History of Nursing in Pacific Canada

The Vancouver Medical Association Bulletin: November, 1949 Vancouver Medical Association Nov 30, 1949

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 T H E
BULLETI
Published By
The Vancouver Medical Association
EDITOR:
DR. J. H. MacDERMOT
EDITORIAL BOARD
DR. D. E. H. CLEVELAND
DR. H. A. DesBRISAY
Editorial and Business Office
203 Medical-Dental Building Publisher and Advertising Manager
Vancouver, B. C. W. E. G. MACDONALD
VOLUME XXVI
NOVEMBER, 1949
OFFICERS, 1949-50
Dr. W. J, Dorrance       Dr. Henry Scott Dr. Gordon C. Johnston
President Vice-President Past President
Dr. Gordon Burke Dr. W. G. Gunn
Hon. Treasurer Hon. Secretary
Additional Members of Executive:
Dr. J. C. Grimson Dr. E. C. McCoy
TRUSTEES
Dr. G. H. Clement Dr. A. C. Frost Dr. Murray Blair
Auditors: Messrs. Plommer, Whiting & Co.
SECTIONS
Clinical
Dr. M. M. MAcPHERSON_Chairman Dr. W. H. S. Stockton Secretary
Eye, Ear, Nose and Throat
Dr. J. F. Minnes Chairman Dr. N. J. Blair Secretary
Paediatric
Dr. J. R. Davies Chairman Dr. C. J. Treffry^ Secretary
Orthopaedic and Traumatic Surgery
Dr. R. H. B. Reed Chairman Dr. D. E. Starr Secretary
Neurology and Psychiatry
Dr. G. H. Gundry Chairman Dr. G. M. Kirkpatrick._Secretary
Radiology
Dr. W. L. Sloan Secretary Dr. Andrew Turnbull.-Chairman
STANDING COMMITTEES
Library:
Dr. R. A. Palmer, Chairman; Dr. E. F. Word, Secretary; Dr. J. E. Walker;
Dr. S. E. C. Turvey; Dr..A. F. Hardyment; Dr. J. L. Parnell.
Summer School:
Dr. D. S. Munroe, Chairman; Dr. A. C. Gardner Frost, Secretary;
Dr. E. A. Campbell ; Dr. J. A. Ganshorn ; Dr. Gordon Large;
Dr. Peter Lehmann.
Medical Economics:
Dr. J. A. Ganshorn, Chairman; Dr. Paul Jackson ; Dr. W. L. Sloan ;
Dr. E. C. McCoy; Dr. J. W. Shier; Dr. T. R. Sarjeant; Dr. John Frost.
Credentials:
Dr. H. A. DesBrisay ; Dr. G. A. Davidson ; Dr. Gordon C. Johnston.
Representative to B. C. Medical Association: Dr. Gordon C. Johnston.
Representative to V.O.N. Advisory Board: Dr. Isabel Day.
Representative to Greater Vancouver Health League: Dr. L. A. Patterson..
Representative to the Board of Trustees for the Medical Care of
Social Assistance Cases: Dr. J. A. Ganshorn till
FOR   NUTRITIONAL
BALANCE
due to prolonged insufficiency or organic disease
FOR PRE- or POSTOPERATIVE USE
to shorten the period of recovery
FOR   THE   CHRONIC   ALCOHOLIC
to correct existing deficiencies
w
B
E
M
N
Al
No. 817
Each dry powder capsule contains:
Thiamin Chloride  • • • • .    25 mg.
Riboflavin „ . . . 12.5 mg.
Niacinamide ........ 100 mg.
Pyridoxine    |       1 mg.
Calcium d-Pantothenate   .    10 mg.
Vitamin C (ascorbic acid)    100 mg.
In bottles of 30 and 100
"SEMINAL"
for vitamin B factors
WITH IRON AND LIVER • CONCENTRATE • INJECTABLE (FORTIS)
GRANULES  •  COMPOUND • INJECTABLE • LIQUID • TABLETS
OfyW*
AYERST,  McKENNA   &  HARRISON   LIMITED
Biological and Pharmaceutical Chemists
MONTREAL Wl&*'4 CANADA 589 VANCOUVER MEDICAL ASSOCIATION
Founded 1898; Incorporated 1906
sli
Programme for the Fifty Second Annual Session
(Fall Session)
AUGUST   30th—SPECIAL  GENERAL  MEETING—Discussion of  "Medical  Economics."
OCTOBER 4th—GENERAL MEETING—"Cardiac Radiology," Sir John Parkinson,
London, England.
OCTOBER 18 th—CLINICAL MEETING—Vancouver General Hospital.
NOVEMBER 1st—GENERAL MEETING—"Medical Economics."
NOVEMBER 15 th—CLINICAL MEETING—St. Paul's Hospital.
NOVEMBER—"ANNUAL DINNER"—Wednesday, November 23 rd.
DECEMBER 6th—GENERAL MEETING—"Quid Pro Quo in Medical Education",
Dr. M. M. Weaver, Dean, Faculty of Medicine, University of British Columbia.
DECEMBER 13th—CLINICAL MEETING—Shaughnessy Hospital.
All General Meetings will be held in the
TUBERCULOSIS INSTITUTE AUDITORIUM—10 th Avenue and Willow Street
n
EXCLUSIVE AMBULANCE
LIMITED
FAir. 0080
NW.   60
OXYGEN THERAPY SUPPLIED ON YOUR
ORDER. 24 HR. SERVICE ||
W. L. BERTRAND
J. H. CRELLIN
Hilli
Page 30 •ft
Amphojel-
double action
with a
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JOHN   WYETH   &   BROTHER   (CANADA)    LIMITED
WALKERVILLE - ONTARIO VANCOUVER HEALTH DEPARTMENT
CASES OF COMMUNICABLE DISEASE REPORTED IN THE
-   JI 10   II. %■   crrY%   '     % till
STATISTICS—OCTOBER,  1949
Total population—estimated      376,000
Chinese population—estimated -         7,455
Hindu  population—estimated  275
September, 1949
Rate-per
Number 1000 Pop.
 324 10.3
 \  7 11.3
Deaths,  residents only 2 88 9.2
Total  deaths  _
Chinese   deaths
BIRTH  REGISTRATIONS—Residents   and  non-residents:
(Includes late registrations)
Male
Female   	
473
420
INFANT MORTALITY—Residents only:                                        September,  1949
Deaths under 1  year of age ;     n
Death rate per 1000 live births     17.2
Stillbirths   (not included in above item)        5
CASES OF COMMUNICABLE DISEASE^ REPORTED IN THE CITY
CASES OF COMMUNICABLE DISEASES REPORTED IN THE CITY
Number    Rate Per 1,000 Population
Scarlet  Fever	
Diphtheria	
Diphtheria Carriers	
Chicken  Pox	
Measles ■—	
Rubella	
Mumps	
Whooping Cough	
Typhoid Fever	
Undulant Fever _:	
Poliomyelitis	
Tuberculosis	
Erysipelas .	
Meningitis	
Infectious Jaundice —
Salmonellosis	
Salmonellosis Carriers
Dysentery	
Dysentery Carriers —
Tetanus	
Syphilis	
Gonorrhoea	
Cancer   (Reportable)
Resident	
Non-Resident	
6
0
0
13
11
0
19
1
1
0
27
If
0
0
0
15
0
0
0
0
21
167
48
6
September, 1949
September,
1948
Cases                 Deaths
Cases
Deaths
0
11
o I
0
1
0
0
0
0
0
30
0
0
5
0
0
8
0
0
3
0
0
1
0
0
0
•
0
0
0
0
3
1
8
60
16
0
3
0
0
0
0
0
0
0
0
3
0
0
0
0
0
0
0
0
0
0
0
0
0
1
24
1
0
176
0
51
78
46
9
15
17
Page 31 Three COMBINED ANTIGENS
Now in General Use
DIPHTHERIA TOXOID and PERTUSSIS VACCINE (Combined)
Diphtheria toxoid of a high degree of potency combined with pertussis
vaccine — for the prevention of diphtheria and whooping cough.
DIPHTHERIA TOXOID, PERTUSSIS VACCINE and TETANUS TOXOID (Combined)
Diphtheria and tetanus toxoids combined with pertussis vaccine —
the prevention of diphtheria, whooping cough and tetanus.
for
DIPHTHERIA TOXOID and TETANUS TOXOID (Combined)
A combination of diphtheria and tetanus toxoids — indicated for
primary immunization of school children or adults, or for administering
recall doses to school children previously receiving a full course of injections
of combined diphtheria toxoid, pertussis vaccine and tetanus toxoid.
DOSAGE |||
Three doses of 1 cc. at
monthly intervals and
a reinforcing dose of
1 cc. after an interval of
at  least three months.
HOW SUPPLIED
For the inoculation of one child—Package containing Four 1-ec. Ampoules.
For a group of  nine  children—Package  containing  Six  6-cc.  Ampoules.
CONNAUGHT  MEDICAL  RESEARCH  LABORATORIES
University of Toronto Toronto 4, Canada
DEPOT FOR BRITISH COLUMBIA
MACDQNALD'S    PRESCRIPTIONS    LIMITED
MEDICAL-DENTAL BUILDING, VANCOUVER, B.C. This month saw the opening of the Crease Clinic of Psychological Medicine at
Essondale—a most significant milestone in the history of mental medicine in this
province. It stands as a memorial to the magnificent work, extending over so many
years, of the man whose name it bears, Dr. A. L. Crease.
Perhaps only those men and women who deal with the care and treatment of the
mentally ill will ever fully appreciate the true value of Dr. Crease's work in British
Columbia—but every medical man, we believe, will agree that the great progress of
mental therapy here during the past twenty-five years is very largely, one might almost
say mainly, due to the vision and personal work of this one man. Today it is a
commonplace that early care, prevention, early application of our knowledge of psychiatry and mental hygiene, are essential if we are to curtail the ever-increasing list of
mental disasters that threaten our modern civilization, and to restore to useful life those
threatened by mental illusion. But this was not the case a quarter of a century ago.
Psychiatrists and alienists were just beginning to realise this fact. A whole new concept
of prevention and treatment of mental disease was coming into being—and Dr. Crease
was foremost amongst those who insisted on the new truth. We can remember, many
years ago, talks that he gave in Vancouver, dealing with this subject, in what was then
almost a revolutionary way. He initiated mental hygiene clinics for children of school
age, which did, they are still doing, an inestimable amount of good.
A year or two ago, a Canadian magazine, Liberty, published a series of articles
dealing with mental hospitals in Canada, and the writer pulled no punches and spared
nobody in his disclosures. Some of them were extremely shocking, and the fact that they
were never denied or refuted, and that no suits for libel ever appeared, made them all
the more alarming and distressing to the conscience of every Canadian. But the Mental
Hospital at Essondale passed the test with flying colours—no reproaches were levelled
at that institution—no charges of inefficiency or cruelty or lack of modern care. That
this is so, is a tribute to the administration of its medical director, Dr. A. L. Crease.
Of course, he is only one man, but he has been the man in charge, and the man who
would have been responsible for any defects or failures. We must, and gladly do, give
him the credit for the excellent and outstanding record which was made by the institution under his care.
Dr. Crease's emphasis has always been on prevention—and on the curability of
mental disease. He has never stressed the incurable conditions, but has constantly worked
for cure by the most modern methods known to medical science. Thus it was to be
expected that the new Crease Clinic is designed especially for the reception and treatment
of early cases of mental disorder, and with a view to prevention of irremediable breakdowns. It is completely modern and up-to-date, and reflects credit on the B. C. Ministry
of Health, which is responsible for its erection.
One regretable note in the matter is the fact that Dr. Crease is due to retire this
year, under the government's ruling that 65 is the retiring age for officials. Perhaps this
is a necessary ruling. Perhaps in the majority of instances, a wise one. But in this
particular case we take leave to question its wisdom. Sixty-five in these days (and
especially to those of us who have attained that measure of age) does not seem so
very old. Much of the greatest work of the world has been done, and is being
done, by men well over that figure; and in medicine particularly, sixty-fiVe does not
by any means necessarily mean senility or decrepitude. But we cannot doubt that
somehow, and in some fashion, the talents and skill and devotion of Dr. Crease will
still be available. Perhaps, however, he needs a rest, and relief from the heavy burden
of administration he has so long carried. We wish him long years to enjoy this rest,
and to watch the growth and expansion of this magnificent institute.
Page 32
f
1! •pfcS
ft' ■ .'
Vancouver  Medical   Association
President | I Dr. W. J. Dorrance
Vice-President . \  Dr.  Henry  Scott
Honorary Treasurer j Dr. Gordon Burke
Honorary Secretary \ : I . j Dr. W. G. Gunn
Editor Dr. J. H. MacDermot
m
'    ■
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[§§83
. . /
■ -  i
(life
ii
LIBRARY NOTES
Library Hours
Monday, Wednesday and Friday 1 9:00 a.m.—9:30 p.m.
Tuesday and Thursday - 9:00 a.m.—5:00 p.m.
Saturday  9:00 a.m.—1:00 p.m.
Recent Accessions
Atomic Medicine edited by C. F. Behrens, 1949.
Clinical Urology by Lowsley, O. W.  and Kirwin, T.  J.,  2  vols.,  2nd edition,   1944'
(reprinted 1949).
Fundamentals of Internal Medicine by W. M. Yater, 3rd edition, 1949.
Historia Musculorum Hominis by Bernardi Siegfried Albini, 1734  (Gift from Dr. V.
St. John, Alert Bay, B. C).
History of the Heart and the Circulation, by Willius, F. A. and Dry, T. J., 1949 (Historical and Ultra-Scientific Fund).
Minor Surgery by F. Christopher, 6th edition, 1948.
Nutrition and Diet in Health and Disease by J. S. McLester, 5 th edition, 1949. ,
Practice of Allergy by Vaughan, W. R. and Black, J. H., 2nd edition, 1948.
Psychosomatic Medicine by Weiss, E. English, O. S., 2nd edition, 1949.
Parathyroid Glands and Metabolic Bone Disease:   Selected Studies by Albright, F. and
Reinfenstein, E. C, 1948.
Operative Gynecology by Crossen, H. S. and Crossen, R. J., 6th edition, revised, 1948.
Surgery of the Hand by S. Bunnell, 2nd edition, 1948.
Symposium on Recent Advances in Surgery—'Medical Clinics of North America, Nationwide Number, October, 1949.      ,
Symptoms and Signs in Clinical Medicine—An Introduction to Medical Diagnosis by
E. N. Chamberlain, 4th edition, 1947.
• • • •
Another valuable book has been given to the Library, this time by Dr. V. St. John
of Alert Bay and we publish below the Library Committee's letter of thanks and appreciation which was sent to him: «§§!
October 14t£ 1949.
Dr. V. St. John,
Alert Bay, B. C.
Dear Doctor St. John:
I am directed by the Library Committee of the Vancouver Medical Association to
thank you very much for your valuable gift of the volume on anatomy dated 1734 by
Bernard Siegfried Albini. This volume is in excellent condition and it is certainly a most
welcome addition to our rare book collection.
The Library Committee appreciate your generosity and thoughtfulness in sending
us this volume as such gifts are of great historic value.
Yours very truly,
(Sgd.) E. FRANCE WORD, M.D.,
Secretary, Library Committee.
Page 33 The following is a further list of the journals taken in the Medical Library
time in the field of special medicine:
American Heart Journal.
American Journal of Digestive Diseases.
American Journal of Medicine.
Annals of Internal Medicine.
Archives of Internal Medicine.
Blood, Journal of Hematology.
Circulation (from January, 1950).
Diseases of the Chest.
Excerpta Medica, Section VI, Internal Medicine.
Geriatrics.
Industrial Medicine and Surgery.
Journal of Allergy.
Journal of Clinical Endocrinology.
BOOK REVIEW
SIR FREDERICK BANTING by Lloyd Stevenson, M.D.,
The Ryerson Press, Toronto—1947 pp. 446.
A book has been received recently in our Medical Library entitled Sir Frederick
Banting, a biography of Dr. Banting written by Dr. Lloyd Stevenson.
I have been honoured by being asked to review this book, the reason given, that
I knew Dr. Banting overseas in the first great war and afterwards in Canada.
Many biographies I fancy, are only partly read and put aside, but not so with this
as it holds one's interest from start to finish. ,
When we consider that up to the year 1921, Diabetes was a much dreaded disease,
taking thousands of lives annually and doctors were, literally speaking, practically up
against a stone wall—an impassable barrier, in trying to stop its ravages. In that year Dr.
Frederick Banting discovered Insulin. The Story by Dr. Stevenson tells how Banting succeeded when other researchers had failed. The writer has included others who had any
part in assistance in this discovery.
I think every Canadian doctor should read this book, in fact it should be in every
Canadian home. In reviewing it, I can do no better than quote the last paragraph of
the epilogue by the author: "Banting fought the good fight, died gallantly, and endures
with joy translated in the myriad lives he blessed and saved through the miracle of Insulin.,
The story is not finished, it has no end. In every hospital and clinic in the world, in
millions of homes and offices and shops, a new chapter is written every day. To such a
tale as this it is not possible to write a conclusion.  It still goes on."
w. c. w.
NOTICE
If any members have copies of the British Medical Journal, volume 2, July-
December, 1947, that they do not wish to keep, the Library would appreciate
receiving them. Unfortunately, this particular volume has been lost and because
back numbers are difficult and expensive to obtain, we are making this appeal.
Copies can be sent to the Librarian at 203 Medical-Dental Building, Vancouver,
British Columbia. SHgs
Page 34 B9
!"'#'
Vasuxuuj&i Qattested cttoAfUtcU Section
HEART IN MYXOEDEMA
DR. V. O. HERTZMAN
Hypothyroidism may be accompanied by alteration in the function and structure
of the cardiovascular system. In the more severe cases of myxoedema, signs and symptoms
of cardiac involvement are evident in about three-quarters of cases, while in the milder
firms of thyroid hypofunction, the heart may be relatively unaffected or may only
show abnormalities in the electrocardiogram.
Clinical Picture
Hypothyroid heart disease in many respects presents features which are the reverse
of those seen in hyperthyroidism. The cardiac rate is usually decreased below normjal
and irregularities of rhythm such as fibrillation, etc., are rare. The circulation rate,
the stroke volume, and the minute output of the heart are diminished. The blood
pressure tends to be normal or low. Congestive failure is an uncommon complication
in untreated patients, although some disagreement exists in the literature on this point.
Symptoms of heart disease are uncommon. The decreased metabolism prevents
the individual from overtaxing this diseased organ, and, as a rule, only when over-
energetic therapy has been started does the patient complain of dyspnoea, anginal
pain, etc.
The most constant changes are those seen in the electrocardiogram. There is flattening or inversion of the T waves, low potential and bradycardia. These findings,
particularly the abnormalities in the T waves, may be the only evidence of cardiac
involvement. The return to normal of the T waves on thyroid therapy is a very useful
diagnostic sign and may be used as a guide in treatment.
Cardiac enlargement occurs. It is found in the more severe c^ses, in which the
hypothyroid state has existed for a considerable period of time. The cause of the cardiac
enlargement is still a matter of dispute—three factors probably play a part in different
cases. The first is generalized dilatation of the heart.. The second factor is the accumulation of myxoedematous fluid in the myocardium, producing a condition of pseudohypertrophy, and finally the tendency to form fluid in the serous centres may result
in the periocardial effusion without pericarditis. These factors are all readily reversible,
and this accounts for the prompt return to normal of the enlarged heart on adequate
theapy.
Prolonged hypothyroidism, in the opinion of certain writers, tends to increase the
incidence of atheroma in many cases. However, anginal pain is uncommon. When
it does occur, it is probably due to marked involvement of the coronary vessels by this
atheomatous process. ^
Although the blood pressure is frequently normal or low in myxoedema/ essential
hypertension does occur, and a higher incidence of hypertension has been found in
successfully treated cases of myxoedema than in the general population.
Treatment *%m
Treatment of myxoedematous heart disease, again, is the treatment of the underlying hypothyroid state. It must be emphasized that only very small doses of thyroid
should be used in treatment, until the size of the heart and the electrocardiogram have
returned to normal. The more severe the hypothyroidism and the longer it has existed
the smaller the dose of thyroid used. One could begin with one-quarter to one-half
grain of the dried gland daily, later increasing the dose to one grain daily or more
if required.
Too rapid restoration of the metabolism to normal levels, has been responsible
for fatal acute myocardial infarction, angina pectoris and congestive failure.   In these
Page 35 W$ cases, of course, it was the underlying impairment of the coronary circulation which
ultimately was responsible for the clinical picture—the increase in metabolism adding
too great a load to an already diseased heart.
In the uncommon cases in which hypothyroidism has resulted in congestive
failure, digitalis has proved relatively ineffective. Cautious use of small doses of thyroid
extract, maintaining a balance between recovery of function of the heart and the
increasing demand on the circulation will usually be effective in restoring cardiac
compensation.
Summary
The heart and cardio-vascular system take part in the altered body metabolism
in both the hyper- and hypo-thyroid states. Thyroid heart disease readily responds to
rational therapy directed toward the underlying thyroid dysfunction. In some respects
it is a very satisfactory disease to treat, since it represents one of the few instances
where therapy may effect a complete cure of a severe disabling heart disease.
EXOPHTHALMOS   RELATED   TO   HYPERTHYROIDISM
Dr. J. R. Sidall, M.D.
After perusal of the most recent literature on exophthalmos related to hyperthyroidism, it seems most fitting to quote Dr. T. G. Martens of Rochester, Minnesota, in his
paper on Exophthalmos of Endocrine Origin, which appears in the American Journal
of Medical Sciences, Vol. 213, 1947, and I quote his opening statement:
"The concept of  the mechanism of production of  exophthalmos with  particular
reference to thyroid disorders has not yet reached the stage of universal agreement."
There are two groups of cases which present different clinical features, but which
seem to have a single etiological basis according to Martens and a different etiological
basis according to Mulvany. In the average so-called case of exophthalmic goitre the
eye changes are not a cause of concern. The change in appearance is not so much pro-
truism of the globe, but is due to the retraction of the lids, and this is seen in cases most
often with other manifestations of hyperthyroidism or thyrotoxicosis. There are other
individuals with thyroid disease in which exophthalmos is often marked, is progressive,
leading to extreme protrusion of the globe, chemosis of the conjunctive, inability to
close the lids, exposure keratitis, and even to the loss of the eye from panophthalmitis. It
is this type of exophthalmos which is often referred to as malignant or progressive
exophthalmos, exophthalmic opthalmoplegia, post-operative progressive exopthalmos,
special opthalmopathic type of of Graves' disease, and thyrotropic exophthalmos. There
are reasons for setting this thyrotropic type apart from the exopthalmic goitre type.
Exophthalmic goitre affects young adults chiefly, and is more common in women than
in man. The urine in these cases shows little or no thyrotropic activity and thyroidectomy as a rule does not aggravate the exophthalmos. In the thyrotropic exophthalmos
those affected are most commonly men of middle age whose urine shows excessive activity
of thyrotropic hormone, and thyroidectomy is usually followed by increasing proptosis,
even to the extent of producing embarrassment of orbital circulation, ocular motility,
exposure keratitis and loss of vision as mentioned alvwe.
The greatest controversy today exists as to the actual mechanism of the protosis.
Mulvany, in his paper on "Exophthalmos of Hyperthyroidism" in the American Journal
of Ophthalmology, 1944, states that the proptosis is due to overactive stimulation of
the sympathetic nervous system in exophthalmos of thyrotoxicosis. He explains retraction of the lids as due to stimulation of Mueller's palpebral muscles and Landstrom's
muscles which are unstriated and under sympathetic control. These muscles, he says,
produce a direct and an indirect pull on the globe, and the forward thrust is unopposed
by the weakened recti muscles, because of thyrotoxic myasthenia affecting the recti
muscles as well as a local neuromuscular degeneration within the muscles themselves. We
know that there is overactive sympathetic stimulation in hyperthyroidism and that
sympathetic stimulation in animals is capable of producing proptosis, but in man Muel-
Page 36
11
'III
1 111
IH'l ler's and Landstrom's are so vestigial, according to Martens, that they could not account
for proptosis alone. Martens, therefore, refutes Mulvany's theory of proptosis, in
exophthalmic goitre on the basis of sympathetic stimulation. Not in all cases
of thyrotoxicosis is there an overactive sympathetic nervous system, as pointed out
by Mulvany. Hence no proptosis. Martens describes the pathological changes within
the orbit and these changes in the extraocular muscles are similar to the description
given by Mulvany. The changes are widespread in neuromuscular degeneration, occassional infiltration of round cells, fat infiltration and some replacement of muscles and
nerve cells by fibrous tissue. Not any marked change in muscle size is noted by Martens.
Neither does he give a tangible reason for the proptosis. However, he suggests a hormonal theory for the production of exophthalmos in thyrotoxicosis. In addition to the
above pathological changes, as described by Martens, Mulvany states that the muscles
are usually small, ribbonlike and weakened with loss of tone, and that there is not any
pathological change in other orbital tissues. Retrobulbar pressure, therefore, does not
produce the proptosis, which is found in thyrotoxicosis or exophthalmic goitre. Since
Martens has not given any tangible reason for the proptosis in exophthalmic goitre, it
seems better to accept Mulvany's theory of sympatheticonia, which accompanies thyrotoxic goitre in many cases. Mulvany goes on to say that experimental animals rendered
hyperthyroid by thyroid extract may not show exophthalmos, and this is because there
is not an accompaning sympathetic, but that in these same animals the exophthalmos
can be produced by administration of sympathomimetic drugs and that this same feature
applies to man. Cervical sympathectomy and stellate block relieve lid retraction on the
other hand. A case of exophthalmos in a young girl was noted in this hospital and following stellate block there was lid lag as well as a receding of the globe into the orbit. The
patient herself noted this displacement of the globe backwards. This phenomenon could
be ascribed to relief of sympathetic control over Muller's muscle. As mentioned above,
Martens believes that the proptosis of exophthalmic goitre and of malignant exophthalmos
have a common etiological basis and this etiological basis will be discussed following a
brief description of proptosis in malignant exophthalmos.
it
Malignant Exophthalmos
The cause of proptosis in malignant exophthalmos in fairly well agreed upon as being
due to an increase in retrobulbar pressure as a result of which the eye is pushed out of
the orbit. The ocular muscles are increased in size and in severe malignant exophthalmos
this increase in size may be to the point of bulging muscles with intraorbital fat decreasing. At the same time there is a strain on the periorbital membrane leading to proptosis
and a fullness of the lide. As the globe proptoses so does the appearance of oedema of the
conjunctiva occur due to compression of the venous arcades at the base of the lids. As
the condition progresses the lids may become everted with large folds of oedematous
conjunctivae presenting. The cornea by this time is exposed. As the cornea is unprotected it may ulcerate, leading to loss of vision. The treatment at this stage is immediate,
for the eye demands orbital decompression either before or after tarsorrhaphy. The orbit
decompression allows an escape of the voluminous orbital mass in another direction to
allow the eye to recede back into the orbit or stop from coming out. The pathological
process within the muscles contrasts sharply with that found in the thyrotoxic type.
There is a degeneration of the muscle tissue, a heavy perimuscular and interstitial fibrosis,
oedema and round cell infiltration. The average circumference of extraocular muscle
is 8 - 10 mm. and this may be increased to 60 and 70 mm. in thyrotropic exophthalmos.
Mulvany, Martens and Mann agree as to the pathological changes in the muscles
while Mulvany alone draws particular attention to the large size of the muscles in
thyrotropic exophthalmos as compared to the muscular attentuation and flabbiness as
found in thyrotoxicosis type.
The Ocular Symptoms of Tyrotropic Exophthalmos are few in number and are
subjective:
Page 37      < 1. Pain—not always present.   It may be throbbing and burning in nature and
behind the eyes or of a supra-or infra-orbital type of neuralgia.
2. Lacrimation—does not depend on the corneal irritation alone, but on disturbance
of secretory activity of the lacrimal gland.
3. Photophobia.
4. Diplopia.
5. Difficulty in convergence.
Physical Signs in Thyrotropic Exophthalmos are as follows:—
1. Proptosis
(a) May be gradual or sudden in onset, as after thyroidectomy—within 2 weeks.
(b) May be uneven on the two sides.
(c) Absence of lid spasm permitting manual eversion of lids which is difficult
in thyrotoxic type.
(d) The degree of proptosis, since there in no lid spasm, is more real than
apparent, which is the converse of the thyrotoxic type.
(e) Sensation of hard resistance in estimating retrabulbar tension, while in
thyrotoxicosis the eye can usually be pushed back into the orbit.
(f) Congestive features of conjunctivae—absent in thyrotoxic exophthalmos.
(g) Subluxation of globe occurs rarely in thyrotoxic type and not in thyrotropic
exophthalmos, since the enlarged recti muscles will not allow the lids to
pass behind the equator of the globe.
2. Upper Lid Retraction—not connected with sympathetic activity. It is brought
about by pathological changes in the elevators, and may occure as an early sign
while later on the orbital septum under pressure may prolapse into the lid,
producing oedema and causing in this case a pseudoptosis.
3. Disturbance of Muscular Coordination—manifested by nystagmoid movements
of the globe followed by restricted ocular movements with elevation of the
globe first involved. The restriction of ocular motility is due to changes in the
muscles themselves as well as limitations of mechanical movement due to their
bulk within small space; hence the term ophthalmoplegia should not be used.
4. Vascular Alterations—congestion in conjunctivae. Congestion and swelling of
the optic disc with retinal haemorrhages from blockage of the central retinal
vein.
Summarizing briefly—
1. Mulvany believes that the exophthalmos of thyrotoxicosis is sympathetic in
origin. He also notes the similarity in the pathological changes in the recti
muscles, stating that in malignant exophthalmos these pathological changes are
more marked, with great increase in size of muscle. He also states that malignant
exophthalmos is no doubt due to combined thyroid and pituitary action.
2. Martens, Mann and Means postulate that: Malignant exophthalmos is a more
advanced stage of thyrotoxic exophthalmos, and both types are of similar etiological basis, explained by some relationship between the thyroid and pituitary
gland.
3. Experimentally the following has been found:
(a) Thyrotropic hormone injected into guinea pigs produces exophthalmos and
this regresses if the injections are withheld.
(b) Thyrotropic hormone, injected into guinea pigs which have previously had
the thyroid removed, causes exophthalmos more rapidly than in the intact
|-£~ animal
(c) Friedgood in 1934 found that exophthalmos due to thyrotropic hormone
regressed on reduction of thyroid function, particularly so when the
metabolic rate fell.
Page 38 (d) Marine (1938) believes that the gonads play an important role because castra
tion  lessens  exophthalmos  produced by thyrotropic hormone in  certain
animals and testosterone brings it back.
(e) Dobyne (1945)  has shown that thyroidectomy alone causes exophthalmos
which he described as prominence of the eyes.
In conclusion, therefore, it seems possible or at least logical from clinical, experimental and from certain pathological findings to assume that:
1. Exophthalmos does not differ in type fundamentally, but rather in degree, depending upon the presence or absence of some compensating mechanism responsible for the control of an exophthalmos-stimulating substance. It is possible
that exophthalmos-stimulating substance is produced by the pituitary gland
and that the amount produced is regulated by the thyroid gland.
Mann states that in malignant exophthalmos where there is an excessive amount
of thyrotropic hormone the thyroid for some reason is not able to keep up its
production of thyroid hormone. This allows the uninhibited formation of
further thyrotropic hormone. Exophthalmos continues to increase and when the
process is of long enough duration and sufficiently severe, then the pathological
processes within the intraocular muscles become irreversible. In the exophthalmos
then of exopthalmic goitre there is an excess of thyrotropic hormone over the
thyroid hormone, but this excess is not great; hence exophthalmos is of slow
onset and not marked. Most writers on the subject express the idea that the
sympathetic nervous system is also involved and plays a part in the proptosis
exophthalmic goitre.
References
1. T. G. Martens, M.D., A.J. of Ophth., Vol. 213, 1947.
2. Herman Zondek, M.D., and Albert Tiche, M.D., B.J. Ophth., June 16th, 1945.
3. J. H. Mulvany, London, Eng., A. J. Ophth., 1944 Vol., pages 589-612, 693-712,
820-829. pH
4. Givner, Bruger, Lowenstein, Arch, Ophth., Vol. 37, 1947, Pages 211-219.
5. McCullagh, Rudemann, Gardner, Trans, of Am. Assoc, on Study of Goitre, 1942-46,
pages 15-30.
6. Dobyns S.G.O., January-June, 1946, Vol. 82, pages 609-617.
Page 39 UTOPIAS, PAST AND PRESENT—PERHAPS TO COME
An address given before the Victoria Medical Society, by Dr. H. H. Murphy, on the
evening of Monday, March 7th, 1949.
I deeply appreciate the privilege of addressing the Victoria Medical Society, and
especially so as the choice of subject was left entirely to me. When our resident, Dr.
Elkington, first spoke to me he suggested that I consider the subject of Cancer. Certainly,
that problem is vast enough to permit of much talking—so vast indeed that only one
phase might be discussed—and then only partially—in one evening. It so happened that
I spoke to this Society on this subject a few years ago and current ideas, both new and
old, are reasonably well covered in the weekly Cancer Clinic—with one exception and
that is what I might call the political—economic aspect. How should the whole problem
be managed—economic aspect. How should the whole problem be managed—what
should be the basic financial details—how should modern medical care of Cancer be
provided? These and many other like questions would provide an interesting, if perhaps
a dangerous, phase of the subject to bring before any medical gathering—almost any
proposals which might be made would be labelled almost at once as Utopian. With
that word it seemed as if perhaps here was an interesting line of thought—why should
we use the word Utopian in connection with any subject and imply that forthwith
further discussion would be fruitless? Has the history of Utopias no successes to its
credit? If we briefly look over the origin of the idea and its development over the years
can we not more wisely view difficult medical problems, such as the care of Cancer in the
future? You will recall that Alice-in-Wonderland came to a place where she could go
forward only by walking beckward so that she might see the road along which she had
come. So for a short time let us turn and face the past and see if any lessons are there
to guide us in the future.
It is always well to start any discussion with a clear definition of the subject and if
we look in the Encyclopaedia Britannica we find UTOPIA defined as follows:
"An ideal commonwealth whose inhabitants exist under perfect conditions."
Hence Utopian is used to denote a visionary reform which fails to recognize defects
in human nature. The word first occurs in Sir Thomas More's "Utopia" published in
Louvain in 1516. It was compounded by More from the Greek OU, not and TOPOS, a
place ... in other words nowhere" but he added that should it ever be achieved it would
be "EUTOPIA"—the good place. Perhaps we may summarize these ideas by defining it
as the good place which does not exist.
However, just as Cod Liver Oil was a good medicine before we knew of the existence
of the alphabetical list of vitamins of today, so plannaing an ideal state intrigued the
minds of clever men long before the advent of Sir Thomas More. As we look back we
find outstanding men from Plato onwards so occupied—and what a strange collection
of men exercised their minds and their imaginations in this way—economists, philosophers, poets, novelists, artists, newspaper writers, religious visionaries, scientists, statesmen—and even the ordinary man in the street like you and me—the amateur, perhaps
par excellence, feels that he can, almost without thinking, tell us all how to recreate
the world more nearly to our hearts desire. This is indeed a pertinent fact to remember
today—more amateurs in the world today think that they, and they alone, have the
answer than at any other time in the history of the world—and many of them are prepared to upset old and tried methods to launch their own particular scheme. It would
probably be as easy to start an actual so-called "shooting war" today to try to establish a
Page 40 '-»"»"
MF&
m
new economic order as it was in the middle ages to begin a "holy war" to establish
a religious ideal.
Perhaps we might.briefly survey some of the outstanding Utopias of the past, with
even briefer note of those who dreamed the visions. In this resume I shall quote directly
and indirectly from "Contemporary Social Movements", by Jerome Davis, Ph.D. and
published in 1930 by the Century Co. of New York.
Naturally, we shall commence with Plato the Greek philosopher (427-347 B.C.) —
the pupil of Socrates—the teacher of Aristotle. He had seen Socrates die and he knew
what political tyranny meant. When he wished to criticize existing conditions he outlined his ideal state. In this ideal state there would be neither rich or poor. There would
be three classes—the workers, the soldiers of defence ("Guardians" was the name he gave
to them) and the rulers. The rulers were forbidden to own any private property and
were supported by the citizens in general. Happiness for any one group was not to be
purchased at the expenses of the happiness of the whole state (here he was anticipating
Marcus Aurelius (121-180 A.D.) who said "What is not good for the swarm is not good
for the bee". But to resume, Plato wished to avoid the jealousies and intrigues of family
life and suggested that having wives in common would prevent any man saying—"this
is my child." This communistic idea, however, did not include artisans or workers, nor
did they have any share in government—remember Plato based his ideal state on slavery—
we shall revert to that point again this evening. Reading his "Republic" today it would
seem that the best of everything was predicated for the rulers. The guardians of the
state—the soldiers—were entitled to food and housing, but were to be allowed no money
lest it might corrupt them, and the workers were never to be allowed enough that they
would be enabled to change their trade. His basic idea was that each individual has
some special endowment or aptitude, which he alone in the world possesses and he must
use this for the good of the community as a whole. In this way and in this way only
would he achieve justice and live a spiritually healthy life.
It would seem that Plato might have been the forerunner of the author or authors
of the Anglican catechism where the injunction in part is "not to covet or desire other
man's goods but to learn and labour truly to get mine own living, and to do my duty,
in that state of life unto which it shall please God to call me". You will recall the verse
recently deleted from the hymn "All things bright and beautiful."
"The rich man in his castle,
The poor man at his gate,
God made them high and lowly,
And ordered their estate."
The discarding of this verse may have been hastened by a modification which seems
to be more in touch with modern times:
"The rich man and the poor man,
God made them high and low,
But made the latter anxious
To change the status quo." M
This phrase—to change the status quo—brings us back at once to our subject
—Utopias, past and present, and will, I imagine, characterize those of the future.
Thomas More, as we mentioned earlier, coined the word Utopia. He was born in
1478—almost 2000 years after Plato. He died in 1535. Trained in Lincoln's Inn he
alternated in his devotion to law with a trial of theology (for a time he was a Carthusian
monk) and also with what we know today as Science, but which he and his contemporaries knew as the "New Knowledge." He succeeded Cardinal Wolsey as Lord Chancellor
of England under Henry VIII. When King Henry made Sir Thomas More Chancellor, he
counted on the Cardinal's support in securing the King's divorce from Queen Catherine
that he might marry Anne of Boleyn, however, More would not countenance this and
was never forgiven. Later he was accused of treason and found guilty as he admitted
having said that "no parliament could make a law that God should not be God" and "no
Page 41 I more could parliament make the King the supreme head of the church." He was beheaded
and the head was displayed on London Bridge.
This very interesting man published his Utopia in Latin in 1516, but the first
English translation did not appear until 1551. In this book he relates conversations between himself and Peter Giles and a fictitious character Ralph Hythodaye, who was
supposed to have sailed with Amerigo Vespucci and discovered the island of Utopia. The
basis of this civilization was a community of goods, a national system of education,
work for all, and all must work for the common good. Of course, all this idealism was
contrasted with the wealth and the povery of England. It is interesting to note that
here, too, slavery and a monarchy were accepted as being sound institutions. "As this
is arr age of discovery," writes Granger, "the learned Budeaus and others took it for
genuine history and considered it highly expedient that missionaries should be sent
thither in order to convert so wise a nation to Christianity." I shall read here a few
extracts from More's Utopia regarding hospitals and medical care.
"But first and chiefly of all, respect is had for the sick, that be cured in hospitals.
For in the circuit of the city, a little without the walls, they have four hospitals, so big,
so wide, so ample and so large that they seem four little towns, which were devised of
that bigness partly to the intent that the sick, be they never so many in number, should
not He too throng or strait, and therefore uneasily and incommodiously: and partly that
they which were taken and holden with contagious diseases, such as be wont by infection
to creep from one to another, might be laid far from the company of the residue. These
hospitals be so well appointed,-and with all things necessary to health so furnished, and
moreover so diligent attendance through the continual presence of cunning physicians
is given, that though no man be sent hither against his will, yet notwithstanding there
is no sick person in all the city, that had not rather lie there than at home, in his own
house. When the steward of the sick hath received such meats as the physicians have
prescribed, then the best is equally divided among the halls, according to the company
of every one; saving that there is had a respect to the prince, the bishop, the tranibores
and to ambassadors and all strangers, if there be any, which be very few and seldom."
"The sick, as I said, they see to with great affection, and let nothing at all pass
concerning either physic or good diet whereby they may be restored again to their
health. Them that be sick of incurable disease they comfort with sitting by them, and
to be short, with all manner of helps that may be. But if the disease be not only incurable, but also full of continual pain and anguish: then the priests and magistrates exhort
xthe man, seeing that he is not able to do any duty of life, and by overliving his own death
is noisome and irksome to others and grievous to himself, that he will determine with
himself no longer to cherish that pestilent and painful disease. And seeing that his life
is to him but a torment, that he will not be unwilling to die, but rather take good hope
to him, and either despatch himself out of that painful life or else suffer himself willingly
to be rid of it by other. And in so doing they tell him that he will do wisely, seeing that
by his death he shall lose no commodity but end his pain. And because in that act he
shall follow the counsel of the priests, that is to say, of the interpreters of God's will
and pleasure they show him that he shall do like a godly and virtuous man. They that
be thus persuaded finish their lives willingly, either with hunger, or else die in their
sleep without any feeling of death. But they cause none such to die against his will, nor
they use less diligence and attendance about him, believing this to be an honourable
death. Else he that killeth himself, before the priests and the council have allowed the
cause of his death, him as unworthy of earth and fire they cast unburied into some
stinking marsh." So today, when physicians and clerics and economists discuss euthanasia
it is well to recall that it was a subject worthy of discussion in the 14th and 15th
centuries of our era.
Again regarding deformities More writes ". . . To mock a man for his deformity or
for that he lacketh any part or limb of his body; it counted great dishonesty and reproach,
not for him that is mocked but for him that mocketh."
Page 42
i .ifa
.■Sfjjs*
■
More's Utopia stands out as the inspiration of many later Utopias and of much
social reform. It suggested such treatises as Campanella's "City of the Sun"—Bacon;
"New Atlantis"—Hobbes; Leviathan—" Harrington's "Oceana" and Filmer's "Patri-
achia." More suggested compulsory and universal education—a thought which has by
no means run its full course as yet. His ideas of penology are current today and the
religious freedom he advocated has been enjoyed to a considerable extent throughout the
civilized world for several generations. He advocated a shorter working day to permit
of cultural development. Wells claims that More's ideals were materialized in the English
poor laws and Owen's ideas brought about the British Factory Acts in 1819, and he
was one of the pioneers in the trade union movement.
About one hundred years later, Francis Bacon was born—his dates were 1561-1626.
To give him his correct title we should speak of him as Baron Verulam, Viscount St.
Albans. He was a philosopher, essayist and later became Lord Chancellor of England.
He studied at Cambridge and his own description of his own mind gives you a clear
idea of the man "I found that I was fitted for nothing as well as for the study of the
truth; as having a mind nimble and versatile enough to catch the resemblance of things
(which is the chief point) and at the same time steady enough to fix and distinguish
their subtler differences: as being gifted by nature with a desire to seek, patience to
doubt, fondness to meditate, slowness to assert, readiness to consider, carefulness to dispose and set in order; and as being a man that neither affects what is new nor admits
what is old, and that hates every kind of imposture. So I thought my nature had a kind
of familiarity and relation with Truth." At the age of 15 he was a member of parliament
and confidential adviser to Essex, the favourite of Elizabeth. Later it was perhaps due
to his address that Essex was executed and it was Bacon who wrote the account of the
intrigues of Essex in an attempt to justify the Queen's part in all this affair. He was
knighted by James and in 1617 became Lord Chancellor. Later on he was convicted
of accepting bribes and the sentence was that he should be fined 40,000 pounds; confined to the Tower for the duration of the King's pleasure; that he should never hold an
office in the State and that he should never sit in Parliament or come within the verge
of the court. The fine was remitted by the King—he spent four days jn the tower and
a general pardon was made out about 1621. He was probably allowed to come to court
but never sat in Parliament again. Five years later he died. In 1627 the "New Atlantis"
was published—one year after the author's death. It deals with the ideal state and the
laws governing such a state were to have been published late but were never written.
He describes a state given over largely to scientific investigation and the assumption and
that this would solve all the problems of life. If scientific research, as we know it today,
is the chief end of man, then there was nothing wrong with the German state, but that
demonstration was to come later in the hisory of he world. A few extracts from Bacon's
"New Atlantis" may interest you.
"We have also certain chambers which we call chambers of health, where we qualify
the air as we think good and proper for the cure of divers diseases and the preservation
of health. We also have fair and large baths of several mixtures for the cure of diseases—
we have parks and enclosures for all sorts of beasts and birds—we try all medicines and
poisons upon them as well as chirurgery and physic ... by art we make them greater
or taller than their kind is, and contrariwise we dwarf them and stay their growth—we
make them more fruitful and bearing than their kind is and contrariwise barren and not
generative . . . and have produced many new kinds and them not barren . . . we have
dispensatories or shops of medicines . . . we have glasses and means to see small and
minute bodies perfectly and distinctly" (you will recall that the first microscope was
made by Johann and Jacob Janssen in 1590 in Holland); to continue our quotation—"We
have (in warfare) wild fire burning in water and unquenchable . . . we also imitate the
flight of birds and have some degree of flying in the air . . . we have ships and boats for
going under the water . . . we have certain hymns and services which we say daily, of land
and thanks to God for His marvellous works, and forms of prayer, imploring His aid
Page 43 and blessing for the illumination of our labours, and the turning of them into good and
holy uses." I .think one extract from his preface to "The maxims of Law" is pertinent
to our discussion this evening—it is as follows: "I hold every man a debtor to his profession; from the which as menr of course, do seek to receive countenance and profit, so
ought they of duty to endeavour themselves by way of amends to be a help and ornament
thereto.*'
We leap forward another 300 years to 1834 when William Morris of England was
born—he died in 1896, so that the latter part of his life overlapped the earlier years of
some still active in medical practice here. He was an architect, poet and successful business man—an Oxford graduate and a friend of the pre-Raphaelites Edward Burne-Jones
and Dante Gabriel Rossetti. He early associated himself with the Socialist league but
withdrew when the anarchist group secured control. About 1885 he wrote his "News
from Nowhere." In this Utopia, large cities have passed away, food is free to all and to
quote Kipling—each "works for the joy of the working." One might, I think, correctly
say that his fundamental point was that man in the mass is a thinking logical being as
evidenced by an absence of any government in his Utopia on the ground and I shall
now quote from "News from Nowhere." But further it is true that a man no more needs
an elaborate system of government with its army, navy and police to force him to give
way to the will of the majority of his equals, than he wants a similar machinery to make
him understand that his head and a stone wall cannot occupy the same space at the
same time . . . for we have seen already that it was the function of government to
protect the rich against the poor. But did not the government defend its rich men
against other nations? I do not remember to have heard that the rich needed defence:
because it is said that even when two nations were at war, the rich men of each nation
gambled with each other pretty much as usual, and even sold each other weapons where*-
with to kill their own countrymen . . . the government itself was but the necessary
result of the careless, aimless tyranny of the times; it was but the machinery of tyranny.
Now tyranny has come to an end and we no longer need such machinery: we could not
possibly use it since we are free. Therefore in your sense of the word we have no government."
Edward Bellamy was born in the United States in 1850 and died in 1898. He was
a barrister, editor, and as a university graduate studied in Germany and devoted most
of his life to working out his ideas of Utopia first outlined in "Looking Backward" and
later more fully elaborated in "Equality", published in 1897. "Looking Backward" sold
a million copies and was translated into many languages and today some think it had
a considerable influence in the initial stages of what is still miscalled communion in
Russia. Briefly the story of "Looking Backwards" is that of a young millionaire in
Boston—Julian West, who suffers from insomnia and is put to sleep by a hypnotist in
a subterranean room in 1887—he does not waken from this hypnotic trance until the
year 2000 and the book deals with the new civilization he then finds in operation in the
United States and in the major portion of the civilized world. The great revolution
against capitalism having occurred one hundred years earlier, Julian West indeed finds
himself in a new world and the former things have passed away. There is no crime—there
are no rich, no poor, no buying or selling, no credit and unemployment is unknown.
Perhaps a few direct quotations ifrom "Looking Backward" might be of interest to you.
On page 50 of the 1926 edition you will find the following:—
"Early in the last century the evolution was completed by the final consolidation
of the entire capital of the nation. The industry and commerce of the nation, ceasing to
be conducted by a set of irresponsible corporations and syndicates of private persons at
their caprice and for their profit, were entrusted to a single syndicate representing the
people, to be conducted in the common interest for the common profit. The nation,
that is to say, organized as the one great business corporation in which all other corporations were absorbed; it became the one capitalist in the place of all other capitalists, the
sole employer,  the final monopoly in which all previous and lesser monopolies were
Page 44 swallowed up, a monopoly in profits and economies of which all citizens shared. The
epoch of Trusts had ended in The Great Trust. In a word the people of the United
States concluded to assume the conduct of their own business, just as one hundred odd
years before they had assumed the conduct of their own government, organizing now
for industrial purposes on precisely the same grounds that they had then organized for
political purposes. At last, strangely late in the world's history, the obvious fact was
perceived that no business is so essentially the public business as the indutry and commerce on which the people's livelihood depends, and that to entrust it to private persons
to be managed for private profit is a folly similar in kind, though vastly greater in
magnitude, to that of surrendering the functions of political governments to kings and
nobles to be conducted for their personal glorification . . . (in the change over) there
was absolutely no violence. The change had been long foreseen. Public opinion had
become fully ripe for it, and the whole mass of the people were behind it."
In this plan, youth was to be devoted to education. At the age of 21 each individual
became part of the industrial service of the nation and so worked for twenty-four years—
at the age of forty-five he was retired but in case of emergency was liable for ten years
more service. In drafting the citizens into the industrial army the natural aptitudes
both physical and mental were to be evaluated and the individual was to be studied and
in this way he was to be placed where he would be of greatest value to the nation. The
hours of labour were to be regulated on the basis of the particular occupation — easier
work meant longer hours — harder manual work meant shorter hours and if the work
was extra hazardous then it was to be a point of honour to volunteer for such service.
For the first three years of service all citizens were to be drafted for manual work and
after that period might select their permanent occupation. In the case of those desiring
to take up professional training it was obligatory that this training should be commenced
before the age of thirty, as it was felt that if this prolonged training were to be undertaken at a more advanced age there would not be a sufficiently long period of active
work left to serve the nation adequately.
Some further quotations from "Looking Backward" may make Bellamy's plan more
real to you.
"I should not fail to mention", resumed the dodtor, "that for those too deficient
in mental or bodily strength to be fairly graded with the main body of workers, we have
a separate grade unconnected with the others—a sort of invalid corps, the members of
which are provided with a light class of tasks fitted to their strength. All our sick in
mind and body, all our deaf and dumb and lame and blind and crippled, even our insane,
belong to this invalid corps, and bear its insignia. The strongest often do nearly a man's
work, the feeblest, of course, nothing—hut none who can do anything are willing quite
to give up.   In their lucid intervals, even our insane are eager to do what they can."
. . . Therefore it is, as I told you this morning, that the title of every man, woman,
and child to the means of existence rests on no basis less and broad than that they are
fellows of one race—members of one human family. The only coin current is the image
of God and that is good for all we have. "In answer to the question of how to fin^ the
immense amount of money necessary to care for everyone in this way and make everybody
so happy Dr. Leete says; "Let us begin with a number of small items wherein we economize wealth as compared with you. We have no national, state, county or municipal
debts or payments on their account. We have no sort of military or naval expenditures
for men or materials, no army, navy or militia. We have no revenue service, no swarm
of tax assessors and collectors. As regards to our judiciary, police, sheriffs, and jailers
the force which Massachusetts alone kept on foot in your day far more than suffices for
the nation now. We have no criminal class preying upon the wealth of society as you
had. The number of persons, more or less absolutely lost to the working force through
physical disability, of the lame, sick and debilitated, which constituted such a burden
on the able-bodied in your day, now that all live under conditions of health and comfort,
Page 45 has shrunk to scarcely perceptible proportions, and with every generation is becoming
more completely eliminated."
In answer to the suggestion that the period of time allowed for this great transition
was too short, the following short paragraph is an interesting answer from the historical
point of view:—
In 1759, when Quebec fell, the might of England in America seemed irresistible,
and the vassalage of the colonies assured. Neverthelss, thirty years later, the first President of the American Republic was inaugurated. In 1849, after Novara, Italian prospects
appeared as hopeless as at any time since the Middle Ages; yet only fifteen years after,
Victor Emmanuel was crowned King of United Italy. In 1864, the fulfillment of the
thousand-year dream of German unity was apparently as far off as ever. Seven years
later it had been realized and William had assumed at Versailles the Crown of Barbarossa.
In 1832, the original Anti-slavery Society was formed in Boston by a few so-called
visionaries. Thirty-eight years later, in 1870, the society was disbanded, its programme
fully carried out."
Jerome Davis sums up the common elements in Utopias along these lines:
1. Where government is outlined it is to function for the good of all.
2. The ideals of equality and mutual helpfulness are stressed.
3. Science is devoted to the bettering of life for the common good.
4. In industry, toil is reduced to the minimum to permit a higher cultural life and
must serve society.
5. Creative production is to take the place of acquisition.
6. Co-operation is to supplant competition.
7. A moral and cultural life is to be preferred to material advancement.
8. Optimism, faith and hope are the key notes.
9. Freedom of speech is considered necessary but there is more regulation of the
individual than before."
The major differences are that each Utopia reflects the outlook of the times—as
mentioned before, Plato accepted slavery, but this would be unthinkable to Bellamy
or to Wells. The basis also differs—with More it is the family—with Andrea, the guild—
with Plato, the city; with Cabet, the nation and with Wells, the world. The older
Utopias regard labour as a joy, the more recent one look on it as an evil.
The Utopian contributions to civilization have been many. All the various religious
Utopias have stressed moral values—usually emphasizing a more strict discipline in this
world with the hope of emancipation from all problems in a world to come—a philosophy
which has inspired mankind through the ages especially in the darker periods of war and
particularly when under the control of some foreign power. The basic idea being that if
the individual lives the good life then the world will progress in righteousness and in
peace. More outlined an approach to crime and punishment that is strictly modern and
his ideal of universal and compulsory education is still far from complete realization.
The Utopians assisted later generations in avoiding social disaster and have probably
played a considerable part in preventing revolutions. They have worked for peace
between the various classes and for social health and security. They have indicated the
errors of the times and suggested remedies, they have always thought of the community
rather than the individual and have worked on the belief that man can always surpass
himself and do better than he has done in the past. They have stood for equality of the
sexes—eugenics and preventive medicine. They have stood for religious toleration and
against bigotry, excommunications, intolerance inquisitions and persecutions. In many
ways the Utopias have set our present conception of property, inheritance taxes and
succession duties. In time of war almost everything can be taken over by the state—
in other words, the essence of property lies in the integrity and good will of the state
and the Utopians apply this idea to peace as well as war to quite a considerable extent.
At all times, Utopians have stood for education of all classes and Bacon's college of
research in the House of Salomon" actually materialized in the British Research Society
Page 46 in the generation following Bacon's. From Plato onwards the state was to be supreme,
but only in the sense that it existed only for the well-being of its citizens—in other words,
that is what we know as democracy today. Harrington's "Oceana" influenced thought
and development in the United States as John Adams was quite familiar with it and
some of its ideas were incorporated in the laws of the state of Massachusetts—again one
hundred years after Harrington outlined the idea of a secret ballot it was introduced in
New York state but not until 1872 did it come into use in England and a little later
still in Canada. All this goes to show that Utopianism is not expression in vain; sooner
or later in its original form or with some modification many Utopian ideals are factors
in the every day life of the community.
Jerome Davis summarizes the reasons for failure of the various Utopias in this way:
"1. They trusted too much in the establishment of a perfect experiment in the
midst of the old order, a thing impossible of achievement.
2. They tried to create a perfect system, forgetful that any social order must be
constructed by imperfect human instruments.
3. They failed to premise the existing social order.
4. They depended too strongly on assistance from the beneficiaries of the existing
order.
5. They did not attach sufficient importance to the natural thirst for self development and personal property.
6. They did not sufficiently realize the effect of protest in effecting reforms.
7. They let their desire run away with their sense of reality.
8. They did not realize the necessity of a revolution of the heart or of a transvalua-
tion of values.
9.   They failed to realize that the transition from the actual to the ideal cannot
be made without a bitter struggle between those interesed in the current system
and those interested in the ideal system."
Lord Macaulay (1800-1859), speaking of Utopia, summed up his ideas as follows:
"An acre in Middlesex is better than a principality in Utopia.  The smallest actual
good is better than the most magnificant promises of impossibilities.   The Wise Man
of the Stoics, would no doubt, be a grander object than a steam engine.   But there are
steam engines and the Wise Man of the Stoics is still to be born.   A philosophy which
should extinguish cupidity would be better than a philosophy which would devise laws
for the security of property.   But, it is possible to make laws which shall, to a great
extent, secure property.  And we do not understand how any motives ancient philosophy
furnished could extinguish cupidity."
There is always a humorous side to all serious discussions—the older members
present may recall one of the early cartoons dealing with Professor Roentgen's discovery
of X-rays. It appeared, of course, in Punch and showed a British scientist fluoroscoping
Emperor William of Germany and "finding everything just I expected—no back bone at
all."
So, too, Utopia has not escaped and again it was natural that it would be Sir William
Gilbert and Arthur Sullivan who would do it.
The play was "The Gondoliers,"
He wishes all men as rich as he
(And he was a rich as rich could be)
Lord Chancellors were cheap as sprats
And bishops in their shovel hats
Were plentiful as tabby cats—
In point of fact too many.
And Party Leaders you might meet
In two's and three's in every street
Maintaining with no little heat,
Their various opinions.
Now that's a sight you couldn't beat—
Page 47 Two Party Leaders in each street
Maintaining with no little heat,
Their various opinions.
And again in "Utopia Limited" we have a picture of the financier—
Some seven men form an association
(If possible, all peers or baronets)
They start off with a public declaration
To what extent they mean to pay»their debts
If you come to grief and creditors are craving
For nothing that is planned by mortal head
Is certain in this vale of sorrow—saving
(That one's liability is Limited)
Do you suppose that signifies perdition?
[f so, you're but a monetary dunce—
You merely file a winding up petition
And start another company at once.
A more modern picture is that which appeared recently in Toronto's "Saturday
Night", under the tide "Drool Britannia."—
O to be in England
Now that health is free—
Not a farthing needed
For an appendectomy:
Dentures for the asking
For husband, child or spouse; *
O to be in England
Now that health is "on the house"
Suffered once in silence?
All is different now;
Doctors come a-running;
Nurse to smooth the brow.
Never more to worry
Let expenses mount
Every little storklet
Has his own expense account.
O, to be in England,
Where pills are running free;
Help yourself   to wooden legs—
Ne'er a penny fee.
This paternal caring
Will it prove a cure-all
For the body politic?"
Or to quote a couplet from the "Victoria Colonist" of Sunday, February 27th, of
this year:—
"These stately homes of England, how desolate they stand,
To prove the upper classes have lost the upper hand."
In his recent book "Education in a Divided World," James Bryant Conant,Presi-
dent of Harvard, looks forward to a period of ten years of the present strained relations
with Russian and the argument of his book is directed to the problem of how to develop
education in our part of the divided world that democracy and the democratic ideal may
not perish but may conquer the miscalled communism of the dictatorship of Russia
without a definite shooting war. Here in British Columbia we have an interesting object
lesson of this division of thought in the world today and in my opinion it should be
very carefully considered by every physician because just as it affects every citizen in
the province so it affects every business venture and every profession.  On the one hand
Page 48 !5*
m<
vou have great capitalistic development planned and on the other hand, extensive social
changes either actually commenced or pending and no matter under what name they
may be known today, it was but yesterday, as Time goes, when they would have been
termed very advanced socialism.
As far as I can see, socialist ideas are current throughout the civilized worlo!—in
some cases extreme socialism with associated dictatorial control, in others capitalism
modified in many ways by socialistic thought. I am not attempting to say which will
ultimately prevail or how far one may influence the other—but tonight I am trying
to impress upon each and every one of you how vital these ideas are to the practice of
medicine in British Columbia. I do not ask you to do more than try to appraise the
force which are operative here today and then to use your best judgment that medicine,
as we know it, may be be continued; that we as a profession may continue to render to
mankind the type of service which we have done in the past and continue to improve
it. I believe that it is essential for us to try to direct the tide of current thought into
as safe channels as may be found, rather than to try to completely obstruct the trend.
I cannot forecast the future of medical practice and development—I hope it may be
steadily improved—but I am by no means sure that such a fortunate outcome may be
predicted. Of one thing I feel reasonably sure and that is that the practice of medicine
in the future will be profoundly different from what it is today.
As you all know, Sir Christopher Wren was the architect for St. Paul's cathedral in
London and his body lies under the choir. A small tablet on the inner north door bears
the well known epitaph in Latin—"If you seek his monument—look about you," so I
say to you tonight, if you wonder why I have talked so long about Utopian ideas and
ideals—look about you and see how far Utopian theories have been materialized and have
changed the face of medical practice in our beloved British Columbia. We have a full
state medical service for mental cases in the province requiring custodial care—we have
a full state public health service—a state medical service for tuberculosis and for venereal
disease and shall we say a 75 % state radiological and pathological service. In that connection I am reminded of that scene in Marmion where after calling Lord Douglas a liar
Marmion makes his escape across the moat—
"To pass there was such scanty room ,
The bars descending grazed his plume."
—and even so did the anaesthetists of British Columbia escape the present chapter of
socialized medicine. Furthermore, we have in this divided world another interesting
combination of the old and the new apparently working out satisfactorily. That is the
Department of Veterans' Affairs where a physician or surgeon or other specialist may
be employed full or part time. If he elects part time he combines practice under present
conditions of fee for services rendered and he accepts a retailing fee, as our legal friends
would call it—for whatever services he may be called upon to give to the Veterans' hospital. Those of you who attended the recent opening of the new Childrens' Ward in the
Jubilee Hospital, will recall that the Hon. Minister of Health promised that a full measure
of health insurance including medical services would be available as soon as the citizens
decided to pay for it. Then almost in the same breath we learn that the College of
Physicians and Surgeons of this province has accepted the capitation methods of payment
by the government for the care of all the social assistance cases. In this connection I
shall quote to you a short paragraph from the January, 1949 issue of Canada's Health
and Welfare" which you all receive at regular intervals. As this publication comes from
the offices of the Federal Department of Health, it must be accepted as authorative.
"The Cancer control grant of 3.5 millions, a grant which must be matched by the
provinces, will stimulate provincial action in the building up of a concerted, well-
planned and organized drive on the malady which is the second greatest cause of death
in Canada. These funds can be used to establish active diagnostic and treatment services
and will open the way towards free diagnosis and treatment in all provinces."
In view of the foregoing I think I am safe in saying that if, as, and when the government of British Columbia wishes to implement the recent promise of the Minister
Page 49 of Health—it can do so along one of many lines and have little trouble in pointing to a
precedent already accepted by the medical profession. So, in our planning for what we
consider best for the public and for the medical profession, we cannot say that only
under our present system of fee for services rendered can a satisfactory medical service
be provided. We may, in all sincerity, decide and argue that one system may have certain
merits over the others, but if we claim that only the older system is correct we are reflecting very seriously on the excellent work being done right today in our own midst by
many thoroughly competent members of our profession. In addition, and this will bear
being stressed, we should be presenting our case illogically.
Furthermore, it would be well for us to remember that democracy, of which we
all talk so much today, means that the will of the majority rules—not the majority in
any one group but the majority of the citizens of the nations, will set the pattern for
our society. Then we must remember that once public opinion has become crystallized
into law, while we may attempt to change that law—until it is changed—it is our duty
to carry it out to the letter. Here we have no alternative and as privileged members of
society we cannot overlook the spick of the law and give it merely Up service. Which
one of the many systems mentioned ma/ be the one under which we may ultimately
work, as I have said before, I do not venture to forecast. However, I would remind you
of the many ways in which we have seen so-called Utopian ideas, materialized into every
day living. In all social legislation, as far as I know, we are travelling along a one way
street—but the time that serious difficulties are evident in any one such scheme, society
has reached the point that the air services have called "the point of no return," which
means that it is easier to go on to some destination other than that originally planned, if
necessary, than to return to the original base. That point of no return in social legislation
means the application of further restrictions, increasing bureaucratic control and further
loss of individual choice.
The only alternative which we as a profession are offering are those plans such as our
own M.S.A. When I hear one after another in our profession, very critical and dissatisfied
with one detail after another, I wonder if they are reporting their difficulties to the
management and also sending in their own suggestions for bettermen of the service.
I have a great deal of admiration and much sympathy for those members of our profession who today hold in their hands the future of medicine in Canada. This includes
the executive group of the Canadian Medical Association and its daughter provincial
associates; the various Provincial Colleges of Physicians and Surgeons; the Federal and
Provincial Health bureaus, where, today, so much control of medical practice is being
concentrated; and lastly those men throughout Canada who are trying to build up in
the various provinces some plan for the prepayment of medical services. Theirs is a
difficult and very responsible task and I feel sure that they all realize that if we as a
profession are to maintain our privileges, we must continue to merit the respect and
confidence of the citizens at large. We must give leadership and cannot allow ourselves
to appear as reactionaries. The idea of practicing medicine on the basis of salvaging a
ship and taking as our fee, a percentage of the cargo, is passing away. It served its purpose in the days when there was a large portion of the work of all physicians done
willingly and gladly for those poor who could not afford to pay any fee—but today we
are rapidly passing into a period when social legislation—Utopia to some—sees to it that
medical care is provided for all and on some basis is paid for—possibly a basis not satisfactory to us but yet some payment basis has been accepted by us and we are accepting
payment on that basis. We must all give great thought to the road ahead for medical
practice in Canada—this is naturally of so much more vital importance to the recent
graduate than to his confreres of my own vintage.
You will no doubt notice that I have offered no solution. I have no blueprint for
the future. My reflections are my own and perhaps mine alone. Certainly, I realize that
some here may not agree with my viewoint either in general or in detail. That would be
most natural and in a world where changes come so rapidly as they do in our world of
today, I may next year find that I, too, have modified some ideas expressed here this
Page 50 evening. In connection with that idea of sudden change being characteristic of today,
it is perhaps profitable to recall that 150 years ago William Pitt introduced the income
tax to England to finance the war against Napoleon. The war against the Kaiser
brought it to Canada, too. No one wonders how long the income tax may be continued—
the only dream we permit ourselves in that connection is whether or not it may be
somewhat reduced.
I feel very strongly that every physician in British Columbia should try to crystallize
his own ideas as to what he considers essential to medical practice in the future. My own
are as follows:
1. That through the direction of the medical profession, modern scientific medicine
shall be available in fullest measure to every citizen.
2. That the pecuniary returns, either in the form of financial remuneration or
money plus opportunities for study, recreation and retirement shall be sufficient
to continue to attract the right type of young man into the medical profession—
a profession demanding long and expensive training both in time and money
and the successful practice of which is arduous and involves great responsibility,
skill, patience and understanding.
3. That in some way—and it may well be that this is the most difficult of all—
organized medicine must begin to assume more responsibility for maintaining
sufficiently high standards of scientific practice that item number one may be
materialized.
I cannot give you a more detailed statement of my own hopes for the future. Very
often the poets are able to express a vision in general terms which we can all understand.
In the hope that this is so, I shall, in closing, remind you of the latter part of Tennyson's
"Ulysses"—
'Tis not too late to seek a newer world.
Push off, and sitting well in order, smite
The sounding furrows; for my purpose holds
To sail beyond the sunset, and the baths
Of all the western stars, until I die.
It may be that the gulfs will wash us down:
It may be we shall touch the Happy Isles,
And see the great Achilles, who we knew,
Tho' much is taken, much abides: and tho'
We are not now that strength which in old days
Moved earth and heaven; that which we are, we are;
One equal temper of heroic hearts,
Made weak by Time and Fate, but strong in will
To strive, to seek, to find and not to yield.
SYMPTOMS AND TREATMENT OF HOARSENESS.
P. E. Ireland, M.D., Toronto
Presented at the Vancouver Medical Association Summer School, 1949
Hoarseness as a clinical symptom requires the careful study of the history of the
patient and the development of a fixed programme of dealing with it in a systematic
manner. Frequently it is a symptom of a benign lesion which can be dealt with easjly
and adequately if we are sure it is of a benign nature. Direct examination and biopsy
may be the only method of ruling out a carcinoma of the larynx. Malignant growths
of the larynx have metastases late and are one of the most favourable lesions for the
complete cure of the disease in the human body.
The following is the abstract of the lantern slides used during the discussion of this
subject and is necessarily only a summary.
Page 51 I.    Hoarseness (Causes)
1. Acute Inflammation:  (a)  Catarrhal type—coughing, smoking, talking.
(b)   Streptococcal type—acute Tracheo-bronchitis.
2. Chronic Inflammation: Nodular, hypertrophic, pachydermia, leukoplakia.
3. Specific Infections: Tuberculosis ,syphilis, diphtheria, rhinoscleroma.
4. Spasmodic Lesions: Infant croup, laryngeal crises of Tabes.
5. Simple Tumors: Polypi, papilloma, angioma, cysts, laryngocele.
6. Malignant Tumors: Carcinoma, sarcoma.
7. Laryngeal Paralysis: (a)  Local irrita.ion causing spasm—F.B., gas, etc.
(b) Interference with local motor supply.
(c) Central nerve lesion.
(d) Hysteria or Functional disorders.
II.    Benign Tumors
Often arise from chronic inflammation, or suddenly with voice misuse.
Age:  60%—25 to 50 years. Sex: Men—70%
21%—50 to 76 years. Women—30%
18.5%—below 26 years.
(of these 79% Papilloma Children)
Site: (1) Vocal cord (2) False cord.
Hoarseness: First and remaining symptom.
Dyspnoea: Only when size great—papilloma in children.
Treatment: Surgical removal by indirect .route.
Papilloma Children—repeated removal.
Large Tumors—laryngofissure.
HI.    Ulceration uncommon in benign tumours not in malignant
Frequency: Mayo Clinic    722 benign to 1100 malignant
Toronto Gen. (3 yrs.)     44 benign to 192 malignant
Biopsy: Thorough and repeated if necessary only diff. diagnostic test.
Malignant Change:
Mitchell—83 malignant had 4 previously innocent
Clerk—250 malignant had 4 previously innocent
Orton^l02 malignant had 3 previously innocent
IV. Benign Tumours vs. Malignant Tumours
Situation: Usually ant. one-third of vocal cord—malignant also here.
Hoarseness: early symptom of both—exception in subglottic.
Appearance: base of benign tumour—no inflammatory injection.
Pain: uncommon in benign—late in malignant.
V. Carcinoma of Larynx
Location (a) Intrinsic (b) Extrinsic (c) Subglottic
Intrinsic—(65%), low grade, metastices late, 10 times more common in men, early
cases hopeful for cure.
Extrinsic—Outside laryngeal box—pyriform sinus, pharynx, active grade, metastices
early, post-cricoid is more common in women.
Subglottic—diffiicult to diagnose early stage.    Hoarseness in late stage.    Lymphatic
drainage good—early metastases to pericesophageal area.
VI. Diagnosis—Carcinoma Larynx
1. All cases hoarseness of over 3 weeks should have expert opinion on larynx.
2. X-ray of chest and Wasserman.
3. If in doubt see at week intervals.
4. Direct laryngoscopy with biopsy all cases.
Page 52 wLflSI
m
%m
1
5. Repeat Biopsy if clinically not satisfied.
6. If biopsy negative and clinically malignant treat as malignant.
7. Do not put Silver Nitrate on base of Biopsy.
VII. Treatment—Carcinoma Larynx
Laryngo-fissure—for early localized grwoths.
Contra indications—growth to ant. commissure.
growth has extended to subglottic space.
growth has reached arytenoid.
Recurrences: If properly selected—20% recurrences: 80% of 5 yr. cures.
Recurrences usually local and further treatment can be given.
Radiation:      Surgical Treatment.
VIII. Treatment—Laryngectomy
Mortality: Previously—as high as 54%
Present—Colledge     42-3
Jackson       70-0
Schall 25-0
Toronto      43-0
Indications: Impaired mobility cord
Extension subglottic or ant. commissure
Extension arytenoid, ventricle, aryepiglottic fold
Survival: 65% of 5 year cures.
Lymphatic Sencondaries—removal plus x-ray therapy.
IX. Laryngeal Paralysis
Sensory Nerve Supply: Vagus by internal laryngeal branch of superior laryngeal.
Motor Nerve Supply:  (1)  Crico-thyroid M.—sup. laryngeal nerve.
(2)  All the rest M. recurrent laryngeal N.
Unilateral Abductor Paralysis:
(1) Bulbar lesions—rare, associated with other paralysis.
(2) Along trunk of vagus or recurrent n.
(Goitre and thyroid operations, aneurysms 6f aorta, mediastinal tumours, mitral sten-
asis, apical fibrosis, Ca. oesophagus, etc., etc.)
X. Bilateral Abductor Paralysis:
—very serious—good voice—Thyroidectomy
Treatment—Tracheotomy; Later—arytenoidectomy
Bilateral Abductor Paralysis:  (functional aphonia)
1. In high strung unstable patient.
2. Complete loss of voice or falsetto.
3. Comes in time of strain.
4. Can not make sound but can cough (cords do approximate in cough).       |
5. Treatment patience—may need psychiatrist.
Conclusions:
1. Hoarseness is an important symptom.
2. Benign lesions can be ruled out readily by expert opinion on the larynx.   A Wasser-
man and pan X-ray of chest should be done on all cases.
3. Any hoarseness of over 3 weeks' duration should be viewed with suspicion until it
is proven by biopsy to be non-malignant.
4. Treatment of Carcinoma of the larynx by surgical means should be very satisfactory.
5. Laryngo-fissure, in suitable cases should give 80 per cent of five-year cures.    If
there is a recurrence in the remaining 20 per cent a laryngectomy is still possible.
6. Laryngectomy in the intrinsic carcinoma should give 65 per cent of five-year cures.
7. Early diagnosis is an essential factor in these cases but fortunately metastases to
glands is later than in most malignancies found in other regions.
Page 53 m  _
The etiology of many cases of vaginitis and
cervicitis is based on a secondary bacterial invasion. Against such infections Triple Sulfa Cream brings to bear three sulfonamides—exerting optimal bacteriostatic and bactericidal action at different, specific pH levels1.
Triple Sulfa Cream has proven clinically
effective in post-operative vaginitis or
cervicitis, ulcerative vaginitis, fusospiril-
losis (Vincent's infection of the vagina)2,
and related gynecological conditions.
Eradication of the infection, healing of
the mucosa and return to normal pH levels
have been observed within twelve to
twenty-one days after institution of this
simple convenient therapy.
ORTHO   PHARMACEUTICAL   CORPORATION   (CANADA)    LIMITED   •   TORONTO
Triple Sulfa Cream represents an* optimal
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REFERENCES: (j) COWLES, P. B.; Yale
Journal of Biology and Medicine, 14:599, 1942.
CO RAKOFF, A, E.; Med. Clin, of North
Am., 1354, Nov. 1945. •Mm';
flDount pleasant Xflnbertafcino Co. Xtb.
KINGSWAY at 11th AVE Telephone FAirmont 0058 VANCOUVER, B. C.
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When prescribing Ergoapiol
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INDICATIONS: Amenorrhea, Dysmenorrhea, Menorrhagia,
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GENERAL DOSAGE: One to two capsules, three to four
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In ethical packages of 20 capsules each, bearing no directions.
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ERGOAPIOL (smith)
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THE PREVENTION AND TREATMENT OF
m CAPILLARY FRAGILITY
it
CER VTIN
rr
"ifiaMf brand of Rutin and Vitamin C
Vascular accidents are among the
most feared complications associated
with hypertension. In a high percentage of cases with hypertension
and with diabetes, the capillary
fragility index (Gothlin) has been
found to be increased and it is
assumed that in such cases the
danger of cerebral and retinal haemorrhage from capillaries is augmented. The control of capillary
fragility is hence a therapeutic
problem of considerable importance.
The clinical use of rutin, a rham-
noglucoside obtained chiefly from
buckwheat, is based on its action in
reducing capillary fragility in certain haemorrhagic conditions in
which capillary fragility and permeability are involved.1 The ability
of rutin to correct capillary fragility
may be quantitatively measured by
the technique of Gothlin. 2>3 Normal capillary strength may be
restored and maintained and relapse
prevented by the continuous administration of rutin.
Rutin is much less effective if there
exists a coincidental vitamin C
deficiency. It is, therefore, important to ensure that patients' intake of vitamin C is well provided
for. "Cerutin" provides a balanced
combination of rutin and vitamin C.
REFERENCES:
1. Proc. Soc. Exper. Biol. & Med. 55, 228,
Wig.
2. Am. Heart Journ. 28, 759, 1944.
S. Act. Med. Scandin. 104, 527, 1940.
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Rutin ...  60 mg.    Vitamin C . . . 120 mg.
MODES OF ISSUE       Mm
Bottles of 40 and 100 tablets.
DOSAGE
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We  will be pleased to send
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MANY PHY|$$IAN$ RECOGNIZE fAEAD ^JOHNSON ANjj
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ith
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PACKAGING
CHLOROMYCETIN (Chloramphenicol, Parke-Davis) is
supplied in 0.25 Gm. Kapseals. Descriptive literature
on CHLOROMYCETIN is
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The cost of medication, of course, is but on©
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patient to his job.
Particularly dramatic results are now obtained
in a disease such as typhoid fever, .where the
illness formerly ran its course for several weeks
because of the lack of specific therapy. The
lengthy hospitalization, special nursing care,
the supportive measures during this prolonged
period—all have contributed to increased costs.
However, CHLOROMYCETIN changes this: the
duration of illness is greatly reduced^ defer*
vescence occurring within 2 to 3 days after
treatment is begun. With control of the infection, general improvement is manifest and recovery is rapid.
The high degree of efficacy of CHLOROMYCETIN;
has also been demonstrated in a number of
other diseases previously unresponsive or poorly responsive to treatment, such as acute un-
dulant fever, urinary tract infection, typhus
fever, Rocky Mountain spotted fever, scrub
typhus, and granuloma inguinale.
C   A   ^
^^^^^^^^^^^^^^S^^^^j^S^^^ ^
w
8S&
5«
5o
*y
£c
«
•HXVV$G<
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£  ft \ KEO-SYNEPHRINE, trademark reg. tf, JSL & Canada
423 Ontario Street East, Montreal, P. Q.
Patency of the normal drainage exits of the
nasal accessory sinuses is of great importance in the care of upper respiratory
infections.
Neo-Synephrine hydrochloride, applied
by any of the common methods—dropper,
spray, tampon, displacement—constricts
the engorged mncosa surrounding the ostia,
promoting free drainage and aeration.
NEO-SYNEPHRINE^ Hydrochloride
Brand of PHENYLEPHRINE HYDROCHLORIDE
Solution 0.25%  {plain ox with ctromatics)
and|p% — 1 oz. bottles.
Jelly 0.5% — % oz. tubes.
Hen Yo*k 13, N. Y.    Windsor, ont.
1019 Elliott Street West, Windsor. Ontario ■'*&
fn vasomotor disturbances
oiLVflsenc
PERIPHERAL VASODILATOR
EFFECTIVE BY MOUTH
INDICATIONS
Raynaud's disease
painful manifestations of the extremities
intermittent claudication
varicose ulcers
muscular cramps in pregnancy
PRESENTATION
Tablets
10 mg. DILVASENE "Mild"
tubes of 100, bottles of 500 and 1000 J||
50 mg. DILVASENE "Strong"
tubes of 20, bottles of 100, 500 and 1000
Ampoules
(2c.c.)  containing 5 mg.
used only in emergency therapy
boxes of 10
Information and samples upon request
pouLcnc
LimiTCD
fllODTRCRL toxic effects, such as depression of blood
prothrombin and hemorrhagic tendency, are
avoided by the administration of
BEREX-the NON-TOXIC product of choice
because it provides, in tablet form, an easily
administered and scientifically-balanced
combination of calcium succinate and acetyl-
salicylic acid.
Full details concerning BEREX in the treatment of acute and chronic rheumatism, with
extensive bibliography, available on request.
Available in bottles of 100 and 500 tablets.
Patented 1949. Manufactured under License from the Proprietors.
BEREX is the trademark of this product.
BEREX Pharmacal Company   •   36-48 Caledonia Road   •   Toronto, Canada
H
nifp
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•
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nada
J^^^fl^l            1^^9 \"&>
A Significant
Advance Against
Tuberculosis...
Established
Therapeutic
Efficacy
^Stce^toMcin
CdciuniChloride
Complex Mer^
Streptomycin Calcium Chloride
Complex Merck, ever since its
introduction, has been a preferred
form of this valuable antibiotic,
characterized by uniform
potency and minimum pain on
injection. The Merck crystallization
procedure assures chemical purity.
Dihydrostreptomycin Sulfate
Merck, produced by the catalytic
hydrogenation of crystalline
streptomycin calcium chloride
complex, is a distinct
chemical and pharmacologic
entity of uniformly high
purity and stability.
These two antibiotics are
valuable companion
products that will care for
every contingency in which
streptomycin therapy is
recognized as of value.
iHrck
MONTREAL
MERCK & CO. Limited ^ilaMiuhcic/itiinv %/ie/nid/^   TORONTO
VALLEYFIELD an improved Triple Sulfa containing
SULFA ,^\AZINE
TRIPANCA
*
advantages
Contains no sulfathiazole thus avoiding the high incidence of
toxic symptoms resulting from the use of this drug.
> Contains three closely related sulfonamides reducing to a minimum the possibility of reciprocal sensitization to other sulfonamides.
An effective therapeutic blood level may be maintained which is
well below that at which crystalluria with resultant kidney damage usually develops.
how supplied
LIQUID
A pleasantly flavoured
uniform suspension
containing 5 grains
of sulfa in each teaspoonful.
Supplied in 16 ozs.,
80 ozs., and 160 ozs.
bottles.
TABLETS
A compressed tablet
creased to facilitate
divided dosage containing 7.5 grains of
sulfa.
Supplied in bottles of
100,  500  and .1000
tablets.
ANGLO-CANADIAN DRUG
COMPANY LIMITED
OSHAWA CANADA '*/>>>'.
v*Wrh--
['£$
" Calcium - Sandoz
95
(Calcium Gluconogalacto Gluconate)
Reduction of cellular permeability
INSECT BITES - EXUDATIVE DIATHESIS - INFLAMMATIONS
Suppression of allergic and anaphylactic reactions
CONTACT DERMATITIS - HAY FEVER - SERUM SHOCK
Sedation of neuro-muscular irritability
SPASMOPHILIA  -   CALCIUM DEFICIENCIES
Granules - Chocolate and Effervescent Tablets - Ampoules
"Calcium-Sandoz Ampoules Never Cloud"
f
V
*Calcibronat-Sandoz
(Calcium Bromide Lactobionate)
Bromide Sedation with Calcium Medication
ITCHING DERMATOSES - ALLERGIC  CONDITIONS - SPASMOPHILIA
| ANXIETY - NERVOUS ERETHISM
Granules -  Effervescent Tablets - Ampoules
SANDOZ
LITERATURE AND SAMPLES ON REQUEST
SANDOZ PHARMACEUTICALS LTD,
391 ST. JAMES STREET WEST
MONTREAL, P. Q.

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