History of Nursing in Pacific Canada

The Vancouver Medical Association Bulletin: January, 1929 Vancouver Medical Association Jan 31, 1929

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 Vol V,
JANUARY, 1929
The Bulle
of the-;
Vancouver Medical Associ
treatment of ^Burns
Public c\Kealth Survey
"Published monthly atlJancouver, tJS.Q., by
McBEATH-CAMPBELL LIMITED
"^Tricev $1.50 per year^ tMSBOMaBB
DESHELL  LABORATORIES  OF
CANADA, LTD., DEPT. V.M.,
Desh ell Laboratories of Canada      24To?onto7 c&o.
Limited Gentlemen:     Please   send   me   copy   of
the   new   brochure   "Habit   Time"    (of
„,__ . _ -T , _ bowel movement) and specimens of Pet-
245  Carlaw Ave.    Dept. V.M.        roiagar.
TORONTO,   ONTARIO Address"" THE  VANCOUVER   MEDICAL  ASSOCIATION
BULLETIN
Published Monthly under the Auspices of the Vancouver Medical  Association in the
Interests of the Medical Profession..
Offices:
529-3 0-31   Birks Building, 718  Granville St., 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 above address.
Vol. V.
JANUARY, 1929
No. 4
OFFICERS, 1928 - 29
Dr. T. H. Lennie Dr. W. S. Turnbull, Dr. A. B. Schinbein
Vice-President President Past President
Dr. G. F. Strong Dr. J. W. Arbuckle
Secretary Treasurer
Additional members of Executive:—Dr. A. C. Frost and Dr. F. N. Robertson
TRUSTEES
Dr. W. F. Coy Dr. W. B. Burnett Dr. J. M. Pearson
Auditors:   Messrs. Price, Waterhouse & Co.
SECTIONS
Clinical Section
Dr.  L.  H.  Appleby i Chairman
Dr. J. R. Davies Secretary
Physiological and Pathological Section
Dr. C. E. Brown ; Chairman
Dr. R. E. Coleman . Secretary
Eye, Ear, Nose and Throat
Dr. W. E. Ainley Chairman
Dr. F. W. Brydone-Jack 1 : Secretary
Physiotherapy Section
Dr. H. R. Ross ~ .Chairman
Dr. J. W. Welch  : Secretary
Pediatric Section
Dr.  E.  D.  Carder  j Chairman
Dr. G.  A.  Lamont '. Secretary
STANDING COMMITTEES
Library
Dr. D. F. Busteed
Dr. C. H. Bastin
Dr. W. A. Bagnall
Dr. Lyall Hodgins
Dr. S. Paulin
Dr. W. A. Wilson
Dinner
Dr. E. M. Blair
Dr. L. Leeson
Dr. H. H. Pitts
Rep. to B. C. Med
Dr. Stanley Pauxin
Sickness and
Orchestra
Dr. A. M. Warner dr.
Dr. W. L. Pedlow dR-
Dr. J. A. Smith £>r.
Dr. L. Macmillan dr.
Publications j)R-
Dr. J. M. Pearson rjR.
Dr. J. H. McDermot
Dr. D. E. H. Cleveland
Credentials Dr.
Dr. J. T. Wall Dr.
. Assn.   Dr. D. D. Freeze Dr.
Dr. W. A. Dobson Dr.
Benevolent Fund   —   The President   —
Summer School
B. D. Gillies
L. H. Appleby
W. T. Ewing
J. Christie
W. L. Graham
R. P. Kinsman
Hospitals
F. Brodie
A. S. Monro
F. P. Patterson
H. A. Spohn
■   The Trustees VANCOUVER MEDICAL ASSOCIATION
Founded 1898 ^'f-  Incorporated 190.6
PROGRAMME OF THE 3 1st ANNUAL SESSION
GENERAL  MEETINGS  will  be  held  on  the  first  Tuesday  and
CLINICAL MEETINGS on the third Tuesday of the month at 8 p.m. from
October to April inclusive.    Place of meeting will appear on the Agenda.
January       8th—General Meeting:
Paper—Dr.   Ralph   C.   Matson,   Portland,   Oregon:
"Surgical Treatment of Pulmonary Tuberculosis."
22 nd—Clinical Meeting.
5th—General Meeting:
Paper—Dr. R. P. Kinsman: "Focal Infections in Infancy and Childhood."
X-ray films to be shown by Dr. H. A. Rawlings.
19 th—Clinical Meeting.
5 th—General Meeting.
The OSLER LECTURE—Dr. H. M. Cunningham.
19 th—Clinical Meeting.
January
February
February
March
March
April
April
April
2nd—General Meeting.
Paper—Dr. F. P. Patterson: Subject to be announced.
16th—Clinical Meeting.
23 rd—Annual Meeting.
151
12.96
19
21.19
112
9.61
234
20.08
VANCOUVER HEALTH DEPARTMENT
STATISTICS,  NOVEMBER,   1928
Total  Population   (Estimated)     : 142,150
Asiatic   Population    (Estimated) r   10,940
(. ; Rate per 1,000 of Population
Total   Deaths 	
Asiatic  Deaths ... j ■_, ...
Deaths—Residents   only !	
TOTAL   BIRTHS      .	
Male      120
Female   114
Stillbirths—not  included  in  above	
INFANTILE MORTALITY
Deaths under one year of age —. .  8
Death rate per  1,000 Births        34.19
CASES OF INFECTIOUS  DISEASES  REPORTED  IN  CITY
December 1st
October, 1928
*"" Cases    Deaths
12
Smallpox     _^ 29 0
Scarlet Fever    11 0
Diphtheria     —        — 76 3
Chicken-pox      24 0
Measles    ~ —  ... 0 6
Mumps         _.. :_ 5 0
Whooping-cough      17 0
Tuberculosis         1'...' 16 7
Erysipelas        —,' 8 1
Poliomyelitis         1 1 1 0
Typhoid   Fever    ~   . 3 0
Cases from Outside City-
Diphtheria , ..  23 2
Scarlet  Fever .  2 0
Smallpox             2 0
Typhoid   Fever     3 0
November, 1928
Cases    Deaths
36 0
to 15th, 1928
Cases    Deaths
Page 73 Jo again quote from
autnority on uttravio/et t/ierapu.
" I 'HERE has been an extraordinary awakening of
-*- interest in the use of light in the treatment of
disease, both on the part of the general public and
the medical profession.
"An astounding variety and number of sources of
'artificial sunlight' have been evolved and are now
available. At this stage the busy general practitioner finds himself somewhat bewildered. Somehow
he appears to be shy about taking up the new form
of treatment, and yet he knows that his patients have
heard of its existence and are talking about it. Several good treatises on the subject of Ultra-Violet
Radiation have been published, but the practitioner
is left rather at a loss as to what type of apparatus he
should purchase, and what exactly he is venturing
in care, cost, and management of such apparatus.
"The writer feels that for the man in general practice and for the busy medical officer of health the
Quartz Mercury Vapour Lamp is the onty practical
proposition."
—J. Bell Ferguson, M. D., D. P. H.,
in his preface to "The Quartz Mercury
Vapour Lamp."
There are logical reasons why many thousands of physicians and hospitals select the mercury vapor
arcin quartz, in preference to all other artificial sources of ultraviolet radiations. The advantages realized
with the Uviarc burner, as used in all Victor Quartz Lamps, are important to every practice, generad?",
or specialized. The scientific advances in ultraviolet therapy, and its widespread adoption in the leading clinics in recent years, are coincident with the availability of the mercury vapor arc in quartz.
You will find some valuable pointers in our booklet"A Few Facts Pertinent to the Consideration of Artificial Sources of Ultraviolet Radiations." Write for your copy, gratis.
Victor X-Ray Corporation of Canada, Ltd*
Physical Therapy Apparatus, Electro-
cardiographs, and other Specialties
Manufacturers of $\.e Coolidge Tube
and complete line of X'Ray Apparatus
524 Medical Arts Building, Montreal
Motor Transportation Bldg., Vancouver
2 College Street, Toronto
Medical Arts Bldg.,Winnipej
A  GENERAL  ELECTRIC
ORGANIZATI O N Accuracy
Is a Habit
Accuracy is a habit which can only be acquired by years of keen concentration. Our
pharmacists are able to concentrate on the
work of dispensing because they are not
obliged to leave the dispensary to wait on
customers in the store.
Nine
Graduate
Pharmacists
Ceovgva
Pharmacy
M4
Granville at CJeortCifc^
Open
All
Night
In pneumonia
Start treatment early
In the
Optochin Base
treatment of pneumonia every hour lost in beginning treatment is to the disadvantage of the patient. Valuable time
may often be saved if the physician will carry a small vial
of Optochin Base (powder or tablets) in his bag and thus
be prepared to begin treatment immediately upon diagnosis.
Literature on request
MERCK & CO. inc.
Railway, N. J* EDITOR'S PAGE
Once in each twelve months we pause in our Editorial labours to
wish our patrons, readers, contributors and advertisers alike, the Compliments of the Season—A Happy New Year. In this, and to partake
also of the blessing, we should include "the Staff" and the Publishers in
gratitude for their exertions and with a lively sense of favours to come.
We can assure our readers that without the heroic endeavours of "the
Staff" this paper would not and could not appear with the regularity
and snap with which, we flatter ourselves, it has hitherto burst monthly
upon a waiting world. We feel guiltily in so doing, that we have grossly
overworked "the Staff," but we continue to look forward hopefully to
the time when the affairs of the Association and the will of the Executive permit us to make arrangements more in keeping with the growing
work and importance of the Society. We can thank the Publishers for
having with patience guided our infant footsteps into the path of editorial
righteousness and for having made us free of the mysteries of their art
and craft.
The language of the printing room is, in some respects, as a familiar
tongue and our knowledge of what can be done in the way of overlooking
errors in proof reading is greatly increased.
Considering the nature of our complex medical 'copy' with its long
words and unfamiliar terms, not to mention the excruciating writing of
some of our contributors we have no fault to find with the compositors
and much appreciation for their ability.
* *      *
We can at this time suitably call attention to the report of the
Committee, printed in this issue, with which Dr. Monro has been prominently associated, on the sort of Health Department which will be required to regulate those affairs in the now greatly enlarged City of Vancouver. What we especially desire to emphasise is that whether the
report be adopted or rejected, modified in whole or in part, the Association has assumed the lead in a public question in which if anywhere it
may be presumed that the special knowledge of the members of the
Society should carry weight.
This, in our opinion, is one of the important functions of the
Association, and in line with the great work it has done in the past on
such community affairs, as Hospitals, the Workmen's Compensation
Board, Health Insurance, Proprietary Medicines, Life Insurance Companies, Education and the like. By our willingness to help the community and the state to solve problems of this sort, we can answer in
a most legitimate way, the accusation so often levelled at the medical
profession that its attitude is one of withdrawal and isolation. There
may be two opinions as to the usefulness and advisability of public lectures or of newspaper articles; on such questions as we have mentioned
and our participation in them there should be but one.
* *      *
The Treasurer will much appreciate it if those members who refused
to accept the drafts recently presented for annual dues and who promised
to "pay direct" will send in their cheques at an early date. Under the
by-laws the names of members whose dues are unpaid on January 1st
will be posted in the Library.
Page  74 NEWS AND NOTES
ai At the regular meeting of the Association held on November 6 th,
Dr. J. Minor Blackford of Seattle, was the speaker of the evening. His
paper on "Some Clinical Aspects of Gall Bladder Disease" will shortly
be published in the Bulletin.
At this meeting Drs. W. L. C. Middleton, G. A. Petrie and W. C.
Whitteker were elected to membership in the Association.
A large framed print of the Council of the Royal College of Surgeons, England, presented by Dr. A. Wynter of Bristol, England, was
accepted by the Association and a vote of thanks sent to the donor.
The picture is hanging in the Board Room of the Vancouver General
Hospital until we move into our new quarters in the Medical and Dental
Building.
A notice of motion re the establishmeent of an Anatomical Section
of the Association was given by Dr. A. C. Frost.
A letter was read from Dr. Routley thanking the members for the
invitation extended to the Canadian Medical Association to hold their
1931 meeting in Vancouver.
The November meeting of the Clinical Section was held at the
Public Hospital for the Insane, New Westminster ,on the 20th of the
month. It was an innovation to have a clinical meeting of our association outside the city. About sixty members motored from Vancouver,
a number going by special bus.    There was a total attendance of 85.
Dr. A. L. Crease, the Medical Superintendent, and his staff, are to be
congratulated on the splendid manner in which the clinic was conducted.
They went to considerable trouble to make it a really interesting evening.
Each case had been carefully chosen and much thought given in the
preparation of each subject. The discussion which followed the presentation by each speaker was evidence of the great interest displayed by the
members.
Our chairman, Dr. Appleby, opened the meeting by calling upon
Dr. Crease, who welcomed us. He then spoke on "Traumatic Psychosis" and presented a very interesting case of a youth who a few years
ago received a head injury. This was followed by a slowly developing
paralysis on one side of the body and a definite psychosis. X-ray following intrathecal injection of air showed the left ventricle to some extent
past the mid-line. Trephining was done and a considerable amount of
straw coloured fluid withdrawn from the ventricle and chromic catgut
inserted as a drain. Due to the operative procedures the doctor was able to
show to us a young man normal mentally and with but slight physical
defect as a result of his injury. This is but one of the interesting cases
shown during the evening. As there were over twenty cases shown it
would occupy too much space to give a detailed description of each. Suffice it to say that any of our members who were unable to be present
missed a rare treat.
Page 75
warn The programme was as follows:
Dr.  A. L.  Crease.-..- . .Traumatic  Phychosis
Dr. Chas. E. Benwell * Dementia Praecox
Dr. Edward J. Ryan . Paranoia
Dr. Louis E. Sauriol   Imbecility and Feeblemindedness
Dr. Benj. H. O. Harry ..Neurological Conditions with Psychosis
Dr. Ultan F. Byrne Manic Depressive Psychosis
Dr. Jas. Edw. Matheson..  General. Paresis
Dr. Arthur M. Gee   l._Epileptic Psychosis
A vote of thanks was tendered the speakers on behalf of the Association by Dr. Vrooman and seconded by Dr. T. Lennie. Dr. Ryan, Assistant Medical Superintendent, replied on behalf of Dr. Crease, and invited
us to return for another meeting, an invitation which will certainly be
accepted by our Association. The meeting was then brought to a close
and refreshments served.
At the regular meeting of the Association on December 4th, the
speakers of the evening were Drs. B. D. and G. E. Gillies. Dr. B. D.
Gillies presented the first paper discussing peptic ulcers from the medical
side. At the outset he drew attention to the apparent rarity of duodenal
ulcers in comparison to ulcers elsewhere prior to 1898 as evidenced by
post mortem reports. The early preponderance which was noted in the
female sex has now been reversed, the greater proportion of ulcers occurring in males. Blood dyscrasias, particularly chlorosis, once considered
as important etiological factors, have now almost disappeared. The theory
that cancer often develops upon the base of an ulcer is apparently abandoned. Supporting this, analysis of a large number of case histories has
shown that the history of symptoms of digestive disturbances goes back
only a few months in practically all cases of cancer. After discussion of
the indications for surgical treatment a series of interesting plates from
the speaker's own practice was shown to demonstrate the end results of
medical treatment. This paper, which was listened to with great attention and interest, was followed by the subject of surgical treatment of
peptic ulcer ably presented by Dr. G. E. Gillies.
Dr. G. E. Gillies said that the proper indications for surgical treatment were considered to be largely determined by skiagraphs and history.
Those cases which did not respond to medical treatment and where pain
is severe called for surgical interference. The case for and against
partial gastrectomy as compared with gastroenterostomy, was gone into
rather fully. The aetiology was further discussed and emphasis laid
upon the role of nervous disturbance and also the fact of chronic appendicitis. The speaker described clearly how in the presence of chronic
appendicitis carmine indigo injected did not follow the normal route
from the lymph circulation of the appendix to the lumbar nodes, but
made a detour by way of the duodenal lymph nodes, thus showing the
route followed by infection from the appendix to the duodenum. The
moral of these points was the necessity of removing the aetiological factors as far as possible before proceeding to work upon the duodenum
itself.
{Continued on page 83)
Page   76 British Columbia Laboratory Bulletin
Published irregularly in co-operation with the Vancouver Medical Association Bulletin,
in the interests of the Hospital and 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.
Volume 3
JANUARY 1st, 1929
No.  1
CONTENTS
Diphtheria Outbreak in a Rural District Ootmar
On the Technique of the Determination of the Specific Gravity
of Urine . Kerr
Note on Bacillus Abortus Infection in Man Pottinger
Editor's Note:
Due to the fact that almost the whole responsibility of the B. C.
Laboratory Bulletin is carried by the staff of the Vancouver General
Hospital Laboratory, where a considerable increase in routine work has
crowded out everything of a progressive, scientific nature, it has been
impossible to publish regularly this year.
During the first eleven months of this year over 27,000 diphtheria
swabs were handled, an unprecedented number; also during this period
there has been an increase over last year of about 10% in the Public
Health work and about 16% in the Clinical work. This laboratory is
being enlarged and rearranged which may relieve the situation sufficiendy
to permit of other than routine work. In the meantime the Bulletin
will be published whenever sufficient material has accumulated.
DIPHTHERIA OUTBREAK IN A RURAL DISTRICT
G. A. Ootmar, M.D., Medical Health Officer, Kelowna, B. C.
In March, 1928, a case of diphtheria occurred in a not densely
populated part of the district, 14 miles from Kelowna. The bacteriological findings confirmed the clinical diagnosis and immediately a search
was begun to locate the origin.
As none of the members of the family had left the district to visit
friends, etc., we could eliminate importation of the case as a source, and
as none of them had paid a visit to other families in the district, except
to neighbours, we had to consider the possibility of one of the family
or of the neighbours being a carrier.
I visited the neighbours, swabbed their throats and when cultures
were still in the incubator, three swabs from children with suspected
throats, etc., were sent in by the attending physicians.    Of the eight
Page 77 swabs I took myself from the neighbours, two were positive, and so were
the three swabs from the throats of the children.
As these three new cases of diphtheria were all in the neighbourhood of the first case we thought we were on the trail of the infection
spread by a carrier. As our Laboratory is not equipped to perform
animal tests we could not prove the virulence of the germs from the
positive swabs we took. Investigating further in the houses of the
neighbours I came to the house of a milkman, or perhaps it is better
to say, to the house of one who delivered milk to the neighbours. Seven
out of nine of that family proved to harbour diphtheria bacilli. Families
in whose houses diphtheria was prevailing got their milk supply from
that farm. Immediately the delivery of all milk, cream or butter from
that farm was prohibited. The farmer was hard to convince that the
source of the epidemic lay in the milk; he said he always took the utmost
care in cleanliness; but when milking, he, a carrier, spit in his hands
to make them slippery. Inspecting the cows, we did not find any lesions
of the udder or teats of the cow which we considered eliminated any
question of the cow being the source of the diphtheria bacilli.
As the number of cases did not increase (in total eleven) we
thought that we had completely fixed the source. Then one morning.
in a far away part of the same district another case of diphtheria was
diagnosed and confirmed bacteriologically. Investigating we found that
there had been no contact with any child suffering from diphtheria and
were nonplussed, but at the end of the interview the father himself
remembered that he had delivered wood to a family living in the infected
neighbourhood ten days before and had stayed in the house to take dinner.
He delivered the wood on a Monday; on the following Thursday there
was a case of diphtheria in the house where he delivered the wood, and
ten days after his visit one of the children got diphtheria. This indicated
a possible connection of this case with those of the milk outbreak. As
the father did not have any complaint of a sore throat after the wood
delivery and swabs from his throat and nose were negative, it was uncertain whether he had become a carrier and ceased to be so within
ten days, or' whether the infection of his child could be due to his infected clothes. Swabs of the other members of the family were negative
too.
As his.children had played with other children and more cases occurred in this! neighbourhood we were afraid-df the spreading of the disease
and resolved to swab all the school children (170). Fifty-seven showed
diphtheria bacilli in nose or throat, of whom twenty-seven showed
evidence of inflammation of the throat.
All carriers were sent home and had to stay home.
In the meantime material for the Schick test had arrived and immediately the test was carried out on all the children attending school,
teachers, janitors, etc., while at the same time the school children who
were at home as carriers were tested.
Every child got a number when it was tested. Twenty-seven positives were found; twenty-six in children attending school; one in a
carrier.
The readings of the test were made after 24 hours, 3 days, and 4
days; 4% of the tentative readings in 24 hours proved to be incorrect.
Page The numbering of the children was done for the following reason:
We had made plans of the class room marking the place of every child
in the class by its number. Years ago, in my native land, Holland, I
had to fight against a diphtheria epidemic in a school of 600 children,
and found that in the beginning of an epidemic the seat of a carrier
•in a classroom was surrounded by seats of children who were suffering
from diphtheria or had brothers or sisters at home suffering from the
same. These children were probably infected by the first carrier; and
either became sick themselves or carried it home to their brothers or
sisters. Here, in this district, we had the same experience. Around the
seat occupied by a school child with diphtheria or of a carrier we found,
in front, behind, to the left, to the right, positive ones (with more or
less negatives between).
One has to work very fast. No time may be wasted because soon
the disease is spread all over the school, and the location of original carriers is impossible.
In the primary division here we found the situation of the class
room as follows. D means a child who has diphtheria or is home on
account of diphtheria in its family. C means carriers and A are absentees
kept home on account of the fear of the parents that the child might
contract diphtheria. Of the three children who were absent the one
between 23 and 24 proved to be a carrier.
c
25
19
14
8
2
31
26
20
15
9
3
C
27
21
16
D
4
33
28
22
D
C
D
34
A
23
17
11
C
35
29
A
D
C
C
36
A
24
18
13
c
All but one of the parents consented to have the positive children
injected with the anatoxine Ramon (diphtheria toxoid) and soon we had
also to arrange for clinics of the Schick test of children of pre-school age.
In one case the Schick test showed induration with an area of one
and one-half inch of redness. The father insisted for very good reasons
on having his child immunized. I consulted the attending physician
and the injections (minute doses) were given without any ill effect at
all.
No fresh cases of diphtheria developed and in May our last case of
diphtheria was out of quarantine.
In September on reopening the school after the Summer holidays,
we swabbed all the carriers again.    No positives were found.
Summary:
1. The disease was spread by the consumption of infected milk.
2. Prompt investigation in the schoolrooms showed that there were
certain foci of infection in the classroom due to the position
in the class of carriers.
3. We found many variations in the proportion of the morphological types of diphtheria bacilli.
Page 79 4. What antitoxin has done in the past to improve the treatment
of the disease it is now doing to improve the prevention of the
disease by detecting susceptibles with the Schick test and protecting them by toxoid immunization.
I remember very gratefully the valuable help of our Public Health
nurse during those so very busy days.
ON THE TECHNIQUE OF THE DETERMINATION OF
THE SPECIFIC GRAVITY OF URINE
Donna Kerr, M.A., V. G. H. Laboratories.
There are two common sources of error in the simple procedure of
determining the specific gravity of urine—one the inaccuracy and inefficiency of the urinometer and two, the carelessness on the part of the
technician.
In taking the specific gravity of routine urines, the following procedure should be adhered to:
The urine specimens are received in this Laboratory in tubes eight
and one-half inches in length and one inch in diameter. The urine tube
should be placed in a steady upright position (usually in a rack). The
urinometer should be thoroughly cleaned (washed in soap and water)
and dried; it is then immersed in the liquid slightly beyond the point at
which it floats naturally and allowed to come to rest before reading. In
reading it the eye should be placed slightly below the plane surface of
the liquid and then raised slowly until the surface first seen as an ellipse,
becomes a straight line;—the reading is the point where this straight
line cuts into the urinometer scale. Even with this care slight errors
may occur through insufficient mixing, changes in temperature and contaminated surfaces (oil). These, however, under ordinary circumstances are negligible.
To eliminate errors due to inaccurate and unsatisfactory instruments,
we test all instruments before putting them into use. Our first difficulty
lay in obtaining satisfactory instruments. The common small sized
urinometers stick to the side of the tube and even when one is dexterous
enough to get it floating it is difficult to read. When the urinometer
sticks to the side, it is possible to get a wide range of readings. This
type we have discarded entirely. Until just recently we have been
using a very accurate instrument, but it is rather large for routine
urines as frequently there is insufficient urine to make a satisfactory
reading with so large an instrument. It makes it necessary to have
the urine tube almost full and even then a reading at the top of the scale
may be difficult. To cover the range of most urines, two urinometers
are required,—one reads 1.000-1.030, and the other 1.030-1.060. The
scale is two and one-half inches and graduated in thirty divisions, making
it quite easy to read.
This year we were fortunate in obtaining smaller urinometers of
the same type. There are again two instruments covering the ranges
1.000-1.025 and 1.025-1.050. These are two and one-half inches shorter
and the scale is one and one-half inches long garduated in twenty-five
Page   80 divisions, making it still possible to read one-half a significant division
which of course is finer than is required for clinical work.
These urnometers are tested as follows:
Four dilute solutions of sulphuric acid were made up intended to
give two readings on each urinometer. The specific gravity of these
were determined by weight for a temperature of 19° C. These were
poured into suitably sized tubes and overflowed so as to have a fresh surface; the temperature was adjusted to 19 degrees and the urinometer
(clean and dry) immersed just below the approximate level at which they
are expected to float. Then they are allowed to come to rest and the reading taken. The tube is again overflowed and the temperature adjusted
and a second reading taken. If the two readings agree within 0.0005 a
mean is taken.    If not, readings are made until the results agree.
Table 1 shows the calculated readings, the observed endings, and the
difference.
Urinometers Ranging 1.000-1.025
No.   Calculated   Observed  Difference   Calculated   Observed   Difference
1    1.0105   1.0105
0      1.0213   1.0216
.0003
2
1.0105
0
1.0210
.0003
3
1.0100
.0005
1.0210
.0003
4
1.0105
0
1.0220
.0007
5
1.0090
.0015
1.0213
0
6
1.0105
0
1.0220
.0007
W$t;        * -e-
1.0105
0
1.0220
.0007
8
1.0105
0
1.0220
.0007
9
1.0100
.0005
1.0215
.0002
10
1.0100
.0005
1.0215
.0002
11.
1.0090
.0015
1.0213
0
12
1.0102
.0003
1.0218
.0005
13
1.0100
.0005       -
1.0215
.0002
Urinometers Ranging from 1.025-1.050
No.
Calculated
1.0308
Ok
jservec
1.0308
1.0305
1.0308
1.0308
1.0310
1.0310
1.0310
i   Diff
erence
0
.0003
0
0
.0002
.0002
.0002
Calculated   Observed   Difference
1.0
95
1.0398
1.0395
1.0398
1.0398
1.0400
1.0400
1.0400
.0003
0
.0003
.0003
.0005
.0005
.0005
Table II gives some readings of an ordinary urinometer, wluch
covers the whole range 1.000-1.050, being considerably smaller in length
and diameter. The whole scale is squeezed into less than one and one-
half inches. Great difficulty was encountered to keep it from clinging
to the side.    However, these readings were taken while it was floating.
Bdge\&l\ Table II.
Calculated
Observed
1.0105
1.0100
1.0213
1.0200
1.0305
1.0300
1.0395
1.0390
1.0105
1.0120
1.0213
1.0230
1.0305
1.0330'
1.0395
1.0410
1.0105
1.0120
1.0213
1.0230
1.0305
1.0330
1.0395
1.0420
Difference
.0005
.0013
.0005
.0005
.0015
.0017
.0025
.0015
.0015
.0017
.0025
.0025
Table I gives readings of twenty urinometers the largest difference
from the calculated value being 0.0015 and that only occurred twice in
the forty readings taken. One showed a difference of 0.001, while the
rest of the readings showed a difference of less than 0.001. Twelve gave
the same readings as the calculated. This was not the case with the
small urinometer,—the largest difference here was 0.0025 and of the
twelve readings eight showed a difference greater than 0.001,—none
were exactly the same. In the ordinary routine urines a difference of
0.0025 would not be of much significance but it is very difficult to
get as good readings with this small urinometer and certainly impossible
when one is required to work rapidly. The length and shape of the bulb
seems to have some effect on whether it floats easily or not. The satisfactory instrument in our experience has a long cylindrical-like bulb
tapering suddenly at the ends.
NOTE ON BACILLUS ABORTUS INFECTION IN MAN
In the recent literature several cases of feVer attributed to infection
of bacillus abortus have been reported.
This organism is usually associated with cattle, producing a condition which the name implies.
It is interesting to note that in this laboratory blood tests were
being carried out on four men from a dairy farm. As an experiment,
agglutinination tests were done using the Bacillus abortus and two of the
men gave positive results, in 160 dilution. One of the men was interviewed and found to have worked among cattle most of his life and
had attended cows that had been attacked with contagious abortion. He
himself had not suffered from anything, the history of which might
suggest the clinical results of infection of the human with B. abortus, i.e.
undulant fever or like conditions.
W. Pottinger.
Page   82 (Continued from page 76)
Indications for and details of the various operative procedures were
then outlined. The speaker was opposed to partial gastrectomy except
when it became imperative for certain reasons or when the ulcer was so
near the pylorus that great sacrifice of healthy tissue was not necessitated.
The operation is one involving high mortality and an unnecessary sacrifice of a large part of healthy stomach tissue. The speaker stated his
series of 150 cases in the last ten years had included all the complications known to surgical literature. Some of these were enumerated and
illustrative cases related. The speaker closed by placing particular
emphasis upon the necessity of after care, since treatment did not cease
with the completion of the operation.
* *      *
The time allotted for business at the meeting on December 4th was
taken up with a discussion of Dr. Monro's report as Chairman of the
Public Health Survey Committee. A special meeting was called to consider this on November 23 rd, but owing to the absence of a quorum
nothing could be done. The report of this Committee is printed in full
on another page of this issue. Considerable discussion took place and
ultimately the plan proposed for immediate adoption was endorsed by
the meeting and the remainder of the report, including the plan allowing
for future development , was accepted as in the nature of an interim
report; the Committee was retained in office to report later to the Association.
The motion re the establishment of an Anatomical section of the
Association was unanimously carried as follows:
"That an anatomical section of this Association be formed with
power to charge members wishing to join such section such initiation
and maintenance fees as may be found necessary."
The following were elected to membership:
Drs. Harold Caple, W. J. MacKenzie, C. J. Roach, D. J. Sweeney
and E. Zito.
Dr. Seldon presented his report as Chairman of the Committee
appointed to enquire into the feasibility of the establishment of three
years of the medical course at the University of British Columbia. The
report showed that such a scheme was financially impossible at the present time.
* *       *
The second meeting of the Osier Reading Society was held at the
Georgia Hotel on November 21st. The first paper on "Syphilis in
Pregnancy" was excellently presented by Dr. W. L. Boulter and gave rise
to much discussion, indicating the wide interest in this subject. The
second excellent paper was given by Dr. A. Y. McNair on the "Evolution
and Involution of the Human Breast."
We congratulate Doctor and Mrs. Hatfield on the birth of their
daughter recently in Grace Hospital.
Page 83 Another defection from the sadly dwindling ranks of bachelors (of
medicine) in the Vancouver Medical Association occurred when Dr. J. E.
Harrison was married to Miss Lucille Stanwood Waugh, a graduate of
the 1927 class of the Training School of the Vancouver General Hospital. The marriage took place at the First Baptist Church on November
22nd. The groom was attended by Dr. E. Hall of Nanaimo, and among
the ushers was Dr. G. O. Matthews. A wedding trip was made to
California and "all points south" as the groom was heard to remark.
Feeling references were made to this event at the Annual Dinner of the
Association on November 29th.
The Eye, Ear, Nose and Throat Section of the Association this
winter inaugurated a new plan to keep the section alive and make the
meetings worth while. Fortnightly luncheons are held in the private
dining room of the Hudson's Bay Company and four speakers, chosen
alphabetically, are notified that they may be called upon for a five
minutes' talk. The subjects must be submitted to the Chairman of the
Section three days in advance of the meeting so that proper discussion
may be arranged. At the meeting on December 14th the section had
the privilege of a talk from Dr. McCool, of Portland, Oregon, on "Some
personal observations on Ophthalmic Surgical Technique. We understand from Dr. Ainley that the attendance at these meetings has so far
been in the neighborhood of 90%.
Dr. M. T. McEachern on his recent visit to Vancouver expressed
unstinted praise and approval of Grace Hospital. Dr. McEachern is in
charge of Hospital Standardization for the American College of Surgeons, and said that as a result of his inspection Grace would certainly
be in the list of approved hospitals for Canada and the United States for
1928. He added that this institution was in the front rank of Canadian
hospitals. The staff organization is most efficient and functioning in a
proper manner for the scientific advancement of the institution and the
best care of the patients.
We would remind our readers throughout the Province that Grace
Hospital has beautifully equipped private maternity rooms for paying
patients, which help to carry the cost of the rescue work carried on in
this institution.
We understand that Dr. R. E. Coleman is resigning his position as
Assistant Director of the Vancouver General Hospital Laboratories on
the 1st of January, 1929, after being associated with that Institution for
thirteen years. It is the doctor's intention to open a laboratory in the
City. We note his resignation with great regret. His keen interest in
his work has helped to build up an institution upon the help of which
we call daily, without, perhaps, much thought of the labour involved
in the demands we make upon it. We wish Dr. Coleman every success in
his new venture.
Page 84 every day
. . . every night!
C^Throughout the year we are always ready
to serve the Physician and his patients.
QCo-operation with the medical profession
has always been one of the fundamentals
of Macdonald's policy.
CJTwo phones and fast motorcycle delivery
guarantees prompt, efficient service.
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MACDONALD'S PRESCRIPTIONS LIMITED
618 Georgia Street West -' Vancouver The Annual Dinner of the Vancouver Medical Association was held
at the Hotel Vancouver on the 29th of November. It was a very successful and pleasant function, as all who attended it seemed to think.
The attendance was fairly large, though we feel that there were many
away whom we should have been glad to see with us. However, it is
proverbially difficult to get a quorum in our meetings, and even the
prospect of a dinner will not attract everyone.
The dinner went with a swing. The programme was ably arranged
by the Dinner Committee, which, under the chairmanship of Dr. E. M.
Blair, worked hard to make a success of its task, a difficult and onerous
one. This Committee deserves great credit for the smooth efficiency
which characterized the whole dinner. The programme of entertainment was evidently to the taste of those present, was not too long, and
those whose duty it was to put it on, did excellent work. Especially
must we mention the genial Commissioner, and his able Counsel, who
have, in one capacity or another, borne the chief load of entertaining us
for so many years. But all were good, and it is a matter for rejoicing
that much new talent was uncovered, a fortunate omen for later dinners.
For the first time, all formal speeches were omitted. We think this
is wise, as neither does the speaker receive a fair return of attention for
the time and labour he expends in preparation, nor do the other parts
of the programme fit well with serious matter. One speech, however,
was made and was the hit of the evening. Combining, as it did, wise
advice with extensive personal experience, it deserves to be written in
letters of gold and hung on the walls of the Library. We refer to Dr.
J. G. McKay's delightful impromptu speech, excellent in matter, as in
manner of delivery and of exactly the right length. We shall hope to
hear from him again.
Financially the dinner was self-sustaining and in fact the final
audit shows a small balance on the right side.
If we may judge by a Christmas card recently received from London, England, Dr. Lewis Smith is still enthusiastic over his trip to
Canada last summer. The card contains a snapshot of the genial Doctor
and Mrs. Smith on the beach at Campbell River with the 53^2 -lb. Tyee
salmon which the Doctor landed during the last day of his visit there,
and his pride is evidenced by the broad British smile. We hope to welcome Dr. Smith in Vancouver again, both as a fisherman and as a lecturer
to our Association.
REPORT OF COMMITTEE-
RE
PUBLIC HEALTH SURVEY of GREATER VANCOUVER
Your Committee appointed May   16 th, to make a survey of  the
Public Health situation in Greater Vancouver, begs to report as follows:
Immediately following the appointment  of  the Committee,  steps
were taken to gather all necessary data and information generally, respect-
Page 8 5 ing the organization and working of Health Departments in other cities.
Early in July, at an interview with Dr. H. E. Young, Provincial Board
of Health, it was suggested that the Committee in preparing its report,
would indicate by a primary plan, the necessary steps required to effect
the amalgamation of the Health Departments of the three units composing Greater Vancouver and a secondary report, outlining the plan of
organization that would need to be developed within the next few years
to meet the needs of the greater city.
A meeting was called early in September, at which the Medical
Officers of Health of Vancouver and South Vancouver were present,
Dr. Blackwood of Point Grey not being able to attend. In addition,
there were present, Dr. Covington of the Rockefeller Foundation, Dr. H.
E. Young, Dr. H. W. Hill, Dr. H. White, Medical Officer to the Vancouver Schools, and Dr. E. D. Carder. At this meeting the purpose of
the survey was outlined and a free expression of opinion took place regarding the various kinds of organization in operation in other cities.
Without entering into details regarding the type of organizations
prevailing in such cities as Montreal, Toronto, Baltimore, Los Angeles
and Berkeley, Calif., the merits of each being fully discussed, it was decided that Dr. F. T. Underhill, with the assistance of Dr. Young and
Dr. Hill, be requested to formulate, first a plan to go into immediate
effect January 1st, 1929, and a second plan which would form the basis
of the organization to be developed for Greater Vancouver in the immediate future.
REPORT BY DR.  F.  T.  UNDERHILL
PRIMARY  PLAN
"In view of the approaching amalgamation of the City of Vancouver and the Municipalities of South Vancouver and Point Grey, when
it will be necessary to take over and co-ordinate the work of the several
Health Departments, I have the honor to give you herein what in my
opinion are the minimum requirements for health services for the whole
district.
In drawing up my recommendations, I have not lost sight of the
fact that there are certain medical services, for which the City pays,
which do not come under the control or direction of the Health Department, nor do I suggest that they should do so at the present time, as
they are separate and distinct services, although under the larger scheme
which I am also submitting to cover the further eventual needs of the
amalgamated area, it may be necessary to include these. They are as
follows:
ROTARY CLINIC FOR DISEASES OF THE CHEST
This is under the direction of Dr. H. A. Rawlings, who is a specialist
in tuberculosis and chest diseases. The Clinic is governed by a joint-
committee of the City Council and the Rotary Club, under a special
agreement entered into at the time the Clinic building was erected.
I would recommend that this arrangement continue for the time
being, with only such changes as will lead to greater co-operation and
follow-up work for prevention as well as cure of this disease.
Page   86 In the larger scheme also submitted, this clinic and its co-relation
with the proposed Bureau of Communicable Diseases should be more
intimate, and probably it ultimately should be incorporated with that
Bureau. Thus the contacts exposed to infection of cases found at the
clinic would come directly under the Health Department and the prevention of the disease as well as its cure be provided. Curative measures
alone provide only for the sick individual without reducing the disease.
Only by preventive measures can the constant inflow of new cases be
diminished and the expense in cash and lives be reduced.
SCHOOL MEDICAL DEPARTMENT
This is under the direction of Dr. Harold White, who is specially
trained in Public Health work. The work of a school medical department is very highly specialized, and it appears to me that, for the present,
it can best be carried out under the Board of School Trustees. In the
larger scheme as designed for the future, this should be entirely a Health
Department matter.
The responsibility for the control of infectious diseases, however,
both in the school and elsewhere, remains and must remain the duty of
the Health Department.
RE BACTERIOLOGICAL LABORATORY
In view of the fact that the Provincial Laboratory at the Vancouver General Hospital is overloaded with work and has no room to
expand, and is therefore unable to carry out all the work required by the
Health Department in the bacteriological examination of samples of
milk and water, I suggest that a small Special Committee of the Council-
elect be formed to discuss with the Provincial and Hospital authorities
the advisability of conducting these examinations in the City Health
Department Laboratory.
CO-ORDINATION   OF   STAFFS
In view of the policy of the various Councils that the employees
already in office in the various districts should be taken care of as far as
possible, all present incumbents, where suitable, who are engaged anywhere in the area in public health work, will be used in whatever capacity
they are best adapted for.
Any additional appointments, however, that may be made, or any
replacements, should be made only on the recommendation of the
Medical Health Officer, with special reference to technical and other
qualifications as already provided for in the Consolidated City By-Laws,
all such appointees to be specially trained and possessed of qualifications
in Public Health work.
To avoid any misunderstanding, I would point out that the following medical services are not the function of a Health Department, which
is concerned with preventive work only and not with the treatment of
disease:
POLICE SURGEON AND INSANITY  COMMITMENTS
These are not the duty of a Health Officer, but require the services
of a physician specially trained in this class of work. The practice has
been to call upon the Health Department for assistance in commitments,
Page  87 and for that reason I suggest that the Police Surgeon be empowered to
engage a specialist in mental diseases as consultant in all cases for commitment to the asylum.
MEDICAL ATTENDANCE  FOR INDIGENT SICK
This now comes under the direction of the Relief Officer and should
remain there. The care and medical attention of the indigent sick is
not the function of a Health Department.
The Relief Officer, by investigation, assures himself as to the circumstances of the sick person and then, if necessary, directs a physician
to make the visit. This feature of the City's medical service can best
be handled by the Relief Officer.
SECONDARY  PLAN
As the City of Vancouver grows in size to a population of 500,000
or more, which may reasonably be anticipated within a short period of
years, it will be necessary to develop a larger and more comprehensive
scheme for the organization of the Health Department so that it will
include all the various preventive services under one head, who shall be
the City Medical Health Officer.
The attached chart indicates in brief how the different branches of
the Department would be organized and the work that would fall to
each sub-head.
Each sub-head would have his assistants and would be responsible
to the Medical Health Officer for the proper performance of the work
allotted to him, and for the duties of those under him.
The sub-departments proposed are as follows:
1. Bureau of Communicable Diseases.
2. Bureau of Child Hygiene.
3. Bureau of Public Health Nursing.
4. Bureau of Laboratories.
5. Bureau of Sanitation.
6. Bureau of Vital Statistics.
No attempt has been made to enter fully into the details of the
duties as it is sufficient, for preliminary discussion, to indicate the broad
outline of the activities which would fall to each sub-head.
I am of the opinion that the principle of operating the Department
from a central authority, as outlined above, is the correct one to adopt.
It is further suggested that the City should be divided into Health
Districts and that a whole time district Medical Health Officer, specially
trained and qualified in public health work, should be placed in charge
of each district and made responsible to the City Medical Health Officer
for the operation of every branch of the work in his particular district."
These plans were laid before your Committee on November 6th,
and after being discussed and some additiojQS-.jpade, the two were approved and adopted by your CommittefScKicrjn? .a ;A
Page. W Your Committee is of the opinion that the plans as presented by
Dr. Underhill, and being the result of a detailed study by experts in
public health work, should receive the endorsation of this Association.
It is the intention of Dr. Underhill, who has been requested by the
Council-elect to prepare a report on the amalgamation of the Health
Departments of Vancouver, Point Grey and South Vancouver, to present
the plans as before outlined, and it will strengthen his hands greatly with
the Council-elect if this Association stands behind him by their endorsation of his plan of re-organization.
Your Committee feels that this is an appropriate time to draw to
the attention of the incoming Council the inadequate salary paid to the
Chief Medical Officer, and which should be remedied at once in view of
the very much increased responsibility that will attach to his office.
The attention of the incoming Council is also especially directed to
the necessity of providing in its budget, and adequate amount to take
care of the necessary development of the Health Services of Greater
Vancouver as outlined in the secondary plan of organization and which
plan should be adopted by the Council as the basis of future development
in this department.
Your Committee also, at this time, desires to draw the attention of
the incoming Council to the fact that Vancouver was one of the first
cities in Canada to appoint in charge of its Health Department, a full
time medical man, qualified in public health work. This has been of inestimable value to the city of Vancouver inasmuch as a very complete
organization has been in operation for many years under the charge of
Dr. F. T. Underhill and which permits of the amalgamation of the
combined Health Services under his direction without unnecessary sacrifice of existing personnel and dislocation of services.
At the various conferences held with the Public Health experts, the
principle was stressed time and time again, that the Health Services
should always be preventive in character and that treatment, in any way,
shape, or form, does not enter into the work of the City Health Department.
Recommendations
This Committee recommends that the time has arrived when the
City Medical Health Officer should be relieved of his duty of supervising
the City cemeteries and that this work should be placed under the Parks
or Public Works Department.
This Committee also recommends that a full time resident Medical
Officer be appointed to the Infectious Diseases Hospitals, his duties to be
fixed by mutual arrangement between the general superintendent of the
Hospital and the City Medical Health Officer and that his salary be paid
by the City.
In conclusion your Committee desires to express its sincere
thanks to all those members of the profession who co-operated and gave
their valuable time and services in assisting in the preparation of this
report.
All of which is respectfully submitted.
(Signed) a. s. monro
s. paulin
A. B. SCHINBEIN
Page 89 B. C. MEDICAL ASSOCIATION NEWS
A clinical meeting of the Fraser Valley Medical Society was held
at the Royal Columbian Hospital on October 23rd, with Dr. O. Van
Etter in charge. This was perhaps the most successful clinical meeting
ever held in New Westminster, seventeen members being present.
■&      *j«      •it
A meeting of the Fraser Valley Medical Society was held on November 9th at the Royal Columbian Hospital, when Dr. J. W. Arbuckle
spoke on "Puerperal Infection." A good attendance was present. It
was decided at this meeting that each member of the local Association
should take an active part in the clinical meetings held each month.
On November 13 th, the Medical Referee and Medical Members of
the Workmen's Compensation Board, Drs. Ney, Bastin and Murphy,
addressed a well attended meeting of the Fraser Valley Medical Society
at the Royal Columbian Hospital, giving some very interesting facts on
the medical work of the Board.
Dr. R. A. Gilchrist has gone to Ladysmith to assist Dr. H. B. Maxwell.
Dr. Wesley Prowd, Radiologist of St. Paul's Hospital, addressed a
well attended luncheon meeting of the B. C. Medical Association on
November 14th, choosing as his subject "Impressions of Recent European
Tour," including impressions of the International Radiology Congress at
Stockholm.
At the close of Dr. Prowd's address, Dr. Wallace Wilson, President
of the Association, who was in the chair, called upon Dr. A. S. Lamb,
of the Provincial Health Department, for a speech. Dr. Lamb had just
returned from Europe the previous day, where he had attended the T. B.
conferences, and his brief impromptu sketch of his impressions and experiences proved most interesting.
Out-of-town doctors present included Dr. H. E. Ridewood of Victoria, and Drs. W. A. Clarke, T. B. Green, and W. J. S. Millar of New
Westminster.
•S* ^' "fc
Dr. J. F. Haszard of Kimberley has been gazetted Medical Health
Officer for Kimberley and district, and Medical Inspector of Schools for
Kimberley, Chapman Camp, Marysville, Meadowbrook, and Sullivan Hill.
*      *      *
The marriage of Miss H. McLeod to Dr. G. A. Lawson of Port Alice
took place on November 31st, the ceremony taking place at the home of
Dr. and Mrs. Lachlan Macmillan, Vancouver.
The November meeting of the Victoria Medical Society was largely
attended, and Dr. R. L. Miller, the newly elected President, introduced
Dr. Theo. Lennie of Vancouver, who presented a paper which dealt in a
most interesting and instructive way with the "Problem of Goitre," dis-
Page 90 cussing the classification and treatment and defining the selection and
preparation of cases for operative treatment. This paper was freely discussed, and Dr. Lennie kindly answered many questions. On motion of
Dr. George Hall a vote of appreciation and thanks was passed to Dr.
Lennie for having come from the mainland to provide such a splendid
evening for the Society.
*      *      *
Dr. E. L. McNiven has recently opened offices in the Union Building, and has established practice in Victoria.
THE MANAGEMENT OF BURNS
READ BEFORE A MEETING OF  THE  OSLER SOCIETY
BY DR. D. M. MEEKISON
INTRODUCTION
Until 1925, no medical man was called to see a badly burned patient
without misgiving, since it was so often a story of death or disfigurement for life. In that year a tremendous advance in the treatment of
burns was made by Davidson of Detroit, with the introduction of tannic
acid therapy. It has revolutionized the treatment, the mortality has been
greatly reduced and the incidence of disfigurement has been appreciably
lessened. A review of the literature in connection with this problem
reveals how the bio and pathological chemist, the pathologist and the
clinician, by their combined efforts and writings have led up to the
institution of such a treatment.
The following paper is based on a review of all available literature
on burns and on the writer's personal clinical experience gained while
serving as Dr. R. I. Harris's house-surgeon in the Hospital for Sick
Children, Toronto. The writer's opinions are his opinions, and the
writer's experiences are his experiences carefully moulded by him in his
capacity as an excellent student and remarkable teacher.
By the system of admissions at present followed at the Hospital
for Sick Children, a particular attending surgeon receives all the admissions of any particular, condition in which he may be interested.
All burns were admitted under Dr. Harris and were directly under his
care. In a twelve year period, there were admitted five hundred and
sixty-seven patients severely burned. The result of a study of such
a. series must be valuable.
DEFINITION
Burns from electricity or chemicals will not be considered. These^
while having much in common with the usual variety, have their own
peculiar problems which we will not discuss. The discussion will be
confined to burns produced by heat either dry or moist. Whichever it
may be, the clinical problem and treatment are the same. A burn may
be defined, then, for the purpose of this paper, as a destruction of skin
by heat. -sadm-a^oV?
CLINICAL  STAGES
First of all let the fact be emphasised that iri dealing with burns
one is not only concerned with  the local lesion.; but with the general
P.(tge°M\ reaction of the organism. With this fact in mind, then, the course of
an extreme burn may be divided into five stages. Each stage is clearly
defined and recognizable. Each presents its own pathology and each its
own therapeutic problem.    In their proper sequence these are:
1. Primary shock.
2. Secondary shock or toxaemia.
3. Sepsis.
4. Repair.
5. Late contractures and deformities.
All burns do not go through the five stages. The burn may be
mild and not show any shock and no ultimate deformity. It may be
severe and the patient dies before toxaemia or sepsis is reached.
The clinical stages and their problems will be considered in turn
and then the question of treatment will be taken up.
shock
The primary shock of a burn in no way differs from the ordinary
surgical shock. It appears within a few minutes and usually lasts from
eight to twelve hours. One finds the usual sub-normal temperature,
small rapid pulse, low blood pressure, cold clammy skin, shallow respirations, and thirst. It rarely causes death and then only in the most
severe and extensive burns.
TOXAEMIA
This phase is the one with which this study is mainly concerned.
In the present state of surgical knowledge it is believed that this secondary shock is due to a specific toxin. This complication is peculiar to
burns, is found in no other surgical condition and constitutes the greatest
problem in treatment, leading as it often does, to a fatal issue. The
onset of toxaemia takes place usually at the end of about twenty-four
hours and lasts from four to five days. The onset is manifested by a
clear-cut group of symptoms—pyrexia (105°), vomiting, muscle
twitchings, and convulsions. They are presumably the result of the
actions of the toxins on the central nervous system. Seventy-five per
cent, of the mortality in burns is due to this toxaemia. Pathologically,
one finds evidence of widespread action of the toxin, in the form of
haemorrhage and focal necrosis. Very careful studies by Weiskotten
in 1919 and Pack in 1926 have contributed extensively to the knowledge
of the pathology. The picture is very similar to that found in deaths
from diphtheria. All the findings can be adequately explained by the
presence of a specific toxin circulating throughout the body and resulting
in damage to nearly all the parenchymal organs of the body. The sup-
rarenals have been especially mentioned in the literature. Macroscopic
damage here is extremely rare, as is the duodenal ulcer so frequently
spoken of in connextion with burns. On the other hand microscopic
degenerative changes in the suprarenals are the rule. Only one case was
to be found in this series of one hundred and thirty-eight deaths in which
there was gross haemorrhage into the suprarenal capsule and a duodenal
ulcer was definite.   This case is being reported by Dr. Harris.
SOURCE  OF  TOXIN
It is now reasonably certain that the burned area is the source of the
toxin.    Bruce Robertson and Boyd produced the toxaemia experimentally.
Page 92 Excision of the burned area within eight hours prevents the onset of
toxaemia. Transplantation of the burned skin to an unburned animal
resulted in toxaemia in the latter;, while the former remained free. Willis
treated a series of eight cases by debridement with prevention of toxaemia.
MANNER OF PRODUCTION AND NATURE
The manner of production of this toxin is hypothetical and will not
be discussed. Suffice it to remark that from the fact that toxaemia
appears slowly, it must be of vitalistic origin. That is to say, the. presence of the burned skin must incite its production in living tissues. If
it were the result of the action of heat on the skin, the toxaemia should
appear at once. The question naturally arises, then, why should not the
presence of dead tissues, such as a gangrenous foot, result in a similar
toxaemia. Two reasons may be tentatively advanced. Firstly, it may be
true that the products of epithelial digestion are more toxic, and secondly
the area of contact of living with dead is much greater in toxic burns.
As far as the nature of the toxin goes, it is believed to be a protein
derivative, probably a proteose.
SEPSIS
The third or septic stage somewhat overlaps the toxaemic. Infection is present in every burn in which there has been any considerable
destruction of tissue. It cannot be treated by applications to keep ii
aseptic. The dead skin moistened by dressings or secretions provides
an excellent medium for bacteria. Locally there is found a foul-smelling
purulent discharge and a recurrence of fever. Septicaemia may supervene with a fatal issue, but sepsis is not a common cause of death. The
septic stage lasts until the sloughs are separated and free drainage is
established. This is usually the end of the second week. In persistent
sepsis amyloid disease may become a fatal complication.
REPAIRS
When the sloughs are separated, sepsis ends and repair begins. There
now remains the ordinary surgical condition of a healing ulcer. This
stage goes on until the ulcer is covered with epithelium. It is here that
the degree of the burn is important (Dupytren's Classification). First
and second degree burns involve no destruction of epithelium and there
is hence no problem of repair. In third degree burns, only the epithelium,
over the tips of the papillae is destroyed while in the valleys between
the epithelium is intact. When the slough separates off, there is to be
found a myriad of tiny ulcers in a sea of epithelium, each of which heals
from its own margin and repair is rapid and complete in a few days.
In burns of the fourth, fifth, and sixth degree, all the epithelium is destroyed and healing, necessarily from the margin of the large ulcer, is
necessarily slow. Contracture of the scar tissue hastens healing by drawing the margins together, but it results in deformities. The scar is produced by the oldest granulation tissue being transformed into scar tissue,
due to the prolonged period of healing. Evidence of this may be seen
in the puckered margin of every deep and extensive burn.
It must not be forgotten that most burns are composite. A fourth
degree burn looks exactly like a third degree, and it is not until the dead
Page 93
H55B skin has separated that the degree may be determined.    When one has a
fourth degree burn, one usually finds areas of all the other milder degrees,
LATE CONTRACTURES AND DEFORMITIES
These occur only in those cases in which the burn has been extensive,
of fourth degree or greater, and in which healing has been slow. Scar
tissue near joints results in contractures. Scar tissue in lax areas results
in great distorting deformities as is seen in burns of the face and neck.
No amount of care during the stage of healing can do more than minimize these deformities. Further, the contracting scar impairs the blood
supply to the thin epithelium which covers it and as a result slight trauma
often produces ulceration in these areas.
TREATMENT
Treatment falls under two general headings. In the first two stages
it is constitutional and in the last three it is local.
SHOCK
The treatment of the primary shock is the usual treatment of any
surgical shock. The surgeon's vade mecum is morphia, while heat and
fluids are his right and left hands. Occasionally transfusion is necessary. Treatment of the burned area should be withheld until the shock
has passed off.
TOXAEMIA
The treatment of the toxaemia is the one that next demands attention. Here, of course, prophylaxis is the key-note. One has an extensive burn. Unless steps are taken to prevent it, toxaemia, frequently
with a fatal issue, is inevitable. In the development of the treatment
which will be emphasised many observations have contributed. The first
clue to its prevention was the result obtained by excision of the burned
area. The result as far as the toxaemia is concerned, is excellent, but
in every other way there are grave objections to its employment. Firstly
it necessitated the use of anaesthesia, contributing further to shock.
Secondly no one has any means at hand, of distinguishing the depth of
a burn, particularly between third and fourth degree. Finally, in burns
about the face, excision of the burned area is out of the question.
Many forms of therapy have been advocated with the idea of fixing
the toxins, depressing enzymatic activity, or constricting the base of the
burn to prevent absorption. Soda bicarbonate dressings as used in Edinburgh were, at the Hospital for Sick Children, very disappointing. These
were supposed to chemically inhibit enzyme activity. The action of
adrenaline as a base constrictor is too evanescent and is followed by a
period of congestion. Absolute alcohol as a fixative is difficult of application and is painful. Picric acid as a fixative, was a step in the right
direction, but it fell far short of being ideal. Alununium aniline has met
with little approval. In the much heralded paraffin protective treatment,
the course of the toxaemia is in no way affected. Where the toxaemia is
well-established, the operation of exsanguination-transfusion of Bruce
Robertson has been of inestimable value. It is virtually a "washing-out"
of the blood stream. It has certain limitations in so far as only a portion
of the toxins are removed, and the highly technical nature of the operation requires it to be carried out in a well-equipped operating room by a
Page  94 competent team of surgeons.    This will greatly limit its use.    Details
of the technique are available in the Archives of Surgery, for July, 1924.
.•:■'■ TANNIC ACID
To Davidson of Detroit must go the credit for the introduction
of the greatest advance-in the treatment of burns that has yet been seen.
One should mention a friend of his, E. C. Mason, of the same city, who
pointed out to Davidson the similarity between tannic and phospho-
tungstic acid in regard to their property of precipitating protein. The
latter was investigating the possible use of phosphotungstic acid as a
coagulant. It was his idea that it might be possible to alter the burned
skin so as to render it insoluble by the enzymes, or at least acted upon
with such difficulty that the elimination of the toxins would be as rapid
as their formation. For this purpose he used tannic acid, the most
powerful precipitant of proteins known. Tannic acid therapy reduces
the toxaemia to an astounding degree. In most cases it prevents it.
The few cases in which it fails to entirely prevent toxaemia are probably due to the mechanical difficulty of tanning a deep burn through
its entire thickness.
SECONDARY  ADVANTAGES
The reduction of toxaemia is the great function of tannic acid, but
there are other advantages of inestimable value in its use. Firstly it
precipitates protein only in faintly acid media. Burned tissue is faintly
acid in reaction. Living tissues are faintly alkaline. Hence it acts only
on the burned skin. Then again, it obviates the use of dressings. The
burned skin is actually tanned to a black, dry, non-sensitive sheet of
leather which effectively protects the underlying living tissues. Until
the slough separates on the seventh to tenth day, no other dressing is
required. Third, all third degree burns and some fourth degree are completely epithelialized when the slough separates. Finally, the leather is a
poor medium for bacteria and sepsis is greatly reduced. These many
virtues establish tannic acid as the best treatment for burns yet devised.
TECHNIQUE
The technique that has been worked out in the Hospital for Sick
Children as the most convenient and effective may be indicated as follows. As soon as possible after admission the patient's clothing is removed and the burned area cleaned with gasoline and ether to remove
any grease that may have been applied.    Blebs are opened at this juncture.
The burned area is then sprayed with a freshly prepared 10%
aqueous solution of tannic acid. This is repeated every half hour for
twenty-four hours by which time the area is usually thoroughly tanned.
The patient lies completely unclothed in what is termed a "burn-bed."
This is simply an ordinary bed covered in with blankets wherein the
temperature is maintained at around 98° F. by a number of electric
lights burning inside.    The patient's eyes are protected from the glare
'Page 9 S of the lights by a curtain. The light bath is an important aid in producing an effective tan, since its drying action produces a firm, parchmentlike sheet of leather. When the stage of sepsis appears at the end of a
week or so, the slough is removed by means of scissors or scalpel. Fluids
are exhibited freely from the onset, intravenously if necessary.
SEPSIS
The most important factor in the treatment of the sepsis is the
removal of the dead skin. This establishes free drainage and the resulting ulcer can be effectively treated with antiseptic dressings. No dressings are of any value over the slough. In all fourth degree burns moisture collects beneath the necrotic skin and becomes infected. From the
end of the first week the slough should be examined daily and loose edges
trimmed off with scissors or scalpel. When the slough has completely
separated, antiseptic dressings are employed. The chlorine dressings
(Eusol, Dakins) have been found to be the most effective.
TREATMENT IN STAGE OF REPAIR
This consists in the use of antiseptic dressings to reduce the infection
to a minimum. In short it is the surgical treatment of an ulcer. When
the wound is clean it is to be decided as to whether skin-grafting will
be necessary or not. All extensive fourth degree burns should be covered
with Thiersch grafts as early as possible. These should be autogenous.
Grafts from donors are a failure, as are whole thickness grafts. Scar
formation is thus greatly reduced. Paraffined mesh gauze tacked to the
margin of the wound supplies the necessary pressure for a successful
"take." Late deformities may be mitigated to some degree in this
stage by maintaining affected limbs in positions of greatest usefulness.
TREATMENT  OF   CONTRACTURES
These occur in certain cases in spite of careful treatment. The only
satisfactory method of handling them is to remove the scar. In some
cases this may be accomplished by excision and saturing of the margins
after undermining. More often it requires the employment of pedicle
skin flaps to the areas from which the scars have been excised.
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