History of Nursing in Pacific Canada

The Vancouver Medical Association Bulletin: November, 1932 Vancouver Medical Association Nov 30, 1932

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 Bulletin
OF THE        f,
Vancouver Medical Association
Contents
Infections of the Lung
Biologic Products
Spinal Anaesthesia
Vol.   IX
NOVEMBER,  1932.
No.
Published monthly at Vancouver, B. C, by
McBEATH-CAMPBtn   Ltd.,  326  Pender  Street  West
Subscription.   $1.50   per  year. .^^ANJMTHEATae  BLDG.
\^ls|QOUy^ CANADA
m
-l THE     VANCOUVER     MEDICAL     ASSOCIATION
BULLETIN
Pa hi nihil  Monthly under the Auspices  of  the Vancouver Medical  Association in  the
Interests of the Medical Profession.
Offices:
203 Medical Dental Building, Georgia Street, Vancouver, B. C.
Editorial Board:
Dr. J. H. MacDermot
Dr. D. E. H. Cleveland Dr.  M.  McC. Baird
All communications to be addressed to the Editor at the above address.
Vol.  IX. NOVEMBER,   1932 No.   2
OFFICERS 1932-1933
Dr. Murray Blair Dr. W. L. Pedlow Dr. C. W. Prowd
President Vice-President Past   President
Dr. L. H. Appleby Dr. W. T. Lockhart
Hon.  Secretary Hon.  Treasurer
Additional Members of Executives:—Dr. A.  C.  Frost;   Dr.  C.  H.  Vrooman
TRUSTEES
Dr. "W. D. Brydone-Jack Dr. J. A. Gillespie Dr. J. M. Pearson
Auditors: Messrs. Shaw, Salter & Plommer
SECTIONS
Clinical Section
Dr.   A.   M.   Agnew :  Chairman
Dr. W. H. Hatfield Secretary
Eye, Ear, Nose and Throat
Dr. J. A. Smith '. Chairman
Dr. A. O. Brown Secretary
Paediatric Section
Dr.   J.   R.   Davies Chairman
Dr.   J.   H.   B.   Grant      Secretary
Cancer Section
Dr. A. Y.  McNair Chairman
Dr. A. B. Schinbein Secretary
STANDING COMMITTEES
Library Orchestra Summer Scliool
Dr. W. H. Hatfield Dr. J. R. Davies Dr- J-  w Thomson
Dr. H. A. Spohn Dr. F. N. Robertson Dr- c- E- Browi<
Dr. D. M. Meekison Dr. J. A. Smith Dr- C H- vrooman
Dr.   H.   A.   DesBbisay Dr. J. E. Harrison Dr- J- W- Arbuckle
Dr. G. E. Kidd Dr- H- A- Spohn
Dr. J. E. Harrison Dr- H- R- Mustard
Publications u   ... ,
Hospitals
Dinner Dr- J- H- MacDermot Dr. A.  W. Bagnall
Dr. D. E. H. Cleveland Dr. F. J. Boller
Dr. H. H. Pitts Dr. Murray Baird Dr.  ^. C.  Walsh
Dr.  A.  M.  Warner Dr   g   B   pEELE
Dr. A. T. Henry
Credentials V.O.N. Advisory Board
_ . n   „   ,, ,    . Dr.  F. P. Patterson Dr. H. H. Caple
Rep. to ii. C. Med. Assn.     t-\at-k>t t%_ " '»■   n>
r Dr.   A   J.   MacLachlan      Dr.   E.  Trapp
Dr. G. F. Strong Dr. S. Paulin Dr. J. W. Shier
Sicknta and Benevolent Fund - ■ The Prfsident ■— The Trustees VANCOUVER HEALTH DEPARTMENT
STATISTICS, SEPTEMBER,  1932
Total Population (Census 1931)
Asiatic  Population   (Estimated)
24
1
Popu
8.0
10.6
7.0
15.7
jber,
th,  1
s     E
6,593
5,000
Rate
per  1,000
162
13
141
318
7
22.0
4
IN CITY
Oct
32         to  15
s             Case
0
6
0
10
0
8
3
0
0
25
0
0
2
0
ation
Deaths—Residents only  ..
Male     159
Female 159
INFANTILE MORTALF
Deaths under one
IY—
year
1,000
:luded
ONT
jf age 	
Death Rate—Per
births 	
Stillbirths   (not in
CASES OF C
Smallpox    -  	
in above
AGIOUS
August,
Cases    D
0
13
1
6
0
0
1
4
0
56
1
1
3
0
) 	
DISEASES
1932
eaths
0
0
0
0
0
0
0
0
0
11
0
0
0
0
REPORTED
September, 19
Cases     Death
0             0
15              0
0 0
11              0
1 0
11              0
13              0
1              1
0 0
48            11
1 0
0              1
0              0
0              0
1st
932
eaths
0
Scarlet   Fever   	
0
0
Chicken-pox 	
Measles   	
0
0
Mumps    	
0
1
0
Paratyphoid   	
0
Pr>lintnyplit'<
0
Meningitis   (Epidemic)
0
1
Encephalitis Lethargica _
0
3oth products are suppliet
in special containers to
hospitals and
institutions
Gardenal
In tubes of:
20 tablets 0.10 gm. {\y2 gr.)
30 tablets 0.05 gm. ( % gr.)
80 tablets 0.01 gm. (1/6 gr.)
Hypnotic-Sedative
Most effective in the treatment of Epilepsy.
/
Soneryl
In tubes of:
20 tablets 0.10 gm. (\y2 gr.)
Hypnotic-Analgesic
A decided relief for pains,
neuralgia preventing sleep.
To   be   preferred   to   morphine and its derivatives.
1
LABORATORY
POULENC FRERES
of CANADA, LTD.
(Under    licence    Rhone-Poulenc)
For sample and literature:
.OUGIER FRERES, 3 50 Le Moyne St
MONTREAL
Pae.e 21
was
JIUMUi
m What is Pasteurized Milk?
DEFINITION
Pasteurized Milk is defined by law as milk heated to 140° to
145° F. for thirty minutes.
OBJECT
The only object of pasteurization is to destroy the disease germs
which are sometimes found  in milk.
MILK-BORNE DISEASES
The following diseases are known to be milk-borne; tuberculosis, typhoid fever, scarlet fever, diphtheria, septic sore throat,
foot and mouth disease, dysentery, and other intestinal troubles,
especially in infants. To this long list has recently been added
epidemic arthritic erythema and undulant fever. Three small outbreaks  of  infantile  paralysis   have  been  traced   to  raw  milk.
In the last twenty years over six hundred milk-borne epidemics
have been reported on this continent. Who can say how many have
occurred   unrecognized?
Pasteurization spells protection so far as these diseases are
concerned.
OFFICIAL SUPERVISION
Our regulations provide ample authority to insure adequate
pasteurization. They also safeguard the cleanliness of milk before
pasteurization. Our Civic Health Authorities are responsible for the
enforcement  of  our  pasteurization  laws.
INSPECTION
Milk should be inspected even though pasteurized. Pasteurization
does not remove the need of sound cows, healthy milkers and clean
dairy methods. Milk is subject to official inspection from pasture
to pail and from pail to palate. In the last ten years, through
inspection, our milk supply has steadily improved. Inspection provides for cleaner, fresher and better milk, but not necessarily safe
milk. Raw Milk, however carefully handled, has frequently caused
disease.
THERE IS NO RECORD OF A MILK-BORNE EPIDEMIC
DUE TO PROPERLY PASTEURIZED MILK.
ASSOCIATED DAIRIES
Limited
distributing rich, safe, clean milk
Phones:
Fairmont 1000—North 122—New Westminster 1445 Just An Old
I Georgia Custom
Medicine and sick-room necessities may be
ordered by the Doctor from his home and
delivered direct to the patient's home any
hour of the night. Everything the Doctor
requires for emergencies is here, ready to
go out on a moment's notice. Our all-night
service is maintained for.the Doctor's
convenience.
SEYMOUR 1050
All Day
Georgia
Pharmacy
W
IiVi-
777 WEST GEORGIA ST.
All Night
In congestive heart failure
Theocalcin
(theobromine'calcium salicylate)
Myocardial stimulation and a
potent diuretic effect is obtained with 1 to 3 tablets t. i. d.
Tablets  7^  grains each,
also   Theocalcin   powder.
Literature and samples upon request
BILHUBER-KNOLL CORP.
154 Ogden Ave., Jersey City, N. J.
Canadian Agents
MERCK & Co. Ltd., 412 St. Sulpice St., Montreal EDITOR'S PAGE
Within a few days, the Vancouver Welfare Federation, or Community Chest, will open its campaign for funds for next year; and medical
men, as well as others, will be asked for subscriptions. There seems to be
a wide variety of opinions as to our obligation and responsibility in this
matter, and it may be well to consider what these are.
It seems to us a pity that the words "Community Chest" are not
used as the name of this organization. It would, we think, remind us
more clearly of what this organization is really doing. "Welfare Federation" has rather a cold sound to most of us, and while it expresses, perhaps more accurately, the nature of the organization, we are apt to lose
sight of the fact that this fund is for the benefit of the community, and
is a community effort.
We have heard the opinion expressed that medical men can hardly be
expected to contribute to this fund—since they are already called upon
to do so much free work, and hence are already contributing in a large
degree to the social work of the community. This is a very plausible
argument, and indeed medical men are doing a large, even excessive,
amount of free work. But we feel that there are other angles to the
question, and that we cannot altogether escape responsibility by this argument.
In the first place, the work of the Welfare Federation is only to a
small degree, concerned with matters of sickness and health. The vast
bulk of its work is social relief, and prevention of the evils that come
from indigency and penury. It cannot give relief in the form of cash,
there are other agencies for that purpose, but, as we will all agree, money
relief will not begin to solve the problems presented by poverty and destitution. The work of the Federation, through its social workers, in the
John Howard Society, in its Family Welfare Bureau, in the children's
organizations, in the Preventorium, is all preventive, and so is more than
worth-while; it returns dividends to the community, in the money it
saves from being wasted on crime, on disease, on delinquency, and so on.
Simply regarded as insurance, it is a profitable investment. We, as citizens,
benefit by that work, we, as citizens, should contribute to it, if we possibly can.
Next, if we have a grievance on the ground that we are to a greater
or less extent being exploited, it is a separate question entirely from our
obligations to the Community Chest. We can and will, it is hoped, settle
this question with the proper authorities, when the time comes, but it
does not apply here. Because Peter is picking our pocket, we should not
neglect to pay our just debts to Paul.
Lastly, there is a selfish argument, but one that is very pertinent in
this case. The Welfare Federation is now considering the question of
payment of the medical men who do work for its various agencies, and
there is little doubt that it intended to make some provision for this in
its next year's budget. This is the first time in Vancouver's history, as
Page 22 far as we know, that any organization has accepted the principle that
medical men doing work in connection with organized charity should be
paid, and we should remember this, and be influenced by it, when we are
asked to do what we can for the Community Chest.
On many grounds then, we should contribute what we can. To many
JO '
of us, the burden of contributions may seem impossibly great, but if we
cannot possibly, at least let the reasons be the right ones. We are not the
only ones asked to make sacrifices, perhaps, it is true, our sacrifices are
greater than many must make, but if only those who find it easy to give,
do so, the fund will never reach its objective. And that would be a
calamity—for this work must be done—and we do not believe it could be
done so economically and efficiently by any other organization.
ANNUAL DUES
Members of the Vancouver Medical Association are reminded that
in accordance with the by-laws, drafts will be presented for unpaid dues
on the first of November.
NEWS AND NOTES
Dr. Strong has presented to the Library his copy of the centenary
volume of the British Medical Association. The book is by Dr. Ernest
Muirhead Little and is an interesting history of the Association for the
the years 1832-1932. It contains some beautiful coloured plates
illustrating the new British Medical Association House in Tavistock
Square, London.
The Vancouver Medical Association is not doing too badly itself.
We may not have a history dating back a century but at any rate we
have pictures, or rather portraits, of thirty-three out of thirty-four past
presidents of the Association ready for our centenary volume in 1998.
We hope to get a picture of the missing president within the next few
weeks.   Luckily he is still available for portrait purposes.
Trail is thinking of starting a Medical Library. Dr. Bain Thorn was
recently a visitor to our Library and was deeply interested in the framed
letter of Sir William Osier to Dr. Pearson which hangs in the Reading
Room. So much so, indeed, that he is anxious to obtain a copy for Trail.
The Library Committee is considering Dr. Thorn's request. Meantime,
our best wishes go to Trail.
Page Dr. R. B. Boucher, the last of the overseas travellers, has returned to
Vancouver. We understand that the reason for this delay on his part
was his anxiety to complete his series of "movies" of Viennese life which
he was studying with a cine-kodak. We hope that the Association may
have the opportunity of seeing these
We are glad to learn that Dr. Mason is taking a well-earned rest at
home. He is very much better and is said to have expressed his intention
of returning to work early in November.
Dr. Frank W. Emmons and Mrs. Emmons have come to Vancouver
from Rochester, Minn. The doctor is opening an office in the Medical-
Dental Building and will specialize in neuro-surgery. Dr. Emmons has
been for some years working in the Mayo Clinic under Dr. Adson. He is
a nephew of the late Dr. A. S. Monro and Mrs. Monro of Vancouver.
A great many of our readers will be delighted to know that Dr. Rin-
near Wilson, of London, England, is to be again a visitor to British Columbia next summer, when he will be one of the speakers at the meeting
of the Pacific North West Medical Association in July. Dr. Rinnear
Wilson is persona grata with the Vancouver medical fraternity, which remembers vividly his delightful lectures on his previous visits.
Dr. Dan McLellan has recently returned from a holiday trip in
southern waters, and we learn from the daily press that he officiated at an
interesting event in which several nationalities and races were inextricably
mixed. The papers say an "infant was delivered on the high seas," and
we should like to know the age of the infant, and did the doctor hum to
himself, "For he might have been a Prooshian, a Frenchman, Turk or
Rooshian . . . ."?
During the next two or three months, it is hoped that the B. C.
Medical Council, in accordance with resolutions adopted by the various
medical bodies of the province, will complete its re-organization of the
profession; so that, as in the case of Alberta, the Council will become the
main body, in control of all medical activities. Our readers will remember
the visit of Mr. Hunt, the Executive Secretary of the Alberta Medical
Council and the Alberta Medical Association, when he addressed us on ths
matter.
A brief outline of the changes may be given as follows: the B. C.
Medical Council will take over the duties of the B. C. Medical Association, except its educational and scientific work, and will give it a grant
annually for these purposes. All legislative work, and such matters as
Page 24 industrial medicine, health insurance, ethics and the adjustment of professional disputes or the difficulties of individual men, will be in the hands
of the Council. There will be a readjustment of fees, no doubt, but the
net result will be a definite saving to the medical man, and, since everyone will be included, a much more representative governing body. Details
are now being worked out.
LIBRARY NOTES
NEW BOORS IN THE LIBRARY
Vitamins—A Survey of Present Knowledge—Medical Research Council
—1932.
A historical introduction mentions that although some twenty or
thirty years ago beri-beri and scurvy were well known as deficiency diseases, eight years ago only three vitamins were clearly recognized. Today
there are believed to be at least eight. Night-blindness, as one of the
effects of vitamin A insufficiency, is mentioned.
It is suggested that vitamin A may play a significant part in preventing the development of certain nervous system diseases, as multiple
sclerosis.
With regard to vitamin D it is mentioned that it is probable that
when diets of young children contain a bare minimum of vitamin D, and
when exposure to sunlight is limited, then the consumption of larger
amounts of cereal may be the determining factor in the onset of frank
rickets.
A warning is sounded regarding commercial vitamin D solutions,
based on standardization by rat units.
Vitamin C deficiency as "latent scurvy" is mentioned as a possible
element in human dental disease.
Vitamin E investigations applied to human fertility are not numerous. Two cases are mentioned where successful pregnancies occurred
after four or five previous miscarriages, where the women were treated
with wheat grain oil.
The report on Vitamin B complex with its three parts makes interesting reading.
In discussing condensed milks, it is shown that antiscorbutic potency
in sweetened condensed milk is almost identical with that of the equivalent of fresh milk, but that unsweetened condensed milk has lost more
than 40% of its vitamin C content.
Medical Clinics of North America—-September, 1932—is made up of a
symposium on Disease of the Heart.
The Manual of Embryology by J. E. Frazer is the latest work in this
subject.
Page 25 ADDITIONS TO LIBRARY
Medical  Clinics North America—Boston,  New York,  Philadelphia  and
Chicago numbers.
Surgical Clinics North America—Chicago, New York, Lahey Clinic and
Mayo Clinic numbers.
Section of Ophthalmology, A.M.A., for 1931.
Diagnosis in Joint Disease.    Allison & Ghormley.
Transactions American Ophthalmological Society for 1931.
Transactions of Ophthalmological Society of the U.R. for 1931.
Peculiarities of Behaviour. Steckel, 1925.
Sadism & Masochism.   Steckel, 1929.
Sexual Life of Savages.   B. Malinouski, 1931.
Cause of Cancer.    Gye & Purdy, 1931.
Diagnosis of Nervous Disease, 7th Ed.   Purves-Stewart, 1931.
Tumours of Bone.    Geschickter & Copeland, 1931.
Treatment of Chronic Deafness.    Cathcart, 1931.
Section of Laryngology & Otology, A.M.A., 1931.
Transactions of American Laryn. Otol & Rhinol, Society, for 1931.
Psyllium Seed—the latest Laxative. J. F. Montague, 1932.
Genesis of Cancer.    Sampson Handley, 1931.
The Medical Annual, 1932.
Transactions American Otological Society, 1932.
Coll. Papers on Eugenic Sterilization in California.    Popenoe, 1930.
Mayo Clinic Volume, 1932.
New and Non-Official Remedies, A.M.A., 1932.
Heredity in the Light of Esoteric Philosophy.    Dr. Irene Bastow-Hudson.
Vitamins—a Survey of Present Rnowledge.    Medical Research Council,
1932.
Manual of Embryology.    Frazer, 1931.
Fraud in Medico-Legal Practice.    Collie, 1932.
Diseases of the Coronary Arteries.   Sutton and Lueth, 1932.
Diet Manual of St. Mary's Hospital, Rochester, 1932.
History of the British Medical Association.   E. M. Little, 1932.
Text book of Pathology—Boyd, 1932.
DIAGNOSIS OF SUPPURATIVE INFECTIONS OF
THE LUNG
By Dr. Leo Eloesser
[Fo rthe following abstracts of Dr. Eloesser's papers, we are indebted
to the author himself, who was kind enough to abstract these after he
returned to San Francisco, and send them to us. They are therefore authoritative—Ed. ]
Page 26 (RESUME)
Non-tubercular suppurations of the lung parenchyma may occur as
part of the picture of a generalized bacteriemia, especially a staphylococcic
one. A blood stained sputum in a profoundly septic patient may awaken
suspicions of multiple miliary or larger abscesses.
Of more practical importance are the larger single abscesses beginning
as an infarct. Embolism often occurs in the second or third week after
an operation. The patient complains of a sudden severe pain in his chest
which cuts his breath short. Breathing is shallow, rapid and painful.
There is a dry hacking cough. The patient is often cyanotic and alarmingly ill. The temperature rises sharply, often with a chill. The affected
area of the chest is held rigid; it is dull and the breath sounds here are
scarcely audible. The signs are due partly to infarction, partly to a surrounding area of atelectasis. Later the breath sounds may be tubular, accompanied by crepitations and a pleural rub. Soon the patient may cough
up bright red blood. Signs and symptoms may disappear or the infarct
may suppurate. Fever, sepsis, and cough continue, expectoration is scanty
until suddenly an abscess which has been forming may burst into a
bronchus, when huge amounts of foul sputum are expectorated. When
this occurs sepsis and fever may recede, and the abscess cavity be gradually obliterated. If, however, communication between the abscess and the
bronchus is insufficient to permit of proper drainage of the abscess contents, then fever and suppuration may recur at more or less frequent intervals, and the abscess become chronic.
The x-ray will show a diffuse density at first; as the lung surrounding the infarct becomes aerated the shadow becomes less dense and smaller,
and finally disappears, or after the abscess has broken into a bronchus,
shows a cavity with a fluid level.
Abscesses occur not only after emboli and infarctions, but also after
aspiration of infectious material, e.g., after operations under general
anaesthesia, especially those about the mouth and air passages, after submersion in polluted water, etc.
A peculiar form occurs in the aged, in diabetics, and in persons with
failing circulation, when gangrene is more pronounced and a larger portion of a lobe may slough. Aspiration abscesses and even embolic ones lie
at a greater or lesser distance from the surface of the lung, rarely quite
reaching it, and are usually covered by a thickened visceral pleura. The
gangrenous areas are wedge-shaped, have their base toward the periphery,
and are accompanied by an empyema.
The cavity of an aspiration abscess or an embolic one contains puttylike inspissated particles of necrotic lung tissue—lung sequestra with a
peculiarly penetrating, foul, rancid odor; gangrene presents itself as a
soft blackish slough without formation of a true abscess cavity.
X-rays are to be interpreted with caution. Apical abscess cavities
are not rare and simulate tuberculosis, neither is basal tuberculosis simulating an abscess uncommon. Typical tubercular foci elsewhere in the
lung will make a diagnosis of tuberculosis rather than abscess likely.
Page 27 Differentiation of secondary abscesses following necrosis of lung
tumours, suppurating cysts, echinococcus cysts, actinomycosis, etc., from
primary abscess may be extremely difficult but is often not impossible if
the various possibilities are thought of. Communicating empyemas and
perforating liver abscesses are to be borne in mind. The bronchoscope,
x-ray with lipiodol injection, the various laboratory aids, repeated sputum
examinations, complement fixation reaction for syphilis and echinococcus,
may have various forms, tubular, sacculated, or bead-like. Dilatation may
peated search fails to reveal tubercle bacilli speaks against tuberculosis.
Sputum containing one organism in pure culture, especially streptococcus,
speaks for a perforating empyema, the sputum of an abscess usually contains countless varieties of organisms, often the spirillae and fusiform
f acilli of Vincent.
Bronchiectasis, a dilatation of the end branches of the bronchial tree
may have various forms, tubular, sacculated, or bead-like. Dilatation may
be congenital or acquired. Among the acquired causes are stenotic processes in the larger bronchi, foreign bodies, strictures, tumours, etc., and
shrinking processes in the parenchyma. If the alveoli intervening between
an area of the chest wall and a portion of the bronchial tree are collapsed,
it may be that respiratory expansion of the chest wall causes the underlying bronchi to be dilated.
Bronchiectasis is a condition, not a disease. Disease and clinical
symptoms come with infection of the dilated bronchi. Many congenital
cystic lungs remain symptom free.
After infection has occurred, long continued cough and copious expectoration are the outstanding complaints. Intermittent attacks of
fever, denoting spread of the infection to the surrounding lung (pneumonitis) , interpreted as "grippe," leave indelible traces. The sputum is
usually greenish or yellow, has a sickly sweetish smell, and is not infrequently bloody. Profuse haemorrhage is not rare. In chronic bronchiectasis, after repeated bouts of fever, the patient becomes more or less
dyspnoeic and cyanotic, and the fingers clubbed.
Signs are deceptive; slight dullness with rough breath sounds and
coarse rales after cough are sometimes heard, but seldom give indication of
the extent of the disease.
The x-ray with lipiodol permits of an exact diagnosis—the dilated
bronchi are readily filled and made apparent; a normal lipiodol filling excludes bronchiectasis. The bronchus may be entered with a bronchoscope.
Two matters of diagnosis are important. Proper treatment demands
that the seat and size of abscesses should be accurately determined with
the help of an x-ray; the diagnosis should not rest with the inaccurate
and usually fallacious one of unresolved pneumonia.
Bronchiectasis should be differentiated from tuberculosis by repeated
sputum examinations and an x-ray with lipiodol so that bronchiectatics
may not be uselessly isolated as contagious.
Page 28 TREATMENT OF ABSCESS
By Dr. Leo Eloesser
(RESUME)
Many abscesses heal spontaneously. In the acute febrile stage the
patient should be kept quiet, lying, if possible, on the affected side, and
certainly not on the unaffected one, in the hope of "establishing postural
drainage." Reeping the affected side quiet by having the patient lie on
it will often suffice to have fever and toxicity abate, and will help the
abscess to localize.
Bronchoscopy may be indicated in acute febrile inflammation coming
on soon (in two or three days) after an operation, and presumably due
to aspiration; it is useless and may be harmful in acute abscesses of embolic
origin—(those coming on usually two or three weeks post operation.)
Neoarsphenamine may be of use in acute abscesses, especially if Vincent's organisms are demonstrable in the sputum.
Artificial pneumothorax may be useful and is not likely to be harmful in the more central abscesses (both acute and chronic). In peripheral
abscesses there is considerable danger that artificial pneumothorax may
cause the abscess to rupture into the free pleura, a complication difficult
to deal with. If artificial pneumothorax is used the needle should be inserted at a distance from the site of the abscess and every effort made
not to puncture the lung, for the constant cough of an abscess may propel
highly infectious material into the pleura through even a small puncture.
If after two or three months of conservative treatment the abscess
does not heal then operation should be considered. Operation should not
be delayed until secondary pulmonary changes and constitutional danger
from sepsis diminish chances of recovery.
Operative Technique
Sodium Amytal gr. vi, is given by mouth one hour before operation. Morphine gr. % is given one-half hour later, and morphine gr.
1/6 added just before operation if the patient is not drowsy. Under local
anesthesia a hockey stick incision is made over 2 or 3 intercostal spaces
for a lower lobe abscess, a U-shaped flap with the base outwards for an
upper anterior abscess, or an incision straight across the anterior part of
the axilla for an upper lateral or posterior abscess. The incision should
give ample room. The ribs are isolated from the periosteum and the intercostal musculature incised, care being taken to expose but not enter the
pleura. If the lung is not adherent and its speckled surface is seen sliding
back and forth under the intact pleura the periosteum is carefully separated from the ribs and a large pack of gauze or paraffin mixture* inserted
under them through the intercostal spaces and the wound is closed. The
pack is left for two weeks. It compresses the underlying pleura and produces adhesions.    It will in time cause perforation of a superficial abscess
*Paraffin 52°  M.P.   ISO;  Paraffin 43°  M.P.  SO;  Bismuth carbonate  10;  Vioform 0.2.
Page 29 into the gauze-filled space. After two weeks the wound is reopened, the
denuded ribs resected and a funnel shaped opening made in the lung with
a massive Percy cautery. The abscess should lie at the tip of the funnel;
if it lies to one side the opening is enlarged until the abscess is widely open.
Its contents are aspirated by suction and the cavity is packed with iodoform gauze. The wound is left wide open. The packing remains several
days to a week before being changed. The resulting bronchial fistula
usually closes spontaneously; if it does not it may be closed by an operation later.
Treatment of Bronchiectasis
Uninfected bronchiectases unproductive of symptoms need no treatment. At the other extreme lie cases of bilateral bronchiectasis exhausted
by repeated bouts of fever and with constitutional changes due to chronic
suppuration, which are beyond recovery. In patients the severity of whose
symptoms scarcely warrants operation, viz., those without pneumonic
exacerbations, without signs of damage to kidney and circulation, and
without excessive or foul expectoration, and also in hopeless patients conservative treatment can accomplish considerable. A warm, dry, equable
climate, and postural drainage, lying over the edge of the bed with the
head down, or lying prone with a pillow under the upper abdomen, at
least once a day; creosote; attention to chronic nasal and sinus infections;
avoidance of contact with sufferers from contagious respiratory troubles,
are important.
In patients who suffer from unilateral bronchiectasis with recurrent
attacks of fever, whose heart and kidneys show signs of beginning impairment, whose cough and expectoration are disabling and repulsive, operation should be considered. Treatment should begin with careful review
of nose and sinuses. The patient should be prepared by several months
of sanatorium regime with open air, and rest in bed. Lobectomy should
then come into question.
Artificial pneumothorax, phrenectomy, and thoracoplasty, fail to accomplish permanent cure.
Technique of Lobectomy
Artificial pneumothorax is carefully instituted a week before operation, 500 cc. of air are introduced daily or every other day until the
chest is under zero pressure. After sodium amytal and morphine preparation, the chest is opened under local anesthesia by a long intercostal
incision. If spreading the wound edges fails to give ample exposure an
inch of 1 or 2 neighboring ribs is resected. Quiet respiration is maintained after the chest is open. Failing this, gas or a few drops of chloroform must be given.
Adhesions if present are infiltrated with novocain, and gently separated with the finger or with the cautery. Bleeding vessels are tied. The
lobe is grasped between the index and middle fingers of the left hand and
the hilum infiltrated with novocain. Two -large curved clamps are
securely applied  and the lobe  removed with the  cautery distal  to the
Page 30 clamps. The hilum is tied with two stout transfixing silk ligatures and
the pulmonary vessels and bronchial stump again ligated separately. The
transfixing ligatures are left long, led out of the wound and surrounded
with a loosely placed large pack of wide gauze. The wound is dressed
with an accurately placed, but not a bulky dressing, and accurately
covered with adhesive plaster so as to make it as airtight as possible. The
patient is laid in bed on his bad side. The ligatures slough off in two or
three weeks. The large pneumothorax is rapidly obliterated. A bronchial
fistula results which may close spontaneously, but which usually has to be
closed at a later operation.
A bilateral lobectomy has been successful; both right and left lower
lobes were removed.
This and the encouraging results of Shenstone and others show that
the operation is no longer too dangerous to warrant consideration.
SURGICAL TREATMENT OF PULMONARY
TUBERCULOSIS
By Dr. Leo Eloesser
(RESUME)
In general, patients with pulmonary tuberculosis who have not yielded
or who are not likely to yield to conservative treatment, the activity of
whose tuberculosis is confined or almost confined to one side or to a small
portion of both lungs, and whose tuberculosis manifests itself as a steady
anatomical progression rather than a steady or increasing failure to overcome toxic symptoms, are likely to be benefited by operation. In many
of these pneumothorax will have been tried ineffectually, in others one
will have hesitated to induce pneumothorax on account of the slight anatomical involvement, on account of circumstances making pneumothorax
impossible to maintain; in still others a previous pneumothorax will have
been allowed to absorb and will have proven impossible to re-establish.
Pneumothorax is usually effectual in proportion to its completeness.
Often adhesions of greater or lesser density hold a cavity or tubercular
area distended in an otherwise well collapsed lung. Such adhesions can
often be separated by cauterization or coagulation through a trocar opening with a properly constructed instrument—closed pneumolysis. This
procedure, first evolved by Jacobeus, has been carried out with great exactitude and skill in a large series of patients by Matson of Portland.
The basal portion of the chest can be put at rest to a certain degree
by inducing a flaccid palsy of the diaphragm. The paralyzed diaphragm
is pushed up by the pressure of the abdominal viscera below and sucked
into the chest by suction of the rib cage above. In rising it compresses
the basal portion of the lung. Although the diaphragm accomplishes only
about one-fifth and the intercostal muscles four-fifths of respiratory
movement, phrenectomy or avulsion of the phrenic nerve, with resulting
diaphragmatic palsy is often useful in basal tuberculosis.   It further comes
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Smallpox Vaccine
Typhoid Vaccine
Typhoid-Paratyphoid Vaccine
Pertussis Vaccine
Rabies Vaccine (Semple Method)
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727 King Street West, Toronto. Ont. into question as a preliminary test where thoracoplasty is considered in a
patient whose vital capacity is low and whose powers of withstanding the
reduction of respiration that a thoracoplasty entails, seem doubtful.
I have rarely seen phrenectomy benefit apical tuberculosis. It should
not be too lightly considered. Although its immediate risk is negligible,
patients with diaphragmatic palsy sometimes complain in after years of
digestive disturbances which may be due to this cause.
In massive unilateral tuberculosis, thoracoplasty, total or partial, with
or without supplementary measures is to be considered. Total thoracoplasty
gives the best immediate and perhaps the best ultimate results. The immediate mortality of the operation (i.e., those dying in the first two
weeks) has been reduced to 10% or less; the cures and marked improvements are over 50%. After following a large series for years one finds
about 1/3 of cure, 1/3 of more or less benefit, 1/3 unimproved or dead;
results markedly better than the ordinary life expectancy of pulmonary
tuberculosis under conservative treatment.
In processes confined solely to the apex, efforts have been made to
conserve the lower unaffected portion of the lung by doing a partial
thoracoplasty, i.e., resecting the upper 6 or: 7 ribs only, and leaving the
lower ones. The immediate results of partial thoracoplasty are perhaps
less good than those of total thoracoplasty, whether the conservation of
the base as a protective reserve in case of involvement of the other side
pays it is too soon to say.
Partial thoracoplasty for apical cavities which cannot be cured by
pneumothorax on account of extensive adhesions has proved successful
when the upper ribs are resected and the basal pneumothorax is maintained
after operation.
Extrapleural compression by means of a mass of a paraffin wax mix-
ture::" introduced between the ribs and the pleura has also been useful both
in purely apical processes with cavitation confined solely to one apex, when
sacrifice of the intact lower portion of the lung by thoracoplasty seemed
inadvisable, and especially in bilateral apical cavities. Although bilateral
apical thoracoplasty has been performed for bilateral apical cavities wax
compression seems equally efficacious and simpler. In none of 11 cases
operated upon in the last two years has the wax been extruded or caused
irritation.
If simple partial thoracoplasty is unable to close unusually large or
unusually stiff-walled cavities, supplementary measures such as anterior rib
resection, resection of the whole extent of rib from the spine to the
sternum, or supplementary wax compression may be added to complete
the effect. Some cavities, however, are so stiff-walle and unyielding that
they resist all attempts at compression, pressure on the lateral wall serving
merely to push them further medially toward the mediastinum.
External drainage of tubercular cavities is almost uniformly disastrous, though certain cases of spontaneous pneumothorax and bronchial
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Page 32 fistula leading into an infected empyema are benefited by external drainage. Cough and expectoration cease and the lung remains entirely collapsed at the bottom of the empyema cavity and the tubercular process
comes to a standstill.
I wish again to express my appreciation of the cordial hospitality and
attention of the Vancouver Medical fraternity as a whole and of many
members most particularly.
THE PLACE OF BIOLOGICAL PRODUCTS IN
GENERAL PRACTICE
Dr. K. F. Meyer
Dr. Meyer defined vaccines and sera, the former being an active
virus capable of producing immunity, the latter being a preparation used
to produce passive immunity. The words are frequently wrongly used
•but this is the meaning that should be given.
Vaccines are used either for prophylatic purposes or for therapeutic
purposes. Prophylactic vaccination should only be practiced in diseases
of known aetiology. As a rule one aims at the production of a general
immunity. The dosage depends upon the rate at which the anti-bodies
are produced. As a rule the largest dose giving the least discomfort is
employed. The strength of the dose increases with subsequent treatments
but it is never necessary to produce violent reactions. Dr. Meyer is
doubtful concerning the value of autogenous vaccine for therapeutic purposes. Theoretically this ought to be a correct method but practically bacteria become greatly modified by passage through a host and their virulence is doubtful. The apparently predominating strain may therefore not
be the one whose action we desire. Stock vaccines of strong strains are
usually better. In giving therapeutic vaccine treatment we must not be
timid in our methods. Dr. Meyer urged the use of intravenous administration.
Prophylactic Vaccination
Dr. Meyer spoke first of smallpox vaccination. "There is only one
way to prevent smallpox and that is through vaccination." No other
method is of any value as a preventive. However, during the past few
years two new developments have given rise to considerable trouble with
regard to vaccination. The first is a wide distribution of variola minor
and the second the recognition of postvaccinal encephalitis, as an occasional complication. Ever since 1922, epidemiologists have been struck by
the mildness of smallpox which is characterized by an almost insignificant
mortality among the unvaccinated as well as the vaccinated, and which,
while presenting the clinical and pathological characterists of smallpox,
only occasionally proceeds after the rash to pustulation. This benign
smallpox is generally known as variola minor or alastrim.
The harmlessness of this disease and the fact that it is not equally
well controlled by vaccination, the fact also that it is often difficult to
Page 33 recognize on account of its mildness, has led to a general impression in
many places that vaccination is unnecessary and even useless. The real
smallpox is as dangerous and as important as ever and still occurs periodically in serious epidemics. Dr. Meyers feels that the time has come when
the problem of smallpox prophylaxis should be approached from a somewhat different angle than that of the Public Health administrator. He
feels that it should be a problem to be dealt with by the medical profession rather than by formal compulsion, and should in general be administered according to the same principles as toxoid immunization for
diphtheria. Compulsory vaccination would be used for the control of
smallpox during an epidemic but not otherwise. Routine vaccination
should be limited to the infant population. The responsibility for the protection of the individual rests with himself, with his parents or with his
physician or medical adviser. In place of compulsory administrative
measures, an unbiassed education by the family physician should acquaint
the population with the safeguards which the individual or family can
obtain by vaccination in infancy. Particularly in view of the problem
of postvaccinal encephalitis, this proposal deserves immediate and earnest
consideration.
Occasionally cases have been noted in Europe since 1905 following
the primary vaccination of school children and adolescents, while since
1922 enough cases have occurred to constitute a serious problem and the
Committee on Vaccination appointed by the British Minister of Health
made a report in January, 1931. In this report the Committee deals with
the type of encephalitis that has followed vaccination. Ie seems to be
limited to a few individuals of the age group between six and twenty, is
rare or non-existent in infants under one year. Holland has had the largest
number of cases, but they have occurred in England, Austria, and even
a few in the United States. Most cases ^were of school. age. While this
complication has obtained wide publicity in the press it is really a very
rare occurrence when one considers the vast number of vaccinations done,
and the incidence would appear to be decreasing. However, if any case
should occur, Dr. Meyer feels that vaccination should be suspended for the
time being, unless an epidemic of smallpox is present when the risk is
infinitesimal compared to the graver danger of smallpox. By vaccinating
children between the ages of two and six months postvaccinal encephalitis can be avoided as has been shown in Holland where the greatest number of cases has occurred. Re-vaccination would appear to be equally
safe. This complication therefore, need not be regarded as a serious contraindication to vaccination.
Diphtheria
Dr. Meyer made a plea for the use of the smear examination in the
diagnosis of this disease with a view to saving time by administering antitoxin as early as possible. He dealt with the question of immunizing
actively against diphtheria, taking up first toxin-antitoxin, which has now
been discarded on account of the danger that may arise from dissociated
mixtures, which become highly toxic. Toxoid was developed following
the recognition that formalin will detoxicate diphtheria toxin. Toxoid is
of course absolutely safe and its use has been attended by no disaster.   The
Page 34 protection afforded varies from 90 to 100% in various groups which have
been checked.
Dysentery
Dr. Meyer quoted Besredka who has found that oral administration
of Shiga vaccine is of value.
Typhoid Fever
Here the prophylactic inoculations have been of immense value in reducing the incidence of the disease. Typhoid, Dr. Meyer finds, is on the
increase in recent years, which is a matter greatly to be regretted, since
we have in the preventive inoculation an eminently useful method of prevention. Children react well to the inoculation and might well be treated.
It must be remembered, however, that the protection afforded is not permanent and should be repeated at intervals of two to three years if danger
still exists. It is important that the vaccine used should give rise to antibodies for both the flagellum and the body of the typhoid germ. Many
commercial preparations only give rise to one of these antibodies and from
this fact many unsatisfactory results have been obtained, and have discredited the use of the vaccine unfairly.
Pertussis
Efficient isolation in whooping cough presents difficulties, one of
which is the long duration of the illness. The chief means for combat
ing the disease, which at the present time exceeds in number of deaths that
from diphtheria and scarlatina, are a bacteriological diagnosis and possibly
inoculation. Dr. Meyer recommends the use of the "cough plate" as a
method of determining when infectivity ends which it does usually during the fifth and sixth weeks. The use of this "cough plate" is simple,
quite effective and prevents lengthy quarantine, since the child can be
returned to school as soon as the plate fails to show active growth. Three
inactive plates are necessary before release of the child. The use of this
does a great deal towards prevention of the spread of the disease, since the
disease can be recognised early in a coughing child. As regards the use of
prophylactic vaccination, there is undoubtedly considerable value in its
administration. In an epidemic 2,094 patients were given three injections of vaccine. The mortality rate in a group of unvaccinated children
was twelve times as great as in this group. In one district 20% of the
vaccinated escaped whooping cough while less than 2% of the unvaccinated escaped. These experiments have been repeated with -similar results sufficiently often to confirm us in the belief that vaccination is
worth while, but the vaccine to be of use must be fresh and given in considerable doses at shortish intervals.
Pneumonia
Dr. Meyer! felt that the results in this disease are very unconvincing.
Page 35
mm Scarlet Fever
Here the difficulty arises from the fact that we have not proved
that scarlet fever is due to a specific streptococcus. Statistics as to the
efficacy of active immunization are unconvincing. The administration, as
usually practised, is difficult, lengthy and a grave burden to the patient.
No simple and efficient method has yet been devised and one cannot prove
the presence of immunity. The greatest encouragement has been obtained
from the use of formalinized non-toxic Dick toxin-toxoid. This is non
toxic, can be injected in large amounts and causes no react
ion.
Only
from two to four injections are necessary, and while it is difficult to
assess the degree of protection conferred, enough benefit has been obtained
to warrant the continuance of this method which is harmless and seems
to offer us the best results
Tuberculosis
The use of the Calmette vaccine is regarded by Dr. Meyer as unjustifiable. Tragedies have occurred in its use and its value is more than
doubtful.
Tetanus
Dr. Meyer urged that in all injuries received where there is the slightest danger of infection, and where the skin has been broken, antitetanic
serum should be given as a routine measure. As regards the treatment of
the disease prophylaxis still remains our major remedy. Iodine should be
used in wounds rather than any other antiseptic. Mercurochrome is usaless
as a prophylactic, and wounds which may conceivably have been infected
should always be treated with iodine. Antitetanic serum is an almost
certain preventive if given immediately, but is of comparatively little
value after the symptoms have appeared. The poison is too potent and too
firmly fixed to be controlled by the antitoxin. The wound treatment is
of great importance if tetanus should develop. Important in the treatment of tetanus is the recognition of the necessiy for treating convulsions, "If the convulsion due to toxin already in the central nervous system can be controlled we may be able to neutralize the unfixed toxin by
the use of antitoxin and the patient may recover." Here we have two
conditions to deal with. The fixed toxin causes convulsions and these
must be controlled at all costs. Morphia, magnesium sulphate, avertin,
amytal and other sedatives are all of value. As regards unfixed toxin, repeated injections of antitoxin in very large amounts are useless and may
be dangerous. Probably 30,000 units will be enough and it is useless to
hope to prevent or control the convulsion by the use of antitoxin.
Common Colds
Dr. Meyer is firmly convinced that the use of so-called mixed vaccine for the use of colds is unscientific and borders on quackery. If results appear to be obtained from their use, he feels that this is due to the
protein shock and not to any specific production of antibodies. Any protein therapy would be of equal value.
Page 36 A RESUME OF SPINAL ANAESTHESIA
W. N. Kemp, B.A., M.D.
From the Anaesthetic Staff, Vancouver General Hospital, Vancouver, B.C.
An effort will be made in this paper to cover briefly the salient features of spinal anaesthesia or subarachnoid block. The subject will be
considered under the following headings:
(1) Indications and contraindications; (2) Technique of induction;
(3) The Physiology of Subarachnoid Block; (4) Operative Complications
and their Treatment; (5) Postoperative Complications and their Treatment.
(1)  Indications and Contraindications
(a) Indications—Spinal anaesthesia has been used for operations on
every part of the body. However it would seem to be more rational,
where anaesthesia of the head and neck is required, to use either some
form of local or paravertebral block or a suitable general anaesthesia. A
considerable number of surgeons use spinal anaesthesia for thoracic surgery. Here again it is probable that gas-oxygen or avertin and local novocain infiltration are preferable. At the Vancouver General Hospital we
have confined the use of spinal anaesthesia to operations below the diaphragm. In this field it is valuable in cases where general anaesthesia may
be contraindicated and is of special value in operations for intestinal obstruction, gun-shot wounds of the abdomen, and in orthopedic surgery
on, and the reduction of fractures of, the lower extremity.
(b) Contraindications—The use of spinal anaesthesia is contraindicated in patients who have suffered from recent severe haemorrhage
such as ruptured ectopic gestation cases. R. M. "Waters, Chief Anaesthetist at Wisconsin State Hospital, is of the opinion that a systolic blood
pressure over 175 mm. Hg. is a contraindication to the use of spinal
anaesthesia. Patients with hyperpiesis do not stand well the drop in blood
pressure that often accompanies a spinal anaesthesia. In this respect the
locus of the operation would have a bearing on the question of anaesthetic
choice. For the amputation of a lower extremity, for example, a low
spinal in which there is little disturbance of blood pressure level can be
satisfactorily used. Any local inflammatory process in the skin or deep
tissues of the lumbar region or any inflammatory condition of the spinal
cord or meninges is, of course, a very definite contraindication to the use
of subarachnoid block.
(2)  Technique of Induction
Sise, Evans, Labat, Lundy, Waters and other spinal anaesthetists emphasize the importance of the use of a fine rustless needle in performing
the lumbar puncture which is done in lumbar interspaces two, three or
four. L. F. Sise, of the Lahey Clinic, is the originator of an "introducer," a short sharp needle-like instrument which is used to pierce the
supraspinous and infraspinous ligaments and through which the fine 22
gauge spinal puncture needle gains easy access to the meninges of the cord.
Page 37
cm Although novocain is the anaesthetic agent usually employed in subarachnoid block there are three modifications of this drug in common use;
,(a) the use of a solution of novocain made lighter than spinal fluid as
"Spinocain"; (b) the use of a solution of novocain made heavier than
spinal fluid by the addition of glucose or some other sugar; (c) the use
of novocain crystals dissolved in spinal fluid itself. We have not used
Spinocain at the Vancouver General Hospital. The use of various sugars
to make the novocain solution heavy offers no practical advantage over
the use of pure novocain crystals dissolved in spinal fluid.
The height of the anaesthesia (and muscular relaxation) is principally controlled by the quantity of spinal fluid withdrawn and reinjected:
viz., 1 cc. for leg amputation or perineal and anal operations; 3-4 cc.
for a prostatectomy or herniorrhaphy; 4-5 cc for an appendectomy;
6-10 cc for a cholecystectomy or a gastric operation . It will be observed
that the latter "expansion" (i.e. the volume of spinal fluid withdrawn
and reinjected) will, in the later stages of the operation at least, give a
cutaneous anaesthesia of the whole body. It is by this method that the
so-called high spinal anaesthesias are obtained.
The duration of anaesthesia is in direct ratio to the quantity of novocain injected. 150 mg. gives anaesthesia for 30 to 45 minutes; 300 mg.
gives anaesthesia for 75 to 90 minutes (approx.). King gives the lethal
intrathecal dosage of novocain as 55 mg. per kilo, of body weight. A
dose of 300 mg. of novocain for an adult weighing 150 lbs. is accordingly,
but one tenth of the lethal toxic dose. The untoward complications of
spinal anaesthesia are attributable to the nerve block induced by a concentrated solution of novocain in the upper third of the subarachnoid
space, rather than to the toxic action of the drug itself.
The preliminary subcutaneous injection of ephedrin in ^4 to 1 grain
dosage is commonly advised. Opinion is divided as to its value. Indeed
some men are of the opinion that its use is contraindicated at any stage
of spinal anaesthesia. Labat stated at a recent meeting of the Regional
Anaesthesia Society of New York that he had never used ephedrin in a
series of 3000 spinal anaesthesias, and that he was dubious of its much
advertised value in spinal anaesthesia. Chen and Meek have shown by
electrocardiographic studies that it produces a progressive paralysis of the
cardiac conduction bundle with the ultimate production of ventricular
fibrillation, in experimental animals in large doses. It is quite possible
that in its use in spinal anaesthesia a heart already handicapped by anoxemia or organic disease or both, may be only further poisoned by such a
drug as ephedrin. Equally important to the above mentioned objections
is the probable fact that ephedrin has no beneficial effect whatever upon
the blood pressure of the patient under spinal anaesthesia. Indeed its action
in the. presence of the anoxemia that often accompanies spinal block is
probably deleterious.
The question of posture following the induction of the spinal
anaesthesia is of considerable interest. When novocain crystals and volume-control technique as outlined above is used in the induction of the
spinal block the subsequent posture of the patient is of little importance
Page 38 as far as its effect upon the height of the anaesthesia is concerned. Labat
puts all of his patients in the Trendelenberg position immediately following the induction of the block. He argues that he thus insures the blood
supply of the vital centres regardless of subsequent fall in systolic blood
pressure. In the light of the theory that the drop in blood pressure that
so often occurs is largely due to anoxemia, the use of a marked degree of
the Trendelenberg position is contraindicated on account of the embarrassment that it adds to an already lethargic respiratory action. A six
or eight inch depression of the head and shoulders is of definite value.
(3) The Physiology of Spinal Anaesthesia
A reasonably sound theory of the physiological action of intrathecal
novocain is essential to the intelligent use of subarachnoid block. The
commonly accepted theory that novocain produces skeletal and vascular
muscular atonia by its action upon the motor (ventral) roots is probably erroneous. The theory outlined by A. I. Willinsky is much more acceptable. He points out that all the phenomena incidental to spinal
anaesthesia may be explained by the selective action of novocain upon the
sensory dorsal roots alone. This affinity of novocain and cocain and
such chemically related anaesthetic drugs for sensory nerve tissue is well
known. Years ago Santesson showed that direct contact with 5 per cent,
solution of cocaine hydrochloride broke sensory conduction so completely
in the sciatic nerve, that the strongest tetanic stimulation peripheral to
the treated area was no longer able to produce a reflex, while the same
concentration of cocaine left the motor conduction unchanged for at least
one hour. The independent experiments of Kochs, Hitzig, and Bernstein
many years ago showed that anaesthetic drugs of the benzol group, of
which cocaine was the most used, affect almost exclusively the sensory
elements in the nervous system. As Willinsky states, "It would be reasonable to postulate from the pharmacodynamic evidence of the elective
affinity of the cocaine group for sensory nerve tissues, that the brunt of
the action of novocain in the subarachnoid space would be on the roots.
From this standpoint alone we are justified in assuming that the tendency
of novocain would be that of blocking the posterior nerve roots and permitting conduction through the anterior (motor) nerve roots."
What of the paralysis and loss of muscle tone that occurs after spinal
block? This is rationally explained by the selective action of novocain
for the dorsal roots. Starling was the first to demonstrate the fact that
section of the dorsal roots causes loss of muscular tone and paralysis of the
related muscles, due to breaking of the reflex arc so essential to tonus and
contraction of the muscles.Jw blocking the sensory afferent nerves of
the dorsal roots, novocain produces the effect of a temporary section of
the dorsal roots with its consequent muscular dysfunction.
Sherrington has classified the filaments of the dorsal roots from the
functional viewpoint, into three broad groups:
(a)   Interoceptive fibres — carrying afferent sensory impulses from
the viscera.
Page 39 (b) Exteroceptive fibres—carrying afferent sensory impulses of pain,
touch, heat and cold from the cutaneous surfaces.
(c) Proprioceptive fibres—carrying afferent impulses of deep sensation or muscle sense essential to the reflex arc and muscle tone
and contraction.
Willinsky has shown that if only 40 mg. of novocain, dissolved in
4 cc of spinal fluid, be injected into the subarachnoid space at the level
of the 2nd lumbar interspace, anaesthesia of the skin of the abdomen is
obtained but there is no loss of muscular tone and no paralysis of the muscles of the lower extremity or the abdomen. As a result of this injection
of novocain, the exteroceptive afferent sensory impulses from the skin of
the abdomen are blocked but the concentration of novocain is not sufficient to block the most resistant proprioceptive fibres. Ranson by the use
of special staining methods has shown that only the proprioceptive fila-
aments in the dorsal roots have a myelin sheath. Ingvar has confirmed
these findings and they have been accepted by Hauptman. This anatomical fact can explain the relative delay noted in spinal anaesthesia between
the speedy loss of cutaneous sensation and the slower loss of deep pressure
sense.
Clinical experience shows that if 150 mg. of novocain be dissolved
in four cc of spinal fluid and be injected intrathecally as in the foregoing 40 mg. injection, not only will there be complete cutaneous and
deep anaesthesia of the lower limbs with cutaneous anaesthesia of the ab-
doraen,but also a coexisting flaccid muscular paralysis of the extremities
and lower abdomen. By the use of 150 mg. of novocain a concentration
of the drug in the subarachnoid space is obtained that is sufficient to
penetrate the protective myelin sheathes of the proprioceptive fibres in the
adjacent dorsal roots and the result is a functional section of those fibres
and an inevitable loss of tone and temporary paralysis in the corelated
muscle It will be noted that the zone of cutaneous anaesthesia extends
to the costal margin or higher while the zone of muscular relaxation only
extends to the umbilicus. According to this principle of the intrathecal
action of novocain, when 200 to 300 mg. of novocain dissolved in 8 to
10 cc of spinal fluid is reinjected to produce satisfactory relaxation and
anaesthesia for a cholecystectomy, there occurs a complete block of exteroceptive, interoceptive and proprioceptive fibres of the lower two thirds
of the body and a block of the exteroceptive and interoceptive fibres only
in the upper third. This complete loss of cutaneous sensation under the
conditions outlined for this operation can be easily proven in the clinic,
in other words, this constitutes one of the so-called high spinal anaesthesias
under which some ultra-enthusiasts perform tonsillectomies and mastoidectomies. The relative safety of this form of anaesthesia depends upon the
fortunate possession of the proprioceptive fibres of the respiratory mechanism of a myelin sheath which makes them immune from the relatively
dilute concentration of novocain which is always present in the upper
third of the subaracfmoid when the anaesthetic tec/unique outlined above
is used. If the concentration of novocain in the upper third of the subarachnoid space is sufficient to block the afferent proprioceptive fibres
Page 40   B* C* Pharmacal Co*
329 Railway Street
Vancouver, B. C.
Phone Seymour 597 Base enclose professional card when requesting1 samples of Mead Johnson products to cooperate In preventing- their reaching- unauthorized persons Powell River, B. C.
Unequalled  intensity  of action—prolonged  effect—effective
by   injection   and   local   application—advantageous   price
characterize   the   new  non-narcotic   local   anaesthetic
NUPERCAINE "CIBA"
POWDER TABLETS AMPOULES
(A compound Nupercaine Ointment under the name of
PERCAINAL, "CIBA" has recently been introduced for
the treatment of painful conditions of the skin and mucous
membranes.)
CIBA COMPANY LIMITED
MONTREAL
Messrs.   Macdonalds   Prescriptions,   Ltd.       -       Vancouver,   B.   C.
Messrs.  McGill  &  Orme,  Ltd.       -       Victoria,  B.   C.
keep a full range of "CIBA" specialties.
MESH 536 13th Avenue West Fairmont 80
Exclusive Ambulance Service
FAIRMONT 80
ALL ATTENDANTS QUALIFIED IN FIRST AID
"St. John's Ambulance Association"
WE SPECIALIZE IN AMBULANCE SERVICE ONLY
R. J. Campbell J. H.  Crellin W.  L.  Bertrand
STEVENS'
SAFETY PACKAGE
STERILE GAUZE
is a handy, convenient, clean commodity
for the bag or the office.
Supplied in one yard, five yards and
twenty-five yard packages.
B. C. STEVENS CO.
Phone
Seymour 698
730 Richards Street
Vancouver, B. C. 

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