History of Nursing in Pacific Canada

The Vancouver Medical Association Bulletin: February, 1930 Vancouver Medical Association Feb 28, 1930

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 VOL. VI.
FEBRUARY,  1930
The Bulletin
of the^
Vancouver Medical Association
^Post Operative Intestinal Obstruction
cAn Interesting cAutopsy
Uictoria oftCedical Society Patient Types:
THE OBSTINATE CASE
The patient with an obstinate case of constipation is generally
addicted to self-medication, has "tried everything," and every new
cathartic that whips the tired bowel means going from bad to worse.
Not a simple matter to get such a patient under control, so that
the favorite cathartic is eliminated and the regimen of bowel re-education through a regular "habit time" may be instituted.
Gentlemen:—Send me copy of "HA-
Petrolagar Laboratories ?PZ££% glXZ*™™^ "*
of Canada Ltd. Dr	
907 Elliott St., Windsor, Ont. Address   	
Dept. V.M.  10. 	 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 and Dental Building, Georgia Street, Vancouver, B. C.
Editorial Board:
Dr. J. M. Pearson
Dr. J. H. MacDermot Dr. D. E. H. Cleveland
All communications to be addressed to the Editor at the abov? address.
VOL. VI.
FEBRUARY, 1930
OFFICERS 1929-30
Dr. T. H. Lennie Dr. G. F. Strong Dr. W. S. Turnbull
President Vice-President Past President
Dr. E. M. Blair Dr. W. T. Lockhart
Hon.-Secretary Hon. Treasurer
Additional Members of Executive:—Dr. W. A. Dobson; Dr. A. C. Frost.
Trustees
Dr. W. F. Coy Dr. W. B. Burnett Dr. J. M. Pearson
Auditors:    Messrs. Price, Waterhouse & Co.
Dr. J.
Dr.  S.
Dr. A.
Dr. R.
Dr. F.
Dr. N.
Dr. H.
Dr. J.
Dr. C.
Dr.  G.
R. Davies	
H.    SlEVENPIPER
M.   Menzies
E. Coleman
W. Brydone-Jack
E. McDougall 	
R. Ross
W. Welch
F. COVERNTON
O. Matthews
Library
Dr. C. H. Bastin
Dr. Wallace Wilson
Dr. S. Paulin
Dr. D. F. Busteed
Dr. W. H. Hatfield
Dr. D. M. Meekison
Dinner
Dr. W. T. Ewing
Dr. W. A. Gunn
Dr. L. Leeson
Rep. to B. C. Med. Assn.
Dr. A. Y. McNair
Sickness and Benevolent
mmm VANCOUVER MEDICAL ASSOCIATION
Founded 1898 Incorporated 1906
PROGRAMME OF THE 32nd ANNUAL SESSION
GENERAL MEETINGS will be held on the first Tuesday and
CLINICAL MEETINGS on the third Tuesday of the month at 8 p.m.
Place of meeting will appear on the Agenda.
1930
February
February 18 th
March 4th
March 18 th
April 1st-
April
April
4th—General Meeting.
Paper—Dr.  W. E.  Scott-Moncrieff,  Victoria;   "The
Importance   of   the   Early   Recognition   of
Glaucoma by the General Practitioner."
Clinical Meeting.
OSLER LECTURE—Dr. J. J. Mason.
Clinical Meeting.
General Meeting:
Papers—Dr. L. H. Appleby; "Sodium Amytal."
Dr. G. O. Matthews; "Common Practices in
Infant Feeding—their Use and Misuse."
15 th—Clinical Meeting.
22nd—ANNUAL MEETING.
VANCOUVER HEALTH DEPARTMENT    .
STATISTICS, DECEMBER,  1929
Total  Population   (Estimated)    g 228,193
Asiatic Population   (Estimated) 12,300
Total Deaths —:     174 10.90
Asiatic   Deaths -       19 18.19
Deaths—Residents only     149 7.70
Birth Registrations      338 17.4
Male       165
Female   173
INFANTILE MORTALITY—
Deaths under one year of age '.       14
Death Rate per  1,000 Births       41.42
Stillbirths  (not included in above) 9
Cases of Contagious Diseases Reported in City
November, 1929
Cases    Deaths
December, 1929
Cases    Deaths
• January 1st
to 15th, 1930
Cases    Deaths
Smallpox         3
Scarlet  Fever   14
Diphtheria 67
Chicken-pox 12
Measles        5
Mumps 13
Whooping-cough    25
Tuberculosis 13
Typhoid   Fever     0
Poliomyelitis : 0
Meningococcus Meningitis     0
Erysipelas     2
0
2
0
0
0
0
22
0
13
0
2
38
0
17
1
0
33
0
55
0
0
4
0
1
0
0
20-
0
20'
0
0
18
0
18
0
8
6
12
14
—
0
1
0
0
0
0
1
0
0
0
0
2
2
0
0
0
9
0
4
0
Page 90 A
EWSIS5HS
An Effective Altif-
in the Treatment of Pneumonia
Anything short of major calibre in a diathermy machine for the
treatment of pneumonia will prove disappointing. The Victor
Vario-Frequency Diathermy Apparatus is
designed and built specifically to the requirements. It has, first, the
necessary capacity to
create the desired physiological effects within
the heaviest part of the
body; secondly, a refinement of control and
selectivity unprecedented in high frequency apparatus.
In the above illustration the apparatus
proper is shownmount-
ed on a floor cabinet,
from which it may be
lifted and conveniently
taken in your auto to
the patient's home.
A REPORT from the Department of Physiotherapy
of a well-known New York
hospital, dealingwith diathermy
in pneumonia and its sequelae,
states as follows:
'As a rule diathermy is indicated in acute pneumonia,
especially so when the symptoms are becoming or already
are alarming: temperature is
high, the patient is delirious, the
pulse is extremely rapid, cyanosis is deep, the respiration
rate is high, the breathing is
very shallow, and the cough
remains unproductive. Not infrequently in a pneumonia case
with such alarming symptoms,
after a few diathermy treatments an entire change of the
picture takes place: cyanosis
lessens, respiration becomes
deeper, the quality of pulse improves, the rate decreases, the
temperature is lowered, and the
cough becomes productive.
Auricular fibrillation that develops occasionally in similar
pneumonias or other types of
pneumonia where the toxemia
is great, has been changed to a
perfect normal rhythm after a
few diathermy treatments."
You will value diathermy as
an ally in your battles with
pneumonia at this season, aside
from the satisfaction derived
from having utilized every
proved therapeutic measure
that present day medical science offers.
A reprint in full of the. article
above quoted, also repssnts of
other articles on this subject,
will be sent on request.
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J EDITOR'S PAGE
We regard with satisfaction what appears to be a more conciliatory atmosphere around the affairs of the Vancouver General Hospital.
The medical Staff of the institution has, we understand, made
suggestions to the Board of Directors looking to some modifications in
the extreme rigours of the recent regulations. The effect of these, as
we noted last month, seemed to indicate a virtual closing of the public
wards of the Hospital to the outside practitioner, as many people seeking
that accommodation would be unable to satisfy the authorities by payment or by security for their expenses, in advance. Especially would
this be the case during times of recurrent seasonal unemployment or of
periodical business depressions, one of which we are now experiencing.
We hope that these more moderate counsels will prevail and we
congratulate the Medical Association upon the dignified way in which its
committee has conducted these negotiations—negotiations so delicate that
they might easily have degenerated into a squabble.
It is indeed puzzling, in the absence of any authorized statement, to
ascertain who will benefit by the proposed change in the present (or
former) conditions. The price which a hitherto united profession in
Vancouver will pay in ill feeling within our ranks and in the inevitable
cleavage which will occur between "ins"- and "outs" should purchase
more than at present seems possible.
Financially it is difficult to see how the position of the Hospital
will be improved by the estrangement of so large a proportion of the
medical profession of the City. We fear that what the Hospital gains
upon the roundabouts, it will more than lose upon the swings.
As it now is (or was) every doctor was a friend to the Hospital, a
smoother-out of ill feeling, a liquidator of complaints, a steady advertiser
of the undoubted merits of the institution. And at times the Hospital
lias needed friends.
The financial intent of the regulations is, we may presume, that a
patient who upon seeking admission is confronted by the possibility of
being unable to continue the attendance of his regular physician will
therefore energetically bestir himself to provide payment or security for
his hospital dues, to prevent such a calamity arising. On the other hand
the alternative presented will be, we fear, in all too many instances too
fatally alluring. Free accommodation with free attendance by selected
physicians or surgeons or specialists, inferentially the best obtainable.
With such an alternative, such an attractive alternative, it needs no
great prophetic vision to see what will happen. The undermining of
the sense of individual responsibility in patients, the substitution of
acquiescence for striving, the assertion of natural indolence in place of
resolution and the gradual evolution of a numerous people becoming
increasingly dependent upon the Hospital. This is the universal experience of closed hospitals and it is a condition against which the
medical profession of this City has steadily and for very many years
set its face.
It is true, all too true and none realize it better than the doctors
who come close to the people in their homes, that sickness in the family,
especially in the family of those living constantly upon the economic
border line, may be devastating in the extreme.
Page 91 11
But this is not the way to meet the condition. The remedy is an
affair of the State, not of the medical profession, certainly to carry alone,
nor even of the Hospital.
The fact is that setting up a closed hospital is a piece of legendary
lore which the medical profession has allowed to develop into the status
of an edict.
For a teaching institution, a medical faculty of a University, it is
inevitable. In its absence it becomes a mere anachronism and this is the
time and this the place to substantiate that contention.
IMPORTANT NOTICE
MOTOR LICENSE PLATES
Inspector Mortimer of the Police Traffic Department has already
received a number of complaints of unnecessary speeding on the part
of certain doctors. Whilst consideration will be given in cases of
emergency, it is hoped that the profession will not abuse the privilege,
as this might lead to its discontinuance.
The fullest co-operation is expected.
NEWS and NOTES
The sympathy of his colleagues is extended to Dr. J. W. Ford whose
wife died recently.
Drs. Colin Graham and Wallace Wilson with their wives are leaving
about January 23 rd for a visit to Vienna. They will travel via Naples,
and expect to return about June.
Dr. C. E. Brown is receiving congratulations upon the arrival of
his first-born. The stork encountered headwinds unfortunately and
arrived (see the daily papers) ten minutes behind schedule. Thus Master
Brown will celebrate his birthdays on January second instead of on New
Year's Day.
The Paediatric Section has requested us to publish the following
scale of charges adopted by them recently:
Minimum Charges
Consultations  $10.00 and up
Consultations—
North Vancouver "^
West Vancouver     I- $25.00 and up
New Westminster  J
House- Call   . $ 5.00 and up
Office   Call—first      $  5.00 and up
Office  Call—subsequent     $ 4.00 and up
Toxoid ^|
Vaccine > $ 2.00 and up
Bact. Vaccines J
Blood  Transfusions     $35.00 and up
Blood   (Subcutaneous) $10.00 and up
Lumbar Puncture   (Diagnostic) $10.00 and up
Page 92 Calls:
North  Vancouver    $10.00 and up
West Vancouver  $15.00 and up
New Westminster  $15.00 and up
Steveston    $25.00 and up
Night   Calls     $10.00 and up
MEETINGS
A Special General Meeting of the Vancouver Medical Association
was held in the Auditorium on December 30th to receive the report of
the Special Committee on the result of their interview with the Board of
Directors of the Vancouver General Hospital in accordance with the
resolution passed at the meeting on December 10th. After outlining
the situation to date the Chairman asked if the meeting wished to hear
the arguments presented to the Board of Directors against the proposed
new regulations and the reply being in the affirmative Drs. Gillespie,
Monro, Lennie, Mason, Glen Campbell and Hunter read the arguments
presented by them respectively. Dr. Gillespie also gave a short summary
of the Board's reply.
After the Secretary had read a letter from the Secretary of the
Board of Directors dated December 24th requesting the co-operation of
the medical men in giving the new Regulations a fair trial Dr. Gillespie
read report of his Committee which concluded with the following three
recommendations:
(1) We recommend that the Association request the Medical Staff
of the Vancouver General Hospital to meet this Special Committee in
order that the Staff be fully informed of the proopsals made by our
Committee with a view to obtaining the active co-operation and support
of the Staff towards getting the acceptance of the Board to the solutions
offered by the Vancouver Medical Association.
(2) We recommend that a copy of the representations made to
the Board of Directors of the Vancouver General Hospital by the Committee from the Vancouver Medical Association be forwarded to the
Hospital Survey Commission.
(3) The recommendation was that the Vancouver Medical
Association does not accept the proposal of the Board of Directors of
the Vancouver General Hospital and further that the Vancouver Medical
Association re-affirms its adherence to the principle that the patient shall
have the right to choose his or her own doctor; and further that the copy
of these resolutions be forwarded to the Board of Directors of the Vancouver General Hospital.
These resolutions were discussed and carried, clause by clause, and a
resolution was passed adopting the report in full.
*      *      *
The regular monthly General Meeting of the Association was held
in the Auditorium on January 7th, with the President in the Chair.
A vote of sympathy with Mrs. Allen and her family in the sudden death
of Dr. Naboth Allen was passed.
Dr. D. P. Hanington was unanimously elected to membership.
Page  9i Dr. Gillespie gave a short progress report of the Special Committee
on the Hospital question.
Dr. C. H. Bastin read a very interesting paper on "Traumatic
Neuroses," and Dr. C. E. Brown spoke on "Chronic Inflammatory
Disease of the Biliary Tract; diagnosis and methods of investigation."
Both papers were well discussed.
*      *      *
The Clinical Section of the Association held its December meeting
at Shaughnessy Hospital through the courtesy of the Staff of that Institution. Interesting cases were shown by Dr. A. B. Schinbein, Dr.
Brown, Dr. Wallace Wilson and Dr. H. H. Mcintosh, the latter showing
X-ray pictures of cardiospasm, carcinoma of the eosophagus and lung
abscess. The attendance was good and at the close of the clinical meeting refreshments were served by Miss Matheson, the Matron. The thanks
of the Association are extended to the Staff of the Hospital for making
such a delightful evening possible.
Annual Dues
Dr. W. T. Lockhart, the Treasurer of the Association, will be glad
if the members whose dues for the current financial year (which ends on
March 31st)  are still outstanding, will send in their cheques as soon as
possible.
LIBRARY NOTES
Recent Additions to the Library
Modern Technique in Treatment 4 vols.
System of Bacteriology in Relation to Medicine vols. 2, 3 and 4
Medical Clinics of North America September, 1929.    Chicago Number
Clinical   Electrocardiograms - Willius
Collected Studies School of Hygiene and Public Health... Johns Hopkins
Dean Lewis  (Surgery) Vols. VII. and III.
Annual Report of the Rockefeller Foundation for 1928 	
Surgical Clinics of North America October, 1929.    Philadephia number
Study of Prolonged Fasting by Benedict Cargenie Institute
Section of Ophthalmology  A. M. A., 1929
Medical Clinics North America November, 1929.    New York number
Chemistry in Medicine    Edited by Julius Stieglitz
Roentgen Interpretation and Diagnosis in Gallbladder disease Beilin
Diabetes Mellitus Sansum
Fractures and Dislocations Kellogg Speed,  1928
Surgical Diseases of the Thyroid Gland Eberts
Infections of the Hand Kanavel,  5 th edition
Surgical Clinics North America December, 1929.    Lahey Clinic number
Orthopaedic Surgery  Jones and Lovett, 2nd edition, 1929
Report on the International Conference on Goitre in Berne. 1929	
Life of Sir Clifford Allbutt, by Sir Humphrey Rolleston, 1929	
Transactions of the Ophthalmogical Society of the U. K	
Treatment of Rheumatoid Arthritis.    Douthwaite,  1929	
The Harley Street Calendar H. H. Bashford
Ambulant Proctology   Blanchard
Newer Knowledge of Nutrition, 4th Ed. McCollum
Page 94 Toxic Reaction Produced by the Application of Trinitrophenol
(Picric Acid)
Charles C. Dennie, Wm. L. McBride, and Paul E. Davis
(Abstr. from Archives of Dermatology and Syphilology. Vol. 20, p. 698,
November, 1929)
As the authors state in their introductory paragraph, "Picric acid
not only occupies a prominent place in the surgical field, but in its many
combinations is utilized extensively in the treatment of diseases of the
skin." For this reason, this paper, read before the last annual meeting
of the American Dermatological Association, merits the attention of all
members of the medical profession.
There is one group of patients, peculiarly sensitive to picric acid, in
whom application of small amounts to normal or abraded skin will produce certain cutaneous, visceral and central system reactions. In the
remainder, who are relatively non-sensitive, enough may be absorbed,
especially from abraded surfaces, to produce severe visceral symptoms
and even death.
Approximately 4 per cent, of all persons belong to the sensitive
group. Members of this class may be detected by a simple test, consisting of painting an area of skin 2 cm. square with the solution. In
sensitive persons a marked dermatitis will appear within 24 hours.
As a result of their experiments on dogs the authors find that picric
acid appears in blood as a protein combination. They believe the phenomenon in sensitive persons to be a true allergic reaction, that the trinitrophenol radical can be broken off from the protein complement, and
redeposited as a protein picrinate in a new cell, which process can be
repeated again and again. Blood positive for trinitrophenol when passed
through a colloidal membrance gives a negative reaction to the cyanide
test.
As a result of extensive clinical observation, and their experimental
work, the authors strongly advise the discontinuance of the use of picric
acid in burns and various dermatoses. They also warn surgeons against
its use as a sterilizing agent preceding operations.
In the discussion which followed presentation of the paper, Drs.
Pusey and Mitchell of Chicago related their experiences of dermatitis
following the use of butesin picrate ointment. Dr. Markley of Denver
characterized it as one of the most virulent local remedies on the market.
It is to be recalled at the same time that ointment of butesin picrate has
been widely advertised recently as a remedy for eczema. Dr. Dennie in
concluding stated that the eruption caused by either picric acid or
butesin picrate is indistinguishable from the other.
—D. E. H. C.
CORRESPONDENCE
To the Editor,
The Bulletin of the Vancouver Medical Association.
Dear Sir:
I trust that you will give me the opportunity of replying to Dr.
H. W. Hill's devastating criticism of my article on the Serological Diagnosis of Syphilis. He refers to the "astounding incorrectness of the data
quoted" and no doubt has intended to soften the impeachment by calling
•
Page 95 it a fallacy. A fallacy I should judge could be defined as an erroneous
interpretation and the term might apply to what he calls my second and
third fallacy, but in no sense can it be applied to the first; a very much
better expression of the idea would be deliberate dishonesty. On that
account alone I would like a hearing.
Dr. Hill, however, seems to assume omniscience and to know positively that I have deliberately eliminated certain cases and presumably
chosen those that would serve my sinister intentions. As a matter of
fact he has no information whatever as to the period or months included
in my series. For the benefit of your readers who may be interested I
will amplify the statement in the article to this extent, that the 152
tests under criticism came from approximately 100 consecutive cases
on the active roster of the Clinic, new cases, those same cases undergoing treatment, a few recurrent cases and an occasional case for diagnosis. In other words the great majority were patients who were suffering from syphillis; the only type I was interested hi and in which it was
reasonable to compare both reactions. Thus you see while only a sample
it is not a random or even a malicious one. Dr. Hill accuses me of
leaving out 135 agreements, but I believe I have left out none, for I
find on reexamining my series of cases that my earliest date is some time
subsequent to the period in which only disagreements were recorded.
Further I have not the faintest interest in the agreements and certainly
not in percentages of agreements and disagreements, unless they concern
known syphilitic cases. There is no advantage to be gained in continuing the discussion on the respective merits of both Kahn and Wassermann reactions and I am quite willing to accept the resolutions of the
League of Nations Conference as a provisional standard, which is all it
pretends to be. Dr. Hill's interpretation of their results is only of
academic interest and is open to criticism, but it might be as well to
draw his attention to the fact that "positive clinically" does not mean
the same thing as "syphilitic cases" and to the following statement in
the report (page 9). "During the Conference 944 sera were tested by
various methods. Of these 502 were derived from known cases of
syphilis in all stages of the disease both treated and untreated, . . . . "
They represent therefore an almost directly analogous series to my own
and it is practically certain that many were not "clinically positive."
A great deal of what he has to say about false positives is nullified by
this distinction and his zeal carries him much too far when he assumes
because the Kahn got six positives out of a total of seven doubtful cases
and the Wassermann only three that the Kahn was obviously right;
This is certainly a fallacy of the logical order and a clinical one as well.
However, all this is beside the point. My sole contention was that
in my belief the Kahn I am using is too sensitive and the Wassermann
the very reverse. One is a very sharp tool, perhaps too sharp, the other
I think rather dull. I am quite capable of using any tool Dr. Hill
provides, but I rather consider it my duty to make some attempt to have
the tool adapted to the work it is supposed to perform, even if it does
disturb the serenity of Olympus.
I have the honour to be
Sir,
Yours sincerely,
J. Ewart Campbell.
Page 96 LEADERS IN BRITISH MEDICINE
Professor Robert Muir
The President of the Section on Pathology at the British Medical
Association in Winnipeg, 1930, is one of the most distinguished English
speaking pathologists. Since 1899 he has been Professor of Pathology,
University of Glasgow, and with the late Professor J. Ritchie the author
of a Manual of Bacteriology which has gone into eight editions.
Like so many men of distinction he is a son of the manse. Born in
1864, he was educated at Edinburgh University where he made a reputation for scholarship. In 1892 he was appointed senior assistant to the
Professor of Pathology, Edinburgh University, and Pathologist to the
Edinburgh Royal Infirmary. In 1898 he went to St. Andrews' as Professor of Pathology and in the following year to Glasgow.
His other publications are Studies on Immunity, Text-book of
Pathology and scientific papers. His recreations are golf, fishing and
curling. He is a Fellow of the Royal Society and a member of the
Medical Research Council.
Sir St. Clah Thomson
One of the most noted authorities on diseases of the throat will be
President of the Section of Laryngology and Otology at the B. M. A.
meeting in Winnipeg, 1930. Sir St. Clair Thomson is a Scotsman by
descent though he was born at Londonderry in 1859. He may be truly
called an international figure as he holds honours and awards from nearly
every European country as well as the United States of America. He
was educated at King's College, London, Paris, Vienna, Lausanne (M.D.
1891). He is a Fellow both of the Royal College of Physicians and the
Royal College of Surgeons and was knighted in 1912; an ex-President
of the Royal College of Medicine and of the Medical Society. In addition
to appointments as Throat Surgeon to numerous hospitals he is Physician
to the Royal Italian Opera. His publications include "Diseases of the
Nose and Throat" which has gone into three editions; "Tuberculosis of
the Larynx;" "Cancer of the Larynx; Atlas of Nasal Anatomy;" the
Cerebro-Spinal Fluid;" "Shakespeare and Medicine;" "A House Surgeon's
Memories of Lord Lister;" various bacteriological Physiological and
clinical papers on the throat and nose; and moreover he is European
editor of the Laryngoscope.   He is a charming after-dinner speaker.
REPORT OF AN INTERESTING AUTOPSY
By Dr. H. H. Pitts
Pathologist to the Vancouver General Hospital
The following case is reported because of the very unusual site for
metastases from a squamous cell cancer of the penis resulting in fatal
haemorrhage by extensive erosion of vessels by the metastatic process.
The patient, a Chinese male 42 years of age was admitted to the
Vancouver General Hospital complaining of inability to open his mouth
due to swelling of the right side of his jaw. His previous history was of
little importance belond the fact that he admited exposure to venereal
infection one and a half years previously and that four months later
noticed a sanguinopurulent urethral discharge which continued for
about a year, when definite ulceration of the penis was noticed.    This
Page  97 ulceration progressed until ultimately almost the entire penis had
sloughed off. Three months previous to admission swelling began in the
right side of jaw. The inguinal glands became swollen about two
months prior to the appearance of the penile ulceration, those on the
right side finally suppurating with the formation of a large ulcer.
Physical examination was essentially negative beyond the presence
of a dirty, sloughing ulcer in the right inguinal region, redness, oedema
and swelling in the right cheek and almost complete absence of the
penis. Blood Wassermanns were done on three different occasions and
were negative with all antigens. Smears for Vincent's Angina from
groin, penis and mouth were all negative. The patient was put on
antiluetic regime and had been given three injections of Novarsenobenzol
with apparently but little definite change when suddenly on the eleventh
day after admission a profuse oral haemorrhage occurred from which
the patient rapidly succumbed despite all efforts at haemostasis.
RFPORT OF AUTOPSY   (A29-14)
The body is that of a fairly well nourished and developed Chinese
■male 42 years of age. A deep sloughing ulcer into which a hen's egg
"might be placed is present in the right groin. The penis has been so
eroded that it is now flush with the mons veneris, necrotic, indurated
and a thick creamy foul pus can be expressed from it. The glands in
both inguinal regions are enlarged and hard. The mouth is filled with
clotted blood and on prying open the jaws an extensive sloughing, inT
durated ulceration is seen in the right superior maxillary region especially
involving the posterior half and the subjacent soft tissues. There is also
involvement of the right cheek and the soft tissues of the posterior right
half of the mandible, apparently some of the palatine vessels having been
eroded producing the fatal haemorrhage.
Examination of the thoracic and peritoneal cavities reveals little of
particular note beyond the presence of a moderate amount of somewhat
altered blood in the stomach and general pallor of the viscera.
The right femoral artery was carefully dissected down through the
base of the ulcer but was found to be intact and not eroded. A number
of both right and left inguinal glands and right pelvic glands are as
large as walnuts and on section present firm, mottled cut surfaces definitely neoplastic in appearance. The penis is so necrotic that it is
impossible to say grossly that it is the seat of an ulcerating, degenerating
neoplasm or a luetic process. However, with the appearance of the
inguinal and pelvic glands it seems reasonable to regard it as a squamous
cell cancer which has metastasized to these glands and to the right
superior maxillary and mandibular regions as a section taken from these
latter areas show a suspiciously gross carcinomatous cut surface.
Gross anatomical diagnosis: Extensive ulcerating carcinoma of
the penis with metastases to inguinal and pelvic glands and right superior
maxillary and mandibular regions with erosion of palatine vessels and
fatal haemorrhage.
Microscopic examination of sections taken from the above grossly
involved areas all show a well defined squamous cell carcinoma.
There are, of course, several possibilities in this case; (1) that the
penile and oral growths are two separate and distinct processes which
Page 98 is, however, rather unlikely; (2) that it is a luetic process even in the
presence of negative Wassermanns on three occasions. The subsequent
lack of response to salvarsan and the microscopic findings would seem to
definitely rule out this presumption.
(I am indebted to Dr. A. S. Monro for his permission to report this
interesting case).
POST-OPERATIVE INTESTINAL OBSTRUCTION
By Dr. Wilfred L. Graham
Read before the December Meeting of the
Vancouver Medical Association.
It is interesting to note, that in the past ten years there has been
practically no literature in the English language on Post-Operative Intestinal Obstruction. With Miss Firmin's aid, I was able to find only
one paper in the Library on this subject and that not at all comprehensive: nor did it give any ideas as to treatment.
The reason for this absence is not far to seek. The occurrence of
post-operative intestinal obstruction is looked upon as an accident of
surgery—and unlike the occurrence of pulmonary embolism for instance,
there is often associated, particularly in the minds of the laity, the idea
that possibly there might be a personal factor in its occurrence. That
there is an operative explanation in certain cases is beyond a doubt, for
instance in the operator neglecting to examine the terminal ileum when
doing an appendectomy. These cases, however, are very much in the
minority.
The subject is of great practical importance because it occurs, in the
majority of cases, as the result of an acute abdominal emergency and
these operations cannot always be done under the most favourable conditions. There has been given us no definite, logical course of treatment
that is applicable to all cases and realizing the tremendous mortality of
intestinal obstruction, even under the best circumstances, one cannot be
criticised for having a feeling of helplessness.
No estimation of the incidence of this condition appears in the
literature: I know that in one service with which I was connected, one in
which our work was largely emergencies, we determined that about 5%
of acute abdomens developed obstruction. This will of course depend
on the severity and duration of the disease before it comes under treatment. It is true that in our service the cases were neglected in the
earlier stages resulting, for instance, in the fact that 40% of our acute
appendices were drained. We might therefore determine that approximately 12% of cases of acute abdominal conditions, which have required
drainage, result in an intestinal obstruction of some degree.
In this series we found a mortality of 75% in those cases which we
determined to have developed a complete intestinal obstruction postoperatively. With the improved treatment following the use of hypertonic saline and jejunostomy the mortality rate was reduced to 54%.
These figures will probably seem abnormally high but I would remind
you that we had a fairly large series, for my own division averaged three
hundred acute appendices yearly apart from other abdominal castastro-
phies.
Page 99
^P*p It will be realized that any suggestions that I offer are the result of
my teaching, clinical observation and experience, and it may seem presumptuous for me to offer the Vancouver Medical Association my ideas
on post-operative intestinal obstruction. My plan of treatment is modified considerably from the plan we adopted at that time and I consider
it an improvement in as much as it makes use of the newer developments
in surgery without losing sight of the fact that the older methods of
treatment had much to recommend them.
The early diagnosis of post-operative obstruction is a very difficult
one to make at the stage when one's ability to aid the patient is not
absolutely rendered impotent by an overwhelming toxaemia. Many
cases which we have judged to have a complete obstruction have recovered with no operative interference, but one still cannot say that
these patients did not have, at some time, a complete obstruction. It
may have resulted from a kink due to fibrinous deposits, glueing coils
of bowel together, that has relieved itself. That same patient might
just as well have developed a partial organization of that fibrinous deposit and the obstruction would have remained complete until it was
released by some operative interference. Time is a very essential factor
in the favourable prognosis of any case of intestinal obstruction. It is
difficult to decide when to interfere and when to leave alone. The first
lesson one learns is to put the proper valuation on post-operative vomiting and abdominal pain. The vomiting may be the result of the anaesthetic which affects some individuals to a greater extent than others.
Abdominal pain and, to some extent, abdominal cramps are the inevitable result of any abdominal incision.
We recognize two types of intestinal obstruction following an
operative insult upon the abdomen. First the adynamic type which is
evidenced by a loss of peristaltic action, resulting in a cessation of intestinal movements, and due either to a nerve interference or to an
interference in the blood supply to a portion of the bowel. The second
type is the dynamic type and is associated with an obstruction to the
lumen either by partially organized fibrinous bands or by a kink in the
bowel due to a plastic exudate gluing coils of bowel together.
In these two types our prognosis is entirely different and to a large
extent so is our treatment.
Let us deal first with the adynamic types of obstruction and I warn
you that in my remarks I am going to be dogmatic, not that I believe
there is a gunshot prescription for each type, nor do I probably believe
in toto some of the statements which I will make. But I believe them
to be a sound basis from which one can adjust one's judgment to the
individual case that confronts him.
The adynamic type might be either the so called paralytic ileus or a
mesenteric thrombosis. Mesenteric thrombosis as a post-operative complication is an extremely rare condition. It is due to an occlusion of one
of the main mesenteric branches by an embolus and it is relatively impossible to diagnose. In the two cases I have seen it was the result of a
cardiac lesion and in all probability had nothing to do with the operative
interference.
Paralytic ileus is also a very uncommon condition, much more uncommon than casual conversation would have one believe.    It is a nerve
Page 100 disturbance of the small intestine and is the result of an operative inter- ■
ference. For while one may see certain grades of distension in extra'
abdominal cases, such as pneumonia or severe injury to the extremities,
they are never so complete nor so serious as in the post-operative condition. One would feel that in- the pulmonary condition it must be toxic
and in the injury, a central nervous system disturbance, but as a matter
of fact in lobar pneumonia it may appear very early and may have more
to do with diaphragmatic movements than an overwhelming toxaemia,
and in severe injuries it often appears several days after the injury.
Let us consider first what controls the normal physiological activity
of the intestinal movements. We know that the bulbosacral outflow is
represented in the walls of the small intestine by the vagus nerve; that
the autonomic system likewise has its representatives in the muscular
coat of the intestines as far down as the ileocaecal valve, through the
splanchnic portion of the system.
Tonic inhibitory impulses are conveyed to the intestines (except the
ileocolic sphincter) for after these nerves are severed the movements
become more distinct, indeed in many animals after opening the abdomen no intestinal movements can be observed until these nerves are
cut. Stimulation of the peripheral end of the nerves also inhibits any
movement.
The action of sympathetic stimulation then, is to relax the musculature of the bowel and to close the various sphincters, that is, the
pyloric sphincter and the ileocaecal valve, whereas the vagal outflow
contracts the intestinal wall and has no effect upon the sphincters.
Therefore when we get a lack of tonicity in the bowel wall due to sympathetic preponderance we get a closure of the ileocaecal valve which
further impedes the progress of the intestinal contents.
Let me make myself clear. The condition known as paralytic ileus
is an affection of the sympathetic nervous system but it is not a paralysis.
Rather is it a stimulation of the sympathetic nerve endings, for the
stimulation of the abdominal splanchnics relaxes the intestinal wall and
gives the appearance of a paralysed gut, for the ordinary stimulation
coming through the vagus, which causes contraction of the bowel cannot
overcome the hyper-stimulation of the splanchnics.
I do not wish to bore you with such facts as these. The point
gained, is that whatever the aetiology of so called paralytic ileus, it is
caused by a stimulation of the autonomic nervous system or, rather, the
peripheral nerve ending of the splanchnic portion of that system which
results in a lack of movement or a paralysis, if you will, of the bowel
wall.
Such a condition resulting post-operatively, one feels must necessarily be the effect of that operation (whether mechanical or chemical
we will not discuss) and I feel that it must, if it is the result of the
operation, develop within the first forty-eight hours after. I have said
it is a rare disease and it may be associated with a clean operative field
or with an infected one. It is very difficult to prove from the end
result whether the patient dies from a paralytic ileus or a mechanical
obstruction, for the appearance on the autopsy table is the same. If the
paralytic ileus is primary the perviousness of the bowel wall, resulting
Continued on Page 107
Page 101
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I . British Columbia Laboratory Bulletin
Published irregularly in co-operation with the Vancouver Medical Association Bulletin,
in the interests of the Hospital, Clinical and Public Health Laboratories of B. C.
Edited by
A. M. Menzies, M.D., of The Vancouver General Hospital Laboratories
Financed by
The British Columbia Provincial'Board of Health
COLLABORATORS: The Laboratories of the Jubilee Hospital and St. Joseph's Hospital,
Victoria; St. Paul's Hospital, Vancouver; Royal Columbian Hospital, New Westminster•;
Royal Inland Hospital, Kamloops;  Tranquille Sanatorium;  Kelowna General Hospital;
and Vancouver General Hospital.
All communications should be addressed to the Editor as above.   Material for publication'
should reach the Editor not later than the seventh day of the month of publication.
Vol. IV.
FEBRUARY, 1930
No. 2
CONTENTS
Why Do We Examine Urine? Matheson
Fatal Credulity  , .. Chisholm
EDITORIAL
Reviewing the laboratory developments during 1929 we find that
the number of Public Health examinations required of the Vancouver
General Hospital Laboratories has been increasing steadily as it has been
for years, a total of 61,916 Public Health Examinations having been
done in 1929. Specimens were received from as far as Alberni in the
West to Fernie in the East; from Dawson in the North to the International Boundary in the South, although of course the bulk came from
Vancouver and vicinity.
While figures are not at hand from other Public Health Laboratories
of the Province, our information would indicate that there has been
a corresponding increase in Public Health examination in these laboratories.
We note with interest, the growth of private laboratories in the
city of Vancouver during 1929. It is mostly clinical work that is being
done in these laboratories, although in one or two cases, at least, examinations of a Public Health nature are sometimes done. We wish these
ventures all success for the future.
In glancing back over the pages of the Laboratory Bulletin for
1929, one is struck by the paucity of contributions from Provincial
Laboratories other than the Vancouver General Hospital Laboratories.
Those contributions which have been received have been of a high standard and reflect credit on the writers. We would like very much to see
more of such articles from the other laboratories.
Page 102 In reviewing the Provincial Public Health activities of the past
year, we wish to note, as probably the most outstanding event, the
appointment, under Dr. H. E. Young, of a full time Epidemiologist for
British Columbia—Dr. A. R. Chisholm, who contributes an article for
this issue.
This official, acting as the direct representative of the Provincial
Board of Health, will be of great assistance, especially to the busy
physicians of districts where no full time health officer exists, in tracing
and controlling outbreaks of the various infectious diseases which may
occur from time to time. When an epidemic is present, the physician
who is part time Health Officer is likely to be so busy caring for his
patients that he has not the required time or energy to devote to the
tracing and control of the infection. Also, in epidemics in which more
or less drastic measures are needed to prevent the spread of infection, an
outside official can take what action may be necessary, and thus prevent
possible bitter feelings arising between the local physician and members
of his community.
WHY DO WE EXAMINE URINE?
J. E. Matheson, M.B.
Technical Medical Assistant
Vancouver General Hospital Laboratories
The common-place usually gains little attention for itself in that
it is common. However important a test or function may be, once it
falls into the class of common-place it at once loses its ability to hold
one's attention. The mechanism, information or results become more or
less uninteresting and of little import, having lost the prestige always
associated with extraordinary material.
So it is with examinations of the urine. These are often either
entirely neglected or done in such a fashion as to be of no value whatsoever—in fact even a detriment in that false information is derived.
More mistakes are made by not looking than by not knowing!
There are two reasons for examining the urine; first, to determine
the functional ability of the kidney and to determine the presence of
lesions, if any, in itself or along the urogenital tract; second, to determine the functional ability of other organs of the body; organs that produce a change in the urine without a pathological change necessarily
being present in the kidney. One obtains information about many and
scattered lesions of the body by examining the urine for bile, various
poisonings, Bence-Jones protein, etc.
In this article I hope to discuss the urinary findings of the lesions
of the kidneys and associated structures of the urinary tract; and other
conditions in a subsequent article.
Nephritis—Although there is a marked disagreement as to the
proper classification of nephritis from the pathological point of view,
yet from the urine examination we can get a fair picture of a clinical
entity.
Page 10} In acute glomerular nephritis the urine is usually diminished in
quantity, highly acid, high specific gravity with a great deal of albumin,
white and red blood cells and casts of the cellular type. The blood
pressure is usually low. This is a variety of nephritis, probably a local
infection of the kidney, following quite frequently on an upper respiratory infection of two or three weeks' duration.
The urine showing similar findings as to albumin, blood and casts,
but with high blood pressure, would suggest a lesion in the kidney of the
arteriosclerotic type of nephritis.
The constant initial sign of tuberculous infection of the kidney is
frequency; later frequency, pyuria, and albuminuria; and in the severe
lesions, pyuria, blood and albumin.
An article on The Various Tests of Kidney Function appeared in
this Bulletin of November, 1929.
Following down the genito-urinary tract the next site of disease
is the pelvis of the kidney. Pyelitis alone, or pyelitis with stone, gives
a urine unchanged in quantity or specific gravity but with a great deal
of albumin, pus and epithelial cells, but no casts. In those cases with
ureteral calculi considerable numbers of red blood corpuscles are also
found. How often has a right-sided renal colic been taken for an acute
appendix?—a very obvious reason indeed why we should examine urine,
a common-place procedure that yields valuable information. Frequently
too, the microscopic examination of the urinary sediment gives some
idea of the nature of the stone; also the type of epithelial cell from the
pelvis of the kidney helps to localize the lesion.
Cystitis—In this condition one finds very turbid alkaline urine of
normal specific gravity and amount, with large quantities of cellular
debris, matted fibrin, pus cells, large epithelial cells and frequently, considerable albumin.
All lesions of the urethra from the standpoint of urine examinations
can be differentiated from other lesions of the genito-urinary tract by
employing a special technique in collecting the specimens.
The sample is collected in three lots into cone-shaped glasses. In
lesions of the bladder and above, all three are cloudy and show similar
laboratory findings. If the major portion of the urine is only tinged
with blood and the terminal urine deeply blood-stained the lesion is most
surely in the bladder; while urine uniformly blood-stained throughout,
arises from lesions of the kidney (unless there be gross hemorrhage into
the bladder). On the other hand, when the first urine is bloodstained, the
remainder clear, the bleeding is no doubt from the posterior urethra or
prostate.
So,—all three uniformly bloody tinged—lesion above, bladder; first
two relatively clear, last deeply blood tinged—lesion of the bladder; first
blood tinged, last two clear—lesion in the urethra or prostate.
yr     Reviewing the finding in the lesions mentioned:
..v.a.NEPHRiTis—acute    glomerular—specific    gravity    high,    quantity
small, albumin, pus, red blood cells, cellular and granular casts.       £*&m
Tage'-lm Nephritis—chronic glomerular—specific gravity average but with
less variation, slighdy diminished quantity, large amounts of albumin,
pus, epithelial cells, all types of casts, with a few red blood cells.
Nephritis—chronic interstitial—specific gravity low, quantity
large, albumin trace, occasional pus and red blood cells and hyaline and
granular casts.   This is.the type showing raised blood pressure.
Tuberculosis of the Kidney—The primary sign even before
gross pathological changes have occurred, is frequency, followed later by
frequency, albumin, pyuria, and blood.
Pyelitis—Urine normal in quantity and specific gravity. Albumin
with considerable pus and pelvic epithelial cells but no casts; with stone,
considerable blood is usually present.
Cystitis—Normal findings in an alkaline urine, as to specific
gravity and amount. Much pus and albumin, squamous epithelium, and
ce lular debris. With bladder-stone and new growth, many red blood
cells are found.
Urethral Infections—Pus, albumin, shreds, blood and epithelial cells in otherwise normal urine. Usually specific organisms are
found.
FATAL CREDULITY
By A. R. Chisholm, M.D.
Epidemiologist, Provincial Board of Health,
Victoria, B. C.
Some time ago I investigated an outbreak of diphtheria in a small
town in the interior. I found a family of ten members who had been
concealing diphtheria for three weeks previous to investigation until one
of the children died. Just previous to this death, six cases of diphtheria
broke out in the village. These latter cases were all subjected to efficient
control. On questioning the father who had been concealing the condition, I learned that he had been solely guided by a clipping from the
"Vancouver Sun," captioned "Modern Methods Against Diphtheria, by
Dr. Frank McCoy." He believed in this so implicitly that he cut the
article out and carried it about in his purse so that it would be on hand
for reference. On questioning him regarding this article, the parent
stated that he accepted the advice in good faith, and having read it in
a widely circulated paper, and seeing the title "Doctor" prefixing that of
the name of the author, he naturally assumed that he could rely on the
advice given.
In conclusion, it will be seen that the father concealed the condition
of diphtheria in his family, and, acting on advice of the article, he
treated four members of his family for diphtheria until the virulence
became so marked that the fourth case was fatal.
Page 10% MONTHLY CHART OF NOTIFIABLE DISEASES REPORTED TO
PROVINCIAL HEALTH OFFICER OF B. C,
YEAR, 1929
2800
2600
2400
2200
2000
1800
1600
1400
1200
1000
800
600
400
200
I
■
I
I J     F
A  I   E
N|B
M I A
A P
R R
1
J  I J  I A I S I 0 I N | D
UUUECOE
NLGPTVC
| E | Y j       I T 1 1
Total Cases January 1 to December 31, 13,944
Provincial Morbidity Statistics are compiled from the reports of the
Physicians of B. C, who are requested to report the Notifiable Diseases
as required by the Dominion Council of Health, which are as follows:
Anthrax; Actinomycosis; Botulism; Cerebro-spinal meningitis (epidemic) ; Chickenpox; Cholera, Asiatic; Conjunctivitis, acute infectious,
including ophthalmia neonatorum; Diphtheria; Dysentery, amoabic and
bacillary; Encephalitis; Erysipelas; German Measles; Influenza, epidemic;
Glanders; Leprosy; Malaria; Malignant Oedema; Measles; Mumps; Paratyphoid Fever; Pellagra; Plague; Pneumonia: (a) Acute Lobar; (b)
Bronchial or Lobular; Poliomyelitis, acute anterior; Puerperal Septicaemia; Rabies; Scarlet Fever; Septic Sore Throat; Smallpox; Tetanus;
Trachoma; Trichinosis; Tuberculosis; Typhoid Fever; Typhus Fever;
Undulant Fever; Whooping-cough; Yellow Fever.
Page 106 Continued from Page 101
trom the atonicity, allows numerous pathogenic bacteria to escape into
the free peritoneal cavity which already contains an excellent culture
medium, the transudate of the bowel wall. The result is a peritonitis
secondary to the primary condition differing in no way even to the
formation of adhesions and subsequent mechanical obstruction, and I do
not believe that any pathologist can say from the end result whether it
was or was not a paralytic ileus.
So much for the adynamic type. The dynamic type of obstruction
I believe never develops except in the presence of an infected field.
We are all familiar with the clean case which has had what appears to
be a technically perfect operation and yet after a period of three or four
days in which they have run a slight temperature of 99-100 and slight
elevation of the pulse develops an obvious intestinal obstruction. These
cases I believe are all due to an operative error or to a slip in operating
room technique. These instances are rarely seen except in those cases in
which at some time during the operation an infected area has been
entered such as an appendectomy, hysterectomy, etc. The infection either
occurs at the time of the operation or from a subsequent leak through
the suture line in the vagina or appendiceal stump.
These are accidents which happen to anyone who is doing any considerable amount of surgery—and will continue to happen, for we are
all human and therefore subject to error.
In those cases in which an infected abdomen has been opened the
patient does well for the first four or five days and then develops an
intestinal obstruction, sudden in onset and rapidly becoming complete
with early and increasing distension and vomiting.
I do not think that anyone will disagree with me when I say that
these cases are all due to partially organized fibrinous bands and are in
every way the counterpart of the obstruction we see years after any
abdominal operation.
We have left then the most difficult group to handle, those cases
showing signs of obstruction from the second to the fourth day.
I do not believe these cases to be a paralytic ileus or else we would
have had definite clinical evidence before this time. They must then be
mechanical. It is too early for organization to occur in fibrinous exudates and yet they may go on to an organized condition and a persistent complete obstruction. Many of these cases will get well with proper
post-operative care and with no surgical interference. Many will go on
to a persistent complete obstruction and we are in danger of losing valuable time in procrastination contributing largely to the tremendous mortality of this complication.
So much for diagnosis. For purposes of treatment we can arbitrarily divide our cases showing post-operative obstruction into three
periods of forty-eight hours each. The first of which may or may not
be a paralytic ileus; the second which is mechanical but may or may
not recover without surgical interference; and a third period in which
surgical measures are urgently demanded if we are to see our case to a
successful conclusion.
Page 10? Let us consider treatment from a non-operative stand point or from
that of pre-operative preparation. I feel that all these cases which are
going to be re-operated should be most carefully prepared.
In any intestinal obstruction there are certain known chemical
changes in the blood which should be corrected, no matter what the
type, cause or location, of the obstruction. There is always a low chloride
content in the blood, brought about, it is thought, by vomiting. Tremendous amounts of hydrochloric acid are lost and this is sufficient to
lower the chlorides of the blood. It is obvious that since the higher
the obstruction the more early and more severe will be the vomiting.
So the chloride loss is greatest in small bowel obstruction. The normal
content is 450 m.g. to 500 m.g. per 100 cc. of blood, and when you
operate below a chloride content of 400 m.g. you are inviting trouble,
not only from a paralytic condition of the bowel, but probably also from
an associated toxic condition, and if the chloride content be below 300
m.g. you are facing disaster just as surely as if the C02 combining power
was below 30 volumes per cent, in a diabetic and the patient already
showing signs of the onset of coma. There is also an increased nonprotein nitrogen in the blood and also a high C02 combining power.
The approved method of correcting the low chloride content is by
intravenous administration of hypertonic saline. Six years ago when
Haden and Orr published their findings, the service with which I was
connected undertook an investigation regarding the relative strengths
and amounts of the saline, and we came to the conclusion that the most
effective dosage was 600 cc. of a 6% solution. There are no ill effects
from raising the chloride content above normal. The effect of raising a
low chloride content to normal seems to be mainly to decrease the
amount of toxicity. I will not go into the chemical theory of this
conclusion but it seems well founded and has to do with the efficiency
of the buffer substances in the blood. The second beneficial effect and
the most obvious one clinically is to increase the amount of intestinal
peristalsis and I can assure you that it is most effective. I have many
times seen a patient with a complete obstipation for a period of twelve
to twenty-four hours defaecate while the intravenous was being given
and before a bed pan could be obtained.
The only objectionable feature of this medication is from the
patient's point of view. It causes pain from the resulting peristalsis
and occasionally in early complete obstruction before there is any considerable atomy of the bowel musculature the medication has to be discontinued for this reason. The bowel musculature still has sufficient
contractile force to cause this amount of discomfort. It must be remembered also that should any of the fluid get outside the vein wall it will
cause a nasty slough.
The other important factor in the treatment of all cases is the replacement of water loss and this cannot be balanced by the fluid content
of the 600 cc. of hypertonic saline. My own preference is to give an
additional 400 cc of 5% glucose following the hypertonic saline and
then start a continuous interstitial of normal saline, if the chlorides
should be judged still low.
Page 108 Of the beneficial effects of the antitoxin of the welchii bacillus and
of the rectal administration of bile I have not had sufficient experience
to give my opinion. I have seen bile used with some beneficial effect, but
not to the extent that Brockman claims. Of the value of hypertonic
saline I can assure you. It is in my opinion the greatest aid to pre- and
post-operative care of a patient that has been given to surgery since the
discovery of insulin and Lugol's solution.
We take it then that all cases of suspected intestinal obstruction
when they come under our observation receive this treatment. Then for
the individual types of obstruction I can only outline what I consider
to be the wisest course.
I believe that all cases of paralytic ileus die. As I have said it is a
rare condition and I have only seen one undoubted case on the autopsy
table. This case died very suddenly forty-eight hours post-operatively
from an undrained chronic appendix. Nothing was found at the autopsy
except a very dilated small bowel with a considerable amount of clear
canary-coloured fluid in the abdomen. Many patients of course I have
suspected of having a paralytic ileus but as I have pointed out these
cases all develop a peritonitis as a terminal condition due to the pervious-
ness of the bowel wall and usually show evidence finally of a mechanical
obstruction. Here, only the clinical history will help you decide the
diagnosis.
The more recent work that has been done on paralytic ileus is by
Markowitz and Campbell of Toronto, and their treatment is in the
admistration of a spinal anaesthetic Let me remind you that paralytic
ileus is an inhibition of the bowel musculature, due to splanchnic stimulation, dependent on the integrity of the reflex arc and the effect of
spinal anaesthesia is to break the reflex arc It paralyses the over acting
sympathetic and allows the vagus to resume its normal function relieving the paralytic condition of the bowel. I have tried this treatment
and it seems to be of some value. The difficulty is, however, that the
spinal anaesthetic is only effective for two or three hours at the most
and while the distension is temporarily somewhat relieved during this
time the paralytic condition returns.
The question of whether a jejunostomy should or should not be
done comes up. In true paralytic ileus I do not believe that it does the
least bit of good as far as the ultimate prognosis is concerned. Why
should it as the paralysis is not a result of distension. The abdomen
should not be opened. However, my position is that a jejunostomy
should be done, for some of these cases of distension will be found to be
due to an early mechanical obstruction produced by a fibrinous kinking
fo the bowel wall which may relieve itself when the distension of the
bowel above is lessened. Even if we are dealing with a paralytic ileus we
will accomplish, in the main, one important factor. It will, in some
cases, relieve the vomiting and by that means render the patient more
comfortable and prevent to some extent the great toxic effect due to the
fall in the chloride content of the blood. The only treatment that we
can suggest at present for this condition is a prophylactic one at the
Page 109 time of the operation. Gendeness in handling tissues, particularly the
mesentery, absolute haemostasis and a faultless technique will, whatever
the etiology, go far in preventing its occurrence.
Let us consider next the treatment of the type of obstruction that
occurs from the fourth to the sixth post-operative day.
I do not doubt that we will all agree that the abdomen should be
opened immediately and the obstruction found and relieved. You will
only need to look in the vast majority of cases in the ileocolic region.
If the case has been neglected and is of over twelve hours duration I
always do a jejunostomy after the Witzel technique and I prefer to do
it in the first eighteen inches of the jejunum through an upper left rectus
incision rather than just above the obstruction through the original
incision.    I like to remove the jejunostomy tube on the third day.
Next we will consider the other type that causes us the most grave
concern from the point of view of whether we should or should not
resort to surgical interference. This is the type occurring from the
second to the fourth day. For those of us who believe a paralytic ileus
can develop during this period the problem is all the more difficult. As
I have mentioned many of these early cases of what I believe to be
mechanical obstruction will relieve themselves, but a delay is such a
vital factor in increasing mortality, that my own plan is to do a jejunostomy through the upper left rectus and not explore the abdomen. This
procedure is most simple. It should be done in every case under local
anaesthesia and will only require from ten to fifteen minutes so that the
question of shock is a negligible one. We have done it many times in bed
without taking our patient to the operating room.
If we are dealing with a paralytic ileus we have done no harm even
if we have not gready benefited the patient. If it is mechanical and
will relieve itself we have prevented any tremendous drop in chloride
loss due to vomiting. If it is a persistent or complete obstruction we
have avoided not only the chloride loss but the extreme distension which
produces a pervious bowel wall with its resultant infection and we can
later open the abdomen and rdieve the obstruction under ideal circumstances.
There is first one further point that I would like to bring out.
Consider a case which has been obstructed by a band and is fairly late.
The recognized treatment is to open the abdomen, snip the band with a
pair of scissors, and to quickly close the abdomen again. Nothing could
be more simple and yet how often have we seen the patient come back
from the operating room in fairly good shape, only within a few hours
go into the most profund shock and die in a short time. There can only
be one explanation and that is that the onward rush of toxic material
from above the obstruction where the rate of absorption because of distension and sluggish blood supply, is slow, coming in contact with a dehydrated rapidly absorbing bowel below the obstruction, produces shock
and toxic death.
How are we to avoid this? The older method of opening the small
intestine above the obstruction inserting a sucker and aspirating the fluid
Page 110 is time consuming and invariably leads to further contamination of the
peritoneal cavity, and one wonders if the bad effects do not more than
counteract its benefits.
I feel personally that given a far advanced case either occurring
post-operatively or not, one should do a jejunostomy under local anaesthesia three or four hours previous to relieving the obstruction. This
should be done and the patient in the interval could be getting the preoperative regime outlined above. We should then have a case with lessened toxicity, lessened distension and one in which the water balance
has been restored.
To recapitulate the treatment in time periods relating to the onset
of the obstruction post-operatively. In the first period one may or may
not do a jejunostomy. In the second period one should do a jejunostomy
and may or may not open the abdomen. In the third period one must
open the abdomen and may or may not do a jejunostomy.
It is obvious that this outline is not applicable to every case. Given
a case of appendiceal abscess which is drained and in thirty-six hours
develops an obstruction, one would not, in that case, suggest a paralytic
ileus, but would feel that it was mechanical—and if care has been taken
at the time of the operation to see that the terminal ileum is free and
not kinked, the treatment applicable would then be that of the second
group. If the condition was such that one could not examine the terminal ileum the case would probably fall into group three. I feel that it
is very important in every case in which an appendectomy is done to
examine the terminal ileum.
I appreciate the attention that has been given me and if the outline
I have suggested will form a basis from which a rational treatment of
this serious complication can be evolved we shall all benefit.
B. C. MEDICAL ASSOCIATION NEWS
Victoria Medical Society Annual Meeting
The Annual Meeting of the Victoria Medical Society was held at
the Empress Hotel following a dinner which was presided over by Dr.
R. L. Miller, the President.
The guest speaker was Dr. A. S. Monro of Vancouver, B. C, who
had prepared a very interesting treat for those present in a paper on the
"Early Medical History of British Columbia." Dr. Monro has done and
is still doing a wonderful piece of work for the profession of this province. • It is daily growing more difficult to gather the data necessary to
make such history complete. Dr. Monro as chairman of the Historical
Section of the B. C. Medical Association will soon have gathered much
very valuable material that some day may be preserved in book form.
A vote of thanks was rendered Dr. Monro on motion of Dr. W. E.
Scott Moncrieff. This was seconded by Dr. G. L. Milne who came to
Victoria to practice in April, 1880.    He spoke very feelingly of those
Page  111 early days in Medical Practice, so many of his contemporaries having
passed on.
Another interesting feature of the Annual Meeting arose out of the
presentation to the Victoria Medical Society by Dr. M. W. Thomas,
Immediate Past President, of a gavel and gavel block. This has a special
interest in that the mallett head which is two inches by five inches is
made of cherry wood taken from one of two trees planted more than
half a century ago by the late Hon. Dr. James Sebastian Helmcken
who came to Fort Victoria in March, 1850 (nearly eighty years ago)
and was then the first practicing physician on Vancouver Island and
the colony which was destined to become British Columbia. Dr. Helmcken named these two trees which grew from cherry stones to full
stature bearing fruit—the one bearing white fruit was named "Jim"
and the other bearing darker fruit was known as "Harry." These were
two sons of Dr. Helmcken. "Jim" afterwards became Dr. James Douglas Helmcken, who practiced his profession in Victoria for many years.
"Harry" afterwards became a successful barrister and was well known
as Harry Dallas Helmcken, K.C., M.P.P., serving in the Provincial
Legislature for many years.
The history of the Helmcken family is an interesting one and closely
woven into the early story of British Columbia before and since Confederation. Dr. Helmcken was a beloved practitioner of medicine as well
as an honourable public man, and much could be written of him.
The head of the gavel carried a panel with cherry branch and fruit
on one surface and on the reverse panel a cherry tree. The handle of the
gavel was made of British Columbia or rather Vancouver Island native
oak. This is about nine inches long and carries on both sides of its shaft
the Rod and Serpent of Aesculapius carved in releif. The end of the
handle which is slightly heavier, is enveloped by four oak leaves and
capped by an acorn which serves to close a recess in the shaft. In this
recess reposes a document with history of the gavel signed by all concerned. The head is adorned with two bands of silver and the whole
is fitted in to a century-old box, together with the gavel block.
On motion of Drs. Forrest Leeder and George Hall, the gavel was
formally accepted and used by President Dr. R. L. Miller.
Later in the evening the Library Committee reported and showed
additional portraits to be added to the almost complete gallery of past
members. A picture of the late Dr. E. B. C. Harrington, one of the
first C. P. R. surgeons in construction, was shown. He was the first
President of the present Victoria Medical Society when formed in May,
1895.
Another, a pastel of the late Dr. I. W. Powell who came in the
ear!y sixties was presented by the surviving children who still live in
Victoria. Dr. Powell was a most active man in the life of the community and made the first address in the cause of Confederation. He
was very active at the time the Medical Act was passed in 1886 and was
elected the first President of the first council of the new College of
Physicians and Surgeons of British Columbia. Another group of four
includes photos of  Dr.  John  Ashe,  who  came in   1862.    Dr.  James
Page 112 applied locally, hot and thick is usually very grateful to
the patient and constitutes a distinctly beneficial adjunct
to the general treatment of these conditions.
TONSILLITIS LARYNGITIS
PHARYNGITIS
In the acute affections of the pharynx ,and larynx
Antiphlogistine applied to the neck will serve to diminish
the pain and reduce the swelling and congestion of the
pharyngeal and laryngeal tissues. The Antiphlogistine
dressing, being plastic, may be fixed in position by an adhesive strip applied over the vertex, a procedure which insures mechanical support, rest and prolonged thermo-
therapeutic action.
THE DENVER CHEMICAL MFG. CO.
153 W. Lagauchetiere Street
Montreal Trimble who besides enjoying a large practice also served in the Legislative Assembly and was the first speaker of the first assembly after
British Columbia entered Confederation in 1871.
There was also Dr. Mathews, a well-known and well-beloved practitioner in those early days and Dr. McNaughton-Jones who came in the
early days and later served at the quarantine station at William Head
until he passed away in 1896.
Another group shows Dr. John A. Duncan and Dr. George H.
Duncan. These will almost complete the gallery of photos of departed
members. Photographs and any data required for their inscriptions are
becoming increasingly more difficult to secure.
Bookkeeping
Collections
NOTICE
Doctors' books and records kept up-to-date.
Statements rendered regularly to patients.
Collections of overdue accounts.
For this service leave message at
Seymour 1896 or Douglas 578-R
J. C. DUNSTERVILLE
Suite 5, 884 Bute Street
Vancouver, B. C.
Say it with Flowers
Cut Flowers, Potted Plants, Bulbs, Trees, Shrubs,
Roots, Wedding Bouquets.
Florists' Supplies and Funeral Designs a Specialty
Three Stores to Serve You:
48 Hastings St. E.
665 Granville St.
151 Hastings St. W.
One Phone:
Seymour 803 3
Connecting all three stores.
Brown Bros. & Co. Ltd.
VANCOUVER, B. C.
Page 113 The True Story of Acterol
CHEMISTS call it by its correct chemical name, solution
activated ergosterol—the name by which we first supplied it.1
The largest manufacturer of rare sterols in America, early having
activated cholesterol2 (1925), being first in America to commercially
produce pure ergosterol3 and to standardize activated ergosterolM
(October, 1927), seeking to protect ourselves and the medical profession against substitution, we coined the name Acterol— signifying
activated ergosterol. The Council on Pharmacy and Chemistry
subsequently coined a name, Viosterol. As servants of the American
Medical Profession, we defer to its wishes and now call our product
Mead's Viosterol in Oil, 100 D. The product remains the same.
Therefore, so long as you specify
MEAD'S
call it Acterol, call it Activated Ergosterol
 call it VIOSTEROL IN OIL, 100 D
so long as you specify Mead's,
You are sure of getting the original brand
backed by the longest manufacturing and
clinical experience. The paramount importance of this is evident from three striking
truths: (l) We established the potency and
(2) the dosage, both of which (potency and
dosage) are now the official standards. (3)
Mead's Viosterol does not turn rancid.
Specify Mead's Viosterol because it is accurately standardized, uniformly potent,
free from rancidity, and safe to prescribe.
Mead Johnson & Co.,
enclose no dosage directions, and never ex-
ploit the medical profession.
i     V- Biol. Chem., 76:2. aIbid., 66:451.
zJbid., 80:15. *Ibid., 76:251.
WATCH FOR SPECIAL COLOR
SUPPLEMENT IN JOURNAL OF THE
AMERICAN    MEDICAL   ASSOCIATION
JANUARY 18th, 1930
Mead Johnson & Co. of Canada. Ltd.
MEAD'S  VIOSTEROL IN OIL.
100 D   (originally   Acterol)
Specific    and
preventive   in
cases of vita'
min D deficiency. Licensed.
Wisconsin Alumni Research
Foundation. Accepted, Council
on Pharmacy  and Chemistry,
A.M.A. All Mead Products are
Council-Accepted
Belleville. Ontario "1
Rest Haven Sanitarium and Hospital
MARINE DRIVE, SIDNEY, B. C.
(Near Victoria)
(Visited by Qualified Physicians)
Semi-Private Wards Surgical Wards
Private Rooms Maternity Wards
Rates as low as $21.00 Weekly.
Beautiful for situation.
For further information apply to:
MEDICAL  SUPERINTENDENT,   SIDNEY,   B.   C.
or the Manager
Tr0lt at Our Expense . %.
♦»
wan
nhalant,J&66;
m
"Return Coupon for Sample
I earn for yourself how promptly out the irritation of inhalants
j and effectively Swan-Myers containing menthol, thymol,
Ephedrine Inhalant, 1%, No. 66, eucalyptus, or other aromatics...
relieves the nasal congestion of Stocked by dealers in 1-ounce
colds, coryzas and hay-fever with- and 1-pint bottles.
THE WINGATE CHEMICAL CO., Ltd., 468 St. Paul St., West, Montreal
Send physician's sample Swan-Myers Ephedrine Inhalant, No. 66, to
Address _	
VMA
.M. D.  —m4 ^°*
Hollywood Sanitarium
LIMITED
citor the treatment of
Alcoholic, Nervous and Psychopathic Cases
Exclusively
Reference * *B. Q. <&ftedica\ ^Association
For information apply to
Medical Superintendent, New Westminster, B. C.
or 515 Birks Building, Vancouver
Seymour 4183
Westminster 288

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