History of Nursing in Pacific Canada

The Vancouver Medical Association Bulletin: March, 1938 Vancouver Medical Association Mar 31, 1938

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Vol. XIV
MARCH, 1938
No. 6
In This Issue:
(With Cascara and Bile Salts)
. . FOR . i
Chronic Habitual
Western Wholesale Drug
(1928) Limited         1
(Or at all Vancouver Drug Co. Stores) THE   VANCOUVER   MEDICAL   ASSOCIATION
Published Monthly under the Auspices of the Vancouver Medical Association
in the interests of the Medical Profession.
203 Medical-Dental Building, Georgia Street, Vancouver, B. C.
Editorial Board:
Db. J. H. MacDermot
Db. M. McC. Baibd Db. D. E. H. Cleveland
All communications to be addressed to the Editor at the above address
Vol. XIV.
MARCH, 1938
No. 6
OFFICERS  1937-1938
Db. G. H. Clement Db. Lavell H. Leeson Db. W. T. Ewing
President Vice-President Past President
Db. W. T. Lockhabt Db. A. M. Agnew
Son. Treasurer Hon. Secretary
Additional Members of Executive—Db. J. R. Neilson, Db. J. P. Bilodeau.
Db. F. Bbodie Db. J. A. Gillespie Db. F. P. Pattebson
Historian: Db. W. D. Keith
Auditors: Messrs. Shaw, Salteb & Plommeb.
Clinical Section
Db. R. Palmeb Chairman    Db. W. W. Simpson Secretary
Eye, Ear, Nose and Throat
Db. S. G. Elliott Chairman     Db. W. M. Paton Secretary
Pcediatric Section
Db. G. A. Lamont Chairman    Db. J. R. Davies Secretary
Cancer Section
Db. B. J. Harrison.. Chairman    Dr. Roy Huggabd Secretary
Db. A. W. Bagnall
Db. S. Paulin
Db. W. F. Emmons
Db. R. Huggabd
Dr. H. A. Rawlings
Db. R. Palmeb
Dr. G. F. Stbong
Dr. R. Huggard
Dr. D. D. Freeze
Dr. J. H. MacDermot
Dr. D. E. H. Cleveland
Dr. Murray Baird
V. 0. N. Advisory Board
Dr. I. Day
Dr. G. A. Lamont
Dr. Keith Burwell
Representative to B. C. Medical
Sickness and Benevolent Fund
Summer School
Dr. J. R. Naden
Dr. A. C. Frost
Db. A. B. Schinbein
Db. A.Y. McNair
Dr. T. H. Lennie
Dr. F. A. Turnbull
Dr. A. B. Schinbein
Db. D. M. Meekison
Dr. F. J. Buller
Metropolitan Health Board
Advisory Committee
Dr. W. T. Ewing
Dr. H. A. Spohn
Dr. F. J. Buller
Association—Db. Neil McDougall.
—The Pbesident—The Tbustees Serum Therapy of Pneumonia
In a large proportion, estimated as well over fifty per cent,
of all cases of lobar pneumonia, the causative agent is a
Type I or a Type II pneumococcus. In treatment of pneumonia caused by either of these types of pneumococcus,
favourable results from serum therapy had become, by
1934, so obvious that international units were then
adopted for standardization of Type I and of Type II
anti-pneumococcus sera.
In using anti-pneumococcus serum, its administration
early and in adequate doses is, of course, a factor of fundamental importance, as is the use of serum specific for
the type of the pneumococcus present in the case under
treatment. By the Neufeld method of rapid typing,
determination of type may be made in hospital or other
laboratories, or a determination may be carried out by
the physician with the aid of a microscope.
Information relating to Concentrated Anti-Pneumococcus Sera
and to Pneumococcus Typing-Sera as prepared by the Con-
naught  Laboratories  -will  be   supplied  gladly  upon  request.
Toronto  5
Depot for British Columbia
Macdonald's Prescriptions Limited
Total population—estimated	
Japanese population—estimated.
Chinese population—estimated—
Hindu population—estimated	
Total deaths   :    257
Japanese deaths .        9
Chinese deaths .      10
Deaths—Residents only    228
Male, 173; Female, 160	
Deaths under one year of age-
Death rate—per 1,000 births...
Stillbirths (not included in above)
Jan., 1938
...     24.0
Rate per 1,000
Jan., 1937
February 1st
to 15th, 1938
Cases Deaths
December, 1937
Cases  Deaths
January, 1938
Cases  Deaths
Scarlet Fever  37           1 47 0
Diphtheria    1           0 4 1
Chicken Pox I  84           0 172 0
Measles    12           0 19 0
Rubella    10 3 0
Mumps  1  49           0 73 0
Whooping Cough  9           0 19 1
Typhoid Fever  12           0 2 2
Undulant Fever  10 0 0
•Poliomyelitis    ..  0           0 0 0
Tuberculosis   36         16 35 21
Erysipelas   3           0 10
Vancouver Hospitals and
Clinic Private Doctors Totals
Syphilis        84                       31 115
Gonorrhoea       89                       14 103
Always Maintain the
Ethical   Principles   of
the Medical Profession
Guildcraft Opticians
430 Birks Bldg\        Phone Sey. 9000
Vancouver, Canada.
Page 124 Literature and samples from:
Some two and a half years ago, a very noble idea was conceived in Vancouver : the idea of a British Columbia Cancer Foundation. Boards of Trade,
the Health League, the B. C. Medical Association, the Vancouver Medical
Association, all contributed members to the committee charged with formulating a scheme to implement this idea. Much excellent work has been done,
and the names of those on the committee are a guarantee of sincerity and
competence for the carrying into effect of an adequate scheme. But the
chariot wheels of progress drive heavily, and we seem to have reached,
temporarily at least, a dead end.
We have said something about this matter before, on this page—and we
cannot help feeling that it is high time that something was said again. We
feel that the medical profession of British Columbia should take an interest
in this project, and should use their thought and influence to further it, and
to see that it is guided aright. Because, unless this question of cancer, its
administration and control, is, from the beginning, and at the beginning, put
on a right basis, we have ample proof, from the experience of other centres,
that much, if not most, of the effort expended will be wasted and useless,
and that proper growth and expansion will be rendered impossible.
A campaign was to be inaugurated to collect money to establish an
institute in Vancouver, with subsidiary branches to cover the province.
Radium was purchased, or optioned, by the B. C. Government, and lies
waiting for disposal, as soon as money can be secured. A very good scheme,
as we understand, was drawn up for inauguration of an adequate provincial
system of cancer control, of education of the public, of diagnosis and research.
What, we ask in all sincerity, is the reason for delay? Such delay is very
much to be deplored. The danger, as we see it, is that some second-best,
narrow, compromise scheme is likely to be adopted, and the original broad
and flexible scheme sidetracked, if not altogether abandoned. We foresee the
danger that the project will be made subsidiary to some existing organization, and that the plan whereby it was to be an independent organism functioning on its own, will be given up. We feel that this would be nothing less
than a tragedy, and that it would retard the progress of Cancer Control very
seriously. This is not mere conjecture; it has been the result, as we have been
told repeatedly by those who know, whenever the centre for cancer control
has been attached to other bodies and organisations.
The reasons are fairly obvious. Suppose, instead of an independent Institute, designing and executing its own policy, obtaining its own financial
resources, devoted solely to the one idea, the diagnosis, treatment and study
of cancer, we have as a substitute a Cancer Department of any hospital, no
matter how large and well managed, we can see what will happen. It will be
a poor relation, bound to the fortunes of an institution which is always
starved for money, and must think only in terms of money and cost, of any
of its departments. Energy that should be devoted to one cause will be dissipated over several, and expediency will take the place of wisdom and far-
sighted policy. Research will be impossible. This has been the experience in
London and many other centres.
That most important thing, the psychological appeal to the public sympathy, will be entirely lost. People can visualise and grasp the importance
and urgency of a cancer centre. From this will come concentrated and intensive educational effort that can never be put forth by any hospital.
And, perhaps one of the most important considerations is that the rest
of the province will have nothing to do with any such scheme or arrangement.
This is a provincial matter, not a Vancouver matter, and we must not lose
sight of this. Only as we deal fairly and generously with the rest of the
province can be hope for success within our own borders.
Must we necessarily start this thing on a large scale, full-grown from the
beginning? We think that size is of no importance as compared with quality
and Tightness of growth. We hope and trust that our fears and anxieties in
Pnr/p 125 this regard will be unfounded; but we feel that every medical man should
talke a deep interest and concern in this thing and should do his share, if
only by expression of opinion and personal influence, in seeing that right
direction and wise counsel prevail. There is plenty of this to be had; we can,
if we so desire, profit by the experience of many larger centres, and it is our
clear duty to do our part towards seeing that the right policy is adopted.
We know the facts and needs of the case better than any other section of the
community, and the driving power and inspiration must come from us. Our
provincial and local committees must receive the support of the profession to
a far greater extent than has been the case hitherto.
The Osier dinner will be held on Tuesday, March 1st, in the
Oval Room at the Hotel Vancouver, and will commence at 7:30 p.m.
(not 7 p.m., as is stated on the tickets).
The Lecture, which will commence at 8:30 p.m., will be given
by Dr. Lyon H. Appleby, who has given the following title to his
address: "Quo Vadis, Medicina?" Members are assured of a stimulating and entertaining evening, and a large attendance is expected.
Tickets are $1.00 and the dinner is, of course, formal.
Surgical Clinics of N. A., October, 1937, Cleveland Number. "Symposium on
Recent Advances in Surgical Technic."
Surgical Clinics of N. A., December, 1937, Philadelphia Number. "Symposium
on Fractures."
Surgical Clinics of N. A., February, 1938, Chicago Number. "Symposium on
Minor Surgery."
Medical Clinics of N. A., September, 1937, Baltimore Number. "Symposium
on Diseases of Children."
Medical Clinics of N. A., November, 1938, New York Number. "Symposium on
Medical Clinics of North America, January, 1938, Chicago Number. "Symposium on Pneumonia."
*      *      *      *
The January number of the Medical Clinics of North America contains
an article concerning arrangements for delivery in the home. The article is
written for the practitioner who has to make the best of whatever facilities,
or lack of facilities, he may find in the poorer homes. There are practical
details as to the arrangement of instruments, sterile towels, etc., which may
be of assistance to men attending Maternity Relief cases in this city.
At this date plans are being laid for the Annual Meeting, which will be
held this year in Victoria, where the President, Dr. Gordon C. Kenning,
resides. The dates of Annual Meetings in the Western Provinces have been
more or less variable during several years, owing to the tour of the President
of the Canadian Medical Association, the General Secretary and lecture team.
The Annual Meeting of your Association will probably fall about the middle
of September, with headquraters at the Empress Hotel in Victoria.
Page 126 OBIIT FEBRUARY 3rd, 1938.
It is difficult to -write adequately regarding our departed friend and
colleague. His was so many-sided a character, and withal so vivid and colourful that one cannot hope to compass it in this short tribute to his memory. But
he leaves a big gap in his passing, and we shall miss him, as one of the larger
and stronger figures of our number.
Others will give the tale of his achievements and honours, and record
his doings. What we want, in our humble way, to do is to draw a sort of
pen-picture of him, as he remains in our memory.
His outstanding feature, perhaps, was his bluntness and forthrightness
of character. He hated shams and pretence and would rather appear in a
bad light than in a false one, so that once or twice his plainness of utterance
got him into some difficulty, as he burst the bonds of humbug and political
He was essentially sane and level-headed in his views of life, and his was
always the voice of reason, and of cool deliberation. The medical profession
of British Columbia owes a very great deal to Frank Patterson: for he was
first and last a doctor, loyal always to his cloth, and a staunch defender of it.
He could always be depended upon to be working for the good of the profession of which he himself was such a shining ornament. And like a good friend,
he was always ready to talk straight, and to point out our mistakes as he
saw them, and he was usually right.
He had a warm desire for friendship, had Frank Patterson, and he had
many friends. Shy by nature, hating any appearance of sentiment, gruff and
at times apparently forbidding in manner, he yet valued and kept his friends
—and he had a great number. "By their nicknames ye shall know them," and
to the world at large he was "Pat" or "Frank"—the former especially—and
it was with affection that the nickname was applied. No mean or unloved
man keeps such a nickname long, and there was nothing mean or ungenerous
about Frank Patterson. He was never too busy (and he was perhaps the
busiest man in town) to listen courteously to an appeal for help and advice
from any of his professional brethren—and neither time nor money figured
in the least in his response to such appeals. And as for the public he served:
well, the writer was five minutes late in getting to the Cathedral where his
funeral service was held, and he could not get in, and the sidewalks were
He was one of the big men of Canadian medicine, and his work was
uniformly excellent. As an orthopaedist, he was an authority, and he had the
gift of teaching. All too seldom could he be prevailed on to lecture or give
papers—but when he did, one marvelled at the wide sweep of his knowledge,
and at the thoroughness and completeness of his work. And his rigid, unceasing insistence on perfection of technique have done much to raise the
standard in the operating rooms of Vancouver. Like Alice in the old song,
the nurses "trembled with fear at his frown," and the going was always
hard when he was at the wheel, but they would be the first to acknowledge
that the training he gave was unique and invaluable.
One could go on and on—but perhaps we have said enough. He will be
a hard man to replace—and this not only in the medical world. And we
shall for a long time miss that slow, deep, resonant voice of his; his caustic
but not always unkindly comments on the frailties of men, and his sane,
wise and helpful counsel, given from a full mind and a generous heart.
We offer our heartiest congratulations to Dr. John E. Walker on the
occasion of his marriage to Miss Edythe Dunn of Vancouver. The wedding
took place on February 5th, after which Dr. and Mrs. Walker left for a trip
to California. They have made their home in Vancouver.
♦ *     *     ♦
Roy H. Fraser, M.D., F.C.I.C., D.P.H., of Winnipeg, has arrived in Vancouver and has taken up his duties as Executive Secretary of the Greater
Vancouver Health League. Dr. Fraser was formerly Lecturer in Physiology
at the University of Manitoba.
♦ N5 H* ♦
Dr. L. H. Turnbull has returned from an extended visit to Eastern Canada
and the Eastern States. Dr. Turnbull drove all the way, and reports an
excellent trip.
♦ ♦      ♦      ♦
Dr. D. E. H. Cleveland attended the meeting of the San Francisco and
Los Angeles Dermatological Societies in San Francisco on February 12th.
# ♦     *     ♦
Dr. G. F. Strong made a flying trip (by train) to San Francisco for a
meeting of the Pacific Interurban Clinical Club, leaving on February 9th and
returning to the city on February 14th.
3|C 9|C 1|C 3|C
We extend our sympathy to Dr. J. G. McKay of New Westminster on the
dea th of his brother, Dr. Alexander M. McKay, in Calgary.
♦ *      ♦      #
We also offer our deepest sympathy to Dr. Fred Bonnell, Radiologist at
St. Paul's Hospital, on the death of his mother, which occurred recently in
* *      *      #
Dr. C. W. Prowd and Dr. T. R. Whaley have left by motor for Southern
California and Mexico.
* *      #      *
Dr. Bliss Pugsley is commencing practice in Prince Rupert.
Dr. Noel Bathurst Hall of Campbell River has been visiting Vancouver
during two weeks. *      *      *      *
Dr. C. H. Hankinson of Prince Rupert is having a short vacation.
* *      ♦      *
Dr. D. J. Fitz Osborne of Minto City called at the office while in Vancouver.
* *      *      *
We regret to report the serious illness of Doctors C. C. Browne and A.
H. Meneely of Nanaimo. The last word showed improvement. We wish
them well. *     *     *     *
Dr. Stuart E. Beech of Salmon Arm is much improved following a recent
illness and will soon return to active work again.
* *     *     *
A recent letter tells us that Dr. Sidney G. Baldwin, late of VernOn, is
now in London doing special work at the Queen Charlotte Lying-in Hospital.
* *     *      *
Dr. H. E. Cannon of Blakeburn, while in Vancouver for a few days, called
at the office of the College.
* *     *     *
Doctors M. J. Keys and Eric H. W. ElMngton of Victoria and Dr. E. D.
Emery of Nanaimo attended the meeting of the Eye, Ear, Nose and Throat
Association of B. C. in Vancouver.
* *     *     *
Dr. J. L. Murray Anderson of Victoria is in Toronto taking a Public Health
Page 128 According to reports from Victoria, Dr. H. G. Chisholm, of the Tuberculosis Division at Victoria, has suffered a severe attack of pneumonia.
5!; * * *
Dr. H. T. Hogan of Tulsequah has been appointed Medical Health Officer.
A letter from Doctor Hogan suggests that he Is happily engaged in the
mining practice in the far North.
* *     *     #
Reports from the No. 4 District tell us that Dr. George Cheeseman of
Field is weary of winter snow and is now anticipating the joy of spring and
an escape in his new Buick.
* *     *     #
Dr. W. A. Drummond of Ashcroft has had a busy winter. The long drives
to Clinton are not enjoyable in deep snow.
* #     *     ♦
Dr. R. W. Irving was down for a mining meeting in February. He looks
Dr. Alan Hall of Nanaimo came out on skis from the Nanaimo Lakes for
assistance when he and Mrs. Hall and party were snowbound for four days.
* *     *     *
Dr. R. B. White of Penticton made the trip to Vancouver to attend the
services for Dr. Frank Patterson.
♦ $ # *
Dr. G. W. C. Bissett of Duncan, the President of the Victoria Medical
Society, attended Dr. Patterson's funeral service, as did Dr. J. W. Lang of
West Vancouver, the President of the North Vancouver Medical Association.
* #     *     #
Dr. George E. Darby of Bella Bella called at the office on his return
after several months away, during which he did special work in Great Britain.
3|t 9|C )fC 3fC
Dr. D. E. Emery of Nanaimo, Secretary of the Upper Island Medical
Association, visited Vancouver and discussed the proposed spring meeting
to be held in April.
* *      *     *
Dr. R. J. Wride of Princeton has left for Eastern centres and will be
absent during several weeks, engaged in post-graduate work.
• #     *     *     *
Dr. Gordon C. Kenning, President of the British Columbia Medical Association, was in Vancouver to attend the funeral services of the late Dr.
Patterson. Dr. Kenning acted as an Honorary pallbearer.
* *     *     *
Dr. A. S. Underhill of Kelowna was in Vancouver participating in the
Bonspiel in February.
Dr. and Mrs. J. Bain Thorn are leaving for a southern trip on February
15th, taking a freighter from San Francisco to Jamaica. Dr. Thorn is an
"old" sailor, having been ship's surgeon on the Empress of India on the Orient
run in 1907. *     *      *      *
Dr. L. B. Wrinch of Hazelton, B.C., has joined the staff of the C. S.
Williams Clinic, to be located in Rossland. The Clinic now has a staff of twelve
doctors. The name "The C. S. Williams Clinic" has been adopted by the
doctors serving in this Trail-Rossland group in memory of the late Dr. C. S.
Williams, whom many of the profession will remember as a pioneer doctor
in that area.
*     *     *     #
The medical profession of Trail learned with deep regret of the death of
Dr. Patterson, who practised there for five years previous to 1908, Dr. Thorn
taking over at that date.
Page 129 ■
The Committee on Public Health of the British Columbia Medical Association held a meeting on February 2nd. Present: Dr. A. H. Spohn, Chairman;
Dr. E. S. James, Secretary; Doctors K. F. Brandon, Metropolitan Health
Board; Clarence E. Brown, J. S. Cull, Provincial Board of Health; Richard
Felton, Victoria; L. Giovando, Nanaimo; Gordon O. Matthews; H. H. Mil-
burn, Chairman, Health Bureau, Board of Trade; S. Stewart Murray, Assistant Senior Medical Officer, Metropolitan Health Board; E. K. Pinkerton,
G. S. Purvis, New Westminster, and M. W. Thomas.
Discussion of the advisability of advocating wider use of scarlet fever
toxoid resulted in the appointment of a sub-committee to study and report
findings based on a review of the present sta»tus of this prophylactic measure.
Further consideration would be given to this subject and it was suggested
that such information might be presented in the pages of the Bulletin.
The necessity for pasteurization properly carried out was discussed and
it was felt that the committee should keep this objective before it.
The benefits which would accrue from close co-operation between the
Departments of Health and the Committee were agreed to be worth the
effort. It was deemed advisable that the profession be fully informed of
proposed and projected programme and through understanding the sympathy
and support of the man in practice could be enlisted.
It was decided to ascertain the prevalence of Bang's disease among dairy
cattle in this province from the Live Stock Department. An effort will be
made to procure from the Indian Affairs Branch figures on the incidence of
trachoma and tuberculosis among Indians in this province.
The Victoria Medical Society had as its guest speaker, at the February
meeting, Dr. C. E. Dolman of the University of British Columbia. The subject, "Septicaemia," excited very considerable interest and Dr. Dolman was
most generous in replying to questions arising out of a lively discussion.
Mr. Ryan, representative of Smith and Nephew, ran the cinema reels,
"Elastoplast in Modern Surgery," during the opening of the meeting.
Members practising in various district municipalities are reminded to
secure the same or better arrangements in respect to payment for medical
care of relief recipients.
The Department of the Provincial Secretary will pay for medical care,
outside of hospital and surgical operations done in or out hospital, provided
always that authorization is secured from the Superintendent, Mr. J. H.
Creighton, Parliament Buildings, a welfare visitor, a government agent, a
provincial police officer or some other responsible representative of the
Government before service is given, except in cases of emergency, when
authority should be obtained as soon as possible.
Page 180 T
President: Dr. W. E. Henderson, Kelowna.
Reba E. Willits, Kelowna.
Dr. Austin F. Gillis.
Dr. J. J. Gillis.
Secretary-Treasurer: Db
Dr. George A. Cheeseman.
Dr. Paul F. Ewert.
Halcyon Springs (Arrow Lake) :
Dr. F. W. E. Burnham.
Dr. James Harry Hamilton.
Dr. A. Llewellyn Jones.
Dr. G. L. Watson.
Salmon Arm:
Dr. H. Baker.
Dr. Alan Beech.
Dr. S. E. Beech.
Dr. Edward Buckell (retired),
Dr. W. Scratchard.
Blue River:
Dr. W. Bramley-Moore.
Dr. George R. Barrett.
Dr. D. M. King.
Minto City:
Dr. D. J. Fitz-Osborne.
Dr. C. H. Ployart.
Dr. J. C. Stuart.
Dr. J. P. Ellis.
Ashcrof t:
Dr. W. A. Drummond.
Dr. M. G. Archibald.
Dr. H. L. Burris.
Dr. J. S. Burris.
Dr. John A. Ireland.
Dr. R. W. Irving.
Dr. Stewart A. Wallace.
Dr. J. C. M. Willoughby.
Dr. F. P. McNamee.
Dr. A. G. Naismith
(Hosp. Laboratory).
Dr. P. S. Tennant
(Indian Affairs).
Dr. H. S. Stalker (Supt.).
Dr. H. A. Jones.
Dr. G. F. Kincade.
Dr. Kingsley Terry.
Dr. A. Hakstian.
Dr. George H. Tutill.
Dr. R. Haugen.
Dr. J. A. Shotton.
Dr. W. B. McKechnie (retired)
Dr. H. J. Alexander.
Dr. Hugh I. Campbell-Browne.
Dr. J. E. Harvey.
Dr. Osborne Morris.
Dr. Frank E. Pettman.
Dr. A. O. Rose.
Dr. N. W. Strong.
Dr. B. deF. Boyce.
Dr. J. S. Henderson.
Dr. W. J. Knox.
Dr. J. McK. Large.
Dr. A. S. Underhill.
Dr. Reba E. Willits.
Dr. L. A. C. Panton.
Dr. Wm. Buchanan.
Dr. F. W. Andrew.
West Summerland:
Dr. A. W. Vanderburgh.
Dr. L. F. Brogden.
Dr. H. McGregor.
Dr. J. R. Parmley.
'     Dr. G. C. Paine.
Dr. W. R. Walker.
Dr. R. B. White.
Dr. A. D. Callbeck.
Dr. V. E. Latimer.
Dr. C.
Dr. Gordon E. Wride.
Dr. D. McCaffrey.
Dr. Paul Phillips.
Dr. R. J. Wride (Coalmont).
Dr. H. E. Cannon.
J. Ball.
B. Munroe.
Note.—Please add the name of Dr. S. Cameron MacEwen to the roster
of the profession in New Westminster, as it was unfortunately missed in the
list of the Fraser Valley Medical Society published in the February number.
Page1S1 [The tendency of modern youth (and older people as well, who should be
wiser) to expose the greatest possible area of skin to the sun, is being more
and more clearly shown to have its real dangers. This article is, we feel, a
very timely one.—Ed.]
D. E. H. Cleveland, M.D.
(Read before the Osier Society)
The cult of the sun is no new thing. I will not try your patience by exhuming from the dust of antiquity evidences of sun-worship. Modern science has
shown the sound basis of ancient myth and tradition in recognizing the sun
as the prime source of energy. Following this it is but natural that popular
science should exalt the health-giving power of sunlight into a dogma which
knows no limits or exceptions. This brings us back around the circle to
modern sun-worship, but the devotion is now purely venal.
It is the function of our profession to utilize with open minds all available
powers of nature to prevent or alleviate disease. It is axiomatic that a remedy
which is literally harmless is equally useless. Like fire or an edged tool, a
useful remedy may be destructive when uncontrolled. The energies in sunlight are essential to the continuance of life; uncontrolled or unmodified, they
destroy life. Fortunately there exist automatic protective agencies, making it
difficult to conceive a situation in which the human body can be exposed to
uncontrolled or unmodified solar radiation. These are not sufficient, however,
to confer adequate protection under all conditions. Modern sun-worshippers,
blindly following blind leaders, are perversely doing what they can to escape
or neutralize natural safeguards, and the tale is not yet told of the injury
they are doing themselves.
To discuss the immediate, remote and conjectural effects upon the entire
human economy of solar radiation is too much to attempt here. But since
the skin is the organ which receives the first impact of this type of energy,
and in which reside the chief reactive and protective mechanisms, it may
be of interest at this time to discuss the effects on normal skin, and then the
effect upon abnormal skin. In the latter category are included skin which is
abnormal through an idiosyncrasy, and skin which is abnormal owing to
disease of the skin itself, or elsewhere in the body. In diseases of the skin
we have especially to consider those in which sunlight is of value as a
remedial agent, and those in which its therapeutic employment is contra-
With regret we must refrain from entering into a discussion of the
fascinating problems of biochemistry which these various reactions indicate.
The only portion of the solar radiation known to have any important
and direct effect upon human skin is that comprised by a very narrow band
in the ultra-violet between 3130 and 2900 A. The infra-red and luminous
rays have but a brief heating effect, since they produce immediate vasodilation which dissipates the heat, although they modify the effect of the
ultra-violet. Sunlight and ultra-violet rays must not be thought of as
synonymous, and it is wrong to speak of ultra-violet from artificial sources
as artificial sunlight. The spectrum produced by a mercury-vapour lamp is
relatively rich in the shorter ultra-violet, and its most potent wave-lengths
are those which scarcely exist in sunlight.
Altitude and atmospheric conditions modify the effects of sunlight, since
water-vapour, smoke and dust filter out ultra-violet by absorption, while
transmitting infra-red and luminous rays. The amount of. ultra-violet in
sunlight varies also with the angle of incidence, and is therefore progressively less as latitude increases and as winter advances. Ultra-violet and
luminous rays are reflected by water, snow and ice, while infra-red is
absorbed. Thus sunburn is more readily produced in proximity to bodies of
Page 182 water, or snow and ice, and awnings or parasols give little protection. The
sky itself is a reflecting surface, and sunlight effects can be produced without
exposure to direct solar rays. It is also important to recognize that ultraviolet is not the sole source of erythema and pigmentation. All forms of
radiation, from heat-rays to x-rays, can produce these effects. They are
distinguishable by such features as the period of latency, the shade of the
erythematous flare, etc.
Different parts of the skin vary in their sensitivity, the determining
factor evidently being the varying thickness of the horny layer of epithelium.
The most sensitive regions are the inner sides of the arms and thighs, the
popliteal space and the sides of the chest and back. The intensity of effect
also varies with the depth of pigmentation, the fat-content of superficial
layers, and local circulation and temperature. Erythema is more or less suppressed or delayed by heating the skin simultaneously with or immediately
after exposure to ultra-violet, but is intensified by preliminary heating.
The higher susceptibility of the skin of children to ultra-violet is chiefly
due to the thinner corneous layer, but also in part to the smaller amount
of pigment.
It is considered that the chief function of pigment is to protect the blood
from heat-effects. Thus, while pigment is produced by ultra-violet as well
as by the luminous and infra-red rays, its main purpose appears to be to
absorb the latter. Since fats absorb the erythema-producing ultra-violet,
the skin is often oiled before sunbathing in order to permit the development
of the coveted tan without the discomfort of erythema and burning. In white
races, however, the pigment, except for a brief period after insolation, is
confined to the basal layer of epidermis. Thus it does not protect the more
superficial prickle-cell layer. In the black races there is abundant pigment
in all the epithelial layers. It is apparent, therefore, that members of the
white race can never develop as complete protection as that with which
members of the black races are naturally endowed. Blondes, who are especially deficeint in pigment-formative powers, are not suitable for tropical
emigration, and it is reported that they are not accepted for tropical service
in the French Foreign Legion. As a digression at this point, the curious fact
may be observed that vitiligo or leukoderma, a skin disorder, in which areas
of skin, apparently by a local exhaustion process, have lost the power of
pigment formation, is seen more commonly among brunettes than blondes,
more commonly among the yellow-brown races, and most commonly in
The ability of ultra-violet to stimulate the growth of hair is greatly overrated, leading to the promotion of the .hatless fad by self-styled health-
culturists, and to commercial exploitation of ultra-violet generators. That
hair-growth in some degree can be stimulated by sunlight is evidenced by
the heavy growth of lanugo on the limbs of children at the end of summer.
The significance of its disappearance before the next spring seems to have
been overlooked. One might expect that the nudist camps would have long
since been abandoned if a growth of permanent secondary hair was the
result of exposure to sunlight. There is much reason to believe that instead
of preventing baldness, the hatless fad increases its incidence.
Much of the drying effect attributed to sunlight is really due to other
factors which accompany sun-exposure, such as wind and heat. Chronic
solar dermatitis is of a dry character, and sunlight is the chief, while not
the only, factor in its production. Diffuse superficial capillary dilatation from
the heat rays is a constant effect, and the arterioles, while not constantly
dilated, dilate more readily than normal. This appears to be associated with
increased metabolic activity in the skin and eventual keratoplasia. Thus
appears the reddened, easily flushed, dry and somewhat later scaly and
rough skin on the face, sides and back of the neck and dorsum of the hands
called "sailor's skin" or "farmer's skin." Senile involution, with atrophy of
elastic tissue and glandular structures and increased pigmentation, commonly
Page 188 overlaps and mingles with the earlier changes to produce a composite picture, of which only a part is due to sunlight. Thus with advance of the
keratoplastic changes there appear local upheavals commonly spoken of as
senile keratoses. These are precancerous lesions, and in a proportion of indi-
iduals one or more of them develop into baso-cellular or squamous-cellular
carcinomas. There is a close similarity to be observed between the foregoing
succession of degenerative changes and those following excessive exposure
to x-rays. If it be accepted that age is not the result of years alone, but
summation of stimuli, then it may be stated that all these are senile changes,
which may occur in any decade.
Thus we might say that climatic conditions may induce premature senility
of the skin, and something like this is recognized at present in the Antipodes.
It has been reported from Australia that the incidence of cancer of the skin
of face and hands is higher in the white population of that country than in
any other country from which records are obtainable. The public health
authorities, therefore, are warning those who are engaged in outdoor occupations particularly, such as men on up-country sheep-stations, to wear suitable
protective head-covering, closed collars, sleeves to the wrist and protection
of the hands. The dry air and strong sunlight found in countries where
moderate altitude is associated -with sub-tropical latitude are evidently not
unmixed blessings.
* Normal skin which has been temporarily modified in some way by chemical or physical agency reacts to sunlight in various manners. It is well
known that the darkening of the skin to a slaty blue colour when it has been
impregnated by silver which has been absorbed into the superficial cells,
either by local deposits formed on the skin by external applications to the
skin, the eye or the nasal passages, or by deeper deposition from ingested
silver, is a photochemical reaction in which silver oxide has been formed
by sunlight.
The continued use of mercury in the form of hair-dyes, face creams and
other cosmetics, as well as medicinal applications, eventually may produce a
grayish-black pigmentation due to mercuric sulphide formed in the same way.
Hypersensitivity to sunlight and varied types of reactions have been
known to occur following the internal administration of gold and of the
arsphenamins. The mechanism is not well known, and the reactions sometimes do not appear until long after the medicament has been discontinued.
Coal-tar is well known as a light-sensitizer, especially toward the ultraviolet, and this faet is utilized in the therapy of certain dermatoses. Certain
fractions of tars have been identified as having carcinogenic properties, when
skin affected by them is subsequently exposed to sunlight.
Some of the ethereal oils used in perfume, notably of bergamot, which
is a constituent of Eau de Cologne, have been observed to produce dark
streaks and patches on the skin of those who applied such perfumes to the
skin before sun-bathing. An attempt to utilize this property in the treatment
of leukoderma has proved abortive, since the darkening of the skin is not
due to stimulating of pigment-formation, as was first thought, but to a
darkening of the corneous layer of epithelium.
A few other chemical agencies remain to be mentioned as modifying the
reaction of normal skin to sunlight. Acriflavine and other acridin derivatives,
which are sometimes administered intravenously, frequently act as photo-
sen sitizers, producing intense erythematous and vesiculobullous reactions
followed by pigmentation. Eosin used over long periods in a similar manner
produces sensitivity to the green rays of the luminous spectrum. If skin upon
which chlorophyll has been rubbed, especially if it is lightly abraded, is
exposed to the red rays of the luminous spectrum, erythema and pigmentation
frequently result. It does'not occur following exposure to ultra-violet alone.
This accounts for a number of cases of dermatitis observed upon those who
have been bathing and then lain in the grass on the banks of a lake or stream
Page 184 to dry in the sunlight; sometimes the marks of individual blades of grass
which have been crushed upon the skin are visible as red streaks.
Coincident with the rapid and widespread increase in the use of sulfanilamide has been observed the development of morbilliform and scarlatiniform
eruptions in patients receiving this drug, and it appears that the eruption is
dependent upon exposure to sunlight for its appearance.
Among physical agencies modifying the effects of sunlight on normal skin,
heat has been mentioned. X-rays and radium evidently impair the protective
mechanisms against light. During and for some time after superficial roent-
genization the skin has been observed to react with unaccustomed intensity
to sunlight. Skin in which a cancer or naevus has been radiated by the beta
and gamma rays of radium has been observed years afterwards to be hypersensitive to sunlight. In the immediate hypersensitivity of brief duration
following light roentgen dosage, it is suggested that there has been a summation of the similar effects produced by the long roentgen and short ultraviolet. In the late hypersensitivity after heavier roentgen or radium treatment, destructive effects upon the pigment-forming mechanism and the capillaries have apparently occurred. It is recommended as a corollary that
patients receiving x-rays or radium therapy should be warned of the danger
of excessive exposure of the skin of the parts to sunlight.
Some individuals give evidence of having cutaneous idiosyncrasy toward
sunlight. Typical urticaria is not rarely seen upon exposure to sunlight, and
that this is not necessarily due to the ultra-violet portion of the spectrum
is shown by its production in these individuals by January sunshine passing
through ordinary window-glass.
In others, exposure to sunlight in spring and early summer is followed
by the development of a vesiculo-bullous erythema on exposed parts, notably
the tips of the ears and nose, the malar eminences and the back of the hands.
This is sometimes associated with congenital porphyrinuria and may not
appear until adult or adolescent life. Porphyrinuria is not always found in
these cases.
A very distressing and fortunately rare affliction of childhood is xeroderma
pigmentosum. In this, the changes in the skin described above in the picture
of chronic solar dermatitis make their appearance in very early childhood,
with rapid development of pigmentation and multiple keratoses on exposed
parts with carcinomatous degeneration of the warty lesions as a constant
sequel. Such patients rarely if ever reach the end of their second decade
of life.
The peculiar phenomenon of vitiligo or leukoderma has already been
mentioned as an effect of solar radiation. It probably belongs properly under
the heading of idiosyncratic reactions. It is familiar to all, and its dependence upon sunlight for its production is shown by its almost complete disappearance in winter months. In the summer the normally reacting areas not
only offer a contrast to the areas which will not pigment, but it will be
observed that the skin contiguous to the white areas acquires an abnormally
deep pigmentation. It is thus not merely a case of some parts failing to
develop pigment, but of others developing pigment to excess.
In pathological conditions of the skin per se, or in skin affections which
are an expression of disease of other organs, the rays of the solar spectrum
in some cases, and in others in the shorter ultra-violet as well, produce
special effects. Some of these effects may be desirable and capable of utilization in therapy, and the contrary also occurs. In brief, in some skin affections
sunlight is indicated; and in others it is contraindicated, while in many it is
a matter of indifference. The first group is a much smaller one than either
of the others, although popular notions, including that of a large part of the
medical profession, run to the contrary.
The evil effects of the modern fad of sun-bathing, and of indiscriminate
use of artificial ultra-violet, arise partly from excess, especially in the case
Page 185 of sun-bathing, where the object appears to be to develop maximum pigmentation in minimum time; and from ignorance of the contraindications in both
cases, but especially in the matter of artificial ultra-violet.
Ultra-violet sensitizes the skin to the effect of certain bacterial toxins.
Lupus erythematosus is a disease, usually confined to exposed parts, due to
circulating toxins from a focus of tuberculous or streptococcic infection. Its
first appearance is often as a sequel to sunburn, and it is niuch aggravated
by ultra-violet.
A commoner skin disease, more often attributable to streptococcal toxins,
is erythema multiforme. Its raised erythematous macules, often circinate,
are most often seen developing upon the extremities in spring or early summer. It is possibly not without significance that the eruption produced in
some people by phenolphthalein, which is related chemically to another
chemical photosensitizer—eosin—has a close morphological resemblance to
erythema multiforme.
Local infections, especially acute varieties, are not favourably affected
by ultra-violet, but are not infrequently aggravated and disseminated by
artificial light-therapy. Even in the chronic infections, such as tubercle, only
the very short ultra-violet, not found in the solar spectrum, is beneficial in
the local lesions, although general radiation of the body by natural or artificial ultra-violet is of very considerable value. According to the best dermato-
logical opinion, the pyogenic infections of the skin, such as impetigo, ecthyma,
streptococcal pityriasis of the face, furunculosis and pustular acne, are
unfavourably affected by ultra-violet, whether in sunlight or from artificial
These latter agencies are commonly and wrongly used in superficial skin
infections on the basis of the knowledge that ultra-violet is lethal to bacteria. There is ignorance of or failure to realize the fact that only the very
short waves, a very small portion indeed of the solar spectrum containing
such, are bactericidal, and these have insufficient penetration to reach the
most superficially placed organisms in the skin. The direct bactericidal effect
of such radiation in skin infection is therefore negligible. This does not affect
the widely recognized fact that artificial ultra-violet is of the highest value
in the therapy of erysipelas, a disease Which is equally well but less conveniently treated with x-rays, which are also deficient in bactericidal powers.
The effect in this, as in other deeply seated skin infections, is due to the
antibody-producing powers of ultra-violet, both natural and artificial.
The apparent good results of sun-bathing on acne and mycotic infections
are due to the drying effect of the infra-red and luminous portions of the
solar spectrum, and are further enhanced by the free exposure to air and
wind. There is no fungicidal effect in solar radiation, but a dry skin is an
extremely unsatisfactory medium for the growth and activity of fungus.
The inability of sunlight to produce any permanent growth of hair on
normal skin has already been commented upon. It will neither prevent nor
cure the common type of masculine baldness, commonly termed seborrheic,
virile or premature alopecia. Whatever part micro-organisms may play in
the production of this condition, and that is far from settled, it is probably
a minor one compared to the factors of hereditary and endocrine constitution.
The often confirmed observation that this condition never obtains in women
or in eunuchs, and that it is rarely found in male subjects who have not hirsute limbs, requires emphasis.
Alopecia areata has not yet received a fully-confirmed etiological explanation, but appears to have the nature of a trophoneurosis, or, as the neurologists more correctly would say, a local nutritional disturbance, sometimes
with a toxic and other times a psychic basis. In the majority of cases regrowth
of hair will take place sooner or later without assistance, but at the same time
it appears to be true that regrowth may be accelerated by rubbing in or
injecting intradermally certain irritants or stimulating substances, and is
Page 186 most conveniently stimulated by artificial ultra-violet. It is quite possible
that if the surrounding scalp was protected, intensive solar radiation might
answer the purpose equally well. No data of properly controlled experiments
in this connection are available.
Psoriasis frequently shows an astonishing improvement in selected cases
as a result of sun-bathing. The most favourable results are obtained in the
subacute disseminated type. If, as has been suggested, psoriasis is a disorder
of metabolism of the fats and sulphur, the well-known effects of ultra-violet
on the cholesterin in the skin may contain the explanation for this, as well
as for those paradoxical reactions seen in chronic psoriasis sometimes, in
which after sun-bathing an acute or subacute disseminated eruption may
develop exclusively upon the parts exposed to sunlight, all protected parts
being free of eruption.
This brings us to the conclusion of what has perforce been a series of
tenuously connected and superficial observations upon some of the effects of
sunlight on the human skin. Our time is limited and our knowledge small.
Probably this is as well, for it has checked any tendency to discursive wandering into the enticing fields of speculation which surround the subject. We
have tried to indicate some of the boundaries within which a therapeutic
utilization of sunlight in skin affections must be contained, and the dangers
which lie beyond them. If this has proved of interest as well as profit, the
aim of the author will have been achieved.
(Given at Vancouver Medical Association Summer School, June, 1937.)
.  PATHOLOGY—Db. Wm. Boyd.
The theme for tonight is : "The less said, the better." You have come here
tonight to get the treatment in cancer of the breast. Now, in so many diseases
you cannot understand the disease until you understand the fundamentals.
First, I want to show a number of slides. There are great variations in the
type and structure of the breast. There is no organ which changes so much
at different age periods. It is not a stable organ. I want particularly to call
attention to the ducts of the breast. We should consider cancer as arising in a
great many of the cases in the ducts. It may start inside the duct and may
remain local for a long time and then spread. The ducts as well as the
acini are played upon by ovarian stimuli. When you inject ovarian extract
in mice you can produce a duct carcinoma. We are sure that cancer can follow
upon this ovarian stimulus. Now the question is, does this cancer start in
one duct only or throughout the whole duct system? Poor drainage in the
breast may occur from blockage of the nipple, and cancer may result because
of stagnation. It is a mistake to think that lactation is a predisposing cause
of cancer, for the breast is so constructed that this function is a perfectly
natural process. When the ovaries were removed from these mice, however,
cancer of the breast did not develop. I want to emphasize the importance of
the difference between intraductal cancer and that which arises outside
the duct.
(1) Pectoral spread. From investigation we know that the pectoral muscle
is involved in 50% of cases at the time of operation. There is no gross
evidence, just pathological evidence.
(2) Lymphatic spread. Adenocarcinoma and duct carcinoma of the breast
rarely involve the lymph nodes. When you diagnose a scirrhous carcinoma
you expect to find involvement of the lymph nodes and so the therapeutic
outlook in this type should be different from the previously mentioned types.
In scirrhous carcinoma we have a bad prognosis. Why can we not treat all
cases of scirrhous cancer with radiation?
Page 181 (3) Blood-stream spread. Now we come to the question of the relation
between chronic mastitis (or cystic hyperplasia) to malignancy. I once
stated that this question should be left in the hands of the clinician and not
to the pathologist, but from my later experience I believe that the cases of
malignancy which appear to arise from chronic mastitis are all relatively
low grade. It remains localized for some time. The surgeon removes this
tumour and ten years later the patient comes back with no cancer of the
breast present. So my opinion is that these cases tend to become malignant
and is a factor in preparing the breast for cancer.
This is a particularly good diagram showing the duct system. This picture
shows a normal breast. This next one is of a normal lactating breast, and
notice the most tremendous epithelial proliferation. Here is a microphoto-
graph, not of a breast but of a rodent ulcer. However, it isn't just one ulcer
—you see there four rodent ulcers developing at the same time..The next is
a chronic mastitis. This is a picture of a gross cancer of the breast. Here is
a good picture of a scirrhous cancer. Here is the medullary form of cancer.
Here is a good picture of intraduct tumour. Here is a diagram of lymphatic
permeation of a cancerous growth. Here again is a cystic hyperplasia. Now,
I want you to have some of these pictures and ideas in your mind as a background when you listen to the rest of the discussion.
*      *      *      *
SURGICAL TREATMENT—Db. Donald Tbueblood.
Dr. Boyd has given all of us a great deal of information about the breast.
Dr. Boyd has been very kind to the clinician, and I think that we as clinicians
owe so much to the pathologist. The pathologist is the backbone of the hospital—we could not get along without him. He should be free to be a critic
and a detective. He should feel free at all times. We could not proceed if we
did not have a pathologist.
Fat necrosis occurs in the breast as a lump and appears as a carcinoma.
How long should we wait before we say that a lump is not a cancer ? If there
is history of an injury, this lump is probably a hsematoma. But we should be
sure of these lumps. It should be removed and examined by a pathologist,
and if it is malignant you can go ahead. Every lump in the breast is malignant
until proved innocent. Should we use surgery alone, should we use radiation
alone, or should be use a combination of the two? And the answer is not
available. We have to depend on several things to determine this—the facilities at hand.
If we are going to compare radiation with surgery tonight, let us be sure
we use the most complete type of radical surgery with the most complete
type of radiation. The pectoralis muscles should be removed and the glands
in the axilla and above the breast, for cancer cells grow away beyond the
area that you can feel and the area that you can see. For if you are going
to use radiation you must know that you have gone away beyond the cancer.
(The technique of operation for a radical was then shown by slides, emphasizing the fact that the dissection should be carried far away beyond the
tumour.) I prefer using the cautery, because I feel that you are obviating
the possibility of spreading the cancer cells. This operation is usually mutilating, but gives good results. If you are careful at operation and following
it, you should avoid swelling of the arm. When the tumour is in the periphery
of the breast, your incision should be away beyond the tumour. These pic*
tures show the results of not doing a wide enough operation—these patients
getting a recurrence of their cancer.
Now, which cases should we select for surgery ? A lump that is attached to
the chest wall is not operable. A woman who has hard masses in the axilla
on that side is not operable. If there are glands above the clavicle, then this
is usually inoperable. If she complains of pains in her back or pain in her
joints, obtain an x-ray picture of those areas to be sure there are no
metastases already there.
Page 138
M (The difference between radiation and surgery was then illustrated by
a slide.)
I have attempted to show you the surgical phase of the treatment of carcinoma of the breast. I would now like to say something about the limitations
of radiation. We have been informed that it requires from 7 to 10 erythema
doses of radiation to destroy cancer cells. I do not believe that the radiologist
can put enough x-ray therapy into the areas of important distribution to
destroy cancer cells. I see no reason to treat an area with radiation if you
are going to remove it; and why treat it afterwards if you have already
removed the cancer?
Db. B. J. Habbison.
I feel something like Cinderella coming here, coming last as I do, and I
am here to defend the Cinderella of medicine. Because radiation is most
distantly removed from .medicine, I can see medicine from the practitioner's
eyes. The surgeon frequently must have an outlook of skepticism, but the
general practitioner cannot afford to show any evidences of skepticism. He
should feel that the system of treatment he chooses is the one which is going
to succeed, and he can afford to forget the other things until he has proven
whether his method is right -or wrong. Because I am approaching ground
which is perhaps not nearly so well known to you as surgery and pathology,
I must start further down the scale. Those of us who have been general
practitioners and have done some radiology have some general ideas which
are not known to the general practitioner. So we will cover some of the
ground of radiophysiology before we commence.
What is this radiotherapy that we talk so much about? Why should we
treat cancer with radiotherapy? We have in the human body certain tissues
which go on throughout the whole of life more or less actively dividing. Let
us consider the development of the cells in the testis. What happens when
we irradiate the testis with a simple dosage? If we treat a testis with
irradiation we succeed in producing a diminution in every type of cell simply
as a result of the effect of irradiation on one type. When we take a section of
malignant tissue, are we to believe that every cell you see in that tissue is
malign? Is it not possible that the mother cell is malignant, but the subsequent ones are not? When we irradiate a malignant mass we find, first, no
change in the mass. Subsequently we find a diminution in the size of the
mass. So much for analogy.
This is a section of scirrhous carcinoma of ordinary type which was taken
in a case that was operated on without irradiation. (Several other types of
cancer were shown.) The question crops up as to how we are going to attempt
to treat these cases. There is a local area in which the cells are numerous
which requires more intense radiation than the more distant fields in which
the cells are less numerous. According to the size and location of the local
tumour, you have to vary your dosage. This slide shows the changes that
have taken place as radiation progressed. The problem from the radiation
point of view is divided into two parts: first, the local tissue, and, second, the
handling of the tissue outside the local region. We have some analogical
arguments, some histological arguments and some clinical arguments in treating cancer of the breast with irradiation. Now the question is, what parts
are we going to irradiate and when are we going to irradiate them? All cases
of cancer of the breast which are not moribund? How are we going to deal
with operative cases? Are not the lesions outside the tissues you removed
the one which are going to.kill the patient? And are they not the important
lesions? The situation ajnounts to this—are we going to wait until* the
surgeon has operated and until the scar healing has been completed before
we irradiate the tissue that we could have irradiated before the operation?
Page 189 As far as recurrence or metastasis is concerned—what are we going to
do with this? First of all, metastases in the liver and abdominal viscera
—they are best left alone. Metastases in the lungs and mediastinum—they
are best left alone. Sometimes we get relief by irradiation. Lesions of the
cerebrum and the meninges—they, too, are best left alone. It is true that
many of the symptoms will be relieved by radiation. Cases of metastases
to bone sometimes react very favourably. In many cases of fractures of
the femur resulting from secondary deposits, complete healing will occur.
In cases of metastases to the spine, the condition can be, at least temporarily,
arrested by radiation; also cases of lordosis. If you get glands in the neck
you will get response to irradiation.
The whole point I want to make clear to you tonight is this—radiation
has a definite effect on malignancy of the breast. That effect is most marked
in cases where amenorrhea is present. So in some cases we advise the production of an artificial menopause. As there is a definite effect on the tissue
which the surgeon is going to leave behind, that is the tissue which should
be tackled first, and irradiation should be carried out prior to the operation.
If I have done nothing else than shown you the why and the wherefore
of radiation, then I feel I have done my duty.
Db. Paul B. Magntjson
(Read at Vancouver Medical Association Summer School, June, 1937.)
Gentlemen, it is certainly a pleasure to come out here again. The first
time was when I was about 17 years of age, when I helped to survey. I
always have a good time when I come" to the west coast.
This subject is one, I think, that interests all of us who come in contact
with this type of fracture more in the last few years, because up until a few
years ago there was just one treatment for fractures of the neck of the femur,
while since then there have been so many types of treatment that it is almost
impossible to keep track of them. The old Whitman method, which was based
on Whitman's opinion of what happened when fractures of the neck of the
femur occurred, has been a standard treatment for many years and is
extremely unsatisfactory. We hear so much these days about methods that
we are apt to talk methods beyond common sense. These fractures vary with
the amount of the force which causes them, with the structure of the bone
and with the characteristics of the patient. There are no two alike, and yet
we talk about them as standard fractures. Even a Colles' fracture has variations, but in them we can get good x-rays, as we can see them, etc. But a fracture of the neck of the femur is not easy to examine, and we have accepted
without too much question the teachings of our seniors and have done what
the textbooks told us to do and what our professors told us to do for years
without thinking why. But when we get down to setting these fractures, we
have been at a disadvantage for many years because we could not get satisfactory x-rays. I speak feelingly, having opened every fracture of the neck
of the femur, and I sometimes feel a little ashamed of myself when I say
this—that I have opened every fracture of the neck of the femur for twelve
years. I have reduced them all first and I have been perfectly astonished at
my inability to reduce a fracture of the femur so that it is really reduced.
I will show you some slides today in which there is apparently perfect reduction of a fracture of the neck of the femur but no union—no union probably
because the thing was never really reduced. So if you will bear with me while
we go into the simple things about the anatomy of the femur, maybe we can
decide that these fractures have to be treated individually and according to
their needs. (Here Dr. Magnuson showed slides dealing with anatomy, etc.)
These days, when we see multiple fractures, and fractures which do not
'ollow any reason or rule because of the velocity and force which caused
?age 140 these fractures, due to our fast-moving automobiles, etc., our opinions regarding reduction have been completely changed. In the olden days we used to
have fairly standard fractures, but the automobile has changed all that.
Now we have fractures which are compound, comminuted, now the tissues
are badly damaged around the fracture. And so it is with these fractures
(showing slide). Here is a bone which bears its weight, not in the long axis
but at a distinct angle to its long axis. The line of weight-bearing passes up
to the middle of the shaft of the femur and is really transmitted up beside
the acetabulum. The thing is pushed out or in. Coxa vara will naturally put
a distinct right-angle strain on the neck.
Now, up through here, running to the upper part of the head from the
inner side of the shaft, is a line of heavy striation of the bone, and in most
femora we see these striae down here, joining with the median edge- of the
cortex. The neck of the femur has two angles; an angle of inclination such
as shown here and another angle of declination. Normally, when the patella
is in the antero-posterior plane pointing directly forward, the posterior rotation, the external rotation of the femur amounts to about 20 degrees. That is
the normal standing and walking position. In extreme rotation there is a
further 25 degrees of external rotation. In order to bring the angle of declination at right angles, that is, the lateral end of the lateral plane, the femur
must be rotated into complete internal rotation. The muscles of the hip joint
limit internal rotation of the shaft to a right angle, so in this position the
patella points inward, in this position it points outward. These two angles
have much to do with the position in which the fracture of the neck of the
femur must be placed. If it is brought into complete internal rotation then
a fixation which pulls the posterior capsule tight is possible. Now, this angle
of rotation is not in the acetabulum, the centre of this angle is about here
and a rotation of the shaft does not always give the desired effect if there is
a displacement or a non-contact between the outer fragment and inner fragment does not always affect the inner fragment, so that rotation may occur
in the lateral fragment and not in the medial fragment. These fractures do
not always occur on the same line. They are irregular in shape. Until a few
years ago it never seemed to occur to me that we could have angular fractures of the neck of the femur. Nobody had talked about that. There were
sub-capital, mid-cervical and basal fractures of the neck and they all seemed
to be perfectly transverse. Yet that is not the case. Having opened many of
these fractures, I found that the x-ray lies very consistently—only 40% of
them were reduced completely and. actually, in spite of the fact that the
x-ray showed satisfactory reduction even in the lateral view. Sometimes short
fragments were broken off. We would have little points of bone reflected
downward which, even with the joint open, interfered with reduction and
maintenance of reduction, so that it was impossible to get along with them
and they had to be cut off, and these fragments, which incidentally are
almost impossbible to show in the x-ray because of our inability to take
many lateral views, are things which have not been taken into consideration
many times and have not been looked for; but this is cancellous bone. The
bone is a considerable distance from the plate in the x-ray, and not only that,
these fragments, when they extend from the head down towards the neck,
are fragments which rotate the head and help to keep it in an abnormal
rotation. They catch in other words, on the rough edges of the proximal end
of the distal fragment and do not allow the head to rotate into its normal
position in the acetabulum. Now, what can happen in some of these cases,
depending on the angle? And what happens when we have a fracture of the
femur, haemorrhage, effusion? The capsule is distended with bloody synovial
fluid. The capsule is bulged out with effusion into this capsule, so that instead
of having a capsule which -runssmoothly from the rim of the acetabulum
to the base of the neck and around the trochanter, we have a capsule which
is bulged out so that this capsule is actually shortened, and when we bring
this head into a straight position, we tighten up on the capsule because the
Page 141 capsule is the thing which limits the extension of the hip, and the capsule
winds around the neck of the femur, binding those fragments, then this fracture is pulled closely to the head because the capsule is actually shortened.
Therefore, with any kind of reduction or fixation, to relax the capsule as
completely as possible is necessary. The old Leadbetter manipulation is still
the best manipulation to reduce fractures of the neck of the femur, but it
depends on the amount of effusion in the joint; if there is much effusion in
the joint, thne even this method will not work. In my opinion, a complete
reduction is of the first importance in obtaining a union in any fracture of
the neck of the femur, as it is in any other fracture.
(Showing new slide.) Now here we have a strange condition of circulation. We have a central artery entering the head and another entering
through the visceral capsule along the inferior surface. There are no vessels
entering posteriorly. These blood vessels intercommunicate. They intercommunicate freely. When a fracture occurs, the blood supply between the head
and this portion of the neck is cut off, more or less completely. For instance,
in this type of fracture, with a heavy fall, this sharp fragment can tear the
important part of the circulation here, so that the circulation of the head
depends entirely on the circulation through the ligamentum teres while the
circulation here is depending on this portion, because the circulation to the
head through the central portion of the acetabulum sends very little blood
supply down to this part of the neck. In addition to that, the circulation
coming through the capsule makes a sharp dip here, coming down to about
that point, and the vessels spread out, leaving this portion the most poorly
supplied with blood of any portion, and what little circulation there is here
does not come from the neck. It comes through the head. So it depends on
the amount of violence and the amount of tearing in the capsule whether the
neck is going to live or not. There is a portion here which is cut off from this
blood supply.
Now, let us take the mechanics of this thing (shewing new slide). We are
told in the Whitman method to bring the leg into complete abduction and
extension. Supposing the upper portion of this neck in a sub-capital fracture
comes in contact with the head; using this point as leverage and bringing
the head into abduction, we can force the head away. This small point may
touch at that point and swing the head into malposition, not reduction. In
this type of fracture there is less chance for a union, much less, than there
is in this other type of fracture, because in the latter, a simple extension
with the head cocked up on top of the. neck, we get a more direct weight-
bearing line than we do otherwise. There is, naturally, one question, and
that is whether pressure here transmitted that way will not push that distal
end of the proximal end upward, allowing the weight to extend here and
pushing this slippery ball into a slippery socket out of position. This is the
most usual one to become ununited. In other words, the line of fracture is
practically in a direct line parallel to the weight-bearing line, and we shall
see these fractures with the lower fragments slipping out this way, this point
caught on some point of the distal fragment and the head rotated into a
varus position. This type is much more easily reduced because there is ample
blood supply. There is little or no danger of tearing in these fractures. In
my opinion that is one reason why these fractures unite with a greater degree
of frequency than do fractures in this line, because here the blood supply is
not interfered with, the head can be-more easily controlled, it does not rotate
so easily, the rotation of the neck of the shaft tightens up on the capsule
and these two fragments can be brought more securely together by the
common method described by Whitman. Now if we rotate we can accomplish
the same thing. In this case it would practically be impossible to do this with
the posterior capsule tight, because with the posterior capsule distended this
would be short and, consequently, it would prevent this from happening,
because under these circumstances you have lengthened the distance from
the acetabulum to the trochanter and you cannot stretch the posterior capsule
Page 142 that way and consequently you could not rotate in that way. Now, one could
rotate these out of position as well as into position, and suppose one had an
x-ray taken, it would not be difficult to show an exact position, but unless
we get the right lateral view we should fail to see these fragments. We
would be very contented with a reduction which was shown in an x-ray
which was shown in this type of fracture. In this type it is easy to rotate
this fragment by catching a point on the proximal fragment against the
rough surface of the distal fragment, and usually the x-rays of these cases
are extremely important. It is extremely important to have them taken from
a number of angles and then to decide which angle one is dealing with and
how best to deal with that particular angle.
This is a fracture which I have never seen fail to unite—a sub-capital
fracture which is caused by a direct fall on the trochanter, so that we have
an impaction with the neck jammed up. This is the ideal position. I have
never seen one fail to unite. I have seen these heads go to pieces some time
after, just as we have all seen heads go to pieces after dislocations of the hip
from an interference with circulation, but as far as the fracture is concerned that patient can get up and walk home, and they do. I have seen a
number of these at the hospital say that they have sprained their hip.
Here is a direct weight-bearing line, directly into the shaft into the
acetabulum. This is an impacted fracture; notice the head and the weight-
bearing line, with the fracture lying almost transverse with the long axis of
the femur. And here it is 2% years afterwards. There is no atrophy here,
and this patient was only in bed about two weeks. Now it occurs to me, after
having seen some of these, that the thing that was best in fractures of the
neck of the femur was to re-establish the direct weight-bearing line between
the shaft and the head, and I believe that when we can do that, if we can
do it—and you cannot do it with some of these angles—then we will have
the answer to at least 90% of fractures of the neck of the femur. This is a
dear friend of mine who had been walking on his hip for 4% years when I
operated on him. Notice the line of fracture. He had constant pain in the
hip. There was great argument between the x-ray man and the surgeon as
to whether this was a union or not. He had been laid up for about 1% years.
He had pain. He was crabby, according to his wife. So, when we examined
this and drew a weight-bearing line along the middle of the femur and another
one at right angles to the line of fracture, we found that he was bearing his
weight exactly at right angles to the line of fracture. Now, why tear that
one all to pieces? Why endanger what circulation he had left in that hip?
All he needed was a mechanical re-position, so we did a high osteotomy,
coming through the trochanter, coming through at practically the lesser
trochanter and bringing this leg out into abduction. Notice the distance
between the trochanter and the edge of the acetabulum, before and after.
Notice the change in line of weight-bearing. Now, this line of fracture is at
45 degrees to his weight-bearing line practically. In other words, when he
steps now he pushes the shaft into the head, not beyond the head. It is some
2% years since his operation and he has no disability in his head. He can
dance, and his disposition is much improved. When he could not carry his
weight comfortably, he tired out.
Here is a depressed fracture of the neck of the femur in which we performed an operation which I will describe to you later, re-establishing the
weight-bearing line. He has a large upper displacement with a good head and
a long fragment running down this way. That fragment comes down about
like that. I know because I saw it. This was a fracture 1% years old .when
I saw it. The head was still good and he has this long fragment. Notice it is
practically parallel to the long axis of the bone. He was about 40 and
strong and vigorous, and I moved the trochanter out because the neck was
somewhat shortened and because I did not want to hollow this head out.
I fastened those two together and he was put to bed and remained there for
Page 148 some eight weeks and I fastened those two together with an ivory screw.
He is now walking on his leg regularly every day, and what he is walking on
is not the head but the impingement of the shaft and the outer edge of the
acetabulum. There was a complete separation of the fragment, because that
fracture was in a direct line with the weight-bearing, and apparently his
muscles were so strong and he bore his weight too early and did not get a
union. I will never do that again. I will cut off that lower fragment and then
he will walk on the head.
My friend, Austin Moore, down in North Carolina, has devised a method
for fastening fractures of the neck of the femur which, in certain types, I
think is "tops." He does not open the head, he reduces it. He confided in me
that the best results were when he could cock the neck right up on top of
the head. He does this thing in old people under anaesthetic and he does it
very successfully. I have not the confidence that I can reduce every fracture
of the neck of the femur without seeing it. So I have done it without, so far,
any bad results. So Dr. Moore Uses some steel nails of his own design, after
reduction, bringing the hip into complete internal rotation, and when I say
he does not open them I mean he does not open them so that he can see. He
makes an incision so that he can "feel" whether this fracture is reduced,
and then he drives these nails in as near to the long axis of the shaft as he
can and spreads them like a three-legged tripod and fastens them into the
head. Then he does not put any fixation apparatus on at all. They are never
put in a cast and get up in a wheelchair 24 hours after operation. It is spectacular. We don't know how good a result it is going to get in the majority
of cases, but certainly I have seen a lot of beautiful results, and it can be
done after one has had time enough to prepare himself to do it. Notice the
angle between those nails. I felt very proud of this case, but the next one,
an old lady of 83, was not so good. The result does not look like this one.
But with this type of reduction and this type of fixation, in the mid-cervical
fractures especially (fractures just in the middle of the neck), reduction in
this way does work beautifully. Here is a lateral view showing, if a lateral
view can show, as near a perfect reduction as one would like. I was satisfied
with this one when I opened it up. It is no better than that one. There is a
nice reduction. Notice the long curve here and a very short fragment above.
The line again practically parallel to the'long axis of the femur; and here,
again, this was a fresh fracture without much violence, and so I fitted it
together nicely, tight, put a little clamp on it and fixed it tight, moved it
around. I know it was tight. And then I put in an ivory screw and said to
my associate, "Isn't that swell?" So we put traction on him, put him back
to bed in abduction, and that's what happened—complete absorption of the
neck. The screws didn't give way; nothing gave way. I did a Whitman operation on this man a year later, took out that head. The ligamentaries were
completely torn in two. The head was dead. There was no circulation, and I
doubt whether any kind of fixation would have done. Nevertheless this sort
of thing didn't last six months. On the other hand, here is a fresh fracture
of the neck of the femur which was reduced by the method described by
Bracket and modified somewhat by his old junior officer, myself; a fracture
of the neck of the femur which had a long lower fragment, and in which
we cut off the lower fragment, and here it is. I think there is one more nine
years afterwards. This patient walked in eight weeks. There is a direct
weight-bearing line for you. We have converted this fracture into the type
of fracture which occurs sub-capital and this patient, and all these patients,
have been on their feet in eight weeks, with nothing but abduction to retain
the fragments. I don't think there is union in eight weeks, but I think the
direct weight bearing line, when the leg comes down into the perpendicular,
when the patient walks on that bone—work makes bone grow and there is
certainly fibrous union, and when the patient begins to bear weight, the
bone grows. We make them work and then nature begins to throw down
bone. Here is another fresh fracture in a patient of 67. This old lady
Page 144 walked out of the hospital in nine weeks. This case shows the x-ray taken
eight weeks after the injury. This is a section of that same bone made some
four months after operation. The.patient was out of the hospital and died
of pneumonia within several days before this section was made. It had nothing
to do with the operation, and he willed me his hip. So after he died I went
down and got it. This is the place where the shaft fits up into the head. Here
is a section through • that. Notice the blood vessels growing across in this
location where this shaft fits up into the head. The operation was done 1%
years after injury. Here's another one, showing the result seven years after
operation. Here's another one of the same type with a fastening here of the
head down on to the shaft. This was the patient of 67. We had this picutre
made about two years ofter operation and she had been walking comfortably
on the hip since nine weeks after admission to the hospital. We get enthusiastic about certain things and we think we are little tin gods and we can
do a lot of things. Here's a patient who had been in bed for 1% years. You
can see that that is a dead head. This patient had Parkinson's Disease in
addition. This is a very poor x-ray of the condition ofter the operation. The
head shows very faintly here. Let's follow it through. Here it is, five months
later. It is beginning to go to pieces here. This part, where the weight-
bearing seems to hold it up against the acetabulum, is still dead but doing
its job. Here it is a little bit later. This is melting away. Still this piece is good
and the patient was walking and walking comfortably. But here it is two
years later—all gone. This is the piece of head that was squeezed out. And
how this patient continued to walk I don't know, after the head had squeezed
These are the operations which should be done in old ununited fractures
of the neck of the femur where we are sure the head is dead and will not
revivify. I am not for taking all heads of femurs out when they show some
areas of hardening. These, I believe, recover some circulation when in contact with bone and they recover, but when they are as dead as this one, then
they should be taken out, and this Whitman operation is the method of choice.
It gives a good weight-bearing hip. These patients never get as much motion
as the others, but they do get good results even at a rather advanced stage.
The following constitutes a challenge to our profession: some medical
man may feel an urge to pick up the gage of battle.—Ed.
Medical Association,
Medical-Dental Bldg.
Vancouver, B. C.
Dear Sirs:
I am only a working man, small salary. Medium large family, no money
to spend for diversion or pleasure.
But I am willing to give any doctor $2.50 for stopping or making quit
I have a nervous and ulcered stomack, I am a war veteran (nerves). I
worry about family finances.
I work and eat at top speed. Have had bronchitis since last year of war.
I am sorry to say I have not enough will power to stop smoking.
Inclosed please find self addressed envelope with stamps to send me name
of doctor who can stop1 me from smoking.
Thanking you in anticipation.
Yours truly,
The Canadian Medical Association Annual Meeting will be held in Halifax, June 20th, 21st, 22nd, 23rd, 24th. Those intending to take this trip are
requested to communicate with the office of the British Columbia Medical
Association signifying which Canadian route they prefer. It is hoped to
develop a special car service for doctors and doctors' parties from British
Columbia and possibly the Other Western Provinces. This would make the
long journey more pleasant and appear shorter. Let us hear as early as
possible regarding your plans. It is advisable that hotel accommodation be
booked early.
Well-lighted corner suite, suitable for Physician, consisting of waiting
room, consulting room and examining room. Waiting room at present
shared with Dentist. Rent reasonable.
Bank of Toronto Building-, 3702 Tenth Ave. W.  Phone: Bay. 3301
Conducted in accord with the ethics of the Medical
Profession and maintained to the standard suggested by
our slogan:
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FORT STREET (opp. Times)      Phone Garden 1196     VICTORIA, B. C.
that will satisfy the most discriminat
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igley Printing & Publishing Co.,
300 Wes
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Page 146 lllit
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THE FACT IS — no farm is put on the Borden list unless its
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This double system of farm and laboratory control
makes possible a highly uniform product. Extra care all
along the line accounts for unvarying high quality. These
are reasons why so many doctors prefer Borden's St.
Charles Irradiated Evaporated Milk.
Writing "BORDEN'S" on every evaporated
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Evaporated Milk was accepted in 1930 by the
American Medical Association Council on Foods.
If you are not familiar with Borden's St.
Charles Evaporated Milk, unsweetened, write
The Borden Company Limited, Yardley House,
Toronto, Ontario, for professional literature
and samples.
Jiortletii THE MARGARET Convalescent and Nursing Home
1185 Harwood St., Vancouver, B. C. Seymour 2885
Contains: Terpin Hydrate,
Guaiacol Carbonate, Calcium
Glycerophosphate, Codeine Phosphate 2 grs. per ounce.
Dose: One or two tea spoonsful
"The All-Canadian House"
Recovery from hypochromic ane-
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and unrestrained, as evidenced by
the early increase in the hemoglobin of the red blood cells. The
suggested daily dose of only three
Hematinic Plastules Plain replaces massive iron, feedings and
diminishes the likelihood of gastric disturbances, constipation
and diarrhoea. Hematinic Plastules provide ferrous iron and
vitamins Bl and B2 in soluble
gelatin capsules, available, in two
types, Plain and with Liver Extract. Inquiries from physicians
are given prompt attention.
Literature upon request.
Short Wave Therapy
Comfortable Footwear
Are Indicated
The use of modern Electrical and
Orthopaedic Equipment enables us
scientifically   to   carry   out   your
GEO.   P.   PARIS,   D.S.C.
Pierre Paris
Foot Clinic
Sey. 3778    Vancouver, B. C.
The Purified
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Doctor, why use ordinary sandalwood
oil when you can just as easily administer the active principle of the oil
with the irritating and therapeutically
inert matter removed—and at a cost
to your patients of only a very few
pennies more?
You can do this by prescribing- the
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now obtainable in bottles of 12, 24 and
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ARHEOL is the purified active principle of sandalwood oil. It is a uniform, standardized product with which
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Dr. P. Astier Laboratories
36-48 Caledonia Rd., Toronto.
Please send me a sample of
ARHEOL (Astier) in the new
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36*48 Caledonia Road, Toronto The New Synthetic Antispasmodic
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Tablets—bottles of 20 and 100. Ampoules—boxes of 5 and 20.
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The product with a tradition behind it"
To the physician conversant with the technique of intravenous
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Offered in powder form only, in vacuum-sealed ampoules,
to maintain its chemical integrity and its full potency.
:»•'■     •«■'      M.!
Safe and effective antiluetic
A product that is particularly adapted for use in the treatment
of children; in adults with inaccessible veins; in rural districts.
Supplied in progressive dosages of from 0.006 Gm. to O.60 Gm.
juulvTalxriif mcruJjejtjc -fx&i£A
Distributors:  ROUGIER FRERES, 3 50 Le Moyne Street, Montreal. STEVENS' SAFETY PACKAGE
is a handy, convenient, clean commodity for the bag or the office. Supplied
in one yard, five yards and twenty-five yard packages.
Phone Seymour 698
73 0 Richards St., Vancouver, B. C.
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Breaks the vicious circle of perverted
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Full formula and descriptive
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Dosage: 1 to 2 capsules
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Ethical protective mark MHS
embossed on inside of each
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Up-to-date treatment rooms;
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DOSAGE, 1 teaspoonful well
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Please send Sample and
Literature of X*yxanthine Astier
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36-48 Caledonia Road, Toronto MAN D EC A L
(Compound Calcium Mandelate B.D.H.)
The advent of Mandecal marks a distinct advance in the evolution of
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Mandecal is a special preparation of pure calcium mandelate; it is
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Gross and microscopic sections through trachea and
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Example of severe rickets in a sunny clime* Couri
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and of "California and Western IViedicineA
Zest we forget—we who are of the
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rickets are still prevalent. Here is a
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judged by weight alone, a farm child
apparently living out of doors a good
deal. This boy was reared in a state
having a latitude between 37° and 42°, where the average amount of fall and wintei
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does occur under these conditions.
How much more likely, then, that rickets will develop among city-bred childrer
who live under a smokepall for a large part of each year. True, vitamin D is more 01
less routinely prescribed nowadays for infants. But is the antiricketic routinely
administered in the home? Does the child refuse it? Is it given in some unstandardized
form, purchased from a false sense of economy because the physician did not specify
the kind?
A uniformly potent source of vitamin D such as Oleum Percomorphum, administered regularly in proper dosage, can do more than protect against the gross
visible deformities of rickets. It may prevent hidden but nonetheless serious malformations of the chest and the pelvis and will aid in promoting good dentition. Because
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tolerated by infants and growing children. Rigid bioassays assure a uniform potency
—100 times the vitamins A and D content of cod liver oil*. Oleum Percomorphum,
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Oleum Percomorphum offers not less than 60,000 vitamin A units and 8,500
vitamin D units (U.S.P.) per gram. Supplied in 10 and 50 c. c. brown
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13,300 vitamin A units and 1,850 vitamin D units, in boxes of 25 and 100.
*U.S.P. Minimum Standard
MEAD JOHNSON & CO. OF CANADA, LTD., Belleville, Ont.
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The most modern medicinals available for physicians — all the new
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Establish** 1893
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Published Monthly at Vancouver. B. C. by ROY WRIGLEY LTD.. soo west Pender street »   T^**»^    • ■
Hollywood Sanitarium
For the treatment of
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Reference—B. C. Medical Association
For information apply to
Medical Superintendent, New Westminster, B. C.
or 5X5 Birks Building, Vancouver
Seymour 4183
Westminster 288


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