History of Nursing in Pacific Canada

The Vancouver Medical Association Bulletin: March, 1951 Vancouver Medical Association Mar 31, 1951

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 VOL. XXVII
B, 6. MEDICAL CENTRE LIBRARY
THE -|ji Jf'
ULLETI
1 OF i
The Vancouver Medical Association
EDITOR:
DR. J. H. MacDERMOT
EDITORIAL BOARD
DR. D. E. H. CLEVELAND DR. J. H. B. GRANT
DR. H. A. DesBRISAY DR. D. A. STEELE
Publisher and Advertising Manager
'^J^^^l W. E. G. MACDONALD
MARCH, 1951
NUMBER 6
OFFICERS  1950-51
Dr. Henry Scott Dr. J. C. Grimson Dr. W. J. Dorrance
President Vice-President Past President
Db. Gordon Burke Dr. B. C. McCoy
Hon. Treasurer Hon. Secretary
Additional Members of Executive:
Dr. J. H. Black Dr. D. S. Munroe
TRUSTEES
Db. G. H. Clement Dr. A. C. Frost Dr. Murray Blair
Auditors: Messrs. Plommeb, Whiting & Co.
SECTIONS
Eye, Ear, Nose and Throat
Dr. N. J. Blair__ Ml— Chairman Dr. B. W. Tanton, Secretary
Paediatric
Dr. C. J. Trefry Chairman Dr. Peter Spohn Secretary
Orthopaedic and Traumatic Surgery
Db. D. E. Starr Chairman Dr. A. S. McConkey Secretary
Neurology and Psychiatry
Db. P. E. McNaib Chairman Dr. R. Whitman Secretary
Radiology
Db. Andbew Turnbull Chairman Dr. W. L. Sloan ^Secretary
STANDING COMMITTEES
Library:
Db. E. France Wobd, Chairman; Db. A. F. Hardyment, Secretary;
Dr. F. S. Hobbs, Dr. J. L. Pabnell, Db: S. E. C. Tubvey, Db. J. E. Walkeb
Co-ordination of Medical Meetings Committee:
Db. R. A. Stanley Chairman Dr. W- E. Austin Secretary
Summer Sphool:
Dr. Peter Lehmann, Chairman; Dr. B. T. H. Majrteinsson, Secretary;
Dr. A. C. Gabdner Fbost; Dr. J. H. Black; Dr. Peter Spohn;
Dr. J. A. Irving.
Medical Economics:
Dr. F. L. Skinner, Chairman; Dr. E. C. McCoy, Dr. T. R. Sarjeant,
Dr. W. L. Sloan, Dr. J. A. Ganshorn, Dr. E. A. Jones, Dr. G. Clement.
Credentials:
Dr. G. A. Davidson, Dr. Gordon C. Johnston, Dr. W. J. Dorrance
Special Committee—Public Relations:
Db. Gobdon C. Johnston, Chairman; Db. J. L. Parnell, Dr. F. L. Skinner
Representative to B. C. Medical Association: Dr. W. J. Dobbance
Representative to V.O.N. Advisory Board : Dr. Isabel Day
Representative to Greater Vancouver Health League: Dr. L. A. Patterson VANCOUVER MEDICAL ASSOCIATION
PROGRAMME FOR THE FIFTY-THIRD ANNUAL SESSION
Founded 1898; Incorporated 1906.
(Spring Session)
FEBRUARY 6th—GENERAL MEETING—Devoted to Medical Economics.
MARCH 6th—OSLER DINNER—Dr. H. A. DesBrisay, Osier Lecturer.
APRIL 3rd—GENERAL MEETING   (Speaker to be announced).
MAY 1st—ANNUAL MEETING.
MAY 2 8th to JUNE 1st (inclusive)—ANNUAL SUMMER SCHOOL.
REGULAR MONTHLY MEDICAL MEETINGS
FIRST TUESDAY—GENERAL MEETING—Vancouver Medical Association—T. B.
Auditorium.
Clinical Meetings, which members of the Vancouver Medical Association are invited
to attend, will be held each month as follows:
SECOND TUESDAY—SHAUGHNESSY HOSPITAL STAFF MEETING.
THIRD TUESDAY—ST. PAUL'S HOSPITAL STAFF MEETING.
FOURTH TUESDAY—VANCOUVER GENERAL HOSPITAL STAFF MEETING.
FIFTH TUESDAY—(when one occurs)—CHILDREN'S HOSPITAL STAFF MEETING.
Notice and programme of all meetings will be circularized by the Executive Office
of the Vancouver Medical Association.
VANCOUVER GENERAL HOSPITAL
Refresher Courses for the General Practitioner
SURGERY—February 12 th, 13 th, 14th, 1951.
EYE, EAR, NOSE and THROAT—March 5th, 6th, 7th, 1951.
OBSTETRICS and GYNAECOLOGY—April 9th, 10th, 11th, 1951.
Regular Weekly Fixtures in the Lecture Hall
Monday, 12:15 p.m.—Surgical Clinic.
Tuesday—9:00 a.m.—Obstetrics and Gynaecology Conference.
Wednesday, 9:00 a.m.—Clinicopathological Conference.
Thursday, 9:00 a.m.—Medical Clinic.
12:00 noon—Clinicopathological Conference on Newborns.
Friday, 9:00 a.m.—Paediatric Clinic.
Saturday, 9:00 a.m.—Neurosurgery Clinic,
edition, 1950.
Page 134 ST. PAUL'S HOSPITAL
Regular Weekly Fixtures
TUESDAY—9-10 a.m _|L I PAEDIATRIC CONFERENCE
2nd TUESDAY of each month—11 a.m.,r. ^Sff^^^-TUMOR CLINIC
WEDNESDAY—9-11 a.m._Jf3ffilife 01_^_.MEDICAL CLINIC
2nd and 4th WEDNESDAY—11-12 a.m. _.... OBSTETRICS AND GYNAECOLOGY
THURSDAY—11-12 a.m II| PATHOLOGICAL CONFERENCE
(Specimens and Discussion)
FRIDAY—8 a.m CLINICO-PATHOLOGICAL CONFERENCE
(Alternating with Surgery)
ALTERNATE FRIDAYS—8 a.m ,_SURGICAL CONFERENCE
FRIDAY—9 a.m Jg: „DR. APPLEBY'S SURGERY CLINIC
FRIDAY—11 a.m INTERESTING FILMS SHOWN IN X-RAY DEPARTMENT
SHAUGHNESSY HOSPITAL
Regular Weekly Fixtures
Tuesday, 8:30 a.m.—Dermatology.
Wednesday, 10:45 a.m.—General Medicine.
Wednesday, 12:30 p.m.—Patiology,
Thursday, 10:30 a.m.—Psychiatry.
Friday, 8:30 a.m.—Chest Conference.
Friday, 1:15 p.m?—Surgery.
BRITISH COLUMBIA CANCER INSTITUTE
Tuesday, 9:00 a.m. to 10:00 a.m. (weekly)—Clinical Meeting.
B. C. Surgical Society Meeting Dates:
Spring Meeting, March  30th-31st—Vancouver Hotel   (open  to  all members  of  the
profession).
THE   BULLETIN
Publishing and Business Office — 17-675 Davie Street, Vancouver, B.C.
Editorial Office — 203 Medical-Dental Building, Vancouver, B.C.
The Bulletin of the Vancouver Medical Association is published on the first of
each month.
Closing Date for articles is the 10th of the month preceding date of issue.
Manuscripts must be typewritten, double spaced and the original copy.
Reprints must be ordered within 15 days after the appearance of the article in question, direct from the Publisher. Quotations on request.
Advertisements
Closing Date for advertisements is the  10th of the month preceding date of issue.
Advertising Rates on Request.
Page 135 Vasoconstriction
combined with
antibiotic therapy in
NEO-SYNEPHRINE
(brand of phenylephrine)
with
CRYSTALLINE
1 PENICILLIN
^
'vvS
In upper respiratory tract infections,
topical application of penicillin to the nasal cavity has a decided bacteriostatic action against
typical respiratory pathogenic microorganisms.
To provide clear passage for such therapy,
Neo-Synephrine is combined with penicillin—
shrinking engorged mucous membranes and
allowing free access of the antibiotic.
Neo-Synephrine—a potent vasoconstrictor—
does noflose its effectiveness on repeated application ... is notable for relative freedom from
sting and absence of compensatory congestion.
NEO-SYNEPHRINE
with
CRYSTALLINE PENICILLIN
Stable •  Full Potency
Supplied in combination package for preparing 10 cc. ot
a fresh buffered solution containing Neo-Synephrine hydrochloride 0.25% and Penicillin 5000 units per cc.
"%.
"V
^
lllis.
V
NEW YORK 13, N. Y.      WINDSOR, ONT.
Neo-Synephrine, trademark reg. U. S. & Canada
443 SANDWICH STREET WEST, WINDSOR, ONTARIO VANCOUVER HEALTH DEPARTMENT
CASES OF COMMUNICABLE DISEASE REPORTED IN THE
CITY
Total Population —
Chinese Population -
Other  — estimated	
STATISTICS — FEBRUARY, 1951
estimated 1 .  397,140
-   estimated       6,2 8 2
  640
Nuumber
Total   deaths    (by   occurrence)  423
Chinese  deaths i     23
Deaths, residents only     3 85
January, 1951
Rate per
1000 pop.
12.8
43.9
11.6
BIRTH  REGISTRATIONS—RESIDENTS   AND   NON-RESIDENTS
(Includes late registrations)
January,  1951
Male     §|  461
Female     470
931
28.1
INFANT MORTALITY—RESIDENTS ONLY
Deaths under 1  year of age   16
Death rate per  1000 live births  £  23.8
Stillbirths   (not included in above item) 1       7
January,  1951
CASES  O FCOMMUNICABLE  DISEASES  REPORTED  IN  THE  CITY
January,  1951
Cases Deaths
Scarlet Fever i— 122
Diphtheria  —
Diphtheria Carriers  —
Chicken Pox . . j j  —
Measles  12
Rubella —- 2 3
Mumps  5 8
Whooping Cough_  —
Typhoid Fever JiL  —
Typhoid Fever Carriers  —
Undulant Fever —i _  —
Poliomyelitis   —
Tuberculosis I—j  5 2
Erysipelas  2
Meningitis :—--  1
Infectious Jaundice  —
Salmonellosis   4
Salmonellosis Carriers— —. —
Dysentery i  3
Dysentery Carriers  —. —
Tetanus -  —
Syphilis ,  14
Gonorrhoea ! i— 245
Cancer (Reportable)—Resident  100
12
January, 1950
Cases deaths
12 —
28
12
292
—
77
49
Page 136 -CCQMNAUCHT>
NPH   INSULIN
%
Following an extended period of clinical trial there is now
generally available a modified Insulin preparation known as NPH
Insulin. The product is distributed as a buffered aqueous suspension
of  a  crystalline preparation  of  Insulin,  protamine,   and  zinc.   It  is
supplied in 10-cc vials containing
either 40 or 80 units per cc
NPH Insulin exerts a blood-
sugar-lowering effect extending for
slightly more than a 24-hour period.
In most instances this new preparation has been found to act more
quickly than Protamine Zinc Insulin
but for a shorter period. Probably
because of the fact that NPH
Insulin is a suspension of crystals,
its use has been found advantageous
in cases where it is desired to administer Insulin and a modified form of Insulin in a single injection without
appreciable alteration of the effect of either of the two preparations.
^
>
*$—
7
feyi
Crystals   formed   of  Insulin,   protamine   and   zinc
in  NPH  Insulin
□
CONNAUGHT   MEDICAL   RESEARCH    LABORATORIES
University of Toronto Toronto, Canada
Established  in  1914  for Public  Service  through  Medical  Research  and  the  development
of Products for Prevention or Treatment of Disease.
DEPOT FDR BRITISH COLUMBIA
MACDDNALD'S    PRESCRIPTIONS    LIMITED
MEDICAL-DENTAL BUILDING, VANCOUVER, B.C. 7<&e &lUo>& Patfe.
In these days of numerous meetings, all held in the evening, it is very often difficult
to take in all that one would like, even when the meeting has been called to consider
matters of importance. Doubtless some such consideration accounted for the poor
attendance the other night at a meeting called to consider the matter of public relations,
and the establishment of a Public Relations Committee within the B.C. Medical
Association.
It is a pity that so few were there to hear the very able report of the Public
Relations Committee of the Vancouver Medical Association, headed by Dr. Gordon
Johnston. This Committee has done notable work since its establishment a year or
so ago. It was in charge of the publicity of the Summer School, and we all will agree
that this was excellent; it did the same for the B.C. Medical meeting in the fall—and
again it did good work. Its hand has been evident in the press of late, in connection
with Hospital Insurance and other matters. This Committee has had one main rule
in conducting its work and that has been to ensure as far as possible, the complete
factual accuracy of any statement it has made.
The members of this Committee, however, have come to certain very definite
conclusions about this matter of public relations. The first is that it should be handled
by the profession of B.C. as a whole and not merely by the Vancouver area. The second
is that we must, in one form or another, have a full-time man, lay or medical, whose
business it will be to gather facts ahead of time on all sorts of questions affecting the
medical profession, its welfare, and the welfare of those it serves. We must, they feel,
establish definite relations with the press, and so on.
One most important conclusion they have reached, is that the medical profession
as a whole needs considerable education in this subject—and not only as regards relations
with the public, but also in their own relations with each other—city with country—
one district with another district—specialist with general practitioner, and one medical
man with another. With this view we most heartily agree. It is high time that we
realize the danger of departmentalism, of parochialism, in a word, of selfishness. Perhaps
as good an example of what we mean by this, was afforded by the recent meeting of
the B.C. Medical Association about the S.A.M.S. Not deliberately, but through lack
of understanding and appreciation of the point of view of others, matters very nearly
reached a point where grave injustice and injury might have been done by a majority,
purely local, to a minority, whose rights in the matter deserved just as much recognition
as those of a more numerous group which was endeavouring, with considerable claim
to justice, to remedy its own lot.    That meeting did a lot of good.
Speaking for ourselves, we regard this work of the Public Relations Committee as
worthy of the highest praise, and as deserving and requiring our closest attention. We
believe they are quite right, and hope this matter will go ahead rapidly. But with one
of their conclusions we are afraid we disagree: and that is the suggestion, if we understood it correctly, we should put things in the hands of a lay Public Relations agent of
some sort, whether individual or corporate. We believe that the responsible man should
be a medical man of experience and with the qualities required. We say this for two
reasons: first, our experiences with trained newspapermen or other laymen in this
Province at least, have been uniformly a failure—we do not talk their language, and
they do not understand ours; secondly, the most successful and the only successful
work along this line of which we have known has been done by medical men. Whitehead in British Columbia did excellent work and really was getting somewhere—and
Kelly, of the Canadian Medical Association, also does a splendid job. Such a man is
not easy to find, we admit—but he should be sought for—and given necessary support
Page 137 in the way of expert opinion, which he will soon locate and make available as he needs
it. But he will represent us authoritatively, and not at second hand; .and he would
at all times, of course, be subject to the control of the Central Committee.
This will cost money—but it will be worth it: and it will benefit, not only ourselves, but the community at large. We should, as a profession, take the lead in medical
matters—not merely explode at irregular intervals, when we feel we are being oppressed.
The public should get our expert opinion from time to time, and be given the facts—
not bewitched by the brews of interested and often uninstructed people. We believe
that if we had followed this policy of maintaining and improving relations during the
past twenty years or so, we should have saved not only ourselves, but our province,
much loss and misdirection.
I
.- •
Library Hours:
Monday, Wednesday and Friday 9:00 a.m.-9:30 p.m.
Tuesday and Thursday 9:00 a.m.-5:00 p.m.
Saturday   j 1 9:00 a.m.-l:00 p.m.
Recent Accessions
Colby, F. H., Essential Urology, 1950.
Dunham, E. C, Premature Infants—A Manual for Physicians, 1948.
Gloyne, S. Roodhouse, John Hunter, 1950 (Nicholson Collection).
Guthrie, D. J., Lord Lister—His Life and Doctrine, 1949 (Nicholson Collection).
Medical  Clinics  of  North  America—Symposium  on  Clinical  Advances  in  Medicine,
Chicago Number, January, 1951. ||||
Penfield, W. G. and Rasmussen, T. B., The Cerebral Cortex of Man, 1950.
Stieglitz, E. J.   (editor)., Geriatric Medicine—The Care of the Aging and the Aged,
2nd edition, 1949.
Surgical Clinics of North America—Symposiums on (1) Surgical Diagnosis and (2)
Diagnosis and Treatment of Premalignant Conditions, Philadelphia Number,
December, 1950.
Woodham-Smith, C, Florence Nightingale, 1820-1910, 1950. (Historical and Ultra-
Scientific Fund).
BIBLIOGRAPHY ON ACTH, CORTISONE AND RELATED COMPOUNDS
The Army Medical Library' at Washington, D.C., have issued recently a bibliography
on "The Pituitary-Adrenocortical Function: ACTH, Cortisone and Related Compounds"
which covers over 3400 references from 1940 to the fall of 1950. The bibliography
is arranged alphabetically by subject with an author index and portions of it have been
annotated, the work consisting of approximately 360 pages. Members wishing to consult
this bibliography of topical interest may do so in the Library of the Associatoin.
Page 138    ' REPRINTS
At a recent meeting the Library Committee decided that a Reprint Section should
be established in the Library. It is planned to maintain an up-to-date selection of
reprints of articles written by members of the Association that appear in any scientific
journal. Members of the Association are asked to co-operate by sending copies of
reprints of articles published by them in the past and any that might be published in
the future to the Librarian.
BOOK  REVIEW
PRINCIPLES   OF   MEDICAL   STATISTICS   by   A.   Bradford   Hill,   B.Sc,   Ph.D.
London: The Lancet Ltd., 5th edition, 1950 pp. 282.
In this day and age with increasing interest by non-medical organizations in medical
care, hospital days, sickness rates, death rates, etc., it behooves' medical men to have
some knowledge of medical statistics if they are to discuss these subjects intelligently.
Textbooks dealing with statistics in the medical field are few. This volume by
Dr. Hill has filled a great need in the medical statistical field, not only as there are few
books dealing with medical statistics but also because it is written in a manner that
appeals to those persons not highly trained in the science of statistics. For those who
have only had a cursory training in statistics it is an excellent handbook.
Medical statistics is such a different field from ordinary statistics because the latter
can be controlled within, reasonable boundaries. Dr. Hill in this book has made an
excellent effort to use as little technical language as possible in an attempt to make the
text easy to read and to understand. The first three chapters are probably one of the
clearest and simplest descriptions of statistical methods and presentation that have been
written. In these chapters he has covered all the points that the inexperienced do not
realize are important and yet the omission of these points throws discredit on their work.
Some of it may seem very elementary but they are the points that are overlooked.
Chapters four to thirteen handle in a very straightforward manner the more technical section of statistical work. Dr. Hill has dealt with this material in such a way
that lack of mathematical background does not affect one's understanding of the details.
Chapters fifteen, sixteen and seventeen are worthwhile reading. By example he
has shown how far one can go astray in interpretation of statistics as applied to medicine.
The merit of this book from the medical point of view is that here is a book in which the
examples are all of a medical nature giving better understanding of how much error
can be made in the interpretation of tables and projects in this field.
For those who wish to test their ability in medical statistics a set of twenty-five
exercises is included at the conclusion of this text.
Medical statistics is a science that requires study apart from ordinary statistics.
This book should be very useful to anyone who wishes guidance and information in the
technique of medical statistics. .
A. E. S. and G. R. F. E.
Page 139 CORRESPONDENCE
COLLEGE  OF
ET
BRITISH COLUMBIA
Registrar's Office,
435 West Broadway
January 31st, 1951.
Dr. Stewart Wallace,
President,
The British Columbia Medical Association,
B. C. Division, Canadian Medical Association,
Kamloops, B. C.
Dear Doctor Wallace:
Re: Laboratories
The Council of the College of Physicians and Surgeons of B. C. have noticed
certain trends in medical practice in the province which have caused them some concern,
and have asked me to call these matters to your attention and that of your Board of
Directors.
There is operating in Vancouver a Laboratory, which is owned and operated entirely,
as far as can be ascertained, by a laboratory technician, who carries on his work without
any medical supervision whatever and expects to be paid fees for this work according
to the Schedule of Fees of the College. We have recently seen a card of notification
of the setting up of another laboratory with no doctor's name attached to it, advertising
the fact that it will operate with registered technicians and that the scale of fees of the
College of Physicians and Surgeons of B. C. will be charged. We have reason to believe
that this laboratory will not have any adequate medical supervision.
A similar situation is apparent in New Westminster, where a laboratory is being,
operated by a technician without any adequate supervision, while ostensibly owned by
a group of medical men who have opposed any attempt by Council to curtail these
activities, and apparently feel that this technician should be paid medical fees according
to our scale for technical work.
In Victoria there was at one time a laboratory ostensibly owned and supervised by
a member of the College who lived and worked on the lower mainland, and could not
possibly by infrequent visits see that the work was well done and that patients were not
taken direct from the street. The Council in his case was able to secure the supervision
of this laboratory by a pathologist in Victoria. Recently, the Council has seen a fee
list put out on the letterhead of a nurse technician quoting fees not only for laboratory
procedures but also for the treatment of such conditions as brucellosis and trichomonas
vaginitis.
All over the country hospitals have set up laboratories in charge of technicians,
who apparently have no medical supervision whatever. Doctors are using these faciltiies,
often because they are the only ones available. Recently, the hospitals have taken the
attitude that they should be paid by Social Assistance Medical Services for out-patient
services performed by these technicians according to the scale of the College of Physicians
Page '140 and Surgeons. Very great pressure has been exerted by the Health and Welfare Dept.
to have S.A.M.S. pay for these services and the Council has refused, on the ground that
these are medical services which must be rendered by or under the direct supervision
of members of the College. Such a condition does not apply in the doctor's, office where
he takes direct responsibility for everything that is done, and also in larger hospitals
where laboratory technicians and procedures are under the direct supervision of a
pathologist.
The Council takes the position that laboratory procedures carried out on sick
people are a part of medical diagnosis and as such are a responsibility of the medical
profession. In our view, it is very questionably legal for a laboratory technician to set
up and operate a medical laboratory without medical supervision. We believe also that
such laboratories do not always demand that the patient be referred by a doctor, and
we know of instances where this has occurred, and where the report has been given direct
to the patient.    This amounts to making a diagnosis and leads to bad medical practice.
The Council has been seriously embarrassed in taking any action in regard to this
situation by the unthinking attitude of many of the members of the College, who refer
their laboratory work indiscriminately to any technician who purports to be able to
do it and collect the fee. Certain such technicians have sent in lists of reputable medical
men who have referred patients to them.
The Council takes the view that good laboratory work requires the constant checking of standards and techniques, also that laboratory technicians are trained to help
medical men, not to practise laboratory medicine independently. We think that medical
men who encourage the present tendency are handing over to unqualified persons a
large part of their birthright and in some cases are actually covering such persons in
the practice of medicine.
The Council has made several attempts to secure help from the Section on Pathology
in this matter without success. We feel strongly that medical men should keep laboratory
medicine within their own control, both from the standpoint of economics and also that
of the good of the patient and good medical practice generally. It has been suggested
that education of the profession in these matters is very much needed, and that this
might properly be done through your organization.
I am authorized to ask therefore—1. Whether some consideration can be given
to these matters by your Directors, and, 2, Whether, if they find themselves in general
agreement with the principles which have gradually been evolved by Council, the
members of the B. C. Medical Association could be apprised of the situation, and be
urged to scrutinize more closely the conduct of their own practices in this regard.
Yours  sincerely,
(SGD.)
Murray Baird, M.D.
President.
COLLEGE OF PHYSICIANS AND SURGEONS
Results of elections held on April 2nd for members of council of the College of
Physicians and Surgeons of the Province of British Columbia:
District No.  1—Victoria.    Re-elected, Dr. F. M. Bryant.
District No. 2—New Westminster.    Dr. L. S. Chippefield.
District No. 3—Vancouver.    Dr. Roy Huggard, Dr. J. H. MacDermot.
Murray Baird, M.D.
Page 141 ROUTINE   CARE   FOR   PREMATURE   INFANTS-
PETER H. SPOHN, M.D., F.R.C.P.(C).
Prematurity takes a higher toll of infant life than any other pediatric condition,
and because these infants require special care, this outline was written to act as a guide
for doctors and nurses in areas where the facilities of a well equipped premature unit
are not available.
For statistical purposes: "A premature infant is one who weighs less than 5l/z
pounds (2500 grams) at birth (not at admission) regardless of the period of gestation.
All live born premature infants should be included, evidence of life being heart beat or
breathing." (Proceedings Fifth Annual Meeting Amer. Academy of Pediatrics, June,
1935.)
Seventy-five per cent of premature deaths occur in the first forty-eight hours so
constant observation and care must be given during this period.
A.    INITIAL CARE OF PREMATURES
Introduction: The most important factors to be considered in the first few days
of the infant's life are (1). Stabilization of body temperature.    (2). Repeated removal
Wire frame Window
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Figure 1.—Electrically Heated Box to be placed over bassinet leaving infant's head
exposed.
*This outline was originally prepared at the request of the Canadian Red Cross,
B.C. Division, to act as a guide in premature care for doctors and nurses working in
the Canadian Red Cross Outpost Hospitals throughout British Columbia.
Page 142 of mucus from the nose and throat.    (3). Provision of additional oxygen.    (4). Maintenance of an atmosphere with a high humidity.
One should not be concerned with feeding these infants in this early period and
attempts to do so may result in fatalities.
1. Stabilization of Body Temperature—The premature infant is not able to maintain a stable temperature, as is the full term infant, so extra heat must be provided.
The infant should be received at birth in a warm, sterile blanket, to prevent initial
chilling. The best method of providing extra heat is to keep the child in an incubator.
If this is not possible extra heat can be provided by hot water bottles placed along the
sides of a lined basket, or by using an electrically heated box placed over a bassinet (see
Fig. 1 and 2). Heavy coverings should not be used. Wrapping the baby in
absorbent cotton is one of the best methods of preventing heat loss. In most incubators
extra clothing is not necessary.
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«&.
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•Head end
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b&tSL^x
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—Foot end
Figure 2.—Homemade basket bed heated with hot-water bottles.
If the child is in an incubator the temperature of the incubator should be in the
region of 90°F. The baby's temperature in the first few days often fluctuates between
94°F and 99°F, gradually stabilizing between 97°F and 99°F, at the end of the first
week. For the first 48 hours the temperature should be taken every 2 to 4 hours to
cletermine the heat required for the infant to maintain a body temperature between
96°-99°F. After the first 48 hours, the temperature can be taken every 4 to 6 hours.
The temperature should be taken with the mercury tip high in the axilla and the arm
held close to the body for three minutes.
2. Removal of Mucus—It is important to remove mucus from the upper respiratory passages of the infant so aspiration will not occur. The child should receive suction
at birth and frequent gentle suctioning later. Mucus may be wiped from the nose and
mouth with soft gauze. A soft No. 12 French Catheter attached to a mucus trap or a
suction machine may be used. The child should be placed in a head down position so
accumulating secretions can escape through the nose and mouth.
3 and 4. Oxygen and Humidity: Oxygen should be administered to all prematures
for the first 24 hours and to those weighing less than 3% pounds for at least 48 hours.
The oxygen should be bubbled through a series of water bottles and it is very important
to have the relative humidity between 60-65 per cent.   Higher humidity can be1 obtained
Page 143 by placing four water bottles in a dish pan of hot water and bubbling oxygen through
the bottles.    (See Fig. 3).
♦
Figure 3..—Demonstrating a very satisfactory method for humidifying the atmosphere
by running oxygen through 4 bottles immersed in pan of hot water.
Respiratory distress characterized by cyanosis, or a sudden change in the rate or
character of breathing should be treated by: (1) Establishing a clear airway by suction
of any mucus. (2) Administering oxygen by funnel. (3) Giving 2 to 3 minims of
adrenaline chloride 1/1000 subcutaneously by hypo and 32 mg. (l/z grain) of caffeine
and sodium benzoate subcutaneously. (An emergency tray with syringes, needles,
suction, airways and the required stimulants should always be ready and available.)
Other Initial Care  Mb
1. See that the cord has been securely tied. The cord should be tied about 1/4
inches from the skin in case the ligature cuts through the cord and necessitates retying.
Cords should not be tied until pulsations cease.
2. See that fresh silver nitrate solution, 1 per cent, has been applied to the eyes
and that the eyes are well rinsed after treatment with normal saline.
3. Cleanse the skin with sterile mineral oil and apply 2l/2 per cent ammonia ted
mercury ointment. If the baby's condition is poor, this procedure may be omitted at
this time.
4. Give 1 cc. (2.0 mg.) of aqueous Vitamin K. intramuscularly q. 12 h. until the
infant is taking oral feedings.
5. For convulsions or twitchings give sodium phenobarbital grain 1/8 (8 mg.)
by hypo.
6. If there is, or has been, any possibility of exposure to infection such as early
rupture of the membranes, or when parenteral fluids are being administered, give 25,000
units of crystalline penicillin in an aqueous solution every 12 hours intramuscularly.
Page 144 B.   ADEQUATE AND PROPER FEEDING
Even more important than the type of milk used are: (1) Time of commencing
feedings. (2) Amount given. (3) Method of administration. The important factor
is to start with very small amounts and increase slowly. Do not increase the feeding
while the infant is gaining.
x[. For the first 24 hours of life give nothing by mouth. In infants weighing
less than 3% pounds give nothing by mouth for at least 48 hours. As mentioned all
efforts in this period should be directed to the prevention of initial chilling, conservation
of heat, removal of mucus from respiratory passages, and the administration of oxygen.
After 24 hours, boiled water or 5 per cent glucose, l/2 to 1 teaspoonful (2 to 5 cc.)
is started. For the smaller infant and the infant that is dehydrated or will not tolerate
oral feedings it- may be necessary to give fluids parenterally, subcutaneously or intravenously in the early period (see table 1). The feedings are gradually increased from
1 to 5 cc. each time. When 15 cc. of clear fluids are tolerated then start half strength
milk feedings for several feedings and then full strength feedings may be commenced
and increased slowly.
Table   1—Approximate  Daily  Fluid  and  Caloric  Requirements  for  the  Premature  Infant
Day  of  Life
Totd
Fluid
Total Calori
ies
cc. per kg.
cc.
per pound
cal. per kg.
cal. per pound
1st
0
0
0
2nd
60
30
0-20
0-10
3rd
70-80
35-40
30
15
4th
90-100
45-50
50
25
5th
100
50
60-70
30-35
6th
100
50
60-70
30-35
7th
^100-110
50-55
70-90
35-45
8th
100-110
50-55
70-90
35-45
"9th
110-120
55-60
90-110
45-55
10th
120
60
90-110
45-55
11th
120-130
60-65
90-110
45-55
12th
120-130
60-65
90-110
45-55
13th
120-130
60-65
90-110
45-55
14th
130-150
65-75
120-130
60-65
1. If the infant is particularly large  and vigorous  5   per  cent glucose  solution or  boiled  water may
be started at 18 hours and the infant may be allowed to reach full caloric intake at 8 to 10 days.
2. If the infant is especially small, feedings by mouth must be withheld for 48  hours or longer and
fluids and calories supplied parenterally.
3. All infants should be given 5 per cent glucose or sterile water for 12. to 14 hours before formula
is offered.
Because of the reduced capacity of premature infants to absorb fat, a formula
prepared from half skimmed milk is recommended (see table 2). If 'breast milk is
available use pasteurized breast milk two thirds and full strength protein milk one third.
If none of these are available, two per cent milk and water is adequate. Refer to the
accompanying feeding chart for further details (table 2). When a premature infant
has reached his full caloric requirement, usually about the end if the second week, he
should be receiving 60 to 65 calories (120-130 cal. per kg) per pound of body weight.
2.    Intervals and Methods of Feeding
The interval between feedings will vary with the amounts taken, in relation to the
total volume required. It is usual to begin with 3-hour feedings and to lengthen the
interval to 4 hours when larger amounts are being taken.
Page 145 Table  2—Premature   Feeding  guide  using   Dryco   (half   skimmed   milk)   and   showing   the   amounts   of
Dryco, Dextri Maltose No. 1 and water to be used to obtain a feeding of 0.7 cal. per cc.
Infants over  four  pounds  usually  tolerate an Evaporated Milk Formula using  Delta  Milk,  water  and
added  carbohydrate.
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560
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378
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75
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75
600
0.7
420
82
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3
75
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80
640
0.7
448
89
12
3
75
8
55
440
0.7
308
55
7
3
75
Catheter or gavage feeding is necessary in very small infants who have an undeveloped swallowing reflex. This should be only practised by an experienced nurse.
If it is not properly done it may cause trauma to the upper gastro-intestinal tractj
or the feeding may enter the respiratory tract. Remember that one of the most
frequent causes of death in a premature infant is due to asphyxiation associated with
aspiration of feedings.   Be careful not to attempt to feed too much too soon.
Usually the best method of administration is by medicine dropper with a short
piece of soft rubber tubing slipped over the end of an eye dropper. Regardless of the
method, food should be given slowly. Most infants soon learn to suckle on the soft
rubber tube when inserted into the mouth. When the infant is strong enough to suck,
he can be fed with a small nursing bottle with a special nipple (see appendix No. 1).
The Breck feeder should not be used, as this forces milk too strongly into the infant's
mouth before he is able to suck.
3.    Accessory Foods
Water: The daily fluid requirement including milk is 2l/z to 3 ounces per pound of
body weight (table 1).   This includes milk.
Vitamins A and D. These vitamins are usually given together. Because of
susceptibility to rickets vitamin D should be started in the second week in a water
miscible or soluble form, to supply at least 1,500 to 4,000 I.U. daily. Vitamin A
should be supplied in a similar form so as to supply 5,000 to 10,000 I.U. daily. Standard
Cod liver oil should not be used because of the danger of aspiration. These vitamins can
be given with about 10 cc. of formula.
Vitamin C. Vitamin C has been demonstrated to have a specific action in protein
metabolism in premature infants. 75-100 mg. of this vitamin should be started in the
second 24 hours after taking oral feedings. Ascorbic acid tablets can be crushed and
dissolved in 10 cc. of formula. Vitamins A, D, C can be given at one time mixed with
10 cc. of formula.
Page 146 Vitamin K. 2.4 to 4.8 mg. every 12 hours intramuscularly until feedings are
taken by mouth.
4.    Parenteral Fluids
During the first week 5 per cent glucose in distilled water or in }4-strength saline
given subcutaneously is a very useful method for preventing dehydration and also
provides extra calories. The daily fluid requirement can be maintained by supplementing
the oral intake with subcutaneous fluids (see fluid chart). A 20 gauge needle attached
to a burette or a 50 cc. syringe is inserted under the skin of the upper back, the lateral
aspect of the thorax or the thighs and up to 10 cc. per pound of body weight is allowed
to flow in or is injected slowly. It is much safer to allow the fluid to flow by gravity
as excessive skin pressure may cause local death of tissue. This may be done several times
daily or on alternate days depending on the fluid requirements. Fresh, 2l/2 per cent
amigen solution may also be used subcutaneously in doses up to 10 cc. per pound of
body weight. Amigen may be combined with 5 per cent glucose but never with saline
as the salt content is too high.
A careful record of total daily fluids should be kept (see table 3).
{ date                                                     i datf
h*me                                                                 na                                 admission j ack                              dihcharoe < ags
RATE BIRTH                                                DOCTOR
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1MB
Table 3.—Sample of nursing record chart used in the Premature Unit, St. Paul's
Hospital, Vancouver, B.C.
5.    Prevention of Infection
Every attempt must be made to prevent infection in these infants. Strict isolation
should be enforced using either a separate nursery or an incubator. No visitors should
be allowed. No person with an upper respiratory infection, skin infection or diarrhea
should enter the nursery. Separate equipment should be provided for each infant. The
premature infant's laundry should be done separately from other hospital laundry.
Diapers should be washed separately from the remainder of the infant's laundry.   Where
Page 147 possible a separate room should be provided for isolation of the infected case. Oil used
for bathing should be autoclaved. Zephiran solution, (1;1000) Merthiolate solution
(1:1000) or 2 l/z per cent Ammonia ted Mercury ointment can be used for cleaning the
skin.     (pHisoderm with hexachlorophene has proved to be useful).
C.    TRANSPORTATION
If an infant is going to require special nursing or the infant is not progressing
satisfactorily, consideration should be given to the advisability of transporting the
child to a better equipped centre. At the present time facilities for special care are
available in only a few hospitals. A new unit has been established at St. Paul's Hospital,
Vancouver, where infants born elsewhere may be admitted. It is hoped that in the near
future other larger hospitals throughout the province will develop similar units to serve
the smaller hospitals in their area.' (See fig. 4). It is, of course, not necessary for all
premature infants to be transported to another centre and because of the high mortality
rate in infants under two pounds, long trips in these cases are probably not warranted
unless the child is exceptionally vigorous. On the other hand one should not wait until
a child is in extremis before considering transporting.
If it is felt that a child should be admitted to the Premature Unit, St. Paul's
Hospital, the physician in charge of the case should contact the nurse in charge of the
Bfl.TlSH
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Page 148
L    Community Hospital
—   Community Hospital (under 50 beds)
+    Red Cross Hospital
* unit by calling MArine 2211. The nurse will then arrange transportation. If the child
is from a Red Cross Outpost Hospital the nurse will contact Red Cross Headquarters,
Vancouver. When the nurse is phoned or wired please inform the nurse of the age,
condition and weight of the child and if necessary transportation or other instructions
will be phoned or wired back immediately. An ambulance equipped with an incubator
and oxygen will be sent to nearby points. A trained nurse will accompany the ambulance
to care for the baby enroute to the hospital. If air transportation is requested similar
arrangements can be made.
Please send the following information with all infants sent to larger hospitals:
All data necessary for the B.C. Hospital Admission Form, date, hour, and place of
birth, father's name and address, mother's name and address, Rh-type, pre-natal health
of the mother,, any. abnormalities in previous pregnancies, character of labor, method of
delivery, type of anesthetic and premedication, whether or not silver nitrate has been
applied to the eyes and whether or not Vitamin K was given to the infant.
ACKNOWLEDGMENT
I wish to express my. thanks to Miss M. T. Brown, R.N., Clinical Instructress,
Pediatric Department, St. Paul's Hospital, and Miss H. A. Vandrishe, R.N., Supervisor,
Premature Unit, St. Paul's Hospital, for their assistance in outlining the various techniques and in helping to establish better premature care.
References:
1. Dunham, E. C, Premature Infants, Children's Bureau Publication, Washington,
D.C.   No. 325, 1948.
2. Levine, S. Z. and Gordon, H. H.: Am. J. Dis. Child., 64: 274, 1942.
3. Spohn, P. H.: Can. Med. Assoc. J., 62: 317, 1950.
APPENDIX
Appendix 1.
Feeding Techniques for Premature Infants.   J|p
Medicine Dropper Method:
1. (a)  Equipment required:
1. Medicine dropper, protected with a soft rubber tip, which is securely attached
to the glass, but protrudes only about % oi an inch beyond the tip.
2. A medicine glass.
3. A small container which can be used for warm water, to keep the feeding warm
during the feeding.
(b)  Procedure:
1. Sterilize medicine glass and dropper, and after measuring out the required
formula, cover and carry to the incubator or bedside.
2. After washing the hands, elevate the head slightly with one hand, (Do not
remove the baby from the incubator) and commence feeding very, very slowly by
placing the dropper firmly, but very gently on the back of the tongue. (This stimulates swallowing.) At the conclusion of the feeding elevate baby to a vertical position
to allow for the eruption of air. Place the baby on the right side and elevate the head
for thirty minutes.
2. Gov age Technique
(a)  Equipment required:
1. Number 10 French Catheter.
2. One ounce glass funnel  (can use the funnel from an Acme syringe).
3. Medicine glass.
Page 149 H the catheter is going to be used for one infant only, measure the catheter from
the bridge of the nose to the tip of the ensiform cartilage of the sternum, and at this
point make a circle around the catheter with indelible ink. Then make a second ring
around the catheter, 2 cm. above the first ring.
(b)  Procedure:
1. Change diaper.
2. Wash hands.
3. Wrap baby carefully in a blanket.
4. Wash hands again.
5. Pick up the sterilized gavage apparatus in the right hand. Grasp the catheter
above second ring, or if rings have not been made, grasp about 10 cm. from tip of
catheter.
6. With left hand support baby's head, and place thumb on lower jaw to open
the mouth.
7. Insert the catheter (do not use any lubricating material) to second ring and
listen carefully for air bubbles. Observe the baby for any cyanosis or respiratory
distress.
8. Turn the head to one side and hold the catheter and funnel in the left hand.
This lessens the possibility of the catheter slipping out.
9. Measure and pour the formula, which has been previously warmed, into the
funnel.
10. Allow the formula to run into the funnel which is raised six to eight inches
above the level of the body.
11. The average infant can usually be gavaged in two to five minutes.
12. As the formula disappears from the tip of the funnel, pinch off the tube tightly
and withdraw it carefully.
13. Elevate baby to a vertical position without removing the infant from the
incubator to allow for eructation of air.
14. Place the baby on the right side with head elevated for 30 minutes.
(c )  Precautions:
1. Insert the catheter with the funnel empty.
2. Pinch off the catheter securely before it is withdrawn.
These two practices avoid the spilling of formula into the pharynx.
3. T^oo rapid feeding is more dangerous than too slow feeding.
4. If the catheter becomes plugged with mucus, the catheter must be withdrawn
and another catheter used.
5. If the baby should regurgitate or vomit during the gavage, it is advisable to
withdraw the catheter and apply gentle suction, then allow the baby to rest for 15 to
20 minutes and then gavage feeding again.
3.    Bottle Feeding:
1. When the baby becomes stronger and shows indications of attempting to suck
on the catheter, then bottle feedings are started. These are commenced gradually by
substituting one gavage feeding by the bottle then two feedings, etc.
2. The premature infant should not be picked up in the nurse's arms to be fed
until he weighs at least four pounds.
3. It is advisable to change the position of the baby between feedings, particularly
if the infant is rather inactive.
4. A very satisfactory nipple is Latex number 1811 (Seamless Rubber Company).
Any four ounce bottle may be used.
Page 150 Appendix 2.    Clothing:
1. While the infant is in the incubator a diaper is the only necessary clothing.
However, when an infant is especially small, heated laparotomy pads or absorbent
cotton placed over the infant helps to maintain the temperature.
2. When the baby is showing regular daily weight gains and when the temperature
is stabilized (in the absence of heat from the incubator) the infant may be moved
into a bassinette. (This usually occurs when the baby weighs about four pounds.)
At this stage standard baby garments may be used.
Appendix 3.    Emergency Tray:
1. It is important to have a prepared emergency tray near any small premature
infant at all times. This tray should be familiar to and checked by every new person
handling the infant.
; 2.    The essential materials to be placed on this tray are:
(a) Three hypodermic syringes. (One for adrenaline solution 1:1000 and the
others for caffeine and sodium benzoate.) If 32 cc. of sterile distilled water, are added
to 1 grain (64 mg.) of caffeine and sodium benzoate, one cc. of this solution will contain
1/32 grain (42 mg.) of caffeine and sodium benzoate. This solution is not stable for
more than one week. The syringes should be kept loaded with adrenaline and the
caffeine sodium benzoate solution.
(b) Four No. 25 or No. 24 gauge needles.
(c) Mucus trap for suction.   If possible weak mechanical suction is more efficient.
(d) Two No. 12 soft French catheters.
(e) Two medicine glasses with sterile water or saline solution.
(f) Cord ties. '^M
(g) Alcohol sponges.
(h) If someone is qualified to use a laryngoscope, an infant size should be included
on the tray with No. .00 and No. .0 Magill tubes. (A. Chas. King Ltd.,
England.)
.(i)    An emergency oxygen tank with a funnel should also be accessible.
OFFICE LEASE AVAILABLE
Consulting Room, three Examination Rooms, Laboratory.   In Pember-
ton Building, Fort Street, Victoria.
For further details, apply to
THE PUBLISHER, 675 DAVIE STREET
Vancouver, B.C.
Telephone MArine 7729
OFFICES FOR RENT
Reception room. Consultation and two Examining rooms. Laboratory
and private lavatory. Ground floor. Automatic Oil heat and Hot water.
Free parking lot.  New building.
Rent only $60.00 month
Apply Bert Emery's Drug Store, Broadway at Yew Street
CHerry 3101
Page 151 THE MENTALLY DEFECTIVE CHILD IN
BRITISH  COLUMBIA
A. F. HARDYMEfrT, M.D.
The purpose of this paper is to:
(1) Describe the procedure for committal of a mentally defective child to the
Provincial Mental Hospital at New Westminster.
(2) Emphasize the inadequacy of the presently available bed space.
We shall begin by defining those types of mental defect found in children in
whom committal to an institution may be indicated. It is true that any mentally
defective child is committable, who presents too great a problem for solution by the
parents at home. The children encountered in the institution are either those recognizable as having a specific condition or those that constitute a very large group of unclassi-
fiable patients. Among the recognized types are mongols, microcephalics, hydrocephalics
and those due to organic defect. For the sake of completeness, we will state here the
usual classification based on intelligence quotients:
Designation Intelligence Quotient
Idiot I WM tt  °"24
Imbecile  j | 25-49
Moron    \ 50-69
Borderline    .—__ip,--70-79
Dull Normal  | 80-89
If a physician in this province wishes to determine the intelligence quotient of a
patient, he may refer the patient to one of the Child Guidance Clinics for examination.
These are permanently established in Vancouver and in Victoria, and in addition, there
is a travelling clinic which travels throughout the remaining parts of the province.
Between the ages of 6 and 70 years, the patients are admitted to the Mental
Hospital, Essondale, provided all forms are correctly, completed. Under the age of
6 years, the child's name must go on a waiting list. This is because of inadequate bed
space. The very rare instance of the mentally defective over the age of 70 years is also
treated in the same way.
If the individual is between the ages of six and seventy, the following procedure
is necessary to arrange his or her committal. Three forms must be completed. These
forms are issued under the Mental Hospitals Act.
Form A is the application form which is to be signed by a relative, if possible.
This form should be dated not later than the medical certificates, and all questions on
it must be" answered.
Form B is a medical certificate. Two separate certificates must be completed by
two physicians who are not in partnership nor related to each other or to the patient.,
It is important to £11 in the patient's name in each place in which it is asked. It
is only required that the answers to the various questions be made in plain English,
that is, it is not necessary to use scientific terminology. The doctors may witness each
other's certificate, if necessary. A relative of the patient can likewise act as a witness
of this certificate, as also can a Justice of the Peace. Care should be taken to see that
the date of the signature on Form B should not be later than seven days after the date
shown as that on which the doctor last examined the patient.
Form C is an order for admission which is completed and signed by a judge, Justice
of the Peace, magistrate, etc.
The parents or guardians can then take the child and the forms to the Provincial
Mental Hospital, Essondale, where admission will be arranged. It would, of course, be
preferable if either the relatives or the attending physician notified the staff of the
Hospital prior to the arrival of the child so that preparations can be made. It goes
without saying that there is no point in sending the child with a covering letter and
Page 152 without the necessary forms, and also that if a telephone call is made, warning of the
arrival of a child, and, for some reason, admission is delayed, it would be advisable to
notify the staff of the delay.
If the child is under the age of six, or in the rare instance that the individual is
over the age of seventy, Forms A and B must be completed in the manner described
above and these forwarded:
1. In the case of children, to Dr. E. J. Ryan, at the Provincial Mental Hospital,
Essondale; and
2. In the case of individuals over seventy, to Dr. T. G. Caunt, at Essondale.
When the arrangements have been made for a bed the forms will be returned to
the relatives and it is then necessary for them to take the child before a magistrate for
the completion of Form C. It is unfortunately true that if a delay of more than 30
days occurs, then new Forms A and B must be completed.
Committal to the Provincial Mental Hospital at New Westminster is now always
arranged through the Provincial Mental Hospital at Essondale; in other words, all cases
are admitted to Essondale and transferred subsequently to New Westminster. Committal is not final. Parents may visit a child at any time, and, provided the individual is
not committed as a result of a criminal charge and provided the visits or discharge
would not be detrimental to the child or to the home, visits from the institution to the
home or discharge from the institution back to the home can be arranged at any time.
There are at present school facilities for the patient-pupil population. There are
eight qualified academic school teachers, one recreational instructor, one manual arts
instructor and one woman occupational therapist. The industrial departments function
also on an instructional basis.
The Provincial Mental Hospital at New Westminster will soon have the name
changed to its proper designation of a "school".
Any study of this subject reveals that there exists a serious need in the province
for more beds for mentally defective children. The provincial government is aware of
this and has recently (February, 1950) opened a new 125-bed unit. Also, the construction of three 100-bed units will be started the first week in February, 1951.
The situation is very bad in spite of the completion of the new unit. This unit,
designed for 75 cribs and 50 beds, now accommodates 105 cribs and 50 beds (January,
1951).
It is estimated that the maximum capacity of the entire hospital at New Westminster is 830 patients. This necessitates great overcrowding. At the time of writing
this paper (January, 1951), 796 patients were in residence and 11 on probationary visits
outside. It is apparent that the present capacity at New Westminster has almost been
reached.
The 300 beds now being constructed will not be ready for 12-18 months. It is
obvious, therefore, that it will be almost impossible to admit to the hospital at New
Westminster for the next 12-18 months.
As well as he number of patients in the hospital at New Westminster, there are
430 mentally defective patients in the Provincial Mental Hospital at Essondale, an
institution intended for the care of psychotics. It is generally recognized that this is
not desirable. Further, there are names of 47 patients on the waiting-list. Of these,
5 have been on the waiting-list since 1947 and 12 have been on the list since 1948. It
is, therefore, apparent that to house at the hospital at New Westminster those patients
presently known (without relieving the overcrowding at all), at least 500 more beds
are required. This estimate makes no allowance for future needs. Death-rates in such
institutions have been very much reduced due to the use of antibiotics and other medical
advances. Life expectancy is, therefore, increased for each patient. That the rate of
increase in institutional population is a formidable one is shown by the figures in Table 2:
Page 153 Month Number of Patients
1950        January  if| 651
February  663
March   694
April  702
May  725
June   : 737
July || 743
August    771
December    796
In summary, the situation in regard to accommodation is this—the Hospital at
New Westminster can admit few more patients. Vacancies will be created only by
discharges and rare deaths. Most patients must be housed for the time being at the
Hospital at Essondale.
In about two years, when physical expansion permits, admission will possibly take
place directly to the "Training School" at New Westminster.
To collect all existing patients at New Westminster would require at least 500
more beds. To be able to care for British Columbia's increasing population, additional
beds will have to be provided in the future.
The following observations can also be made:
The capacity of the present site is probably between 1500 and 1800 patients.
Present administrators consider that more than this would be an inefficient number to
administer in one location. The new site for a second hospital will need to be found
in the near future.
The new unit has a supposed capacity of 125 beds and the planned units a proposed
capacity of 100 beds each. The older buildings have a much greater capacity. It is
generally accepted that the cottage-type of building, housing between 50 and 100
patients, is preferable.    This fact should be considered in future construction.
Teaching facilities should be considered. It is the earnest hope of those connected
with this work that the tremendous amount of clinical work available can be used in
the instruction of medical students. Demonstration and lecture-rooms should be
provided for this purpose.
SUMMARY
The procedure for the committal of a mentally defective child to the Provincial
Mental Hospital at New Westminster has been outlined.
Certain facts about the present bed situation have been stated.
Certain recommendations for future policy have been made.
The author wishes to express his appreciation of the help given him
in the preparation of this paper by Dr. L. E. Sauriol, Medical Superintendent of the Provincial Mental Hospital at New Westminster.
2525 Pine Street,
Vancouver, B. C.
Page 154 CLINICAL  SIGNIFICANCE  OF  EXTRASYSTOLES
J. FREUNDLICH, M.D.
(Read at Clinical Meeting, St. Paul's Hospital)
The disturbance of cardiac rhythm is of great practical importance. Formerly it
was a source of difficulty to the clinician. It was known that the irregularity of the
pulse mighty signify a serious disease of the heart, and on the other hand it might be
of no practical importance. With the help of the electrocardiogram we are now able
.to classify into types every case of irregular action of the heart, to determine its origin,
character and prognosis.
Extrasystoles are premature contractions interrupting cardiac rhythm. They are
due to an abnormal stimulus formation in an abnormal focus, initiated by the beat
preceding the premature contraction. A slight alteration of the cell membrane in one
of the numerous muscle fibres17 leads to an abnormal polarization of this cell and to a
stimulus formation which causes the abnormal contraction.
Extrasystoles may arise from a focus in the ventricle: ventricular extrasystoles—or
in the auricles: auricular extrasystoles. In rare cases they may originate in the sino-
auricular or auriculo-ventricular node. They may appear occasionally or frequently,
after a few beats, or after every sinus beat as bigeminal rhythm; or they may appear
in groups causing attacks of paroxysmal tachycardia. As the extrasystoles occur early
in the diastole when the filling of the ventricle is still incomplete, the pulse wave caused
by the extrasystole is smaller than the normal pulse. If the extrasystole appears very
early in the diastole, no pulse is observed in the radial artery because the premature
contraction is not able to open the semilunar valves, owing to the poor filling of the
ventricle. This mechanism is also responsible for the heart sounds caused by extrasystoles. The more incomplete the filling of the ventricle the louder is the first heart
sound caused by premature contraction, while the second sound is soft or may be absent
since the semilunar valves are not opened by the premature systole.
When the normal rhythm is interrupted by premature beats which are followed
by a long pause a correct diagnosis can be made without an electrocardiogram. However,
an electrocardiogram is necessary when extrasystoles occur in a great number and in
irregular sequence, as they could be confused with auricular fibrillation.
Extrasystoles may occur at any age and in any healthy individual without a
manifest reason. Meteorism, constipation, and chronic cholecystitis are often responsible
for premature beats. Also drugs, such as caffeine (strong coffee), or nicotine (excessive
smoking), may sometimes cause them. More significant are the auricular .extrasystoles
when they appear in coronary sclerosis or mitral stenosis, as they are often a precursor
of auricular fibrillation.
In every case of extrasystoles it is important to determine the myocardial condition.
If the myocardium does not show abnormality, if there is no history of infectious
diseases (diphtheria, scarlet fever, pneumonia), no coronary sclerosis, or previous
coronary thrombosis, the extrasystoles are of no clinical significance. We may then
look upon the extrasystoles as an expression of a disturbance in a very small area or in
a single cell. They are harmless and do not cause circulatory disturbance even though
they persist for years. They do not require treatment. Care of chronic indigestion,
meteorism or gallbladder disease may abolish the extrasystoles. faster than drugs whose
effect is often  temporary;^ Administration of quinidine is indicated only when  the
Page 155 extrasystoles are frequent and obstinate.    Sometimes small doses of digitalis may abolish
the extrasystoles when they appear independently of digitalis treatment.
However, of more serious nature are the ventricular extrasystoles when they occur
in a great number in the course of advanced myocardial disease, or in response to digitalis
treatment. Here the electrocardiogram is of great assistance. In a healthy individual
the ventricular extrasystoles always originate in the same focus and show the same
ventricular complex in the electrocardiogram. But extrasystoles caused by organic
heart disease or due to digitalis medication originate in multiple foci and show varying
forms of ventricular complex or they are of bigeminal type. The multifocal extrasystoles
require extreme vigilance as they always indicate a serious prognosis and may be forerunners of fatal ventricular fibrillation.
The treatment is directed toward the disease itself and not against the extrasystoles,
with the exception of acute coronary thrombosis when the extrasystoles may often
cause ventricular fibrillation. They should therefore be treated immediately with
quinidine. When the extrasystoles appear during the digitalis treatment in chronic
myocardial disease, prompt discontinuation of this drug is indicated and it can only
be resumed with caution and in small doses.
CONSENT FORMS FOR OUT-OF-TOWN PATIENTS
ADMITTED  TO VANCOUVER HOSPITALS
Hardly a week passes that the daily or weekly newspapers of British Columbia do
not carry a story about some man, woman or child being rushed, often by plane, to
Vancouver for medical attention.
All admissions to the Vancouver hospitals are required to sign a consent form
granting the attending physician and hospital staff permission to carry out any form
of examination, test treatment or operation deemed necessary or advisable. irM
At present, it sometimes is difficult to secure consent for treatment of out-of-town
patients. Hospitals would appreciate patients' physicians making sure that consent
forms for diagnosis and treatment accompany the patient to Vancouver or are immediately forthcoming by mail or telegraph.
Any form of consent, such as a note or telegram, is satisfactory.
| The consent of the parents or legal guardian should accompany children sent
from a distance. Where the child has 'been under jurisdiction of someone else, the
consent of the parents or legal guardian should be mailed or wired as quickly as
possible. wgjm
Independent children under 21 may sign their own consent forms, although
parents' consent is desirable.
H| FOUND
Doctor Bag on No.  1 Highway, 6 miles east of Yale, on March 13 th.
R.C.M. Police, Vancouver, B.C.
Page 156
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