{"http:\/\/dx.doi.org\/10.14288\/1.0214615":{"http:\/\/www.europeana.eu\/schemas\/edm\/dataProvider":[{"value":"CONTENTdm","type":"literal","lang":"en"}],"http:\/\/purl.org\/dc\/terms\/isReferencedBy":[{"value":"http:\/\/resolve.library.ubc.ca\/cgi-bin\/catsearch?bid=1179642","type":"literal","lang":"en"}],"http:\/\/purl.org\/dc\/terms\/isPartOf":[{"value":"History of Nursing in Pacific Canada","type":"literal","lang":"en"}],"http:\/\/purl.org\/dc\/terms\/creator":[{"value":"Vancouver Medical Association","type":"literal","lang":"en"}],"http:\/\/purl.org\/dc\/elements\/1.1\/date":[{"value":"1950-07","type":"literal","lang":"en"}],"http:\/\/purl.org\/dc\/terms\/issued":[{"value":"2015-01-30","type":"literal","lang":"en"},{"value":"1950-07","type":"literal","lang":"en"}],"http:\/\/www.europeana.eu\/schemas\/edm\/aggregatedCHO":[{"value":"https:\/\/open.library.ubc.ca\/collections\/vma\/items\/1.0214615\/source.json","type":"literal","lang":"en"}],"http:\/\/purl.org\/dc\/elements\/1.1\/format":[{"value":"image\/jpeg","type":"literal","lang":"en"}],"http:\/\/www.w3.org\/2009\/08\/skos-reference\/skos.html#note":[{"value":" BULLETIN\nOF\nThe Vancouver Medical Association\nEDITOR:\nDR. J. H. MacDERMOT\nEDITORIAL BOARD\nDR. D. E. H. CLEVELAND DR. J. H. B. GRANT\nDR. H. A. DesBRISAY DR. D. A. STEELE\nPublisher and Advertising Manager\nW. E. G. MACDONALD\nVOL. XXVI JULY, 1950 NUMBER 10\nOFFICERS 1950-51\nDe. Henby Scott Dr. J. C. Grimson Dr. W. J. Dorrance\nPresident Vice-President Past President\nDr. Gordon Burke Dr. Ei. 0. McCoy\nHon. Treasurer Hon. Secretary\nAdditional Members of Executive:\nDr. J. H. Black Dr. D. S. Munroe\nTRUSTEES\nDr. G. H. Clement Dr. A. C. Fbost Dr. Murray Blair\nAuditors: Messrs. Plommer, Whiting & Co.\nSECTIONS\nEye, Ear, Nose and Throat\nDr. J. F. Minnes Chairman Dr. N. J. Blair. \u2014Secretary\nPaediatric\nDr. J. R. Davies Chairman Dr. C J. Treffry Secretary\nOrthopaedic and Traumatic Surgery\nDr. D. E. Stabb. Chairman Dr. A. S. McConkey Secretary\nNeurology and Psychiatry\nDr. F. E. McNair Chairman Dr. R. Whitman\u2014_ Secretary\nRadiology\nDr. Andrew Turnbull Chairman Db. W. L. Sloan Secretary\nSTANDING COMMITTEES\nLibrary:\nDe. E. France Wobd, Chairman; De. A. F. Haedyment, Secretary;\nDe. F. S. Hobbs, Db. J. L. Pabnell, Db. S. E. C. Tuevey, Dr. J. E. Walkee\nGo-ordination of Medical Meetings Committee:\nDe. R. A. Stanley Chairman Db. W. E. Austin Secretary\nWm Summer School:\nDb. E. A. Campbell, Chairman; De. Gobdon C. Labge, Secretary;\nDb. A. C. Gabdneb Fbost; Db. Petee Lehmann; Db. J. H. Black;\nDb. B. T. H. Mabteinsson.\nMedical Economics:\nDb. J. A. Ganshobn, Chairman; Db. E. C. McCoy, Db. T. R. Saejeant,\nDb. W. L. Sloan, Db. F. L. Skinneb, Db. E. A. Jones, Db. G. Clement.\nCredentials:\nDb. G. A. Davidson, Db. Gobdon C Johnston, Db. W. J. Doebance\nSpecial Committee\u2014Public Relations:\nDb. Gobdon C. Johnston, Chairman; Db. J. L. Pabnell, De. F. L. Skinner\nRepresentative to B. C. Medical Association: De. W- J. Doebance\nRepresentative to V.O.N. Advisory Board: Db. Isabel Day\nRepresentative to Greater Vancouver Health League: Db. L. A. Pattebson\ni.ft HAY FEVER\nThe extra long action of\nNeo-Synephrine hydrochloride\nmakes possible control of hay fever\nsymptoms with infrequent\ndosage, thus enabling the patient\nto be comfortable during the day\nand obtain sleep at night.\nAverage dose: 2 or 3 drops in\neach nostril.\nNo appreciable interference with ciliary\naction. Virtually no side reactions.\nand night...\nFOR NASAL USE: '\/4% solution\n(plain and aromatic), 1 oz.\nbottles; 1% solution, 1 oz.\nbottles; Vz% water soluble\njelly, % oz. tubes.\nFOR OPHTHALMIC USE: V8% low\nsurface tension, aqueous\nsolution, isotonic with\ntears, 15 cc. bottles.\n\u2022^ new York 13 *n. y. Windsor, Ont.\nNeo-Synephrine, trademark reg. U.S. & Canada\n443 SANDWICH STREET WEST, WINDSOR, ONTARIO\nWiN?HKOMU\u00abWS Write to Secretary, B. C. Medical Association\n203 Medical-Dental Building\nTHE BULLETIN\nPublishing and Business Office \u2014 17 - 675 Davie Street, Vancouver, B.C.\nEditorial Office \u2014 203 Medical-Dental Building, Vancouver, B.C.\nThe Bulletin of the Vancouver Medical Association is published on the first of\neach month.\nClosing Date for articles is the 10th of the month preceding date of issue.\nManuscripts must be typewritten, double spaced and the original copy.\nReprints must be ordered within 15 days after the appearance of the article in ques-'\ntion, direct from the Publisher. Quotations on request.\nAdvertisements\nClosing Date for advertisements is the 10th of the month preceding date of issue.\nAdvertising Rates on Request. fLHX6DIL\n\". . . Of the curarising agents now available Flaxedil\nappears to be the most satisfactory.\" \"&\nDESCRIPTION:\nFLAXEDIL [triiodoethylate of tri-(dimethylamino-ethoxy) 1, 2, 3\nbenzene] is a curarising agent discovered by Poulenc Laboratories of Paris\nand widely used in France and Great Britain. Flaxedil possesses curarising\nproperties very similar to those of naturally occurring curares and offers\na wider margin of safety\nADVANTAGES:\nconstant standard activity\nno influence on the cardiovascular system\nslight antihistaminic activity\nfewer cases of fall in blood pressure\naqueous, stable solution, miscible with soluble thiopentone\nneostigmine is an effective antidote\nINDICATIONS:\nabdominal surgery\nthoracic and pulmonary surgery\noperations under intravenous barbiturate anesthesia\noperations with endotracheal anesthesia\nMETHOD OF USE:\nDosage varies with the particular case. Injection, as necessary, of 40 to\n80 mg. (1 to 2 ampoules) immediately after the induction of anesthesia.\nHOW SUPPLIED:\nAmpoules of 2 c.c. and vials of 10 and 30 c.c. containing 20 mgv-per c.c.\nAs with all curares, it is imperative that the anesthetist using FLAXEDIL\nhas at his disposal the necessary equipment for intratracheal intubation,\noxygentherapy and closed circuit anesthesia.\n^DOUGHTY, A. G.: Flaxedil in Laryngeal Intubation,\nThe Lancet, May 13, 1950, p.899.\npouLcnc\nLlflllTCD\nmonTRcm W&P&\noffgrstwonew\n50 CAPSULES\n3 OUNCES tSSGS-S\n^IlAMHf WSPEBSgl\n&\u25a0\nWATCRSC\n(*\u00ab-\n*t\nl*\u00bbi\nor\nOHNSON *\nC\u00bb'\nc*\u00bbA\u00bb*L|iSJ*#\nto\n'\"\u25a0\u00ab\u25a0\u25a0' \u25a0 t L F \u00bb*T* \"'\nMead's Polyvitamin Dispersion\nOne level teaspoon (2.8 Gm.) supplies:\nVitamin A\nVitamin D\nAscorbic Acid\nThiamine\nRiboflavin\nNiacinamide\n5000 Int. units\n1000 Int. units\n50 mg.\n1 mg.\n0.8 mg.\n5.0 mg.\nMIXED VITAMINS\nemmts\nFor\nsupplementation\nof the diet\nMead Johnson * c*-\nMead's\nMixed Vitamins Capsules\nEach capsule supplies\nVitamin A\nVitamin D\nAscorbic Acid\nThiamine\nRiboflavin\nNiacinamide\n10,000 Int. units\n1,000 Int. units\n100 mg.\n4mg.\nSoundly formulated\nfor reliable, convenient diet supplementation\nFor Infants and Young Children...\nMEAD'S Polyvitamin Dispersion\n6 important vitamins finely dispersed in a\nwater-soluble powder.\nEasily mixed with formula, fruit juice, .\ncereal or other solid food.\nSuggested daily dose: 1 teas|>oon for infants; 1-2 teaspoons for children.\nAvailable in 3 ounce jars.\nThese vitamin products are\nFor Older Children and Adults...\nMEAD'S Mixed Vitamins Capsules\nGenerous supplementary amounts of 6 important vitamins.\nDesigned for patients whose dietary intake of vitamins is inadequate.\nOne capsule daily meets the needs of\nmost patients.\nAvailable in bottles of 50 capsules.\nnot advertised to the laity.\nMEADS\nMead Johnson & company\nOF CANADA, LIMITED\nBELLEVILLE. ONTARIO\nLOCAL REPRESENTATIVE: D. M. TURNER, THE BRANCHES\nDeep Cove. B.C., Canada \u2014 Deep Cove-2261 ff Premarin\"\nin terms of actual results at the menopause\n\n'*f\"$\n&o,\n!..' do not work with them, we retire into our shell, muttering maledictions on the newspapers, and doing nothing about it. Such a procedure, however, as we have outlined,\nwould have done much to avoid the necessity under which we now are, or puncturing\na great many bubbles of unjustified hopes and disillusioning a great many people whose\nexpectations of cure had been aroused by unwise and ill-informed publicity.\nWe have received the following note from Dr. A. W. Bagnall, so well-known in\nconnection with Rheumatism and Arthritis. A more complete programme will be published before the Refresher Course in September, (see below).\nPrior to the Annual Meeting of the B.C.M.A., a Refresher Course in the Rheumatic\nDiseases will be held on Sunday and Monday, September the 24th and 25 th. This will\ncommence at 10:00 a.m. on the 24th of September in the Lecture Hall at the Vancouver\nGeneral Hospital and is sponsored by the University of British Columbia Medical School\nand the B. C. Medical Association through its Special Committee on Arthritis and\nRheumatism.\nGeneral practitioners particularly are invited since the presentations are designed to\nprovide information of practical value rather than of didactic interest. While there is\nno charge for registration, all those with a real intention of attending are asked to notify:\nDr. F. W. B. Hurlburt, 1701 West Broadway, who is Course Secretary.\nThe subject matter will include Cortisone and ACTH in Rheumatic Fever and\nRheumatoid Arthritis, other lectures of current interest, and practical demonstrations of\nti action, splinting and exercise therapy. The detailed programme will be published in\nthe next issue of the Bulletin.\nLIBRARY NOTES\nHours during the summer months:\nMonday to Friday 9:00 a.m. to 5:00 p.m.\nSaturday -. - 9:00 a.m. to 1:00 p.m.\nRecent Accessions\nAnus, Rectum, Sigmoid Colon: Diagnosis and Treatment, by H. E. Bacon, 2 vols., 3rd\nedition, 1949.\nClinical Biochemistry by Cantarow, A. and Trumper, M., 4th edition, 1949>\nMedical Clinics of North America\u2014Symposium on Cardiovascular Diseases, New York\nNumber, May, 1950.\nPrinciples and Practice of Obstetrics by De Lee, J. B. and Greenhill, J. P., 9th edition,\n1949.\nPsychodynamics and the Allergic Patient by H. A. Abramson, 1948.\nResearches on Pre-Natal Life by Sir Joseph Barcroft, vol. 1, 1946.\nTextbook of Ophthalmology by Sir W. S. Duke-Elder, vol. 4, 1949.\nThe Yellow Emperor's Classic of Internal Medicine (Huang Ti Nei Chin Su Wen)\u2014\nChapters 1-34 translated from the Chinese with an Introductory Study by Ilza\nVeith, 1949 (Historical and Ultra-Scientific Fund).\nWilliam Stewart Halstead, Surgeon: by W. G. MacCallum, 1934 (Nicholson Collection).\nPage 239 BOOK REVIEW\nSIR WILLIAM GOWERS, 1845-1915. A BIOGRAPHICAL APPRECIATION, by\nMacDonald Critchley. London: William Heinemann Medical Books Ltd., 1949 pp. 118\nillustrated.\nThis short monograph about \"the greatest clinical neurologist of all time\" is one\nof the most fascinating and readable medical biographies that I have ever read. The\ncorrelation of historical events and the lives of other famous physicians with the unfolding life of Gowers is a fine example of the scholarly research of the author. Even those\nwho have been familiar with the medical writings of Gowers will be astonished to read\nof the catholicity of his interests and skills. The author who has long been known for his\nlucid writing and command of English, enhances his reputation in this volume. Even\nthose not directly interested in neurology would enjoy it.\nPROMINENT B. C. DOCTOR HONOURED BY\nCANADIAN MEDICAL ASSOCIATION^^\nWe are advised by the Canadian Medical Association that Dr. Frederick Moore Auld\nof Nelson, B. C., has been elected to Senior Membership in the Canadian Medical Association at the Annual Meeting in Halifax on Wednesday, June 21st, 1950.\nThis honour is conferred on a very limited number of prominent medical men who\nhave taken an active part in medical and community leadership.\nThe medical profession of British Columbia and his many friends outside the profession will be very gratified that Dr. Auld has received this honour.\nFREDERICK MOORE AULD was born on the farm at Cove Head, Prince Edward\nIsland, on October 18th, 1879. Dr. Auld received his early education at the rural school\nand later matriculated to Prince of Wales College at Charlottetown. Here he qualified\nas a teacher and taught school for five years, part of which time was spent in his native\nprovince and part in Saskatchewan. In 1903 he entered McGill University, from which\nhe holds degrees in Arts and Medicine.\nDuring the first World War, he served with the Royal Army Medical Corps in\nFrance.\nSubsequently, circumstances developed which necessitated his return to Canada and\nresignation from the work in China. He took over the work of the late W. Oliver Rose\nof Nelson, whose failing health necessitated retirement in 1929.\nDr. Auld took an^active part in the affairs of the Bi. C. Medical Association and the\nCollege of Physicians and\\Surgeons. He was President of the Association from the year\n1939 - 1940.\n:\nYoung married man, age 32, desires a position as accountant or\nbusiness manager in a modern medical clinic. Has had five years\nexperience -with hospital accounting and general administration.\nFor full details please send enquiries to\nTHE BULLETIN\n1\u2014675 Davie Street\nVancouver, B.C.\nPage 240 We take great pleasure in publishing the following programme of Professor G. W.\nPickering's visit to Vancouver in October.^ Professor Pickering is Professor of Medicine\nin the University of London, England and he will be Visiting Chief of the Department\nof Medicine at the Vancouver General Hospital from October 2nd to October 6th, 1950.\nAll clinics, general meetings, ward walks and clinical conferences, are open to all\nmedical practitioners, and an invitation to attend is extended by the Vancouver General\nHospital.\nPROGRAMME\nPROFESSOR G. W. PICKERING\nProfessor of Medicine, University of London\nDirector Medical Clinic\nSt. Mary's Hospital Medical School\nLondon\nVISITING CHIEF, DEPARTMENT OF MEDICINE\nTHE VANCOUVER GENERAL HOSPITAL\nOCTOBER 2nd - 6th, 1950\nMONDAY, OCTOBER 2nd\n8:30 to\u2014Ward Walk, Ward \"A\" (Male Medicine)\n10:00 a.m. Dr. D. S. Munroe, Dr. T. K. MacLean, Dr. H. Scott, Dr. H. C. Slade,\nDr. G. A. Davidson.\n12:15 p.m.\u2014Surgical Clinic.\nDr. J. R. Neilson, Chief Lecture Hall, Main Building.\n2:00 p.m.\u2014Conference with Resident and Assistant Residents regarding:\nMaterial for Clinical Meetings.\n6:30 p.m.\u2014Private Dinner.\nTUESDAY, OCTOBER 3rd |g\n8:30 to\u2014Ward Walk, Ward \"B\" (Female Medicine)\n10:00 a.m. Dr. E. F. Christopherson, Dr. B. M. Fahrni, Dr. J. L. Parnell, Dr. F. J.\nHebb, Dr. C. E, G. Gould.\n11:00 a.m.\u2014Lecture to First Year Medical Students\u2014\nRoom 200, Physics Building, University of British Columbia.\n12:15 p.m.\u2014Luncheon\u2014\nFaculty Club, University of British Columbia. Arranged by Dr. M. M.\nWeaver, Dean of the Medical School.\n2:15 p.m.\u2014Clinical Conference.\nDr. G. W. Pickering.\nSubject: \"Peripheral Vascular Disease.\"\nLecture Hall, Main Building.\n6:00 p.m.\u2014Dinner with Executive Committee, Vancouver Medical Association.\n8:15 p.m.\u2014Meeting, Vancouver Medical Association.\nDr. G. W. Pickering.\nSubject: \"Pain in Peptic Ulcer\".\nAuditorium, British Columbia Institute of Tuberculosis.\nPage 241 WEDNESDAY, OCTOBER 4th\n9:00 to \u2014Clinical Pathological Conference.\n10:00 a.m. Chairman: Dr. R. E. McKechnie.\nPathologist: Dr. H. K. Fidler.\nDiscussion opened by Dr. G. W. Pickering.\nLecture Hall, Main Building.\n10:30 a.m.\u2014Medical Clinic.\nChairman: Dr. M. M. Baird.\nLecture Hall,' Shaughnessy.\n11:30 a.m.\u2014Pathological Conference, Shaughnessy Hospital.\n12:30 p.m.\u2014Luncheon, Shaughnessy Hospital.\n2:15 p.m.\u2014Clinical Conference.\n. Dr. G. W. Pickering.\n. Subject: \"Clinic on Hypertension\".\nLecture Hall, Main Building.\n6:30 p.m.\u2014Private Dinner.\nTHURSDAY, OCTOBER 5th\n9:00 a.m.\u2014Medical Clinic.\nDr. G. W. Pickering, Visiting Chief.\nLecture Hall, Main Building.\n11:00 a.m.\u2014Official Opening of the B. C. Research Institute.\n12:30 p.m.\u2014Luncheon.\nAfternoon Free.\n8:15 p.m.\u2014Special Meeting, Attending Staff The Vancouver General Hospital.\nDr. G. W. Pickering.\nSubject: \"Present Status of Hypertension Problem\".\nAuditorium, British Columbia Institute of Tuberculosis.\nFRIDAY, OCTOBER 6th\n9:00 a.m.\u2014Paediatric Clime. WJm\nDr. J. R. Davies, Chief, Lecture Hall, Main Building.\n10:00 a.m.\u2014Health Centre for Children.\nDr. D. H. Paterson.\n12:30 p.m.\u2014Luncheon.\nSeniors, Attending Staff, Department of Medicine, Board Room,\nThe Vancouver General Hospital.\n2:30 p.m.\u2014Concluding Lecture for Resident and Interne Staff.\nDr. G. W. Pickering.\nSubject: \"The Place of the Experimental Method in Medicine\".\nLecture Hall, Main Building.\nPage 242 A BRIEF PRESENTED TO THE HEALTH COMMITTEE,\nH VANCOUVER BOARD OF TRADE,\nH BY DR. J. H. MacDERMOT, MAY, 1950\nX-RAY MACHINES FOR FITTING SHOES\nThere has been a great output of X-ray machines for fitting shoes. They constitute\na strong sales appeal for the store that has them. They are spectacular, appeal to the\naverage man's curiosity and his desire to see into the mysteries of electricity, etc. The\nstore that has one is regarded as being more up-to-date than its rival down the street\nthat has none.\nOf late there has been a good deal of investigation by health and scientific authorities into the question of whether these machines can be operated, or are being operated\nin such a way to be safe for use, or whether they constitute a menace to health. They\nhave been banned altogether by the State of New York, and other States, I believe, are\ninvestigating their use.\nThe machine consists of a cabinet into which the customer's foot is placed. There\nis a fluoroscope adjusted so that the operator can, by pushing a button, turn on the X-ray\ntube, and then see the foot, and, it is said, judge whether the shoe that is being tried\non fits the foot or not.\nThe following questions come to one's mind in connection with this machine:\n1. Is it a valuable aid to shoe-fitting, and is it thus a useful machine?\n2. Is it safe (a) to the customer? (b) to the operator? (c) to other people in the\nstore, or nearby?\n3. If not safe, what are the dangers that may attend its use? (a) to the customer?\n(b) to the operator? (c) to the others nearby?\n4. If not safe, as at present operated, can it be made safe? Should there be legal control\nof these machines, and what restrictions should be imposed? ^p'\n5. Do these considerations apply to other X-ray machines in commercial use\u2014such\nas those used in examining metals, which undoubtedly are of great value? What\nrelation do these machines have to industrial disease, workmen's compensation, etc.?\n6. Should there be standards of knowledge set up for all who operate any form of\nX-ray machine, for their own protection, as well as that of the public, and should\nthere be standards of training in this work?\nQUESTION 1.\nIs the machine of value in shoe-fitting? The consensus of opinion among those\nwho know most about the foot and shoes, that is, trained and registered chiropodists, is,\nas far as we can ascertain, that the machine is of no value at all for the\u2014purpose of\nfitting shoes. The main bulk of the foot, especially in children, where this nmehine is\nchiefly used, is soft tissue\u2014the bones are small, and take up little room. All that the\noperator can see, in the brief vision he has of the foot, is the bones. . He knows nothing\nof anatomy, physiology, or orthopedics, and cannot recognise abnormalities or deformities.\nThe radiologist will tell you that fluoroscopy done under the conditions which\nprevail in a busy shoe store is of little or no value. When he himself is going to do\nfluoroscopy, he wears heavy red glasses for half an hour or more, he does the work in\na darkened room, and so on. The machine is used in a brightly lighted store, there is\nno preparation of the eyes, and it is very doubtful if the operator can see anything at\nall of any value. The exposure, if the directions which are supposed to ensure safety,\nare followed, cannot be more than a few seconds.\nQUESTION 2.\nIs it safe to the customer, to the operator, and to people in the vicinity of the\nmachine?\nPage 243 S To answer this question, we must first make some general statements about X-rays,\nand any form of ionic radiation.\nExposure to X-rays is never safe, and there are wide individual variations in\nsusceptibility to their effect. Every trained worker with X-rays knows this, and takes\nendless and meticulously detailed precautions. If we visit a thoroughly modern X-ray\ndepartment, say at a hospital like St. Paul's, we shall find all the rooms that house the\nmachines heavily shielded by heavy lead linings\u2014covering the walls, the doors, the floors,\nthe ceilings, for the rays can go anywhere, up through the ceiling as well as through\nan open door, and affect patients upstairs. Over 100 tons of lead sheeting have been\nused for this purpose, I understand.\nThe technicians and radiologists must not go nearer to the machine than a prescribed\ndistance, and if they have to do so, they must wear special lead-lined aprons. They stand\nbehind lead-glass and leaded partitions when working. If an operator can help it, he\nnever puts his hands or any part of his body in the direct path of the rays. If he must\ndo so, he wears heavily lined gloves. These precautions clannot be taken in any store.\nThere it has been frequently noted that the operator, happily unaware of any danger,\nputs his hand occasionally into the cabinet to adjust the foot, while another operator is\nworking the machine.\nThere are other rules observed in properly controlled laboratories. When fluoro-\nscoping, the milliamperage, i.e., the amount of strength of the current, is set at 5 m.a.\nor less, and not allowed to exceed this amount. The duration of any given exposure\nis rigidly controlled, and the total amount of exposure is also rigidly fixed, and nobody\nis allowed to transgress this.\nLastly, there are two most important things to remember about X-rays. Their\neffect is cumulative\u2014that is, repeated small amounts of exposure, too close together,\neven though relatively harmless in themselves, tend to add up to a dangerous dose, and\nserious effects may ensue.\nThe other important point is that the effects of damaging doses of X-rays may\nnot appear for some time. They may not appear for months or even years.. This is\nespecially true in the case of children, as will be shown later, where permanent and\nsevere damage may be done to the growth and well being of the child, which yet will not\nbecome manifest for a long time..\nQUESTION 3.\nWhat are the dangers (1) to the customer (2) to the operator (3) to others?\nThe dangers of X-rays are mainly as follows: A. To the skin.\n1. Burns\u2014This is the most serious effect as regards the skin, and may be very\ndeadly. It requires considerable over-exposure to bring this about\u2014but there may be;\nother damage done to the skin by too many and too closely-repeated small doses\u2014e.g.,\ndryness and scaling of the skin, etc.\nB. To the Mood. Anaemtfrsoi various degrees of severity is one of the dangers\nattending too prolonged exposure. All those operating machines in properly controlled\nlaboratories have their blood tested at frequent intervals.\nC. To the genitalia. This is a very real danger, and in days gone by, before this\nwas understood, many of those who pioneered in X-ray work were rendered sterile.\nTo guard against these dangers, certain standards have been set by such bodies as\nthe American Bureau of Standards, the New York City Health Department, and others.\nThe unit of exposure in X-ray work is the \"roentgen;\", and this is divided into parts,\nsuch as the milliroentgen, and so on. The standards of safety set the maximum permissible dose per exposure at 2r, i.e., 2 roentgens. There shall not be more than 3 exposures\nin one day, and not more than 12 exposures in one year. This is the maximum.\nActually, these maxima are constantly exceeded. For a twenty-second exposure\n(the one most commonly used) doses ranging from 10 to 116r could be delivered. The\nPage 244 child may have several shoes tried on in the same store, or may go to other stores, or\nmay have a virtually unlimited number of exposures in the same year.\nThe machine \"scatters\" radiation, which adds to the dosage received and definite\nleakage of small amounts of energy also occurs. This is chiefly of importance to the\noperator, but may also affect other parts of the child's body, notably the genitalia.\nThus, we may see that there is definite danger:\n1. To the child, from overlong or too frequently repeated exposures\t\nA. To its skin.\nB. To its bony structure. In childhood the ends or \"epiphyses\" of the long\nbones are the part of the bone from which growth mostly takes place. If they are\ndamaged, distortion, deformity, or stoppage of growth will occur. They are particularly\nsensitive to ionic radiation, such as X-rays. The effects do not appear for a long time\nafter the exposure, and can only be prevented by the most rigid care.\nA child is small, and its body is more easily reached by the emanations from the\nmachine. Its genitalia are relatively close to the source of exposure. There is no doubt\nthat repeated and excessive exposures are a menace to the child's gonads, especially in\nthe case of boys.\n2. To the operator. These people are quite untrained. They have no knowledge\nof the dangers of X-ray machines, or how to avoid these dangers. They have no protection, and they are entitled to this protection. They definitely face danger, to their hands,\nto their blood, to their genitalia, and it is quite wrong that there should be no restrictive\ncontrol that would protect them.\nThe maximum permissible daily dose of radiation to which persons can be safely\nexposed throughout their working lives has been considered for many years to be O.lr.\nper day, i.e., 100 mr. Recently, the advisory committee on X-rays and radium has\nreconsidered this dose, and recommended that it be lowered to 0.3 per week.\nScattered radiation will account for 100 mr. per hour at 10 feet from the cabinet,\nand 15mr. at 25 feet. If the operator is careless, and gets his hands or other parts of his\nbody too close to the rays, the exposure is even greater..\n3. To others in the vicinity. There is probably no danger to these.\n\"Whatever the permissible exposure may be, all workers must recognize that any\namount of radiation is potentially dangerous. There is no exposure which is absolutely safe,\nand produces no effect.\" (Lapp and Andrews.)\n\"Any X-ray apparatus represents a source of insidious harmful radiation, the use\nor abuse of which may lead to significant damage, often without recognition of clear-\ncut casual relationship. The early history of the use of diagnostic irradiation without\nprecaution and the subsequent appearance of skin and neoplastic ('cancerous') change\nafter years of latency should provide adequate warning against careless exposure to any\nsource of ionizing radiation.\"\nQUESTION 4. Can these machines be made safe?\nPossibly they can, in the hands of operators who are properly trained, know the\nproper use and the dangers of abuse, of the machine, are subject to rigid control and\ninspection. The machine setting must be rigidly controlled (it is too high in many\nmachines).\nThe number of exposures, per day and per year, must not be exceeded. The public\nshould be told of the dangers of over-exposures. We question whether any parent, if\ninformed of these dangers, would be willing to expose his or her child to them, unless the\nmost rigid standards were observed. We question, too, whether any of the operators\nknow what is their own personal stake in the matter, and whether any of them will be\nwilling to do this work if they did know, without adequate protection.\nSUMMARY\nIn view of the fact that these machines are relatively, if not entirely, useless for\nshoe-fitting, that they are very easily abused, by over-eager, uninformed, or unscrupu-\nPage 245 lous owners and operators, and that such abuse can be productive of very serious damage\nto operators, and to customers, especially children, it is a question whether the sale and\nuse of these machines should be permitted at all. If they are permitted, it is urged that\nthe most rigid safeguards and controls should be imposed on their use.' These safeguards\nshould be imposed, not only on foot-machines, but on all X-ray machines used anywhere,\nin industry, where they are of very great value and are constantly used\u2014in offices of\ndoctors, dentists, and others who use them for diagnostic or other purposes.\nWe would suggest that a careful study be made of this whole question. There\nshould be consultation, between physicists, radiologists, paediatricians, orthopaedists, and\nso on. The Board of Trade would be interested in safeguarding the legitimate interests\nof businessmen who deal in this type of product. It is not suggested for a moment that\nthere should be a witch-hunt in this matter. If these machines can be shown to be of\nuse, and can be made safe, there should be no objection to their use. But we suggest\nthat this use should be under strict legislative control, and that the conditions of use,\nif the machine is to be permitted at all, should be laid down by the Provincial Board\nof Health, and should be made law. The University of British Columbia, with its\nPhysics Department, could be of (immense assistance in these deliberations.\nWe feel, too, that this is a matter in which the Workmen's Compensation Board is\nvitally interested, since X-rays are used in industry, and X-ray damage is, or should be,\ncompensable. The men working in shoe stores should possibly come under the W.C.B.\nalso.\nLastly, we feel that the public as a whole should be aware of the dangers of X-ray\nand other ionic radiation. Without any scarehead methods, surely a wider knowledge\nof the potential dangers of what many of them regard as a scientific toy or a magical\nmachine, would be of value and would at least put the onus of abuse on the right\nshoulders.\nReferences: Journal Amer. Med. Ass'n. Vol. 139:15, 1949, p. 1004 (Editorial).\nNew England Journal of Med. Vol. 241:9, 1949, pp. 333-335 (Williams; Hempelmann.)\nCalifornia Medicine (Leon, Lewis & Paul E. Caplan). Vol. 72:1, 1950, p. 26.\nCanadian Medical Journal\u2014early in 1950\u2014Editorial.\nMINISTER OF NATIONAL HEALTH AND WELFARE\nOttawa, Canada.\nJune 28th, 1950.\nDr. J. H. MacDermot,\nVancouver Medical Association.\nDear Doctor MacDermot:\nIt was indeed an honor to address the Vancouver Medical Association on\nmy recent visit to Vancouver, and I was delighted to have this opportunity of\nmeeting the members of your Association. May I tell you how much I appreciate\nthe warm welcome extended to me on this occasion.\nWith kindest personal regards, I am,\nYours sincerely,\nPAUL MARTIN.\nPage 246 ft\nPi\nHEADACHE*\nL. R. F. ZELDOWICZ, M.D.\nHeadache, one of the most common complaints, often presents a diagnostic problem.\nHeadache is not a diagnosis\u2014it is most often a symptom or syndrome. The headache\nmay originate from tissues within the head or from tissues outside the cranial cavity.\nIt may accompany almost any systemic disease, as it may be referred to the head from\nquite remote organs. The most common type, however, does not show any demonstrable\ntissue pathologic charge and is presumably due to functional disorder cf the autonomic\nnerves and frequently is associated with a psychogenic condition.\nEstablishment of the diagnosis calls for full clinical investigation\u2014medical, neurological, psychological and often otorhinolaryngological. X-ray of the skull, and eye\nfundi, should be routine examination, and in some etiologically doubtful cases electro-\nencephalographic investigation is required.\nIn this short paper the classification of different groups of headaches and the\npresent view on the mechanism of headache will be discussed and some forms of cephalalgias will be reviewed.\nClassification:\n1. Headache due to organic, circumscribed or diffuse diseases within the cranial\ncavity, the most common of which are tumours, abscesses, vascular anomalies,\nmeningitis and others.\n2. Headaches due to involvement of tissue outside the cranial cavity such as the\neyes, ears, nasal sinuses, teeth and throat. This type of headache is usually\nconsidered as of reflex origin due to rich interconnections on the periphery\nbetween sensory cranial nerves themselves (nerves 5, 7 and 9 and with autonomic nervous fibres).\n3. Headaches connected with different systemic diseases of general infections, such\nas pyrexial headache due to hypertension, blood diseases, etc.\n4. The so-called \"primary\" headaches\u2014*MiM\n(a) Migraine.\n(b) Histaminic Headache.\n(c) Sympathetic Headache\n5. The tension headache.\n6. The post-traumatic headache.\nThe Mechanism of Headache.\nAccording to newer investigations the tissues which are capable of giving rise to\npainful sensations are:\u2014 ||p\n1. The dura mater which is sensitive to traction, especially in the tentorium. The\nmaximal sensitiveness is in the region of the vessel, especially the dural sinuses.\n2. The intracranial and extracranial vessels with their adjacent tissuesy\u2014namely,\nthe internal carotid artery, the middle cerebral artery (more in the region of the\nSylvian fissure), and the external carotid artery with its branches, particularly\nthe temporal artery. The arachnoid and the brain tissue by itself is painless.\nHow then does pain originate? It may arise because of traction or displacement\nof the dura or its sinuses. Distension of the wall of dilated vessels is another important\nfactor in pain production according to experiments of Hess and Pickering (22, 23). The\nvessels may distend.because of increased intravascular pressure, diminished support from\noutside or active vasodilatation. These two mechanisms (traction of the dura and distension of the cranial vessels) may co-exist and may account for almost all types of\nheadache irrespective of their etiology. Those painful stimuli are mediated centrally by\nsensory cranial nerves which are, mainly, branches of the trigeminal nerve. In this way\nwe understand that the headache commonly associated with a raised intracranial pressure\nis not directly related to the pressure, although the headache usually manifests itself more\n*Read at the May, 1949 meeting of Federation of Medical Women of Canada (B.C. Branch).\nPage 247 when the intracranial pressure is very low. In the intracranial expanding processes the\nstretching, displacement or distension of the enumerated pain-sensitive organs is the main\npain-producing factor. The same is true in a post-lumbar puncture or the so-called\n\"drainage\" headache. According to Pickering, Kunkle, Ray and Wolff (16) the post-\nlumbar puncture headache increased when the jugular veins are compressed as it augments the distension of intracranial veins. On the other hand, they decrease by intrathecal administration of physiological sodium chloride which restores the volume of\ncerebrospinal fluid. In meningitis the pain-sensitive nerve endings are probably stimulated\nby a chemical substance from the inflammatory foci. In hypertension the headache is\nexplained by increase of the amplitude of intracranial pulsations and by increased internal\npressure exerted upon dilated vessels.\nAs will be discussed later in the primary headaches, in migraine, histaminic headaches and probably sympathalgic and tensional headaches, the exaggerated vasomotor\nreflexes (chiefly vasodilation) seem to be of great significance in production of painful\nvascular stimuli.\nClinical Review of Some Forms of Headaches.\nMigraine.\nMigraine is characterized by:\u2014\n1. Cortical disturbances (scotoma, photophobia, paresthesias in the extremities,\nspeech disorder, etc). These symptoms and signs are understood to be due to the\nvasoconstriction.\n2. Periodicity of cephalalgia which is often connected with the menstrual period.\nThis usually starts as unilateral pain and then is more generalized. This phase is\ndue to vasodilation of pain-sensitive arteries inside and outside the head.\n3. Gastrointestinal disturbances (nausea, vomiting, diarrhoea, abdominal pain),\nvestibular disturbances (vertigo, unsteadiness), often increased excretion of\nurine, sometimes sleep disturbances, all of which are due to dysfunction of the\nautonomic nervous system.\n4. Positive familial history which manifests the hereditary trait of the disease.\nIf not all of the features are present, some of them beside headache should be\npresent, otherwise the diagnosis of migraine is not certain.\nIn discussing this condition, the importance of personality structure in patients\nsuffering from migraine should be stressed. Usually they are tense, driving people who\nare rigid, ambitious and perfectionistic. According to Marcussen Wolff (19) they are\n\"considered reliable, conscientious and hard working. To this is added more stress by\nthe belief that no one could do a job quite as efficiently or as thoroughly as they. They\nbecome resentful because they cannot keep up with the load which the world and they\nthemselves impose. The outcome: tension, fatigue and exhaustion.\" It is understood\nthat the headache itself is the end manifestation of a chain of bodily changes ('autonomic and endocrine) set off by insidious, slowly accumulating emotional tension. Strenuous emotional experiences may ajso precipitate an attack of migraine immediately or as\nlate as 24 hours afterwards. In light of the above considerations, the preventive treatment in migraine should include psychotherapy. The treatment of the attack itself\nis pharmacological.\nHistaminic Headache.\nHistaminic headache was described as a new entity by Horton, McLean and Craig\n(15). In 96% of the cases the pain is unilateral or hemicranial, often spreading to the\nface and neck. The attacks are much shorter than in migraine, lasting from 10\nminutes to 5 hours, and there is often a history of several attacks in a 24-hour period.\nAdditional signs are typical vasomotor unilateral symptoms such as blushing, nasal\ncongestion, marked epiphora and increased skin temperature with sweating on the\ninvolved side of the face. The vessels are commonly grossly distended, particularly the\ntemporal artery. In contrast to migraine, gastrointestinal disturbances are uncommon.\nPage 248\nSf: 4.\n5.\nCortical disturbances (scotomata, hemianopia and others) are absent. It bears no relationship to menstruation and in this type of headache the reclining position is intolerable.\nUsually the patient sits up or paces the floor with his hands clasped over the painful\narea and this probably helps to reduce the engorgement of the vessels. Some patients\ncan obtain temporary relief from their attacks by digital pressure on the common\ncarotod artery, the temporal artery or over the orbit. In the painful period these patients\nshow Hypersensitivity to histamine as determined by the size of the wheal produced by\nintradermal injection. 0.1 to 1.0 mgm of histamine base reproduces the attack of\nheadache the treatment of choice is histamine desensitization.\nSympathalgic Headache.\nSympathalgic headaches were first described by French neurologists Souques, Ala-\njouanine and Thurel (2). The nosological identity of this condition still remains open\nto discussion as to whether they represent a special entity. This problem also involves\ndiscussion concerning the part played by the sympathetic nervous system in pain production and pain conduction. Various syndromes connected with involvement of specific\nparts of the sympathetic nerves and ganglia have been isolated and described as:\u2014\n1. Sluder's Syndrome (spheno-palatine ganglion) (24).\n2. Charlin Bonnet Paufique Syndrome (ciliary ganglion) (6).\n3. Heymanowich's Syndrome (sinus caroticus) (13).\nBarre-Lieou Syndrome (vertebral or so-called cervical sympathetic posterior\nnerve) (17).\nSyndrome of the Temporal Artery isolated by Siccard, Chavany, Alajouanine\nand Proby (7).\nProbably in the same category might be included cases described as \"Atypical\nMigraine\" of Penfield, Mixter, White and Adson (20,21, 1); \"Atypical Facial Neuralgia\"\nof Frazier and Glasez (3, 12); \"Autonomic Facio-Cephalalgias\" of Briekner and Riley\n(5); and many others described under different names.\nThis group of headaches, improved best under operative procedures on the cervico-\nthoracic sympathetic fibres and ganglia. In my personal clinical experience, good\nresults were obtained by cauterization and, in some cases, by alcoholization of the sphenopalatine \"ganglion (10).\nThe sympathalgic headache seems to differ from migraine, the histaminic headache\nand trigeminal neuralgia by the following characteristics:\u2014\n1. Their constancy. They are of months, sometimes years duration with episodes\nof exacerbation superimposed on the persistent pain.\n2. Their location. The pain is widespread involving various areas of the head,\nusually the face, overlapping as a rule, the area innervated by the trigeminal\nnerve. The pain often extends to the upper extremity and sometimes to the\nchest. It is more restricted to one side but not strictly unilateral. ||||\n3. Their character. Often true causalgic with burning, itching seiisations. Some\npatients complain of dull pain, numbness, pulsations, crawling sensations, compression and other very bizarre sensations.\n4. The vasomotor and secretory signs are common and are similar to histaminic\ncephalalgia. Palpitation and cardiac pain are also rather a common complaint.\n5. Sensory disturbnees in the form of hypoalgesia and less common, of hyperalgesia, are present in the involved area.\n6. Psychic manifestations (emotional instability, depressive mood, loss of interest)\nare interpreted as phychic repercussion due to neuro-vegetative dysfunction.\nTensional Headache.\nThe headache appears in conjunction with emotional conflicts. The diagnosis is\nbased on personality study, assessment of traumatising factors, and social, economic\nand psychosexual adjustment of the patient, providing, of course, that structural lesions\nwere excluded. According to Friedman (11) two mechanisms may account for this\ngroup of headache.\nPage 249 1. Changes in the calibre of cranial vessels (chiefly vasodilation.) and\n2. Spasm or tonic contraction of skeletal muscles of the head and neck.\nThis latter by itself may produce or aggravate the already existing headache.\nPost Traumatic Headache.\nSome intractable post-trauma tic headaches in which all investigation (x-ray,\npneumoencephalography, electroencephalography) rules out their \u2022 organic nature, are\nclosely related to tensional headaches. Similarly in this group, physiologic and psychogenic mechanisms are probably responsible for the headache. Physiological mechanism\nincludes distension of the cranial vessels and sustained contraction of skeletal muscles\nof the head and neck. In some cases scarring of the external tissue is blamed for reflex\nheadache. Psychogenic mechanism may include the immediate effect of the injury\n(anxiety, depression, resentment or frustration), the pre-traumatic neurotic features or\nconflicts and stresses incidental to the injury.\nI have attempted to give a short review of the different groups and forms of\nheadache. From the vast and often confusing field I have chosen only those groups of\nheadache which were proven not to be connected with any organic disease. Although\nthese various forms have different clinical characteristics and different etiology, it seems\nmore and more evident that the pathogenic mechanism is overlapping, and, possibly\nin all these forms, vasomotor disorder, chiefly vasodilatation, can be considered as the\nmain pain producing factor. This vasodilatation may be due to familial pre-disposition\nto exaggerated vascular reflexes, as in migraine; to hypersensitivity to histamine, as in\nthe histaminic cephalalgias. There is also a theory that emotional factors on higher\nautonomic integration level may set off reflexes, possibly through the hypothalamus,\nwhich are mediated to the vessels, probably by chemical acetyl choline mediators (histamine, and others) released by nervous stimulation.\nOur knowledge of the subject of headaches still remains unsatisfactory. Presumably\nwe get one glimpse on the various possible links in pain producing mechanism and interrelation between different clinically isolated forms of headache.\nMETHODS OF TREATMENT\nThe therapeutic approach to the reviwed groups of headache include the following:\n1. Psychological.\n2. Pharmacological.\n3. Combined psychological and pharmacological.\n4. Surgical.\nThe psychological approach consists of psychotherapy which aims to solve the\nunderlying conflict, to release the nervous tension and to promote better adjustment.\nThe pharmacological approach includes the following groups of drugs\u2014vasoconstrictors, vasodilators, desensitizing and analgesics.\nAs a vasoconstrictor Gynergen (Ergotamine Tartrate) is used mainly, early in an\nattack of migraine. The dosage is 0.25 to 0.5 mgm. intramuscularly or intravenously\nor 1 mgm. tablet sublingually, followed by 2 tablets every half hour. Maximum dose\nis 10 mgms. Dihydroergotamine^proved to be less toxic. The dose is 2 to 4 mgm intramuscularly.\nAs a vasodilator of quick action, a face mask of a mixture of 10% carbon dioxide\nand 90% oxygen usually applied three times, each of four minutes duation, with intervals\nof five minutes, is used. Amyl nitrate is a potent vasodilator used in inhalation. Both\nmethods are chiefly used early in an attack of migraine or in the vasocconstrictor phase.\nAs a vasodilator of prolonged action, used as preventive measures for treatment of\nmost popular are Phenobarbital Gr. l\/z three times a day, of Nicotine Acid 50 mgms.\n3 times a day. Atkinson's method is more effective (3). The tolerance is first checked\nwith 25 to 30 mgms. of Nicotinic Acid given intramuscularly (flush reaction) then\nintravenous doses, starting with 20 to 30 mgms. and increasing daily by 5 mgms. until\na 50 mgm. dose is reached. Afterwards intramuscular injections of 25 to 50 mgms. are\ngiven daily or every second day. At the same time 50 to 150 mgms. are given by mouth.\nPage 250\n\u2122- ill\nm\n\u25a04i\nPS\n18 r\nother drugs such as Priscol, Octin \"Merck,\" and Prostigmin were found to be helpful\nalthough their action on cranial vessels not, as yet, been well proven.\nOf the desensitizing drugs, histamine seems to be the method of choice in histaminic\ncephalalgias, although a large percentage of improvement was obtained in cases of\nmigraine. It is said that the best results were achieved by the combined intravenous and\nsubcutaneous administration. The method is tedious and requires thorough and prolonged\nadministration. 0.275 Histamine Phosphate corresponds to 0.1 histamine base. The first\ninjection of 1\/10 of the 1 c.c. solution subcutaneously. Later the dosage is increased by\n0.05 c.c. of the solution twice daily until 1 c.c. of the solution is reached. Flush reaction,\nheadache and discomfort calls for decrease of the dosage by 50% and later the schedule\nis continued as before. In the combined intravenous subcutaneous method, histamine\nis given intravenously in isotonic solution of Sodium Chloride (1 mg- of histamine\nbase as 2.75 mg. of histamine phosphate in 500 c.c. of isotonic solution of sodium\nchloride) by drip method daily for two weeks, avoiding the flush reaction, then histamine azoprotein is given subcutaneously. Epinephrine and ascorbic acid are used to\ncombat side effect. Benadryl, antistine and pyribenzamine are often effective,\nOf the analgesics the most commonly used is Codein Gr. l\/z to Gr. 1 combined with\nAcetlysalicylic Acid. Morphine and other addiction-producing drugs are condemned.\nSurgical treatment includes different methods as simple novocaine infiltration of the\nengorrged vessel (i.e. the temporal artery), novocaine block of the sympathetic ganglia,\nand various operations on the sympathetic nervous system such as periarterial sympathectomy, ganglionectomy and rmsectomy..\nIn some intractable headaches, Watts and Freeman (25) recommend lobotomy.\nAccording to them, after frontal lobotomy and the presumed degeneration of the dor-\nsomedial nuclei of the thalamus that follows, patients state that they still fe:l their pain,\nbut that it has ceased to bother them.\nBIBLIOGRAPHY\nAdson, A. W., J. A. M. A., 1931, 18.\nAlajouanine, Th. Thurel, R. J. Med. Francais, 1933, 22, 181.\u2014Revue\nNeurologique, 1933, 2, 81.\u2014Revue d'oto-neuro-opht. 1935, 13, 645\u2014P6resse\nMedicale, 1934, 1, 345.\nAtkinson, M. Arch., Neur. Psych., 1946, 56, 464.\nBonnet and Paufique. Revue d'oto-neuro-opht., 1934, 12, 308.\nBriekner, R. M., Riley, H. A. Bull. Neur. Inst. N.Y., 1935, 4, 423.\nCharlin, C. Revue d'oto-neuro-opht., 1934, 12, 308.\nChavany, J. A., Presse Medicale, 1936, 1, 347.\nClark, D., Hough, H. Wolff, H. S. Arch. Neur. Psych., 1936, 35, 1054.\nFrazier, C. H. Arch. Neur. Psych., 1928, 19, 650.\nFiszhaut-Zeldowicz, L. Neurologia Polska, 1938, 21, 359.\nFriedman, A. P., Brenner, C. H., Carter, S., J. A. M. A., 1949, 139,^9-5^\nGlaser, M. Arch. Neur. Psych., 1928, 20, 537.\nHeymanowitsch, A. J. Revue Neurologique, 1936, 2, 498.\nHorton, B. T., MacLean, A. R., Craig, W., Proc. Mayo Clinic, 1939, 14, 257.\nHorton, B. T., J. A. M. A., 1941 116 377.\nKunkle, E. C, Ray, Wolff, H. G., Arch. Neur. Psych., 1943, 49, 323.\nLieou. Theses de Strassbourg, 1928.\nLove, G., Adson, A. W. Arch Neur. Psych., 1936, 35, 1203.\nMarcussem R., Wolff, H. G., J. A. M. A., 1949, 139, 198.\nPenfield, W. Transact. American Acad. Opht. Otol., 1932.\nMixter, W. J., White, J. C Arch. Neur. Psych., 1931, 25, 986.\nPickering, G. W. British Med. Journal, 1939.\nPickering, G. W., Hess, W. British Med. Journal, 1932.\nSluder, G. Annales Oto-Rhino-Lar. St. Louis, 1912, 21, 160. \u2014 J.A.M.A., 1922,\n79, 370.\nWattt, J., Freeman, W. Research Publ. Arch. Nerv. Mental Diseases, 1948, 27, 715.\n1.\n2.\n3.\n4.\n5.\n6.\n7.\n8.\n9.\n10.\n11.\n12.\n13.\n14.\n15.\n16.\n17.\n18.\n19.\n20.\n21.\n22.\n23.\n24.\n25\nPage 251 RECENT DEVELOPMENTS IN THE USE OF RADIOACTIVE\nISOTOPES f|||~ :W$m\nBy S. H. Zbarsky\nDepartment of Chemistry, University of British Columbia\nRadioactive Isotopes of Phosphorus and Sodium.\nIt is my purpose now to continue from what Dr. Wood has said about the use\nof radioactive iodine and to discuss somewhat briefly some applications of two more\nvery useful radioactive isotopes, namely, radioactive phosphorus and radioactive sodium.\nRadioactive phosphorus has been used for the treatment of various diseases since\n1936 when it was prepared in small amounts in the cyclotron. Since then, of course,\nradioactive phosphorus has become abundantly available because of the development of\nthe atomic pile. Radioactive phosphorus, P32, emits B-partides of high energy which\ncan penetrate body tissues to a depth of approximately 7 mm. The use of radioactive\nphosphorus depends on the fact that it is selectively taken up by certain tissues and cells\nof the body. These tissues are chiefly those which are involved in various blood diseases\nand lymph node diseases. Because it is selectively taken up, radioactive phosphorus can\nbe used as a means of supplying internal radiation. The introduction of radioactive\nphosphorus as well as other radioactive elements is not without its hazards, however,\nsince for therapeutic purposes, a rather high dose of the radioactive isotope must be\nadministered. The high energy of the radiation may injure other adjacent tissues,\nespecially if the isotope has a relatively long half-life. Radioactive phosphorus has a\nhalf-life of 14.3 days and, since the body retains up to 75% of a given dose, steady\nirradiation will take place for several weeks.\nOne of the early pioneers in the use of P32 in the treatment of blood disorders was\nJ. H. Lawrence. Since his studies began, many others have expanded the work so that\nnow information is available on several hundred cases. In general, the treatment is\nsimple and consists merely of giving the P32 as a solution of sodium hydrogen phosphate\norally or by intravenous injection. A very informative review of the use of P32 as a\ntherapeutic agent in blood disease is that by Rheinhard and his associates1. I shall give\nyou only their general conclusions.\nIt was felt by these workers that radioactive phosphorus is the best therapeutic\nagent available at the present time for polycythaemia vera. In the vast majority of the\npatients there was complete haematologic and almost complete symptomatic remission.\nRemission from a single treatment was found to last from six months to several years\nand the cases are still being followed. Therapy with P32 appeared to have very little\neffect on the clinical course of patients with acute or subacute myelogenous leukaemia,\nbut in the chronic form, P32 was at least as good as X-radiation with the advantage that\nthere was freedom from radiation sickness. The results of Reinhard and associates\nindicate that P32 is also as effective as X-ray therapy in prolonging life in these cases.\nIn the great majority of patients suffering from acute lymphatic leukaemia, the\nclinical course was not favourably influenced by P32 therapy. The results were no better\nthan with roentgen radiation. P32 was of no value in the treatment of monocytic\nleukaemia and, in Hodgkin's disease, lymphosarcoma, reticulum cell sarcoma and multiple\nmyeloma, X-ray was better than P32 therapy. In all the various types of diseases treated,\nP32 was shown to have a profound effect on the bone marrow so that complications may\noccur as a result of therapy\u2014leucopenia, thrombocytopenia and anaemia.\nLawrence has published extensively also reports concerning his studies on the treatment of various blood disorders with P32 and notes,2 that, after oral or intravenous administration of P32, the red count returns to normal, the spleen decreases almost to\nnormal size and there is relief from all symptoms of the disease. Associated with this is\nan increased life expectancy and a low rate of remission. Lawrence and his colleagues3\nhave recently published results of the treatment of 100 cases of chronic lymphatic\nleukaemia by use of P32. Thirty-three of these patients have lived for five or more years\nafter the onset of the disease, and ten have lived eight or more years. Another advantage\nPage 252\n' is the convenience of the treatment both for the patient and the physician. All that is\ninvolved is the matter of the few minutes required to make an intravenous injection or\nto swallow the dose, and, as has been mentioned already, there is no radiation sickness.\nAmong the many problems involved in cancer work is the precise location of the\ntumour tissue, either preoperatively or at the time of the operation. Radioactive phosphorus is being used for this purpose also. Low-Beer and his group have done considerable work4 in attempting to distinguish preoperatively between benign and malignant\nbreast tumours by surface measurement of the P32 radiation from breasts of patients\ngiven radioactive phosphorus. Each patient was given 300-500 microcuries of P32 as\nisotonic disodium hydrogen phosphate 24 to 48 hours before surgery. Two, four, six,\nand twenty-four hours later, surface measurements were made directly over the palpable\nbreast tumour and over comparable areas on the opposite normal breast and other fleshy\nparts of the body.\nAt the time of this report, Low-Beer's group had studied 25 patients. Of these\nfive had obviously malignant lesions. The counts over the palpable tumour were 25%\nhigher than in corresponding areas of the opposite breast and adjacent areas of the same\nbreast. Twenty had palpable tumours with unresolved malignancy. Of these, eleven had\na 25% higher count over the tumour area and all eleven were shown to have malignancies. Nine showed less than 25% excess counts and of these eight were found to\nhave benign tumours.\nRadioactive phosphorus has been used recently to obtain precise location of cerebral\ntumours at operation, using a very fine counter as a probe5. After injection of P3-\ninto the patient it was found that the radioactivity in the tumour tissue may be up to 11\ntimes greater than that of adjacent normal white matter. The activity found in gray matter is higher than in white matter but never approaches that of tumour tissue. In all\nthe patients the approximate location of the tumour is determined by the other techniques\nof neurological examination and the P32 used for precise location. After exposure of the\nappropriate area of the cerebrum or cerebellum, the counter is introduced into a convolution as far from the site of the tumour as is permitted by the exposure, in order to\nobtain a normal count. The probe is then withdrawn, carefully cleaned and then inserted\ninto the suspected convolutions until an immediate increase in the counting rate is\nencountered. This indicates at once the presence of the tumour.\nI would like now to discuss very briefly uses made of isotopes of another element,\nsodium. One such radioactive isotope is Na24 which emits gamma.rays, which are very\npenetrating and can easily be detected from within the body tissues by externally placed\ncounters. The limiting factor in the use of Na24 is that it has a very short half-life,\nabout 14 hours, and so must be used for short-term experiments. This isotope has been\nused to determine circulation time6 or rate of blood flow in a limb. For example, the\ntracer is injected at one point and the time of arrival of radioactivity at another point\nis determined by use of a counter. In this manner it has been ascertained that the foot-\ngroin flow time is 18+ 0.9 seconds with a range of 4-50 seconds.\nFor longer term experiments, it is advantageous to use another radioisotope of\nsodium, namely Na22, which has a half-life of three years so that it remains detectable\nfor many weeks. Using this isotope, Reaser and BurchT showed that a normal person\nexcreted, over a ten week period, about ninety times as much sodium as did a person with\ncongestive heart failure, when both were given salt ad lib.\nA very interesting application of radioactive sodium to medical problems has been\nin the development of the technique known as radiocardiography in which a record is\nmade of the passage of radioactive blood through the cardiac chambers*. This technique\nhas been found useful in diagnosis and prognosis of a number of cardiac conditions. In\nthis technique a Geiger-Muller counter tube is placed over the precordium and 100-200\nmicrocuries of Na24 are injected into one of the antecubital veins. The counter tube is\nattached to an ink-writing recorder and a record is traced out as the radiations from the\nPage 253 sodium in the blood pass into the counter through the body tissues. In normal subjects\na curve as shown below is obtained.\nActivity\n10\n-Time (sees.)\nThe injection point is at the far right. The first wave is called the R-wave and\ntraces the blood on its way through the chambers on the right side. The L-wave traces\nthe \"labelled\" blood through the large pulmonary veins behind the heart and through\nthe left cardiac chambers. In the R-wave, the upstroke represents the arrival of the\nNa24 into the superior vena cava and the right cardiac chambers. This wave rises abruptly\nl\/4 second - 2 seconds after the injection. Sometimes the R-wave describes a sharp\npoint and descends sharply, other times there is a plateau before descent. The R-wave\ndescends here because the labelled blood is leaving the right side. The curve is J-shaped at\nthis point. The bottom of the R-wave is T, the transition point or zone, and corresponds\nto the time when most of the labelled blood is in the lungs on the way from the right\nto the left side of the heart. The L-wave is lower than the R-w!ave and is about twice\nas long in time. This is explained by the fact that the radioactive sodium is diluted in\na large volume of blood as it flows through the pulmonary vascular bed into the veins and\nthe left chambers. The ascending limb represents the filling of the great veins on the\nleft side of the heart, occupying about 3 seconds. The long, gentle descending slope\nrepresents emptying of the left cardiac chambers of the bulk of the labelled blood. The\ndescending limb of the L-wave is comparatively long and in the normal radiocardiogram\nis equal in time to the R-wave plus the ascending limb of the L-wave. The taking of a\nradiocardiogram requires only about 25 seconds from the time of injection of the\nradioactive sodium.\nThe use of this technique in diagnosis requires, of course, the establishment of the\nnormal pattern and characteristic patterns to be found in various heart conditions.\nPrinzmetal8 has determined many of these patterns and by comparison has been able\nto rule out suspected heart cases on the one hand and to establish unsuspected cases on\nthe other.\nIn conclusion, I should like to say a few words about the apparatus required for these\nvarious applications of radioactive isotopes. For example, in order to take radiocardio-\ngraphs, the following pieces of equipment are required: a Geiger-Muller counter tube,\na lead shield for the counter, a counting circuit and a recorder. The sad point is that\nall are expensive items, a factor which limits their use to institutions which have money\navailable for the purpose. Further, the apparatus required for radiocardiography is\nrelatively simple. Other applications require more elaborate setups. Another point to\nremember is that the use of a Geiger-Muller tube is often fraught with frustration.\nThe construction of these devices is still in part empirical, and though attempts are made\nPage 254 to make them behave according to accepted standards, they may suddenly stop working\nor may function in some utterly impossible manner. A good deal of the apparatus is\nelectronic in nature so that unless one is well-grounded in electronics it is highly desirable and comforting to have at hand the services of a competent specialist, preferably a\nphysicist, who can not only treat the apparatus correctly but, what is perhaps more\nimportant, can design better apparatus and thereby extend the usefulness of the isotopes.\nREFERENCES\n1. Reinhard, E. Ii., Moore, C. V., Bierbaum, O. S., and Moore, S.\u2014J. Lab. & Clin. Med., 31, 107 (1946)\n2. Lawrence, J. H.\u2014Br. J. of Radiol., 21, 531 (1948).\n3. Lawrence, J. H., Low-Beer, B.V.A., and Carpender, J. W. J.\u2014J.A.M.A., 140, 585 (1949).\n4. Low-Beer, B. V. A., Bell, H. G., McCorkle, H. J., and Stone, R. S.\u2014Radiology, 47, 492 (1946).\n5. Silvemone, B., Solomon, A. K., and Sweet, W. H.,\u2014J.A.M.A., 140, 277 (1949).\n6. Wright, H. P., Osborn, S. B., and Edwards, D. G.\u2014Lancet, 2, 767 (1548).\n7. Reaser, P. B., and Burch, G. E.\u2014Proc. Soc. Exp. BioL Med., 63, 543 (1946).\n8. Prinzmetal, M., Corday, E., Spritzler, R. J., and Flieg, W.\u2014J.A.M.A., 139, 617 (1949).\nThis article should be read in conjunction with that written by Dr. A. J. Wood, B.S.A.,\nD.S.C., of The University of B. C, published in the May issue of The Bulletin.\nIf\nIk\nTUMORS OF THE NECK\nBy H. H. PITTS, M.D.\nDept. of Pathology, St. Paul's Hospital\nProbably no one region in the body affords such a diversified pathological showroom as the neck, for within the relatively narrow confines of the anterior and posterior\ntriangles congenital abnormalities, cysts, inflammatory lesions, primary benign and\nmalignant and secondary malignant tumors may arise. In this short paper I propose to\ndeal only with those subdermal tumors, using the word tumor in the broad sense of a\nswelling or mass, arising at this site and under the following headings:\nCYSTS\u2014Branchial cleft or Branchiogenic; Thyroglossal; Dermoid; Cystic hygroma;\nSebaceous or Epidermoid.\nINFLAMMATION\u2014Specific Parotitis (Mumps); Non-specific submaxillary and parotid salivary adenitis; Thyroiditis; Non-specific lymphadenitis (Acute and Chronic);\nTuberculosis adenitis.\nPRIMARY TUMORS BENIGN\u2014Lipoma; Fibroma; Thyroid adenoma; Carotid body\nadenoma or tumor; Mixed tumors of salivary glands; Diffuse thyroid hypertrophy.\nPRIMARY TUMORS MALIGNANT\u2014Branchial Cleft carcinoma; Malignant adenoma\nof thyroid; Diffuse carcinoma of thyroid; Malignant mixed tumors of salivary\nglands; Lateral aberrant thyroid tumor; Lymphoblastomas\u2014HodgkinTlymphosar-\ncoma, etc.\nSECONDARY MALIGNANT TUMORS\u2014From tongue, lip, larynx, buccal and alveolar mucous membrane, nasal accessory sinuses, pharynx, naso-pharynx, pyriform\nsinus, lung, stomach, etc.\nCYSTS.\nBranchial cleft or branchiogenic cysts generally arise from the 3rd branchial cleft,\nare usually at the level of the hyoid bone, slowly growing, painless swellings that may\nhave been present for a period of years with very little appreciable change in size but\nsuddenly may become quite large, tense, tender and red, suggesting secondary infection.\nThey are smooth and semi-fluctuant to palpation but, if they become suddenly larger\nand present a firm consistency to the palpating fingers with some fixation to the adjacent\ntissues, the possibility of malignant change must be borne in mind. Less frequently these\ncysts may arise from the 2nd cleft and then present themselves as a swelling beneath the\nmastoid process and usually extend into the oral cavity. Histologically they are charac-\nPage 255 teristically lined by ciliated columnar epithelium if fairly deeply situated, but if more\nsuperficial the lining is of a stratified squamous type and there is abundant lymphoid\ntissue both in follicular and diffuse arrangement in the wall.\nThyroglossal duct cysts are always in the midline, being a patent vestigial remnant\nof the duct passing from the foramen caecum at the base of the tongue to the thyroid\nisthmus, and cystic dilatation may occur from the secretion of its lining columnar\nepithelium. It is usually below the level of the hyoid bone but it is sometimes found at\nthe base of the tongue in those instances where the entire canal does not remain canalized. The diagnosis of this condition affords no particular difficulty, a fact which, unfortunately, may not hold true for the remedial measures.\nIn the sense that the so-called Cystic Hygroma is of a cystic nature it seemst reasonable to describe it under the cyst category, although actually it is a tumor composed of\ndilated lymphatic channels. It arises usually in the anterior triangle as a soft, cystic\nswelling probably somewhat lobulated in outline and may attain a considerable size with\nsufficient pressure on the trachea and adjacent tissues to cause no little apprehension.\nThey are generally seen in babies or young children and are said to frequently undergo\nspontaneous cure, probably owing to the fact that they seem prone to secondary inflammation, which, with the subsequent fibrosis, probably constricts and obliterates the\nlumina of the dilated lymph channels.\nDermoid cysts containing sebaceous material and hair may appear in the midline of\nthe neck and in the sites of the bronchial clefts, usually the 2nd. They are congenital\ninclusion cysts along the line of the embryonic fissures and from the standpoint of different diagnosis would appear to be most likely confused with thyroglossal duct and\nbranchiogenic cysts but their rather doughy consistency on palpation may be a point in\nmaking the distinction.\nSebaceous or epidermoid cysts may sometimes attain a considerable size in the\nrelatively loose tissues of the neck and may appear in many positions. If secondary infection intervenes and frequently, consequent calcification, a very firm, somewhat fixed\ntumor mass may result which may present no small problem in diagnosis. However, one\nmay find a small stoma in the skin overlying it from which, on pressure, some of the\nsebaceous material may be expressed.\nINFLAMMATIONS\nOne may mention, in passing, the specific inflammatory hypertrophy of the parotid\ngland in Mumps. Though occasionally only unilateral it is more consistently bilateral\nand in general, the diagnosis presents no great difficulty.\nAcute inflammations of both the submaxillary and parotid salivary glands occur\ngenerally by direct extension of inflammation from the oral cavity through Wharton's and\nStenson's ducts as in the so-called surgical mumps. Chronic inflammations occur usually\nby reason of a sialolith or calculus in the duct, and the history of considerable swelling\nof the gland during meals with gradual decrease after is very significant and probing o\u00a3\nthe duct or radiographic examination should disclose the sialolith. The anatomical position\nof the swellings usually furnishes the clue to the structures involved.\nTuberculous cervical adenitis is probably much less frequent at the present time\nthan it was some 15-20 years ago. This may appear as a few or a chain of enlarged glands\non one or both sides of the neck, relatively painless and not particularly tender and at\nfirst, fairly discrete. Gradually, however, they become matted together as periadenitis\nbegins and if caseation becomes marked they may coalesce to form a large abscess cavity\n\u2014the so-called \"cold abscess\". Aspiration of at least some of the pus for examination,\nwhich is usually productive of no non-specific bacteria, the possible finding of tubercle\nbacilli on direct smear or the inoculation of a guinea-pig and appropriate special media,\nshould eventually establish the diagnosis. One, of course, may extirpate all enlarged and\ngrossly involved glands in the area but there appers to be considerble controversy as to\nthe relative merits of surgery or X-ray as remedial agents and one might wish to establish\nPage 256 the diagnosis first before deciding upon the plan of therapy. In this respect removal of\na single node for microscopic examination would probably expedite the decision.\nAcute cervical lymphadenitis may usually be traced to some acute inflammatory\nprocess in the tonsils, teeth or oral cavity generally. The glands become suddenly enlarged to a varying degree, painful, tender and with possibly some redness of the overlying skin and some hperpyrexia. The lymph nodes may still remain definitely enlarged\nafter the acute process has subsided but are no longer particularly painful or tender but\nmay be firm and rubbery and we now have a more or less chronic lymphadenitis.\nWhile acute inflammations of the thyroid gland are extremely rare, there are two\ndistinct entities which may be described under Chronic Thyroiditis, viz.\u2014 RiedePs\nStruma or Woody Thyroiditis and Hashimoto's Struma or Struma Lymphomatosum.\nThese practically always occur in women, the former in a younger age group (20 to 40\nyears) than the latter (40 to 60 years). Pain, tenderness, swelling and dysphagia are\nthe prominent symptoms, with a sensation of pressure on the trachea a very consistent\none. The duration of symptoms in Riedel's is usually one to two years, while in the\nHashimoto type it-is usually many years. In the latter it is usually a diffuse process,\nwhile in the former it is unilateral in about 30% of cases. Signs of gradually developing\nhypothyroidism, even to a myxoedemic state, are usually present. The chief differentiation is from carcinoma of the thyroid, as the thyroid in both conditions is very firm and\nmay be fairly well fixed to the surrounding tissues, but instead of weight loss there is\nUsually weight gain due to the myxoedema. However, one must resort to surgery to\nexplore the thyroid and either extirpate it or remove a portion for histological examination in order to determine the diagnosis. The Hashimoto type is said to respond well to\ndeep X-ray therapy but one is probably desirous of first establishing a diagnosis before\ndeciding on the mode of therapy, which must be, as stated above, by surgical exploration. One should also mention another type which is relatively uncommon, known as\nthe Giant Cell variant of de Quervain. In this type a fairly consistent radiation of pain\nto parietal, occipital, shoulder and neck areas may serve as a possible clue to this process\nand of the three is characterized by pain as an almost paramount symptom, the Hashimoto type being the least consistent in this respect.\nBENIGN PRIMARY TUMORS\nLipomas and Fibromas are sometimes found in the neck, not necessarily at the sites\nof the various congenital cysts, which fact is a clue in differential diagnosis. They\nusually are slow-growing, well circumscribed, painless, freely moveable masses of varying size and shape, the consistency of the fibroma probably more rubbery and firmer than\nthe lipoma which may, in addition, have a somewhat lobulated outline to palpation.\nMixed tumors of the salivary glands, chiefly the parotid but also the submaxillary,\nare not uncommon. While the mixed tumors of the parotid, may not, anatomically\nspeaking, be within the realm of tumors of the neck, nevertheless it oftentimes originates\nin the tail of the gland and presents in the supero-posterior portion of thealrterior\ntriangle just beneath the angle of the jaw, those of the submaxillary gland, of course,\npresenting in the anatomical site of this gland. Like the branchial cleft cysts they may\nbe very slowly growing, reach a stationary period and then later, again enlarge. They\nmay be semi-fluctuant to feel, slightly lobulated and relatively freely moveable but if\nvery sudden, rapid enlargement occurs with a firmer consistency and relative fixation to\nsurrounding tissues thepossibility of malignant change must be entertained.\nCarotid body tumors are worthy of mention, although I believe one may freely\nassert that they are rare. They occur at the bifurcation of the common carotid, which\nthey may completely encompass, thus affording extreme difficulty to complete extirpation. They usually occur about puberty as unilateral, slowly growing, smooth, fairly\nfirm, rather deeply situated tumors which are non-productive of any signs or symptoms\nother than for the presence of a tumor mass. They usually do not attain any great size,\nprobably walnut to pigeon's egg being the average. They belong to the chromaffinoma\ngroup such as the pheochromocytoma of the adrenal.\nPage 257 The enlargements of the thyroid gland, whether due to adenomata, Grave's disease\nor hyperthyroidism and simple colloid goitre with their various signs, symptoms, etc.,\nare so well known that I will not burden you with their repetition here, for the anatomical site, the movement of the mass on deglutition all point to the structure affected,\nand the diagnosis of the particular type of affection may be established by a number of\nprocedures (basal metabolic rate, blood cholesterol, etc.) However, I should like to\nmention the so-called Lateral Aberrant Thyroid tumors here. Usually situated in the\nanterior triangle they occur most frequently in young persons and are entirely separate\nfrom the thyroid gland proper. They tend to grow slowly and remain well circumscribed\nbut metastasize to the cervical lymph nodes, in this respect being at variance with the\nusually malignant thyroid adenomas which metastasize by the blood stream. They are\nusually unilateral and histologically present a cystic papillary type of structure. Being\nof a generally low grade of malignancy, their complete excision is curative, uness they\nhave already metastasized.\nPRIMARY MALIGNANT TUMORS\nAs previously mentioned, branchial cleft cysts and mixed tumors of the salivary\nglands may undergo carcinomatous change or may probably be carcinomatous from the\noutset. The possibility of this malignant process is suggested by their sudden rapid\nincrease in size, hardness and fixation especially in a patient over 40 years of age.\nWhile sarcoma of the thyroid has been reported it is extremely rare and many\nauthorities are of the opinion that actually, they are more likely to be extremely anaplastic carcinomas, as it is a well known fact that carcinomas of the thyroid may present\na variety of bizarre histological pictures in their cellular structure. Carcinoma of the\nthyroid, however, is not particularly infrequent. Approximately 80-85% of the carcinomas of the thyroid arise in adenomas and there is usually a history of a nodular swelling in the neck over a period of years with often very little symptomatology. This may\nshow sudden, rather rapid increase in size, firmer consistency and may or may not be\nadherent to adjacent tissues. Symptoms of hyperthyroidism are not infrequently associated. As metastases are haematogenous and usually early the secondary growths may be\nfar afield before the patient seeks medical advice. Diffuse carcinoma of the thyroid may\nbe of medullary, adenocarcinomatous or scirrhous type and in these cases the whole\ngland may be enlarged, usually rather rapidly and be firm, fixed to surrounding structures, painful quite frequently and symptoms of dysphagia and dyspnoea from tracheal\nand oesophageal pressure may be present. Surgery and deep X-ray therapy are certainly\nworthwhile as therapeutic measures especially if the carcinomatous process has not yet\npermeated into the adjacent tissues. Unfortunately, in the late cases especially, the\nrecurrent laryngeal nerves on one or both sides may be involved by actual tumor\ninvasion necessitating a permanent tracheotomy.\nThe lymphoblastomas from a very interesting group with generally, very little\ndifference in the appearance in situ and consistency to the palpating fingers can be discerned between the various types\u2014Hodgkin's granuloma, lymphosarcoma, reticulum\nsarcoma, lymphoid leukaemia, giant follicular lymphoma or lymphoblastoma and I\nbelieve, infectious mononucleosis should be mentioned in this category, although, it is not\na neoplasm but an inflammatory process. However, it can be more easily discussed in the\ndifferential diagnosis in this group.\nThere may be unilateral or bilateral enlargement of the lymph nodes in both\ntriangles and they are usually discrete as opposed to the matting together of the tuberculous nodes. Usually painless and not tender. There may be some degrees of pyrexia,\nnotably in Hodgkin's granuloma and infectious mononucleosis\u2014in the former of the\nPel-Ebstein type, i.e., lasting a few days with an afebrile period of one to two weeks intervening. In infectious mononucleosis, diagnostic points are the almost absolute lymphocytosis of generally not more than 20,000 lymphocytes per cmm., with varying numbers of large monocytic cells noted in the blood smears and the heterophile antibody or\nPaul-Bunnell reaction and the process is usually initiated with a fairly severe sore throat.\nPage 258 A white blood cell count and smear will also be of diagnostic assistance in lymphoid\nleukaemia in differential diagnosis from other cervical masses and here the count may\nrange from 50,000 to 1,000,000 or even more with a predominance of immature lymphocytes. However, in the terminal stages of lymphosarcoma, a leukaemic blood picturg\nmay present.\nThe giant follicular lymphomas may present the greatest lymphadenopathy and\ntheir histological character apart from the marked hypertrophy and hyperplasia of the\nlymphoid follicles is not particularly atypical. Despite this fact and their relatively slow\ngrowth, however, they eventually resolve into a frank lymphoblastoma of one or other\ncf the malignant lymphoblastomas.' They are highly radio-sensitive. Probably the most\nexpedient aid in diagnosis is the excision of one of the larger lymph nodes for histological\nexamination but even here the pathologist is often hard put to it to arrive at a dogmatic\ndiagnosis in the early stages of the disease.\nSECONDARY TUMORS\nSecondary tumors or metastases to the cervical lymph nodes may originate from a\ngreat many immediate or adjacent primary growths such as the lip, tongue, larynx,\noesophagus, epiglottis, pharynx, naso-pharynx, thyroid, buccal and alveolar mucous\nmembranes to mention a few, while carcinoma of the stomach frequently metastasizes to\nthe left supraclavicular nodes\u2014the so-called Virchow's gland and bronchogenic carcinoma and indeed, carcinomas of more distant organs such as testis, uterus, ovaries and\ncervix, etc., are, with a fair degree of frequency, found to metastasize in this site. The\nlymphoepithelioma of the pharynx metastasizes early to the cervical nodes and probably\nthe largest secondary growth of all this group are produced by the transitional cell carcinomas of the naso-pharynx and nasal accessory sinuses and the squamous cell carcinoma\nof the pyriform sinus or fossa of Rosenmueller, the primary growth in this latter instance often being so small as to be overlooked on more than one examination at the\nhands of experienced specialists.\nIn conclusion, I must apologize for my effrontery in presenting such a hackneyed\nsubject. However, I do feel that, in an anatomical site, small though it may be, where\nso many pathological processes may arise and are presented almost daily to the physician\nin his routine practice, reiteration of some of the salient features of these tumor masses\nmight not be amiss.\nTHE SOCIAL BURDEN OF MENTAL DISEASE\nBy WM. C. GIBSON, M.D.,\nDirector of Research, Mental Hospital of B.C.,\nGiven at Vancouver Institute, February 4, 1950.\nAlmost one hundred years ago a patient at the Glasgow Royal Infirmary for Lunatics\nwrote: ''Lunacy, like the rain, falls upon the evil and the good; and although it must\nforever remain a fearful misfortune, yet there may be no more sin or shame in it than\nthere is in an ague fit or a fever.\" It is with the assumption that my audience tonight\nhas arrived at this enlightened view of mental illness that I venture to discuss the\nsocial and financial burden which it currently represents. I stress the term \"social\" lest\nanyone think it is not his burden. As I hope to show you, it is a heavy burden, borne\n.collectively, and much heavier, borne individually.\nAt the outset I want to define the problem. Then I want to break it down into\nunits which we can comprehend, and finally, I will deal with some of the solutions to\nthe problem, which we may use.\nEvery ten-year period in Canada sees the known expenditures of one-half billion\ndollars on mental illness, from public treasuries. From the private pockets of individuals,\nwhose number is uncounted, a like sum is probably spent. This figure stuns us, possibly,\nPage 259 owing to the immensity of the sums of money involved. How many oi us realize that we\nhave as many mental hospital beds as general hospital beds in Canada? Five cents out\nof every tax dollar in British Columbia goes to combat mental illness. And yet we know\nthat is not enough. (New York State spends one-third of its total operating budget\non its psychiatric institutions.)\nBritish Columbia has a special problem to face in this field, i.e., the mental diseases\nattributable to an increasing life expectancy. Between the years 1940 and 1980, Canada's\npopulation over age 65 is going to double. British Columbia today has a disproportionately\nhigh number of citizens in this age group, and by 1980 we will be swamped unless we\nstart medical and social research on this group soon. Whereas a person will die when\nhis heart or kidneys give out, he will not necessarily die when his brain ceases to function\nnormally, with the result that such a person becomes a burden to himself, to his family\nand to society. The increasing cost of old age pensions and geriatric care means that the\nincidence of the tax load in 1980 upon a proportionately reduced labor force, will be very\nheavy, unless we find means to prevent or reduce cerebral arteriosclerosis.\nAmerican experience is similar to our own. Each year the public treasuries pay\nout for mental illness, through the State Hospitals and Veterans Hospitals, over $200,-\n000,000. The additional cost for private cases is unknown. The cost to the community\nin labor lost, in jail costs and in social disruption is incalculable. It is known, however,\nthat there is one mental incompetent per 250 American people, which averages out at\none per sixty f amilies\u2014counting only those committed to mental hospitals. For every\nperson inside a mental hospital, there is one on the outside in need of treatment or care.\nOne out of every 17 Americans is going to spend some time in a mental hospital. There\nare now 1,000,000 children in American elementary schools who are destined to spend\nsome time in mental hospitals. It is little wonder, then, that in dollars and cents alone,\nthe American bill exceeds one billion dollars annually. It represents a total loss at present.\nIn wartime it is possible to get exact figures as to mental disability in a finite group\nof men. For instance, we know that each psychiatrically disabled veteran of World\nWar I had cost the U.S. government, up to the time of Pearl Harbor, $30,000, or a total\nof one billion dollars for the whole group. At that time 27 of the Veterans' Administration's 90 hospitals were reserved for neuropsychiatric cases.\nIn World War II the situation was staggering. The Director of the Selective Service\nSystem, Major General Hershey, summed it up thus: 4,800,000 men were reviewed by\ndraft boards and of these 1,700,000 were found unsuitable for induction into the armed\nservices for neuropsychiatric reasons. From those who actually were taken into thel\narmy a final total of 500,000 men was discharged for neuropsychiatric reasons. These\ndischarges were not solely due to combat, as witness the fact that by 1944, 80 per cent\nof the discharged cases had never been inside a combat zone.\nSince hostilities ended, the air has been blue in the United States on the subject of\nunpreparedness for these heavy psychiatric casualties. Johns Hopkins Medical School's\nfamous medical researcher on the sulfa-drugs, Perrin Long, has made an illuminating\nsurvey of the records of an American General Hospital in the North African-Mediterranean theatre. Professor Long was sent to this theatre as its medical consultant. In\nreviewing the 70,365 admissions to one general hospital over a 2 5-month period, he\nuncovered the fact that 45 per cent of the cases were neuropsychiatric\u2014and the worst\npart of it was that such a hospital was entitled, in its establishment, to only two neuro-\npsychiatrists! A further survey of eight U.S. divisions landing on D-Day showedthat,\nfor the succeeding two months one out of every two medical admissions was psychiatric\nin type. Be it said to the great credit of the doctors doing psychiatry in that area, that\nthey were able to return 65 per cent of their cases to duty in the field, as against 60\nper cent for the medical cases and 9 per cent for the surgical.\nThese, then, are the broad outlines of the problem. Now for the details of some\nof the contributing causes. Environmental and personal maladjustment per se are\nundoubtedly the cause of a great deal of unhappiness and neurotic behaviour in the\nPage 260 world, but they do not fill the mental hospitals. It is the grossly psychotic, the feebleminded and the deteriorated epileptics who must be committed. It is a waste of valuable\ntime to chronicle the day to day maladjustments of these latter cases, for the cause lies\nfar back of mere symptoms\u2014it is in many cases biochemical or developmental in the\nembryological sense of the term.\nThere is a no-man's land lying between organic and environmental mental illness\nin children. I refer to the group of cases loosely called \"the behaviour disorders\". It has\nbeen shown recently that many of these children have grossly abnormal brain waves,\nas demonstrated by the electroencephalograph. There is also a much misunderstood group\nof children, those with reading and writing problems, as the result of some cerebral\ndysrhythmia. These children, by the nature of their brain function, cannot use their\ntemporal lobes or have damaged or malconstructed temporal lobes. We do nothing\nbut manufacture truants among these children by blindly trying to force formalized\neducation upon them. They cannot read because they do not get the same stimuli as\nnormal children relayed from their eyes and ears, often because the \"circuits\" are \"busy\"\nwithin the brain.\nThis brings us to a brief consideration of epilepsy as a neurological problem. It\nis not a mental disease, although epileptics who have gone untreated for long periods\nwill so deteriorate mentally that they may need to be committed. One American in\nevery 200 is an epileptic. This does not mean that each epileptic has overt, thrashing\nseizures. Some may have no more than fleeting well-formed hallucinations. Some will\nhear a little tune, or an odd sound, or may experience a little dream. Some will pace\nthe house doing quite complicated things without any knowledge of it subsequently.\nBirth injuries, brain scars, brain tumors or cerebral infections may be the cause of these\ndeviations from normal. Once recognized these cases may be helped in a truly marvellous\nmanner. Research into anti-convulsant drugs has yielded such results that the future\nof many epileptics has changed from darkness to light. Some less fortunate, find themselves in conflict with the law at time, and for lack of understanding, medically, they\njoin the already large group of delinquents which cost the country so much.\nNow as to delinquency, and what it costs us. The best Canadian data are to be\nfound in the Archambault Report, arising from the Royal Commission of 1938. This is\nthe most forthright report I have ever read, and had it cost $5.00 instead of $1.00 iV\nmight well have become a \"best seller\".\nThe report gives detailed cost figures on a group of 188 recidivists, who have been\nconvicted a total of 3,434 times, or an average of 19 times per man. The cost of\nconvicting these delinquents was $18,005 each, or a total of $3,250,960. Add to\nthat the cost of institutionalizing these citizens, averaging three years in reformatories\nor jails, and eleven years in penitentiaries, and we find that the taxpayer has paid out\n$25,453 for each of them. This is a dead loss too. Place over against this the cost to\nthe state of educating a child from age 6 to agel6 \u2014 a mere $l,006^and you\nwill soon see the costliness of delinquency devoid of effective rehabilitation. The\ncomparison is doubly relevant in that 32 per cent of the 188 recidivists were convicted\nof their first offence at the age of 16 years or less! Less than two per cent of the 188\nmen ever finished high school. Only 12 per cent ever went to high school. And lest\nanyone clings to the quaint notion that the 188 \"must be foreigners,\" may I say that 83\nper cent of the group were Canadian born.\nAnother social cost of mental illness manifests itself in the problem of alcoholism.\nNew York State, with a population of 13,000,000, has 280,000 excessive drinkers, 70,000\nof them chronic alcoholics. An excellent survey was made in the city of Buffalo for thfj\nyear 1940-41, covering Erie County, whose population was approximately 800,000.\nIn that year 7,280 alcoholics (or one person in every 110 approximately) were either\napprehended, convicted or hospitalized at public expense, the total cost being $162,616.\nThe social cost apart from dollars and cents, and the loss of productive labor which\nthis disease entailed, must be added to this figure.\nPage 261\n\u25a0Ml\nM Habituation to drugs is another mental illness which costs us, as taxpayers, a\ngreat deal of money. The crime associated with drug addicts' attempts to get money\nfor drugs by strongarm methods is well known in most large cities.\nThe solutions to these expensive problems are beginning to dawn upon us. Once\nwe see in psychiatric treatment an active force, rather than a custodial technique, wd\nhave set out upon the right road. Our watchword must be, \"spending to save\". Custodial\nmethods of dealing with mental hospital cases, with delinquents, alcoholics, drug addicts,\nchronic truants and epileptics, have failed to halt the rising tide of illness, which the\ntaxpayer is called upon to finance. The new outlook in this vast field is epitomized in\nthe recently opened Crease Clinic at Essondale. There, early diagnosis and early, active\ntreatment, are available to any resident of British Columbia. I know of no other part\nof Canada in which such facilities are available to such a large group of mentally ill people,\nin the early stages, and of few in the United States. A total of three hundred patients,\nmany of them voluntary (i.e. not committed cases) can be housed in the Crease Clinic\nfor a period not exceeding four months. Within ten years this clinic will have more\nthan paid for itself, through early diagnosis and treatment, and through positive rehabilitation of the patients.\nMental hygiene has a great deal to offer, and properly practised, will save B. C.\nuntold financial and social losses later. It has long seemed to me that with most of\nB.C's teachers passing through our university for some part of their training, we have\na natural bottleneck here at which to work. If all teachers-in-training could be taught\nto recognize the incipient signs of mental disturbance in their pupils we would soon\nhave an adequate reporting system, and truly \"preventive psychiatry\" could be established here. On an even broader scale, all students, whether in law, theology, medicine,\nengineering or what not, would be more useful citizens if they could be given an\norientation course in mental health..\nFinally, what hope does research in mental disease offer to the community? Perhaps\nwe should ask first, \"What does the community offer to research?\" The figures are\nunbelievable! In the United States, for every dollar spent on scientific research into\nmental disease, $65 is spent on other medical research, and $2,500 on industrial research!\nIn Canada the amount spent in mental research is infinitesimal. And yet the annual\ncost to us of mental disease is $100,000,000. With Ottawa grants, it is hoped to\nfield teams of researchers, who can devote all their energies to these problems in research\nand teaching centres. The recent discoveries in endocrinology, or the hormone ACTH,\nand the synthesis of cortisone, offer very important tools to us in this field. Radioactive\ntracers and electron microscopes have further widened the field, which must now be\nstocked with trained researchers. Epilepsy has been brought out of the Dark Ages\nwithin the last twenty years, thanks to new methods of electrical recording from the\nexposed human brain in patients who trust the skill of a neuro-surgeon. Synthetic\ndrugs have been developed for the control of convulsive seizures, and the search goes\non for agents which will help children with cerebral dysrhythmias.\nIn the field of schizophrenia\u2014still the largest single mental disease\u2014we have learned\nmore in the past 25 years than in all history, thanks to well-planned and generously\nsponsored research. For the fifteen years, 1920-1934 alone, almost 1,800 medical papers\nwere published on this single disease.\nThe most useful physical treatments in psychiatry\u2014electro-convulsive therapy,\ninsulin shock therapy, and fever therapy\u2014are all empirical to date. If we knew how\nthey aided the patient, we might generalize from them or greatly increase their value,\nand possibly develop improved variants of them. Electroconvulsive therapy was developed\nas the result of an incorrect theory\u2014which was that epileptics, because of their seizures,\nrarely developed schizophrenia. Insulin shock therapy was developed for the treatment\nof chronic alcoholics, and only incidentally was it found to help schizophrenics. Fever\ntherapy for syphilis of the nervous system developed from a vesy astute observation by\na German medical officer in the Balkans in the First World War, that his patients with\nPage 262 G.P.I, improved greatly if they contracted malaria. Penicillin, of course, combined with\nfever, has produced good results in a large proportion of these cases.\nResearch is crying out to be done at the cellular level, though to administrators\nharassed by relatives of patients, the thing may sound ridiculous. I am reminded of\nthe statement of Sir Walter Morley Fletcher when he was Secretary of the British Medical\nResearch Council. He said, \"If I had $5,000,000 to spend on medical research I should\nemploy it in developing particular applications of primary physiology and biochemistry\nwhich would assuredly bear fruit later on. The new method, a new clue that has helped\nto conquer a disease, again and again emerged from a study of something else.\"\nTo pool the resources of a group of researchers in the biological and the social\nsciences is our hope here. I am convinced that in a university setting, where people\nare encouraged to enquire, we will be able to elucidate some of the abysmally dark\nsections of the problem.\nI can only conclude, with Raymond Pearl, that \"If there are difficulties in the\nsubject, there are also great opportunities and promise; and furthermore there is a kind\nof moral necessity to go forward in the attempt to get a better understanding of the\nwhole nature of man lest he perish.\"\nDOCTOR'S ASSISTANT\nAvailable after September 1st.\nExperienced Typist and Receptionist.\n5 Years Lab. Experience.\n1140 Haro Street\nMRS. D. LATHAM\nTelephone MArine 0082\nVancouver\nPage 263\nm HYPOTHYROIDISM AND MYXOEDEMA\nD. MOWAT, M.D.\nThese two terms have come to be synonymous but actually they are not. Hypothyroidism can exist without myxoedema, it is described in articles on the subject but\nclinically it is most difficult to recognize because its signs and symptoms are indefinite\nand varied. One author states that in most cases when it is diagnosed it is a misnomer.\nMyxoedema is a form of hypothyroidism with characteristic signs and symptoms.\nManifestations of myxoedema vary according to the age of the patient but in this\npaper only the adult form will be discussed. A classification of the disease according to\nits etiology is as follows:\u2014\nA. Myoedema with Goitre.\n1. nodular\u2014-actually this is more likely the result of myoedema than the\ncause.\n2. diffuse\u2014enlargement due to various forms of chronic thyroiditis or specific\ninfections.\n3. hyperplastic\u2014spontaneous cessation of Grave's disease, or the gland rendered inactive by X-ray, iodine, or thiouracil.\nB. Myxoedema without Goitre.\n|| primary\u2014congenital absence of the gland, idiopathic atrophy, post-operative or post-radiation effects.\n2. secondary\u2014pituitary tumour or destruction.\nBy far the commonest cause is idiopathic atrophy, the etiology of which is entirely\nunknown.\nWomen are affected from 4 to 8 times as frequently as men. The highest incidence\nis between the ages of 30 to 50. The onset is insidious and gradual. Occasionally there\nappears to be a relationship between the onset and pregnancy, menopause or an acute\ninfection. The disease occurs all over the world, but is more prevalent in goitrous\nregions. Some authors claims there is a familial tendencv.\nThe symptoms of myxoedema may be divided into two groups. Those appearing\nearly such as increase in weight, decrease in sweating, increase in susceptibility to cold,\ndjyness and coldness of the skin, and a sensation of chilliness even in moderate temperatures, can be directly attributable to the lowered B. M. R. The later and more pronounced symptoms such as the non-pitting edema, fatigue, mental dullness, slowing\nof speech and muscular movements, memory loss, constipation, falling of hair, menstrual\ndisturbance (more often menorrhagia than amenorrhoea), deafness, thickness and\nsmoothness of the tongue, sluggishness of the reflexes, hoarseness, various sensory disturbances are specific manifestations of thyroid defiiciency.\nThe B. M. R. may be from low normal to 45 %> lowered B. M. R. from other\ncauses will not give this symptom complex. Hypercholesterolaemia is characteristic but\nnot pathognomonic or necessary. A decreased urine volume is seen and albuminuria is\ncommon. The reason the patient first seeks medical aid may be because of anaemia which\nmay be of normochromic, hyperchromic or hypyochromic variety. Other changes found\nare, lowered fasting blood sugar, decreased blood iodine levels, increased blood viscosity\nand gastric anacidity. Some authors describe an increased capillary fragility to which\nthey ascribe the cause of the oedema, but this certainly requires confirmation.\nIf the condition remains untreated it becomes progressively more severe over a\nperiod of 10 to 15 years, death usually occurring from some intercurrent infection.\nThe treatment of spontaneous myxoedema requires very small doses of thyroid.\nLarger doses as given initially in the past should not be administered, as fatalities have\nPage 264 occurred. One quarter to one half a grain of thyroid daily is the usually accepted initial\ndose. The patient should be carefully watched and frequently checked during the initial\ntages of therapy. Extra caution is required if the disorder is of long standing or when\nit occurs in older patients. If the initial dose causes anginal pain or any evidence of\ncardio-vascular discomfort then it should be reduced and maintained at that lower\nlevel for two months before attempting to increase it. At weekly or longer periods the\ndaily dose is gradually raised to 1 to 2 gr. which is usually sufficient to maintain the\npatient in normal health.\nTreating the anaemia depends on what type is present. Thyroid and iron will control the normochromic or hypochromic anaemias, but liver extract may be required\nfor the typerchromic form.\nThere are several reasons why the treatment may be partially or completely ineffectual.\n1. Using a non-potent brand of drug.\n2. Initiating therapy when the disease is far advanced and permanent changes\nhave occurred.\n3. Lack of cooperation on the part of the patient either per se or because at one\ntime the patient has carelessly taken an overdose of the drug. iSpi\n4. If the myxoedema is secondary to hypopituitarism. In this case the condition\ndoes not respond as well to thyroid alone and co-administration of anterior pituitary\nextract is probably necessary.\nMyxoedema is frequently said to cause or assist various degenerative diseases such as\narteriosclerosis but this is difficult to prove or disprove because they both commonly\nbegin at about the same age. However, myxoedema is certainly not incompatible with\nlife. The first patient to be treated with thyroid and who maintained her treatment\nfor over 52 years, died 4 to 5 years ago from hypertension and pneumonia at the age\nof 92.\nPage 265 This month the internes of Vancouver hospitals will take diverse paths into the\nmedical world.\nTHE VANCOUVER GENERAL\nDr. George Pehrcey will enter General Practice at Trail, B.C.\nDr. Eric Smith will study ophthalmology at the Montreal General Hospital.\nDr. Robert Walton will become assistant resident in dermatology at Stanford University Hospital in San Francisco.\nDr. W. A. Davies will enter general practice at Invermere.\nDr. G. Marion will take a year in medicine at Queen Mary Hospital in Montreal.\nDr. George Burton will practice at Yarmouth, N.S.\nDr. John Woods will commence general practice at Dauphin, Manitoba.\nDr. R. Hitchen will study obstetrics in Honolulu.\nDr. R. E. Beck will continue his internal medicine course at the Royal Victoria in\nMontreal.\nDr. Glen Ankenman and Dr. D. A. Boyes will conduct a joint practice at Ganges\nHarbour on Salt Spring Island.\nDr. C. A. MacLean will study medicine at the Royal Victoria Hospital.\nDr. Michael Turko will also study obstetrics at the Royal Victoria.\nDr. Lois Crawford will undertake anesthesia at Shaughnessy Hospital.\nDr. T. R. Osier and Dr. E. F. Weir will continue in surgery and medicine at the\nVancouver General.\nDr. Helen Martin will enter general practice at Prince Albert, Saskatchewan, and\nplans to be married late in the summer.\nDr. W. D. Panton will do General Practice at Hope.\nDr. J. D. Blaine will do a year of general practice at Val Marie, Saskatchewan, before\ncontinuing surgical studies.\nDr. Don Oakley and Dr. M. H. Wong will commence anesthesia studies at the\nVancouver General Hospital.\nDr. E. A. Johnson will return to his hometown of Smith Falls, Ontario.\nDr. J. W. Evans will continue the Vancouver General Hospital obstetrics and\ngynecology.\nDr. J. S. Kennedy and Dr. R. Kennedy will practise at Climax, Saskatchewan.\nDr. A. E. Robertson will do staff medicine at Tranquille.\nDr. L. Friesen will take a year in Surgery at Shaughnessy Hospital.\nST. PAUL'S HOSPITAL\nThis year many of the junior internes will remain as seniors to form the first group\nof residents.\nDr. Leonard A. Maher will be on pediatrics.\nDr. Patrick Doyle will be on medicine.\nDr. Clarence Chouinard will do surgery.\nDr. Robert McNaughton will be on Obstetrics and Gynecology.\nDr. Joseph Petriw will continue a rotating internship.\nDr. Jack Tufteland will step into general practice in Vancouver.\nPage 266 To Shaughnessy Hospital will go Drs. Stephen P. Murphy as surgeon and Dr. William\nT. Armstrong as internist.\nDr. L. Y. Chou will study pediatrics at Johns Hopkins.\nDr. J. R. Wynne will join the R.C.A.F. at Edmonton.\nDr. Donald F. Fletcher will go to Hamilton General Hospital in the department of\nmedicine.\nDr. John A. Raragosky will do surgery at the University Hospital in Edmonton.\nDr. Philip C. Fitzjames will work for the National Research Council at London,\nOntario.\nDr. F. M. Auld of Nelson was made an honorary senior member of the CMA at the\nconvention in Halifax.\nDr. G. J. Wherrett said in Vancouver last month that the TB rate in Canada will\nprobably decrease by half in the next 25 years.\nDr. R. W. Boyd of Vancouver has been elected president of the Pacific Northwest\nRadiological Society and Dr. Fred Bonnell of Victoria is a vice-president.\nDr. Hugh Brown of Vancouver will become PHO at Prince George after a holiday\nin Victoria.\nDr. G. M. Foster of Vancouver has retired from active practice\nBIRTHS\nDr. and Mrs. John McCaffrey of Vancouver, a son.\nDr. and Mrs. A. A. Larsen of Nanaimo, a son.\nDr. and Mrs. L. A. Patterson of Vancouver, a son.\nDr. and Mrs. N. L. Auckland of Vancouver, a daughter.\nDr. and Mrs. J. L. McMillan of Vancouver, a son.\nDr. and Mrs. Harold Capte of Vancouver, a son.\nDr. and Mrs. E. M. Stephenson of Vancouver, a daughter.\nDr. and Mrs. E. F. Word of Vancouver, a son.\nThe following were the B. C. representatives who attended the Annual Meeting of\nthe Canadian Medical Association in Halifax, held June 19th to 23rd:\nDoctors J. C. Thomas, J. A. Ganshorn, Lynn Gunn, E. C. McCoy, R. A. Stanley,\nFrank Turnbull, G. L. Watson, E. O. DuVernet, D. B. Collison, B. Blair, F. P. Patterson,\nA. W. Bagnall, J. A. Cluff, D. E. H. Cleveland, all of Vancouver; Doctors F. M. Bryant\nand H. M. Edmison, of Victoria; Dr. C. C. Browne, Nanaimo; Dr. F. M. Auld, Nelson;\nDr. W. L. Chisholm, Port Alberni; Dr. E. J. Ryan, Essondale; Dr. Ryall, Smithers; and\nDr. G. K. McNaughton, Cumberland.\nDr. D. M. Whit\\ey of Victoria has left for England and Scotland wjnere he will\nreside for some time.\nDr. G. E. Singer who has completed his internship at St. Joseph's Hospital, Victoria,\nis taking up practice in Queen Charlotte Islands.\nDr. Donald R. Johnston has left Victoria for Niagara Falls.\nPage 267\nMB \u25a01\nand highly effective\nJlfiL\n(fyenAt\nr\n\/\nUM\/VEfiSJMyyfAR\/\nAYERST, McKENNA & HARRISON LIMITED\nBiological and Pharmaceutical Chemists\nMontreal, Canada.\nExorbin\nBrand of Polyamine Resin\n\/\/\nroauces\nPrompt acid neutralization\nEffective pepsin inhibition\nwithout\nAlkalinization\nAcid \"rebound\"\nAlteration of acid-base balance\nof body fluids\nRemoval of phosphorus or\nsodium chloride\nDestruction of important\nnutritive factors\nInterference with normal bowel\nfunction\nToxicity (even with massive\ndosages)\nIn the treatment of\nGastric hyperacidity\nGastric and duodenal ulcers\nHeartburn of pregnancy\nIs available as\nTablets (No. 373) \u2014 0.25 Gm.\n(4 grains) per tablet.\nIn bottles of 100 and 500.\nPowder (No. 375)\nIn jars of 2 ounces.\n307S For local therapy and prophylaxis of\noral infections caused by penicillin-sensitive organisms.\nDelightful tasting\u2014welcomed by\nyoung or old. Potent\u2014supplies 3,000\nunits penicillin in slowly dissolving hard\ncandy base. Effectiveness lasts approximately one half hour.\npenicilli\nin\nDelicious\nHard Candy\nForm\nPondets\nPenicillin\ns\u00bb *\u00abrs * *\u00bb\u00bb!*\u00ab ;sm*s* \u00bb*\nSupplied ia screw-top\njars of 20, individually\nwrapped ia glistening\ncellophane.\na^atff\nRegistered Trade Mark\nJOHN WYETH & BROTHER (CANADA) LIMITED \u2022 WALKERVILLE, ONTARIO ffrcZ*- fit Quick fie\/etence\n* >\\\nQUESTRIN\n^COMPOUND\nThe product with J\nthe PLUS factors\nTreatment of oestrogen deficiency symptoms with Questrin\nCompound presents several advantages:\n\u2022 The addition of vitamin B complex assures adequate concentration of B factors which are essential for the full capacity of\nthe liver to metabolize oestrogenic hormones.\n\u2022 Questrin Compound contains natural oestrogenic hormones.\n\u2022 Questrin Compound is orally active, readily absorbed and\nrapidly effective.\n\"QUESTRIN COMPOUND 10 M \"QUESTRIN\" COMPOUND 5 M\nS.C.T. No. 430 \"KiMf S.C.T. No. 429 \"Sort\nColoured Pink Coloured Orange\nEach tablet contains:\nQuestrin, equivalent to the Each tablet contains:\nactivity of Questrin, equivalent to the activity of\nsodium oestrone sulphate 1.25 mg. sodium oestrone sulphate.... 0.625 mg.\nplus plus\nBrewer's yeast concentrate.... 100 mg. the same factors listed under\nThiamine HO 3 mg. S.C.T. No. 430\nRiboflavin 2 mg.\nNiacinamide 10 mg. DOSE\nPyridoxine HCI 1 mg. 1 to 3 tablets daily.\nCalcium d-pantothenate 5 mg.\nAscorbic add 25 mg. MODES OF ISSUE\nVitamin D 500 I.U. Bottles of 20 and 100 tablets.\n\u2022\"QUESTRIN\"\u2014'Sottf brand of naturally occurring,\norally active, water soluble, oestrogenic conjugates\n(equine), standardized colorimetrically and by\n^JS^&L^ biological assay.\nMONTREAL CANADA OSTOCO DROPS\nAn Aqueous Preparation \"\nMULTI-VITAMIN THERAPY\nI for I\nINFANTS and CHILDREN\nOSTOCO DROPS contain vitamins A, D, B, and C\nwhich aid growth and normal function of the body,\ntogether with Iodine for prophylaxis against Iodine\ndeficiency.\nDIRECTIONS FORMULA\nInfants \u2014 5 to 10 Ostoco Drops (0.25 to Each cc contains:\n0.5 cc) from precision dropper added to Vitamin A 8,000 Int. units\none feeding bottle of the day's supply. Vitamin D 4,000 bit. units\nwhen cool. Shake well and use this bottle Vita min B i 4 mg\nfor the next feeding. Vitamin C ,7.7.7 .'.' 120 mg!\nChildren\u2014 5 to 10 Ostoco Drops (0.25 to *Niacinamide 10 mg.\n0.5 cc) daily, mixed thoroughly in a glass- Sodium iodide 0.02 mg.\nfill of milk or cocoa. *Not declared on label.\nIf desired Ostoco Drops may be administered directly into the mouth.\nMODES OF ISSUE\nBottles of 8, 15 and 30 cc. with precision dropper.\neharie* 8Mkodbt6c6o.\nMONTREAL\nCANADA OUABAINE ARNAUD\nSTRICTiy ETHICAL SPECIALTIES\n350 LEMOYNE STREET, MONTREAL 1, P.Q. He's heard Hie ca\/lfor\nVhDAYUN\nTRADE MARK\nEach average teaspoonful\n(5 cc.) contains:\nVitamin A 5000 Int. Units\n(from fish liver oils)\nVitamin D 1000 Int. Units\n(Viosterol)\nThiamine\nHydrochloride.... 1.3 mg.\n(Vitamin Bi, 444 Int. Units)\nRiboflavin\n(Vitamin Bj) 1.5 mg.\nAscorbic Acid 80 mg.\n(Vitamin C, 1600 Int. Units)\nNiacinamide 10 mg.\nIn a palatable emulsion.\n(Homogenized mixture of Vitamins A, D, Bi, 82, C and Nicotinamide, Abbott)\nAnd that's one call he'll answer \u2014 come hill or high fences.\nFor Vi-Daylin's pleasing, citrus-like flavor and odor make a\nhit with children every time. A glance at the formula reveals the\nsound vitamin therapy in this sparkling yellow liquid. One 5-cc.\nteaspoonful is the average daily dose for children up to the age\nof 12. They like it direct from the spoon. For infants, Vi-Daylin mixes\nreadily with milk, fruit juice or cereal. For grown-ups who dislike\ntablets, capsules or unpleasant-tasting preparations, Vi-Daylin is\na refreshing alternate. It is Stable at room temperature, has no\nfishy odor. Available at all prescription pharmacies\nin 90-cc. and 8-fluid ounce bottles.\nAbbott Laboratories Limited, Montreal.\n@5?) m\nEXCLUSIVE JMBIILMCE\nLIMITED\nFAir. 0080\nNW. 60\nJ\nnMfjtf\nOXYGEN THERAPY SUPPLIED ON YOUR\nORDER. 24 HR. SERVICE\nJ. H. CRELLIN\nW. L. BERTRAND\n0?V\nWhen prescribing Ergoapiol\n(Smith) for your gynecologic patients,,\nyou have the assurance that it can be obtained only\non a written prescription, since this is the only manner\nin which this ethical preparation can be legally\ndispensed by the pharmacist. The dispensing of this\nuterine tonic, lime-tested ERGOAPIOL (Smith)-only\non your prescription \u2014 serves the best interests\nof physician and patient.\nINDICATIONS: Amenorrhea, Dysmenorrhea, Menorrhagia,\nMetrorrhagia, and to aid involution of the postpartum uterus.\nGENERAL DOSAGE: One to two capsules, three to four\ntimes daily\u2014as indications warrant.\nIn ethical packages of 20 capsules each, bearing no directions.\nLiterature Available to Physicians Only.\nERGOAPIOL (smith)\nEthical protective mark,\nM.H.S., visible only -\nwhen capsule is cut hi.\nhalt at seam.\nMARTIN H. SMITH COMPANY\n150 LAFAYETTE STREET\nHCW Y0IK U.JbJB CAMPBELL & SMITH LTD.\n820 Richards Street :: Vancouver, B. C. :: PAcific 3053\nc^jfzati(jE i\/^%iriHna","type":"literal","lang":"en"}],"http:\/\/www.europeana.eu\/schemas\/edm\/hasType":[{"value":"Periodicals","type":"literal","lang":"en"}],"http:\/\/purl.org\/dc\/terms\/identifier":[{"value":"W1 .VA625","type":"literal","lang":"en"},{"value":"W1_VA625_1950_07","type":"literal","lang":"en"}],"http:\/\/www.europeana.eu\/schemas\/edm\/isShownAt":[{"value":"10.14288\/1.0214615","type":"literal","lang":"en"}],"http:\/\/purl.org\/dc\/terms\/language":[{"value":"English","type":"literal","lang":"en"}],"http:\/\/www.europeana.eu\/schemas\/edm\/provider":[{"value":"Vancouver : University of British Columbia Library","type":"literal","lang":"en"}],"http:\/\/purl.org\/dc\/terms\/publisher":[{"value":"Vancouver, B.C. : McBeath Spedding Limited","type":"literal","lang":"en"}],"http:\/\/purl.org\/dc\/terms\/rights":[{"value":"Images provided for research and reference use only. Permission to publish, copy, or otherwise use these images must be obtained from the Digitization Centre: http:\/\/digitize.library.ubc.ca\/","type":"literal","lang":"en"}],"http:\/\/purl.org\/dc\/terms\/source":[{"value":"Original Format: University of British Columbia. Library. Woodward Library Memorial Room. W1 .VA625","type":"literal","lang":"en"}],"http:\/\/purl.org\/dc\/terms\/subject":[{"value":"Medicine--Periodicals","type":"literal","lang":"en"}],"http:\/\/purl.org\/dc\/terms\/title":[{"value":"The Vancouver Medical Association Bulletin: July, 1950","type":"literal","lang":"en"}],"http:\/\/purl.org\/dc\/terms\/type":[{"value":"Text","type":"literal","lang":"en"}],"http:\/\/purl.org\/dc\/terms\/description":[{"value":"","type":"literal","lang":"en"}]}}