History of Nursing in Pacific Canada

The Vancouver Medical Association Bulletin: July, 1937 Vancouver Medical Association Jul 31, 1937

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 The BULLETIN
OF THE
VANCOUVER MEMSAB
I ASSOCIATIONS'
»1. XIII.
JULY,  1937
No. 10
Jin This Issue:
SUMMER SCHOOL
B. C. MEDICAL ASSOCIATION ANNUAL MEETING
September 13th to 15th, 15>37
TUMOURS OF THE NECK
TUMOURS OF THE LIP and ORAL CAVITY§ BULKETTS
(With Cascara and Bile Salts)
. . FOR . .
Chronic  Habitual
Constipation
BULKETTS POSSESS ENORMOUS BULK
PRODUCING PROPERTIES AND BEING
PROCESSED WITH CASCARA AND
BILE SALTS PRODUCE BULK WITH
MOTILITY.
WE WILL BE PLEASED TO PROVIDE
ORIGINAL CONTAINERS FOR TRIAL
ON REQUEST.
Western Wholesale Drug
(1928) Limited
456 broadway west
vancouver|- British Columbia
(Or at all Vancouver Drug Co. Stores)
■ THE   VANCOUVER   MEDICAL   ASSOCIATION
BULLETIN
Published Monthly under the Auspices of the Vancouver Medical Association
in the interests of the Medical Profession.
Offices:
203 Medical-Dental Building, Georgia Street, Vancouver, B. C.
Editorial Board:
Dr. J. H. MacDermot
Dr. M. McC. Baird Dr. D. E. H. Cleveland
All communications to be addressed to the Editor at the above address
Vol. XIII.
JULY. 1937
OFFICERS  1937-1938
Dr. G. H. Clement Dr. Lavell H. Leeson Dr. W. T. Ewing
Presiden t Vice-Presiden t Past President
Dr. W. T. Lockhart Dr. A. M. Agnew
Hon. Treasurer Hon. Secretary
Additional Members of Executive—Dr. J. R. Neilson, Dr. J. P. Bilodeau.
TRUSTEES:
Db. F. Brodie Dr. J. A. Gillespie Dr. P. P. Patterson
Historian: Dr. W. D. Keith
Auditors: Messrs. Shaw, Salter & Plommer.
Library
Dr. S. Paulin
Dr. W. F. Emmons
Dr. R. Huggard
Dr. A. W. Bagnall
Dr. H. A. Rawlings
Dr. R. Palmer
SECTIONS
Clinical Section
Dr. R. Palmer Chairman     Dr. W. W. Simpson Secretary
Eye, Ear, Nose and Throat
Dr. L. H. Leeson Chairman     Dr. S. G. Elliott Secretary
Pediatric Section
Dr. G. A. Lamont— Chairman    Dr. J. R. Davies..  Secretary
Cancer Section
Dr. B. J. Harrison Chairman    Dr. Roy Huggarp     .Secretary
STANDING COMMITTEES
Dinner
Dr. G. F. Strong
Dr. R. Huggard
J)r. D. D. Freeze
Publications
Dr. J. H. MacDermot
Dr. D. E. H. Cleveland
Dr. Murray Baird
Summer School
Dr. A. C. Frost
Dr. R. Mustard
Dr. J. R. Naden
Db. H. A. DesBrisay
Dr. A. B. Schinbein
Dr. A. Y. McNair
Credentials
Dr. A. B. Schinbein
Dr. D. M. Meekison
Dr. F. J. Buller
Metropolitan Health Board
Advisory Committee
Dr. W. T. Ewing
Dr. H. A. Spohn
Dr. F. J. Buller
Representative to B. C. Medical Association—Dr. Neil McDougall.
Sickness and Benevolent Fund—The President—The Tbustees
V. 0. N. Advisory Board
Dr. I. Day
Dr. G. A. Lamont
Dr. Keith Burwell TETANUS...
PROPHYLAXIS
Modern practice calls for prompt administration of tetanus
antitoxin in conjunction with surgical treatment of contused
and puncture wounds. Depending on the extent of the injury,
either 1500 units or 3000 units (3000 or 6000 international
units) of this antitoxin should be given as a prophylactic.
The value of this procedure is evidenced by the fact that few
of the forty deaths from tetanus recorded in Canada last year
resulted from injuries treated in hospitals where the procedure is followed as a matter of routine.
Recent studies have demonstrated the efficacy of tetanus
toxoid in active immunization. A series of three doses of this
product affords protection against tetanus comparable to
the protection against diphtheria which is conferred by the
administration of diphtheria toxoid. This is of special interest,
to persons engaged in certain occupations in winch the
menace of tetanus is relatively great.
TREATMENT
In treatment of tetanus the usefulness of tetanus antitoxin
has been well established. To be properly effective, howrever,
the antitoxin must be administered as promptly as possible
and in large quantities. With this in mind the tetanus antitoxin prepared in the Connaught Laboratories is mose carefully refined and concentrated for use intramuscularly, intravenously and intra spinally.
CONNAUGHT LABORATORIES
UNIVERSITY OF TORONTO
TORONTO 5      •      CANADA
Depot for British Columbia
Macdonald's Prescriptions Limited
MEDICAL-DENTAL BUILDING, VANCOUVER, B. C. VANCOUVER HEALTH DEPARTMENT
STATISTICS—MxlY, 1937
Total Population—estimated  253,363
Japanese Population—estimated      8,522
Chinese Population—estimated      7,765
Hindu Population—estimated         352
Rate per 1,000
Number       Population
Total deaths    207 9.6
Japanese deaths        5 6.9
Chinese deaths        10 15.2
Deaths—residents only    181 8.4
BIRTH REGISTRATIONS—
Male, 191; female, 203    394 18.3
INFANTILE MORTALITY— May, 1937      May, 1936
Deaths under one year of age        8 5
Death rate—per 1,000 births..      20.3 18.9
Stillbirths (not included in above)      10 5
CASES OF COMMUNICABLE DISEASES REPORTED IN THE CITY
April
Cases
Smallpox  0
Scarlet Fever  26
Diphtheria    1
Chicken Pox  59
Measles   47
Rubella    2
Mumps    126
Whooping Cough  23
Typhoid Fever  0
Undulant Fever  1
Poliomyelitis    0
Tuberculosis    40
Meningitis (Epidemic)  0
Erysipelas i  7
June
1st
t, 1937
May
1937
to 15th,
1937
Deaths
Cases
Deaths
Cases Deaths
0
0
0
0
0
1
38
0
13
0
0
0
0
0
0
0
119
0
33
0
0
5
0
5
0
m
, 2
0
1
0
0
105
0
55
0
0
16
0
5
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
21
23
24
15
0
0
0
0
0
1
2
0
• 2
0
Colonic Irrigation Institute
Superintendent: E. M. LEONARD, R.N.
Fast Graduate Mayo Bros.
Up-to-date treatment rooms; scientific care for cases such as Colitis,
Constipation, Worms, Gastro-intestinal Disturbances, Diarrhoea,
Diverticulitis, Rheumatism, Arthritis, Acne.
INDIVIDUAL TREATMENT $2.50; ENTIRE COURSE $10.00.
MEDICATION (If Necessary), $1 to $3 EXTRA
631 BIRKS BUILDING, VANCOUVER, B. C.   SEY. 2443
506-7 CAMPBELL BUILDING, VICTORIA, B.C.   EMPIRE 2721
W0t    f    Wf»    «f    ■»■    ■_.      ■_.
Page 198 OF HYPERTENSIVE
HEADACHES
RELIEVED
FOR rapid, efficient and safe relief of high
blood pressure and its associated symptoms, you can rely on Hypotensyl.
This is a synergistic combination of dependable hypotensive agents—Viscum album ( Au-
ropean mistletoe) and hepatic and insulin-free
pancreatic extracts. It hastens recovery and
wins your patient's confidence.
Viscum album has proven remarkably effective for relief of hypertension (O'Hare and
Hoyt 1928, Barrow 1930 and Danzer 1934).
Frequently Hypotensyl effects a reduction of
20 to 30 mm. Hg. in 12 hours. Headaches and
dizziness vanish and reduction is sustained.
Excellent results are obtained in cases of essential hypertension or benign hyperpiesia.
Hypotensyl is also efficacious in treatment of
high blood pressure accompanying pregnancy
or due to fibrotic kidney. The benefit obtained
from careful control of diet, as well as mental
and physical rest, is accentuated by Hypotensyl.
The usual dose is 3 to 6 tablets daily, one-
half hour before meals. Best results are
obtained when treatment is given in courses
lasting two to three weeks, with a week's
interval between, upplied in bottles of 50
and 500 tablets.
HYPOTENSYL
The Anglo-French  Drug Company
3 54 St. Catherine Street East Montreal, Quebec EDITOR'S PAGE
Elsewhere in the Bulletin we are publishing advance notices of the
Annual Meeting of the B. C. Medical Association in September. This session
will also be the occasion of the Annual Meeting of the British Columbia
College of Physicians and Surgeons.
We urge our readers to consider carefully the notice referred to. It has
been written by the Executive Secretary of the B. C. Medical Association,
Dr. M. W. Thomas, and it will be seen that several entirely new and original
features are introduced. There is an excellent scientific programme, which
we cannot afford to miss; but great stress will also be laid, first on medical
organization and medical economics; secondly, on public health (in this
connection the intimate interrelation that should exist between preventive
and curative medicine will be emphasized) ; thirdly, on what one might call
departmental matters, coroners' work, contract work, etc.
This bids fair to be a meeting of very great significance. We are moving
out into clearer light and wider horizons. We are beginning to see other ships
and find that they with us form a great fleet, a mighty Armada of Medicine.
The crews of these other ships, though their vessels may vary in size, are
like men with us, and have the same loyalties and the same port in view.
The ships have different functions: there are the lordly liners, and the lowly
cargo-boats and the grimy tramps, but they are all part of one great service,
and the bond that unites them can never be broken by any but ourselves,
the crews. Kipling's words come to our minds:
"The game is more than the player of the game
And the ship is more than the crew."
We must get a hotter glow in our union; before we can be firmly welded
there must be white heat. We need to talk union more—to think it more—to
demand it, and to work for it ourselves. We must not only refuse to listen to
defeatism—we must burn it out by the] flame of our own keenness for unity
and close federation. We are waiting anxiously to hear about the meeting of
the Canadian Medical Association. How is federation getting on? How soon
shall we have it ? Why have we not got it yet ? These are questions we should
ask, and to which we should take no hesitating or ambiguous answer. We
have only to take one step forward, and we shall have put behind us, let us
hope for ever, provincialism and sectionalism and parish-pump politics. As
a Canadian profession we can be a power: not for selfish ends, for that, we
hope, will never be our aim, but a power for the betterment of social conditions in our country. These and many other things will, we hope, be discussed in September, and we should all be there to take part in the discussion. These be stirring days, my masters: and there is something exciting in
the air: we are beginning to "go places."
SPECIAL NOTICE
LIBRARY HOURS IN JULY AND AUGUST
During the months of July and August the Librarian will be
on duty from 9 a.m. until 5 p.m. instead of from
10 a.m. until 6 p.m.
J
Page 199 NEWS AND NOTES
Dr. C. H. Vrooman left for the Eastern States early in June. He will
attend the Annual meeting of the American Medical Association at Atlantic
City while he is in the east.
* *     *     *
Dr. A. W. Hunter is attending the meeting of the American Urological
Association in Minneapolis from June 28th to July 1st, and then will visfji
Detroit, Montreal, and Durham, in Ontario.
...      ♦
Dr. H. Dyer has recently returned from a three months' visit in England.
m ■_■ •F V
Dr. W. H. Hatfield returned recently from a visit to Eastern cities and
the Mayo Clinic.
* *     *     *
Congratulations are in order to Dr. and Mrs. Learoyd on the birth of a
daughter at St. Paul's Hospital on June 1st.
* *     *     *
Dr. and Mrs. Harold Caple returned in June from England, where for the
past two years Dr. Caple has been engaged in post-graduate work in various
large cities. Dr. and Mrs. Caple motored across the continent, and will now
make their home in Vancouver again. Dr. Caple will occupy offices in the
Medical-Dental Building.
.      *      *     ♦
We offer sincere good wishes to Dr. and Mrs. G. C. Large, who were
married in New Westminster on June 19th. Mrs. Large was Miss Evelyn
Trapp, a sister of Dr. Ethlyn Trapp, and Dr. Large is well known in Vancouver.
sp •> «|* m
Weddings are always a part of the June news items. Dr. Hugh J. Alexander of Vancouver was married on June 3rd to Miss Mary H. Stevens of
Edmundston, N.B. Dr. Alexander has been in Montreal for some years, but
is now returning to Vancouver, motoring out with his bride from New
Brunswick.
We extend our sympathy to Dr. H. W. Riggs on the death of his mother,
Mrs. Robert Riggs, who died on June 7th at Pasadena, California.
f 1* v 1*
Holiday schedules have been arranged in the offices of the College and the
Vancouver Medical Association. Miss Jean Balfour left in June for an
extended trip to the prairies. She will probably be away for several weeks.
Mrs. Bender will be away during the last two weeks of July and the Librarian
will be away for one week early in July.
* m m "P
Dr. Earle Hall left in June for Chicago to attend a reunion of former
assistants of Dr. H. L. Kretschmer, Professor of Urology at Rush Medical
College of the University of Chicago. During the past twenty-five years Dr.
Kretschmer has trained eighteen men who during their course of training
acted as assistants in his work—Dr. Hall being one of them. This is the first
reunion of this kind. Dr. Hall also plans to attend the annual meeting of the
American Urological Asso'ciation, to be held in Minneapolis, and before he
took in any of the academic work he saw the Braddock-Louis fight!
V _(■ S(S sp
Dr. R. D. Coddington has taken up practice in Vancouver, having opened
offices in the Vancouver Block. Dr. Coddington has recently returned from
Great Britain, where he devoted himself to post-graduate work during the
past two or three years. Prior to his departure he was actively engaged in
practice in this Province in Blakeburn and Coalmont.
Page 200 Dr. and Mrs. Ernest A. Campbell of Essondale are receiving congratulations on the birth of a daughter on June 4th.
* #     *     #
Dr. and Mrs. T. G. B. Caunt of Essondale have been blessed by the happy
arrival of their first-born—a son—on June loth.
* *     *     *
We wish to tender congratulations to Dr. and Mrs. R. D. Coddington on
the birth of a son on June 9th.
* *     #     #
Dr. L. C. Steindel, formerly at St. Joseph's Hospital in Victoria, is now
associated with Dr. R. B. Brummitt of Smithers.
* *     *     *
Dr. W. 0. Pitts and wife are leaving practice at Fraser Lake and will
take up residence in Victoria while Dr. Pitts is doing special work at the
Royal Jubilee Hospital.
* *      *      *
Dr. J. C. Poole and Mrs. Poole (formerly Dr. Lois F. Stephens, daughter
of Dr. George Stephens of the Winnipeg General Hospital), who have recently
been married, are going to Fraser Lake to take over the practice vacated by
Dr. W. C. Pitts' departure. Dr. and Mrs. Poole were both serving as internes
at the Vancouver General Hospital, and go to their new home and field of
endeavour with the best wishes of the profession.
♦ ♦ ♦ ♦
Dr. C. H. Beevor-Potts of Cowichan Lake has been appointed Medical
Health Officer and School Health Inspector for Cowichan Lake area (including Youbou and Cowichan Lake schools).
3p 3p •? SfS
Dr. J. V. Murray of Creston has been appointed temporary Medical Health
Officer and temporary School Health Inspector for Creston area.
♦ ♦ ♦ ♦
Dr. H. E. Cannon of Blakeburn will be absent from the Province during
the next few months, doing post-graduate work in Eastern Canada and
United States.
* *     *
Dr. H. J. Alexander is temporarily!doing the practice at Blakeburn during
Dr. Cannon's absence.
* ♦     ♦
Dr. G. E. Bayfield of West Vancouver will be serving with the Columbia
Coast Mission, with headquarters at Rock Bay, during the summer months.
ap ♦ ♦ sp
Dr. J. P. Gussin will be associated with Dr. A. E. Perry of Port Simpson
in the Essington Hospital during the fishing season.
*_■ st- s»- .;-
Dr. J. M. MacKinnon, a recent registrant in this Province, who has been
an interne- in the Royal Jubilee Hospital at Victoria, will be associated in
the practice of Dr. J. M. Fowler of Victoria.
Dr. C. E. Derkson has taken up practice in Vancouver and will occupy
offices with Dr. W. Elliot Harrison in the Vancouver Block.
* ♦      ♦      ♦
Dr. L. G. C. d'Easum of Atlin is coming out of the far North for a respite
and post-graduate study.
•P *P *P sp
Dr. F. B. Roth, who has been an interne at St. Paul's Hospital, has left
for Atlin, where he will do locum tenens for Dr. d'Easum during two summer
months.
* *     *     *
Dr. Wm. Bramley-Moore of Blue River will be absent from the Province
during four months doing post-graduate work.
Page 201 DR. GORDON E. STANLEY
THE passing of Doctor Gordon £. Stanley has saddened his medical
friends in that this bright young man had just ventured into the
first years of what promised to be a successful career. His relationship
and letters to the Registrar of The College of Physicians and Surgeons
■were marked by ambition and courage and a justifiable optimism in his
medical life.
Dr. Stanley was assistant to Dr. Leonard B. Wrinch at Hazelton
when he developed the illness to which he succumbed on May 24th, 1937.
Dr. Stanley was a native son of British Columbia, attending High School
in Nelson. Following graduation from the University of Alberta in 1934
he did two years' hospital work, and after securing Dominion and
Provincial registration in 193 6 he worked with Dr. Thomas 0*Hagan of
Jasper Park, and then came to Hazelton. Both Dr. O'Hagan and Dr.
Wrinch were much impressed by his sterling qualities and bespoke for
him a future full of promise.
His parents, Mr. and Mrs. A. B. S. Stanley, 2537 Woodland Drive,
Vancouver, have the sincere sympathy of his professional colleagues, who
understand the full extent of this loss and the disappointment which
such a bereavement carries. —M   W   T
DR. F. J. COULTHARD
THE passing of Dr. Coulthard marks the uprooting of another Vancouver landmark. The writer remembers vividly, when he came to
Vancouver thirty years ago, meeting Dr. Coulthard, and the friendly,
cordial welcome that he was given by our late friend, who was then a
busy practitioner. In late years, the affliction of deafness gradually
narrowed his field of activity and he was less and less seen by his colleagues, to most of 'whom in late years he was but a name.
He was, however, one of our good citizens: always keenly interested
in the arts, especially perhaps music, popular, a good clubman, and "with
many friends. His wife, a well-known musical artist, died a short
time ago.
DR. H. E. LANGIS
WHEN the medical history of Vancouver comes to be written, Dr.
H. E. Langis will appear as one of the colourful characters of its
Dramatis Personae. The younger generation of medical men knew him
not at all—but there is a generation of practitioners here who always
indulge in a reminiscent chuckle when they speak of "old Langis."
He retired from active practice many years ago, twenty-five or more.
While in practice, he was one of the busiest and easily one of the most
popular medical men that ever lived here. His nationality and his general
make-up predisposed him to an intense humanism. He was friendly with
everyone: genuinely friendly. He had an immense tolerance for the
weaknesses and frailties of mankind, a delightful wit—somewhat
Rabelaisian in spots—and a genuine gift of humour and a love of people.
He had no snobbishness in him, and those at whom society generally
looks askance found in him a friend and adviser and helper.
He had the sense to retire to the life he preferred, that of a farmer,
as soon as he was able, and on his farm he lived out a long and happy
life. Every little while he was to be seen strolling along the streets of
Vancouver, stopped every few yards by someone who knew him, and so
liked him. His old patients still speak affectionately of him, and will miss
him greatly.
Page 202 Dr. E. Aiello, who has been an interne at the Vancouver General Hospital,
will relieve Dr. Bramley-Moore in the practice at Blue River.
H* sp sp ♦
The Fraser Valley Medical Society held its annual meeting on June 10th,
when the following officers were elected: President, Dr. C. Roydon Learn, of
Sapperton; Vice-President, Dr. E. W. Wylde, New Westminster; Secretary-
Treasurer, Dr. L. R. Williams, New Westminster; Dr. L. S. Chipperfield, of
Coquitlam, is Chairman of the Programme Committee.
Dr. K. L. Wray-Johnston, who has been serving with the Columbia Coast
Mission at the hospital at Rock Bay, is leaving on an extended visit to Great
Britain, where he will do post-graduate work in London and Edinburgh.
Dr. F. H. Stringer has returned to the Province and will carry on the work
at Rock Bay during Dr. Wray-Johnston's absence.
ap sje ap 3p
Dr. R. If Nodwell, formerly in general practice in Victoria, is now on the
permanent force and as an officer in the Royal Canadian Army Medical Corps
is Medical Officer to the Royal Canadian Air Force at Jericho.
sp sp sp Sp
Dr. J. A. Taylor, who has been an interne at the Vancouver General Hospital, will be associated with Dr. G. B. Henderson and Dr. J. V. Murray in
practice at Creston.
IMPORTANT NOTICE
APPOINTMENTS and CONTRACTS
Members of the College of Physicians and Surgeons of British
Columbia ARE REQUESTED NOT TO APPLY for any APPOINTMENT or enter into negotiation with reference to any CONTRACT
without having first communicated with either or both:—
DR. A. J. MACLACHLAN, Registrar,
COLLEGE OF PHYSICIANS & SURGEONS OF B. C.
or/and DR. M. W. THOMAS, Executive Secretary,
COLLEGE OF PHYSICIANS & SURGEONS OF B. C.
THE BRITISH COLUMBIA MEDICAL
ASSOCIATION        I I
FORTY-FIFTH ANNUAL MEETING
SEPTEMBER 13th, 14th and 15th, 1937
VANCOUVER, B. C.
Headquarters: Hotel Georgia
The Executive of the B. C. Medical Association and its Committee on
Programme is at this date ready to announce a full three-day programme
for the Annual Meeting in September.
Those who will present papers include: Dr. Burgess Gordon, Associate
Professor of Medicine, Jefferson Medical College; Dr. Myron O. Henry,
Orthopaedic Surgeon, of Minneapolis; Dr. Edwin Eugene Osgood of the
Faculty of Medicine, University of Oregon, Portland; Dr. M. R. MacCharles,
Department of Clinical Surgery, University of Manitoba : Dr. J. D. Adamson,
Page 208 Associate Professor of Medicine, University of Manitoba; Dr. T. H. Leggett
of Ottawa, President, Canadian Medical Association, and Dr. T. C. Routley,
General Secretary, Canadian Medical Association.
The subjects covered by the various speakers will be sufficiently divers!--
fied to provide much of interest to the entire membership.
The Executive anticipates a large attendance and has set up a complete
organization to serve the members, their parties and all visitors. This convention should present a strong appeal to the profession because it is its
annual meeting.
The Annual Meeting of the College of Physicians and Surgeons will be
held on the evening of the second day and that is one session which every
member should plan to attend.
New features to be introduced this year should have a widespread appeal:
1. Round table conferences. Scientific Sections.
2. Lectures and demonstrations of newer technique—diagnostic procedures and aids—newer methods of treatment and their application—-
clinical demonstrations.
3. Special sessions: (a) Health Officers and School Medical Inspectors.
Papers—discussion—round table conference, (b) Contract Practice:
Papers and discussions on the economic phase of this type of practice,
(c) Coroners. Papers and discussion.
4. Special entertainment for ladies and juniors.
Round Table Conferences—Scientific Study Sessions
This method of introducing study groups into scientific programmes has
proven popular largely because of the real value of such conferences. It is
planned to interpose such conferences during the morning session. Three or
four such groups would meet in separate rooms and one would choose the
subject in which he is most interested. Such subjects as Diabetes, Orthopaedics, Cardiac clinic, Paediatrics, Obstetrics would be allotted to the groups.
These conferences would be held in the hotel and not disrupt the morning
series of lectures.
Practical Medicine Hour Each Morning at 11 o'clock
The clinical meetings will not replace all the papers, but the Committee
wishes to offer the members an opportunity to observe newer methods used
in diagnosis and the laboratory, more recent technique in procedure and latest
forms of treatment and their application. This feature is planned to give men
something of value in actual practice.
Special Sessions on Health, Contracts and Coroners
The conference on the Health programme in this Province should interest
every member and will be open to all. The various phases of the work and
its relation to modern practice will be explained. The activities of the Metropolitan Health Board in Greater Vancouver will be outlined, Health Units
will be defined, Medical Inspection of Schools, Milk Problems, the programme
of the Tuberculosis Division and of the Division of Venereal Disease Control
will be open for free discussion. Much information should be disseminated
and a better understanding of the many ramifications of the Public Health
phase of our work should produce a fuller co-operation among all our membership towards a fuller and better preventive medicine in B. C.
Dr. T. C. Routley on European Experiences
Dr. Routley has had a unique opportunity presented of studying conditions of practice in Europe in a very intensive survey during a three months'
sojourn on the Continent. This information will be presented and discussed
at the Annual Meeting of the College of Physicians and Surgeons and should
be heard firsthand, as much of it will not be published.
Page 20k To the Ladies
The Ladies of the profession are urged to come to Vancouver during the
Annual Meeting, September 13th, 14th and 15th, and they will find a busy
three days awaiting them. A Reception Committee will ask them to register
and signify their choice of a full programme of social features. If you can
plan ahead it is requested that you advise this office that you are coming.
This is also the Ladies' Annual Meeting.
The Hotel Georgia Is the Convention Headquarters
The management of the Hotel Georgia has generously placed at the disposal of the Association all the facilities of the Hotel. In the past it has been
necessary to pay for lecture-hall, etc., but these charges have been waived.
We gratefully acknowledge this friendly gesture by the management of the
Hotel Georgia
The management of the Hotel Georgia suggests that early reservations
will be helpful and much appreciated.
THE SUMMER SCHOOL
The Summer School of 1937 has passed into history, and it remains for
us to hold a careful postmortem on its remains, as all good and pathologically-
minded editors should do. This is not with a view to ascertaining causes of
death, but that we may find hints and suggestions to hand on to later generations charged with the conduct of subsequent Summer Schools. Bridge experts
say that the post-mortem held after each hand can teach the learner more
quickly and effectively than anything else, and perhaps it is so in this
case too.
Speaking as one who earnestly tried to attend as many lectures as he
could, the Editor has just this to say: Every lecture he attended, without
exception, was worth many times the small fee he paid for the whole course.
If we had heard nothing but that epoch-making address of Dr. Rowntree's
on Friday morning, we should still have felt that the autocratic gentleman
who held us up and made us sign a cheque for $7.50 some weeks ago was a
first cousin of Santa Claus, and in reality a benefactor of the human race.
But there was much more to it than this. We honestly think that this has
been one of the best of a long series of very good Schools. There was not a poor
address, nor a poor speaker. It is hard to institute comparisons, and we shall
not try. Every one of the speakers gave generously of a wealth of material
which must have impressed us all.
The programme was splendidly arranged. We feel that the increase in
clinics was a good move, and the devotion of each evening to a subject, presented in the form of a symposium, gave a comprehensiveness and completeness to the presentation that cannot be obtained in any other way. The
presentation of arthritis, for instance, from the angle of pathology, followed
by the medical, then the surgical considerations of the disease, made a most
valuable contribution. The same must be said of the other symposia.
The attendance was, if not the biggest, surely almost the biggest we have
had. This is, of course, gratifying from a purely material point of view, but
it has other aspects. First, as to those registered. The great majority, of
course, were from the Greater Vancouver area, and this includes North
Vancouver and New Westminster, but there were a great many men from
out of town. Alberta, Saskatchewan and Manitoba sent their contingents, and
there were many from Oregon, Washington and California. The various areas
of British Columbia, too, were well represented, and altogether, the Summer
School can be seen to be developing into a definite institution which gives a
recognized educational service to the Pacific Northwest. This is a matter of
great pride to all of us who feel that Vancouver is capable of becoming a real
medical centre, but it also imposes certain responsibilities on us to see that
Page 205 the standard of the Summer School is maintained at its high level, and raised
even higher as opportunity affords. The great merit of the Summer School
Committees of the past few years is that they have consistently put quality
first, and they are now reaping their reward. Bring the right men here, give
them the facilities for lectures and clinics, and we shall never have the
slightest difficulty in securing attendance. One had only to listen to the comments on this School from every quarter to realise that the Vancouver
Summer School is definitely established as an educational entity. We cannot
but congratulate the Committee on their farsightedness and courage.
The machinery, too, of the School was in splendid running order. Everything went so very smoothly that it seemed uncanny. The loud-speaker
system, installed by Murray's Limited, was the best we have ever had,
and made every part of the room a good spot to hear from. There were
occasionally some queer sound effects when the lapel gadget fell on the floor
or was struck by the pointer held in the speaker's hand, but it was an
admirable system, and a great improvement on previous years.
The staff work, headed by Dr. J. R. Naden, was also excellent, and we
owe sincere gratitude to Miss Choate, our Librarian, and Miss Smith, her
assistant: these two ladies sat at the receipt of custom from 9 a.m. to 12
p.m., took messages, answered questions, never seemed flurried or in a
hurry, and never, as far as one could see, took time off for eating or rest
One takes these things for granted altogether too easily; our enjoyment of
the programme, and our satisfaction and profit therefrom, are largely conditioned by this perfect service "at the door."
We were fortunate, too, in having a full-time stenographer this year, Mrs.
G. Ellis, and we feel that this will have been of great value in obtaining this
material for future reference, and for recording in the Bulletin.
It is very interesting to note the changes that have been made in the
technique, if one may use the phrase, of lecturing at this type of medical
meeting: changes, we feel, entirely for the better. The old method was the
reading of papers, admirably written, meticulously prepared, but unrelieved
by illustration. Twenty minutes is the limit for such a paper, and twenty
minutes is not very long; moreover, the congregation fell asleep. Gradually
the introduction of the serial use of slides has come to be the backbone of
the lecture. The speaker devotes an hour to the subject, and uses his slides
as texts. The hour slides by with amazing speed, everyone is interested
every minute of the time, and an hour gives a speaker full time to give a really
worth-while coverage of his subject. The visual appeal adds immensely to
the permanence of the impression made, and there is no fatigue involved in
listening. That this is so is proven by the way in which men sat through
one lecture after another, with no weariness and no satiety. It is a great
improvement.
One speaker, we feel, deserves our special gratitude. Dr. Boyd, of Winnipeg, was suffering all week from a laryngitis, which got steadily worse,
till talking must have been an agony. It was, undoubtedly, quite wrong that
he should have had to talk so much with a larynx which, from his description at secondhand from his laryngologist, must have looked like a Chamber
of Horrors, and we can only hope that no serious harm has been done. But
he kept on with his work, and, thanks to his generosity and courage, we were
not deprived of what were undoubtedly most essential parts of the subjects
dealt with. He jested at his own scars and was careful not to let his own
discomfort appear more than he could possibly help; but there is no doubt
that he was quite a sick man.
One other advantage of a week of this sort is that one learns to know
each individual speaker, and to like him for himself as well as for what he
gives. Also one learns to appreciate the true metal of these men, each <
whom is a leader in medicine. One is lost in wonder at the wide vision and
deep erudition of a -man like Dr. Rowntree, for instance, whose unforgettable
lecture on the thymus and pineal and other glands, climaxed by his descrip-
Paae 206 tion of the work now in progress with regard to the causation of carcinoma,
was perhaps the highlight of the School; and as one sees the keenness and
inexhaustible vitality of Dr. Magnusson, with his great capacity for detail,
with his passion for work and his amazing ingenuity, one realises why he
holds the rank he does. Again, hear Dr. Trueblood describe how he removes
a breast, and you see why he is justified, if any man is, in claiming so much
for surgery as against other methods of treatment. Then Dr. Brunn, whose
gift of humour and deep bass chuckle can not conceal the fact that he is
making real contributions to our study of chest conditions, and the adequate
treatment of intrathoracic infections; and, to return to Dr. Boyd for a minute,
one will not lightly forget his talk on nephritis, and the simple ease with
which he weaves the warp of pathology into the woof of clinical knowledge
and treatment, to make the finished fabric.
Have we any criticism? Not really—but there is, perhaps, one thing that
might be considered by subsequent committees. If we are going to ask people
to come to our School, we should remember that sitting in the most comfortable of chairs, in the most beautiful of rooms, listening to the best of
lectures, is not everything. Vancouver-is too big a place now to maintain this
attitude of indifference to its visitors. There was some entertainment, it is
true, for the ladies visiting, but it was not organised, and the cost of it fell
on the wrong shoulders. It is not for us to define or to do more than suggest
—but we are really glad to see these medical friends of ours, and many of
them know nobody here. We should, surely, provide some sort of relief and
entertainment for them—add to the plain roast beef and potatoes a dessert
and a savoury, and make the meal not only filling, but aesthetically satisfying.
We make this suggestion for what it is worth. This is not by way of criticism,
for there were difficulties and obstacles, no doubt, in the way of organising
any sort of entertainment, and the Summer School Committee owes no
apology to any one for its work this year; but one way of paying a tribute
to superlatively good work is to ask for more of the same, and it is in that
spirit that we make these humble suggestions. Meantime, our warmest thanks
to these gentlemen, and our sincerest congratulations.
*    .    *
One of the most gratifying features of the Summer School was the
unusually large attendance of doctors from outside Vancouver. Sixty-five
men registered from British Columbia, Alberta, Saskatchewan and Washington. From Victoria came Drs. R. A. Hunter, O. C. Lucas, Thos. Miller,
J. P. Vye and H. Winter. The New Westminster delegation consisted of
Drs. D. A. Clark, W. A. Clarke, F. R. G. Langston, S. C. MacEwen, W. J.
Millar, G. S. Purvis and G. T. Wilson. The following came from various parts
of the Province: Drs. F. M. Auld, Nelson; M. R. Basted, Trail; S. E. Beach,
Salmon Arm; G. A. Cheeseman, Field; C. A. Graves, Steveston; J. C.
Grimson, Ladner; W. E. Henderson, Chilliwack; W. D. Higgs, Port Alberni;
G. Inglis, Gibson's Landing; W. F. MacKay, Port Washington; Gordon
Johnston, Michel; N. H. Jones, Nelson; C. R. Learn, Sapperton; G. K. Mac-
Naughton, Cumberland; G. More, Shawnigan Lake; J. R. Parmalee, Penticton ; N. J. Paul, Squamish; G. A. Roberts, Chilliwack; C. R. Symes, Port
Moody; K. Terry, Tranquille; A. S. Underhill, Kelowna; S. A. Wallace,
Kamloops; Reba Willets, Kelowna; L. B. Wrinch, Hazelton.
From Alberta and Saskatchewan the following men were registered: Dr.
J. W. Bridge, Edson; Dr. Kraminsky, Regina ; Dr. T. K. MacLean, Coleman;
Dr. I. Steiman. Kamsack; Dr. F. E. Wait, Saskatoon; Drs. A. D. Konkin
of Saskatoon and J. Yakimishak of Vegreville were visitors at the School for
one session.
The contingent from Washington included the following: Dr. R. K.
Behrns, Mt. Vernon; Dr. A. H. Buis, Tacoma; Dr. R. B. Goglon, Yakima;
Dr. L. A. Greenwood, Bellingham; Dr. C. C. Hills, Custer; Dr. M. R. Mac-
Avelia, Mt. Vernon; Dr. R. C. McCartney, Oak Harbour; Dr. G. H. Mathis,
Toledo; Dr. J. R. Morrison, Bellingham; Dr. G. R. Marshall, Seattle; Dr.
S. Sawamura, Seattle; Dr. J. W. Schori, Bellevue; Dr. P. Whelan, Seattle.
Page 207 TUMOURS OF THE NECK
Dr. Wm. Bo_d, Winnipeg.
Presented at the Vancouver Medical Association Summer School, June, 1937.
When a patient walks into a doctor's office or into the outpatient department of a hospital with a mass or swelling of the neck, so many possibilities
crowd into the mind of the examiner that a state of mental confusion may
readily result. But the possibilities are limited, and if a definite plan of
campaign is followed it is much more likely that the final conclusion will be
a correct one. From a fairly extensive experience in a tumour clinic and in
a hospital outpatient department I have found the line of thought outlined
in the following pages to be of considerable use.
We shall use the word tumour in the clinical sense of a swelling, and this
swelling may be a cyst or a solid tumour. There are two possible sources from
which this swelling may arise: (1) the tissues of the neck, (2) the lymph
nodes. I propose to exclude certain readily recognized lesions such as enlargements of the thyroid, tumour of the parotid gland, and sarcoma of the
mandible.
The tumour may be in the middle line of the neck, or it may be lateral in
situation. If it is exactly in the middle line it is practically certain to be
congenital in origin, and this at once limits the possibilities to a very marked
degree. Indeed, the only conditions which need be considered are dermoid
cyst or tumour and thyroglossal cyst.
Dermoid cyst. As this is an inclusion dermoid produced by the inclusion
of epidermal structures in the deeper tissues of the neck during the process
of closure of the mid line, it is usually mesial in position. The cyst is lined by
stratified epithelium derived from the skin, and the wall naturally contains
the sebaceous glands which are derived from that layer. It is the secretion of
these glands which forms the characteristic sebaceous contents of the cyst.
The condition is essentially benign.
Thyroglossal cyst. This is formed from the thyroglossal dust which passes
from the foramen cecum of the tongue to the isthmus of the thyroid. The duct
itself is derived from the first branchial cleft. The lesion may be either a cyst
or a solid tumour. The cyst is lined by columnar ciliated epithelium. The
tumour presents the structure of the thyroid. A fistulous tract may open on
the skin, in which case the superficial part will be lined by squamous stratified epithelium and the deeper part by columnar ciliated epithelium. Perhaps
the most outstanding clinical fact is the complete immunity that these lesions
have from malignant change.
Of the lesions which arise from the lateral tissues of the neck, the most
important are branchial cyst, branchial carcinoma, cystic lymphangioma,
carotid body tumour, tumour of the lateral thyroids, and tumour of the parathyroid. So rare as merely to deserve mention are tumours of the nerve
sheaths (Schwannoma, perimurial fibroblastoma) and tumours of the cervical
sympathetic ganglia (ganglioneuroma).
Branchial cyst. The structure known to embryologists as the cervical sinus
is an elongated passage which extends from the tonsillar fossa above to the
anterior border of the sternomastoid in the lower part of the neck. It is ectodermal in origin, and represents the common chamber into which the ento-
dermal branchial or gill clefts open in the lower vertebrates such as the air-
breathing fishes. The thyroid is derived from the first cleft, the tonsil from
the second cleft, the thymus and carotid body from the third cleft, and the
lateral thyroids and parathyroids from the fourth cleft. It is evident that
lymphoid as well as epithelial elements are developed from the various clefts
(e.g., thymus).
The branchial cyst appears to arise from the cervical sinus, and as this is
an elongated structure it may occur at any point along a line from the tonsillar fossa to the lower part of the neck. The cyst, which usually appears
about the time of puberty, forms a rounded swelling which mav be of con-
p
age 208 siderable size. It is generally lined by squamous stratified epithelium, but if
it arises from the deeper part of the cleft the lining may be a columnar
ciliated epithelium. A characteristic feature of the cyst is the presence in its
wall of a large amount of lymphoid tissue, a fact readily understood when
the principles just enunciated are taken into consideration. The branchial
fistula, with which we are not concerned here, has also a large amount of
lymphoid tissue in its wall.
Branchial carcinoma. Whilst branchial cysts are comparatively common,
carcinoma arising from branchial remnants and particularly from the cervical sinus is very rare, and is naturally difficult to diagnose clinically.
Occurring almost solely in men, it forms a hard mass in the region of the
bifurcation of the carotid artery, which infiltrates the surrounding tissues
and spreads to the regional lymph nodes. Although it is composed of squamous
epithelial cells, these show no tendency to cornification or cell-nest formation,
so that it belongs to the transitional cell type of tumour, of which more will
be heard presently.
Cystic lymphangioma. The condition known clinically as cystic hygroma
is a watery tumour occurring in the neck in children, usually just above the
clavicle but sometimes at higher levels. It is a true congenital lesion, probably
arising from sequestrated lymphatics which have failed to establish communication with veins. These swellings, which may attain a large size, are
seldom met with after puberty. They appear to undergo spontaneous regression, perhaps as the result of attacks of inflammation to which they are liable.
Carotid body tumour. A tumour of the carotid body naturally arises at
the bifurcation of the carotid artery. It forms a slowly-growing circumscribed
mass which commonly appears about the time of puberty. Although not infiltrative, it tends to surround the carotid artery and to involve the carotid
sinus, so that attempts at removal are attended by a high mortality. As the
carotid body belongs to the chromaffin system, the tumour may be regarded
as a chromaffinoma, usually benign in character, but occasionally involving
adjacent lymph nodes.
Lateral aberrant thyroid tumours. From the fourth branchial cleft arise
the masses known as the lateral thyroids, the parathyroids originating in the
same way. The stalk of the lateral thyroid buds becomes reduced to a fibrous
cord, but in rare cases the tissue majy persist as a chain of nodules in the
anterior or posterior triangles of the neck. Although they present an imperfect thyroid structure, they have a great tendency to a cystic papuliferous
change, as a result of which tumours are formed which may be either innocent or malignant. The distinction between the innocent and malignant papillary cystadenomas may be very difficult, for the malignancy is of low grade.
The tumours are likely to appear during adolescence or early adult life. The
tumour may be removed and a new one may take its place. I have seen four
tumours appear in the neck of the same patient at intervals of one or two
years. These are not recurrences, but fresh tumours arising from aberrant
thyroid tissue. The tumour may.attain a large size, as in another of our cases,
where the mass was the size of an orange and extended up as far as the
mastoid process. It will be seen that these tumours form a very distinct
entity. The lesion is supposed to be very rare, but this is probably a mistake,
for I have encountered three of these tumours in the course of the past
two years.
Parathyroid tumour. One of the most interesting tumours of the neck is
that arising from the parathyroid glands. The all-important disturbances of
calcium metabolism which are an expression of the overactivity of the
adenomatous mass and the strange skeletal lesions known as osteitis fibrosa
cystica are familiar to all of you. The tumour may arise from the superior
or inferior parathyroid on either side, and the resulting mass may be readily
palpable or it may be tucked away behind the deep fascia so that nothing
can be felt even at operation until the fascia has been divided. It would
appear that in rare cases the tumour may arise from aberrant parathyroid
Page 209 tissue which may be situated anywhere in the branchial area. One very char^
acteristic example which I examined was found by Dr. Gordon Fahrni to be
situated for the most part in the mediastium, and in one of Walton's cases
a tumour the size of a plum lay in front of the second and third dorsal vertebrae. It is evident that if the clinical and biochemical evidence points strongly
to the presence of a parathyroid adenoma, the surgeon must not rest content
until he has made a very thorough dissection of the neck.
TUMOURS OF THE LYMPH NODES
By far the commonest tumours of the neck are those involving the cervical
lymph nodes. These must be divided into the two great .groups of the primary
and secondary tumours. It may be very difficult to make this distinction
clinically, and even after a biopsy has been done the question may still be
in doubt. The reasons for these difficulties will develop as we proceed.
Primary lymph node tumours. In this division are included the three
great groups of lymphosarcoma, lymphatic leukaemia, and Hodgkin's disease.
There must always be a difference of opinion regarding the value of classification and the degree to which it may with advantage be carried. Classifiers
themselves can be divided into the two great groups of lumpers and splitters,
the lumper, with a rooted aversion to hair-splitting, brushes aside minor distinctions and performs a useful function by presenting us with a broad and
comprehensive view of the subject. The splitter is equally useful. By analysis
and subdivision he shows that perfectly distinct entities may have passed
unrecognized through being unjustifiably grouped together under a.common
heading. If we are lumpers we may collect the three conditions just named
into the one group of the lymphoblastomas or malignant lymphomas. If we
are splitters we may still further subdivide the primary conditions into
different varieties of lymphosarcoma and Hodgkin's disease. For our present
purpose we may play the dual role of lumper and splitter. In the former
capacity we may rearrange the grouping, whilst in the latter we may enquire
into the advisability of still further subdivision.
Leukaemia is commonly regarded as consisting of two main types, the
myelogenous and the lymphatic, and the leukaemic process itself is contrasted
with lymphosarcoma. The former is characterized by the appearance in the
blood of white cells which are abnormal in variety or amount, whilst in
lymphosarcoma the disease process is confined to the tissues, the blood
remaining unaltered. But closer analysis shows that this is a superficial way
of regarding the matter. The essential lesion in leukaemia is in the tissues, not
in the blood. Now there is no similarity between the lesions in the myelo-
geneous and lymphatic forms. The former is a neoplastic disease of the
myelocytic elements of the bone marrow, whilst the latter involves the
lymphoid tissues throughout the body. To group the two conditions under
a common hea ding merely because in both cases the neoplastic cells overflow
into the blood stream is to be guilty of an unphilosophic and narrow outlook.
On the other hand, there is a very close resemblance between lymphatic
leukaemia and lymphosarcoma. In both the essential lesion is a neoplastic
proliferation of the lymphoid tissue involving essentially the same -organs.
If the newly formed cells appear in the blood stream the process becomes
leukaemic; if they remain confined to the tissues the lesions are those of a
pure lymphosarcoma. The gap between the two is still further bridged by
the occasional occurrence of a transition of the one into the other. A case
may pursue the characteristic course of lymphosarcoma for a considerable
time, but towards the end the neoplastic cells may overflow into the blood,
giving a typical picture of lymphatic leukaemia.
As regards the differential diagnosis between the various forms of lymphoblastomas of the neck, a biopsy will usually serve to distinguish between
lymphosarcoma and Hodgkin's disease. The microscopic picture in the
lymphocytic type of lymphosarcoma and lymphatic leukaemia is identical, but
an examination of the blood film will make the distinction, for what it is
Page 210 worth. A greater difficulty lies in the differentiation between the reticulum
cell type of lymphosarcoma and certain forms of secondary carcinoma. In
one of my cases which was registered with the Registry of Lymphosarcoma,
some of the leading pathologists of the country favoured the first diagnosis,
while others voted for the second. This brings us to secondary carcinoma of
the cervical lymph nodes.
Secondary carcinoma of the lymph nodes. This forms the largest and
most important group of tumours of the neck. In my experience as a pathologist it is the first possibility which should be considered. It may be easy to
determine the source of the primary tumour from combined clinical and
biopsy examination, it may be difficult, or it may be impossible. As has just
been pointed out, it may even be hard to be certain if the lesion of the lymph
node is a secondary carcinoma. The most likely source of the primary tumour
is the lip, the tongue, the mouth, the breast, and the lung. In the first three
instances the carcinoma is of the epidermoid type, but the microscopic picture
may vary from one of complete differentiation with well marked cornification
and cell nest formation to an equally complete loss of differentiation. The
greater the anaplasia the more difficult will it be to determine from biopsy
the exact nature and location of the primary lesion. The length of time
which may elapse before the development of the secondary tumour in the
neck is sometimes remarkable. In a case which I studied recently the breast
had been removed for carcinoma ten years previously, and at the end of this
long interval a secondary mass appeared in the lymph nodes of the neck. Such
an occurrence is of great theoretical interest, because it must surely mean
that the malignant cells have lain dormant in the lymphoid tissue all these
years, and it demonstrates with deadly emphasis the difficulty of determining
when a patient has really been cured of carcinoma.
A tumour which deserves special consideration because of the ease with
which it may give rise to errors in diagnosis even after biopsy has been done
is the transitional cell carcinoma arising in the pharynx and nasopharynx. It
owes its name to the fact that it originates from epithelium which may be
regarded as transitional between a simple and a stratified type. It is also
known as lympho-epithelioma, because it frequently arises from epithelium
covering lymphoid tissue, and lymphocytes may be mingled with the carcinomatous cells. Its clinical importajnce lies in the fact that the primary
tumour may remain latent for a considerable time, tucked away in the
nasopharynx or the pyriform sinus, and manifest itself entirely by setting
up bulky metastases in the cervical lymph nodes which are readily mistaken
for lymphosarcoma. Even the biopsy may be misleading, because the sheets
of large, pale, undifferentiated cells of which the tumour is composed may
closely mimic the appearance seen in the reticulum cell type of lymphosarcoma. An instance of this difficulty has already been given. An important
feature is the fact that the tumour is markedly radiosensitive, but the ultimate prognosis is extremely bad, the patient sometimes dying of invasion of
the floor of the skull by the primary tumour.
The primary lesion to which the lymph node tumour is secondary may be
in the oesophagus. As this is an epidermoid carcinoma which is usually well
differentiated, and as no other source of an epidermoid tumour (lip, tongue,
skin) is evident, it is not difficult to arrive at a correct diagnosis.
At this point, however, we encounter another diagnostic pitfall. A not
uncommon but easily overlooked primary site is the bronchial tree. Bronchogenic carcinoma or primary carcinoma of the lung is a form of cancer which,
as everyone knows, is being diagnosed with very increasing frequency. Many
tumours which in the past have been regarded as lymphosarcoma of the
mediastinal glands with involvement of the lung are now recognized as
bronchogenic cancer metastasizing to the regional lymph nodes. The reason
for this mistake becomes evident when we consider the histologic appearance
of primary lung cancer. There is probably no form of tumour in which greater
variation of microscopic structure can occur. It may appear as a fully
Page 211 developed adenocarcinoma with abundant secretion of mucin, as a medullary
carcinoma composed of masses of cells with an attempt at acinar formation,
or as a highly anaplastic growth composed of small round cells so undifferentiated as to be distinguished with difficulty from a sarcoma apart from the
fact that a number of cells have a characteristically oval or oat-shaped form.
Many bronchial carcinomas resemble the transitional cell carcinoma in respect
to the latency of the primary growth and the early centrifugal spread with
widespread involvement of regional and more distant lymph nodes. In this
way a mass of considerable size may be formed in the neck at a time when
the primary growth in the lung is too small to be detected or to lead to bronchial obstruction. Assistance may be gained from the fact that the tumour
tends to spread by the blood stream as well as by the lymphatics, so that
there may be secondaries in the liver, bones or brain.
From this brief survey of the possibilities it becomes only too evident that
the clinician must not expect too much of the pathologist when the latter is
called upon to make a biopsy examination of a lymph node removed from
the neck. The microscopic picture of lymphosarcoma, transitional cell cor-
cinoma, and the anaplastic form of bronchogenic carcinoma may be so similar
as to deceive the very elect. To this list may be added branchial carcinoma
arising in the neck and anaplastic carcinoma of other organs. For this resume"
has by no means exhausted all the possibilities. Cancer of almost any organ
may metastasize to the cervical lymph nodes. The malignant sentinel gland
situated immediately above the clavicle in many cases of cancer of the
stomach immediately occurs to the mind, but the upper set of glands may
also be involved, and if the cancer is of the anaplastic type a correct microscopic diagnosis may be impossible. I have seen a large cervical mass in
cancer of the ovary, and to this list we might add the uterus, rectum, kidney,
thyroid, choriospith of testicle, and so on.
If I may repeat the summary with which this lecture commenced, it
becomes evident that a tumour of the neck may arise from structures of the
neck itself, structures which may be normally present as in the case of the
parathyroids or the carotid body, or which may occasionally occur as
vestigial remains as in branchial carcinoma or thyroglossal cyst. On the other
hand, it may arise from the regional lymph nodes, and such a tumour may
belong to the primary lymphoblastomas or, far more frequently, it may be
a secondary carcinoma from almost any organ in the body. Such an outline
may serve to lessen some of the difficulties which strew the path of the
clinician in his task of making a correct diagnosis when confronted by a
case of tumour of the neck.
VICTORIA NEWS
Contributed by Dr. W. M. Thomas
DR. GEORGE HALL EMBARKS ON THE SEA OF MATRIMONY
The members of the Victoria Medical Society were the hosts at a colourful
banquet at the Union Club on June 4th, when Dr. George Hall was the guest
of honour. This was an outstandingly brilliant setting for the befitting recognition of the honoured guest and his approaching wedding.
Dr. H. E. Ridewood, the President, as toastmaster, was in happy vein, and
the speakers, of which there were many, inspired by the buoyancy of spirit
which pervaded the party and the illumined countenance of the prospective
bridegroom, reminisced, indulged in temperate eulogism, and told George just
how much happiness and health they hoped the years ahead would hold for
him. A shower of advice and words of counsel were gratefully received by
George and he was tendered a great ovation, rounds of thundered applause
and throaty cheers as he rose to accept the gift of his colleagues, which was
a silver tray of breath-taking dimension and Maurice Carmichael quality.
George appeared to enjoy the party and seemed unusually at ease among so
Page 212 many old and tried friends. He was unabashed by the heart-rending orations
of such old-timers as Doctors M. J. Keys, Herman M. Robertson, J. W.
Lennox, A. E. McMicking, J. D. Hunter, Gordon C. Kenning, Wallace Bapty,
D. M. Baillie, W. C. Bissett, Frank M. Bryant, Stuart G. Kenning, W. Allan
Fraser, John H. Moore, John A. Stewart and the Chairman, Dr. H. E. Ride-
wood.
Altogether it was a bright and cheery party, reflecting the spirit of the
occasion, and we hope foreshowing much of the future as a happy augury of
what there is in life for this popular member of the profession in Victoria.
George has deservedly held and honoured many high offices in organized
medicine in British Columbia, and the esteem of his confreres in the Province
was expressed in a congratulatory message from Dr. S. Cameron MacEwen,
New Westminster, the President of the College of Physicians and Surgeons
of B. C, an office which George held during part of those years he served as
a member of the Council. Another telegram from Dr. G. F. Strong, President
of the British Columbia Medical Association, coupled with the felicitations
an appreciation of his service on the Executive Committee and as one-time
President of the provincial association. A wire from Dr. G. H. Clement,
President of the Vancouver Medical Association, carried greetings to the
Victoria Medical Society and a message from the Vancouver profession wishing for Dr. George Hall all the blessings which are bestowed only upon a
benedict.
Dr. George Hall and Miss Elsa Michaelis of Victoria were married on
June 12th and are visiting in California.
The whole profession in B. C. extends to Dr. and Mrs. George Hall its
sincerest wishes for many bountiful years of health and happiness.
TUMOURS OF THE LIP AND ORAL CAVITY
Dr. Donald V. Trueblood
(Read at Vancouver Medical Association Summer School, June, 1937.)
There should be no deaths from cancer of the lip or oral cavity. All such
are the result of neglect. This neglect rests definitely either upon the patient
himself or upon his physician. We a& doctors cannot be held responsible for
the deaths of those individuals who, knowingly or otherwise, procrastinated.
But we can be blamed if a patient presented to us an early lesion which we,
because of lack of knowledge, or because we prescribed empirically a salve
or mouthwash, hoping for the better, or because we forgot that the most
important disease to think of and eliminate is cancer, or because referring
the patient was an admission, or because we did not institute the proper steps
toward a diagnosis, or because we did not take a biopsy and so failed to make
a diagnosis, then we and we alone are to blame. Deaths that are the result of
hidden or symptomless cancer can be excused.
Every lesion on the lip or within the oral cavity had a small beginning.
The sensitiveness of these two areas would suggest that the smallest alteration from normal would attract the attention of the patient immediately, and
that he would be prompt to seek early advice. That such an obvious reaction
is not true is proven in every clinic. There advanced cancer is seen, having
received no medical attention at all. Other hopeless cases are encountered
who consulted a physician early. Indication of neglect either by patient or
physician is further substantiated by the statistical record, showing that
7000 people die every year of cancer of the lip or oral cavity in the United
States.
In recent years there has been a growing interest on the part of the public
in regard to cancer, fostered by efforts toward their education. They have
been urged to acquaint themselves with the early signs and symptoms of the
possible existence of cancer. The lip, the oral cavity, likewise the skin, are
the areas most likely to attract their attention. These people are advised to
Page 213 see their family physician at once regarding any condition which has seemedj
abnormal.
It is, therefore, necessary that we as clinicians equip ourselves with the
knowledge of the various diseases of which they might complain, be prepared
to make differential diagnoses and determine the type of therapy most suitable for each particular case, so that when the layman asks our advice he be
not deceived. It is true that the average doctor, unless he is associated with
a tumour clinic, sees very few malignancies a year; but he can, he must, be
stimulated to appreciate their importance, and as a consequence become more
or less tumour conscious. The result will be that when he examines a lip or
the oral cavity and its contents he will think of malignancy first and other
diseases next. He will appreciate that an early diagnosis is essential, and
will be imbued with the idea that he can always take a biopsy for the purpose
of making that diagnosis.
Cancer is the most important lesion occurring upon the lip or within the
oral, cavity. Consequently, our remarks here will be directed in most part
toward that disease. Tuberculosis, syphilis, thrush, Vincent's angina are some
of the other diseases that force themselves upon our consideration.
Tuberculosis of the mouth or lip practically always is secondary to that
disease being present in the lung. The lesion is usually one with ragged edges,
these being undermined. Occasionally in the tongue it is a hard lump where
apparently the tubercle bacilli have lodged deeply in a furrow, developing
there a granuloma beneath the surface. Ulceration will appear on top later.
Even though pulmonary tuberculosis is present in this patient, biopsy is
indicated inasmuch as cancer and tuberculosis can exist in the same patient.
Vincent's angina presents multiple small ulcerations. They may coalesce
and form larger ones ; while thrush covers a rather large area. The finding by
means of a smear, the causative bacillus and spirochete for the former or
fungus for the latter, is diagnostic of the disease. However, if any such
ulcerated area persists despite treatment, again a biopsy is indicated to rule
out the disease most feared, namely, cancer.
Syphilis may have its primary lesion on the lip; this can simulate a cancer,
and vice versa. When the history is short, the ulcer possesses an indurated
ring around it and large glands palpable found in the neck, the lesion is very
suggestive of lues. A dark field examination should be made. If positive,
specific treatment is, of course, indicated. Should the lesion fail to show
regression after three weeks of such treatment, a biopsy is indicated for
more accurate diagnosis. Secondary luetic lesions within the mouth are
superficial ulcerations with ragged edges but no undermining. A dark field
examination may or may not be positive; but these patients usually show a
positive Wasserman. Again, three weeks of luetic treatment may be not only
diagnostic, but curative. A gumma, or tertiary syphilis, in the mouth may be
located on the tongue, cheek or lip. These soon ulcerate, and offer a most
disturbing picture of malignancy with induration and ragged edges. A biopsy
and Wasserman are indicated. Should the Wasserman be positive, syphilitic
treatment is instituted for a period of three weeks as a therapeutic test. If
the biopsy indicates cancer the positive Wasserman need not be considered
for diagnosis. But in such an instance it is well to treat the patient for lues
while attacking the cancer, not because the diagnosis is inaccurate, but
because the patient—including his mouth—is elevated to a better general
condition for cancer therapy.
The patient may have noticed a white patch on the lip, on the buccal surface or tongue; or his attention may have been called to it by his dentist. The
members of the dental profession are very alert to observe abnormalities
within the oral .cavity, and are energetic in insisting that the patient consult
a physician regarding them. The average physician doing a complete physical
examination spends very little time in inspecting the mouth, except visualizing the absence or presence of tonsils. It requires only a minute longer,
Page 21k
mm with the aid of a good light and a finger cot on each forefinger, to give the
mouth a thorough inspection and palpation. Holding the tongue out with a
piece of gauze permits special inspection and palpation of the posterior and
lateral surfaces of the tongue. These white patches spoken of, called leukoplakia, are the result of the piling up of superfiicial epithelium to such a
degree that the capillary bed underneath is prohibited from showing its usual
red colour. Syphilis is a frequent cause. These, regardless of etiology, are
precancerous lesions. Smoking should be prohibited, dental and gum infection
should be eradicated, good habits of mouth hygiene should be instituted. It is
thought by some that the existence of two types of metal, as tooth fillings,
lying adjacent, produce leukoplakia. If these areas—despite treatment—
become more thickened or show papillomatous growths, a biopsy is advisable.
Should this be positive for cancer, radium application or complete removal
with the cautery is indicated.
Cancerous lesions within the mouth are usually ulcerated and possess an
indurated edge. Occasionally, early ones may be covered by mucous membrane for a time. Palpable lumps below the surface may be due to cancer,
fibroma, angioma or mucous cysts, as well as syphilis and tuberculosis, mentioned above. Trauma to the mucous membrane of the lip or oral cavity may
force mucous producing epithelial glands below the surface, where they
continue to form mucous, causing cysts. Fibromata may also be the result of
trauma, and if so usually disappear. Should they persist (not becoming
smaller) they are removed surgically and biopsied. Angiomata are easily
cured by coagulation.
Finding, then, an ulcer or lump in the lip or oral cavity with no history
of recent trauma, we must think of tuberculosis, especially if the lesion is
in the tongue. The lungs should be examined. We must also obtain a Wasserman, followed by luetic treatment, if positive, for two or three weeks. If
there is then no change, the lesion must be biopsied. There is one exception
to the above which I should like to mention, namely, a hard, painful or
painless swelling resting on the jawbone. This is apt to have bone or tooth
significance, and will be discussed later.
When a biopsy is taken of a suspicious lesion, it is ideal to have an expert
pathologist at hand who will give you an immediate answer. But if such
service is not possible, requiring thkt the tissue be sent away, the wound
should be immediately cauterized—either chemically or thermally. If, however, expert pathological service is at hand, preparation should be made in
advance for either radical surgery or the application or implantation of
radium.
Cancer of the tongue. A small lesion, 1 cm. in diameter, located in the
anterior third of the tongue and not encroaching upon the midline can be
removed surgically with the cautery by extirpating the anterior half of the
tongue on that side. If it is posterior to this, or if it encroaches upon the
midline, the surgery for which being very mutilating is discarded for radium
implantation. I believe that cancer located on the floor of the mouth, unless a
small tumour, should be treated by radium; because the surgical procedure
for its adequate removal is apt not to result with a watertight mouth.
Cancer of the buccal surface, however, is slightly different. Here, more
excess tissue is available; consequently, if the lesion is not too large, radical
surgical excision, with or without later plastic repair, may be instituted.
When a lesion is seen in the roof of the mouth an x-ray picture should be
taken of the sinuses to rule out the possibility of this growth having its
origin in either of the antrums, reaching the mouth by invasion from above.
If found to be confined to the mouth, it may be treated properly with the
cautery or radium.
Occasionally one sees on the hard palate a rather soft, non-ulcerated
tumour, which a biopsy proves to be a mixed tumour of aberrant salivary
tissue. Such tumours may arise also in the tongue, floor of the mouth, on the
Page 215 skin of the face or scalp, giving rise in those areas to mixed tumours. If these
are completely removed, they do not recur.
Cancer which arises on a dental ridge presents a different problem, because
the thinness of the soft tissue in that region suggests that the tumour has
already invaded the underlying bone. Even though the x-ray picture of the
adjacent bone is negative, yet one must suspect that microscopic cancer has
already penetrated the periosteum. I believe the therapy of choice is either
the extensive use of radium or the hot iron, giving no regard to the damage
caused in the bone. Following either treatment, osteomyelitis with sequestration and pain will occur. Later, if necessary, this area (providing the
original tumour is under control) can be resected.
Cancer of the lip. Any lesion on the lip which does not heal within a few
weeks should be considered malignant unless proven otherwise. The cracked
lip that recurs during the winter months, disappearing in the spring, is
suspicious. A small surgical procedure obviates its recurrence, and furnishes
tissue for biopsy. Larger lesions, 2 cm. in diameter, more or less superficial,
covering a large surface of the lip, with little infiltration, are best treated by
radium. Those that are infiltrative with surrounding induration, or bulky,
can be treated either with radium or surgery, providing that if radium is
used it be done by an expert who has sufficient radium available and who has
had sufficient experience to realize thoroughly the problem at hand, or provided the surgeon who operates is willing to forget the cosmetic result for the
time being and do a radical excision, trusting to later plastic surgery for a
correction of the deformity which must occur. It is my opinion that it is more
logical to remove cancerous tissue, which tissue never again can cause trouble,
than it is to attempt to make such tissue innocuous, knowing the possibility
that at any time (its not having bee adequately destroyed) it may again
produce the original disease. When radiation therapy has failed, the damaged
tissue is not favourable for surgery; but when surgery has failed the application of radiation treatment is not hampered.
When radiation therapy be elected, a biopsy should be obtained first, not
so much for determining the grade of malignancy, but for statistical purposes
to verify that the lesion was really malignant. The grading of cancer of the
lip, I believe, is of some value; not because on the finding of Grade I or IV
the therapy should be altered a particle; but because occasionally in a very
old person or one not classified as a good surgical risk the diagnosis of a
Grade III or IV (radiosensitive types) may cause one to lean justifiably
toward the selection of radiation therapy.
Glands of the neck. Should the glands of the neck be removed in cancer
of the neck and oral cavity, and if so, under what circumstances? This is a
very much discussed and argumented question. Medical literature is abundant
with articles on the subject. No one has apparently as yet been able to devise
a rationale of procedure plausible enough to satisfy all of the observers. If
we believe that cancer emboli leave their original home and plant themselves
in the nearest gland or glands, draining that area, it must be inferred that
those glands, if still present, can—by reason of their being invaded—serve
as a fairly early evidence of the disease having extended that far. If they
have been removed routinely, this early evidence of continuation of the
process—even though the primary lesion may show no recurrence—is lost.
The statistics that are available (replete, unfortunately, with many variables) lead us to believe that the routine removal of lymph nodes of the neck
in cancer of the lip and oral cavity gives a larger percentage of 5-year cures
than when this operation is not used. It is also known that a large percentage
of the glands removed in such cases reveal no evidence of cancer, unless
repeated sections of these glands be made—which is technically beyond the
power of the usual pathological laboratory—it cannot be stated accurately
that they were not involved.
If surgery of the neck glands is not instituted, what can we expect from
Page 216 radiation therapy? Inasmuch as there is required from seven to twelve
erythema doses to destroy adult squamous cell carcinoma cells, I am unable
to convince myself that sufficient dosage can be placed beneath the skin into
the gland-bearing areas to accomplish that purpose. I do not believe the
normal tissues can survive such dosage. Smaller dosage would be inadequate.
However, the implantation of radium element or radon seeds in the one or
two glands which have enlarged is adequate to destroy squamous cell cancer
cells contained therein. But one must not lose sight of the fact that the great
majority of men who are seeing cancer patients today throughout North
America have not access to such radiation facilities—even though they wished
to select that as a means of therapy. Must they send their patients to distant
clinics for proper treatment, or is there some other choice as good? I firmly
believe that if no glands are present when the patient is first seen, no treatment should be instituted in their direction unless the individual is one who
cannot be followed month after month for observation of the primary lesion
and examination for the appearance of involved glands. If such follow-up is
impossible, then I believe excision of the gland-bearing tissue of both the
upper triangles of the neck (which will be described later) should be performed.
The next exception to my first statement is that in those cases of lip cancer
where the tumour is large, requiring a radical surgical procedure for its
necessarily wide excision, the gland-bearing tissue on each side of the neck
in the upper triangles must be removed. If metastatic glands are found in
either of these two exceptions, then a more radical excision of the neck
should be instituted on the side in which they are found.
If one or two suspicious glands are found at the first examination, and if
it is reasonable to suppose that the primary lesion can be controlled by
surgery or radiation, I believe that a dissection is indicated on both sides of
the upper neck, and should be continued more radically if microscopic
examination proves these glands to be positive.
In those more advanced cases in which multiple enlarged hard glands are
found, fixed or not (providing one can reasonably suppose that the primary
lesion has been controlled) one is justified in giving the patient the benefit
of radical block dissection of the neck, even though the prognosis is poor. I
am unable to reconcile myself to the! belief that x-ray therapy or radium
packs are adequate for such extensive cancerous disease beneath the skin.
Surgery offers him his only hope, though a slim one.
Tumours of the jaiv. One cannot discuss intraoral tumours without
including tumours of the jaw. These bones are subject to all the tumours
of bone found elsewhere in the body; but in addition they are the bones and
the only ones which may contain tumours from pre-dental or dental structures. I wish to discuss here these tumours.
The ordinary gumboil swelling, painful or not, may arise from an
abscessed tooth or from a tumour growing at the roots of one or more teeth,
and breaking through the overlying bone into the soft tissue. Before such a
lesion is opened for drainage, x-ray studies of the apices of these teeth
should be taken to see if this disease (abscess resembling) has extended
over to the adjoining teeth. If such an extension is seen, an x-ray of the
entire jaw is indicated. When these teeth are extracted a biopsy from the
tooth socket and underlying caving should be taken, because such a condition
may be a jaw tumour.
A tooth that becomes loose without a logical reason ought to arouse
suspicion, despite no apparent swelling of the tissues overlying the jaw, or
the jaw itself. An x-ray should be furnished to determine why such a tooth
is not firm in its socket. An early tumour of the bone may in this manner be
discovered when its thorough eradication is simple. The epulis, a rubbery
swelling occurring in young people close to a tooth or in a tooth socket following extraction, is a giant cell tumour, but not a giant cell sarcoma. It is not
Page 211 malignant, but if not completely removed will recur. A square piece of bone
must be removed, including the tooth and socket, in order to avoid this
recurrence. Curetting of the socket itself in many of these instances has
proved to be inadequate, and responsible for a more destructive operation
later.
Pregnant tumour. A rare tumour-like process which develops in the mouth
of pregnant women on rare occasions is the plasma cell granuloma, which
resembles an epulis. It may or may not be ulcerated, but disappears at the
termination of pregnancy.
Tumours which expand the bone are usually benign. Those which, in the
x-ray picture, evidence bone destruction, without encapsulation, are usually
malignant. Osteomyelitis must be differentiated. The terminology of the
various types of bone tumours arising from dental structures is very extensive, differing with various writers.
The treatment of these tumours, benign or malignant, is primarily surgical.
One should be prepared to do a bone resection if the tumour is malignant, and
to cauterize soft tissue if the growth has invaded beyond the cortex of the
bone. Most of the benign ones can be easily shelled out, the bed being treated
either chemically or thermally. Packing the cavity is unnecessary. If the
tumour bulges more inside the mouth, the approach can be made at that
point, the reverse being true if the protrusion is external. Some have recommended the use of radium within the cavity, but this causes bone necrosis,
and interferes with later bone regeneration. If the tumour is malignant, a
resection is selected in most instances.
Conclusion :
There should be no deaths from cancer of the lip or oral cavity. The
attitude and intelligence of the public forces all of us to become more
familiar with the early recognition and therapy of malignant lesions than
ever before. The lesion that is difficult to diagnose is the one—if cancer—
that can be easily cured. Hence, watchful waiting, hoping for diagnostic
revelation, should be cast aside in favour of early biopsy. The selection of
therapy for these people depends upon the experience of the physician in
charge, his tumour-mindedness, and the facilities at hand. Radiation therapy
has its definite place in the treatment of cancer in certain of these areas,
and where available should be considered; but if not available, surgical
treatment, comprising operations that are well known and within the ability
of a great many, if they will keep in mind the problem at hand, can justifiably be chosen.
NEW REQUISITION AND REPORT FORMS
ADOPTED AT THE PROVINCIAL
I      LABORATORIES
New requisition and report forms are being issued by the Provincial Board
of Health Laboratories at 763 Hornby Street. These new forms are introduced
in order to help bring the local organization of Public Health Laboratory
services into closer conformity with current and anticipated trends in the
best quarters elsewhere.
Form Ll (Requisition for Special Laboratory Examination) replaces all
earlier requisition forms for laboratory examination of specimens relating
to the diagnosis and control of syphilis and gonorrhoea. Form L2 (Requisition
for General Laboratory Examination) replaces a multiplicity of requisition
forms covering the various other types of examination afforded by the Provincial Laboratories. Physicians are asked to take an early opportunity of
discarding the old forms in favor of the new. The Laboratories will be glad to
Page 218 send, on request, a supply of new requisition forms to those who ha\e in
the past extensively availed themselves of the facilities provided. It is particularly hoped that physicians will encourage the performance of services
of even greater value to themselves, and to their patients, by providing the
minimal information asked for on these requisition forms.
C. E. Dolman, Director,
Provincial Board of Health Laboratories.
PAN AMERICAN MEDICAL ASSOCIATION
745 Fifth Avenue, New York, N. Y.
The Executive Committee of the Board of Trustees takes great pleasure
in announcing that the Queen of Bermuda has been chartered for the Seventh
Cruise-Congress. As you know, we had this boat for the last Cruise and it
proved to be most ideal for our purposes. Following is the itinerary:
Leave New York January 15, 1938
Arrive Havana  "       18     "
(4^4 days and 5 nights in Havana)
Leave Havana  "       23     "
Arrive Port au Prince  24
Leave Port au Prince  24
Arrive Trujillo City (Santo Domingo)  "       26
Leave Trujillo City (Santo Domingo)  26
Arrive San Juan (Puerto Rico)  27
Leave San Juan (Puerto Rico)  27
Arrive New York  "       31     "
The main part of the Congress will be held in Havana. There will be three
days of scientific sessions with operative clinics. These will be divided into
sections for the various specialties. This year we have four new sections:
Tuberculosis, gastroenterology, dentistry and industrial medicine. Meetings
will be arranged with our medical colleagues at the other ports of call.
The Hotel Savoy-Plaza in New York and the National Hotel in Havana
will be our official hotels.
Travelways, Inc., have chartered the Queen of Bermuda on behalf of our
Association and will act as our official Travel Agents. As this Congress
promises to be the most successful ever held by the Association, it would be
highly advisable to book reservations as early as possible with Travelways,
Inc., who will make every effort to satisfy the requirements of the members
of the Congress. Applications for reservations should be addressed to the
Pan American Medical Association at 745 Fifth Avenue, New York City.
The programme committee would be pleased to receive applications for
the presentation of scientific contributions.
Cordially yours,
Joseph J. Eller, M.D.
°3€?°
Page 219 AHAI1/_MIN B.D.
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Furthermore, not only is anahaemin remarkably effective, but the cost of
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Stocks  of  Anahaemin  B.  D.   H.   are  held  by  leading  druggists
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• ___ ;c a tendency tc
E°seness. l^^tes; • • • ,T_1
the sugars ?i}^^^™«JTJi£&tim*
the sugars ai^---Tn      d mai.o^.   . - ~ aS ag&u^
ith
ertence wit
July, 1916.
. Jn di
S£xtri-m
can be
A  dis
infant
the diets
arrhea,  "Carbohydrates,
altpse. well"""
-.--nyurates     in   tt_3_____
ieT^n7!7a'wi?00ked cereals or »•    fon»
^ssion  ofWs'^°Ut /rouble ••-_:« ««
Dextri-maltose is a very excellent carbohydrate. It is made _p
Of maltose, a disaccharide which
in turn is broken up into two
molecules of glucose—a sugar that
,.s not as readily fermentable as
[levulose and galactose—and dextrin, a partially hydrolyzedstarch.
Because of the dextrin, there is
Bess fermentation and we can therefore give larger amounts of this
arbohydrate without fear of any
(tendency of fermentative diarrhea."—A. Capper: Facts and fads
\pi     infntff    f»«<1i.."      TT^n   IT        n      I
In cases of diarrhea, "For the
first day or so no sugar should
be added to the milk. If the bowel
movements improve carbohyi
drates may be added. This should!
be the one that is most easilyp
assimilated, so dextri-maltose is
the carbohydrate of choice." —
W. H. McCaslan: Summer diar-
^easininfanls and young child-
rnents^bohvdri^^^nt in
ins- th.  ._„ °un._drate; .may be add.
ing the teaching of th. / :"* aaa€
the carbohydrateIi?e .0r.ginator.
™_„* ...,karate added should b.
most easily assimilated
fore tfv° —L "*
rh
\9
tarrhea
used ta.
SERIOUSNESS
OF DIARRHEA
There is a widespread opinion that,
thanks to improved sanitation, infantile diarrhea is no longer of serious aspect. But Holt and Mcintosh declare that diarrhea "is still
a problem of the foremost importance, producing a number of
deaths each year. ..." Because dehydration is so often an insidious
development even in mild cases,
prompt and effective treatment is
vital. Little states (Canad. Med.
A. J. 13:803, 1923), "There are
cases on record where death has
taken place within 24 hours of the
time of onset of the first symptoms."
Wl_t IS
easi
ly
•Maltose  is  »»«- ^    -    ^
brbed than.cane^or^.^
P
ne
FJfi&z S3I
,ly of sugar." ses diarrtof
*• When sugar cause        ^
Mead s __^^nc_Ty absot^
Hoses is muj.- <IJ    castor lc_l
and s°TsuPe"   is expensive]
sugar. Lf^e better W
seems not to y__. " D    ninAtm
B    Glaidk
and   mm
-^rnantij Ltd., Q
tor   sugar. '""„
Infant   Feeding
William
don, 1928, PP-
"laxat^rei--"d h^ Me.*
when
severe
naf
ive  tendency,  whichU™
i  carried   to   excess, 1
:re intestinal irritation. J
"The more complex car|)hi
drates,   of  which  dextrin is
type, ferment more gradually.,
do not h"— xu'
- - -aye this laxative effe
Regarding   the   treatme,
our experieu
carbohyd
diarrhea, "In
most   satisfactory
for r~■-'■' ■
Imaitpse^No.  l
'■Sum
routine use is Mead's dextS
..■^■iiniarea. JJextri-maltose is there
>re the carbohydrate of choice."—Summer diar
teas  in the ^___g    Tnternnt{(\\\\\l   %*  '  •*
*«r Complaints^' Sonlhsi
£55-559, Atj
"The condition in which dextri-maltose is partic  __
in acute attacks of vomiting, diarrhea and fever. It seem
covery is more rapid and recurrence less likely to take place if dex
tri-maltose is substituted for milk sugar or cane sugar when thes
have been used, and the subsequent gain in weight is more rapid.
"In brief, I think it safe to say that pediatricians are relying les
bottle.
"In brief, I think it safe to say that peaiatncians arc rcrying _<_*  "• "y -«y_.»----__..--=-jl ~... ■■ aa iva___ _. nu.,i.u..
implicitly on milk sugar, but are inclined to split the sugar element  where the maltose is only slightly in excess of the
 .££,_-;_ _f ,to1,,o   and rlp.-_t.ri-maltose a decidedlf dextrins, thus diminishing the oossibility of ei-
giving cane sugar a place of value, and dextrimaltose a decidedl
prominent place, particularly in acute and difficult cases."—W. _J
Hoskins: Present tendencies in infant feeding, Indianapolis M. J\
July, 1914.
—^^«__
     ■■■      ULUUtig
a whole milk or
evaporated milk formula, which wi t,l..} auuui
one and one-half to two ounces of whole milk to
every pound of body weight, is reached. This also
Should final." _ ■*■'-
T64-J68Da)
diarrl
oea.
of lactose may cause uic.__._uca. _.<. a mo     ■ m
centage of sugar be required it is better to replace
it by dextri-maltose. such as Mead's Nos. 1 and 2a
„,„  r. n -■_ —t—«.'_.i.ii-_
dextrins, thus diminishing the possibility of «•
cessive fermentation."—W. J. Pearson; Commtm
Practices in infant feeding, Post-Graduate Med. I
6:38. 1930; abst. Brit. J. Child. Dis. 28:152-163,
April-June, 1931.
t^unu ui ooay weight, is reached. This also
should finally have the addition of dextri
amounting to five to seven per cent."—-35.
Strong: Summer diarrheas i
Chtldhood^Arrh   J>*
per
infancy and
ose
early
Just as DEXTRI-MALTOSE is a carbohydrate modifier of choice, so is CASEC (calcium caseinate) an accepted protein modifier. Casec is of special value for (1) colic and loose green stools i_
breast-fed infants, (2) fermentative diarrhea in bottle-fed infants, (3) prematures, (4) marasmus, (5) celiac disease.   MEAD JOHNSON & CO., EVANSVILLE, IND., U.S.A.
When requesting samples of Dextri-Maltose, please enclose professional card to cooperate in preventing tbt
reaching unauthorized persons. In Partnership
for Health » » »
Seymour 2263 carries a cord
which binds us to many doctors
who place implicit confidence in
our ability to supply what they
ask for—accurately and quickly
Day and Night
Service—
Sey. 2263
GEORGIA PHARMACY
W.OEO-.OIA
Crater Sc 3f atma UiiX
Established 1893
VANCOUVER, B. C.
North Vancouver, B. C.    Powell River, B. C.
published Monthly at Vancouver, b. c. by ROY wrigley LTD.. 300 west Pender stree u^m^\r
Hollywood Sanitarium
Limited
For the treatment of
Alcoholic, Nervous and Psychopathic Cases
Exclusively
Reference—B. C. Medical Association
For information apply to
Medical Superintendent, New Westminster, B. C.
or 515 Birks Building, Vancouver
Seymour 4183
Westminster 288
Ha

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