CONTENTdm
History of Nursing in Pacific Canada
Vancouver Medical Association
'Infections of the lung ; Biological products ; Spinal anasthesia.' -- Title page
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Bulletin OF THE f, Vancouver Medical Association Contents Infections of the Lung Biologic Products Spinal Anaesthesia Vol. IX NOVEMBER, 1932. No. Published monthly at Vancouver, B. C, by McBEATH-CAMPBtn Ltd., 326 Pender Street West Subscription. $1.50 per year. .^^ANJMTHEATae BLDG. \^ls|QOUy^ CANADA m -l THE VANCOUVER MEDICAL ASSOCIATION BULLETIN Pa hi nihil Monthly under the Auspices of the Vancouver Medical Association in the Interests of the Medical Profession. Offices: 203 Medical Dental Building, Georgia Street, Vancouver, B. C. Editorial Board: Dr. J. H. MacDermot Dr. D. E. H. Cleveland Dr. M. McC. Baird All communications to be addressed to the Editor at the above address. Vol. IX. NOVEMBER, 1932 No. 2 OFFICERS 1932-1933 Dr. Murray Blair Dr. W. L. Pedlow Dr. C. W. Prowd President Vice-President Past President Dr. L. H. Appleby Dr. W. T. Lockhart Hon. Secretary Hon. Treasurer Additional Members of Executives:—Dr. A. C. Frost; Dr. C. H. Vrooman TRUSTEES Dr. "W. D. Brydone-Jack Dr. J. A. Gillespie Dr. J. M. Pearson Auditors: Messrs. Shaw, Salter & Plommer SECTIONS Clinical Section Dr. A. M. Agnew : Chairman Dr. W. H. Hatfield Secretary Eye, Ear, Nose and Throat Dr. J. A. Smith '. Chairman Dr. A. O. Brown Secretary Paediatric Section Dr. J. R. Davies Chairman Dr. J. H. B. Grant Secretary Cancer Section Dr. A. Y. McNair Chairman Dr. A. B. Schinbein Secretary STANDING COMMITTEES Library Orchestra Summer Scliool Dr. W. H. Hatfield Dr. J. R. Davies Dr- J- w Thomson Dr. H. A. Spohn Dr. F. N. Robertson Dr- c- E- Browi< Dr. D. M. Meekison Dr. J. A. Smith Dr- C H- vrooman Dr. H. A. DesBbisay Dr. J. E. Harrison Dr- J- W- Arbuckle Dr. G. E. Kidd Dr- H- A- Spohn Dr. J. E. Harrison Dr- H- R- Mustard Publications u ... , Hospitals Dinner Dr- J- H- MacDermot Dr. A. W. Bagnall Dr. D. E. H. Cleveland Dr. F. J. Boller Dr. H. H. Pitts Dr. Murray Baird Dr. ^. C. Walsh Dr. A. M. Warner Dr g B pEELE Dr. A. T. Henry Credentials V.O.N. Advisory Board _ . n „ ,, , . Dr. F. P. Patterson Dr. H. H. Caple Rep. to ii. C. Med. Assn. t-\at-k>t t%_ " '»■ n> r Dr. A J. MacLachlan Dr. E. Trapp Dr. G. F. Strong Dr. S. Paulin Dr. J. W. Shier Sicknta and Benevolent Fund - ■ The Prfsident ■— The Trustees VANCOUVER HEALTH DEPARTMENT STATISTICS, SEPTEMBER, 1932 Total Population (Census 1931) Asiatic Population (Estimated) 24 1 Popu 8.0 10.6 7.0 15.7 jber, th, 1 s E 6,593 5,000 Rate per 1,000 162 13 141 318 7 22.0 4 IN CITY Oct 32 to 15 s Case 0 6 0 10 0 8 3 0 0 25 0 0 2 0 ation Deaths—Residents only .. Male 159 Female 159 INFANTILE MORTALF Deaths under one IY— year 1,000 :luded ONT jf age Death Rate—Per births Stillbirths (not in CASES OF C Smallpox - in above AGIOUS August, Cases D 0 13 1 6 0 0 1 4 0 56 1 1 3 0 ) DISEASES 1932 eaths 0 0 0 0 0 0 0 0 0 11 0 0 0 0 REPORTED September, 19 Cases Death 0 0 15 0 0 0 11 0 1 0 11 0 13 0 1 1 0 0 48 11 1 0 0 1 0 0 0 0 1st 932 eaths 0 Scarlet Fever 0 0 Chicken-pox Measles 0 0 Mumps 0 1 0 Paratyphoid 0 Pr>lintnyplit'< 0 Meningitis (Epidemic) 0 1 Encephalitis Lethargica _ 0 3oth products are suppliet in special containers to hospitals and institutions Gardenal In tubes of: 20 tablets 0.10 gm. {\y2 gr.) 30 tablets 0.05 gm. ( % gr.) 80 tablets 0.01 gm. (1/6 gr.) Hypnotic-Sedative Most effective in the treatment of Epilepsy. / Soneryl In tubes of: 20 tablets 0.10 gm. (\y2 gr.) Hypnotic-Analgesic A decided relief for pains, neuralgia preventing sleep. To be preferred to morphine and its derivatives. 1 LABORATORY POULENC FRERES of CANADA, LTD. (Under licence Rhone-Poulenc) For sample and literature: .OUGIER FRERES, 3 50 Le Moyne St MONTREAL Pae.e 21 was JIUMUi m What is Pasteurized Milk? DEFINITION Pasteurized Milk is defined by law as milk heated to 140° to 145° F. for thirty minutes. OBJECT The only object of pasteurization is to destroy the disease germs which are sometimes found in milk. MILK-BORNE DISEASES The following diseases are known to be milk-borne; tuberculosis, typhoid fever, scarlet fever, diphtheria, septic sore throat, foot and mouth disease, dysentery, and other intestinal troubles, especially in infants. To this long list has recently been added epidemic arthritic erythema and undulant fever. Three small outbreaks of infantile paralysis have been traced to raw milk. In the last twenty years over six hundred milk-borne epidemics have been reported on this continent. Who can say how many have occurred unrecognized? Pasteurization spells protection so far as these diseases are concerned. OFFICIAL SUPERVISION Our regulations provide ample authority to insure adequate pasteurization. They also safeguard the cleanliness of milk before pasteurization. Our Civic Health Authorities are responsible for the enforcement of our pasteurization laws. INSPECTION Milk should be inspected even though pasteurized. Pasteurization does not remove the need of sound cows, healthy milkers and clean dairy methods. Milk is subject to official inspection from pasture to pail and from pail to palate. In the last ten years, through inspection, our milk supply has steadily improved. Inspection provides for cleaner, fresher and better milk, but not necessarily safe milk. Raw Milk, however carefully handled, has frequently caused disease. THERE IS NO RECORD OF A MILK-BORNE EPIDEMIC DUE TO PROPERLY PASTEURIZED MILK. ASSOCIATED DAIRIES Limited distributing rich, safe, clean milk Phones: Fairmont 1000—North 122—New Westminster 1445 Just An Old I Georgia Custom Medicine and sick-room necessities may be ordered by the Doctor from his home and delivered direct to the patient's home any hour of the night. Everything the Doctor requires for emergencies is here, ready to go out on a moment's notice. Our all-night service is maintained for.the Doctor's convenience. SEYMOUR 1050 All Day Georgia Pharmacy W IiVi- 777 WEST GEORGIA ST. All Night In congestive heart failure Theocalcin (theobromine'calcium salicylate) Myocardial stimulation and a potent diuretic effect is obtained with 1 to 3 tablets t. i. d. Tablets 7^ grains each, also Theocalcin powder. Literature and samples upon request BILHUBER-KNOLL CORP. 154 Ogden Ave., Jersey City, N. J. Canadian Agents MERCK & Co. Ltd., 412 St. Sulpice St., Montreal EDITOR'S PAGE Within a few days, the Vancouver Welfare Federation, or Community Chest, will open its campaign for funds for next year; and medical men, as well as others, will be asked for subscriptions. There seems to be a wide variety of opinions as to our obligation and responsibility in this matter, and it may be well to consider what these are. It seems to us a pity that the words "Community Chest" are not used as the name of this organization. It would, we think, remind us more clearly of what this organization is really doing. "Welfare Federation" has rather a cold sound to most of us, and while it expresses, perhaps more accurately, the nature of the organization, we are apt to lose sight of the fact that this fund is for the benefit of the community, and is a community effort. We have heard the opinion expressed that medical men can hardly be expected to contribute to this fund—since they are already called upon to do so much free work, and hence are already contributing in a large degree to the social work of the community. This is a very plausible argument, and indeed medical men are doing a large, even excessive, amount of free work. But we feel that there are other angles to the question, and that we cannot altogether escape responsibility by this argument. In the first place, the work of the Welfare Federation is only to a small degree, concerned with matters of sickness and health. The vast bulk of its work is social relief, and prevention of the evils that come from indigency and penury. It cannot give relief in the form of cash, there are other agencies for that purpose, but, as we will all agree, money relief will not begin to solve the problems presented by poverty and destitution. The work of the Federation, through its social workers, in the John Howard Society, in its Family Welfare Bureau, in the children's organizations, in the Preventorium, is all preventive, and so is more than worth-while; it returns dividends to the community, in the money it saves from being wasted on crime, on disease, on delinquency, and so on. Simply regarded as insurance, it is a profitable investment. We, as citizens, benefit by that work, we, as citizens, should contribute to it, if we possibly can. Next, if we have a grievance on the ground that we are to a greater or less extent being exploited, it is a separate question entirely from our obligations to the Community Chest. We can and will, it is hoped, settle this question with the proper authorities, when the time comes, but it does not apply here. Because Peter is picking our pocket, we should not neglect to pay our just debts to Paul. Lastly, there is a selfish argument, but one that is very pertinent in this case. The Welfare Federation is now considering the question of payment of the medical men who do work for its various agencies, and there is little doubt that it intended to make some provision for this in its next year's budget. This is the first time in Vancouver's history, as Page 22 far as we know, that any organization has accepted the principle that medical men doing work in connection with organized charity should be paid, and we should remember this, and be influenced by it, when we are asked to do what we can for the Community Chest. On many grounds then, we should contribute what we can. To many JO ' of us, the burden of contributions may seem impossibly great, but if we cannot possibly, at least let the reasons be the right ones. We are not the only ones asked to make sacrifices, perhaps, it is true, our sacrifices are greater than many must make, but if only those who find it easy to give, do so, the fund will never reach its objective. And that would be a calamity—for this work must be done—and we do not believe it could be done so economically and efficiently by any other organization. ANNUAL DUES Members of the Vancouver Medical Association are reminded that in accordance with the by-laws, drafts will be presented for unpaid dues on the first of November. NEWS AND NOTES Dr. Strong has presented to the Library his copy of the centenary volume of the British Medical Association. The book is by Dr. Ernest Muirhead Little and is an interesting history of the Association for the the years 1832-1932. It contains some beautiful coloured plates illustrating the new British Medical Association House in Tavistock Square, London. The Vancouver Medical Association is not doing too badly itself. We may not have a history dating back a century but at any rate we have pictures, or rather portraits, of thirty-three out of thirty-four past presidents of the Association ready for our centenary volume in 1998. We hope to get a picture of the missing president within the next few weeks. Luckily he is still available for portrait purposes. Trail is thinking of starting a Medical Library. Dr. Bain Thorn was recently a visitor to our Library and was deeply interested in the framed letter of Sir William Osier to Dr. Pearson which hangs in the Reading Room. So much so, indeed, that he is anxious to obtain a copy for Trail. The Library Committee is considering Dr. Thorn's request. Meantime, our best wishes go to Trail. Page Dr. R. B. Boucher, the last of the overseas travellers, has returned to Vancouver. We understand that the reason for this delay on his part was his anxiety to complete his series of "movies" of Viennese life which he was studying with a cine-kodak. We hope that the Association may have the opportunity of seeing these We are glad to learn that Dr. Mason is taking a well-earned rest at home. He is very much better and is said to have expressed his intention of returning to work early in November. Dr. Frank W. Emmons and Mrs. Emmons have come to Vancouver from Rochester, Minn. The doctor is opening an office in the Medical- Dental Building and will specialize in neuro-surgery. Dr. Emmons has been for some years working in the Mayo Clinic under Dr. Adson. He is a nephew of the late Dr. A. S. Monro and Mrs. Monro of Vancouver. A great many of our readers will be delighted to know that Dr. Rin- near Wilson, of London, England, is to be again a visitor to British Columbia next summer, when he will be one of the speakers at the meeting of the Pacific North West Medical Association in July. Dr. Rinnear Wilson is persona grata with the Vancouver medical fraternity, which remembers vividly his delightful lectures on his previous visits. Dr. Dan McLellan has recently returned from a holiday trip in southern waters, and we learn from the daily press that he officiated at an interesting event in which several nationalities and races were inextricably mixed. The papers say an "infant was delivered on the high seas," and we should like to know the age of the infant, and did the doctor hum to himself, "For he might have been a Prooshian, a Frenchman, Turk or Rooshian . . . ."? During the next two or three months, it is hoped that the B. C. Medical Council, in accordance with resolutions adopted by the various medical bodies of the province, will complete its re-organization of the profession; so that, as in the case of Alberta, the Council will become the main body, in control of all medical activities. Our readers will remember the visit of Mr. Hunt, the Executive Secretary of the Alberta Medical Council and the Alberta Medical Association, when he addressed us on ths matter. A brief outline of the changes may be given as follows: the B. C. Medical Council will take over the duties of the B. C. Medical Association, except its educational and scientific work, and will give it a grant annually for these purposes. All legislative work, and such matters as Page 24 industrial medicine, health insurance, ethics and the adjustment of professional disputes or the difficulties of individual men, will be in the hands of the Council. There will be a readjustment of fees, no doubt, but the net result will be a definite saving to the medical man, and, since everyone will be included, a much more representative governing body. Details are now being worked out. LIBRARY NOTES NEW BOORS IN THE LIBRARY Vitamins—A Survey of Present Knowledge—Medical Research Council —1932. A historical introduction mentions that although some twenty or thirty years ago beri-beri and scurvy were well known as deficiency diseases, eight years ago only three vitamins were clearly recognized. Today there are believed to be at least eight. Night-blindness, as one of the effects of vitamin A insufficiency, is mentioned. It is suggested that vitamin A may play a significant part in preventing the development of certain nervous system diseases, as multiple sclerosis. With regard to vitamin D it is mentioned that it is probable that when diets of young children contain a bare minimum of vitamin D, and when exposure to sunlight is limited, then the consumption of larger amounts of cereal may be the determining factor in the onset of frank rickets. A warning is sounded regarding commercial vitamin D solutions, based on standardization by rat units. Vitamin C deficiency as "latent scurvy" is mentioned as a possible element in human dental disease. Vitamin E investigations applied to human fertility are not numerous. Two cases are mentioned where successful pregnancies occurred after four or five previous miscarriages, where the women were treated with wheat grain oil. The report on Vitamin B complex with its three parts makes interesting reading. In discussing condensed milks, it is shown that antiscorbutic potency in sweetened condensed milk is almost identical with that of the equivalent of fresh milk, but that unsweetened condensed milk has lost more than 40% of its vitamin C content. Medical Clinics of North America—-September, 1932—is made up of a symposium on Disease of the Heart. The Manual of Embryology by J. E. Frazer is the latest work in this subject. Page 25 ADDITIONS TO LIBRARY Medical Clinics North America—Boston, New York, Philadelphia and Chicago numbers. Surgical Clinics North America—Chicago, New York, Lahey Clinic and Mayo Clinic numbers. Section of Ophthalmology, A.M.A., for 1931. Diagnosis in Joint Disease. Allison & Ghormley. Transactions American Ophthalmological Society for 1931. Transactions of Ophthalmological Society of the U.R. for 1931. Peculiarities of Behaviour. Steckel, 1925. Sadism & Masochism. Steckel, 1929. Sexual Life of Savages. B. Malinouski, 1931. Cause of Cancer. Gye & Purdy, 1931. Diagnosis of Nervous Disease, 7th Ed. Purves-Stewart, 1931. Tumours of Bone. Geschickter & Copeland, 1931. Treatment of Chronic Deafness. Cathcart, 1931. Section of Laryngology & Otology, A.M.A., 1931. Transactions of American Laryn. Otol & Rhinol, Society, for 1931. Psyllium Seed—the latest Laxative. J. F. Montague, 1932. Genesis of Cancer. Sampson Handley, 1931. The Medical Annual, 1932. Transactions American Otological Society, 1932. Coll. Papers on Eugenic Sterilization in California. Popenoe, 1930. Mayo Clinic Volume, 1932. New and Non-Official Remedies, A.M.A., 1932. Heredity in the Light of Esoteric Philosophy. Dr. Irene Bastow-Hudson. Vitamins—a Survey of Present Rnowledge. Medical Research Council, 1932. Manual of Embryology. Frazer, 1931. Fraud in Medico-Legal Practice. Collie, 1932. Diseases of the Coronary Arteries. Sutton and Lueth, 1932. Diet Manual of St. Mary's Hospital, Rochester, 1932. History of the British Medical Association. E. M. Little, 1932. Text book of Pathology—Boyd, 1932. DIAGNOSIS OF SUPPURATIVE INFECTIONS OF THE LUNG By Dr. Leo Eloesser [Fo rthe following abstracts of Dr. Eloesser's papers, we are indebted to the author himself, who was kind enough to abstract these after he returned to San Francisco, and send them to us. They are therefore authoritative—Ed. ] Page 26 (RESUME) Non-tubercular suppurations of the lung parenchyma may occur as part of the picture of a generalized bacteriemia, especially a staphylococcic one. A blood stained sputum in a profoundly septic patient may awaken suspicions of multiple miliary or larger abscesses. Of more practical importance are the larger single abscesses beginning as an infarct. Embolism often occurs in the second or third week after an operation. The patient complains of a sudden severe pain in his chest which cuts his breath short. Breathing is shallow, rapid and painful. There is a dry hacking cough. The patient is often cyanotic and alarmingly ill. The temperature rises sharply, often with a chill. The affected area of the chest is held rigid; it is dull and the breath sounds here are scarcely audible. The signs are due partly to infarction, partly to a surrounding area of atelectasis. Later the breath sounds may be tubular, accompanied by crepitations and a pleural rub. Soon the patient may cough up bright red blood. Signs and symptoms may disappear or the infarct may suppurate. Fever, sepsis, and cough continue, expectoration is scanty until suddenly an abscess which has been forming may burst into a bronchus, when huge amounts of foul sputum are expectorated. When this occurs sepsis and fever may recede, and the abscess cavity be gradually obliterated. If, however, communication between the abscess and the bronchus is insufficient to permit of proper drainage of the abscess contents, then fever and suppuration may recur at more or less frequent intervals, and the abscess become chronic. The x-ray will show a diffuse density at first; as the lung surrounding the infarct becomes aerated the shadow becomes less dense and smaller, and finally disappears, or after the abscess has broken into a bronchus, shows a cavity with a fluid level. Abscesses occur not only after emboli and infarctions, but also after aspiration of infectious material, e.g., after operations under general anaesthesia, especially those about the mouth and air passages, after submersion in polluted water, etc. A peculiar form occurs in the aged, in diabetics, and in persons with failing circulation, when gangrene is more pronounced and a larger portion of a lobe may slough. Aspiration abscesses and even embolic ones lie at a greater or lesser distance from the surface of the lung, rarely quite reaching it, and are usually covered by a thickened visceral pleura. The gangrenous areas are wedge-shaped, have their base toward the periphery, and are accompanied by an empyema. The cavity of an aspiration abscess or an embolic one contains puttylike inspissated particles of necrotic lung tissue—lung sequestra with a peculiarly penetrating, foul, rancid odor; gangrene presents itself as a soft blackish slough without formation of a true abscess cavity. X-rays are to be interpreted with caution. Apical abscess cavities are not rare and simulate tuberculosis, neither is basal tuberculosis simulating an abscess uncommon. Typical tubercular foci elsewhere in the lung will make a diagnosis of tuberculosis rather than abscess likely. Page 27 Differentiation of secondary abscesses following necrosis of lung tumours, suppurating cysts, echinococcus cysts, actinomycosis, etc., from primary abscess may be extremely difficult but is often not impossible if the various possibilities are thought of. Communicating empyemas and perforating liver abscesses are to be borne in mind. The bronchoscope, x-ray with lipiodol injection, the various laboratory aids, repeated sputum examinations, complement fixation reaction for syphilis and echinococcus, may have various forms, tubular, sacculated, or bead-like. Dilatation may peated search fails to reveal tubercle bacilli speaks against tuberculosis. Sputum containing one organism in pure culture, especially streptococcus, speaks for a perforating empyema, the sputum of an abscess usually contains countless varieties of organisms, often the spirillae and fusiform f acilli of Vincent. Bronchiectasis, a dilatation of the end branches of the bronchial tree may have various forms, tubular, sacculated, or bead-like. Dilatation may be congenital or acquired. Among the acquired causes are stenotic processes in the larger bronchi, foreign bodies, strictures, tumours, etc., and shrinking processes in the parenchyma. If the alveoli intervening between an area of the chest wall and a portion of the bronchial tree are collapsed, it may be that respiratory expansion of the chest wall causes the underlying bronchi to be dilated. Bronchiectasis is a condition, not a disease. Disease and clinical symptoms come with infection of the dilated bronchi. Many congenital cystic lungs remain symptom free. After infection has occurred, long continued cough and copious expectoration are the outstanding complaints. Intermittent attacks of fever, denoting spread of the infection to the surrounding lung (pneumonitis) , interpreted as "grippe," leave indelible traces. The sputum is usually greenish or yellow, has a sickly sweetish smell, and is not infrequently bloody. Profuse haemorrhage is not rare. In chronic bronchiectasis, after repeated bouts of fever, the patient becomes more or less dyspnoeic and cyanotic, and the fingers clubbed. Signs are deceptive; slight dullness with rough breath sounds and coarse rales after cough are sometimes heard, but seldom give indication of the extent of the disease. The x-ray with lipiodol permits of an exact diagnosis—the dilated bronchi are readily filled and made apparent; a normal lipiodol filling excludes bronchiectasis. The bronchus may be entered with a bronchoscope. Two matters of diagnosis are important. Proper treatment demands that the seat and size of abscesses should be accurately determined with the help of an x-ray; the diagnosis should not rest with the inaccurate and usually fallacious one of unresolved pneumonia. Bronchiectasis should be differentiated from tuberculosis by repeated sputum examinations and an x-ray with lipiodol so that bronchiectatics may not be uselessly isolated as contagious. Page 28 TREATMENT OF ABSCESS By Dr. Leo Eloesser (RESUME) Many abscesses heal spontaneously. In the acute febrile stage the patient should be kept quiet, lying, if possible, on the affected side, and certainly not on the unaffected one, in the hope of "establishing postural drainage." Reeping the affected side quiet by having the patient lie on it will often suffice to have fever and toxicity abate, and will help the abscess to localize. Bronchoscopy may be indicated in acute febrile inflammation coming on soon (in two or three days) after an operation, and presumably due to aspiration; it is useless and may be harmful in acute abscesses of embolic origin—(those coming on usually two or three weeks post operation.) Neoarsphenamine may be of use in acute abscesses, especially if Vincent's organisms are demonstrable in the sputum. Artificial pneumothorax may be useful and is not likely to be harmful in the more central abscesses (both acute and chronic). In peripheral abscesses there is considerable danger that artificial pneumothorax may cause the abscess to rupture into the free pleura, a complication difficult to deal with. If artificial pneumothorax is used the needle should be inserted at a distance from the site of the abscess and every effort made not to puncture the lung, for the constant cough of an abscess may propel highly infectious material into the pleura through even a small puncture. If after two or three months of conservative treatment the abscess does not heal then operation should be considered. Operation should not be delayed until secondary pulmonary changes and constitutional danger from sepsis diminish chances of recovery. Operative Technique Sodium Amytal gr. vi, is given by mouth one hour before operation. Morphine gr. % is given one-half hour later, and morphine gr. 1/6 added just before operation if the patient is not drowsy. Under local anesthesia a hockey stick incision is made over 2 or 3 intercostal spaces for a lower lobe abscess, a U-shaped flap with the base outwards for an upper anterior abscess, or an incision straight across the anterior part of the axilla for an upper lateral or posterior abscess. The incision should give ample room. The ribs are isolated from the periosteum and the intercostal musculature incised, care being taken to expose but not enter the pleura. If the lung is not adherent and its speckled surface is seen sliding back and forth under the intact pleura the periosteum is carefully separated from the ribs and a large pack of gauze or paraffin mixture* inserted under them through the intercostal spaces and the wound is closed. The pack is left for two weeks. It compresses the underlying pleura and produces adhesions. It will in time cause perforation of a superficial abscess *Paraffin 52° M.P. ISO; Paraffin 43° M.P. SO; Bismuth carbonate 10; Vioform 0.2. Page 29 into the gauze-filled space. After two weeks the wound is reopened, the denuded ribs resected and a funnel shaped opening made in the lung with a massive Percy cautery. The abscess should lie at the tip of the funnel; if it lies to one side the opening is enlarged until the abscess is widely open. Its contents are aspirated by suction and the cavity is packed with iodoform gauze. The wound is left wide open. The packing remains several days to a week before being changed. The resulting bronchial fistula usually closes spontaneously; if it does not it may be closed by an operation later. Treatment of Bronchiectasis Uninfected bronchiectases unproductive of symptoms need no treatment. At the other extreme lie cases of bilateral bronchiectasis exhausted by repeated bouts of fever and with constitutional changes due to chronic suppuration, which are beyond recovery. In patients the severity of whose symptoms scarcely warrants operation, viz., those without pneumonic exacerbations, without signs of damage to kidney and circulation, and without excessive or foul expectoration, and also in hopeless patients conservative treatment can accomplish considerable. A warm, dry, equable climate, and postural drainage, lying over the edge of the bed with the head down, or lying prone with a pillow under the upper abdomen, at least once a day; creosote; attention to chronic nasal and sinus infections; avoidance of contact with sufferers from contagious respiratory troubles, are important. In patients who suffer from unilateral bronchiectasis with recurrent attacks of fever, whose heart and kidneys show signs of beginning impairment, whose cough and expectoration are disabling and repulsive, operation should be considered. Treatment should begin with careful review of nose and sinuses. The patient should be prepared by several months of sanatorium regime with open air, and rest in bed. Lobectomy should then come into question. Artificial pneumothorax, phrenectomy, and thoracoplasty, fail to accomplish permanent cure. Technique of Lobectomy Artificial pneumothorax is carefully instituted a week before operation, 500 cc. of air are introduced daily or every other day until the chest is under zero pressure. After sodium amytal and morphine preparation, the chest is opened under local anesthesia by a long intercostal incision. If spreading the wound edges fails to give ample exposure an inch of 1 or 2 neighboring ribs is resected. Quiet respiration is maintained after the chest is open. Failing this, gas or a few drops of chloroform must be given. Adhesions if present are infiltrated with novocain, and gently separated with the finger or with the cautery. Bleeding vessels are tied. The lobe is grasped between the index and middle fingers of the left hand and the hilum infiltrated with novocain. Two -large curved clamps are securely applied and the lobe removed with the cautery distal to the Page 30 clamps. The hilum is tied with two stout transfixing silk ligatures and the pulmonary vessels and bronchial stump again ligated separately. The transfixing ligatures are left long, led out of the wound and surrounded with a loosely placed large pack of wide gauze. The wound is dressed with an accurately placed, but not a bulky dressing, and accurately covered with adhesive plaster so as to make it as airtight as possible. The patient is laid in bed on his bad side. The ligatures slough off in two or three weeks. The large pneumothorax is rapidly obliterated. A bronchial fistula results which may close spontaneously, but which usually has to be closed at a later operation. A bilateral lobectomy has been successful; both right and left lower lobes were removed. This and the encouraging results of Shenstone and others show that the operation is no longer too dangerous to warrant consideration. SURGICAL TREATMENT OF PULMONARY TUBERCULOSIS By Dr. Leo Eloesser (RESUME) In general, patients with pulmonary tuberculosis who have not yielded or who are not likely to yield to conservative treatment, the activity of whose tuberculosis is confined or almost confined to one side or to a small portion of both lungs, and whose tuberculosis manifests itself as a steady anatomical progression rather than a steady or increasing failure to overcome toxic symptoms, are likely to be benefited by operation. In many of these pneumothorax will have been tried ineffectually, in others one will have hesitated to induce pneumothorax on account of the slight anatomical involvement, on account of circumstances making pneumothorax impossible to maintain; in still others a previous pneumothorax will have been allowed to absorb and will have proven impossible to re-establish. Pneumothorax is usually effectual in proportion to its completeness. Often adhesions of greater or lesser density hold a cavity or tubercular area distended in an otherwise well collapsed lung. Such adhesions can often be separated by cauterization or coagulation through a trocar opening with a properly constructed instrument—closed pneumolysis. This procedure, first evolved by Jacobeus, has been carried out with great exactitude and skill in a large series of patients by Matson of Portland. The basal portion of the chest can be put at rest to a certain degree by inducing a flaccid palsy of the diaphragm. The paralyzed diaphragm is pushed up by the pressure of the abdominal viscera below and sucked into the chest by suction of the rib cage above. In rising it compresses the basal portion of the lung. Although the diaphragm accomplishes only about one-fifth and the intercostal muscles four-fifths of respiratory movement, phrenectomy or avulsion of the phrenic nerve, with resulting diaphragmatic palsy is often useful in basal tuberculosis. It further comes Page 31 SCIENCE INDUSTRY B. C. SCIENTIFIC INSTRUMENT MANUFACTURERS LTD. 1832-40 WEST GEORGIA STREET Manufacturing and Repairing of Mechanical Electrical Optical Apparatus Medical and Dental Instruments plated and reconditioned. Microscopes a Specialty. TRINITY 1539 Inventors Service Developments Researches Model Making Electro Plating If Others Cannot Do It, Bring It to Us. In response to numerous requests we have recently opened an EXCHANGE DEPT. for the exchange of used instruments. 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Vfl=T©M! t hot or colo '"nicfooo sever*'' Nt*TRACTIONOFHA1' PUBLIC HEALTH BIOLOGICAL PRODUCTS Diphtheria Antitoxin Diphtheria Toxin for Schick Test Diphtheria Toxoid (JnatuJne-Ramon) Scarlet Fever Antitoxin Scarlet Fever Toxin for Dick Test Scarlet Fever Toxin Tetanus Antitoxin Anti-Meningitis Serum Anti-Pneumococcic Serum (Type 1) Anti-Anthrax Serum Normal Horse Serum Smallpox Vaccine Typhoid Vaccine Typhoid-Paratyphoid Vaccine Pertussis Vaccine Rabies Vaccine (Semple Method) INSULIN Price List Upon Request CONNAUGHT LABORATORIES University of Toronto TORONTO 5 - CANADA Depot for British Columbia MACDONALD'S prescriptions limited Medical-Dental Building Vancouver TheT onic Up-To-Date Fresh liver and spleen . . . for bloodbuilding Cod liver oil for its food value Malt extract . . . for its nutritive influence Hypophosphites .... for remineralization combine to make WATERBURY'S COMPOUND Plain or with Creosote and Guaiacol the preparation of choice as a tonic and reconstructive at every age period, at every season of the year. Its palatability is unusual—no oily taste or odor. A bottle of each form is at your service. Shall we send them? qBv Waterbury Chemical Company of Canada, Ltd. 727 King Street West, Toronto. Ont. into question as a preliminary test where thoracoplasty is considered in a patient whose vital capacity is low and whose powers of withstanding the reduction of respiration that a thoracoplasty entails, seem doubtful. I have rarely seen phrenectomy benefit apical tuberculosis. It should not be too lightly considered. Although its immediate risk is negligible, patients with diaphragmatic palsy sometimes complain in after years of digestive disturbances which may be due to this cause. In massive unilateral tuberculosis, thoracoplasty, total or partial, with or without supplementary measures is to be considered. Total thoracoplasty gives the best immediate and perhaps the best ultimate results. The immediate mortality of the operation (i.e., those dying in the first two weeks) has been reduced to 10% or less; the cures and marked improvements are over 50%. After following a large series for years one finds about 1/3 of cure, 1/3 of more or less benefit, 1/3 unimproved or dead; results markedly better than the ordinary life expectancy of pulmonary tuberculosis under conservative treatment. In processes confined solely to the apex, efforts have been made to conserve the lower unaffected portion of the lung by doing a partial thoracoplasty, i.e., resecting the upper 6 or: 7 ribs only, and leaving the lower ones. The immediate results of partial thoracoplasty are perhaps less good than those of total thoracoplasty, whether the conservation of the base as a protective reserve in case of involvement of the other side pays it is too soon to say. Partial thoracoplasty for apical cavities which cannot be cured by pneumothorax on account of extensive adhesions has proved successful when the upper ribs are resected and the basal pneumothorax is maintained after operation. Extrapleural compression by means of a mass of a paraffin wax mix- ture::" introduced between the ribs and the pleura has also been useful both in purely apical processes with cavitation confined solely to one apex, when sacrifice of the intact lower portion of the lung by thoracoplasty seemed inadvisable, and especially in bilateral apical cavities. Although bilateral apical thoracoplasty has been performed for bilateral apical cavities wax compression seems equally efficacious and simpler. In none of 11 cases operated upon in the last two years has the wax been extruded or caused irritation. If simple partial thoracoplasty is unable to close unusually large or unusually stiff-walled cavities, supplementary measures such as anterior rib resection, resection of the whole extent of rib from the spine to the sternum, or supplementary wax compression may be added to complete the effect. Some cavities, however, are so stiff-walle and unyielding that they resist all attempts at compression, pressure on the lateral wall serving merely to push them further medially toward the mediastinum. External drainage of tubercular cavities is almost uniformly disastrous, though certain cases of spontaneous pneumothorax and bronchial *Paraffin 52° M.P. 150; Paraffin 43° M.P. 50; Bismuth carbonate 10; Vic-form 0.2. Page 32 fistula leading into an infected empyema are benefited by external drainage. Cough and expectoration cease and the lung remains entirely collapsed at the bottom of the empyema cavity and the tubercular process comes to a standstill. I wish again to express my appreciation of the cordial hospitality and attention of the Vancouver Medical fraternity as a whole and of many members most particularly. THE PLACE OF BIOLOGICAL PRODUCTS IN GENERAL PRACTICE Dr. K. F. Meyer Dr. Meyer defined vaccines and sera, the former being an active virus capable of producing immunity, the latter being a preparation used to produce passive immunity. The words are frequently wrongly used •but this is the meaning that should be given. Vaccines are used either for prophylatic purposes or for therapeutic purposes. Prophylactic vaccination should only be practiced in diseases of known aetiology. As a rule one aims at the production of a general immunity. The dosage depends upon the rate at which the anti-bodies are produced. As a rule the largest dose giving the least discomfort is employed. The strength of the dose increases with subsequent treatments but it is never necessary to produce violent reactions. Dr. Meyer is doubtful concerning the value of autogenous vaccine for therapeutic purposes. Theoretically this ought to be a correct method but practically bacteria become greatly modified by passage through a host and their virulence is doubtful. The apparently predominating strain may therefore not be the one whose action we desire. Stock vaccines of strong strains are usually better. In giving therapeutic vaccine treatment we must not be timid in our methods. Dr. Meyer urged the use of intravenous administration. Prophylactic Vaccination Dr. Meyer spoke first of smallpox vaccination. "There is only one way to prevent smallpox and that is through vaccination." No other method is of any value as a preventive. However, during the past few years two new developments have given rise to considerable trouble with regard to vaccination. The first is a wide distribution of variola minor and the second the recognition of postvaccinal encephalitis, as an occasional complication. Ever since 1922, epidemiologists have been struck by the mildness of smallpox which is characterized by an almost insignificant mortality among the unvaccinated as well as the vaccinated, and which, while presenting the clinical and pathological characterists of smallpox, only occasionally proceeds after the rash to pustulation. This benign smallpox is generally known as variola minor or alastrim. The harmlessness of this disease and the fact that it is not equally well controlled by vaccination, the fact also that it is often difficult to Page 33 recognize on account of its mildness, has led to a general impression in many places that vaccination is unnecessary and even useless. The real smallpox is as dangerous and as important as ever and still occurs periodically in serious epidemics. Dr. Meyers feels that the time has come when the problem of smallpox prophylaxis should be approached from a somewhat different angle than that of the Public Health administrator. He feels that it should be a problem to be dealt with by the medical profession rather than by formal compulsion, and should in general be administered according to the same principles as toxoid immunization for diphtheria. Compulsory vaccination would be used for the control of smallpox during an epidemic but not otherwise. Routine vaccination should be limited to the infant population. The responsibility for the protection of the individual rests with himself, with his parents or with his physician or medical adviser. In place of compulsory administrative measures, an unbiassed education by the family physician should acquaint the population with the safeguards which the individual or family can obtain by vaccination in infancy. Particularly in view of the problem of postvaccinal encephalitis, this proposal deserves immediate and earnest consideration. Occasionally cases have been noted in Europe since 1905 following the primary vaccination of school children and adolescents, while since 1922 enough cases have occurred to constitute a serious problem and the Committee on Vaccination appointed by the British Minister of Health made a report in January, 1931. In this report the Committee deals with the type of encephalitis that has followed vaccination. Ie seems to be limited to a few individuals of the age group between six and twenty, is rare or non-existent in infants under one year. Holland has had the largest number of cases, but they have occurred in England, Austria, and even a few in the United States. Most cases ^were of school. age. While this complication has obtained wide publicity in the press it is really a very rare occurrence when one considers the vast number of vaccinations done, and the incidence would appear to be decreasing. However, if any case should occur, Dr. Meyer feels that vaccination should be suspended for the time being, unless an epidemic of smallpox is present when the risk is infinitesimal compared to the graver danger of smallpox. By vaccinating children between the ages of two and six months postvaccinal encephalitis can be avoided as has been shown in Holland where the greatest number of cases has occurred. Re-vaccination would appear to be equally safe. This complication therefore, need not be regarded as a serious contraindication to vaccination. Diphtheria Dr. Meyer made a plea for the use of the smear examination in the diagnosis of this disease with a view to saving time by administering antitoxin as early as possible. He dealt with the question of immunizing actively against diphtheria, taking up first toxin-antitoxin, which has now been discarded on account of the danger that may arise from dissociated mixtures, which become highly toxic. Toxoid was developed following the recognition that formalin will detoxicate diphtheria toxin. Toxoid is of course absolutely safe and its use has been attended by no disaster. The Page 34 protection afforded varies from 90 to 100% in various groups which have been checked. Dysentery Dr. Meyer quoted Besredka who has found that oral administration of Shiga vaccine is of value. Typhoid Fever Here the prophylactic inoculations have been of immense value in reducing the incidence of the disease. Typhoid, Dr. Meyer finds, is on the increase in recent years, which is a matter greatly to be regretted, since we have in the preventive inoculation an eminently useful method of prevention. Children react well to the inoculation and might well be treated. It must be remembered, however, that the protection afforded is not permanent and should be repeated at intervals of two to three years if danger still exists. It is important that the vaccine used should give rise to antibodies for both the flagellum and the body of the typhoid germ. Many commercial preparations only give rise to one of these antibodies and from this fact many unsatisfactory results have been obtained, and have discredited the use of the vaccine unfairly. Pertussis Efficient isolation in whooping cough presents difficulties, one of which is the long duration of the illness. The chief means for combat ing the disease, which at the present time exceeds in number of deaths that from diphtheria and scarlatina, are a bacteriological diagnosis and possibly inoculation. Dr. Meyer recommends the use of the "cough plate" as a method of determining when infectivity ends which it does usually during the fifth and sixth weeks. The use of this "cough plate" is simple, quite effective and prevents lengthy quarantine, since the child can be returned to school as soon as the plate fails to show active growth. Three inactive plates are necessary before release of the child. The use of this does a great deal towards prevention of the spread of the disease, since the disease can be recognised early in a coughing child. As regards the use of prophylactic vaccination, there is undoubtedly considerable value in its administration. In an epidemic 2,094 patients were given three injections of vaccine. The mortality rate in a group of unvaccinated children was twelve times as great as in this group. In one district 20% of the vaccinated escaped whooping cough while less than 2% of the unvaccinated escaped. These experiments have been repeated with -similar results sufficiently often to confirm us in the belief that vaccination is worth while, but the vaccine to be of use must be fresh and given in considerable doses at shortish intervals. Pneumonia Dr. Meyer! felt that the results in this disease are very unconvincing. Page 35 mm Scarlet Fever Here the difficulty arises from the fact that we have not proved that scarlet fever is due to a specific streptococcus. Statistics as to the efficacy of active immunization are unconvincing. The administration, as usually practised, is difficult, lengthy and a grave burden to the patient. No simple and efficient method has yet been devised and one cannot prove the presence of immunity. The greatest encouragement has been obtained from the use of formalinized non-toxic Dick toxin-toxoid. This is non toxic, can be injected in large amounts and causes no react ion. Only from two to four injections are necessary, and while it is difficult to assess the degree of protection conferred, enough benefit has been obtained to warrant the continuance of this method which is harmless and seems to offer us the best results Tuberculosis The use of the Calmette vaccine is regarded by Dr. Meyer as unjustifiable. Tragedies have occurred in its use and its value is more than doubtful. Tetanus Dr. Meyer urged that in all injuries received where there is the slightest danger of infection, and where the skin has been broken, antitetanic serum should be given as a routine measure. As regards the treatment of the disease prophylaxis still remains our major remedy. Iodine should be used in wounds rather than any other antiseptic. Mercurochrome is usaless as a prophylactic, and wounds which may conceivably have been infected should always be treated with iodine. Antitetanic serum is an almost certain preventive if given immediately, but is of comparatively little value after the symptoms have appeared. The poison is too potent and too firmly fixed to be controlled by the antitoxin. The wound treatment is of great importance if tetanus should develop. Important in the treatment of tetanus is the recognition of the necessiy for treating convulsions, "If the convulsion due to toxin already in the central nervous system can be controlled we may be able to neutralize the unfixed toxin by the use of antitoxin and the patient may recover." Here we have two conditions to deal with. The fixed toxin causes convulsions and these must be controlled at all costs. Morphia, magnesium sulphate, avertin, amytal and other sedatives are all of value. As regards unfixed toxin, repeated injections of antitoxin in very large amounts are useless and may be dangerous. Probably 30,000 units will be enough and it is useless to hope to prevent or control the convulsion by the use of antitoxin. Common Colds Dr. Meyer is firmly convinced that the use of so-called mixed vaccine for the use of colds is unscientific and borders on quackery. If results appear to be obtained from their use, he feels that this is due to the protein shock and not to any specific production of antibodies. Any protein therapy would be of equal value. Page 36 A RESUME OF SPINAL ANAESTHESIA W. N. Kemp, B.A., M.D. From the Anaesthetic Staff, Vancouver General Hospital, Vancouver, B.C. An effort will be made in this paper to cover briefly the salient features of spinal anaesthesia or subarachnoid block. The subject will be considered under the following headings: (1) Indications and contraindications; (2) Technique of induction; (3) The Physiology of Subarachnoid Block; (4) Operative Complications and their Treatment; (5) Postoperative Complications and their Treatment. (1) Indications and Contraindications (a) Indications—Spinal anaesthesia has been used for operations on every part of the body. However it would seem to be more rational, where anaesthesia of the head and neck is required, to use either some form of local or paravertebral block or a suitable general anaesthesia. A considerable number of surgeons use spinal anaesthesia for thoracic surgery. Here again it is probable that gas-oxygen or avertin and local novocain infiltration are preferable. At the Vancouver General Hospital we have confined the use of spinal anaesthesia to operations below the diaphragm. In this field it is valuable in cases where general anaesthesia may be contraindicated and is of special value in operations for intestinal obstruction, gun-shot wounds of the abdomen, and in orthopedic surgery on, and the reduction of fractures of, the lower extremity. (b) Contraindications—The use of spinal anaesthesia is contraindicated in patients who have suffered from recent severe haemorrhage such as ruptured ectopic gestation cases. R. M. "Waters, Chief Anaesthetist at Wisconsin State Hospital, is of the opinion that a systolic blood pressure over 175 mm. Hg. is a contraindication to the use of spinal anaesthesia. Patients with hyperpiesis do not stand well the drop in blood pressure that often accompanies a spinal anaesthesia. In this respect the locus of the operation would have a bearing on the question of anaesthetic choice. For the amputation of a lower extremity, for example, a low spinal in which there is little disturbance of blood pressure level can be satisfactorily used. Any local inflammatory process in the skin or deep tissues of the lumbar region or any inflammatory condition of the spinal cord or meninges is, of course, a very definite contraindication to the use of subarachnoid block. (2) Technique of Induction Sise, Evans, Labat, Lundy, Waters and other spinal anaesthetists emphasize the importance of the use of a fine rustless needle in performing the lumbar puncture which is done in lumbar interspaces two, three or four. L. F. Sise, of the Lahey Clinic, is the originator of an "introducer," a short sharp needle-like instrument which is used to pierce the supraspinous and infraspinous ligaments and through which the fine 22 gauge spinal puncture needle gains easy access to the meninges of the cord. Page 37 cm Although novocain is the anaesthetic agent usually employed in subarachnoid block there are three modifications of this drug in common use; ,(a) the use of a solution of novocain made lighter than spinal fluid as "Spinocain"; (b) the use of a solution of novocain made heavier than spinal fluid by the addition of glucose or some other sugar; (c) the use of novocain crystals dissolved in spinal fluid itself. We have not used Spinocain at the Vancouver General Hospital. The use of various sugars to make the novocain solution heavy offers no practical advantage over the use of pure novocain crystals dissolved in spinal fluid. The height of the anaesthesia (and muscular relaxation) is principally controlled by the quantity of spinal fluid withdrawn and reinjected: viz., 1 cc. for leg amputation or perineal and anal operations; 3-4 cc. for a prostatectomy or herniorrhaphy; 4-5 cc for an appendectomy; 6-10 cc for a cholecystectomy or a gastric operation . It will be observed that the latter "expansion" (i.e. the volume of spinal fluid withdrawn and reinjected) will, in the later stages of the operation at least, give a cutaneous anaesthesia of the whole body. It is by this method that the so-called high spinal anaesthesias are obtained. The duration of anaesthesia is in direct ratio to the quantity of novocain injected. 150 mg. gives anaesthesia for 30 to 45 minutes; 300 mg. gives anaesthesia for 75 to 90 minutes (approx.). King gives the lethal intrathecal dosage of novocain as 55 mg. per kilo, of body weight. A dose of 300 mg. of novocain for an adult weighing 150 lbs. is accordingly, but one tenth of the lethal toxic dose. The untoward complications of spinal anaesthesia are attributable to the nerve block induced by a concentrated solution of novocain in the upper third of the subarachnoid space, rather than to the toxic action of the drug itself. The preliminary subcutaneous injection of ephedrin in ^4 to 1 grain dosage is commonly advised. Opinion is divided as to its value. Indeed some men are of the opinion that its use is contraindicated at any stage of spinal anaesthesia. Labat stated at a recent meeting of the Regional Anaesthesia Society of New York that he had never used ephedrin in a series of 3000 spinal anaesthesias, and that he was dubious of its much advertised value in spinal anaesthesia. Chen and Meek have shown by electrocardiographic studies that it produces a progressive paralysis of the cardiac conduction bundle with the ultimate production of ventricular fibrillation, in experimental animals in large doses. It is quite possible that in its use in spinal anaesthesia a heart already handicapped by anoxemia or organic disease or both, may be only further poisoned by such a drug as ephedrin. Equally important to the above mentioned objections is the probable fact that ephedrin has no beneficial effect whatever upon the blood pressure of the patient under spinal anaesthesia. Indeed its action in the. presence of the anoxemia that often accompanies spinal block is probably deleterious. The question of posture following the induction of the spinal anaesthesia is of considerable interest. When novocain crystals and volume-control technique as outlined above is used in the induction of the spinal block the subsequent posture of the patient is of little importance Page 38 as far as its effect upon the height of the anaesthesia is concerned. Labat puts all of his patients in the Trendelenberg position immediately following the induction of the block. He argues that he thus insures the blood supply of the vital centres regardless of subsequent fall in systolic blood pressure. In the light of the theory that the drop in blood pressure that so often occurs is largely due to anoxemia, the use of a marked degree of the Trendelenberg position is contraindicated on account of the embarrassment that it adds to an already lethargic respiratory action. A six or eight inch depression of the head and shoulders is of definite value. (3) The Physiology of Spinal Anaesthesia A reasonably sound theory of the physiological action of intrathecal novocain is essential to the intelligent use of subarachnoid block. The commonly accepted theory that novocain produces skeletal and vascular muscular atonia by its action upon the motor (ventral) roots is probably erroneous. The theory outlined by A. I. Willinsky is much more acceptable. He points out that all the phenomena incidental to spinal anaesthesia may be explained by the selective action of novocain upon the sensory dorsal roots alone. This affinity of novocain and cocain and such chemically related anaesthetic drugs for sensory nerve tissue is well known. Years ago Santesson showed that direct contact with 5 per cent, solution of cocaine hydrochloride broke sensory conduction so completely in the sciatic nerve, that the strongest tetanic stimulation peripheral to the treated area was no longer able to produce a reflex, while the same concentration of cocaine left the motor conduction unchanged for at least one hour. The independent experiments of Kochs, Hitzig, and Bernstein many years ago showed that anaesthetic drugs of the benzol group, of which cocaine was the most used, affect almost exclusively the sensory elements in the nervous system. As Willinsky states, "It would be reasonable to postulate from the pharmacodynamic evidence of the elective affinity of the cocaine group for sensory nerve tissues, that the brunt of the action of novocain in the subarachnoid space would be on the roots. From this standpoint alone we are justified in assuming that the tendency of novocain would be that of blocking the posterior nerve roots and permitting conduction through the anterior (motor) nerve roots." What of the paralysis and loss of muscle tone that occurs after spinal block? This is rationally explained by the selective action of novocain for the dorsal roots. Starling was the first to demonstrate the fact that section of the dorsal roots causes loss of muscular tone and paralysis of the related muscles, due to breaking of the reflex arc so essential to tonus and contraction of the muscles.Jw blocking the sensory afferent nerves of the dorsal roots, novocain produces the effect of a temporary section of the dorsal roots with its consequent muscular dysfunction. Sherrington has classified the filaments of the dorsal roots from the functional viewpoint, into three broad groups: (a) Interoceptive fibres — carrying afferent sensory impulses from the viscera. Page 39 (b) Exteroceptive fibres—carrying afferent sensory impulses of pain, touch, heat and cold from the cutaneous surfaces. (c) Proprioceptive fibres—carrying afferent impulses of deep sensation or muscle sense essential to the reflex arc and muscle tone and contraction. Willinsky has shown that if only 40 mg. of novocain, dissolved in 4 cc of spinal fluid, be injected into the subarachnoid space at the level of the 2nd lumbar interspace, anaesthesia of the skin of the abdomen is obtained but there is no loss of muscular tone and no paralysis of the muscles of the lower extremity or the abdomen. As a result of this injection of novocain, the exteroceptive afferent sensory impulses from the skin of the abdomen are blocked but the concentration of novocain is not sufficient to block the most resistant proprioceptive fibres. Ranson by the use of special staining methods has shown that only the proprioceptive fila- aments in the dorsal roots have a myelin sheath. Ingvar has confirmed these findings and they have been accepted by Hauptman. This anatomical fact can explain the relative delay noted in spinal anaesthesia between the speedy loss of cutaneous sensation and the slower loss of deep pressure sense. Clinical experience shows that if 150 mg. of novocain be dissolved in four cc of spinal fluid and be injected intrathecally as in the foregoing 40 mg. injection, not only will there be complete cutaneous and deep anaesthesia of the lower limbs with cutaneous anaesthesia of the ab- doraen,but also a coexisting flaccid muscular paralysis of the extremities and lower abdomen. By the use of 150 mg. of novocain a concentration of the drug in the subarachnoid space is obtained that is sufficient to penetrate the protective myelin sheathes of the proprioceptive fibres in the adjacent dorsal roots and the result is a functional section of those fibres and an inevitable loss of tone and temporary paralysis in the corelated muscle It will be noted that the zone of cutaneous anaesthesia extends to the costal margin or higher while the zone of muscular relaxation only extends to the umbilicus. According to this principle of the intrathecal action of novocain, when 200 to 300 mg. of novocain dissolved in 8 to 10 cc of spinal fluid is reinjected to produce satisfactory relaxation and anaesthesia for a cholecystectomy, there occurs a complete block of exteroceptive, interoceptive and proprioceptive fibres of the lower two thirds of the body and a block of the exteroceptive and interoceptive fibres only in the upper third. This complete loss of cutaneous sensation under the conditions outlined for this operation can be easily proven in the clinic, in other words, this constitutes one of the so-called high spinal anaesthesias under which some ultra-enthusiasts perform tonsillectomies and mastoidectomies. The relative safety of this form of anaesthesia depends upon the fortunate possession of the proprioceptive fibres of the respiratory mechanism of a myelin sheath which makes them immune from the relatively dilute concentration of novocain which is always present in the upper third of the subaracfmoid when the anaesthetic tec/unique outlined above is used. If the concentration of novocain in the upper third of the subarachnoid space is sufficient to block the afferent proprioceptive fibres Page 40 B* C* Pharmacal Co* 329 Railway Street Vancouver, B. C. 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Periodicals
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Medicine--Periodicals
The Vancouver Medical Association Bulletin: November, 1932
Text