"CONTENTdm"@en . "http://resolve.library.ubc.ca/cgi-bin/catsearch?bid=1179642"@en . "History of Nursing in Pacific Canada"@en . "Vancouver Medical Association"@en . "1950-02"@en . "2015-01-29"@en . "1950-02"@en . "https://open.library.ubc.ca/collections/vma/items/1.0214411/source.json"@en . "image/jpeg"@en . " r\nIBULLETIN\nPublished By\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 FEBRUARY, 1950\t\nK OFFICERS, 1949-50\nDr. W. J. Dorrance Dr. Henry Scott Dr. Gordon C. Johnston\nPresident Vice-President Past President\nDr. Gordon Burke Dr. W. G. Gunn\nHon. Treasurer Hon. Secretary\nAdditional Members of Executive:\nDr. J. C. Grimson Dr. E. C. McCoy\nTRUSTEES fH\nDr. G. H. Clement Dr. A. C. Frost Dr. Murray Blair\nAuditors: Messrs. Plommer, Whiting & Co.\nSECTIONS\nClinical\nDr. M. M. MAcPHERsoN_Chairman Dr. W. H. S. Stockton Secretary\nEye, Ear, Nose and Throat\nDr. J. F. Minnes\u00E2\u0080\u0094^\u00E2\u0080\u0094Chairman Dr. N. J. Blair '. Secretary\nPaediatric\nDr. J. R. Davies Chairman Dr. C J. Treffry Secretary\nOrthopaedic and Traumatic Surgery\nDr. R. H. B. Reed Chairman Dr. D. E. Starr Secretary\nNeurology and Psychiatry\nDr. G. H. Gundry Chairman Dr. G. M. KntKPATRiCK\u00E2\u0080\u009E._Secretary\nRadiology\nDr. W. Jj. Sloan Secretary Dr. Andrew Turnrull Chairman\nSTANDING COMMITTEES\nLibrary:\nDr. R. A. Palmer, Chairman; Dr. E. F. Word, Secretary; Dr. J. E. Walker;\nDr. S. E. C. Turvey; Dr. A. F. Hardyment; Dr. J. L. Parnell.\nSummer School:\nDr. E. A. Camprell, Chairman: Dr. Gordon C. Large, Secretary;\nDr. A. C. Gardner Frost; Dr. Peter Lehmann; Dr. J. H. Black;\nDr. B. T. H. Martensson.\nMedical Economics:\nDr. J. A. Ganshorn, Chairman: Dr. Paul Jackson ; Dr. W. L. Sloan ;\nDr. E. C. McCoy; Dr. J. W. Shies; Dr. T. R. Sarjeant; Dr. John Frost.\nCredentials:\nDr. H. A. DesBrisay ; Dr. G. A. Davidson ; Dr. Gordon C. Johnston.\nRepresentative to B. C. Medical Association: Dr. Gordon C. Johnston.\nRepresentative to V.O.N. Advisory Board: Dr. Isarel Day.\nRepresentative to Greater Vancouver Health League: Dr. L. A. Patterson\nRepresentative to the Board of Trustees for the Medical Care of\nSocial Assistance Cases: Dr. J. A. Ganshorn\nNo. 5\n\u00E2\u0080\u00A2.:\u00E2\u0096\u00A0'\nif\nW\nffl's!\n! If if l\ni .iljyil\nw\nill Clinically proved . \u00E2\u0080\u00A2 \u00E2\u0080\u00A2\ntherefore preferred\ntruly therapeutic dosages of all\nthe individual vitamins known to\nbe essential in human nutrition.\nTHERAPEUTIC FORMULA\nVITAMI\nNC Squibb\nthe standard of comparison b\nottles of 100 capsules\nSquibb\nE. R. SQUIBB & SONS OF CANADA LIMITED\n2245 VIAU STREET, MONTREAL\nManufacturing Chemists to the Medical Profession since 1858 VANCOUVER MEDICAL ASSOCIATION\nFounded 1898; Incorporated 1906\n.PROGRAMME FOR THE FIFTY SECOND ANNUAL SESSION\n(Spring Season)\nMARCH 2nd\u00E2\u0080\u0094SPECIAL MEETING Speaker\u00E2\u0080\u0094Professor F. H. Bentley, Department\nof Surgery, University of Durham Medical School, England.\nMARCH 6th\u00E2\u0080\u0094SPECIAL MEETING, Lecture by Sir Reginald Watson-Jones, title:\n\"The New World of Orthopaedic Surgery.\"\nMARCH 8th (WEDNESDAY) \"OSLER LECTURE\"\u00E2\u0080\u0094Presented by DR. GEORGE\nA. DAVIDSON, HOTEL VANCOUVER Title: \"Men of Osier's Time.\"\nMARCH 28th\u00E2\u0080\u0094SPECIAL MEETING\u00E2\u0080\u0094\"Lecture by Dr. Cecil Watson, Professor of\nMedicine, University of Minnesota, Title: \"Some Fundamental and Clinical Aspects\nof the Problem of Hepatic Cirrhosis.\"\n[APRIL 4th-\nWood.\n-GENERAL MEETING\u00E2\u0080\u0094\"The Problem of the Prostate\", Dr. L. G.\n[MAY 2nd\u00E2\u0080\u0094ANNUAL MEETING.\nIt has been the practice in the past to hold a meeting of the Clinical Section of\n[ the Vancouver Medical Association on the third Tuesday in each month. These meetings\nwere held at alternate hospitals and owing to this fact, often two Clinical meetings were\nheld at a hospital in one month. To overcome this situation a plan has been worked\nout whereby the members of the Vancouver Medical Association are invited by the\nvarious hospital Directors to attend their Clinical Staff meetings. These meetings will\n[be held as follows:\nSecond Tuesday\u00E2\u0080\u0094Shaughnessy Hospital\nThird Tuesday\u00E2\u0080\u0094St. Paul's Hospital\nFourth Tuesday\u00E2\u0080\u0094Vancouver General Hospital\nNotice and programme of these meetings will be circularized by the Executive\nOffice of the Vancouver Medical Association.\nAll special and general meetings will be held in the Tuberculosis Institute Auditorium.\nI\nTHE BULLETIN\nPublishing and Business Office \u00E2\u0080\u0094 17 - 675 Davie Street, Vancouver, B.C.\nEditorial Office \u00E2\u0080\u0094 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 question, 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.\nPage 102 when sleeplessness is associated with pain . . .\nsonnLGin\na NEW DRUG which during the past four years in Great\nBritain has proved extremely beneficial\nm\nDESCRIPTION\nSONALGIN combines the hypnotic properties of\nSONERYL* with the analgesic actions of codeine\nand pheriacetin\nINDICATIONS\nDOSAGE\nPRESENTATION\ninsomia due to pain\nrestlessness of fevers\ndysmenorrhea, migraine\nneuralgia, sciatica\n1 to 2 tablets three times a day\nEach tablet of SONALGIN contains:\nSONERYL* 65 mg. (1 grain)\nphenacetin 0.23 Gm. (3J4 grains)\ncodeine phosphate 8 mg. (l/% grain)\nTubes of 20, bottles of 100, 500 and 1000\n* Trade mark of butyl-etbyl-malonylurea\nSamples upon request\npouLenc\nLIIMTCD\nmonTRCBL NOW...iii Chemotherapy of tuberculosis\nStreptomycin\nCalcium Chloride Complex\nMerck\nPAS\nPara-Aminosalicylic\nAcid Merck\n(and the Sodium Salt)\nDihydrostreptomycin\nSulfate\nMerck\nMERCK & CO. LIMITED\nMONTREAL \u00E2\u0080\u00A2 TORONTO \u00E2\u0080\u00A2 VALIEYFIELD\nMerck Antitubercular Agents\nStreptomycin\nCalcium Chloride Complex\nMerck\nPAS\nPa ra-Aminosalicylic\nAcid Merck\nL (and the Sodium Salt)\nDihydrostreptomycin.\nSulfate\nMerck conjugated estrogenic substances (equine)\nTABLETS: No. 865: 2.5 mg. per tablet\nNo. 866: 1.25 mg. per tablet\nNo. 867: 0.625 mg. per tablet\nin bottles of 20 and 100\nNo. 868: 0.3 mg. per tablet\nin bottles of 100\nLIQUID: No. 869: 0.62 5 mg. per teaspoonful\nin bottles of 4 fluid ounces\nWhen sedation is also desired:\nTABLETS: No. 877: 0.625 mg. per tablet plus\nx/l gr* phenobarbital\nin bottles of 100\nCfyMt\nTreatment with \"Premarin\" will also be found effective in\nother conditions of estrogenic deficiency, such as vaginitis,\npruritus vulvae, amenorrhea, functional uterine bleeding and\npostpartum breast engorgement.\nAyerst, McKenna & Harrison Limited \u00E2\u0080\u00A2 Biological and Pharmaceutical Chemists \u00E2\u0080\u00A2 Montreal, Canada VANCOUVER HEALTH DEPARTMENT\nCASES OF COMMUNICABLE DISEASE REPORTED IN THE\nCITY\nSTATISTICS \u00E2\u0080\u0094 DECEMBER, 1949\nTotal Population\u00E2\u0080\u0094Estimated 376,000\nChinese Population\u00E2\u0080\u0094Estimated 7,455\nHindu Population\u00E2\u0080\u0094Estimated .__ 275\nNOVEMBER, 1949\nNumber\nTotal deaths (by occurrence) 349\nChinese deaths 19\nDeaths, residents only _ 321\nRate per\n1000 Pop.\n11.1\n30.5\n10.2\n'ii\ni * i\nJfl'r\nwK\n\u00E2\u0096\u00A0\nBIRTH REGISTRATIONS\u00E2\u0080\u0094RESIDENTS AND NON-RESIDENTS\n(includes late registrations)\nNovember; 1949\nMale 44g\nFemale *442\n890\n28.4\nINFANT MORTALITY\u00E2\u0080\u0094Residents only:\nNovember, 1949\nDeaths under 1 year of age 12\nDeath rate per 1000 live births 18.6\nStillbirths (not included in above item) 5\n.\u00C2\u00AB*'\nCASES OF COMMUNICABLE DISEASES REPORTED\nScarlet Fever \t\nDiphtheria \t\nDiphtheria Carriers \t\nChicken Pox\t\nMeasles '^-'hS\nRubella\t\nMumps\t\nWhooping Cough\t\nTyphoid Fever\t\nTyphoid Fever Carriers\nUndulant Fever\t\nPoliomyelitis\t\nTuberculosis\t\nErysipelas\t\nMeningitis .\t\nInfectious Jaundice\nSalmonellosis __\nSalmonellosis Carriers _\nDysentery\t\nDysentery Carriers\t\nTetanus\t\nSyphilis\t\nGonorrhoea \t\nCancer (Reportable)\t\nResident \t\nNon-Resident \t\nD IN\nTHE CITY\nNoveml\n>er, 1949\nNovember\n, 1948\nCases\nDeaths\nCases\nDeaths\n19\n0\n8\n0\n0\n0\n0\n0\n0\n0\n0\n0\n100\n0\n306\n0\n80\n0\n61\n0\n10\n0\n10\n0\n79\n0\n17\n0\n! 1\n0\n0\n0\n0\n0\n0\n0\n0\n0\n0\n0\n5\n0\n2\n0\n1\n0\n2\n0\n49\n11\n42\n6\n0\n0\n1\n0\n2\n0\n1\n1\n0\n0\n0\n0\nyfe\n0\n1\n0\n0\n0\n0\n0\n2\n0\n1\n0\n0\n0\n0\n0\n0\n0\n0\n0\n38\n2\n26\n1\n180\n0\n171\n0\n63\n57\n77\n45\n19\n5\n42\n7\nPage 103 WHEN AN ANTICOAGULANT IS INDICATED\nHEPARAN\nFor over 10 years heparin has been extensively employed in\nvascular surgery and for other purposes where it is necessary or desirable\nto prolong the clotting time of blood.\nIts rapidity of action and freedom from toxicity enhance its\ntherapeutic value as an anticoagulant.\nHOW SUPPLIED\nA. Solution of Heparin\u00E2\u0080\u0094Distributed in 10-cc. rubber-stoppered vials containing neutral\nsolution of the sodium salt of heparin, 1000 units per cc, for clinical and laboratory\npurposes.\nB. Dry, amorphous sodium salt \u00E2\u0080\u0094 Dispensed in 100-mg. and 1-gm. phials, containing\n95 units per mg., for the preparation of solutions for laboratory use.\nw\nCONNAUGHT MEDICAL RESEARCH LABORATORIES\nUniversity of Toronto Toronto 4, Canada\nDEPOT FOR BRITISH COLUMBIA\nMACDONALD'S PRESCRIPTIONS LIMITED\nMEDICAL-DENTAL BUILDING, VANCOUVER, B. C. Ike. \u00C2\u00A3dito*l Peuf&\nIn the daily press one read last week an announcement that the B. C. Govepiment\nplans to spend twenty million dollars on new schools in this provinde within the next\nyear or two. This is good news, and one would not grudge a penny of this sum. But\nthere was no mention of any immediate programme of hospital construction, and we\nconfess to a feeling of disappointment, to put it very mildly. The only mention of the\nmatter came in a paragraph or two which pointed out that even if construction were\nbegun immediately, it would be some three years before any actual good could come of it.\nSome vague statement about plans now in progress for the new buildings of the Vancouver General Hospital was made\u00E2\u0080\u0094we seem to have been reading statements of that sort at\nregular intervals for the past few years\u00E2\u0080\u0094but nothing has yet come of it.\nWe cannot help wondering what the long-suffering public would say if they really\nknew how bad things really are in the present hospital situation. How more and morel\ndifficult it is getting to be, almost to the point of impossibility, to get sick people, who\nreally need hospital care, into hospital beds. How disgracefully crowded the hospitals\nare\u00E2\u0080\u0094and what agonies every admitting office has to go through daily in their herculean\nefforts to find accommodation for desperate cases. How operations must be cancelled\nagain and again, some five or six times, because there is no bed^ available. We understand\nthere is a survey proposed or under way, to examine into this.\nIt is difficult to estimate at all accurately the enormous loss of time and money that\nthis entails\u00E2\u0080\u0094the real hardship that it brings to people, the added length of invalidism\ncaused by conditions which, while perhaps not immediately fatal or menacing to life,\nyet cause disability at work, pain and ill-health and suffering. The woman who needs\nan operation or hospital care, and has to undertake prodigies of effort to arrange about\nher household and family's care while she is in hospital\u00E2\u0080\u0094then is told there is no bed\u00E2\u0080\u0094\nand has to repeat this process several times. All this and many other considerations\ncome to mind. ^M\nWe know, of course, that there are many explanations of the present woeful situation, nor do we seek to place it on the shoulders of Hospital Insurance, as the average\nlayman is vociferously doing a thousand times a day. Hospital Insurance is a noble\nidea, and a great forward step. We believe sincerely that it was an act of statesmanship,\nand definitely the right thing to do. But whether it is that the timing was not quite\nright, or that unforeseen and unpredictable complications have risen, we see a state of\naffairs that is rapidly reaching a very critical point.\nThere does not seem to be any planning, or definite idea of how to meet this\nproblem\u00E2\u0080\u0094or if there is, it is being kept very dark: and the public is becoming very\nmuch disturbed about it. Why cannot hospitalization in the province be put on a\nlong-term basis, as schools are, as water-supply is, as electrical power is? Why cannot\nwe have a Hospital Commission, or some such body, similar to the Water Commission,\nthe Power Commission, the Workmen's Compensation Commission\u00E2\u0080\u0094where men appointed to the job can study the whole problem from a long-term viewpoint, assigning hos-\npital beds to areas on the basis of needs, and not according to the local ideas of local\nHospital Board?\nOur hospital system suffers from a lack of cooperation between the various hospitals, each of which is administered by a Board, which struggles jealously to maintain\nand improve the standing of its own hospital, without any regard to the others. We\nneed someone to do what Dr. A. K. Haywood, the former superintendent of the Vancouver General Hospital, did in Montreal many years ago, get the hospitals together and\nworking along a plan of mutual adjustment and cooperation, of which we have none\nhere at present. Certainly we want to preserve free action and independence in our\nPage 104\nI I\nWi'i] ,';. i - '\ni\n111\nISi hospitals, but perhaps this is being carried too far, and leading to overlapping, delay\nin constructive action, and waste of time, effort and money. We have no doubt that\nbetter minds than ours are working on this problem and can only hope and pray that\nthey will soon reach an adequate solution.\nM*\nliijj,.\nCANADIAN RED CROSS BLOOD TRANSFUSION SERVICE\nWe publish herewith a letter from the Red Cross Blood Transfusion Service, which\nis self-explanatory, and should be read by every medical man.\nDr. Moore, we understand, told Dr. Johnston in conversation that they are very\nmuch gratified by the results they have obtained from the leaflets which have been left\nin doctor's offices. He stated that over 250 donors had come forward since this practice\nwas inaugurated. This is excellent, and we should do our best to help this along\nby drawing our patients' attention to these leaflets, as well as in other ways. Editor.\nBritish Columbia Depot\nDr. Gordon Johnston, Secretary,\nVancouver Medical Association,\nVancouver, B.C.\n28 th Avenue West & Laurel\nVancouver, B.C.\nJanuary 31st, 1950\nDear Doctor Johnston:\nI would like to take this opportunity of bringing to the attention of the Blood\nDonor Committee of the Vancouver Medical Association the following rules of the\nCanadian Red Cross Blood Transfusion Service, which have been devised for the safeguarding of persons who suffer from hypertension.\nAs you are aware, we accept donors only between the ages of 18 and 65. Under no\ncircumstances are donors accepted outside these age limits. Where a person has hypertensive disease, we require a letter from the patient's doctor requesting and recommending\na donation of a pint of blood each time the person attends the clinic.\nWe would much prefer the doctor to mention in his letter the blood pressure of the\npatient. The reason for this is that it is a proven fact that there is a risk attached to\ntaking a pint of blood from a person whose systolic pressure is over 200.Where we are\naware that the pressure is over this figure, we do not accept a donation.\nOne factor is that we are from time to time requested by a doctor to take half a\npint or less of blood from a patient suffering from hypertension. As outlined above, I\nthink that you will agree that we are within our rights in only accepting donors who\nare willing to donate a full pint of blood. There must be some risk attached if the\npatient can only donate half a pint of blood without suffering ill effects.\nThe reason for these rules is simply that we feel that to take blood from such a\npatient in a busy clinic is a definite hazard both to us and to the person concerned. We\nbelieve that it is much safer for the patient to have such treatment performed by the.\nphysician who is treating the disease.\nI would be grateful if you would disseminate this information among the practioners\nin the Vancouver area, as several instances have occurred which have given rise to inconvenience to the patients in that we have refused them.\nYours very truly,\nSigned, B. P. L. Moore, M.B.,\nProvincial Medical Director\nPage 105 BOOK REVIEW\nSurgery of the Hand\nBy STERLING BUNNELL, M.D., 2nd edition, 1948\nIn ljis second edition Sterling Bunnell has incorporated the advances and references\ngained from many thousands of hand injuries occuring in the second world war. This\nbook is an exhaustive study of the surgical diseases of the hand and as such involves\ngeneral, plastic, orthopedic, traumatic and reconstructive surgery.\nOne may find a detailed account of the origin and development of the hand, its\nnormal anatomy and physiology and methods of diagnosing deviations from this. Surgical\ntechnique is thoroughly discussed, with special emphasis on how to deal with acute injuries, how to close wounds and skin defects, where best to place skin incisions and how\nto adequately splint the hand.\nSpecial attention is paid to injuries of joints, bones, tendons and nerves and the\nvarious reconstructive procedures to be used under varying circumstances. In addition\nto traumatic conditions a detailed account of congenital, infectious and neoplastic\nlesions of the hand are also included.\nIn short this scholarly work is pleasant to read, is replete with illustrations and\ncontains an enormous amount of information on the hand and its surgical care. It\ncannot be too highly recommended. G.C.J.\nm\nij\nHi\nli.i\n\u00C2\u00BB\\nI\nST. PAUL'S HOSPITAL\nThe New Premature Unit\nIn order that adequate care may be given to small infants born prematurely in institutions and localities where special nursing care and special equipment are not available,\na new Premature Unit is being opened at St. Paul's Hospital in the Department of\nPaediatrics. This unit is to serve as the nucleus of a premature programme for the\nsurrounding area, and will co-ordinate'the services of the physicians, the V.O.N, nurses\nand the social service personnel. It will also function as a teaching unit for nurses from\nother parts of the province, so that similar units may be established elsewhere.\nThe unit will be supervised by two \u00E2\u0096\u00A0 graduate nurses who have recently returned\nfrom a course in premature care at Johns Hopkins Hospital. Strict nursing technique\nwill be carried out and all new admissions will be isolated for forty-eight hours. Before\ndischarge home visits will be made by the V.O.N and instruction given to the mother\nif requested.\nInfants admitted to the unit may be cared for by their own physicians. It is hoped\nthat a follow up on all cases will be carried out through cooperation with the doctor\nin charge in private cases and by following staff cases in the out-patient's department.\nIn order to provide adequate transportation two ambulances are being equipped to\ncarry electric incubators and oxygen, and if necessary these incubators can be similarly\nconnected in an ambulance aircraft. It will not be necessary or possible for all premature\ninfants to be cared for in such a unit and it is intended for only the very small infants\nrequiring special care. It should be remembered that 50% of these infants will\nexpire in the first 24 hours and 70% in the first 48 hours so it is this period when special\ncare is especially required. A notice has been sent to outlying hospitals concerning care\nin this early period and care in transportation. Any physician desiring the admission of\nan infant to the unit is requested to contact the Admitting Department, St. Raul's\nHospital and transportation arrangements will be made.\nPage 106\ntku\nI\nI\nil* lMW\nAMYLOID DISEASE\n(Based on 46 Post Mortems)\nby DR. C. S. RENNIE\nRead before N.W. Pacific Internists' Society\nI wish to thank you for the opportunity to speak to you today. I am going to\ndiscuss the subject of amyloid disease, not because I have anything new to offer, but\nrather to summarize the findings of 46 cases found in the postmortems performed at\nthe Vancouver General Hospital between the years 1939 and 1948, and at the same time\nattempt to present today's thoughts on the subject.\nThe condition was first drawn to the attention of the medical profession in 1832\nby Hodgkin who described it in the spleen but did not name it. In 1838 Bright noted\nthe \"spleen has the appearance of suet\". Carswell, in 1838, was of the opinion that the\ncondition was malignant. Budd in his writings in 1845 refers to it as the \"scrofulous,\nenlargement of the liver\" expressed by the epithet \"waxy\". Rokitansky considered the\nprocess a species of fatty degeneration. At the Physiological Society meeting in Edinburgh in 1853 Bennett and Gairdner stated \"the condition of the liver was common\nin scrofulous, syphilitic and other chronic exhausting conditions.\" It was Gairdner's\nopinion that the condition was due to a peculiar modification of protein compounds. In\n1854 Sanders stated that waxy degeneration of the spleen, liver and kidneys occurred\nin 10 percent of all necropsies at the Edinburgh Royal Infirmary. Shortly after this\nVirchow named the infiltrating material as amyloid or starch-like degeneration. This\nname has persisted ever since.\nAt St. George's Hospital between 1867 and 1894 Dickinson encountered this condition in 201 autopsies while at Guy's Fogge found 244 in 21 years. From the literature\nit would appear that this condition which was reasonably common prior to 1900 is\nmuch less common today.\nWickmann in 1893 made a comprehensive survey of amyloidosis and classified it\ninto \"local\" and \"generalized\". Lubarsch in 1929 suggested \"typical\" and \"atypical\".\nReemann, Kouchy, and Ecklund in 1935 put forth the following clinicopathological\nclassification which, until the etiology is known I would recommend to you:\n1. Primary amyloidosis\u00E2\u0080\u0094localized or systemic.\n2. Secondary amyloidosis.\n3. Tumour-forming amyloidosis.\n4. Amyloidosis associated with multiple myeloma.\nIn 1882 Birch-Hirschfeld produced amyloid disease experimentally in the dog by\ninjection of pus subcutaneously. This was later confirmed by Charrin. Several experimenters since have produced the condition by injection of pyogenic organisms^ pus and\ninorganic substance. Kuezynski produced it by feeding mice a diet rich in proteins.\nAmyloid disease is an entity, recognized by the presence of characteristic homogeneous protein material in various organs of the body. Its exact chemical nature is\nunknown. It has been shown to be composed of two protein fractions and one polysaccharide fraction. Analysis have shown it to consist of a variety of amino-acids\nwhich vary qualitatively and quantitatively in different individuals and even in the\nsame individual in different organs. The theories proposed as to its etiology are as\nfollows:\n1. The allergy theory.\n2. The antigen-antibody union and precipitation theory.\n3. The theory of disordered endogenous protein metabolism.\n4. The hyperproteinemia (hyperglobulinemia) theory.\n5. The theory of disordered endogenous protein metabolism in which the reticuloendothelial is involved.\nI give you these to emphasize the fact that the etiology is unknown.\nPage 107 The pathology of this condition is still controversial. The type of the disease\nwould appear to have a direct bearing on this. In the primary type there is no predisposing illness or disease, there is a marked affinity for smooth and striated muscles,\nespecially the myocardium\u00E2\u0080\u0094tongue\u00E2\u0080\u0094skin\u00E2\u0080\u0094gastro-intestinal tract and blood vessels. The\nstaining reactions are variable and the substance tends to be deposited in a nodular form.\nIn the secondary type which is commonly associated with chronic suppuration, neoplasm,\nchronic infection or chronic debilitating disease there is an affinity for organs such as\nspleen, liver, kidneys, and adrenals. In type 3 \"Tumour-forming amyloidosis\" the\ntumours are found in relation to the nasal septum, larynx and bronchi. Type 4 resembles\nthe primary type but is associated with multiple myeloma.\nAmyloid is a protein in nature\u00E2\u0080\u0094a compound of albumen with chondroitin\u00E2\u0080\u0094sulphuric acid. There would appear to be some relationship to cholesterol metabolism (according to Boyd) with an involvement of the reticuloendothelial system (Aschof,\nJacobi, and Grayzel).\nBy far the commonest division is the secondary type. Here we find the spleen,\nin which the disease usually begins, to be enlarged, firm, elastic and translucent. The\namyloid may be distributed in two ways:\na. The common one\u00E2\u0080\u0094in the walls of the arteries of the malpighian bodies\u00E2\u0080\u0094the\nsago spleen.\nb. Changes affect the connective tissue of the venous sinuses and the reticulum\nof the pulp in a diffuse manner\u00E2\u0080\u0094the \"bacony\" spleen.\nThe liver enlarged, firm but elastic\u00E2\u0080\u0094the cut surface is ^translucent. The process\nappears in the connective tissue between the sinus endothelial liver cells. The tissue\nbecomes swollen, so that the liver cells are comprised, atrophy, and the sinusoids become\nnarrowed.\nThe kidneys present special problems on account of secondary changes. The changes\nbegin in the connective tissue of the vessels in the glomerular tufts, and also involve the\nwalls of the arterioles and the connective tissue under the basement membrane of the\ncollecting tubules. Owing to the obstruction to the glomerular circulation the convoluted are deprived of their blood supply and may undergo degenerative changes. They\nmay gradually atrophy and be replaced by fibrous tissue.\nPRIMARY AMYLOID DISEASE\u00E2\u0080\u0094occurs in middle life or later. It is comparatively rare. Wild described the first case in 1886. About 45 cases have been-reported\nin the literature. It is, however, a well recognized entity. The four outstanding characteristics are:\n54% 1. High incidence of congestive failure\u00E2\u0080\u0094an intractable type with a very\nrapid downhill course. This occurs in spite of vigorous therapy. The patient usually\nshows an enlarged heart without evidence of valvular disease, hypertension or coronary\nsclerosis. The myocardial failure is directly related to the infiltration of the heart with\namyloid material. It was found to be due to:\na. ^ Widespread interstitial deposition of this amyloid material with consequent\nstenosis or complete obliteration of the venules and capillaries of the myocard-\ndium.\nb. Mechanical interference with the function of the valves.\nc. Obliterative infiltration into the walls of the coronary arteries with coronary\ninsufficiency.\nd. Obliterative infiltration into the walls of the pulmonary vessels leading to\nchronic corpulmonale.\ne. Pericardial or endocardial deposits followed by interference of cardiac function.\nf. A combination of any of the above.\nThe electrocardiogram frequently shows myocardial damage in altered T ways\u00E2\u0080\u0094\nprolonged P.R. interval and low voltage.\n42 % 2. Macroglossia\u00E2\u0080\u0094It is often mistaken for malignancy. The involved\nmuscles become greatly enlarged and firm, often resulting in dysphonia and dysphagia.\nPage 108\n'.\nIf:\n*iS\n4T\n\u00E2\u0096\u00A0 I\n!\nk>,|\nm $\u00C2\u00BB\nIt is occasionally accompanied by swelling of the neck and face due to amyloid involvement of skin, subcutaneous tissues or muscles. A fixed .staring expression may result\nin an appearance similar to that of paralysis agitans. >\u00C2\u00A3|j\n42% 3. Asthenia\u00E2\u0080\u0094progressive weakness and fatigue due to the involvement of\nskeletal muscles which are enlarged and firm. The clinical picture can simulate myotonia.\n31% 4. Weight loss.\nPRIMARY AMYLOID DISEASE of the SKIN may produce lesions varying in\nappearance from extensive eruption of sharply defined firm opalescent papules, firm\ntranslucent waxy papules, nodular lesions or the sclerodermic type. They are usually\nfound about the eyes and mouth and on the neck, trunk, extensor aspects of the extremities and fingers. When this disease affects the INTESTINE the symptoms are constipation\nor diarrhea, constipation being more frequent. Abdominal pain, vomiting and meteor-\nism, haematemesis or gastrointestinal haemorrhage. Infiltration of the BLOOD VESSELS produces the frequent symptoms of purpura. The diagnosis is usually made by\nthe history, physical examination, the congo red test plus biopsy. The danger is overlooking of the condition due to its infrequency. One should keep in mind:\n1. The absence of primary disease.\n2. The spleen, liver, kidney and adrenals are not involved.\n3. The high incidence of congestive failure which fails to respond to treatment.\n4. Macroglossia.\n5. Asthenia\u00E2\u0080\u0094out of proportion to physical findings, and the loss of weight.\nSECONDARY AMYLOID DISEASE\u00E2\u0080\u0094is by far the most common type. It usually occurs at a much earlier age. It can occur during the course of many chronic illnesses, most commonly in tuberculosis and chronic suppuration. The organs usually\ninvolved are the spleen, liver and kidneys. It is found most prevalent in males and\nmost commonly in the first, second and third decades of life. The average length of the\ninitial disease prior to the complication of amyloid disease is about five years (Jacobi\nand Grayzel). The clinical features can vary considerably and be coloured by the primary illness. The pattern is usually PALLOR, changing to a pasty or waxy color.\nWEIGHT LOSS\u00E2\u0080\u0094a marked loss of subcutaneous fat in the extremities. WEAKNESS\u00E2\u0080\u0094!\npoor muscle tone and flabbiness. POOR APPETITE. ENLARGEMENT OF THE\nABDOMEN\u00E2\u0080\u0094due to increase in size of liver and spleen with absence of ascites. The\nsuperficial abdominal and thoracic veins become prominent, dilated and tortuous.\nOEDEMA OF THE FEET AND LEG'S\u00E2\u0080\u0094usually moderate only. BLOOD PRESSURE\n\u00E2\u0080\u0094usually low or normal. EYE\u00E2\u0080\u0094Signs\u00E2\u0080\u0094absent at any stage. Early in the disease there\nis normal output and normal ability to concentrate. In some cases, as the disease progresses the output decreases and the ability to concentrate, leading to a terminal anuria.\nAlbumin is usually found in the urine and can vary from a slight amount to a great\namount. The albumin globulin ratio reverses and later the serum protein decreases.\nThe N. P. N. is normal but may rise moderately. Casts of all description with occasional\nR. B. C. and W. B. C. The liver function tests depend on the extent of liver involvement. There is usually a hypochromic microcytic anemia. In the diagnosis: v'cj|\n1. The history is most important. Presence of a primary chronic disease, infection or suppuration.\n2. Pallor or waxy appearance\u00E2\u0080\u0094weight loss to emaciation, weakness, large abdomen,\npalpable liver, spleen, absence of ascites, dilated, tortuous abdominal or abdominal veins, peripheral oedema (usually occurring in one-half or more of cases)\nnormal eye grounds. -gh$h\n3. Laboratory findings of albuminuria, revers:d albumin, globulin ratio, decrease in\nserum protein, positive congo red test. Biopsy gingival, liver or spleen.\nIn the differential diagnosis one must keep in mind glomerular nephritis, lipoid\nnephrosis, renal tuberculosis and congestive heart failure.\nPage 109 TYPE 3: TUMOUR-FORMING AMYLOIDOSIS\u00E2\u0080\u0094may be solitary or multiple,\nusually seen in the larynx, tongue, eye, bladder and bones. In its characteristics it\nresembles primary amyloid disease.\nTYPE 4: AMYLOID DISEASE ASSOCIATED WITH MULTIPLE MYELOMA\n\u00E2\u0080\u0094It is stated that in multiple myeloma amyloid disease is a frequent accompanying\ndisease, and in every case of amyloid disease without a primary cause one should look\nfor multiple myeloma. It should be remembered that it has the characteristics of primary\namyloid disease.\nA word about the congo red test: It is a reasonably simple and safe test. Precaution\nmust be taken in the time it is used and the condition of the dye. The test was introduced by H. Bennhold in 1923 and has received a few modifications. Tests to be considered positive must show an absorption of 90% or more of the dye.\nNo specific treatment has had universal success. Potassium iodide, liquor potassii\nhave been favorite drugs. Whitbeck introduced the use of liver by mouth and reported\nexcellent results in 5 out of 7 cases. Trasoff and co-workers cite 29 cases of recovery\nsince 1880. 13 children with chronic suppurative disease were successfully treated with\noral liver. Jacobi and Grazel treated 16 patients for one year or more with secondary\namyloid disease to tuberculosis with oral liver and reported 9 cured. Experimentally\nmice have recovered when the dietary cause was removed. It has been shown that\nsecondary amyloid disease is a reversible condition.\nThe evidence today suggests that the fundamental disturbance in all types of amyloid disease is the same. It would appear likely that under certain conditions a fundamental disturbance in protein metabolism may occur which'results in this abnormal\ndeposition of an unusual protein. The basic mechanism will be discovered sooner or\nlater. Until then we should suspect the condition oftener and attempt to diagnose it\nearlier. Any and all forms of known treatment should be instituted early and actively.\nWe should be well advised as medical men to concentrate a little more diligently on the\ndietary requirements of the chronically ill, and the ageing person.\nAt the General Hospital in Vancouver over a period of ten years, 1939 to 1948 inclusive, 46 cases were found in routine post mortem examinations out of a total of\n9418. 45 cases were of the secondary type of amyloid disease and one was associated\nwith multiplemyeloma. A more detailed breakdown of these figures is as follows:\n32 of these 45 cases had as a primary disease tuberculosis, 2 being bone tuberculosis\nand 30, other forms of tuberculosis.\n13 cases had the following illnesses as a primary disease:\nBronchiectasis and pulmonary abscesses\u00E2\u0080\u0094One case.\nBronchiectasis and carcinoma of the lung\u00E2\u0080\u0094One case.\nBronchiectasis and carditis\u00E2\u0080\u0094One case.\nCirrhosis of the liver (portal)\u00E2\u0080\u0094One case.\nCirrhosis of the liver and chronic glomerulonephritis\u00E2\u0080\u0094One case.\nChronic osteomyelitis\u00E2\u0080\u0094One case.\nChronic dermatopathy\u00E2\u0080\u0094One case.\nMyocardial degeneration\u00E2\u0080\u0094Two cases.\nChronic colitis\u00E2\u0080\u0094One case.\nChronic arthritis\u00E2\u0080\u0094One case.\nBronchogenic carcinoma\u00E2\u0080\u0094One case.\n1 case associated with multiple myeloma.\nThe involvement of organs was as follows:\nSpleen\u00E2\u0080\u009439 cases.\nKidneys\u00E2\u0080\u009437 cases.\nLiver\u00E2\u0080\u009422 cases.\nAdrenals\u00E2\u0080\u00945 cases.\nPage 110\n\u00E2\u0096\u00A0\nM\ Other organs involved were:\nPancreas\u00E2\u0080\u0094One case.\nColon\u00E2\u0080\u0094One case.\nSmall bowel\u00E2\u0080\u0094One case.\nLymphatic glands\u00E2\u0080\u0094One case.\nLungs\u00E2\u0080\u0094One case.\nOf the 46, 10 were female and 36 were male, the youngest being 16 years and the\noldest 76 years, with an average age of females 39 years, and average age of males 54\nyears, an over-all average of 50 years.\nNo cases between the ages of one and 10.\n2 cases between the ages of 10 and 20.\n1 case between the age of 20 and 30.\n9 cases between the ages of 30 and 40.\n8 cases between the ages of 40 and 50.\n13 cases between the ages of 50 and 60.\n10 cases between the ages of 60 and 70.\n2 cases between the ages of 70 and 80.\n1 case age unstated.\nThe average length of illness, female 8 years, male 9 years.\nOf the 46 cases 7 died shortly after admission, 3 deaths were outside hospital. In\nthe remaining 36 case records we find amyloid disease to be suspected and proven in\n2 cases, both by liver biopsy and one the congo red test.\nIn reference to the one case associated with multiple myeloma we find that in this\nsame period of time, 1939 to 1948, 21 cases were admitted to the Vancouver General\nHospital, of which 5 were treated and discharged, 16 died in the Institution with 12\nhaving postmortem examinations performed, and of these 12 one case showed amyloidosis'\nof the lungs.\nHow do our findings compare with those of other hospitals?\n1. Our rate in routine post mortem examinations is lower\u00E2\u0080\u00940.48 % as compared\nto 0.6%.\n2. Our average age in which secondary amyloid disease was found is much higher\nthan the general average. Ours had ages between 30-70 with the greatest\nnumber between 50 - 60 as compared to the usual ages of 1 - 30.\n3. Tuberculosis as an initial disease is found to be less of a factor in our series.\nSaleeby found tuberculosis to be the underlying cause in 82% of cases.\nWaldenstrom 93% and Rosenblatt 88%.\nIn ours 72%.\n4. The percentage of bone tuberculosis is lower in our cases. |\n5. The frequency of involvement of the organs\u00E2\u0080\u0094spleen\u00E2\u0080\u0094kidneys\u00E2\u0080\u0094liver and adrenals, is the same.\n\u00E2\u0096\u00A0K\nCONCLUSIONS\n1. It would appear from this brief review that there is the need in our chronically\nill and tuberculosis cases for a more thorough, carefully recorded history and\nphysical examination with appropriate laboratory investigation, and more frequent progress notes with periodic re-assessment of the condition. Our approach\nand handling of this group must be revised.\n2. We should suspect amyloid disease more frequently than we do, and institute\ninvestigations earlier and more promptly in the illness.\n3. We should use biopsy with congo red test more often.\n4. Liver therapy by mouth should be tried over a long time in diagnosed cases.\nPage 111 B. C. MEDICAL CENTRE LIBRARY\n5. In the treatment of chronically ill and ageing patients more attention should\nbe paid to the dietary habits and needs.\nSUMMARY\n1. A brief review of amyloid disease is given.\n2. The pathological-clinical features, etc. are given.\n3. 46 cases of amyloid disease of which 45 are secondary amyloidosis and one\nassociated with multiple myeloma are reviewed and summarized.\nVANCOUVER GENERAL HOSPITAL\nPHYSIOLOGY AND ENDOCRINE RELATIONSHIPS OF THE\nJ| THYROID\nDR. T. R. OSLER\nThe thyroid gland contains approximately 20% of the total body iodine, thus\nhaving a far greater concentration than other tissues. The normal gland contains 2 to\n28 mg. (.1 to .5% dry weight) of iodine. It is present practically entirely in the colloid and varies with the iodine intake, geographical location and state of endocrine function. The quantity increases from birth to puberty, reaching a maximum at about 20\nyears, and decreasing after 50. By far the largest amount of the thyroid iodine is in the\norganic form.\nNature of Thyroid Hormone\nThe tissue cells of the thyroid produce a protein substance \"thyroglobulin\" within\nthe follicles and this acts as a scaffolding for the iodine-containing amino acids. The\nthyroglobulin then fixes the iodine absorbed from the gut, etc. as \"iodothyroglobulin\"\nwhich is a composite protein molecule containing thyroxin (25 to 35%) and di-iodo-\ntyrosine (60 to 65%) in a peptide combination. The colloid is believed to contain a\nproteolytic enzyme which breaks the iodothyroglobulin down into an \"iodoprotein\"\nwhich is felt to be the true thyroid hormone.\nThis then passes into the blood stream and circulates as an integral part of the\nplasma proteins in much the same way as do antibodies.\nThe thyroxin and the di-iodotyrosine which make up the iodothyroglobulin are\nsynthesized from tyrosine by the thyroid gland. It may be said at this time that thiouracil and related compounds exert their antagonistic effect on the thyroid hormone\nby reducing the glands' ability to take up iodine and thus inhibiting the synthesis of\nthe di-iodotyrosine and thyroxine. The mechanism of the benefit obtained in hyperthyroidism by iodine is not clear, but Marine suggests that it may be due to mechanical\nblockage of the hormone output by rapid formation of colloid.\nBy virtue of the glands' ability to trap and fix iodine in the organic molecule and\nrelease it as required, the thyroid maintains the blood iodine level within normal limits.\nThe remarkable affinity of the thyroid colloid* for iodine may be demonstrated by the\ninjection of radioactive iodine, the isotope finding its way into the thyroglobulin of\nthe gland within 2l/z minutes, and pratically saturating the organ within 15 minutes.\nIt appears first in the di-iodotyrosine and later in the thyroxin.\nDi-iodotyrosine is physiologically inert by whatever the route of administration.\nThyroxin is relatively inert by mouth, owing to its low solubility.\nIodothyroglobulin and desiccated thyroid are active orally, and their action appears\nto be related to the total iodine content rather than the thyroxin content alone.\nPage 112\n\u00E2\u0096\u00A0\u00E2\u0096\u00A0 I?!\nii\nSecretion of the thyroid hormone is regulated by:\n1. Thyrotropic hormone produced by the anterior pituitary. Administration of\nthis substance results in a disappearance of the colloid, a hyperplasia of the\nepithelium with an increase' in mitotic figures, a decrease of the iodine content\nof the gland and an increase of the blood level.\nAll signs of hyperthyroidism are produced including exophthalmos. The normal\nrate, after an initial response period in which hyperplasia of the thyroid and a\nrise in the metabolic rate occur, becomes refractory to the thyrotropic hormone.\nThe refractoriness has been shown by Collip and Anderson to be due to the\nformation of an \"antihormone\" which they have found in the serum of the\ntreated animals. Exophthalmos occurred to the greatest extent during the\nrefractory phase. Thus the effect on the eyes appears to be independent of the\neffect on the B.M.R. In fact, anterior pituitary extract may produce exophthalmos in thyroidectomized animals.\n2. Sympathetic Stimulation:\nThis indirectly controls the ouptut of hormone by nervous regulation of the\nblood supply to the gland.\n3. Work with tracer substances has provided evidence that tissues other than\nthyroid retain a primitive ability to synthesize thyroxine.\nEffects of Thyroid Hormone:\n1. Hypothyroid\u00E2\u0080\u0094Experimental thyroidectomy produces in animals of all ages\na marked diminution of basal and general metabolism. In the young, there\nfollow retardation of general growth, of ossification and development of sex\norgans, delay in involution of the thymus and slight enlargement'of the A.P.\nand adrenal cortex. The skin thickens and its hairy covering develops imperfectly. Body temperature is subnormal. There is usually marked lack of intelligence indicating involvement of C.N.S. and especially the brain. Corresponding effects as far as they are possible are produced in the adult animal.\nMuscle loses tone and becomes weaker; sexual function is depressed; dullness\nand apathy are marked. The skin is dry, hair tends to fall out. Anaemia is\nusual. Tissue regeneration is retarded. Temperature is sub-normal. Heat\nproduction is lessened and consumption of iodine and production of carbon\ndioxide decreased.\n2. Hyperthyroidism\u00E2\u0080\u0094Artificial hyperthyroidism produces the most diverse results.\nThe normal animal loses weight and excretes more urea and creatine. It uses\nmore oxygen and produces more carbon dioxide and heat. It oxydizes more\nCHO and depletes liver of glycogen stores. There is frequently a hypergly-\ncaemia.\nPhysiologic Actions of Thyroid Hormone.\n1. Calorigenic\u00E2\u0080\u0094The thyroid hormone acts directly on the tissue cells and accelerates their oxidative processes without mediation of the sympathetic nervous\nsystem, as we once thought. Thyroid tissue alone is unresponsive and its oxidative processes are probably depressed. There is a latent period of several hours\nfollowing administration before the effect is noted and the action last for\n10 to 20 days or longer.\nThe nature of the stimulating activity is peculiar. The pulse rate and minute\nvolume \u00C2\u00A9f blood flow are increased far more by thyroid than they are by substances such as dinitro-phenol that increase oxygen consumption to the same\ndegree. Also, hyperthyroid patients appear to waste out of all proportion to the\nmetabolic rate. In part .this may be due to greater muscular activity, though\nin part it must be attributed to a certain type of inefficiency. In other words,\nmuscular activity seems to cost the hyperthyroid patient more.\nPage 113 r\n2. Effect of Carbohydrate Metabolism\u00E2\u0080\u0094It has been shown by studies of respiratory\nexchange that the hyperglycemia which follows the administration of carbohydrate is due to more rapid absorption of sugar from the intestine, and that\nthe hyperthyroid subject oxidizes sugar just as readily, if not more so, than\nthe normal. In myxoedema, no characteristic disturbances of carbohydrate\nmetabolism can be detected.\n3. Effect on Insensible Perspiration\u00E2\u0080\u0094Some observers have reported an increase of\ninsensible perspiration in the hyperthyroid subject and a decrease in hypothyroidism.\nRelationship of the Thyroid to Other Endocrine Organs\n1. The relationship to the pituitary has been discussed.\n2. Adrenals:\n(a) Subjects of hyperthyroidism show an increased susceptibility to adrenalin.\nThe threshold dose of adrenalin for oardiac acceleration is reduced by a previous administration of thyroxin.\n(b) Thyroxin administration to normal dogs results in a hyperglycaemia which\ndoes not occur if the adrenal veins have been tied first.\n(c) Injury to the adrenal cortex\"caused an increased of 60% in heat production which does not occur if the B.M.R. had been first lowered by thyroidectomy.\nMarine suggests that the adrenal cortex normally exerts, through the pituitary,\nsome inhibitory control over thyroid function.\n3. Gonads:\nThe following observations suggest an inter-relationship between the thyroid\nand the gonads:\n(a) Thyroid enlargement is frequently observed at puberty and during menstruation or pregnancy.\n(b) Castration in the dog usually leads to slow reduction in the size of the\nthyroid and a depression of the B.M.R.\n(c) The continued injection of estrogenic substances into rats results in thyroid\nenlargement followed after a few days by involution of the gland.\n(d) Thyroid feeding is said to inhibit estrus. These relationships are probably\nabout through the pituitary gland.\nTREATMENT OF HYPERTHYROIDISM\nDR. B. F. PAIGE\nThe treatment and the outlook in thyrotoxicosis have undergone great changes\nsince the advent of the anti-thyroid drugs, of which propylthiouracil is the latest and\nthe one in general use.\nWhether or not the patient is going to have medical treatment right through or is\ngoing to be prepared for sub-total thyroidectomy, the initial treatment of a case of\nhyperthyroidism is the same. The patient should be started on 100 mgms. of propylthiouracil t.i.d. before meals, simultaneously with 4 minims of Lugol's iodine daily. This\ntherapeutic programme should be maintained until the B.M.R. is 0, and the thyrotoxicosis\nis adequately controlled as judged by the subjective and objective manifestations. If\nsurgery is chosen subtotal thyroidectomy should then be performed without changing\nthe medication. If surgery is not employed, the B.M.R. should be allowed to decrease\nto just below 0. The propylthiouracil dosage is then reduced to 150 mgm. per day and\nlater to 75 mgm. per day if the B.M.R. continues to fall, always supposing in doing\nthis that you are continuing to treat this patient without operation. A further reduc-\nPage 114 mv\ntion of the B.M.R. when the patient is receiving 75 mgm. suggests that the medication\ncan be discontinued with the probability that the remission will continue for a long\ntime. In general, it is advisable to continue the medication until the B.M.R. has been\nmaintained below 0. for 10 months. When and if this is done the expectation of a\npermanent remission is about 8 0 % according to the experiences of Dr. Sturgis and of\nhis group Ann Arbor, Michigan.\nThe type of patient who is \"curable\" by medical treatment alone is usually one with\na non-nodular goitre, relatively young, and not suffering from pressure symptoms or\na substernal goitre, and who does not show a toxic reaction with propylthiouracil\n(which makes the drug unsuitable).\nI will leave to Dr. Warcup the more detailed discussion of the types of cases for\nwhich surgery is obviously indicated from the beginning. It is advisable from the point\nof view of treatment to regard hyperthyroidism as a single problem, whether it is\nprimary or secondary. If it is of the so-called secondary type with a toxic adenoma,\nthe response to propylthiouracil is not likely to be so good, and there are other reasons\nalso which Dr. Warcup will mention.\nIndications for the Use of Propylthiouracil:\nIt should be used as preoperative treatment in all cases of toxic goitre, and also in\nall those cases where it is hoped medical treatment alone will suffice. It is advisable to use\nit even in mild cases with minimal toxic symptoms, as even these patients may come to\nsurgery and will occasionally have a severe postoperative course without propylthiouracil.\nIf surgery becomes necessary, it is felt that the patient can be handed over to the\nsurgeon in better shape if prepared with propylthiouracil than if he had been treated\nwith iodine alone. It is permissible to use propylthiouracil and iodine as the sole form\nof therapy in an attempt to cure the following patients:\nThose with persistent or recurrent thyrotoxicosis following thyroidectomy.\nPatients over 50 years of age with severe heart disease; those patients who are\nconsidered to be too old to withstand operation; patient with vocal cord paralysis\nand parathyroid tetany; and finally, patients with exophthalmic goitre in whom\nthe gland is inconspicuous and in whom there are no pressure symptoms.\nWith regard to the toxicity of propylthiouracil, the drug was originally thought\nto have no untoward effects. However, there are now three case reports at least of\nagranulocytosis and 11 instances of severe leukopenia due to its use. (Seen in Vancouver) . Agranulocytosis and drug fever are the only toxic reactions that will require\ndiscontinuing the drug. One must warn the patient to report immediately if he has\nfever, sore throat, skin rash, malaise or enlarged glands. If these appear, stop the drug\nimmediately and do a white cell count and differential. If there is a leukopenia of less\nthan 4,000 WBC per cu. mm. or a polymorphonuclear percentage of 30% or less, the\ndrug should be discontinued and penicillin given to prevent or control sepsis. Remember\nthat leukopenia of some degree is common in untreated thyrotoxicosis, so that a total\nblood count must be done before treatment is started to serve as a reference base line.\nDo not advocate repeated white counts, as previously.\nIt has been found that patients do just about as well on 150 mgm. of propylthiouracil per day as they used to do on 600 mgm. per day of thiouracil. However, it has\nbeen shown that they do even better when the dose of propylthiouracil is raised to 300\nmgm. per day and that is why we recommend this higher dosage.\nOther Forms of Treatment:\nDr. Warcup will deal with the surgical side.\nThere seems to be no place nowadays for X-ray therapy in the treatment of thyrotoxicosis.\nThe other drug to be considered is radioactive iodine, the one now in use being\n1.131, which has a half life of 8 days. There is no doubt about the fact that the thyroid\nPa\u00C2\u00A7e 115 HS'\ngland in hyperthyroidism takes up a very great proportion of the administered dose of\nradioiodine, in some cases as much as 80% as against about 20% in the thyroid of the\nnormal person. As might be expected, it has proved possible to reduce the symptoms\nof thyrotoxicosis by the effffect of the drug on the gland. The difficulties are that we\nare not yet certain about the carcinogenic possibilities, and also animal experiments\nhave shown a toxic effect on the renal tubules. In addition, it takes expensive equipment\nand a highly trained, specialized team to use the drug at all. This cannot be done in\nsmall centres therefore. At present it should be used only in patients unsuitable for\nsurgery or propylthiouracil. It may prove of great value in carcinoma of the thyroid\nespecially as the drug is taken up by the metastases in many cases, though not in all.\nTo sum up, all patients with thyrotoxicosis should now be treated initially with\npropylthiouracil and iodine, irrespective of whether or not they are ultimately going to\nneed surgery.\nThe only exception to this will be in the case of patients who prove to have toxic\nreactions to propythiouracil.\nPurely medical treatment with propylthiouracil and iodine is likely to cure patients\nwith thyrotoxicosis in whom the gland is, inconspicuous and in whom there are no\npressure symptoms, particularly if they are in the younger age group. Medical treatment is also indicated in those with a recurrence after thyroidectomy, in cases with\nsevere heart disease (particularly if over 50), in patients too old for surgery, and in\nthose who refuse operation.\nThe chief use of iodine in thyrotoxicosis today lies in augmenting the antithyroid\neffect of propylthiouracil preoperatively.\nThe possibilities and limitations or radioactive iodine have been stressed.\nNews and Notes\nContributions to News and Notes will be welcomed by Dr. J. L. Mcmillan, 4622\nN.W. Marine Drive, Vancouver, B.C.\nFOR SALE !\nSix-room house, separate entrance to waiting room and office, one\nacre. Landscaped garden. Located in rapidly growing municipality.\nPreviously owned by Dr. Marr.\nFor particulars apply:\nE. G. BARTEAUX, BOX 404, FORT LANGLEY, B.C.\nPhone: Langley 18X1\nPage 116 \u00E2\u0096\u00A0Us **-\n!$f&\nf.t-\n\u00E2\u0096\u00A0\nJi\nI\nTHE SURGERY OF THE THYROID\nDr. L. W. Warcup\nTo open my discussion on the surgery of the thyroid gland, I will first give a\nclassification of the disease. This falls into four main groups, namely:\n1. Disturbances of Function:\n(a) Diffuse Goitre Without Hyperthyroidism.\n(b) Diffuse Goitre With Hyperthyroidism (Graves, Disease or Primary Toxic\nGoitre).\n(c) Nodular Goitre Without Hyperthyroidism.\n(d) Nodular Goitre With Hyperthyroidism. (Secondary Toxic Goitre.)\n(e) Benign Solitary Adenoma.\n2. Neoplasms:\n(a) Papillary Carcinoma or Haemangio-invasive.\n(b) Non-papillary Carcinoma or Lymphangio-invasive.\n(c) Adeno-or Squamous Carcinoma.\n3. Congenital:\n(a) Lingual Thyroid.\n(b) Thyroglossal Cysts.\n4. Questionably Ineffective:\n(a) Subacute Thyroiditis.\n(b) Riedel's Struma.\n(c) Hashimata's or Lymphadenoid Goitre.\n1. DISTURBANCES OF FUNCTION:\n(a) The diffuse goitre without hyperthyroidism is usually, if not always, found in\nchildren in endemic areas. The period of adolescence is one of iodine insufficiency due to\nincreased demands. The gland hyperthrophies and undergoes hyperplasia; then, after the\nperiod of insufficiency is passed and there is sufficient hormone to satisfy the body\nrequirement involution takes place. The follicls then again become filled with pink\nstaining colloid, but although the compensation is restored, the gland is no longer normal\nin size or in histological structure. Instead it is enlarged, the follicles have increased in\nsize with their cells flattened. This is the diffuse goitre. Although the thyroid gland is\ncapable of undergoing repeated cycles of hyperplasia and hypertrophy, followed by\ninvolution in response to repeated cycles of iodine deficiency, each cycle produces further\nchanges, and with each cycle the gland undergoes a further change.\nLarge diffuse goitres are rarely seen because, with repeated cycles of hyperplasia and\ninvolution, the gland develops involutionary nodules, as in the study by Wegelin in\nSwitzerland, where he showed the transition of diffuse to nodular goitre with advance\nin age. gjj\nAdolescent goitre or diffuse goitre in adolescence can often be prevented, but once\nestablished can rarely be cured by medical treatment. Adequate doses of iodine, supplemented by desiccated thyroid, produce a physiological rest for the thyroid, but the most\nthat can be expected is to prevent further enlargement.\nTherefore we know that practically 100% of all diffuse goitres without\nhyperthyroidism occur in adolescents, and that they are due to goitrogenic agents,\nabsolute or relative deficiency of iodine. Treated medically to prevent further cycles\nof hyperplasia, there is no\" indication for surgical removal unless they are extremely\nlarge, or for cosmetic reasons, and in this regard it should be emphasized that a goitre\nthat appears very large in an adolescent may not be noticeable when the subcutaneous\nfat deposits in later life.\nWe have stated how the diffuse goitre of an adolescent becomes a multinodular\ngoitre without hyperthyroidism; here we have to deal with other factors; namely, the\nserious complications of this established disease. They are: W^\nPage 117 (1) Hyperthyroidism.\n(2) Intrathoracic Growths\u00E2\u0080\u0094practically all are adenomas from a normally situated\ngland.\n( 3 ) Growth to excessive size.\n(4) Development of malignant tumours\u00E2\u0080\u0094malignant tumours of the thyroid are\nseven times as common in regions of endemic goitre as elsewhere.\nThe removal of all nodular goitres would be impractical. In the first place, the\nincidence of adenomatous goitre is extremely high; in some regions the majority of the\npopulation may be affected. In the second place, the type of adenomatosis which is\npresent in these cases appears, as Reinhoff's studies indicate, to be a physiological process\nof degeneration and regeneration that involves the entire gland, so that even after a\nsubtotal thyroidectomy has been performed a certain amount of adenomatous tissue\nremains. Since in cases of multinodular goitre it is impractical to perform a total ablation\nof the thyroid for adenomatous goitre, and since the condition involves the whole gland,\nit is not surprising that the recurrence rate is high.\nIndications for thyroidectomy in a patient with a multinodular goitre are:\n(1) Enlargement of an Adenoma.\n(2) Development of Hyperthyroidism.\n(3) Pressure Symptoms Denoting Intrathoracic Extension.\n(4) Cosmetic Reasons.\nA different problem is presented by the finding of a firm, circumscribed, discrete\nadenoma, amongst the other nodules. This adenoma should be removed, regardless of\nthe fact that there is no hyperthyroidism; even if the adenoma is small, or enlarging, it\nshould be removed. These discrete adenomas have certain clinical and pathological\nqualities of neoplastic growth. It is in this type that malignant change is commonly\nseen\u00E2\u0080\u0094at least 5 % of such adenomas are found by the pathologist to be malignant. These\ntumours\u00E2\u0080\u0094discrete adenomas\u00E2\u0080\u0094should be removed, not because of the possibility of the\ntumour becoming malignant, but because the tumour may be malignant at the time.\nCalcified adenomas\u00E2\u0080\u0094are important only to be distinguished from carcinoma. X-ray\nwill do this, but does not mean that there cannot be a carcinoma in the same gland\u00E2\u0080\u0094\nbecause again carcinoma is seven times more common in multinodular goitres than in\nnormal glands.\nIn the intrathoracic goitre\u00E2\u0080\u0094which is practically always an adenoma from the left\nlower pole\u00E2\u0080\u0094the indications for removal may be listed as:\n(1) Hyperthyroidism Developing in the same Gland.\n(2) Dyspnoea.\n(3) Choking Sensation.\n(4) Stridor.\nDiffuse goitre with hyperthyroidism\u00E2\u0080\u0094is a systemic disorder involving widespread\ndisturbance of the neuro-endocrine system. It is difficult and often impossible to draw\nsharp lines of differentiation between Graves' disease and nodular goitre with hyperthyroidism. The goitres of patients with Graves' disease obey the same law that Wegelin\nhas so clearly demonstrated in the incidence of involutionary nodules and adenomas in\nendemic goitre. Elderly patients with long-standing Graves' disease usually have nodules.\nThe glands of children and young adults with Graves' disease of short duration are\nrarely nodular.\nAs has been mentioned in a previous paper, the increased incidence of cardiac complications in patients with nodular goitre is not dependent upon any qualitative difference\nin the thyroid hormone, but results from the increased incidence of organic heart disease\nin the older groups of patients who have nodular goitres.\nThe average age of patients with hyperthyroidism associated with nodular goitre is\napproximately 13 years greater than that of patients with Graves' disease. There is\nlittle clinical difference between hyperthyroidism associated with Graves' disease and\nthat associated with nodular goitre, and, also, it is impossible always to determine before\nPage 118\ni<\u00C2\u00BB\nil !\n!\u00C2\u00A7| I\n1 i\n411\ni' ii\n\u00E2\u0096\u00A0Wk 1 a I\n\u00E2\u0096\u00A0P ll\n\u00E2\u0080\u00A2mill\n'33\n!f|||| m\nm.\niii\nII\nMW\noperation whether or not adenomas are present, since early adenomatous changes cannot\nbe palpated easily.\nUp until 1900 a surgeon only saw a patient when he or she was moribund. After\n1900 the surgical conquest of hyperthyroidism was greatly established in safety by the\npreoperative use of iodine\u00E2\u0080\u0094so well accepted that up until 1942 few chose to consider\nhyperthyroidism as other than a surgical problem. Today, as a result of the discovery of\nthe powerful and effective antithyroid drugs, the controversial issue of whether or not\nhyperthyroidism is better treated by medical management has again arisen.\nIn the not too distant future it is quite possible that the radiologist using radioactive iodine will be called upon to play an ever-increasing part in the treatment.\nThe medical treatment of hyperthyroidism is not as simple as it sounds; too often\nthere is a tendency to deviate from schedule dosages, to interrupt treatment, or to change\nto some other form of therapy. Propylthiouracil is a weaker antithyroid drug than\nthiouracil. After an effective single dose of propylthiouracil the uptake of radioactive\niodine is blocked for only four hours. The physician who is content to treat hyperthyroidism symtomatically by giving enough propylthiouracil to effect a gratifying improvement in the patient's symptoms without bringing the B.M.R. to 0 will obtain few\nlong-standing remissions.\nThe results of inadequate medical treatment are comparable in every respect to\nthose of inadequate thyroidectomy. Judging from the experiences of a large American\nclinic, they find that about 50%, probably less, if adequately treated, and they stress\nstrongly the fact that these patients must have had a B.M.R. of 0, plus absence of all\nsigns for a least one year's treatment with propylthiouracil, will remain in remission. It\nis entirely possible that the treatment of Graves' disease may become comparable to\nthat of duodenal ulcer. The initial treatment may be medical, excepting in certain cases\nof unusual severity. Surgical treatment is indicated in those patients who\n(1) Do not respond to medical treatment.\n(2) Do not co-operate.\n(3) Are subject to recurrences and do not wish to continue indefinitely on\nWm medical treatment.\nFor patients with nodular goitres with hyperthyroidism, thyroidectomy after appropriate preparation is the treatment of choice. There is reason, to believe, though not\nclearly understood, that the hyperthyroidism associated with a nodular goitre is not controlled by propylthiouracil and then, as before, there is the complication of the adenomas\n\u00E2\u0080\u0094the danger that they will enlarge, the possibility of carcinoma.\nFollowing this brief discussion we can then summarize our findings by dividing\npatients with hyperthyroidism into four main groups from the therapeutic point of view:\nGroup I. Patients to be treated definitively by antithyroid drugs and the hyperthyroidism completely controlled for one year in the hope of inducing a long-standing, j\nremission include:\n(1) Patients with mild Graves' disease, with a small diffuse gland.\n(2) Patients who refuse operation or who prefer to try medical treatment.\nGroup II. Patients to be treated by antithyroid drugs in preparation for operation\ninclude:\n(1) Patients with large diffuse goitres and hyperthyroidism .\n(2) Patients whose goitres enlarge under medical treatment.\n(3) Patients with nodular goitre and hyperthyroidism.\nGroup III. Patients to be prepared for operation with iodine:\n(a) Patients intolerant of antithyroid drugs.\n(b) Patients with nodular goitre and mild hyperthyroidism.\nGroup IV. Patients in whom operation is contra-indicated and who are treated\nindefinitely, if necessary, with antithyroid drugs:\n(a) Aged patients.\n(B) Patients with short life expectancy.\nPage 119 (c) Patients with recurrent hyperthyroidism when the technical difficulties of\noperation are greatly increased.\nPre-operative Management of Patients with Hyperthyroidism\nThe complications of hyperthyroidism, such as thyroid crises and cardiac decompensation, are difficult to treat, but easy to avoid. The chief factors influencing the risk\nof thyroidectomy are:\n(1) The condition of the heart.\n(2) The age of the patient.\n(3) Response of the pulse curve to preoperative treatment.\n(4) High B.M.R. at time of operation.\n(5) Degree of extension of goitre into the thorax. .\nThe presence of cardiac decompensation, auricular fibrillation, valvular heart disease\nor severe myocarditis increase the risk of thyroidectomy, the mortality being seven\ntimes as high. It is advisable that these patients be well controlled with digitalis before\nsurgery is considered.\nIn regard to age, mortality in the aged is four times as great, a prime factor\nbeing pneumonia. In consideration of this factor the time can be well chosen when\nthe patient has no respiratory involvement.\nIn regard to the pulse curve, although the pulse rate at the time the patient is seen\nbears no definite relationship to mortality, the response to preoperative treatment does.\nThe pulse rate should be reduced to normal before operation. This shows a physiological\nremission of the hyperthyroidism.\nThe suggested routine of preparation for a hyperthyroid patient before operations\nin a well known American clinic is as follows:\n(1) Allow 1 day's treatment with proplythiouracil for everyone plus of B.M.R.\n(2) 15 days after this should be the ideal day to perform surgery.\nTheir routine is 50 mgms. of propylthiouracil t.i.d. and h.s.\u00E2\u0080\u0094that is a total of\n200 mgms. daily; 21 days before surgery Lugol's iodine 10 mgms. is given t.i.d. That is,\nfor 1 week the patient receives Lugol's and propylthiouracil. For the last 15 days the\npatient receives only Lugol's, the patient being admitted to the hospital 7 days before\nsurgery. ^s\nUnder this regime they have never operated on a patient with a B.M.R. of over\n-(-10, and have had no reactions to thyroidectomy.\nIn regard to diet, it must be remembered that a patient with a B.M.R. of -{-50 is\nusing 50% more energy, and therefore requires this amount more calories. The diet\nmust be arranged to supply this.\nIn regard to the technique, it does not warrant description outside of saying that\na radical subtotal thyroidectomy must always be performed. There are many ways of\ndoing this. The mortality rate has been below 1% for over 10 years now.\nBriefly, the complications of thyroidectomy are:\n(1) Injuries to recurrent laryngeal nerve. The incidence in a very large series was\nquoted as 0.4%.\n(2) Postoperative haemorrhage.\n(3 ) Serum.\n(4) Infections.\n(5 ) Tetany.\nHypocalcaemia, probably due to oedema, has occurred in 1.5%.\nThe incidence of permanent symptoms of tetany is 1.18%.\n(6)Residual or recurrent hyperthyroidism. The incidence of recurrent hyperthyroidism averages 2.1% to 8.6%. However, this last figure was in a series up\nto 1939.\nPage 120 w*l l<-\n(7) Postoperative hypothyroidism. Inversely proportioned to the incidence of\nrecurrent hyperthyroidism, its appearance is a welcome sign and is easy to treat.\nPostoperative care requires only a few remarks: |p||\nMorphine.\nCarbohydrate fluids as early as desired, diet increased as rapidly as tolerated.\nLugol's should be given for a day or two postoperatively, so that there will\nbe no exacerbation of symptoms incident to its withdrawal.\nThere are many other factors that could be dealt with in regard to hyperthyroidism,\nbut cannot be handled in a short time, so the next subject that requires mention is\ncongenital abnormalities:\n(1) Cysts and sinuses of the thyroglossal tract\u00E2\u0080\u0094\nAre epithelial-lined cvsts and sinuses of the neck and are congenital. The cyst\nand sinus are always in the midline and may be above or below the hyoid bone.\nThe treatment is surgical excision, the entire tract being dissected out from\nthe foramen caecum to where, if it is a sinus, it has ruptured into the skin.\n(2) Lingual Thyroids\u00E2\u0080\u0094are rare. The only point bearing mention here is that the\npresence or absence of a normal thyroid must be established before removing\na lingual thyroid, the absence being quoted by one man as 10% to as high as\n100% by another author.\nIII. Neoplasms of the thyroid.\nFrom a clinical point of view carcinomas of the thyroid can be divided into\ntwo main groups\u00E2\u0080\u0094the papillary and the non-papillary. Papillary act as\nlymphangio-invasive and metastasize to lymph nodes, whereas the non-papillary\nare haemangio-invasive and metastasize by blood stream, the great differences\nin their behaviour being explainable by the above faculty of spread.\nThe incidence of Carcinoma of the Thyroid.\nVital statistics rate the thyroid as sixteenth in the list of organs affected by malignant disease. Analyzing a surgical series of 537 surgically removed Nodular Goitres the\nfollowing figures were arrived at:\nIn 537 nodular goitres (toxic, non-toxic, benign and malignant):\n30 malignant tumors were found j . \u00E2\u0080\u0094 5.6%\n263 nodular goitres with hyperthyroidism, non malignancies \u00E2\u0080\u0094 0 %\nIn 274 nodular goitres with hyperthyroidism:\n20 malignancies I\u00E2\u0080\u009410.9%\nOf these:\n176 multinodular\u00E2\u0080\u00946 were malignant 1 .\u00E2\u0080\u0094 3.4%\n98 solitary tumours\u00E2\u0080\u009424 were malignant \u00E2\u0080\u009424.5%\nHere then I may repeat what I have tried to indicate before when dealing with\nindications for removal of nodular goitres without hyperthyroidism. ,\nSurgeons realize that conservative treatment of adenomatous goitre is frequently\nunwise. Often errors are made and enlarging tumours of the thyroid treated by iodine;\ndelay is disastrous. These occasional errors have encouraged an over-statement of dangers\nof carcinoma of the thyroid in nodular goitre. Surgeons who suggest that all nodular\nenlargements of the thyroid should be removed, regardless of history, physical findings,\nor apparent benign quality of involuntary nodules, may be conscientiously attempting\nto give their patients maximum protection against carcinoma. However, indiscriminate\nthyroidectomy performed on everyone with nodular goitre would entail morbidity and\nmortality out of all proportion to the number of cases of fatal cancer that it might\nprevent. But, here I wish to emphasize again the points which indicate surgery:\n(1) Any adenoma which is firm and of different consistency from the rest of the\ngland.\n(2) Or, one giving pressure symptoms indicative of growth.\n(3) Conspicuous adenomas for cosmetic reasons.\nPage 121 (4) All adenomas in children.\nAnd finally, and most important of all:\n(5) All discrete or solitary adenomas, regardless of age.\nAge of the patient is not a factor; carcinoma of the thyroid jnay appear at all\nages. Also, the size of the tumour is no criterion; they may be very small, but most are\nhard and firm.\nThe relationship of benign adenomas to malignant adenomas is a subject of great\ncontroversy, as to whether a benign adenoma becomes malignant, or, as more likely in\na nodular goitre, the malignancy develops in the parenchyma and forms a nodule. That\nis again, the concern is not whether the adenoma will become malignant, but\u00E2\u0080\u0094is it\nmalignant now?\nPapillary Carcinomas\u00E2\u0080\u0094Are defined as epithelial neoplasms, formed by cuboidal or\ncolumnar epithelium, partly or wholly in papillary arrangement. These tumours are\nusually unrelated but occasionally are present in the contralateral lobe. They are not\nencapsulated. Papillary tumours are found in the younger age group\u00E2\u0080\u0094the average age\nin one series being 31 years. They metastasize to the lateral cervical glands. There is\na very slight tendency to spread distantly. There is a marked tendency for the tumour\nto calcify. There is a marked tendency for the tumour and metastases to grow slowly.\nIn an analysis of 34 cases of papillary carcinoma of the thyroid with and without\nlateral cervical metastases, 20 are alive without recurrence over 2 years; 2 are alive but\nhave recurrences, 3 are dead of the disease, 3 died of other causes, 6 could not be traced.\nIt is recommended that, regardless of the extent of invasion of the lateral cervical\nregion and mediastinum the tumour should be removed surgically. The operation should\nbe a lobectomy, leaving* none of the affected lobe and dissection of the involved glands.\nEven should glands reappear, they should be excised.\nIrradiation therapy, either by radium or deep X-ray, has not affected a regression\nor even controlled the growth of these tumours.\nNon-papillary Carcinoma of the Thyroid\u00E2\u0080\u0094This is the type that arises in an adenomatous goitre; that is the older age group. They are much more invasive, penetrating the\ncapsule and surrounding tissues. They spread distantly via the blood stream. In these\ncases evidence of metastases, even to the lateral cervical nodes, is a sign of incurability.\nThe average age in a series is 51 years of age. 68% were women.\nThe most common symptom was referable to pressure, but about 20% complained\nof systemic symptoms such as nervousness, loss of weight, palpitation or fatigue, hyperthyroidism being suspected, but there was no increase in B.M.R. Amongst the important\nphysical findings may be mentioned.\n1. A hard tumour.\n2. Fixed to deep structures of the neck so that it does not move with swallowing.\n3. Preoperative paralysis of the vocal cords, one or both.\nDifferential diagnosis must include:\n1. Subacute thyroiditis.\n2. Reidel's struma.\n3. Hashimota's disease.\nIndications \u00C2\u00A3or radical operation:\nA history of a recent enlargement of a pre-existing goitre and the finding of a\nhard uncalcified mass indicates an excision of the affected lobe; extension bilateral\ninvolvement of the thyroid by a malignant tumour is usually associated with invasion\nof contiguous structure and indicate incurability. Likewise, paralysis of one or both\ncords before operation shows extracapsular extension. Pain is a bad prognostic sign,\nusually indicating invasion of the capsule and cervical plexus. The demonstration of\nsecondaries in the lungs or bones, of course, indicates inoperability.\nWhenever possible, a radical operation should be performed, consisting of removal\nof the affected lobe, of the jugular vein and thyroid veins. Often this is impractical,\nbut is the ideal method.\nPage 122\n> \u00C2\u00A3\ni\niU>|\nM\nm\nI\nmm It is also recommended that a course of postoperative X-ray therapy should be\ngiven. An analysis of results in 49 cases shows:\n26% were alive and apparently free from ca. for a period from 3 to 17 years after\noperation.\n35% were alive after 5 years.\n65% had died within 5 years.\nAt the end of 10 years 68% were dead.\nIt is apparent that when a permanent cure is not affected the majority die within\n5 years. However, surgery enters even these incurable cases. A lot of these cases develop\nsevere dyspnoea due to the infiltration and growth and there are two types of treatment\nnecessary or available, namely:\n(1) Tracheotomy and irradiation.\n(2) Resection of the isthmus and any surrounding tissue that can be cut away,\nplus irradiation. This is not curative but relieves the great distress of the\ndyspnoea.\nThe third and final type that requires mention is the small but important group\n\u00E2\u0080\u0094the small tumours not suspected preoperatively\u00E2\u0080\u0094adenocarcinoma.\nTheir size varies from 1.5 cm. to a few cm. They are not encapsulated. Their\ncut surface resembles a scirrhous carcinoma of the breast. They do not appear to metastasize. They can almost be classified as carcinoid tumours or, as Dr. Allen Graham\ncalls them, adenocarcinoma not arising in an adenoma.\nThe fourth group of disease of the thyroid that I will deal with is the thyroiditis\nclass:\nSubacute thyroiditis\u00E2\u0080\u0094has been variously named tuberculosus, psuedotuberculous,\nor giant cell thyroiditis; tubercle bacilli cannot be demonstrated in these lesions. The\npossibility that the disease is a virus infection cannot be excluded. The onset is usually\nsudden and often synonymous with an upper respiratory infection:\nMore common in women.\nPain on swallowing, radiating up to the ear, characterisitc of subacute thyroiditis.\nThe gland is usually tender.\nThere is an elevated temperature and a greatly accelerated B.M.R.\nThe pulse rate is very rapid.\nThe natural course of the disease is towards spontaneous recovery. It will respond\ncompletely to X-ray therapy. This is mentioned only to state that surgery is ndt\nindicated.\nHashimotos Disease\u00E2\u0080\u0094Is a progressive disease associated with systemic disorders, in\nwhich there is degeneration of epithelial elements of the thyroid and replacement of\nlymphoid and fibrous tissue. The etiology is unknown. It is characterized by:\nOccurs in late 40's and 50's. ,\nPractically always in women.\nOnset is insidious.\nGlands are not tender; there is no fever, no increased pulse rate of B.S.R.\nThe entire gland is usually involved.\nThere does not appear to be any tendency to spontaneous remission.\nThe thyroid is firm, friable, and not very vascular.\nThe gland is diffusely enlarged, often with retrotracheal extensions.\nThe treatment is again X-ray therapy, but this depends on the diagnosis being made\npreoperatively. If at operation it is recognized, then only the isthmus should be removed\n\u00E2\u0080\u0094to prevent development of hypothyroidism.\nRiedel's Struma\u00E2\u0080\u0094A chronic, proliferating, fibrosing, inflammatory process, involving\nusually one, but sometimes both lobes of the thyroid, as well as the trachea and the\nmuscles fascia, nerves and vessels in the vicinity. It produces a bulky tumour and may\nbe indistinguishable preoperatively from an inoperable carcinoma.\nPage 123 Affects women much oftener than men and occurs beyond the age of 50:\nOnset is insidious and painless.\nThe tumour grows slowly.\nSymptoms of pressure are often severe.\nThe temperature and pulse are normal and rarely is there any systemic reaction.\nB.M.R. is usually normal.\nThe thyroid is stony, hard and fixed to other tissues.\nThe entire lobe of the thyroid will be strong, hard, adherent and avascular.\nThe gland is brittle and white and cuts almost like cartilage.\nIn treatment X-ray has not been satisfactory. Treatment is indicated usually to\nrelieve the obstruction. Complete surgical removal is usually impossible without irreparable damage to vital structures, so one must be content with less radical removal. An\nimportant point in the surgery of this is that in the centre of the hard lobe will be\ndegenerating tissue and if the surrounding tissue is opened it will be possible to relieve\na lot of the obstruction by removing this.\nOREGON ACADEMY OF OPHTHALMOLOGY OTOLARYNGOLOGY\nPortland, Oregon\n announces Us \u00E2\u0080\u0094j\u00E2\u0080\u0094\nELEVENTH ANNUAL SPRING CONVENTION IN\nOPHTHALMOLOGY AND OTOLARYNGOLOGY JH\nMarch 19 Through March 24, 1950\nIn response to numerous requests from those attending the convention in the past,\nthe meeting this year has been divided into two separate programs. The otolaryngology\nlectures and demonstrations will be held all day Monday and Tuesday, and Wednesday\nmorning. The ophtalmology lectures and demonstrations will be held Wednesday afternoon, all day. Thursday, and Friday morning.\nYou may register for one or both programs. The fee for either program is $50.00 and\nfor both is $75.00.\nThe guest speakers will be Dr. John R. Lindsay, Professor of Otolaryngology University of Chicago Medical School; Dr. Gordon D. Hoople, Professor of Otolaryngology\nSyracuse University Medical School; Dr. Paul Chandler, Professor of Ophthalmology\nHarvard University Medical School; and Dr. Michael Hogan, Associate Professor of\nOphthalmology University of California Medical School.\nIf you plan to attend the Convention, kindly write to the Secretary. Arrangements\nfor hotel accommodations have been made through our organization. If you desire hotel\nreservations, so designate on the form. DO NOT write directly to the hotels.\nThe fee for either section is $50.00. The fee for both sections is $75.00. This will\ninclude the cocktail party, the annual banquet, the daily lunches and a printed abstract of\nthe lectures given by the guest speakers.\nPLAN TO ATTEND OUR MEETING THIS YEAR. IT WILL BE WELL\nWORTH YOUR TIME.\nIMPORTANT: In order to make the course more personal and practical we will\nbe forced to limit registration to 125.\nWRITE IMMEDIATELY TO THE SECRETARY:\u00E2\u0080\u0094\nDR. DAVID D. DeWEESE\n1216 S.W. YAMHILL STREET\nPORTLAND 5, OREGON\nPage 124\n1\nP\n1\n11\nm\nI\n1\nHSR\nill\nm\ntiT\ns\ni\ni\nj\u00C2\u00A5,!|j\nli\nm\n1\nml\n1 1\nNEWS AND NOTES\nAmong new Canadian Fellowship winners are Drs. V. O. Hertzman and Jack\nBalfour, now practising in Vancouver; and T. McMurty now in Vernon.\nDr. Moe Chepesiuk is now practising at Shaughnessy Hospital again after a prolonged\nillness in Oakland, California.\nDrs. W. Stark and A. Trotter have opened orthopaedic practices in Victoria. Dr.\nStark has spent the past year in Los Angeles.\nWashington medical students now spend one month of their final year with a\ngeneral practitioner. Dr. E. C. McCoy has Dr. William Stewart with him this month in\nVancouver.\nDr. Howard Black, president of the General Practitioners' Association of Vancouver,\nattended the annual meeting of the American Academy of General Practitioners in St.\nLouis this month. Dr. McKenzie Morrison also attended as an observer.\nA Medical Curling Club has been conducting a successful winter programme in\nVancouver.\nDr. A. C. McCurrach from Edmonton has joined the X-Ray staff of Drs. Turnbull,\nDickey and Sloan in Vancouver ^ho have opened a new office in the Medical Dental\nBuilding.\nDr. Max Earle has opened a practice of obstetrics in Vancouver on his return from\nEngland.\nDr. Shillabeer has begun general practice in Vancouver West Point Grey. He was\nformerly in Alberta.\nDr. Tom Bridges is now practising in Vancouver with Dr. John Parks.\nDr. Malcolm Allan is now on the surgical staff of the B.C. Tuberculosis Institute.\nDr. C. S. Allen is practising orthopaedics with Dr. Don Starr, in Vancouver after a\nyear at Mayos.\nDr. James Ireland has opened a urologic specialty in New Westminster.\nNew Paediatricians in Vancouver include Drs. Ben Schuman, Sandy Lang and Campbell.\nDr. A. Gray is now practising in Victoria, B.C. after leaving Duncan.\nDr. J. Gibbings is practising in Woodfibre and hopes to continue obstetrics interne-\nship next year. His predecessor Dr. K. C. Boyce is now back at Kingston, Ontario.\nDr. C. H. Ployart has opened new offices in Vancouver Jericho district for general\nand physical medicine.\nDr. Lennox Arthur, formerly on the staff of General Hospital is now resident\nphysician at Harrison Hot Springs.\nDr. G. L. Smith is back in practice after a severe auto accident in December.\nDr. M. Pickering has begun general practice in the South Hill Medical Dental Building in Vancouver.\nNew fathers include Drs. Myles Plecash, R. M. Foxgard, J. Gibbings, WaUie Boyd.\nW. Charlton.\nDr. Murray Enkin, former interne at the Grace Hospital in Vancouver is now\npractising in Regina.\nDr. Hector Gillespie, former orthopaedic resident at the Vancouver General Hospital\nis now studying in Princess Elizabeth Hospital, Exeter, England. He will return to\nCanada in June.\nDr. Palmer MacLean is taking further studies in bone surgery in Liverpool.\nDr. James Routledge, is now in Montreal after a year in Hospital for Women's\nDisease in Chelsea.\nDr. Frank Wilson is now interning in orthopaedics in Atlanta, Georgia.\nDr. R. G. Hart is now practising in Vancouver after two years in Victoria.\nDr. R. E. Beck will undertake a residency in medicine at Royal Victoria Hospital\nin Montreal next year. At the same hospital in obstetrics will be Dr. M. Turko.\nPage 125 \u00E2\u0080\u00A2 ^.tgp^r\n**&\u00E2\u0096\u00A0*;\n\u00C2\u00ABm\n\u00E2\u0096\u00A0.*mr\nlexible\normulas\n; '-- --v7 ''\"\u00E2\u0096\u00A0:\u00E2\u0096\u00A0\nwith DEXTRI-MALTOSE\nsimple to prescribe...simple to prepare\nV\nm\nill\n\u00E2\u0096\u00A0;V' f\nMis\n\u00E2\u0096\u00A0I\nMilk plus water plus Dextri-Maltose*\u00E2\u0080\u0094simple to prescribe\u00E2\u0080\u0094\nis the mixture most widely used in the flexible formula system\nof infant feeding. Dextri-Maltose has helped physicians\nto build this system, now recognized the world over.\nFormulas with Dextri-Maltose are simple to prepare,\nDextri-Maltose is easily\nmeasured, is readily Ifc\nsoluble, and can be used\nin any method of\nformula preparation.\n\u00E2\u0080\u00A2Trademark Registered\nMead J&aN$ON|& company\nOF CANADA. llitlTED\nB E l^JS^Xti^E. E . ONIAR llSi\nSi*\nm\nm Neohetramine prevented the development of the common cold in 95% of\n300 subjects during a six month period\nOctober 1948\u00E2\u0080\u0094April 1949. \u00C2\u00AB\nARMINIO & SWEET, INDUSTRIAL MED. DEC. 1949.\nNo side reactions\n\"Throughout the entire course of Neohetramine prophylaxis there\nwere no manifestations of toxicity ... as described with other\nantihistaminics.\"\nEarly administration is essential\nArminio, Murray and Brewster all reported excellent results when\nan antihistaminic was administered at the first signs of a cold.\nBrewster, commenting on \"the phenomenal cure of the very early\ncolds\" with antihistaminic therapy, concluded that \"if properly\nand universally used, the antihistaminics could reduce the incidence\nof colds to near the vanishing point.\"\nDosage\nNeohetramine 100 mg. daily in divided doses. 25 mg. before each\nmeal and at bedtime or 50 mg. twice daily. In patients known -to\nbe unusually susceptible to colds, Neohetramine may be used daily\nas a prophylactic measure during the fall, winter and spring months.\nNeohetramine tablets\nTHONZYLAMINE HYDROCHLORIDE\n25 mg. Bottles of 25,100,1000\n50 mg. Bottles of 100,1000\n100 mg. Bottles of 100,1000\nRegistered Trade Mark\nJOHN WYETH & BROTHER (CANADA) LIMITED \u00E2\u0080\u00A2 WALKERVILLE, ONTARIO \mi\nwhen pain stime\u00C2\u00A3b\nmore and more physicians\nare turning te\naV\n6\nThis highly potent synthetic Analgesic is replacing morphine\n^p| in a multitude of uses. There are several reasons:\nJ^Jf No withdrawal symptoms after therapeutic use.\nNo cumulative effect in ordinary courses of use.\nQJ Withdrawal syndrome after long use is very mild compared fo that\nof other narcotics.\ntL\u00C2\u00A3 The hypnotic effect is slight, the action of Methadon E.B.S. being almost\nentirely analgesic in nature.\nMethadon E.B.S. relieves some types of pain, such as renal colic, not controlled by opium derivatives.\n1\nTo help avoid the confusion inherent in a multitude of proprietary\nnames for single-drug products, the E. B. Shuttleworth Chemical Co.\nhas adopted the policy of naming such products with their official names. Physicians are\nrequested to co-operate in this effort by adding the letters E.B.S. fo the product name\nwhen writing prescriptions. Thus:\nAVAILABILITY:\nC.T. # 452 Methadon E.B.S. 5 mg.\nC. T. #453 Methadon E.B.S. 10 mg.\nin bottles of 100, 500 or 1000.\nH.T. Methadon E.B.S. 2.5 mg.\nH.T. Methadon E.B.S. 5.0 m.g.\nH.T. Methadon E.B.S. 10.0 m.g.\nin bottles of 25 or 100.\nT\n&\u00C2\u00A3>., \u00C2\u00A3>\nSterile Solution Methadon E.B.S.\nNo. A-86, 10 mg. per cc. in 30 cc. rubber capped vials.\nNo. A-87, 10 mg. per cc. in 1 cc. ampoules in boxes\nof 6 or 25.\nLEWORTH CHEMICAL CO. LTD., TORONTO, CANADA\nAN ALL CANADIAN COMPANY . . . SINCE 1879\nRepresentatives: Mr. V. Garnham, 3228 West 34th Avenue, Vancouver, B.C.\nMr. F. R. Clayden, 3937 West 34th Avenue, Vancouver, B.C,\n1\n11\nt: Even a flood,\nfailed to stop GE Setvii\nDon't wait for a flood to call for GE Service...\"}\nit's available always at \u00E2\u0080\u0094\nVancouver - . . . 645 Hornby Street\nWinnipeg \u00E2\u0080\u00A2 . . . 402 Graham Ave.\nIt was spring in Marietta and the OWl\nwas on its seasonal rampage. In fact, its si\nwaters were even licking at doorsteps in the busyi\ntown section \u00E2\u0080\u0094- eagerly reaching higher and i\nIs it any wonder, then, that one of the town's 1\nx-ray technicians should be alarmed for the sal\nher charge \u00E2\u0080\u0094 vital, valuable x-ray equipment!\nflood-threatened office of her employer, a well-i\nMarietta doctor. Quite naturally she telei\nGE's Columbus, Ohio office \u00E2\u0080\u0094 told of hen\nGE Service went into immediate aciton. Q\nState Highway Department \u00E2\u0080\u0094 found roads to M\nwater-blocked. Then, chartered a plane which 1\nacross the river from Marietta at William\nW. Va., about an hour later. After reaching dcrai\nMarietta by flatboat and walking a few blocks, o\nserviceman arrived across the street from the fl\noffice. However, flood waters blocked the wayi\nproblem was neatly solved when a stalwart j\nfriend happened along and volunteered to cafl\nand his equipment across the street piggy\nThe x-ray equipment was speedily disma\nloaded on a high wheeled truck and taken\ndoctor's home which was located on higher j\nThis story is typical of the hundreds of docul\nGE Service reports in our files. A servicd\nproudly lends a new, broader conception I\nguarantee that stands back of every GE install\nGENERAL |gp ELECTR\nX^RAY CORPORATION\nLIMITED\n\u00E2\u0096\u00A0 OKTItU TQRONTO VANCOUVER tllHIPH AS THE SIGNATURE O\nPIONEER\nOf THE\n. .. also known and described as Digitaline Nativelle in the\nU.S.P-XIH (Official April 1947). In the year 1868 Digitaline\n(Digitoxin) was first isolated by Claude Adolphe Nativelle\nand has been used since that date, as it is today by world\nrenowned clinicians such as: Basil-Parsons-Smith, James Orr,\nHarry Gold, S. A. Levine, Sir James MacKenzie and many\nother authorities in the field of digitalis therapy.\nDIGITALINE NATIVELLE\nThe Digitoxin Original as the Name it Bears.\nCANADIAN DISTRIBUTORS\nROUGIERfFRERES\n350 LE MOYNE STREET - - MONTREAL, P.Q.\nStrictly Ethical Preparations.\nj\u00C2\u00BB\u00C2\u00BB; m\n<\u00E2\u0096\u00A0%*\nPatency of the normal drainage exits of the\nnasal accessory sinuses is of great importance in the care of upper respiratory\ninfections.\nNeo-Synephrine hydrochloride, applied\nby any of the common methods\u00E2\u0080\u0094dropper,\nspray, tampon, displacement\u00E2\u0080\u0094constricts\nthe engorged mucosa surrounding the ostia,\npromoting free drainage and aeration.\nNEO-SYNEPHRINE\u00C2\u00AE Hydrochloride\nBrand of PHENYLEPHRINE HYDROCHLORIDE\n1\nMr\nIlk*\nIll\ni\nw\nIr\n\u00E2\u0096\u00A0\naflfe\nNEO-SYNEPHRINE, trademark reg. U. S. & Canada.\nSolution 0.25% (plain or with dramatics)\nand 1% \u00E2\u0080\u0094 1 oz. bottles.\nJelly 0.5% \u00E2\u0080\u0094 % oz. tubes.\nNew Yomc 13, N. Y. Windso*, Ont.\nnc.\n443 SANDWICH STREET WEST, WINDSOR, ONTARIO RESERVED\nfor the medical profession\nIf\nrr\n.:;.:> :* :.\u00E2\u0096\u00A0\u00E2\u0080\u00A2\u00E2\u0080\u00A2\u00E2\u0096\u00A0\u00E2\u0096\u00A0 J?\"\n^\" > ^ \"\n- continuous penicillin\ntreatment of mouth and throat infections\n-SB\nAlso available:\n\"CILLENTA\" COMPOUND\nTABLETS \u00E2\u0080\u0094 No. 891\nEach tablet contains:\nPotassium Penicillin G\n(Crystalline).. 25,000 I.U.\nSuKamerazine.. 2.5 grains\nSulfamethazine. 2.5 grains\nSulfadiazine . .. 2.5 grains\nfa vials of 12 and bottles of 50.\ndhettt\nAYERST, McKENNA & HARRISON LIMITED ^r^^aL* MONTREAL, CANADA\nCILLENTA\nThese lozenges have given excellent\nresults in the treatment of\nvarious forms of Vincent's infection\nof the mouth and throat.\nIn oral surgery, their use pre- and\npost-operatively tends to\nkeep the area free of pathogenic\norganisms. When pain is an\nimportant factor, the benzocaine\ncontent of No. 859 will provide\nan anesthetic effect.\nFOR SLOW RELEASE\nNo. 850\u00E2\u0080\u00941,000 Int. Units penicillin.\nFOR FAST RELEASE\nNo. 849\u00E2\u0080\u00941,000 Int. Units penicillin.\nNo. 858\u00E2\u0080\u00943,000 Int. Units penicillin.\nNo. 857\u00E2\u0080\u00945,000 Int. Units penicillin.\nNo. 859\u00E2\u0080\u00945,000 Int. Units penicillin plus\n2.5 mg. benzocaine.\nNo. 860\u00E2\u0080\u009410,000 Int. Units penicillin.\nAll are supplied fa bottles of 20 and 100.\nNo. 861 \u00E2\u0080\u0094 25,000 Int. Units penicillin.\nIn bottles of 20.\nNo. 862 \u00E2\u0080\u0094 50,000 Int. Units penicillin,\nfa bottles of 12. PIONEER\nMEAT EATER\n(5years later)\nSs\nFive years ago, little Betsy\nTraynor was a participant\nin Swift's Meats for\nBabies first feeding test.\nCurrent Clinical\nMeat Feeding\nStudies\nREPORT No. 1 ~\nMEAT FOR\nALLERGY\nFEEDING\nFrom this research has\nevolved a milk substitute for\nfeeding to allergic infants\nand children who cannot\ntolerate milk. The formula,\nwhich may be easily made\nup by the mother, consists of\nSwift's Strained Beef supplemented with calcium, phosphorus salts, carbohydrate\nand fat. Studies show that\nthe calcium, phosphorus and\nprotein are utilized as well\nas these same nutrients when\nderived from milk.\nThis study on the nutritional value of a meat\nformula is part of an extensive clinical research program now being conducted\nthrough grants-in-aid made\nby Swift.\nWay back when Betsy started Swift's Meats,\nmeat was a \"revolutionary\" food for a baby.\nBetsy and her fellow participants were the\nfirst babies ever to eat Swift's specially prepared strained meats. Many of the infants\nin this original group were only six weeks\nold at the time!\nBetsy's bubbling good spirits and sound,\nsturdy development testify to the benefits of\nregular meat-feeding early in life. And Betsy's mother will tell you, \"She's the very\npicture of health!\"\nToday any baby can have the same right\nstart in life that lucky little Betsy had. Doctors recommend Swift's Meats for Babies\nnow in the early weeks of life\u00E2\u0080\u0094to provide\nthe complete high-quality proteins and iron\nevery infant needs every day for sound\ngrowth and development.\nSwift prepares an appetizing variety of:;;\nbeef, lamb, pork, veal, liver and heart\u00E2\u0080\u0094to\nhelp infants form sound eating habits.\nSwift's Meats for Babies are expertly\ntrimmed to minimize fat content\u00E2\u0080\u0094carefully\ncooked to preserve a maximum of essential\nmeat nutrients. Swift's Strained Meats for\nBabies\u00E2\u0080\u0094Diced Meats for Juniors\u00E2\u0080\u0094are convenient and economical, cost less than home-\nprepared meats.\nSwiffeMeats\nWeats-Bahiesr 11 for juniors\nSWIFT\n. \u00E2\u0080\u00A2. fbrewosf /?an?e //r meafs\nAll nutritional statements made in this]\nadvertisement are accepted by the Council\non Foods and Nutrition of the American\nMedical Association.\n\u00E2\u0080\u00A2 I, f/rsffo t/ei/e/cp a/tc/c//h/ca//y fesfZOO%/Pfeafc ZbrBa6/es *aUm. tP:H EXCLUSIVE AMBULANCE\nLIMITED\nOXYGEN THEKAPY SUPPLIED ON YOUR\nORDER. 24 HR. SERVICE\nJ. H. CRELLIN\nW. L. BERTRAND\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) \u00E2\u0080\u0094only\non your prescription \u00E2\u0080\u0094 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\nlimes daily\u00E2\u0080\u0094as 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., risible only\nwhen capsule is cut In\nhalt at seam.\nMARTIN H. SMITH COMPANY\n150 LAFAYETTE STREEf\nKEW YQBK 13. JK\u00C2\u00A5i fem\nWhen\nMASSIVE\nsalicylate.therapy\nisjMdie1Uted\\ntoxic effects, such as depression of blood\nprothrombin and hemorrhagic tendency, are\navoided by the administration of\nBEREX-the NON-TOXIC product of choice\nbecause it provides, in tablet form, an easily\nadministered and scientifically-balanced\ncombination of calcium succinate and acetyl-\nsalicylic acid.\nFull details concerning BEREX in the treatment of acute and chronic rheumatism, with\nextensive bibliography, available on request.\nAvailable in bottles of 100 and 500 tablets.\nPatented 1949. Manufactured under License from the Proprietors.\nBEREX is the trademark of this product.\nBEREX Pharmacal Company \u00E2\u0080\u00A2 36-48 Caledonia Road \u00E2\u0080\u00A2 Toronto, Canada w\nvfflm>\nflDount Peasant XHnbertafcing Co. %tb.\nKINGSWAY at 11th AVE Telephone FAirmont 0058 VANCOUVER, B. C.\nKINDLINESS\nUNDERSTANDING\nDEPENDABILITY\nDELTA BRAND\nConcentrated Partly Skimmed Milk\nFor Infant Feeding\nDelta Brand Milk is a low butterfat evaporated milk of 4%, Irradiated\nand Vacuum Packed under careful control which when diluted with\nwater presents a milk of 2% butterfat. Non-fat solids are the same\nas standard evaporated milk, but calories per ounce in Delta Milk are\n31.5 instead of 42.\nCOMPOSITION OF DELTA BRAND MILK\nFat 4% Total Solids 22%\nVitamin D 324 International Units per Imperial quart\nCalorific value per ounce (avoirdupois)\u00E2\u0080\u0094.. 31.5\nPacked by\nTHE PACIFIC miLK COmPIMY\nm\n2559 Cambie Street, Vancouver, B. C.\n*"@en . "Periodicals"@en . "W1 .VA625"@en . "W1_VA625_1950_02"@en . "10.14288/1.0214411"@en . "English"@en . "Vancouver : University of British Columbia Library"@en . "Vancouver, B.C. : McBeath Spedding Limited"@en . "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/"@en . "Original Format: University of British Columbia. Library. Woodward Library Memorial Room. W1 .VA625"@en . "Medicine--Periodicals"@en . "The Vancouver Medical Association Bulletin: February, 1950"@en . "Text"@en . ""@en .