History of Nursing in Pacific Canada

The Vancouver Medical Association Bulletin: September, 1929 Vancouver Medical Association Sep 30, 1929

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 Vol. V.
SEPTEMBER, 1929
No. 12
The Bull
of the^
Vancouver Medical Association
Sodium cAmytal
trigeminal J\(euralgia
'{Histamine
"Published monthly atUancouver, <3J.(^., by
McBEATH-CAMPBELL LIMITED
"^Trico $1.50 per years- Patient Types:
THE OBESE PATIENT
is frequently in the chronic constipated class because of the factors of
dietary excesses and lack of exercise.
The general form of treatment calls for a regimen of exercise and
diet Petrolagar is a very important aid in the management because, being
unassimilable, it is impossible for it to increase or produce obesity
Petrolagar, a palatable emulsion of 65% (by volume) pure mineral oil
emulsified with agar-agar, has many advantages over plain mineral oiL
It mixes easily with bowel content, supplying unabsorbable moisture with
less tendency to leakage.   It does not interfere witih digestion.
Petrolagar restores normal peristalsis without causing irritation, producing a soft-formed consistency and real comfort to bowel movement.
IBetroI
agar
Gentlemen:—Send me copy of  "HA-
Petrolagar Laboratories   S^ZfS^.*09"™* and
IHC. Dr	
245 Carlaw Ave.
Toronto, Ontario     Dept. V.M. 9 Address   ...._	 THE   VANCOUVER   MEDICAL   ASSOCIATION
BULLETIN
Published  Monthly under  the  Auspices  of  the  Vancouver  Medical  Association  in  the
Interests of the Medical Profession.
Offices:
203 Medical and Dental Building, Georgia Street, Vancouver, B. C.
Editorial Board:
Dr. J. M. Pearson
Dr. J. H. MacDermot Dr. D. E. H. Cleveland
All communications to be addressed to the Editor at the abov; address.
VOL. V.
SEPTEMBER, 1929
No. 12
OFFICERS 1929-30
Dr. T. H. Lennje Dr. G. F. Strong Dr. W. S. Turnbull
President Vice-President Past President
Dr. E. M. Blair Dr. W. T. Lockhart
Hon.-Secretary Hon. Treasurer
Additional Members of Executive:—Dr. W. A. Dobson; Dr. A. C. Frost.
Trustees
Dr. W. F. Coy Dr. W. B. Burnett Dr. J. M. Pearson
Auditors:    Messrs. Price, Waterhouse & Co.
SECTIONS
Clinical Section
Dr. J. R. Davies Chairman
Dr.  S.  H.  Sievenpiper Secretary
Physiological and Pathological Section
Dr.  A.  M.  Menzies . Chairman
Dr.  R. E.  Coleman § Secretary
Eye, Ear, Nose and Throat
Dr.  F.  W.  Brydone-Jack  , Chairman
Dr. N. E. McDougall  Secretary
Physiotherapy Section
Dr. H. R. Ross , ! Chairman
Dr. J.  W. Welch  , Secretary
Pediatric Section
Dr.  C.  F.  Covernton ! Chairman
Dr. G. O. Matthews Secretary
STANDING COMMITTEES
Library Orchestra Summer School
Dr. C. H. Bastin Dr. J. R. Davies Dr. L. H. Appleby
Dr. Wallace Wilson Dr. J. H. McDermot Dr. B. D. Gillies
Dr. S. Paulin Dr. F. N. Robertson Dr. W. T. E-wing
Dr. D. F. Busteed Dr. J. A. Smith Dr. R. P. Kinsman
Dr. W. H. Hatfield Publications Dr. W. L. Graham
Dr. D. M. Meekison Dr. J. M. Pearson Dr. J. Christie
Dinner Dr. J. H. McDermot
Dr. W. T. Ewing Dr. D. E. H. Cleveland Hospitals
Dr. W. A. Gunn Credentials Dr. J. W. Arbuckle
Dr. L. Leeson Dr. A. W. Bagnall Dr. F: Brodie
Rep. to B. C. Med. Assn.    Dr. W. L. Graham Dr. A. S. Monro
Dr. A. Y.McNair Dr. A. J. MacLachlan Dr. F. P. Patterson
Sickness and Benevolent Fund — The President — The Trustees VANCOUVER HEALTH DEPARTMENT
STATISTICS,  JULY,   1929
Total   Population   (estimated) 228,193
Asiatic   Population   (estimated) 12,300
Rate per 1,000 of Population
Total   Deaths        156
Asiatic   Deaths          14
Deaths—Residents   only        142
Birth   Registrations   	
Male        190
Female    193
INFANTILE MORTALITY—
Deaths under one year of age_
382
8.05
13.40
7.33
19.76
Death   rate  per   1,000   births  18.21
Stillbirths   (not  included   in  above)
15
Cases of Contagious Diseases Reported in City.
June, 1929
Cases Deaths
Smallpox       13 0
Scarlet   Fever       15 0
Diphtheria     26 1
Chicken-pox      27 0
Measles    23 6 5
Mumps       77 0
Whooping-cough        17 0
Tuberculosis       22 26
Erysipelas     12 1
Typhoid   Fever        1 0
Poliomyelitis         0 0
Meningococcus Meningitis .           1 1
July, 1929
Cases    Deaths
7
-'•7,
36
10
25
4
2
22
7
0
0
0
0
0
2
0
0
' 0'
0
18
*i0
0
0
0
August 1st
to 15th, 1929
Cases     Deaths
0
2
15
1
2
2
1
8
1
0
0
0
0
1
0
0
0
0
0
0
0
0
0
Notice
VANCOUVER MEDICAL PROFESSION
Are your accounts and records always kept up-to-date?
I specialize in this work and will be glad to be of service to you on
any basis best suited to your own particular need, and would appreciate
an appointment to go more fully into this matter.
A message left at Seymour 1896 will reach me, or my house phone
is Douglas 578-R.
I am able to offer the names of several Doctors for my reference.
J. C. Dunstervelxe,
Suite 5-884 Bute Street,
Vancouver, B. C.
Page 239 important JJevelopments in oJpparatus
Increasing the Efficiency of Source,
and Offering a Practical Basis for Determining Individual Tolerance and
Administering Dosage Accordingly.
/^\NE of the pres'
ent-day prob
lems in the field of
ultraviolet therapy is
that of correct mea'
surement of dosage.
With a myriad of types of ultraviolet
lamps on the market, little wonder that
there is confusion when it comes to com'
parison of clinical results obtained with
two or more types of lamps, in the hopes
of standardising ultraviolet dosage.
TheVictor organization is mindful of the
fact that the efficiency of any therapeutic
energy can be dertermined only when the
physician using it knows its potentialities,
and has a means of absolute control of
the energy, to the end that it
can be intelligently administered
with a definite knowledge of the
dosage given the individual patient.
Several important developments
have been recently incorporated in
the Victor line of Mercury'Arc
Quartz Lamps, offering definite ad'
vantages to the profession. Treat'
ment time is reduced from min'
utes to seconds, enabling the clinic
to administer a considerably greater
number of treatments per hour or
day, and conserving the physician's
time during office hours
Write for information on the
latest models of Victor Quartz
Lamps, also regarding the basis
for greater accuracy in the measurement of dosage to the individual patient.
ror Ultraviolet
<jherapu.....
Model A" Combination
Air * and Water - cooled
Quartz Lamp, one of the
Victor line of mercury
vapor lamps designed to
permit the use of intensified,   short   time  technic.
Victor X-Ray Corporation of Canada, Ltd*
Manufacturers of the Coolidge Tube
and complete line of X'Ray Apparatus
524 Medical Arts Building, Montreal
Motor Transportation Bldg., Vancouver
Physical Therapy Apparatus, Electrocardiography  and  other  Specialties
2 College Street, Toronto
Medical Arts Bldg.,Winnipeg
A   GENERAL  ELECTRIC
ORGANIZATION *l
"In Foro Conscientiae"
In choosing medicinals used in the preparation of prescriptions we keep in mind the fact
the Doctor's confidence in us is based on our
integrity.
eft®
Phone Seymour 1050
Nine
Graduate
Pharmacists.
Ceovgxa
Pharmacy
7
Irt4-
Granville &.1 Qeor^it^
For 21 Years
Prescription
Specialists.
Therapeutical activity, innocuity, solubility
are the features of
1NOVARSENOBENZOL-
BILLON
This product, widely used throughout the
world, has always given satisfactory clinical results,
has never disappointed the physician.
It commends itself to the attention of the
clinicians and practitioners.
f •"   LABORATORY POULENC FRERES
OF CANADA LIMITED
Canadian Distributors:
ROUGIER FRERES    -    MONTREAL EDITOR'S PAGE
We publish in this issue a preliminary account by Dr. Appleby of
the anaesthetic agent Sodium Amytal.
We have been privileged to observe some of these cases and can
quite appreciate the enthusiasm of those who have used it.
Having lived through a medical life of considerable length embracing a period which has seen many if not most of our modern medical
marvels introduced we have rarely, if ever, seen anything so dramatic,
not to say uncanny, as the immediate effect of its administration.
That any medical device can act so smoothly on its first introduction is extraordinary and so contrary to our usual experience that we
can fully appreciate also the shaking of wise heads and the reservations
of the judgments of experience.
We sincerely hope that presently we shall all have reason to rejoice
together even if it does mean the partial eclipse of the two or three
anaesthetics which have held the field practically unchallengd for more
than 80 years.
It has of course always seemed improbable that the last word on the
subject of anaesthetics could have been said so long ago. All we have
since done has been to better the methods of administration to reduce
somewhat the incident mortality, to recognize dimly the best anaesthetic
for the individual case and to combat some at all events of the dangers
inherent in any form of anaesthesia. That there was and is room for
improvement none will deny. Whether or not the present drug in its
present form is proved so safe as to be fit for general use, undoubtedly
a lead has been given and along these lines it is probable that ultimate
success will be obtained.
Meantime we shall wait and watch with interest. Following along
the same lines as the Univesrity of Toronto and the Connaught Laboratories took with regard to the release of Insulin, this new anaesthetic is
being tried out upon sound lines and whatever the outcome a very
creditable piece of work has been brought forward and handled judiciously.
«
NEWS AND NOTES
Dr. B. C. Cushway, Chairman of the Publicity Committee has
asked us to insert the following notice:
The next meeting of the Radiological Society of North America
will be held at Toronto, December 2nd to 6th inclusive. Headquarters
at the Royal York Hotel. The facilities and accommodations at this
hotel are the best in the history of the Society and it is expected to have
a banner meeting in every way. The scientific programme, clinics,
scientific and commercial exhibits will be of the highest character and
exceedingly interesting and instructive. The programme will be interesting not only to the radiologists but to the physicians practising other
medical specialties and general practice as well. A cordial invitation is
extended to all physicians as well as radiologists to attend the Toronto
meeting. Secure reservations at once through Dr. W. C. Kruger or
Dr. G. H. Reid, 20 College Street, Toronto, Canada. Excellent arrangements have been made to take care of the visiting ladies.
Page 240
b ' Bagfflgg Dr. Rollin Stevens, of Grace Hospital, Detroit, Past President of
the Radiologic Association of North America and President of the
American College of Radiology was taken ill with appendicitis recently
while in the City en route to Alaska. Dr. Stevens was operated on in
St. Paul's Hospital.    He is now convalescent and has resumed his trip.
Lieut.-Col. Cunningham, Shawnigan Lake, writes us that he has a
trial case of optical lenses for sale. Anybody interested may see this at
5515 Balsam Street (Phone Kerrisdale 1102L). We are told that no
reasonable offer will be refused.
Will all doctors who are changing offices owing to the opening of
the new building kindly send in their change of address to the Librarian
as soon as possible, otherwise notices of meetings, etc., may go astray.
Miss Grace Fairley, Superintendent of Nurses, Victoria Hospital,
London, Ontario, has been appointed Superintendent of Nurses at the
Vancouver General Hospital, her duties to commence not later than
January 1st, 1930. Miss Fairley is well and favourably known in hospital work in Eastern Canada. She has been successively Superintendent
of the Alexandra Hospital, Montreal, Superintendent of Nurses of the
Hamilton General Hospital and for the last five years at London, Ontario.
Keys to the new Library quarters may be obtained from the Librarian.    Price 25c each.
Dr. Charles B. Crittenden of the American Public Health Association visited Vancouver early in August on vacation. He is engaged on
an automobile tour of inspection of rural health conditions all over the
United States, he an dhis wife, formerly Miss Lucy Edwards, M.A., of
Vancouver, having totalled some 21,000 miles so far, with many more
to come. Miss Edwards will be remembered by many Vancouver Medical
men as a brilliant technician of the Vancouver General Hospital Laboratories. She went to the State Board of Health of Tennessee and later
studied at Johns Hopkins, making another brilliant record towards a
Doctor of Science degree. But meeting Dr. Crittenden, she took the
Doctor instead of the degree—"and all lived happily ever after"—surely,
if the sincere good wishes of her Vancouver friends are realized.
SODIUM AMYTAL AS A GENERAL ANAESTHETIC
Lyon H. Appleby, M.D., F.R.C.S. (Eng.)
In our progressive world, perhaps nothing has so exercised thinking
minds through the ages as the problem of relieving pain—unless perchance the alchemist's dream of metallic transmutation.
Nowadays the relief of pain may be brought about by various
hypnotics, narcotics and anaesthetics. There is no hard and fast rule of
classification but very roughly, the hypnotics are substances producing
a fairly normal type of sleep, narcotics substances which produce a condition resembling coma and anaesthetics substances producing unconsciousness.
Page 241
 = In considering the anaesthetics, we may recall the days previous
to 1846 when ether was discovered. We read of the carotid compressions of the Assyrians and the crude surgery performed during the
period of cerebral anaemia so produced. We remember the Indian
Hemp of the old Chinese dynasties, the hypnotism of India, nor can
we forget the anaesthesia of Dingbat Land so graphically illustrated in a
recent well-known calendar. Yes, and in Canada's more remote regions,
many a crude piece of bonesetting is carried on under the soothing solace
of our government liquor.
The birth of modern anaesthesia really dates back to the commencement of the last century: Davy, in 1800, discovered the analgesic properties of nitrous oxide; Morton, in 1846 and Simpson, in 1847, discovered the anaesthetic use of ether and chloroform respectively. These
three products with various modifications such as ethylene, ethyl chloride,
etc. are still the standard anaesthetics of today.
Great as has been the boon conferred on suffering humanity by
anaesthesia, the actual vehicles of anaesthesia are most unpleasant, not
wholly devoid of after-effects, both mild and serious; somewhat feared
by the public, and, although almost, not quite free from danger.
Let us imagine we are taking a modern anaesthetic properly given.
What may we expect?    And what actually happens?
The preliminary stage of anaesthesia produces several phenomena
almost wholly the result of fifth nerve irritation, smarting in the nose
and conjunctiva, tracheal irritation resulting in coughing, usually a
voluntary cessation of respiration until one is forced to breathe, slowing
of the heart, salivation, mild excitement, various reflex effects, disturbances of judgment, emotional reactions, vertigo, analgesia, increased
respiration, dilated pupils and finally, loss of consciousness. The second
stage of anaesthesia depends, in a measure, upon the individual—who
he is and what he has been. One becomes drunk with ether; then the
old adage is applicable: "What's in when you're sober come out when
you're drunk." The patient becomes excited, there is a delirium ranging from inarticulate muttering to shouted profanities or Hosannas.
There are tonic and clonic muscular discharges.
This picture presents a typical response to over-stimulation of the
sympathetic nervous system. Respiration is irregular, it may be struggling or it may be increased, there is profuse perspiration and the pupils
are dilated, frequently there is coughing and retching, diminished reflexes and unconsciousness.
This gradually passes into the third stage of surgical anaesthesia.
Reflexes are lost, muscles are relaxed (we hope), breathing becomes more
regular, some patients snore and the pulse quietens down to normal or
to what it was before the administration of the anaesthetic. The blood
pressure falls slightly, temperature drops a little, the pupils become fixed
and contracted, blood sugar becomesi mobilized, loss of sphincteric
control may occur.
To reach this stage of surgical anaesthesia, one must pass through
the preliminary unpleasantness, though the actual consciousness of such
a sequence of events may be abolished by such rapidly absorbed "starters"
as ethyl chloride.
And now suppose we are over our operation, and coming out of
the anaesthetic.    We have a  great  and  abiding  thirst, we vomit  fre-
Page 241
fiaafiHUUUiiiiAi
""' -    ' - *nmi-- quently and every spell of retching hurts. The odor is vile, and our
friends and visitors hate it. We cough, and that hurts; light hurts our
eyes, our conjunctivae smart; we cannot void, and have to be catheterized. We are still drunk. So we try to get out of bed. We have a
violent headache. Finally we get a hypo and under the influence of
morphine we sleep it off and awake properly this time—more thirsty
than ever.
Of most of tins torment we are quite unconscious, but the reflex
discharge of nervous energy must exact its toll from a nervous system
which may perhaps already have been overtaxed.
The odd case in a thousand develops some pulmonary change—
bronchitis, inhalation, pneumonia or some nephitic change. The resultant vomiting causes a very occasional hernia to develop—a broken
stitch, a very occasional haematoma and—a wealth of unuttered profanity in the attending ministering angel.
Although all the foregoing is thoroughly well known, it is recalle4
in order that a comparison may be made with the new anaesthetic
which is on trial, and a description of which now follows:
It is only fair to state that the following is my own personal idea
of it based upon careful observation of about a hundred cases, and my
own use of it in about thirty other cases.
Sodium Amytal is a new barbituric compound recently introduced
to the profession as an anaesthetic, analgesic and hypnotic.
Sodium Amytal is a white crystalline powder with no particularly
distinguishing features as far as I can see. It is manufactured by Eli
Lilly & Co., Indianapolis, who are distributing it on trial to various
surgeons throughout the country, and from whom they are receiving
careful reports and case histories. The product itself is not yet commercially available.
Sodium Amytal is the Sodium salt of Iso-amyl-ethyl-barbituric acid,
and is, in consequence, not a great way removed from Veronal. It is
readily soluble in water. In common with the barbituric compounds,
it is hypnotic, very slowly excreted, causing a prolonged natural sleep
without unpleasant after-effects. The barbituric acid compounds are
excreted largely as urea, a non-toxic product of normal metabolism.
As an anaesthetic, Sodium Amytal comes in hermetically sealed glass
tubes of 1 gm each and accompanied by an ampoule of 12cc sterile distilled water. The drug is readily soluble, is dissolved with the aid of a
Record syringe and is given intravenously at the rate of 1 cc per minute.
The median basilic vein is most commonly selected but in operations
where the patient must be turned over, any other vein will do.
Administered thus, into a vein, at the rate of 1 cc per minute, the
average patient of normal weight is asleep in from fifty seconds to
three or four minutes. The induction is absolutely peaceful. I have yet
to see a patient so much as move. There is no preliminary excitement,
no irregular respiration, no apprehension, no vertigo or dizziness, and
the actual departure is very pleasant.
A medical man upon whom I operated a week ago and who took
this anaesthetic, was asked to describe his sensations as he felt himself
going. His last remark on the table before lapsing into unconsciousness was "Just like a good friend seeing you safely home!"
Page 243 As soon as the patient is unconscious, in three or four minutes, the
preparation of the operation field may be commenced. During this stage,
several phenomena may be noted. The blood pressure drops about 12'
points in a hundred on an average; respiration becomes more shallow
and thoracic in type; the pulse rises from 5 to 10 beats per minute. The
colour is good, no cyanosis nor pallor; reflexes are gradually lost and
complete anaesthesia supervenes. The blood pressure then gradually
climbs back to normal or a little above, respiration becomes snoring, the
jaw drops, the pupils contract, the pulse becomes slow and steady, and
what, to my mind is the most beautiful part of the anaesthesia, there is
a complete absence of sweating and consequently normal amount of heat
loss and dehydration.
The dose for a full-sized adult should not exceed 2 grams, and as
this is dissolved in about 20 cc of water, it requires about 20 minutes to
adminster. However, the incision and entry may be effected after the
first 10 cc, as a rule. The patient, to all intents and purposes, is simply
sound asleep. The dose varies greatly, depending upon the weight of the
patient.
I have removed a kidney on 0.6 gram, and used 2 full grams for the
removal of a gall-bladder.
I have kept accurate blood pressure records; they have been quite
uniform in showing an initial drop, followed by a quick return to
normal. Blood sugar rises from around 100 on an average to around
150, and this level is maintained for several days. N.P.N, is apparently
little affected either during or after the operation.
It is with the phase following the operation that I am most favourably impressed. As I have mentioned previously, the patient is bone-dry,
requiring no removal of saturated garments with the attendant risk
of chills.
I have yet to see a patient vomit under Amytal anaesthesia; thirst
is practically negligible. I have not seen any coughing; there is no
odour in the room—other patients in the ward do not object to their
neighbours having operations. The colour remains good and the pulse
is usually full and strong in patients who were not seriously ill before.
These latter usually sleep for varying periods—depending upon their
size and the dose they received. The actual anaesthesia lasts several
hours, the post-anaesthetic sleep lasts 12-14 hours. They can then be
aroused; they converse intelligently, they will do what they are told,
then they promptly fall asleep again and have no memory of having
previously wakened. They do not hurt their incisions by coughing,
vomiting and straining, and are content, as a rule, to sleep 36 hours.
Compare this with the previous description of ether or chloroform
anaesthesia with the host of unpleasant sequelae;—no vomiting, no
retching, no coughing, no sore eyes, no salivation; no pulmonary complications or renal complications recorded thus far. No odour in the
room to disturb friends and patients, no thirst, and no reason why thirst
should not be relieved if any is felt—for drinks do not nauseate—no
headache. I have not had a single patient complain of post-operative headache except a Gasserian ganglion case, and she can be excused for obvious
reasons. No broken teeth or scratched fauces from attempts to introduce breathing tubes.
Page 244
afiBaaBU All this sounds almost too good to be true. Now let us consider
the theoretical disadvantages. The introduction of a substance into a
vein irrecoverably, certainly is a disadvantage—at least theoretically no
matter how inocuous that substance may be. Recognition of this fact
has led to much research by the manufacturers. They have sought to
perfect an antidote. Now they announce that Ephedrine and Caffeine
sodium benzoate hypodermically definitely controls the action and assists
in bringing the patient back to a conscious state. But I have yet to see
a case that I would want brought back to a conscious state.
I might remark in passing, that I consider Sodium Amytal unsuitable for short cases—that is the type we believe to need only a "whiff,"
for example, the simple reduction of dislocations, minor operations, dental
work, etc. These cases are still best done under a "whiff" of gas or
ethyl chloride.
Another objection—but one which is not really important—is that
these cases require catheterizing at least as often each day as deep ether
or chloroform cases. All anaesthetic cases, however, will probably continue to require this measure of relief, whatever drug is administered.
I have also noticed that the dosage at present recommended for
very robust, heavy patients—i.e. 2 grams at most—needs to be supplemented by the merest whiff of gas—at least, such was my experience
with this type of patient. I found that the full dose did not completely
relax the upper abdomen (this was the gall-bladder case mentioned
before). However, I believe this to be merely a temporary objection
resulting from the extreme caution being exercised by the manufacturers
in limiting the dose to 2 grams. In the foregoing case, I felt quite sure
that relaxation was just round the corner—probably 2l/z grams might
have brought about the desired result—but I faithfully followed the
advice of those from whom I received it, and I have never given more
than 2 grams.
Even in these difficult upper-abdominal cases in heavy people, I
have been greatly gratified by the after-effects of the Sodium Amytal.
And now the most important question of all, and the one which
will make or break the new discovery.    Is it safe?
While my own experience is limited to the witnessing of a hundred
administrations in a large Eastern clinic, and to thirty operations on
cases under its influence, I can at least say this: I have not had a single
moment's apprehension at any time.
And in communicating with those whose experience far exceeds
mine, I have yet to receive an unfavorable comment.
It is, however, only reasonable to expect that patients will be
found who possess idiosyncrasies to Sodium Amytal, just as there are
patients sensitive to ether, chloroform or anything else, as witness the
anaesthetic deaths listed as status lymphaticus. Should such cases appear,
they will not damn its use unless the frequency is greater than those resulting from other forms of anaesthesia. So far there is no recorded
instance of such sensitivity.
The only known danger, as far as I am aware, would be due to
carelessly rapid introduction which would be quite as inexcusable as
it is with chloroform.
It is true that the death of a couple of dogs has occurred under the
use of Amytal in the hands of a prominent Eastern research worker, but,
Page 245 in the course of personal conversation with him, he stated that no
effort had been made to see that it was given to these animals in proper
rates—that they were merely two of a large group injected en masse
without particular care.
It is not for me to say or even to guess what the future of Sodium
Amytal will be. That must be left to those whose duty it is to assess
many thousands of case records. And here I would like to express appreciation of the very commendable restraint being exercised by the
manufacturers in refusing even now to release this product commercially.
They believe it to be absolutely safe, but they wish to make assurance
trebly sure.
So much for Sodium Amytal the anaesthetic. But Sodium Amytal
is more than an anaesthetic.    What of Sodium Amytal the drug?
Its possibilities are limitless. It is known that a small dose of 0.5 gm
will not affect either mother or child during labour (anaesthetic doses
will stop labour pains); smaller doses promote sleep or such an analgesic
state that labour is completed unconsciously. Many other possibilities
suggest themselves; control of tetanic seizures or sustained epilepsy,
tetanus, strychnine poisoning, delirium tremens, acute mania, insomnia,
drug addiction, eclampsia—the list might go on forever. However, I
have no personal experience with these cases.
Sodium Amytal is on trial, and like many another forgotten panacea, we cannot say what will become of it. Whatever its fate as a
general anaesthetic time alone can tell, but all those who have used it
appear to be frankly enthusiastic. Anyhow, Sodium Amytal as a drug
has arrived, and one very potent in cases of alarming severity. So,
however doubtful we may be of its use as an anaesthetic, however
sceptical as yet, there is absolutely no question of its potency in assuaging
the pains of labour, in controlling the seizures of sustained convulsions,
in achieving many other results in which its early use would prove invaluable.
THE  PHYSIOLOGICAL  SIGNIFICANCE  OF  HISTAMINE.
Editor's Note: This paper has been constructed in part from a
summary supplied by Dr. Best of his lecture at the Summer School of
the Vancouver Medical Association, in part from notes taken at the
lecture and supplemented {owing to the importance of the subject) by
extracts from a recent paper by Dr. H. H. Dale, appearing in the Lancet
of June 15th, 1929).
Histamine is the amine derived from the amino-acid histadine by
loss of a molecule of carbon dioxide and is a very potent physiological
substance. In 1910 Barger and Dale seeking for a principle in certain
ergot extracts which they had recognized by its stimulating action on
the muscle of the isolated uterus associated apparently with a pronounced depressor action when administered intravenously to a cat, isolated
a small quantity of the substance in pure form which they were able
subsequently to identify as histamine. This substance has since been
found to occur in varying amounts in many organs of the body. The
lung tissue is particularly rich in histamine which has also been found in
the spleen, liver, muscle, etc.
Page 24t The concentration of histamine in the lung may be about 50 mg.
per kilo, while that of the liver is only 5 mg per kilo.
Dr. Best, in the course of his work on liver extract in relation to
its supposed effects on high blood pressure concludes that in part at all
events it seems probable that its transient depressor effect, such as it is,
is due to its histamine content—to that and to choline.
A study of the physiological properties of this substance has shown
that histamine produces a profound fall in blood pressure in most species
of animals on intravenous adminstration. With a small dose this fall
is transient. With a large dose the depressor effect is persistent and
extreme producing the condition known as histamine shock. While
this depressor effect is found according to Dale, particularly marked in
the cat, the dog, and the monkey, it is distinctly less evident in the
rabbit. Dale suggests that the two effects of histamine described by
Lewis—direct dilatation of minute vessels and reflex dilatation of stronger arterioles—differ in relative prominence in different mammalian types.
In the frog there is evidently a complete lack of the vasodilator
action.
The second physiological effect of histamine is shown in the production of a contraction of smooth muscle such as that of the intestine,
uterus or bronchi. In 1919 Abel and Kubota succeeded in isolating
histamine from the pituitary body and wrongly supposed they had then
identified the essential oxytocic principle of the posterior lobe.
It seems probable that the material they used had undergone some
putrefactive alteration with the excess production of histamine thus
known to occur.
Histamine also stimulates the secretion of gland cells, particularly
those of the fundus of the stomach. The injection of this substance
produces as one of its properties an intense secretion of gastric juice and
hydrochloric acid. It is interesting to note that the H substance of
Lewis, to the action of which he attributes the whealing effect on the
skin following irritation or injury, is regarded by Dale as being probably histamine free or in a loose combination.
In subjects showing dermatographism or factitious urticaria, this
H substance is evidently liberated from the cells of the skin in response
to relatively mild irritation.
H. Kalk has recently published observations to demonstrate that
stimulation of the skin in subjects of dermatographism is followed by
secretion of an acid gastric juice.
According to Dr. Best histamine produces characteristic wheals
when pricked into the skin.
There is also a remarkable similarity between the signs and symptoms of anaphylaxis and those produced by large doses of histamine.
While wound shock and histamine shock are suspiciously similar
and while there are also many resemblances to the symptoms of intestinal obstruction such as the pronounced fall in blood chlorides, Dr.
Best emphasized the fact that there is as yet no proof that histamine is
responsible for any part of either of these syndromes.
Page 247 BRIGHT'S DISEASE
By
Dr. T. Addis
Stanford University Medical School,
San Francisco.
Being an abstract of lectures given at the Summer School of the
Vancouver Medical Association, June,  1929.
Within the term "Bright's Disease" is included all conditions of
whatever sort associated with an albuminuria and cylinduria which
exceed the upper limits of normal variation. This is of course a purely
clinical definition but it is objective and excludes renal tuberculosis,
pyogenic infections and tumours of the kidney, since these conditions
are not accompanied by an abnormal number of urinary casts. There is
no sharp line of demarcation between "Bright's Disease" and what we
call normality. The difference is one of quantity not of quality. Normal individuals excrete albumen and casts but never more than 50 mgs.
of protein per 12 hours, nor more than 5,000 casts. It is a definition
which for the time being neglects all the varied symptomatology of
bilateral non-suppurative renal disease and rests solely on the direct
evidence of a special type of pathological process in the kidney which is
revealed by a quantitative study of the rate of protein excretion and of
the rate of excretion of casts and of cells from the kidney.
The methods of examination of the urine are simple but they require that certain conditions be observed. These consist in abstention
from fluids on the part of the patient from after breakfast, and in the
collection of night urine from bedtime until the patient gets up from
bed next morning. These conditions almost invariably lead to the production of an acid concentrated urine, and they are necessary because in
alkaline dilute urines hyaline casts and red blood cells dissolve. The
period of time over which the urine has been collected must be known
exactly in order that the results may be expressed as rates of excretion
per 12 hours. The urine is collected directly into a wide-mouthed rubber stopped botde containing a trace of formaldehyde. This is thoroughly mixed, a 10 cc sample centrifuged, the supernatant fluid decanted,
the sediment mixed in a known volume by a capillary pipette and drops
transferred to a blood counting chamber. The counting of casts is
easy and it is also simple to make a differential cast count, but considerable experience and judgment is necessary in the ennumeration of
red blood cells, which are partially lysed and vary in shape and size.
With this quantitative anatomical method we have a clinical means
of approach to a problem which has hitherto been left almost entirely in
the hands of the pathologists, the question namely as to the nature of
the renal lesion. By the nature of the renal lesion is meant the original
and predominating type of lesion, whether inflammatory, degenerative
or atrophic. But the clinician has a great advantage over the pathologist
in that he can observe the progress of the lesion from the beginning to
the end whereas the pathologist is restricted to a single terminal observation. It seems reasonable that a kidney in which the glomeruli
are inflammed should show a type of urinary sediment very different
from that of the urine from a kidney whose tubule cells are the site
{Continued on Page 253)
Page 248
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I ,'HHI British Columbia Laboratory Bulletin
Published irregularly in co-operation with the Vancouver Medical Association Bulletin,
in the interests of the Hospital, Clinical and Public Health Laboratories of B. C.
Edited by
Donna E. Kerr, m.a., of The Vancouver General Hospital Laboratories
Financed by
The British Columbia Provincial Board of Health
COLLABORATORS: The Laboratories of the Jubilee Hospital and St. Joseph's Hospital,
Victoria; St. Paul's Hospital, Vancouver; Royal Columbian Hospital, New Westminster;
Royal  Inland  Hospital,  Kamloops;   Tranquille  Sanatorium;  Kelowna  General  Hospital;
and Vancouver General Hospital.
All communications should be addressed to the Editor as above.   Material for publication
should reach the Editor not later than the seventh day of the month of publication.
Vol. Ill
SEPTEMBER, 1929
No. 6
CONTENTS
Sedimentation Rate of Erthyrocytes in Pulmonary Tuberculosis .Darling
THE SEDIMENTATION RATE  OF ERYTHROCYTES
IN PULMONARY TUBERCULOSIS.*
G. Darling, Tranquille Sanatorium.
The phenomenon of blood sedimentation it not new to medical
science. Galen observed and identified it as the "crusta phlogistica."
It was described in English and German manuals a century ago; John
Hunter and Virchow have recorded their impressions of settling out
of the blood corpuscles about that time. The first detailed study of
blood sedimentation seems to have been made by Prof. Biernacki of
Warsaw, who published several papers commencing in 1894, enumerating his observations on seventy-five cases. His work apparently elicited
little notice and no great importance was attached to it. In 1918,
Fahraeus revived interest in blood sedimentation by attributing to it
certain aid in diagnosing the several stages of pregnancy. He further
observed that menstruation increased the sedimentation rate. Since that
date a comprehensive literature has been published, and many theories
evolved to explain the phenomenon.
If healthy citrated blood is allowed to stand, the blood corpuscles
settle very slowly; in certain pathological disorders the sedimentation
is rapid, and the degree of sedimentation is accepted as an index to the
severity, but not the extent, of the infection. Increased sedimentation
is found in acute and chronic infections, malignant tumours, high
fevers, syphilis, carcinoma and sarcoma.
Glaus in differential diagnosis of psychoses found increased sedimentation in senile dementia, neurosyphilis, general paralysis, catatonia
and immediately following epileptic seizures. The phenomenon was
absent in neurasthenia, hysteria, paranoia, and manic depressive psychoses.
Physiologically it is increased in pregnancy and during the menstrual
cycle,  (Fahreaus).
In its application to pulmonary tuberculosis, the sedimentation time
of erythrocytes is probably of greatest importance.    We have completed
* Read before the Medical Staff at Tranquille Sanatorium, July 1.9,
1929.
Page 249 a study of 200 cases, and in addition have applied the test to fifty
apparently normal subjects. All techniques are fundamentally based
on three methods. Fahreus added a given amount of blood to a test
tube graduated in millimetres, and noted readings at 1 hour, 2 hours, and
24 hours. Linzenmeier recorded the time in minutes taken for the erythrocytes to sink to a marked level, and Cutler uses graphs charting his
readings at fifteen minute intervals for two hours.
We adopted a modification of Fahraeus' method advocated by
Forman. Sahli haemoglobin tubes were used, and sodium citrate 5%
run in to the 30 mark. Blood was aspirated from a basilic vein, added to
the 100 level, gently inverted five times, and observations recorded at
l/2 hour, 1 hour and 24 hours. The latter reading indicating the volume
index. Fifty tests were performed on apparently healthy individuals.
The average would indicate a reading of 94 at the end of one hour, a
normal sedimentation rate for males, and 90 for females.
Of our series of cases, fifty have been tabulated in the accompanying table, for comparison, divided into the following classifications:
minimal, moderately advanced, moderately advanced fibroid, far advanced, and advanced fibroid.
Of the minimal cases, numbers 1 to 8 are within normal limits or
are approaching normal limits. Nine and ten would both be interpreted
as being moderately active. Blood sedimentations repeated this week
show that Case No. 9 is now normal, and No. 10 has improved.
Of the moderately advanced cases No. 11 would be classified as
normal, No. 12 and No. 13 approaching normal, No. 14 to No. 18
moderately active, and No. 19 and 20 markedly active.
Of the moderately advanced fibroid cases No. 21 to No. 30 are
all normal or approaching normal limits.
Of the far advanced types No. 31 is the only moderately active
case:—the remainder are, or were, markedly active. They are all
deceased.
Of the advanced fibroid cases No. 41 and No. 42 are normal, No.
43 and No. 44 slightly active, No. 45 to No. 49 moderately active, and
No. 50 markedly active.
The blood sedimentation rate is in direct proportion to the severity
of the infection. A far advanced active case of pulmonary tuberculosis,
and an incipient, but progressively active case would both show a high
sedimentation rate. As the active process diminishes, the rapid settling
out of erythrocytes show a corresponding decrease, and if the case becomes quiescent the blood sedimentation returns to a normal standard.
Sometimes the phenomenon disappears before death. It is greater
in cases with cavity formation than in those without cavitation.
I would like particularly to draw your attention to the following
observation by Grafe. "In doubtful cases in which the sedimentation
test was not of marked assistance, in helping to make a diagnosis, a
provocative test was performed with subcutaneous injections of 0.03
to 0.1 mgm. of old tuberculin. Grafe noted that an increased sedimentation resulted in cases of incipient tuberculosis, but that the test
remained normal in healed cases, or normal individuals. It is also noted
that these small doses of tuberculin influence the sedimentation at a
time when they do not affect the temperature, local or general processes."
Page 250 Poppar and Krindler believe the test to be valuable in diagnosis of
tuberculosis and other infections. With progressively accelerated tuberculosis sedimentation is obtained, while in minimal and non-progressive
forms the rate remained within normal limits. Most investigators, however, believe the test is without value in diagnosis, although, if Grafe's
investigations could be corroborated it would be of unquestionable
value in segregating the incipient case.
All investigators insist upon the value of the test in prognosis.
Cutler, whose 1. cc. technique we have now adopted, believes the blood
sedimentation to be a more trustworthy aid in estimating activity than
pulse-rate, temperature or weight. The rapid settling down of cells
within the first ten minutes would suggest a grave prognosis. Delhaye
believes a persistently high blood sedimentation gives a poor prognosis,
invariably fatal.
No correlation is to be found between cases with positive sputum
and high blood sedimentation, although the highest percentage of patients
with an increasing sedimentation rate is to be found with those who have
tubercle bacilli in the sputum. Ritter considers the test may be used
as a criterion to indicate necessity for treatment.
Discussion. There have been many conflicting theories advanced
to explain the phenomenon of the suspension rate of erythrocytes. There
is an accumulation of data to support the claim that it is entirely due
to the amount of fibrinogen in the blood. For example, in pregnancy
there is a physiological increase of the fibrinogen content of the blood,
and an increased sedimentation rate. In the newborn the fibrinogen
content is low, and the sedimentation rate is correspondingly decreased.
Pathologically, where the stability of the erythrocytes is altered in disease
we find a corresponding increase in fibrinogen. Marloff's observations
point to the conclusion that the sedimentation rate is influenced by the
size of the red cells, and the haemoglobin content. Other investigators
claim that the electrical charging of the red»cells is responsible for
sedimentation changes.
Colloids affect the sedimentation time. Fibrinogen and globulin
increases the rate while albumin decreases it. Tuberculin retards the
sedimentation rate. Norris suggests that surface tension and capillary
attraction may influence the degree of sedimentation. Levinson has
demonstrated that an intercurrent disease such as influenza, influences
the test in the same way that an acute relapse would; that is, a moderate
curve would become markedly active in the event of a secondary invasion.
The cases cited only show blood sedimentation on admission. We
propose commencing a new series repeating the curves every two weeks,
over an extended period, in an endeavour to determine to what extent
the test may be employed in prognosis.
Conclusions:
1. The sedimentation rate of erythrocytes is not specific. It is in
evidence in acute infections with high fever and in chronic diseases.
2. It is of no value in diagnosis, unless used in conjunction with
tuberculin (O.T.)  on incipient cases.
Page 251 In
the
5. in prognosis, the degree of sedimentation is in proportion to
the extent of tissue destruction,—a persistently high sedimentation rate
invariably has a fatal ending.
4.    The blood sedimentation rate is not an index of the extent of
the tuberculosis, but rather the degree of activity.    A rapid sedimentation is an indication of lack of resistance.
Case No.        Classification Blood  Sedimentation
1 Hour      24 Hours
1.
2
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
13.
14.
15.
16.
17.
18.
19.
20.
21.
22.
23.
24.
25.
26.
27.
28.
29.
30.
31.
32.
33.
34.
35.
36.
37.
38.
39.
40.
41.
42.
43.
44.
45.
46.
47.
48.
49.
50.
yi Hour
Minimal     :  98
    96
    98
  97
  96
      94
  91
  92
  79
  8 0
  9 7
  9 3
  92
._     89
  ._..   90
  86
   76
  8 8
  6 5
   44
Moderatel
aavancec
Far   advanced
fibroid     99
  9 8
  9 8
  98
  9 8
  94
  94
  92
  91
  82
  77
   73
  73
  57
   61
      5 6
   70
   54
    6 0
  48
fibroid    i _,  97
  96
  92
_.  91
>le
86
82
86
80
65
98
96
91
94
94
91
85
85
84
70
67
91
84
82
79
76
75
70
64
53
40
97
96
95
95
91
83
82
74
66
59
58
47
47
46
45
44
43
39
93
92
83
81
77
76
74
73
68
53
94
90
Normal
Normal   female ' 97
Of 25 apparently normal men the average reading at the end of one hour was 94.
Of 25 apparently normal women the average reading at the end of one hour was 90.
Page 252 {Continued from Page 248)
of cloudy swelling and fatty degeneration or from that of a kidney
whose blood supply is diminished on account of arteriosclerosis. It has
in fact been found through the study of patients who have died and
whose kidneys have been examined, that the nature of the renal lesion
can be predicted from the nature of the urinary sediment. By this means
it has been shown that all cases of Bright's disease fall into three cata-
gories, first, the inflammatory group which have been called haemorrhagic Bright's disease because an abnormal number of red blood cells is
found throughout all the progressive stages of the disease, second the degenerative group called degenerative Bright's disease because characterized
by the presence of large numbers of renal cells in various stages of degeneration and third the atrophic group which has been called Arteriosclerotic Bright's disease because the slight albuminuria and the relatively
small numbers of casts and cells are the expression of a malnutrition of
the kidney due to arteriosclerosis of the renal vessels.
Having then a method by which the nature of the renal lesion may
be determined, the question arises as to whether we can determine the
extent of the lesion. Can we make successive observations and find
whether the amount of still functioning renal tissue is increasing or decreasing? It is not possible with the methods now in use because there
is no constant relation between the results of these tests and the quantity
of functioning renal tissue. It was found, however, under conditions
which call for the full activity of all the kidney units that the value
of the ratio between the rate of urea excretion and the blood area concentration varies directly as the weight of the kidney in normal animals.
This ratio is a measure of the volume of blood freed from urea in unit
time and under proper conditions varies only with the amount of secreting renal substance.
Over 500 patients with Bright's disease have been studied over the
past ten years by the aid of these methods and certain general clinical
conclusions can be drawn.
First, the arteriosclerotic Bright's cases comprise patients with
hypertension and arteriosclerosis in which the renal lesion is of little
clinical importance. The kidneys gradually grow smaller but only
slowly and before the quantity of renal tissue has been dangerously
reduced they die of cardiac failure or from cerebral accidents.
Second, in the degenerative Bright's cases the renal lesion is secondary to some other disease and when that disease ceases the renal lesion
soon disappears.
Third, the haemorrhagic Bright's group is due to a streptococcal
infection, but the renal lesion frequently continues to progress after
the infection has disappeared. If healing does not occur within the first
two years after the infection the renal lesion will continue and will
lead to uraemia in the end unless the patient dies from some intercurrent
disease. It is, however, a condition entirely compatible with apparent
health for several decades. In a minority of the patients there is a
clinically obvious downward progress with oedema and marked albuminuria. In approximately half of the patients who have been followed
from the beginning to the end complete healing has been attained. There
is no specific treatment. Undernutrition, particularly protein undernutrition, is very harmful.
Page 253 TRIGEMINAL NEURALGIA
By Dr. Ernest Sachs, St. Louis, Mo.
Given before the Vancouver Medical Association,
Summer School, June, 1929.
One of the most satisfactory diseases the neurological surgeon is
called upon to treat is trigeminal neuralgia, or tic douloureux.
There are but two important points to keep in mind,—making the
correct diagnosis and mastering the operative procedure. Though this
may appear a frivolous way of expressing the situation, in the last
analysis a review of these two phases of the question tells the story of
trigeminal neuralgia.
I know of no more terrible sufferers than these poor people, for
though some patients have only a comparatively mild form of the
disease,—what is spoken of as minor neuralgia, in its severe form, the
major neuralgia,—it causes intense suffering. It will awaken a patient
out of a sound sleep causing him to sit up in bed rocking to and fro
grasping his face, while he experiences one after another lightning
like flashes in a part or the entire distribution of the fifth nerve. The
pain, no matter how severe, never crosses the midline, and never goes into
the neck nor behind the ear. The pain always remains in the distribution of the fifth nerve. If it is described as crossing the median line or
as going to the neck or shoulder, the diagnosis of a true tic douloureux
must be doubted. As a rule the patient will tell you that there are one
or more spots which if touched but slightly, will set off a paroxysm.
These spots are spoken of as "trigger zones." They may be on the side
of the tongue, in the nostril, on the cheek or a single hair in the moustache. I have seen patients, many of you no doubt also have, who are
dehydrated because they dared not drink water as it would start up
their pain, and others who were hungry and had lost much weight because they dare not take food. I recall one dried up, wizen-faced little
woman, who had on her dresser in the hospital when I entered her room
an iron, which the ladies call a frilling iron. When asked about it, her
husband explained that while she held her face, rocking to and fro, he"
heated the iron in the stove, wrapped it in a cloth and she would put
this against her face, and that this was so, was evinced by the mottled
appearance of her skin from constant application of heat. I have this
iron among my trophies. Another patient had allowed a doctor to burn
her entire fifth nerve area with a Paquelin cautery, so that there were
hundreds of punctate red spots all over her face, in the hope of getting
relief. I have never yet seen a major trigeminal neuralgia patient who
had any teeth, for as the pain is referred to the teeth innervated by the
fifth nerve the patient and dentist think that extracting them will stop
the pain. Many of these patients have had their pain for ten or fifteen
years. The disease is absolutely curable. Why then do they procrastinate?
Many of the leading text books on surgery still contain the statement that the operation on the Gasserian ganglion is the most dangerous
in surgery and certainly all of the text books on the shelves of doctors
who graduated fifteen or twenty years ago contain this statement. The
patients, hearing this, are so frightened that they put up with the pain
rather than risk what they have been led to believe is almost certain
death.    They finally come, frequently referred not by a doctor but by
Page 254 another patient who has obtained relief. There is a camaraderie among
patients with trigeminal neuralgia that would be amusing were it not
pathetic. An underground method of communication seems to exist
also as it did among the slaves in the pre-Civil War days in the United
States.    One patient tells the other.
The terrifEc mortality of this operation twenty years ago was due
to the fact that the general surgeon was doing the operation and had
not mastered the technique and did not know the anatomy. The first
Gasserian ganglion operation I saw as an interne twenty-five years
ago, was carried out in a pool of blood and at the height of the haemorrhage the surgeon swept a curette around the operative field and said
dramatically "Now we have removed the ganglion" and then packed a
huge gauze pad into the wound to control the haemorrhage and gave
the patient a hemiplegia from pressure on the motor area. He saved
the patient's life, but the pain continued. There was no anaesthesia in
the area supplied by the fifth nerve. There is always anaesthesia if the
posterior root of the Gasserian ganglion has been divided. The second
ganglion operation I saw was done by that master of technique, my former teacher, Sir Victor Horsley, and you may imagine my amazement
when in a bloodless field he pointed out to me the various fibres of the
posterior root and demonstrated a separate group forming the ophthalmic
division.
Because of the great mortality, men turned to other methods of
treatment, and alcohol injection was introduced. If alcohol is injected
into a nerve, it causes it to degenerate, and when introduced into the
fifth nerve the patient is relieved of pain until the nerve regenerates.
It is, however, only a palliative measure, and is never curative unless the
alcohol is inserted accidentally or intentionally into the ganglion itself.
This I am strongly opposed to, as alcohol in the subarachnoid space can
do harm. I have seen a case with permanent cerebellar symptoms due
to the alcohol running back into the posterior fossa. Since the operation
is practically only done today by neurosurgeons, the mortality has dropped to less than one per cent. In my own clinic, we have done 140
cases without a death. But the operation must not be undertaken
lightly for there are complications.
Nobody removes the Gasserian ganglion any more. By dividing the
posterior root of the ganglion, there is no chance of regeneration, for the
posterior root is composed of the dendrites of the ganglion cells in the
Gasserian ganglion, not the axis cylinders. In the past few years we
try to save the ophthalmic fibres in the posterior root, thus preventing
an anaesthetic cornea which, if not carefully protected arid taken care
of, may become the seat of a corneal ulcer and result in loss of the eye.
The other complication that occurs in about two per cent, of cases
is a facial paralysis. Those I have had have all cleared up but they are
very distressing. If the ophthalmic fibres have been removed, a facial
paralysis means almost certain loss of the eye as the patient is unable
to close the lid. Before recommending the operation, therefore, I always
tell the patient about the possible corneal anaesthesia.
The cure of the disease we understand, but we do not know its
pathology though we do know the seat of the disease is in the Gasserian
ganglion itself. The diagnosis, however, still offers great difficulties.
A typical case, such as I described at the beginning of my paper is clear
Page 255 but there are many cases that have pain in the face in whom the diagnosis
is in question. If we doubt after all other diagnostic measures have been
exhausted, it is wise first to do an alcohol injection in such cases. If a
good hit is obtained, that is, anaesthesia of the particular branch in
question is obtained, and the pain still persists, one may be quite certain
one is not dealing with a true tic douloureux. I have also found it wise
to use alcohol injection if only one branch is involved, when the patient
first presents himself, as the permanent anaesthesia following a section of
the posterior root sometimes worries patients a great deal and if they
have first experienced this sensation following an alcohol injection they
are more willing to put up with this permanent anaesthesia when
they finally come to operation.
B. C. MEDICAL ASSOCIATION NEWS
PROGRAMME of the
ANNUAL MEETING,  SEPTEMBER  25-26,   1929
at the HOTEL GEORGIA, VANCOUVER, B. C.
9:00— 9:50  a.m.
10:00—10:50 a.m.
11:00—11:50  a.m.
12:15  noon.
2:00-
2:50 p.m.
3:00— 3:50 p.m.
4:00—
4:50
p.m
7:30—
8:20
p.m
8:30—
9:30
p.m
9:40—10:40 p.m.
9:00-
9:50 a.m.
Wednesday, September 25 th
Dr. K. A. Mackenzie, Halifax, N. S.
Associate Professor of Medicine, Dalhousie University,  Halifax.
"The   great   instruments   of   precision   in   the   diagnosis   of   heart
disease—the eyes, the ears and the fingers."
Dr. Geo. S. Young, Toronto, Ont.
Associate Professor of Medicine, University of Toronto.
"Periodic Headaches  (based on a review of 100 cases)."
Dr. Gordon E. Richards, Toronto, Ont.
Professor of Radiology, University of Toronto.
"The X-ray investigation of the Urinary Tract."
Illustrated by slides and films.
Part I.
Luncheon—Hotel Georgia.
Speaker:—Dr.   A.  T.   Bazin,  President  Canadian   Medical  Association, on "Medical Organization."
Dr. Geo. S. Murphy, Halifax, N. S.
Associate Professor of Surgery, Dalhousie University, Halifax.
"Fractures of the Neck of the Femur."
Dr. H. B. Van  Wyck, Toronto, Ont.
Senior Demonstrator in Obstetrics and Gynaecology, University of
Toronto.
"Uterine Haemorrhage."
Dr. K. A. Mackenzie.
"Treatment of Functional Nervous  Disorders."
Dr. Geo. H. Murphy.
"The Chronic Appendix."
Dr. Geo. S. Young.
"The Surface Marks of Disease" and a Film on
Examinations."
Dr. A. T. Bazin.
President, Canadian Medical  Association.
"A Pot-Pourri—The Pitfalls of Practice."
Thursday,  September  26th
Dr. Gordon E. Richards.
"The  X-ray  investigation  of  the  Urinary Tract.'
Part II. 10:00—10:50 a.m.    Dr. H. B. Van Wyck.
"Treatment  of  Eclamptic   Toxaemias."
11:00—11:50 a.m.    Dr. Gordon E. Richards.
"X-ray   examinations   of   the   accessory   nasal   sinuses   with   special
reference to the use of lipiodol."
12:15 noon. Luncheon—Hotel Georgia.
Speakers:
1. Greetings  from  the Department of  Health for  Canada—
Dr. Ross Millar.
2. Dr.  G. Harvey Agnew—Department  of Hospital  Service,
Canadian Medical  Association.
Afternoon Golf Tournament
6:30 p.m. B. C. M. A. Annual Dinner  (Informal) Hotel Georgia.
7:30 p.m. Speakers:
Dr. W. A. Wilson, President's Address.
Dr. T.  C. Routley, General Secretary C. M.  A.
"More Medical Organization."
Secretary-Treasurer's   Report,   Reports   of   Chairmen   of   Standing
Committees, election of officers, new business, etc., etc.
LADIES' PROGRAMME
Wednesday
3:00 p.m.    A   tea  given by  Mrs.   Wallace  Wilson   at   Jericho   Country   Club   to   the
wives of visiting doctors and the wives of the members of the Executives
of the British Columbia and the Vancouver Medical Associations.    Tea to
be preceded by a drive, cars leaving the Hotel Georgia at 3 p.m.
Thursday
2:00 p.m.    Drive along the North Shore and tea at Whytecliffe Park.    Transportation
will  be   arranged  for  visiting   ladies,   cars   leaving   the  Hotel   Georgia   at
2 p.m.
7:00 p.m.    Dinner for visiting ladies and  their friends and  the wives  of Vancouver
doctors at the Hotel Georgia, followed by bridge for  those who wish to
play.    Tickets,  $1.50.
OBITUARY
Peter D. Van Kleek
He was born of United Empire Loyalist stock at Van Kleek Hill,
Ontario. It would be his Grandfather who settled there, when he
came from the United States.
He was a Graduate in Medicine of the Trinity University, Toronto,
in the year 1899.
He practised in Armstrong, B. C. for a good many years and was
held in very high esteem in that district and throughout the Province
generally.
The Owl Drug Co., Ltd.
All prescriptions dispensed by
qualified Druggists.
You can depend on the Owl for Accuracy
and despatch.
We deliver free of charge.
5 stores, centrally located.
We would appreciate a call while in our territory.
Page 25/ £//££;<.  f.10 tr/ntZtv-e-P,
Mammary Complications
During Qestation Distinctly Benefited by
Mastitis
The liberal application of a hot Antiphlogistine dressing
over and beyond the affected breast will promptly deplete the
inflamed area and may accomplish much in the way of aborting suppuration. Being thermogenetic, circulatory stasis is
quickly relieved inducing prompt relaxation of the tissues.
The increased supply of blood induced, removes the debris
consequent upon the pathologic condition and favors the restoration of the normal physiologic process of repair.
By virtue of its 45% c.p. glycerine content, Antiphlogistine is bacteriostatic, nutritional and being plastic has the
added advantage of clinging to the breasts, exerting its therapeutic action over a long period of time, with complete absence of tissue irritation or toxic action.
The Denver Chemical Mfg. Co.,
163 Varick Street, New York City.
Dear  Sirs
You may send me a complimentary copy of
your booklet "Pregnancy—Its Signs and Complications"  (sample included).
Name   	
Address
City	
.Province^ HOTEL GEORGIA
Vancouver, B.C.
320 ROOMS 320 BATHS
Cor* Georgia and Howe Sts.
Coffee Shop Windsor Dining Room
Choicest Location     Fireproof
Headquarters of
The Annual Meeting
B. C. MEDICAL ASSOCIATION
September 25th, 1929
Tel. Seymour 5742
S. B. Willoughby, Mgr. Say it with Flowers
Cut Flowers, Potted Plants, Bulbs, Trees, Shrubs,
Roots, Wedding Bouquets.
Florists' Supplies and Funeral Designs a Specialty
Three Stores to Serve You:
48 Hastings St. E.
665 Granville St.
151 Hastings St. W.
One Phone:
Seymour 803 3
Connecting all three stores.
Brown Bros, & Co. Ltd.
VANCOUVER, B. C.
In pneumonia ■     B
Optochin Base 1
For the specific treatment of pneumonia give
2 tablets of Optochin Base every 5 hours,
day and night for 3 days. Give milk with
every dose but no other food or drink.
Start treatment early
MERCK & CO. Limited
412 St. Sulpice St.
Montreal McKEE-COLEMAN
CLINICAL LABORATORIES!
Vancouver, B. C.
1030 Medical Dental Building
Telephone Sey. 2996
C.
S. McKee, M.B., Res. Bay. 268.
R.
E. Coleman, M.B., Res. Bay 5194
M
ary M. McKee, B.A.
A New and Valuable Aid in
Rickets and Osteomalacia
PARKE, DAVIS & CO.'S
■ VIOSTEROL
i
(Irradiated Ergosterol in Oil)
Licensed under the S teen bock patent administered by the Tl
Alumni Research Foundation of the University of Wisconsin J|
Viosterol, P. D. & Co., is supplied in the form of a vegetable oil
solution of irradiated ergosterol standardized to an antirachitic
(vitamin D) potency of one hundred times that of high-grade
cod-liver oil. It will be furnished in 5-cc. and 50-cc. packages
accompanied by a dropper standardized to deliver approximately
3 drops to the minim.
Viosterol, P. D. & Co., was recently released for sale to the drug trade.    If your
druggist does not as yet have it in stock he can get it for you on short notice.
Please specify "P. D. & Co."
Viosterol, P. D. & Co., has been accepted for inclusion in N. N. R. by the Council on Pharmacy
and Chemistry of the A. M. A.
■Hi PARKE. DAVIS & COMPANY-
WALKERVILLE, ONTARIO 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.
ESTABLISHED   NEARLY A
tCENTURY^
B.C. STEVENS CO.
Phone
Seymour 69%
730 Richards Street
Vancouver, B. C ■■■» >o«
aie-^^^^ic
aa^«~-
Hollywood Sanitarium
LIMITED
^or the treatment of
Alcoholic, Nervous and Psychopathic Cases
Exclusively
Reference -. <23. (?. effledical Association
For information apply to
Medical Superintendent, New Westminster, B. C.
or 515 Birks Building, Vancouver
Seymour 4183
Westminster 288
«6*r
3»©>» 

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