THE NOVA SCOTIA MEDICAL BULLETIN

Editor-in-Ch ief Editorial Board Manaqinq Editor DR. lA~ E. PURKIS DR. c. J. w. BECKWITH

Board Corresponding Members Departments D R. I. D. ~1AXWELL Secretaries of Branch Societies ~Iedico-Legal Column D R. D. A. E. SIIEPUARO DR. I. D. ~IAX WELL D R. W. E. P oLLETT Ad vertising D R .\. J. B o oR DR. D. A. E. SHEPHARO

T his issue contains a Symposium on Anaesthesia based on papers presented at t he Atlantic Regional Meetin g of the Canadian Anaesthetists' Society, St . J oh n 's, Newfoundland, September 1967. Coordinating Editor: Dr. David Shephard

Anaesthesia in the Atlantic Provinces

c. 1:. HuoEnsox. ~ID. c:.r. CRCP(C). FACA*

St. J ohn"s, Newfoundland

The pre entation of this ymposium by anaes­ .\dvances in medical cience are progre sing at thetists or the Atlantic Province is in itseif signifi­ such a rapid rate that within the past twenty years can t. It points to the increasingly important role there has been an almost complete change in the ~· hi ch the specialty and its practitioners are playing practice of anae thesia and doctors practi ing in m the medical and urgieal care of patients in thi this field need constant refreshment and renewal. part of the world. The regular attendance at regional and national meetings cannot help but make one appreciate the Tht subjects co,·ered in thi ympo ium are largely nature and rapidity of these changes. For many tho t' presented at the Annual Regional ~ Ieeting of years anaesthe ia was limited to the subduing of the Canadian Anaeslhetists· ociety of the Atlantic patients for surgical inten·entions and very little, Provinces held in t. John's, Newfoundland, last if any, empba is was laid on the proper maintenance autumn. These meetings, or which this was the of phy iological normalcy in the major body systems. ~v('nt h. have been held regularly at various centres \\"ith the coming of a deeper understanding of In the Atlantic Provinces and have grown in stature various body functions and subsequently the man­ OV('r the years both in the quality or paper presented agement of malfunctions it has become necessary and t he number of doctors in attendance. The Cor the modern anaesthetist to become what has merr ber of the joint division s of the Canadian been described as the internist of the operating and .\na('sthetist's ociety in the Atlantic Pro,·inces are post-operative reco,·ery rooms. This is most ob­ happy to present to the members or The Xova 'ions when one considers the great number and co 1a :\l edical ociety this symposium and hope Yariety of surgical and diagno tic procedures now that the ubjects treated are or such a broad nature being carried out on the Yery young, the Yery old a to be of general interest to all readers. and the very ill patient.

From the Department or Anaesthesia. t. John's General Hospital. St. John's, ~ewroundland.

'i'H E ~OVA COT!A MEDICAL BULLET!, 97 JU~E. 1968 Anaesthetists are constantly pre ented with a full might be of some interest to note that a recent re. spectrum of abnormal body fun ction related to the 1-iew of are idency program at the t. John' Gen. disease, the surgical procedure and the drug which era! Ro pita! (Kfld.) reveals that of thirty- c1·en they them eh·es u e to carry the patient through residents who have passed through the program the particular illness and operation. In order to ince 1955 thirty ha1·e continued on in anae the.~ia cope adequately with tbi wide nriety of problem and have been ucces ful in obtaining Certification it i essen tial that the anae thetist be very broadly or Fellowship. or are presently qualified to write trained. AIt bough techu.ical expertise is considered the e examinations. ~lost of the anaesthetist in a sine qua non of the e:-.--pcrt, the indi1·idual must the pro1•ince of Xewfoundland at this time ha1·e had resist the temptation to become a mere technician contact in some way with the training program at and must keep abreast of change in knowledge the t. John's General Hospital but others have un­ and technique and be malleable enough to apply fortunately for us migrated to distant areas where these changes so that they will help to impro1·e the economic and climatic conditions appeared to be care of patient entrusted to him. more de irable. Anaesthesia in the Atlantic Pro1·inces, we belie1·e. Another important aspect of the overall training program in this area has been the series of refresher has kept up to date and in fact certain advances cour es produced by the t;nivcrsity staff primarih· ha1·e been introduced by anaeslhetisls in the first instance. orne of the c were post-anaesthesia for part-time anaesthetists. or to e:-.--pre it mo~ reco1·ery rooms, followed more recently by intensive clearly family physician who do some anaesthesia. care units, inhalation therapy departments and re­ The e courses have been run at least annuallv bv the staff of Dalhousie t;ni1·er ity. and hal'e suscitation teams. In these area the anaesthetist a l~ra~:s has become recognized as a leader and plays a large been popular and useful. The Atlantic Regional role in the teaching of programs for the treatment of ~1eet ing of the Canadian Anaestbetists' ocietv ha en·ed as a refresher course for pecialists in th~ shock, respiratory di order~ and resuscitation to field and bas the added adl'antage of permitting the both medical and paramedical personnel. physicians in volved to meet annually, and thus get . \ rough un·ey of the health department tatistic to know one another's problem . in the Atlantic region re1•eal the urprising fact Furthermore the new medical cbool which is pro­ that approximately two hundred thousand (200.000) gres ing rapidly at the ~Iemorial University of Xcw­ anaesthetics are administered in the four Atlantic foundland will bring ad1·ance in anae the ia edu­ Prol·inces annually. or the e it is estimated that cation in this area. The formation of a full unil·er­ from fifty to sixty percent are administered by fully sity department of anaesthesia and the inception of a trained specialists. These figures would point to full training program in the specialty of anaesthesia the fact that. if we believe that e1·ery patient de­ i being acti1·ely pur-ued and will undoubtedly lead serves anaesthesia supervised and administered by to the pro1·ision of more and better trained physicians fully trained specialists we still have a lot of work for the field of anae the ia. left to be done. Ha1·ing said this, we hould hasten Recent ur1·ey by The Royal College of Physi­ to com mend those of our colleagues doing part-time cians and Surgeons of Canada rCI'eal a large de­ anaestbe ia, who are doing an excellent job. often ficiency in numbers of physicians in the field of under ad1·erse conditions. Tho e of us who for anae the ia in Canada based on a uggested ideal economic and population reasons ha1·e ample scope of one anae thesiologist per fifteen thousand popu­ to practise the specialty full time have a responsi­ lation. This opportunity then should be taken to bility at all limes to encourage part time physician pre ent a plea to those of you who may now be part­ interested in anaesthesia to obtain more training. time anaestheti t . or tudent or interne contem­ For many years in the Atlantic Pro1inces there plating a future career, to con icier coming into this were several indi1·iduals known to many of us who field, which has become a 1-itally intere ting multi· pioneered the specialty of anae the ia. but it was not disciplinary specialty, one which if practi ed at a until about twenty years ago that an organized high standard provides physicians with a most satis­ teaching program was started at Dalhou ie t;ni­ factory form of sen·ice to their patient . Yersity ~Iedical cbool. Graduates of this training In presenting this ymposium it is hoped that a program have made themseh·es felt throughout picture will form highlighting some of the aspects of the Atlantic region and many have settled in distant medical practice with which anaesthetists in the parts of Canada and in fact throughout the world. Atlantic region concern themseh·es. \\"e thank Undoubtedly, they have made their pre ence felt The Medical ociety of X ova eolia for the oppor­ in an upgrading of anaesthetic care wherever they tuu.i ty of presen ling this material and we hope that ha1·e settled. In Xew Brunswick and Xewfound­ light ha thus been cast on the 1-itally important land training programs of a less ambitious nature role played by the specialty or anaesthe ia in medi· ha1·e been going on for about fifteen year , and it cine today. o

THE XOVA COTJA :\rEDICAL BvLLETIX 98 JLl\E, 1008 Problems of Iatrogenic Disease With Special Reference to Anaesth esi ::1 J. \Y. DcxnEE. :\ID. FFARC * Belfast, Northern Ireland

.\<·rt•tion. sepsis, parturition). The e are the ub­ of ,·cntricular fibrillation. ject of the present paper. Their danger lies partly (c) re piratory depression: probably more of in the difficulty in diagnosis. ince many of the e a nuisance than a threat to life; ·•pro­ drug~ have no obviou toxic eUect in the conscious longed curarisalion" has been re­ pall!'nt or el e the complications which they cau c ported in patients who had not re­ arc quite different from those normally associated cei,·ed mu cle relaxants. with their therapcu tic usc. Furthermore, the iatro­ (d) mi cellancou : including convulsions, gemc errects of orne agents may Ia t for a con ider­ pseudo Parkin oni m, ,·omiting and abl( time after their ad mini !ration ha been stopped. the great problem of yet unknown in !'< thi topic fir t came into prominence about 10 reactions. Years ago, many drugs have been incriminated and Drugs the list is still growing. This brief survey cannot be HYPOTEXSIVE AGE:OVTS: Irrespective Of their exact exprcted to di cuss all of them; however, it is hoped mode of action, these drug produce their thera­ that it will show what kind of reactions can happen, peutic effect by a reduction of peripheral Yaseular and how unexpectedly they can occur. As with so tone. Thus it is not surprising to find that their many other medical conditions, when doctors are hypotensi,·e action can be augmented by general aware of the problem. they are well on their way to anaesthetics, all of which produce some degree of its solution, so that awareness of the enormous po­ vasodilatation. Theoretically, the risk should be lenllal of iatrogenic disease should make catas­ greater when thiopentone or halothane are used, trophies le s likely, particularly for the occasional because of their errect on circulating catechol anarsthetist. amines. \\' hile more accident were reported with

'Ouest Lecturer at the Atlantic Regional ~I ee ting, Canadian Anaesthetists' Society, September 1967; Professor of Anaes­ thetics, The Queen's University or Belfast.

THE ~ OVA SCOTIA MEDICAL BULIJE'r!N 99 JUNE, 1968 the early hy])otensi,·e drugs. such as the methonium will be intensified and prolonged by either neo­ compounds. than with more recent preparations, this mycin or streptomycin. may be due to the greater awarene s of the problem \Yhile it is established that Large do es of both today. H must be remembered that the effect of neomycin and streptomycin can cause neuromuscu­ hyvotensive drugs lasts for everal days after stop­ lar block, this is unlikely to occur with the thera­ ping treatment and that their action is increased peutic doses employed in man. However, if the during very hot weather. hould severe hY]>oten ­ patient happens to be suffering from myasthenia sion follow the admini tration of an anaesthetic gravis then muscular weakness may occur. Pa­ given to a patient on hypotensi,·e therapy. the initial tients may not show clinical evidence of the di ease treatment hould be aimed at increasing the blood but fall into the group of subclinical ca e who react ,·olume with dextran. ])lasma. lactate-Ringer's solu­ execs ively to clinical dose of curare. This may tion or blood as required. with recourse to vasa­ explain the une.\:pected happenings in three reported pressors only as a last resort. Great care should be case •. taken in the u e of the latter as some patients may Antibiotic-induced iatrogenic disease is of gen­ show sensi tivity to nor-adrenaline, as occurs in eral interest for a number of reasons. patients who have undergone sympathectomy. (a) It is a type or drug in teraction not previ­ The postural effects of hypotensi,·c drugs must al so ously described in clinical literature. be remembered and considered in the treatment of (b) It is of particular significant to those study­ hypoten ion. ing the effects of new drugs. Early pharma­ ANTIB IOTICS: These are recent additions to the cological studies of one of the antibiotics Li st o! drug incriminated in iatrogenic disease a - suggested that, under appropriate conditions, sociated '''ith anaesthesia and their importance i the drug could augment the action of certain Limited almost entirely to major urgery carried muscle relaxants, but the clinical circum­ out in hospital. In 1956 and 1957 there were re­ stances when this wa likely to occur were ports of fatal apnoea following the instillation of not appreciated. neomycin into the peritoneal cavity1.2. These occur­ (c) The thoroughness with which these anti­ red in patients who had received ether or non-de­ biotics and their effect on anaesthetics and polarising relaxants (drugs of the curare type: muscle relaxants have now been investigated tubocurarine, gallamine) and it is known that a large testifies to the importance attached to iatro­ number of compound can cause myoneural block genic disease. The results have been report­ of the curare type. Thi i long lasting and is po­ ed in journals devoted to surgery. pharma­ tentiated by ethers and antagonised by neostigmine. cology. anaesthe ia, and antibiotics as well In most reported cases apnea was evident at the as in general medical journals. end of anaesthesia or else re piratory depression (d) A review published in 19636 listed I 6 ref­ occurred shortly after the end of surgery. erences to this event occurring since 1956. H is possible to incriminate (at least theoreti­ Now that the phenomenon is understood cally) a large number of antibiotic in these e\·ent . there have been virtually no reports in the They differ greatly in their myoneural blocking past five years. activity. which partly depends on whether they are PHENOTHL<\ZINES: The word Largactil, one of given preoperatively or by the intraperitoneal or the trade name for chlorpromazine. gives some indi­ intrM·enous routes during operation. In the ab­ cation of the multiple u es to which this group of sence of more precise information on the relative drugs can be put. In view of their ''idespread elfects potency of the available antibiotics with respect to on the body one might expect this group of drugs their ability to potentiate the neuromuscular effects to head the list of those im·olved in iatrogenic dis­ of ether or relaxants care should be taken when any ea es. This is not o and it is instructive to con­ of the following are given: neomycin. streptomycin sider some reasons for thi and the possible inter­ sulphate, polymyxin B. kanamycin, viomycin. bac­ actions that can occur. itracin and colistin. Should prolonged apnoea occur Chlorpromazine. probably the first phenothia­ following the rise of any of the e in association with zine to gain wide popularity, was one of the most ether or curare, the eUect of neostigmine (2.5-5.0 toxic. In addition to its oral use in psychiatric mg.) given with the appropriate dose of atropine practice, it was frequently given intravenously by (1.2 - 2.0 mg.) should be tried. Animal experi­ anae thetists when it acute toxic effects were ments' and clinical reports• show that under certain quickly observed and its hypotensive action was circumstances calcium gluconate may succeed in full y appreciated. Anaesthotists placed more reversing the block and restoring respiration when emphasis on the toxicity of chlorpromazine than neostigmine has failed. One must not imagine their surgical, psychiatric or medical colleagues, so that the use of depolarising relaxants will entirely that they were naturally very careful in the manage­ elimina te thi risk since large doses or prolonged ment of a patient on phenothiazine therapy. use of succinylcholine results in a type of neuro­ The preoperative administration of any pheno­ muscular block (dual block: phase two block) which thiazine makes patients more susceptible to the

THE XOVA COTIA MEDICAL BULLETIK 100 JUKE, 1008 hypoten i,·e action of general anaesthetics, particu­ complications a sociated with two new drugs which 7 larly the rapidly-acting barbiturates • They are are becoming increasingly popular in anaesthetic also unduly sensiti,·e to the effects of blood loss. practice and as anti-emetics, viz. haloperidol (Hal­ Thiti appears to apply whether patients are on long dol) and dihydrobenzperidol (Droperidol). These term therapy or receh·e a single preoperative dose as side effects occur less frequently and are less severe routine preanaesthetic medication or as an anti­ when t he drugs are given with an opiate. emetic. Animals experiments point to a potenti­ OTHER TRAKQUli-LIS ERs: The problems or cross ation of barbiturate narcosis by some phenothia­ tolerance with most other tranquillisers is similar to zincs8. but if this were a factor of real importance that for the phenothiazines. Recently attention many cases of delayed recovery should be reported has been drawn to the potentially harmful effects in the literature by now. of some monoamine oxidase inhibitors. These include Algesimetry studies carried out on volunteers overaction of some opiates. particularly meperidine by the author and colleagues show that some pheno­ (D emerol) and ipron·iazid i the tranquilliser most thiazines make patients more sensitive to some pain­ implicated. omc monoamine oxidase inl1ibitors fu l stimuli (so-called "antanalgesic .. effect) and in­ also make patients unduly susceptible to the hyper­ crease the incidence of involuntary spontaneous tensive effects of methamphetamine (~Ieth edrine ) - muscle movements, tremor or hypertonus following and possibly other pressor amines. In t he light of barbi turate induction.uo This effect is so marked pre ent knowledge it is impo sible to predict what following methylated barbiturates, that it is unwi e can occur when opiates or vasopressors are given to to gi,·c promethazine (Phenergan), perphenazine patients on monoamine o:-.idase inhibitors. It is (Trilafon ), fluphenazine ( ~Ioditen ) before induction suggested that, when in doubt, a test dose of one with methohexital (Brevedil) and they must not be tenth of the normal therapeutic dose of the former combined with scopolamine9 . The above effect should first be gi,·en, followed by twice this amount has only been observed following intramuscular in­ if the response to the previous on e is normal, etc. jection of the phenothiazines and is unlikely to occur until the desired effect is obtained. fo llowing their prolonged oral administration. They SEDATrvEs AXD AxALGESICS: These are currently are of clinical importance in anaesthesia for minor prescribed to so many patients, in so great a variety surgery in ambulant patients - often outpatients. of doses and for so many conditions that it would be Here one may prefer methohexital because of its quite impossible to predict all the various iatrogenic brevity of action and some patients may recei,·e conditions that could be associated with their use. As anti-emetic premedication as a result of a history of a compromise these are classified below in the order previous postoperative vomiting. of their importance and related to the method of Chronic administration of phenothiazines - like their administration. tha t of any other sedative - results in tolerance to l. Long term use: their soporific effects and this ma)- cause cross toler­ (a) Cross tolerance to other sedati,·es, including ance to the action of intravenous barbiturates. general anaesthetics; The extent of this ,·aries from patient to patient and (b) Tolerance to curare-type drugs and some­ while it does not always occur anaesthetists must be times sensithity to succinylcholine; aware of the possibility of its happening. About (c) Risk or "withdrawal" symptoms in t he post­ I : 100 patients on long term chlorpromazine develop operative period if opiates are not given, or liver dysfu nction of the obstructive type which may following compounds containing levallor­ result in prolongation of the action of opiate anal­ phan or nalorphine. gesics (including their respiratory depressant ac­ 2. Preoperative use: tion). This can also cause resistance to the nou­ (a) Increased risk of postural hypotension; depolarising relaxants (curare, gallamine) or sensi­ (b) Opiates are a major factor in the aetiology tivity to succinylcholine. of postoperative vomiting; T he extrapyramidal effects, which are most (c) Augmentation of the respiratory depressant common following the use of phenothiazines with a effects of barbiturates; Piperazine side chain, are worth mentioning as the (d) Prolongation of action of succinylcholine advice of anaesthetists may be sought in their di­ if the opiate is combined with tacrine (THA) agnosis and treatment or, on the other hand, they or other anticholinesterases. The latter may may be responsible for their occurrence. The most be the constituents Of some eye drops. distressing effects are oculogyric crisis, restlessness The resistant patient can be best managed by or other dystonic muscle movements and they re­ the preoperative administration of a suitable dose of spond rapidly to the intramuscular injection of 25- opiate or sedative related to their daily require­ 50 mg. promethazine. The phenothiazines most ments. The tolerance to the non-depolarising re­ commonly involved in their occurrence are flu­ laxants is accompanied by a corresponding ease of Phenazine ( ~od i ten ), perphenazine (Trilafon), lhie­ reversal by neostigmine. The other interactions are thylperazine (Torecan) and trifluperazine (Stelazine). easier to avoid than treat and this policy should be Atten tion should be drawn to the occurrence of these followed.

'i'BE KOV A SCOTIA MEDICAL BULLETI N 101 JUNE, 1968 CoRTICOSTEROIDS: Steroid t herapy, with its after­ increase in steroid dosage. An interesting approach math of adrenal insufficiency, may affect the pa­ to this problem has recently been suggested 11 in tient's ability to respond to any severe stress, of which a large single dose giYen every 48 hours which anaesthesia is only one form. It was the does not cause adrenal suppression because ACTH severe hypotension during and after anaesthesia, release and adrenal stimulation occurs in the second sometimes accompanied by respiratory depression part of the 48-hour period. This approach to and delay in return of consciousness, which first therapy certainly has some limitations and patients drew attention to steroid therapy as a cause of with life threatening diseases who require large iatrogenic disease. The administration of any of doses of steroids may not respond to this regime. the corticosteroids can result in adrenal hypofunc­ From the above it will be e,·ident that a few bottles tion. which may persist for up to two years after of 100 mg. cortisol (or other soluble equi,·alent) t he drugs haYe been stopped. Dose does not seem should now be routine in every anaesthetic drug to be important a some degree of impairment has cabinet and anaesthetist's bag. It is safe to gi1·e been detected after a single intra-articular injection se,·eral of these intraYenously, if in doubt. with no of cortisone. This is due to inhibition of the pitui­ fear of a delayed effect on wound healing. tary by tho exogenous steroid. thus reducing the Miscellaneous leYel of circulating corticotropin once the steroid There are a number of other drug interactions therapy is stopped. ACTH t herapy will have a which are either not related directly to anaesthesia. similar effect since it stimulates the adrenal cortex or which occur less frequently than those discussed to produce an excessive amount of cortisol, which in aboYe. These are discussed in detail in recent re­ turn causes pituitary inhibition. views6· 12·13 and are listed below for the sake of com­ In adrenocortical insuffic iency. pat ients react pleteness: to the stress of anaesthesia and surgery by hypo­ (a) AdditiYe hypertensive effects of ergo­ tension (out of proportion to the blood loss), res­ metrine and pressor amines: piratory depression and delay in return of conscious­ (b) Potentiation (often dangerous) of the ness. Different degrees of response are seen de­ sedati,-e effects of barbiturates (and pos­ pending on t he extent of the adrenal hypofunction sibly of some antihistamines) by alcohol; and the se,·erity of the stress. There are published (c) stimulation by phenobarbital of the rate of cases of peripheral circulatory failure de,·eloping breakdown of coumarin anticoagulants during or after anaesthesia in patients who had and decrease in effi cacy so that larger steroid therapy which was stopped for more than doses may be required. The prothrombin one year before operation, and in others in whom the will faU to dangerously low leYels if the treatment continued right up to the day before barbiturate is stopped ; surgery, but in whom the all-important preoperative (d) Loss of potassium induced by thiazide dose was missed. I t has also occurred in patients diuretics which increases the toxicity of who because of delayed recovery from anaesthesia, digitalis and prolongs the action of muscle mis ed the dose they were due at the end of the op­ relaxants ~ eration. It. is worth noting that in many instances (e) Alkalinisation of the urine (as foUowing the operatiYe procedure was a very minor one and bicarbonate administration) decreasing ex­ the period of anaesthesia was n ry brief. cretion of weak bases such as meperidine These catastrophies are easily preventable. and amphetamine and prolonging their Patients on steroid therapy should have the dose action; increased before operation. If treatment has been (f) E nhanced cardiovascular depressant ef­ stopped for some time it should be started again on fects of anaesthetics, particularly of the the day before operation, a double dose being given intra,·enous drugs, by Emetine; with the premedication. In all preoperative visits (g) Adrenergic blockers and an ad verse effect patients should be questioned routinely regarding in the cardiovascular response to stress steroid therapy. Many clinics issue cards stating (or anaesthesia), including blood loss. tha t the patients have had or are receiving steroids (h) Oxytocic drugs, which may contain vaso­ and these should become as routine (and as import­ pressin as an impurity, can cause coronary ant) as cards gi\·ing the dose of insulin. II in doubt, constriction which may be enhanced by in emergency cases, or in comatose patients, one light cyclopropane anaesthesia. may either give a prophylactic preoperative dose (i) Massive blood transfusion, or a large trans­ or else be prepared to give intravenous cortisol if fusion in a hypothermic patient or one unexpected and unexplained hypotension deYelops with liver disease can cause 'citrate in­ during surgery. This should then be continued for toxication', which should be suspected in several days after operation '"ith a gradual reduc­ the presence of an unex-plained rise in tion in dosage depending on the patient's response, central venous pressure and hypotension bearing in mind that an acute respiratory or other with progressiYe cardiac failure. The infection may act as a stress requiring a further treatment is with calcium gluconate or

THE KOVA SCOTIA MEDICAL BULLET!),' 102 JUKE, 1968 chloride. preferably gi,·en undPr electro­ 3. Molitor, H., Graessle. 0 . E., Kuna, S., Mushett, cardiographic control. C. W., and Silber, R. H . : orne Toxicological and Pharmacological Properties of treptomycin. J. f'hq rm,­ acol. t:xper. Thrrap., 86, 151. 19-!6. Com m ent 4. Mullett, R. D., and Keats, A. S.: Apnea and He;;­ It is e\·ident that the mos t hazardous part or piratory lnouffieieney After Intraperitoneal Adminis­ iatr· !.'(enic disease is that preceding the first appreei­ tration of Kanamycin. S11rgtry, 49, 530, 1961. atior of its relation hip to \'ariou drug . T here are 5. Loder, R. E., and Walker, G. F. : :\euromuscular examples of the significance or animal re ults not Blocking Action of Streptomycin. J., ancd. I, 12, 1959. being fully appreciated when unu ual reactions 6. Dundee, J . W. : Anaesthesia Associated with Iatro­ ocr urred in man. as with the antibiotic-relaxant in­ genic Conditions. Chapter in "Recent Admnces in tera<'tions. In t he thalidomide tragedy t he type . l naest~esi~ awl .l nalgesia" 9th edition. p. 324. edited of "hnormal reaction was one not een before in by C. Langton llewer. London. Churchill. 1963. 7. Dundee, J . W. : Safer Intravenous Anaesthesia. Irish clin cal practice. Thus one cannot predict what J. mer/. ci .. 6th ~eri es. p. 12. 1961. iatrogenic disease may hold in t he future - whet her Dobkin , A. B. : Potentiation of Th1opentj)ne Annes­ it bt an interaction wi th an anae thetic. a edati,·e the ia. Comparison of Promethazine, Chlorpromazine, or ~o me quite unexpected complication. Clinical Perphenazine. ~' luphen azine. Thiopropazate, Pipama­ Pha macology and Therapeutics attache so much zine and Triflupromazine. Brit. J . . l naesth .. 32, 42~ . imJ o lance to thi topic a to publi h regular papers 1960. on · Di eases of ~l edica l Progre . " It i hoped 9. Dundee, J . W.: &me Effeet> of Premedication on the tha thi publication will emphasize the type or Induction Characterihtics of Intravenous Anaesthetics. biza ·rr reactions that can occur and make one t hink .! naesthesia, 20, 299. 1965. of ,;orne drug interaction when an unusual response 10. Dundee, J . W., a nd Moore, J . : The Effect of scopo­ lamine on ~ l ethohexi tal Anaestesia. Anaesthesia, 16, dot·,; occur. o 19-l , 1961. 11. Orr, F . R.: Complications of St«.>roid T herapy. .l ppl. References Therap .. 9, 2'H. 1967. 12. Symposium Nu mber 7. Clinical Effeet· of Interac­ I. Prigden, J . E.: Respiratory Arrest Due to lntraperi­ tion Between Drugs. Proc. Roy. oc . .II ed .. 58, 9-13,

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D. A. E. REPHARD, :\IB, B ' DA. CRCP(C)*

H alifax, N . .

The patient who is about lo undergo anaeslhe ia where almost eYery detail of daily routine is dif­ fo a surgical operation is faced ";th an uncertain ferent from that to which they are accustomed''. 2 si t 1ation. It is one which frequently leads lo The urgical floor has also been likened to a foreign an xic t~·, a state which ha been defined as "a specific country. Feelings of strangeness and helplessness unpleasurable state of tension which indicates the augment the feeling of dependency resulting from pn·sence of some danger to the organi m". 1 l\Iuch illnes ; it i not surpri ing that under such circum­ contributes to this uncertainty; the effects of illne stance patient are con fu sed and apprehensi\·e. on the patien t and his life-situation. the reaction to Particularly poignant are the effects of illness and hospitalization, the anticipation of anaesthesia and hospitalization upon children. In Langford's words, surgery. as well a po lopcratiYe discomfort and ··phy ical illne in a child, no matter how trivial,

ility. are all factors which besiege the patient. ha it own unique meaning...... and may be a Th ~urgical experience i a stre which require focu out of which emerge emotional disturbances bo h psychological and phy iological adaptation. of far-reaching significance".3 All children appear Preoperative anxiety is often accepted as being to show at lea t minimal reactions to the experience pa t of the reaction to urgery, and it is assumed of ho pitalization. that of overt anxiety being com­ tha most patient overcome this a peel of their monh· ob erYed. dis. bili ty. llowe\·cr, eYen uperficial contact with (3). JGXIFIC.\:\CE OF GRGERY. The Surgical patil•nts demon trates not only the wide range in patient ha a particular concern, that of "mutila­ in tPn~ily of their anxiety (extending from the pa­ tion". Deutsch has stated that the patient views lieJ t. so terrified of anae the ia and urgery operation a a bloody attack; her explanation for th;, he refu es to ubjecl him elf lo an operation. anxiety formation i that old fear of ca tralion or to he patient who apparently i unconcerned) but parturition anxiety are mobilized. • ~lore accept­ also the kaleido copic pattern of individual fear and able to man) perhaps would be the reali tic contri­ fan a~ies which giYe ri e lo lhi anxiety. Apparent bution of Titchener and Ledne, who emphasise al ~o '" the patient' gratitude for inlere l e\·inced by the special meaning of operation such a ma lec­ thl· :•nae lheli l on his preoperali\·e \'i it; his rea - tomy, hysterectomy and orchidectomy.~ They ex­ sur· nee is beneficial. and indeed the patient's re­ plained that "emotional reactions are .. . .. quite action to anaesthesia and surgery may be influenced specific for the individual and the exl)criencc he is from this moment. undergoing·· and sugge ted that " this i further It i the purpose of this article to empha ize reason Cor a deeper cruliny of sw·face emotional SOlllf significant aspects of anxiety. a condition per­ reaction .. . urgery therefore creates an intrinsic hap~ considered intangible and in ignificant by and special source of anxiety which is related to the many physicians, ~· ct of greater reality to the patient p ycho exual development of the individual. than some of the more concrete a peels of urgery. (4) FE.\RS .\SSOClATED WITH .\X.\ESTHESL\. Origins of A n xiety imilarly. the concept of anaesthesia creates an RE.\CTJOX TO ILLXESS. The ick person de­ intrin ic source of anxiety. Preoperative inter­ Yelops change in his per onalit~· and hi view of the \ciews lap a rich vein of fears and dislikes as ociated world becomes very different from that of the with anaesthesia, which often extends into the deep­ healthy. Illne means disability: and this in it elf er strata of the p yche. Repre eutative attitudes leads to apprehension and anxiety. Anxiety al o were readily di covered during a si:~: -month period re u ts from the effects of illness on the total life- of ob en·atiou (Table 1). \Yhile it is unnecessary ituahon; worry about the family, about employ­ here to detail these altitudes, the information gath­ ment and earning ability affect the patient, as do ered merits orne eli cussion. mon obYiou factor such as concern over diagno i (a) The variety of attitudes reflects the fre­ and fc.ar of pain. quency of preoperative anxiety. For each (2 RE.\CTIOX TO 11 0 PITALIZATION. It is ea .Y patient, the experience of an operation is for those who work in ho pitals to forget that hos­ unique, an eYent of a lifetime, while for Pitals haYe their own environment; that, as Ken­ the anae lhetist and the surgeon it is ned~ has written: ''..\dmi ion to a ho pi tal ward in­ merely one more job. The patient's fears Yah s for mo t patient translation into a world are real and demand attention.

r'rom the Departments of Anaesthesia, Dalhousie University and Halifax Infirmary, Halifax.

'I'H E KOVA SCOTIA l\IEDICAL BuLLETIX 107 Jli1\E, 1968 (b) However fantastic such fears may seem, dea th under anaesthesia. There have been many they are often founded upon a rational reports of patients, often apparently healthy and basis. Tho person who fears anaesthesia young a nd requiring but simple surgery, who have because of some earlier suffocative e:..-peri­ died at induction of anaesthesia or soon afterwards, ence with a mask; the patient whose fear in which one etiological factor was that of fea r. originated in his ha,ing been told '·we tephenson remarked that "Ca es of cardiac arrest nearly lost you·· owing to tongue-obstruc­ in which the patient expressed a tremendous amount tion ; the one who worried about not wak­ of terror at the onset of induction have been noted ing after an operation , having slept un­ frequently". 6 EckenhoCf also declared that "The duly long after a previous operation; and markedly apprehensiYe patient is a potential candi­ the person who remembered being awake date Cor death in the operating room'"; he told of but paralyzed during earlier surgery: "four patients who died during or immediately alter these patients had quite explicable anxiety. operation having e,·inced marked preoperatiYe (c) Equally worrisome for patients appeared apprehension· '. 7 to be certain attitudes which could be con­ V\nat evidence is there that preoperative appre­ sidered part of the " mythology" of anaes­ hension might cause the most serious of all organic thesia. Deutsch has pointed out that derangements, namely cardiac arrest? The fright­ anaesthesia, like loss of consciousness, ened or anxious person shows evidence of many represents a going away of liie, and hence physiological changes; the most significant affect leads to a fear of death. • The e:..-pression the endocrine, cardiovascular and nerYous systems. "being put to sleep" may be equated with (1) T HE E~ D OCR I NE SYSTEM . that fatal step, albeit performed on ani­ The iniluence of the pituitary and adrenal mals. Patients are aware that death does occur in the anaesthetised indi,idual: glands in the reaction to stre s wa emphasised par­ ticularly by Cannon and elye. Cannon. half a stories and film ed scenes often underline this. An awarene s of death as a possi­ century ago, showed that adrenaline is important in the body"s adaptation to stres , and since then, bility is not far beneath the urface: this the correlation between the secretion of catechola­ was illustrated by the patient who re­ mines and variou s types of stress has been confir­ marked to his surgeon. just before con­ med ; for example. preoperatively, levels of cate­ sciousness was lost. " If I die, I'm going catecholarnines may be abnormally high. 3 The catc­ to come back and haunt you··. cholamines haYe especial relevance to preoperatiYe TABLE anxiety and anaesthesia, which Le,·y·s work in con­ Fears and Dislikes of An aesthesia nection with deaths under chloroform first under­ 1. Not going to sleep lined; an association was found between light chloro­ 2. Waking during operation: (a) Awake and paralyzed (b) In pain form anaesthesia in cats, in jection of adrenaline. 3. ~ot waking afwr operation: (a) Fear of death and Yentricular fibrillation.' Moreo,·er, any factor 4. Heart and lungs not strong enou~h increasing cardiac work. such a ensory stimula tion, 5. Loss of self-control: (a) Participation vs. passivity (b ) ··Secrets" being gi,·en away injection of adrenaline, a change from deep to light (c) Shameful behaviour anaesthesia, as well as excitement, could precipilat() (d) Interference - ""bad things an arrhythmia. H is now realised that certain hap~n" - puniShment hydrocarbon inhalational agents may cause cardiac 6. Body exposure arrhythmia by sensitizing the heart to the action of i. uffocabon mells, sights, sound>: (a) ··Lights and flashing endogenous or exogenous catecholarnines. Price kni'"es" in O.R. has indicated that ··A primary increase in cardiac (b) Hospital and antiseptic rate, no matter how caused, can produce serious atmosphere 9. Keedles disturbance of cardiac rhythm during anaesthesia 10. Miscellaneous sensations: (a) Aura of music at induc­ producied by certain agents, particularly cyclopro­ tion pane, tirchlorethylene, halothane and chloroform";10 (b) Sadness - thoughts or family at home and since fear is one cause of tachycardia, cardiac 11. Spinal and other regional techniques arrest may be related to the endogenous release of 12. Postoperative sequelae: (a) Vomiting (b) Alteration of personality adrenaline in those who are apprehensive before Effects of Anxiety operation. When a patient is terrified that he will not sur­ (2) T HE C.\RDJOVASCULAH YSTEl l. 'ive anaesthesia and surgery, the question arises as Cardiac work is increased in an:..;ous patients; to the effects of this state of mind upon the course of increases in cardiac output, arterial pressure. heart anaesthe ia. For since the day when poor fright­ rate and usually peripheral resistance and oxygen ened Hannah Greener found a place in history by consumption have been found. Certain types of being the first person to die under chloroform anaes­ peripheral vascular activity are also associated with thesia, fear or fright has been involved as a cause of anxiety, as indicated by digital plethysmography.

'I'TTF: KOVA SCOTIA )1EDICAL BULLETI~ 108 JUNE, 1968 Jt •s therefore not surpri ing that abnormal electro­ Per·onality factors would seem from general cardiographic patterns haYe been di CO\'ered in prr­ l:'xperience to be important. While attempts to find op(·ratiYe patient . Arrhythmia are commonly ob­ a relationship between phy iological factor and sern•d in anxiou patient . and in the surgical pa­ patient re ponse to surgery under anae the ia have tient the e may disappear alter induction of anac - been made, it is doubtful wheth('r we can elaborate th• ,-1a . Howe,·rr. some ECG change may persist. on what Crampton. year ago. said: "The patient's In one study or apparently healthy patient . who mentality undoubtedly affect anaesthe ia. "--e can had normal ECO patterns before their being in­ render a patient unconsciou in a matter of seconds. form<'d of impending surgery. abnormal patterns but '·frigh tened'' respiratory, cardiac and spa - drn•lopcd immediately before induction of anac - modic effect may persist afterwards . .. .'''7 th(·,-ia .11 'rhe e were similar to tho e of coronary Manage:nent of t he Anxious Surgical Pa tient insufficiency: incc the technical condition for re­ A ''deeper scrutiny of surface emotional re­ <'01 ling were unchanged. and a drugs were exclud­ action .. should be made for sc,·eral rea on : ed from this study. the finding were attributed to (l) A far as the illne s and the operation are pn'OperatiYe fear. ~ L oreo,·er. although in mo t the concerned. au explanation of these is im­ ECG became normal either immediately after in­ portant. Thi i not to ay that detailed du!'lion or wit hin 24 hours, in three ca e the ECO account of surgical technique or pathology had not returned to normal e,·en after 24 hours. are desirable; but accurate information. 'l'ht·"<' author concluded the "Death from anae - however brief. will di pel orne concern and th(·,-ia as well a during anae the ia should. there­ will prepare the patient for postoperative for• , at least in ome ca es. be considered as the tresse . Patients ju tifiably complain of l?:>. tn•mc outcome of an otherwise usual fear-reac­ lack of information. tion . ... . increa ed by the excitement whiJI? under (2) Preopcrali,·e anxjety may be a sociated with th t• anae the tic. .. abnormal beha,·iour during induction and There i . therefore, circum tantial e,·idence to maintenance or anae the ia. orne of thi SUJ oorl the idea that fear may be a factor in other­ ha been mentioned. Eckenhoff ha hown wi,- unexplained cata trophes. \"ot only may the that preoperati,·e up et. due to lack or cardio,·ascular system be the target or efreclor proper preparation or edation, may lead to organ in anxiou . con ciou patients. but aloin the problems at induction such as cyanosis, patit>nt anae thcti ed with the o called "sen itiz­ struggling. ''omiting, and respiratory ob- in ~" agent . it i ubjeet to further train by ,·irtue truetion. '8 or the potential hazard or circulating catechola­ (3) Preoperati,·e anxiety may al o be followed m mf·~ . by a poor po toperati,·e course. In children :l) 'I' HE N Ell\' OUS YSl'EM. having otolaryngological operations, un­ The influence of the higher centres and per on­ satisfactory premedication and induction a lit~, quite apart from the relation of the central of anaesthesia wa a ociated with a high ncrvou· system to the endocrine and cardio,·a cular incidence of per-ouality change .'g And in sys m . is manife l in many way . Difference orne anxiou adults a poor reco,·ery from IX' v een patient - between tho e who are well-pre­ operation may be obsen·ed. pan d inwardly and tho e who are a "bundle of (4) incc an ex perience like forceful induction nl'rYCs"- are often marked. :\Iany factors influence by rna k may act as a trauma, fear of anaes­ th<' personality - hereditary, en\'ironmental. cul­ the ia may be created. Careful and con­ lu r:~l. and ~ocial - which in turn affect the preopcr­ siderate management or the patient re ulting ahn tate. The self-control of tho e of strong re­ from an understanding of hi problems may lig•ous faith is a clinical imprc sion which recei,·es allow him to realise that such fear need not 0111<' corroboration from the finding that there i a continue to haunt him. diffpre nce in analgesic requirement for person of (5 ) Anxiety often results from misconceptions diff(•rent faiths.12 imilarly, racial differences in or misunder landings in the patient's mind. rea~tion to pain ha \'e been described, •a also to anaes­ Through explanation and reassurance anxie­ th<'sm ; it has been uggested that differences in ty may be dissipated. analsthetic re pon e are due in part to differences in (6) There is e,;dence that patients benefit from th <· sympathetic nen·ous sy tern, e pecially in re­ the attention paid to their difficulties by the latton to the circulation•• and carbohvdrate mel:l.­ anae thetist. Egbert and others ha,·e dem­ bolism. u \Yriting of Zulus, Findlay !;a remarked onstrated "psychologic benefits lasting for that they often hold the nai,·e view that the hospital at least I hour after the ''isit by the anaes­ i the place where peo!)le are sen t to die. 16 "They thetist'';~' both the immediate preoperati\'e arc mordinately afraid of anae thetic and surgical and po toperati,·e condition are affected. J>roc·('dures''; he reported exaggerated responses to This reasoning recognises the part played in mod<•rate physiological and pharmacological inter­ treatment by what Beecher has termed ·'nonspecific fer<'nce. forces". 22 The management of the frightened surgi-

1'l!f, NOVA SCOTIA ~1EDICA L BULLETIX 109 JUNE, 1968 cal patient will mostly consist of " nonspecifi c·· threatening situation. were best managed therapy; in other words, the physician should show by causing them to become in,·oh·ed with sympathy, interest, and confidence in the outcome, the likely stresses ahead of them. complementing this wit h the judicious use of drug (2) 8ED.\1'lON: The commonest means of les­ and technical skill. sening anxiety is the use of drugs which depress dif­ In brief, helpful aspect of management are ferent parts of the central nervous system. Some these: comments may be made about this. First, drug· (1) PREOPEHA1'J\"E PSYCHOLOGICA L PHEP .~R.\TION: have undo irable ide-effects such as depression of All patients benefit from some form of preparation t he respiratory and cardiovascular systems; second, which helps them to adapt to the surgical experience. perhaps a greater use should be made of tranquiJJiz­ (a) Children especially benefi t from careful ing and ataractic drugs; third, drugs such a bar­ preparation, for behavioural changes biturates are sometimes less effective than t he en­ often follow ho pitalization. \·ernon eta!., com·aging preoperative ,;sit by the anaesthetist. in a reYiew of the subject of illnes and However. drug will always be of value. especially hospitalization of children. have described for unusually apprehensi,·e patients and patients the benefits of such preparation: infor­ with whom contact i difficult to establish, for mation is gi,·en to the child, his emotional example very young children and retarded children. e:-.-pression is encouraged and trust and edation does help protect the anxious patient from confidence are gained in the ho pita! a potentially traumatic experience which would in­ staff. 23 Robertson, from a parent.'s poin t. duce fear of future anaesthesia. of view. has underlined the nlue of prep­ (3) Il'\1'EHPERSO:'

THE -OVA COTJA MEDICAL BULLETIN 110 JUKE, 1968 th<> tic, this young man took him from the security anae thetized per-on, to reduce anxiety in the im­ of hi father' arm and carried him creaming. ki c~\ ­ mediate po toperati,·e period. to reduce the amount ing and violent into the theatre him elf. He re­ of analgc ia required following operation. and to ported to u later. quite gleefully. that he had had peed com·ale eenee. n Hypnosis i a controver-ial "fistcuffs" with him on the table. Phy ically our technique: one may or may not agree "ith Ragin­ son reco,·ered quickly again. but emotionally he has ky' ,·iew of it a being "The mo t forceful method still a ,·cry long way to go:·u of allaying anxiety without res:>rt to medication.''!i Comment on thi object les on i superfluou . Comment. -!) H YPXO IS : .\ n ex ten ion of the idea that In "The Doctor's Dilemma·· George Bernard t h<> p h~· ician's per onality signiiicantly affects the haw claimed that anaesthesia expunged merely the patiE>nt i the applica tion of hypnosis. Kolouch has pain of the knifc. ' 0 haw wa dramati ing the idea tated that the introduction of ether anaesthesia was that the urgical patient has much to bear from and rt>sponsible for the neglect of hypno i as analge ic operation; although the operation itself. performed and anae thetic agcnt-!7 but a number of anaes­ when the patient is uncon cious, is ,-irtually free thet ists and urgeons continue to use hypno is. no t. of di comfort, there is much else which he find s un­ only to aboli h pain during urgery, but al o to plca ant. \\.hilc thi ma.'· be an exaggeration, there reassure the patient before. during and after urgery. is yet a grain of truth in it. Thi article has dis­ Ch<'ek. too, has advocated hypno is to allay pre­ cu cd on e a peel of di comfort of the surgical op<'rative anxiety due to fear. to protect the patient patient, with haw ' general idea a a tou chstone. from ad\·er e effect Of COn\·ersa tion heard by the 0

References 16. Findlay, R. A.: T he Emotional Pattern or the Tribal Zulu ~ it .H rccts Prl'anae>thetic Assesseent and ~[an- agement. . . l fric~n .lied. J .. 34,854. 1960. I. Weiss, E. S . and English, O.S . : P,ychomatic ~Iedi­ 17. Crampton, H. P.: F'actors. Other T ha n Anae.thetics, eine. (3rd. Ed. 1, \\'. B. aunders. Phi/1 .. 1957. Arrecting Anae,th!'sia. Proc. Roy. Soc ..li ed .. 28, 9 1. 2 Ken nedy, A.: T he P~ycho l ogy or the urgical Patient. 1934-5. H .. II .J . I, 396. 1950. 1 . Eckenhoff, J. E. : Prea naesthetic Seda tion or Children. 3. Langford, W. S.: Ph~· , i ca l lllne's and Corwale;;cence. . I rch. Otol-Jrynyol.. 57, 411. 1953. Their ~ l ean i ng to the Child. J. Paediatrics. 33, 242. 19. Eckenhoff, J. E.: Relationship of Anaesthesia to 1940. Postoperative Personality Changes in Children. A mer. 4. Deutsch, H.: orn e Psychoanalylie Observations in J. Dis. Chil,l. 86, 587. 1953. Surgery. Psychosomat . .1 / e-1 .. 4, 105. 1942. 20. J anis, I. L.: Psychological tress. .\'ew l'ork, John 5. Titchener, J . L. and Levine, M.: urgery as a \\'iley, 1958. !Iuman F:xperiencl'. (2nd . ed.). Oxrord Uni,·er ·ity, 21. Egbert, L. D., et a.l. : '!'he \'alue or the Preoperative Yew l'ork, 1960. \ i•it bv a n Anaesthetist. J .tl..ll .• l., 185, 553. 1963. 6. S tephenson, H. E.: Cardiac Arrest and Resuscitation. '2'2. Beech~r, H . K.: Xonspeciric Force· nrrounding 2nd. eel. ) 1. Louis, C. \ . :Mosby. 1964. Di

TliE XOVA COTIA :\rEDICAL BL'LLETIX 111 JL"XE. 1968 ~rumhrr 27, 1867

Situated on the Grand Parade

'fhe Dean reported the following communication from Jas. Thompson, secretary of the Board of Go,·­ ernors. ··Extract from :\Iinutes of a meeting of the Board of Go,·ernors of Dalhousie College held on February 25. 1 6 ." "James F. Avery, :\I.D. then moved the Hon. I. W. Ritchie seconded and it was passed unanimously that the proposed Medical Faculty consisting of the following officers and lecturers Yiz: Rev. James Rop, D.D., Principal per officio William I. Almon, M.D., President Alexander P. Reid. :\I.D., Dean Wm. I. Almon, M.D. & Alex G. Hattie, M.D. Lecturers on :\Iidwifery (or Obstetrics) Edward Farrell, ~I.D. Lecturer on Anatomy Prof. G. Lawson, Ph.D., L.L.D. Lecturer on Chemistry Alex P. Reid , ~I. D. Lecturer on Physiology or Institutes or :Medicine A. H. Woodill. ~L D. Lecturer on ~fateria Medica James Rop, M.D. Demonstrator of Anatomy Thomas R. Almon, M .D. Prosecutor to Chair of Anatomy appointed and confirmed as the :.\fedical Faculty of Dalhousie College. The Hon. I. \f. Ritchie then moYed James F. Avery Esq. :\LD. seconded and it was passed unanimously thafthe statutes and Byelaws submitted by the said Faculty for the approval of this board be the statutes and Byelaws goYerning and regulating the said ~Ie dica l Faculty", James Thomp on, ecretary, Dalhousie College." THE NOVA SCOTIA MEDICAL BULLETIN 112 JUNE , 1968 1868 Qlcntcnnial 1968

Come to the ~aiqousie Jffaruitu of ~ebicine CENTENNIAL

Sept. 11, 12, 13

Halifax, N. S. THE PHYSICIAN OF THE FUTURE: HIS UNIVERSITY AND HIS COMMUNITY

* major scientific meeting

* keynote speakers and

group leaders

* daily concurrent medic­ panel discussions * round table sessions

* seventy contributors

IN '68 of international acclaim

THE NOVA SCOTIA MEDICAL BULLETIN 113 JUNE, 1968 The Years Ahead Focus on Dalhousie A look at the future of medicine in three rapidly Dalhousie will be well represented on the par­ developing and expanding areas - genetics, organ ticipants roster at the centennial meeting of the transplants and medical education will be the theme Faculty of Medicine next September. Among the of three days of scientific meetings next September 70 contributors, 40% are Canadian and of these, when world leaders in medicine participate in Dal­ seven are graduates of the Dalhousie Medical School. housie UniYersity's Faculty of Medicine's centen­ Dr. C. B. Stewart host-dean will sen·e on a !our­ nial program. man panel on the first day when the theme of their On the occasion of its l OOth birthday, Dal­ discussions will centre on the medical education of housie's medical school will be host to scientists, the undergraduate. Joining him on the same panel researchers, educators and administrators of inter­ will be Dr. Ian Rusted, Dean of the newly estab­ national acclaim when they take part in the cen­ lished medical school at Memorial UniYersity, St. tennial proceedings on ept. 11, 12 and 13, in Hali­ J ohn's, Xewfoundland. fax. In his capacity as medical educator, Dr. tewart The keynote speakers and chairman of each of has provided valuable assistance and information the si.x panels which will run concurrently on all to the Memorial University Committee and the three days are impressiYely qualified. All have had New Brunswick Medical Sun·ey Committee on the distinguished careers and have made major contri­ feasibility and need for new medical schools in the butions to the advancement of medicine. Atlantic Provinces. In addition he has reported One of the prominent visitors will be Dr. Ralph on the adequacy of medical education for the prac­ \'i·. Tyler, recently retired director of the Centre for tising doctor and has carried out research on the Ad\·anced tudies in the BehM·iourial Sciences at future availability of medical schools. Stanford University, California, who will give the Dr. Rusted has been active in the medical edu­ keynote address on Sept. 11, when the sessions will cation and residence program in X ewfoundland. be de,·oted to medical education and practice. The He is familiar with the pattern of medical care in continuing education of the practising physician, the proYince and has been prominent in medical the training of the doctor at the undergraduate and education affairs nationally through his positions post-graduate level, a study of the learning process, with the Royal College of Physicians. the patterns of future practice and the use of para­ medical personnel and improved techniques of prac­ Before his appointment as dean he serYed as tice will constitute the six sections of this phase of director of the postgraduate medical education - the program. the first position filled in the newly created Faculty The keynote address at the ept. 12 session on of :\fedicine at :\f emorial. genetics will be given by Dr. Murray L. Barr, head Dr. Paul Cudmore, assistant director of Dal­ of the department of microscopic anatomy at the housie's postgraduate division has been interested University of Western Ontario. This will be fol­ in the evaluation of the learning process and has lowed by fi ve panel presentations by leading geneti­ just returned from a year of training at the Univer­ cists, biologists, paediatricians and statisticians. sity of Illinois investigating this process as it applies Outstanding scientists and surgeons, and per­ t() medicine. He is the first Canadian doctor to sons connected with the church and the law will spend a full field year of training in medical edu­ take part in discussions on organ transplants on cation and one of two authorities on the learning Sept. 13, the final day of the centennial meeting, problems in the learning process of the graduate when the major address will be given by Sir Peter doctor. The panel on which Dr. Cudmore will Medawar, director of the National Institute for sen·e will be devoted to the learning process. Medical Research in London and president-elect Dr. Walter Mackenzie, a Cape Breton native of the British Association for the Advancement of and Dean of Alberta's Medical School in Edmonton cience. will act as group leader in discussions on the medical Canadians will be high on the list of over 70 education at the postgraduate level. He is con­ contributors to this major scientific meeting which sidered one of Canada's most prominent medical will have representation from France, England, educators with international experience in his cotland, CzechosloYakia and the United States. association with administrative medical institutions. Among them are scientists, researchers, nobel prize The interrelation of paramedical personnel will winners, Markle and Rhodes scholars from a number be examined by a panel of six. Dr. Arthur H. of major teaching institutions and medical centres. hears in his capacity as medical director of the The meeting \Yill be of special interest to Dal­ No,·a cotia Rehabilitation Centre and director of housie medical alumni who will be on hand for the Dalhousie's chool of Physiotherapy will participate. IOOth anniversary of the medical school, but the Dr. Shears has been training physicians to make use Faculty of Medicine expects to attract many others of physiotherapy methods. to these centennial meetings. o (continued on page 115) THE NOVA SCOTIA MEDICAL BULLETIN 114 JUNE, 1968 Speakers and Sessions to 1968

When Dalhousie's Faculty of Medicine hosts Ralph W. Tyler, recently retired director of the a major scientific program next September on the Centre for Advanced Studies in the BehaYioural occasion of its centennial, it will have marked 100 Sciences. Stanlord University . years of growth and achievement. . . . teacher and author of such publications on The Medical School today is recognized as one education as: constructing achievement tests; of the best and has over the years established itself appraising and recording student progress, basic as a model in the field of instruction and in continu­ principles of curriculum and instruction. ing education . . . . viewpoints on medical education and practice will be Yo iced on ept. 11th by deans representing Housed in a small wooden structure on the sight leading Canadian medical schools, educators, where the present Halifax City Ball now stands, psychologists, research director for the Ball the chool made its humble beginnings in 1868. Commission, president of the American Medical Fourteen students registered for instruction in "\•sociation and personnel in the paramedical such primary subjects as obstetrics, chemistry, field. anatomy, physiology, medicine and materia medica which was given by eight lecturers. The first class graduated in 1872. In the school's 99th year, it moved into its Murray L. Barr, department of microscopic fourth home - a fifteen storey medical complex anatomy at McMasters . . . pioneer researcher which was olficially opened by Queen Elizabeth the on sex chromatin. Queen Mother. The new structure which was Nova ... contributors from major centres for genetic cotia's memorial to the centennial of Canadian studies will focus attention on this theme on confederation was appropriately named the ir ept. 12, the second day of Dalhousie's centennial Charles Tupper Medical Building. meeting. In 100 years the Faculty of Medicine has gradu­ ated oYer 2200 students. It is the research centre for the Atlantic provinces, and is developing new programs in such areas as medical genetics, computer science, electron microscopy, X-ray microscopy and Sir Peter Medawar, director of the National virology in addition to others in the clinical and Institute for Medical Research, London and Nobel scientific fields. laureate for his disco,·eries in tissue transplanta­ In keeping with the theme of the centennial tion. meetings which will take a forward look at medical ... presentations encompassing ethical, legal and education and practice; genetics; and organ trans­ surgical aspects, graft rejection, transplant toler­ plants - the chool is in the process of doing the same ance and doner selection by a renowned roster of thing. A thorough revision of the medical curricu­ international scientists on Sept. 13 ... theme for lum is underway, the first appointee in genetics has the final day of the scientific sessions will be been made and two more will follow shortly and a organ transplants. researcher in the field of kidney transplantation will take up his duties in July. o

Focus on Dalhousie (continued from page 114) . Future patterns of health care will be developed Organ transplants, a field of medicine which m a panel discussion with Professor Bernard Blishen. has developed rapidly in recent years will occupy research director of the Ball Commission; Dr. discussions on the final day of the Dalhousie sci­ Alexander Leighton, Harvard professor of Mental entific meeting. Dr. S. G. Lannon, who graduated liealth; Dr. Dwight L. Wilbur, president-elect of the from Dalhousie in 1957 and now with the depart­ American Medical Association and Dalhousie gradu­ ment of urology will join in talks on the surgical ate Dr. Donald I. Rice. Dr. Rice is executive di­ aspects of organ transplants with Dr. Thomas rector of the College of General Practice. Be has Starzl, University of Colorado chool of Medicine, travelled extensively in Europe, Africa, United Dr. R. C. Lillehei, experimental surgeon at the Uni­ States and Canada. Be has been studying what versity of Minnesota and Dr. Thomas King, pro­ ~he family practitioner does and what he should do fessor of surgery at the University of Utah. o In the future.

'I'BE NOVA SCOTIA :MEDICAL BULLETIK 115 JUNE,l968 People and Panelists . . .

. . . Dr. Christine M&uire: on study of curriculum organization, instructional systems, and edu­ cational evaluation ... Profusor Brendan A . Maher: authority in clinical psychology and ex­ perimental psychopathology ... Profusor Mark Field: investigator of systems in Russia and author of a paper on the Doctor and Patient in Soviet Russia ... Dr. Gordon lV. Thomas: the use of the Outpost Nurse as an illustration of the assistance provided through paramedical personnel .. . Dr. E. Harvey Estes: on Physician's Assistance Program at Duke University .. . Oliver Smithies: outstanding researcher in the whole field of genetics ... Willys K. Silver: on the genetics of transplantation ... James German: on the use of auto-radiography of chromosomes . .. Victor .McKussick: studies in clinical and population genetics . . . Francis D. Moore: featured on cover of TIME for his distinguished achievements in surgery and author of laymen's book on the history of tissue transplantation ... John Edwards: director of Institute of Criminology, University of Toronto, who has given attention to the ethical, legal and moral problems as­ sociated with medicine ... Sherwood Lawrence: of the Infectious Disease and Immunology Division of New York University's Medical School with some answers to key problems in disease and in homograft rejection . . . William Curran: lecturer in legal medicine and researcher on legal and legislative bases of governmental medical care systems in European countries ... Jean Dausset : from the Universite de Paris and noted for his research in blood types ... R. C. Lillehei: Markle Scholar and experimental surgeon at the University of Minnesota. o

And Places .. .

. . . R. S . .i\JcLaughlin Examination and Research Centre, University of Alberta: now doing studies in multi-choice examinations for the R<>yal College of Canada ... Scripps Clinic and Research Foundation, La Jolla, Calif.: the centre where samples of blood and other materials are sent for analysis on any human organ transplant taking place in the US ... Permanente .Medical Group, Hayward, Calif.: who have had great success with paramedical personnel in their medical clinic . . . Ontario Cancer Treatment Centre and Atomic Energy of Canada, Ltd. . . . University of Colorado School of Medicine: where director Thomas Starzl's as organ trans­ plant program has encompassed 198 kidney transplant patients and 18 liver transplant patients; Carl B. Pollock whose staff handles all psychiatric consultations from the medical and surgical services of the Colorado centre; and E. A. Murphy, biostatistician and author of works on genetics and haemotology . . . Glasgow University: a centre for studies in human genetics; Division of :Medicine and Religion for the American Medical Association. o

SEPTEMBER Dalhousie Medical School I 11, 12, 13 1868 @£ni£nnial 1968

• SCIENTIFIC PROGRAM OF INTERNATIONAL STATURE Mark the dates • GALA ALUMNI HOMECOMING SOCIAL EVENTS in your diary now

'J'HE NOVA SCOTIA MEDICAL BULLETIN 116 JUNE, 1968 Fluid and Electrolyte Requirements During Anaesthesia and Surgery D. c. FINLAYSON, MD, FRCP(C)* Toronto, Ontario

In trodu ction In short, anaesthesia and surgery do not repre­ In 1831, Latta in cotland successfully treated sent a "stress" of the type proposed initially. All a patient with cholera using ::\1arcet's solution inlra­ evidence would seem to indicate that if the body's Yenously.' ince then there has developed a "·ide­ functional extracellular flu id stores of water and spr<'ad awareness of the importance of both water electrolytes are maintained at normal levels, the and electrolytes in the management of disease excretion of water and electrolytes will remain '1\·ith­ states. in normal ljmits. In other words. parenteral therapy In relation to anaesthesia and surgery the guide will lead to normal responses on the part of the body, linrs for parenteral therapy ha\·e changed radically and not antidiuresis or salt retention. Thus. homeo­ in the past everal years. n 6 sta is would appear to require a replacement of an "Stress" Theory amount of fu id and electrolytes in an amount In 1959, Moore proposed that anaesthesia and equi\·alent to that sequestered. su rgC'ry were a tress. the response to wh.ich was anti­ Normal Requ irem en ts diuresis and salt retention in the postoperative On con idering the implications of this for the period3• These proposals stemmed from data show­ management of per-operatiYe infusions i11 normal ing postoperative falls in urinary output and sodium patients. two general statements can be made. excretion after major intra-abdominal surgical pro­ These are: (a) the ordinary requirements of the cedures. T his was assumed to be due to a pituitary­ indi\-idual patient must continue to be met. (b) if adrenal response inhibiting normal water and Plec­ sequestration occurs in a ociation with the anaes­ trolyte clearances by the body. thetic or the operation. an amount of ECF-Jike "Third-Space" Theory flu id equal to that volume sequestered should be During this same period other studies were ap­ administered to maintain normal homeostasis. As pearing suggesting that the ability of the body to a corollary it may be sajd that if sequestration does handle both water and salt was unimpaired by not occur, fluid in excess of normal daily require­ surgery.'·5 These latter studies suggested that ments should not be given. Moore's original data could be interpreted as show­ :;\ormal fluid requirements for a 70 kg. adult ing t hat the body was, after trauma, fu nctionally generally fall between 2 and 4% of body weight in short of both water and electrolytes. From these kgs. per day; therefore the usual 2,500 - 3.000 ml. proposals the '·th.ird-space" concepts haYe C\·olved. administered per day can be considered normal. These ideas may be clarified by considering the \-alues for children and smaller adults are closely general response of the body to surgical trauma. If related to tills on a proportionate basis. For the one considers, for example, an operation on the patient's water and electrolyte status to be normal, peritoneal cavity. the pathophysiological response to adequate hydration must be present on arrival in the in jury consists of: (a) ileus, (b) retroperitoneal, vis­ operating room. In ordinary practice this is rarely ceral and omental oedema, and (c) intraperitoneal the case. Patients usually come to the operating effusion. The fl uid invoh·ed. extracellular fluid room ha\·ing had nothing by mouth since some time (ECF), is sequestered by virtue of the proce s in­ in the eYening prior to operation. Therefore a volved, and thus relati\·ely inaccessible to other body normal-sized adult may have a negative water compartments. It is functionally, in effect, another balance of 1000 - 2,000 mi. depending upon the body compartment or "third-space". length of this inten·al; and can be given these This inaccessible ECF "third-space" is drawn amounts of fluid fairly rapidly - even before t he in­ from other body compartments. The body will duction of anaesthesia, and still not be oYer-by­ therefore then be relati\·ely short of both water and hydrated. Since the patient is not in need of a great electrolytes. Tests designed to evaluate t his would deal of sodium ion, the majority of this fluid can show antidiuresis and salt retention due to the effort be gi\·en as dextrose and water or as a pre-mixed of the body to conserve both water and electrolytes. maintenance solution. Replacing the body's ECF stores with an amount of The normal daily adult requirements for min­ fl uid and electrolyte equal to that sequestered erals generally include 5 to 10 gms of sodium chlor­ should in theory, and does in fact, appear to restore ide. For purposes of comparison it should be noted normal function. that the 154 mEq. of sodium contained in 1,000 ml.

*Guest Lecturer at the Atlantic Re,ponal Meeting, Canadian Anaesthetists' Society, September 1967; Assistant Professor of Anaesthesia, St. Michael's Hospital, Toronto, and University of 'f oronto.

THE NOVA SCOTIA ~EDICAL BULLETIK 117 JUKE, 1968 of normal saline are equi,·alenl to approximately change appear to be table o,·er the cour e or the 3.5 gms or odium which i • in turn. equh·alent to next 24 hours. Clinically it seem that ileu for­ approximately 9.0 gms of odium chloride. There­ mation i completed at or almo t immediately after fore for ordinary daily replacement or this patien l operation. In any ca c it would eem safe to in fu e the indicated olution will probably be 1 3 normal the olu tions to be used at a rate uificicnt to allow aline or a mixed electrolyte olution of the type for the almo t complete development or ileus within containing daily electrolyte requirements in 3,000 a 12 hour period during and following the operation. mi. (eg .. Normosol ~~A bbott ). 'fhe olution infu ed hould be ECF-like in char­ Requirem ents for Operation acter; that is. a balanced salt olution. the cia it During operation normal requirement may be example being lactated Ringer· solution. modified by: (a) the need to upply Cluid to augment In ummary then. at time of operation. the the ize or the intra\·a cular portion of the extra­ patient hould have infu ed the type of olution ap­ cellular fluid compartment in order to maintain propriate to maintain adequate hydration. In ad­ rea onable eardio,·a cular stability during the cour·e dition to tlli , there should be infu ed on or about the in anae thesia; (b) the pathophy iological effects of day of operation an amount of balanced salt olu­ the operation; and (c) intercurrent disea e with any lion equivalent to that amount likely to be sequc t­ of the fluid -electrolyte disorders which mar be Hed due to the patient' di ea cor operation. pre ent. Wi th recoYery the inflammatory change will Effect of Anaesthesia ub ide. The fluid sequc tered will then be re- ln relation to anae the ia it hould be noted mobilized and made a,·ailable to the patient. It will that u e of halothane i a ociated with a moderate then be necessary for him to be capable of handling­ ri c in pia ma volume which. in ordinary situation . thi ,·olume of fluid. Capacity to do thi may be tend to be largely complete approximately -!5 compromi ed by cardiova cular or renal di ea e. minutes after induction.7 lt i or intere t that lhi The remobilized fluid may therefore be a potential ri e parallels the hemod)•namic impro,·ement which hazard . In such ca e the amou nt of fluid infu cd occurs after the initial fall in blood pre sure a oci­ in exec of the patient's daily needs at time of oper­ aled with induction of anae thesia. H i probably ation hould then be ublracted from the ,·olumcs true to say that. a the patient' blood ,·olume in­ or infu ion gi,·en at lime of remobilization. i.e .. crea e . cardio,·a cular lability in term of blood resol ution of the ileu . Thi hould minimize the pre· ure improve . It i widely appreciated that cardio-renal embarra mcnl. induction or anae the ia in hypo,·olemic or dehy­ Po toperatiYely. after sa ti faction of the extra­ drated patient . u ing halothane. may certainly be a cellular fluid compartment. continued u e of bal­ hazardous undertaking; and that thi hazard i much anced salt olutions would be ill-ad,·i ed since con- les in the optimally hydrated patient. The effect ervation or the daily water need in the face of the of halothane on the pia rna volume would appear to great exec of electrolytes pre ent in such solution do much to explain this. 'fhere i then a logical would impo e a.n inordinate amoun t of metabolic ground for \'igorou hydration of the patient before work on the kidney - the body need the water. but induction or anaesthesia - espeeiaJiy in the ligh t or not that much electrolyte. Balanced salt olution the length of time the patient ha been depri\"Cd of arc for the replacement of actual or relatiw lo es Cluids prior to thi . of ECF - not maintenance of water and electrol~·tc Jn term of operation it i ob,·iou that not all balance. procedures will re ul t in equc tration of extracellu­ lnfu ion regimen de igned for normal mainten­ lar fluid by creat ion of a ·'third- pace''. In general ance hou ld in clude. a ide from the nece sar.v water. it may be aid that if there is no deYelopment of carbohydrate (dcx tro c) for it caloric and protein- ileu . effusion. or gro s cellular oedema. there will be. paring action and uffi cicnt amount of electro­ in effect. no '" third- pace". Tran laled in to clinical lyte to make up for normal los e . For odium and term it is ob,·iou that, in operation which a\·oid polas ium these figure arc thought to be approxi­ a body ca,·ity. little or no eque !ration deYelop . mately 150 and 60 mEq . per da~· re pecti,·ely for On the other hand. with abdomino-perineal re ec­ ad ult . Magnesium may be a ,·aluable addition. tion the "third- pace"" mar be large indeed.8 but calcium i probably not necessary due to the Balance ludic in patient ha,·ing tandardizcd large body re erve . 'rhe c need may be mel using upper abdominal procedure indicate that the size or the conYentional 1 3 aline to 2 3 dexlro e mixtures. thi non-functional extracellular fl uid compartment adding whatever else is needed. or by the pre-mixed i approximately 1.5 - 3.0 litre in adult men under­ pccial olution . eg., Xormo ol ~~ in D5-\\', (_\b­ going cholecy tecto my. 9 I l ha been ho\m to be bott). a large a 4 to 5 ~ of body weight with other type or urgical trauma and not pre ent at all after minor Specific Solutions procedure . F'i,·e per cent dextro!'e in water i a orne·., bat Fluid eque tralion due to intraperitoneal acid olution with a pH of abou t 5.5 and. when in ­ trauma i largely complete within 24 hours. The c fu ed, i capable of expanding both the extracellular

TTIE KOVA SCO'l'IA )!EDICAL BliLIJETIX Jl JtJXE. 19f and mtracellular Cluid compartment . but at the co t lion; iJ. like sodium chloride. it is wholly ionized of hemodilution. The consequent fall in serum into two particles il will then exert two unit . and if, odmm may produce neurological and cardio,·ascu­ like calcium chloride. ionized into three particles lar depre sion if sudden and scn~ re enough; in ad­ it will then exert three unit (eg .. 1 mEq. XaCl dition, acute depression of serum odium below 120 give I mOsm. sodium and I mO m. chloride). It mEq. may al o compromise the ability of the kidney is the o molic pressure which controls the distribu­ to ('XCrete the extra fluid wh ile still con en·ing the tion of water in the body; t hat is, t he water follow odmm necessary to correct the problem. There- the di tribulion of electrolytes which create the Con ii there i any need for electroly te a part of osmotic pressure. It is this osmotic pre ure that th<' patient' problem. that is. where t here has not the body's homeostatic mechanisms Yigorously bN·r a lo of water alone. dextro e and wa ter should attempt to keep al stable levels. not be u ed. It use is pecific only for the correc­ Disorders of Cluid and electrolytes may come tioP of implc dehydration or a part of a regimen from: Cor maintenance of water balance. (a) Loss - mainly water. or water and electro­ Xormal saline is another somewhat acid solu­ ly tes in 1·arying combinations up to the tion containing 154 mEq. of odium and chloride per concentration or extracellular Cluid. lil<'r. Thi repro ents a light execs of sodium in relation to normal le1·els found in the body. but a (b) Inappropriate treatment - with conse­ gn·: I exec of chloride. Rapid infu ion of this quent losses or gain of water or one or solution. (eg .. amounts equal to or greater than more electrolytes depending upon the 50 mi. per minute) dilutes the bicarbonate side of antecedent problem in the patient's man­ th<' Ilendcr on-Has-elbach equation and pro1'ides a agement. large chloride exce s thus expanding the body's (c) Change in osmotic pressure - from "chloride space". The con equence of this for the blood sugar or urea (t•icle inf ra). patient may be a rclali1·e or actual los or bicarbon­ (d) Asymptomatic hyponatremia - often ate and the deYelopmenl or ignificant leYels Of seen in patients with cardiac and hepatic metabolic acido i 10• Infused al moderate rates in disease in the ab ence of other obviou ordinary amount it is of cour-e economical and well abnormalities and which may only ignif~ · tokrated. resetting of the body' osmo-receptor Balanced salt solutions, the clas ical example mechani ms. of which i lactated Ringer's. contain electrolytes :\Iaintenance of normal o molality appears to and bicarbonate precursor in amount similar to be a dominant homeo talic mechanism of the body. those exi ling in the body. There are many ex­ I n imple dehydration, the body will lose electro­ amples of this type of solution. Calcium is ab ent ly le in an attempt lo restore osmolality to normal. in the more recent of the e (eg., Normosol R. , imil ar l ~- after over-hy dration with dextrose and .\bhott). This. in a patient who i digitalized, water. marked salt retention by the kidney may be hnltrH•ntilated , and thu potentially hypokalemic een. probably represent a safety factor. Osmolar attraction may also be exerted by com­ For routi11e maintenance. olution containing pounds other than the odium, chloride and pola - lh<' u ual daily requirement Cor electrolytes and sium ion u ually con idered. The principle ones dextro e in e1·ery 3 lit res probably represent a tep are urea and glucose. For c1·ery 5 mgms. 1>ercen t for1•ard. lJnle specific fluid and electrolyte that the blood urea nitrogen is raised abo1·e normal. therapy is needed, it is now, for the most part, only 2 mO m. or osmotic pres ure are added. Thi nect·ssary to give extracellular fluid-like balanced nece itale a compen alory lo s or 1 mOsm. or a salt ~o lution equal to the amount of extracellular cation and l mOsm. of an anion - usually sodium fl uid seque lered on the day of operation and main­ and chloride, through the kidneys. For e1·ery 35 tenance type fluids during and after operation to mgm . percent ri e in blood sugar aboYe normal. mamtain perfectly normal electrolyte and water there i a similar change in o motic pre ure and a balance. similar lo or odium chloride. Therefore in a Som e Considerations Regarding Disease patient with a B'GX of 11 5 mgm percent one would I n disea e. a in health, one must bear in mind not be surprised lo see a serum odium of about that there i , in the EC.F compartment, mainly 125 mEq. per litre. imilarly with a blood sugar of odium, chloride and potassium; in ICF'. potassium 450 mgm. per cent one might expect a reduction and phospha tes. By virtue of the osmotic pressure in erum odium of about 10 mEq. per litre. In these ions exert, water is distributed throughout both examples the abnormal amounts of urea and the body. Osmolality, usually expressed in terms glucose igni!icantly rai ed the osmolar attraction of milliosmoles per litre, repre ents the osmotic at­ in the extracellular Cluid compartment and cau ed a traction exerted by the ionic or solute particles in a lo of odium. Failure to recognize that hypona­ solution be they large or small. H a compound is tremia in such ea es is compensatory and that not ionized one mole will exert one o mole of aUrae- urinary odium losse may be obligatory could lead

THr; XOVA COTIA MEDICAL BULLETJK 119 JUXE, 1968 to Ol'er-trc.'ttment with electrolyte-containing fluids; a sumption implie that the treatment pool will in­ surely a dangerous course in orne patients. clude part of the intracellular compartment. Em­ \\hen hyponatremia is not associated with pirica l!~- this has pro,·ed successful in our hands. either of the e di turbance . or ,,·ith cardiac or Evaluation of Water a nd Electrolyte Balance hepa tic di ea e, the patient will probably benefit E1·aluation of water and electrolyte balance fro m treatment with sodium-containing solution . depend upon clinical e1·aluation and laboraton· How could the deficieucv be a e ed and what solu­ tudie . History and phy ical examination hould tion should be u ed ? · gil·e a reasonable idea of what. in terms of water As e men t will depend upon ability to esti­ and electrolyte. wa lo t. and perhaps some su~ ­ mate the ,·olume of the total body water. The picion of the amount that was lost. El"idence of "functional" extracellular fluid compartment is clin ical dehydration in terms of tissue turgor does probabl~- about I 3 of the total. The total body not generally appear in adults until 4 to 6 litre· water depend upon age. sex, and body habitus. have been lost. This, with laboratory investiga­ and lies between 75 % of body weight in infant and tion should give more specific idea of what ha been 50 % in des icatcd lillie old ladie . For clinical going on. 1n the laboratory, le1'els of electrolytes purpo es in emergencies it may be considered to be should be correlated with: (a) evidence of pos iblt> about 60% of body weight in all indi,·iduals. The hemo-concentration expressed by raised level of fun ctional part of the ECFY will be I 3 of Uti - BL~ and hemoglobin or hematocrit, and (b) the therefore about 20% of the body weight in kgm., relation of the e to the hourly ,-olurnes of urine out­ (eg .. in a 75 kgm. man it is about 15 kgms. or 15 put and central venou pressure. litres). If, for example, after lran urethral re ec­ Conclusion tion of the pro tale. serum odium i found to be 124 Re1'iewed are the normal responses of the body mEq. i.e .. 20 mEq. below the normal of 144. then to anae the ia and urgery. orne of the foundat ions one may elect to treat 10 mEq. of this deficit. The for the variou regimen that have been used for size of the EC F' pool in thi 75 kgm. patient i 15 maintenance of flu id and electrolyte requirements litre ; therefore he need 15 X 10 or 150 mEq. of in the operati1'e period. and some of the approachc sodium. If this patient is under-hydrated he may which could be u ed to e1·aluate and guide treatmen t be gil·en this as 1 litre of normal saline (containing in patient during the operati1·e period. u 154 mEq. of odium) ; if well hydrated he may be R eferences gi1·en hy-pertonic (5%) aline ( 55 mEq. per litre of odium) - I 0 cc will give approximately 153 I. Latta , T. : ~ f alignan t Cholera... Relative to the Treat­ mEq. or sodium. ment of Cholera by the Copious Injection of Aqueous \rith t his approach the factor of 20% is not a and aline Fluids Into the Veins. L ~ncet, 2, 274 , 1831. critical one and depen ds upon how one describe the 2. Coller, F. A., et al : Postoperative Salt Intolerance. Atm. Surg., 119, 533, 1944. ECF comparlmcn l. One may take a factor of 30% 3. Moore, F. D.: ~f e tabo lic Care of the Surgical Patient. or almost 1 3 of body weigh t in kgs. as does Astrup. Phi/a., aunder. Co., 1959. In any ca e it should be realized that this approach, 4. De Cosse, J . J ., Randall, H. T., Habif, D. V., if it errs, does o on the ide of under-treatment. Roberts. K. E.: The Mechanism of llyponl\lremi& The other approach 10 u es a a guide for the ize of Hypotoxicity After urgical Trauma. Surg., 40 : 2i. the treatment pool the total body water. and as­ 1956. sumes that this i what i nece san· to be treated. 5. Randall, R. E., Papper, S. : ~Iechanism of Postoper­ This is al o a legitimate approach, but may tend to ative Limitation in Xa Excretion: the Role of the o1·ertreat the problem when ECF-like fluids rich ECFV and of Adrenal Cortical Activity. J. Clin . in sodium are used. ince more than half the total lm:t&t .. 37 : 1628, 19' . 6. Shires, T. , J ackson, D. E. : Postoperative Salt Tol­ body water i sodium-poor fluid. erance. .l rch. S urg .. 84 : 703, 1962. In summary it hould be empha ized that the 7. Grable, E., Finch, A. J ., Abrams, A. L., Williams, ability to treat electrolyte. and indeed some acid­ J . A.: The Effect of Cyclopropane and Halothane on base, di orders, depends upon our ability to esti­ the Blood Volume in i\£an. .lneslhesiol., 23 : 28, 1962. mate the size of the compartment of the body in Pa rks, C. R.: Operative Fluid Shifts. A nes .. Ana/g., which we hope our trea tment "·ill act. Due to the 45 :495, (J uly-Aug.) 1966. way water is partitioned in the body it would cern 9. Marks, L. J ., Gibson , R. B., Oya ma, H. T .: Effect most logic.'tl to use a factor of 1 5 to 1, 3 of body of Preoperative Isotonic Expansion of ECFV on Post­ operative Renal Sodium Excretion. Surg., 54 : 456, weight in kgms; that is to as ume that the extra­ 1963. cellular fluid is almost half of the total body water. 10. Maxwell, N. H. and Kleem a n , C. R., eds. Clini­ Since the fun ctional part of the extracellular fluid cal Disorders of FJujd and Electrolyte M etabolism: Yolume is somewhat smaller than this, making this .lfcOraw- Hill, New York, 1962.

THE KOVA SCOTIA :\IEDICAL BliLLETIK 120 JUXE, 1968 Postoperative Hypoxia

I. E. Pt:RKIS, ~1B. B • FFARC • Halifax. N. S.

In the days of deep ether anaesthesia. of high mechanism of breathing. Xevertheless. the fact spinal blocks and of procedures carried out entirely that adequate concentrations of oxygen reach the "itr intravenous barbiturates. postoperative hyp­ lungs docs not necessarily mean that there will be oxia was rela th·ely common. Tho more observant adequate levels of oxygen in the blood. since the and concerned anaesthetists dealt with cyanosis by oxygen may be poorly distributed, and the blood gi\·ing oxygen, and tried to a\·oid chest complica­ vessels in unoxygenated areas of the lungs will then tions by using carbon dioxide-oxygen mixtures or carry venous blood to the arterial side without oxy­ rebr('athing bags to stimulate respiration. Later, a genation. 'l'he pattern of distribution of inspired generalised stimulating regime was advocated, and air and of the blood vessels surrounding the alveoli this postoperative "stir-up" did much to offset the differs in different parts of the lung. leading to a depr('ssant effects of anaesthesia, and surgery. degree of shunting in normal individuals. referred to Gntil accurate methods of measuring carbon as •·the physiological shunt... The fact that blood dioxide tensions in expired air or blood became avail­ from the bronchial arteries is returned to the arterial abl(', it was not generally appreciated that moderate side of the heart \·ia the pulmonary veins accounts depr('ssion of respiration led to carbon dioxide ac­ for some of the physiological shunt. T hus the cumulation, which was in it ell depressant and could oxygen tension of arterial blood is always lower than lead to further accumulation, depression. coma and that present in the ah·eoli. and a gradient or dif­ death. ference exists between them. called the alveolar­ The e mea urements showed that ventilation arterial oxygen gradient. which wa depres ed by carbon dioxide retention The alveolar-arterial gradient for oxygen could could be further depressed by the administration of be increased by defects of diffusion of o:~.·ygen across oxygen, since this remo\·ed tho stimulus of hypoxia. the alveolar-capillary membrane. a situation seldom Consequently, the impression grew that oxygen encountered in normal indi\·iduals, but which may should not be given in respiratory failure, and its usc, become important in pulmonary oedema. in certain together \\ith that of carbon dioxide-oxygen mix­ chronic lung di eases or following cardio-pulmonary tures and the rebreathing bag, fell into disfavour. bypass. Recently, it has become a practical possibility The commonest cause of an increased alveolar­ to measure oxygen tensions in blood samples and it arterial oxygen gradient is an alteration of venti­ has been demonstrated tha t marked falls in the lation-perfusion relationships secondary to changes o:-.·ygen tension of arterial blood may occur in a very in the pattern or ventilation produced by disease, wide \'ariety of circumstances, and that many or anaesthesia or surgery. th e~c merit closer attention. 'Within the bloodstream, the ability to carry Since anacsthetists have been in the fore­ adequate amount of oxygen to the tissues i front of the development of these methods of measur­ profoundly influenced by the haemoglobin concen­ ing changes in the oxygenation of the blood, it is not tration, since a fall in haemoglobin is reflected in a surprising that many of the significant observations disproportionately large decrease in the o:~.·ygen on this subject have been made in relation to anaes­ carrying capacity of the blood. This cannot be com­ thesia and surgery. pensated for by increa ing the concentration of in­ The purpose of this paper is to re\·iew the mech­ spired oxygen, for once the a\·ailable haemoglobin anism through which lowered oxygen tensions may is saturated, additional oxygen can only be carried be produced in the postoperative patient. to re\iew in simple solution in the plasma, and plasma has an the e\idence that anaesthetic techniques may con­ oxygen carrying capacity some 200 times less than tribute to postoperati\·e hypoxia and to suggest haemoglobin. ways in which this hypoxia may be avoided with Of greater clinical importance is the cardiac safety. output, since a lowered cardiac output will result The .Chain of Oxygen Transport in the carriage of a smaller quantity of oxygenated Atmospheric oxygen may fail to reach the lungs blood to the tissues. in adequate concentration when inert gases are mixed The parameters of haemoglobin concentration with air, where there is obstruction to the inflow of and cardiac output contain the elements of a vicious air into the lungs, or when there is a. failure of the circle: il less oxygen is anilable to the tissues,

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TliE ~0\A COTIA :\IED!CAL llULLETIK 121 .n:.iXE, 1968 there ,,-ill be increa ed extraction of oxygen from This confirms the ob en ·ation of Bendixen's arterial blood, and venous blood will be more de­ group in 1964 1 that the oxygen tensions of patients saturated. A proportion of this more desaturated under anaesthesia, after falling progressively, mav blood is shunted to the left side of the heart, thus be raised by three or four deep inflation . This increasing still further the desa lura tion of arterial group has popularised the use of the deep sigh at blood. Through the hypoxic dri,·e to respiration, intervals in patients being ,·entilated at a steady rate. respiration increa es in rate and depth. and this in­ From these observations it would cem that crease in respiratory work becomes progre sivcly anaesthesia is a sociated with an incrca ed phy io­ less efficient, requiring more oxygen to sustain it. logical sh unt, or venous admixture. as shown by tbe The increased oxygen requirements of the tis ucs increased ah·eolar-arterial oxygen gradien l. 'I' hi is will thus lead to more oxygen extraction and de- due in part to alterations in the number of ah·eoli aturation of Yenous blood, with further desa tur­ pcrfu ed but not adequately ''entilated. This ation of arterial blood. change i increased by artificial ,·entilation. which One may therefore summari c the chain of increa e dead space and fu rther alters ,·entilation­ oxygen transport as follows: perfusion relationships. However, normal safe oxygen ten ion s in arterial blood can be obtained by Inspired oxygen concentration u ing large tidal volumes and a minute volume about Ah•eolar ox·ygen concentration twice that of normal \·entilation. Ventilation-perfusion ratio Durrusion capacity These ob en·ations recei,·e confirmation from a Physiological shunt theoretical anah·si of Fairle,· in 1966' which showed Cardiac output II Mmoglobin concentration that while h}l>~n·entilation ·could rai e the tension Tissue pcrrusion of oxygen in the alveolus, oxygen tension in arterial 'Pissue oxygen consumption blood would ri e to a les er degree. thus producing Desaturation or venous blood an increased ah·eolar-arterial oxygen gradient. (2) THE EFFECT or BRE.\TH I XG OxYGEN Aetiology of P ostoperative Hypoxia In 1965, Xunn and other ~dem onstrated in While unden·entilation due to the respiratory ,·oluntecrs that forced expiration produced radio­ depressant affects of anaesthetics or to restriction of logical evidence of atelectasis with lowering or the respiration by the pain of surgery could result in arterial p01, but that thi change wa readily re­ hypoxia. hypoxia can occur without unden·entila­ ,·ersible on return to a normal breathing pattern. tion. 1\unn and Payne demonstrated in 19621 that If. howe,·cr. oxygen was breathed. forced expiration hypo:-.;a occurred almo t uni,·ersally in healthy pa­ produced more marked atelectasis which persisted tients undergoing minor electiYe surgery. and cer­ for a much longer period. tainly. few of their patients could ha,·c had ignifi­ I n the arne year, Dery and hi co-authors' cant re piratory depression. .Among possible actio­ showed that alveolar coUap e could be induced by logical factors, attention ha been directed to alter­ dcnitrogenation under anae thesia and in con cious ation in the mechanic of breathing during and after ,·olunteers breathing oxygen. 'f he e change did not anaesthe ia and urgery. the effect of breathing occur when the ,·olunteers were given mixture of Yarious gas mixture , and of alterations in cardiac 50% oxygen and 50'1; nitrogen, and anae thctised output and haemoglobin concentration. patients given the e mixtures a! o showed no change. (! ) THE P.\TTERX OF BHEATHING This implies that the steady fall in p01 ob cn·ed Using ether and air mixtw·e . :.rarshall and bv Bendixen et al. 1 wa in deed due to progres i,·e Grange demonstrated in 19662 that on spontaneous atelectasis, and could be prevented by breathing re piration on air there was a fall in arterial oxygen oxygen-nitrogen mixtures. ten ion per i ting for up to three hours po toper­ (3) A LTER.\TIOX 1x CAHDl.\C OuTPUT. ati,·cly. and that this was accompanied by a fall in The marked fall in cardiac putput frequently alveolar Yentilation and a rise in the alveolar-arterial demonstrated during anaesthesia has been attributed oxygen gradient. During this time the pC02 and to the direct myocardial depre ant effects of anaes­ the ratio of dead space Yolume to tidal Yolume re­ thetic agent , combined with the effects of h~l>er­ mauled unchanged. '\nen patient were giYen ,·cntilation. " 'hile increa ed cardiac outputs ha,·e artificial ventilation at normal minute Yolume , been demonstrated in the po toperati,·e period in pO t' remained low, the a!Yeolar-arterial oxygen association with C01 retention, it i likely that gradient increa ed further, and the ratio of dead cardiac output may remain subnormal in many space to tidal volume increa cd. \\'hen ventilation surgical patients where there is hypo tension, ,·aso­ wa increased to twice the normal minute YO!ume, constriction and persistent h~1>ovolaemia . l;nder as would be expected. ah·eolar Yentilation increa ed these circumstance . ,·euou blood will be more and pCO, fell. \\nile there was a further increa e desaturated, and the normal physiological hunt in the alveolar-arterial oxygen gradient, the p02 will therefore add blood of a lower oxygen content now rose to normal Je,·els, and there was no further to the arterial side, resulting in an increased alveo­ increase in the ratio of dead space to tidal Yolume. lar-arterial oxygen difference. This effect will be

THE NOVA SCOTIA ~IEDICAL BULLE'l'IX 122 JUNE, 1968 enhanced by ass is~ed or control_led respiration, by a shown prolonged hypotension under anaesthesia. lowered hemoglobm concentratiOn~ or by the gr_eat Correction of acidosis will also assist in counteract­ increase in resptratory work followmg many surgiCal ing the effects of residual curarisation. In the minor procedures. elective patient, rebreathing devices may encourage (4) T H E EFFECTS OF SuRGERY the patient to take deep brea ths, and expand ate­ In addition to the restrictions imposed upon lectatic areas. Al ternatively, chemical stimulants, respiration by postoperative pain, it must be recog­ such as Dopram 20 mg by slow intravenous injec­ nised that whenever the chest or abdomen is entered, tion, will encourage deep breathing and improve there is a loss of t he normal intracavity negative cardiac ou tput. With these two methods, our own pressure, with _compres~i o n of t~e lung to a new level studies haYe demonstrated a small but useful rise of light deflatiOn. T his deflation may be remforced in arterial p02 following their use. b,. the residual effects of muscle relaxant drugs. In our intensive care area, it has become our If ,·oluntary deflation of the lw1g can lead to ate­ practice to carry out vigorous hypen ·entilation with lectasis6. then it is equally likely that atelectasis will the Ambu bag using air, on all patients maintained follow this deflation of t he lung induced by surgery on respirators, and this practice has been fo llowed by and anaesthesia. The marked reduction in com­ a marked improvement in p0 2 levels where the p0 2 pliance and functional residual capacity a~ d the had previously been below normal. In addition, frequent occurrence of bronchospasm seen m pa­ t he evidence of Frumin and others in 1959 10 that tients with flail chests is but an exaggeration of the a positive pressure of 5 mm Hg. applied to the air­ sta te of affairs which may exist in many postoper­ way during e}..--pira tion will cause an increa e in ati,·c patients. functional residual capacity and an increase in (5) T H E EFFECTS OF P noLOXGED Oxr GEN THER.\PY arterial oxygena tion has been put to work in patients Pratt in 19657, reported that patients who had showing lowered p02·, on artificial Yent ilation, par­ recei,·ed concentrations of more than 50% oxygen ticularly the post-open-heart patient. It has be­ for more than two days show thickening of alveolar come our practice in t hese patients to u e the retard septae and capillary proliferation at post-mortem. cap of the Bird respirator, or the expiratory positi,·e :\orthway and others in 19678, showed profound pre sw·e device of the E ngstrom respirator. to pro­ clinical, radiological and pat hological changes in a vide continuous positive e:-..--piratory pressures in these group of infants treated with warmed humidified patients, with resulting improvement in arterial oxygen for more than 24 hours., and felt t hat these oxygen satttraiions. We belieYe that this impro,·e­ change could be directly related to t he con centra­ ment is caused by returning the chest from a position tion of oxygen employed and the duration of treat­ of partial deflation favouring atalectasis, to a more ment. This indica tes that the usc of oxygen is not normal position where atelectasis i less likely to without risk, and that care must be taken to u e low occur. concentration for as hort a period as it appear In addition to these measures, we are much more clinirally necessary. critical of our standards of adequate ventilation, The Tr eatment of Postoperative Hypoxia and will maintain patient intubated, and on respira­ \re have seen that anaesthesia, whether carried tory assistance in the recovery room until there is on under spontaneous respiration or under con­ ample eYidence that t he patient has recovered from trolled respiration, i almost invariably followed by all re idual effects of respiratory depressants and ome degree of hypoxia for varying periods. It has curarising drugs. been shown tha t t his hypoxia can be avoided by the In t he relief of postoperati,·e pain, there are a administration of 30% ox~· gen 9 , and it is probable number of measures which may be helpful. T he use that this simple mea ure hould be applied to aU of neurectomy at t he time of surgery, the combin­ postopera tive patients, but should certainly be used ation of narcotic with narcotic antagonist to reduce in those who are most at risk from hypoxia. Thus, respiratory depression, and t he use of contin uous elderly patients, those showing vasoconstriction, or segmental epidural blocks all have their place in the in whom hypovolaemia is suspected, and those pa­ trea tment of patients at risk from chronic lung tients w·ith myocardial impairment, should certainly diseases. be given oxygen postoperatively for at least two to \Thenever prolonged ventilation is contemplated three hours. Adequate measures may be needed to or undertaken, an a.ttempt is made to ventilate the restore blood volume and lost haemoglobin in many patient on oxygen air mixtures containing less than Patients, but are vitally necessary in this elderly 30% oxygen. If higher percentages of oxygen are poor risk group. Care should be taken to reverse required, then they are given, but the arterial p02 residual curarisation, or if this is not possible, ade­ is carefully monitored, and oxygen is withdrawn as quate ventilation must be maintained \vith a respir­ rapidly as t he clinical circumstances permit. In ator. The correction of postoperative acidosis with this connection it is worth emphasising that the pres­ 50 - 100 mls of sodium bicarbonate solution (44.3 sure-cycled respirators such as the Bird or Bennett, mEqj vial) should be carried out empirically in any deliver from 70 to 90% oxygen when t hey are driven Patient who shows poor tissue perfusion, or who has from an O}..-ygen source, even when they are set on

THE KOVA SCOTIA MEDICAL BULLETIN 123 JUNE, 1968 full air dilution. To deliver lower percentages, these frequent occurrence, and that the effects of this hy. respirators must be operated on air, and a low flow po :~.--ia can be avoided by the administration of of oxygen added in through the Venturi air intake, 30% oxygen. Concentrations greater than 30% or through the nebuliser supply. The Engstrom employed for periods longer than 24 hrs may lead respirator operates normally on room air, and oxygen to pathological changes in the lungs. In avoiding percentages can be increased by the addition of cal­ the effects of tissue hypoxia, an adequate cardiac culated volu mes of oxygen through a rotameter. output must be sustained through volume replace­ ment, and the haemoglobin concentration and elec­ Summary trolyte balance maintained at normal levels. Ad­ ditional measures which may prove helpful in thE.> In summary, it may be said that postoperatiYe management of both minor and major clecti1·e hypoxia is a widely unrecognized syndrome of surgical procedures have been discussed. 0

References 6. Dery, R., Pelletier, J., J acques, A. Clavet, M. and I. Nunn, J . F . and Payne, J . P. lfypoxaemia After Houde, J . : Alveolar Collapse fnduced by Denitro­ General Anaesthesia. /janceJ. 2, 631, 1962. genation. Canad. Jlnaes. Soc. J . 12 : 531, 1965. 2. Marshall, B. E. and Grange, R. A. : Changes in 7. Pratt, P. C. The Reaction of Hu man Lung to En­ Respiratory Physiology During Ether /Air Anaesthesia. riched Oxygen Atmospheres. Ann. New l"ork A cat/. Brit. J. !I naesth.. 38 : 329, 1966. Sc. 121 : 809. 1965. 3. Bendixen, H . H ., Bullwinkle, B., Hedley- White, J ., Northway, W. H. Jr., Rosan, R. C. and Porter, and Laver, M. B.: Atelectasis and Shunting During D. Y.: Pulmonary Disease Following Respirator Spontaneous ventilation in Anaesthetised Patients. Therapy of Hyaline Membrane Di ease. S ew E11g. Anesthesiology 25 : 297. 1964. .lied. J., 276 : 357, 1967. 4. Fairley, H. B. : The Effect of Hypen ·entilation on 9. Conway, C. M. and Payne, J . P. Postopera tive Arterial Oxygen Tensions. A Theoretical Analysis. Hypoxia and Oxygen T herapy. Brit. .II ed. J .. I : 844, Can. Anaes. Soc. J . 14 : 7, 1967. 1963. 5. Nunn, J . F., Coleman, A. J ., Sachithanandan, T., 10. Frumin, M. J ., Bergman, N. A., Holadav, D. A., Bergman, N. A. and Laws, J . W.: Hy poxaemia and Rackow, H . and Salanitre, E.: Alveolar-Arterial Atelectasis Produced by Forced Expiration. Brit. Oxygen Differences During Artificial Ventilation in man. J . . l naeslh. 37 : 3. 1965. J. A ppl. Physio/. 14 : 694, 1959.

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lA MAXWELL , M .B., Ch.B.

LEGISLATION REGARDING ABORTION

" ...... Similarly I will not gil'e to a woman a pessary to caust abortion"- Oath of llippocrales 460-$70 B.C. medical practitioner . two barri tcrs and olici tors. and two ocial workers. such hearings being held in camera. It has been e timated that C\'ery year one out In June. 1967. the ouncil of the Can­ of e,·ery twen ty Canadian women undergoes a crim­ adian ~ l edical .\ s ociation appro\'ed the inal abortion. mall wonder then that there ha,·e first of these two point . but not the been extensi,·e discu ions of this ma tter o,·er the ccond one which recommended the es­ past ten years in medical and legal circles and in the tabli hment of T ermination Board . It lay press. communicated its recommendations to the The rele,·ant law in Canada is contained in J.Iini ter of J u tice. ections 287 and 288 of the Criminal Code which In D ecember. 1967. the ~Iiniste r indi­ state in effect that anyone. including the pregnant cated his intention to in troduce a Bill woman herself. who employs any means to procure amending the Criminal Code, Clause 17 a mi carriage is guilty of an indictable offence and is of which. no doubt in part due to the sub­ liable to life imprisonment. Sections 195 and 209 mis ion , would amend . ection 287 to per­ arc in conflict with the e later section s: ec 195 de­ mit a qualified medical practitioner to fine a human being a "a child which ha completely car r~· out therapeutic abortion with th<:' proceeded in a living tate from the body of it permi ion of the pregnant woman on th<:' mother. whether or not it ha breathed" and ec authorization of a ho pita! abortion com­ 209 specifically exonerates ·'any person who, by mittee if this committee certifies in writing means that. in good faith. he considers necessary to that continuation of pregnancy would en­ preserve the life of the mother . ... causes the death danger her life or health. of a child which ha not become a human being.·· \\"e di cussed the que lion of abortion In August. 1966, the Canadian Bar A socia tion pre,·iou8ly in THE B{;'LLETI~ in J une, recommended the following amendment to the 1967, and in July the Committee on ~led i­ Criminal Code: cal Legal Liai on conducted a panel dis­ (A) That, if performed by a licensed medical cussion on the subject at the ummer practitioner in an accredited hospital on ~1ee ting of the ~f edieal ociety. the written con eni of the woman or her In )l'o\'ember a second panel discus ion legal guardian and after approval by the was held under the aegi of the :\l <:'dical Therapeutic Abortion Committee of the Legal ociety of :\om cotia. hospital. an operation for the termination It occurred to u t hat the \'iew of the of pregnancy be la\dul: di tingui bed paneli ts would be of interest (i) iC continuation of the pregnancy en­ to the man\' members of the ~ Jedica l o­ dangers the I ifc or health of the preg­ cicty who ,,:ere unable to attend the e dis­ nant woman. cussion s. Accordingly . each of the pan­ (ii) there is substantial ri k that the child elists was asked to an ,,·cr the following may be born with a graYe mental or two questions: phy ical disability. (A) II' hat are your comments concerning thr (iii) there are reasonable and probable recommendations by the Canadian Bar .l s­ grounds to believe a ex ual offence sociation and the Canadian Jl edical .1.~ ­ has been committed from which sociation with respect to legalizing abortions? pregnancy has resulted. (B) What changes would you recommend your­ (B) That such termination of pregnancy be self? lawful only if a pplication ha been made In this, and the subsequent two is ues of T HE to a pro,·incial "Termination Board" con­ Bt;LLETI • we shall be publishing the answers sisting of eYen member , three being which we haYe reeeiYed.

THE NOVA SCOTIA ~IE D!CAL BULLETIN 126 ,Till;' E, 1968 H. B. Atlee, M.C., M.D., C.M., LL.D. he simply requests that a properly qualified doctor F.R.C.P.S., F.I.C.S. do the abortion in a properly run hospital. It should be as simple as that. Emeritus Professor of Obstetrics and Gynecology. u nder the grounds proposed by the Bar and the Dalhousie University :.1edical Profession, the onus would fall on the doctor. Human nature being what it is, he will be asked to strain the points laid down to coYer a much wider license than intended in the legislation. The My comment on the recommendations of the situation so created will not be unlike that which Canadian Bar Association and the Canadian :.Icdi­ beset the medical profession under prohibition, cal Association with respect to legalized abortion where every doctor in the country was plagued to is that they are hopelessly inadequate to meet the write prescriptions - and practically e\·ery doctor abortion situation. They are designed simply to did - knowing fuJI-well that the liquor so prescrib­ legalize medical inten ·ention where the life of the ed was for a thirst and not a sickness. )I'or would mother and well being of the child are at take. This this legislation in any way cut down the illegal merely touches the hem of the garment, since of all abortions. The woman who wants to get rid of an the abortions done yearly on this continent, those unwanted fetus, and is unable to do so legall ~·. will done for medical reasons are a fraction of a percent. continue to do so as at present- illegally. The real problem is the abortion done illegally While as an obstetricia n I welcome any legis­ either by doctors or others under such inferior lation that safeguards my profession in a situation urgtral conditions that there is a high mortality to where at present there are no legal grounds for in­ the woman and an even higher morbidity. What we terrupting pregnancy, I feel that sooner or later need to do is so legislate that this human wastage legislation must be enacted to deal with the very can be ended. This means taking the onus of de­ much more serious and deadly circumstances I have ciding who will ha\·e an abortion and under what indicated. My recommendation therefore is that circumstances away from the medical and legal pro­ a ll statutes in the criminal code dealing with abor­ fessions. and gi\·ing it to the woman concerned. It tion be rescinded. means that a woman should be as free to obtain an abortion as she now is to obtain an automobile. ('l'o be continued)

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Bank of Canada Bldg. Phone: Olfice 423-7144 1583 Hollis St., Halifax Home 423-2198 ,_ Inadequate Prenatal Care and Toxemia of Pregnancy

Reprinted from The Canadian l\Iedical Association Journal, August 27, L966, Vol95, page 410.

A 31-year-old married woman. pregnant for the is present. The placenta is in the upper uterine second time and with a history of a spontaneou egmcnt." abortion seYen years befo re the second pregnancy . After 17 t hours of labour the cen ·ix was dilated made her fir t prenatal vi it to her physician at 29 em.; however, mo t of the fetal head wa abo\·c weeks' gestation. At this time she weighed 206 lb. the pelvic inlet. The cen ·ix was full y dilated after (a weight gain of 31 lb. from her non-pregnant 21? hours of labour and the fetal head appeared to weight); her height "·as 64 in.; her urine was normal; be engaged. itrous oxide, ether and oxygen and her hemoglobin (Hb.) was 11.5 g. % The blood anesthesia wa given after 22t hours of labour. and a pressure was not recorded. he wa of low men­ Yaginal examination showed the cervix to be fulh· tality and was extremely unco-operati\·e during the clilated; the fetal head was in ·'deep transvers-e pregnancy. arrest" in the right occipital transverse position. The patient made her econd prenatal office lJsing forcep . an unsuccessful attempt was made to Yisit when 35 weeks pregnant. In the six weeks be­ rotate the fetal head to the anterior occipital posi­ tween the first and second office Yisits she had gained tion. After this failed, the a ttencling phy ician and l4 lb. Her blood pressure was 220/ 110 mm. Hg; the other general practitioner who had been gi\·ing her urine contained 150 mg. % of albumin and she the anaesthe.ia agreed that a Cac arean section was had pitting edema of her legs. he refused hospital­ indicated. The blood pressure was still ele\·atcd ization at this time and was placed on 50 mg. of and the fetal heart sounds were normal. A third hydrochlorothiazide daily. doctor was summoned from a neighbouring town to The patient clid not return for a third office visit give the anaesthe ia while the two local doctors per­ until four weeks later, when she was 39 weeks preg­ formed the surgery. nant. At t his time she was immecliately hospitalized Two hours after the '·failed forceps'', a second because of severe headache, edema of her legs. a anaesthesia of ni trous oxide, ether and o;.;ygen was blood pressure of 220/ 120 mm. Hg. and 200 mg. % given and a Caesarean section was begun. It is not of albumin in her urine. She was not in labour and known whether a classical or low transverse Caesarean would not stay in bed a requested. The patient section was performed. On exposure of the uterus. was placed on a salt-free cliet. t grain of pheno­ 10 units of oxoytocin was injected into the myo­ barbital three times daily and 0.2 mg. of reserpine metrium. After the uterine incision had been made. and 50 mg. of hydralazine (Serpasil-Apresoline) the attending physician and his assistant took 10 three times daily. minutes to dislodge and deliYer the impacted fetal On the third hospital day, her blood pressure head. When the head was delivered 20 minutes was 150/96 mm. Hg. and the urine albumin was after the beginning of surgery. " it came out with a 200 mg. o/c. Because the patient had refused surgi­ plop". Immecliately. after the delivery of the head, cal induction of labour, an unsuccessful meclical the blood pressure, wh ich had been 230/ 140 mm. induction was attempted using 2 minims of oxytocin Hg before deliYery, fell to 80/20 mm. Hg. The pla­ (Syntocinon) intramuscularly every half hour for centa was manually remoYed and there was no ex­ si..x doses. cessive bleecling or laceration of the uterus. The Her blood pressure varied from 160/88 mm. patient received 0.5 mg. of ergonovine maleate Hg. to 220/ 124 mm. Hg on the si..xth hospital day. (Ergotrate Maleate) intramuscularly after the de­ On the seventh hospital day, her blood pressure livery of the placenta. Dextran was given intra­ was 205/ 105 mm. Hg, her fasting blood sugar was venously, but the blood pressure continued to fa ll 114 mg. % and her Hb. was 8.6 g. % Oral iron and respirations ceased 55 minutes after the de­ therapy was begun. livery of the head. Autopsy permission was re­ Spontaneous labour began on the tenth hospital fused. day. Racliographic pelvimetry, done on the eleventh The 10 lb. 1 2~ oz. female infant was in poor hospital day, was reported as follows: "A single condition at birth and, when respiration was estab­ fetus is presenting in the right occipital anterior po­ lished, the infant had a "shrill cry". She was re­ sition. The head is engaged and at the level of the suscitated at birth by ox')'gen and mouth-to-mouth ischial spines. There are no maternal or fetal ab­ breathing. The infant's conclition appeared to im­ normalities. 1\o definite cephalopelvic clisproportion prove up to two days of age when she suddenlY

*This series of articles arranged by an editorial subcommittee of the C.M.A. Committee on Maternal Welfare, and origin­ ally published in the Canadian Medical Association Journal, is being reproduced in the Bulletin at the request of The Medical Society or N. S. Committee on Maternal and Perinatal Health, by kind permission of the Editor or the Canadian ~ed i cal Association Journal.

'f HE KOVA SCOTIA ~EDICAL BULLETIN 128 Jtr.\1' E, 1968 died . after developing petechiae on the arms and home \'i its by the attending physician. regional face. Autopsy was not done but the clinical cause medical officer, or public health nurse. of death was considered to be "cerebral hemor­ Delayed hospitalization and/ or inadequate ther­ rhage". apy fo r pre-eclamp ia have been reported following Decision of the Provincial Committee on many maternal mortality tudies. This patient did Mat ernal Welfa re not seek prenatal care until she was 29 weeks preg­ T he following conclusion were reached by the nant. he did not return to the physicians office Pro\·incial Committee on Maternal 1\elfare after for a second Yisit until si.'l: weeks later. At this a review of this case. time she had gained an additional 14 lb. (a total "T his was a preventable direct maternal death. weight gain during pregnancy of 45 lb. up to this As an autopsy was not done, the exact cause of the time), the blood pressure was 220/ 110 mm. Hg. maternal death was unknown. I n a patient with a and albuminuria and pitting edema of the legs were blood pressure of 230/ 140 mm. Hg, the precipitous present. The patient refused to go to hospital at drop in blood pressure following the traumatic this time. \\n en a physician is pre ented with such efforts during Caesarean section to dislodge the a si tuation, he must explain to the patient in the impacted fetal head suggests that death was due most forceful manner that she is seriously ill and either to cerebral hemorrhage or pulmonary infarc­ must be immediately hospitalized and treated. If tion. There were combined patient and profes ional he is not successful in convincing the patient of the pren•ntable factors. need for hospital care, the husband or other re­ "The patient did not seek early and adequate sponsible members of the family must be informed prenatal care and was extremely uncooperative of the seriousness of the situation and their co-op­ during the course of her pregnancy. eration sought. If this patient had been admitted "The profes ional factors were: inadequate pre­ to hospita l and the pre-eclampsia adequately natal care; failure to determine the Hb. until the treated when she was 35 weeks pregnant, this death eventh day after admission to hospital; inadequate would probably have been prevented. Adequate treatment of the anemia; inadequate treatment of treatment of the pre-eclampsia at this stage would the pre-eclampsia; the use of intramuscular oxytocin have included bed rest, diet. sedation, oral diuretics to induce labour; the use of an ergot preparation in and hypotensive agents or magnesium sulfate intra­ a patient with hypertension; performance of a muscularly. If the pre-eclampsia did not improYe Caesarean section in the presence of severe anemia with this regimen. a pre-term induction of labour without blood for transfusion and without addi­ should have been undertaken. and if this was un­ tional specialized assistance, or without trans­ successful or if the labour did not proceed normally. Cerring the patient to a hospital where blood tran - a Caesarean section should haYe beon performed. fusion. adequate facilities and specialists were The use of oxytocin intramuscularly to induce available. labour is a dangerous procedure which may result "This maternal death was considered ideally in hypertonic uterine contractions with the risk of 'preventable' under the terms of reference of the fetal ano:-.i a. fetal death, or uterine rupture. \\hen Pro\·incial Maternal Welfare Committee and there it is used to induce labour, oxytocin should only is no implication of any negligence.'' be administered in a dilute intraYenous drip, be­ Discussion ginning with 2 to 5 units or oxytocin in 500 c.c. This patient' hemoglobin level was not de­ of 5% glucose in water at the rate of 15 drops per termined until the seventh day after her admission minute. This rate of intravenous infusion should be to hospital, at which time it 'was found to be 8.6 varied according to the uterine response and should g. ~- Prenatal Hb. determination should be done be under the constant superYision of the attending when the patient is first seen. should be repeated at physician. least once during the pregnancy, preferably at 36 Cases ha\·e been described in the literature weeks' gestation. and should be done again when where the use of ergo t preparations following the the patient is admitted to ho pital. \\'hen deli\·ery delivery of the infant and placenta has resulted i imminent and the Hb. is found to be at a critical in se\·ere hypertension with cerebrovascular hemor­ level, arrangements for immediate blood procure­ rhage. Because of this association it i sound ob­ ment and replacement should be made. stetrical practice to use 10 units of oxytocin intra­ Ideally. maternity patients should make pre­ venously instead of ergot preparations after the natal office \'isits at least monthly for the first seven delivery of the placenta in hypertensive or pre­ months, e\·ery two weeks during the eighth month eclamptic patients. Some obstetricians now use 5 and weekly during the ninth month. \\hen an un­ to 10 units of oxytocin (Pitocin or Syntocinon) in­ cooperati\·e maternity patient does not seek ade­ travenously after the deliYery of the placenta for Quate prenatal care, the attending physician has all parturients. because of the hypertensi\·e effect an obligation to attempt to stimulate the patient to of ergot deri\·atives in some patients. obtain such care. There are several ways to accom­ The 10 units of oxytocin which was injected into Plish this: telephone contacts with the patient or the myometrium immediately before the delivery

'l'BE KOVA SCOTIA MEDICAL BULLETIK 129 JUKE, 1968 of the infant probably contributed to the difficulty uncooperative patient. e\·ere pre-eclamp ia. evero in extracting the fetus at Caesarean section. Such anemia, failed induction of labour and probable intramyometrial injection of oxytocin before de­ ccphalopch·ic disproportion). He would ha,·e been lh·ery by Caesarean section is noL recommended be­ well advised to tran fer the pittient to a larger cause it may cause uterine pasm and make extr-ac­ ho pita! where blood tran fu sion, additional pecial­ tion of the infanL difficult. ized a i lance and adequate facilitie were avail­ After a trial of labour or ··failed forceps··. par­ able. a was unfortunate that the attending J>hy. ticularly when Lhe membranes have been ruptured ician did not in i t thaL an autop y be performed for several hollr , the head may become deeply im­ before he signed the death certificate. pacted in the peh·is. In such an instance it i not unusual to have diffi culty in extracting the fetal Summary head at Caesarean section. \Yhen the head is thus .\ maternal death was reviewed by the Pro­ impacted. an assistant should push the head up vincial Committee on l\Iaternal \Yelfare. An au­ from below (i.e. with a hand in the vagina) to help topsy was not done; therefore the exact cau e or its prompt delivery after the uterine incision has death was unknown. However. the clinical course been made. uggests that the death wa due either to cerebral The attending physician in this case wa con­ hemorrhage or pulmonary infarction. The pre\·ent­ fronted with many obstetrical complication (the able factors are discussed. o

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DOSAGE: A minimum therapy for adults may be considered to be AVAILABLE 10 grain s four times a day. lntermittent administration Is ineffective. FOR Sl DE EFFECTS : Tinnitus, nausea, vomiting and diarrhea. Idiosyn­ crasy to acetylsalicylic acid is uncommon, bei ng manifest as skin LOCUM rash but rarely anaphylaxis.

Bottles of 100 and 500. Available fir t t hree weeks in August. NOTE: In Canada, acetylsalicylic acid Is one of the most frequent causes of accidental poisoning in infants and toddlers. It should, therefore, be stored well out of reach of all children. D r. Edward Day, ~@ """uN "''""''"'"''nc:ALS: I Fu/1/n(ormalion on r equest. Clunk> ~Jio;,t & Co. Children's Hospital. /_ IOOoo r::,..~ • .:~ - *Patented,1959 Halifax A number of se,·ere reactions had been reported Public Health News throughout the world. he said when the " killed'' vaccine was gi,•en followed by ~ dose of the "live'' Rehabilitation ~;a~cm~.. The pro'i_nee had planned to use the The rehabilitation J>rogram of the Depart­ . k1lled. v~cc m e by mcorporaling it in the general ment of Public Health is expected to be lrans­ 1mmumzallon program. In lead it will wait for fem•rl to the Department of Public Wellare and further te ls on the Yaccine. expanded considerably there, F. G. \\" ellard, director of rehabilitation. said. Cattle with Tuberculosis He said it was expected thi would be done T hree cattle herds in the Fundy Health t;'nil .. for practical reasons and to pro,·ide better services were found in fected with tubcrculosi but the risk to more handicapped persons." .\ s yet "there has of humans con_tracting the disca e i not too great. been no action on this at the ministerial le,·cl,·· Dr. G. ~ I. . m1lh, uni t director, aid. ;-Ir. \Ycllard said. He pomled out that testing of one of the herds The expected transfer follow a recommenda- rc,·ealed .J. 3. reactors. which on slaughtering. re­ tion of the Welfare ~l ini ler's Ad,·i on· Com­ :ealed I '''llh extensi,·e glandular le ions. in fi ve milt<'C on Rehabilitation. This committee also mslanees so great that the carcas es were condem­ called for a rehabilitation ad,·i er. rcspon ible ned. . The u ual le ting of ramilie who bad to the director of welfare senices, to advise on how been Lll contact with the herd revealed nothing best to de,·elop an effecti,·e rehabilitation pro­ unusual. gram in the proYince. " ~n )."'o,·a coli~. it would appear. he said, that In addition, the com mittee recommended the bo\ me tuberculosiS as a cause of disease to the appointment of a pro\incial adYisory committee general population i negligible'· but it wa a "po i­ on n•habililalion to ad,·ise the ~Iini ter of Public ble source of mfeclion and disease to ,·eterinarians Welfare on how best to spend the fu nd available. and lh~ e working with cattle or in laughtering It abo called for the setting up of local ad,·isory h_o~ se · ~XClUSI\·e of the three herd . the infec­ committees. tlnty rate .1? ~attle for the pro,·ince was fo und to The committee wants the province to pro· be m the \'ICilllly of O. l per cent, as for all of Canada. moll· the de,·elopment of integrated sheltered work­ . ~ e fell attention hould till be gi ,·en to families shops in all communities where there is a need and '''llh mfected herds and he urged \'eterinarians and to pay 0 per cent of the costs inYolved in estab­ those in slaughter house to haYe annual X-rays. o lishing these workshops. The pro,·ince should institute, the report said. "a program of re earch to determine the needs of disabled children and particularly what can be done to assist in their treatment and rehabilitation. BillltordtheK· as well as in establishing pre,·enti,·e sen·ices." The committee recommended that considera­ tion be gi,·en to allowing trustworthy prisoners to the guanmteed altlnd_ training courses during the day and to return to thmr cells at night until their confi nement ends. ch~with "\n altcrnati,·e suggestion was to make a,·ail­ ~ bl training courses for prisoners in the e,·ening m trades training schools or academic institutions. builtin credit Th1 committee felt "studY clas es and libran· • Good for goods and fac•lities" should be "made. a,·ailable in jails" to good fo r cash. encourage prisoners to fu rther their education. • Provides $500-or ~ ! embers of the committee were: G. P. Cole­ more- instant credit man, Q.C. chairman; Frank '\Yellard, rehabili­ when you need it. tation director; H. S. Farquhar. director. old age as-tslance. XoYa cotia Department of Public • Guaranteed by ':·t·lfa re; D . A. ~IcLeod, Plant Manager, Cros ley­ Bank of Montreal. Kara tan, Carpet i\Iills Limited, Truro: P . T. See your local branch soon. :.\Ieyer, Retired t;niled tates Consul-General; and :.\Irs. Edith A. Phillips. Port ~1oricn, X. . Measles Vaccine Program ~ ·SoYa Scotia has halted its proposed program of measles \'accination for the time being", said Dr. Bank of Montreal H. B. Co!Iord. Communicable Disea es Control Canada's Arst Bank D1rector, )[ova eolia Department of Public Health.

JUXE, 1968 TilE XOVA SCOTIA :\!EDTCAL BULLE1'1X 131 you need a rest.

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