History of Nursing in Pacific Canada

The Vancouver Medical Association Bulletin: September, 1946 Vancouver Medical Association Sep 30, 1946

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 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. G. A. Davidson . Dr. D. E. H. Cleveland
All communications to be addressed to the Editor at the above address.
VOL. XXII. SEPTEMBER, 1946 No. 12
OFFICERS, 1946 - 1947
Dr. H. A. Des Brisay Dr. G. A. Davidson Dr. Frank Turnbull
President Vice-President Past President
Dr. Gordon Burke Dr. Gordon C. Johnston
Hon. Treasurer Hon. Secretary
Additional Members of Executive: Dr. W. J. Dorrance, Dr. J. W. Shier
TRUSTEES
Dr. A. W. Hunter        Dr. G. H. Clement      Dr. A. M. Agnew
Auditors: Messrs Plommer}/ Whiting & Co.
SECTIONS
Clinical Section
Dr. E. R. Hall Chairman Dr. Reg. Wilson Secretary
Eye, Ear, Nose and Throat
Dr. Roy Mustard Chairman Dr. Gordon Large Secretary
Paediatric Section
Dr. R. P. Kinsman Chairman Dr. H. S. Stockton Secretary
Orthopaedic and Traumatic Surgery Section
Dr. K. J. Haig Chairman Dr. J. R. Naden Secretary
Section of Neurology and Psychiatry
Dr. A. M. Gee Chairman Dr. J. C. Thomas Secretary
STANDING COMMITTEES
Library:
Dr. W. J. Dorrance, Chairman; Dr. D. E. H. Cleveland, Dr. J. E. Walker,
Dr. R. P. Kinsman, Dr. J. R. Neilson, Dr. S. E. C. Turvey.
Publications:
Dr. J. H. MacDermot, Chairman;  Dr. D. E. H. Cleveland,  Dr.  G. A.
Davidson, Dr. J. H. B. Grant, Dr. E. R. Hall, Dr. Roy Mustard.
mm Summer School:
Dr. L. G. Wood, Chairman; Dr. J. C. Thomas, Dr. A. M. Agnew,
Dr. L. H. Leeson, Dr. A. B. Manson, Dr. D. A. Steele.
Credentials:
Dr. H. H. Pitts, Dr. A. E. Trites, Dr. Frank Turnbull.
V. O. N. Advisory Board:
Dr. Isabel Day, Dr. J. H. B. Grant, Dr. G. F. Strong.
Representative to B. C. Medical Association: Dr. Frank Turnbull.
Sickness and Benevolent Fund: The Presidents—The Trustees. MARGIN OF SAFETY* I
= 16.7 Plus
... JritfocLwiuActticiw irtpecticn, of Mercuhydrin
Sodium   Solution  provides  an  absorption  site
from which the medication is released to the circulation slowly.    This measure spares conduction
centers of the heart from the shock of relatively
massive drug concentrations which follow intravenous  adrninistration  of  mercurial  diuretics.
* The margin of safety for a mercurial diuretic was calculated for
the first time in Mercuhydrin
Sodium. The maximum tolerated
dose in dogs has been found to be
10 mg. of mercury as Mercyhydrin
Sodium per kilogram of body weight
and the minimum effective dose,
0.6   mg.   per  kilogram.    Thus,  the
margin of safety = —s  16.7.
REFERENCES
1. De Graffs A. C, and Nadler, J. E.:
J.A.M.A.   119:1006,   1942.
2. "Wexler, J., and Ellis, L. B.: Am.
Heart   J.   27:86,   1944.
3. Finkelstein, M. B., and Smyth, C. J.:
Jrroc. Cent. Soc. Clin. Research 16:69,
1943.
4. Friedgood, H. B.,: New Eng. J. Med.
227:788,   1942
5. Finkelstein, M. B., and Smyth, C. J.:
J.  Lab.   and   Clin.  Med.  31:4J4,   1946.
6. Modell, W.; Gold, H., and Clark, D.
A.: J. Pharm. Exper. Therap. 84:284,
194S.
As a class of critical drugs mercurial diuretics when
properly administered not only are highly effective but
remarkably safe1 . . . this is particularly true when the
intramuscular route is employed.2 Investigators have
reported that Mercuhydrin Sodium is definitely less irritating to intramuscular tissue.3»4»5 "Blind tests" confirm
this.6 Mercuhydrin Sodium thus is adaptable to the safer
intramuscular route.
Mercuhydrin Sodium Solution is the sodium salt of meth-
oxyoximercuripropylsuccinylurea — theophylline. It is
supplied in lcc. and 2cc. ampuls. Lakeside Laboratories,
Milwaukee 1,. Wisconsin.
For literature write
MARSH, WILDE & CO.
Vancouver, B. C.
628 Vancouver Blk. VANCOUVER MEDICAL ASSOCIATION
Founded 1898
Incorporated 1906
PROGRAMME OF THE 49th ANNUAL SESSION
GENERAL MEETINGS will be held on the first Tuesday of each month at 8:00 p.m.
CLINICAL MEETINGS will be held on the third Tuesday of each month at 8:00 p.m.
October    1      GENERAL MEETING—Symposium~"Recent Advances in P     *i
Doctors E. J. Curtis, E. S. James, W. H. S. Stockton and Reg. Wilson.
October 15      CLINICAL MEETING—Vancouver General Hospital.
November    5 GENERAL MEETING. ||
Doctors A. R. Anthony, L. H. Leeson and J. A. McLean.
November 19 CLINICAL MEETING—St. Paul's Hospital. ||
December    3   GENERAL MEETING.    Symposium on Gynecology.
Doctors Leigh Hunt and Gardiner Frost.
December 10   CLINICAL MEETING—Shaughnessy Hospital.
»w^$55^o§«$>^5$j5S»
Breaks the vicious circle of perverted
menstrual function in cases of amenorrhea,   i
tardy periods (non-physiological) and dysmenorrhea. Affords remarkable symptomatic
relief by stimulating the innervation of the-
uterus and stabilizing the tone of its
musculature. Controls the utero-ovamn    i
J
k circulation and thereby encourages a    JJ
I   normal menstrual cycle.
• MARTIN H. SMITH COMPANY
W 'SO lAfATtTTl STMtT. NIW TOM. N. Y.
•wSSKJS&kfc&SS***
Full formula and descriptive
literature on request
Dosage: 1 to 2 capsules
3 or 4 times daily.' Supplied
in packages of 20.
Ethical protective mark MHS
embossed on inside of each
capsule, visible only when capsule is cut in half at seam.
Page Two Hundred and Sixty-seven PENICILLIN  INJECTIONS REDUCED
TO ONE OR TWO IN TWENTY-FOUR HOURS
Since the first publication by Romansky of the satisfactory blood levels
of penicillin obtained and maintained for a period of eighteen hours
following the intramuscular injection of 300,000 units of calcium penicillin
in beeswax and peanut oil, both laboratory investigations and collaborative
clinical studies in the treatment of gonorrhea and pneumonia have been
made by the Connaught Medical Research Laboratories. It has been widely
confirmed that penicillin prepared according to the Romansky formula
maintains the blood levels which are required in the treatment of gonorrhea
and certain other conditions, and permits of one injection every twelve to
twenty-four hours.
The Connaught Medical Research Laboratories have prepared a suitable
product which can be readily administered with the use of a disposable
plastic syringe provided in each package. This syringe, with sterile, built-in
needle, is ready for immediate use with a special cartridge containing
300,000 units of calcium penicillin in 1 cc. of beeswax and peanut oil.
Other Penicillin Preparations Available from these Laboratories
For Injection
SODIUM PENICILLIN in sealed
rubber-stoppered vials containing:
100,000
International
Units
200,000
<<'
j>
300,000
M \
<c
500,000
«
««
For Oral Use
CALCIUM PENICILLIN in suitably
buffered tablets in tubes containing:
12 tablets each of
25,000 International Units
12 tablets each of
50,000 International Units
CONNAUGHT MEDICAL RESEARCH LABORATORIES
University of Toronto fe Toronto 4# Canada
DEPOT FOR BRITISH COLUMBIA
MACDONALD'S PRESCRIPTIONS LIMITED
MEDICAL-DENTAL BUILDING, VANCOUVER, B.C. VANCOUVER HEALTH DEPARTMENT
STATISTICS—JULY, 1946.
Total population—estimated 	
Chinese Population—estimated  _
Hindu Population—estimated 	
323,850
6,566
361
Number
Total deaths . _  294
Chinese deaths       18
Deaths,  residents only  248
BIRTH REGISTRATIONS:
Male  408
Female.  416
Rate per 1,000
Population
10.7
32.3
9.0
824
INFANT MORTALITY: July, 1946
Deaths under 1 year of age       26
Death rate—per 1000 live births       31.6
Stillbirths (not included above)       11
CASES OF COMMUNICABLE DISEASE REPORTED IN THE CITY
May,  1946
Cases      Deaths
June, 1946
Cases      Deaths
July 1-15, 1946
Scarlet Fever i  21
Diphtheria     2
Diphtheria  Carrier  0
Chicken Pox  233
Measles     9
Rubella  6
Mumps  351
Whooping Cough  0
Typhoid Fever  1
Typhoid Fever Carrier   0
Undulent Fever  0
Poliomyelitis  0
Tuberculosis  93
Erysipelas ,  1
Meninboccus Meningitis  3
Infectious Jaundice ,  0
Salmonellosis  2
Salmonellosis   (Carrier)     22
Dysentery ,  0
Syphillis     176
Gonorrhoea  301
Cancer  (Reportable)
Resident __:  62
Non-Resident  41
BIOG LAN
iif*l7
Prepared separately for male and female.
Composition: Anti-thyroid principles of the pancreas, duodenum, em-
bryonin, suprarenal cortex, tests (or ovary). Each 1 cc. ampoule
contains the equivalent of approximately 29 grams of fresh substance.
Indications: Graves's disease, hyperthyroidism, exophthalmic goitre,
thyrotoxicosis.   The most effective therapy available.
Stanley N. Bayne, Representative
Phone MA. 4027 1432 MEDICAL-DENTAL BUILDING Vancouver, B. C.
Descriptive Literature on Request
THE SCIENTIFIC HORMONE TREATMENT
Page Two Hundred and Sixty-eight SHOULD VITAMIN  D BE
GIVEN ONLY TO INFANTS?
ITAMIN D has been so successful in preventing* rickets during infancy that there has been little emphasis on continuing its use after
the second year.
But now a careful histologic study has been made which reveals
a startlingly high incidence of rickets in children 2 to 14 years old.
Follis, Jackson, Eliot, and Park* report that postmortem examination of 230 children of this age group showed the total prevalence
of rickets to be 46.5 % •
Rachitic changes were present as late as the fourteenth year, and
the incidence was higher among children dying from acute disease
than in those dying of chronic disease.
The authors conclude, "We doubt if slight degrees of rickets,
such as we found in many of our children, interfere with health
and development, but our studies as a whole afford reason to prolong administration of vitamin D to the age limit of our study, the
fourteenth year, and especially indicate the necessity to suspect and
to take the necessary measures to guard against rickets in sick
children."
*R. H. Follis, D. Jackson, M. M. Eliot, and E. A. Park: Prevalence of rickets in children
between two and fourteen years of age, Am. J. Dis. Child. 66:1-11, July 1943.
MEAD'S Oleum Percomorphum With Other Fish-Liver Oils and Viosterol
is a potent source of vitamins A and D, which is well taken by older children because it can be given in small dosage or capsule form. This ease of
administration favors continued year-round use, including periods of illness.
MEAD'S Oleum Percomorphum furnishes 60,000 vitamin A units and
8,500 vitamin D units per gram. Supplied in 10- and 50-cc. bottles and
bottles of 50 and 250 capsules.  Ethically marketed.
MEAD JOHNSON & CO. OF CANADA, LTD., Belleville, Ont. EDITOR'S PAGE
From time to time this Journal, like every other medical publication, receives printed
material from firms which manufacture pharmaceutical preparations or other things of
which we may make use in our daily practice. With these enclosures comes a request
or a suggestion that we run the material in our columns—as the information contained
therein may be of interest or value to our readers.
We have always made it a rule, in the Bulletin, to decline to do this—as we
regard it as advertising, pure and simple, no matter how innocent it often looks. We
believe that this is more or less the rule with most of our contemporaries, though occasionally we find that some medical journal has opened tis columns to this material. This
is, of course, entirely their own business, and we have no criticism to offer, but a recent
experience has made us more sure than ever that it is wiser to resist the lure so temptingly set.
In a recent issue of the Bulletin, we published a report by Dr. K. D. Panton, of
Vancouver, on some results he had had from the use of Absor-Vite and Ray-Vite
products in his practice. These results he had found surprisingly good. He had gone
further, and submitted the material in question to the Department of Chemistry at
the University of B. C. Here very careful analyses had been made, which Dr. Panton
set forth. He referred, also, to the effect of these earths in agricultural work—in fact,
he went to a great deal of trouble to ensure that every effort should be made to .prove
the worth of these preparations, before he wrote the article. We, in turn, knowing Dr.
Panton as we do, and knowing that his good faith was beyond any question at all, gladly
published his report for what it was—a personal report of his own experiences. It goes
without saying, that in doing this, there was no endorsement, on the part of the Bulletin, and much less on the part of the Vancouver Medical Association, which publishes the Bulletin, of any of these preparations, any more than in the case of any
other medical journal, which publishes similar case reports. V
To the dismay of ourselves and of Dr. Panton, the publication of this issue was
followed by reports in one or two of the Vancouver newspapers, and later in a Victoria
daily, to the effect that the Vancouver Medical Association had endorsed this miracle-
working drug, which these puffs declared was also endorsed by the B. C. Medical Association, in at least one paper. Nothing, of course, could be further from the truth,
and Dr. Panton at once got in touch with the manager of the firm making" these preparations, and received, as we understand, from him, assurances that this would not recur,
and that it had been done without the manager's knowledge or consent. We accepted,
of course, these assurances. Believing that this would end the matter, we took no further steps hoping that we had seen the last of this misleading type of publicity. As,
however, a runner appeared in a Victoria paper, some two weeks ago, we wrote to the
Editor of that paper, and he was good enough to publish our letter in full.
Advertising is a perfectly legitimate thing, and any maker of a reputable product
has a perfect right to do all that he honourably can to promote public knowledge of
the goods he has to offer. But we question very strongly the ethics of such a proceeding as we have described. We are very glad to have the assurance from the head of the
firm that it will not happen again. Meantime, we feel that some explanation is due to
the readers of the Bulletin, since many medical men must have seen the advertising
referred to, and must have wondered what underlay it. We have written a letter to the
manager of this firm, setting forth our position, and have impressed on him that we do
not intend to let any such misstatements go unanswered in the future. As in most
advertising of this kind, there is a tendency to make claims of a somewhat extravagant
nature—and we cannot preverit that. But when the manufacturer makes these claims,
or allows them to be made, on the totally unjustified grounds that publication of tm?
kind of report constitutes a blanket endorsement hy the medical profession, it is time
to call a halt. Our readers may rest assured that we shall leave nothing undone to
prevent such a thing happening again.
Page Two undred and Sixty-nine THE LIBRARY
LIBRARY HOURS:
Commencing Wednesday, October 2nd, evening hours will be resumed and the
library will then be open—
Monday, Wednesday and Friday: 9:00 a.m. to 9:30 p.m.
Tuesday and Thursday: 9:00 a.m. to 5:00 p.m.
Saturday: 9:00 a.m. to 1:00 p.m.
RECENT ACCESSIONS TO THE LIBRARY:
Recent Advances in Neurology and Neuropsychiatry, by W. Russell Brain and E.
B. Strauss, 5th ed., 1946.
Medical Clinics of North America, Symposium on Splenomegaly, Mayo Clinic Number, July, 1946.
Supplements to Acta Medica Scandinavica:
No.  175—Haemodynamic factors and retinal changes in hypertensive diseases.
No. 176—The normal plasma protein values and their relative variations.
NARCOTICS REGULATIONS
Effective September 1, retail druggists will no longer be required to keep under lock
and key the codeine preparations detaild in section 8 of the Opium and Narcotic Drug
Act, the Hon. Dr. J. J. McCann, acting minister of National Health and Welfare,
announces.
Other changes in the Act are the consolidation into a single list of the narcotics
named in the schedule of the Act and a provision that certain codeine preparations,
when combined with suitable medicinal ingredients, may be sold by retail druggists
without a prescription, providing such items are properly labelled. These preparations
include all items containing one-eighth grain codeine when in solid form, or one-third
grain codeine per fluid ounce when in liquid form, providing such drug is combined with
other suitable medicinal ingredients.
N.B.—The wartime regulations allowing druggists to accept over the telephone and
fill emergency prescriptions for codeine have been cancelled. K. C. Hossick, chief of
the narcotic division, pointed out that removal of this privilege has, however, been
offset by the fact that prescriptions are no longer required for codeine preparations mentioned in section 8 of the Act.
Section 8 of the Act is as follows: Et(a) any retail druggist may have in possession
or may sell or distribute preparations containing one-eighth grain or less of codeine per
tablet or other solid form, or liquid preparations containing one-third grain or less of
codeine per fluid ounce, when such preparations are combined with other medicinal
ingredients and the maximum dose prescribed for the preparation contains (i) one such
ingredient not less in quantity than the amount prescribed by the British Pharmacopoeia as a niinimum dose for such ingredient; (ii) two such ingredients having a
similar action, each not less in quantity than one-half the amount prescribed by the
British Pharmacopoeia as a minimum dose for each such ingredient respectively; or (iii)
three such ingredients having a similar action each not less in quantity than one-third
the amount prescribed by the British Pharmacopoeia as a minimum dose for each such
ingredient respectively.
■  | | NOTICE % :
Members of the Profession are reminded that under the provisions
of the Narcotic Act, prescriptions must be DATED as well as signed in
their own handwriting.
Page Two Himdred and Seventy Vancouver Medical  Association
President	
Vice-President	
Honorary Treasurer	
Honorary Secretary	
Editor	
-Dr. H. A. DesBrisay
-Dr. G. A. Davidson
 Dr. Gordon Burke
-Dr. Gordon C. Johnston
 Dr. J. H. MacDermot
SUMMER SCHOOL
The 24th annual Summer School was held later than usual because of the Canadian
Medical Association Convention at Banff in June.
The attedance at the sessions reached a peace-time high of 404 registrations with a
goodly number of doctors from Washington and Oregon again enrolled.
The calibre of the lectures and clinics were pronounced on all ^ides as extremely
good and certainly the speakers were more than usually interesting and instructive.
The round table on Thrombophlebitis, an innovation this year, was so well received
that similar discussions will likely prove permanent fixtures at future Summer Schools.
Our lecturers, one and all, proved to be outstanding men both personally and professionally and we cherish the hope that they will remember us as long as we do them.
The speaker at the opening luncheon was Dr. Elmer Belt, just back from "Operation
Crossroads," and his talk was most timely as well as most terrifying by its implications
of the havoc that any future war would bring.
At the final banquet Dr. E. L. Turner, Dean of Medicine at the University of
Washington, spoke on the requirements for the proper functioning of a modern medical
school. He emphasized the proper integration of preclinical and clinical teaching, the
need for a coordinated teaching of medicine, sociology and economics to meet present
day problems in our profession. He also staggered us with estimates of the probable
cost of such projects.
The Golf Tournament was held again at Capilano Golf and Country Club and a
large number of those registered turned out despite the threat of inclement weather.
The successful prize winners are as follows:
First Low Gross: Long Drive:
S. Durkin—83. Gerald Burke.
Second Low Gross: Hidden Hole:
Geo. Langley—84. R. DeBoyrie—3 on the 7th.
. First Low Net: Nearest the Pin:
Fred Sinclair—90-20—70. M. R. Caverhill.
Second Low Net: High Gross:
John Balfour—95-24—71. C. H. Ployart—132.
Trophy Winners
Joe Bilodeau Memorial Trophy—-Low gross in the third game of the season—
George Langley—84.
Worthington Cup—Donated annually by Dr. George Worthington—low net in the
third game of the season—
Fred Sinclair, Cloverdale, B.C.—70. ;|f
Ram's Horn Trophy—Donated by Dr. Dan McLellan—best low gross in two of the
three games of the season—George Clement—141.   George Langley also had 141 for
two of three games played.  ^j|j|
Page. Two Hundred and Seventy-one Macdonald Trophy—Donated by Austin & Vans Macdonald—for the low gross in two
of three games of the season for, annual competition—
The winner this year received a handsome silver tray—W. Morton, 170.
Lockhart Trophy*—To be donated by Angus Matheson of Wyeths for the best net in
any one of three games played in one season by a player with a handicap over 18~—
The best score was 66 turned in by Dr. George Clement but by reversion goes
to a tie:
L. W. McNutt—94-23—71; Douglas Milne—91-20—71.
This trophy will be available as soon as a suitable one can be secured.
The Seniors' Trophy to be donated by Mr. T. O. Turner for the golfer over 55 years of
age making the lowest gross score in any one of three games played in the season.
The nature of this award has not been settled but it is hoped to have a cup in
the near future.
The first winner is Tom Nelles with 89 in
A number of exhibitors showed their products
help was much appreciated.
The full list of registrations follows:
the first game of the season.
during the sessions and their financial
Dr.'A. M. Agnew ■- Vancouver
Dr. E. H. Alexander—-- Vancouver
Dr. J. D." Alexander j , Vancouver
Dr. J. A. Alton Lamont, Alta.
Dr. R. N. Anderson Ladner
Dr. W. F. Anderson I Kelowna
Dr. L. H. Appleby- : Vancouver
Dr. W. S. Archibald | Kamloops
Dr. T. F. H. Armitage Vancouver
Dr. F. M. Auld __*_ \ Nelson
Dr. W. E. Austin___ l____Vancouver
Dr. F. R. Atridge_ j Vancouver
Dr. T. W. Arbuckle \ Vancouver
Dr. H. J. Alexander Vancouver
Dr. Blackwelder  '. Vancouver
Dr. E. J. Badye Vancouver
Dr. S. G. Baldwin Vancouver
Dr. A. W. Bagnall Vancouver
F/L. P. J. Bailey —Vancouver
Dr. John Balfour Vancouver
Dr. H. G. Baker Vancouver
Dr. Harry Baker Vancouver
Dr. H. A. Barner Bremerton, Wn.
Dr. P. J. Baron Vancouver
Dr. C. E. Battle i Vancouver
Dr. B. G. Barkman I Spokane, Wn.
Dr. D. Berman Victoria
Dr. J. C. Becher Vancouver
Dr. W. N. Bell Vancouver
Dr. B. Berge Vancouver
Dr. W. F. Bie Vancouver
Dr. J. H. Black ! Vancouver
Dr. D. Black	
Dr. J. H. Blair	
Dr. A. Bogoch	
Dr. F. H. Bonnell	
Dr. W. L. Boulter	
Dr. H. H. Boucher	
Dr. R. deBoyrie	
Dr. R. W. Boyd	
Dr. E. W. Boak	
Dr. W. R. Brewster	
 Vancouver
 Vancouver
 Vancouver
 Vancouver
 Vancouver
 Vancouver
 Vancouver
 Vancouver
 Victoria
-New Westminster
Dr. W. A. Brown Renfrew, Ont.
Dr. John Brown Vancouver
Dr. C. E. Brown ) Vancouver
Dr. F. W. Brydone-Jack Vancouver
Page Two Hundred and Seventy-two
Dr.
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Dr.
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 Victoria
_—Essondale
 Kemloops
 Vancouver
 Vancouver
F. M. Bryant	
B. F. Bryson	
H.  L.  "Rurris- 	
Gordon Burke        	
R. B. Burroughs	
Gerald Burke j '. Vancouver
Douglas Bush : Spokane, Wn.
D. F. Busteed j _. Vancouver
V. P. Byrne Essondale
W. J. Blakeney '. ',  .." Vancouver
A. W. Bowles New Westminster
M. Baird ! . Vancouver
S. T. Baldwin Vancouver
C. E. Benwell j Essondale
C. Campbell— -Vancouver
E. H. Campbell . Vancouver
R. M. Campbell Vancouver
H. H. Caple_ Vancouver
T. G. Cannt.         : j Essondale
R. S. P. Carruthers _ Vancouver
H. H. Cheney Vancouver
C. A. Cawker Vancouver
H. L. Chambers Vancouver
E. F. Chase j Seattle, Wn.
M. W. Chisholm : Port Alberni
W. A. Clarke     .   .       New Westminster
D. B. Collison	
N. C. Chivers	
E. F. Chase I	
H. R. Christie	
H. C. Christopher	
G. H. Clement	
H. G. Cooper	
C. F. Covernton .—
L. S. Chipperfield	
"C. Creighton	
R. L. Crook	
E. J. Curtis	
L. G. C. d'Easum	
L. S. Durkin	
H. R. L. Davis	
G. A. Davidson	
E. E. Day	
G. R. Dempsay	
O. DeMuth	
M. R. Dickey	
 Vancouver
 .Vancouver
-Seattle, Wn.
£ Trail
-Seattle, Wn.
 Vancouver
 Vancouver
 Vancouver
-New Westminster
 -Vancouver
 China
 Vancouver
 Essondale
 Vancouver
 Vancouver
 Vancouver
Vancouver
       Seattle, Wn,
 Vancouver
 Vancouver Dr. V. Drache Vancouver
Dr. H. Dumont -Vancouver
Dr. H. Dyer North Vancouver
Dr. W. Dykes . Vancouver
Dr. W. J. Dorrance Vancouver
Dr. W. A. Dodds Vancouver
Dr. F. Day-Smith Vancouver
Dr. H. A. DesBrisay Vancouver
Dr. C. M. Eaton Vancouver
Dr. B. S. Elliott Vancouver
Dr. W. J. Elliot Victoria
Dr. J* P. Ellis Vancouver
Dr. W. G. Evans Vancouver
Dr. A. M. Evans Vancouver
Dr. Fraser Vancouver
Dr. J. W. Fielding . Vancouver
Dr. Wm. Finlayson ■ Vancouver
Dr. S. Fitzhaut Vancouver
Dr. E. Fleck Vancouver
Dr. W. J. Fowler Vancouver
Dr. A. Francis Ganges
Dr. A. C. Frost Vancouver
Dr. Gardner Frost Vancouver
Dr. H. M. Frost Vancouver
Dr. J. W. Frost Vancouver
Dr. C. A. Fraser Vancouver
Dr. F. R. Fursey j Spokane, Wn.
Dr. L. B.. Fratkin Vancouver
Dr. J. R. Farish Vancouver
Dr. H. K. Fidler ——Vancouver
Dr. G. H. Francis j Vancouvre
Dr. J. A. Ganshorn . Vancouver
Dr. Dale Garrison Bremerton, Wn.
Dr. M. K. Garner '. I Vancouver
Dr. R. A. Gilchrist Vancouver
Dr..R. E. Gilham Langley Prairie
Dr. A. F. Gillis Merritt
Dr. B. D. Gillies Vancouver
Dr. C. E. Gould . : ; Vancouver
Dr. G. A. Gould Vancouver
Dr. A. A. Gordon .-Vancouver
Dr. W. Graham , Vancouver
Dr. W.- M. Graham Vancouver
Dr. G. Grant Vancouver
Dr. L. J. Genesove Vancouver
Dr. R. Grier Vancouver
Dr. I. B. Greene Everson, Wn.
Dr. J. W. Green j Salmon Arm
Dr. W. R. S. Groves Vancouver
Dr. C. H. Gundry Vancouver
Dr. P. B. Guttormsson .— Vancouver
Dr. M. L. Gaudin New Westminster
Dr. H. Carson Graham North Vancouver
Dr. J. S. Gwynn ; : Vancouver
Dr. A. M. Gee Essondale
Dr. Gendron . Vancouver
Dr. A. Hakstian j Vancouver
Dr.. C. H. Hankinson ' Prince Rupert
Dr. A. F. Hardyment j Vancouver
Dr. M. Hardie : Vancouver
Dr. J. E. Harrison Vancouver
Dr. S. R. Harrison Vancouver
Dr. W. E. Harrison Vancouver
Dr. B. J. Harrison i Vancouver
Dr. K. J. Haig .. Vancouver
Dr. D. P. Hannington Vancouver
F/L. J. A. Hay Vancouver
Dr. J. F. Haszard Vancouver.
Dr. A. Herstein , Vancouver
Dr. A. Herriman Tacoma, Wn.
Dr. F. S. Hobbs . Vancouver
S/Ldr. R. J. A. Hogg Vancouver
Dr. J. E. Hill 1_Vancouver
Dr. P. W. Hudson Vancouver
Dr. A. L. Hunt Vancouver
Dr. A. W. Hunter Vancouver
Dr. L.R. Hutchims Seattle, Wn.
Dr. G. H. Hutton ; Vancouver
Dr. A. Taylor Henry Vancouver
Dr. F. Hebb Vancouver
Dr. M. Halperin Vancouver
Dr. Hoehn Vancouver
Dr. A. M. Inglis Gibson's Landing
Dr. R. H. Irish Vancouver
Dr. R. W. Irving Kamloops
Dr. I. Kennedy-Jackson Vancouver
Dr. Paul Jackson Vancouver
Dr. E. A. Johnson Vancouver
Dr. F. D. Johnston Vancouver
Dr. G. C. Johnston Vancouver
Dr. T. A. Johnston Vancouver
Dr. N. H. Jonese .,..., Port Alberni
Dr. H. E. H. Johnston Vancouver
Dr. S. Kaplan Vancouver
Dr. A. T. Karsgaard Vancouver
Dr. W. M. Kemp . Vancouver
Dr. W. S. Kergin Prince Rupert
Dr. W. D. Kennedy Vancouver
Dr. O. E. Kirby Vancouver
Dr. F. E. Kinsey Vancouver
Dr. D. M. King Vancouver
Dr. J. H. Kope Enderby
Dr. R. G. Knipe Vancouver
Dr. W. J. Knox Kelowna
Dr. N. Knott Vancouver
Dr. G. Kunz -Tacoma, Wn.
Dr. G. J. A. Kirkpatrick . j Vancouver
Dr. W. D. Keith Vancouver
Dr. P. L. Lavers Vancouver
Dr. J. W. Laing Vancouver
Dr. R. Laird Vancouver
Dr. W. Laishley— Nelson
Dr. G. A. Lamont '. Vancouver
Dr. J. W. Lang ■ Vancouver
Dr. G, E. Langley , Vancouver
Dr. G. Lawrence Vancouver
Dr. E. Landa Vancouver
Dr. Gordon Large Vancouver
Dr. P. Lehmann Vancouver
Dr. D. R. Learoyd Victoria
Dr. G. H. Lee \ Vancouver
Dr. L. H. Leeson Vancouver
Dr. J. A. Leroux Fernie
Dr. T. H. Lennie Vancouver
Dr. H B. Lockhart Port Moody
Dr. E. J. Lyon Prince George
Dr. A. L. Lynch Vancouver
Dr. Lim Vancouver
Dr. H. Mallek Vancouver
Dr. J. Mallek Vancouver
Dr. A. B. Mason Vancouver^
Dr. R. S. Manson Vancouver
Dr. B. T. H. Marteinsson Vancouver
Dr. J. Margulius  New Westminster
Dr. S. May .Vancouver
Dr. E. L. Margetts Essondale
Dr. G. O. Matthews Vancouver
Dr. I. D. Maxwell  Vancouver
Page Two Hundred and Seventy-three Dr. A. M. Menzies Vancouver
Dr. B. Meth , loco
Surg. Lt. D. K. Merkley Vancouver
Dr. R. D. Millar Vancouver
Dr. T. Miller Victoria
Dr. W. J. S. Millar Vancouver
Dr. W. E. Milbrant Vancouver
Dr. H. H. Milburn Vancouver
Dr. D. W. Moffatt Vancouver
Dr. C. D. Moffatt Vancouver
Dr. G. Morse Haney
Dr. C. G. Morrison ! —Trail
M. Morrison Vancouver
-Nel
son
Dr.
Dr. N. E. Morrison.
Dr. C. R. Mowery Spokane, Wn.
Dr. D. Mowat Vancouver
Dr. B. B. Moscovich Vancouver
Dr. J. C. Moscovich Vancouver
Dr. W. A. Morton Vancouver
Dr. W. H. B. Munn ; Summerland
Dr.  D.   Munroe Vancouver
Dr. J. S. Murray Vancouver
Dr. M. Mullinger -Vancouver
Dr. R. Mustard ■ Vancouver
Dr. D. F. Murray Vancouver
D. I. A. McCaffery Vancouver
Dr. H. M. Morean Bellevue, Wn.
Dr. Marcellus Vancouver
Dr. W. M. McCallum Vancouver
Dr. D. McCallum Vancouver
Dr. R. P. McCaffrey : j Vancouver
Dr. J. S. McCarley North Vancouver .
Dr. E. C. McCoy Vancouver
Dr. J. H. MacDermot Vancouver
Dr. A. D. McElvie_ Vancouver
Dr. E. H. McEwen New Westminster
Dr. S. McFetridge Vancouver
Dr. H. B. McGregor i Penticton
Dr. R. McGregor Vancouver
Dr. H. J. MacKay Vancouver
Dr. C. E. McKinnon Vancouver
Dr. A. J. MacLachlan Vancouver
Dr. T. K. MacLean Vancouver
Dr. D.  McLellan Vancouver
Dr. E. C. McLeod Vancouver
Dr. J. A. MacMillan Vancouver
Dr. L. Macmillan Vancouver
Dr. T. S. McMurtry Vancouver
Dr. A. Y. McNair, . Vancouver
Dr. C. G. McNeil Vancouver
Dr. N. McNeill Vancouver
Dr. M. MacPherson Vancouver
Dr. G. A. McLauchlin North Vancouver
Dr. J. R. Naden Vancouver
Dr. A. B. Walsh . Victoria
Dr. J. R. Neilsen Vancouver
Dr. M. Nicholson Vancouver
Dr. J. A. Nicholson j Essondale
Dr. Agnes 0*Neil Vancouver
Dr. T. R. Osier ] Vancouver
Dr. H. M. Page Portland, Ore.
Dr. K. D. Panton Vancouver
Dr. L. A. C. Panton Kelowna
Dr. F. P. Patterson Vancouver
Dr. S. Paulin Vancouver
Dr. E. Peacock West Vancouver
Dr. K. A. Peacock West Vancouver
Dr. V. Pepper . New Westminster
Dr. D. A. Perley Grand Forks
Page Two Hundred and Seventy-four
 Ganges
—Vancouver
-Vancouver
—Vancouver
-Vancouver
—Vancouver
Dr. D. Perry	
Dr. S. C. Peterson i	
Dr. S. C. Peterson	
Dr. G. A. Petrie	
Dr. J. Piters	
Dr. C. H. Ployart	
Dr. J. A. Porter Vancouver
Dr. K. K. Pump Vancouver
Dr. G. S. Purvis New Westminster
Dr. W. H. Perry Vancouver
Dr. R. A. Palmer Vancouver
Ragon a Vancouver
Dr. P.
Dr. R
Dr. G
M. Rice	
A. Roberts	
Dr. F. N. Robertson.
Dr. R. Robertson	
Dr. G. E. Robinson—
 Essondale
 Chilliwcak
—.Vancouver
 Vancouver
 Vancouver
Dr. A. C. Ross New Westminster
Dr. G. S. Rothwell New Westminster
Dr. R. D. Rush Vancouver
Surg. Cmdr. R. H. Ruttan Esquimalt
Dr. C E. Robertson Vancouver
Dr. C. E. G. Robinson Vancouver
Dr. H. Rooke Robertson Vancouver
Dr. T. R. Serjeant Vancouver
Dr. E. S. Sarvis Huntingdon
Dr. F. E. Saunders Vancouver
Dr. W. G. Saunders Vancouver
Dr. G. D. Saxton Vancouver
Dr. J. W. Schori i Bellevue, Wn.
Dr. M. Schreiber Coquitlam
Dr. J. U. V. Schwind Tacoma, Wn.
Dr. H. Scott Vancouver
Dr. G. E. Seldon Vancouver
Dr. J. Shier ! Vancouver
Dr. I. J. D. Shuler Seattle, Wn.
F/L. Siddall  Vancouver
 Vancouver
——Vancouver
 Vancouver
——Vancouver
 Vancouver
 Vancouver
Dr. R. A. Simpson	
Dr. W. W. Simpson .	
Dr. J. A. Sinclair	
Dr. F. L. Skinner	
Dr. W. D. Smaill	
Dr. J. A. Smith	
F/L. Sochowski	
Dr. E. Rex Speelmon	
Dr. H."D. Sparkes	
Dr. R. A. Stanley	
Dr. D. H. Stanwood	
Dr. W. J. Stark	
Dr. I. W. StofFman Vancouver
Dr. J. A. Street Vancouver
Dr. G. F. Strong Vancouver
Dr. K. B. Sunderland Essondale
Dr. A. Swanson ^Essondale
Dr. M. Sylling = Vancouver
Dr. A. C. Sinclair Victoria
 Vancouver
——Spokane, Kn.
 Vancouver
 Vancouver
 Vancouver
 Vancouver
Dr. W. H. Sutherland.
Dr. Olive Sadler	
Dr. Lee Smith	
Dr. Stevenson 	
Dr. D. A. Steele	
Dr. G. L. Smith	
Dr. F. D. Sinclair	
Dr. R. Miller Tait	
Dr. W. M. Tait	
Dr. B. Tanton	
Dr. D. Telford	
Dr. K. Terry	
Dr. E. A. Thacker	
—Vancouver
—Vancouver
—Vancouver
 Vancouver
 Vancouver
 Vancouver
 Cloverdale
 Vancouver
—Vancouver
 Vancouver
—Vancouver
—Victoria
 Vancouver Dr. J. C. Thomas < Vancouver
Dr. G. I. Theal Vancouver
Dr. J. W. Thomson—  Vancouver
Dr. W. J. Thompson .Vancouver
Dr. W. M. Toone -North Vancouver
Dr. Ethlyn Trapp Vancouver
Dr. E. B. Trowbridge Vancouver
Dr. A. E. Trites ! Vancouver
Dr. A. Turnbull , Vancouver
Dr. F. A. Turnbull- , Vancouver
Dr. A. S. Turner Vancouver
Dr. H. Wackenroder Vancouver
Dr. J. T. Wall Vancouver
Dr. S. A. Wallace Kamloops
Dr. W. C. Walsh Vancouver
Dr. G. L. Watson Vancouver
F/L. A. B. Watson : Vancouver
Dr. H. G. Weaver Vancouver
Dr. W. H. White Penticton
Dr. W. A. Whitelaw Vancouver
Dr. E. M. Wilder New Westminster
Dr. L. J. Williams Vancouver
Dr. S. L. Williams 1 Vancouver
Dr. D. H. Williams Vancouver
Dr. J. R. Wilson Vancouver
Dr. W. E. Wilkes Vancouver
Dr. R. E. Willits Vancouver
Dr. L. G. Wood Vancouver
Dr. E. F. Word Vancouver
Dr. G. T. Wilson New Westminster
Dr. H. E. White Vancouver
Dr. L. H. Webster Vancouver
Dr. Wilkey Vancouver
Dr. Vookes Vancouver.
Dr. C. H. Vrooman Vancouver
Dr. J. P. Vye Victoria
Dr. D. P. Vollans West Vancouver
m VANCOUVER GENERAL HOSPITAL |
THE  PATHOLOGY OF  CHRONIC THYROIDITIS
J. Sturdy, M.D. ^
In the differential diagnosis of affections of the thyroid there is, perhaps, no more
confusing combination of symptoms encountered by the surgeon than that of the condition to which the ill-considered generic term "chronic thyroiditis" has been applied.
Its importance from a practical viewpoint is its differentiation from malignant disease
of the thyroid, for which it is all too frequently mistaken. The recorded cases of so-
called inoperable carcinoma of the thyroid, who are alive and well many years after
the establishment of that diagnosis clinically, are legion, and most of them indubitably
fall into this hitherto obscure group of thyroid strumae. The condition has a further
significance to the surgeon as a disease entity in its own right, one which is unquestionably much more common than was heretofore thought to be the case, and one which
presents a symptom-complex of an order recognizable with moderate facility in the
wards and in the operating theatre. It is in receipt currently, in the larger centres, of
an increasing amount of attention, both experimental and clinical, with the result that
one is now able to discuss its pathogenesis and symptomatology much more categorically
than was possible a few years ago.
It would be inconsistent with the accepted behaviour of tissues elsewhere to assume
that the anatomical juxtaposition of the thyroid gland and such sources of acute and
chronic infection as the nasopharynx, the tonsils and the teeth, this considered in association with its extremely rich blood supply, would not lay the organ constantly open
to bacterial and toxic invasion, and there is indeed abundant evidence that infection is
common. It is on account, however, of that same rich blood supply, that the acute
suppurative lesions of acute thyroiditis rarely develop, but having done so, cultures from
the infected gland have yielded, according to the literature, such organisms as the
staphylococcus, streptococcus, bacillus coli, bacillus typhosus and pneumococcus, all of
which lends support to the clinicopathological assumption that the gland is frequently
inoculated. As a result of recent animal experimentation, it has been ascertained that
the thyroid, because of its abundant blood supply, tends to become sterile shortly after
its bacterial contamination via the blood stream or lymphatics. It is undoubtedly the
case, however, that transitory inflammatory processes in the thyroid almost invariably,
leave a local aftermath in the form of bacterial exotoxins, which in turn leave their
marks in most instances upon the acinar epithelium. The circulating toxins in such
systemic conditions as scarlet fever, typhoid fever, diphtheria and septicaemia likewise
leave their issue. The result is the sequence of inflammation elsewhere, namely, tissue
damage and replacement fibrosis of the damaged areas. The partially fibrosed condition
of the thyroid in a large series of necropsies on an older age group, led Joll many years
Page Two Hundred and SeVenty-five ago, to the conclusion that transitory infections are frequent during a life-time. The
appearance of chills and fever in these mild attacks of non-specific thyroiditis, depend
of course upon the virulence of the organism concerned, the resistance of the tissue
involved, and the amount of foreign protein, including inactivated thyroglobulin, released.. The resistance of the tissue is doubtless accentuated in older persons with general arterial dysfunction. The course of repair and reabsorption of damaged epithelial
elements may be long or short, and should the fibrosis progress to clinical recognition
with signs of enlargement and pressure, the result is the lesion known as Riedel's struma,
or synonymously "lignous" or "woody" thyroiditis, or perhaps even better, the term
Struma Fibrosa. Pathologically, upon occasion in the operating room, and rarely clinically, a variant of Riedel's struma known as the giant-cell variant of deQuervain is
now recognized. Its pathogenesis is presumed inflammatory, as is Riedel's struma fibrosa,
the presence of foreign-body giant cells being as yet considered an unexplained tissue
response to bacterial infection, and not a disease sui generis.
Included in the term "chronic thyroiditis" is the more obscure, almost equally
common, struma of Hashimoto, or better (since Hashimoto was not the first to describe
it) one must consider the term Struma Lymphomatosa more acceptable, and certainly
more descriptive. This lesion is of doubtful etiology, but experimental evidence would
indicate that its initiating process is degenerative rather than inflammatory. There is
strong experimental support to the theory that its pathogenesis may be concerned with
dysfunction of the pituitary gland, in much the same way that an endocrine imbalance
is associated with such conditions as mazoplasia, and endometrial hyperplasia, the thyrotropic hormone in this instance being the offender. That this is a precursor of Riedel's
struma fibrosa has no less an advocate than Ewing but there has been amassed such a
quantity of evidence to the contrary that it is now generally accepted as a disease entity
quite distinct from Riedel's struma.
In the November issue of Surgery, Gynaecology & Obstetrics, an article by J. A.
Schilling of Rochester, N.Y., describes eleven cases of Struma Lymphomatosa, Struma
Fibrosa, and its giant-cell variant of de Quervain, from the Strong Memorial Hospital.
A search of the records of The Vancouver General Hospital over the seven-year period
rom 1939 to 1946 yielded, to our surprise, a comparable number of cases, which on
thorough investigation presented similar characteristics to those of Schilling's series.
With your permission, I would like to refer to these briefly, summarizing the essential
qualities of each. It might be pointed out that in only one instance was the diagnosis
recorded preoperatively.
The first four cases are examples of Struma Lymphomatosa.
Case Histories
1. Miss B.: A seventeen-year-old white female with a history of increasing pressure
in the thyroid area of a fairly rapidly growing nature for eleven months. The swelling
was diffuse and bilateral. There was noticeable gain in weight since the onset. She
tired easily and complained of inability to concentrate. There were no signs of thyro-
toxicity. She was operated on the day following admission, and was discharged twelve
days later. The swelling recurred in one year's time and subsided of its own accord one
month later. There are present at the time of writing definite signs of myxedema being
controlled by minimal doses of thyroid extract.
2. Mrs. D.: A forty-nine-year-old female presented with definite pressure symptoms
of one year's duration—both dysphagia and difficult inspiration. She had periodical
gastro-intestinal upsets with frequent bouts of palpitation and subjective asthenia for
the same length of time. Both lobes were removed surgically three days after admission,
and fiv days later, after an uneventful convalescence, she was discharged. A follow-up
one year after discharge revealed no definite signs of myxedema.
3. Miss Y.: A ninteen-year-old girl with a two-month history of recent enlargement of a previous thyroid swelling for two years and at the time of admission causing
pressure symptoms.    An interesting feature was the history of menstrual disorders be-
Page Two Hundred and Seventy-six ginning at the same time as the onset of the struma. She was lugolized although there
were no signs of thyrotoxicity and was operated on eight days after admission. The
post-operative period was uneventful. The follow-up done twenty months later revealed the patient taking thyroid extract for dry skin and hair. One year after discharge
she was found to be suffering from pulmonary tuberculosis, which may account for the
very mild myxedematous symptoms.
4. Mrs. F.: The last case of struma lymphomatosa was a twenty-one-year-old woman
admitted with a four to six year history of swelling in the neck, emotional upsets, weakness, night sweats and tremors. She had, further, additional pressure symptoms. She
was lugolized for a nine-day period, the struma being removed surgically. Convalescence was uneventful.
The following six cases, presented briefly, are of Riedel's struma fibrosa.
5. Mrs. J5.: The first is a fifty-eight-year-old woman with symptoms predominately
of pressure, notably dysphagia and dyspnoea and stridor for six months, the struma
being present for one year.. The follow-up four and one-half years later revealed no
post-operative complications.
6. Mrs. S.: The second case of woody thyroiditis was a sixty-year-old woman admitted with an eighteen-month-old thyroid tumour exerting pressure upon adjacent cervical structures. The post-operative period was uneventful, and according to a surviving sister, there were no myxedema or voice changes in the two-year period following operation and preceding her death.
7. Miss S.: The third case was a twenty-one-year-old girl with an eight month
history of swelling in the neck, and a one month history of pain therein. There were
vague pressure symptoms. Her pre-operative basal metabolic rate was plus 27. A
follow-up six years later revealed the patient to be definitely myxedematous and to
exhibit definite signs of laryngeal involvement. She is at present taking both thyroid
extract and parathormone.
The last three cases are more classical.
8. Mrs. M.: Presented with a definite myxedematous, facies, had signs of embarrassing pressure upon the trachea and oesophagus for seven months, and the painless
bilateral goitre made its subjective appearance two months after the onset for the first
symptoms. She was forty-nine years old when operated on and twenty months later
the follow-up showed her suffering minimal myxedema symptoms with laryngeal nerve
involvement.
•
9. Mrs. C: This sixty-three-year-old woman complained of a rapidly growing
right-sided struma with few signs of pressure. Her pre-operative basal metabolic rate
was minus 9. The post-operative period was stormy, and her subsequent history reveals
her suffering from myxedema controlled by moderate doses of thyroid extract.
10. Mrs. B.: The last case of struma fibrosa is in a forty-five-year-old American
woman with a four month old painful struma exerting recent pressure upon the oesophagus and laryngeal nerves. The pre-operative basal metabolic rate was plus 1. Follow-
up a year later showed no laryngeal nerve involvement but a very definite myxedema
which appeared to respond to minimal doses of thyroxin.
11. Mrs. D. B.: The only available case in the hospital records of the giant-cell
variant of Riedel's struma was operated on by Dr. Lennie only last month. She is
fifty-one years of age, and was admitted with symptoms of acute respiratory embarrassment due to pressure of a seven-week-old right-sided enlargement of the thyroid gland.
The struma was painful and typical of this variety; the pain radiated to the back of the
head, the homolateral ear, and to the shoulder area. Her convalescence was uneventful
and follow-up to this early date shows no evidenc of myxedema, laryngeal involvement
or tetany.
Page Two Hundred and Seventy-seven Table I.
STRUMA LYMPHOMATOSA
STRUMA FIBROSA
GIANT CELL VARIANT
Schilling
V.G.H.  Cases
Schilling
V.G.H.   Cases
Schilling
V.G.H.  Cases
AGE
40-60
17-39
(3 in 2nd,
3rd decades)
20-40
20-63
20-40
Single case
age 51.
Sex—% Female
Almost 100
100
60-80
100
60-80
Female.
Predominant
Presence of
Goitre, mild.
Predominant
Pressure
Mod. pressure
Marked
Symptons
Goitre—
Vague Pressure
signs.
Pressure signs
with
occasional
symptoms of
hypothyroid.
pressure
symptoms.
symptoms and
occasionally
signs of
myxedema,
some pain.
signs, pains
in shoulder,
neck, ear.
Dysphagia,
Dyspnoea,
Pain radiated
to shoulder
and occiput.
Duration of
Symptoms
Usually years.
Recent
Acceleration.
1 to 6 years
1 to 2 yeras.
3 months to
18 months.
1 to 12
months.
7 weeks.
Presence of
Goitre
Yes.
Yes.
Yes.
Yes.
Yes.
Yes.
Duration of
Goitre
Usually
years.
1 to 6 years.
1 to 2 years.
3 months to
18 months.
1 to 12
months.
7 weeks.
Amt. Thyroid
Involved
Always
diffuse.
Bilateral.
30%
Unilateral.
Iin6
Unilateral
30%
Unilateral.
Unilateral.
Response X-ray
Excellent.
Not tried.
None.
Not tried.
Unknown.
Unknown.
Post-operative
Uneventful
Uneventful.
Often stormy.
2/6 stormy.
Uneventful.
Uneventful.
Follow-up
Myxedema
and general
metabolic
disorders.
2 /4 myxedema,
No trace 3rd
4th—general
metabolic
disorders.
No myxedema,
Sometimes no
relief pressure
symptoms.
Laryngeal
paralysis and
tetany.
4/6 myxedema,
1 recurrence,
3/6 laryngeal
paralysis, 1 on
Parathormone.
No follow-up
on two.
Usually
prompt remission
symptoms—
No recurrence.
In hospital
at time of
writing.
AGE: To recapitulate the symptom-complex in its presently accepted form, first
considering age, the tendency for struma lymphomatosa to occur in the fourth and fifth
decades is noted. Struma fibrosa and its giant-cell variant usually occur in the third
and fourth decades. It was our experience that there is considerable overlapping, and
considerable variation in these ascribed limits, so that age is a most unreliable criterion.
SEX: With regard to sex incidence, it is remarked that whereas the ratio in thyroid
disease generally of female to male is 5 or 6 to 1, the proportion in struma fibrosa is about
4 to 1. Our cases were all female. In struma lymphomatosa there are only six strictly
authnticated cases of the condition reported in males.
History and Symptoms
Struma lymphomatosa is frequently of longer standing than struma fibrosa and its
variant and is usually attended by a history of recent enlargement in a previously hyper-
trophied gland.
The usual presenting symptom in struma lymphomatosa is a diffuse and bilateral
enlargement of the thyroid with such pressure symptoms (often vague) as dyspncea,
dysphagia, hoarseness of voice, cough, or subjective sensations of constriction. An early
or well advanced myxedema may be present, and such symptoms as tremor, palpitation,
nervousness and dizziness which are in fact symptoms rather referable to the sympathetic and central nervous systems than to hyperthyroidism, not infrequently lead to
the mistaken impression that the latter co-exists. There may be a well defined history
of gain in weight.
Page Two Hundred and Seventy-eight
umm In struma fibrosa and the de Quervain variant, pressure symptoms almost invariably
predominate. The commonest signs are dyspnoea and dysphagia, the former upon occasion giving rise to a sensation of imminent asphyxia. Schilling makes the remark that
the anxiety state so produced may render a basal metabolic rate grossly inaccurate.
PAIN: In all three conditions, pain is inconstant. It is rarely present in struma
lymphomatosa, frequently present in struma fibrosa, and almost always severe in the
giant-cell variety of de Quervain, where it tends to radiate to the occipital and prietal
regions and to the back of the neck and shoulders.
Tenderness is common to all three conditions but may not be present.
BRUIT: There is no bruit heard in the region of the struma.
CLINICAL PALPATION: Clinically, the gland is always diffusely and bilaterally
enlarged in struma lymphomatosa. It is firm to the touch and rarely possesses the bone-
hard consistency of Diedel's struma fibrosa. A further differentiating eature is the
occasional unilateral growth of the latter and its giant-cell variant.
Table II.
Surgical Characteristics
STRUMA LYMPHOMATOSA
STRUMA FIBROSA
GIANT CELL VARIANT
Schilling
V.G.H.   Cases
Schilling
V.G.H.   Cases
Schilling
V.G.H.  Cases
Surgical
Appearance
Pseudo-
loculated
Yellow.
Compact,
gray-pink
to yellow.
White
smooth.
Finely
lobulated,
fibrous.
Gray-white
smooth.
Gray-white
smooth.
Bleeding
Tendency
Variable.
Increased.
Decreased.
Not
mentioned.
Usually
decreased.
Not marked.
Adjacent
Adhesions
Pretracheal
only.
Pretracheal
sometimes
lateral.
Invariable
Dense.
Very dense,
Diffuse.
Variable,
Usually
none.
Marked in
involved
lobe.
Extent
Involved
100%
diffuse,
100%
diffuse.
1/3
Unilateral.
1/5
Unilateral.
1/3
Unilateral.
Single case
Unilateral.
Consistency
Firm.
Firm, 1 of
4 soft.
Bone-like.
Very hard.
Hard.
Hard.
Presence of
Adenomas
None.
Small
adenoma in 1.
Occasional.
None.
Occasional.
None.
Surgical differentiation is upon occasion difficult. The bleeding tendency is variable
instruma lymphomatosa and usually decreased in RiedePs disease. Admissions are inevitable in all three forms. Struma fibrosa and its giant-cell variant are of inflammatory origin, and as one might therefore reasonably expect, are invariably associated with
adhesions, upon occasion indeed being densely adherent to almost every adjacent structure. It is for this reason that post-operative complications are rarely avoidable. Struma
Lymphomatosa on the other hand, being degenerative in origin, is not markedly adherent to the periglandular tissues, but is requently found to be strongly attached to
the pretracheal fascia.    The tumour therefore sometimes moves with deglution.
Gross Appearance
The exterior of the gland in struma lymphomatosa presents a smooth pinkish, finely
lobulated appearance. The cut surface is faintly yellowish. Struma fibrosa presents a
white, glistening, smoothly enlarged, very hard, fibrous appearance and on the cut surface may be discerned fine fibrous trabeculae. The giant-cell form of de Quervain is
said to be somewhat more gray than its unembellished affiliate.
Microscopically the distinction is more pronounced. In struma lymphomatosa there
is a predominance of lymphoid tissue, a scanty stroma, hyperplastic germinal follicles
and scanty colloid.    In struma fibrosa, there is complete fibrous tissue replacement of
Page Two Hundred and Seventy-nine Table III.
Microscopically
STRUMA LYMPHOMATOSA
Acinar
Epithelium
Colloid
Presence
Stroma
Cellular -
Infiltrate
Blood
Vessels
Schilling
Degenerate,
Low and
Cuboidal.
Scanty to
Absent.
Slight Increase in
Fine C.T.
Lymphocytic
with Lymph
Follicles.
Uninvolved.
V.G.H.   Cases
Degenerate,
Low and
Cuboidal.
Scanty.
Slight increase in
Fine C.T.
Lymphocytic
with Lymph
Follicles.
Not noteworthy.
STRUMA FIBROSA
Schilling        V.G.H.   Cases
GIANT CELL VARIANT
Schilling        V.G.H.   Cases]
Compressed,
Absent in
Involved
Areas.
Normal in
Uninvolved
Areas:
Fibrosis and
Hyalinization.
Moderate
Lymphocytic
and Polys, in
Fibrous C.T.
Thick Intima
and Media
Compressed,
Absent in
Involved
Areas.
Very
Scanty.
Broad bands
Fibrous
Tissue.
Somtimes
Massive
Lymphocytic
and Polys.
Thick Medial
Coat.
Ac. Degeneration in
Involved
Areas.
Intercellular
in Involved
Areas
Perilobular
whorls of
Dense C.T.
Dense Lymph
Plasma and
Histiocytes
Giant Cells.
Peri-art.
Fibrosis.
Compressed,
Degenerate
in Involved
Areas.
Intercellular
in Involved
Areas.
Perilobular I
whorls of
Dense.OT. J
Dense Lymph
Plasma and
Histiocytes
Giant Cells.
Peri-art,
Fibrosis.
the normal acini, with compression and atrophy of the residual thyroid elements. The
picture is frequently conused by a well-marked infiltration by lymphocytes and inflammatory cells. In the de Quervain variant there is both a true and a pseudo-giant-
cell reaction superimposed upon the usual picture of struma fibrosa propria. The true
giant cells are of foreign body type, the pseudo-giant? cells are often undistinguishable
and appear to be of colloid-monocyte genesis.
Post-Operative Course
The post-operative course in thyroiditis is usually more stormy in Riedel's than in
the other forms. A severe bout of pyrexia may attend convalescence following surgical extirpation. Myxedema is an almost inevitable post-operative consequence of
--"Struma lymphomatosa, and according to Graham (and our own experience) may accompany removal of a Riedel's struma. Owing to the dense adhesions found in struma fibrosa,
laryngeal paralysis or tetany are grave and sometimes unavoidable consequences of surgical interference.
Differential Diagnosis
In malignant disease of the thyroid from which these conditions must be differentiated both by reason of the firm, adherent gland and the usual occurrence in the so-
called "cancer-age" group, it is as well to bear in mind that carcinoma rarely occurs in
a previously normal thyroid. A history of nodular thyroid tumor is frequent and it has
in fact been estimated that 80 to 85 percent of carcinomata arise in adenomata associated with thyrotoxicosis.
Cancer is characterized by a relatively rapid increase in size and hardness in a soft
goitre. Pressure signs are common; pain is not uncommon. There may be considerable
concomitant cardiovascular disturbance. Metastases are common, especially in the lungs
and bones. Differentiation is most usually confirmed at operation, and its confirmation
by rush diagnosis should be an inflexible rule. The opinion offered at rush diagnosis
should affect the course of the operation radically. Complete as possible surgical resection of a carcinomatous thyroid, followed by intensive radiotherapy, is the procedure
of established custom. On the other hand, should the case prove to be struma fibrosa,
complete removal is unjustifiable owing to the consistent prevalence of post-operative
Page Two Hundred and Eighty complications.   Only sufficient tissue therefore should be removed to ensure relief of pressure symptoms.
In the instance of struma lymphomatosa it has been ascertained that the lesion
responds in remarkable fashion to radiotherapy, and it is thus highly recommended that
x-ray therapy beaccepted method of choice in the case of struma lymphomatosa,
after initial biopsy to finally rule out the question of malignancy.
In conclusion it is suggested that chronic thyroiditis is a much commoner clinical
entity than has in the past been recognized, and that further studies may both serve to
elaborate its treatment and to assist in its all-important differentiation from malignant
disease of the thyroid.
• ••
• ••
: ::..iimiiiiimwttTfTtt]ji
BRIEFS
Over a thousand more cases of venereal disease were reported in Canada in the
second quarter of this year than in the same period of 1945, the Hon. Dr. J. J. McCann,
acting minister of National Health and Welfare, announced at Ottawa recently.
"Authough the most recent reports show a decline in new cases, venereal diseases
continue among the top-ranking problems facing Canada today," Dr. McCann said.
"Venereal disease can be eradicated. This year the federal government has set aside
over $270,000 ot combat the V.D. menace, but legislation, money and medical skill are
not enough. To eliminate this scourge requires an enlightened community and wholehearted co-operation, not only on the health front but equally on the moral, welfare
and legal sectors.
In the first six months of this year 21,933 cases of syphilis and gonorrhoea were
reported.    Of these 8,283 were syphilis and the remainder gonorrhoea.
The total number of cases in the April-June quarter was 10,235 as against 11,698
in the first three months of the year. For the April-June period of 1945 total new
cases of all types of V.D. were 9,188.
Dr. B. D. B. Lay ton, chief of the venereal disease control- division, Department of
National Health and Welfare, explained that these statistics are provided by provincial
health departments and compiled by the Dominion Bureau of Statistics. The laeest
figures are "encouraging," he said, but would not in any way modify the all-out effort
to eradicate these infections.
The rate of syphilis for Canada has fallen from 147 per 100,000 population during
the first quarter of 1946 to 125 per 100,000 in the April-June period. The rate of
gonorrhoea per 100,000 has declined 11 per cent., from 236.8 to 210.8 per 100,000
population.
Page Two Hundred and Eighty-one m       * ACUTE PELVIC PERITONITIS     §■
(Given at V.M.A. Summer School)
By Dr. Philpott
Dr. Philpott considers "acute pelvic inflammation" a better term. This pelvic inflammation includes upper and lower tract inflammations, and is not limited to the
peritoneum, besides the condition is not merely one of peritonitis, even as regards its
abdominal manifestations. Along with peritoneal involvement we have parametritis,
and salpingitis, and these last two are inseparable from the peritonitis present. So that
pelvic peritonitis as a separate clinical or pathological entity does not exist.
There are two types of inflammation of the pelvis—
1. Upper tract inflammation—the acute primary inflammation—that type which
occurs primarily in the genital organs. This type may follow complications of pregnancy or labour, whether the latter be normal or instrumental. Or, secondly, it may
follow gonorrhoea.
Besides occurring, as has been said, as a sequel to normal or interrupted labour, it
may, and frequently does, follow criminal abortion, and here, of course the added
risk of ignorant handling, sepsis, etc., makes the probability of infection all the greater.
But other forms of mechanical upset are frequently responsible for pelvic infection.
Douches, various appliances, such as pessaries, may be the causative agent, and contraceptive devices, too, have to be taken into account.
Infections from the cervix and vaginal mucosa are a very frequent cause of infection,
and at this point Dr. Philpott laid special stress on the importance of the pH of these
areas. This plays a great part in the causation or prevention of pelvic infection. Normally, the higher we go in the pelvic tract, from the vaginal outlet, the more alkaline
the pH. The normal and proper pH of the cervical mucus should-be 7.1% at least.
Streptococci will not live in a vaginal cavity or cervical mucus higher than pH 5,
and staphylococci grow freely at this pH level. Therefore, if the pH of the vagina or
cervix is acid or at any significant level below 7.1, we have a very good medium for
bacterial growth, i.e. pathogenic bacterial growth.
There is another important consideration here; two, in fact. The first is that the
spermatozoon wants a pH of 7. This is the optimum level from its standpoint, and,
of course, in normal conditions, this is the pH it would find, with a normal cervical
pH of 7.1, as defined above. But there is another micro-organism which thrives at this
pH of 7, and that is the gonococcus—so that this, uniquely among the pathogenic
bacteria that we have reason to fear, thrives in the presence of a normal pH.
Contraceptive preparations which are alkaline, do harm. As one can see from what
has been said, their use predisposes to bacterial growth. The use, too, of alkaline douches
can be injurious, and lessens the chances of pregnancy, if this is desired.
Bacillus coli will thrive in any pH.
The spread of infection takes place in any one of three ways:
1. Surface spread—as in the case of the gonococcus, which can ascend by this
method to the endometrium, and spread thence to the parametrium and adnexa.
2. Lymphatic spread, as through lacerations of the cervix—extending to the parametria! tissues, giving rise to parametritis, and so to further involvement of the peritoneum, etc.
3. Haematogenous—where there is a pelvic thrombophlebitis, for example.
Salpingitis, parametriittis, pelvic peritonitis, may occur singly or all together at
a time.
In diagnosing acute pelvic isflammation, we are guided by the following main signs
and symptoms:
1. Fain—on movement or even when the patient is at rest.
2. Fever—101-103, or even 104.
3. Rapid pulse.
Page Two Hundred and Eighty-two The pregnant woman truly has a "whim
of iron." And when she gets a longing
for pickles (usually at 3 a.m.) even the
strongest-minded.find it simpler to just
go and get them for her.
The addition to her diet of Squibb
Viophate "D" helps to counteract the
effect of these whims of the mother and
makes more certain the development of
a healthy babyi 2 capsules of Squibb
Viophate "D" 3 times daily conveniently afford a total of 7.8 grains of
supplementary calcium (about half the
daily requirement) with sufficient vita--
min D to assure its utilization.
Sqjjibb
E. R. SQUIBB & SONS OF CANADA, LTD,
l/icfl* u»tl- v
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Yet systemic absorption, even with
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obviating likelihood of systemic toxic
reactions.
The product retains full potency under all ordinary conditions.
Its clinical value has been clearly established in a substantial and fast
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Supplied in packages of 24 tablets—
3% grs. (0.25 Gm.) per tablet—sani-
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ortant
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ulfathiazolegum "•saswgJP
The Ay erst group of vitamin B complex preparations—
the "Beminal" family—provides six separate and distinct
answers to the problem of B complex administration.
TABLETS        CONCENTRATE INJECTABLE
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This variety of forms and potencies facilitates selection
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BEMINAL
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4. Spasticity and tenderness of the lower abdomen, usually bilateral.   There is pain
on movement of the cervix or uterus on vaginal examination.
5. Sometimes there is abscess formation, in the later stages.
So far the speaker had dealt with the acute primary type of pelvic inflammation.
He referred next to the secondary type of infection, where the primary source of the
bacterial invasion is elsewhere in the body, and the pelvic tissues and organs are invaded
secondarily.    This infection may come:
First, from the vicinity—e.g. the bladder, or urinary tract. This is, of course, quite
often the case. The bowels may also be the source of secondary infection of the pelvis,
and even the appendix may give rise to such infection. But there are other sources of
secondary infection, often very far removed from the pelvic area.
Second—We have non-specific, and non-gonorrhoeal infections causing secondary
infection in the pelvis—carried through the blood stream. Among these, the commonest are: scarlet fever, acute tonsillitis, acute upper respiratory infections.
These are usually streptococcic infections, but the staphylococcus may be the exciting organism.
Differential Diagnosis. Briefly the following main conditions have to be excluded
in our diagnosis of pelvic inflammation:
1. Local uterine infection without spread. Here we note the absence of pain, except very slight manifestations. There is no tenderness—the temperature and pulse are
less affected.
2. Tubal pregnancy. Here the history is of great importance—the missing of a
period, spasmodic pain and bleeding, shock of more or less intensity—absence of high
temperature, which is usually normal or below normal.
3. Lower bowel lesions, such as diverticulitis, ulcerative colitis, etc. Here the character of the stools, blood in the faeces, obstructive symptoms, localization of masses or
tenderness, and rectal and proctoscopic examinations, are all important in differentiation,
as is the temperature and the history.
4. Urinary tract infections.   Here examination of the urine tells the tale.
5. Twisted ovarian cysts, degenerated fibroids, occasionally present difficulties, and
demand careful examination and differentiation.
6. Acute appendicitis is, of course, the most important condition that we have to
differentiate from acute pelvic inflammation. The importance of this diagnosis, of
course, lies in the fact that early operation is so often a matter of urgent necessity, in
the case of appendicitis, while the exact opposite is true as regards pelvic inflammation
in the acute stage. We have, of course, several very definite points of difference between the two—localization of pain and tenderness, a lower temperature in appendicitis as a rule, history of digestive disturbance, and so on—but with all this, there will
be cases where a subsequent general peritonitis has set in, which will tax all our powers
of diagnosis. Dr. Philpott considers the sedimentation rate of very great value in making
a differential diagnosis, as this, in his experience, is never high in acute appendicitis.
In doubtful cases, he feels that it is a grave error to start therapy too quickly, as this
is apt to mask symptoms, and confuse us in our diagnosis. As soon as this is made, we
begin therapy at once.
Treatment of acute pel vie inflammation—pelvic peritonitis.
Dr. Philpott divided this into four stages:
1. Immediate—acute stage.
2. Following acute stage, when there is abscess formation.
3. Where there is no abscess formation, and when patient has got over the acute
stage, and is recovering.
4. Later stages, when operation may be done, if this is necessary or advisable.
As regards the first stage. Treatment during this acute stage should be immediately
instituted, and it is of the greatest importance that there should be no delay or waiting.
Page Two Hundred and Eighty-three This is because it is vital to avoid secondary spread and permanent residual damage, and
this end cannot be achieved if there is delay.
The first step is bed rest, which must be complete.
Next, we apply hot or cold applications. Either is good, and the choice varies with
the individual case to a great extent.
Mild sedation must be given, to the point of being effectual, even if we have to use
morphine or dilaudid. But before these are given, the diagnosis must be absolutely
certain.
An enema may, and generally should, be given.
Chemotherapy. Vaginal cultures should be made as a routine. Seventy per cent of
g.c. cases will give a positive culture.
Penicillin, to the amount of 200,000 to 250,000 units daily, should be given. We
may also give the sulphonamides, and in^cute cases, we usually obtain a prompt response.
In the second stage, when these is abscess formation, this may be in the tubes, or in
the pouch of Douglas. Ninety to. ninety-five per cent of cases show a dropping down
of the abscess into the pouch, where it is readily accessible. On examination we feel a
mass, sometimes a large mass, which may be quite hard. We recognize the formation
of pus by the onset of a septic type of temperature, or we may feel fluctuation. If this
occurs, we must secure drainage. In nine out of ten cases, this can be done most readily
and safely through the posterior fornix. If the collection is not drained, it will rupture,
either through the bowel wall, or into the bladder, and this is a very deplorable ending,
as it often results in fistula formation, and these fistulae are apt to be very hard to
get healed.
In the third stage, when there has been no abscess formation, and the patient is
getting better. These patients should be thoroughly checked in a month. The white
blood count, and especially the sedimentation rate, should be taken. At this stage, treatment by short wave, heat in various forms, may be given. The red blood count and the
haemoglobin level should be checked.
Patients suffering from this disorder are frequently hypothyroid, and the B.M.R.
will give us a valuable lead as to treatment. Thyroid medication is often of very great
value.
We must be on the lookout for the tuberculous type of pelvic peritonitis. This is
subacute in type, and is of long duration. It is practically always secondary to infection
elsewhere, either in the lungs or in the gland. The diagnosis can always be made, as
distinct from other types, by diagnostic curettage, done immediately before the menstrual flow is due.
Treatment consists in X-ray therapy, and operation should not be done.
Lastly—and this takes in the last stage of the four mentioned above—do not be too
anxious to operate on women after acute pelvic inflammation. Most women will weather
the storm, and recover without operation. Remember, that if anything is done everything must be done, and this involves considerable mutilation, especially in young
women, and these women are usually young. So be conservative as far, and as long,
as possible.
No operation should be done within from three to six' months after the acute attack
has subsided. Always check the sedimentation rate. If this is over 30, Dr. Philpott is
very emphatic that no operation should be done.
Page Two Hundred and Eighty-four mn
. . . h f-kf - - ■ -
Sympathy is extended to Dr. O. E. Kirby in the loss of his brother, Mr. Harold
Kritzweiser of Regina, and to Dr. I. B. Cameron of Youbou, who lost his father recently.
Dr. Gordon McL. Wilson of Kelowna, Dr. David Christie and Dr. C. W. E. Seale
of Vancouver, have our sympathy in the loss of their mothers.
Congratulations are being received by Dr. and Mrs. C. J. F. Phillips-Wooley on the
birth of a son on September 2nd, by Dr. and Mrs. A. C. Walsh on the birth of a daughter on September 10th, and by Dr. and Mrs. E. J. P. Badre on the birth of a son.
5p 5^ »T *»
Lieut.-Col. G. W. C. Bissett, who served with the R.C.A.M.C, is now in practice
in Victoria.
Major C. G. G. Maclean of Vancouver, following his discharge from the Army, is
with the Department of Veterans' Affairs.
Lieut.-Col. E. F. Christopherson has returned to Vancouver from overseas, and will
be resuming practice shortly. For the past year Dr. Chistopherson has served as Officer
in Charge of Medicine with No. 22 Canadian General Hospital, Bramshott, England.
* * •    *       *
Capt. L. E. Margetts, R.C.A.M.C, who recently received his discharge, is now serving on the staff of the Provincial Mental Hospital ,Essondale.
* ;:- * *
Capt. J. A. McLaren, R.C.A.M.C, has received his discharge, and is doing postgraduate work in Montreal.
Capt. C J. F. Phillips-Wooley has taken up practice in West Vancouver, following
his discharge from the R.C.A.M.C
* *      *      *
Dr. G. O. Hallman is now in practice at Cloverdale.   Capt. Hallman served with
the R.CA.M.C
*•      *      *      *
Lieut.-Commander Eric Boak, D.S.C, R.C.N., son of Dr. E. W. Boak of Victoria,
has been awarded one of the oldest military orders in the world. For his service as commander of H.M.C.S. Sioux in Norwegian waters, in 1945, the Norwegian government
has made him a Knight First Class of the Royal Order of St. Olav.
sj- * * *
Dr. W. H. Hatfield, Director of the Division of Tuberculosis Control for B. C, has
been honoured by the Surgeon-General's Department of the United States by being
invited to become a consultant in its Tuberculosis programme.
•t it Sfc 3$»
Lieut.-Colonel J. S. McCannell, O.B.E., has recently been posted to Headquarters,
Military District 11, as District Medical Officer. Prior to 1939, Colonel McCannell was
in practice in Victoria. He enlisted with 13 Canadian Field Ambulance in September,
1939, and proceeded overseas in 1942. He commanded 24 Canadian Field Ambulance
in Italy, and in Northwest Europe, and later served as A.D.M.S., First Canadian Army
in Holland.
Page Two Hundred and Eighty-five Dr. T. C Holmes of Burns Lake has been enjoying a well-earned vacation. During
his absence Dr. F. N. Elliot has taken over the practice.
*
Dr. John Nay, who for many years served as Chief Medical Officer of the Workmen's Compensation Board of B. C, has resigned. Dr. Nay filled a difficult position
with wisdom and ability, and he has enjoyed the respect and confidence of the doctors
of this Province. On retiring from office we wish him many long and happy years in
which to enjoy the leisure so well deserved.
*       *     ■ *       *
Dr. Nay will be succeeded by Dr. John F. Haszard. On assuming his new duties
Dr. Haszard has the best wishes of the medical profession in the Province. He brings
to the task a wealth of valuable experience that assures his success. Prior to Great
War II, he had a large indutrial practice at Kimberley. He enlisted for active service
at the outbreak of hostilities in September, 1939, and served with distinction until late
in 1945. He commanded 8 Canadian Field Ambulance, then 16 Canadian General
Hospital in Europe. Later he served as A.D.M.S. of various formations in England
before returning to Canada in 1945.
Middle aged couple with finest references, no children, total abtain-
ers and non-smokers, would like employment care for convalescent or
elderly couple.    For further information phone MArine 7729.
DISTRICT  ANNUAL  MEETINGS
Annual meetings of District Medical Associations have been arranged or the following dates:
East Kootenay Medical Association Annual Meeting to be held at Cranbrook on the
afternoon and evening of September 30th.
West Kootenay Medical Association meeting to be held at Trail on the afternoon
and evening of October 2nd.
District No. 4 Medical Association meeting to be held at Penticton on the afternoon and evening of October 4th.
Victoria Medical Society meeting on the evening of October 7th.
Dr. Ethlyn Trapp, President of the British Columbia Medical Association, .accompanied by Dr. Karl Haig of Vancouver, Dr. D. W. Johnstone, Department of Veterans'
Affairs, and the Executive Secretary will attend these meetings. The party will be joined
by Dr. A. E. Archer, Consultant in Economics for the Canadian Medical Association.
Nrnrn $c 5Hjflm00n
t
2559 Cambie Street
ancouver
, B. C.
Page Two Hundred and Eigbty-six    tish Columbia Librarv
£ DATE
RIALS
-m-cr' ,9^/3'
^
NIVERSITY OF B.C. LIBRARY
9424 04406 340
WOODWARD
IBRARY
WOODWARD LIBRARY
UNIVERSITY OF BRITISH COLUMBIA
VANCOUVER 8, CANADA
4»      Vat <re
h
*\ V* la
fed   ^iis*   WSi 

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