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The Vancouver Medical Association Bulletin: July, 1927 Vancouver Medical Association Jul 31, 1927

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THE VANCOUVER MEDICAL
ASSOCIATION
BULLETIN
Published monthly at Vancouver, B. C
Subscription $1.50 per
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'©Tie Uienna School of <fM.edicine
c6he"<Toor,rRisk" ^Patient
JULY, 1927
Tublished by
cMc'Beath Spedding Limited, cVancouT>er, "23. Q.
>X ill"
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11 fir
W'M   :
III
I ■ IP' If'
TflTz?/ an Emulsion
A SIMPLE demonstration shows
the Physician at once why
Petrolagar is preferable as an intestinal lubricant.
Mix equal parts of Petrolagar and
water in a tube or glass.
In another tube or glass, try to
mix equal parts of plain
mineral oil and water!
Deshell Laboratories of Canada Ltd.
245 Carlaw Avenue
TORONTO, Canada
«s
I Petrolagar
fi-i increases the ■iificmticy as an
intestinal lubricant—mitas intimately with intestinal content,
and the tendency to Iwttafjr is
te<e««ed.
Petrolagar
Page 298 THE   VANCOUVER   MEDICAL   ASSOCIATION
BU.LLE.TI N
Published Monthly  under  the Auspices  of  the  Vancouver Medical  Association  in  the
Interests of the Medical Profession.
Offices:
529-30-31  Birks Building, 718 Granville St., Vancouver, B.C.
Editorial Board:
Dr. J. M. Pearson
Dr. J. H. MacDermot Dr. Stanley Paulin
All communications to be addressed to the Editor at the above address.
Vol. 3. JULY 1st, 1927 No. 10
OFFICERS, 1927 - 28
Dr. A. B. Schinbein
President
Dr. W. S. Turnbull Dr. A. W. Hunter
Vice-President Past President
Dr. G. F. Strong Dr. A. C. Frost
Secretary Treasurer
TRUSTEES
Dr. W. F. Coy Dr. W. B. Burnett Dr. J. M. Pearson
Representative  to B.C.  Medical  Association
Dr. C. H. Vrooman Auditor
SECTIONS
Clinical Section
Dr. Gordon Burke   Chairman
Dr. L. H. Appleby  Secretary
Physiological and Pathological Section
Dr. J. E. Campbell  : Chairman
Dr. F. J. Buller  Secretary
Eye, Ear, Nose and Throat Section
Dr. E. H. Saunders  '. Chairman
Dr. W. E. Ainley _. \  Secretary
Genito-TJrinary Section
Dr. G. S. Gordon  . Chairman
Dr. J. E. Campbell  I ____.  Secretary
Physiotherapy Section
Dr. H. R. Ross  \ Chairman
Dr. J. W. Welch Secretary
STANDING COMMITTEES
Library  Committee Credit Bureau Committee
Dr. C. H. Bastin Dr- d- McLellan
Dr. W. C. Walsh dr- l- Macmillan
Dr. W. A. Bagnall Dr- J- w- Arbuckle
Dr. D. F. Busteed Credentials   Committee
~    ,    .       _        ... Dr. F. W. Lees
. Orchestra   Committee .->,     c   T   ^
Dr. E. J. Gray
Dr. J. A. Smith Dr. w. F. McKay
Dr. H. A. Barrett « c r    ;   /->        ■,,
r.     t    t.. Summer   hchool   Committee
Dr. L. Macmillan
Dr. H. C. Powell Dr- G- R Strong
Dr. W. D. Keith
Dinner Committee Dr. H. R. Storrs
Dr. D. D. Freeze Dr.  R.  Crosby
Dr. C. H. C. Bell Dr. B. D. Gillies
Dr. O. Large Dr. L. H. Appleby VANCOUVER MEDICAL ASSOCIATION
Founded 1898. Incorporated 1906.
THE 30th ANNUAL SESSION
GENERAL MEETINGS will be held on the first Tuesday of the
month at 8 p.m., from October to April.
CLINICAL MEETINGS will be held on the third Tuesday of the
month at 8 p.m., from October to April.
Place of meeting will appear on Agenda.
General Meetings will conform to the following order:—
8:00 p.m.—Business as per Agenda.
9:00 p.m.—Paper of Evening.
CITY HEALTH DEPARTMENT
STATISTICS — MAY, 1927
Total Population  (Estimated)   137,197
Asiatic Population   (Estimated)     10,576
Rate per .1000 of Population
Total Deaths      141 12.1
Asiatic   Deaths          22 24.5
Deaths—Residents  only      109 9.4
TOTAL BIRTHS      296 25.4
Male     148
Female 148
INFANTILE MORTALITY—
Deaths under one year of age        13
Death rate per 1000 births        43.9
CASES OF INFECTIOUS DISEASES REPORTED IN CITY
June 1
to  15,1927
Cases Deaths
April
Cases
2
21
Smallpox 	
Scarlet Fever 	
Diphtheria   27
Chickenpox      12
Measles     365
Mumps     11
Whooping Cough          6
Typhoid Fever   1
Tuberculosis    8
Erysipelas     8
Cases from outside city-
Diphtheria   7 0
Scarlet  Fever    1 0
Typhoid Fever   1 0
, 1927
Deaths
0
0
0
0
0
0
0
0
19
0
May,  1927
Cases Deaths
4 0
7 0
15 1
28 0
134 1
7 0
23 0
0 0
17 14
8 1
-included in above
1 0
0 0
0 0
0
3
19
9
2
0
6
4
0
0
0
0
1
0
0
0
0
0
0
0
0
0
Page 300 Prescription
Service Only
means that we are wholly dependent upon rendering excellent
service to physicians and their
patients.
The very satisfactory growth
of our business is evidence of
the fact that this exclusive and
ethical service is appreciated.
Tnaakalu1'
SEY.
S M
limited
iph
cnofions
Phone Seymour 112
618 Georgia St. West
Page 3 01 EDITOR'S PAGE
We publish in this issue the charmingi address given before the Association by Colonel MacArthur. Those of our readers who were fortunate enough to hear the lecture will be glad of the opportunity to
peruse it at leisure.    It reads uncommonly well.
Osier says somewhere that there is, in the British school of medicine
or in its best representatives, a scholarly tincture which is as distinguishable as it is unique. This observation recurred to our mind as profoundly true as we sat enjoying the lucid presentation, the apt quotation and
the delightful irony of Colonel MacArthur's address.
The very considerable amount of work entailed in the preparation
is, we understand, wholly original in that the speaker, over many years,
has himself traced or verified the numerous references to persons, places
and periods.
A little—as little as possible—of the address has been omitted
through dimensional difficulties with the publishers.
We are grateful to Colonel MacArthur, we hope he will return to
London this way. We shall then be able to show him both our gratittide
and our appreciation by asking him to talk to us again.
During the week of July 18 th, the University of Washington,
our neighbours to the south, begin their annual course of post-graduate
medical lectures.
There can be no question as to the standard of the course. The reputation of the University guarantees that, even apart from the excellence
of the names appearing on the programme. By the time this date comes
around, the nourishment derived from our own clinic should be well
shaken down and we commend this further source of supply to our
members.
The Library Committee desires to call attention to the new stamp
on the Journals. This stamp registers the date of receipt and no Journal
is allowed to be taken from the Library until one month has elapsed.
We would call our readers' attention to the fact that under the
recent amendment to the Income Tax Act, every medical man practising in B.C. must render a return to the Provincial Government of his
receipts of income for the six months ending June 3 0th. This return
must be made not later than July 31st in order to avoid the penalty. We
do not know what forms are necessary in connection with this return,
Page 302 but they will probably be otainable at the Court House in the larger
centres, or the Government Offices in other localities.
The next and succeeding numbers of the Bulletin will be largely devoted to the publication of some of the excellent addresses given before
the recent Summer School.
That annual event has this year been even more successful and popular than ever before. The registration was, we understand, the largest
in the history of the School and the attendance, which began in earnest
at 8 o'clock on Tuesday morning, continued undiminshed until the end
on Friday night. The selection of the Hotel Georgia as the place of
meeting was a happy one. The acoustic properties of the hall were very
satisfactory and the spacious lounge and rotunda formed convenient
places for social relaxation.
We congratulate the hard-working Committee upon its undoubted
success and vigilant attendance to all the details—and they are many—
which make for the smooth working of such a function. Especially
we were struck with the punctuality with which the lectures started,
and, what is, perhaps, quite as important, stopped. No delay, no overlapping, and yet no lecture appeared to be unduly hurried.
We trust that the Committee is feeling comfortable in its financial
department. While we cannot measure the success of these congresses by
their balance sheets there is, nevertheless, a very satisfactory feeling when
the balance is on the right side.
It has been a great pleasure to meet the various lecturers even in the
brief manner possible at such a gathering. We hope they have enjoyed
their short stay with us and will leave with kindly regret. The luncheon
arranged conjointly with the B.C. Medical Association and addressed by
Dr. Moffitt of San Francisco, formed a lighter interlude of friendly reunion.
While it will not be possible to print all the addresses, we hope to
make such a selection as will be useful and instructive to our readers.
TYPHUS FEVER
Notes of an address delivered by Lt.-Col. W. P. MacArthur, M.D.,
D.S.O., before the Vancouver Medical Association, at Shaughnessy Military Hospital, June 7th, 1927.
I feel very highly honoured at being asked to address you this evening. As the time at my disposal is short, and as every variety of tropical
medicine is met with within the British Empire, I think it will be better if I talk to you about some of the epidemic diseases in their historical
rather than in their purely medical aspect, and I will especially talk to
you about typhus, and the old epidemics of this disease.
Page 303 '.".■
We have a great deal to learn from these epidemics of old times.
Nowadays we are so interested in the marvellous discoveries of bacteriology that we are likely to forget that in the world of medicine there
were heroes before Agamemnon, and that these old worthies very often
saw the truth, perhaps through a glass darkly, but still the truth.
Before touching on the history of typhus, I should like to mention a
few of the characteristics of lice in order to make my talk more intelligible to the non-medical members of my audience. The head louse and
body louse of man are different varieties of the same species, the former
representing the original stock from which the body louse branched off
when mankind took to wearing clothing. These two sub-species now
show certain differences in structure, the most obvious of which is the
more slender antennae of the body louse. The head louse is of a much
less irritating type, its bite is less irritating. There is never the least
doubt about the bite of a body louse.
These insects are parasites and at no stage do they lead an independent existence. They are unlike all other insects which prey on man.
When separated from their host they wander about in an aimless fashion
and unless they secure another host they die; like a sunken ship's crew
clinging to wreckage, unless they are rescued they cannot hope to survive. They jump not neither do they fly, they are transmitted by actual
contact with the host or his clothing. Shakespeare says " 'Tis a familiar
beast to man and signifies love." But given the necessary contact the
beast transfers himself with remarkable rapidity. I remember the case of
a nurse who found her little charge playing with some very dirty native
children. She picked him up and carried him home and from the child's
clothing she retrieved 145 lice.
Lice thrive best at a temperature a little lower than the body temperature. If the host develops a fever they become restless and given an
opportunity they will migrate. Therefore, a person suffering with typhus
fever transmits his vermin more readily than he otherwise would. This
accounts for the high degree of typhus infectivity associated with beds
and bedding which has been recognized for centuries. Some of the old
chronicles recording the ravages of plague and small-pox mention the
curiously named "disease of the bed," which, I think, refers to typhus.
Similarly, if the host's temperature falls the lice become uneasy and
very active so that a person recently dead will be seen to swarm with
vermin which were not in evidence during life. Thomas a'Beckett was
murdered in Canterbury Cathedral and the body lay there all night. The
next day it was decided to remove his clothing and prepare him for
burial. He was clad in an extraordinary accumulation of garments.
Outside everything was a large brown mantle, next a white surplice, then
a fur coat of lamb's wool, then a woollen pelisse, then another woollen
pelisse, then the robe of the Benedictine order, next a shirt, and next to
the body a closely fitting suit of coarse hair lined with linen, which, according to an old chronicler, was so infested with lice that it boiled over
with them like water in a cauldron, and the bystanders alternate.y
laughed and cried, between the sorrow of having lost such a head and
the joy of having found such a saint.
Page 304 Louse eggs are attached to the hair, or threads of fabric by a tiny
drop of cement, absolutely indissoluble. Substances said to dissolve the
cement have not the slightest action, they merely affect the hair so that
the egg slips along it more easily. The top end of the egg is perforated
with holes and the young louse emerges from the egg by drawing air
through these holes, and swallowing it and ejecting it, and as the pressure
of the confined air increases the young louse is propelled gently forwards,
knocking off the egg cap and so emerges.
In old times most of the present day lousing methods were in use,
moist and dry heat, fumigation with sulphur and so on, but sometimes
employed with curious additions, for example the Book of Quinte Essence advises "For to destroy lice, take a little quantity of mercurie and
mortify it with fasting spittle." Another treatment, which probably
was very popular was for the infested person to take a little neat alcohol
and drink a little at once. Thereupon the vermin released their hold and
fell swooning to the ground which suggests to us that the mediaeval
quinte essence had some of the potent principles of prohibition whiskey.
The same book sums up the principles of lousing in one sentence, which
I do not think could be improved upon today, after five hundred years,
"The best is for to wash oftentimes and to change oftentimes clean linen.
Down through the centuries typhus fever does not leave the clear
trail discernable in the wake of epidemics of plague, probably owing to
the fact that the symptomatology has no feature as arresting as the
plague bubo. Shakespeare, who showed a striking knowledge of the
plague, makes no mention of the symptoms of typhus and the only reference to this disease in his plays is in Macbeth where he says of the besiegers beyond his castle walls "There let them lie, Till famine and the
ague eat them up." Ague originally signified fever and had no connection with chills and rigors. In Elizabethan times the word was applied
to typhus. Shakespeare's conjunction of famine and typhus were invariable concomitants and Shakespeare doubtless had heard of many an
army first prostrated by famine and then devoured by the spotted ague.
The name typhus was not given to this disease until about the middle of the 18 th century, though the word itself is an old one and signifies
stupor or coma. Older names given to the disease were,—from its distribution,—gaol fever, prisoners' fever, hospital fever; from the rash-
spotted fever; from its malignancy-putrid fever. The earliest description
of the disease which is clearly identifiable without any question, dates
from the year 1500, but centuries before that time we have records of
great famine fevers universal throughout England, with always the same
sequence of events—failure of crops, famine, fever. The Anglo-Saxon
Chronicle, recording the great famine of 1087, says that such a malady
came upon mankind that almost every other person was ill with fever.
The writer does not give any definite name to the pestilence, simply calls
it fever.
William of Newburgh in his chronicle of the great famine which
devastated England in 1196 says that the hand of God was lifted against
the people of Christendom and testifies of what he has seen.    He describes
Page 3OS how the bodies of those dead of starvation corrupted the air, causing a
most raging pestilence which did not spare even the rich. He says that
the fever, which he calls the ague, seized so many in the course of a
single day that barely sufficient people were left to look after the sick
and bury the dead. The usual funeral ceremonies were abandoned and
deep trenches were dug to receive the bodies because of the great number
of the dead.
I do not want to weary you with the details of the famine fevers of
1315 and so on for they differed in no respect for the description given
by William of Newburgh of the fever of 1196. These old pestilences are
described in terms too general to allow of any clear identification, but the
circumstances of their incidence and spread are exactly those of the
famine fevers of the 17th and 18th centuries where we know quite definitely in each instance that the fever was, in the main, typhus, and I have
no doubt that the earlier pestilences associated with famine were the
same disease.
About one hundred years before the first clinical description of
typhus we have records of a distemper associated with gaols. In a Survey of London Stow notes that in 1414 the gaolers of Newgate and Lud-
gate and 64 prisoners died. A few years later Henry 5 th abolished the
debtors' prison of Ludgate and had the prisoners removed to Newgate.
Later in the same year Ludgate prison was re-established because "so
many of the transferred prisoners were already dead by reason of the fetid
and corrupt atmosphere of Newgate." We cannot doubt that the English prisons were hotbeds of typhus and from the accounts given by John
Howard we might almost imagine that they were designed solely for the
propogation of this disease. Howard, the great philanthropist who died
of typhus fever, was appointed High Sheriff of Bedfordshire in 1773, and
when his proposal to replace the gaolers' fees by fixed salaries was rejected
in Bedford for want of a precedent, he visited several other prisons in the
hope of finding the precedent required. He was so horrified by the conditions of the prisons he visited that he determined to continue his itinerary all over the country and his book on the state of the prisons in England and Wales contains an account of the horrors he found. The whole
prison system was rotten from top to bottom. Some gaols were rented
by the gaolers who reimbursed themselves by fees extorted from
the miserable prisoners and their friends. Even in the state institutions
the gaolers adopted the same methods. Against the law the prisoners
were loaded with chains so that the gaolers could obtain bribes for removing them. Even prisoners found not guilty at trial were returned to
gaol until all the gaoler' fees had been settled. The prisons were frightfully overcrowded and horribly filthy. In order to avoid payment of the
window tax the gaolers had the windows built up. In many prisons
there was absolutely no provision for what we call "sanitation." In some
there was no water supply. In others, where there was a well inside the
walls, the prisoners had no access to the water, as they were kept locked
up. Many of the cells were underground dungeons with no light, heat
or bedding, the starving prisoners huddling together oh bundles of filthy
rags and straw to keep themselves warm. In Plymouth three men were
confined for two months in a cell measuring 15x8, so low that even a
Page 306 short man could not stand upright, lighted and ventilated only by a
small grating in the door. When Howard visited this gaol there was only
one occupant in this cell, but the door had not been opened for five
weeks. In many gaols the gaoler refused to accompany Howard into the
gaol because of the fever raging there. Howard states that often after
visiting a prison his clothing emitted so foul a stink that he could not
remain in his coach but had to travel on horseback and even the flask of
vinegar which he carried with him became offensive. Many untried
prisoners lay so long in prison that in the end they would be carried into
court and propped up in the dock dying of gaol fever. I like to think of
one of these crying out like Samson "Remember me I pray thee and
strengthen me this once that I may be avenged." If his prayer were
heard, the Black Assizes might be the answer. The most important of
these Black Assizes were the one at Cambridge in 1522, that at Taunton
in 1730 and the Old Bailey in 1750. No description of typhus fever in
its historical aspect can omit mention of these, and also the Black Assize
at Oxford in 1577.
Rowland Jencks, living at Oxford, described, according to the opinion of the writer, as "a worthy man," or "a popish recusant," was arrested by order of the University for causing a scandal by speaking ill
of the Government and staying away from Church. He was committed
to prison and ordered to stand his trial at the coming Assizes (1577). In
a few days we have the ominous information that several prisoners in
Oxford gaol died in their chains. Jencks case aroused much interest and
the Court was crowded. He was arraigned and condemned to have his
ears cut off, which was duly done. Following the Assize, gaol fever broke
out amongst those who had been present in Court. The two Judges,
both the Sheriffs, six Justices of the Peace and nearly all the Jury died,
also a hundred members of the University. The total death roll amounted
to over five hundred. As long as gaol fever kept in its proper place
within the gaols it was of little importance, but when it attacked Judges
and other eminent persons, that was quite another matter. The Black
Assize at Oxford created quite a stir, and the author of a poem called
"The Dance of Death" took the opportunity of pointing a moral:
"I came and made the Judges all aghast
And Justices that did appear ....
Took many a worthy man that day
And all their bodies brought to clay."
Even Francis Bacon took time from composing Hamlet and Macbeth
to consider the evidence and strangely enough he did not father his findings on some medical man, but published them under his own name. He
holds the smell of the gaol entirely responsible, but goes on to say that it
is not those stinks which the nose most abhors that are most pernicious,
but such as have most likeness with man's body. Stow and other historians accepted this theory of Bacon's and state that the stench of the prisoners was so overpowering that the judges on the bench were overwhelmed there and then. But there were other explanations of a sectarian nature. Some regarded it as a judgment from God on an heretical
court.    The opponents contended that the whole affair had been arranged
Page 307 by the Roman Catholics—that they had compounded diabolical and papistical blasts which had been secretly conveyed to Oxford and there let
loose. Without enquiring into these questions of higher chemistry, it is
interesting to record the views concerning the spread of this disease. The
prisoners who were responsible for the outbreak could hardly have harboured sufficient lice on their persons to infect over five hundred fatal
cases, to say nothing of the cases which recovered. So it would seem as
if the members of the University of Oxford cannot be held guiltless of
being themselves verminous. I remember reading a letter written by an
old English lady who did not approve of James the First's accession to
the English throne. She wrote that she attended Queen Elizabeth's
Court for years and never saw a single louse there but that since King
James and the Scottish lords came she could not go near the Court without being infested. But even the most Johnsonian of Englishmen could
hardly hold the Scottish lords responsible for the Black Assize of Oxford.
Papistical winds might blow from Louvain but Calvinistic lice from Edinburgh could hardly be held responsible. I may say that Roland Jencks,
the innocent cause of the catastrophe, lived for 33 years after. The
Black Assize at Exeter 12 years later resembled the Oxford Assize; there
was the same death toll of judges and landed gentlemen, but at Exeter
we are told that some of the prisoners were so ill that they had to be
helped into Court by attendants or carried in on stretchers. The epidemic spread all over Devonshire and lasted for many months.
I must now speak of the Black Assize at the Old Bailey in London
in 1750. By reason of the interest taken in one of the cases up for trial,
the Court was crowded. Some days afterwards, gaol fever broke out and
the distribution of the cases was very peculiar as practically only those
who had occupied the left side of the Court were affected. There were
six persons on the Bench, with the Lord Mayor in the middle, the jury
were on each side. The Lord Mayor and the two men on his left all
died. All of the jury on the left, except four, died, and forty other persons, who had all occupied seats on the left of the Court. One cannot
do more than suggest a possible reason. Running round the Court was a
gallery for the public. The gallery to the left probably held some person who harboured infected lice. He may have removed his wig and
outer clothing owing to the heat and so shed a rain of lice on the people
below. These lice wandering about would seize hold of any fabric which
brushed upon them and soon penetrate to the wearer's body.
In fear of a distemper which did not spare even the Lord Mayor and
Aldermen, the Corporation of London appointed a Committee to consider
ways of preventing such outbreaks. This Committee decided that lack
of ventilation was responsible and advocated a windmill-like erection on
the roof of Newgate to abstract the foul air from the cells. The Corporation approved the scheme but nothing was done until another Lord
Mayor had died of the fever. Sir John Pringle then visited Newgate and
had the windmill put into operation. It was rumoured that when the
first blasts of foul air escaped, two men working on the roof fell down
dead. This story is credible, but not true, but it is true that two-thirds
of the men engaged in building the apparatus contracted gaol fever. But
however much the prisoners benefitted from the ventilation, the inci-
Page 308 dence of gaol fever did not abate. After the scheme had been in operation several years it is recorded that gaol fever prevailed all over Newgate, sixteen prisoners dying in one month. Lind, who wrote about this
time, stated definitely that ventilation would not check gaol fever. His
opponents quoted the case of one of His Majesty's ships recently returned
from a long voyage without a single case of typhus on board. This ship
had been fitted with ventilating shafts to which this immunity was attributed. Lind disputed this post hoc ergo propter hoc contention and
when the ship was overhauled it was found that the ventilation tubes had
never been in operation.
The lecturer here gave a short biographical sketch of Lord
George Gordon and the Gordon riots which he mentioned owing to Gordon having died of typhus in Newgate gaol where
he had spent some time amusing himself, "sometimes with music
and sometimes with the bagpipes."
Continuing the lecturer said:
Just as typhus justified its name of gaol fever, so it equally deserved
its name of ship's fever and camp fever. Lind, writing in the middle of
the 18 th century, says it was the most fatal and general cause of sickness
in the navy. It was an invariable accompaniment of naval and military
operations and when epidemics of other kinds broke out, typhus was
usually engrafted on the original infection. This was seen during the
great epidemic of the bloody flux, after the battle of Dettingen, when
typhus broke out among the troops exhausted by dysentery. Half the
sick died and over a third of the medical staff. Orders were given to
transport some 3000 sick to Ghent. During the voyage typhus rose to
such a pitch that more than half of the sick perished on the way. When
the remainder arrived at Ghent there was an extension of the epidemic
due to some old tents which had been used on the voyage and were sent to
Ghent for repair. Twenty-three men were employed to repair these tents
and seventeen of them died of typhus.
Until the campaign against the Jacobites in 1746, gaol fever and
typhus were regarded as the same disease but proof was lacking until an
outbreak in the Duke of Cumberland's army set the matter at rest. A
French ship was captured off the English coast and on board was a number of deserters who had gone over to the French. These deserters were
thrown into prison to wait an opportunity of sending them to Scotland
for trial by Court martial. Afterwards they were put on board a transport conveying reinforcements to Nairn after the battle of Culloden.
Within a few days after disembarkation 200 men of the regiment fell
sick with gaol fever—they infected the hospital, and the epidemic spread
to the civilian population of Inverness—all the train of events so familiar
in hundreds of outbreaks of hospital fever, but, in this case, to the enlightenment of observers, arising in the first place from gaol fever.
With regard to the general population, epidemics of typhus occurred
at intervals until the end of the 18 th century and in Ireland for fifty
years later, and over all this period we find symptomatic descriptions of
Page 3 09 the disease which leave no possible doubt of its nature.   Especially during
the later epidemics like that of 1741 we find evidence of relapsing fever.
In the 17th and 18th centuries a curious change in the class incidence of typhus is noticeable. Under the Stuarts, although epidemics
began among the poor and hungry, the rich and great enjoyed no immunity. Many examples of this are to be found in the records of the
times. In a collection of letters published about 150 years ago entitled
"The Court and Times of James the First," we find the names of many
notable people affected by the great typhus epidemic in 1623. It is
stated that the spotted ague reigns almost everywhere. The Duke of
Lennox is dead of the disease and the Marquis of Hamilton and Lady
North's youngest daughter. Owing to the danger, the opening of Parliament was postponed from September to February, but when February
came- round Parliament was again adjourned. Some thirty years later
Pepys writes in his diary that the Queen's sickness is spotted fever and
that she is as full of spots as a leopard, and he adds a note, with his customary prudence "to stop the making of my velvet cloak till I see
whether she lives or dies." During the last years of the 17th and the
early years of the 18 th centuries the universal pestilential spotted fever
was rampant until, in 1741, the death rate in London reached a figure
only equalled by the plague in 1665. As the 18th century advanced
typhus became more a disease of the poor, people in better circumstances
escaping, except those whose duty brought them in contact with the
destitute, a condition exisiting in Ireland within the memory of many
people still living.
In the early 19th century, due to the temporary prosperity during
the Napoleonic wars, though typhus fever still persisted, there was no extensive prevalence of the disease, but with the peace after Waterloo, there
came unemployment and a lowering of wages. Several bad seasons spoilt
the crops. This was followed by fever, bad in England and Scotland,
worst in Ireland, the poorest country of the three. In England and Scotland the epidemic was relapsing fever, but in Ireland this was quickly
swamped by typhus. Even in prosperous years the poor Irish are never
much above hunger level, but at the time of which I am speaking, when
the potatoes were green in November, the peasants were faced by actual
famine. On account of the heavy rains the peat could not be dried and
even those ordinarily clean could not cleanse themselves and quickly became covered with vermin. In Ireland there was no poor law nor relief
as there was in England. Hordes of starving families wandered over the
country seeking for assistance. Dysentery, relapsing fever and finally
typhus broke out, and a single focus served to infect whole villages and
many peasants fell a victim to their kindly custom of never refusing to
any wanderer the poor shelter they could give. Thousands died until the
good harvest of 1818 slowly brought famine and fever to an end.
the great famine which began in  1847,
th
e mortality was sti
11
In
more awful. The census gives the dead from fever and dysentery as
290,000. The total mortality in Ireland due to fever and famine
amounted to probably half a million. England experienced nothing so
bad, where the number of deaths from typhus in the worst famine year
310 only reached 30,000. A curious difference is recorded of the case mortality of the peasants as compared with the wealthy classes. Although the
total mortality was appalling, the recoveries among the peasants far outnumbered the deaths, but of the doctors, clergy and others attacked the
great majority perished. It is also to be noted that when people of this
class came into contact with the fever stricken peasants, they escaped the
relapsing fever and contracted typhus.
Typhus lingered on in England with occasional exacerbations during
years of shortage, (as during the cotton famine at the time of the American Civil War). Even today typhus is not extinct in England and in
the last ten years' returns there is only one year where the typhus column
is blank.
We cannot read these old accounts of this disease without being
struck by the profound knowledge of typhus shown. Indeed clinical
descriptions written two hundred years ago are better than we sometimes
read in our modern textbooks: the early resemblance to a commencing
cold in the head; the quickened pulse; the suffused eyes; the tremulous
hands; the parrot tongue and so on are all emphasized. The characteristics
of the rash are noted. These old writers noticed that the face was not involved, that the rash might appear on the 4th or 14th day or not till after
death. They noted many cases without any rash at all. In cases without a
rash the effect of a ligature tied around the arm in producing petechiae
was noted by Pringle centuries ago. They also recognized an atypical variety of typhus like Brill's disease very difficult to diagnose because of its
mildness and they recognized the "disease of concentration" as they called
it; when such cases were crowded together into hospitals or prisons, the
infection assumed a malignant character and was very fatal. They
knew of the complications, the deafness, the eye lesions including late
cataracts, inflammation and suppuration of the parotid and sub-maxillary
glands, orchitis, adenitis, gangrene of the feet and of the skin and of the
intestine, even the softening of the brain with paralyses. Indeed, I do not
think there is a single complication mentioned in Danielopolu's monumental monograph that cannot be found recorded by the old writers, and
their teaching was far better than that which I received myself as a
student. Their observations on the spread of the disease were amazingly
accurate. They knew that naked persons transmitted the disease less
readily than those who were clothed. Army doctors when taking the
pulse were warned to step forward, pick up the patient's wrist, and step
back as quickly as possible. They found that typhus patients if thoroughly cleansed and given fresh straw could be nursed amongst others without danger, and if such measures were taken hospital fever would not
break out. Once, during the Seven-Years' War, when the army doctors
were unable to isolate their typhus patients, they kept them scrpulously
clean and managed to nurse them in the general wards withput any
spread of the disease. Monro introduced this practice into St. George's
Hospital on his return, with complete success.
Even the louse as a possible conveyor of typhus was not overlooked.
Lind, while recommending sulphur fumigation for infected clothing,
pointed out that sulphur does not destroy lice, from which we might be
Page 311 led to imagine that contagion is not propagated by animalcules. Probably, in his experience, the sulphur killed the active forms of lice and
ended the disease, but the eggs hatched out later, so the clothing, though
disinfected, was not loused.
Lind's recommendations for preventing gaol fever could not be improved on today. He advised that all prisoners should be stripped,
cleansed, and their clothing fumigated with sulphur or baked. He pointed
out that these measures would not only check gaol fever but would louse
the prisoners. To prevent outbreaks in the navy he advocated depot
ships where all drafted men could be stripped, cleansed, and given fresh
clothing. If his advice had been followed the navy would have been
spared many epidemics of ship's fever during the American and other
wars. But his advice was not heeded and ship's fever continued for many
years. Smollett in "Roderick Random" says it was surprising not that
sick should die, but that any should recover.
But my time is nearly up and in this short address I fear I have, like
Mark Antony, talked right on and only told you that "which you yourselves do know." It might have been better, perhaps, to have restricted
the field and delved more deeply. I might have enlarged on the habits of
lice, most interesting creatures, though not generally esteemed a subject
for drawing-room conversation. We might have discussed house-flies.
Even these creatures of filthy and repulsive habits may be mentioned
without offence, but any reference to the clean-living louse would be considered absolutely scandalous. Why? I'll tell you. If in some family
of your acquaintance you find the subject of capital punishment studiously avoided, or if the subject is introduced, there is a sudden uneasy
silence with a quick change of conversation, you will probably find, on
enquiry afterwards, that the grandfather had been hanged by the neck
till he was dead. And that is why the subject of lice makes people so uncomfortable and self-conscious. It is so short a time since they themselves were liable to be infested and they are still touchy. I know people
who would not quote Robbie Burns about seeing ourselves as others see
us if they knew these lines were addressed "To a Louse." We were not
always so refined. The Tudor ladies carried long-handled combs to scratch
their backs. The Stuart gentlemen shaved their heads and wore wigs—
not always with success, for Pepys examined his new wig and found it
full of nits. When the Countess of Holland quarrelled with Theodore
Hook she said he was not worth three skips of a louse. Hook retaliated
with a verse worth repeating:
"Her ladyship said when I went to her house
That she did not esteem me three skips of a louse;
I freely forgave what the dear creature said,
For ladies will talk of what runs in their head."
Typhus has a personal interest to us here tonight for it has taken
heavy toll of our profession. From the time when Thucydides wrote that
physicians were among the first victims down to the German prison
camps, we cannot read the story of any outbreak of typhus and not see
the souls of them that were slain, surgeons, hospital orderlies—they died
Page 312 in their tens, in twenties and even in hundreds. In Ireland alone out of
1200 doctors attached to institutions, 550 died of typhus in 25 years.
And so the total mounts up, a great multitude which no man can number. And there is yet another list. The recent Polish Commission dedicated their report to the memory of the research workers who had died
of typhus fever contracted in the course of their research work. Hardly
was that dedication written when one of the dedicants, A. W. Bagot, of
the Lister Institute, died of this vile disease. And since then another,
Major Cragg. Tragic, lamentable, but most noble deaths "Homines enim
ad Deos nulla re propius accedunt quam salutem dando." In no wise can
mankind more nearly resemble the Deity than in bestowing health.
A vote of thanks to the lecturer was proposed by Dr. A. P. Proctor,
and carried unanimously.
NOTE:—The substance of this address is also published in the Journal of the Royal Society of Tropical Medicine for April, 1927.
SYMPOSIUM
"THE POOR SURGICAL RISK"—Continued.
(3) R. E. Coleman, M.B., Vancouver General Hospital Laboratories.
Of the various aspects of the poor operation risk, the clinical pathologist is most conversant with those which, are associated with laboratory
findings. Unfortunately any detailed discussion of all such aspects would
require all of the time of all of the speakers tonight. I will, therefore,
assume that the careful surgeon has in every case availed himself of the
suitable, well-established analyses, for there is really no legitimate excuse
for omitting them. Experience has thoroughly established the high mortality from tonsillectomy, etc., in bleeders, and the risk to every such
bleeder can be determined prior to the operation. Also it has been long
recognized that operations on patients with haemoglobin below 50% have
a high mortality rate. Today with transfusion of whole blood, a daily
procedure, such a blood condition is seldom present at operation. This
does not mean that every operation should be preceded by a transfusion,
for it is very questionable whether the risk of operative interference is
ever improved when the haemoglobin is over 80%. Operative interference when the non-protein nitrogen is over 50 mg. per 100 cc. of
blood, increases the risk very materially, more especially when the operation is of a genito-urinary nature. In cases of thyroid toxicity with a
basal metabolic rate over plus 50%, thyroidectomy should not be considered until every method has been attempted to reduce it. Of course,
the risk of operating on a diabetic has been so long recognized that it
need hardly be mentioned. Today we do assume the risk but only after
the diabetic condition has been brought under control. I wiil therefore
assume that the careful surgeon has availed himself of every one of the
established laboratory procedures, insofar as Yhey are applicable to the
particular case.    Even with every precaution, however, the surgeon may
Page 313 ij i!
)
II #
consider that the case is a poor operative risk but necessity compels him
to proceed with the operation.    What, then, is there new to offer him?
The possibility of applying, some of the more recent advances in
pure physiology to just this problem, has attracted me for several years.
It was not until last fall, however, that I was able, with the co-operation
of Dr. Hugh Macmillan and Miss Donna E. Kerr, to commence any investigation. To clinicians, of course, it is entirely unnecessary to emphasize the close interdependence of the innumerable metabolic factors.
Neither is it necessary to draw attention to the paucity of information
in this direction. Every physician looks forward to the day when laboratory analysis will enable him to investigate completely the entire
scheme of disturbed metabolic processes involving the poor surgical risk,
but in the meantime we must content ourselves with fragments here and
there. It was with the hope of adding one small unit to the sum of
knowledge that our investigation was commenced. I will therefore briefly outline to you our general premises and then detail the various therapeutic proceedures indicated.
The introduction of basal metabolic determinations has had one
rather unfortunate result, in that it has tended to connect this form of
laboratory investigation with a single disease in the mind of the clinician.
It has made him prone to forget that the metabolism of the individual
is but the rate at which the individual is using up energy. Though in
the treatment of all diseases the clinician is constantly attempting to
meet the demand for free energy on the part of his patient, he seldom
seems conscious of the fact that life is but the struggle for free energy
and that failure to achieve it means death. It has been the factors controlling the patient's struggle for free energy during operation that we
have been investigating. Briefly, the problem has been, why in presence
of ample reserves of potential energy in the form of fat and protein and
often of carbohydrates, does the patient fail to produce it rapidly enough?
Why we assume such a failure would require another paper in itself but
I think that even this brief discussion will show you that it, at least, is a
possibility.
In any consideration of the body as a mechanism for producing
energy at a variable rate, the active principal of the thyroid gland is not
the only factor determining this rate. On the contrary, the various other
factors taken together are of much greater magnitude. One immediately
thinks of such factors as muscular work which may increase the rate of
demand to many times the basal rate. It is true that hyperthyroidism may
double the basal rate but this is not common. On the other hand, in the
absence of all thyroid activity such as occurs in myxoedema, the basal
metabolism is not reduced to half, showing that even at rest the thyroid
secretion does not account for even half the normal demand at rest.
Clearly, then, the general metabolic demands on the part of the body for
energy are considerable and must be met.
It is true that the energy demands in the poor surgical risk are less
than those of a normal individual but the same factors that mark clinically a poor risk usually indicate a potential deficiency in the production of even that little energy.
Page 314 A brief consideration of the recent work by A. V. Hill and others
suggests the sequence of events. These workers have shown that when a
normal muscle works, glycogen is first converted into lactic acid. This
first stage of the reaction is explosive and anaerobic, i.e., it takes place in
the absence of oxygen. The second stage is accompanied by the reconversion of part of the lactic acid into glycogen with the simultaneous
further oxidation of the remaining lactic acid into CO, and water. Thus
there are two chemical stages which synchronize with the normal muscular contraction and its liberation of free energy. The first stage requires an adequate supply of preformed glycogen and the second stage requires an adequate supply of free oxygen for the oxidation of the lactic
acid.
It therefore remains for us to consider what the factors are which
control, first, the supply of preformed glycogen and, second, the supply
of oxygen to the tissues. The factors controlling the supply of preformed glycogen are the supply of glucose and of insulin in the blood. In
the presence of an adequate supply of insulin the glucose is converted
into glycogen, in the individual cells. Therefore, in the presence of an
adequate supply of both glucose and insulin, there will be an adequate
supply of preformed glycogen. The chief factors controlling the supply
of oxygen are the oxygen tension of the respired air (constant at sea
level) ; the concentration of haemoglobin in the blood; the H ion concentration of the blood; the concentration of C02 of the blood; and the
rate at which the blood flows past the cells, as determined by the pulse
rate and the volume output of the heart.
My reason for laying so much stress on the chemistry and physics
of muscle metabolism is, first, because we know so much more about it
than we do of any other type of cellular metabolism; second, because the
muscular system makes up such a large part of the actively metabolizing
cells of the body; third, because there are indications that much of the
remainder of the body cells carry on a very similar type of energy metabolism. In the poor operation risk, however, it is not the muscular system so often that fails as the nervous system, so I will establish certain
relations between these two systems. The nerve cells per gram carry on
a much more active rate of energy metabolism than the muscle cells, but
being so much smaller in mass than the total muscular system, no stimulation of the nervous system could be expected to materially affect the
total metabolic rate. When the organism fails, this rate of energy demand on the part of the nervous system becomes of prime importance
and when we look for the source of supply of preformed glycogen for
the nervous system we find that the nerve cell is very much handicapped,
as compared with the muscular system, in that it has little or no reserve
of glycogen stored in the cell itself. The nerve cell is such a highly
specialized cell that it has no room for a store of energy and it is possible that the individual nerve cell has only enough glycogen for a single
explosive reaction. The nerve cell, therefore, is probably dependent from
minute to minute on an adequate supply of glucose in the blood and also
an adequate supply of insulin to convert this glucose rapidly into glycogen in the nerve cell. It is, therefore, necessary that we consider where
the glucose for the blood is stored.    We find that normally this supply
Page 315 is in the liver and this large organ with its large reserve readily yields its
glycogen to the blood as glucose. Therefore, a depleted glycogen supply
in the liver is synonymous with a depleted glycogen supply to the central
nervous system. Such an inadequate supply of glycogen in the liver may
result in the poor surgical risk arising from a general deficiency of preformed carbohydrate in the body as in starvation, or from an inefficient
hepatic function such as is associated with a fatty liver in which a large
portion of the liver cell is occupied by fat.
There is, however, another very potent factor which may materially
affect the supply of insulin and this is one that we have been clinically
investigating in our laboratory. We have confirmed the observations of
others that during a major operation the blood sugar rises considerably
with the onset of the ether anaesthetic. We have also found that this
effect, though it lessens with the cessation of the administration of the
anaesthetic, does not return to the normal for a period of over 24 hours.
We have also found that the effect of the operation and the anaesthetic
can still be demonstrated at the end of seven days when the patient is
clinically comparatively normal. This clearly indicates that, to the already impaired function of supplying the body with energy, we add a
further burden in the anaesthetic and in the operative trauma.
Turning now to the oxygen factor, it is obvious that a decrease in
the haemoglobin of the blood will impair the body's capacity to oxidize
the lactic acid formed in the first stage of the reaction. If the haemoglobin is below 50% experience shows that this extra load may lead to
untoward results. If the blood is inclined to the acid side of neutrality
the blood cells will not be as efficient in absorbing the oxygen in the
lungs. Also, if the heart is unable to compensate by increased pulse rate
or volume output, the rate of supply of oxygen may be inadequate.
What, then, are the indications for meeting these various factors in
the poor operation risk, since by our definition we have selected those
cases whic'h are likely to show a marked weakness in one or more of the
above very briefly outlined factors? First, with a haemoglobin below
50%, the operation should be preceded or accompanied by a transfusion
of whole blood; second, with a high metabolic rate the patient should
be brought into a condition with a minimal rate of energy demand; third,"
measures should be taken to ensure an adequate supply of preformed carbohydrate; fourth, an increased oxygen tension may increase the efficiency of an otherwise impaired function; fifth, the use of an anaesthetic which has a minimal effect upon the activity of the insulin-producing cells of the pancreas; sixth, every means should be taken to conserve the rate of energy demand on the part of the body, by keeping the
patient warm, etc.; seventh, our experiments to date, though not complete, suggest the possibility of counteracting the unfavourable and inadequate glycogenic function.
(Part 4) By Dr. A. B. Schinbein.
You will notice that I appear last in this symposium. This was done
intentionally so as to impress upon you the fact that this is the position
whoch surgical interference takes in the handling of these cases.
Page 316 The term "bad surgical risk" is self explanatory and needs no definition.   We use it daily.   A patient may be a bad surgical risk either
(1) on account of the disease itself for which surgical interference
is necessary
(2) or the patient may be handicapped by physical defects and
must submit to operation for another condition otherwise in
curable.
The
most
important groups are:
(1)
Diabetic
(2)
Depressed heart and circulatory system
(3)
Aged
(4)
Hyperthyroidism
(5)
Peritonitis and septic cases
(6)
Obstructive
(a) Stomach
(b) Intestine
(c) Biliary
(d) Urinary
(7)     Traumatic cases.
To prepare these patients for operation, to carry them through the
operation and through the stormy first post-operative days requires the
application of every method of restoration and conversation at our command.    It is not a one-man job.
There must be the closest co-operation, a pooling of the knowledge
and therapeutic resources of the internist, the laboratory, the anaesthetist
and the surgeon and the nursing staff, if we would carry treatment to a
successful termination in the handicapped patient.
The laboratory is most essential in these cases. It aids us in our
diagnosis. It gives us an estimation of the degree of disturbed function
and the ability of the patient to acquire a resistance. Blood chemistry is
now necessary to the surgeon. We must have basal metabolism for the
goitre case; vital capacity for the thoracic case; blood urea creatinin
and non-protein nitrogen for renal function; blood urea, plasma C02
volume, blood chlorides, for the alkalosis of stomach retention and intestinal obstruction; blood sugar for the diabetic. It provides the proper
donor for blood transfusion, etc. *
Dr. Brown has very thoroughly given us the pre-operative examination and care of these cases. The chief cause of poor surgical results is
incomplete examination. I can only again stress the necessity of very
careful examination and attention to every detail as he has outlined them.
The selection of cases for operation in very important. There will
be cases in every one of these groups where operation will be absolutely
contraindicated. The surgeon must not be stampeded. Judgment and a
conscience are necessary.
Page 31) Operating at the proper time is a most important factor to success.
Dr. Freeze has dealt with anaesthesia in these cases and I wish here to
congratulate him on the principle of using interstitial saline so freely in
his service.
The Diabetic.—Today the mortality rate of general operations on
the diabetic can be reduced almost as low as the rate on the non-diabetic.
It is fortunate that the majority of diabetic cases can be brought to the
operating room fully prepared, as Dr. Brown has outlined. There is,
however, the acute case which demands immediate operation, the surgical
condition deserves precedence and the treatment of the diabetes is commenced immediately after. Foster states that major operations performed while the blood sugar is above 350 mgms. and the C02 combining power of the blood below 35 volumes per cent, end fatally.
If we should have such high chemical findings the risk can be considerably lessened by waiting 2-3 hours during which radical measures
are adopted. Large doses of insulin with quantities of glucose'and saline
can be given.
Clinical experience teaches that infection is more rampant in the
presence of hyperglycaemia.
One of the commonest complications of diabetes is gangrene, usually
in patients over 50. This is due to sclerosis of the vessels diminishing the
blood supply.
Partial foot amputations court disaster. While one foot may be
saved in this manner, many lives may be lost. Amputation above- the
knee is the operation of choice. However, if the patient is relatively
young and there is a well pulsating popliteal artery and no infection in
the leg, amputation below the knee may be done. The choice should be
that of the surgeon and not the patient.
Hyperthyroidism.—Since the use of Lugol's solution has been introduced and the treatment as outlined by Dr. Brown carried out, it has
been found that multiple operations are not so often necessary, the gland
being removed at one sitting. However, cases do arise in which it is advisable to do ligations followed later by removal of the gland in one or
more days.
Peritonitis.—Fortunately today, due to early diagnosis and operation for acute appendicitis and ruptured duodenal and gastric ulcers,
we are getting comparatively few cases of general peritonitis. However,
when we do get one we certainly have a "bad risk case."
Drainage of the general peritoneal cavity surgically is most unsatisfactory, in fact, is impossible. Patients have a better chance if no operative interference is done at this time.
Fowler's position, morphine in sufficient amounts to keep the patient
quiet, the respirations 15-18 per minute.
Glucose  anc
dailv
saline   interstial
or  intravenously.
2500-3000   cc.
Gastric lavage.   Hot fomentations to the abdomen.    The patient
Page 318
J in this way is given the best chance to fight his infection and to localize
it. Operation should be reserved to the draining of localized collections
of pus.
Obstructive cases.—In a great many of these bad risk cases, a two-
stage operative interference is necessary to give the patient the best
chance, more often in cases of obstruction than in any of the others,
the first operation being to secure drainage and thus relieve the patient
of his toxaemia and the second to remove the cause.
Pyloric obstruction.—This never requires immediate operation. These
cases can always be brought to the operating room after a period of
preparation and then drainage secured by either a gastroenterostomy or a
resection of the pylorus, if indicated. I would like again to draw attention to the alkalosis of pyloric and intestinal obstruction and to impress
upon you, as Dr. Brown has done, the necessity of giving chlorides in
these cases.
Intestinal obstruction.—We now have very little trouble with strangulated inguinal or femoral herniae. In these cases the patient can feel the
mass and localize the site of the obstruction and the doctor is called
early and the case dealt with soon after appearance of the initial symptoms, if we could diagnose and secure our other cases of intestinal obstruction as early we would have just as little trouble. Such, however,
is not the case, and the mortality of intestinal obstruction still remains
high.
If the patient is operated on before he becomes toxic and dehydrated,
with his intestine greatly distended and waterlogged, then we can deal
with the obstruction just as in a strangulated hernia. If, however, we
only get them late, when the patient is very toxic, dehydrated and with a
greatly distended intestine, then what procedure shall we adopt? Dr.
Brown has told you that these patients must be filled with fluid and
sodium chloride. Drainage of the upper portion of the small intestine
must be obtained. Under local anaesthesia, a small incision is made
through the left rectus muscle above the umbilicus and a loop of jejunum
as close to the duodeno jejunal junction as possible, is brought up and
an enterostomy done. Later, when the patient is in good condition,
the cause of the obstruction can be dealt with.    The enterostomy open-
ill
mg will close in the majority of cases without any interference.
Biliary obstruction.—I would like to quote from Crile to whom we
are indebted more than to any other person for our knowledge of how
to deal with a bad risk case. He states that "in cases- of biliary obstruction it must be borne in mind that we are encroaching upon an organ
of vital significance. As jaundice means not only a bile pigment present
in the blood stream but," and this is of more significance, that "the liver
cells themselves have been affected by the damming back of the bile."
Dr. Brown has dealt with the preparation of the patient witlj biliary
obstruction. He stressed the necessity of giving these patients large
quantities of carbohydrate before operation and also of increasing the
coagulation of the blood on account of the increased danger of haemorr-
Page 319 hage due to the increased clotting time of the blood which results in the
presence of bile cells. The calcium is given by mouth, 10 grs. of calcium
lactate every four hours for from 3-4 days or, if the blood clotting time
is more than five minutes, 5 cc. of a ten per cent, solution of calcium
chloride intravenously once a day for three days.
If the obstruction is due to stone in the common duct, this can be
removed. If due to a growth at the head of the pancreas, then a cho-
lecysto-duodenostomy or cholecysto-gastrostomy will be indicated. If inflammatory, such as secondary to cholecystitis, then drainage of the gall
bladder should be done. I would state here that if the gall bladder has
been drained, in most cases it would be advisable to remove the gall bladder a few weeks later. It is now the opinion that cholecystectomy is advisable rather than a choletcystostomy in cases of gall bladder disease.
As stated above, however, in some cases a two-stage operation will
have to be done.
Urinary obstruction.—Ten years ago I had a man who had a large
stone in the bladder. I did a suprapubic cystotomy, removed the stone
and left in suprapubic drainage. Three days later my patient was dead
from uraemia. Such a catastrophe would not happen today. In such a
case we would know what the nitrogen retention is and what the kidney
function, and we would not operate until the case was as safe as possible
by the means Dr. Brown has outlined. In these cases we would now
put in a catheter securing constant drainage and wait.
Prostatectomy is never an emergency operation. I want to mention
the danger of emptying a distended bladder at once. A distended bladder
should always be emptied very, very gradually.
Traumatic cases.—We learned how to deal with traumatic cases
from our experience in the war. Cases in shock should be treated for
that shock, given morphine, the application of heat, intravenous glucose
and saline and blood transfusion and operative interference should only
be done after recovery from shock.
(Dr. Schinbein cited cases illustrative of each of the groups mentioned.)
B. C. MEDICAL ASSOCIATION NOTES.
The Annual Meeting of the B.C. Medical Association was held at
the Hotel Georgia, Vancouver, on June 22nd. Dr. H. E. Ridewood, of
Victoria, assumed office as President, and the following other officers
were elected: Dr. Wallace Wilson, Vancouver, President-elect; Dr. W.
A. Clarke, New Westminster, Vice-President; Dr. Theo. H. Lennie, Vancouver, Secretary-Treasurer.
The following doctors were elected to membership on the recommendation of the Credentials Committee:
Page 320 Byrne, Ulton Patrick; Bleecker, George Harry; Brummitt, Redvers
Buller; Blair, James Harold; Carson, Julius Harry; Cousland, Phillip
Alexander Clyde; Gomm, William Edward; Gung, Edward Basil; Gunn,
William George; Grimson, Julius C; Kelman, Geo. Alexander; Kelman,
Geo. Arthur Edward; Lang, Benjamin E.; Laing, Jack Wilfred; Mitchell,
William Eric Marcus; McEown, Frank; McKee, Josiah; McDiarmid, J.
M.; Pitts, Harry Herschel; Richardson, William Augustus; Steele, John
Taylor; Sauriol, Louis Edward; Turpel, William Nicholson; Thornton,
Norman McLeod; Underhill, Ambrose Stanley; West, Christopher Hur-
field; Wride, Reginald John; Wilson, Percy Milton; Wilson, George
Hudson.
Full particulars of the meeting will be published in the next issue of
the Bulletin.
The first meeting of the new Executive of the B^C. Medical Association was held immediately after the Annual Meeting, when Chairmen of
Standing Committees were elected as under*
Dr. Geo. Hall of Victoria, Legislative Committee; Dr. A. J. MacLachlan of Vancouver, Industrial Service Committee; Dr. A. C. Frost
of Vancouver, Constitution and Credentials Committee; Dr. Lyall
Hodgins of Vancouver, Publicity and Educational Committee; Dr. A. W.
Bagnall of Vancouver, Ethics and Discipline Committee.
THE VIENNA SCHOOL OF MEDICINE
Contributed by Dr. Neil McNeill.
After having visited various countries and numerous hospital centres during the past year, I have been invited by "The Bulletin" to
write something of a practical nature regarding the clinics of Vienna.
I have decided to do so, thinking that what I may say will be of interest
and, perhaps, of some value, to members of our own Association who may
be contemplating post-graduate work abroad.
The University of Vienna, the second oldest German language University, was founded in 1365; the medical school, however, not until a
little later, the first records dating from the end of the 14th century.
Soon after its inauguration, it began to attract attention, but it was not
until the latter half of the 18 th century that its fame spread beyond the
borders of Austro-Hungary.
In 1754, a clinic was established similar to that at Ley den and in
1784 this clinic became the Allegemeines Krankenhaus (General Hospital) which immediately forged ahead in medical research, so that by
1845 it had reached a high pinnacle of fame as a great medical centre.
As a result of the collaboration of various men of the time in the
several branches of medicine,—Hyrtle,  the anatomist,  Rokitansky,  the pathologist, Skoda, the clinician, Politzer, the otologist and Billroth, the
surgeon,—a complete revolution was wrought in the conception of disease processes and their clinical manifestations, and thus, logically, hi
their diagnosis. In this work these pathfinders followed in principle the
Paris school of medicine, but soon passed far beyond anything at that
time achieved there. The founders of the Vienna school have been followed by men in whose keeping the best traditions of the past are held
sacred, so that today the same searching for new methods and new truths
is still an integral part of the routine of the Faculty. It is, therefore, no
wonder that Vienna is still the city toward which all medical men,
young and old, turn to renew their knowledge and learn new methods.
Vienna today affords unsurpassed opportunities for the post-graduate
study of medicine and the facilities for operations on the cadaver are unequalled at any medical centre that I have had the pleasure of visiting.
All courses are given in English except where German is specified and
one doesn't have to take these to get good work as there is usually a
junior covering the same work at another clinic who does speak English.
However, after being over there for a while, one finds that he can usually
get a good deal out of a case or specimen being shown, even if German
is the language used.
In surgery, Professors Eiselberg and Hochenegg at the Allegemeines
Krankenhaus, (the largest hospital in Europe with 6000 beds), although
both getting old, (the former 72 years), are very often in the clinic and
at work at 7 a.m. In fact, work in all the hospitals begins about that
time of day.
The results being obtained by Prof. Finisterer at the Franz Josef
Ambulatory, in his abdominal operations under splanchnic anaesthesia,
were new to me. Finisterer is one of those who favour radical resection
for gastric and duodenal ulcer, and the low mortality and excellent remote results lend weight to his opinions.
Prof. Frankel, Piham clinic, although also getting old, has not lost
interest in the wonderful pathological organization that he has, through
long years of hard work and study, built up around him. Concerned, as
he always has been, in endocrinology, he is today, perhaps, more specially
interested in the effect of altitude on the thyroid gland. In this particular line he hopes to have something new for publication, perhaps next
year.
Prof. Lorenz Bohler at the Webbergasse spital, a fracture hospital of
some 1200 beds, is a young man with the physique of a Hercules who
speaks only broken English. He is, to my mind, about to revolutionize
the work by what he calls "the functional treatment of fractures." He
treats a broken bone as if it were a plant or tree by rest, warmth, food
from secretions of body and extension. Local anaesthesia is used in the
treatment of all fractures and dislocations. Few compound fractures are
opened up. No Dakins or any other solutions are used for irrigation
purposes, if possible to avoid them. All compound wounds are cut out
at once and sewed up. In his laboratory he has a working model in wood
of almost every conceivable kind of fracture, which is studied, if necessary, at the time of treatment.
Page 322 Dr. Plenk, first assistant surgeon at the Jubilaums spital, is a young
man of 35 years, who, according to his own story, has dissected on a
cadaver every day for the past 15 years and operated on the living subject almost every day for the past nine years. He is a regular wizard at
work, and as a demonstrator of gross anatomy, I know of none better.
He is one of the men over there of whom we shall probably hear more,
for, I understand, he is being brought to one of the large clinics on this
side of the Atlantic this summer.
All the men I met in Vienna were very kind and if one showed any
interest at all in any particular line of work, there was nothing that
they would not do to see that you obtained that which you were looking
for.
The American Medical Association of Vienna was established in 1903
and the objects of the Society are to promote the scientific advancement
and the social intercourse of its members and to provide information as
to the scope and relative values of courses. At its foundation the Association had only 35 members, at the present time there are 4000, more than
1000 having joined in the last two years. Men are coming and going
daily. There were about 150 working there at the beginning of this
year, mostly Americans, many of whom stay from one to two years.
There were 15 Canadians, several from the British Isles and other parts
of the world. The latest achievement of the A.M.A. of Vienna is its official organ "Ars Medici," published monthly in Vienna, giving abstracts
and reviews of all branches of foreign medical literature, especially Viennese and German. All physicians are invited to enrol their names in the
registration book and to become members, the fee for which is approximately ten dollars of our money.
Work in Vienna can be obtained in two ways, either through the
A.M.A. of Vienna or by private arrangement, the latter costing from $3
to $10 per hour. All courses controlled by the Association are called
book courses, and the right of priority to enter a book course is established by the date of registration, so that it is wise to register early and
avoid a possible future delay in getting in on a course you want to take.
The A.M.A. of Vienna is recognized by the medical facutly of the University of Vienna to be the official organization for arranging courses for
its members. The cost of a course is divided between the students—-a
typical example of which is General Diagnosis, ten hours—each student
pays $12.50 for the entire course.
It is difficult to estimate the whole cost of post-graduate instruction.
It depends on the character of the work, the number of limited or private
courses—in fact, on the individual needs of the student. A general
average might be made with a minimum of $50 and a maximum of $200
per month. There are opportunities for appointment to internships, or
as "hospitants" in many of the medical or surgical clinics. Qualifications, duration of service, fees, etc., vary in different places, choice of applicants and arrangement of duties being determined by the chief of the
hospital or clinic.
The University of Vienna will grant for post-graduate work done
there, a certificate to a physician who proves to the dean, by diploma or
Page 323 official certificate that he is a graduate of a reputable medical school
recognized by the A.M. Association. These certificates are granted only
to those who have taken courses covering a period of not less than three
months under the teaching staff of the University.
Physicians arriving in Vienna usually have no difficulty in obtaining work as the Association is in a position to rapidly orientate new members. The cost of furnished rooms in the neighbourhood of the hospitals
ranges from $10 to $30 per month. Furnished rooms do not usually
include light and heat. The Continental breakfast of coffee and two
rolls is served in one's room for a slight additional charge. Dinner and
supper cost, in any of the numerous cafes and pensions, from 50 cents
a meal up.
This, I think, is a fair and, I believe, correct statement of conditions
as I found them in Vienna. I hope they may prove of service to some
poor brother journeying in search of information so far afield. To him
I would say that no matter what particular branch of medicine he is
interested in, he will find in Vienna plenty of material, and teachers only
too ready and anxious to help him use it. At the same time on coming
back from a post-graduate course of this sort, one has again a return of
the conviction that it ought not to be necessary for us in Vancouver to
go so far and so often to obtain this instruction. When we think of the
thousands of patients who are from year to year passing through our
own hospitals and the great variety of disease manifested there, when also
we consider the number of doctors in the city and province anxious for
post-graduate study, but for one reason or another, unable to obtain it,
one wonders why some action has not been taken with the idea of utilizing some of this wealth of material for the purpose of instruction. There
are men on the staffs of our hospitals who, I am sure, know their work
as well as some of those teaching at large medical centres. These, if
given the right opportunity, might well develop into men of international
reputation and in so doing build up around them a teaching centre which
in time to come might even rival Vienna.
I
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Reference | <33. (?. offledical ^Association
For information apply to
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or 515 Birks Building, Vancouver
Seymour 4183 Westminster 288
v®w
Page 328

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