History of Nursing in Pacific Canada

The Vancouver Medical Association Bulletin: December, 1942 Vancouver Medical Association 1942

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 The BULL__ffN
of the
I        VANCOUVER
MEDICAL ASSOCIATION
Vol. XIX
DECEMBER, 1942
With Which Is Incorporated
Transactions of the
Victoria Medical Society
the
Vancouver General Hospital
and
St Paul's Hospital
In This Issue:
NEWS AND NOTES jflfe-- M	
MEDICAL SERVICES ASSOCIATION ANNUAL REPORT
A PROBABLE CASE OF ACTINOMYCOSIS
THE MODERN TREND IN TREATMENT OF FRACTURES
THE HEMORRHAGIC BLOOD DISEASES *»f»,
'Hi
Each tablet
contains  freshly
killed bacilli of—
Pneumococci
15 billion
Streptococci
7.5 billion
H. Influenzae
125 million
M. Catarrhalis
125 million
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Combatting
Secondary
Respiratory
Infections]
with
Oral
Vaccine
■ At this season, one of the greatest causes of disability, and by far the
most frequent, is infection of the upper respiratory tract. Lowered resistance, due to the strain of long hours under crowded conditions, and
irregular and insufficient sleep, contribute to the frequency and severity
of these infections.
It has been shown by extended clinical use that a degree of immunity can
be attained by the administration of oral vaccine.
IMUNOVAX E.B.S. is a mixed vaccine, prepared
in tablet form, |for oral administration, containing
material from—
15 billion|pneumococci
7.5 billion streptococci
125 millon H. influenzae
125 million M. catarrhalis
%
SPECIALTIES
Aquaphedrin . . . Bronexol. I. Codophen
... Digifolia Capsules ... Digestophos ...
Dilaxol .JU Ferrochlor with Vitamin Bi
||| . Hemroydine Ointment . |li, Heparol
Ampoules ... Magnesil... Minerovite ...
Neurovit ... Orestol ... Rheumatol .mm
Scilexol... Theobarb.. .Viplex (B complex).
which has been shown to initiate antibody response and
so induce effective immunization against the organisms
which cause respiratory infections. It has been shown
by many reputable investigators that oral treatment of
such infections with a vaccine, prepared from freshly
killed organisms, lessens the incidence, severity and
duration of the common cold. There is also some indication that Imunovax E.B.S. may be useful as a prophylactic against influenza and other secondary bacterial
invaders, and that the severity of the attack is decreased
in those individuals who do become infected.
IMUNOVAX E.B.S. is available as
chocolate-coated tablets N<|| 387 in
bottles of 25 or 100.
When Prescribing
Specify E.B.S.
Preparations...
Jvtt to Be Sure I
THE E. B. SHUTTLEWORTH CHEMICAL CO. LIMITED
TORONTO
MANUFACTURING   CHEMISTS
CANADA THE    VANCOUVER    MEDICAL    ASSOCIATION
BULLETIN
Published Monthly under the Auspices of the Vancouver Medical Association
in the interests of the Medical Profession.
Offices: 203 Medical- Dental Building, Georgia Street, Vancouver, B. C.
EDITORIAL BOARD:
De. J. H. MacDermot
De. G. A. Davidson Dr. D. E. H. Cleveland
All communications to be addressed to the Editor at the above address.
Vol. XIX.
DECEMBER, 1942
No. 3
OFFICERS, 1942-1943
Dr. J. R. Neilson Dr. H. H. Pitts Dr. C. McDiarmid
President Vice-President Past President
Db. Gordon Burke Dr. A. E. Trites
Hon. Treasurer Hon. Secretary
Additional Members of Executive: Dr. Wilfrid Graham, Dr. J. A. McLean
TRUSTEES
Dr. F. Brodie Dr. J. A. Gillespie Dr. W. T. Lockhart
Auditors: Messrs. Plommer, Whiting & Co.
SECTIONS
Clinical Section
Dr. D. A. Steele Chairman Dr. J. W. Millar Secretary
Eye, Ear, Nose and Throat
Dr. A. R. Anthony Chairman Dr. C. E. Davies Secretary
Pcediatric Section
Dr. J. H. B. Grant Chairman Dr. John Piters | Secretary
STANDING COMMITTEES
Library:
Dr. F. J. Buller, Dr. D. E. H. Cleveland, Dr. J. R. Davies,
Dr. A. Bagnall, Dr. A. B. Manson, Dr. B. J. Harrison
Publications:
Dr. J. H. MacDermot, Dr. D. E. H. Cleveland, Dr. G. A. Davidson.
Summer School:
Dr. J. E. Harrison, Dr. G. A. Davidson, Dr. R. A. Gilchrist
Dr. Howard Spohn, Dr. W. L. Graham, Dr. J. C. Thomas
Credentials:
Dr. A. W. Hunter, Dr. W. L. Pedlow, Dr. A. T. Henry
V. O. N, Advisory Board:
Dr. L. W. McNutt, Dr. G. E. Seldon, Dr. Isabel Day.
Metropolitan Health Board Advisory Committee:
Db. W. D. Patton, Db. W. D. Kennedy, Db. G. A. Lamont.
Greater Vancouver Health League Representatives:
Db. R. A. Wilson, Db. Wallace Cobubn.
Representative to B. C. Medical Association: Db. C. McDiabmid.
Sickness and Benevolent Fund: The Pbesident—The Tbustees. IN THE FIELD OF NUTRITION    1§|
PARGRAN-V    PARGRAN-M
(Squibb Multivitamin Pedes)
(Squibb Calcium-Iron Capsules)
ffi
B
• MOmm.nd.d  b.
Com  O' Foodt &
f.iliilww. NeliwMl
InHffh Conned
VITAMIN NICOTINIC    VITAMIN
6? ACID C
(RIBO- (ASCOBUC
IIAVINJ ACIOI
SHADED AREAS SHOW
PROPORTIONS SUPPLIED
BY  PARGRAN
2 PARGRAN.V
PIBliS
CAICIUM I8QN
4 PARGRAN-M
CAPSULES
pOVERNMENT authorities estimate that the chances are
three to one against the average family getting enough of the
foods that are needed for the efficiency and stamina upon which
our success depends. There is need then, for a balanced
vitamin-mineral supplement for use where food sources are
inadequate.
Based on the new trend in multivitamin and mineral therapy,,
the House of Squibb provides Pargran-V and Pargran-M—two
products which, as shown on the chart—
# supply in proper balance the vitamins and minerals most generally
lacking in the diet;
%  embody the recommendations of the Committee on Food and Nutrition
of the National Research Council, U.S.A.;
%   afford flexibility of dosage—supplying vitamins or minerals or both—
in J^, 3^_* % or the full recommended daily allowance;
# provide the advantages of convenience and economy.
Write now for complete information about Pargran-V and
Pargran-M and for the new authoritative booklet, "Practical
Nutrition."    Address  36  Caledonia Rd.,  Toronto, Ontario.
MANUFACTURING   CHEMiSTS
MEDICAL   PROFESSION   SINCE  I8S8 VANCOUVER     HEALTH     DEPARTMENT
West North
Burnaby   Vancr.   Richmond   Vancr
Syphilis	
Gonorrhoea.
Phone MA. 4027
STATISTICS—OCTOBER, 1942
Total Population—estimated 272,352
Japanese Population—estimated ; 8J69
Chinese Population—estimated  „      8,558
Hindu Population—estimated .J         360
Rate per 1,000
Number        Population
Total deaths  |    262 11.3
Japanese deaths .        4   Population evacuated
Chinese deaths       15
Deaths—residents only ,    220
BIRTH REGISTRATIONS :
Male, 312;  Female, 288	
INFANTILE MORTALITY: Oct., 1942
Deaths under one year of age        9
Death  rate—per  1,000 births %      15.0
Stillbirths   (not included in above) _•     12
CASES OF COMMUNICABLE DISEASES REPORTED IN THE CITY
September, 1942
Cases   Deaths
Scarlet Fever  . ;  35
Diphtheria     0
Diphtheria Carrier   0
Chicken Pox   36
Measles    .  5
Rubella     2
Mumps   98
Whooping Cough   20
Typhoid Fever   0
Undulant Fever   0
Poliomyelitis    .  13
Tuberculosis  ^_  42
Erysipelas  0
Meningococcus Meningitis 	
V. D. CASES REPORTED TO PROVINCIAL BOARD OF HEALTH,
DIVISION OF VENEREAL DISEASE CONTROL
Figures for October f^jj yet available
A DYNAMIC MENTAL AND PHYSICAL TONIC
INDICATED IN THESE DAYS OF STRESS
BIOGLAN "A
Another Product of the Bioglan Laboratories, Hertford, England
Stanley N. Bayne, Representative
1432 MEDICAL-DENTAL BUILDING
Descriptive Literature on Request
THE SCIENTIFIC HORMONE TREATMENT
Vancouver, B. C S^IO MALT
**«**!
**«««» ill ESStAHO BY
II__
iJiPiDOM
rapio-malt
Standardized Vitamins A B± B2 and D
A N ideal product in those cases of malnutrition
** so frequently encountered during the Winter months in which the vitamin deficiency is
general but not acute.
Stocks  of Radio-Malt  are held  by  leading  druggists  throughout  the
Dominion and  full particulars  are obtainable from
THE BRITISH DRUG HOUSES (CAHADA) LTD.
Toronto Canada
RM/Can/4212 VANCOUVER MEDICAL ASSOCIATION
FOUNDED 1898
INCORPORATED 1906
Programme of the Forty-fifth 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.
1943
January    5—GENERAL MEETING.    Round Table Discussion of Functional Diseases.
Chairman, Dr. George A. Davidson, who will be assisted by six other
speakers.
January  19—COMBINED CLINICAL MEETING and CLINICAL STAFF MEETING
at VANCOUVER GENERAL HOSPITAL.
Just
barley
hops
yeast
water
\
AN ANALYSIS OF GUINNESS STOUT  100 cc.
Total solids __    5.87 gm.
Ethyl alcohol   (7.9%   by volume)       6.25 gm.
Total carbohydrates      3.86 gm.
Reducing sugars as glucose     0.66 gm.
Protein        None
Total   nitrogen        0.10 gm.
Ash    I     0.28 gm.
Phosphorus    —' -   ,38.50 mg.
Calcium           7.00 mg.
Iron        0.072 mg.
Copper           0.049 mg.
Fuel value        61 cat.
Vitamin Bl         §|      6 Int. Units
Vitamin G 33  Sherman Bourquin Units
Ii   GUINNESS
Analysis is only a partial indication of the attributes of Guinness Stout. The
physical equilibrium of colloidal properties is important, and the well-nigh
perfect balance  bet-ween the alcohol  and the malt  and hops constituents.
LITERALLY    thousands    of   physicians   in   Great
Britain have testified to the value of Guinness
as   a  tonic  daring convalescence.
...  as   a   stimulating   and   appetizing   food    for
older people.
... in the treatment of insomnia, to obviate
the depressing after-effects which most hypnotics
produce.
All the natural goodness is retained in Guinness
for,   unlike   other   stouts   and   porters,   Guinness   is
unfiltered and unpasteurized. The active yeast
which thus remains is a source of Vitamin B and G.
Guinness has been brewed in Dublin since 1759,
and is the largest selling malt beverage in the
world. It is matured over a year in oak vats and
bottle. Foreign Extra Guinness is obtainable through
all legal outlets. Write for convenient 3"x5" file
card giving complete analysis and indications to
Representative, A. Guinness, Son & Co., Limited,
501  Fifth Avenue, N.Y.C.
A. GUINNESS, SON & CO., LIMITED
DUBLIN and LONDON
S314
Page 63 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
H EPINEPHRINE is prepared in the
Connaught Laboratories 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.
EPINEPHRINE HYDROCHLORIDE INHALANT (1:100)
Distributed  in special dropper bottles containing 6-cc.
as an inhalant in the treatment of bronchial asthma.
Used
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. THEEDITOR'SPAGE
We are printing in this issue, some letters received from colleagues of ours who are
in the armed forces overseas. Just from this point of view alone they are of intense
interest to us; we know that our readers will be delighted to read the chatty letter of
H. R. L. Davis, in which he mentions so many of our old friends, who are doing such
excellent work overseas. Roy Huggard, too, comes to bat again with one of his inimitable letters, full of courage and confidence in the ultimate triumph of right and justice.
Roy's letters are a tonic, and one of them should be forthcoming at each of the crises
that we encounter every so often. They have this in common with the speeches of that
tower of strength, Winston Churchill, that they breathe defiance to the foe, and simply
do not admit the idea of defeat. And in this letter Roy indulges in a little quiet exultation, because he sees the prophecy that he made some time ago, of the coming turn of
the tide, in process of fulfilment.
But one of these letters has a poignancy all its own—the short note from gallant
young Reg. Laird, whose present address is a German Kriegsgefangenlager, or war prisoner's camp. We find no note of defeat in this letter, either. But we find room for
sorrow in his loss of a leg. Still, for a medical man, this is not by any means an irremediable loss—while if his hand or eye had been the victim, it would indeed have been very
bad. His manner of losing it, as we have heard the story, brings Reg. Laird into the
membership of heroes. He stayed by his wounded, himself suffering from wounds, and
when finally captured, had very little clothes on—he had torn up the rest to make bandages and dressings for his men. We wish him a safe convalescence, and a speedy return
to his own country.
We had hoped to publish in this copy of the Bulletin, an extract from the November number of the Western Druggist, covering the matter of Health Insurance. This
issue has in it two articles of the greatest interest and importance. The first is a report
by Hugh Wolfenden, well-known actuary, who has done so much for the Canadian
Medical Association—the other is a resolution passed by the Health Insurance Committee
of the B. C. Pharmaceutical Association, and sent to all the members of that body for
Consideration and study. It is, to say the least, the most radical expression of opinion
on this subject that we have seen in this part of the world, though several people whose
opinion is of great value, have taken the same attitude to this question of social medicine.
This attitude is in some ways a very logical one. Its exponents feel that Health Insurance
is in no way a complete answer to the problem of inadequate medical care. They argue
that it is merely a sop, and actually delays solution of the greater social problems of
security against "need, sickness, and other adversity," as the Anglican Book of Common
Prayer so beautifully puts it. Their solution is a better economic system, which would
provide everyone with the wherewithal to pay his or her bills, without resort to charity
or cheap schemes of so-called insurance. We confess to a good deal of sympathy with
this point of view. One reads that one of the things that we are aiming for, after this
war is over, is a radical improvement in the economic set-up. Perhaps it might be wiser
to wait for this, before devising stop-gap schemes of collective insurance on the cheapest
scale possible, based on the old ideology that we are told must go. We feel that there is
something in what the druggists are saying. We hope to do more than this in our next
issue.
Finally, we wish to all our readers, the very best wishes for Christmas and the coming
year. Perhaps we shouldn't say this, but we have been infected by the bad example of
Roy Huggard, and we feel that the horizon is brightening, and that we are beginning to
Page 64 see, afar off though it may be, the glirnrnering of dawn—a brighter dawn than we have
seen for many years. Let us all hope that the day that it ushers in will be also a new day
for mankind, a day of better things, of greater justice and better relations between man
and man—a day of greater and more real freedom, not only for the privileged, but for
everyone.    In the immortal words of Tiny Tim, "God Bless Us ALL."
H.Q. D Group, C.R.U.
31st Oct., 1942.
Dear Dr. MacDermot:
I am writing to let you know of a change of address. The Bulletin has been
reaching me each month through my old address at 1 C.M.G.R.U. It is always interesting to read of what the people are doing at home.
I see numbers of Vancouver men, including Lee Boulton, Roy Huggard, Gordie
Frost, almost every week. Clarence Ryan is stationed near here and every once in a
while I see others. I saw Lavell Leeson last Saturday just after he arrived. Of course
Archie DesBrisay is home now, but I saw him twice, once just after he arrived
in 1940 and just before he went home this year. Jack McMillan was at 3 C.M.C. and
is now at 8 th General Hospital. Card, one of our former internes, is at 4 C.M.C. I
saw Murray Meekison during the summer. He called on me^and we went over to see
the 16th in their tented camp. However, most of them were on leave. We did see
Brun, McEwen and Christopherson. I had previously called on them and had met many
I knew, including Hammy Boucher.
My old regiment arrived recently and I attended a dinner on the 26th August to
celebrate the third anniversary of our calling up.    It was quite a party.
Yours sincerely,
H. R. L. Davis.
.   Nov. 10, 1942.
Dear Jack:
As it is not feasible to extend by mail a personal greeting to every associate I know
in Vancouver and the Province throughout, will you be good enough to extend to all,
every good wish for the Xmas season and an earnest hope that thej coming New Year
will herald in reality, the Prince of Peace. I hesitate to say a Merry Xmas, for somehow
in a war-torn world, the word "Merry" does not seem to fit. However, I do wish all
a real old family Xmas, and perhaps this year we shall have greater cause for rejoicing
than any of the festive seasons of the war so far.
I m sure you will agree that my optimism of the last epistle I sent to you, has had
some basis in fact. The most heartening news of the last month will,T am sure, prove
a stimulus and lift to all. Let us work ever harder and prepare for even greater tasks
ahead. I am certain that the gate to victory is opening ever wider, and only requires
the effort and will to exploit these recent successes. I do not suggest, however, that
there is not great struggle ahead, but I do feel the velocity of our movement towards a
victorious destiny is being rapidly accelerated.
It is not one's purpose to burden you with a long letter—but rather to use this note
to communicate every good wish to all for the. coming season.
Again thanks for the Bulletin.   It is eagerly looked for in the mails.
V for victory.
As ever,
Roy.
L. H. A. R. Huggard, Major, R.C.A.M.C.
C Group H.Q., C.R.U.
Canadian Army Overseas.
Page 65 POSTKARTE
Kreegsgefangenenpost No. 353 Luftpost
Dr. A. J. MacLachlan
Medical-Dental Bldg.,
Vancouver
British Columbia
Canada.
Absender:
Capt. R. R. Laird (ARZT)
Gef angenennummer: 39740
Lager-Bezeichnung: M-Stammlager EK C
Res. Laz. 1247
Deutschland (Allemagne)
Kriegsgef angenenlager Datum:   18/10/42.
Dear Dr. MacLachlan: If this reaches you in time, the best of Christmas to you and
yours. Reached here via a "canoe trip" to Dieppe and the Canadian Government owes
me a right leg. But I'm darn lucky, I think, in comparison to others. Someday will be
back to bother you again and until then—cheers. Reg. Laird.
NEWS    AND    NOTES
The sympathy of the profession is extended to Dr. and Mrs. C. R. Marlatt of Powell
River, their son, Flying Officer S. P. Marlatt, R.C.A.F., having been killed in action
Overseas.
Congratulations to Major E. F. Raynor, R.C.A.M.C, who has just received his promotion, and is now consultant medical officer in Eye, Ear, Nose and Throat in northern
British Columbia.
Congratulations to Dr. and Mrs. N. H. Jones of Port Alberni on the birth of a son
on November 4th.
sj- ;{- *C- sS-
Dr. and Mrs. J. W. Millar of Vancouver are receiving congratulations on the birth
of a daughter on November 5 th.
Dr. and Mrs. W. R. Sutherland Groves are to be congratulated on the birth of a
daughter on December 3rd.
We regret to report that the father of Wing-Commander Murray Meekison passed
away.
*       *       *       *
Sympathy is extended to Dr. W. F. Emmons of Vancouver, whose mother died
recently, and also to Dr. L. Giovando of Nanaimo, whose father, a well-known resident
of Ladysmith, passed away recently.
*t A A 5$.
Capt. R. R. Laird, R.C.A.M.C, took part in the Dieppe attack, and his splendid
work on that occasion has been the subject of comment by his raiding comrades. A
recent card from Capt. Laird tells us that he is attempting to make himself comfortable
in a prison camp. We regret to learn that he suffered a leg amputation, but are very
glad to know that some day he will return to us.   He can be assured of a warm welcome.
Dr. W. Laishley of Nelson visited Vancouver.
Page 66 Capt. W. Roy Walker, R.C.A.M.C, formerly of Penticton, is stationed at Vernon
and is able to visit his family in Penticton on occasion.
We are glad to learn that Dr. George- C. Paine of Penticton is so much improved in
health that he is very actively engaged in practice.
Dr. G. A. Brown, who has been associated with Drs. F. W. and W. O. Green of
Cranbrook, has left for St. Paul and is serving with the Army Air Corps, U.S.A.
We are glad to report that Dr. F. W. Green is fit and may be working too hard,
however, he will enjoy the rest, if any, in attending the Conservative Convention in
Winnipeg.
Dr. and Mrs. J. S. Daly of Trail spent a week at the coast during November.
Drs. W. J. Endicott and F. L. Wilson of Trail are entering the R.C.A.M.C The
Trail-Rossland group have previously lost Flight-Lieut. H. R. Christie, Flight-Lieut. C
G. Morrison, R..CA.F., and Capt. N. D. C. MacKinnon, R.C.A.M.C, formerly Health
Officer of Trail.
*t »^ *_ *t
Dr. D. J. M. Crawford of Trail was temporarily indisposed, but is back at the office.
The Victoria Medical Society held its annual dinner at the Empress Hotel on Saturday, November 28th. It was largely attended. The Navy was represented by Surgeon-
Lieut.-Commander C. W. MacCharles, the Army by Colonel H. M. Cameron, A.D.M.S.
of the 6th Canadian Division, and the Air Force by Wing Commander S. G. Chalk.
Dr. A. Howard Spohn, President of the British Columbia Medical Association, and Dr.
A. E. Trites, representing the Vancouver Medical Association, were among the out-of-
town guests. Dr. M. W. Thomas, Executive Secretary of the College of Physicians and
Surgeons, and a life member of the Victoria Medical Society, travelled to Victoria to
attend the Annual Dinner.
The guest speaker was Flight-Lieut. Hugh Parker of the R.A.F. Intelligence, who
gave a very interesting address on "War Appreciation." Dr. E. L. McNiven showed an
interesting series of movies of the golfing members of the Victoria profession.
A large number of the Medical Officers in the area were present, and taking it all in
all the annual dinner was a successful and very delightful affair. It is hoped that Dr.
M. J. Keys, who was unable to attend the dinner through illness, is now around again.
Dr. J. L. Gayton, Medical Officer of Health, Saanich, and Dr. L. W. Cromwell of
Victoria attended the Gas Warfare course in Montreal. They are scheduled to jointly
address the Victoria Medical Society at the December meeting.
Dr. J. A. Macdonald, formerly of Kincolith, and who has recently been associated
with Dr. L. M. Greene at Smithers, is moving to Prince Rupert and will be associated
with Dr. C. H. Hankinson.
j*. **. »•» «_
Dr. J. C Kovach, who entered the service of the Department of Pensions and
National Health, has resigned and returned to Quesnel and will be associated with Dr.
Gerald Baker in the practice there.
Dr. and Mrs. J. G. MacArthur and their son John, of Prince George, are having a
few days' vacation at the coast.
Lieut.-Col. R. L. Miller, Officer in Charge of Medical Boards, Pacific Command, has
been in Ottawa, and has made a tour of northern hospital areas in British Columbia on
his way home.
Page 67 Drs. G. F. Amyot and P. A. C Cousland of Victoria, T. A. Briggs and P. L. Straith
of Curtenay, A. H. Meneely of Nanaimo, H. L. Burris of Kamloops, H. McGregor of
Penticton, attended the meeting of the Board of Directors of the British Columbia
Medical Association on November 11 th.
Dr. D. H. Williams has left British Columbia to join the R.C.A.M.C He has been
Chairman of the Committee on Public Health of the British Columbia Medical Association.   Dr. G. O. Matthews will carry on as Chairman for the balance of the year.
Dr. G. F. Strong, Chairman of the Committee on Economics of the British Columbia
Medical Association and also a member of the Committee of Seven of the Canadian
Medical Association, has travelled to Ottawa to attend an important conference with
the Advisory Committee on Health Insurance of the Department of Pensions and
National Health.
The Board of Directors at its last meeting favoured the holding of the Annual
Meeting of the British Columbia Medical Association in 1943. The Annual Meeting
will be held in September in Vancouver at a date to be set later, by arrangement with
the other three Western Provinces.
Recent entries to the R.C.A.M.C include: J. R. Ireland, formerly of Port Alice;
G. McL. Wilson, recently of Revelstoke; Peter Semenchuk of Fernie, and P. J. Venini,
formerly an interne at the Vancouver General Hospital.
The needs of the local residents at Blue River are being provided for by Dr. M. H.
W. Fizzell, who is caring for the Japanese evacuees at that point under the British
Columbia Securities Commission.
Dr. E. W. Boak, Chairman of the Victoria Branch of the Committee on Industrial
Medicine of the British Columbia Medical Association, came to Vancouver to discuss
with Dr. W. G. Saunders, Director of Industrial Services in Shipyards under the Wartime Merchant Shipping Limited, the question of establishing industrial service in two
shipyards in Victoria. Dr. Boak has associated with him on the Victoria Committee,
Drs. G. F. Amyot, F. M. Bryant and P. A. C Cousland. On another page a letter sets
forth the plan now operating in four Vancouver shipyards.
Col. Gordon C Kenning has just returned from Great Britain. Colonel Kenning
left British Columbia in command of No. 16 General Hospital, which unit is now doing
good work in the Old Country.
COMMITTEE ON INDUSTRIAL MEDICINE
BRITISH COLUMBIA MEDICAL ASSOCIATION
All Doctors in practice in the GREATER VANCOUVER AREA are asked to read
this announcement.
Dear Doctor:
On advise and under guidance of the Committee on Industrial Medicine, the Wartime Merchant Shipping Limited has set up an Industrial Health Department to serve
the Shipyards in the Vancouver area.
This Department has a central office staff including a Medical Director, a Nursing
Supervisor, Safety Inspector and a Secretary. At each Shipyard a Medical Office, part-
time physicians and full-time nurses.
This Service is preventive—no treatment provided. It includes supervision of health,
sanitation, living and working conditions, and embraces first aid and safety measures
both for accident and health. It expects the worker to be fit and kept efficient. Cause
of absence is determined and cases of injury and illness followed up.
ill Page 68 This programme cannot be entirely successful without the full co-operation of the
employee's doctor.    The worker reporting ill will be referred to his own doctor with a
brief form which the doctor will be asked to complete and return to the Medical Director in the particular shipyard.
Medical Staff:
Director: Dr. W. G. Saunders, 92 Lonsdale Ave., North Vancouver, B.C  North 72.
Assistant Directors:
Burrard Dry Dock Co. Ltd., north yard—Dr. R. A. Gilchrist, North 102.
Burrard Dry Dock Co. Ltd., south yard—Dr. J. C Thomas, HAstings 2801.
North Vancouver Ship Repairs Ltd.—Dr. M. Morrison, North 1771.
West Coast Ship-builders Ltd.—Dr. J. W. Millar, FAir. 2751.
This Industrial Health Department will have the co-operation of Health and Welfare organizations.    The Directors will be ready and willing to discuss with the doctor
in attendance any condition which arises among employees.
We are asking the doctors to extend fullest co-operation to the Industrial physicians.
With your help Industrial Medicine in British Columbia can be organized on a sound
basis.
A. W. Bagnall, Chairman.
M. W. Thomas, Secretary.
Committee on Industrial Medicine,
British Columbia Medical Association.
LIBRARY NOTES
RECENT ACCESSIONS TO THE LIBRARY:
Compendium of Aviation Medicine, 1939.    Translation.    Published by the Medical
Staff of the German Air Corps.
Donated by the Army Medical Library, Washington, D.C
Surgical Clinics of North America, Symposium on Emergency Treatment.   (Shock
and Vascular Diseases.)    Baltimore Number, October, 1942.
Disease of Metabolism, 1942, by Garfield G. Duncan.
You Don't Have to Exercise!   1942, by Peter J. Steincrohn.
New and Non-Official Remedies, 1942.
NICHOLSON FUND:
The Medical Career and Other Papers, 1940, by Harvey Cushing.
Tumors of the Glioma Group, 1926, by Harvey Cushing.
INDUSTRIAL MEDICINE:   j
The Library Committee, in collaboration with the Committee on Industrial Medicine
of the British Columbia Medical Association, has recently added to its collection of literature on industrial medicine and surgery, the following books:
Occupational Diseases, 1942, by Rutherford T. Johnstone.
Symposium on Industrial Medicine, Medical Clinics of North America (2 copies).
Symposium on Industrial Surgery, Surgical Clinics of North America (2 copies).
Year Book of Industrial and Orthopedic Surgery (on order).
Through the kindness of Dr. H. H. Milburn, a member of the Sub-committee on
Literature, the Library is now receiving the following two journals on this subject:
Industrial Medicine.
The Journal of Industrial Hygiene and Toxicology.
Other books already in the Library are:
Industrial Hygiene, 1939, by Lanza and Goldberg.
Occupational Diseases of the Skin, 1939, by Schwartz and Tulipan.
Occupational Affections of the Skin, 3rd ed., 1928, by R. Prosser White.
Industrial Toxicology, 1934, by Alice Hamilton.
Analytical Chemistry of Industrial Poisons, Hazards and Solvents, 1941, by Morris
B. Jacobs.
Page 69 Secona Annual Report
MEDICAL SERVICES ASSOCIATION
rrcAi.   scuwTi
IgCIATJ
DIRECTORS' REPORT
To Employee, Employer and Professional Members:
Your Directors submit herewith the Balance Sheet and Statement of Income and Expenditure for
the fifteen-month period ended August 31, 1942, together with the Auditor's Report to the Members.
This is the second annual report and with the first report submitted at the last General Meeting
completes twenty-two months of operation*
During the fifteen-month period contributions from employee and employer members were
$30,971.25. Out of these contributions, the sum of $1,332.56 has been carried to the reserve for
contingencies, and the sum of $26,601.25 spent in providing services at cost (including accrued
charges). Administrative and other expenses for the period amounted to the sum of $7,884.62,
resulting in an excess of expenditure over income of $4,847.18. Funds to cover this cash deficiency
have been provided from non-recurring registration fees and the balance out of repayable advances. The
expenses for administration tend to be larger in proportion to the contributions than will be the case as
| the Association grows in membership. This is natural and has been anticipated by providing that the
registration fees may be then devoted to retiring the outstanding notes of $5,400.00 and providing "a
further contingency reserve. These notes are payable out of registration fees only and when subscribers reach and are maintained at 5,000. It will be seen that the cost of providing medical care
has been kept within the contributions and that the contribution rates set are not more than may be
reasonably considered adequate.
Your Directors consider that the plan has proved sound in operation and that it should not be
necessary to call upon our underwriters—the doctors of the Province. Our experience, however, is of
too limited duration to recommend any change in contributions or services-.
Your Association now includes some 58 groups which are shown in an appendix to this report.
We are sure that members will be pleased that industrial firms are particularly prominent. In many
cases contributions are made equally by employer and employees. Some include dependent cover. "While
the basis of employer-employee contribution is optional, according to employer policy, dependent cover
without a substantial employer contribution is not feasible.
Our relations with employees, employers and doctors have been very happy and it is with pleasure
that we record that we have received the utmost cooperation and help.
In providing a general medical service under which the individual is at liberty to consult any
medical practitioner in the Province, immediately upon enrolment, including specialists' services,
consultations, X-ray, surgery or operations, for sickness and non-occupational accidents, it is natural
that other forms of social insurance should be considered by employers and employees. A notable
development has been cooperation with the life insurance companies so that proposals and announcements are combined in one package. In every case, where an employer has found it possible to contribute, we find that employees welcome the greater security afforded and happy industrial relations
are improved.
Early in the year the Board lost the services of Mr. F. C. "Whitehead to the Armed Services and
Mr. David Davidson was appointed Director in his stead and shortly after he also joined the Armed
Services. Mr. C. W. MacSorley filled the vacancy. During their terms of office Mr. Whitehead and
Mr. Davidson were of great help to us and although we are sorry to lose them, we realize that their
services are of more benefit to the Armed Forces than to the M-S-A.
A great deal of the success of the M-S-A is due to the work of our Director of Medical Services,
Dr. S. Cameron MacEwen, whose services have been freely given to us. We recommend that the
incoming Directors consider remuneration for his services as soon as it is practicable.
Cooperation and help from the College of Physicians and Surgeons and its Officers has been
continuous.    We feel confident that our successors will enjoy the same measure of cooperation.
JOHN YOUNG,
JOHN MacKENZIE,
M. W. THOMAS, M.D.,
CHAS. W. MacSORLEYj
Directors.
925 West Georgia Street, Vancouver, B. C.
November 16, 1942.
Page 7b MEDICAL SERVICES ASSOCIATION
BALANCE SHEET AS AT AUGUST 31, 1942
ASSETS
CURRENT ASSETS:
Cash  in  banks ■ $     5,108.01
Cash in hands of trustees -~ 400.00
Dues receivable from  members: j       1,445.83
 $     6,953.84
DOMINION OF CANADA VICTORY LOAN BONDS, 3%, due March  1,
1954, at cost (market value $992.50) j $     1,000.00
Accrued interest  thereon - 15.00
       1,015.00
FURNITURE AND FIXTURES less depreciation \  487.86
DEFICIT ACCOUNT:
Deferred organization and administrative expenses written off—
Balance as at May 31,  1941 i $    4,311.43
Add—
Excess of expenditure over the proportion of members' contributions credited to income account during the fifteen months
ended August 31, 1942   (Exhibit A) |      4,847.18
$     9,158.61
Deduct—
Registration   fees    (non-recurring)    received   in   the
fifteen months ended August 31, 1942 $    3,265.50
Excess of income over expenditures, etc., as at May
31,  1941    59.65
        3,325.15
        5,833.46
$  14,290.16
LIABILITIES
CURRENT LIABILITIES:
Accounts payable and accrued $    5,163.70
Salary payable I       1,250.00
 $    6,413.70
NOTES PAYABLE on demand out of the funds obtained from registration fees of subscribers after the number of subscribers has reached and while it is maintained at
5,000 or over .       5,400.00
DEFERRED CREDIT TO INCOME:
Members'  contributions   unearned  451.18
RESERVE FOR CONTINGENCIES  (Exhibit C)       2,025.28
$  14,290.16
AUDITORS' REPORT
To  the Members
Medical Services Association:   .
We have made an examination of the books and accounts of the Medical Services Association for the fifteen months
ended August 31, 1942, and have obtained all the information and explanations we have required. We report that, in
our opinion, the above Balance Sheet is properly drawn up so as to exhibit a true and correct view of the state of the
affairs of the Medical Services Association, according to the best of our information and the explanations given to us
and as shown by the books of the Association.
PRICE, WATERHOUSE & CO.,
Vancouver, B. C. Chartered Accountants.
November  12, 1942.
Page 71 MEDICAL SERVICES ASSOCIATION
EXHIBIT A
STATEMENT OF INCOME AND EXPENDITURE
FOR THE FIFTEEN MONTHS ENDED AUGUST 31, 1942
INCOME:
Members'  contributions    $ 30,971.25
Less—
Proportion credited to reserve for contingencies       1,332.56
 $  29,638.69
Deduct—
Expenditure:
Provision for Doctors' and Hospital accounts paid and payable  $ 26,601.25
Administrative and other expenses  (Exhibit B)       7,884.62
Excess of expenditure over the proportion of members'  contributions credited to income
account during the period, carried to Deficit Account  (Balance Sheet) . .. $    4,847.18
ADMINISTRATIVE AND OTHER EXPENSES
FOR THE FIFTEEN MONTHS ENDED AUGUST 31, 1942
Salaries :	
Printing, stationery and supplies  543.64
Postage - ; .  13 5.03
Telephone and telegraph i  150.82
Travelling  275.3 5
Insurance  3 5.44
Legal and audit fees ! . j  168.50
Rent  742.51
Depreciation of furniture and fixtures : __,  58.71
Interest and bank charges   (net)  184.18
Equipment, rent and service charges T  629.00
Miscellaneous I  3 6.44
Total—carried to Exhibit A 1 $7,884.62
EXHIBIT C
STATEMENT OF RESERVE FOR CONTINGENCIES
FOR THE FIFTEEN MONTHS ENDED AUGUST 31, 1942
Balance as at May 31,  1941 . 1 $   390.72
Add—
Transfer of balance of reserve for Medical, Surgical and Hospital Care Account as at
May 31,  1941      302.00
Add-
Proportion of members' contributions during the period credited to Reserve for Contingencies    : J j $1,332.56
Balance as at August 31, 1942 - $2,025.2
BOARD OF DIRECTORS
JOHN YOUNG Henry Birks & Sons  (B.C.)  Limited
J. W. G. MacKENZIE . Seaboard Lumber Sales Company Limited
M. W. THOMAS, M.D \ College of Physicians and Surgeons of British Columbia
CHARLES W. MacSORLEY I Shell Oil Company of British Columbia Limited
OFFICERS
JOHN YOUNG __ President    A. L. McLELLAN  Secretary-Treasurer
J. W. G. MacKENZIE __Vice-President   DOROTHY MYERS Assistant  Secretary
S. CAMERON MacEWEN, M.D __Director of Medical Services
ASSISTANT DIRECTORS OF MEDICAL SERVICES
F. M. AULD, M.D Nelson, B.C.
J. S. DALY, M.D Trail, B.C.
C. H. HANKINSON, M.D Prince Rupert, B.C.
GORDON JAMES, M.D Britannia Beach, B.C.
$   692.72
W. J. KNOX, M.D Kelowna, B.C.
E. J. LYON, M.D Prince George, B.C.
THOMAS  McPHERSON, M.D Victoria, B.C
T. J. SULLIVAN, M.D Cranbrook, B.C.
Page 72 WHO  HAS  IT
MEDICAL SERVICES ASSOCIATION
MEMBER GROUPS
INDUSTRIAL:
Allard Machine Works Ltd.
Clark Bros. Timber Co.
G. H. Cottrell Ltd.
Crossman Machinery Co. Ltd.
Dominion Rustproofing Co. Ltd.
Electric Power Equipment Ltd.
Graham Electric Co. Ltd.
Hayes Manufacturing Co. Ltd.
M. B. King Lumber Co. (North Shore) Ltd.
Kootenay Engineering Co. Ltd.
Lawrence Manufacturing Co. Ltd.
Langley Manufacturing Co. Ltd.
Letson & Burpee Ltd.
Mohawk Handle Co. Ltd.
Mohawk Lumber Co. Ltd.
North Arm Lumber Co. Ltd.
Pacific Veneer Co. Ltd.
Patterson Boiler Works Ltd.
Shell Oil Co. of B. C. Ltd.
Stewart Sheet Metal Works
Westminster Hog Fuels Ltd.
WHOLESALE AND RETAIL:
Ash Temple Co. Ltd.
Henry Birks & Sons  (B.C.) Ltd.
Canadian General Electric Co. Ltd.
Fleck Bros. Ltd.
Galbraith & Sulley Ltd.
Fred C. Myers Ltd.
George Straith Ltd.
Victor X-ray Corporation of Canada Ltd.
SALES OFFICES:
Associated Dairies Ltd.
Fraser Valley Milk Producers' Assn.
International Business Machines Co. Ltd.
Powell River Co. Ltd.
Seaboard Lumber Sales Co. Ltd.
FINANCIAL:
Blane, Fullerton & White Ltd.
General Accident Assurance Co. of Canada
Great West Life Assurance Co.
Montreal Life Assurance Co.
H. A. Roberts Ltd.
Sun Life Assurance Co. of Canada
Yorkshire & Pacific Securities Ltd.
PROFESSIONAL:
Crehan, Meredith & Company
Cowichan District Teachers' Assn.
Creston Valley United School District
Canadian Association of Social Workers
—B. C. Mainland Branch
Income Tax Specialists Ltd.
Metropolitan Health Committee
North Vancouver General Hospital
Port Coquitlam School Board
Robertson, Douglas & Symes
GOVERNMENT:
Agriculture, Food & Drug Division Employees
Dominion Income Tax Employees
Victoria City Hall Employees
SERVICE ORGANIZATIONS:
Vancouver Board of Trade
Young Women's Christian Association
PUBLISHING AND PRINTING:
Campbell & Smith Ltd.
Roy Wrigley Printing & Publishing Co. Ltd.
Western Sales Book Co. Ltd.
fT7A,l    SE»v7
>_S£
LOCIATi!
A Non-profit Medical Service Plan managed by the members
(employees, employers and doctors).
Page 73 MEDICAL SERVICES ASSOCIATION
Extracts from Report submitted by Dr. S. Cameron MacEwen, Director of Medical
Services, at Annual Meeting of Medical Services Association.
M.S.A. commenced operation November, 1940.
Membership has now reached approximately 5,000.
To the Members of the Medical Profession:—
I have to report practically 100% co-operation from the Doctors of the Province,
and extend my thanks for the many courtesies extended to me in reviewing accounts and
discussions of cases. Authorization of major surgery, X-rays, etc., in all but emergencies should be more frequently used. X-rays and the "little black box" of Dr. Alvarez
are undoubtedly very usefulr and often essential adjuncts to the diagnosis of many cases,
but never replace the clinical findings and history taking of the careful physician.
"We aim to give a complete service, but this should not be taken to mean a luxury
service. All ancillary services should be used when necessary, but not as a routine for
diagnosis. You will realize that these services add to the cost of operation tremendously,
and as you are members of this association you should keep expenses down as far as possible, compatible with good service.   Authorization is required in all but emergency cases.
Thanks are also due to the Assistant Directors of Medical Service for their interest
in the Association. I hope to make more and more use of their services as time goes on
and our membership increases in their areas.
The help from the Council of the College of Physicians and Surgeons of British
Columbia, and particularly of their Committee on Economics, is much appreciated.
Lastly an appreciation of the work of our efficient Secretary-Treasurer, Mr. A. L
McLellan, and his assistant, Miss Myers.
WARTIME PRICES AND TRADE BOARD
Dr. M. W. Thomas,
203 Medical-Dental Building,
Vancouver, B. C.
Dear Doctor Thomas:
We wish to express our appreciation to the Medical Association for giving such good
publicity to RUBBER CONSERVATION in the Bulletin, and also wish to express
our appreciation for the co-operation which the individual doctors have been giving us
in applying for RETREADING SERVICES.
This not only will prove beneficial from the point of view of tire conservation, but
will, we feel sure, set an example for lesser services to follow.
We know that we have the wholehearted co-operation, not only of yourself, but of
every member of the Medical Association in British Columbia.
Yours faithfully,
318 Marine Building
December 1st, 1942
Vancouver, B. C.
B. M. BREMNER,
Regional Tire Rationing Officer
Page 74 British  Columbia  Medical  Association
(Canadian Medical Association, British Columbia Division)
President j ! Dr. A. H Spohn, Vancduver
First Vice-President ! Dr. P A. C. Cousland, Victoria
Second Vice-President -Dr. H. McGregor, Penticton
Honorary Secretary-Treasurer Dr. G. O. Matthews, Vancouver
Immediate Past President Dr. C. H. Hankinson, Prince Rupert
Executive Secretary '. _Dr. M. W. Thomas, Vancouver
A MESSAGE FROM THE PRESIDENT OF THE
BRITISH COLUMBIA MEDICAL ASSOCIATION
As medical years pass by questions are settled, new questions arise, and unsettled
affairs often have to be considered from new points of view, and so progress is made.
Health Insurance is still in the making, but is assuredly coming, and will probably be
one of the first post-war reconstruction acts. Your Association and particularly the
Committee on Economics are studying and watching all the trends in this important
subject. However, if medical practice is to continue satisfactorily we must present
a United Front, and this is possible only if membership in the C.M.A. represents all our
profession.    Every man has an individual responsibility in attaining this end.
Industrial Medicine is a new endeavor as far as the Association is concerned. Our
new Conimittee has accomplished a great deal and is working enthusiastically in an
activity which may become one of the most important phases of our work.
The Military Advisory Committee continues to work overtime, and we should appreciate the manner in which this Committee is functioning.
It may perhaps be some comfort in these strenuous times to realize that we have an
active Association and I wish to express my grateful appreciation to all who have
worked so faithfully and willingly on all the different committees.
In regard to the War—we are perhaps at the "beginning of the end," or perhaps
only in the middle. At whatever stage it may be we can rest assured that the Medical
Profession will continue on with the same quiet fortitude that has always characterized
our profession.
To all the members and their families, especially to those in the Armed Services, I
wish to extend every good wish, and may we all be privileged to participate in the Victory and Peace that is to come.
A. Howard Spohn, President.
COMMITTEE ON THE STUDY OF CANCER
CANCER OF THE STOMACH
At a recent meeting where cancer of the stomach was discussed, some very interesting figures were quoted. The first of these was that one out of every twenty-one persons die of carcinoma of the stomach. The second interesting set of figures was that
50% of the carcinomas of the stomach that were operated on in the very early stages
lived for five years or more.
The difficulty is to make the early diagnosis. If one reads the literature or the text
books, a confused viewpoint is obtained, because apparently many of the figures are
contradictory. The fact must be borne in mind that if the doctor makes a mistake, no
matter what the figures show, it costs the life of the patient.
Page 75 There are two rules to go by, both rules in reality meaning the same thing. The
first is that a gastric ulcer that does not respond promptly to adequate medical treatment within ten days, should be considered malignant until proved otherwise. The
second rule is that all chronic gastric ulcers that have been present over a period of time,
and have not healed, owing to either inadequate facilities for dietary care, carelessness on
the part of the patient, penetration oir perforation, should be considered potentially
malignant, particularly if the individual is in the cancer age group.
More frequent partial gastrectomies for early uncontrollable gastric ulcers, and
chronic uncontrollable gastric ulcers, will save many lives.
THE MEYERS MEMORIAL
The Canadian Medical Association receives the sum of $100.00 a year from the
estate of the late Dr. Campbell D. Meyers to provide an honorarium known as The
Meyers Memorial.
The award is made in accordance with the instructions of the donor, which are:—
(1) That the award shall be made ". . . to such member or guest of the Canadian
or of one of the Provincial Medical Associations as shall write and read at the
annual meeting of any of the said Associations the best thesis or dissertation ..."
(2) That the subject shall be ". . . the study and treatment of those functional
neuroses which, if untreated, or not treated sufficiently early might probably
terminate in insanity ..."
*\- . . it is impossible to classify definitely the types of diseases referred to above.
I desire however to refer to those Functional Neuroses in which the psychological symptoms form the essential part of the syndrome, and to that type of
Neurosis which develops in late adolescent or in adult life in a patient of previous good mental and nervous history, especially such neurosis as has its etiology
in emotional overstrain caused by excessive grief, worry and allied conditions ..."
"I desire to exclude from this thesis the study of Mental Defectives, Paranoia
and similar conditions of mental disease due to hereditary or organic states ..."
(3) That the award shall be made ". . . by a Committee consisting of the President,
a physician and a neurologist. . . ."
Those who wish to submit a thesis are advised to confer, in advance, with the Chairman of the Meyers Memorial Committee in order to make sure that their thesis will
come within the terms of the award.
The thesis must be in the hands of the Chairman of the Meyers Memorial Committee
on or before May 31st if it is to be considered for the award of that year and should be
forwarded to him at 184 College Street, Toronto. Any thesis received after May 31st
will be considered as being submitted for the following year.
CANADIAN MEDICAL ASSOCIATION
HOW TO BECOME A MEMBER!
THE FEE IS $8.00 NOW
The office of the College of Physicians and Surgeons accepts the $8.00
fee for transmission to the Canadian Medical Association office.
THE CANADIAN MEDICAL ASSOCIATION NEEDS YOU.
YOU NEED THE CANADIAN MEDICAL ASSOCIATION.
The C.M.A. must speak for Canadian Medicine and represent it with
95 to 100% membership.
Page 76 A PROBABLE CASE OF ACTINOMYCOSIS
W. Keith Burwell, M.D.
This case is of unusual interest because of the difficulty in arriving at a correct diagnosis, and also because the removal of the source of the infection did not cure the disease.
The patient is a single man, 36 years of age. He was born in Russia, lived there
until the age of 15, after which he went to Poland. After nine years in that country,
he moved to Canada, where he has resided ever since. In Europe he worked on a farm
until he learned the shoemaking trade, and since coming here, has done nothing but
shoemaking.    His incisor teeth are worn from holding shoe tacks in his mouth.
The present illness began suddenly on May 14, 1935, with acute pain in the right
lower quadrant, but no vomiting. He was operated on that night as a surgical emergency for an acute appendicitis. At this time a large normal appendix was removed
and in addition two masses were found—a larger one involving the lower end of the
caecum and adjoining portion of the ileum, and a smaller one a little farther on in the
ileum. They were considered to be of tuberculous origin, and he was told he had "T.B.
of the stomach" and thaf it would be necessary for him to return in a few months' time
for bowel resection. He made a good recovery from this operation, and was discharged
on June 8, 1935. At this time and subsequently, x-rays of the chest and repeated
sputum examinations were always negative for tuberculosis.
Several years went by. His general condition was fairly good, and he worked continuously in the shoemaking business. He reported to his physician from time to time,
his condition seemed satisfactory, and a resection operation was never done.
About September 15, 1941, he developed pain of an increasingly severe character in
the right lower quadrant. After a month of suffering, he was admitted on October IS
to the same hospital, and under the same physician. At that time his treatment consisted of bed rest, hot fomentations and "lamp treatment." His doctor ha dto go away,
the patient became dissatisfied, and he signed his release from the hospital on November
1, 1941.   Once he overheard a nurse speak of his condition as a "cold abscess."
The patient came under my care on November 10, 1941. He complained of severe
pain in the right side, and a swelling which was hard and becoming larger. The pain
was relieved with hot applications and when the leg was flexed on the abdomen. There
was no vomiting. He was admitted the following day to St. Paul's Hospital. Examination revealed a well-nourished man, about the stated age, and obviously in pain. There
was a hard painful red brawny indurated swelling over the right lower quadrant. The
temperature was 101°, and from then until the time of his operation, it varied from
98 to 103°. It is interesting to note that during this interval he vomited only once or
twice, although the abdomen became increasingly more distended. A diagnosis of probable tuberculosis of the caecum with commencing obstruction was done.
A gastro-intestinal series was done. The conclusions reported were: "Findings suggest a lesion involving the terminal ileum and lower portion of the caecum, with partial
obstruction. The small bowel is probably granulomatous in type. There is a regional
ileitis involving the caecum, possibly a tuberculous infiltration." On November 21,
1941, he was operated on by Dr. L. H. Appleby, at which time a large mass was found
involving the terminal ileum, caecum, ascending colon and mesentery. The mass was not
disturbed. Tn anastomosis was effected between the terminal ileum and the transverse
colon. After the abdomen was closed an incision was made out toward the anterior-
superior spine. A small amount of pus was found between the anterior wall of the
caecum and the abdominal wall.   A hard rubber tube was inserted.   Recovery from this
Page 77 operation was, as might be expected, somewhat stormy, but with the use of the gastric
suction, intravenous glucose saline, one blood transfusion and the sulfa drugs, recovery
ensued. The patient was discharged from the hospital exactly one month after operation.
At the time of his discharge the sinus was draining a moderate amount of watery
purulent secretion.
The patient was readmitted to St. Paul's Hospital on June 11, 1942, for a bowel
resection. During this almost 6-month interval following his discharge from the hospital he was reasonably well except for periodic blockage of the sinus which persisted
following the removal of the tube. He ate heartily, gained a lot of weight, his colour
improved, and he even did a very considerable amount of work around home. During
the times he was feeling well, he was loathe to come in again for a major procedure, but
when the sinus occluded and severe pain developed, he was very anxious. On June 17,
1942, Dr. Appleby removed the entire right half of the transverse colon, ascending
colon, caecum and terminal ileum, which, of course, was that part of the bowel between
the anastomosis performed six months previously. At the conclusion of the operation
it was felt that a cure would almost certainly be effected, because the sinus was found
to open directly into the caecum. Recovery was much less stormy than at the time of
the previous operation. A summary of the pathological report is as follows: "Grossly
this mass certainly resembles a tuberculous lesion of the terminal ileum and caecum.
Microscopic study from numerous portions of this gut fail to show or even suggest
tuberculosis. There is no microscopic suggestion of actinomycosis or new growth. This
apparently is a chronic inflammatory lesion of some considerable duration, with marked
cellular infiltration and scarring, with very little evidence of breaking-down. Its
chronicity and recurrence very strongly suggest that this is a tuberculous or actinomycotic lesion. Numerous tests are still continuing in an effort to establish a definite
diagnosis."
Unfortunately our confidence that he would be well was relatively short-lived. The
sinus persisted and opened and closed from time to time, with the same painful symptoms. About August 15, a hard swelling appeared just medial to the crest of the ilium.
It was very painful and progressively increased in size, with the development of a.
brawny discoloration of the skin and a high temperature. When it was felt that it was
relatively near the surface, an incision was made along the line of the inguinal canal and
through both oblique muscles. The muscular tissue was very edematous, and a relatively
small amount of pus was found. However, the infection ahd burrowed downward as
far as the external ring, medially across the midline and upward and laterally into the
loin. It was thoroughly exposed, sulfathiazole powder was spread through the broad
infected surface, and the wound left wide open. A few days after this, the infection
pointed just lateral to the uppermost part of the incision, and opened spontaneously,
with the discharge of a fairly large amount of green watery pus. It is surprising that
following this operation, the patient had a lot of distress, pain and vomiting. An
abscess in the region of the prostate opened spontaneously into the rectum. Whether or
not this infection was definitely in the prostate, it is impossible to say. In due course,
he was discharged from the hospital, still draining.
Since this time, he has been relatively well, has gained some weight. The discharge
is persisting and the wound is gradually closing. However, there is no reason to believe
this sinus is going to close; and until such time as we are able to determine the type of
infection, it will be impossible to cure the condition.
Is the infection a tuberculous process, actinomycosis, or one of the more unusual
types of fungus infection? It would seem that the probability is that it is an actinomycotic infection, and the history of his farm work in Russia and Poland and his working with leather in the shoemaking business, would bear out this supposition.
Page 78 Victoria  Medical   Society
President j 1_ Dr. R. B. Robertson
Vice-President Dr. W. H.  Moore
Honorary Secretary ■ . Dr. G. A. McCurdy
Honorary Treasurer : Dr. P. A. C. Cousland
THE MODERN TREND IN THE TREATMENT OF I
FRACTURES
By H. S. Morton, F.R.C.S.
. Surgeon Lieutenant-Commander, R..C.N.V.R.
The modern trend in treating fractures is the application of the results of clinical
and laboratory research. This means the full use of radiographic technique, knowledge
of sound mechanical principles and a fundamental understanding of biological laws
which are being elucidated in the study of animals. I shall, therefore, trace very briefly
the evolution of these principles in the treatment of fractures, while a few selected cases
will be used to illustrate types of treatment.
The diagnosis of a broken bone has been obvious since the earliest times, and its
treatment has always been reduction of the deformity, and immobilization. Various
methods have been used to attain these objects. Hippocrates advised the use of two strong
men for making extension and counter-extension, and even as late as the 19 th century
this method was in use: there is to be seen today in the board room of the London Hospital a bell which was rung to summon the nearest strong men from the street for this
purpose.   Today, however, skeletal traction is used to eliminate this show of force.
The materials that have been used for immobilizing limbs are innumerable, and the
splints which have been devised are legion. Raw hide, bark, wood and metals of all
kinds have been used, and for the most part are now only to be found in museums.
Almost the only splint which has survived the last war is the Thomas'. It is really an
adaptation of his original knee splint for the treatment of tuberculosis of that joint.
This splint is now mainly used for first aid in transportation of cases, and as a framework for the application of skeletal traction during reduction.
The use of casts is of great antiquity, and its history may enable us to understand
its modern application. Over five thousand years ago the Egyptians used linen stiffened
with plaster, while Hippocrates used bandages smeared with cerate or resin. In Arabia,
Rhazes1, 860 A.D., used lime and white of egg, stating "It will be much handsomer
and still more useful . . . nd will not need to be removed until healing is complete."
From Arabia the use of gypsum was made known in Europe by Mr. Eton2, British
consul in Bassora, in 1798.    He wrote:
"By enclosing the broken limb after the bones have been put in their place in a
case of plaster of Paris or gypsum which takes exactly the form of the limb without
any pressure and in a few minutes the mass is solid and strong." He saw a compound
fracture of the leg and thigh cured in this manner.
Suetin3, senior medical officer of the Belgian army, over 100 years ago used bandages
soaked in starch and insisted on ambulatory convalescence. In 1852, Matthysen4, a
medical officer in the Dutch army, invented plaster bandages. His technique was used
extensively by both sides in the Crimean war, while, in the last war, Bohler5 on the
German side made full use of X-ray for accurate reduction, and by no padding and
meticulous attention to detail both supported the soft parts and maintained immobilization of the fragments, so that the limb could be kept supple by use.
Page 79 Thus, the development of emphasis has passed through three phases. Until the 18th
century, concentration was entirely on the bone. During the 19 th century, they sacrificed accurate alignment for functional results. Finally, Bohler considered both the
soft parts and the bones. He advocates accurate anatomical reduction of the deformity
and maintains this in a carefully-applied unpadded cast. He then insists on the active
use of the muscles above and below the break by occupation and calisthenics.
During the Spanish Civil War, Trueta's technique6 for compound fracture emerged,
which is based on Winnett Orr's7 treatment of soteomyelitis. Trueta applies plaster as
a dressing to the wound, which serves the dual purpose of completely immobilizing the
limb and keeping out further infection. His technique should be reiterated in detail in
order to understand the healing of infected wounds:
The method consists of:
(1)  Classification of cases on admission, and injection of 3,000 units of tetanus
antitoxin.
(2) Treatment of shock, with blood transfusion if necessary.
(3) General anaesthetic for the severe, spinal for less severe cases.
(4) Soap and water and a brush to clean the skin thoroughly.
(5) Debridement, of the skin, careful removal of all damaged muscle and preservation of as much bone as possible.
(6) Sterile gauze drainage.
(7) Unpadded, closed plaster cast, which is left on as long as possible.
The results may be judged from the following figures:
In the last war, the American Army Medical Corps treated 3,296 fractures with a
mortality of 12.3%. Trueta had 1,073 cases with a mortality of 0.6%. Some objection
may be taken to this comparison, as the American Army casualties occurred in the filthy
fields of Flanders, while the Spanish cases were mainly air raid casualties seen within
eight hours. However, the mortality after Dunkirk with often a five-day delay yielded
less than a 5% mortality using this method; and these figures are certainly comparable
with the last war.
The reason for its success leads to consideration of the pathology. Rest as supplied
by immobilization is essential in the treatment of infection, because it gives the tissues
the best chance of dealing with infection. The bacteria travel mainly by the lymphatics
and less so by the blood. Heat and movement increase the flow of lymph and the
absorption of toxins, while conversely low temperatures and rest reduce them. The
muscles may be in spasm some distance from the wound, therefore it is essential that the
cast be sufficiently extensive. It is interesting to note in this connection that the ice
pack method for immersion foot has been used successfully on the east coast to lower
the metabolism until the circulation is sufficiently restored to preserve the limb at body
temperature. This, as you know, has been developed in the Canadian Naval Medical
Service by Solanat and Webster8.
In considering the healing of bones without infection, it must be realized that a
bone is living connective tissue, and its repair is achieved by cellular growth which
characterizes all living tissues. A haematoma repidly forms around the ends of the bone,
which is invaded by young blood vessels and soon becomes granulation tissue. Within
a week bony trabeculae are seen in the narrow space and under the periosteum: these
form the primary callus. When union by primary callus has taken place, mature lamellar bony trabeculae are laid down in the lines of stress and strain. The periosteal and
endosteal callus is eventually absorbed and the original contour restored. This only
takes place if adequate immobilization is secured. Otherwise, the granulation tissue does
not become organized, small cystic spaces appear, primry callus does not bridge the
gap and non-union results.
The bio-chemical changes may be summarized as follows: There is a high calcium
and phosphorus concentration in the haematoma during the first week, while the reaction is markedly acid. After two weeks the pH swings to the alkaline side, and the
phosphatase enzyme rises to twice its normal level to aid the deposition of calcium phos-
Page 80 phate. This continues until about the third month. The hyperemia is associated with
decalcification, and ischaemia with sclerosis. When the initial hyperaemia subsides in
about a week, recalcification begins in the granulation tissue, and the final stage of
fibrosis and ischaemia is followed- by dense sclerosis. On the other hand, disuse from
prolonged recumbency causes excessive decalcification and atrophy of bone.
Infection causes a more intense and more prolonged hyperaemia, but the rate of
repair is influenced by several factors, such as age, type of fracture, the gap between
the fragments, and fixation. The vitality seems to depend directly on the vascularity of
the bone, while complete loss of blood supply leads to avascular bone necrosis and
non-union.
Watson-Jones9 dramatically states there is only one cause of non-union—the failure
of adequate irnmobilization. Other causes of non-union are complete lack of blood
supply, and an interposition of soft parts. These occasionally occur, but by far the
most common cause is lack of adequate immobilization.
To sum up: in seven seconds a haematoma is formed, in seven hours there are
fibrinous adhesions, in seven days recalcification starts, in seven weeks dense cortical
bone is manifest, in seven months resorption is complete in most bones.
It will be noticed that Trueta recommended general anaesthesia for severe compound
injuries. Since then, there has been more extended use of spinal anaesthesia provided the
blood pressure is sufficiently high. Intravenous anaesthesia for small procedures and
local or block anaesthesia are used in many cases. The last two eliminate more elaborate
methods and may be conveniently employed on board ship and in the field.
The use of antiseptics has been a subject of debate since Lister; and Trueta, recognizing that an efficient antiseptic damages the tissues, uses only soap and water in the
wound. But since his initial paper the use of the sulfonamide drugs has become widespread, and their oral administration has controlled many cases of streptococcal infection, which with gas gangrene is the greatest danger in compound fractures. The local
application of sulfanilamide or sulfathiazole may be added to the Trueta technique
because the drug is absorbed and does not interfere with healing. The intra-muscular
route is frequently accompanied by complications such as peripheral neuritis and cold
abscess, and has no compensating advantages.
The place of physiotherapy in treatment of fractures becomes delightfully controversial depending on the point of view of the advocate. Most physiotherapists dislike
plaster of Paris because they cannot get at the limb and the ambulatory method greatly
reduces the number of patients referred for massage, electrical stimulation, etc. Nevertheless, there is a very definite place for physiotherapy in the treatment of fractures;
the difference lies only in who does the work—that is, the patient should perform the
active movements rather than suffering passive manipulation and stretching which
aggravates joint stiffness. All fractures should have physiotherapy while in plaster casts.
Walking, weight-bearing with sand bags up to 40 kilo, on top of head while in a body
cast, greatly improve muscle function. Active calisthenics are eseential and the cooperation of the patient must be enlisted.
The following slides are shown to illustrate various methods which are in use today
for the reduction and immobilization fo fractures.
The first group of cases are those without displacement, and these only require adequate immobilization:
Case 1: Fissured fracture of the right tibia caused by "marching." Six weeks' immobilization in plaster.
Case 2: A recent fracture of the carpal scaphoid without displacement. Three
months in an unpadded plaster cast.
The second group: fractures with moderate displacement corrected by mechanical
manipulations.
(a)  Using a wedge of wood to disempact a fracture of the head of the radius.
Page 81 Case 3: This was performed without bruising the skin, and the patient wore a
collar and cuff support for five weeks.
(b) Reduction by means of a clamp.
Case 4: A "Y"-shaped fracture of the lower end of the humerus with lateral separation of the fragments, caused by severe hyperextension in a motor-car injury. The
fragments were approximated by pressure exerted through lateral plaster strips using a
"C" clamp. The cast was completed afterwards with circular bands. This method is
dangerous as it may cause sloughing of the skin, but, if the strips are allowed to harden
before pressure is applied and the pressure is distributed sufficiently evenly, damage to
the tissues can be avoided.
Case 5: A fracture of the shaft of the 5th metacarpal with posterior angulation,
illustrates the use of the 3-pronged Lowman femur clamp, the prongs padded with rubber
tubing. It is applied with the double prongs on the concave side of the break, and the
single one exactly centred over the fracture line. The clamp is gradually tightened until
correct alignment is obtained, then immediately released. A plaster cast is applied and
held manually until firm.
(c) The next method is the application of leverage using the femur clamp again.
Case 6: This was a three-week-old fracture of the neck of the 5 th metacarpal, an
injury which has been fairly common in the Navy, and one which is usually not seen
until from one to six weeks after injury. Manual reduction is usually only successful in
early cases; when it fails, the use of the femur clamp has succeeded as late as six weeks
after injury. The clamp is applied as already described and only partially tightened.
It is then gradually moved in an arc toward the wrist, when the leverage exerted by the
distal prong raises the flexed head of the bone and corrects the deformity. Immobiliza-
tios in plaster for three or four weeks completes the treatment.
The same principle of leverage I10 have also applied to the reduction of fractures
of the cervical vertebrae. The method of traction described by Taylor11 and the
manipulation of Walton12 leave the head and neck unsupported until the plaster cast is
applied. On the other hand, after reduction has been accomplished, Bohler uses a board
and Watson-Jones a wooden slab nailed to the table to support the head and neck during
the application of the .cast. This necessitates that the patient be moved after reduction
and before he is safely immobilized. In order to eliminate this disadvantage I devised
the method of reduction by leverage.
The equipment consists of a metal or wooden "ironing" board which projects 18
inches beyond the end of the table. This board is % irich thick and tapers from a
width of six inches to three inches at the free end, which is suitably padded. The
shoulder supports are appropriately extended beyond the table. The patient is placed on
the table and board in the supine position so that the head overhangs the tapered end,
and the shoulder supports are adjusted for counter-traction. Using the "board" as a
fulcrum and the jaw as a lever, pressure is applied to the chin to bring the head into
the hyper-extended position, thus raising the upper fragment and correcting the deformity.    Then, without further movement, a cast can be applied.
Case 7: A fracture of the axis was safely and accurately reduced by this method.
Case 8: A fracture dislocation of the sixth cervical vertebra on the seventh was
similarly treated.   These two cases demonstrate the simplicity and control of this method.
The next method of reduction is that of Hyperextensoin. There are various ways
of applying this, either raising the ankles or the chest. The method I prefer is the two-
table method which was used in Case 9. This patient was injured by the crank-shaft of
a marine engine. He sustained a crush fracture of the body of the 4th lumbar vertebra
and a fracture of the transverse processes of the 1st, 2nd, 3rd and 4th lumbar vertebrae.
A body cast was applied to maintain the corrected position and worn for four months,
as he had a few neurological complications.
The third main group of methods of reduction is the application of Traction.
Page 82 Case 10 shows an injury of the 2nd phalanx of the little finger treated by pulp
traction using rubber bands stretched over a wire hook fixed in a plaster cast. This is
the foundation of the banjo splint used for fingers and toes.
Skeletal Traction is more commonly used for the larger bones.
Case 11: Is a comminuted fracture of the femur reduced by skeletal traction through
the tibia.   This patient was injured when he fell down five decks on a battleship.
Case 12: Is a rating who fell out of a second-floor window and suffered a comminuted fracture of both tibiae and fibulae with marked deformity. Skeletal traction
through the os calcis was applied, using the leg traction apparatus described by Stevenson, which I have found to be a very useful piece of equipment. The patient was walking in his casts two weeks later. SkeletaJ traction may also be used in stubborn fractures of the upper limb. This method of traction counter-traction may be applied in a
variety of ways, such as the use of two pins in the dis-traction apparatus; but whether
the fast or slow process is used, the underlying principles are the same.
Passing on to the group of Open Reductions and Internal Fixation,—the two outstanding indications for open reduction are fractures of the patella and the olecranon.
As the principles are the same in both, only a fractured olecranon will be shown.
Case 13: This patient fell on board ship and was operated on by one of our Surgeon
Lieutenants at Pearl Harbor on the 6th of December, 1941. Fortunately it was not a
day later! While on leave he injured the elbow a second time and broke the wire. At
a second operation the wire was replaced by stout silk, using both figure-of-eight and
circumferential sutures.    A cast was applied with the elbow at right angle.
In Case 14, two Parham bands were used to control a long spiral fracture of the
tibia. The experience was not entirely free from incident. Proper Parham bands not
being available, some were made locally. A few were made of copper, and in this case
one copper and one iron band were used. These set up a local electrical potential, and
aseptic pus formed around the bone. As soon as this was discovered, the bands were
removed. Although they were not touching each other, the iron band was found to be
partially copper-plated and gave a positive test for copper. Fortunately union had
taken place in spite of this alien activity, and both the wound and the bone healed normally. Only the use of inert metals such as vitallium or stainless steel can be recommended.
One of the most useful methods of splinting is the Metal Plate, and as just mentioned vitallium is the metal of choice.
Case 15: Is one of two cases of fracture of the left femur caused by the parting of
a hawser, in which skeletal traction had failed to attain satisfactory alignment. Open
reduction and plating was performed.
Case 16: This patient was injured at sea when he was washed up against a bulkhead,
fracturing the right tibia and fibula. He was treated at a U.S. naval hospital where
they had some difficulty with skeletal traction. An excellent correction was obtained
union was complete he returned to sea, plate and all.
One of the more recent innovations has been the introduction of the Smith Petersen
Pin which has been used so successfully for intracapsular fractures of the neck of the
femur. As this injury is more frequent in older people, there has not been a case under
my care since the war.
The same principle has been applied to the clavicle.
Case 17: Was a fracture of the clavicle with mrked overriding and a dislocated
shoulder. The dislocation was first reduced, then a Kirschner wire was inserted under
local anaesthesia from the posterior aspect of the outer end of the clavicle, and passed as
a medullary pin across the fracture line when the fragments had been brought into
approsition. Active movements were encouraged from the day after the operation, and
full function was regained within two weeks.
Page 83 Case 18: Another fractured clavicle, in which the Kirschner wire was inserted as a
medullary pin, only this time the anterior approach was used, as the break was nearer
the inner end.   The route of approach seems to depend solely on the site of the fracture.
Although bone grafts were considered by the Greeks, Albee13 first made practical
use of them. The following Case 19 is one of non-union of the femur with marked
bowing and four inches of shortening. The injury occurred in a motorcycle accident,
and when first seen was already of three years' duration. After removing the plate and
freshening the bone ends, an inlay bone graft was inserted, with the result that he
obtained bony union with less than an inch of shortening and returning function of
the long-unused knee.
Non-union of the scaphoid has been one of the commonest fractures we have encountered in the Navy. The treatment of this is bone grafting if no arthritis is revealed; the technique described by Murray14 is very satisfactory.
Case 20: Injured his hand by a fall three years ago and he had had some weakness,
frequent pain and general loss of function ever since. On X-ray examination, the nonunion was evident and bone grafting was done. Several of these operations have been
performed with satisfactory results. They are usually immobilized for three months in
an unpadded plaster cast and encouraged in active use of the hand by being kept on duty
and reporting once a fortnight.
riaving discussed the various methods of open reduction and internal splinting, there
remains only the group of Compound Fractures. The ideal, of course, is reduction with
primary closure and first-intention healing.
Case 21 was a patient who had his hand jammed by a hatch-cover and received compound fractures of the phalanges of three fingers. He was sutured within two hours
of the accident, the skin was preserved and primary closure was possible. Sulfathiasole
was used locally and the hand was immobilized in plaster for a month. Active movements were carried out faithfully from this time on. while malleable metal splints were
used as much as possible because firm union was not yet complete. One is frequently
•confronted by this dilemma, stiff fingers with firm union, or functionable digits and
non-union.    Judgment is required to steer the mean course.
Case 22 is a head injury due to an automobile accident. A compound comminuted
fracture of the right frontal bone which extended into the frontal sinus and orbit.
Debridement involved removal of about 15 fragments of bone, a blood clot the size of
a hen's egg and two teaspoonsful of damaged brain. The supraorbital ridge was replaced,
as the muscular pedicle was attached; sulfathiazole was applied locally, and primary
closure performed. He had an uneventful convalescence with slight enophthalmos and
a mild degree of ptosis, and his vision remained at 6/5 in both eyes.
The remaining cases were treated by Truetd's method.
Case 23 is a compound comminuted fracture of the lower end of the humerus and
olecranon. Debridement was done and closed unpadded plaster applied with the elbow
at right angle.   Bony union and full range of movement were obtained.
Case 24 was a rating who slipped off the bridge of a French merchantman at the
time of the collapse of France. He had a T-shaped fracture of the lower end of the
femur involving the knee joint, and the upper fragment protruded through the skin
when he was admitted to hospital 36 hours later. Firm union and 60% movement of
the knee joint was obtained, with no shortening of the leg.
Case 25: A compound comminuted fracture of the tibia and fibula was admitted to
hospital five days after his injury in a heavy sea. The wound was discharging pus, and
the tibia projected through the skin on the medial side of the leg, while the fibula protruded through the lateral skin. There was over two inches of shortening. Skeletal
traction through the os calcis, debridement, sulfanilamide locally, and a Thomas splint
for the first month resulted in very little improvement, and amputation was advised.
I preferred to try the application of a plaster-of-Paris cast, as the swelling had subsided
and there seemed to be no danger of gangrene.    Firm bony union and no shortening
Page 84 was obtained in six months, and he was discharged to his home base walking with only
the aid of a cane. This was the first case of compound fracture that was treated in the
Canadian Navy shortly after war began.
All types of gunshot wounds, whether the small punched holes of a high-velocity
bullet, the jagged wound caused by shrapnel, or fragments of high-explosive bombs,
etc., are treated by precisely the same methods.
The main points to be stressed are accurate reduction, adequate immobilization by
the simplest apparatus, and the early use of active exercises. Accurate reduction controlled by radiographic exarnination is an established fundamental. It has been less
widely appreciated that adequate immobilization is equally essential. Whatever means
are used to accomplish this end, it is imperative that the strictest attention be paid to
all details.
The modern trend is to use the simplest possible apparatus, and plaster-of-Paris
usually meets this demand, because it is only in a perfectly fitting unpadded cast that
active exercises and ambulatory treatment can be used to the fullest extent. This fulfils our last desideratum—that of making the patient do his own physiotherapy.
1. Rhazes: quoted by L. W. Bacon, Bull Soc. Med. Hist., 1923, 3:122.
2. Eton I
3. Suetin f  quoted by J. K. Monro, B. J. S., 1935, 23:257.
4. Matthysen J
5. Bohler, L.: Treatment of Fractures, 3rd Ed., 1932, Vienna, translated by E. W. Hey Groves, 1935,
Bristol.
6. Trueta, J.: Lancet, 1939, 1:1452; B. M. J., 1939, 2:1073.
7. Winnett Orr: Osteomyelitis and Compound Fractures, 1929, London.
8. Webster, D., et ah Immersion Foot: Canadian Naval Medical Reports, Vol. II,  1942.
9. Watson-Jones, R.: Fractures and Other Bone and Joint Injuries, 1940, Edinburgh.
10. Morton, H. S.: A Method of Reduction of Cervical Vertebrae, in press.
11. Taylor, A.: Ann. Surg., 1929, 90:321.
12. Walton, G. L.: Boston Med. and Surg. Journal, 1903, 149:445.
13. Albee, F. H.: Bone Graft Surgery, 1915, New York.
14. Murray, D. W. G.: B. J. S., 1934, 22, 85.
ROYAL CANADIAN AIR FORCE
Extracts from letter from Wing Commander S. G. Chalk, Principal Medical Officer, Western Air Command.
Personnel Reporting Sick.
1. With reference to my letter to you on September 25 th and your publication in regard to it in the October number of the Vancouver Medical Association Bulletin.
It has been brought to the attention of this Headquarters that as a result of the comments on my letter published, a Vancouver practitioner refused to give emergency
treatment to an Army Officer, who died.
2. It would be appreciated if you would publish in your next issue a clarification which
would remove the impression that the "Offender" means the civilian practitioner.
3. It seems extraordinary that a civilian practitioner should so interpret your publication, which was requested with a view to creating the best understanding and co-operation between civilian practitioners and R.C.A.F. Service Regulations.
4. Any comments you have to make would be appreciated. Thanking you for your
co-operation.
NOTE:—It is to be regretted that any misunderstanding would deprive any member of
His Majesty's Forces of immediate treatment by a civilian practitioner in case of
emergency.
Page 85 THE HEMORRHAGIC BLOOD DISEASES
John W. Scott, M.D.,
University of Alberta.
Of the many ills that befall human kind, uncontrollable bleeding is probably the
most alarming. The normal mechanism for defense against haemorrhage works so efficiently and unobtrusively that its action is taken for granted. The surgeon in making
an incision needs only to secure the larger vessels- and leaves to nature the sealing of the
countless capillaries, venules and arterioles that he has cut through. The wear and
tear of everyday work and play with its frequent minute bodily injuries would not be
possible without an efficient mechanism of haemostasis. When the mechanism breaks
down we are faced with one of the haemorrhagic blood diseases.
By the term haemorrhagic blood disease is meant a condition characterized by a
tendency to bleed abnormally from a tissue which shows no gross evidence of primary
local disease. We must assume then that we are dealing with a constitutional state in
whcih any or all bodily organs may be affected, which may show itself in a great variety
of ways. It may appear as minute petechiae on the skin or mucous membranes, linear
haemorrhages under the nails, or massive subcutaneous or submucous haemorrhages. It
may appear as epistaxis, haematemesis, haemoptysis, melaena, menorrhagia, metrorrhagia or
haemarthrosis. With such a definition one must include a great variety of conditions from
meingococcic meningitis to haemophilia.
What are the physiological processes that operate in the mechanism of haemostasis?
There is a dual mechanism involved, first the clotting of blood, and secondly the vascular
response to injury.    The latter is the more often called into play.
Factors controlling hcemostasis
1. Blood clotting
2. Capillary integrity
3. Deposition of platelets at site of injury
4. Retraction of damaged vessels
5. Contraction of clot.
The coagulation of the blood is a complex and still little understood process in which
there is an interplay of plasma constituents.
Blood clotting
Thrombokinase arises from:
disintegrated platelets damaged tissue
Thrombokinase reacts with antithrombin to form prothrombin
Prothrombin -|- ionized calcium = thrombin
Thrombin -J- fibrinogen = fibrin
Fibrin -J- blood cells = clot
Later clot retraction occurs from the action of thrombokinase.
Prothrombin has assumed a new significance in the past twelve years. This substance is formed in the liver. Vitamin K is necessary for the synthesis of prothrombin.
In order for this vitamin to be absorbed from the food, bile salts must be present in the
intestine. In hepatic disease, obstructive joundice and upper intestinal disease there may
be diminished prothrombin in the blood due to faulty synthesis or defective absorption
of Vitamin K. In such conditions the normal process of clot formation breaks down
and we have a haemorrhagic state. The normal prothrombin time by the Quick method
is 12-20 seconds.
The next important element in this mechanism is the state of the capillaries. The
capillary wall is a very delicate structure of unicellular thickness. Yet in health it
provides an impermeable barrier to the red blood cell. In addition, it has been recently
shown that when the capillary is injured it contracts, thus acting as the first line of
defense in haemostasis.
Page 86 We may carry out a simple clinical lest of capillary integrity by constricting the arm
with a sphygmomanometer cuff for 5 minutes. If the test is positive a crop of petechiae
will appear below the site of constriction.
The blood platelets or thrombocytes are minute formed elements in the blood which
are only about one-third the size of a red blood cell. The platelets disintgrate quickly
when blood is shed and in. doing so they liberate an enzyme thrombokinase, which, as
has been noted* plays an essential role in blood clotting. Further, the platelets cling to
any water-wettable surface. The latter property accounts for the tendency to form
platelet thrombi in damaged vessels. These thrombi tend to plug minute vessels and to
control bleeding.
When a blood clot has formed, it contracts within ^a few hours and becomes much
tougher and a more effective agent in preventing blood loss. The diminution or absence
of blood platelets leads to failure of clot retraction as in essential thrombocytopenic purpura. The platelet content of the blood is normally 150,000 to 300,000 per cmm. In
some forms of purpura, as we shall see, the platelets may decrease to one-tenth of the
normal number. In such a case there is likely to be a prolongation of the bleeding time
and a tendency to spontaneous bleeding.
The bleeding time is tested by puncturing the lobe of the ear and absorbing the escaping blood on a piece of filter paper. The normal bleeding time by the Duke method is
2-5 minutes.
Qualitative as well as quantitative changes may occur in the platelets. Thus in haemophilia and hereditary haemorrhagic thrombasthenia the platelets, while existing in normal
numbers, are believed to be abnormally stable. The failure to break down impairs normal
clot formation leading to prolonged clottiong time and alarming blood loss from minor
trauma. The clotting time is determined by sucking up blood into a capillary tube or
by collecting it in a small test tube. The normal clotting time varies from 2-10 minutes
depending on the method used.
In the investigation of every patient with haemorrhagic blood disease, the above mentioned tests must be carried out in addition to the routine blood examination.
Laboratory investigation of bleeding states
1. Complete blood count 4.    Bleeding time
2. Platelet count 5.    Prothrombin time
3. Clotting time 6.    Hess capillary test
7.    Clot retraction time
With this brief survey of these physiological factors in the background, let us look
at some of the haemorrhagic statse that we recognize clinically. On an aetiological basis
the logical classification would be into those states due to quantitative or qualitative
platelet defects, those due to defective capillaries, those due to a diminution of prothrombin in the blood. Actually such a grouping is not above criticism because we must
recognize that more than one of these factors we have mentioned operate in some of the
bleeding states.
The following classification after Whitby and Britton and Quick is helpful if not
perfect.
Classification of haemorrhagic diseases
A. Purpuras showing quantitative deficiency of platelets
B. Purpuras showing slight or no deficiency of platelets
C. Haemorrhagic conditions with qualitative platelet defect
D. Haemorrhagic conditions due to prothrombin deficiency.
Purpuras showing quantitative deficiency of platelets
1.   Essential thrombocytopenic purpura <afu e.
(chrome
Page 87 Gaucher's disease
2.   Symptomatic purpura
(a) Bone marrow defect
Pernicious anaemia Bone marrow metastases
Aplastic anaemia Benzol and N.A.B. poisoning
pr  Leukaemia Advanced malignancy
X-ray and radium intoxication
(b) Splenic defect
band's syndrome
Essential thrombocytopenic purpura is the most important condition in this group.
It was first described by Werlhof in 1735 and the disease sometimes goes by his name.
The condition, arising without known causee, may occur at all ages. It is characterized by well defined symptoms of spontaneous bleeding involving skin, mucous membranes and internal organs. Petechiae, ecchymoses, haematoma, epistaxis- haeatemesis,
melaena, and haematuria are common. The spleen may be enlarged. The liver and lymph
nodes are not affected.
The blood picture usually shows a normal red and white cell count except for
changes such as may be secondary to haemorrhage. The blood platelets are usually markedly diminished, the bleeding time is prolonged, the clotting time normal. There is
decreased capillary resistance with a positive Hess capillary test. There is absence of
clot retraction.
Acute thrombocytopenic purpura differs from the chronic variety in its more severe
onset and shorter course.    This form is often fatal.
The chronic form is much the more common and may show varying degrees of severity. The condition tends to remission and even spontaneous recovery in some cases.
During the periods of remission the symptoms and signs may completely disappear and
the blood findings may become normal. The question of differential diagnosis and treatment will be referred to later.
Of the symptomatic purpuras in this group those arising from bone marrow defect
are much the more common. Here we are dealing with hypoplasia, aplasia, or replacement of the megakaryocytes of the marrow from which the platelets arise. This leads
to diminished platelet production and purpura.
Symptomatic purpura from splenic defect is believed to be due to an increased destructive attack by the enlarged spleen on blood platelets.
The treatment of symptomatic purpura is the treatment of the primary condition.
Group B
Purpuras with slight or no deficiency in blood platelets
1. Anaphylactic purpuras
Purpura simplex, Schonlein's purpura,
Henoch's purpura, Allergic purpura.
2. Purpura fulmtnans
3. Simple symptomatic purpura
(a) Fevers
Typhoid, Bacterial endocarditis, Influenza, Measles, Cerebrospinal meningitis,
Small-pox.
(b) Toxic
Snake venom, Nephritis'
Drugs, e.g., Quinine, Belladonna, Sulphonamides, Gold.
(c) Miscellaneous
Scurvy, Mechanical constriction,
Senility, Congestive heart failure,
Convulsions, Paroxysmal haemoglobinuria.
Page 88 In this group of purpuras the platelet count is usually normal and the essential defect
is believed to be in the capillary endothelium.
In the anaphylactoid group we have collected a number of purpuric states which at
one time held the dignity of being classed as separate entities. It is likely, however, that
they are manifestations of the same allergic disease. They are each characterized, at any
rate, by signs and symptoms which are found in the allergic state, viz., urticaria* joint
pains, cedema of subcutaneous and submucous tissues and often visceral manifestations.
The exciting agent may be an article of food or a septic focus. The streptococcus
often is an offending agent. The attack of purpura may follow an acute sore throat.
Skin manifestations are common to all types. In Henoch's purpura, which usually
affects children, the lesions are often visceral. The condition may simulate or indeed
cause intussusception.
Schonlein's purpura is characterized by joint pains and peri-articular effusions. Haemorrhage into a joint is said never to occur. The condition must be differentiated from
acute rheumatism to which it bears no relationship.
Fever and leucocytosis are common in this group. The blood platelet count, bleeding and clotting times are normal.
Anaphylactoid purpura usually runs a course of a few weeks and tends to spontaneous recovery.
In the treatment of the condition a search for allergens should be made. Any focus
of infection present should be eradicated. Vitamin P in 50 mg. daily doses has been
described in the treatment.
Purpura fulminans is an extremely rare condition occurring only in children. It is
characterized by massive subcutaneous haemorrhages, which go on to necrosis, and submucous haemorrhages. Internal bleeding never occurs in this disease. The blood findings
are normal. The cause of the bleeding is unknown, but is thought to be due to defective
vascular innervation.   Death invariably occurs in three or four days.
The symptomatic purpuras of this group need little further comment. Those occurring in fevers are commonly observed by all of us, and make up 50 per cent of all cases
of haemorrhagic states. We are in most cases dealing with defective capillary endothelium resulting from the toxins of the primary disease. The degree of purpura
present is usually a measure of the virulence of the infecting virus. In bacterial endocarditis and cerebrospinal meningitis the skin lesions may be embolic in origin.
In the toxic group we are all familiar with the purpuric manifestations of nephritis.
Haemorrhages into skin, mucous membranes and retina are often seen in the advanced
stages of the disease. Here we are almost certainly dealing with increased capillary permeability.
With regard to the action of drugs. It need only be mentioned that in the investigation of every case of purpura enquiry should be made as to the taking of drugs. Purpura as a toxic manifestation of gold and sulphonamide therapy is not infrequenty.
In the miscellaneous groups one should keep in mind that adult scurvy still occasionally occurs. There is the characteristic objective picture with submucous, subcutaneous nd subperiosteal haemorrhages. The diagnosis is made on the history of a Vitamin C deficiency diet, the diminished excretion of cevitamic acid in the urine after its
ingestion and the response to dietary treatment.
In all the members of this group we are dealing with decreased capillary resistance.
In congestive heart failure, mechanical constriction and convulsions increased intra-
capillary pressure also plays a part in the production of purpura.
Group C llll
1. Haemophilia
2. Hereditary haemorrhagic thrombasthenia
(Pseudo-haemophilia, Glantzmann's disease)
In this group the defect is believed to be a qualitative one in the blood platelets.
These elements are present in normal numbers but are believed to be defective in the
production of thrombokinase.
Page 89 1,
2.
Haemophiliac male       -j-
males normal
Female carrier -f-
50% males haemophiliac
Haemophiliac male -}-
100% males haemophiliac
Haemophilia, on of the most interesting of the haemorrhagic blood diseases* was recognized as early as the fifth century A.D. The first reference to it was the occurrence
of uncontrollable" bleeding after ritual circumcision.
The condition is a sex-linked, recessive, hereditary disease transmitted by the female,
but occurring only in males. Nasse in 1820 was the first to call attention to its hereditary characteristics. It is interesting to note that colour blindness behaves in a similar
fashion. A great deal has been written regarding the likelihood of a member of a haemophiliac family transmitting or acquiring the disease. The basic principles of its heredity
may be summarized thus:
Heredity in haemophilia
normal female
all female carriers
normal male
50% females carriers
female carrier (unknown)
50% females carriers
50% females haemophiliac
The above conclusions were arrived at from a study of 171 haemophiliac families by
Bullock and Fildes in 1910.
Theoretically on a genetic basis it is possible for the disease to occur in females, but
such occurrence has never been proven.
Haemophilia has been regarded with a peculiar sanctity because of its occurrence
among the royal families of Europe. Those of you who have read that fascinating book
"Disease and Destiny" will recall an intriguing chapter in this regard entitled "The
Legacy of Bleeding."
Haemophilia in the descendants of Queen Victoria
Queen Victoria
King Edward Czar Nicholas II Prince Henry of Battenberg
Princess Alice Alexis Czarevitch Princess Victoria
Princess Louis of Hesse (Haemophiliac) King Alfonso of Spain
Alice Princess Beatrice Prince of the Asturias
(Haemophiliac)
This family is familiar to all of you. Queen Victoria must have been a carrier of
haemophilia. Among her male children and their descendants there is no authentic record
of haemophilia. However, two of her daughters, Princess Alice and Princess Beatrice,
were carriers. Princess Alice married Prince Louis of Hesse and their daughter Alice in
turn became a carrier. She married Czar Nicholas II and the only male child of this
union, the Czarevitch Alexis, was a bleeder.
Princess Beatrice, Queen Victoria's youngest daughter, was the mother of Princess
Victoria who became the Queen of King Alphonso of Spain. The eldest child of this
union, the Prince of the! Asturias, was born a haemophiliac.
The clinical picture of haemophilia is readily recognizable. Uncontrollable bleeding
in the male from minute trauma showing early in life is the rule. Bleeding may occur
from the skin, mucous membranes or into joints. Petechiae do not occur as in purpura.
There is no defect of capillary, integrity and the Hess capillary test is normal. The blood
platelets are normal in number. The clotting time is abnormally prolonged. The bleeding time is normal. Most haemophiliacs succumb in their teens but survival to old age
has been recorded.
Hereditary haemorrhagic thrombasthenia or pseudo-haemophilia is a much rarer condition. It is chiefly of interest because it is readily confused with haemophilia and
accounts for most of the so-called cases of the latter disease reported in females.
The condition is hereditary, as a dominant characteristic, appearing in both sexes
with a preponderance in the female. There is excessive bleeding from trivial injuries
and purpura.    The bleeding time is prolonged* but the clotting time is normal.    The
H Page 90 platelets are normal in number.    It has been suggested that there is a qualitative platelet
defect.    There is no specific treatment.    Transfusion is of value.
_
Hemorrhagic disease due to prothrombin deficiency
Lack of Vitamin K
1. Dietary origin (absence of bacteria in intestine)
Haemorrhagic disease of the new-born
2. Faulty absorption—lack of bile salts
(a) Obstructive jaundice
(b) Biliary fistula
(c) Sprue, intestinal polyposis, chronic ulcerative colitis
3. Liver damage—faulty utilization of Vitamin K
(a) Post-anaesthesia liver damage
(b) Acute yellow atrophy
(c) Phosphorus poisoning.
This is the most recent and most interesting chapter in the haemorrhagic diseases.
In 1930 Dam, in Denmark, discovered a haemorrhagic disease in chicks which was found
to be due to a dietary deficiency, later identified as avitaminosis. This substance (Vitamin K) was found to be present in Alfalfa. In 1939 the chemical structure of the substance was identified as 2 methyl 1, 4 naphthoquinone. Shortly afterwards the substance
was synthesized and is now available for parenteral and oral use. The oral dose is 5-10
mgms. and the parenteral dose 1-2 mgms. daily.
Quick of Milwaukee demonstrated that associated with the Vitamin K deficiency
was a low blood prothrombin.
In the new-born child the prothrombin content of the blood is below the normal
level, supposedly due to the absence of bacteria in the gut. Vitamin K has been shown
to be produced by bacterial action. Under such conditions bleeding may occur which is
controllable by the use of Vitamin K.
Faulty absorption of Vitamin K because of absent bile salts in the gut as in obstructive jaundice or biliary fistula and in intestinal disease can give rise to bleeding states.
Vitamin K is not then available for synthesis in the liver to prothrombin. The jaundiced
patient should be given the vitamin parenterally pre-operatively.
With liver damage there is a defective synthesis of the vitamin. The only way of
overcoming the deficiency in such cases is by giving transfusions.
The investigation of a case of haemorrhagic disease
1. The clinical history
Age, sex, family history, duration, diet, drugs.
2. Physical examination
Complete physical examination. Exclude local organic disease. Look for glandular and splenic enlargement. Look for purpura of skin and mucous membranes
in all patients with unexplained bleeding.    Hess capillary test.
3. Laboratory investigation
Routine urinalysis Clotting time
Blood Wassermann Bleeding time
Complete blood count Prothrombin time
Platelet count Clot retraction
The investigation of a patient who shows signs of the haemorrhagic diathesis resolves
itself into a clinical history, a physical examination and a laboratory investigation.   •
Clinical History
Age.    Bleeding in the new-born will suggest melaena neonatorum or haemophilia.
Sex.   If the patient is a female we can definitely exclude haemophilia.
A family history may point to haemophilia, hereditary haemorrhagic thrombasthenia
or haemorrhagic telangiectasia.
Diet.   Enquiry as to dietary deficiency may help in the diagnosis of scurvy.
Page 91 /"
Physical Examination
A complete physical examination should be carreid out for the purpose of detecting
organic disease to which the purpura may be secondary. Local organic disease such as
ulcer, inflammation or tumor should of course be kept in mind. Glandular and splenic
enlargement should be searched for.
In all patients who show unexplained bleeding from a mucous membrane a search
should be made for petechiae.    The Hess capillary test should be carried out.
Laboratory Investigation
The routine examination of blood and urine is essential. A positive Wassermann
may aid in the diagnosis of paroxysmal haemoglobinuria. The platelet count, the clotting, bleeding and prothrombin times should be determined.
Treatment of essential thrombocytopenia
1. Prophylaxis—avoidance of injury
2. Transfusion
3. Splenectomy in chronic cases 5.   Adrenalin injections
4. Ligature of splenic artery 6.   Injection of foreign protein
7.   Snake venom
(a) local application 1:10-000 Russell viper venom
(b) subcutaneous injection.
Treatment of hemophilia
1. Eugenic control
2. Immediate treatment
(a) local application of  1:10,000 snake venom
(b) intramuscular injection of whole blood
(c) transfusion
3. Sensitization to foreign protein 5.   Ovarian extracts
4. High protein diet 6.   Frequent venesection.
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jSeaface Qallofi
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Page 92  r>,jr-i-fe _fe«tea •*&' saVefflnte JSjf:f»e^rl§|ttg $%f*mm
because $.M,A. simplifies *¥%m6l9K:??o|BsMe$,^
DoVt take our word- for .Hrr«| '^*p*R&'jHkin^
among  3)935   physicians who  fed^S»M/4^*> .of'4
'those reporting—
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t^X BlbCHEMICAl DIVISION; — John Wyeth' & Brother |tana4a}|l|h>i|||
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%eiT$k
m
M
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mm. Chemotherapy of
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COMPLICATING
INFECTIONS
pn^Hiii
he sulfonamides are highly useful not only in the treatment of certain
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primary infection.
In the application of chemotherapy, consideration is given to the type of organism
causing the spread of infection from its original source and to the sulfonamide
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Neoprontosil has been found to exhibit pronounced bacteriostatic potency in complications caused by the hemolytic streptococcus. Many cases of septic sore throat,
otitis media, sinusitis and a number of other intercurrent conditions have yielded
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How Supplied: For oral use only: Neoprontosil tablets of 5 grains, bottles of 50 and 500;
Neoprontosil capsules of 3 grains, bottles of 50 and 500.   Caution: Not to be used for injection.
For parenteral administration: Neoprontosil 2.5 per cent solution, ampules of 5 cc, boxes of 5 and
50; ampules of 10 cc, boxes of 5; bottles of 50 cc. with rubber diaphragm stopper.
Neoprontosil 5 per cent solution, ampules of 5 cc, boxes of 5 and 50; bottles of 50 cc. with rubber
diaphragm stopper.
WINTHROP
Neoprontosil
Trademark Reg. U. S. Pat. Off. _ Canada
Brand oj AZOSULFAMIDE
Disodium 4-sulfamido-p_enyl-2-azo-7-acetyI-
amino-1-hydroxynaphthalene 3,6-disulfonate
WINTHROP
WINTHROP CHEMICAL COMPANY, INC
Pharmaceuticals of merit Jor the physician
General Office: WINDSOR, ONTARIO
Professional Service Office: Dominion Square Building, Montreal, Que.
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&.   •'       ISO  lAFAYETTt  STRUT.  NIW YORK. N. Y.
Full formula and descriptive
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Dosage:   l to 2 capsules
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Ethical protective mark MHS
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CIBA COMPANY LTD.
Montreal Trade Mark Registered
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Brand of Benzyl-Tftalkonium Chloride
CHLORIDE
Zephiran Chloride is a mixture
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Trade Mark Regiile
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IN granting the seal of Acceptance
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Professional Service Office
1010 St. Catherine St. W.
MONTREAL, P.Q.
Office and Laboratories
1019 Elliott Street West
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350   Le Moyne   Street,   Montreal
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Recent Research
Finds Wide Difference
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Digestion of "Fibre"
fTUDlES recently under-
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While heretofore nutritionists generally have held to the
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Obviously, the more fibre is
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Address., mart
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GEORGIA PHARMACY
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ESTABLISHED 1893
VANCOUVER, B. C.
North Vancouver, B. C.
Powell River, B. C. 

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