History of Nursing in Pacific Canada

The Vancouver Medical Association Bulletin: May, 1927 Vancouver Medical Association May 31, 1927

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THE VANCOUVER MEDICAL
§      ASSOCIATION
BULLETI
Published monthly at Vancouver
Subscription $1.50 per year
^Annual efflCeeting
Lister cSAddress
(<cPoor Sur§}ca^ "T^sks"
MAY, 1927
^Published by
dMc'USeath Spedding Limited, 'Vancouver, ^B. Q. 1/Vhy an Emulsion
A SIMPLE demonstration shows
the Physician at once why
Petrolagar is preferable as an intestinal lubricant.
Mix equal parts of Petrolagar and
water in a tube or glass.
In another tube or glass, try to
mix equal parts of plain
mineral oil and water!
Deshell Laboratories of Canada Ltd.
245 Carlaw Avenue
TORONTO, Canada
Peirolag<
o't inawtos the iiiiiciitrtcy as an
intestinal tuDfteant—mixes in-
litrtateiy with intestinal content.
an,! the tendency to leakage* is ■
Petrolagar
Page 234
u THE   VANCOUVER   MEDICAL   ASSOCIATION
BULLETIN
Published Monthly under the Auspices of  the Vancouver Medical  Association  in  the
Interests of the Medical Profession.
Offices:
529-30-31  Birks Building, 718  Granville St., Vancouver, B.C.
Editorial Board:
Dr. J. M. Pearson
Dr. J. H. MacDermot Dr. Stanley Paulin
All communications to be addressed to the Editor at the above address.
Vol. 3. MAY 1st, 1927 No. 8
OFFICERS, 1927 - 28
Dr. A. B. Schinbein
President
Dr. W. S. Turnbull Dr. A. W. Hunter
Vice-President Past President
Dr. G. F. Strong Dr. A. C. Frost
Secretary Treasurer
TRUSTEES
Dr. W. F. Coy Dr. W. B. Burnett Dr. J. M. Pearson
Representative  to  B.C.  Medical  Association
Dr. C. H. Vrooman Auditor
SECTIONS
Clinical Section
Dr. Gordon Burke  : Chairman
Dr. L. H. Appleby Secretary
Physiological and Pathological Section
Dr. J. E. Campbell _j Chairman
Dr. F. J. Buller ; -..Secretary
Eye, Ear, Nose and Throat Section
Dr. E. H. Saunders  , Chairman
Dr. W. E. Ainley  Secretary
Genito-Urinary Section
Dr. G. S. Gordon  . Chairman
Dr. J. E. Campbell    Secretary
Physiotherapy Section
Dr. H. R. Ross  % '. Chairman
Dr. J. W. Welch  , *. Secretary
STANDING COMMITTEES
Library Committee Credit Bureau Committee
Dr. C. H. Bastin Dr- d- McLellan
Dr. W. C. Walsh DR. L. Macmillan
Dr. W. A. Bagnall Dr- J- w- Arbuckle
Dr. D. F. Busteed Credentials   Committee
r\   u   *      ^ , Dr. F. W. Lees
Orchestra   Committee ^     t?   t   /-
■r\    f   . Dr. L. J. Gray
if. J- A; Smith Dr   w_ f. MgKay
Dr. H. A. Barrett _      •        c ,    ,   „
Dr. L. Macmillan Summer   School   Committee
Dr. H. C. Powell Dr- G. F. Strong
Dr. W. D. Keith
Dinner Committee Dr. h. R. Storrs
Dr. D. D. Freeze Dr.   R.  Crosby
Dr. C H. C. Bell Dr. B. D. Gillies
Dr. O. Large Dr. L. H. Appleby VANCOUVER MEDICAL ASSOCIATION
Founded 1898. Incorporated 1906.
THE 30th ANNUAL SESSION
GENERAL MEETINGS will be held on the first Tuesday of the
month at 8 p.m., from October to April.
CLINICAL MEETINGS will be held on the third Tuesday of thej
month at 8 p.m., from October to April.
Place of meeting will appear on Agenda.
General Meetings will conform to the following order:—
8:00 p.m.—Business as per Agenda.
9:00 p.m.—Paper of Evening.
CITY HEALTH DEPARTMENT—Vancouver, B.C.
STATISTICS — MARCH, 1927
Total Population  (Estimated)    1 137,197
Asiatic Population (Estimated)     10,576
Rate per 1000 of Population
Total Deaths      182
Asiatic Deaths        20
Deaths—Residents only      146
TOTAL BIRTHS—
Male      184
Female 182
Stillbirths, not included in above         14
16.1
23.0
12.9
INFANTILE MORTALITY—
Deaths under one year of age        18
Death rate per 1000 births  ...      49.2
CASES OF INFECTIOUS DISEASES REPORTED IN CITY
Feb., 1927
Cases Deaths
Smallpox   5
Scarlet Fever  25
Diphtheria     29
Chickenpox  26
Measles     422
Mumps     7
Whooping Cough   1
Erysipelas     5
Typhoid Fever  0
Tuberculosis    9
Cases from outside city-
Diphtheria     4 0
Scarlet Fever     4 0
Typhoid Fever   0 0
0
0
0
6
0
0
1
0
11
April
1
March
, 1927
to
15,
1927
Cases
Deaths
Cases D
eaths
M*
0
2
0
17
0
9
0
44
2
10
0
37
0
3
0
708
4
286
0
5
0
2
0
5
0
1
0
2
0
1
0
3
1
2
1
10
18
5
-
includ
ed
in above
11
0
3
0
7
0
1
0
3
1
2
1
Page 236
U ^L_J?
Jtfodtl"Snt>o}(' e '
^Apparatus
a^s3i«sgssaa^ssms^S3^s
■ J Sn ooH Sp t c i nl
§ Tfeeplherapy
]~ -TJiagmwl ic
.§ crfpparatus
^Ray Standards that
are Itbur Standards
NEVER has the Victor X-Ray Corporation considered
itself solely a manufacturer of X-Ray equipment. Its
lim has always been to play a leading part in the advance-
nent of roentgenological technique, thru the develop-
llnent of new improved apparatus which makes this possible.
Thus the quality of Vicor X-Ray equipment is per-
||iaps not easily explained except when this attitude of the
Victor X-Ray Corporation is taken into consideration. If
tpou hear it said that Victor X-Ray apparatus is better
[than necessary, remember that we have developed this
[equipment in cooperation with medical science. The
itandards of the roentgenologist have guided us—rather
:han the question of a large or small profit.
Victor research—from which some of the outstanding
i developments in X-Ray apparatus have resulted— is simply
line manifestation of our ambition to be of service to the
(inedical profession. Thirty-three branches, advantage-
tfcusly placed, make it possible for the Victor users to
tfthare to the utmost in all that Victor has to offer.
I Write for address of Victor Branch nearest you.
VICTOR X-RAY CORPORATION
2012 Jackson Boulevard, Chicago
Tor the    |
Office or    # &
Small Hospital % ^
MOTOR TRANSPORTATION BUILDING
VANCOUVER, B.C. EDITOR'S PAGE
The Annual Meeting of the Vancouver Medical Association was held
on Tuesday, April 19th. At this meeting the reports of the various activities of the Society were presented and it is gratifying to note the continued interest shown by these various groups which are such an essential
part of the Society's work. The membership of the Association is, we
lieve, the largest in its history, which, by the way, is now entering upon
its 30th year.
Having arrived at that age, any institution may be regarded as fairly established and it is very gratifying to those who have been permitted
to follow the career of the Society since its inception, to note the robust
and flourishing proportions to which the erstwhile young infant has attained.
We trust that the increase in size is not due to an unhealthy obesity
or that a sense of accomplishment, of being at ease in Zion, will not
overcome its membership. A tremendous power for good and for achievement lies awaiting the necessary stimulus. Looking over the new list of
officers, in whose hands rests chiefly the guidance of the Society through
the coming year, we can feel every confidence that wisdom and discretion
have joined hands in making the choice. Not that this choice absolves
the rest of the membership from responsibility. No effort on the part
of the executive can be effectual unless it meets with a sympathetic response from the members at large.
Our cordial thanks are due to the retiring officers for their arduous
work during the past year. An official position in the Association is no
sinecure. Time and thought must be given, and given freely, if results
are to be obtained.
A wise provision in the Bylaws now gives us the benefit of the help
and advice of the retiring President for another year. We think that at
times it might be of advantage if certain offices were occupied by the
same person two or more years in succession. One year's tenure in a
large Society is scarcely enough. We think that a second term would
bring a wider acquaintance and a more mature judgment, without interfering with energy or enthusiasm.
We may perhaps be pardoned for expressing our personal gratification concerning the results of the financial examination of the affairs of j
this Bulletin during the last two and one-half years. We see no reason
why these results cannot be improved nor any reason why an attempt
should not be made to improve them. No evil result that we can see
is likely to arise from making this little publication a sound financial
proposition.
The extended programme of the Summer School is now in the hands
of the profession. By the time this paragraph reaches our readers little
more than a month will preceed the meeting itself. We earnestly bespeak your support, especially the loyal support of the medical men of
Vancouver, whose particular affair the School is. We must have a better
attendance than was the case last year. The time is opportune, thel
speakers are excellent, and a full house for each and every meeting is in
order.    Come and bring a friend with you.
Page 23 8
,L-^» NEWS AND NOTES
The March meeting of the Clinical Section of the association was
held at Shaughnessy Military Hospital on Tuesday, the 15 th. About 40
members were present.
Dr. Schinbein presented a case of Kienboch's Disease, a rare condition of chronic osteitis of the semilunar bone. This patient injured his
wrist in 1915, a diagnosis of fracture of the radius being made at that
time. He has suffered pain and more or less disability at intervals since.
When seen a year ago there was no X Ray evidence of an old fracture of
the radius but there was found an osteitis of the semilunar bone with
apparently an old fracture. The treatment of this condition has been
generally unsatisfactory. Henderson of the Mayo Clinic advises immobilization. Dr. Royle, recently with us from Australia, advises removal of the whole first row of the tarsus. From statistics neither line
of treatment gives a satisfactory result, discomfort and disability being
usually permanent. The condition may be complicated by a general
arthritis of the whole wrist and a similar condition may develop in the
navicular bone of the tarsus. Dr. D. G. Perry, however, reported a
fracture of the scaphoid in which he had removed the bone for pain
and disability a year after the injury, the patient being able to return to
his work as a painter three months after the operation. A discussion of
this condition may be found in Annals of Surgery, November, 1926.
The second case presented by Dr. Schinbein was one of carcinoma
of the breast in a man of middle age, a rare condition, and in this case
unfortunate for the profession as well as for the patient. This man presented himself 15 months ago with a small tumour under the nipple
which was excised, in an office, under local anaesthesia, the specimen be-,
ing destroyed without a proper examination. Patient was later seen by a
surgeon for pain in the arm, when an X-Ray of the arm proved negative.
Three days before applying for treatment at the General Hospital he was
seen by an osteopath and a proper diagnosis made. At this time patient
complains of pain in the right arm and axilla, the part showing swelling
and oedema. The axillary and supraclavicular glands are enlarged and
tender. The nipple is reddened about the margin, the tumour beneath
being about two inches and three-quarters to one inch in thickness. Discussion only emphasized the necessity for extreme care in the handling of
tumours of the breast either in the male or female. Dr. Hunter advised
never cutting into tumour of the breast without an immediate frozen
section and facilities for radical amputation at once, if necessary. Dr.
Schinbein advised against frozen section except when section was removed with the cautery, maintaining it was better to take off the breast
immediately, even for benign conditions, than to take a chance of disseminating malignant cells through the blood stream.
Dr. Schinbein presented a case of osteosarcoma of the 12th rib in a
man 30 years of age. This patient suffered a fracture of the 12th rib in
1915 when buried by a shell explosion in France. In February 1925 a
swelling developed over the site of the fracture, becoming the size of
naif a grape fruit. X Ray showed the 12 th rib destroyed and some new
bone formation, a diagnosis of osteosarcoma being made.    The condition
Page 239 being inoperable patient was put on X Ray treatment. The tumour has
gradually increased in size until now it is about 14 inches long, 7 inches
in width and 2 inches in thickness, of extreme hardness, the skin being
broken down in several spots. There are no metastases. The pathological diagnosis is osteochondromyxosarcoma. Patient is still at work, his
weight and strength being remarkably good.
The question arises as to the relationship between the old fracture
and the sarcoma. The Imperial Pensions Board in this case ruled against
such a relationship; the Canadian Pensions Board would consider the
sarcoma due to the old injury and would grant a pension. It would
seem that such a case should get the benefit of the doubt. In discussion
Dr. Hunter spoke of finding a sarcoma of the rib at autopsy in a patient
dead from other causes, who had given a history of having had a fracture
at the same site years before. Dr. Pitts believes there is a definite relationship between the old fracture and the development of the sarcoma.
Dr. D. G. Perry cited a case of a patient dying from carcinoma of the
liver which, at autopsy showed a small piece of shell casing in the liver
at the site of the tumour, the wound having been received 9 years before.
Dr. A. S. Monro presented a case of recurring duodenal ulcer which was
a striking commentary on the apparent futility of operation in many
cases. This patient in 1917 was wounded in France. In 1919 he had a
severe haemorrhage from the stomach. In 1920 a gastroenterostomy was
done for duodenal ulcer followed by improvement. In 1922 another
haemorrhage—in 1923 patient collapsed with a perforation found to
be at the site of the anastomosis. A piece of linen thread was found in the
margin of the ulcer which had perforated. Patient has been in hospital
off and on since, there being several haemorrhages and a double suppurative otitis media. In 1925 there was a perforation of the jejunum opposite the old anastomosis. The old union was uncoupled and the jejunum rebuilt. Condition was fair up to September 1926 when a recurrence of symptoms arose and X Ray showed an ulcer of the duodenum.
Treatment since then has been along the lines laid down by Dr. Arthur
Hurst of Guy's Hospital. This treatment allows a more liberal diet
than the Sippy treatment and usually returns the patient to better weight
and better strength more quickly. This treatment dispenses with antacids, giving instead frequent food to neutralize the hyperacidity of the j
stomach. General directions include eating slowly, proper mastication,;
no condiments, no fruit skins or salads or other irritating articles of diet,
olive oil before each meal, no tobacco or alcohol, regularity, and never al-J
lowing oneself to become hungry. The case presented showed a gain of
ten pounds in the first month of treatment. In discussion Dr. Seldon cited
a series of 15 gastroenterostomies done by himself some years back, with
one death and recently three recurrences of ulcer. He emphasized the
necessity for medical supervision following operation. Dr. Wallace Wilson would get on without the surgeon entirely, except for a definite
emergency. He thought gastroenterostomy was a far from ideal operation. He considered there were many cases with an "ulcer diathesis," particularly in individuals who showed hyperacidity with an over-active
stomach. Dr. Pitts mentioned the wide resection of the stomach as practised by a surgeon at Mr. Sinai Hospital in order to reduce the extent*
Page 240
u of the acid bearing mucosa. Dr. Buller quoted from a symposium in the
Surgical Clinics of North America in which the concensus of opinion
seemed to be that resection was too radical a treatment. Dr. Bastin
quoted Dr. Hurst that over a large series of examinations in normal
men 40 per cent, showed hyperacidity and were potential ulcer cases.
He emphasized the possibility of trauma being an etiological factor, also
obstruction as being the only operative indication.
Dr. Wallace Wilson presented four cases of mitral stenosis, three of
which showed auricular fibrillation. Among the points emphasized were
the importance of rheumatic affections, either acute or chronic as an etiological factor, the sudden onset of fibrillation following trauma, illness
or unusual strain; the absence of response in many cases to treatment,
and the fact that fibrillation often seems not to alter the prognosis made
on a mitral stenosis alone. In discussion Dr. Vrooman mentioned the
occurrence of fibrillation after a long period of hypertension in individuals of about fifty. Allbutt described this condition as one of "heart
defeat." Digitalis is of little help and the prognosis is usually one of
months. Dr. Schinbein remarked upon the way in which cases of hyperthyroidism, with fibrillation, stood up under operation and their subsequent improvement. Dr. Strong called attention to the importance of
old rheumatism in the etiology and the uncertainty of the prognosis in
these cases, also the occurrence of short attacks of paroxysmal fibrillation before the condition becomes permanent, these attacks being often
described by the patient as palpitation. Dr. Keith called attention to the
cases of extreme myocarditis without fibrillation, i. e., syphilitic myocarditis, coronary disease and similar conditions in which there may be
a sudden death but never fibrillary disturbance.
At the close of the meeting refreshments were served to those present by Miss Jean Matheson, the Matron, and the Sisters on the hospital
staff.
On April 2nd, Dr. J. J. R. Macleod, Professor of Physiology, Toronto University, who was passing through Vancouver, addressed the
Association on "The Place of Physiology in Medicine." Sixty members'
were present and much enjoyed Dr. Macleod's interesting lecture. In the
discussion which followed ,Dr. Macleod touched on the question of the
ductless glands and referred to Harrington's recent research work in
thyroxin.
Another special meeting was held on April 13 th to hear a lecture
by Dr. Philip H. Kreuscher, Clinical Professor of Orthopaedic Surgery
at Loyola University, Chicago. Dr. Kreuscher's lecture was illustrated
by lantern slides.
The April regular meeting of the Association was held on the 5 th of
the month, when sixty members were present. Dr. W. F. Coy presented
report of the committee appointed to enquire into the question of group
accident and sickness insurance.   Dr. Coy moved that a sick and indigent fund be established, the details and administration of which should be in
the hands of the trustees of the Association. After some discussion this
resolution was carried. As this meeting fell on the 100th anniversary of
Lister's birth, Dr. R. E. McKechnie gave a short "Lister address" which
appears in this issue of the Bulletin. Following Dr. McKechnie, Drs. C.
E. Brown, D. D. Freeze, R. E. Coleman and A. B. Schinbein presented a
symposium on "The Poor Risk Surgical Patient." Two of the papers are
published in this issue and the others will be printed in our next number.
LIBRARY NOTES
The Library is situated in 529-531 Birks Building, Granville Street,
Vancouver, B.C.
Librarian: Miss Firmin
Hours: 10 to 1, 2 to 6
ABSTRACT
In the Journal of Anatomy for January 1927, Robert Orton Moody,
late of the staff of the University of California, and now of University
College, London, publishes some conclusions based on a series of X Ray
photographs of the abdominal viscera of healthy adults. He took radiographs of one thousand American and one hundred and fifty British
students, while they stood in the erect position after a barium meal. He
used as a landmark a line joining the highest points of the iliac crests.
(According to Gray's Anatomy, this line crosses about 2 cm. below the
average level of the umbilicus). In view of the teachings of standard
text books as to the normal levels of the stomach, colon, etc., his observations are most interesting.
In his series of photographs it was shown that in 87% of British
males, and in 75% of American males, the lowest part of the greater
curvature of the stomach reached below the level of the interiliac line.
In 32% British and 27% American, it reached between one and two
inches below this line. In 39% British and 23% American it reached
between two and three inches below; while in 23% British and 8% % I
American, it reached more than three inches below. In the females examined the stomach reached to a slightly lower level than in the males.
The difference between the British and the American, is due, he
states, to a difference in the form of the body cavity.    The average American has a broad short thoracic cavity, a wide intercostal angle, and a j
broad abdominal cavity, while the British type tends to a long thoracic |
cavity, a long narrow abdominal cavity, with a lower stomach.
Comparing his series of radiographs with a series of ofie hundred
borrowed from the X Ray Departments of University College Hospital,
taken of patients who suffered from gastrointestinal trouble, he found
that the average level of the stomach was lower in the healthy than in the
diseased cases.
He concludes:—
1. Long stomachs with the lowest part of the greater curvature asi
far as six inches below the interiliac line, are normal.
2. Transverse colons dipping far into the true pelvis are normal.
Page 242
u 3. Livers with the lower border an inch or more below the interiliac
line are normal.
4. The ability of a stomach or caecum to function normally is independent of their position.
5. Enteroptosis, gastroptosis, and colopto'sis seldom or never exist
as pathological conditions. G. E. K.
BOOK REVIEW
"The Beloved Physician." By A. McNair Wilson. 1926. John Murray, London.    Price 12s net.
This book is in no sense a "Life" of Sir James Mackenzie, but is
rather a portrait of a character, carefully drawn, with special emphasis
laid on the features which, by their nobility and rugged force, have impressed the painter, as they must all who study the portrait.
It is a curious paradox that Sir James Mackenzie, who began life
with an immense respect, almost an awe, for authority in medicine, did
more than any man of his time to overthrow and discredit this authority.
A Nemesis to dogmatic and authoritative medical teaching, he became so,
because, though he gave it every opportunity to justify itself and prove
its value, though again and again he stood back, waiting for it to function and assume the position of leadership which it claimed as its right,
again and again the idol was dumb, unresponsive, unavailing, as Baal to
his priests who called on him.
From morning till the going down of the sun, Mackenzie had to
work out his own salvation, to find and prove his own rules, to evolve,
ab initio, a new theory of disease. How patiently and wonderfully he
did this, few realize, and Dr. Wilson has performed a genuine service to
us in his fascinating sketch of the processes of Mackenzie's growth. Here
was a true "physician," basing the meaning of that word on its origin,
physikos, a man who deals with nature and studies the laws of nature.
To us now his ideas are so much a part of our medical being, that it is
hard to realize that they were revolutionary at first. That symptoms
should be of little importance, unless you know to what they lead, and
whence they sprang, even now is a hard saying—that signs should be of
no value, except insofar as they are milestones between which one must
patiently chart out and observe the weary miles of progress of the disease,
is perhaps harder, for us of this mechanical age of electrocardiographs,
and blood-pressure instruments, and basal metabolimeters. It is refreshing and stimulating to read what Mackenzie thought of these.
I The book is very readably written and not unduly partizan. No
reader can fail to profit by the lessons it emphasizes drawn from the life
and example of the man it portrays. —/. H. McD.
LISTER LECTURE
Delivered before the Vancouver Medical Association, April 5th, 1927, by
Dr. R. E. McKechnie
I have been asked to give you, in the short space of 20 minutes, the
story of Lister—a story which could not adequately be told in as many
hours.   But still, in the short space allotted to me, much of interest can
Page 243 be told and much information imparted. We, at the present day, have a
very hazy impression of the work of Lister, the majority merely giving
him credit for seizing an idea developed by Pasteur and adapting it to
surgery. But I shall show that his previous training had fitted him to be
the only one ready to appreciate Pasteur's work, and, the fact that only
with difficulty did he convince the rest of the profession of the truth of
his theory, proves that the rest of the profession was not prepared to appreciate or believe in it.
Joseph Lister was born April 5th, 1827—one hundred years ago today—at Upton, in Essex, England. His father, Joseph Jackson Lister,
F.R.S., was eminent in science, especially in optical science, his chief claim
to remembrance being, that by certain improvements in lenses he raised
the compound microscope from the position of a scientific toy, "distorting as much as it magnified, to its place as a powerful engine of research.'"
Lister's early education was in Quaker schools, but he entered University College, London, in 1844, at the age of 17, and took his B.A. in
1847 at 20. He continued in medicine, graduating in 18 52 at the age
of 25, as M.B. and F.R.C.S. This led to a house surgeoncy at University
College Hospital. An epidemic of hospital gangrene then gave him an
opportunity to study the disease and note the effects of treatment on it.
Even at this early period he was led to suspect the parasitic nature of
hospital gangrene.
Thus in his "Third Huxley Lecture" he narrates this experience
saying "I was greatly struck with the clear evidence which these cases
seemed to afford, that the disease was of the nature of a purely local poison. In the hope of discovering its nature, I examined microscopically the
slough from one of the sores, and I made a sketch of some bodies of pretty
uniform size which I imagined might be the 'materies morbi' in the shape
of some kind of fungus. Thus as regards that form of hospital disease,
the idea that it was probably of parasitic nature was at that early period
already present to my mind." This would be in 1852, the year following
his graduation and years before Pasteur's publication of his discoveries,
which was in the year 1866, in a paper entitled "Etudes sur le vin."
In 1854 Pasteur had been appointed Professor of Chemistry and
Dean of the Faculty of Science at Liile. In his inaugural address he made
use bf an expression, which I deem worthy of repeating at this time as it
is applicable to the subject of tonight's discourse. He said "in the field of
observation, chance only favours those who are prepared." And Lister
was prepared—prepared eagerly to see the light and with it illumine the
vast* fietd of surgery. In the same "Third Huxley Lecture" Lister says
"it will thus be seen that I was prepared to welcome Pasteur's demonstration that putrefaction, like other true fermentations, is caused by microbes growing in the putrescible substance. Thus was presented a new
problem, not to exclude oxygen from wounds, which was impossible, but
to protect them from the living causes of decomposition, by means w^hich
would disturb the tissues as little as is consistent with the attainment of
the essential object."
I have been running considerably ahead of my argument, but sometimes it is well to let it be known what the drift of the argument will be
Page 244 so that, as the proofs are brought forward, they will be unconsciously
applied by the listeners.
We left Lister in 1852 as a house surgeon in London. Thence he
transferred to Edinburgh and came under the influence of Syme, later in
1860 transferring to Glasgow, where he held the Chair of Systematic
Surgery in Glasgow University till 1869. Back again to Edinburgh in
1869 as Professor of Clinical Surgery, in the University of Edinburgh,
till his fame called him to London, in 1877, as Professor of Clinical Surgery in King's College.
Among those who influenced the development of the scientific mind
in Joseph Lister, the first to be mentioned is his father, who was a merchant of London, who devoted his leisure to scientific pursuits and especially to the perfecting of the microscope. He was a man of extreme accuracy of thought, a most methodical worker, a good classical scholar
and skilful with the brush and pencil. He instructed young Lister in
the use of the microscope, and the use of the brush and the pencil, evidence of which can be seen in Lister's subsequent works, where most accurate drawings were made of what he saw, his practice being to use the
Camera Lucida.
Later, as a medical student, he came under the influence of Sharpey,
Professor of Physiology, and at this early period Lister published papers
on the contractile tissues of the iris, on the muscular tissues of the skin,
and on the flow of lacteal fluid in the mesentery of the mouse. He also
took keen interest in his chemistry, under Graham, and gained knowledge
which later helped him in his groping after antiseptics.
Lister, from the beginning of his career, was a hospital man and a
teacher, but more than all else he was an investigator. When his hospital
life began, he was greatly impressed by the sights he saw in the wards.
Every wound discharged pus freely and putrefractive changes occurred
in the discharge of all, producing in the atmosphere of every surgical
ward, no matter how well ventilated, a foetid sickening odour, which tried
the student, on his first introduction to surgical work, just as much as
the unaccustomed sights of the operating theatre. The mortality was
frightful, the only chance of saving life in a case of compound fracture
was amputation, and most of the amputation cases died. So Lister on
his introduction into hospital work, started a study of inflammation, not
only studying wounds, but studying the action of irritants on the blood
stream in the web of a frog's foot and like investigations. His results
are found in various published papers, numerous on histology and physiology at the beginning, and changing to pathology later on, all previous
to Pasteur's paper in 1866. Following this date are many papers on pathology and antiseptic treatment. His observations largely covered new
ground, he was pioneering the way with his microscope and his keen power of observation, always keeping in mind the one object set before him,
to get at the bottom of suppuration. In reference to this one writer
says "on the expiry of his house surgeoncy in Edinburgh, Lister started in
that city an extraacademical course of lectures on surgery; and in preparation for these, he entered on a series of investigations into inflammation
and allied subjects.    These researches, which were detailed fully in three
Page 245 papers in Phil. Trans. 1859, and in his Croonian Lecture to the Royal
Society in 1863, testified to an earnestness of purpose, a persevering accuracy of observation and experiment, and an insight of scientific conception, which show that if Lister had never developed the aseptic
method of surgery, he would have taken a very high place in pathology—
and all this is antedating Pasteur's paper of 1866.
Lister by this time had come to the conclusion that wounds heal by
the aid of Nature and not by the aid of the various applications in general use at that time. He realized that collections of fluid in the wound
formed the nidus for trouble and had sought to avoid this by adopting
Syme's method of dressing and he had a hazy idea of the influence of some
undiscovered agents in the air, which contaminated wounds. As before
noted, even as a house surgeon in London, he has so expressed himself.
Then in 1866 came Pasteur's paper on the cause of fermentation in
wine and on March 16th, 1867, in the Lancet, appears Lister's first paper
on the treatment of compound fractures by antiseptic methods. One
author says "But though Lister saw the vast importance of the discoveries
of Pasteur, he saw it, because he was watching on the heights; and he was
watching there, alone."
In this article of Lister's of March, 1867, Lister expressly acknow-i
ledges his debt to Pasteur and wrote "We find that a flood of light has
been thrown on this most important subject by the philosophic writings
of M. Pasteur, who has demonstrated, by thoroughly convincing evidence, that it is not to its oxygen, or to any of its gaseous constituents;
that the air owes this property" i.e. (decomposing organic substances),
but to minute particles suspended in it, which are the germs of various
low forms of life, long since revealed by the microscope and regarded as
merely accidental concomitants of putrescence; but now shown by Pasteur to be its essential cause, resolving the complex organic compounds
into substances of simpler chemical constitution.
From this time, and for a great many years to come, Lister, knowing from Pasteur's researches, that the germs contained in the atmospheric dust occasioned the decomposition of putrescible substances outside the
body, assumed that they would have the same effect in wounds, and hence,
attributed to the atmosphere, an importance in surgery, which his own
researches and experience showed him, in after years, that it did not.
possess.
Lister's use of the spray, overshadowed in the popular mind, and
even in that of some of the profession, his other methods to practice antiseptic surgery. Even before Pasteur's discovery, Lister had introduced
into the wards of Glasgow Infimary routine cleanliness in dressings, insisting on fresh towels, washing of hands between dressings, etc. Later,
in his practice of antisepsis, besides trying to purify the air, the hands
were^ carefully cleansed and an antiseptic used—the instruments were
kept immersed in 5% carbolic, the skin of the operating field was also
carefully cleansed and sterilized by use of antiseptics. If his work had
been imperfect he would not have had the successes he had, successes
readily acknowledged by his Edinburgh and Glasgow colleagues, who
knew him for his past scientific work, as a teacher and investigator; and
Page 246 acknowledge finally by a hostile group in London, who, in the end, had
to acknowledge the truth of his theory.
Lister's whole future life was thereafter spent in blazing a trail to
better and simpler methods of applying antiseptic methods to combat con"
tamination by germs.
One of his earliest innovations was the introduction of the drainage
tube—and the catgut ligature. Formerly, arteries were tied with long
linen or silk ligatures, which, gathered together, were led out of either
angle of the wound. These themselves were not sterile and continued as
a contamination in the wound until they came away. By experiments
with various substances, in animals, Lister found that it was safe, as far
as haemorrhage was concerned, to tie the vessels with sterile absorbable
material, and so did away at one stroke with the prolonged suppuration
caused by the septic ligatures. Seeing that discharges, accumulating in
the wound, favoured chances of infection, as providing food for germs,
he introduced rubber drainage tubes. Gauze for dressing was also first introduced by Lister. In his earlier treatment of wounds by the.antiseptic
method, Lister sought to preserve an antiseptic atmosphere over the
wound, hence his dressings were covered by an impervious material holding in the vapour of carbolic. Later he sought to absorb the discharges
and introduced gauze as the agent needed, but the fear of germs ascending through the discharge to the wound, caused him to incorporate in
the gauze some antiseptic compound, finally arriving at the double cyanide of mercury and zinc.
But Lister was ever progressive, for in spite of the time and thought
spent in arriving at a satisfactory method of wound dressing, and the
material to be employed, Lister was the first to introduce non-antiseptic
dressings sterilized by dry heat.
For skin sutures Lister used silk or linen prepared in 1 in 20 carbolic,
also catgut in carbolic oil, while silkworm gut, horse hair and silver wire
were largely used in septic cases.
It would be tedious to pursue further the improvements in the antiseptic art introduced by Lister. We are living in a different age and
think we are practising aseptic surgery. But if so, why use iodine on the
skin, why use sterile dressings, or in some cases dressings moistened with
an antiseptic, why use drainage tubes to keep our wounds from becoming
a field for bacterial growth, why use sterile catgut ligatures or sterile
sutures. Lister taught you all that and to him, who saw the light of
day one hundred years ago, belongs the undying gratitude of the human
race. Lucas-Championniere said there were only two periods in surgery
—that before and that after Lister.
Sir Hector Cameron in 1906 in a lecture in Glasgow said "It is unnecessary that I should endeavour to portray the contrast which may
easily be drawn between surgery as it exists today, and surgery as I witnessed it on my introduction to hospital as a student. Let it suffice to
say that we who practise surgery today, do so with confidence and a sense
of safety, to which the surgeons of forty-five years ago were entire
strangers, and this is the outcome of the application of scientific truths.
Page 247 The very fact that it is such an outcome, makes it as necessary now, as
it was declared to be at first, that we shall constantly keep before our
minds what those scientific truths demand of us in the treatment of each
individual case. If we maintain such a mental attitude we need not strive
for, or indeed expect, absolute uniformity of practice. The more clearly
we recognize the principles which are the common guides of all of us, the
more we shall agree in that which is essential, and be free to differ as we
please in carrying out the various details of our everyday procedures."
The principles thus stressed by Sir Hector Cameron are the principles of antiseptic surgery as developed by Joseph, Lord Lister. The methods of following out the application of those principles may vary but the
principles are the same, immoveably based on sixty years of successful
application.
And tonight we are gathered to do honour to Joseph Lister, the genius, who seeing the light, has illumined the path for all who follow to
the end of the ages.
SYMPOSIUM ON
"THE POOR SURGICAL RISK"
Held before the Vancouver Medical Association, April 5th, 1927.
(2) Dr. C. E. Brown.
As a result of the investigations of the physiologist and biochemist
our knowledge of disturbed physiology associated with diseases of the
cardiovascular system, pancreas, kidneys or prostate, thyroid, gastrointestinal tract and biliary passages with jaundice, has been greatly extended. With the application of this better understanding of disturbed
physiology associated with organic disease and the closer co-operation between the internist, the laboratory worker and the surgeon in the preparation and after care of surgical risks there has been a corresponding improvement in the care of such cases and a lower mortality and morbidity
rate.
The chief cause of poor surgical results is the incomplete examination. Surgical relief of patients burdened by deranged physiologic function should not be undertaken until the condition of the patient affords
a reasonable assurance of success. With the methods now available for
estimating the excretory function of the kidneys there is little excuse
for post-operative renal complications.
In gastric surgery the tendency to place complete reliance on the
result of the roentgenologic examination to the exclusion of a gastric
analysis and a careful case history is to be deplored.
It is my intention to discuss certain of these deranged functions
which tend to handicap our patient and indicate wherein they may be
improved and the risk lessened.
I have nothing new to present to you on the subject but believe that
a review of certain of these derangements of physiologic function with
discussion as to their diagnosis and treatment, may be worth while to
bring before you.
Page 248 Acidosis.—The reaction of the blood is slightly alkaline and dependent for the most part on the sedium bicarbonate reserve, which is used
by the body to combat excess formation of acid or its accumulation in
the blood.
An increase of acid in the blood produces a slight decrease in alkalinity, diminishing the ability of the blood plasma to combine with carbon dioxide. The normal COa combining power of the blood plasma has
been determined to be about 60 per cent, by volume of carbon dioxide
(van Slyke's method). With acidosis present the combining power may
decrease to as low as ten per cent.
Acetone and diacetic acid in the urine usually indicate an acidosis
but these substances may be present during alkalosis. There is as well,
diminished tension of carbon dioxide in the alveolar air (Marriott's method) and lowered p¥L of the blood (Cullen's method).
One of the most important causes, if not the chief cause, of acidosis
is the body's deficient utilization of carbohydrates, as in diabetes, anoxaemia, starvation, persistent vomiting, post-operative shock, hyperthyroidism, liver destruction and kidney deficiency.
Diseases of the liver which interfere with its ability to supply glucose to the tissues and so result in an incomplete combustion of fats and
an overproduction of protein waste, tend to produce an acidosis. The
same tendency to acidosis results from depletion of the liver glucose as
from undue activity, post-operative shock or the toxaemias of pregnancy.
The essential factor in the treatment of acidosis is the administration
of carbohydrates and the carbohydrate upon which we rely is glucose.
The intravenous administration of 5 to 10 per cent, solution of glucose given slowly and in sufficient amounts is the surest method of supplying this food.
Insulin may be given subcutaneously as deemed necessary, one unit
of the extract to each 2 gms. of glucose. Fluids are given in large
amounts.   Cathartics are to be avoided.
In preparing the diabetic for operation it is advisable to reduce the
sugar output by a properly balanced diet, but of far more importance is
the elimination of any acidosis that may be present. This may be assumed to have been accomplished with the disappearance of diacetic acid
from the urine.
Approximately 100 gms. of carbohydrate daily for several days preceding and again following operation may be given, sufficient insulin being used to burn the excess. The fat content of the diet should be low—
50 to 75 gms. daily. Fluids up to 3,000 cc. a day may be given intravenously if not tolerated by mouth.
Alkalosis.—In alkalosis the C02 combining power of the blood may
increase to 160 per cent, by volume, the normal being in the neighborhood of 60 per cent.
It is most commonly encountered in cases of high intestinal or pyloric obstruction and vomiting with excessive loss of hydrochloric acid,
Page 249 or after excessive dosage with alkali and may be associated with tetany.
There is a rise in the non-protein nitrogen of the blood with a marked
fall in the chlorides. The pri of the blood increases. The urine shows
an increase in the excretion of nitrogenous waste with a fall of the
chlorides to very small amounts.
It is important to differentiate the condition from an acidosis. Patients in an extremely poor condition after persistent vomiting may have
either an acidosis or an alkalosis.
Sodium chloride solution has been found to be almost a specific in
cases of high intestinal obstruction. In severe cases which show a blood
chloride of 400 or under large doses are given intravenously. One gm.
per kilogram of body weight should be given as an initial does intravenously in 5 to 6 per cent, solution.
Anaemia.—Many of our poor risk patients, even though there is no
definite degree of anaemia, withstand operation much better if supported
by blood transfusion. Those cases with a haemoglobin of 50 per cent, or
under and a low systolic blood pressure will have a much greater margin
of safety after a few daily intravenous saline infusions, and a blood transfusion.
Cholaemia.—Mann has prolonged the lives of liverless dogs 30 hours
by means of intravenous glucose solution. Twenty-five per cent, of the
liver has been found sufficient to maintain life in experimental animals.
The tests for insufficiency of the liver function are not very satisfactory. Rosenthal's test of hepatic function by means of the dye
phenoltetrachlorphthalein is based on the fact that normal liver removes
all but 3 per cent, of this dye from the blood stream in fifteen minutes
after its intravenous injection. There is retention of the dye in proportion to liver damage.
Bile pigments in the blood stream may be measured by the van den
Bergh method.
Five cc. of 10 per cent, calcium chloride solution is part of the routine preparation in jaundiced patients. It increases coagulation in jaundice, prevents post-operative haemorrhage and has a detoxicating effect
on the bile pigments.
The intravenous administration of glucose, a generous carbohydrate
diet and abundance of fluids all help to lessen the dangers of operation.
Dehydration.—Water in sufficient quantities is a solvent and a diuretic and assists in the elimination of nitrogenous waste. A diminution
of the fluids of the blood leads to increased viscosity with a decrease in
the oxygen carrying power of the red cells of the blood. The concentration of the water in the blood stream affects the regulation of the body
temperature.
Dehydration is a prominent factor in pyloric obstruction, persistent
vomiting, diarrhoea, thyrotoxaemia and diabetes.
The best method of giving fluids to a very sick patient is by intravenous injection.    Fluids should be given slowly.    If the dehydration is
Page 250 of long standing blood transfusion may be advisable and the fluid intake
should be kept at a high level.
Oedema.—The presence of excessive fluid in the tissues and serous
cavities may indicate a failing circulation and draws our attention to
the operative risk in cardiac cases. Dr. Hugh Cabot has recently remarked "I do not remember a single instance in which patients with
badly damaged hearts for whom surgical operations were imperative have
died as a result of the added strain thrown upon the heart by the operation."
Auricular fibrillation does not contra-indicate surgery. It adds a
slight risk and indicates digitalization, possibly the only indication for
digitalis. A grain and a half for every ten pounds of body weight in
twenty-four hours (or a single dose) and one and a half grains daily
thereafter.
The practice of delaying an operation for three weeks after relief of
congestive heart failure appears to be a safe rule, where it is practicable
to adhere to it. Graphic study of the heart is not of great assistance in
determining operative risk.
Obesity.—The risk associated with obesity is a well-known factor.
If possible it is best to reduce the weight before operation is undertaken.
In the ordinary type of obesity due to over-indulgence in food and insufficient exercise the weight can be readily reduced by restricted diet
and increased exercise. In the smaller group, that which includs the type
of obesity associated with disturbance of the internal secretions, often of
obscure origin, restricted diet and exercise fail to give necessary reduction.    These cases fortunately are comparatively rare.
Toxaemia.—Under this heading hyperthyroidism will be referred to.
The principal conditions which tend to a greater operative risk in this
type of case are emaciation and dehydration with acidosis, myocardial
changes and nervous instability. Forced fluids, to allow for the increased
evaporation associated with the high metabolism, increased caloric intake
by means of concentrated food, mental and physical rest and sedatives
are essential.
Digitalis may or may not be of value in toxic goitre with myocardial
changes.    Auricular fibrillation is an indication for its use.
There seems to be no doubt as to the value of iodine in the hyperplastic type of goitre case in reducing toxicity and preparing the patient
for operation. Ten to fifteen minims of Lugol's solution well diluted in
water three times daily after meals is the usual dosage. The maximum
effect is reached in ten days and the operation is performed about the
seventh day in order that the maximum effect may be reached during
the stormy post-operative period.
In delirious or very toxic patients it may be desirable to give as
much as 50 minims of Lugol's solution in 1000 cc normal saline intravenously and 100 minims daily for a few days until the danger has passed.
Foci of infection should not be disturbed until the hyperthyroidism
has been controlled.
Page 251 Retention of nitrogenous waste.—The ability of the kidneys to remove nitrogenous waste products from the blood may be accurately
measured by the estimation of the urea and non-protein nitrogen of the
blood. The phenolsulphonephthalein test of kidney function as introduced by Rowntree and Geraghty has been found reliable.
Incomplete obstruction, whether in the stomach, intestine, common
bile duct or urinary tract produces a toxaemia with the accumulation of
non-protein nitrogen in the blood. This may be associated with an acidosis or an alkalosis. The establishment of adequate drainage is essential
and the restoration of impaired renal function imperative. Water in
sufficient quantities assists the kidneys in eliminating waste products as
urea and creatinin. Intravenous injection of 1 per cent, sodium chloride
with ten per cent, glucose supplies fluid, affords nourishment and combats
the toxaemia.
Conclusions.—For the rehabiliation of the bad-risk patient certain
fundamental measures are required:
1. Closer co-operation of the various branches of medical and surgical practice with a more thorough examination of the patient.
2. An abundance of fluids and a normal acid-base balance. Elimination and neutraliation of toxins and nitrogenous waste products.
3. Sufficient glucose reserve established by giving carbohydrates by
mouth or glucose intravenously.
4. Adequate circulation by rest, sedatives and digitalis.
5. Less drastic purgation especially within twenty-four hours of
the operation.
"THE POOR SURGICAL RISK"
(2) Dr. D. D. Freeze.
In discussing a subject such as the one tonight I always feel the
necessity of trying to give it a definition, in order to see first of all if I
am likely to know anything about it; and in my endeavour to formulate
one I was very much reminded of a phrase which blazoned forth some
few years ago, with the popularity of a slogan. I refer to "the acute abdomen." So widespread was the use of this phrase and so contentious
and controversial and I might also say so acrimonious became the discussion concerning its use, that one gifted member of our profession
actually burst into verse, the closing line of which the "acute abdomen
bang" carried such a degree of finality in its wake, that it just about
settled the controversy. However, through the mazes of it all I think
perhaps I understood one thing, viz: that it referred pretty much to a
"surgical belly."
Now, to my mind, the title of this paper conveys much the same
idea—surgery. The role of the anaesthetist tonight is not an unpleasant
one as, with the exception of emergencies, the internist and the biochemist have both ferretted out all pathology and instituted such remedial
measures as should permit this type to safely navigate the short but dangerous passage between surgical Charybdis and anaesthetic Scylla.
Page 252 What, then, constitutes a poor surgical risk?
The condition is obviously purely relative and dependent, as I see
it, upon five main factors which should be aligned in the following order
as suggesting the natural sequence of investigation in determining the
risk assumed:
1. Condition of patient.
2. Type of operator.
3. Surgical skill.
4. Duration.
5. Anaesthetic.
In other words, with the condition of an individual patient as a
constant the relative risk would vary with the type of operation and
surgical skill, (duration being dependent, in great part, upon these two)
and the character of the anaesthetic. It is mainly with the latter that I
shall deal tonight.
With these five relative factors in view I am led to consider a poor
surgical risk as one in which death would not be unexpected. At the
outset, then, I am going to eliminate that small group of unexpected
deaths on the operating table for which no one is prepared and which
show p.m. no really demonstrable cause of death. Poor risks enough
they prove to be, but so also do cases of post-operative embolism. In
other words, all poor risk cases do not die, nor do all good risk cases
survive.
It is usual to classify surgical risks as
1. Good.
2. Fair.
3. Poor.
and it is also usual to estimate the risk in great part from a cardio-vascular point of view, as e.g.:
Moot's rule of operability is dependent on the ratio of pulse pressure to
diastolic pressure(25-75% operable). McKesson working on the same
basis speaks of 3 types of depression during operation:
1. Safe—10-15*/  increase in pulse—no blood pressure changes.
10-15% decrease in blood pressure—no pulse changes.
2. Dangerous—15-25'/   increase in pulse—15-25%   decrease in
pressure.
3. Fatal—Increasing pulse above 100, with decreasing blood pressure 80
or less, with pulse pressure 20 or less for a period of 20 minutes.
Miller, of Providence, in speaking of the three groups named above,
described (1) Good—as all cases free from organic diseases whose surgical
condition is not likely to prove fatal. (2) Fair—as cases of organic
disease but surgical condition not specially serious. (3) Poor—cases in
which surgical condition is likely to result in fatality.
In a series of 1000 consecutive cases
Group 1 showed a mortality of      .27%.
Group 2 showed a mortality of    7.82%.
Group 3 showed a mortality of 3 3.33"/.
This included deaths up to 3 weeks post-operative, no deaths occurring on the table.
Page 253 In applying Moot's rule to the above cases, there were 3% deaths in
operable cases, 23% deaths in inoperable cases.
Now, while the cardio-vascular system is a pretty good guide in
estimating the pre-operative risk and the operative condition, especially
where the cardio-vascular system is involved, as in chronic valvular
disease, myocarditis, atheroma, hypertension of whatever cause, and toxic
conditions as hyper thyroidism, there are numerous cases, which may and
do result fatally, in which it is no guide.
Without taking into consideration surgery during the prodromal
stage of the infectious fevers, where an operation, as for tonsils and
adenoids just prior to the onset of, say, scarlet fever, may greatly endanger the patient's life, these cases might readily be grouped by systems,
as under:
1. Respiratory—common   cold,  laryngitis,   chronic  bronchitis,   asthma,
emphysema, lung abscess, etc.
2. Digestive—pharyngitis, tonsillitis, leading to infection of the respir
atory tract, also infected teeth and gums.
3. Genito-urinary—nephritis.
4. Constitutional—diabetes.
In none of these cases will the cardio-vascular system, as indicated by
pulse and blood pressure, show any indications of impending trouble, and
yet they are capable of causing post-operative conditions fraught with a
good.deal of anxiety.
On the other hand there are malignant conditions with cachexia
which, despite a good pulse and blood pressure during operation, do not
do well post-operative, seeming unable to overcome the operative load
they have been burdened with.
Without, then, going into greater detail, we have those cases in
which
1. The cardio-vascular system is a good guide.
2. The cardio-vascular system is not a good guide where other compli
cations are lighted up, or a recrudescence of previous   (latent
or active) pathology occurs.
How, then, are all these groups to be handled, in order to best safeguard their very life?
First of all, we must remember that there are two general groups to
be considered:
1. Emergency—where operative procedure must proceed at once or in a
very limited time.
(a) Traumatic—e.g., ruptured spleen or liver.
(b) Pregnancy—ruptured ectopic—eclampsia.
(c) Gastro-intestinal—acute bowel obstruction—ruptured bowel, general peritonitis—strangulated hernia
—volvulus, intussusception, and so on.
2. Elective—where contemplated surgery is for the relief or cure of the
pathology, as in prostatectomy, or where some concurrent
pathology complicates surgical procedures, e.g., prostatectomy
in diabetes.    This group is dealt with tonight by the internist
Page 254 and biochemist.    Here an attempt can be made to improve the
patient's condition for a necessary but not immediate operation.
I have taken up these conditions in this way because anaesthetists in
estimating a risk are not thinking only of the patient withstanding the
operation but of the chances of actually surviving it. Consequently the
condition of the cardio-vascular system, urinary system, respiratory system and blood, as well as presence of infections and constitutional anomalies, are equally important to them.
Now, what factors influence one in the choice of an anaesthetic?
As this is a practical discussion tonight I am not considering any materials
such as ethylene, not in use by my department. Per se, nitrous oxide
would appear the anaesthetic of choice where it is feasible, as, irrespective
of the character of the pathology present, it is most likely to do the least
harm. This is true as far as its toxic action on tissue is concerned, but
during its administration difficulty may arise which may complicate the
picture and create an end result more harmful than even ether. Let me
give an example—acute bowel obstruction with faecal vomiting. Necessary relaxation is difficult to obtain and the regurgitation or vomiting of
any stomach contents into the mouth (not an unlikely happening) cannot be removed without the patient practically coming out of the anaesthetic, and vomiting continuing, aspiration of contents is almost certain
to follow, with its certain results. In ether a much deeper anaesthesia can
be rapidly obtained, diminishing the possibility of vomiting and should
Vomiting occur, immediate aspiration of the vomitus can be instituted
without markedly interfering with the course of anaesthesia. The result
is a better operative field, less straining, meaning conservation of energy,
and a dry respiratory tract.
Another group in which I prefer ether to nitrous oxide comprises
cases of chronic bronchitis, asthma and emphysema. In chronic bronchitis there is a constant secretion in the respiratory tract and under
nitrous oxide this must remain to be bandied back and forth, causing irritation and the almost certainty of spasms of coughing, whereas it can
be readily controlled under ether.
In asthma and emphysema we are dealing with respiratory difficulty
and diminished aeration, rendering the introduction of nitrous oxide into
the blood stream in sufficient quantities a most difficult matter, besides
actually increasing the respiratory difficulty by expiring against a positive
pressure. These cases do show a definite respiratory fatigue following a
nitrous oxide administration of any length.
And besides all this there is sometimes great difficulty in maintaining
a free airway, as artificial means to overcome a stridor or stertor cannot
be instituted with the same freedom and success as in deeper anaesthesia
and the continued presence of this condition is a big factor in creating
post-operative fatigue. True, a patient's colour may be maintained a
bright pink, in the presence of stridor, especially with the administration
of oxygen as we give it, but even a pure oxygen atmosphere, while maintaining a good colour, will not counteract fatigue if one has to work to
obtain it.
Another factor in nitrous oxide to be considered is the inevitable re-
Page 255 breathing which takes place. Some patients appear particularly susceptible to the presence of C02 and a varying degree of hyperpnoea results,
extremely difficult to control.
We have been for the past two years using chloroform as a synergist
for gas in place of ether with most gratifying results. It serves a double
purpose—increasing the depth of anaesthesia, and also the oxygen range.
This latter is a big factor in increasing the safety of nitrous oxide as the
concensus of opinion today favours the view that nitrous acts by virtue
of partial asphyxia. Certainly the oxygen content seldom reaches that
of inspired air, even when a good colour is being maintained.
I have administered chloroform to a child of one year for intussusception without any change in its condition and a rapid regaining of
consciousness. I have given it to a 7 years boy with whooping cough for
an enucleation. In only one case over a period of two years could I attribute any post-operative complications to its use, and prostatectomies,
hysterectomies, chloecystecomies and gastroenterostomies have been done
with it. In fact it has been responsible more than any other single factor
for enlarging our uses of nitrous oxide and oxygen though it in no way
diminishes the troubles with nitrous oxide that I have previously mentioned.
Within the last year we have instituted the procedure of tracheal
aspiration during and after ether anaesthetics and have been astounded
at the amount of tracheal secretion removed. While I am not prepared
to be dogmatic in this regard there have been a sufficient number of cases
to demonstrate that the presence of tracheal secretion is a big factor in
the production of post-operative nausea and cough following ether. If
this is so, then oxygen and tracheal aspiration have combined to rob ether
of a good deal of its dread and render it a most satisfactory anaesthetic
(Continued in the next issue.)
ANNUAL MEETING
The twenty-ninth annual meeting of the Vancouver Medical Association was held in the Auditorium, Tenth and Willow Streets, on the evening of Tuesday, April 19th, the retiring president, Dr. A. W. Hunter,
in the Chair. The Minutes of the last regular meeting were read and
adopted. Communications were read from the Secretary of the Staff
Committee of the Vancouver General Hospital and from the Victorian
Order of Nurses asking for the support of the Association in their annual
campaign for funds.    Both letters were received and filed.
Dr. W. S. Turnbull presented a joint report as Secretary and Treasurer which showed a very satisfactory year's work. Seven regular and five
special meetings were held. These were, on the whole, well attended and
the papers and addresses presented were of a high order.
The special meetings were addressed by: Dr. Norman D. Keith, of
the Mayo Clinic, who spoke on cardio-vascular renal diseases; Dr. Maude
Abbott,  of Montreal,  who  gave  an  interesting   address  on   the  Osier
Page 256 Memorial Volume; Dr. W. J. Boyd, of Winnipeg, gave a lecture on Endocarditis and Dr. W. J. Galloway spoke on the treatment of some common fractures. These two speakers came out under the auspices of the
Canadian Medical Association's Post-Graduate Education Committee.
Other recent speakers were Dr. N. D. Royle, of Australia, who gave a
lecture on his special work in connection with the autonomic nervous
system, and Dr. J. J. R. MacLeod, who lectured on "The Place of Physiology in Medicine."
The Secretary referred to the loss sustained by the Association during the year in the deaths of Dr. Alison Cumming, Dr. J. W. Good and
Dr. L. N. McKechnie. The passiing of these members meant a very distinct loss to the medical profession, not only in Vancouver, where they
were known and loved, but to the profession at large.
As Treasurer, Dr. Turnbull presented a very satisfactory financial
statement, showing a credit balance of $2000.79 in current account and
satisfactory balances in the Ultra Scientific and Dr. Stephen's Memorial
accounts, in addition to approximately $2600 invested. The membership was the highest on record, 209 names being on the roll. Fees to the
value of $4060 were collected during the year.
The Auditor's report was read by Dr. F. W. Lees, and the Trustees'
report was presented by Dr. Coy.
In the absence of Dr. Pearson, the Editor, Dr. Turnbull read a statement of the financial position of the Bulletin which showed a net profit
of $527 on the 31st of March, 1927. A hearty vote of thanks was tendered to Dr. Pearson and the Editorial Board for their work in connection
with the Bulletin.
Dr. Frost reported as representative of the Association to the B.C.
Medical Association Executive.
Dr. L. H. Appleby reported as Secretary of the Summer School
Committee and outlined the plans for the 1927 Summer School in June,
and reported a balance to the credit of the Committee of $1143.
The report of the Library Committee was read by Dr. W. D. Keith.
$1146.76 was spent—$822.56 on books and journals, $175.20 on binding, $10.00 subscription to the Medical Library Association and $139
had been spent from the Ultra Scientific Fund to complete the file of the
Journal of Biological Chemistry, copies of which were becoming hard to
obtain.
During the year 934 journals and 594 books had been borrowed by
members. Sixty journals are on file in the Library. Dr. Keith thanked
the members who had contributed abstracts of articles and reviews of
books for insertion in the Bulletin and those men who had presented
books and journals to the Library during the year.
The Dinner Committee reported through the Chairman, Dr. G. B.
Murphy. The Annual Dinner was held on November 18th, 1926, and
. was a big success.    155 tickets were sold, the deficit being $61.07.
Drs. J. H. MacDermot and F. N. Robertson reported for the Orchestra Committee.
The Credentials Committee's report was read by the Secretary in the
absence of Dr. E. H. Saunders, the Chairman. Eighteen applications
for membership had been considered and favourably reported on. Ten
new members had been elected and eight await election in the Fa
Page 257 The Credit Bureau report was presented by Dr. D. McLellan and
showed a slight increase in the volume of collections during the year.
The Bureau was successful in locating 139 parties who had left the city
and whose accounts had been considered entirely lost. The Directors
thought a larger number of accounts might be collected if sent in to the
Bureau before they became too old. The financial report showed a net
present worth of $888.79. The total amount collected during the year
was $25,710.12, an increase of $742.16 over the previous year.
The Clinical Section's report showed that six meetings were held
with an average attendance of fifty. The meetings were marked by the
wide variety of cases presented and by a commendable freedom of discussion. The staffs of the Vancouver General and St. Paul's Hospitals each
presented an evening's programme and many interesting and instructive
cases were shown. The last and one of the best meetings was given by
the staff of the Shaughnessy Military Hospital.
Dr. C. H. Bastin reported for the section of Physiology and Pathology. No report was presented by the Ear, Eye, Nose and Throat Section or the G.U. Section. The Physiotherapy Section reported through
Dr. H. A. Barrett, who referred to the efforts of the American Medical
Association to define the status and regulate the practice of physiotherapy
and standardize the apparatus, and he drew the attention of the members
to the findings and recommendations of the Council on Physical Therapy
of the A.M.A. He also referred to the practical course on physical
therapy given by Dr. Greaves at the Vancouver General Hospital.
Under New Business Dr. McLellan moved that the Association send
a communication to the Superintendent of the Vancouver General Hospital advising that a doctor be appointed to check over all convalescent
cases with a view to discharge. After some discussion the motion was
withdrawn and a motion was carried to the effect that the Association
go on record as willing in any way to co-operate with and assist the administration of the hospital with regard to the discharge of patients and
relief of congestion.
Dr. . S. Turnbull gave notice that at the next regular meeting he
would move the following notice of motion:
"That Article IV., page 6, of the Constitution and Bylaws of
the Association be amended by eliminating the word 'auditor'
on line 4 and that Section E of Bylaw 3 on page 10 be altered
to read as follows: 'An auditor shall be appointed each year
by the Executive Committee and he shall examine the books
and vouchers of the Hon. Treasurer within the week prior to
the Annual Meeting and shall present a report to the Association at that meeting.' "
Dr. A. W. Hunter, retiring President, thanked the Officers and
members for the valuable assistance given during his term of office.
Among his well-chosen remarks the following were outstanding: (a)
The advisability of co-operation with medical officers on trans-pacific
liners in securing names of possible speakers for meetings; (b) the securing of more adequate and comfortable quarters for meetings; (c) an adequate appreciation of the work of Dr. Pearson as Editor and the possibility of an honourarium;   (d)   the incorporation of the medical phone
Page 258 service with  the Association,  and   (e)   the  appointment  of  a  business
manager.
The election of officers, members of standing committees, and officers
of sections then followed:
Dr. A. B. Schinbein was unanimously elected President, with Dr.
W. S. Turnbull as Vice-president. Dr. A. C. Frost was elected Treasurer
and Dr. G. F. Strong Secretary. Dr. J. W. Arbuckle was elected to the
Credit Bureau and Dr. C. H. Vrooman was elected as the representative
of the Association on the B.C. Medical Association Executive. Dr. Pearson was re-elected Editor. The appointment of a new Auditor was deferred to the Fall pending Dr. Turnbull's notice of motion. The Trustees, Drs. W. F. Coy, W. B. Burnett and J. M. Pearson were re-elected.
Dr. Gordon Burke was chosen to head the Clinical Section, with a seat
on the Executive, and Dr. L. H. Appleby was elected Secretary.
The following elections were made to Standing Committees:
Library Committee—Drs. A. W. Bagnall and D. F. Busteed.
Dinner Committee—Drs. D. D. Freeze, Harry Bell and O. S. Large.
Orchestra Committee—Drs.  J. A. Smith, H.  A.  Barrett, I. Macmillan and H. C. Powell.
Credentials Committee—Drs. F. W. Lees, E. J.  Gray and W.  F.
McKay.
Dr. Hunter then introduced the new President, Dr. A. B. Schinbein,
and the meeting adjourned at 11 p.m.
There was a small attendance.
The University of Washington
invites the physicians and surgeons of British Columbia to attend the
Seventh Qraduate (fNLedical lectures
Five Days of Lectures, Clinics and Social Events
JULY 18-22 INCLUSIVE
The Committee has secured a Faculty of Outstanding Scholarship:
Dr. GEORGE CRILE, of Cleveland, on "surgery"
Dr. CHARLES L. MIX, of Chicago, on "medicine"
Dr. CHARLES L. SCUDDER, of Boston, on
"fractures and allied injuries to bones and joints"
The lectures this year will doubtless be crowded; hence we ask you to secure
your ticket well in advance for fear you may be disappointed. Every effort
will be made to accommodate all out of Seattle applicants. Precedence will
be given in order of application. The fee of $ 15 covers all social events managed by the Committee as well as the lectures. Make cheque payable to
University of Washington.
Address:—
University Extension Service, Roo?n 121, Education Hall
University of Washington, Seattle, Washington
Page 259 MEDICAL
SUPPLIES
Sometimes you experience difficulty in procuring an out-of-the
ordinary office requirement from
your usual source of medical supplies. In such case—as also in
the regular supplies—may we offer our wide facilities for filling
every order? Quickest possible
service.    Full co-operation.
j    PHONE
SEYMOUR  112
618 Georgia St. West "Quickest Possible Service"
Phone Seymour 112
Page 260 'jlknfXfiay Supplies 'PD-Q"?
There are over 30 Direct Branches now estab'
lished by the Victor X'Ray Corporation
throughout U. S. and Canada. These branches
maintain a complete stock of supplies, such as
X'Ray films, dark room supplies and chemicals,
barium sulphate, cassettes, screens, Coolidge
tubes, protective materials, etc., etc. Also
Physical Therapy supplies.
The next time you are in urgent need of sup*
plies place your order with one of these Victor
offices, conveniently near to you. You will ap-
predate the prompt service, the Victor guar'
anteed quality and fair prices.
Also facilities for repairs by trained service
men. Careful attention given to Coolidge tubes
and Uviarc quart? burners received for repairs.
VICTOR X-RAY CORPORATION
Main Office and Factory: 2012 Jackson Boulevard, Chicago
^
Motor Transportation Bldg.
Vancouver, B.C.
Victor X-R-P Safe
A lead-lined steel cabinet for storing
films and loaded cassettes.
Write SUPPLY SALES DIVISION
for price and detailed information.
Quality   Dependability   Service    Quich - Delivery
» » <Price applies to Ml »|
R C. Pharmacol Co. Ltd.
329 Railway Street,
VANCOUVER.
Manufacturers of Hand-made Filled Soluble
Elastic Capsules.
Specimen Formulae:
No. 60—
Blaud Pill, 10 gr.
Arsenious Acid, 1/50 gr.
Ext. Nux Vomica, \ gr.
Phenolpthallin, \ gr.
No. 61—
Blaud Pill, 10 gr.
Arsenious Acid 1/50 gr.
Ext. Nux Vomica, J gr.
Phenolpthallin, \ gr.
Special Formulae Made on a Few Hours' Notice.
Price Lists and Formulae on
Application.
Page 261 The Owl Drug
Co., Ltd.
Jill prescriptions dispensed
by qualified Druggists.
l]ou can depend on the Ou?l
for ^Accuracy and despatch.
IDe deliver free of charge.
5 Stores, cenlrally located.    We
would appreciate a call while
in our territory.
Ambulance
Service
TELEPHONE
Fair. 58 & 59
Mount Pleasant
Undertaking Co.   Ltd.
R. F. Harrison    W. E. Reynolds
Cor. Kingsway and Main
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.
Phones Sey. 988 and 672
Phones Sey. 9513 and 1391
Phone Sey. 1370
Brown Bros. & Co. Ltd.
VANCOUVER, B. C.
Page 262 STEVENS'
Safety Package
STERILE GAUZE
Soft        Pure        Absorbent
STERILIZED BY 20 lbs. STEAM PRESSURE
The Stevens Safety Package is designed to enable the gauze
to be withdrawn from the carton without removing the
whole roll.
READY FOR USE IN THE OFFICE
HANDY FOR THE BAG
B.C. STEVENS CO. LTD.,
730 Richard Street,
Vancouver, B.C.
PRESCRIPTIONS
filled exactly as written
Phones: Seymour 1050 -1051
Day and Night Service
Qeorgia Pharmacy Ltd.
Qeorgia and Qranville Sts. Vancouver, B. C.
Page 263 -He©»=
^s.
5I^H~"
,V"*4
*^^J3£*
||^|t
fcf
•ft
#1
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HI
III -
SBit BTm J^B > fe&P^feSc£r       MBgj
P
- i*
■    1    *■ - •" ---M"    'f:K:H
N-     '"   "•??'»
wiis^
irffcr $
10$$:
w&s? *IB*M
|j|
ai
nbMji£^fy£7:       I *v<SS
flfaiiMa^
■ '- - -- - f%
ll§i
Hollywood Sanitarium
LIMITED
^or the treatment o/
Alcoholic, Nervous and Psychopathic Cases
Exclusively
Reference - "3. (p. oMedical ^Association
For information apply to
Medical Superintendent, New Westminster, B. C.
or 515 Birks Building, Vancouver
Seymour 4183
Westminster 288
e^sXS
■MSk*
Page 264

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