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History of Nursing in Pacific Canada
Vancouver Medical Association
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Tfeelw of the iplll. Mii|eAf| association!! With Which Is Incorporated Transactions of the 0ictoria medica^societ^ Vancouver general hospital and ST. PAUI/S HOSPITAL In This Issue: page ^S|Li^SUMMER: SCHOOL PttOQRAM .■ ;^M^^^^p^jJ4s THE USE OI^RADIOACTIvii ISOTOPES IN BIOLOGT AND MEDICINE By Simeon llgC*nt^f^M.n. ^^^^^^-' ?1^S^'.IS^- EUSTAOHIAlilTUBE FUNCTION ANMfil RELATION TO DEAFNESS ByO|iR. Lindsay, VL.TtJf^^^^^^^M.;. .-gg;-. . 'm^ntU. INJURIES OF THE FACE AND^JAW By Robert- G. \,angst*.p0d.n: ?||||g|||»^. '. ■ ! jljlg|jj£3rttt A CASE OF OBSTRUCTIVl^|AUNDICE • By E*& James, B^^^^^^^^^^^^^B' iiWiiilM AN UNUSUAL CASE& SPONTtiNEOUS| jgi PNEUMOTHORAX By T. KS^cI^an^ M.n^g^g^^^. Wll^itilP^^^^^P POLYPOSIS OF THE COLON By c g. Pow, ^^mimsmmmmSm \mmmmm/^^^m pANCOUVER MEDICAL ASSOCIATION 1 SUMMER ICHOOll June 2nd ty 6th, incl. Hotel Vancouver Vancouver, B. C. Lv« I 4< fa hi Mr >i VOLiXXII.. NO. 7 APRIL, 1947 NEW APPROACH TO THE TREATMENT 0 TINEA PEDIS f/ftktete's foot) <*^ E. L. Keeney* has shown the marked lethal effects of sodium propionate on dermatophyte fungi. Fungol E.B.S. provides sodium propionate in convenient ointment and .powder form for combating many types of dermatomycosis. Epidermophyton interdigitale hlete's foot), trichophyton barbae (tinea sycosis), trichophyton capitis (ringworm of the scalp), and numerous other mycotic infections all respond to treatment with Fungol. *Bull: Johns Hopkins Hosp. 73:379 E\ FUNGOL 4 oz. Jars |^E^3prinkier j FUNOO THE HUTTLEWORTH CHEMICAL Contains 10% SodivmJhrdf^on^ COI LTD. §0R0NTd3cAHA THE VANCOUVER MEDICAL ASSOCIATION «» BULLETIN Published Monthly under the Auspices of the Vancouver Medical Association in the interests of the Medical Profession. Offices: 203 Medical-Dental Building, Georgia Street, Vancouver, B.C. EDITORIAL BOARD: De. J. H. MacDermot De. G. A. Davidson De. D. E. H. Cleveland All communications to be addressed to the Editor at the above address. % I vol. xxm APRIL, 1947 No. 7 OFFICERS, 1946 - 1947 De. G. A. Davidson De. Frank Turnbull Vice-President Past President De. H. A. Des Brisay President Dr. Gordon Burke Hon. Treasurer De. Gobdon C. Johnston Hon. Secretary Additional Members of Executive'. De. W. J. Dorrance, Dr. J. W. Shier TRUSTEES Dr. A. W. Hunter Dr. G. H. Clement De. A. M. Agnew Auditors: Messes Plommer, Whiting & Co. Dr. E. R. Hall. SECTIONS Clinical Section .Chairman Dr. Reg. Wilson. Secretary Secretary Eye, Ear, Nose and Throat Dr. Rot Mustard- Chairman Dr. Gordon Labge. Paediatric Section Db. R. P. Kinsman Chairman Dr. H. S. Stockton— -Secretary Orthopaedic and Traumatic Surgery Section Dr. K. J. Haig Chairman Dr. J. R. Naden— Secretary Dr. A. M. Gee. Section of Neurology and Psychiatry Chairman Db. J. C. Thomas. Secretary STANDING COMMITTEES Library: Db. W. J. Doebance, Chairman; Dr. D. B. H. Cleveland, Dr. J. B. Walker, Dr. R. P. Kinsman, Db. J. R. Neilson, Db. S. E. C. Tubvet. Publications: Db. J. H. MacDermot, Chairman; Db. D. E. H. Cleveland, Db. G. A. Davidson, Db. J. H. B. Gbant, Db. E. R. Hall, Dr. Rot Mustard. Summer School: Dr. L. H. Deeson, Chairman; Dr. D. S. Munroe, Dr. L. G. Wood, Dr. A. B. Manson, Dr. D. A. Steele, Db. J. A. Ganshobn. Credentials: Db. H. H. Pitts, Db. A. B. Tbites, Dr. Frank Tubnbull. V. O. N. Advisory Board: Dr. Isabel Dat, Dr. J. H. B. Grant, Dr. G. F. Strong. Representative to B. C. Medical Association: Dr. Frank Tubnbull. Sickness and Benevolent Fund: The President—The Trustees. C U i v i* n £1 * *****a*0*a*a**^^^ !i5 ,«i ' I 1 X li 1 I I in m I » 9 M>. is Kiwi' Licuron-B LIVER COPPER IRON B-COMPLEX EACH LlCUrOn-B TABLET CONTAINS: Liver Fraction from 10 Gm. (155 grs.) of Fresh Liver. Copper Sulfate 0.0025 Gm. Ferrous Sulfate, Dried 0.084 Gm. Thiamine Hydrochloride 033 mg. Riboflavin 0.62 mg. Niacinamide 3.32 mg. »>> 8898 MR |H Efficient therapy in hypochromic Indications: Hypochromic anemia of preg- anemia is provided by the definite j§ ^ convalescence, periods of rapid !p| growth, prolonged hospitalization. In- ratio of copper-iron in Licuron-B. #fe ^L^_ nf jLl-^. ui i .„ u rr fc:::$ stances of chronic blood loss, such as This reduces the amount of iron re- |#| uterine bleeding. quired, and avoids the constipation ||| Dosage: Two tablets three times daily, and gastrointestinal upsets caused by ( after meals' until a satisfa<*ory blood ||j§ response is obtained. Then as indicated. large doses of ferrous sulfate alone. §jj P$ Supplied: Licuron-B is supplied as small, Copper further assures that the ad- |j easy-to-swa!low, sugar-coated tablets in ministered dose of iron will be most BK bottles of 100. rapidly and properly utilized, thus W$ f ^ LAKESIDE LABORATORIES INC. shortening the period of treatment. Milwaukee, Wisconsin rH-inn htn* and <z£a/nfiLe. on NAM, WILDE & CO. Distributors: 628 Vancouver Block Vancouver, B. C. Phones: PA. 8818, MA. 0282 A SIMPLIFIED NEW TECHNIQUE FOR PROVIDING '« ^#Cs~ i< Penicillin in Oil and Wax, providing the prolonged action afforded by prolonged absorption1'2, can now be administered quickly and easily. Three major Squibb improvements greatly simplify and improve administration technique: readily-injectable. The new Squibb Penicillin in Oil and Wax can be readily injected through 20-gauge needles without preheating when at room temperature. DOUBLE-PURPOSE CARTRIDGES. One 1 cc. cell contains Squibb Penicillin in Oil and Wax, 300,000 units; second cell con- AVAILABLE NOW IN LIMITED QUANTITIES ONLY tains sterile Aspirating Test Solution^ permitting aspiration to check proper location of needle before penicilKn adminis tra ti on. METAL CARTRTOGE SYRINGES. The new B-D* Cartridge Syringes are designed for repeated use with readily changeable cartridges and needles. *T.M. Reg. Becton, Dickinson & Co. Squibb 1. Kirby, W. M. M., Leifer, W.; Martin, S. P., RammeL kamp, C H., and Kinsman, J. M.: J.A.M.A. 129.940 (Dec. 1) 1945. 2. Romanslcy, M. J., and Rittman, G. L: Science 100:196 (Sept. 1) 1944. \ jMrtiliJUlJMS IN OIL AND WAX 2-47A DOUBLE-CELL CARTRIDGES-METAL CARTRIDGE SYRINGES i E. R. SQUIBB & SONS OF CANADA LIMITED • 36-48 CALEDONIA ROAD • TORONTO .;' it t # Ji;. J.': i# i IP Ji Breaks the vicious circle of perverted menstrual function in cases of amenorrhea, tardy periods (non-physiological) and dysmenorrhea. Affords remarkable symptomatic relief by stimulating the innervation of the uterus and stabilizing the tone of its musculature. Controls the utero-ovarian circulation and thereby encourages a ^ normal menstrual cycle. r « MARTIN H. SMITH COMPANY 8^ ISO IAFAYITTI STRUT. NIW YORK. N. T. w Full formula and descriptive literature &ti request Dosage: l to 2 capsules 3 or 4 times daily. Supplied in packages of 20. Ethical protective mark MHS embossed on inside of each capsule, visible only when capsule is cut in half at seam. BIOPSV SERVICE Surgically removed tissues will be examined and reported within 48 hours. A stained microscopic section will be included with the report when requested. Specimens should be placed in 10% formalin before being submitted. Telephone PAcific 4839 mEDICAL LRBORPTORV OF Dr. P. 5. RUTHERFORD 312 Vancouver Block, Vancouver, B.C. VANCOUVER HEALTH DEPARTMENT STATISTICS—FEBRUARY, 1947. J r Total population—estimated . Chinese population—estimated Hindu population—estimated Number Total deaths . 355 Chinese deaths t 20 Deaths, residents only 1 311 339,350 5,980 118 At Rate per 1,000 Population 12.3 39.4 11.9 BIRTH REGISTRATIONS: Male Female 755 26.2 INFANT MORTALITY: February, 1947 Deaths under 1 year of age 21 Death rate per 1,000 live births 27.8 Stillbirths (not included above) 10 CASES OF COMMUNICABLE DISEASE REPORTED IN THE CITY January, 1947 Cases Deaths Scarlet Fever 17 1 Diphtheria 0 0 Diphtheria Carrier 0 0 Chicken Pox 136 0 Measles 544 0 Rubella 17 0 Mumps 579 0 Whooping Cough : 14 0 Typhoid Fever j 0 0 Typhoid Fever Carrier 0 0 Undulant Fever 0 0 Poliomyelitis 0 0 Tuberculosis 43 15 Erysipelas : , 6 0 Meningococcus (Meningitis) 2 0 Infectious Jaundice 0 0 Salmonellosis I 5 0 Salmonellosis (Carrier) 1 0 Dysentery 1 0 Dysentery (Carriers) 0 0 Tetanus 0 0 Syphilis 112 3 Gonorrhoea ! 258 0 Cancer (Reportable) Resident 90 0 Non-resident 45 0 February, 1946 February, 1947 March, 1947 Cases Deaths Cases Deaths 15 1 14 0 2 0 7 0 0 0 0 0 119 0 160 0 710 a 805 0 12 0 9 0 401 0 432 0 8 0 39 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 42 16 59 14 4 0 3 0 2 1 3 0 1 0 0 0 0 0 3 S'O 0 0 0 0 0 1 0 1 0 0 0 0 0 0 0 0 94 3 0 ■afc 199 0 0 0 92 0 103 0 30 0 35 0 v, ii ih y> f*\? % «': « Page One Hundred and Forty-one 't * •;' I \t'r ■U at . i Ik i. IL w m m '■[■ 1"; l» CRYSTALLINE PENICILLIN IN OIL AND WAX (ROMANSKY FORMULA) A FURTHER ADVANCE The use of crystalline penicillin in the Romansky formula of penicillin in peanut oil and beeswax permits the Laboratories to make available to the medical profession an improved product with distinct advantages. Ease of Administration—The improved product flows more freely through a hypodermic needle. Minimum of Local Reaction— Because of the high purity of the crystalline penicillin in the mixture, local reactions are reduced to a minimum. HOW SUPPLIED DISPOSABLE PLASTIC SYRINGE PACKAGE Included in this package Is a sterile B-D* Disposable Cartridge Syringe, ready for immediate use with a special cartridge containing 300,000 International Units of crystalline penicillin in 1 cc. of peanut oil and beeswax. The plastic syringe is discarded after use. METAL CARTRIDGE SYRINGE PACKAGE This package includes a B-D* Metal Cartridge Syringe, two sterile 20-gauge needles, and a cartridge containing 300,000 International Units of crystalline penicillin in 1 cc. of peanut oil and beeswax. The metal syringe is designed for repeated use with readily changeable needles and cartridges. REPLACEMENT CARTRIDGE PACKAGE Replacement cartridges containing 300,000 International Units of crystalline penicillin in 1 cc of peanut oil and beeswax are obtainable separately from the Laboratories. These cartridges are supplied for use with the metal cartridge syringe. *T. M. Reg. Bee ton, Dickinson & Co. Disposable Plastic Syringe Metal Cartridge Syringe CONNAUGHT MEDICAL RESEARCH LABORATORIES University of Toronto Toronto 4, Canada DEPOT FOR BRITISH COLUMBIA MACDONALD'S PRESCRIPTIONS LIMITED MEDICAL-DENTAL BUIIMNQ, VANCOUVER, B.C. <7<4e CdUoAri Paae At a recent meeting of the Vancouver Medical Association, Dr. H. W. Riggs gave a brief summary of the hospital situation in Vancouver. His remarks are equally applicable to other parts of British Columbia. Dealing with present population figures, the speaker showed that we should, at the present moment, have about one thousand more beds available than is now the case. He reminded us that, even if construction were begun immediately, it would be approximately three years before these extra beds would be available. By that time, the natural increase in population would have presented us with a new problem—the urgent necessity for more beds, to meet the then existing situation. It sounds like something out of Alice in Wonderland, and might appeal to our sense of the comic, but as a matter of fact, it is a pretty grim state of affairs. Every medical man knows just how grim it is. For today no medical man can practise medicine adequately, unless proper access is given him to adequate hospital facilities. This is axiomatic, and requires no argument to prove it. Further, this is especially true in the case of the man who does general practice; the man who, from the public's point of view, is their first contact with the machinery of healing. We tend often to lose sight of the fact that well-trained, keen and competent general practitioners are even more important, from the general public's standpoint, than well-trained specialists. From the latter we so often hear comments that cases do not come to them till they have been mishandled, improperly diagnosed, etc., by the man in the ranks. This is especially true of certain types of cancer, certain eye conditions, and so on. Thus, if medical practice is to improve at all, if earlier and better diagnosis is to be attained, we must do all in our power to help the general man to keep up to date, to keep in touch with advances in his profession, and so on. The very first essential in such a programme is to ensure for him constant access to hospital, laboratory, and other modern facilities. Thus we are failing as a community, to give our medical workmen the tools with which they can finish their job. And any steps which tend to lessen the already far too scanty supply of hospital beds available to the medical profession as a whole, are, in our opinion, greatly to be deplored. We rejoice, therefore, to read in the press that the forthcoming Hamilton report on Hospital matters recommends a plan whereby hospital accommodation in Vancouver will be considerably increased in the near future. The full report will doubtless be released later—and it is too soon to comment upon it. We hope that, either in this report, or in future hospital developments, rather more attention will be paid to regional needs. We are quite sure that the plan suggested will be an excellent one, and that the development of the Vancouver General Hospital will make for real progress—but we confess to a desire for a greater degree of decentralization in the location of future hospital centres—so that all parts of this very rapidly growing city may be more readily and easily in touch with hospital service Our readers will find in this issue a brief report of the new Benevolent Fund of the British Columbia Medical Association. This carries with it an account of the origin and purpose of this fund, and we shall not enlarge on this here—except to say that we most heartily endorse this move on the part of the Provincial organization. It is decidedly a forward step that this body has taken. It must not be forgotten, either, that the step could not have been taken, had not the College of Physicians & Surgeons, which afer all, is the body charged with the collection of fees from the medical profession of the Province, made it financially possible. And we think that another thing should be said, in fairness to the Vancouver Medical Association. For many years this body has had a benevolent fund in operation, Page One Hundred and forty-two *tt 1 fa 4k and, as all of us know, this fund has been of great help to many who sorely needed it. Our historian will no doubt record its early history, and the difficulties that beset those who were charged with its administration, since collections were purely voluntary, and all sorts of complications arose from time to time. We were fortunate, however, in the calibre of the men who were our Trustees, and their sound judgment and wisdom ensured the most advantageous use being made of the fund at their disposal. Still, it was an activity and project of the Vancouver Medical Association, and it is the more admirable that this body was willing and ready to submerge its identity in the wider scheme: an act which was statesmanlike and wise, as well as being generous. Of the fund that was accumulated over the years, the major portion has been handed over to the senior organization, the B.C.M.A., to speed the establishment of its new fund, which will be available, without any local bias or influence to affect its disposal, in all parts o£ the Province of British Columbia, wherever it may be needed. Let us hope the need for it will seldom be felt—but it is good to know that the means are there whereby we may ensure that none of our colleagues, and this may include their families too, shall suffer hardship or want, through malign chance, without the knowledge that a helping hand will be there for them to grasp. The present scheme is, we think, a great advance on previously existing methods. It is, to begin with, provincial in scope, and we shall all rejoice that this is so. Its supplies are guaranteed, and every medical man will be doing his share toward its support. This is far more equitable than any voluntary system—and, too, removes any possible feeling of charity. Since we all subscribe equally to it, nobody who may unfortunately need its aid, need feel hesitant about accepting such aid, since he, too, contributed to it in the time of his prosperity. Here, however, perhaps it is well to emphasize a point which it touched on in the report. This is not an insurance plan in any sense of the word, nor a finance agency. No member of the profession should feel for one moment that he has any claim, or can have any access, to the funds of the plan, simply because he has contributed over the years to these funds. The use of the money, and the reasons for its use, are matters for the sole judgment and decision of the board that will administer the fund. The names of those who have been chosen, will assure every medical man in B. C. that the administration will be sound and equitable and that the new Benevolent Fund of the British Columbia Medical Association will be in excellent hands. '■A* 4U ANNOUNCEMENT Re Messenger Service for Library Commencing June 1st the Library will introduce a new service to members in Vancouver whose offices are outside the Medical-Dental Building. Free messenger service will be provided from the Library to Doctors' offices for books requested on loan, and also for pickup up volumes to be returned. Consent has been obtained from the Executive Committee to try out this plan, and your Library Committee is confident that it will prove to be a popular and valuable innovation. Jfe Hi RE NEW BOOK RECOMMENDATIONS The Library Committee wishes to remind members that suggestions for new books or journals that they feel to be essential to the Library, will always be welcome. Such recommendations may be filed with the Librarian and will be presented for consideration of the Committee at its next regular meeting. Page One Hundred and Forty-three !| LIBRARY NOTES LIBRARY HOURS— Mondays, Wednesdays and Fridays—9:00 a.m. to 9:30 p.m. Tuesdays and Thursdays—9:00 a.m. to 5:00 p.m. Saturdays—9:00 a.m. to 1:00 p.m. RECENT ACCESSIONS TO LIBRARY— Surgical Clinics of North America, Symposium on Clinical Advances in Surgery, Chicago Number, February, 1947. The Diseases of Children, five volumes, 1935, M. Pfaundler and A. Schlossmann, English translation, American Editor-in-Chief, M. G. Peterman. (Gift of Dr. Ben Kanee.) National Research Council of Canada—Fundamentals of Aviation Medicine. History of Associate Committee on Aviation Medical Research. Review of Work of Subcommittee on Protective Clothing of the Associate Committee on Aviation Medicine Research. (Gift of the National Research Council.) Functional Neuroanatomy, 1947, by Wendell J. S. Krieg. Diseases of the Blood and Atlas of Hematology, 1941, by Roy R. Kracke. Transactions of the Association of American Physicians, 1941, 1942, 1944, 1946. (Gift of the Association.) Operative Gynaecology, 1946, by Richard W. Te Linde. "•ii' NOTICE The Executive Committee wishes to draw attention to a regrettable incident in connection with the annual Osier Dinner held on March 4th at the Hotel Vancouver, when fourteen people were served who did not have tickets. This amount had to be made up from the funds of the Vancouver Medical Association. It is hoped that any members who attended the dinner, and neglected to get tickets, will get in touch with the office of the Association, telephone MArine 4622. ipi RESULT OF ELECTION FOR MEMBERS OF COUNCIL THE COLLEGE OF PHYSICIANS & SURGEONS OF BRITISH COLUMBIA April 7th, 1947 Dr. F. M. Bryant. Dr. G. S. Purvis. Dr. M. M. Baird. H. H. Milburn, M.D., Acting Registrar. DISTRICT No. 1 DISTRICT No. 2 DISTRICT No. 3 Page One Hundred and Forty-four 1 J Ifc i U1 it p f 4»> I VANCOUVER MEDICAL ASSOCIATION SUMMER SCHOOL, 1947 JUNE 2nd to 6th, INCLUSIVE HOTEL VANCOUVER # * » SPEAKERS Dr. Alfred J. Elliot, Professor of Opthalmology, University of Toronto, Toronto, Ont. Dr. D. Nelson Henderson, Department of Obstetrics and Gynaecology, University of Toronto, Toronto, Ont. Dr. Arnold S. Jackson, Surgeon, Jackson Clinic, Madison, Wis. Dr. Clement A. Smith, Department of Paediatrics, Harvard Medical School, Boston, Mass. Dr. Cyrus C. Sturgis, Professor of Medicine, University of Michigan, Ann Arbor, Mich, PROGRAMME MONDAY, JUNE 2nd 9:00 a.m.—Dr. Sturgis: "Evolution of Our Present-day Theories of the Etiology of Hypertension and Methods of Treatment." 10:00 a.m.—Dr. Smith: "The Physiological Peculiarities of Newborn Patients." 11:00 a.m.—Dr. Henderson: "The Common Disorders of Menstruation." 12:30 p.m.—LUNCHEON—Hotel Georgia, Spanish Ballroom, Speaker: Dr. Clement A. Smith: "Observations on a Recent Tour of Europe." 2:30 p.m.—Surgical Clinic: Vancouver General Hospital, Dr. Jackson. 8:00 p.m.—Dr. Jackson: "Traditions in Surgery." 9:00 p.m.—Dr. Elliot: "The Differential Diagnosis and Treatment of an Acutely Red Eye." TUESDAY, JUNE 3rd 9:00 a.m.—Dr. Smith: "Diseases of the Newborn, Their Diagnosis, and Treatment— Asphyxia, Atelectasis, Erythroblastosis." Dr. Sturgis: "The Treatment and Diagnosis of the Anaemias." Dr. Jackson: "Non-drainage and Early Ambulation in Acute Perforated Appendicitis/' -Medical Clinic: Shaughnessy Hospital, Dr. Sturgis. Dr. Henderson: "Delayed and Difficult Labour." Dr. Sturgis: "Haemorrhagic Disorders." 10:00 a.m 11:00 a.m 2:00 p.m 8:00 p.m 9:00 p.m WEDNESDAY, JUNE 4th 9:00 a.m.—Dr. Elliot: "Ophthalmic Indications of Systemic Disease." 10:00 a.m.—Dr. Smith: "Diseases of the Newborn, (continued)—Diarrhoea, Prematurity, etc." 11:00 a.m.—Dr. Sturgis: "Discussion of Some Aspects of Leukaemia, Infectious Mononucleosis and Agranulocytosis." 2:00 p.m.—Obstetrical Clinic—St. Paul's Hospital. Dr. Henderson. 8:00 p.m.—Dr. Jackson: "The Diagnosis and Treatment of Hyperthyroidism." 9:00 p.m.—Round Table Discussion: "Thyroid Diseases." Dr. Roy Huggard, Chairman. Page One Hundred and Forty-five THURSDAY, JUNE 5th 9:00 a.m.—Dr. Jackson: "The Acute Surgical Abdomen." 10:00 a-m.—Dr. Elliot: "Ocular Signs in Important Neurological Conditions." 11:00 a.m.—Dr. Henderson: "The Late Toxaemias of Pregnancy." 2:00 p.m.—GOLF TOURNAMENT. Vancouver Golf and Country Club, Burquitlam. FRIDAY, JUNE 6th 9:00 a.m.—Dr. Henderson: "Ovarian Neoplasms." 10:00 a.m.—Dr. Smith: "The Causes of Abdominal Pain in Infants and Children." 11:00 a.m.—Dr. Elliot: "Treatment of Ocular Injuries in General Practice." 2:00 p.m.—Combined Clinic—Venereal Disease and Tuberculosis. 6:30 p.m.—Final Banquet—Banquet Room, Hotel Vancouver. -1 Guest Speaker: Rev. E. D. Braden. PROGRAMME SPEAKERS The Summer School Committee is again proud of the outstanding medical men who comprise this year's slate of lecturers. The subjects for presentation have been carefully selected by the speakers to interest the general practitioner as well as the specialist. In Medicine, Dr. Cyrus C. Sturgis, Professor of Medicine at the University of Michigan, is outstanding in his profession. The study of blood diseases has been one of bis particular interests, and a field to which he has made valuable contributions. In Surgery we have secured Dr. Arnold Jackson, who is much sought after as an outstanding speaker at surgical meetings. He is Chief Surgeon of the Jackson Clinic at Madison, Wisconsin. The lecturer in Obstetrics and Gynaecology, Dr. D. Nelson Henderson of the University of Toronto, is a most capable gynaecological pathologist and clinician. He has studied ovarian tumours particularly and will lecture on this subject. Coming to lecture in Paediatrics is Dr. Clement A. Smith, Department of Paediatrics at Harvard Medical School, Boston, Massachusetts. Dr. Smith is outstanding in his field. He has been particularly interested in nutrition and has recently returned from Europe where he made up part of a survey, group who studied starvation in Europe. He will address us particularly at the noon-day luncheon on June 2nd on post-war Europe. Dr. Alfred J. Elliott, lecturer in Ophthalmology, is now Professor of Ophthalmology at the University of Toronto. The department under his leadership has planned a postgraduate training centre in Toronto. He is a native of New Westminster. A clinic is being held each afternoon, and on Wednesday evening, June 4th, a round- table discussion on thyroid diseases is planned with all speakers participating. It is intended that questions from the audience will be answered by the group. FEES The fee will be the same as last year—$7.50. HOSPITAL INTERNES Internes may also enroll free of charge and may obtain tickets from the Committee or at the Registration Desk on the opening day. HOTEL ACCOMMODATION AND RESERVATIONS A number of rooms have been reserved at the following hotels: Vancouver, Georgia, Devonshire, Ritz, Sylvia Court, Belmont, Grosvenor and Alcazar. The Committee expects to have reserved sufficient accommodation for those attending the School from out of town. The hotels stipulate that these reservations should be completed two weeks in advance and we urge that reservations be sought early. Page One Hundred and Forty-six tr if 1». FINAL BANQUET Last year the Summer School Session ended with a successful banquet. Such a banquet is again planned—the Committee would like to see everyone enrolled at the Summer School attend this final dinner. The Rev. Dr. E. D. Braden has been chosen to speak. He is a most capable and entertaining after-dinner speaker. PHONE SERVICE A private phone will be installed at the Registration Desk and a special screen in the lecture hall will make transmission of calls a simple procedure. GOLF The Golf Tournament will be held on the afternoon of Thursday, June 5 th, at the Burquitlam Country Club. The usual worthwhile prizes will be offered. REGISTRATION It is hoped that all those who can, will buy their tickets before the School commences. The registration desk outside the Ballroom in the Hotel will be open at 8:30 a.m. on the morning of June 2nd for those who have been unable to register previously. Medical officers in the Services who wish to attend are requested to register at this time, when they will be provided with tickets. Holders of tickets will be requested to show them at each session. • ti Ife- ■1* m W * IN 1* CANADIAN MEDICAL ASSOCIATION I ANNUAL MEETING f June 23 rd to 27th inclusive, in Winnipeg TRAVEL FARE AND TIMES TRANS CANADA AIR LINES FARE: $162.00 Return Lv. Vancouver 6:20 a.m. (Approx. 7l/z hrs.) Ar. Winnipeg 3:55 p.m. 12:25 p.m 11:30 p.m. 10:00 p.m. 9:05 a.m. CANADIAN PACIFIC RAILWAY COMPANY FARE: $85.50 Return plus $13.80 Lower Berth each way. Lv. Vancouver 7:15 p.m. (Two Days) Ar. Winnipeg 6:00 p.m. 7:45 p.m. 6:45 p.m. * Lv. Winnipeg 10:30 a.m. Ar. Vancouver 8:45 a.m. 11:10 a.m. 9:20 a.m. CANADIAN NATIONAL RAILWAYS Lv. Vancouver 7:15 p.m. (Two Days) 7:45 p.m. Lv. Winnipeg 10:15 a.m. 11:20 a.m. Times shown: "Standard Time". FARE: $85.00 Return plus $13.80 Lower Berth Ar. Winnipeg 6:00 p.m. 6:50 p.m. Ar. Vancouver 8:45 a.m. 9:20 a.m. Page One Hundred and Forty-seven ■Vancouver Medical Association President _Dr. H. A. DesBrisay Vice-President _— Dr. G. A. Davidson Honorary Treasurer Dr. Gordon Burke Honorary Secretary Dr. Gordon C. Johnston Editor Dr. J. H. MacDermot HISTORY OF V.M.A. (Continued) IRREGULAR PRACTITIONERS The Charlatan has been with us since the beginning of orthodox medicine, and nowhere does he thrive so well as in any district which is passing through the pioneering stage. We still have them, but they now tend to be accepted as an unavoidable evil, and do not get under the skin of the modern qualified Doctor as they did in the case of the Medical Man of other days. At the earlier meetings of the Vancouver Medical Association tempers often waxed hot, and much time was spent trying to correct the condition, but with little success. The quack came into the Province with the earliest settlers. He was accompanied by what Dr. Cousland of Victoria called the "Fly-by-Night" man. This was the itinerant Practitioner who had obtained his degree from one of the many second rate schools which flourished across the Border during the last century. Previous to the establishment of the Medical Council in 1886 theie was no curb on these gentlemen, and mention has already been made in this history of Dr. Milne's description of how they preyed on the citizens of the early days. In his paper on "Early Medicine on Vancouver Island", read before the CM.A. meeting at Banff in 1946, Dr. Cousland cites the cases of two such men who spent some time in Victoria during the 1860's. One of these, Dr. de Wolf, guaranteed a cure: "No matter how bad your case, or what the nature of the malady". Once while in Court on an alcoholic case in which he figured, he admitted that 150 such patients had died by their own hands while under his care. A second case referred to by Dr. Cousland was a Doctor Flattery, who put up at the Colonial Hotel in Victoria: "to give the afflicted an opportunity to consult with a distinguished Physician and Surgeon from San Francisco". The editor of the British Colonist had something to say about this Doctor's habit of borrowing money and forgetting to pay it back, and soon afterwards he left town. From Portland he wrote to the Colonist, promising shortly to forward seven dollars which he owed the paper; but he added as a P.S. "If I see any impudence in your Journal relative to my unfortunate departure, I will never pay you and therefore serve you right." Even with a Provincial Medical Council to protect their interests', the men of the Vancouver Association, had, during the early years of the century, their troubles with the quack. During the summer of 1906, at a special meeting of the Society, the following resolution was passed: "Whereas gross irregularities in contravention of the Medical Act have existed in the city for some time, and whereas three members of the Association are also members of the Council of Physicians and Surgeons; be it resolved that we request them to take immediate action against all offenders, specifying the case of Sneffer and the Dominion Hospital Company. That in case action has already been taken, that this Association be made aware of the fact. Further, that if no action has been taken or contemplated, that our representatives be requested to resign." This man Snepper is described as a Russian barber, calling himself a Doctor, and in association with him were some half dozen others: "Doctors whose names are either real or fictitious". Dr. Fagan, who was a member of the Council, pointed out that Snepper claimed to be only the manager of the company, and further that the legal adviser of the Council Page One Hundred and Forty-eight $ ii !% V 1 liB J n w^ to had declared that there was absolutely no case against him. In reply the Association requested that the said legal adviser be changed. The question remained as a thorn in the side of the Association for several years. Members of the Council had a difficult time explaining their inability to mitigate the evil, owing to the impossibility of prosecuting the culprits under the existing Provincial laws. These explanations did nothing to appease the irate members of the Society, since in 1908 we find representatives of the Council referred to: "In terms of strong condemnation for their ineptitude and inefficiency, mentioning especially the constantly increasing influx of quacks of all descriptions." The Society recommended the total abolition of the existing Board." In 1912 the incoming president, Dr. Coy, again referred to the question and urged more effective action. Dr. Proctor, a member of the Council, in a lengthy report, defended that body. The discussion of this report was: "Very free and energetic", and was climaxed by a resolution that: "The legal advisers at present employed by the Council are not satisfactory". Months later Snepper was still the guiding factor in his Hospitals Association, and the records of the Society leave no doubt as to what its members thought of him and his organization, but nothing ever came of their protests. Naturopaths and Chiropractors infiltrated into the city just before the outbreak of the first World War. Both groups have since been legalized by Provincial legislation. There are still in Vancouver numerous Irregular Practitioners of Medicine in one form or another. Being a new city, we perhaps have more than our share of them. Theirs is about the lowest conceivable form of human activity for gainful purposes, in that they prey on the credulity and infirmities of their fellow humans, giving nothing in return. Orthodox medicine tends to put up with them as a prevalent evil regarding the removal of which little can be done. THE FIRST WORLD WAR The first world war affected the Vancouver Medical Association to a marked degree. By the end of 1915, out of its one hundred and seventeen members, fifty two were already enlisted. Those who remained at home played their parts heroically. Within ten days of the declaration of war, we find a committee being appointed by the Society to look after the dependents of such Doctors among its members who might enlist. It was also agreed that free attendance should be given to dependents of all enlisted men who received less than a stated monthly income. One half of the regular medical fee was to be charged those receiving above this amount. While no distinctly all-Vancouver Medical units went overseas, the Association was represented on all of the various units which were organized within the Province, in many cases forming a majority of the officer personnel. This was notably so in No. 5 General Hospital which was staffed largely by Vancouver Medical Officers. Others went as Officers in Field Ambulances or as Regimental M.O.'s, while many were assigned to military units after reaching Europe. A few, who are now members of the Association, were then either undergraduates, or had not yet begun their medical courses. Most of these served in combat units. The only member of the Association to become a war casualty was. Dr. F. L. de Verteuil. He was a Naval Surgeon serving on the battleship Good Hope, and went down with his ship when she was sunk in the South Pacific in the autumn of 1915. The names of those Doctors who served in the armed forces during the first World War, and who were at the time, or who subsequently became members of the Vancouver Medical Association; are listed below. Ainley, W. E. Appleby, L. H. Atkinson, J. R. Bagnall, A. W\ Baird, Murray Page One Hundred and Forty-nine Baird, W". S. Baldwin, S. G. Barker, P .W". Bastin, C. H. Bell. F. C. Bell, C. H. C. Bilodeau, J. B. Blair, E. M. Boucher, R. B. Boulter, W. L. Brodie, F. Brown, C. E. Brown, Harold. Brown, John. Campbell, E. Campbell, J. E. Clarke, W. A. ' Clement, G. H. Cleveland, D. E. H. Coy, P. Coy, W. F. Curtis, E. J. Davis, H. C Davis, H. R. L. Day, E. E. De Muth, O. Des Brisay, H. A. Dobson, W. A. Draeseke, G. C. Dunbar, D. A Duncan, G. E. Elliot, B. S. Ewing, W. T. Freeze, D. D. Frost, A. C Funk, E. H. Gibson, G. H. R. Gibson, Richard Gillies, G. E. Graham, Colin Graham, H. C Graham, "Wilfred Gray, E. J. Greaves, G. A. Harwood, R. de L. Hodgins, L. Houston, J. A. Hunter, A. W. Kennedy, W. W. Kidd, G. E. Lamb, A. S Lamont, G. A. Lang, B. E. Lees, F. W. Leeson, L. H. Lineham, D. M. Lockhart, W. T. Logie, F. C. McAlpine, T. K. McCallum, C. T. McCarley, R. V. MacDermot, J. H. McDiarmid, C. A. McDougall, N. E. MacEwen, H. B. Mcintosh, H. H. Mcintosh, J. W. McKechnie, W. B. McKee, C S. McLellan, D. McNair, A. Y. McNichol, J. McTavish, F. C. McNeil, N. McNutt, L. W. McKenzie, W. J. Magee, C. F. Manchester, G. H. Matthews, G. O. Meekison, D. M. Millar, D. J. Monro ,A. S. Murphy, G. B. Murray, Fraser Mustard, Roy Neilson, J. R. Panton, K. D. Paton, W. M. Patterson, F. P. Paulin, S. Pedlow, W. L. Peele, S. R. Perry, D .G. Perry, Hugh Petrie, G. Pitts, H. Planche, H. H. Proctor, A. P. Rawlings, H. A. Schinbein, A. B. Smith, Lee Thomas, M. W. Tompsett, D. A. Trites, A. E. de Verteuil, F. L. Wall, J. T. Walsh, W. C. Warner, A. M. Welch, J. W. Weldon, R. C. White, H. Wilson, Wallace. Manson, A. B. There were two important problems which confronted the Association about this time. One was the influenza epidemic, which was incidentally associated with the war. The other arose more or less directly as a result of war conditions. This was the B. C. Liquor Prohibition Act. Vancouver's fight against the great influenza epidemic of 1918 probably paralleled that of most Canadian cities. At the time Dr. Carder was in charge of Infectious Diseases for the city. He asked that all cases he reported, and that persons suffering from the disease be treated so far as possible in their own homes, leaving hospital accommodation to those cases coming in from the trains and the boats. Treatment of the disease was discussed at length at the Society's meetings. One report which was given, covered the findings of 38 autopsies. The Association supported the Board of Health in putting a complete ban on all public meetings. The Prohibition Act was a burning question with the Medical Fraternity of the whole Province during the final and immediately succeeding years to the first World War. The act had been passed in 1916 and specified that all alcoholic liquors might be obtained only through Government liquor stores and on prescription issued by a Medical Doctor. It was not until the advent of the influenza epidemic in 1918 that the abuse of prescription writing, as permitted under the Act, became marked, although as early as the summer of 1917 several special meetings of the Association were held, and long and bitter discussions of the question had taken place. The Government accused the Medical Profession of making it impossible for the former to carry out the spirit of the Prohibition act. The term: "Medical Bootleggers", was freely used. With the influenza epidemic at its height people turned to alcoholic liquors as a preventive and cure for the disease. The Association countered by passing a resolution—which was published in the newspapers—to the effect that: "The value of alcohol as a preventive of influenza is non-existent". The Association held many special meetings to consider the question, and night after night it was the basis of a greater part of the discussions at the regular meetings. It is worthy of note that while many resolutions were offered, not a single one was agreed on. The problem finally solved itself by the Government withdrawing the Act. Page One Hundred and Fifty mm /*! IIli •i- u M ii \,\h\ IP BENEVOLENT FUND OF THE B. C. MEDICAL ASSOCIATION Within the past few months, the above Fund, the planning and organization of which have been under consideration for some years, has become an actuality—and the B. C. Medical Association has set up a Benevolent Fund Committee to administer it. We all know, as members of the College of Physicians and Surgeons, that our Annual Dues include a sum of $10.00, to be donated to this Fund. The purpose of this fund is to ensure assistance to doctors practising in British Columbia or their families, where such assistance is necessary for any good and sufficient reason. The Fund was started in 1944 by the contribution of $10,000.00 by the College oj| Physicians and Surgeons of B. C. This body then, by virtue of its power to levy annual dues, decided to institute an annual levy of $10.00 per member, as stated above. Certain moneys held by the.Vancouver Medical Association for a similar purpose, have been donated to the B. C. Fund. The V.M.A. has for many years had a Benevolent Fund, which has been of great value, but it was felt that this system of aid should be province-wide, and that adequate provision be made to ensure a regular supply of money—and this has been done. The committee that will administer this fund has been appointed by the B. C. Medical Association. It is to be noted that this fund is the property of the B. C. Medical Association, and not the College of Physicians and Surgeons, and is administered by the former. The present committee is as follows: Dr. W. E. Ainley, chairman; Dr. M* R. Caver- hill, secretary; Dr. A. J. MacLachlan, Dr. Ethlyn Trapp, Dr. D. F. Busteed. Doctors Ainley, MacLachlan and Busteed will act as Trustees. It is necessary to form a committee from those who would be immediately available, and for this reason they are chosen from the Greater Vancouver and New Westminster area. It is the Committee's wish however to have "corresponding members" throughout the Province, one to represent each District Medical Society, someone who would be in the best position to know and to make it his business to know of anyone who might need help, and bring such cases to the attention of the Committee. This Committee will operate under a set of bylaws drawn up by the B:C.M.A. executive. A complete set of bylaws has been drawn up and will be published later. It may be noted that the fund is not to be considered as insurance nor as a source of funds for refinancing purposes. Aid of any sort is not mandatory but entirely at th*£ discretion of the committee. MEDICAL OFFICES FOR RENT Suites Consist of Treatment and Examining Rooms, Office, Laboratory and Darkroom, General Office and Waiting Room. This Modern Building has automatic Radiant Oil Heating, Tile-Tex floors, etc. Apply HOULGATE & SUMMERFIELD LIMITED MArine 7749 MArine 2655 Page One Hundred and Fifty-one THE USE OF RADIOACTIVE ISOTOPES IN BIOLOGY AND MEDICINE By SIMEON T. CANTRIL, M.D. Read at Vancouver Medical Association 1946 Summer School The recent release of information relative to atomic energy has particularly stressed the importance of these new discoveries to the advancement of knowledge in the fields of biology and medicine. Official as well as lay journalism described the revolutionary discoveries in more healthful living shortly to be unfolded as a result of the splitting of the atom. This stress given to the biological and medical uses of atomic energy would seem to be founded on a definite need to foster some purpose other than ghastly destruction in the great effort made during the war to produce atomic bombs. It is perhaps more than mere coincidence that the official release of information on the destructive effects of the Bikini experiments was made on the same day that the government released the first quantity of radioactive carbon for the study of the causes underlying neoplastic disease. The flood of information and misinformation on the present and future possibilities of atomic energy in understanding and controlling disease has resulted only in conf usion and false optimism in the minds of most laymen and physicians who have had no opportunity to view for themselves in proper perspective the actual status of our knowledge and the devious paths which lead into a distant future. For this reason those of us who have been close to the medical aspects of the atomic energy program feel very strongly a responsibility to further informed discussion among the profession and to re-educate the public in competition with irresponsible elements of the press, both lay and professional. For this reason I chose to discuss the subject of radioactive isotopes, hoping thereby to bring to you some information which can be useful in analyzing your future reading, as well as encouraging you to keep abreast of knowledge in the older and established fields of medicine, as I do not see within our lifetime the millennium wherein Hippocrates will perform miracles of cure with a radioactive caduceus. It is altogether true that a great advance has been made in giving to science a new and very useful tool in biology and medicine. This cannot be questioned, and I shall give you examples of its usefulness to indicate the manifold possibilities of its application to varied problems in research, many of them having already a practical but indirect application to the treatment of disease. This is the field in which we can look for benefits from atomic energy, rather than the more spectacular one of direct application of atomic energy or its products to the eradication of disease in the patient. In this latter field both caution and perspective are badly needed. We shall later examine the present possibilities of its application as a therapeutic agent and try to envisage future possibilities. It is not appropriate here to enter into a description of the physical means whereby scientists have succeeded in harnessing the energy which holds matter together, or describe in any detail the production of artificially radioactive substances. The accomplishment of these wonders is a tribute to man's ingenuity, if in the end it is not his complete undoing. It is possible now to produce a radioactive counterpart of practically all the elements, and by suitable chemistry to make both inorganic and organic chemical compounds which have these radioactive elements in them. This radioactive counterpart »f an otherwise stable element is called an isotope. They are chemically identical, being merely two species of the same chemical element, having the same atomic number but a different mass number. The chemical and physiologic properties of the two or more forms of the element are identical, providing that the radiations from the radioactive: isotope are not sufficiently intense to alter the physiologic effect. By using very small quantities of these radioactive isotopes—so called "tracer" amounts-^the physiological^ effect of their irradiation can be ignored, and one can thus use them as "tagged" or. "labelled" substance to study the biochemistry or physiology desired. The great ad-i vantage of this method is the relative ease with which extremely minute amounts of an Page One Hundred and Fifty-two a M II i»;Hj ■!». ft. m I! J* it ' it* element in its compounds can be detected in the organism or its waste, without resorting to elaborate and often impossible analytical chemical assays. One other feature of the radioactive isotopes needs mentioning. This is the duration of their state of radioactivity. This is spoken of as the "half-life" of the element— namely the time required for one half the atoms initially present to disintegrate by conversion to energy. The half-lives of radioactive materials range from fractions of a second for the very unstable ones to millions of years for those only slightly unstable. For any one element there may be a choice of isotopes of widely varying half-lives for use in biologic research. Perhaps it is well at the outset to give some description of the natural radioactive environment in which the plant and animal kingdoms have lived and evolved. The earth, its soil, rocks, water and atmosphere contain small but measurable quantities of radioactivity. These are the radium which starts from one isotope of uranium, the actinium series from another isotope of uranium, and the thorium series from thorium. The final product of each series, after radioactive decay, is lead. The earth's crust, for example, contains about 2 x 10-12 grams of radium per gram. The air over most land masses contains redioactivity equivalent to about 1 x 10-16 curies per cubic centimeter. The natural radium content of man is of the order of 0.015 microgram, which is derived from food and water as products of the soil and atmosphere. Furthermore every living thing is continuously subjected to bombardment from radiations coming from the remote limits of the universe—the cosmic rays which penetrate all living matter. There is thus nothing essentially new in subjecting living matter to either internal or external irradiation. We have only learned to increase the number and quantities of these radiations and radioactive substances on our own planet. They no doubt exist naturally in other reaches of the universe, where in their presence life as we know it would be impossible. ——The first hinlngiral /?¥jv»riinpnfc tn /Wprminf i4ip effects of radioactive substances were those made in 1905 with the soluble salt of radium. Soon thereafter experimental research was begun on the biological effects of radon, mesothorium and its derivatives, actinium, polonium and uranium. These were all the radioactive elements existing in nature and were also naturally the ones which should first be utilized to determine whether or not they had a biological and therapeutic usefulness. From these early experiments as well as from the later industrial and therapeutic experiments with radium, considerable information has been built up which is a background for interpretation of some of the newer biological effects which are now appearing. Some of the techniques which were utilized in these early days are still applicable. It is of interest that the first radioautographs were made as early as 1925 when Lacassagne studied the biological effects of polonium when introduced into animals. A radio-autograph is made by superimposing the microscopic section of tissue previously impregnated with radioactive materials onto a photo plate and thereby obtaining a precise definition of the location of the radioactive materials in tissue. This remains one of the most useful methods to determine the specific uptake of radioactive materials when injected. Other methods of radiobiological assay have been perfected, and include predominantly the ashing of tissues and a determination of the radioactive content by ionization of electronic measurements. In other instances it is necessary to chemically extract the particular radio-element in question and assay its quantity. The early work with the naturally occurring radioactive elements left little doubt that they had no therapeutic application. Radium, for example, is highly toxic by reason of its radioactivity. As much as one microgram deposited within the skeletal system of man can be lethal and the tolerance concentration of radium in the body is of the order of .10 microgram. It is of interest that this is ten times the quantity which. occurs naturally due to the ingestion of the natural radioactivity of radium through food and water. Apart from the failure o£ these early experiments to indicate a therapeutic usefulness they did lay the ground work for a considerable amount of knowledge concerning the biological effects of radioactive substances. The present status of our Page One Hundred and Fifty-three knowledge resulting from the great impetus given to it by the atomic energy program is therefore much further ahead because of these early experiments. With the discovery of artificial radioactivity by Curie and Joliot in 1934 a renewed interest was taken in the possible biologic and therapeutic applications of radioactive substances. When it became evident that the number of elements which could be made radioactive was considerably greater, the number of attempts to use these new materials was greatly increased. Until the advent of the chain reacting piles which were developed in the recent atomic energy program the artificially radioactive substances were largely manufactured with the use of the cyclotron. The quantities which could be thus manufactured were necessarily limited, inasmuch as the output of energy of the cyclotron was far less than that which has more recently become available. The discovery of uranium fission and the development of nuclear physics and chemistry have currently made available radioactive isotopes for almost all elements. These are commonly referred to as "fission products" and are actually by-products of the primary use to which the chain reacting piles were placed during the war, namely the manufacture of plutonium of which atomic bombs are made. It is important to realize however that before the advent of the atomic energy program during the recent war a large biological and medical literature had accumulated on the use of radioactive isotopes. If one will but search the Index Medicus for the years preceding 1940 he will be somewhat amazed at the number of papers published in which radioactive isotopes were the subject of biological investigation. It seems likely that the security regulations will shortly be Hf ted which may permit the publication of the biologic work done in connection with the atomic energy program which will considerably augment the past literature. All of the biologic work done in conection with the program of manufacture of atomic bombs was undertaken to have a bearing upon the protection of workers engaged in the project. The number of radioactive elements encountered was such that no previous experience indicated their possible toxicity or hazards and only by biologic experimentation could these hazards be ascertained and therefore prevented. It is impossible at this time to make any complete summary of the experimental work about artificially produced radio elements. Examples of this work however will serve to indicate the lines of research which have been followed, both for the academic knowledge which they are intended to give, and for the practical application which they may have in therapeutics. The first of the radio-elements which received wide'study was radio-phosphorus. Radioactive phosphorus was first made by bombarding P31 with heavy hydrogen in the cyclotron by which mechanism it was converted to P32, or the radioactive isotope of phosphorus. The half-life of this isotope is 14.3 days. During its decay it emits beta radiation of considerable energy. Since phosphorus itself is an element common to the organism tracer amounts could be utilized without in themselves producing a chemical toxic effect. It was found that radio-phosphorus was selectively taken up by bone, bone marrow, lymphoid and other rapidly growing tissues. These tissues were therefore selectively irradiated. Knowing the energy emitted by the radio-phosphorus during its period of decay it was therefore possible to compute the dose delivered per cubic centimeter of tissue which selectively deposited the isotope. It was also possible to study not only the absorption but the excretion of radio-phosphorus via the urine, bile, and feces. The selective absorption of radio-phosphorus in tissues concerned with hematopoiesis early suggested its possible application in the treatment of blood dyscrasias and the allied diseases of the lymphoma group. The use of radio-phosphorus in the management of the leukemias and allied diseases is however more complicated than it appears on the surface. Early work indicated that the amount of radiorphosphorus retained by the body from a given total amount injected is considerably higher when the element is administered in small fractions than when given in a single large dose. The utilization of phosphorus depends upon the need of tissues for this metabolite, and the need is greatest during an active mitotic stage of the disease. The body is incapable of utilizing more phosphorus than its daily requirement so that small repeated doses result in better utilization than when larger doses are given which may further depress erythropoietic activity Page One Hundred and Fifty-four ii \< » 3 «' 4 ,f i* "4« m ■i"> m when anemia may already be a complication of the leukemia. Those who have used radio-phosphorus have repeatedly warned that in the presence of anemia the initial therapy may so depress the bone marrow that further improvement is thwarted. The method of therapy now commonly used, is the so called fractional method, by which small increment doses of radio-phosphorus are administered intravenously at weekly intervals until satisfactory remission is obtained. In this respect the blood picture is not the only guide to therapy, but as in the management of leukemic patients by roentgentherapy one relies heavily upon improvement in the general condition of the patient irrespective of his leukocytosis. Increment doses range for 500 to 3000 micro- curies, the exact dose depending upon the reaction of the patient and the disease to doses given. It was not expected that radio-phosphorus would be a curative agent in the treatment of the leukemias or lymphomas. Previous experience with roentgenotherapy indicated that considerable improvement could be obtained and that the patient's life span although not appreciably lengthened could be a more comfortable one. Experience with radio-phosphorus has now covered a period of some 10 years. It is evident from the analysis of reports by those groups having the m<<st experience with it that it has certain indications, limitations and contra-indications. The acute leukemias are not benefited by radio-phosphorus. The chronic lymphatic and myelogenous leukemias in general have a satisfactory response which however is entirely palliative rather than curative. It may also have some usefulness in the treatment of patients who have become refractory to roentgen irradiation. As compared with roentgen irradiation there is an ease of administration of radio-phosphorus, in that an intravenous injection is a somewhat simpler procedure for the patient than submitting frequently to roentgen irradiation. Extreme caution however must be utilized in the administration of radio-phosphorus because it is readily possible to induce an irreversible aplastic anemia or thrombocytopenia. It is of interest that one of the first radio elements which was the object of biologic study received so early and extensive therapeutic trial. Although radio-phosphorus is now available in quantity one sees no immediate application of it to other than palliative treatment of leukemia or more rare disorders such as polycythemia. With respect to the latter, radio-phosphorus is a useful agent to reduce the red blood count in polycythemia when the symptomatology warrants this reduction. Its use in the treatment of lymphosarcoma and Hodgkin's Disease has likewise been a palliative one. In certain clinics it has been combined with roentgenotherapy. The results on the whole have not been more spectacular than those obtained by roentgenotherapy and in certain categories of lymphosarcoma the results are inferior. This refers to the group of lymphosarcomas in which the nasopharynx, tonsil, or cervical glands are the site of the presenting tumor. Systemic irradiation by radio-phosphorus may so depress the entire economy that there actually may be a hastening of the systemic development of the disease which with roentgenotherapy acting upon the local foci as they are presented may be more advantageous in the initial stages. The use of radio-phosphorus in the treatment of metastatic; carcinoma has been entirely disappointing, as one might expect in that there is as yet no mechanism to selectively localize radio-phosphorus in the metastatic lesions. Both intravenous and local tissue injections have been tried out and by either method the results are inferior to roentgenotherapy locally applied. A second radio-element which received early investigation was radio-iodine. There are several isotopes of iodine which are radioactive. Those initially used were l130 and l131, obtained by deuteron bombardment of tellurium in the cyclotron. I130 has a half- life of 12.6 hours while l131 has a halfrlife of 8 days. A mixture of these two isotopes has been used by some investigators. It is of interest that the principle of fractionation in radiation therapy, utilized to advantage in roentgen and radium therapy, has already been studied in relation to the varying half-life of the two isotopes. Since the advent of uranium fission Iodine131 is a by-product of the fission and results in quantity. It emits an active beta radiation together with weak gamma rays. Physiologically in tracer amounts it behaves entirely as inert iodine. In quantities however which exceed a tolerance value the effect of its radiation overshadows its chemical properties. It was Page One Hundred and Fifty-five learned long ago that iodine is selectively deposited in the thyroid gland. Radio-iodine thus seemed to be a useful tool in studying iodine metabolism. Using radio-iodine it has been shown that the thyroid gland selectively deposits iodine within a matter of seconds following its intravenous injection. Since it was found that the excretion of radio- iodine was fairly rapid and with a half-life of only 12.6 hours or 8 days was deemed safe to study human thyroid metabolism at an early date. It was very soon evident that previous iodinization greatly limited the ability of the thyroid gland to take up and deposit radio-iodine injected. It was also very early seen that patients with a hyperactive thyroid had a great avidity for radio-iodine deposition in the thyroid gland. It was only natural therefore to postulate that radio-iodine might someday be of therapeutic use in the treatment of hyperthyroidism. As early as 193 8 radio-iodine was being extensively studied, not only in relation to the normal but the abnormal physiology. Normal Controls in patients with hyperthyroidism, nontoxic goiter, hypothyroidism and carcinoma of the thyroid have already been studied with this technique. The quantity of radio-iodine required to produce effect is small. In summary one can say that the hyperplastic gland absorbs and deposits radio-iodine in the active cellular constituents and to a lesser degree in the colloid. Carcinoma of the thyroid does not deposit radio- iodine to a degree making it useful in the treatment of carcinoma of the thyroid as it more commonly occurs. More recent work indicates that a small and selected group of cases of carcinoma of the thyroid, namely the papillary aberrant carcinomas occurring in younger individuals, may have a sufficient uptake of radio-iodine to justify its use in the treatment of this disease. The more rare forms of hyperactive functioning carcinomas of the thyroid, as well as their functioning metastases, have already been made the subject of investigation and therapy utilizing radioactive iodine. Several reports have already appeared in which radio-iodine has been used in the treatment of Graves' Disease. The most extensive is that from the Thyroid Clinic of the Massachusetts General Hospital in Boston. Twenty-two patients with hyperthyroidism have been treated using a mixture of l130 and l131. Of this number 14 patients responded well to a single dose of radioactive iodine. Three required two doses, and five rqeuired three doses, to obtain a clinically satisfactory response. A satisfactory response was determined as one in which the basal metabolic rate returned to normal range and a clinical symptomatology was otherwise satisfactory. Radio-iodine is as readily absorbed from the gastrointestinal tract as by the intravenous route and its ease of administration orally has been well demonstrated. In this group of patients myxedema followed radio-iodine therapy in four cases. The calculated dose to the thyroid gland was of the order of 1700 to 3500 roentgens which is somewhat higher than that which is used when roentgenotherapy is the agent in the treatment of hyperthyroidism. They have found that some patients who were sensitive to thiouracil have responded well to radioactive iodine and they conclude that this form of therapy may in the future have considerable usefulness in the management of thyrotoxicosis. This brief summary of the use of radio-iodine in hyperthyroidism does not however contain an adequate description of the great care and possible hazards of its use on any large scale. Extreme precautions must be utilized in the preparation of the isotope and in the determination of the proper dosage. Since radio-iodine is largely excreted by the kidneys we have yet to learn the possible deleterious effects over a long period of time upon the renal system. Some popular accounts of this work would have us believe that the treatment of hyperthyroidism by the oral administration of radio-iodine is as simple a procedure as the taking of a cathartic for constipation, and one popular account indicated that its greatest benefit rested on the fact that the entire treatment would not cost more than $2.50. The writer failed to realize the many thousands of dollars that were spent in the development and current production of radio-iodine, as well as the scientific knowledge required to administer it properly in selected cases. Hyperthyroidism is still essentially a disease of endocrine imbalance. Both the administration of radio-iodine and roentgenotherapy in the treatment of hyperthyroidism are essentially crude methods to depress the over active gland. Neither aims to rectify the causes for the metabolic im- Page One Hundred and Fifty-six •» J #: I till! I I II 1 i. II balance. In this respect thiouracil is a more reasonable and perhaps more fruitful path of investigation toward a true understanding of the disease and its management. Together with radio-phosphorus and radio-iodine, radio-strontium was a subject of early investigation. Strontium is an element which physiologically is closely allied to calcium. Radio-strontium therefore was a very useful tool in studying clacium metabolism and the deposition of calcium salts in skeletal growth and repair. Radio-calcium is not as useful a tool because of the technical difficulties associated with the handling and chemistry of the isotope. Radio-strontium serves as a useful substitute. One particular isotope of radio-strontium with a half-life of 55 days was originally prepared using the cyclotron, but more recently as one of the fission by-products of uranium fission it is now available in quantities for biologic experimentation. As an example of the application of radio-strontium to the physiology of bone one may cite the study of the healing of bone following trauma. Analytical chemical assays of bone salts are notoriously complicated. Both radioactive strontium and phosphorus when used in a study on the bone growth can be quickly detected by electronic methods both in vivo and following sacrifice of the animals. It has been found for example that the maximum uptake of both phosphorus and strontium occurs on about the 8th day in younger animals as compared with double that time in the older ones. These times parallel the gross healing of fracture, in both the old and young bones. Radio-elements are also beginning to be used in the study of dental metabolism, and here as well radio-strontium is already being used in a lengthy study concerning dental caries. Since radio-strontium deposits selectively in the cortex of more actively growing bones it was originally felt that it might have some practical use in the treatment of bone tumors. Hamilton published one such trial in 1942 in which radio-strontium was given to a young adult with an osteogenic sarcoma of the upper tibia. The radio- strontium was selectively deposited in the rapidly growing osteogenic tumor, with small amounts in the surrounding bone but little in the soft tissue. This initial trial was purely experimental and preceded a planned amputation. It was the first attempt to study a radio-element in the presence of a bone tumor. At this writing there is no known method which will localize radio-strontium only within the tumor. It localizes in the cortex of other bones as well and when given in amounts which could have any possible therapeutic effect upon an osteogenic tumor the patient would succumb to radiation effects of the strontium deposited throughout the skeleton. However if he were to survive these, other bone tumors would develop, owing to the continued bombardment of normal bone by strontium which is similar to production of osteogenic sarcoma by those workers who ingested radium. It would seem that the radio-element strontium can lend itself to considerable advancement in ovr knowledge of bone growth and physiology. Therapeutically it would seem to have little possibility for use. Other examples of the use of radio-isotopes are many, and a few additional ones will be cited in order to indicate the great realm of possibilities which they have from the point of view of biologic investigation. The mechanism of shock from burns and trauma has been studied using tracer amounts of radio-sodium. The entire problem of shock received great attention during the past war, and many of the studies utilized radioactive isotopes. Using radio-sodium it was learned that in shock as much as half of the total extra-cellular sodium in the body may have been removed from the active circulation and was fixed as intracellular sodium. The treatment of shock had somewhat neglected the old role of metabolites in favor of wholeblood, serum or plasma. This study together with many others indicated that it is extremely urgent to replenish the extracellular sodium, and that when this was done mortality from shock was greatly diminished. -Studies have also been made using radioactive plasma protein which incorporates amino- acid lysine synthesized with radio-nitrogen. Such labelled proteins are apparently indistinguishable biologically from proteins of normal isotope concentration. These studies indicate that the plasma proteins are normally in constant and rapid exchange with a mobile pool of body protein. In shock there is a shrinkage of the plasma volume and plasma protein mass. That indicated a decreased flow of protein into the plasma during Page One Hundred and Fifty-seven shock. Substitution of plasma protein in shock tends to offset this shrinkage in plasma volume and plasma protein content. Another example of the use of radioactive isotopes is in the study of iron metabolism. Radioactive iron has been used to study the utilization of ferrous as compared with ferric iron in anemia. In the human it has been found that the ferrous salt is much more readily absorbed and subsequently utilized than the corresponding ferric salt. The whole problem of hemoglobin metabolism and iron conservation is also under investigation utilizing radioactive tracers. Still another example of the usefulness of radioactive substances is seen in the studies made upon the absorption of insulin, when the insulin has incorporated in it radio- iodine. Previous methods necessitated quite elaborate biochemical assays. The use of radioactive msulin has the advantage that determinations are easily and rapidly made. It was found that in normal controls, and in patients with uncomplicated diabetes, in- . sulin absorption took place at an almost equal rate, which was rapid during the first 2 hours but became progressively slower in areas of subcutaneous induration or pad formation causing a pronounced retardation of insulin absorption. Patients with idiopathic insulin resistance showed significant delay in insulin absorption. In the resistant patients the blood sugar rose during the first 2 hours and had not reached normal levels at the 6th hour. Wide variations in the initial level of blood sugar did not of themselves affect the rate of insulin absorption. The cause of delayed insulin absorption is not related to a long duration of diabetes, but is resident in the tissues at the site of injection, and tends to be corrected by the continued use of insulin in amounts large enough to control glycosuria and hyperglycemia. In this respect one should mention the possibilities which will ensue when radioactive carbon14 is more readily available. The radioactive isotope14 carbon is made in the chain reacting pile. It has not been heretofore available because of the tremendous energy requirements necessitated by production in quantity. One can imagine with what curiosity those psychologists particularly concerned with carbohydrate metabolism look forward to having radioactive sugar at their disposal. Radioactive sugar within the near future is a definite possibility. There is not yet sufficient quantity of carbon14 to furnish the biologists with that quantity needed for the many phases of physiology in which carbon is of prime importance, but it can be postulated that carbohydrate metabolism will be one of the first subjects to receive consideration. Fundamental research into the whole problem of photo-synthesis utilizing radioactive substances was begun as early as 1939 by Ruben and Kamen. They demonstrated that plants and algae containing chlorophyll had the ability to assimilate a measurable proportion of labelled carbon dioxide from the aid m the absence of light. This was at variance with the older concepts of photo-synthesis which postulated that light was essential in the synthesis of starches from carbon dioxide in the atmosphere. They found that the so called "dark reduction'" was reversible and that at the end of an hour as many labelled molecules were leaving the plant as new molecules of gas from the surrounding atmosphere entered the leaves. When the experiment was conducted in the presence of light the uptake of carbon dioxide continued rapidly and was not reversible. In barley for example as much as 20 per cent of the labelled carbon dioxide was permanently synthesized into sugar within 2 hours, when in the presence of light. An analysis of their data indicated that the simple sugars are not synthesized directly in the plant, but that photochemical reactions requiring both chlorophyll and light follow upon an initial synthesis wherein light is not a factor. These experiments are cited only to indicate the contribution which radio-elements can make in understanding certain of the more fundamental processes in nature. A still more varied use of radioactive tracers is seen in the use of radio-sodium in a study of peripheral vascular disease. Radio-sodium24 emits a rather energetic gamma radiation, and it is therefore possible to follow its course in the circulation by measurements made on the outside of the body using a Geiger counter. Following the injection of a tracer dose of radio-sodium into the antecubital fossa the circulation time for it to arrive in the lower extremity can be readily determined, which in the normal individual Page One Hundred and Fifty-eight % '<* IJ Hi r M ranges between 20 and 55 seconds. The arrival of radioactive sodium in the tissues of the lower extremity is signalled by a definite increase in the counting rate. If however the counter is left in position against the foot following antecubital injection it is found that the count increases steadily. This should be expected as the result of interchange of injected radio-sodium between plasma and extravascular fluid until equilibrium is established between the two. The manner in which the equilibrium is brought about depends upon the rate of delivery of the isotope to the part by the existing main and collateral circulations, as well as on the relation between the local intravascular and extravascular space. These depend upon the normal and diseased condition of the extremity. The shape of the build-up curve gives valuable clinical information relative to the condition of the arterial vessels maintaining the viability of the part. Variations from the normal in the shape of this build-up curve have been seen in hypertension, arteriosclerosis, thromboangiitis obliterans, acute thrombosis, Raynaud's Disease, as well as other vascular disorders. The method would seem to have value in determining the advisability of persisting with conservative as compared to more radical local surgery, and particularly in determining the site of amputation in which healing might be expected. Since the quantity of radio-sodium injected is a dose of less than 1 roentgen per test and the half-life of radio-sodium is short there is no contraindication to its repetition at reasonable intervals. A practical application of the new alchemy in public health is seen in the field of industrial medicine. Many examples could be given. As a matter of fact the success with which the atomic energy program met its problems of radiation hazards was largely dependent upon the detection of radiations and radioactivity at levels below those at which they could be more hazardous. Although these are common procedures within the plants and laboratories of the atomic energy project the methods have already found application in other industries. An example of this is seen in the use of radio-active mercury used in tracer amounts in the mercury industry, to detect concenration of mercury fumes in the air. The measurement of concentrations of mercury by this method is simple, reliable and can be done continuously. The prevention of mercurial poisoning by inhalation of mercury fumes is thus possible with greater surety than by older methods. This example can be multiplied many fold in its application to other industrial toxins and problems. The foregoing examples of the use of radioactive substances in fundamental and applied biologic and medical research will indicate the manifold paths into which this new tool can lead the investigators. Indication has also been given that as yet the therapeutic application of isotopes is limited to its palliative use in the blood dyscrasias and in the treatment of hyperthyroidism. We have no indications to date that any of the radio-elements have or will have a curative value in the treatment of cancer. Both the professional and lay press would at times have us believe that the cure of cancer is just around the corner, and that its therapy may become quite comparable to intravenous injections of the arsenicals or penicillin in the treatment of syphilis. Unfortunately, before we can arrive at this stage of therapy there is much to be learned about the causes which induce organisms to spontaneous uncontrolled growth. I do not look with new hope in the future that the radio-elements will have any considerable place in the therapy of cancer. It is entirely possible however that they will play a considerable part in unraveling the biologic mysteries which surround our present ignorance into the causes of cancer. It is not entirely unphilosophical to believe that the study of neoplastic metabolism utilizing radio-carbon, radio-nitrogen, radio-oxygen and other of the more fundmaental building blocks will eventually give us fundamental information relative to the abnormalities of growth which cumulate in neoplasia. The causes of cancer when found will be those associated with abnormal growth and the treatment of the disease will then be one directed toward correcting the imbalance of growth rather than eradicating the disease by surgery or irradiation either by external or internal sources. It has been said that when as much organization, money and scientific ability have been placed at the disposal of those interested in cancer as were placed in the hands Page One Hundred and Fifty-nine I of those whose responsibility it was to make atomic bombs then the cancer problem will be readily solved. Greatly as I marveled at the scientific vision which undertook and completed the problems of controlled chain reacting piles and intricate chemical separation of plutonium and the isotopes, I cannot but feel however that the problem of understanding the causes of cancer is a very much more difficult one and will require decades for each year that was consumed in advancing the science of nuclear physics to its present status. EUSTACHIAN TUBE FUNCTION AND ITS RELATION TO DEAFNESS By J. R. LINDSAY, M.D. Read Before the Summer School of the Vancouver Medical Association, September, 1946. Much attention has been focused on the Eustachian tube in recent years as a result of the great expansion of aviation, and other occupations involving a rapid change of barometric pressure. These occupations demand that the tubes be capable of performing their function of equalizing the pressure in the middle ear with the outer air. The early otologists recognized the fundamental importance of normal tubal function for the preservation of the hearing as well as for protection from spread of infection to the middle ear. In recent years, with the relative degree of safety from infections which has been realized with sulfonamides and penicillin, there is likely to be a tendency to disregard the fact that the future welfare of the ear as an organ of hearing may not have been adequately safeguarded by elimination of the infection alone. Disturbances of tubal function usually take origin in early childhood at which time their recognition presents a special problem. Hence this discussion will concentrate upon the basic anatomic and physiologic features governing the action of the Eustachian tube and a review of diagnostic and therapeutic measures which can be utilized during childhood years. The existence of the auditory tube was known, according to Politzer1 in his "Ges- chichte der Orenheilkunde" even to Aristotle, Celsus and later Vesel, although their conceptions were not clear. The honor of discovering it has been accorded to the Italian anatomist Bartolomeo Eustachio, of the sixteenth century, who first gave a careful description of the tube and recognized its great physiologic importance and its value to therapy. Page One Hundred and Sixty / '/; ; h m i* hi- ir II : A m •p According to Politzer the first real contribution to otologic therapy was made by a French postmaster in Versailles, Monsieur Guyot, as a result of the failure to get any help from various doctors for his impaired hearing. In 1724 he hit upon the idea of attacking his trouble through the pharyngeal orifice of the tube, and by means of a tube made of tin with a knee bend, inserted through the mouth, he irrigated the Eustachian canal. This was the beginning of therapy directed to the Eustachian tube for relief of impaired hearing. One after another, and apparently independently, different authors began to describe similar procedures. The first to suggest the insertion of a catheter through the nose was an English army doctor, Cleland, who published his method in 1741. He used a flexible silver tube whose anterior end was ensheathed with the urethra of a sheep and whose posterior end was equipped with a piece of ivory to which a syringe could be fitted to permit the injection of either air or tepid water to aid in removal of obstructing material. About the same time Jacob Wathen gave a careful description of a method of catheterization which is essentially the same as that now in general use. But while air is about the only medium injected nowadays, then and for a long time afterwards, different solutions were used to a great extent. Thus Wathen suggested warm water and a little honey of roses. While the therapeutic procedure of catheterization of the tube developed as a result of necessity it was not until about a century later that the physiology began to be understood. Anatomy The tube which connects the middle ear with the nasopharynx consists of a bony and a cartilaginous part. The bony part is about 12 mm. long in the adult and is surrounded by pneumatic cells (peritubal cells) of varying extent in the majority. It is lined by columnar ciliated epithelium which may extend a short distance into some of the peritubal air cells. There are no glands in the bony portion. The rigid walls of the bony tube provide for a funnel-like action permitting air to pass from the middle down the tube involuntarily to equalize pressure. The cartilaginous portion consists of an elongated plate of cartilage with the upper border rolled outwards so as to give the appearance of an inverted J. in cross section. The anterior end of the cartilage forms the torus tubarius in the lateral wall of the nasopharynx. The tube lumen appears as a vertical slit parallel to the cartilage extending upwards beneath its upper rolled border or hook. The lateral wall of the tube in its lower two-thirds or more is supported by connective tissue and a pad of fat and is subject to the action of certain muscles, the most important of which is probably the tensor veli palati (Ricb.2), and of lesser importance, the levator palati and salpingopharyngeus. The cartilaginous tube is lined by ciliated columnar epithelium and contains many mucous glands which empty into its lumen and provide a sheet of mucus moving towards the pharynx. The tube is thereby provided with a mechanism suitable for protection against ascending infection. Physiology The various protective functions performed by the Eustachian tube were apparently not realized until late in the nineteenth century. These functions were later shown to include prevention of ascending infection, the shutting out of the various noises present in the pharynx from the middle ear, protection of the ear from the constantly changing air pressures in the pharynx during respiration, sneezing, coughing, and noseblowing, along with a mechanism to provide for equalization of air pressures during rapid changes of barometric pressure consequent on certain occupations. Toynbee8 of the Cornwall Infirmary in England.in 1853 was the first to show that Page One Hundred and Sixty-one il the tube is normally closed, and opens only under certain conditions. The manoeuvre which bears his name, consisting of swallowing while holding the nose closed, was thought by him to force air into the middle ears, and that swallowing afterwards without holding the nose then opened the tubes to relieve the pressure. Politzer4 later (1864) showed by means of a manometer sealed in the external canal that Toynbee's manoeuvre caused an inward movement of the drums due to removal of air from the middle ears. Jago5 working with Toynbee supported the view that the tube is normally closed in a classical series of observations on himself on a group of symptoms which he correctly interpreted as due to a continuously open tube. In 1897 Hartmann6 worked out basic quantitative data on Eustachian tube function using a pressure chamber and manometers. He found that rapid decrease of pressure caused a spontaneous exit of air through the tube beginning when the pressure was lowered 30 mm. Hg. below that of the middle ear and that an increase of pressure to 130 mm. Hg. would not force the tube open but resulted in a sense of extreme pressure and pain in the ears. Only by active swallowing could the development of such symptoms be prevented. He also found that in order to inflate the ear by Valsalva's method a pressure of 20 to 40 mm. Hg. was normally required and also that flexing the head on the chest increased the resistance. Politzer showed that when a vibrating tuning fork was held in front of the nose until it could no longer be heard the action of swallowing caused it to be heard again momentarily (autophony). He interpreted this to mean that the tube normally opens during swallowing. In 1936 Zoellner,7 in the effort to determine criteria for normal tubal function in candidates for the aviation service studied the pressures necessary to open the tube during swallowing. He found that positive pressures of from 0.5 to 4.0 mm. Hg. in the nasopharynx were normally required to inflate the ear during swallowing with the patient in the erect position. Further efforts to obtain information on the state of tubal function are represented by the work of Van Dishoeck8 of Amsterdam who devised and used an apparatus called the "pneumophone" to determine the existing pressure in the middle ear. On the basis of the observation that the abnormal tension on the drum caused by an unequal air pressure on the two sides caused a depression of hearing, the pressure in the middle ear could be estimated by determining the degree of positive or negative pressure in the external auditory canal necessary to equal it. The pressure at which a tone of constant intensity conducted through the tube was heard the loudest indicated the middle ear pressure. Perlman9 has constructed an apparatus combining that used by Zoellner with the pneumophone and has made quantitative studies of tubal function in a variety of clinical conditions involving the auditory apparatus. The unusual demands placed upon the Eustachian tube by the development of aviation as well as the submarine, Caisson work and diving have stimulated extensive studies in recent years. Armstrong and Heim10 at Wright Field made detailed observations during ascent and descent in a pressure chamber, confirming in principle the observations of Hartmann. They measured the pressures at which the tubes opened spontaneously during ascent, and noted that lacking such movements as swallowing, yawning or similar movements to open the tube during descent after a pressure of difference of 90 mm.Hg. had been reached, voluntary opening of the tube was no longer possible. The application of this information to aviation and other occupations requiring adjustment to variations in pressure is that the persons exposed must be aware of the necessity of voluntarily opening the tubes during descent, and in case of any tubal occlusion should be familiar with the means of facilitating opening of the tube such as chewing gum, Valsalva's manoeuvre, use of a vasoconstrictor before descent, or the use Page One Hundred and Sixty-two i . M \ L tt HR I 4 '*! JL M .•f i<r jfo 1 il fit i> .1 of an inflated balloon with the nozzle inserted in One nostril, while holding the other closed to raise nasopharyngeal pressure during swallowing. In order to prevent inconvenience and disability to passengers the rate of descent has been limited to 500 feet per minute on commercial lines, and because of the fact that the tubes open less easily in the lying than in the erect position, and swallowing occurs only about once a minute during sleep, passengers should be awakened during descent. The presence of any known chronic difficulty in opening the tubes or any acute inflammatory condition involving the nasopharynx should serve as a warning either to remain at normal pressures or to be prepared for difficulty by having various means at hand to aid in opening of the tubes. Practical methods for testing Eustachian tube function objectively are of value, both in clinical practice and in the selection of personnel for occupations at abnormal barometric pressures. Tests which have long been available are: 1. Valsalva's manoeuvre using the auscultation tube to hear the click as the tube opens or observing the drum for the bulging that occurs as air is forced into the middle ear. The pressure normally required is 20 to 40 mm.. Hg. with the individual in erect position. Exercise causes the tube to open more easily and while in the lying position the resistance to inflation is increased. The pressure can be measured easily by attaching a nasal bulb and tube to the manometer used in reading blood pressures, the pressure exerted by the Valsalva test can then be read off on the manometer. This simple test is of especial value where the complaints suggest an abnormally patent tube, since the tube would then be either constantly open or open on slight pressure. 2. By observing the drum through a Siegel's speculum it can be seen if the bulge caused by the Valsalva test is relieved by swallowing. 3. If the bulging isn't relieved by simple swallowing Toynbee's manoeuvre may be tried. 4. If these methods fail Politerization may be tried during phonation or swallowing. While these methods have been of practical value in experienced hands the demands of aviation in particular have demonstrated a need for more accurate methods, and the following have been developed. 1. Zoellner's method of measuring the pressure necessary in the nasopharynx to open the tube during swallowing, as compared to the normal of 0.5 to 4.0 mm. of mercury. 2. The pneumophone (Van Dishoeck) by which the middle ear pressure can be estimated and the presence of an abnormal pressure detected, thereby indicating a failure of tubal function. 3. A combination of these two principles in an apparatus devised by Perlman, which allows for making either of these determinations as well as the pressure necessary to open the tube by Valsalva's manoeuvre. This apparatus also provides for inflation of the tubes during swallowing and is useful for therapy, particularly in children. Clinical Application While these methods have a place in evaluating the degree of abnormal function the information gained from the clinical history, hearing tests and observation of the drum provide the most practical indication of the existence of tubal dysfunction. A convenient method for classification of clinical states based upon disturbances of tubal function is as follows: 1. Disease due to failure to compensate for rapid changes in barometric pressure, a. Acute aero-otitis media or acute barotrauma. This term refers to the changes in the middle ear resulting from failure of the tube to open during the increase of external air pressure, for instance during descent in an Page One Hundred and Sixty-three aeroplane or compression in a pressure chamber. It may occur in the presence of normal tubal functions if the tubes are not opened voluntarily, or in tubes with impairment of function of an acute or chronic nature. When the pressure difference reaches about 80 mm. Hg. the tubes cannot be opened voluntarily, and pressure can only be equalized by returning to the former altitude or by Politzerization. Great pressure differences tend to cause haemorrhages in the middle ear mucosa and accumulation of fluid in the air spaces. Rupture of the drum and middle ear infection are infrequent. Treatment consists of equalization of pressure by the Eustachian catheter or Politzerization and the use of vasconstrictors in the nasopharynx. About two weeks are required for complete recovery. b. Repeated attacks of aero-otitis or barotrauma apparently lead to chronic changes in the middle ear with symptoms of blockage, head noises and difficulty in clearing the ears by opening the tubes. The type of deafness is usually a combination of inner ear and conduction types. The inner ear component may be due in part to acoustic trauma, but may also occur in caisson workers who have not been exposed to acoustic, trauma, apparently as an effect of caisson disease. 2. Disease occurring at normal barometric pressures: a. Abnormal patency. Jago5 of Cornwall in 1867,. Rumbold11 of St. Louis in 1873 and Perlman12 of Chicago in 1939 have presented accurate observations on abnormal patency. The condition may vary in degree from a tube which opens more easily than normally to one which is continuously open while patient is in the erect position. Such a tube fails to protect the middle ear from noises and pressure changes during respiration, sneezing, coughing and phonation. The continuously open tube may be diagnosed by observing movements of the drum on respiration, facilitated by use of a Siegel's speculum and by autophony (nasal sounds may be clearly heard through an auscultation tube from the patient's ear). Hearing is impaired. One patient was observed to keep the nasopharynx closed involuntarily during speech (rhinolalia clausa) apparently to protect the ears and as soon as the tubes were closed the speech became normal. Such patients hear well when in the lying position. Lesser degrees of abnormal patency may be detected objectively by measuring the pressure necessary to inflate the tubes by Valsalva's method. Pressures of over 15 mm. Hg. are normally required. Abnormal patency is not common. It has been observed in women who have lost weight rapidly, also in some stages of a subacute pharyngitis, and following retrogas- serian neurectomy. Treatment by insufflation of a small amount of boric and salicylic powder, equal parts through a Eustachian catheter gives immediate relief lasting several days. Attention to the predisposing factor such as loss of weight is indicated. b. Obstruction of the Eustachian tube. Varying degrees of obstruction may occur. Complete obstruction to the degree which resists all attempts at producing a passage by inflation or bouginage is rare, but does occur. Etiology. In childhood the common predisposing cause for tubal obstruction is hypertrophied pharyngeal tonsil (adenoids). The obstruction is due mainly to apposition of the mass of lymphoid tissue to the torus tubarius and to the tubal orifice. Lymphoid tissue within the tubal orifice is also reported to be a frequent occurrence, by the Johns Hopkins group. Less frequently tubal blockage may be caused by an allergic reaction in the upper respiratory tract and also any chronic inflammatory reaction due to the purulent drainage from the nose and sinuses. The occurrence of cleft palate and primary atrophic rhinitis also predispose to interference with tubal function. In the adult, tubal obstruction is usually of the chronic variety and can be traced Page One Hundred and Sixty-four t% I: ftHl 1? IS i ft ti'*' Ik. -9 W back to an origin in childhood. The degree of obstruction may gradually increase over a period of years, and only in adult life reach the stage of producing serious impairment of the auditory apparatus. Obstruction may also develop first in adult life. It is a characteristic accompaniment of tumors in the nasopharynx and may appear during a prolonged allergic reaction or sinus suppuration, or may follow a severe acute inflammatory episode. Lymphoid tissue has been thought to occur in adult tubes also and produce obstruction. The presence of such tissue in adult tubes has not been satisfactorily demonstrated although the obstruction caused in childhood years may persist after the lymphoid tissue has regressed. Clinical Course. A mild degree of obstruction produces a lowering of air pressure in the middle ear and impaired hearing due to the tension exerted on the drum and ossicular chain. Such a degree of obstruction is never complained of by a child and will rarely be detected without a careful and skilled examination. In the adult, acute obstruction of this degree causes subjective sense of blockage and hearing impairment whereas in the chronic state there may only be mild symptoms. A further degree of obstruction results not only in failure of admitting air but in accumulation of fluid in the middle ear and its connecting air cell system. Such fluid is in part mucus secreted by glands of the tube and the epithelial lining and may be transparent and viscous, or it may have more characteristics of an exudate, with a yellowish color and a high-protein content. A small amount of fluid may be easily detected by the appearance of fluid lines through the drum, but as obstruction increases all air disappears and the middle ear and cell system become completely filled with fluid. The presence of chronic tubal obstruction appears to be associated in many cases with decreased resistance against invasion by infection from the pharynx. The obstruction is always increased during infection at the nasopharyngeal orifice and fluid is likely to accumulate in the middle ear cell system at that time. Regression of the infection may allow the fluid to be removed and the middle ear again become aerated in a period of two to four weeks, but with.repeated attacks or with increasing obstruction aeration of the middle ear may not return. The middle ear system may remain filled with sterile fluid for months or even years. Fibroplastic changes are likely to occur in such ears leading to permanent impairment to the action of the conclusion mechanism, so that eventually removal of the fluid and improvement of tubal function will fail to bring the hearing back to its former level. The tendency for recurrent attacks of either non-suppurative or suppurative otitis media to occur in such ears also predisposes to fibro-plastic changes in the middle ear resulting in irreversible hearing impairment. Chronic tubal obstruction predisposes to formation of an attic cholesteatoma, through prolonged retraction of Shrapnel's membrane and accumulation of desquamated epithelium in the pocket thus formed. During an acute exacerbation of middle ear inflammation the process of desquamation speeds up, the accumulation increases, becomes secondarily infected, attic suppuration occurs and the beginning of an attic cholesteatoma is established. Diagnosis. In the adult the early degree of chronic obstruction causes subjective impairment of function which is most noticeable with upper respiratory infections and may cause difficulty during flying. Objectively there may be retraction of the drum and measureable impairment of hearing for low tones. The pneumophone reading shows decreased middle ear pressure. Impairment of ability to open the tubes may be demonstrated on such tests as Valsalva, swallowing, Toynbee, and the pressure required to inflate during, swallowing. In a later stage when the middle ear is filled with fluid there is hearing loss for high and low tones, middle ear pressure may be normal (pneumophone) and the patient cannot inflate the tubes. Page One Hundred and Sixty-five Wi 'rema/rm .AT THE MENOPAUSE HIGHLY POTENT ORALLY ACTIVE NATURALLY OCCURRING ESSENTIALLY SAFE WATER SOLUBLE WELL TOLERATED IMPARTS A EEELING OF WELL BEING conjugated oestrogenic substances (equine) supplied in two strengths: No. 866— 1.25 mg. per tablet No. 867 — 0.625 mg. per tablet Both strengths are supplied in bottles of 20 and 100 AYERST, McKENNA & HARRISON LIMITED Biological and Pharmaceutical Chemists MONTREAL CANADA LABORATORIES OF CANADA, Ltd., 64-66 Gerrartl Street, East, Toronto, Ontario TOPICAL CHEMOTHERAPY in oropharyngeal infections Prompt and long sustained in effect, the sulfonamide is maintained in intimate therapeutically effective concentration throughout the entire oropharyngeal area. Systemic absorption is negligible even in maximal dosage, therefore likelihood of systemic toxic reactions is virtually obviated. Full stability, and therefore potency, is retained under all conditions. Its clinical value in the topical treatment of oropharyngeal infections has been established by longer professional use than any other local chemotherapeutic or antibiotic agent. Each tablet contains 3% grs. (0.25 Gm.) of sulfathiazole. Supplied in packages of 24 tablets, sanitaped, in slip-sleeve prescription boxes. IMPORTANT: Please note that your patient requires your prescription to obtain this product from the pharmacist. ulfathiazoleoum •' J t'; ■ '- . 1 , ' H t] - 1 > § -. i ■>. ■ ■' '■ t ' I ii i f * SK| ' $ j I W i u i * 1 , H1 * *, 5 L ( i * ■ i ' i". ^ y > ' ?*1 »... ,i j 119 ir **# •' 1! 'V ill i : i I 17, K A i ^ ji •:(? ^H <»i > ■ > fe j u ' J. f i r> *fi! r ■ a ■ i Mi! H i * $4 * ' ■? . *• J '^ r«M * ' * i i - m t » ■ • i e * '5 i •'* f( v 1 J** »■' j£ lb i «i| L (i i |i^ • i < ii L ^^^ Ji. announcing. a New Chemotherapeutic Agent The nitrofurans, a new class of antibacterials, are a recent discovery of Eaton Laboratories1: One, especially, is highly effective. This has been named Furadn, ,n CHNNHCONH, Furacin is bacteriostatic and bactericidal to many gram-positive and gram-negative bacteria, and remains effective in the presence of body fluids It is stable and low in toxicity it ,o, W First Available in FURACIN SOLUBLE DRESSING Indications: .ft^ 1. Dodd, M. C and Still man, W. B., J. Pharmacol. & Ex- per. Therap. 82:11,1944. 2. Snyder, M. L., Kiehn, C. L. Christopherson, J. W., Military Surgeon P7:380, 1945. 3. To be published. Dissolved in a bland, water-soluble base, Furacin is first presented in Furacin Soluble Dressing, for topical treatment of wound and surface infections. This preparation liquefies at body temperature and is soluble in blood, pus and serum, which aids penetration to all parts of wounds. It is non-irritating, has a low index of sensitization and does not interfere with healing processes. The outstanding results of clinical trials in both military2 and civilian3 practice indicate, that it possesses important advantages in comparison with sulfonamides and penicillin used topically. Infected surface wounds, or for the prevention of such infection—infections of third and fourth degree burns—carbuncles and abscesses after surgical intervention—infected varicose ulcers—superficial ulcers of diabetics—secondary infections of eczemas—impetigo of infants and adults—treatment of graft sites preparatory to skin grafting, and later, to prevent infection—osteomyelitis associated with compound fractures—secondary infections of dermatophytes. For * further information, address: Canadian Office, 77 Wellington Street West, Toronto, Ontario. Attention Medical Director. Now available in Canada, through your regular source of supply. 3-47 The diagnosis of fluid filling the middle ear space is made on the transparent, faintly yellowish appearance of the drum with the narrow chalky appearance of the handle of the malleus. Such a drum, if not retracted or distorted and not reddened is invariably thought to be normal by the inadequately trained observer. An X-ray examination shows diffuse clouding of the cell system. This is the characteristic condition in tubal obstruction due to tumor and in obstruction due to adenoid hypertrophy in children. In the child it is unfortunately the fact that all degrees of tubal obstruction up to, and including, complete filling of middle ear space with fluid, if affecting only one ear, produce no complaint and require for detection unusual care and skill on the part of the examiner. The child makes no complaint unless pain occurs and hearing impairment is only detected by the parents when both ears are involved. As the child gets old enough to respond the hearing test will confirm the diagnosis. When fibrotic changes have developed in the middle ear the diagnosis is made more easily by the presence of distortion, retraction and possible scars due to former suppurative episodes but this represents an advanced stage of the condition when restitution to normal function is no longer possible. Simple tubal obstruction with decreased air pressure in the middle ear produces impaired hearing for air conducted sounds of frequencies up to about 2000. The stiffness of the conducting mechanism has been increased by the unequal pressure on the drum. Tubal obstruction with complete filling by fluid causes both a low and high tone impairment. The middle ear pressure may become normal as the air is all displaced by fluid. >J.ti; Fibrotic changes in the middle ear are accompanied by conduction impairment for low and high tones. Treatment. Once the diagnosis has been made the treatment is relatively simple. Hypertrophied adenoids are removed surgically. When the tubal obstruction is in the early stage the tubes usually open up within a month afterwards and if the child is old enough to respond to tests the hearing will be shown to be normal. Failure of the tubes to open, or recurrence of lymphoid hyperplasia, common in the young child, is usually an indication for radiation therapy. When tubal dysfunction is associated with fibrotic middle ear changes radiation may be tried as well as adenoid- ectomy and inflation of the tubes. The type of radiation therapy which has met with greatest approval is the radium applicator applied by way of the nose to the mouth of the tube as developed by Crowe13 and co-workers of Johns Hopkins Hospital. Since obstruction usually occurs at the pharyngeal orifice this method is more direct than deep X-ray therapy. The dosage worked out at Johns Hopkins Hospital appears to be safe and satisfactory. The results depend upon the nature and stage of tubal occlusion. Simple occlusion with middle ear system filled with fluid may exist for several months and yet restitution to almost normal hearing be possible. The presence of fibrotic changes in the middle ear may however permit only partial restoration. Adults with blockage due to nasopharyngeal carcinoma usually have restoration of tubal function and normal hearing after deep X-ray therapy although obstruction was of many months duration. An exudative catarrh (middle ear system filled with fluid) may be brought on by an allergic state or by upper respiratory infections. In such cases a chronic tubal impairment is usually a predisposing factor. Failure of tubes to open up in the adult is an indication for direct treatment. Removal of the fluid from the middle ear by myringotomy and inflation may be necessary. Myringotomy is seldom required in the child. In advanced obstruction in adults the use of a bougie in skilled hands may give definite improvement. The state of tubal function and the future welfare of the ear as an organ of hearing Page One Hundred and Sixty-six it t-i 4 \n A i.i I it' II is often decided in early childhood years, at a time when no subjective complaint will be offered short of actual pain. The detection of impaired function in early years usually depends upon the examiner's ability to detect certain signs of tubal blockage on otoscopic examination. Unfortunately these signs are likely to escape detection except by the specially trained observer. As the child becomes old enough to respond reliably the hearing test becomes an important part of the examination. The cessation of aural discharge, with healing and disappearance of redness of the drum which occurs almost universally under adequate chemotherapeutic treatment is not a reliable indication that tubal function has been restored. Care must always be taken to detect and correct those conditions which produce tubal impairment and predispose to slowly developing middle ear damage and irreversible impairment of hearing. BIBLIOGRAPHY 1. Politzer, Adam: Geschichte der Ohrenheilkunde, Stuttgart, S. Enke, 1907-13. 2. Rich, Arnold Rice: Physiologic Study of the Eustachian Tube and Its Related Muscles, Bull. Johns Hopkins Hosp. 31: 206, (June) 1920. 3. Toynbee, J.: Proc Roy. Soc. London, 6: 286, 1853. 4. Politzer, A.: Textbook of the Diseases of the Ear. Ed. 3, translation by O. Dodd, p. 63. Philadelphia: Lea Brothers and Co., 1894. 5. Jago, J.: Brit, and For. Med. Chir. Rev., 34: 175 and 496, 1867. 6. Hartmann, A.: Experimentelle Studien uber die Funktion der Eustachischen Rohre. Leipzig: Vert. u. comp., 1879. 7. Zoellner, F.: Archiv. f. Ohren-Nasen-u Kehlkopfh., 140: 137, 1936. 8. Van Dishoeck, H. A. E.: Negative Pressure and Loss of Hearing in Tubal Catarrh, Act. Oto-laryng., bt: 303, 1941. 9. Perlman, H. B.: Quantitative Tubal Function, Arch. Otolaryng. 38: 453-465, 1943. 10. Armstrong, H. G., and Heim, J. W.: Effect of Flight on the Middle Ear, J. A. M. A. 109: 417 (Aug. 7) 1937. 11. Rumhold, T. E.: The Function of the Eustachian Tube. St. Louis: Southwestern Book and Publishing Co., 1873. 12. Perlman, H. B.: The Eustachian Tube, Abnormal Patency and Normal Physiologic State, Arch. Otolaryng., 30: 212-238, 1939. 13. Crowe, S. J. and Burnam, Curtis F.: Recognition, Treatment and Prevention of Hearing Impairment in Children, Ann. Oto. Rhin. & Laryng., 50: 15-31, (March) 1941. and Crowe, S. J.: Local Use of Sulfadiazene Solution; Radon, Tyrothricin and Penicillin in Otolaryngology, Ann. Otol. Rbin. & Laryng. 53: 227-241 (June) 1944. Page One Hundred and sixty-Seven INJURIES OF THE FACE AND JAW By DR. ROBERT G. LANGSTON (at V.M.A. Meeting of January 7th, 1947) The title that I have taken for my paper tonight—"Injuries of the Face and Jaw", may better have been "War Injuries to the Face." It is based upon cases treated personally in the past five years as a member of a Maxillo-Facial division of the Ministry of Health of Great Britain and later of the Department of Veterans' Affairs. After some thought, I discarded the academic approach to the subject, dispensing with the usual form of a rigid classification—physical signs, examination, treatment and prognosis, etc. I decided rather to treat the subject more from a practical clinical view point. In this way, I hope that I may give those having a face wound to treat, a practical point or so that will be of use. If I can share with you some of the methods of procedure that have evolved during the past 5 years, I shall be pleased. After all, it makes little difference whether the wound was caused by a shell splinter or a splinter from a shattered windshield—they are both mutilating to human tissues and require almost identical treatment. In round figures there were 600 faces to draw from, with 1100 operations—averaging almost 2 operations to the case. Of this number there were 240 fractured mandibles and 75 fractured maxillae—not including the simple malar fractures. In reviewing the case histories, one can see a gradual change in method of treatment with a much more marked improvement in the results—both in the time of convalescence and the final cosmetic result. I believe this improvement was accomplished by: 1. Acquired knowledge and familiarity with injury and complications. 2. Standardization of procedures in conjunction with one's fellow surgeons in the same unit, as well as a competitive spirit with other units. 3. Newer methods of treatment, particularly the introduction of Penicillin—advance in methods of anaesthesia and development of better means of fixation in case of fractures. Facial surgery has some aspects and principles that are peculiar to itself. Being so close to the oral and nasal orifices, it must at all times be considered an infected area— Occasionally there is an exception to this axiom. Practically, all wounds involve the muscles of expression—in repair, this must be considered as well as some appreciation of the final cosmetic result. Where a wound enters the oral or nasal cavity, one must realize that it is very important to close the wound on the inner side as well as on the outer. The abundant blood supply, and especially the excellent venous return, make it possible to carry out procedures impossible elsewhere in the body. Finally, the close proximity of vital structures, eye, nerves, large vessels, parotid, etc must be remembered. If the sight of one eye has already been lost, the other eye appears to be particularly vulnerable to mishap. In starting a discussion of this kind, it is usual to get everything down in an orderly classification. This can be done and there are several ways of classifying face wounds. But I think little can be gained by such a system, so I am going to proceed with a description of what I think is the best procedure in the treatment of a compound comminuted fracture of the face. This can then be modified to cover any lesser type of facial injury. There is one exception and that is fracture of the jaws, which will be dealt with separately. On initial examination, one attempts to assess the magnitude of the injury. I think it is safe to say that one almost invariably underestimates the amount of damage done. X-ray is of some aid, but not as much as elsewhere in the body, certainly one does not wait for it, if there is a suspicion of continuing haemorrhage. However, should there be signs of skull or brain damage, the value of x-ray increases. The ability of the patient to stand operation should be estimated, haemorrhage and/or respiratory embarassment being the more important factors. The latter is usually relieved by the anaesthetist. And ■r^w~ Page One Hundred and Sixty-eight '<* .Xh fe. I • this brings me to an important part, the role of the anaesthetist in facial injury. His work is equal to that of the surgeon and at times is more life-saving. As soon as the decision is made to operate, the patient is turned over to the anaesthetist. He examines heart, lungs, B.P. and haemoglobin and makes his decision on the type of anaesthetic. A big percentage of facial cases have swallowed and inhaled blood-, mucous and sometimes foreign bodies. If the chin or upper neck has been lost, or the tongue badly lacerated, the patient will be having respiratory embarrassment. The usual anaesthetic is Pentothal induction followed by Cyclopropane and oxygen until the patient is relaxed. Then laryngoscopy is done, a McGill endo-tracheal tube inserted, and larynx and bronchi cleaned of all mucus and blood. Occasionally it is necessary for the anaesthetist to do a bronchoscopy at this stage to get the lungs dry. As soon as this toilet is done, the pharynx is packed tightly and the anaesthetic continued away from the vicinity of the head on a closed circuit. If his condition was poor to start with, the patient now greatly improves. Heart and respirations become normal almost immediately. Also the surgeon is able to proceed deliberately with his work, with perfect freedom and relaxation. I want to pause here a minute to pay my respects to the anaesthetist. Try to picture a face that feels and looks like a bag of jelly with an odour which is peculiarly nauseating because it is 48 hours since wounding, a patient that is apprehensive and sick of himself because of this B. Coli odour and the fear that he will never look like a human being again. His lungs and bronchi are full of pus and blood and you can hear his rales all over the ward, saliva is streaming down his torn lips and "his chin is resting on his sternum, his colour is terrible and he is begging for a drink.** In this condition, he is taken to the operating room and the anaesthetist takes over. In about half an hour, he is breathing quietly, dry and of a healthy pink colour, ready for operation. "All open face wounds, regardless of age or condition of infection, should be treated by surgery**. That is a sweeping statement to make, but I have yet to see one that has been improved by waiting. If blood is urgently needed, it can be given while the operation proceeds; most surely a severe infection or cellulitis needs adequate and radical drainage and the anaesthetist invariably benefits the case of respiratory embarrassment. In operating, one should proceed with despatch and thoroughness. First, the face and open part of the wound should be thoroughly cleaned, removing all foreign bodies in the skin and the wound. There should be no hesitation in using a brush and excision if necessary to rid the wound of powder marks, road dirt, pieces of wood or other debris. There is a commercial demulcent—called C. tab—cetyl-tri-methyl ammonium bromide that is much superior to soap. It cleans better, is less irritating and is far superior as a skin antiseptic There is no danger in using this around the eyes or nose. After this scrubbing, the wound is flushed with saline and debridement done. The latter should be minimal and confined to entirely devitalized tags of tissue. About the face, one is safe to save as much as possible because of the vascularity. This, however, does not apply to bone fragments. The bones of the face are thin and fracture like an egg-shell. A concerted effort must be made to remove all loose pieces. At times, when getting up into the region of the ethmoids, sphenoids and palatine bones, one wonders when to stop. But, unless a complete removal of all loose fragments is made, a draining sinus is most surely to result which will be traced to a sequestrum or a catgut suture. There is quite an effective way to remove small fragments of bone. Pack the wound with dry gauze and then twist it as it is removed. The pieces of bone catch in the cotton meshes. After this is done, the next step is to identify and separate the different layers. The skin edges must always be undercut and sometimes fairly widely undermined. It is wise, also, to loosen the edges of the muscle layers, so that they may be brought together. When the wound involves the mucous membrane, it should be treated as one does the skin layer and be undermined fairly widely. Page One Hundred and Sixty-nine Haemostasis. Bleeding is usually profuse at first and should be controlled as one goes along, by haemostats. But I think it is a mistake to put a ligature around every bleeding point immediately. I like to leave the haemostats on until just before starting to close; and then take them off—often twisting them while doing so. I believe that 90% of the bleeding can be controlled this way. Those that continue to bleed are caught a second time and ligatured with 4 or 5'0' plain catgut. The less catgut that one leaves in an infected wound, the less likely it is to break down. This is important, as along with pieces of dead bone, catgut is an arch offender as a cause of a persistent draining sinus. Just before the closure is started, a dusting of the wound with 50,000 to 100,000 units of Ca. Penicillin is made. I have used sulpha compounds alone, later incorporated with Penicillin powder, but I am firmly of the opinion that sulpha used locally does no good and may cause some harm. If sulpha therapy is indicated, it should be confined to systemic administration and never used locally. Also, before starting closure, one should attempt to orientate all separate flaps and find out where they belong. The axiom of Sir Harold Gillies, to return normal to normal as a first step in facial repair is a good way to proceed. First the mucous membrane layer is sutured, putting the catgut suture knots on the oral side. This layer should be tightly closed, draining if necessary, outwards. After the mucous membrane, the muscle layers come next. These should be accurately approximated and as far as possible, returned to their normal position. This is often impossible, if the wound is ragged and lacerated. The muscle layer is held in position by the minimum number of fine plain catgut sutures, tied loosely so as to accomplish approximation without seriously cutting off blood circulation. At this stage, it is wise to insert a Penrose drain below the layer of the sutured muscle. The next layer is the skin. Those edges that can be returned to their normal positions are first sutured and the remaining defect will be a measure of the skin loss. For closing this defect, one of the methods presently to be discussed should be used. The skin suturing should be carefully done, using fine braided silk or stainless steel wire on a fine cutting needle. Care should be used to see that all edges are everted. Better results will be obtained by using many fine stitches close to the skin edges rather than heavier sutures with skin edges gaping between them. Another precaution, is to avoid bruising or pinching the skin edges. Small minute haematomata form—followed by oedema and finally a minute gangrenous area, at a place where healing by primary intention is important. Another drain is inserted below the skin layer along with the deep layer drain. Finally a firm elastic pressure dressing is applied. The patient is turned back to the anaesthetist, who uses particular care to clear the pharynx and bronchi of any blood or secretion, so that he returns to the ward, in good color, breathing quietly and with all wounds closed. The drains are only safety valves and can be removed in 24 hours. One is always surprised at how well and appreciative the patient feels the next day. Methods of replacing skin losses at the time of the initial operation. After one has estimated the amount of skin loss—there are several recognized ways of dealing with it. One should never succumb to the temptation to cover the defect with a sterile dressing with an idea of returning later or allowing it to granulate. It is much better to shave off a piece of split skin from upper arm or leg and apply it as a dressing. Should the defect prove small, it may be possible by widely underniining of the skin, to suture it directly. This is often possible, but care should be taken that there is very little tension on the skin sutures. The wound is potentially infected and this type of wound edge does not hold if there is tension. The second method of procedure is the rotation flap and this, on the face, can be very successful. It needs careful planning before execution and it requires a certain amount of experience to execute. Essentially, the principle is to utilize skin that is available in excess, and adjacent to the wound, and then to close the secondary defect by undermining and under tension. The Page One Hundred and Seventy ?* ■I ■;;* ,« I' i i I If 1 *Hf i ii t» .» flt moving picture to follow will show one of these flaps. A third method is the use of a pedicle flap—usually brought from the forehead down. These are particularly valuable when the defect is m the region of the nose or the upper cheeks. A fourth method of temporarily closing a defect where it involves a cavity, such as lips, lower cheek or nostril, is the mucous membrane to skin suture. Here, both the skin and >mucous membrane are undermined and then pulled over the edge of the wound and sutured. This is a most valuable procedure, especially where a complete lower lip is lost and one does not feel equal to, or the patient cannot stand, a double rotation flap from .the cheeks. It is also valuable when a complete nasal ala is lost and until a lined forehead flap is prepared. And finally, there is the method already mentioned, of filling the defect with a split skin graft. This will be a permanent dressing until one is able to plan and prepare a more pleasing and satisfactory repair. Where there has been a great loss of muscle and bone, it may be impossible to fill the defect. The best procedure is to pack the cavity with vaseline mesh unless there is skin available, when a pack of Whitehead varnish may be packed into the cavity with some protruding into the mouth where it is later removed. Later, bone grafting may be done or the cavity filled by a tantalum plate. This latter is especially applicable to the forehead or skull. This closed treatment of infected and granulating face wounds has proven a big advance over the open treatment. One who has been brought up in the "drain*', if in doubt*' school had many sleepless nights when he first tried it, along with his colleague, in our unit. But the results have justified the method. There is much less scar contracture and the patients have been much more comfortable. They feel better immediately, the temperature comes down and the swelling comes down rapidly. The snug elastic, well-padded dressings are important. I do not wish to convey that all the stitches hold—usually some give away. But there is very little gaping, and healing is rapid. The sinuses, where the drains were removed, discharge for a few days and they may need closure 10 to 14 days later. But this is usually excision and suturing only. A secondary, but important consideration, is the mental effect upon the patient. He comes in acutely distressed, physically and mentally; and very much depressed. His face is a large, fungating, stinking cavity with saliva drooling away uncontrolled. Breathing is difficult because of blood, mucus and secretion in the throat and bronchi. He is thirsty, and to drink makes him worse. . Then he is operated upon. When he awakes, he is dry, breathing easily and he has some semblance of a face. His nightmare has passed. Fractures of the Jaw This is one type of injury of the face that, I feel, we as medical men have sadly neglected. It is so often our policy when we are presented with a fractured jaw, to refer them to a dentist for whatever fixation they see fit. The dentist does the best he can in his own way without the benefits of a surgical approach to the problem. The result often is indifferent and the dentist continues treatment of the case after the fracture is set, by adjustment of the biting surfaces, extraction and/or plates. In normal civilian life, fracture of the mandible is a fairly common occurrence and I think we should be prepared to accept and to handle it competently. Years ago, a fracture of a bone was not considered an emergency, and was often allowed to go for several days before treatment. The Orthopaedic section of our profession has proven that a fracture is an emergency, and by treating it as such with early accurate, rigid fixation, has shown results far superior to those of a by-gone day. Exactly the same holds true for a fracture of the jaw. It should be set immediately, accurately and firmly fixed. If this is done, union is primary, the results are excellent and the patient is left with a mandible as good as before his accident. As is the case with fractures elsewhere, those of the mandible must be diagnosed as simple or compound, and then treated accordingly. This is important, if one is to prevent the ever present complication of infection of the area—which if left or in- Page One Hundred and Seventy-one completely treated so often leads to chronic recurring osteo-myelitis. When the fracture occurs in a dentulous (tooth-bearing) area of the bone it should be considered compound. The mucous membrane is so closely attached to the bone at the tooth junction that it splits with the slightest displacement and infection from the mouth is introduced. With an edentulous mandible, this occurs somewhat less frequently. When one can be certain that he is dealing with a simple fracture with no break in the mucous membrane around the tooth, treatment revolves itself into rigid fixation alone. These cases, when teeth are present, can be safely referred to a dentist. But the percentage of this type is usually small and the majority of fractures must be placed in the compound class. One is firmly convinced, after treating many hundreds of fractured jaws, that the problem is solely a surgical responsibility—calling in the help of the dentist when intra-oral fixation is decided upon; for tooth extraction, when necessary; and for oral hygiene during the period of fixation. This view is held by the British, Canadian and American Armies. All units dealing with fractured jaws, placed the responsibility on the shoulders of the surgeon. As I proceed with my outline of what adequate treatment is, I think you will agree with me. A fractured jaw should be treated and fixed as soon as possible after being first seen. Certainly within 12 to 24 hours. The only contra-indication that I can see for immediate operation, is a recent meal which may cause post-anaesthetic vomiting, or some more serious injury elsewhere which contra-indicates anaesthesia and operation—such as severe head injury. An accurate diagnosis of the extent and position of the injury before operation gives one a good idea of the best method of fixation. This should be by X-Rays and examination. Unless the fracture is just a crack or definitely a simple fracture, the case should be hospitalized and a general anaesthetic given. The experience of the Army units, was that pentothal induction followed by cyclopropane and oxygen was much the best, to prevent post-operative vomiting. This is important if fixation is inter-dental wiring or cap splints where the jaws are fixed together. In this respect, there was always a wire cutter at the bedside of the post-operative patient until he was fully awake, but I cannot remember a time that they were ever used. To start the operation, the jaw is examined to check diagnosis. Any teeth that appear to be in or adjacent to the line of fracture are removed, and should any loose small pieces of bone be found, they should be removed as well. The question of sacrificing teeth in the line of fracture has often been a controversial one, especially with our colleagues, the dentists. It is true that occasionally a loosened tooth may re-establish its root socket. But so often, non-union or localized infection can be traced to a tooth that has been allowed to remain in the line of fracture. Again, such a tooth is sometimes needed to maintain position, and it is allowed to stay. But almost without exception, it has to be taken out before union will proceed. This usually means that the patient has to remain wired up for a second six-week period and that is always embarrassing and unsatisfactory. Should there be a haematoma in the floor of the mouth, under the tongue, it should be drained. Such a haematoma presses the tongue upwards and may cause difficulty in swallowing after the jaws are fixed together. The next question is one of establishing through and through drainage. There has been much pro and con discussion for this procedure. I think that the tendency is towards more early drainage at the fracture line prophylactically. I feel that, should one suspect that infection could have entered into the fracture line, drainage should be done. Certainly if there is any swelling below the jaw in a fracture 24 or more hours old, drainage is needed. A small stab incision is made well under the ramus of the mandible—taking care to avoid the facial vessels, a pair of forceps or scissors is thrust up to the bone and the fracture line identified; the forceps is continued up along the inside of the ramus and brought out into the mouth and a piece of hard rubber drain inserted. This is removed in 24 to 48 hours and very little scarring is left. I cannot remember seeing the complication of infection or osteo-myelitis in a Page One Hundred and Siventy-two t* * ft IB HI V k rit iV* 1 ." jaw that was drained when first fixed. Whereas, I would think one sees it in 20% of cases of compound fracture when not drained. After these points are taken care of, fixation of the jaw is the next problem. There are many ways of fixing a broken mandible, and different sets of conditions call for different methods. As a general rule, the simplest type should be used as long as it effectively fixes the broken bones with fair comfort to the patient. To ascertain and maintain proper position, use is made of the maxilla—thus some type of inter-dental fixation is the usual method. This may be by wiring the lower teeth to the uppers by one of several methods. A much more comfortable, effective, but elaborate means is the construction of cap splints. These are made by casting silver to a mould of the teeth, one plate in the uppers and one in the lowers. These are cemented on the teeth and then held together by small plates and bolts. It is possible to make these cap splints to the normal position of the pre-fractured mandible, so that when they are cemented onto the teeth, position of the fragments must be correct. In a well run maxillo-facial department, where there is complete coordination between the surgeon and the dentist —such as we have at the Army and D.V.A. hospitals, these cap splints are ready for setting 8 to 12 hours after the patient is admitted. Other methods are or should be entirely surgical. They involve open reduction where much comminution is present and wiring the fragments together. A method of fixation, which is practical and extremely effective is the use of the Roger-Anderson type of pinning. This involves the placing of stainless steel pins in the bone from the outside and conncting them by adjustable bars and locks. Just as the success or failure of the Roger-Anderson type of fixation depends upon asepsis, in Orthopaedic Surgery, so does it apply to Maxillo-facial Surgery. When one decides to pin a jaw, the pins should be put in before the oral cavity is exposed or the fracture examined from inside the mouth, that is at beginning of operation. When all the aseptic precautions are used, the incidence of pin infection is very low. One has seen a 30-bed ward devoted to fractured jaws with at least 50% pinned—go for several weeks without an infected pin in the lot. One has also had the opportunity of seeing at least 35% of the pins infected and loose when used indiscriminately by operators who did not really understand surgical orthopaedic asepsis. I have not discussed the advantages of pin fixation. The main advantage is the mobility of the mandible which may be allowed at once or usually within a week. This is important and allows a working man to get back to some sort of work early. With jaws wired together, the average loss of weight due to a fluid diet is 15 lbs. in the 6 weeks of fixation. These are also quite uncomfortable, are unable to speak distinctly and need to have a meal every 2 hours. With the pinning, the feeding is not a problem, neither is the oral hygiene. They also are quite comfortable after the first few days. I have only covered a few of the many methods of fixation. Some others are practical occasionally—others are almost bizarre—and have been conceived in the desperation of attempting to get fixation of some particularly difficult fracture in the days before a rational surgical approach was considered. I must here make note that it is entirely possible that the use of the sulpha group of drugs and penicillin may have made possible the progress in the surgical approach. However, of this one is not entirely convinced, as of late I have used less penicillin with what appears to be just as favourable results, I would urge in treating fractures of the jaw, that they be done as soon as possible, that fixation be complete and adequate, that teeth in the line of fracture and small detached pieces of bone be removed and that when one is in any doubt as to infection, do a through and through drainage. The complications, non-union, infection, osteo-myelitis, mal-union and arthritis of the temporo-mandibular joint or a detached head of the mandible are separate problems and need treatment suitable to the individual case. Fractures of the Maxilla The incidence of fractures of the superior maxilla is much less than that of Page One Hundred and Seventy-three the inferior mandible. It is less exposed than the protruding chin which goes with the mandible and also is much stronger because it is fixed to the cranium. However, blows to the face or the upper teeth may cause it to fracture. This break is much less likely to be compounded and more apt to be comminuted. It may involve only a segment of the tooth-bearing area or it occasionally may crack completely around about the tooth prominences from one maxillary tuberosity to the one on the opposite side. This allows the fractured bone to behave much like a loose dental plate—that is to be moved up or drop down. Again, the break may extend up into the floor of the orbit, in the maxillary antrum or the floor of the cranial vault. The diagnosis of this fracture is often quite difficult even when x-ray plates are taken. Usually the face is swollen and there is some disturbance of the bite. The upper teeth are often anaesthetic and the patient is not certain exactly what is wrong. The displacement may be minimal, and as the lower jaw is brought up, it reduces the fracture so that one is apt to conclude that no fracture is present. With a fracture of the infra-orbital margin, diplopia, conjunctival haemorrhage and a flatness of the cheek is noted. I think the best method is the use of stereo. X-Rays when an appreciation of the extent of the break is best visualized. As to treatment, reduction should be done as early as possible. If more than a week elapses, reduction becomes most difficult and requires a great deal of force or even open cutting along the fracture lines. The trouble lies in the fact that the deformity does not become very evident until after the facial swelling has subsided. The deformity is due to impaction of the thin facial bones with shortening of the longitudinal length of the face. After reduction is done, fixation is maintained by inter-dental wiring or cap splint utilizing the mandible as a splint. If the mandible is fractured as well, one has to go further afield to get a point of fixation. This is usually the skull. It is possible to put a Plaster of Paris band around the head so that it is fixed to the head and yet remain comfortable. In the Plaster of Paris headcap is embedded an attachment to steel rods which can be formed and carried to any position of the face. Then an attachment is made to the loose fractured maxilla. This can be done by inserting an ordinary bone screw into the fragment or if a straight pull is needed to attach a wire to an upper tooth and bring it out through the cheek. And, here again, the moulded cap splint can be utilized. This is cemented to the teeth and connected by a steel rod to the rod attached to the headcap. Any one of these methods give fairly rigid fixation. In the case of the fractured mandible as well, the fixation can be made to include that bone as well. I admit that all of this sounds very much like building with a mechano set or a Heath Robinson fantasy, but when properly applied and well adjusted the results are very good and the patient is very comfortable. To reduce the fracture, it is often necessary to expose the fracture line. It may be compounded and the approach already there. If not, a modified Caldwell-Luc approach is excellent, going through the anterior wall of the maxillary antrum from the superior sulcus of the mouth. It may be necessary at times to use this approach in an old unreduced malar zygomatic fracture. Position is maintained in this case by packing the antrum. I have covered my subject very sketchily. I hope that you may be indulgent if at times I have seemed dogmatic. But I feel that all too often injuries of the face and jaw could be treated with more care. Except for superficial lacerations, I do not think that satisfactory repair can be made in an office or under local anaesthetic. Surely, the face, with its cosmetic importance, should rate extreme care when it comes to repair of injury to it. Too often one sees road dirt or tar tattooed into a face or nose that could have been scrubbed out easily at the time of the accident. This may never be removr- able later, or if so, only with extensive plastic procedures. And surely a fractured jaw requires as urgent and complete treatment as a fractured arm. Page One Hundred and Seventy-four fyoHcotuAen, QenesixU cftaifUtal Section *> A CASE OF OBSTRUCTIVE JAUNDICE By E. S. JAMES, M.D. Jaundice of the newborn as in adults may be classified as hemolytic, infective, and obstructive. The commonest types of haemolytic jaundice are physiological icterus, icterus gravis, or congenital haemolytic disease as it is now called, and familial haemolytic icterus. The second group, infective jaundice, may be due to sepsis, or congenital syphilis. In sepsis, the portal of entry is most commonly the umbilicus and the skin; the most common offending organisms are the streptococcus, staphylococcus and colon bacillus. Obstructive jaundice at this age is due to atresia or stenosis of the bile ducts. In complete obstruction the icterus comes on shortly after birth and the skin becomes progressively more jaundiced until it is dark green. The stools are white. The serum bilirubin is very high and the Van den Bergh, direct. Mechanical obstructions are often asociated with atresia and other lesions in this region of the duodenum. Some of these abnormalities can be attributed to arrested development, but others in which abnormal bile ducts communicate with one another cannot be explained in this way. The obstruction may be complete or partial. Rolleston and McNee suggest that congenital obliteration of the bile ducts may be caused by a localized peritonitis. Obstruction may involve the larger passages or the intra-hepatic ducts. Occasionally unilateral obstruction of a hepatic duct occurs. Baby W. was a full term infant born on July 20th, 1946. Birth "weight was 7 pounds, 3 oz. The baby lost weight for 4 days then began to gain on a formula of whole milk, water and dextro-maltose. The baby appeared normal and on the 6th day was transferred to the Infant's department to await adoption. Physical examination at this time was negative. The following day the baby was noticed to be slightly jaundiced. On July 31st the jaundice began to fade and it was thought to be physiological jaundice. A few days later it was thought that the jaundice was becoming deeper. The stools were pale yellow. The W.B.C., R.B.C., and Hb. and differential count were within normal limits. The blood Kahn was negative. The Van den Bergh was direct and the serum bilirubin was 12.5 mgm. Bile was present in the urine but no urobilin. The fragility of the red cells was normal, hemolysis beginning at 0.4%. During the following month the infant's general condition remained good and the child gained weight, so that by the middle of September she weighed over 10 pounds. The jaundice varied from slight to moderate from week to week while the stools varied from light to light yellow to white in colour. The baby was given bile salts by mouth during this period. A surgical consultation was requested with the possibility of an exploratory laparotomy in mind. Dr. Neilson saw the infant and suggested that this should be done as the obstruction was obviously only partial and the variability of the intensity of the icterus suggested that the obstruction might be due to pressure from without on the extra-hepatic ducts. This might possibly be caused by an aberrant vessel or band which might be removed surgically. Moreover, the longer obstruction was unrelieved the greater danger of biliary cirrhosis. Operation was performed on October 7th. Under ether anaesthesisia the abdomen was opened through a right rectus muscle splitting incision. The presenting liver was enlarged slightly beyond what would be normal for this child's age. It was finely trabeculated with greyish colored strands and finely lobulated, presumably the early stages of a cirrhotic liver. There was no free fluid in the abdominal cavity. Page One Hundred and Seventy-five The biliary tract was exposed by elevating the liver and retracting the viscera downwards. After division of a few fine adhesions it was found that the biliary tract was practically surrounded by hypertrophied glandular tissue in a fairly dense mass. The doudenum was mobilized to a small degree. Structures taken to be the gall-bladder and common duct were visualized but the surrounding tissue seemed to be so firmly adherent that it was thought to be poor judgment to dissect out these structures. In other words much harm could be done and it was thought that the separation would only become adherent again and that the glandular hypertrophy, if it subsided, would allow patency of the tract to re-establish itself. The other abdominal viscera were in normal position and the spleen was not enlarged. The ileocaecal angle was exposed and a considerable number of glandular masses found ia the mesentery similar to those found about the biliary tract. A biopsy was not taken because they were of the usual mesenteric adenitis type so far as appearance was concerned and removal of one from the biliary tract would entail considerable dissection. No further manipulation or exploration was done and the wound was closed with interrupted fine silk sutures in three layers. The conclusion was reached that the diagnosis as to the cause of jaundice was pressure from an enlarged gland. Treatment is suggested with this child to be given general support, possibly the use of iodides and quartz lamp, all of which may cause the glands to disappear and allow the biliary tract to function.'* The post operative course was uneventful and the child is receiving 5 grs., of potassium iodide t.i.d. If no improvement is noticed in two or three weeks it is suggested that radiation therapy be given a trial, in the hope that the adenopathy may regress. 7 TREATMENT OF AN UNUSUAL CASE OF SPONTANEOUS PNEUMOTHORAX By T. K. McLEAN, M.D. This is the history of J. B., a twenty-year-old white male, who is 6f eet, 3 inches tall, and broad-shouldered. His past history is essentially negative, except for the usual childhood illnesses, and infantile paralysis at the age of three, which involved his right leg. During the last week of February, 1946, he had a loose cough, mainly during the day. On February 28 th, he had a chest survey. On March 1st, after coughing, he developed a pain in the epigastrium which he described as "indigestion-like'* in character. This later radiated up to the right shoulder, causing several severe bouts of coughing. Following this, it was noted that he was somewhat short of breath. I saw him that evening, at which time he had a right-sided pneumothorax. He was admitted to hospital where he remained for twenty days. His treatment during this time consisted of bedrest, and on one occasion, sixteen days after admission, 300 cc. of air were removed from the chest, leaving a slight negative pressure. He was discharged to his home where he remained in bed for a short time. On March 27th, he developed a mild upper respiratory infection with cough which lasted approximately one week. From April 13 th to April 20th, two lots of 500 CC. of air were removed from his chest at home. On April 30th, he was re-admitted to hospital where he remained for fifty-five days. On this second admission, it was decided first to remove air* in frequent small amounts of 200-300 cc. From May 1st to May 11th, 930 cc of air were removed from his chest. He was given codeine, grs. J4, every four hours, to suppress a mild irritating cough. On May 18 th, he was bronchoscoped by Dr. Harrison. On May 22nd, it was decided to remove larger amounts of air at a time, and from May 22nd to May 26th, 2000 cc of air were removed. On May 30th, Dr. Harrison operated upon him, repairing the leak in the lung which was due to a ruptured emphysematous bleb. Twenty-four days later he was discharged to his home. Since that time he has been well, has resumed his work, has been out shooting, and has recently gone by air over the Rockies. gfe> Page One Hundred and Seventy-six 'if .ii •ft Forty years ago it was considered that all spontaneous pneumothoraces were due to tuberculosis, but gradually it came to be recognized that there was a form which occurred in healthy, young adult males that did not carry such a grave prognosis. These cases were first thoroughly described by Kjaergaard1 in 1932, who, after a laborious search of the literature found reports of nine autopsies, in six of which emphysematous blebs were found protruding from the pleural surface, usually in the region of the apex of the lung. In five of the six, rupture of one of the blebs had occurred. In the other three cases, no cause was found for the pneumothorax, the lungs having been described as normal. None of Kjaergaard's fifty-one personal cases came to autopsy; but in some he thought he could demonstrate by X-Ray emphysematous blebs. He called this condition "pneumothorax simplex'* but it has been more commonly described as "idiopathic spontaneous pneumathorax". In 1933, Kjaergaard2, after further investigation concluded that all cases of spontaneous pneumothorax due to ruptured vesicles resulted from one of three causes: . 1. Localized emphysematous changes in the lung. 2. Scar tissue in the lung or pleura. 3. Congenital cystic disease of the lungs. In 1939 Hamman3 suggested a fourth cause, namely, rupture of the mediastinal pleura when there is mediastinal emphysema present. The presence of emphysematous and other blebs of the pleura is now thought to be the cause for the occurrence of idiopathic spontaneous pneumothorax. Kirchner4, however, in 193 8, called attention to the fact that the disease will "occur in young people who rarely show emphysema and spare the aged, in which emphysema is fairly common," and suggested that ideopathic pneumothorax may be the result of a "congenital pleural defect or an acquired pleural defect with a congenital analogy" and that the formation of pleural blebs may be a secondary manifestation of a primarily weakened pleura. Lorge5, agreeing with Kirchner, states "the primary cause of idiopathic pneumothorax is to be found in a constitutional inferiority of the pleural structure" and gives the following factors in support of this theory: 1. Age incidence, usually below 40. 2. Sex distribution, practically all male. 3. Adhesions, usually absent. 4. Fluid, usually absent. 5. Recurrences, common. 6. Familial occurrence, recorded several times. 7. Re-expansion rate, possibly slow. In regard to this last point it is here that our case presented the greatest anxiety. Most cases make steady progression after the first week and usually are completely re- expanded at two months, although it would be safe to say that the majority are re- expanded at a month. LeWald6, in 1928, reported two cases, one of which was a year re-expanding and the other had not re-expanded at the end of eleven years. This second case may have been congnital absence of the lung. The other case, he did not state the degree of collapse of the lung. You will note, in our case, that the lung seemed to be totally collapsed and our problem was to know how long an apparently healthy lung might remain collapsed and not develop fibrosis which might in later years leave a lung an easy prey to disease. Gun-shot wounds of the chest, in as short a time as six weeks, may give sufficient fibrosis to make re-expansion almost impossible, but here we are dealing with damaged lung. In our case the lung re-expanded well under anaesthesia althuogh it was somewhat slow coming up the first time. Bibliography: 1. KJAERGAARD, H.—Spontaneous Pneumothorax in the Apparently Healthy Acta Med. Scand. 43: 1. 1932. 2. KJAERGAARD, H.—Pneumothorax Simplex Acta Med. Scand. 80: 93. 1933. 3. HAMMAN, Louis—A Note on the Mechanism of Spontaneous Pneumothorax, Ann. Int. Med., 13: 923. 1839. 4. KIRCHNER, J. J.—A. J. Med. Sc, 196: 708, 1938. 5. LORGE, H. J. The Etiology of Idiopathic Pneumothorax, A. J. Med. Sc, 199: 635, 1940. 6. LEWALD, L. T.—Persistent Nontuberculous Pneumothorax, Arch, of Surg,, 16: 426, 1928. Page One Hundred and Seventy-seven POLYPOSIS OF THE COLON By C. G. POW, M.D. Senior Interne in Surgery, Vancouver General Hospital By definition, this condition consists of the presence in the colon, caecum to rectum inclusive, of polypi, pedunculated or sessile tumours of the mucosa, whose essential component is glandular tissue and whose supporting structure is fibrous tissue with a vascular supply. I would classify these polypi as follows: (1) Pseudo polypi, in reality hypertrophic folds in the mucosa on an irritative or inflammatory basis, arising in cases of Ulcerative Colitis, Amoebic Dysentery or Chronic Bacillary Dysentery which I will mention just to dismiss with the statement that they are never malignant and disappear with the cure of the disease. (2) Multiple or Familial Polyposis, a fairly rare condition in which the polypi occur in large numbers, often obscuring or replacing the mucosa from the ileo-caecal valve to the ano-rectal junction. There are about 100 cases of this reported in the literature and in most of them there is a strong hereditary predisposition. The incidence of malignant changes in one or more of these polypi is very high. (3) Single or at any rate few polypi. The incidence of malignancy in these varies greatly with the criteria employed to assess malignancy, but in most large series the malignancy is placed at from 20% to 35%. These vary in size from a few millimeters to two centimeters in diamtter for the stalk, while the head may be any size up to the size of a man's fist. The incidence of polyposis as reported from various centres varies greatly. .1 will not bore you with numerous statistics, but three or four of the reports from the literature will illustrate the frequency of this condition. Lawrence in 7000 autopsies performed in the Cook County Hospital reports 2.37% of the polypi in the colon and 0.42% in the rectum. Susman in 1,110 autopsies reports 6%. These can be reconciled by the fact that in the latter case fewer children were included in the autopsy material. In the larger clinics where proctoscopic examinations were performed routinely on large numbers of patients, the incidence of rectal polypi has been variously reported in the neighborhood of 3% to 6%. The presenting symptom or symptoms in patients with polypi or polyposis varies with the keenness of observation of the patient. First in appearance is the presence of red blood on the outside of the stool at defaecation. This has to be differentiated from that caused by haemorrhoids. In every case of haemorrhoids the possibility of polypi should be kept in mind and the condition ruled out, as in many cases the two conditions occur simultaneously in the same patient. Connected with this is the complaint of anaemia, due to the persistent loss of blood. A second early complaint is that of a sense of something protruding on defaecation when there is a polyp on a long pedicle near enough to the anal orifice. A third presenting symptom is chronic persistent diarrhoea with the passage of six to eight stools per day. A fourth symptom is an early morning urgency to defaecate. A fifth symptom that is generally a little later is the passage of white mucus on defaecation. Lastly, in the case of a large polyp, obstruction may be the present symptom. Diagnostic methods for polyposis are as follows: (1) Digital examination. This simple procedure will reveal a surprising number. (2) Anoscopic Examination. (3)—Sigmoidoscope—after adequate preparation with castor-oil and cleansing enemas. (May just precede the radiological examination). (4) Radiological Examination—after adequate preparation as above; it should include post evacuation films and double contrast films. Page One Hundred and Seventy-eight J I The danger from polyposis may be due to: (1) Malignancy. (2) Diarrhoea. (3) Anaemia. ( 4) Obstruction. (5) Intussusception. Treatment: The treatment of polyposis is entirely surgical, but the method varies with the operator, the location of the polyp, whether single or multiple, and finally whether cancerous or precancerous. (1) If single and below the peritoneal reflection of the rectum: (a) Method of choice—excision with the electro-cautery and fulguration of the base, (b) Some operators favor the paracoccygeal approach with surgical excision of the polyp and its base, and repair of the rectum. (2) If single and above the peritoneal reflection of the rectum: (a) Excision of the polyp and the base with repair of the colonic wall, (b) Local resection of that section of bowel. (The previous two operations are done with an abdominal approach after adequate preparation of the patient with sulfasuccidine and a non-residue diet.) (3) If multiple (a) If few polypi are in the rectum subtotal colectomy with an ilio-sigmoidostomy and fulguration of the remaining polyps in the rectum, (b) If many polypi are in the rectum down to the ano-rectal junction, total colectomy with an ileostomy. d«S ■ii n J'4: 4U if) CAMERA SALON TO HOLD THIRD ANNUAL SHOWING The third annual showing of the Canadian Physicians* Fine Art and Camera Salon will be held in the Hudson's Bay Auditorium in Winnipeg during the week of the 23 rd to 27th of June, in conjunction with the Convention of the Canadian Medical Association. The Salon will play an important part in the Convention and many doctors are expected to submit entries. The Canadian Medical Association Salon Committee—a committee of Canadian doctors—is composed of Dr. G. E. Tremble, Dr. J. L. Notkin, and Dr. A. Jutras, of Montreal; and Dr. Harvey Agnew, of Toronto. Dr. Tremble has been elected Chairman of the Committee. The judges of the Salon this year will be Mr. Alex Musgrove, D.A., Curator of the Winnipeg Art Gallery Association, Professor W. Leach and Mr. Newton Brett, of Winnipeg. Since its inception, the Salon has been met with increasing enthusiasm, as there are a surprising number of doctors who have adopted painting and photography for hobbies as a welcome relief from the constant strain and overwork of the past few years. At the request of Canadian doctors, the Salon this year will be divided into three sections: the Fine Arts and monochrome photography of last year will be retained while, an additional section for Kodachrome transparencies has been added. The Fine Arts section includes: paintings in oil, water colours and tempera, charcoal drawings, pastels and etchings. Two bronze plaques, sculptured by Miss Eugenia Berlin, S.S.C., will be presented, one to the winner in the Fine Arts section, and one to the winner in the Photographic section. Awards of merit will also he presented. The prizes and awards will be made at a meeting of the Medical Council on Thursday, June 26. The Salon is sponsored by Frank W. Horner Limited, of Montreal. Page One Hundred and Seventy-nine DR. WILFRED L. GRAHAM Obitt 6 February, 1947 In the sudden death of Dr. Wilfred Graham, at the comparatively early age of 51 the medical profession of Vancouver lost a man who promised to become one of its most distinguished surgeons. In fact, one might say that he had already qualified in this capacity. His ability as a surgeon and especially as an abdominal surgeon, was well-known, and his work in gastric surgery particularly was rapidly bringing him into the front rank of Canadian surgeons in this department alone. Dr. Graham came to Vancouver from Toronto in 1927. He had served with distinction overseas in the first war, in the C.A.M.C, as it was then called, and held the rank of Lieut.-Colonel. Shortly after his arrival in Vancouver, he joined the attending staff of the Vancouver General Hospital and was a member of that staff till his death. His work and qualities as a surgeon soon brought him to the front, and he became established as an authority in his subject. To those who sought his opinion and advice as a consultant, he was unfailingly cordial and helpful, generous with his time and attention. We extend our deepest sympathy to his wife and family. DR. WALTER SCATCHARD M.D., M.R.C.S. (Eng.), L.R.C.P. (Ireland), L.M. MObiit 13 April, 1947 l-f Born in Yorkshire, England, January, 1861. Obtained his M.D. at London University, and was made a Member of the Royal College of Surgeons in 1882, a Licentiate of the Royal College of Physicians of Ireland and of Midwifery in 1892. He was for some time house surgeon of Leeds Hospital in Yorkshire, with the late Mayo Robson. Married at Faversham, Kent, England, April, 1888, to Ada Kemble Donne. Around 1887 he purchased a practice at Bough- ton, Kent, which he conducted until 1907, when, on account of ill health, he was advised to come to Canada. He settled at Armstrong, B.C., and practised there until 1910 when he moved to Chase, which town was then in the making. Besides his general practice, he was company physician and surgeon for the Adams River Lumber Co. Ltd.; also under the Department of Indian Affairs at Ottawa he was physician and surgeon to the Indians of the Adams River, Squilax, Chase and Shuswap Reserves He practised at Chase continuously fromi 1910 to February of this year, when on account of ill health he was forced to discontinue his work. During his forty years of practice in Canada, he had only four days holiday which were spent on a week end trip to Banff with his eldest son who was visiting him from Ascension Island. During the serious 'flu epidemic of 1918 only one of his scores of patients so afflicted died. He was a member of Salmon Arm Lodge No. 52, A.F. & A.M. Was an excellent sportsman, one of his greatest thrills being when after a two-hour struggle he landed a 19-lb. trout on a 9-oz. rod and light fly tackle at Adams River. He was an excellent wing shot also, a year or so ago bringing down 13 ducks with 11 shells. It was very seldom that he did not make every shot count. His wife died 27 July, 1940, also a son, Mowbray, died April, 1912, at the age of 17. He has one daughter, Mrs. Mildred Gating, living at Chase; also 4 sons, Charles Edward of Kent, England; Walter Kemble of Rossland, B.C.; Gerald Cowper of Kamloops, B.C., and Geoffrey Howard of Millet, Alta. There are 9 grandchildren and 2 great grandchildren. *s it m Page One Hundred and Eighty ji 'i r m 44 *t m 1 -j, 4*1 if 1 Bl L 1% Ae«*f. a«f^ Ao^W The profession extends to Miss Vera Smith, for a number of years Secretary for the British Columbia Medical Association, best wishes for happiness in her new life as Mrs. Paul Keating. Congratulations to Dr. R. W. Irving, of Kamloops, on his recent election to senior membership in the Canadian Medical Association. Dr. J. S. Kitching has left the Metropolitan Health Committee to join the Health Department of the City of Hamilton, Ontario. Dr. O. O. Stromberg has left Vernon and is now residing in North Battleford, Sask. Dr. T. J. Speakman has joined the Montreal Neurological Clinic, Montreal, Quebec. Dr. P. W. Hudson has moved from New Westminster and is now practising in Trail, B. C. Dr. K. P. Sunderland has left Essondale and is now with the Provincial Mental Hospital at New Westminster, B. C. Dr. Don Wah Lim has left St. Paul's Hospital and has taken residence at Beattie Anchorage, B. C. Dr. B. D. Prosterman is now practising in Ladysmith, B. C. Dr. A. R. Hicks has left Vancouver to practise in Princeton, B. C. Dr. Robert H. Gourlay is, at present, doing post-graduate work in Surgery at McGill University. Dr. Grant A. Gould attended the Washington State Medical Association course in Surgery, in Seattle during the month of March. Dr. G. I. Theal is visiting in Ontario until July when he will return to British Columbia to take up practice in Courtenay. Dr. and Mrs. J. S. Henderson of Kelowna are enjoying a three months holiday in Eastern Canada and the United States. Recent visitors to aVncouver from outlying points: Dr. F. M. Bryant and Dr. T. McPherson of Victoria. Dr. H. F. P. Grafton and Dr. J. S. Burns of Kamloops. Dr. V. G. Goresky of Castlegar. At the monthly meeting of the New Westminster Medical Society, Dr. D. E. Starr gave an interesting illustrated talk on "Backache". Congratulations to the following parents on the birth of daughters: Dr. and Mrs. A. R. Anthony. Dr. and Mrs. C. H. Hankinson (Prince Rupert). Dr. and Mrs. G. H. Stephenson. and on the birth of sons: Dr .and Mrs. T. F. H. Armitage. Dr. and Mrs. Gordon H. Francis. Dr. and Mrs. . O. R. Garner. Dr. and Mrs. J. A. Ireland. Dr. and Mrs. F. E. Kinsey. Dr. and Mrs. G. A. Nicolson. Dr. and Mrs. Donald Starr. Dr. and Mrs. John P. Wellwood (New Westminster). 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When mixed, each cc contains not less than 1000 units of penicillin at pH 6.0. holds the pH at 6.0—optimal pH for maximum stability of penicillin in solution ... physiologically approximating the slightly acid pH of normal, healthy nasal secretions. in the treatment of acute and chronic sinusitis, by displacement, irrigation or tampon ... full strength or diluted with one part normal saline.. as combination package containing one vial each of dried calcium penicillin (approximately 15,000 units) and specially buffered Neo-Synephrine Hydrochloride Solution %% (15 cc). Available on prescription only. &i*a/ 6u/t/i/y teflon teowe&f New York S-77A • Kansas City • WINDSOR e ONTARIO San Francisco • Atlanta B Detroit • Sydney, Australia • Auckland, New Zealand 1 Ann. 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C. exclusive nmeuLnncE " SERVICE I VANCOUVER: 13th Avenue and Heather Street f Air. 0080 NEW WESTMINSTER: 814 London Street ||UJ. 00 We Specialize in Ambulance Service Only J. H. GRELLIN W. L. BERTRAND NEXT IN IMPORTANCE TO DIGITALIS aea&frjadkte... Salyrgan-Theophylline Mersalyl and Theophylline m In many cases of congestive heart failure, mercurial diuretics, are next in importance to digitalis in maintaining the patient's comfort and prolonging life. Following an injection of Salyrgan-Theophylline in patients with marked edema the urinary output frequently amounts to three or four liters in twenty-four hours. Ampuls of 1 cc and 2 cc for intramuscular or intravenous administration. Also tablets (bottles of 25, 100 and 500), for oral use as an adjunct to decrease the frequency of injections and when parenteral therapy is impracticable. '% "Salyrgan" trademark Reg. U. S. Pat Off. & Canada CHEMICAL COMPANY, INC. Now York 13, N. Y. Windsor, Ont. im t I '.M I i. I ti i* i, d& Jvl t" jr. js; S C CE I C jj A T THE SERVICE OF JLE D I GIB E ij D 1 C 1 N E Um C3 CO CO ILANTJrTSOII the champing teeth, the tonic and clonic contractures, the incontinence—all may yield to DILANTIN SODIUM. The E.E.G. can trace the pathologic brain wave, yet the epileptic may be spared bis terrifying episodes. Powerfully anti-convulsant rather than dullingly hypnotic, DDLANTIN SODIUM KAPSEALS* offer to the epileptic a sense of security and an opportunity to lead a more normal and useful life. flffPj DDLANTIN SODIUM KAPSEALS—another product of revolutionary importance in the treatment of a specific disease; another of a long line of Parke-Davis preparations whose service to the profession created a dependable symbol of significance in medical therapeutics—MEDICAMENTA VERA. DILANTIN SODIUM KAPSEALS (dtpnenylhydantoin sodium), containing 0.03 Gm. (% grain) and 0.1 Gm. (1% grains), are supplied in bottles of 100, 500 and 1000. Individual dosage is determined by the severity of the condition. * Trademark Reg. r-V- C A A? PARKE, DAVIS & COMPANY, LTD., WALKERVILLE, ONT. £ B (8 i|$ T <'/1 k"' 4 i ■■■ \u , >jl * T 111 H ► T" ' '-I •f. •r . V ris M ' .■ i di? | v" 'iii 3 V' •l Si "' i ■rl \ ! \$ ' 2 -' • f ,/ t, *u t *■■* ' r* !i' ill j !•' J • 4$ ' f #:• < "THE SUPER-CONCENTRATE "... Yet possesses all the Erythropoietic properties of relatively-unrefined Liver Preparations ANAHAEMI B. D (Liver Extract Injectable 15 units per cc.) ^ The principal indications for Anahaemin B.D.H. are the treatment of pernicious and other macrocytic anaemias, and, the prevention of the onset of subacute combined degeneration of the cord as well as the correction of all the remediable symptoms of this syndrome if it has become established. ^ A third important application of Anahaemin B.D.H. is for the treatment of debility, diminished vigour and undue 'fatigu- ability'. ► In all these indications Anahaemin B.D.H. is unsurpassed by the less highly refined liver products, in efficacy, volume, frequency of dosage and in economy. Available in: 1 cc ampoules 15cc. vita's 2 cc ampoule* THE BRITISH DRUG HOUSES (CANADA) LIMITED TORONTO CANADA •*• 77A-47 Laxative A d ion of Kellogg's All-Br an NOT MECHANICAL recent research indicates REASONS for the laxative properties of bran have long been debated. Some have held that the laxative effect of bran is due to mechanical action. Evidence now indicates that this action is biological, rather than mechanical. Recent studies conducted by Reynier (1) now shed more light on the reason for bran's action. Reynier succeeded in rearing axenic, or germ-free animals—animals lacking intestinal flora. They were bora through Caesarian section, and continuously maintained in aseptic environment. From different types of feeding, research workers were able to make the following observations: 1. Animals in a non-axenic (natural) state usually obtain a definite laxative effect from bran. 2. Axenic (germ-free) animals become constipated when sterile bran is included in their diets. 3. When axenic animals are inoculated with certain multiple flora, bran then exerts its characteristic laxative effect. The investigators concluded that the laxative effect of bran is not due to mechanical action on the intestinal mucosa, since it failed to act in axenic animals. The investigators also concluded that the laxative effect Of bran is due to a biological reaction in the intestinal tract, and that this effect is imparled lo the bran by symbiotic intestinal flora which feed upon it. As shown in earlier research, these beneficial ■microorganisms evidently produce gases occluded in the colonic content and thus help to fluff up the mass and prepare it for easy elimination. Kellogg's, makers of Kellogg's ALL-BRAN, will be pleased to send you reprints of the articles from which this report has been summarized. Use coupon below. (1) Reynier. J A.. GERM-FREE LIFE APPLIED TO NUTRITION STUDIES. Laboratory of Bacteriology, University of Notre Dame. PLEASE SEND: 1. Germ-free Life Applied to Nutrition Studies Q 2. Mode of Action of ALL-BRAN in Laxation D 3. ALL-BRAN and Intestinal Flora . . . D T« CAMPBELL & SMITH QDjjecixve C/rtnftno" All types of Social, Commercial and Magazine Printing. PI. 3053 820 RICHARDS ST., VANCOUVER, B.C (Mail to Kollogg Company, London, Ontario, Canada) Both are claimed to bo allergic Both suggest mineral deficiency and impaired elimination. Clinically, each is symptomatically improved by the oral use of LYXANTHINE ASTIER which combines the therapeutic actions of iodine, calcium, sulphur, and lysidin bitartrate — a potent eliminator of endogenous toxic waste. Writ* for Information. L-M Canadian Distributors ROUGIER FRERES 350 Le Moyne Street, Montreal J i if t& A i , * *1 hjji t If • . I ft .1 1 r It fl •:' I-; r r ■ T H k | . fr .ill 1 4 'I ' . »*. j f I ■ . L * r " ( 4 1 !| r § #! v. a • . : ('•i- u ■•' 1 ! ... If • ■, r »■ ,'■ *lji- •f1! !* I« ti1 ■ 1,. I <o> 4i 1 1 C** : ^ • i rj ! ' T ' v P t ; 6' ' JJV ip T$ *» * i < ■ < t r:' '■ [.' I jj H It - "-T /|&f ' ♦ 1 1 ' t FEEDING UP the wasted patient and convalescent ' Pronutrin' provides a readily absorbed source of nitrogen for use in all cases conditioned by a protein deficiency. It is both a natural antacid and a rich source of nutriment. Containing all the amino acids necessary for human nutrition, "Pronutrin' is indicated where there is inability to take or digest protein, and where there is a protein deficiency. For example, in peptic ulcer; before and after operation; in colitis; gastro-enteritis, dysentery, chronic sepsis and burns; convalescence. 1 Pronutrin' is an enzymic digest of casein. The casein is broken down into smaller units of amino acids and polypeptides. ' Pronutrin' is soluble in water, and may be given in hot, cold, or iced water, stirred into milk or soups, or combined with meat extracts. 'PRONUTRIN' SI A booklet giving fuller details of ' Pronutrin' will gladly be sent on request. TRADE MARK CASEIN HYDROLYSATE BRAND 1 LB. TINS HERTS PHARMACEUTICALS LTD., WELWYN GARDEN CITY. HERTS, ENGLAND Distributing Agents: MESSRS. VANZANT & COMPANY. 387 COLLEGE ST., TORONTO. ONTARIO (M.28) Constant Carefulness Only an|Junderstanding professional skill coj|4ld maintain the confidence of the Medical Profession which we enjoy. Phone MArine 4161 Leslie G. Henderson Gibb G. Henderson :■*:-■ MIOHT (GEORGIA PHARMACY LIMITED W.OSOROIA STRUT ®tvfci.:&%wm ESTABLISHED IMS VANCOUVER. B. C. North Vancouver, B. C. Powell River, B. C. / V ii ,i. ■'Pi v* H m I ■ *■ Ml I f »t|" *■: ■ li JJ if I Iff I A*» : > # # ** WWf (to- Xitmtti. * 1 New Westminster^ B. G. For f&# treatment of NEUROPSYCHIATRY DISORDERS Rfferenca—B. C. Medical Association For information apply to Medical Superintendent, New Westminster. B. C. New Westminster 288 or 721 Medical-Dental Building,[Vancouver, B. C. PAcific 7823 PAcific 8036 Z1
Periodicals
W1 .VA625
English
Vancouver : University of British Columbia Library
Vancouver, B.C. : McBeath Spedding Limited
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Original Format: University of British Columbia. Library. Woodward Library Memorial Room. W1 .VA625
Medicine--Periodicals
The Vancouver Medical Association Bulletin: April, 1947
Text