Articles which could not be obtained
at Montreal (principally instruments) were numerous, and these were notified to the
purchasing agent at New York so that he might obtain them there. By arrangement
with Purveyor-General Baxter of the United States Army, Surgeon-General Bergin was
enabled to make all such purchases at the contract rate charged to the U. S. Purveyor-
General's department.
"Cots, mattresses, sheets, pillows and other articles of the kind required for the Field
Hospitals were not on the market and had to be manufactured to order. They were put
in hand the same day (Sunday) and on Wednesday, the 8th, the complete equipment of
Number One Field Hospital was shipped by car attached to mail train and reached
Winnipeg on the morning of the Tuesday following. The equipment of Field Hospital
No. 2 was despatched within a few days after and the reserve supplies early in the following week."$
Meanwhile, basing his plans on similar vehicles in use in the United States, the
Surgeon-General had found time, among his other multifarious duties, to draw up in
minutest detail specifications for medical transport carts; therein was also set out everything to be contained in each tray of the cart, and even in each compartment of each
tray, from "paper, cap, ruled, quire 1," through medicines and surgical instruments of
the most varied description to "sinapisms, prepared, package, 1."* The Surgeon-General
further specified his requirements for mess chests, each with "a set of black walnut trays
each 12 inches wide and 16 inches long, fitting one above another," together with contents consisting of a modest but presumably sufficient equipment for a small hospital
■fSee Report, page 121, of the Purveyor-General on the contents of the packages despatched by Dr.
Douglas.
$See Appendix "A" to the Surgeon General's Report, page 81.
§Report of the Surgeon-General, page 72.
*See Appendix "B" to Report of Surgeon-General.
Page Seventy-five mess.1 "It is believed that everything that can contribute to the well-being of the sick
men of a small command in the field," wrote Surgeon-General Bergin, "has been provided in these chests so far as space would allow."2
The organization of the Medical Service was a complete departure from precedent
and like all departures from old established customs was not acceptable to all. There
were Regimental Surgeons who resented the controls and checks to which they were
inevitably subjected. So recently as the date they left their homes with the regiments
to which they were attached the Medical Service had not been thought of. A fortnight
later they were already feeling its hand in the checking by the Purveyor-General of
their demands for medical supplies and in orders from the Deputy Surgeon-General as to
disposal of wounded. On the prairie trails they had been out of touch with the latest
astonishing development, and there were Regimental Surgeons who refused to believe
that a higher power in the Medical Service than themselves had come into existence.
They resented curtailment of extravagant demands for medical supplies to fill, and more
than fill,3 the empty medical panniers they had brought with them, and they flatly
declined, at first, to regard with more than amazed incredulity the instructions of the
Deputy Surgeon-General.4
Nor did the opposition to the newly organized Medical Service confine itself within
the bounds of the regimental medical staffs. To Lieut.-Colonel Jackson, the officer who
as "Deputy Adjutant-General, M.D. 10, Principal Supply, Pay and Transport Officer of
the North West Forces and Chairman of War Claims Commission," had established
himself on the 2nd April at Winnipeg, the Medical Staff at that point had the right to
look for assistance. The Purveyor-General reported to Lieut.-Colonel Jackson on arrival.
The latter officer, to use Surgeon Sullivan's words, "expressed his entire ignorance of my
position and duties, or even the existence of such a department as had been entrusted
to me."5
A few days later there arrived the first carload of medical supplies consigned to the
Purveyor-General, but acting on orders from Lieut.-Colonel Jackson the Railway Com-
. pany were unable to release it until that officer approved. On the Purveyor-General
making application to Lieut.-Colonel Jackson the latter refused on the stated ground
that he did not recognize the existence of a Purveyor-General. The circumstances were
urgent; many regimental requisitions were in hand which could only be filled from the
stores in the car, and the complete supply of No. 1 Field Hospital was in the same car.
A second urgent appeal was made, also in vain. A third application was submitted with
offer of bonds to cover the value of the contents of the car, but the same reply was
given. The Purveyor-General thereupon wrote to the Principal Supply Pay and Transport Officer disclaiming any further responsibility, and transferring the car and all its
contents to that much burdened official to do as he liked with. Lieut.-Colonel Jackson's responsibilities were already great enough without adding "Principal Medical
Officer" to his many titles; he released the car.6
Colonel Jackson's explanation of the incident is curious. He states he did not doubt
the Purveyor-General's word "for a moment," but a formality regarding stores being
accompanied by a transport requisition had not been complied with, and he supposed
that.the requisition (which the shippers at Montreal were responsible for furnishing)
would be forthcoming "in a day or two." He therefore held up the car "knowing the
contents could not be utilized till the Hospital corps proceeded West."7 This suggests
that Lieut.-Colonel Jackson, though not willing to assume the position of a P.M.O. or
Medical Purveyor-General, did, at least, claim to have some power to pass upon the
purely medical question of the issue of stores.
1—Ibid, page 87.
2—Ibid, page 89.
3—See Report of Purveyor-General, page 121.
4—See Report of Surgeon-General, page 77.
5—Report of the Purveyor-General, page 121.
6—Report of the Purveyor-General, page 122.
7—Report of Lieut.-Col. Jackson dated 24-12-86   in separate Blue Book, p. 20.
Page Seventy-six In another respect it would appear from the Reports that the work of the Medical
Department was greatly hampered. To the proper authority the Purveyor-General
applied for letters of credit and authority to purchase goods. To frequent requests
no satisfactory reply was forthcoming. "I could not therefore," says the Purveyor-
General, "pay the hotel and other expenses of dressers and surgeons which I was asked
to do. They were constantly arriving and going forward, and were much dissatisfied
when I could not pay their bills."f
The sympathetic interest of the public in the soldiers at the front naturally led to
extensive gifts in the shape of bandages, clothing, necessaries, medical comforts and even
delicacies for the sick and wounded from associations of ladies in different centres, and
from individuals, friends of the militiamen. The distribution of these gifts rested with
the Purveyor-General and resulted in an enormous amount of extra work. It was a
difficult problem, transport being extremely limited in view of the military demands
upon it. Much of the material was utterly useless and occupied valuable space that
could better have been utilized for other purposes.$ Some of the supplies were in a
convoy captured by Poundmaker and never reached those for whom they were intended.
Instead "Poundmaker and his braves for some days feasted gloriously upon potted meats,
preserved fruits, marmalades and jellies, and held high carnival with the fine brandies and
luscious wines intended for the brave fellows shut up in Battleford."$
The Surgeon-General recommended that in any future war the distribution of such
gifts should be the work of some central association formed especially for the purpose,
thus with remarkable acumen forecasting one of the main functions of the Red Cross
Society in the Great War.
Much information is forthcoming in the reports on the actual working of the
medical arrangements in the field, but it is not proposed to follow them through in this
narrative. Base Hospitals were established at Winnipeg and Swift Current, the latter
heing subsequently transferred to Moose Jaw. A Field Hospital was located at Saskatoon and sub-divisions of the other Field Hospital joined General Middleton at Fish
Creek, General Strange at Edmonton and Colonel Otter at Battleford. The organization
of the medical services having to be carried through at Ottawa when the campaign was
already starting in the West, it was physically impossible to make new arrangements
hefore columns were on the march and to some extent pre-arranged plans had to be
altered to fit the existing situation. Under Deputy Surgeon-General Roddick, who was
constantly on the move observing conditions for himself, transfers of medical personnel
and equipment from one point to another to meet requirements were carried through
with remarkable celerity and smoothness, and the all-important end of caring for and
transporting the sick and wounded was attained with astonishing success. To move the
wounded by trail from Fish Creek to Saskatoon most ingenious ambulances were improvised by slinging canvas and fresh cowhide to the sides of wagon boxes, protected by
canvas awnings stretched over bent willows. With a plentiful supply of hay to He on,
the forty-two-mile journey might thus be made in comfort. Evaluation of wounded
from the Field Hospital at Saskatoon to the Base Hospital at Moose Jaw were made by
steamer Nortbcote as far as "the Elbow" of the South Saskatchewan River, and thence
hy trail.
For the final transfer of remaining invalids from Saskatoon to Winnipeg on the conclusion of the campaign a bargeSzr John A. Macdonald was fitted up as a hospital ship,
towed by steamer down the Saskatchewan River until Cedar Lake was reached, when
transfer was made to the steamer Marquis. On arrival at Grand Rapids patients were
moved by tramway across the neck of land (six miles) to Lake Winnipeg and placed on
steamer Princess for the journey down the lake to the Red River. At Selkirk a final
transfer was made to river steamer Marquette for the short remaining run to Winnipeg.
tReport of Purveyor-General, page 122.
$See Report of die Surgeon-General, page 76.    See also Report of the Purveyor-General, page 123.
§Report of the Surgeon-General, page 76.
Page Seventy-seven This long journey of eleven days, with its many transfers, was made without a hitch,,
and the patients, who were provided with fresh milk from cows carried on a second
barge, stood it well. Reports are silent as to the sufferings of the bovine passengers, but
it is recorded that most of the nurses and some of the patients were victims of sea sickness while crossing the shallow waters of Lake Winnipeg. As to the earlier part of the
journey, it is on the official records that "the barge rode smoothly and easily, being free
from the jar of the machinery by day, and the never-to-be-forgotten snoring of Captain
Maloney at night."*
In apportioning the credit for the remarkable success of the medical services in 1885
a generous meed of praise is due to the Honourable Mr. (afterwards Sir) Adolphe Caron*
the Minister of Militia. He it was who decided on a medical service and selected Dr.
Bergin to organize it. Having selected Dr. Bergin he delegated to him the fullest and
completest authority and acceded to his every recommendation, save one. In his draft
gazette containing list of appointments, Dr. Bergin detailed himself as "Medical Director
General." The Minister considered that the higher status of Surgeon-General was more
appropriate and altered the draft gazette accordingly.
INGUINAL HERNIA
Major R. E. McKechnie, R.C.A.M.C,
No. XI A.R.C., Vancouver, B. C.
In the routine examination of recruits and members of the Canadian Army by the
R.C.A.M.C. the problem of what constitutes an inguinal hernia is constantly recurring.
One medical officer will diagnose an inguinal hernia and the fact is recorded on a man's
documents, yet repeated examinations at subsequent times by other medical officers, often
in other sections of the country, will fail to confirm the diagnosis, and uncertainty, delay
• and often incorrect categorization of the man ensue. That this apparent disagreement
may occur is readily recognized when one considers the number of examinations being
made, the number of doctors from all branches of the medical profession making the
examinations and the varied criteria that have been used in civilian life by the doctors
to diagnose inguinal hernia. The following remarks are made to reaffirm the basic principles used in determining the diagnosis of an inguinal hernia.
A hernia is defined as the protrusion of a loop or knuckle of an organ or tissue
through an abnormal opening. An inguinal hernia is a hernia into the inguinal canal.
For army purposes a hernial sac must be present and it must protrude through the external inguinal ring. Bulging inguinal canals and large rings which expose bulging
posterior walls of-the canal are not considered as herniae although they are recognized
to be precursors of hernia in some cases.
The anatomy of the inguinal canal has been the proving ground for anatomy
students for years and it would seem logical that all medical officers have sufficient
knowledge of this part to preclude the necessity of discussing it further.
The diagnosis of an inguinal hernia is usually considered as easily made with little
chance of error, but I have seen three experienced medical officers on a medical board
diagnose a small inguinal hernia on one side of a man and miss a larger one on the other
side. When the matter was called to their attention the medical officers re-examined the
man and were still unable to detect the hernia until the hernia was reduced and again
made to appear. To prevent such errors in the diagnosis of inguinal hernia a rigid
routine of examination must be followed and a complete understanding of the pathological anatomy that greets the examining finger must be had by the Medical officer.
The examination must be made with the subject in the erect posture, otherwise any
hernia that is present will reduce itself and pass undetected.  The inguinal regions are
* Report of Captain Thomas H. Tracey, embodied in the Report of Surgeon-Major James Bell, p. 118.
Page Seventy-eight inspected and any abnormal bulgings noted. The examiner's finger is made to approach
the external ring from below and medially as the axis of the inguinal canal, with the
man in the erect posture, is directed medially and downward. This approach is best
made by using a digit of the right hand to examine the right inguinal canal and one of
the left hand for the left inguinal canal. The finger approaches upwards and laterally,
invaginating the scrotum, riding over the spine of the pubis to which is attached the
medial end of the inguinal ligament, and comes to rest with the tip of the digit inserted
in the external inguinal ring. Now the crura of the ring rest against the pulp of the
finger and the pubic ridge against the nail. The spermatic cord is usually scooped to one
side and lies in front of and below the finger. This careful placing of the finger must
be carried out in every examination or the examination immediately loses a great deal of
its value. In some men, particularly if they are inclined to be obese, the external ring
may be difficult to locate. In these individuals the examining finger should be rotated
and the readily located spine of the pubis palpated with the pulp of the finger. The ring
will then be easily found immediately above and slightly laterally to the spine.
Once the finger is located in the region of the external ring the presence or absence
of any soft tissue masses is noted. If a mass is found the finger is used to explore and
determine if the mass extrudes through the external ring, the source of all inguinal
herniae. If no mass is found the external ring itself is examined. Some are large and
lax, whereas others are small and firm. The size and consistency of the ring does not
seem to be necessarily related to the presence or absence of a hernia as some large herniae
appear through small firm rings, and often no hernia can be found with very large lax
rings.
Having explored the area for masses and examined the rings the subject is asked to
cough. The sudden rise and fall of the intra abdominal pressure caused by the cough
will activate any labile tissues in the area, and an impulse is transmitted through them to
the examining finger. If a hernia is present the examiner will note an impulse delivered
against and often past the finger by a soft tissue mass. If the hernia is of the oblique
type the mass and impulse are in front of and below the finger as they follow the spermatic cord. If the hernia is of the direct type, the impulse will come primarily from
behind the finger unless the hernia originates high up in the inguinal canal.
A soft tissue impulse is not always caused by a hernial sac. The labile posterior wall
of the inguinal canal is composed of peritoneum, transvers^lis fascia and fat and may
give a definite impulse on coughing, particularly in those individuals with large inguinal
rings. To differentiate this condition, the finger is rotated and the cough is repeated
with the pulp of the finger in contact with the posterior wall of the canal. The origin
of he impulse will then immediately become apparent. If the posterior wall bulges appreciably through the external ring, a direct hernia is present.
Another cause of error in evaluating the impulse is the impulse given to the finger
by blood in the pampiniform plexus of veins situated in the spermatic cord. If the
plexus is thickened, such as when a varicocele is present, the soft tissues may seem to
protrude like an indefinite hernia sac and closely simulate a hernia. Readjustment of
the finger, exerting different pressures while the subject is coughing, should facilitate
the detection of the characteristic palpable bruit caused by the passage of the impulse
through the venous blood. It should be noted at this point that great care must be taken
not to miss a hernia associated with varicocele.
A hernia may be missed at times by inserting the finger too firmly into the external
• ring and compressing and fixing a small hernial sac against the margins of the ring and
thus minimizing the impulse.    This error is prevented by not completely occluding
the external opening with the finger, keeping the finger resting against the pubis and
allowing room for passage of the impulse in front of the digit.
A femoral hernia may sometimes be confused with an inguinal hernia but the two
can be differentiated by withdrawing the finger from the invaginated scrotum and passing it upwards beneath the protruding hernia and attempting to palpate the spine
of the pubis.   This can be done if the hernia is inguinal in origin but if it is of the
Page Seventy-nine A LOCALIZED OUTBREAK OF DIPHTHERIA
Dr. A. Weston Black
M.H.O., Burnaby, under the Metropolitan Health Committee, Vancouver.
Although the incidence of diphtheria has decreased markedly in the Vancouver Metropolitan Area during the past ten years, a complacent attitude should not be adopted.
That diphtheria still does occur and can spread is reflected in the following report.
In August, 1943, a case of Faucial Diphtheria was diagnosed after admission to hospital, the subject being a young man of 23, a resident of Burnaby. Investigation of
home contacts, numbering nine, including father, mother and seven children, revealed
the presence of four presumed missed cases and one carrier. Three of the cases gave a
history of tonsillitis one, two and four months before, followed by palatal paralysis in
each instance. Throat cultures of these cases proved positive and were confirmed by
the virulence test. The other presumed case had tonsillitis three months before, followed
by tonsillectomy.    Present cultures were negative.
Three children of primary school age had been given diphtheria toxoid a year before.
One child received three doses and diphtheria was not suspected in her case either by
history, clinical findings or culture. The other two children had received only two
doses of toxoid. Both had positive throat cultures, one had mild tonsillitis followed by
palatal paralysis while the other was clinically negative and is listed, as a carrier.
The mother and father were clinically negative and all cultures were negative. The
parents slept in a downstairs room while the children were berthed in one large upstairs
room. There was definite overcrowding in this room, which was poorly partitioned for
sleeping purposes, and it is felt that this factor facilitated the spread of the infection.
All children have been home with the exception of one older boy in the Army. His
visits were infrequent, he did not sleep at home and his history and findings were entirely
negative.
There is evidence that five cases of diphtheria and one carrier developed among seven
young individuals sharing a common sleeping room.
All cases showing positive cultures were removed to Isolation Hospital. Fortunately
the mortality was nil, in spite of the fact that four cases had been missed and had not
received specific treatment.
In every case of acute tonsillitis the possibility of diphtheria should be considered.
The findings of palatal paralysis with a nasal intonation to the voice should merit sus-
pision. Enquiry should be made regarding past disease experience and immunization.
Nose and throat cultures should be taken in all suspicious cases. Cultures should be
submitted promptly to the Provincial Board of Health Laboratories for examination.
Virulence Tests should be made on all positive cultures and those suspect. The Provincial Laboratories routinely perform virulence tests on all positive and suspicious cultures.
This valuable test distinguishes between C. Diphtheriae and Diphtheroids.
Prompt reporting of all cases of Diphtheria and those suspect to the Local Health
Department is essential, so that necessary Public Health measures may be employed in
conjunction with the family physician, viz. isolation, hospitalization, quarantine, observation and swabbing of contacts, biological testing and specific prophylaxis.
The best prophylactic to date is diphtheria toxoid. Three doses should be given during
a child's first year of life and a small reinforcing dose every five years thereafter.
ERRATA
In the November, 1943, issue of the Bulletin, page 41, paragraph 1, line
5 of Dr. S. E. Turvey's article on Status Thymicolymphaticus, this should read:
"Its physiological function is truly ««known . . ." in place of "is truly
known."
Page Eighty-four A MESAGE FROM THE PRESIDENT OF THE BRITISH
COLUMBIA MEDICAL ASSOCIATION
At the beginning of a New Year I should like to send my greetings and best wishes
to all fellow members of the Canadian Medical Association, British Columbia Division.
If the profession is to provide leadership, as it is best fitted to do in any changing
order of medical practice in Canada, it must have a mouthpiece. This mouthpiece is the
Canadian Medical Association, which must be in a position to state that it truly represents the profession and speaks with authority. It should be our aim to build our Provincial membership in the Canadian Medical Association to a very high figure.
P. A. C. Cousland, President.
A MESSAGE FROM THE PRESIDENT OF THE COLLEGE
OF PHYSICIANS AND SURGEONS OF B. C.
Let me, at this time of the year, wish you one and all a Happy New Year. I realize
that you all have worked too hard during these dreadful years we have passed through.
It is my sincere wish that the time will very soon arrive when we will be able to welcome back those members of our profession who are serving our country so magnificently.
I would ask you one and all to diligently study and become familiar with the impending changes that are going to take place in the very near future, so that we will be
a united profession in guarding for our members returning from service the magnificent profession to which we are privileged to belong. I would ask you one and all to
take out membership in the Canadian Medical Association—the voice of the profession
in Canada. Frank M. Bryant, President.
NEWS AND NOTES
Major F. S. Hobbs and Dr. Donald Beach announce the birth of sons, and S/L
G. R. F. Elliot and Lieut. J. Tysoe, of daughters.
We regret to record the passing of Doctors W. F. Drysdale, Nanaimo; J. Oliver,
White Rock; Robert Elliot, Parksville, and J. A. Mongtomery, Vancouver.
Sympathy of the profession is extended to Dr. David A. Steel, who lost his father by
death recently. *      4      *      *
We regret to report that the six-weeks-old baby of Dr. and Mrs. W. H. Ormond of
Slocan died suddenly on Christmas Eve.
Sympathy of the profession is extended to Dr. and Mrs. J. J. Gibson of Prince
Rupert in the sudden passing of their four-months-old son.
We are glad to report that Dr. Wilfrid Laishley's mother is much improved. He was
called hurriedly to Ottawa. *      |      *      *
A large number of the profession have suffered from grippe during the past month
and Victoria was no exception. The President of the British Columbia Medical Association, Dr. P. A. C. Cousland; Dr. F. M. Bryant, President of the Council; Dr. M. J.
Keys and Dr. H. E. Ridewood were all laid low for some time, but are now recovered.
*      *      *      si-
Doctors G. F. Amyot, P. A. C. Cousland and Thomas McPherson of Victoria attended a meeting of the Divisional Advisory Committee in Vancouver on January 6th.
Dr. H. Emanuele of Penticton called at the office and is in Vancouver making application for appointment as Medical Officer.
Major Edna E. Rossiter, R.C.A.M.C., Principal Matron in the Pacific Command,
received a Royal Red Cross in the New Year's honours in recognition of her service.
Page Eighty-five We congratulate Major T. Miller, V.D., on being included in the New Year's honours
when he received membership in the Order of the British Empire as a deserved recognition of his valued service during many years in the Pacific Command.
The following promotions were announced at New Year's: Acting Surgeon Commander A. Marshall, Arcting Surgeon-Lieutenant-Commanders H. G. Baker, D. M.
Whitelaw, J. W. Frost, J. T. Maclean and R. J. Wilson.
We congratulate Lieut.-Col. M. R. Caverhill, who is now in command of a Field
Ambulance Overseas.
Dr. J. M. Hershey, who has been Director of the Health Unit at Kelowna, is now
Director for the Nanaimo District, extending North to Qualicum and South to Ladysmith. fcs^
Nutm Sc atyfltttBon
2559 Cambie Street
^c»>M^»^w^^^^g!i^Mg&yS:::3Sy:
Breaks the vicious circle of perverted
menstrual function in cases of amenorrhea,
tardy periods (non-physiological) and dysmenorrhea. Affords remarkable symptomatic
relief by stimulating the innervation of the
uterus and stabilizing the tone of its
musculature. Controls the utero-ovarian     ,
\    circulation and thereby encourages a    M
%   normal menstrual cycle. jf
• MARTIN H. SMITH COMPANY
Full formula and descriptive
literature on request
Dosage:   l to 2 capsules
3 or 4 times daily.   Supplied
in packages of 20.
Ethical protective mark MHS
embossed on inside of each
capsule, visible only when capsule  is cut in half at seam.
Page Eighty-six Oroiicliitis
Two specific difficulties are experienced by the bronchial
patient. Firstly, a hacking cough tires him throughout the
day and interrupts his rest at night. Secondly, he may suffer
from a useless "dry" cough, which never seems to loosen
the mucus. For treatment of these two conditions, the E. B.
Shuttleworth Chemical Co. Ltd. offers, Scilexol and Bronexol.
SCILEXOL...
Hgr.
16 grs.
2 mins.
4 mins.
A sedative expectorant, containing in each
fluid ounce:
* Diethylmorphine Hydrochloride
(Dioniri)    .    .    .' .   . "'.   .    .
Ammonium Chloride   ....
Chloroform	
Acid Hydrocyanic Dil. B.P.
Syrup Scillae 90 mins.
Syrup Tolu   •   .,_ 120 mins.
Dose: One or two fluid drachms, every four hours.
Indications: Asthma, bronchitis, general colds and
coughs, influenza, laryngitis.
Note: Also supplied with 1 grain of codeine phosphate, in place of Diethylmorphine Hydrochloride
(Diomn).
*A narcotic order required.
\ When
I Prescribing
Specify E.B.S.
BRONEXOL...
A  non-narcotic,  stimulating  expectorant,
containing in each fluid ounce:
Ammonium Carbonate    ...       8 grs.
Ammonium Chloride   .... 16 grs.
Prunus Serotina        6 grs.
Senega        8 grs.
Menthol   .  H gr-
Chloroform        2 mins.
Glycyrrhiza  Q. s.
Honey   .    ,  q.s.
Dose: One or two fluid drachms, every three hours.
Indications: Recent and tight bronchial conditions.
Is antispasmodic and effective in controlling
coughs.
THE E. B. SHUTTLEWORTH CHEMICAL CO. LIMITED
I!
TORONTO
MANUFACTURING   CHEMISTS //
rf 'Powi SeAelcut. . .
MA N Y a child is scolded for dullness "when he should be treated for undernourishment. In hundreds of homes a "continental" breakfast of a
roll and coffee is the rule. If, day after day, a child breaks the night's fast of
twelve hours on this scant fare, — or less — small wonder that he is listless,
nervous, or stupid at school.
Pablum offers a happy solution to the problem of the school-child's breakfast. Mothers who learn about Pablum from their physicians are delighted
to serve it, for it needs no cooking and can be prepared in a minute at the
table — more quickly than many less nourishing foods. Right now, this feature
is especially valuable in homes where the mother is engaged in war work.
Pablum not only ends the bane of long cooking of cereals but in addition furnishes a variety of minerals (calcium, phosphorus, and iron) and the vitamin
B complex. It is an excellent vehicle for milk.
PABLUM is rich in calcium and iron, minerals likely to be deficient in the school-
child's diet yet needed in more than average amounts during childhood. Numerous
clinical studies have demonstrated that Pablum gives good weight gains and increases
hemoglobin values in both normal and sick
infants and children. Reprints on request of
physicians. Pablum (Mead's Cereal thoroughly cooked) is a palatable cereal enriched with vitamin- and mineral-containing
foods, consisting of wheatmeal, oatmeal,
wheat embryo, cornmeal, beef bone, alfalfa
leaf, brewers' yeast, sodium chloride and
reduced iron. MEAD JOHNSON & COMPANY OF CANADA, LTD.. BELLEVILLE, ONT.
"TOMMY, that?s the third time this week
haven't learned your lesson! Why don't you listen
to me when 1 tell you how to work the problems?"
Please enclose professional card when requesting samples of Mead Johnson products to co-operate in preventing their reaching unauthorized persons. c
'reamalin promptly reduces stomach acidity. Moreover,
the antacid effect is sustained.
With Creamalin there is no compensatory reaction by the
gastric mucosa and no oversecretion of hydrochloric acid.
Furthermore, there is no risk of producing alkalosis.
When employed with an ulcer regimen, Creamalin often
induces unusually rapid healing of peptic ulcer.
Supplied in $ oz. and 12 oz. bottles
WINTHROP    CHEMICAL     COMPANY,     INC.
Pharmaceuticals of merit for the physician
General Office: WINDSOR, ONTARIO
Professional Service Office: Dominion Square Building, Montreal, Que.  flDount pleasant TUnbertakinQ Go. Xtb.
KINGSWAY at 11th AVE. Telephone FAirmont 0058 VANCOUVER, B. C
R. F. HARRISON W. E. REYNOLDS
Jfead CoJdi Checked    :•'§§
WITH 3 DROPS IN EACH NOSTRIL ...
PRIVINE "Ciba"
(1:1000 solution of 2—(naphthyl—1—methyl)-imidazoline hydrochloride)
NASAL   DROPS
Clinical investigations on Privine Nasal Drops have proved that
they are excellently suited for the treatment of all forms of nasopharyngeal affections. In head colds, a few moments after the
instillation of 3 drops of Privine in each nostril, the headache and
sensation of heaviness in the head disappear, while the nasal respiration becomes easier, the watering of the eyes stops, the voice regains
its normal tone and the sense of smell is restored.
ISSUED:
In bottles of Vi ounce with dropper, and bottles of 4 ounces.
CIBA COMPANY LTD.
Montreal JXaflid and \SuStcUned
REDUCTION 4 sDmad
^^^^*«M«c«C6»^^^p^pi^S iiTtlw jitomaclfc
|jll|s?stent antacid effect,. *
7 WiHi\G*eefmali*t no secondary rise in secretion
^pictd gast^^Mce occurs. Wor«p^^^^^^^^^^
SgRof producing alkalosis.
. p4e«Mftz^|bftei^^&ces rapid healing of peppii
IhKIIP*^ emp^^^^Pl an n^pSegin|^S       §ljj§
t?«ec^r<a/^^^^8ls are convenient to'carry and
jjjasy to tafee--aii|Mh^^^p^^^^bleV*'
Supplied in bottles of 50 and 200 tablets.
CREAMALIN
Trade Mark Registered in Canada
Brand of Aluminum Hydroxide Gel
TABLETS
{formerly CREMORIN)
CRIAMALIII
tmS'"""
WINTHROP CHEMICAL COMPANY, INC o^ro/ofrW
^Professional service office: Dominion Square Bldg., Montreal, Que.      WINDSOR, ONT. SAVE
TIME
IN   URIls
TES
SAVE
LABOR
CHNIITEST
SUGAR
I.NG
1
EXTERNAL
HEATING
REQUIRED
5 drops urine
2
10 drops water
3
Drop in tablet
Allow for reaction*
then compare with
color scale.
By substituting Clinitest Urine-Sugar Analysis Tablets for the
usual type of reagent solution, you effect these advantages:
Saving of Time
Each test requires less than 1 minute and can be made in the
physician's office, his laboratory or in the patient's home.
1 Saving of Labor
Just a few simple steps; no external heating required;
no water bath; no bulky reagent solutions; no compounding;
no assaying.
CLINITEST IS DEPENDABLE—
a copper reduction test involving the same
chemical principles underlying Benedict's,
Fehling's, and Haines' tests. Complete seta
and tablet refills are available through your
surgical house or prescription  pharmacy.
Write for full descriptive
literature.
EFFERVESCENT   PRODUCTS   INC.
Sole Canadian Distributors
FRED.    J.     WHITLOW    &    CO.,     LTD.,     187    DUFFERIN     STREET,,    TORONT© ARTHRITIS and ECZEMA
of endogenous origin
claimed to be allergic, may be
favored or induced by calcium
and sulphur deficiency, impaired
cell action, and imperfect elimination of toxic waste.
LYXANTHINE ASTIER
administered per os, brings about
improved cell nutrition and activity, increased elimination, resulting symptom relief, and general functional improvement.
Write for Information
Canadian Distributors
ROUGIER FRERES
350  Le  Moyrie   Street,  Montreal
Colonic and
Physiotherapy Centre
Up-to-date Scientific Treatments
COLONIC IRRIGATIONS, SHORTWAVE
DIATHERMY, SINNEWAVE GALVIN-
ISM, IONIZATION, ULTRA VIOLET
RAY,  STEAM   BATHS  AND  SHOWERS
Medical and Swedish Massage
Physical Culture Exercises
STAFF OF GRADUATE NURSES
Superintendent:
E. M. LEONARD, R.N.
Post Graduate Mayo Bros.
1119 Vancouver Block
MArine 3723      Vancouver, B.C.
if
DIGESTIVE DIFFERENCES
FOUND IN VARIOUS
BULK"-FORMING MATERIALS
{K3S§§8SS3§W§g§KSS
%.<J»
__J53K»»   TK   I* OX.  1
Diets included
known equalized
amounts of fibre from
various common food
sources. Subjects reported tbat of all the
foods tested only one
other gave as satisfactory laxative action as KELL OGGS
ALL-BRAN.
STUDIES recently undertaken at
one of the leading universities
bring new evidence to an understanding of digestive differences of various
sources of "bulk" in the diet.
While heretofore nutritionists generally proceeded on the theory that
"fibre" from one food is no more or
less digestible than the fibre from
another, results of this research
indicate that there are wide differences in the human digestion of fibre
from different sources.
Obviously, the more fibre is
digested, the less remains to aid
proper elimination. Therefore, when
diets do not appear to supply
adequate "bulk", it may be desirable
to consider other sources of "bulk"
rather than merely adding more
"bulk" from the same sources.
Subjects of this experiment also
reported that of all the foods tested
the most desirable laxative action was
produced by KELLOGG'S ALL-
BRAN and by one of the raw vegetables (cabbage).
KELLOGG COMPANY OF CANADA, LTD
London, Canada
Kindly send me free reprint of full
report on the recent research of digestion of fibre from different sources.
Doctor	
Address	 tllllllllllllllllllllllllllilllllllllllllllllllllllllllUIIIIilllllilllllllllllllllHIillllllllllllllllllllllllllllllllilllllllllllllllllllllllllllllllllllllllllllllllllllllllillllllllllllllllllllllllllllllHIIIIIIIt
When baby
graduates
W HEN the formula-fed infant starts
drinking milk from a cup, or when the
breast-fed infant is weaned, Irradiated
Carnation Milk admirably meets the
milkrequirementsof the growing child.
Sterility, soft-curd quality, lessened
antigenic properties, and uniform nu-
tritiousness (with increased vitamin D)
especially recommend this milk. Economy and availability are also important.
In a 1:1 (whole-milk) dilution,
Carnation is a palatable drinking milk
for children. In cookery, it may often
be used up to full strength, greatly increasing the milk solids per serving.
Milk-rich desserts made with Carnation
are notably appetizing.
Physicians are invited to write for
"Continuing After Weaning With
Irradiated Carnation Evaporated Milk,"
an authoritative new publication for
the medical profession. . . . Carnation
Company, Limited, Toronto, Ontario.
IRRADIATED
Carnation
'FROM CONTENTED COWS"
Milk
A Canadian Product Our l36tlMfearm
Today theg^mes||| Georgia Pharmacy
and Leslie G^Hendersorte^^f the confidence of the Medical Profession pj
just as they did a generation^p.
Phone
MArine 4161
^S3l^J^^«4^\
GEORGIA PHARMACY
tl*K«A
•mm? w»
€^ntei&l|anttaEt&
ESTABLISHED 189S
VANCOUVER/ B.C.
North Vancouver, B. C.
Powell River, B.C.
J ^l&ffZttif
(Eo. CHmteii V
I
New Westminster, B. C.
Far the treatment of
NEUROPSYCHIATRIC
DISORDERS
Reference—B. C. Medical Association
For information apply to
Medical Superintendent, New Westminster, B. C.
or 721 Medical-Dental BuiLDmG, Vancouver, B. C.
PAcific 7823
Westminster 288

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