History of Nursing in Pacific Canada

The Vancouver Medical Association Bulletin: September, 1926 Vancouver Medical Association Sep 30, 1926

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Published monthly at Vancouver, B. C.
Subscription $1.50 per year
■ /  ;.• W\
Summer School 'Programme^
cAnaesthetic 'Department, lAQ.^.
^Water-Qooled Quartz Light therapy
• <x
Tublished by
dMd&eath Spedding Limited, UancouDer, <23. Q. -~*-^S>t-
A few distinctive features of
PETROLAGAR (Deshell) is a corrective, not a cathartic. It
forms no habit, permitting decreasing instead of increasing
dosage and may be discontinued when regularity is established.
Its oil content is the greatest—65% mineral oil of the highest quality.    This
means maximum lubricating power and is of paramount importance.
The oil being emulsified, leakage is practically eliminated.
Agar is the sole emulsifying agent used—no fermentative gums or soaps.
Petrolagar   (Deshell)   is particularly palatable, more like ice cream thus making
the physician's  task easier;   both children and  adults find  it pleasant to  take.
Three   years  of  satisfactory   results   in   clinical   usage  solely   under  physicians'
prescriptions, prove conclusively the therapeutic value of Petrolagar   (Deshell).
1 Blue Label
The palatable ' emulsion of pure mineral
oil and agaragar is
indicated in the ordinary cases of constipation and as a follow
up in severe cases
when Petrolagar Phe-
nolphthalein has been
previously used.
Petrolagar        Petrolagar        Petrolagar
No. 2 Red Label
Phenolphthalein % gr.
to the tablespoonful,
is indicated in severely" constipated individuals who have used
drastic purgatives. We
recommend reducing to
Plain after one or two
No.   3   Green  Label
Contains magnesia calcined and is indicated in hyperacidity
and acidosis, and is
extremely useful in
gastric ulcer where
constipation is present.
Useful in Pyorrhea
and   acid-mouth.
No. 4 Brown Label
Indicated for those
who do not
sweets    and    may
prescribed safely
Diabetic patients,
is bland like
other numbers and
while unsweetened, is
unusually   palatable.
The principle of lubrication and balk calls for the usage of Petrolagar Plain
in all cases unless special considerations indicate one of the other forms.
Deshell Laboratories of Canada, Limited, Dept. V.,
245 Carlaw Avenue, Toronto, Canada.
Please send without obligation, copy of Habit Time and samples of Petrolagar.
Dr.  ,	
Published Monthly under the Auspices of the Vancouver Medical Association
in the Interests of the Medical Profession.
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. 2.
SEPTEMBER 1st, 1926
No. 12
OFFICERS, 1926-27
Dr. A. W. Hunter
DR.  A.  B.  SCHINBEIN Past President
Vice-President DR.   J.   A.   GILLESPIE
Secretary Treasurer
Dr. F. W. Brydone-Jack Dr. W. S. Turnbull
Dr. W. F. Coy Dr. W. B. Burnett
Representative to B. C. Medical Association
Dr. A. C. Frost
Clinical Section
Dr. F. N. Robertson	
Dr.  L.  Leeson	
Physiological and Pathological Section
DR.   C.   H.   BASTIN - - - -
Dr. C. E. Brown - -
Eye, Ear, Nose and Throat Section
Dr. Colin Graham      -
Dr. E. H. Saunders	
Genito-Urinary Section
Dr. G. S. Gordon -       -       -       -
Dr. J. A. E. Campbell -
Physiotherapy Section
Dr. H. A. Barrett	
Dr. H. R. Ross	
Library Committee
Dr. W. D. Keith
Dr. C. H. Bastin
Dr. W. C. Walsh
Orchestra  Committee
Dr. F. N. Robertson
Dr. J. A. smith
Dr. L. Macmillan
Dr. W. L. Pedlow
Dinner Committee
Dr. A. C. Frost
Dr. G. B. Murphy
Dr. J. M. Pearson
DR.  F.  W.  LEES
Credit   Bureau   Committee
Dr. Lachlan Macmillan
Dr. D. G. Perry
Dr. D. McLellan
Credentials Committee
Dr. E. H. Saunders
Dr. B. H. Champion
Dr. T. R. B. Nelles
Summer School Committee
Dr. W. D. Keith
Dr. G. S. Gordon
Dr. Murray Blair
Dr. G. F. Strong
Dr. H. R. Storrs
Dr. R. Crosby The Basis of all Artificial
Infant Feeding
The basis of infant feeding is human milk, and
the principle involved in the artificial feeding of normal infants is the imitation of human milk.
Cows' milk is the basic material used in practically all artificial feedings. It is modified one way
or another to make it better suited to the infant's
digestion, and to have more or less the same proportions of food elements as human milk.
Pediatrists say that fresh cow's milk is, therefore, a logical diet for normal infants, provided that
it is diluted with water to reduce its fat and protein
contents and that a suitable sugar is added to the
mixture to give it approximately the same percentage
of carbohydrate as in human milk.
Mead's Dextri-Maltose 1
is a special sugar to be added to diluted milk, which
has been found to be more easily assimilated by infants and less likely to produce diarrhoea than cane
sugar or milk sugar.
DEXTRI-MALTOSE is advertised only to
the profession in order that the physician may control each case and be the sole judge of the proper
formula to suit the needs of the individual baby.
On request, a Mead's Feeding Calculator, showing usual formulas for normal infants suggested "by
the results of pediatrists, will be supplied to physicians, together with samples of Dextri-Maltose.
Mead, Johnson & Company
Page Four Victor Air-
Cooled Quart*
UmP for Alternating Current.
Cooled i
{or Alt,.
courtesy ^
Victor Air-
Quartz Lamp
for Direct
FiT Comfc;. J
"ation Air.
*7"«-Cooled |
Egg   Uir
Victor Aic-
Cooled Quartz
Lamp   with
Victor Quartz Lamps
Efficient •« Convenient •» Practical
Victor quartz lamps for ultraviolet therapy are made in sev-
eral types, designed not only to
apply the principles now firmly
established by medical research,
but to meet the conditions of
the physician's office or the
Whether the space available is small
or large, whether the current is direct
or alternating, a Victor quartz lamp is
sure to be obtainable which will enable the physician to treat his cases
with the utmost facility and economy.
Reprints of papers on ultra-violet
therapy by distinguished authorities
will be sent free of charge on request.
Victor water - Cooled
Quart: Lamp with Self*
Contained Cooling System,
Victor X-Ray Corporation
Main Office and Factory:
2012 Jackson Boulevard, Chicago
33 Direct Branches—Not Agencies—Throughout
United States and Canada
Meet us at the
American College of Physical Therapy Meeting
Drake Hotel, Chicago, October 18-22, 1926
Publication Bureau, 2012 Jackson Blvd., Chicago
Please send me descriptive bulletin on Victor Quartz Lamps.   Also
reprints of authoritative papers' on Ultra-Violet Therapy.    1 am especially interested in the treatment of.    ..	
I am also interested in Victor Apparatus for
UMedical Diathermy DSurgical Diathermy DPhototherapy
Clonic Medication      OSinusoidal Therapy EDITOR'S PAGE.
The treatment of asthma, despite the great amount of serious and
suggestive work in this connection, still remains eminently unsatisfactory.
"While some or even many are benefitted by the application of the
more modern methods of treatment, in only too many instances are we
still driven, unable to ascertain the causal factor, to endeavour to find
relief for the paroxysm itself.
Only those long enough connected with the practice of medicine,
whose early experiences were concerned with the use of stramonium and
similar preparations or with the inhalations of the various sodium nitrite
fuming powders, or as a final resort, to be postponed as long as possible,
with the hypodermic injection of morphia, can properly appreciate the
great benefit conferred by the introduction of adrenalin. With all its
drawbacks, and notwithstanding certain inconveniences attending its
use, we consider that it is one of the noteworthy, perhaps the most
noteworthy, addition to our armamentarium for the treatment of this
most embarrassing affection which has been placed at the disposal of the
profession during the last quarter of a century.
So universal is its use and so general is its acceptance that its
presence in our pharmacopoeias is taken for granted and its origin in
danger of being forgotten—if indeed it was ever formally recognized.
The drug itself was first extracted as the benzoyl compound by Abel
under the name of epinephrin the U.S.P. tells us. A few years later it
was prepared in crystalline form by Takamine and also by Aldrich. The
former worked out its chemical formula and also attached to it the present name of adrenalin. Almost immediately, judging by the references
in the Surgeon-General's Catalogue, its place in medicine was found
and numerous trials made, chiefly of its blanching and styptic qualities.
But not for a considerable time was its use suggested in spasmodic respiratory disorders. The first reference we can find is to a paper by
Cohen which appeared in the Journal of the American Medical Association in 1900 on the use of adrenalin in asthma, though it is not clear
from the title whether the hypodermic method is suggested. In 1903,
however, Bullowa and Kaplin in the Medical News of New York definitely suggest its hypodermic use in this disorder. Probably the most
important article in this connection, and one which evidently went far
to establish permanently the place of adrenalin as the drug par excellence
for the relief of the asthmatic paroxysm, is that by Melland which appeared in the London, England, Lancet of May 21, 1910. This article
not only sets forth in considerable detail the description of several cases
in which it was used with the happiest—if temporary—results, but discusses the known properties of the drug, its recognized physiological
principles and prbbable modes of action in such elaboration that little or
nothing has since been added of theoretical importance.
Thus quietly by aggregation of work, knowledge and experiment
and not at all with eclat or noise of trumpets does this important member of the really select band of useful drugs—few though fit—take its
Page Six rightful place. Awaiting still the solution of the etiological problem of
asthma, empirically we can thankfully relieve or mitigate suffering by
its use.
We are very sorry to report that Dr. J. H. McDermot, President of
the B. C. Medical Association has been in the Vancouver General Hospital for the past four weeks. Dr. MacDermot had only spent a few days
of his holiday with his family on Savary Island when he was taken ill.
We are glad to learn from the doctors in attendance that he has slightly
improved during the past few days.
Dr. and Mrs. .D E. H. Cleveland are receiving congratulations on
the birth of a daughter on August 8 th.
We offer our hearty congratulations and all good wishes to Dr.
and Mrs. Hugh Macmillan on their recent marriage. Dr. and Mrs.
Macmillan have just returned from a honeymoon spent in Seattle and
Alaska. Mrs. Macmillan was a graduate of the 1923 class of the Vancouver General Hospital Training School and as Miss Dorothy Hall had
many friends in the City.
Dr. George Seldon left on August 5th for a lecturing tour in the
Prairie Provinces and expected to be away about a month. The tour
was undertaken in connection with the scheme for postgraduate medical
instruction of the Canadian Medical Association made possible through
the generosity of the Sun Life Insurance Company.
Dr. George Lamont recently left in his auto for a trip to Quebec
and other eastern cities.    We wish him luck and a safe return.
Dr. H. H. Pitts, recently on the staff of the Cleveland Clinic, has
arrived in the City and taken up his appointment as pathologist to the
Vancouver General Hospital, vacant through the resignation of Dr. A.
W. Hunter.
The Treasurer desires to call the attention of members to the
necessity of paying up outstanding dues. Voluntary payment of the
dues will be much appreciated, otherwise a draft for the required amount will be issued to those in arrears. The dues for 1926-27
were payable on April  1st,  1926.
(By H. C. L. Lindsay, M.D.)
Finsen, Lotett and Genoud developed the Water-cooled Quartz
Lamp using the carbon arc as their source of rays. It remained for
Kromayer and Burdick to perfect the water-cooled mercury quartz
burner, now used in our modern lamps on this continent. Each expert
developed his own particular technic and did magnificent work because
he was an artist in the profession. Unfortunately others were not able
to duplicate their wonderful results and the older lamps fell unjustifiably
into disuse in America. With the advent of the Kromayer and Burdick
improvements the Ultra-Violet Ray treatment of many dermatoses has
been deservedly revived. The technic employed by different operators
varies considerably and having had experience with both the old and
latterly the modern lamps, I have pursued the intensive treatment for
such chronic conditions as lupus vulgaris and port-wine naevi.
The best opportunity to get a good result is at the first exposure.
Pigment is formed so rapidly that in subsequent raying of the parts
much is lost due to the absorbing and filtering power of this pigment.
Having estimated the time required to accomplish any particular result,
the lamp should be applied with pressure, as a rule, and as continuously
as possible (without a single let up) until the requisite time has expired.
Personally I have given, with an active lamp, continuous exposure,
maintaining heavy pressure throughout, of a duration of one hour and
fifteen minutes. Many would be horrified with the idea that the result would be proportionately severe to a one minute exposure, but be
assured that such is not the case.
The reaction to an exposure to the Water-cooled Quartz Lamp
does not appear immediately but it is very well developed in sixteen
hours. The result sixteen hours after a one minute seance to the Water-
cooled quartz lamp, using pressure continuously, is decidedly more angry
looking than a spot similarly treated with the same lamp for one hour.
This longer seance does not blister the skin and is practically healed over
in from three hundred to five hundred hours, without damage to the tissues, macroscopically, other than a tanning, which gradually fades and is
a very happy substitute for a naevus or lupus ulcer.
With th eco-operation of Doctors Barrett, Cleveland, Christie, Coul-
thard and Mr. Clark of the B. C. Stevens staff, I submitted my own arm
to an exposure to the Kromayer lamp for one hour, maintaining heavy
pressure continuously, and the result was exactly as stated above.
A case of recurrent lupus vulgaris which had the disease removed
once by X-rays and freezing, appeared for treatment again. The duration
of the disease on the face and nose was five years before it received any
treatment whatsoever. A single exposure to the Kromayer Lamp, (maintaining pressure as described above) resulted ultimately in a healthy not
overly white, and pliable, smooth area, level with the rest of the skin
of the face.   There has been no recurrence in several years.
Page Eight A port-wine naevus covering half the upper lip but without thickening of the tissues and no irregularities on the surface received the
same dose. Care was taken to protect the non-involved parts with adhesive tape. The result was such that you could not afterward detect the
naevus at speaking distance.
Undoubtedly judgment must be used in giving Intensive Water-
cooled Quartz Light (Ultra Violet Ray) treatment. Intensive treatments
are unnecessary in unsuitable cases and often exposures of shorter duration will attain equally good results—-thus I was able to remove a scar
from a girl's cheek with two seances of fifteen minutes each.
NOTE:—An article on this subject by myself will appear shortly
in the Urologic Cutaneous Review, hence I do not care to have this
re-printed in other papers before the longer essay appears. It will be
,, Granville Street,
Hours:  10 to 1, 2 to 6.
(The Library is situated in 529-531 Birks Buildin
Vancouver.    Librarian: Miss Firm in
The  following is  a  list  of  some  of   the  journals  received  in  the
library with dates from which files are available:
"Archives Internal Medicine," 1908
"American Journal Medical Sciences," 1888.
"Annals of Surgery," 1898.
"Archives of Surgery," 1920.
"Archives Neurology and Psychiatry," 1919. i
"Archives Derm,  and Syphilology,"   1920.
"American Journal Dis.  Children,"   1911.
"American Journal Orthopaedic Surgery," 1906.
"Annals Otol. Rhinol.  and Laryngol,"  1909.
"Archives Ophthalmology,"  1915.
"American Journal Ophthalmology  (Oph. Record)," 1915.
"American Rev. Tuberculosis," 1920.
"American Journal Syphilis,"  1921
"Annals of Clinical Medicine."
"Archives Path, and Exp. Medicine."
"American Journal Roentgenology."
"American Journal Dis. Children,"  1911.
"American Journal Physiology," 1921.
"British Medical Journal," 1862.
"Bulletin Johns Hopkins Hospital," 1889.
"Brain," 1921.
"British Journal Derm, and Syphilis,"  1910.
"Boston Med. and Surg. Journal," 1906.
"British Journal Radiology," (Arch. Roent. Ray), 1909.
"British Journal Children's Diseases," 1904.
"British Journal Surgery,"  1913.
"British Journal Obstet. and Gynaecology," 1903.
"Canadian Medical Association Journal," 1911.
"Journal State Medicine," 1913.
Page Nine "Journal Pathology and Bacteriology,"  1910.
"Journal Urology," 1917.
"Journal d'Urologie,"
"Journal Trop. Med. and Hygiene," 1907.
"Jour. Amer. Med. Association," 1901.
"Jour. Anat. and Physiology," 1907.
"Journal of Anatomy,"
"Journal  of  Physiology,"   1922.
"Journal of Infectious Diseases," 1914.
"Journal Neurology and Psychopathology."
"Journal Biological Chemistry."
"Heart,"  1909.
"Indian Journal Med. Research,"  1913.
"Laryngoscope,"  1915.
"Lancet," 1823.
"Mental Hygiene,"
"Med. Journal Australia," 1908.
"Med. Science Abs. and Reviews," complete.
"Medical Research Council Reports."
"Northwest Medicine."
"Public Health Journal," 1913.
"Practitioner,"  1868,  1893,  1907,  1910.
"Surgery Gyn. and Obstetrics," 1906.
"Postgraduate Journal,"
"Quarterly Journal Medicinei" 1907.
"Journal de Med. de Lyon."
"Guy's Hospital Reports."
''Journal Clinical Investigation."
Neuritis and Neuralgia by Wilfred Harris, London-Oxford University
Press,  1926,  12/6.
This work, contained in one volume of some four hundred pages,
is an original and valuable contribution to medical literature. It is
particularly acceptable on account of its conclusions being drawn from
a clinical study of a large number of personally observed cases. The
first chapter is devoted to multiple neuritis, its etiology, symptoms and
treatment, being dealt with very exhaustively. In subsequent chapters
the affections of individual nerves, or groups of nerves are systematically
described, with special emphasis on the fifth cranial, based, as the author
states in the introduction, on a study of experiences with some eight
hundred cases of trigeminal neuralgia. Herein is virtually the pith of the
whole volume. The etiology and pathology of tic douloureux together
with the theories and opinions of many authorities are fully discussed,
while a whole long chapter is devoted to treatment. Alcoholic injection
is almost always the ultimate treatment to which these sufferers come.
Five cubic centimeters of a 95% solution of alcohol is the usual dose,
Page Ten and may be administered in the affected peripheral branches of the nerve,
deeply through the various foramina or directly into the ganglion, depending on the exigencies of the case. No general anaesthetic is given
but after the nerve has been pierced by the needle a few drops of novo-
came are injected; when cutaneous anaesthesia is complete the alcohol
is then quite painlessly injected. In this method the value of the patient's co-operation is obvious. Much intricate anatomical detail is
given to explain the procedure but such difficult operations as picure via
foramina rotundum vel ovale are not to be attempted except after long
practice on the cadaver.
Many case histories are reported which add greatly to the interest
in and lucidity of the book. In the final chapters a simple technique for
the Swift-Ellis treatment, which is advocated for tabetic neuralgias, is
Although the book is well written and easily read there are many
places where details are hard to grasp and difficult to retain; nevertheless,
it contains much of real value and is an excellent addition to a medical
library.—F. B.
None of the books listed in last month's issue as "missing" have
so far been returned to the Library. The Committee will much appreciate it if the members will look up these books and return them as
soon as possible.
Dr. F. C. Bell recently very kindly brought the laboratory a specimen of what is commonly known as "Red Snow," obtained about the
first of August from one of the mountains in Jasper Park. He states
that this is found at altitudes of over 8,000 ft., so that most of us
would never otherwise have an opportunity of seeing it.
It usually occurs in patches and streaks on the snow and might be
thought to be discoloration from soil or mineral. I had an opportunity
to see "Red Snow" on Mt. Ranier about the end of August a year
ago. It appeared as a pink streak upon the snow suggestive of a red stain
seen through slightly frosted glass. The color is due to the growth
of a small plant, Chlamydomones ohioensis, belonging to the same group
of algae that sometimes colors water green. As examined in the laboratory microscopically the material appeared as single ellipsoidal cells,
slightly smaller than the ova of the parasitic round worm, ascarus. Within the thick transparent covering appeared the usual green of chlorophyll,
Page Eleven completely filling the cell except where a yellowish transparent fluid
immediately underlay the covering. The yellow color was identical with
that of red cells and uric acid crystals under the microscope and both
these substances appear bright red in the gross. These pigment spots
tended to be polar and appeared to be more extensive in the older cells.
In the snow these unicellular algae occur in macroscopic groups called
pyrenoids, surrounded by a transparent envelope, but the material examined showed only the debris of the main envelope.
Life under such extremes as those in which this plant lives must always fascinate the student of human physiology, since he deals with the
body's adaption to extremes in meeting the conditions produced by
disease. Liebig's Law of Minimum applies equally well to man as to
plants, when any single factor becomes sub-minimal, death follows disease
whether plant or animal. Liebig stated his law as follows: "A plant requires a certain number of foodstuffs if it is to continue and grow, and
each of these food substances must be present in a certain proportion. If
one of them is absent the plant will die; if one is present in a minimal
proportion, the growth will also be minimal. This will be the case no
matter how abundant the other foodstuffs may be. Thus the growth of
a plant is dependent upon the amount of that foodstuff which is presented to it in minimal quantity."
The conditions under which this plant lives strikingly suggest the
possibility of a number of such sub-minimal factors. Water for example
is limited. Physiological adaptation to periods of water famine is a
common experience, but the absolute deficiencies, however, in the following elements Calcium, Magnesium, Potassium, Phosphorus, Sodium,
Chlorine and Nitrogen, which are essential to the plant's very existence,
must present much more difficult problems of adaptation. A familiar
example of the importance of small quantities of an element is illustrated
by the voluminous literature on iodine and its relation to human physiology.
None of the above listed elements with the possible exception of
Nitrogen are available to the plant in the form of atmospheric gas.
Hence, they must have been transported as atmospheric dust. The fact
that these and other forms of life occur on the surface of snow so
constantly when all the above elements are essential in certain definite
proportions, strongly suggests that the atmosphere of the world must
carry a dust presenting a mixture of all these elements between very definite but probably wide ranges. Frequently some of these elements must
be present in sub-minimal quantities, thus presenting physiological problems similar to those presented in iodine, calcium and vitamine deficiency
in human physiology.—Donna E. Kerr.
It will no doubt be a surprise to many physicians to learn how much
time is required to make the examination of  the routine' urines every
Page Twelve morning in this hospital. Last year this laboratory reported on the examination of 65,000 specimens of urine. Examined individually and
centrifuged for sediment examination, one specimen takes 15 minutes.
Examined en masse in the morning routine (150 to 200 at a time) a complete examination of each specimen requires five minutes.
Sixty-five thousand examinations of five minutes each makes a
total of 32 5,000 minutes or would require one full-time worker for two
years, .eight months and two days. To be of practical use, however, the
examinations must be restricted to three hours in the morning. This
would require the time of six workers for three hours every morning,
making it necessary to exclude microscopic examinations as a routine for
each specimen.
PRESENT PROCEDURE.—Between 80 and 200 specimens of urine
are received in this laboratory every morning of the year. The mean
average for week days is over 150 specimens. Before the actual examination is commenced the specimens are taken from the racks as received
from the ward and arranged in racks holding forty tubes each.    The
order o
f th
j cubes is made to agree with the oi
in which the nurses
have listed the names of the patients.    This takes the equivalent of one
worker's time for half an hour.
The routine chemical examination comprises the reaction, specific
gravity, albumen test and sugar test. The reaction is determined by
means of litmus paper. This procedure takes the equivalent of one
worker's time for fifteen minutes.
The specific gravity is determined by the use of two sets of urino-
meters. One set of urinometers reads from 1.000 to 1.025, the other set
reads from 102 5 to 1050. The wide spacing of the divisions in these
instruments, about twice that of the ordinary urinometer, permits a
rapid and accurate reading. This procedure takes the equivalent of one
worker's time for one hour and twenty minutes.
The heat and acetic acid test is used to detect the presence of albumen. A small rack holding the same number of tubes as the large
rack is filled with small empty tubes. About 1 cc. of urine is poured
from each large tube into the corresponding small tube. The entire rack
containing the small tubes is then placed in a boiling water bath for
five minutes. The rack is then removed and one or two drops of 30'^
acetic acid are added. The presence of albumen is indicated by the
characteristic flocculent precipitate at once recognized by the experienced
worker. (The heating dissolves the urates, the acetic acid dissolves the
phosphates; fresh specimens clouded by the presence of bacteria always
have albumen present.) Thus filtration, which presents many more
serious technical difficulties than appear on the surface, is dispensed with.
A roughly quantitative report is indicated as follows:
£ 1—a trace of albumen.
+ 2—a flocculent precipitate.
+ 3—a large mass of solid albumen.
+ 4—an almost solid precipitate.
Page Thirteen One  worker   makes   the   readings   while   another   records   them.     This
procedure takes the equivalent of one worker's time for two hours.
Benedict's Qualitative Solution is used to detect the presence of
sugar; 1 cc. of Benedict's solution to about two drops of urine. The
small tubes from the albumen test are inverted momentarily. This leaves
about two drops of urine which run down the sides when the tubes are
returned to the upright position. To these two drops of urine are added
1 cc. of Benedict's Solution from a burrette and the small racks are again
placed in the boiling water bath for five minutes. At the end of this
time the racks are removed. One worker makes the readings and another
records them. All positive tests are checked by repeating the test. This
procedure takes the equivalent of one worker's time for one hour.
The microscopical examination is made directly on the sediment
from tubes which are known to have stood at least two hours. Each
tube, not known to have stood two hours, has its contents mixed and a
sample centrifuged. Since a microscopical examination takes three minutes, all specimens cannot be examined. Only those showing albumen
and those with special requisitions have a microscopical examination
made. On Sundays and holidays only those urine specimens specially
requisitioned for are examined microscopically. If any microscopic elements are found the contents of the specimen tube are thoroughly mixed
by pouring the specimen from one tube to another and back again. A
sample of this mixed specimen is again examined under the microscope
for a roughly quantitative report indicated as follows:
+ 1—less than one element per low power field.
+ 2—between one and ten per low power field.
+ 3—between ten per low power field and twenty'per high
power field.
+■ 4—over twenty per high power field.
Clumping indicates clumping of white blood cells in the un-
centrifuged specimen.
The above attempt at a quantitative expression leaves all interpretation to the physician, since obviously + 1 white blood cells may be
of no clinical importance but the same can not be said of +1 granular casts. The time required for this procedure can not be given, for
as stated above, it is subject to variation, unrelated to the total number
of specimens received.
Finally all the report forms are checked to ascertain that all examinations have been recorded and that the laboratory carbon copy can
be read.   This takes the time of one worker for half an hour.
Thus the apparently impossible task of examining such a large
quantity of material with only a subminimal staff available is accomplished. The per cent, of error is surprisingly small and only attained by minute .attention to uniformity of detail. "We have long
wished to actually determine our error by regularly repeating ten per
cent, of the examinations but that must be left a dream of the future.
We must still depend upon that high degree of accuracy which comes
from numberless repetitions.—Mabel M. Malcolm.
Miss C. Wilson and Miss R. Welsh have summarized the basal
metabolism examinations between January 1, 1925 and August 10, 1926.
as follows:
Readings in per cent. No.
-  10   to      +15
-f   15   to      +60
over        +60
Below     —10
The total number of examinations was 674; 7 or 1.6% had a
return of symptoms after operation. The symptoms returned between
9 months and 9 years after operation.
per cent, of Total
The third (possibly the last prolonged) trip on "The Indian Tuberculosis Question" was made by Drs. C. H. Vrooman, A. S. Lamb and
H. "W. Hill, August 11-23, 1926. A visit was made to Port Essington
and neighbourhood where the Indians, men, women and children, are
now assembled, engaged in fishing for the canneries and actually canning.
The Columbia Coast Mission boat "Columbia," Captain the Rev.
John Antle, supplied the transportation and X-Ray service. W. E. Col-
linson, Indian Agent, and Dr. William Sager, co-operated. 300-400 Indians were examined in the six clinic days, exclusive of travel.
Thirty-eight talks on Public Health, Bacteriology and allied subjects
were given during the year ending June 30, 1926, by Dr. H. W. Hill before Medical and other Societies, Public Service Classes, City Councils,
Teachers' Meetings, Lumbermen, Indians and others, reaching a total
of over 2,500 persons in small groups, in Victoria, Vancouver, Oregon,
Washington and "up the Coast;" a total of about 13 hours of formal
address and over 14 hours of questions from the audience, discussion, etc.
This brings Dr. Hill's record up to over 500 such addresses in the last
15 years.
Within the last month in three cases examined malarial parasites
of the Tertian variety were found in the blood smears. One case showed
symptoms five months after leaving Japan.
Doctor and Mrs. Kingsley Terry of Blubber Bay, Texada Island,
are to be congratulated on the birth of a daughter on June 16th.
Similar congratulations may be extended to Dr. and Mrs. L. G. C.
d'Easum of Ocean Falls on the arrival of a daughter on July 15 th.
Page Fifteen Further felicitations will be in order in the case of Dr. and Mrs. C.
H. Hankinson of Smithers to whom a son was born on June 21st.
Dr. A. K. Connolly had a narrow escape from drowning in Shuswap
Lake when answering an emergency call from Sorrento. Driving on to
the scow to be ferried across, the brakes of his roadster failed to hold,
with the result that the car shot over the apron of the scow into ten feet
of water. After a great effort to get clear the doctor managed to extricate himself, and was hauled aboard by the ferry man. The car was
later pulled ashore by means of a cable attached first to a boat and then
to a car on shore.
Later in the morning in his larger car, the doctor sustained another
mishap when the car fell into a ditch from which it was not extricated
for about one hour and a half.
Dr. J. P. Gussin is relieving Dr. R. A. Yeld of Edgewood during the
latter's absence in England.
Our Executive Secretary has just returned from a business trip
through northern B.C., visiting the doctors at the following places:
Powell River, Blubber Bay, Ocean Falls, Prince Rupert, Hazelton,
Smithers, Telkwa, Burns Lake, Vanderhoof, Prince George, McBride and
Jasper. He found an improvement on last year in conditions generally
all along the line and a more optimistic spirit prevailing. Numerous
problems of an economic nature were discussed, advice asked for and
given, and every man is eagerly awaiting the Extra Mural postgraduate
meeting to be held in Prince Rupert and Prince George in the early part
of October.
The doctors in northern 1B.C. doing work for the Indian Department were pleased to hear that Mr. Ditchburn, Indian Commissioner,
would be visiting there in the near future with a view to getting a better
understanding of their work for the Department and improving their
financial lot. They were also gratified to know of the work done in
this connection by the special committee appointed by the Canadian
Medical Association.
Arrangements are being made with the Canadian Medical Association for an Extra Mural postgraduate tour through British Columbia
in the latter part of September and early October. We have asked for
three doctors each especially qualified to speak on the following subjects:
Surgery (Orthopaedic).
Internal Medicine (one able to explain the practical value of newer
tests such as "Dick," "Schick," etc.).
Obstetrics and Gynaecology.
The following towns will be visited in order named: Cranbrook,
Nelson, Kamloops, Victoria, Nanaimo, New Westminster, Prince Rupert
and Prince George.
The visiting doctors will be as under:
Dr. D. S. MacKay, Winnipeg  (Gynaecology).
Page Sixteen Dr. B. G. Brandson, Winnipeg (Surgery).
Dr. D. Nicholson, Winnipeg   (Laboratory Methods).
It should be noted that this further excellent opportunity for postgraduate instruction is in addition to the Annual Meeting of the Vancouver Medical Association Summer School which will be held in Vancouver September 13 th to 16th, the full programme of which appears
on another page. Although not included on the Programme it is understood that Clinics will be arranged for men attending the School.
By Dr. D. D. Freeze, in charge of department.
In furnishing a report on the anaesthetic department there is little
in the way of statistics that I can offer, as no tabulated analysis of the
work of this department has ever been kept; that is to say no separate
number of E.C., E, CHCL3, and Gas Oxygen anaesthetics administered;
no separate grouping of good and poor risks—with an analysis of the
types of poor risks under some such scheme as: heart, myocardial,
toxic: lungs: T.B., bronchitis; kidney: eclampsia; high blood pressure:
diabetes. I repeat, no such scheme has ever -been in use and consequently
I am only able to quote you some such uninteresting figures as have
been submitted to me as follows:
" (1) The number of general anaesthetics given during the past
three years has been estimated for the purpose of the Hospital Annual
Report submitted to the Honourable Provincial Secretary as follows:
1922, 8,400
1923, 8,900
1924, approximately  11,000
It is likely that the figure for 1922 does not include anaesthetics
given in the Emergency Department.
(2) The deaths which occurred under general anaesthesia are as
1924, 2
1925, (to date, October 13th,  1925),  5
Obviously any analysis of the gross figures covering administrations
as outlined would entail at this date a volume of work quite beyond me,
so I shall confine my analysis to the death statistics covering the years
1924-192 5. An analysis of these cases will show how difficult it really
is to arrive at a definite cause of death, i.e, a cause so concrete as to afford some basis for a means of prevention; in other words what is to be
learnt from these cases?
Page Seventeen For the purpose of this report, deaths may be divided in to 3 groups:
, a beginning
1. During anaesthesia only . fc wl advanced
o   r\ j 1 a beginning
2. Oper. procedure  { .      °u    . &       ,
I b well advanced
3. Subsequent to operation, where patient is returned in a precarious condition and does not revive.
Groups 2 b and 3 are obviously closely associated, it being purely
a question of degree, but as group 3 cases do not occur in O.R. they are
not included in the above statistics.
FACTORS.—Before taking up these cases in detail, let us pause for
a moment and consider just in what ways it is possible for death under
anaesthesia to occur, as then we may, to some degree at least, be able
to place these cases in their proper setting.
1. Duration of anaesthetic. The normal organism cannot resist
indefinitely the action of an anaesthetic, i.e., a pefectly healthy individual must eventually succumb to an anaesthetic atmosphere, irrespective
of how skilfully it may be administered. Anaesthetics therefore must
act as poisons and time is a factor.
Again, individuals react quite differently to poisons in similar doses,
and this brings us to:
2. Susceptibility.—Under ordinary conditions, susceptibility is
counteracted by graduation of dosage, i.e., profound intoxication
(an anaesthesia is a profound intoxication) is reached with much less
of the drug and all is well; but suppose that in one's hurry or from
casualness this susceptibility is overlooked, profound intoxication, or so-
called, toxic anaesthesis is reached. Not without warning (for there
are sign posts in plenty) but, unusually, rapidly, and without observation; we are now brought face to face (with pallor both)  with
3. Overdosage.—Now, no one should die from overdosage." This
stage is reached many times a day in our hospital administrations and
spontaneous recovery will always take place, provided it is recognized at
once, but any further saturation at this stage is highly dangerous. An
important point here is that respiration invariably ceases first.
Now, let us go a step further and suppose that we have an individual upon whom our anaesthetic is not acting in its usual way, i.e., it will
produce in concentration capable of being respired only an excitable
intoxication. Here there is no guide to dosage, quantities of the drug
being poured or blown at the patient in order to overcome the excitability. Sometime in these cases there is really no third stage, the patient
passing from second to fourth, and sometimes passing very rapidly. Re-
suscitative measures are frequently required in these cases, and any lack
of understanding as to what is actually taking place may easily lead to
a casualty. This is, of course, overdosage—but in a less recognisable
Page Eightc 4. Instability or lack of physical balance in well developed cases.
In this group we are in reality dealing with that condition known as
status lymphaticus, but every grade exists. These cases are particularly
susceptible to sudden death, and it may occur at any time during the
anaesthetic, though the induction period is considered the most dangerous.
Here the circulation ceases first, respiration continuing for a variable time, from a few gasps to minutes which seem like hours. Let me
quote some high lights on status lymphaticus.
"A condition, of the features of which are not well defined, or constant, every degree existing, but which may be
described as a condition associated with a hyperplasia of the lymphoid
structures and an enlarged or persistent thymus gland, in which there is
a greatly diminished resistance against injury or disease, and a particular
susceptibility to poisons, especially alcohol, arsenic, Ether, and CH CL3
While the general lesions of status lymphaticus are constantly associated with an enlarged thymus, all cases of enlarged thymus are not
necessarily accompanied by status. Many cases die in infancy and childhood, but a moderate number reach adult life. The condition is congenital but is not a case of persistent infantile type or arrested development, but a constitutional anomaly, though infantilism may be associated
with it. It is more frequent than supposed, being present in about 2%
in over 2000 autopsies, at Bellevue Hospital, N.Y., a considerable number
of deaths from Caisson disease being status cases and it has been frequently noted in diseases of the ductless glands and epilepsy."
5. Reflex Cardiac Inhibition.—This has been definitely proved an
entity, but is much more liable to occur under light CH CL3 anaesthesia than with the other anaesthetics.
6. Asphyxia.—This may sound a trifle far-fetched, but in gas
oxygen anaesthesia particularly, where the supply of oxygen is
entirely under the control of the anaesthetist, it may easily occur, and
in my opinion does, and has occurred, and is not so readily recognized
as one may at first suppose.
Take, for example, a curettage in a severe case of secondary
anaemia from uterine hemorrhage—shades of colour in these cases are
extremely difficult to recognize, so great is the pallor, and the only real
guide—the blood colour—is out of sight.
It is positively essential in gas oxygen anaesthesias, that the
surgeon keep the anaesthetist informed of the blood colour, particularly
' where the field of operation is outside the anaesthetist's view. Team work,
under these circumstances is tantamount to a safe anaesthesia; yet how
infrequently is it present. Time and time again have I enquired regarding the blood colour, only to be told, "It's rather dark." Asphyxia going
on under the surgeon's very nose and not a murmur. These cases may
not die on the table, but their tissues may be so badly damaged from
suboxidation as to render their period of recovery an anxious one.
Page Nineteen 7. Intercurrent Disease, i.e., ruptured aneurysm, embolism.
8. Operative or Traumatic Shock.—Both these latter factors,
while mentioned, are so obviously self-sufficient of themselves, even without the incidence of anaesthesia, that they may be passed over without
further comment as far as concerns this report.
To recapitulate.—Deaths during anaesthesia may be due to the following factors:
1. Duration of anaesthesia or anaesthetic shock.
2. Susceptibility or relative overdosage.
3. True overdosage.
4. Instability—status lymphaticus.
5. Reflex cardiac inhibition.
6. Asphyxia or prolonged suboxidation.
7. Intercurrent disease.
8. Operative and traumatic shock.
There may be other factors which I have overlooked; I do not pretend this to be an exhaustive study, but to represent gleanings from my
experiences and meditations upon this always unfortunate occurrence.
Now let us consider, with this information before us, our cases of
death during anaesthesia, in detail.
1924, 2
1925, 5 to date
Now as to the risk:
1.    Practically moribund from starvation,   (gastrotomy).
1.    Well-advanced   carcinoma   root   of   tongue   and   haemorrhage,
(ext. teeth).
1.    Severe secondary anaemia,   (curettage).
of these:
4 under gas oxygen
2 EC
and E
1 Ethanesol on
as follows:
Anaes.     D
ur. Mins.
Gas Oxy.
Gas Oxy.
Cauterizing lung
Gas Oxy.
Gas Oxy.
E. C. & E.
Ts. and As.
M     under
1 yr.
E. C. & E.
Rep. cleft palate
M             9
Page Twenty 1.    Malnutrition and sepsis.   (Repair cleft palate).
1. Old   pulmonary  involvement,   fair  risk.   (Cauterizing  Luns^
2. Apparently healthy boy 11 and baby boy 9 months.  (Circumcision) .
DEATHS, 1924
1. D. F. F.—21—Married; admitted March 15, 1924. 8:30 p.m.
Emergency case. DIAG. uterine haemorrhage—inconmplete abortion—
History of intermittent flowing, severe 4-5 days. Up and about day
of operation. Condition at operation: 98. 156. 22. Well-developed,
well-nourished, decided pallor, in good spirits. No pre-operative preparation done. Morphia 1/4, atropin 1/150 at 8:45 p.m. (Ordered by
surgeon on admission).
Hurried to O. R. No pre-operative or ward examination. Seen in
O. R. by anaesthetist for first time. Anaesth. N20-0 8:50 p.m., 20
min. after admission. Induct, normal. No motor excitability or larnyn-
geal spasm. R. deep and regular. Eyes act—Lithotomy position and
operation commenced.
After 10 min. R. irreg. and suboxidation apparent at nails. O increased; R. shallow and irregular for a few minutes, finally ceasing, with
pupils dilated. Art. resp. 9.05—no further signs of life. Oper. curettage,
in progress. P. M. findings: Heart, lungs, viscera, brain, negative.
Possible causes of death in this case may include 1. Reflex cardiac
inhibition. Asphyxia, anaesthetic shock in a case of increased susceptibility from profound anaemia.
2. W. C.—M.—Mid. Age. Adm. Oct. 21, 1924. 99-120-22.
Cough, pain left side. Purulent sputum. DIAG: Pulmonary abscess.
History: ll/2 years' duration. Oper. Oct., 1923. Good p.o. recovery.
Condition at operation: Well-nourished, well-developed, M.M. good color.
Operation: Cauterizing left lung cavity. Anaes. Oct. 24, 1924: N 20
and 02 8:30 a.m.    R. lateral position.    Induction quiet, other than short
period of nausea and retching causing
erate cyanosis from respira
tory obstruction. Color improved on respiration becoming free and
operation proceeded for 3 5 min. when color suddenly became livid;
there was a deep gasp, pupils dilated—pulseless. A few gasps occurred
after this, but no sign of pulse.
During operation air entered through wound with inspiration. P.
M. findings:  Heart, no pathology, well contracted;  stomach distended.
Possible causes of death here may include, 1. Asphyxia. 2. Reflex
cardiac inhibition.
1. O. K.—Oriental. Adm. Jan. 9, 1925. Complaint: loss of
weight, difficulty in swallowing, weakness. DIAG: Carcinoma esophagus.
Esophagoscopy. Jan. 10, 1925. No anaesthetic. Condition at oper. moribund. Operation, gastrotomy. Anaesthetic, morphia 1/4, atrop. 1/150,
9:45 a.m. Gas Oxygen. Induct. 10:25 a.m. Pulse imperceptible at
wrist. Resp. shallow.    R. ceased 10:43 a.m., pupils dilated.
Probable cause of death: Anaesthetic shock in a practically moribund case.
2. S. K.—M.—65—white.    Adm. April 3, 1925   (Stretcher case).
Page Twenty-one
uZSm^oi^Q Diag:    Advanced carcinoma tongue and haemorrhage.    Oper. April 8.
Extraction of teeth to prevent further irritation of cancerous area.
Condition at operation: Weak, anaemic, B.P. 120/80, resp. free.
Anaes. N 20, 02, Morph. 1/6, Atr. 1/150. Commenced 9:15 a.m. Induction normal, blood color good. After three teeth extracted respiration ceased. Pupils dilated. P. M. findings: Ch. aortic endocard;
narrowed opening, area calcified.    Oedema of glottis and pharynx..
Possible causes of death: Diseased heart with probably some asphyxia.    Reflex inhibition.
3. K. D.—11—white—M. Adm. April 13, 1925. Operation Ts.
and As. Cond. at operation apparently in perfect health. Anaes. E. C.
and E. and 02. 8:.30 a.m. Induction quiet, no struggling, no laryngeal spasm or cyanosis. Course normal. Color pink for 40 min. (Tonsils
removed); then patient turned pale, resp. shallow; collapse. P. M.
findings: Enlarged mesenteric lymph glands. Rt. undescended testicle.
Enlarged thymus, 32 grms. Heart normal. Peyer's patches and solitary
follicles increased in size and number.
Cause of death:    Status Lymphaticus.
4. A.C.—Baby—white—male—8 mos. Adm. April 19, 1925.
Hist.: Congenital hare-lip and cleft palate. Previous operation, April
19, 1925, repair, EC and E. 1 hr. 20 min. Good recovery. May 8, repair. E.C. and E. 1 hr. 20 min. Good recovery. Oper. June 3 0, 1925,
repair. Cond. at oueration: double ortis media. Poorly nourished; on
liquids and brandy for some time previous. Anaes. E.C. and E. 02 9:20
a.m. induction normal, whimpering at Degihning with slight motor disturbance. Coughing, following introduction of E. via naso-pharynx
gradually subsided and resp. shallow and pallor present. Operator commented on this but advised to proceed, in meantime anaesthetic being
discontinued. As patient showed no signs of improving, operation discontinued. 02 fed via naso-pharynx and artif. resp. resorted to. Respiratory movements present; gasping in character, but no apparent air movements; color dark and pupils dilated. Under artif. resp. pupils would
contract and color of face improve. R. movements continued for 40
mins. P. M. findings: Pus from both ears. Heart distended, right side
dilated, no congenital abnormality, thymus unusually small, apparently
enlarged mesenteric glands, brain negative.
Probable causes of death: Malnutrition; susceptibility, anaes. schock.
5. M. Mc. M.—9 mos.—white. Adm. October 10, 1925. T. 98,
130, 30. DIAG: Phimosis. Oper. circumcision. General cond. apparently in perfect health, well-developed, well-nourished. Color pink.
Crying lustily when brought to O.R. X-Ray, Thymus normal. Anaes.
10:8 a.m. Ethanesol only. Crying during induction. Resp. deep and
noisy. By the time the child was ready for operation, a matter of a
few minutes, anaes. was discontinued, as the child appeared completely
relaxed. Doctor noted there was no bleeding as soon as incision was
made and commented on it, but as respirations were normal and no
further anaesthetic was being  administered,  operation was completed.
Page Twenty-two The child, however, showed no signs of reviving as in normal cases,
following cessation of anaesthetic, but respirations gradually became
shallower and slower; skin a greyish color. On ascultation, no heart's
sounds were heard. Artif. resp. commenced, and other resuscitative
measures, without avail.
P. M. findings: False vocal cords; oedematous; thyroid not enlarged; thymus enlarged (26l/2 as against 15 estimated); congenital
mesentery to all large bowel. Slight enlargement of iliac portion mesenteric glands but no general hyperplasia.
Cause of  death:     status  lymphaticus—moderate  grade.
There is considerable food for thought in this analysis. The period
of induction is a trying period for any anaesthetist. He is up against
many unknown quantities, with sudden death, over which he may
have little or no control but must assume the responsibility, hovering
in the offing.
With marked excitability occurring, he must in some way guide his
patient through this, yet knowing full well the dangers of forced anaesthesia during excessive exertion, even in apparently normal individuals'.
Fear on the part of the patient is a very important item to be considered under induction, creating, as it does, a lack of stability, and a
few moments spent in reassurance may prevent an otherwise unhappy
course. And yet this is the very time that many surgeons become
exceedingly restive, pacing the corridor or anxiously scrutinizing the
clock and sending frequent messengers to ascertain, not how much
trouble one is having, but how much longer one is going to be!
If there is any time an anaesthetist needs to keep his head it is when
the surgeon appears to have lost his.
Under  such   circumstances,   there   is   a   great   tendency   to   hurry
matters—a bad business at any time but positively unjustifiable in
the face of trouble.
I am not one of those who believe that the value of an anaesthetist
is in direct ratio to the rapidity with which he has the patient ready
for the knife. His real value is reflected in the patient's condition at
the end of the operation. A badly administered anaesthetic can jeopardize the very life of the patient, even more so than bad surgery—and it
is a marvel of health that will stand both.
Just here would seem an appropriate place to mention some of our
trials with obviously poor-risk cases.
Frequently these cases are posted routinely, and one's first intimation
of any abnormality comes about the time the anaesthetist is ready to
commence. One is then called upon to make a snap judgment as to
what is best. This does not seem to me quite fair particularly where there
has been plenty of opportunity for previous discussion, and these cases
are seldom so urgent that they become emergencies. I refer to cases such
as heart disease, high blood pressure, diabetes, T.B.—latent or active—
and other pulmonary conditions, and malnutrition and anaemia.
Page Twenty-three There seems to be a prevailing opinion that in any case gas and
02 can be given with perfect safety, and at any time, so why worry
about the anaesthetic? Let me tell you that gas and oxygen is not
always the safest anaesthetic; in fact it may do considerably more harm
than a well-conducted ether anaesthetic, in the way of pulmonary overactivity, or some degree of suboxidation occasionally necessary to maintain anaesthesia at all. Abdominal and pelvic operations under gas are
being slated with increasing frequency without the slightest discussion
as to its relative value. If the patient is a good gas subject (and many
do not take it well) all well and good; but if not, what happens?
Either every means available to make the patient take it are tried,
including degrees of temporary suboxidation, additions of E. or CHCL3.
even over-ventilation of lungs by means of increased pressure,
or—what in my opinion is the only proper thing to do—a
change to Ether, the anaesthetist thereby in all probability creating the
impression in the mind of the surgeon that he does not understand gas,
and criticism on this very point is sometimes not wanting; and yet, as
I have said, to change is the proper thing.
There is another matter happening with increasing frequency which
is unfair to the anaesthetic staff. I refer to the admission of adults to
hospital on the morning of an operation. Frequently these cases reach
the O. R. unexamined, without medication, and all fussed-up as the
result of a hurried preparation and enema.
This, of course, brings one to the question of responsibility in anaesthesia, a point in my mind still unsettled in the Vancouver General
Hospital. How frequently have I heard something like this: "Use your
own judgment; you are the anaesthetist." Fine! But supposing one
does not consider any anaesthetic safe? Ah! that's a different story.
It is: "Go ahead; I will take all the responsibility." On one occasion I
had the extreme pleasure of being called to the office for refusing to
administer an anaesthetic—advising local instead—owing to, in my opinion, a too weakened condition for general anaesthesia. The surgeon refused to operate under local and the patient was returned to the ward
where he had the good grace to give up the ghost within 24 hours.
Was such a case fit for general anaesthesia? And it could have been
done quite well under local.
We are willing to, and do, take all kinds of risks where it is necessary, but as one member of the anaesthetic staff tersely remarked: "We
object to playing the role of executioner." Let us now consider some of
the salient points of the materials used in anaesthesia.
I have been asked recently on a number of occasions, if E. C. is a
safe anaesthetic, and I have invariably replied "Yes". Deaths have oc-
cured under anaesthesia in other parts, where E. C. is never used, and I
see no reason to stigmatize E. C, because two deaths during induction
have recently occurred in this city, E. C. being the anaesthetic used. It
is evtremely volatile, reaches the blood and c. n. s. rapidly, causing
rapid loss of consciousness and the toxic stage is easily reached.
Page Twenty-four It is used as a preliminary in all ether anaesthesias here, but, owing
to its extreme volatility, it should be given with plenty of air in early
stages, i.e. well diluted, as high concentrations (and they are easily res-
pirable) administered rapidly may easily paralyze the respiratory centre.
This applies particularly to young children who frequently cry and
struggle, and where there is a tendency to force matters in order to
obtain peace. Far better to let them cry for a while longer and play
safe. It usually causes increased R. and P. and capillary dilation, though
occasionally the R. are depressed.
CHCL3 produces a delightful anaesthesia, but is very much the
most poisonous. It depresses respiration and circulation, and frequently
causes mental excitability in the early stages and masseteric spasm. High
concentrations are exceedingly dangerous in early stages causing a marked
increase in cardiac irritability which may go on, under unfavourable
operative conditions, to ventricular fibrillation or reflex inhibition. A
condition resembling syncope is sometimes met with during induction,
causing considerable misgiving.
Nitrous oxide has already been considered.
Its action is well known, but there is one point that should be considered here.     There  seems  to  be  an impression  among  the  profession
that oxygen is in some way antagonistic to anaesthesia.    A glance at the
physiology of anaesthesia will clear this point.
Anaesthesia is entirely dependent on the vapor tension of the
material used in the blood irrespective of how it gets there, whether via
lungs, colon or even intravenously. If this be so, and it is so, then it
would seem ridiculous to say that a patient takes more say, Ether, by
one method than another, to reach the same state of anaesthesia. More
Ether may be used but the patient does not get it. Now, in inhalation
anaesthesia, the Ether vapor blood tension is dependent on the Ether vapor
lung tension, so that if the lung tension is sufficient, anaesthesia will
be produced and maintained, irrespective of how the lung tension is
produced, whether the ether is carried in by air or any other gas, in this
case oxygen. The 02 is merely acting in the capacity of a vehicle, and
if it is capable of carrying sufficient Ether anaesthesia must be produced.
Of course, a pure oxygen atmosphere in the lungs would speed
up the metabolic process to such a degree as to materially complicate
the picture, but since by the method of introducing Ether with 02 the
pulmonary 02 content is only actually raised about 2-4%, there is
very little ground for anxiety. It is interesting to know that this mixture is highly explosive and yet the use of ethylene may not be permitted
owing to its explosiveness.
We depend a great deal on saline, administered interstitially, intravenously and intraperitoneally.
Very little medication is ever given during operation, and most
frequently it is strychnine to improve a depressed and slow respiration,
Page Twenty-five which is naturally interfering with the introduction of sufficient anaesthetic vapor. Seldom anything else, unless at the completion of the operation, when the anaesthetic is becoming light and depression is apparent.
But saline and lots of it, is given in many of the cases that are likely to
continue for an hour and a half or more, and the patient apparently in
good condition.
There is a considerable loss of fluid during an hour's operation
especially with the abdomen opened. Moist warm serous surfaces give off
moisture very rapidly. Blood loss drains the tissues and perspiration is
practically always present, frequently to an excessive degree, and it
seems to me rational to replace this loss at the time, instead of waiting
for symptoms to appear. This is not always understood and the presence of a saline set with some operators is a cause for considerable misgiving. In fact we have sometimes been instructed not to give it until
the patient shows symptoms requiring it, but happily this does not occur
Now let us consider briefly the incidence of P. O. respiratory complications and endeavor, if we can, to ascertain the role played by general
To me, the number of P. O. respiratory complications is so small in
comparison to the total general anaesthesias administered that the question of direct irritation from the various anaesthetic vapors is practically
negligible. By this I mean an irritant in the sense that mustard gas is
an irritant, whereby a laryngitis, tracheitis or bronchitis is rapidly set
up, according to the strength of its vapor. If they were irritant in this
sense, then one should expect the greatest incidence among those administrations where the vapor is administered direct into the pharynx or
trachea, as opposed to ordinary inhalation anaesthesia, where vapor dilution takes place prior to reaching the larynx and trachea. But the incidence amongst our head and neck cases including tonsillectomies, is
certainly no greater than among the other types of operative surgery,
while the opportunity for direct irritation is considerably greater; and
the same thing may be said of the chilling action of anaesthetics (applicable only to E. and E. C). In my opinion it does not exist.
But I do feel that certain anaesthetic vapors of the toxic type, including E. C; E.; CHCL3 do have a definite inhibition upon
the respiratory mucous membranes, rendering them less resistant to the
presence of infection, and undoubtedly a certain proportion of the cases
of tracheitis and bronchitis can be accounted for in this way, cases of
oral sepsis, post-nasal catarrh and chronic pharyngitis being prone to
such complications. What about aspiration as a cause? It seems to me
a very difficult thing to aspirate mucus or infective material much beyond the bifurcation, if that far; and even so, it would seem reasonable to
expect at most an ^acute bronchitis, and ot a broncho-pneumonia, as a
primary manifestation. Aspiration may—and it undoubtedly does—
carry infective material into the trachea, the mucus membrane of which,
during anaesthesia is more liable to infection, but as to its being a fruitful cause of our actual pneumonic complications, I very much doubt it.
Page Twenty-six We have now disposed of:
1. The irritant cause of anaesthetics.
2. The chilling cause of anaesthetics.
3. The lowered resistance of respiratory mucus membranes by
4. Aspiration.
And I have endeavored to show the improbability of these as a
cause of the true pneumonic, not bronchitic, conditions which do occur following anaesthesia.
There is another possible cause in which the anaesthetic is incidentally to blame. I refer to the overheating of the patient, the superficial
vascular dilation and the profuse perspiration, which frequently accompany the administration of an anaesthetic, especially E. C, E. and Gas
oxygen. That this leaves one prone to subsequent chilling if not carefully watched, and its accompanying ills, there can be no doubt. Pleurisy
and pleuro-pneumonia might easily occur. This opens up a large field
of possible causes under the general heading of exposure, and here, in
my opinion, we reach realities.
In studying the incidence of p. o. respiratory complications, it is
noted at once that the peak is reached during the winter and spring, i.e.
its incidence is in great part seasonal. There are two great factors associated with this.
1. Greater tendency to the presence of latent or incipent respiratory conditions.
2. Greater liability of infection from exposure or chilling.
I do not think anyone will question the possibilities following operative procedure under general anaesthesia in incipient respiratory conditions: No improvement in the respiratory condition can be expected
in any case.    Now, what opportunities occur from exposure?
1. The drive to hospital previous evening (it's nearly always evening despite the regulations), possibly in an open car.
2. Pre-operative preparation, always in the evening. In the case of
a double change, there may be considerable exposure.
jn a cold carriage.
3. Transfer to O. R.-
4. Further exposure during O. R. preparation in cool anaesthetic
5. Loss of heat from exposed viscera or from soaked drapings, as
in caesarean section and prostatectomy.
6. Exposure in O. R. during the change of clothing, previous to
returning to ward, and later down a drafty corridor or even across an
open space, with the patient hot and perspiring.
7. Exposure to drafts on ward during recovery from anaesthetic.
Here patients are frequently restless and will easily uncover themselves
unless closely watched, with garments often wet from, perspiration.
Page Twenty-seven 8.    P. O. alcohol rubs and sponging.
But there are still cases occurring which cannot be accounted for by
the foregoing. I refer to those cases following upper abdominal operations. Here there seems to be an added—and so far inexplicable—factor.
Whether some interference with the diaphragm is present influencing
the pulmonary ventilation; or some nervous influence or circulatory
change, causing a tendency to partial collapse, I am not prepared to
say. It would seem to occur under circumstances quite beyond our
control at present.
It has been my own experience to find a relatively high incidence
also among herniorrhaphies equally inexplicable, unless the embolic theory is brought to bear. Here it is thought that numerous minute emboli
become lodged in the lung tissues as the result of operative work.
In this discussion of P. O. complications, I would like to mention a
very interesting case of recent date.
Mrs. F.—middle aged. Adm. September 29. T98, P76, R20. Diag.
Carcinoma umbilicus. Gen. cond. Heart case (first brought to my
attention, by-the-way, just prior to the operation). Has suffered previous
attacks of decomposition and has been on digitalis and strophanthus
since admission. October 8, date of operation. Heart irregular. B. P.
146/60. Urine negative. Lungs negative. Operation completed 2:45
p.m. 2 hours 2 0 minutes duration. Four hours later patient showed
flushed face, pallor about mouth and nose. Resp. labored. P. irregular.
Seriously ill. Labored R. increased, fluid present in resp. pass. Cough.
Free perspiration. Rapid pulse and ascending temp, which reached 104'5
just before death 28 hours P. O.
With such a clinical picture what chance for an alibi would Gen.
Anaesthesia have, were it not that the entire operation had been performed under novocaine.
However, despite the incidence of certain cases of inexplicable origin, it would seem rational to at least endeavor to overcome every possible cause, many of which I have mentioned. One thing appears to me
through all this well defined—viz.: that the anaesthetic in reality plays
a very minor role.
Page Twenty-eight Vancouver Medical Association, Summer School, Programme
September 13th to 16th, 1926
Meetings will be held in the Lecture Room of Wesley Church, Burrard
and Georgia.    Fee, $10.00.
9- 9:50 a.m.    Dr. C. A. Hedblom, "A Study of End Results following
Radical Amputation of the Breast for Carcinoma."
10-10:50  a.m.    Dr. Geo. Hale, "Nephritis from the Standpoint of the
General Practitioner."
11-11:50 a.m.    Dr. R. R. MacGregor, "Common Nutritional Disturbances of Infancy Observed in Practice."
2- 2:50 p.m.    Dr. Geo. Gellhorn, "Causes and Treatment of Vaginal
3- 3:30 p.m.    Dr. T. C. Routley (Canadian Medical Association).
8- 8:50  p.m.    Sir Henry Gauvain, "The Use of Heliotherapy."
9- 9:50 p.m.    Dr. A. S. Warthin, "The Causes of Renal Insufficiency."
8- 8:50 a.m.    Dr. Geo. Hale, "Functional vs. Organic Heart Disease."
9- 9:50 a.m.    Sir Henry Gauvain, "Some Aspects of Surgical Tuber
10-10:50 a.m.    Dr. Geo. Gellhorn, "Milk Injections for Pelvic Infections
in Women."
11-11:50 a.m.    Dr. Fraser Gurd, "Empyaema, Acute and Chronic."
8- 8:50 a.m.    Dr. R. R. MacGregor, "Pyelitis of Infancy."
9- 9:50  a.m.    Dr. A. S. Warthin, "Some Unusual Forms of Diseases of
10-10:50 a.m.    Dr.  C.  A.  Hedblom,  "The  Differential Diagnosis  and
and Treatment of Acute Abdominal Conditions."
2- 2:50 p.m.    Dr.  Geo.  Gellhorn, "Syphilis in Gynaecology and Ob
3- 3:50 p.m.    Dr. Geo. Hale, "The Patient Complains of Dyspepsia."
8- 8:50 p.m.    Dr. R. R. MacGregor, "Chronic Intestinal Indigestion."
9- 9:50 p.m.    Dr. A. S. Warthin, "Syphilis of the Heart and Aorta."
8- 8:50 a.m.    Dr. Fraser Gurd, "The Treatment of Compound Frac
9- 9:50 a.m.    Dr. C. A. Hedblom, "Phrenicotomy and Extra Pleural
Thoracoplasty  in  the  Treatment  of  Pulmonary  Tuberculosis."
10-10:50 a.m.    Dr. R. R. MacGregor, "Intestinal Intoxication."
11-11:50 a.m.    Dr.   Geo.   Gellhorn,   "The   Treatment   of   Postpartum
2- 2:50 p.m.    Dr. Fraser Gurd, "The Treatment of Acute Perforated
3- 3:50 p.m.    Dr. A. S. Warthin, "The Nature of the Inherited Sus
ceptibility to Cancer."
8- 8:50 p.m.    Dr. Geo. Hale, "A Confusing Syndrome."
9- 9:50 p.m.    Dr. C. A. Hedblom, "Differential Diagnosis and Treat
ment of Chronic Pulmonary Suppurations."
Page Twenty-nine
hi »-T WIMri"''! ^ M»B'<iftlrt<L? ' CITY HEALTH DEPARTMENT
STATISTICS — July, 1926.
Total Population ( estimated)  I 12 8,366
Asiatic Population  (estimated)     10,100
Rate per 1000 of
Population per Annum
Total Deaths  -—    125
Asiatic Deaths         17
Deaths, Residents only        87
Male,  15 5
Female,   149        304 27.9
Stillbirths, not included in above         11
Deaths under one year of age   9
Death rate per 1000 Births      29.6
1, to
June,  1926
Cases Deaths
July,  1926
Cases Deaths
Smallpox  i  0 0 0            0
Scarlet Fever  7 0 4           0
Diphtheria  14 2 11           0
Chicken-pox   68 0 16           0
Measles     186 2 69           1
Mumps     45 | 0 1           0
Erysipelas     12 0 2           0
Whooping cough   12 0 1            1
Tuberculosis    13 7 9         12
Typhoid Fever   3 0 10
Cases from outside city included in above.
Diphtheria  5 0 10
Scarlet Fever  2 0 3           0
Typhoid Fever   0 0 10
15,  1926
Cases Deaths
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There are very many doctors who are
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Page Thirty-three SPECIAL OFFER
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Page Thirty-four  —*-£g*)1£
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For information apply to
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Westminster 288
Page Thirty-six    University of British Columbia Library
llAtV 1   ft i
WR   8198T
^PA-13 w<i n :%
u GT l ^ ^^'
FORM  310S  


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