History of Nursing in Pacific Canada

The Vancouver Medical Association Bulletin: May, 1948 Vancouver Medical Association May 31, 1948

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Published By
The Vancouver Medical Association
dr. j. h. MacDermot
Editorial and Business Office
203 Medical-Dental Building
Vancouver, B. C.
Publisher and Advertising Manager
Vol. XXIV.
MAY, 1948
OFFICERS,   1948-49
Dr. Gordon C. Johnston
Dr. Gordon Burke
Hon. Treasurer
Dr. W. J. Dorrance        Dr. G. A. Davidson
Vice-President Past President
Dr. Henry Scott
Hon. Secretary
Additional Members of Executive:
Dr. A. S. McConkey, Dr. Rocke Robertson
Dr. A. M. Agnew Dr. G. H. Clement Dr. A. C. Frost
Auditors: Messrs. Plommer, Whiting & Co.
Dr. Reg. Wilson Chairman Dr. E. B. Trowbridge Secretary
Eye, Ear, Nose and Throat
Dr. Gordon Large Chairman Dr. G. H. Francis Secretary
Dr. J. H. B. Grant Chairman Dr. E. S. James Secretary
Orthopaedic and Traumatic Surgery
Dr. J. R. Naden Chairman Dr. Clarence Ryan Secretary
Neurology and Psychiatry
Dr. J. C. Thomas Chairman Dr. A. E. Davidson Secretary
Dr. Andrew Tubnbull Chairman Dr. Marvin R. Dickey Secretary
Db. J. E. Walker, Chairman: Dr. F. S. Hobbs, Dr. R. P. Kinsman,
Dr. R. A. Palmer, Dr. S. E. C. Turvey, Dr. E. F. Word
Summer School:
Dr. A. B. Manson, Chairman: Dr. E. A. Campbell, Dr. J. A. Ganshorn,
Db. D. S. Munroe, Dr. D A. Steele, Dr. G. C. Large.
Dr. H. A. DesBrisay, Dr. Frank Tubnbull, Dr. G. A. Davidson.
Representative to B. C. Medical Association: Db. G. A. Davidson.
Representative to V. O. N.: Db. Isabel Day.
Representative to Greater Vancouver Health League: Dr. J. W. Shier. ■■■»
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|. .  CITY >|r
Total Population—Estimated . j 354,045
Chinese Population—Estimated !       7,979
Hindu Population—Estimated i 275
Number   Rate Per 1,000 Population
Total deaths £ 406 14.5
Chinese deaths .       23 36.4
Deaths, residents only—, 372 13.3
Female    '. .     344
INFANT MORTALITY: February, 1948 February, 1947
Deaths under 1 year of age—j       15 21
Death rate per 1000 live births       29.1 27.8
Stillbirths (not included above)       11 10
Number   Rate Per
February, 1948
Cases     Deaths
Scarlet Fever |  12             0
Diphtheria  7             1
Diphtheria Carrier  15              0
Chicken Pox ■  125             0
Measles  351             0
Rubella  10             0
Mumps , : .  14            0
Whooping Cough  2             0
Typhoid Fever  0            0
Undulant Fever j  1             0
Poliomyelitis -  0            0
Tuberculosis :  40 14
Erysipelas ■  1             0
Meningococcus (Meningitis)  1             0
Infectious Jaundice  0             0
Salmonellosis  1             0
Salmonellosis (Carrier)  0             0
Dysentery ;  0             0
Dysentery (Carriers) -  0             0
Tetanus—  0             0
Syphilis (not available)  79            2
Gonorrhoea (not available)  197             0
Cancer (Reportable):
Resident HZ  69            0
Non-Resident y j,  13             0 PROCAINE PENICILLIN G
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559 *7/te ZdUwA Pcuje.
From time to time, the medical profession is reproached or blamed for its tendency
to inarticulateness. We are told that we should advertise more—let the public know
what we are doing, and so on.
There is an element of truth in this from some points of view—no doubt there are
things on which we could safely and profitably enlighten the public—and we have
always felt, and still believe, that there should be a clearer understanding on the part
of the public of our position in a great many matters.   But there is also a great deal of
'danger of actual harm, where publicity in medical matters is premature and merely
I sensational.
An example of this occurred in our daily press during the past month.    A report
[got into the papers, of work that has been in progress in St. Joseph's Hospital, along
the lines of the treatment of cancer. This work is in the nature of research, is still in
an early stage, is entirely experimental and unproven—and yet it was widely hailed as
a definite step in the cure of cancer—statements were made (by the press) that were
quite unfounded. Names were mentioned. Everything was set for another Braund
episode—and only the prompt action taken, chiefly by the Victoria Medical Society, to
warn the public against an entirely unwarranted optimism, averted a regular stampede
i of cancer patients to Victoria. The statement made by the Victoria Medical Society
was admirably worded, and was temperate and at the same time perfectly clear.    The
; B. C. Medical Association had also prepared a statement, which was given to one newspaper. This paper, which happened to be the first to publish the original article, did
not print the statement—but, since the Victoria Medical Society had already covered
the ground so admirably it was felt unnecessary and perhaps unwise to go on flogging
a horse which, if not dead, was very near its end.
We accept, of course, the statement of St. Joseph's management, that this publicity
j was premature, and that they had not intended to claim anything more than progress
along a certain line. But this episode just shows the truth of what we started out by
saying, that medical publicity is a most delicate and dangerous thing to handle. No
matter how guardedly and how carefully we phrase it, the public, and especially the
public press, invariably get it all twisted and take a meaning out of it that was not
intended. The press, naturally, wants news, and wants it as vivid and spectacular as it
can be made. The public tends always to jump to a conclusion unwarranted by facts—
to take as a cure what is merely an item in a process of treatment. This is all very
natural—but it has its dangers.    And that is why the articles published in various
: digests and magazines and so on dealing with medical discoveries and medical processes
' still under trial, are so misleading arid dangerous. To us it is obvious that no matter
how valuable a new remedy or treatment may appear to be, it is still sub judice, and
requires long testing and constant checking and rechecking by hundreds of patient
workers, before it can be definitely accepted. But the written word has a curious and
entirely spurious value for the average man—and once he (or she, for the matter of
that) reads in the X Digest that thiouracil has replaced surgery in the treatment of
thyrotoxicosis, or that teropterin has replaced morphia in the treatment of cancer, or
that the amazing properties of folic acid will cure pernicious anaemia, it is very difficult
to disabuse his mind of these errors, and point out the facts.
The B. C. Medical Association, at a recent meeting of its Executive, has taken steps
towards the promotion of better public relations between the medical profession, the
press, and the public at large. This is to be commended. It will need time and much
care, to work this out satisfactorily, but meantime these steps are important ones, and
will, we hope, lead to better understanding on both sides of problems that are always
difficult, but should be, too, always capable of solution.
Page 256
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British Columbia Medical
Honorary Secretary-Treasurer     ....
Immediate Past President	
Dr. Lavell H. Leeson
Dr. Frank Bryant
Dr. W. Laishley
Dr. J. C. Thomas
Dr. Ethlyn Trapp
A regular meeting of the Board was held on Monday, May 3rd, with the following I
members present:
Doctors L. H. Leeson, F. M. Auld, F. M. Bryant, G. F. Amyot, T. M. Jones, S. G.
Kenning, E. D. Emery, F. W. Green, Wm. Leonard, H. Campbell-Brown, H. L. Mooney, ]
G. S. Purvis, W. A. Clarke, H. Carson Graham, H. H. Milburn, G. D. Saxton, D. F. I
Busteed, G. O. Matthews, J. H. MacDermot, A. H. Spohn, D. H. Williams, A. M.
Menzies, G. F. Strong, G. F. Kincade, W. W. Simpson, H. A. DesBrisay, Ethlyn Trapp,
J. C. Thomas and F. L. Whitehead.
The Royal College of Physicians and Surgeons—Oral Examinations
At the Annual Meeting last year a resolution regarding the holding of oral examinations for certification in the various specialties was unanimously passed and was subse-
quently forwarded to the Royal College and to each of the Provincial Divisions. Dr.
J. E. Plunkett, Honorary Secretary of The Royal College, has replied in the following
"Consideration has been given by the College on several occasions to the possibility
of holding oral and clinical examinations in more than one centre in Canada. Some
years ago, examinations were actually held in Winnipeg as well as in a central point but
the difficulties of conducting oral and clinical examinations at more than one point are
many and no acceptable solution has as yet been devised to meet them.
Your letter containing the viewpoint of The British Columbia Medical Association
will undoubtedly lead to further consideration and discussion of these problems."
All the provinces have acknowledged receipt of our resolution and three have sent
letters to The Royal College endorsing the idea presented by this Division.
The Greater Vancouver Health League has a division devoted to Arthritis and
Rheumatism and has been referring a considerable number of inquiries from the public
to the Executive Secretary, asking specifically for the names of doctors who are skilled
in, and specially interested in, the treatment of rheumatism and allied disorders.
The B. C. Society of Internists, the Orthopaedic Section, the Paediatric Section, and
The Vancouver Medical Association have been consulted in the matter and their advice
requested.    Nothing concrete is yet available.
The problem was discussed and it was felt that no specific action could be taken by
the Board at present. It is understood that the Canadian Arthritic and Rheumatic Association recently formed is becoming more active and will probably have provincial divisions in the near future.
Shaughnessy Post-graduate Course
The post-graduate course for general practitioners Hfeld at Shaughnessy Hospital in
March of this year was most successful.    Forty-seven doctors registered and of this
Page 257
mM number 31 were from outside Vancouver.   The general opinion was that the course was
worth doing and should be repeated.
The D.V.A. authorities at Shaughnessy have indicated that their staff is willing to
put on a similar course next year. The Board of Directors unanimously approved of the
idea of a second course, along similar lines, to be held in March, 1949, and has assured
Dr. W. R. Lyn Gunn and his staff of all possible co-operation.
Hospital Insurance Act—-Possible Implications  re Radiologists,  Anaesthetists
and Pathologists:
These three specialty groups submitted a jointly prepared brief which was read and
thoroughly discussed. The main point in the brief is that the services of these doctors
are medical services and should be excluded from the benefits provided under the hospitalization scheme. A number of conflicting points of view were expressed and, as the
details of what is to be provided will be decided by regulation and have not yet been
clarified, it was felt that no specific action could be taken by the Board at this meeting.
The same brief was considered by Council and by the Committee on Medical
Public Relations
There is increasing concern about the profession's inarticulateness re the developments in Hospitalization and many other spheres in which doctors are or may be vitally
The matter of public relations and publicity in general was discussed and a small
committee was set up to study the matter and report. Acting in this capacity are
Doctors J. H. MacDermot, G. F. Kincade, D. H. Williams, R. C. Gilchrist and F. L.
it ■•■■   ■ i¥X>
The Practice of Clinical Pathology By Other Than Qtialified Doctors
This matter was raised by the Pathologists' Society and concerns our Association as
a whole chiefly because of the possible implications arising when doctors refer cases to
laboratories which are not under the direction of fully qualified doctors. This question
is an involved one and will require considerable study from the ethical and legal points
of view and has been passed to Council.
Building of an "Academy of Medicine"
Dr. H. H. Milburn, Chairman of the Building Committee, made a statement regarding the present status of the project of the building of an "Academy of Medicine." The
general feeling of the members present at the meeting was one of approval of the idea.
It is understood that the project is being actively explored now by the Building Committee.
Progress re the Establishment of Sections
The Committee on Constitution and By-laws had prepared a draft of amendments
to the Constitution to allow for the setting up of sections officially within the framework of The British Columbia Medical Association. Briefly these proposed amendments,
if finally authorized, provide for the recognition of sections by the Board of Directors
when the sections concerned make application for official recognition. The drawing up
of the aims and objects, election of officers, and rules and regulations of each section
will be a matter for them to decide to suit their own particular requirements. If the
general set-up is satisfactory to the Board of Directors it is assumed that they would
then be recognized as the body representing that specialty.
The necessary amendments will be prepared and distributed to all doctors prior to
the Annual Meeting, at which time the matter will come up for final decision.
Page 258
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Meeting held on May 18 th and 19 th at Prince Rupert
The visiting team comprises:  Dr. W. A. McElmoyle of Victoria  and Doctors
L. H. Leeson, J. E. Walker, D. W. Johnstone, F. L. Whitehead of Vancouver.
Clinical Programme:
"Hypertension"—Medical Aspects by Dr. Walker
Surgical Aspects by Dr. McElmoyle
"Differential Diagnosis of Discharges from the Nipple" by Dr. McElmoyle
"Duodenal Ulcer"—Surgical Aspects by Dr. McElmoyle
Medical Aspects by Dr. Walker
"Cardiovascular Syphillis" by Dr. Walker
"Chronic Otitis Media, with special reference to children" and
"Chronic Frontal Sinusitis" by Dr. Leeson
Cases of Jaundice, Heart Disease, Hypertension, Hernia and Ozena were presented
by the local doctors in a clinical meeting in the Prince Rupert General Hospital on
Wednesday morning and discussed by the visiting team.
On Wednesday the local and visiting doctors were the guests of the Gyro Club of
Prince Rupert at a luncheon. Dr. Whitehead was guest speaker and gave an address on
"Current Trends in Medical Practice."
The social arrangements comprised a reception at Dr. W. S. Kergin's residence on
Tuesday evening, a buffet supper at Dr. C. H. Hankinson's home on Wednesday evening and an informal dinner at the Prince Rupert Civic Centre just before departure
for Prince George.
Dr. J. D. Galbraith, President of the Prince Rupert Medical Association was in
charge of the local arrangements and the meeting was voted by all concerned an outstanding success. The participation of the local doctors in the clinical programme
appears to be a move in the right direction.
Annual Meeting, May 20th to 22nd, 1948, at Prince George
The arrangements were in charge of the President Dr. J. G. MacArthur and the
Secretary Dr. Larry T. Maxwell.
The same clinical programme was presented as in Prince Rupert.
On Friday at noon the local and visiting doctors were guests of the Prince George
Rotary Club at a luncheon, at which Dr. L. H. Leeson was the guest speaker, and, in
the evening, at a delightful mixed banquet at which the Mayor of Prince George and
Mr. John Mclnnis, M.L.A., were the principal guest speakers.
The doctors were entertained at the homes of Mr. and Mrs. J. G. MacArthur, Dr.
and Mrs. L. T. Maxwell and Dr. and Mrs. E. J. Lyon.
On Saturday morning after a surgical round at Prince George and District Hospital a "Round Table" on medical economics and current problems in the practice of
medicine was participated in by all concerned, under the chairmanship of Dr. Whitehead. This feature appeared to fill a definite gap and perhaps would be worth repeating
at each district meeting in the future, at least during the time when the profession is
faced with rapidly changing conditions.
An impression gained at Prince George was that in future the clinical programme
would be more instructive if it were built up around actual cases in the hospital, the
local doctor working up a case and presenting it with the visiting team taking part in
Page 259 the discussion. It is hoped that this policy can be put into practice for the district
meetings next year.
The officers elected for the Central Interior Association for the ensuing year are:
President :: Dr. L. T. Maxwell
Secretary-Treasurer Dr. J. G. MacArthur
Representative to:
The British Columbia Medical Assn Dr. L. T. Maxwell
Committee on Medical Economics Dr. L. M. Greene
ivisb to announce
Effective June 1st, 1948
For surgical, medical, maternity (including baby),
mental and infectious cases $8.00 for 8 .hours
For alcoholic cases $9.00 for 8 hours
Basic minimum salary for a registered nurse
in full employment $150.00 per month
This includes registered nurses employed in hospitals, industry, offices
and clinics.
'" >*'.? ' ■■■:
..   .•   "     .
Doctor who has been in practice for over eight years in the Cariboo
wishes to locate within 100 miles of Vancouver. For information on
above please contact Dr. F. L. Whitehead, Executive Secretary, 203
Medical-Dental Bldg., MA. 3657, in the first instance.
By DR. D. N. HENDERSON, University of Toronto
(Read before V.M.A. Summer School, June, 1947.)
Eclamptic toxaemia terminating in convulsions, is one of the gravest complications
of pregnancy and a leading cause of maternal deaths. Yet of all causes of maternal mortality none can be considered more preventable. During the years 1935 to 1945 deaths
from toxaemia in Ontario made up from 18% to 2 5 % of the yearly maternal death rate,
a total of 706 deaths during the 11 year period. Adequate medical supervision and treatment throughout pregnancy would have prevented the majority of these tragedies. For
example, as a result of prenatal supervision, in slightly over 10,000 pregnant patients
attending the prenatal clinics at the Toronto General Hospital, there has been only one
maternal death resulting from eclampsia. This remarkable result has been accomplished
by several factors, the chief of which are:
1. Frequent observation during the later months of pregnancy.
2. Prompt admission to hospital of all patients showing even mild degree of albuminuria, hypertension, and oedema.
3. Prompt induction of labour in cases that fail to improve with hospital treatment.
It is true, however, that occasionally toxaemia will develop so rapidly that convulsions may occur and death result almost without warning. This type of case is fortunately rare; and, as a rule, there is ample warning of the approaching crisis so that time is
available to institute therapeutic measures to avert the onset of convulsions.
The term "toxaemia of pregnancy" is an all-inclusive one, used to designate a
variety of metabolic disturbances of unknown etiology and presenting a varied clinical
picture. During early pregnancy the clinical manifestations of toxaemia are usually related to the gastro-intestinal tract with nausea and vomiting being the common symptoms. During late pregnancy albuminuria, hypertension and oedema are the most
constant signs of toxaemia but are usually associated with a variety of renal, gastrointestinal, and nervous symptoms, the most important of the latter being convulsion
and coma.
The pathology of the disturbance is as varied as the clinical manifestations and no
single lesion can be considered typical or pathognomonic of eclampsia. The lesions encountered in liver, brain, kidneys and gastro-intestinal tract are secondary manifestations
of the disease and not the cause.
As a result of the failure to discover an etiological toxic agent, treatment is symptomatic rather than specific, and the ultimate relief from the toxaemia can only be
obtained by termination of the pregnancy.
For the practical clinical purpose of management and treatment, the diagnosis of
pre-eclampsia is made on the occurrence of albuminuria, oedema, and hypertension after
the 24th week of gestation. Pregnancy, without toxaemia, however, may be the factor
that aggravates a latent hypertension or low grade chronic nephritis and brings them
into clinical prominence. Most of these cases are considered pre-eclamptic if signs develop
late in pregnancy, and in the absence of a definite history, their true nature can be determined only by physical examination and kidney function tests months after delivery.
On the other hand, the development of albuminuria or hypertension before the 74th
week of pregnancy is highly suggestive of renal or vascular disease.
This easy confusion of true pre-eclampsia with hypertensive disease and renal disease is not of major importance as far as the immediate management of a given pregnancy
is concerned, but is of considerable importance in regard to the prognosis of future pregnancies. For this reason, patients in whom the diagnosis is in doubt during pregnancy
should be foil owed-up post-partum. and available kidney function tests such as the two-
hour, water and urea clearance should be employed to estimate the degree of kidney
damage, so that advice given in regard to future pregnancies may be based on all available
Page 261 The occurrence of pregnancy in a patient already suffering from hypertension
presents a serious hazard, and in the majority of instances is accompanied by a gradual
increase in the degree of hypertension which will remain after the pregnancy has ended.
Vascular accidents and abruptio placentae are potential dangers, and further increase the
hazards of pregnancy. Such patients require frequent observation throughout the prenatal period. Extra rest, avoidance of nervous and physical strain, and the prevention of
excessive weight gain are general therapeutic measures of value. Blood pressure readings
and urinalysis at least every two weeks are necessary even during the early months, as
sudden increase in the hypertension may occur and the appearance of albuminuria is of
serious import and warrants admission to hospital.
It is frequently difficult to make a decision for or against termination of pregnancy
in the hypertensive patient. The disease is a progressive one, and in subsequent pregnancies it will in all likelihood be more severe. Termination of pregnancy cannot be entertained in the hope that a future pregnancy will be tolerated more successfully. Pregnancy
may be allowed to proceed to term if the hypertension is mild, if it does not rapidly pro-,
gress, if retinal vascular changes are minimal and if the urine is albumin-free.
Once the period of viability is reached and the baby is of reasonably good size,
termination of pregnancy is usually indicated both in the interest of mother and child.
Pregnancy occurring in a patient suffering from chronic nephritis is of even greater
seriousness than in the hypertension case. Abortion, death of foetus in utero, and accidental haemorrhage are all risks to the pregnancy, while increased albuminuria, hypertension, retinal haemorrhage and nitrogen retention place the mother in great danger.
Therapeutic abortion and sterilization are clearly indicated in the majority of cases of
chronic nephritis when seen early in pregnancy. When first recognized during the later
months, expectant treatment may occasionally succeed in carrying the patient to the
period of viability, but is nearly always accompanied by further aggravation of the kidney damage.
As previously stated, eclamptic toxaemia is characterized by albuminuria, oedema
and hypertension occurring after the 24th week of pregnancy. The disease is considered
as peculiar to pregnancy in contrast to the hypertension and renal states just described,
which though aggravated by pregnancy are co-incidental to it. The American Committee of Maternal Welfare recognize this distinction, and their classification of Toxaemias
of Pregnancy, which is widely accepted, is as follows:
Group A:   Diseases not peculiar to pregnancy:
1. Hypertensive Disease
2. Renal Disease
Group B:   Diseases peculiar to pregnancy:
1. Pre-eclampsia
2. Eclampsia
Pre-eclamptic-mild is reserved for those patients showing hypertension not over
160 systolic or 100 diastolic; slight oedema, and albuminuria of not more than 0.6 gms
per 100 cc. of urine or about two plus acetic acid test. The eye grounds are normal and
show no vascular changes.
In severe pre-eclampsia, the blood pressure systolic is over 160 and diastolic over
100. Oedema is usually marked, the urine contains more than two plus albumin and
vascular changes are usually evident in the retinal arteries.
This division of the pre-eclampic state into mild and severe is purely an arbitrary one
and of very doubtful value. In the first place, the term "mild" suggests that the condition is not serious and therefore may be treated, perhaps, with justified indifference.
Nothing could be further from the truth. It cannot be too strongly emphasized that a
Page 262
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$Wi patient with mild pre-eclampsia may develop convulsions without progressing to the state
of severe pre-eclampsia. Cosgrave of the Margaret Hague Hospital states that 2/3 of all
eclampsia occurring in that institution occurs in cases classified as mild pre-eclampsia.
An even more striking example of the danger of mild pre-eclampsia is the same author's
statement that one out of every twenty-nine mild pre-eclamptic patients developed
eclampsia without passing through the phase of severe pre-eclampsia. It is therefore of
predominant importance that all patients suffering from mild pre-eclampsia should be
considered as potentially dangerously ill and adequate treatment promptly instituted.
It is doubtful if prenatal management can do anything to lessen the incidence of
pre-eclampsia. There is some suggestive evidence that an adequate well balanced diet, and
salt restriction during the last trimester and adequate rest may reduce the incidence, but
this is by no means conclusive. The important role of prenatal care in regard to toxaemia
is one of early recognition so that treatment may be promptly instituted and convulsion
prevented. The mortality from pre-eclampsia is practically zero, from eclampsia nearly
Early recognition to some extent depends on the co-operation of the patient, who
should be advised to report promptly the occurence of swelling or persistent headache.
Rapid gain in weight in excess of normal should excite the suspicion of occult oedema and
the beginning of toxaemia. Most patients have bath-room scales and should be instructed
to weigh themselves weekly and report any gain exceeding two pounds in a week. In the
presence of rapid or excessive weight gain, specific instructions should be given in regard
to food, salt and fluid intake. This is best accomplished by written instructions, outlining
a diet of about 1,600 calories made up of salt-poor foods. No salt should be used in cooking or at the table and fluids should be restricted to not more than eight glasses per day.
With such a regime, fluid output will usually exceed intake, weight will be lost and an
early toxaemia may be arrested. Urine for albumin test should be sent every two weeks
during the last month. While pre-eclampsia is characterised by albuminuria, oedema
and hypertension, all three major signs do not appear together. Frequently oedema or
slight rise in blood pressure are the first warnings and the other signs make their appearance later.
Treatment of pre-eclampsia, as previously mentioned, is largely symptomatic and
has one primary aim: The prevention of eclampsia. Secondary aims of treatment are
two-fold: 1) The prevention of permanent damage to the maternal cardio-vascular and
renal systems and 2) The attainment of a low foetal mortality. The treatment consists of:
(1) Rest
(2) Diet
( 3 )   Elimination
(4)   Termination of pregnancy.
Pre-eclampsia, even of the mild type, is a sufficiently serious disease to warrant hospital care. This is probably the most important single procedure in management, not
only allowing complete rest, but also permitting daily urinalysis, the accurate measurement of fluid intake and output, complete control of diet particularly in regard to salt,
and twice daily blood pressure readings should be complete, visitors limited to the husband, and a mild hypnotic administered at night so that sleeplessness is avoided. The diet
should be salt-poor, contain adequate protein of about 40 grams, and have a total caloric
value of approximately 1,600 calories. When salt is restricted, fluids up to 1,500 cc. per
day may be given. Fluid intake and output should be recorded and a negative balance
expected, with satisfactory response to treatment. Strong purgation is no longer as
widely employed as formerly, a mild cathartic, preferably saline, being sufficient. Daily
urinalysis performed on 24 hour specimens for albumin, urobilin and microscopic examination for casts and R.B.C., are the most important contribution of the laboratory.
Blood N.P.N, is usually normal. Serum proteins are consistently low. A high or rising
blood N.P.N, or uric acid are indicative of severe kidney damage and are rarely found
except in severe pre-eclampsia and eclamspia. Failure of improvement to occur in a
reasonable time of from seven to ten days of such treatment, or an increase in the
Page 263 severity of the signs or symptoms at any time, warrants consideration of termination of
pregnancy. Experimental evidence in animals shows that chronic poisoning will produce
irreversible changes in the afferent arteriole and the glomerulus in about three weeks.
This, confirms the clinical impression that even in pre-eclampsia—mild the conservative
treatment prolonged more than three weeks results in permanent damage. The more
severe the toxaemia the shorter this period becomes. It is here that the secondary aims of
treatment appear to be in conflict, i.e. the attainment of a low foetal mortality and the
prevention of permanent damage to the maternal cardio-vascular and renal systems. All
evidence obtained by post-partum follow-up examinations of pre-eclamptic patients
points to the duration of the toxaemia rather than its severity as the important factor
which results in residual hypertension or kidney damage. It would appear, therefore,
that the sooner pregnancy is terminated, the better for the mother. On the other hand,
early termination may result in a small, premature infant and high neonatal death rate.
The conflict of aims, however, is more apparent than real. The baby is in an unhealthy
environment and accidental haemorrhage and death in utero are not infrequent. The
foetal accidents in toxaemia must be balanced against the risks of prematurity. The general trend seems to be toward the more prompt termination of pregnancy after the 34th
week. The hazards of intra-uterine life increase as the danger of prematurity lessens. If
eclampsia should occur, the foetal mortality is over 30%.
Occasionally in private practice, but more frequently in ward practice, the patient
is not seen until a state of severe pre-eclampsia exists. Such patients may seem very close
to the convulsive state and the natural tendency is to induce labour immediately or
terminate the pregnancy by surgical means. In most instances this is unwise, as the onset
of labour or the trauma of caesarean section may be all that is required to excite the
onset of convulsion. The severe pre-eclampsia should receive (1) only milk and glucose
drinks, up to 1,000 cc. (2) sedative, preferably nembutal or sodium luminal in dosage
sufficient to produce drowsiness; and (3) moderate purgation. With such a regime,
oedema usually is decreased, the blood pressure lowered, and the general toxicity lessened.
Then induction of labour may be practiced or caesarean section employed, with considerably less risk to the mother.
Termination of pregnancy in the toxic patient may be accomplished by the medical
or surgical means of induction of labour or by caesarean section. The severity of toxaemia, the age and parity of the patient, the condition of the cervix and the duration
of the pregnancy are all factors that influence the choice of method to be employed in a
given case. For the mild pre-eclamptic, in whom urgency is not a factor, medical induction should be employed, using castor oil, small doses of quinine and pitocin. This may
be tried two or even three times if further delay is judged not harmful. When greater
urgency exists rupture of the membranes combined with medical induction if labor is
not promptly initiated is most satisfactory. The use of bag or bougies belongs to a past
era, offering too great danger of infection and mal-presentation to warrant their use.
The role of caesarean section in the termination of pregnancy for toxaemia is a
limited but nevertheless important one. Certainly in the rapidly progressing toxaemia of
the fulminating type in which blood pressure and albuminuria are increasing almost
hourly, caesarean section is clearly indicated. These cases are rare, however, and should
not be confused with the severe untreated pre-eclamptic in whom 24 hours of treatment
almost uniformly is followed by an improvement. The elderly primipara or the primi-
parous patient close to term in whom the head is unengaged and the cervix not effaced,
are suitable for caesarean section. On the other hand, it should be recalled that in the
toxic patient labour is usually easily induced and is frequently of short duration. Caesarean section in itself is a maternal hazard, must be repeated in subsequent pregnancies,
and is frequently followed by voluntary sterility, because of fear of another operation.
The restricted use of caesarean section for the termination of pregnancy in toxaemia
cannot be criticized. If its use is limited by definite indications, as outlined, the number
of caesarean sections performed for pre-eclamptic toxaemia will be small.
Page 264
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The occurrence of convulsions in the pregnant patient is one of the most serious of
all complications of the pregnant state, and results in a high foetal and maternal mortality. Many of the salient features of eclampsia can be best emphasized by citation of
statistics, and for this reason I have reviewed the histories of 93 cases of eclampsia which
have occurred at the Toronto General Hospital. The following tables summarize these
Maternal Foetal
15% 38%
No other common complication of pregnancy offers nearly the same risk to mother
and child as eclampsia.
Alive and well   58
Died m utero :— 27
Died undelivered     2
Neonatal deaths 6
Three sets of twins A & W
There is greater danger of toxaemia in multiple pregnancy.
60 Deaths
Toronto General Hospital
Toxaemia 26.6%
Sepsis 26.6%
Haemorrhage I 25.0%
This table emphasizes the importance of toxaemia as a major cause of maternal
Primiparae 60 cases—6 deaths—10%
Multiparae 32 cases—7 deaths—22%
This disease is nearly twice as frequent in the primiparous patient but the risk is
nearly twice as great in the multiparous patient.
Clinic Family Doctor No Care
15 cases 29 cases 30 cases
1 death 3 deaths 8 deaths
6% 10% 26%
Treatment of pre-eclampsia, if not adequate to prevent convulsions, seems to
lessen the severity of the eclampsia if it does occur.
55 cases ante partum 13% died
21 cases intra.partum 18% died
15 cases post partum 13% died
(2 unknown)
This table emphasizes the danger of convulsions regardless of their time of onset.
22 Patients had 27 Pregnancies
Normal 15
Toxaemia 10
Convulsions     2
5 patients had convulsions with previous pregnancies.
Page 265 This table is further evidence to support the present trend of early termination of
pregnancy in cases of pre-eclampsia which fail to respond to treatment. Once convulsions
occur, the chance of another pregnancy ending in toxaemia is early 50%.
There is little, if any, difference of opinion in regard to the basic principles of
treatment of the eclamptic patient. They may be generally outlined as follows.
I    Protection of the patient from external stimuli that may excite convulsion.
II    Protection of the patient from self-inflicted harm during convulsion.
HI    Control of convulsion by hypnotic and sedative drugs.
IV    Stimulation of diuresis and prevention of acidosis.
V    Avoidance of all attempts to terminate the pregnancy during the eclamptic
This is accomplished in different clinics by various procedures and various drugs.
But in general it may be said that over-treatment is worse than under-treatment. The
induction of labour or the forceful efforts to dilate the cervix to terminate pregnancy
or the performance of caesarean section, are each in turn a progressively worse form of
treatment and will be accompanied by increasing foetal and maternal mortality. The
following is a summary of the management of eclampsia at the Toronto General Hospital:
(1) The patient is placed in a quiet, darkened room, with one or two nurses in constant
attendance. Mouth gags, equipment for aspiration of mucus and the administration
of oxygen are all immediately and readily available.
(2) Drugs used for the control of convulsion are:- Morphine, Sodium amytal, Sodium
luminal. The patient is given an initial dose of % grain of morphine, followed by
7l/z grains of sodium amytal administered intravenously. Morphine grain % is
repeated once, and occasionally twice, but as a rule sodium amytal controls the
convulsions satisfactorily with the initial dose of morphine. Intra-muscular sodium
luminal is employed later when a milder and more prolonged sedative action is
required. These drugs are all toxic to a greater or less degree, and, while control
of convulsions is imperative, it should not be accomplished by administering larger
doses of these drugs than is actually required for the individual case. This necessitates constant supervision of the patient by the physician himself.
(3) Diuresis is stimulated and acidosis prevented by the intravenous administration of
50 cc. of 50% glucose every four hours for as long as it is considered necessary.
(4) As soon as practicable, the patient is given continuous oxygen, either by mask or
by the use of a tent.
(5) Venesection is occasionally performed for cases of right heart failure with pulmonary oedema.
(6) No attempts to induce labour are made during the stage of convulsion and coma.
If, the patient is in labour, the second stage may be shortened by the use of low
forceps, but the majority of the patients are allowed to deliver spontaneously. Labour is
induced usually by rupturing the membrances from twelve to twenty-four hours after
convulsions have been controlled. The immediate induction of labour after the control
of convulsions only adds another disturbing factor to an exhausted and shocked patient
who, having weathered a storm of convulsions, is now faced with the ordeal and
trauma of labour. Caesarean section has been performed on only three occasions during
the past twenty years. One patient died and two recovered. One of these latter died as
a result of pulmonary embolism following a second caesarean two years later. All available statistical evidence substantiates the statement that caesarean section should not
be employed in the delivery of the patient with eclampsia.
Not infrequently the eclampsia patient immediately after delivery enters into a
state of shock characterized by rising pulse rate and falling blood pressure. It is probably
unwise to administer intravenous fluids in a great quantity to these patients, but 500 cc.
of plasma or a similar amount of whole blood in the absence of pulmonary oedema or
signs of right heart failure may be given with safety and may prevent a fatality.
Page 266 m*\
In conclusion it may be said that the maternal death rate from toxaemia will further
be reduced by
(1) The recognition of essential hypertension and chronic nephritis during the first
trimester of pregnancy.    - ,J|
(2) The early recognition of beginning toxaemia during the third trimester.
(3) The full appreciation by the profession of the seriousness of mild pre-eclampsia
and the value of hospital care for such cases.
(4) The prompt interruption of pregnancy in cases that fail to improve with adequate
(5) The avoidance, in cases of eclampsia, of induction of labour, manual dilatation of
cervix or the employment of caesarean section.
By DR. D. N. HENDERSON, University of Toronto
Difficult and delayed labour presents the obstetrician with problems that test his
diagnostic acumen to the utmost and require the exercise of patient, skill and manual
dexterity which in many cases exceeds that required in any other branch of surgery.
Two lives are at stake and often the safest course for the mother is the most dangerous
for the child. Delay and procrastination may end in disaster as great as that caused by
early and hasty efforts at delivery. Even the wisest and most experienced may err, but
care in prenatal examination, careful observation and examination during the early part
of the first stage of labour, will in many cases warn of approaching difficulties. These
may be circumvented if recognized early, but will only end.in tragedy if recognized
too late. Failure of labour to proceed in an orderly, progressive and normal manner warrants careful examination and diagnosis of the cause of the departure from normal. The
cause should be sought for in the three major factors involved in parturition: the
passage, the passenger and the powers. The state of the passage should be determined
during the prenatal period. External pelvic measurements are only the roughest sort
of guide to the size of the bony pelvis and may give a completely false sense of security.
Nevertheless they may warn also of an unusually small pelvis. A careful vaginal examination made during the 7th month of pregnancy to determine the diagonal conjugate
by palpation of the sacral promontory will give a good estimate of the adequacy of
the pelvic Jbrim. The capacity of the mid-pelvis is difficult to estimate by digital examination but such is not true for the outlet, and if outlet and inlet are adequate,
serious contraction of the mid-pelvis is unlikely. Examination of the outlet should
include an estimation of the depth of the symphysis pubis and the width of the pubic
arch, the distance between the ischial tuberosities, and an estimation of the posterior
sagittal diameter, none of which is difficult to do and with care and practice can be
done with considerable accuracy. If departures from the average normal are encountered,
then further information may be obtained by X-ray pelvimetry. There are several
excellent techniques for X-ray pelvis mensuration, the "Thorns," "Snow," and "Caid-
well and Moloy." The accuracy of all depends on the skill of the X-ray technician and
his attention to details of technique. X-ray pelvimetry will establish with reasonable
accuracy pelvic size and also pelvic shape. Armed with such information, the obstetrician
can face breech delivery with confidence and adopt an attitude of watchful expectancy
in a slowly engaging occipito-posterior position. Lateral films taken during labour will
reveal the level of engagement of the presenting part. In cases in which the presenting
part is not engaged, X-ray estimation of the foetal head size is by no means accurate,
and the radiologist's opinion in regard to cephalo-pelvic disproportion in the absence of
contracted pelvis should be accepted with considerable reservation.
Page 267
bsi Abnormalities of the passenger may be noted by palpation of the abdomen during
the prenatal period. Hydrocephalus may be suspected and unusual presentation, position
or lie may be recognized. Toward the end of pregnancy or during labour, uncertainty
in regard to any of these may be relived by X-ray examination and an accurate diagnosis
X-ray examination is an important adjunct to clinical examination in obstetrical
diagnosis. The problems of difficult labour, however, have not been reduced, as yet, to
simple mathematical formulae obtainable by X-ray mensuration of the pelvis, but still
require mature judgment based on experience and knowledge of the factors involved
in the physiology of labour.
The salient features in the management of delayed and difficult labour due to the
following causes will be discussed in order:
(1) Cephalo-pelvic disproportion
(2) Primary uterine inertia
(3) Occipito-posterior position and breech presentation.
.. ■  • ■:   ■ * - •
In the primiparous patient, failure of the presenting vertex to engage early during
the first stage of labour suggests mal-presentation or cephalo-pelvic disproportion. Frequently the two are combined and present together the most common cause of dystocia.
The study of such cases should by systematic, each step in examination being directed
to the establishment of impressions or facts of pelvic size and shape, foetal size, position
and attitude so that no clues may be missed that will aid in arriving at a full appreciation
of the case and an accurate diagnosis of the cause of lack of engagement.
Despite the marshalling of all the facts, it is frequently impossible to assess accurately whether foetal position or true disproportion is responsible for the delay of engagement. Such cases constitute the border-line group upon which judgment cannot be
passed until a reasonable test of labour has been allowed. The duration of the test and
the management of the patient during the test determines whether or not caesarean
section can be safely employed for delivery. Should the test fail, the duration of it depends
on the frequency and intensity of the labour pains, the stage at which the membranes
rupture, and the general condition of the patient. A rising pulse rate, beginning distension of the large bowel, dehydration, and fever are the warning signs of maternal
exhaustion, whether they occur at the end of 12 or 24 hours of labour.
During the test of labour, the patient should be protected against dehydration,
emotional and physical exhaustion, and infection. This requires adequate intake of fluids
and glucose given by mouth early in labour, but later intravenously because of the
slow absorption of fluids from the gastro-intestinal tract during labour. The judicious
use of sedatives in dosage sufficient to give both physical and emotional rest is of major
importance. These aspects of the management of delayed labour will be mentioned in
detail, when uterine inertia is discussed. To prevent infection during the test, the patient
should be isolated from friends and relatives, and all those in contact with the patient
should wear masks. During the period of observation, careful abdominal examination
to note fixation or descent of the head will make repeated rectal examinations unnecessary, which in themselves are not without danger of causing infection. Repeated vaginal
examinations must be avoided but a single vaginal examination made in the labour room
with the patient prepared as though for delivery, is often justified, before a final decision is made in regard to vaginal or abdominal delivery. Early rupture of the membranes prejudices the prospects for caesarean section and after 24 hours of ruptured
membranes the incidence of maternal morbidity and mortality rises sharply if a caesarean
performed. Strong, regular and frequent labour pains enhance the value of the test and
allow decision on the method of delivery to be made earlier than when the contractions
are irregular or weak. The presence of show is encouraging, and. indicates dilatation of
the cervix and probable descent of the vertex.
Page 268
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The knowledge that the pelvis is normal in size warrants a longer test in the hope
that engagement will eventually occur. The age of the patient is a factor of importance
in the border-line case. A difficult vaginal delivery and possible still-birth is much more
readily faced in the young than in the elderly primipara. High or classical caesarean
section should never be performed after a test of labour. Low caesarean section should
not be performed after manipulations from below, repeated vaginal examinations, or
after the membrances have been ruptured over 12 hours in an unfavorable case, or 36
hours in a favorable case. Even with intact membranes labour prolonged beyond 40 hours
even under favourable conditions prejudices the election of caesarean section. Foul or
pungent vaginal discharge and fever are evidence of birth canal infection, and warn of
the grave danger of abdominal delivery. Undoubtedly the sulphonamides and penicillin
have added greatly to the safety of caesarean section. Nevertheless, a low mortality from
caesarean section ,may be expected only when the contra-indications to operation are
not ignored. If» as occasionally occurs, faulty judgment has carried the test of labour
too far for the safe performance of low caesarean, extra-peritoneal section or Porro are
the only alternatives to craniotomy. Such dangerous problems should not be met with
often, and their occurrence implies that the fundamental decision for section has been
too long delayed.
In some cases, delayed or prolonged labour occurs where the only factor seems to be
a failure of the uterus to contract with normal power and regularity and the cervix to
dilate continuously, a condition of primary uterine inertia. Characteristically the pains
are of short duration, vary in intensity and frequency, and usually cease when a sedative
is given. They resemble the Braxton-Hicks contractions of late pregnancy, more than
true labour pains. Unfortunately these ineffectual contractions are often aggravatingly
painful. The patient seems to apprehend their ineffectualness and early in labour becomes
nervously exhausted. In such cases, labour often begins with the cervix only partially
effaced, the lower uterine segment poorly formed, and, as a result, the presenting part
is high in the pelvis.
As a rule, if unwise and hasty efforts to stimulate labour are avoided the majority
of these patients will eventually develop normal type pains, the cervix will dilate and
even spontaneous delivery may occur. During the waiting period however, rest must
be provided by suitable sedation, and the patient's strength maintained and acidosis
prevented by the administration of fluids and glucose. It is important that the moral
courage of the patient be sustained and physical strength conserved by the judicious use
of sedatives. It is unwise to attempt prolonged analgesia and amnesia. Labour will be
further prolonged needlessly. The sedative used should be adequate to provide 4 to 6
hours complete rest. Heroin in 1/12 grain dose combined with 3 grains of nembutal,
usually is sufficient the first night. Later during the more severe phases of a prolonged
labour, a better effect will be obtained by morphine in ^4 grain doses combined with
nembutal, when these are given during the late evening, the dark depressing hours of
night will be slept away and the patient will awaken emotionally and physically refreshed in the morning.
If labour is prolonged over 48 hours or if signs of infection occur at any time,
sulphonamides or penicillin should be administered during the remainder of the labour
and early puerperium. Attempts to stimulate labour by the administration of quinine
and pituitrin before the cervix is effaced are usually ineffectual and may be harmful
to mother and baby. Rupture of the membranes, a procedure frequently resorted to,
should be avoided. If the membranes are prematurely ruptured, the incidence of infection in prolonged labour is nearly doubled and the baby placed in greater danger.
Occasionally, however, despite the eventual effacement of the cervix and the deep
descent of the head into the pelvis, the uterine contractions fail to increase in strength
and frequency and the cervix remains only partially dilated. In such cases the administration of pituitrin in 1 min. doses every 30 to 40 minutes for 3 to 5 doses or the
artificial rupture of the membranes may result in adequate uterine contractions and
Page 269 dilatation of the cervix. Pituitrin when administered during labor is a potent, dangerous drug of uncertain action, and its infrequent use should be restricted rigidly to conditions such as have been outlined—labor delayed over 24 hours with inadequate labor
pains, effaced cervix and engaged presenting part. The potential dangers in the use of
pituitrin are uterine spasm, uterine rupture and foetal anoxia. These dangers are minimal if doses of not more than one min. are used. Nevertheless, the obstetrician should
remain with the patient to observe the effect of the drug and to administer anaesthetic
if the uterine response to the pituitrin is exaggerated. Pituitrin even in one min. doses
should never be administered to the multiparous patient, para. IV or more. The danger
of ruptured uterus is too great.
While spontaneous delivery may occur, the majority of patients are too exhausted
after the prolonged first stage of labor to bear down during the second stage and forceps
delivery is necessary. Attempts to terminate labor before the cervix is fully dilated are
mentioned only to be condemned. Manual dilatation of the cervix results in lacerations
and infection of the cervix, tearing of bladder and rectal supports and a high foetal
The dangers of prolonged labor are not over with the end of the second stage. Delayed
separation of the placenta and post-partum hemorrhage are frequent complications that
face the exhausted patient. Forewarned should be forearmed. Whole blood or plasma
should be available at delivery and promptly used if manual removal of the placenta is
necessary or blood loss is excessive.
The cause of this type of dystocia remains obscure. It frequently occurs in premature labour and in labour that has been induced by medicinal or surgical means. The induction of labour for the convenience of the patient or the doctor is without justification,
and may terminate in a long delayed labour and still-birth. Age does not appear to be a
factor, but when such labour occurs in an elderly primipara, caesarean section is often
indicated if vaginal examinations have been avoided and manipulations, such as rupturing the membranes and rimming the cervix, have not been employed.
OccipMo-posterior Position
Occipito-posterior position may be associated with delay in either the first or second
stage of labour. During the first stage engagement of the presenting part is often slow,
owing to incomplete flexion of the bead and weak, ineffectual labor pains of the inertia
type. Disproportion is therefore frequently suspected. Delay during the second stage
is due most commonly to failure of the occiput to rotate anteriorly. In the majority of
cases if sufficient time is allowed to elapse and the patient is given relief from the severe
second stage labor pains by the interrupted administration of nitrous oxide and oxygen,
anterior rotation will occur spontaneously. During this waiting period frequent auscultation of the foetal heart should be practised and delivery accomplished if irregularities,
or marked slowness or rapidity of rate are noted. Delivery is most easily accomplished
with minimal harm to baby and maternal soft parts by anterior rotation of the occiput
before extraction. The rotation may be done manually or with forceps. The method
chosen should be the one with which the operator is most familiar. For the average
obstetrician manual rotation is simpler and less likely to harm the baby or the maternal
soft tissue, than forceps rotation. Many posterior positions can be delivered with the
occiput posterior but the traction exerted will be greater, and damage to the maternal
soft tissues more extensive than that which follows anterior rotation and delivery. The
essentials for success in difficult forceps delivery are adequate anaesthesia for relaxation,
correct diagnosis of position and gentleness in its correction and accuracy in the application of the blades to the foetal head.
In considering the problems of delayed and difficult labour, the role of the so-called
dangerous multipara is frequently forgotten. The multiparous patient with a past
history of normal labours is likely to receive less than the usual observation during labour,
yet is prone to certain complications of both pregnancy and labour due to a combination
of both age and multiparity.   The incidence of the late toxaemias of pregnancy, placenta
Page 270
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Hill praevia, unusually large babies, uterine inertia, faulty position, ruptured uterus and postpartum haemorrhage are all increased in the multiparous patient. To be constantly
mindful of these dangers will prevent neglect and lead to watchfulness and early recognition of these complications of labour. As previously mentioned, the multiparous
patient with more than three previous labours should never be given pituitrin during
labour because the danger of rupture of the uterus is great.
Breech Presentation
Breech presentation is an important cause of difficult labour and still-birth. It creates
greatest concern when encountered in the primiparous patient, but it is also accompanied
by a relatively high foetal mortality in the multi-parous patient. The diagnosis of
breech presentation should be made during the prenatal period when an opportunity is
afforded to convert/ the breench into a vertex by external version. Objections to the
performance of the manoeuver are the possibilities of knotting of the card, partially
separating the placenta, or the creation of an even less favorable presentation. Such
objections are mostly theoretical, and if reasonable gentleness is employed, traumatic
separation of the placenta need not be feared. Unfortunately the type of breech presentation most likely to cause serious dystocia is the frank breech and external version in
this variety frequently is impossible to perform. Anaesthetics should never be given
for the performance of external version.
When the presentation is encountered in the primiparous patient, the size of the bony
pelvis should be determined as accurately as possible by both clinical and X-ray examination before the onset of labour. With a pelvis and baby of normal size, the labour need
not be feared unduly if hasty and unwise interference is avoided. Favourable signs at the
onset of labour are strong uterine contractions, intact membranes, and engagement of
the presenting part. Frequent vaginal or rectal examinations should be avoided, on
account of the danger of accidentally rupturing the membranes and causing prolapse of
the cord. For this reason too, the patient should remain in bed during the first part of
labor. A slow first stage is to be expected and efforts to hasten the dilatation of the
cervix by rupturing the membranes or by bringing down a leg are extremely unwise.
To wait for full dilatation of the cervix and maximum descent of the breech, particularly in the frank variety, before beginning interference, requires great patience but
in the end will be rewarded by less difficulty with arms and after-coming head and a
lowered foetal mortality. When delivery of the breech is imminent a deep medio-laterat
episiotomy in all primiparae and most multiparas will prevent lacerations of the rectal]
sphincter and bowel and allow room for manipulations for release of the arms and delivery
is a welcome surprise. Failure of the breech to engage early in labor, particularly if the
baby seems large, is an ominous sign in the primiparous patient and caesarean section
should be seriously considered if the patient is over 30 years of age. If delivery per
vaginam is decided upon, extreme conservation is essential. Non-interference should be
practised till maximum dilatation of the birth canal by the foetus has occurred and interference practised only when arrest has occurred after perhaps even several hours in the
second stage, or if there are sign of foetal distress.
Difficult manipulations and forceps delivery require a surgical degree of anaesthesia
to provide adequate relaxation. The time has surely passed when the labour room nurse
or inexperienced house surgeon is expected to act as anaesthetist for such cases. The
obstetrical patient at the end of a long labor is on the verge of physical exhaustion, and
even the most experienced anaesthetist may find himself called upon to exercise all the
skill of his art to carry the patient through a difficult and shocking operative delivery.
The choice of anaesthetic agent depends on the expected duration of anaesthesia, the
degree of relaxation required, and the condition of mother and baby. Of the inhalation
anaesthetics the three most commonly available are nitrous oxide and oxygen, ether, and
cyclopropane. Nitrous oxide and oxygen; owing to the low oxygen content, is the
least desirable and most likely to increase foetal anoxia.   Cyclopropane has the advantage
Page 271 of being combined with a high percentage of oxygen and is excellent for relatively short
light third stage anaesthesia. As cyclopropane diffuses rapidly through the placenta, deep
and prolonged administration frequently results in a baby that is difficult to resuscitate.
Cyclopropane is not a suitable anaesthetic for intra-uterine manipulations because of its
stimulation of uterine contractions and tone. Ether is ideal for this purpose. In many
cases of prolonged labour, the baby is the chief cause of concern at delivery and is often
exhibiting signs of distress before extraction is started. Any form of inhalation anaesthetic affects the baby and will add to the depression and shock of delivery. In such
cases if the mother's general condition is satisfactory, low spinal anaesthesia, using a
minimal dose of the anaesthetic agent, is ideal. It has no effect on the baby, and provides
excellent relaxation of the perineal and levator muscles which markedly facilitates
Difficult delivery, particularly if preceded by prolonged labour, is frequently followed
by haemorrhage and shock. This should always be anticipated, and necessary steps taken
to prevent it if possible and treat it adequately if it occurs. Before delivery is attempted,
on intravenous of glucose and distilled water should be started and matched blood available in the operating room for immediate use if necessary. At the first sign of rising
pulse or falling blood pressure, or if blood loss is in the least excessive, transfusion of
blood is indicated. Plasma is excellent in an emergency but nothing equals the value of
whole blood in the treatment of obstetrical shock and haemorrhage.
If what has been outlined for the management of prolonged and difficult labor sounds
like "old stuff" and lacks the attractiveness of -new and elaborate procedures of delivery
and anaesthesia. It may be stated that such conservative management will result both
in a low incidence of caesarean section and a low maternal and foetal mortality.
YOU SAVE TIME when you dictate your lectures, articles for publication, etc. An experienced medical stenographer can assist you and
free your Secretary for her daily routine.
PHONE PA. 6720
518 Ford Building, Vancouver, B. C
Page 272
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Vancouver General Hospital
Presented: May 27, 1947
There is an unusual condition which occurs in children and adults which is called
Dermatomyositis. In adults, the symptomatology may vary widely, but in children the
disease follows a more characteristic pattern. In fact the clinical picture is so distinctive
and striking that, having seen one case, the condition will be forever fixed in one's
This fact has prompted me to demonstrate tonight's case, which illustrates the usual
features of this disease in childhood.
CAROL M.   Aged 7.
Present Illness
This began six months ago when she complained of tiredness and malaise. Gradually,
after this the following symptoms made their appearance.
1. Progressive weakness and tenderness chiefly in the muscles of the thighs, shoulder
and trunk.
2. A rash which started in the extremities and gradually involved the trunk and
face. At first it was blotchy and red, later scaly. It was aggravated by exposure to
ultra-violet light.
3. Continuous mild fever.
Past History
Carol has always been a healthy child except that since the age of four she has been
subject to attacks of bronchial asthma each winter. The present disease was not apparently initiated by any infection. There is no history of ingestion of uncooked pork or
raw milk.
Family History
There is a strong predisposition to allergy in that her father has been subject to
asthma throughout his life.
Functional Enquiry and other aspects of the family and past history were irrelevant.
Physical Examination
This revealed the following positive findings:
1. There was generalized muscular weakness, so marked that the child could not
roll over in bed or sustain her head or limbs against gravity.
2. A scaly rash was present over the trunk and extremities.
3. A puffy, non-pitting oedema of the face and eyelids.
4. A peculiar induration of the skin and loss of normal elasticity.
5. Exquisite pain on flexion of the trunk.
6. Depression of most tendon reflexes.
7. A continuous temperature ef 100 to 102.
Page 273 Laboratory Investigations
The following positive findings were discovered:
1. Eosinophilia 20%.
2. Increased Sedimentation Rate—20/80.
3. The amount of creatin in the urine was increased (280 mgs. per cent) whereas
the creatinine co-efficient (the number of mgs. of creatinine excreted per Kg. body
weight) was reduced.   It was 16.   The normal is given as 18 to 30.
4. Muscle biopsy shows degenerative changes in the muscle bundles. There are also
exudative and proliferative changes in the intertitial tissues. The infiltrate is composed
of lymphocytes, histiocytes and plasma cells.
5. Other laboratory tests such as X-rays of the long bones and chest, blood culture,
urinalysis, tuberculin test, enteric agglutination and spinal fluid were all essentially
While the results of the muscle biopsy and creatin studies are not absolutely specific
for this condition, when taken in conjunction with the other clinical findings they
establish the diagnosis of dermatomyositis beyond reasonable doubt. Prior to the results
of these tests the diagnosis was uncertain and the following conditions were included in
the differential:
1. Polyneuritis—from such causes as diphtheria, lead intoxication, or tick paralysis.
2. Trichinosis.
3. Myopathy.
4. Rheumatic Fever.
5. Disseminated lupus erythematosus.
6. Avitaminosis.
7. Nephritis.
The etiology of dermatomyositis is unknown. There are marked clinical and pathologic similarities to peri-arteritis nodosa and disseminated lupus erythematosus. But
the cause of these diseases is also unknown. The enthusiasts for the toxi-allergic hypothesis would like to include these diseases with rheumatic fever and nephritis and postulate
a common etiology. But the factual data to support a pathogenetic relationship are
The treatment is symptomatic. The present case appears to have improved with
penicillin.   There was no improvement with Benadryl.
The prognosis is usually very grave but the chances of recovery in this case appear
tb be favourable.
JPage 274
• ■:-.. yy^W,
1 We regret to record the death of Dr. T. H. Agnew, well-known Vancouver physician. Dr. Agnew graduated from Trinity College in 1894 and registered in British
Columbia in 1913. For the past 33 years he has served the Grandview district of Vancouver and recently retired from active practice. Sincere sympathy is extended to Mrs.
Agnew and family.
Dr. J. W. Neville, formerly of Williams Lake, has now taken up practice in Lady-
Dr. F. D. L. Crofton of Victoria has accepted a position on the staff of the Yan-
couver General Hospital.
Congratulations and best wishes extended to the following doctors on their recent
Dr. and Mrs. L. C. Kindrea, who plan to live in Squamish.
Dr. and Mrs. M. A. Nicholson, who will make their home in Vancouver.
Dr. and Mrs. J. W. Warne, who will reside in Vancouver.
At the Annual Meeting of the Canadian Public Health Association recently held in
Vancouver, Dr. Stewart Murray was elected a Vice-President for the ensuing year.
Dr. F. W. Tysoe of Britannia Beach is doing post-graduate work at the Royal
Victoria Hospital in Montreal, Quebec.
Dr. H. R. Ross has left Vancouver to make his home in Cloverdale.
We note the appointment of Dr. Helen Zeman as Medical Health Director of the
Okanagan Health Unit at Kelowna. Dr. Zeman will succeed Dr. A. W. Beattie, who has
been transferred to Nanaimo.
Deepest sympathy is extended to Dr. J. K. Kelly on the death of his father, and to
Dr. George Wilson of Harrison on the death of his mother.
Dr. G. E. Smith has recently taken up practice in Haney in association with Dr.
S. R. Arber.
Dr. W. M. Carr of Kelowna has recently moved to Victoria, where he has taken up
Dr. S. McClatchie, who was at Woodfibre for some time, is now practising in New
Congratulations to the following parents on the birth of daughters: Dr. and Mrs.
J. W. Arbuckle, Dr. and Mrs. A. P. Brown, Dr. and Mrs. E. N. East, Dr. and Mrs.
George Elliot, Dr. and Mrs. J. H. Hutchinson-Hamilton, Dr. and Mrs. C. J. F. PhiHips-
Wolley, Dr. and Mrs. A. N. Reid, Dr, and Mrs. G. W. Robson, Dr. and Mrs. J. F. Tysoej
and on the birth of sons: Dr. and Mrs. W. H. Cockcroft, Dr. and Mrs. G. H. Grant,
Dr. and Mrs. J. I. Horsley, Dr. and Mrs. D. R. Johnston, Dr. and Mrs. A. F. McGill,
Dr. and Mrs. J. A. McLaren, Evanston, 111., Dr. and Mrs. L. L. Ptak.
Dr. J. H. Lindsay, who has been on the Interne Staff of St. Paxil's Hospital, has now
settled in Britannia Beach, and Dr. A. A. Larsen is practising in Nanaimo.
Dr. S. A. Strachan of Vancouver is relieving Dr. E. E. Tomashewsky at Grand Forks.
Dr. Douglas Findlay, formerly of Chemainus, has gone to England, where he will
do post-graduate work for the next two years.
Page 275 We are very glad to publish the following at the request of the Board of Health
of B. C—Ed.
To the Editor:
Dear Sir:
The Provincial Department of Health would greatly appreciate it if you would give
publicity to enclosed instructions on chlorination of wells which have been flooded.
These instructions will be of particular value when flood waters begin to recede.
Division of Health Education,
Department of Health.
When wells have been flooded, they should be chlorinated before the water is again
used for domestic purposes. Chloride of lime (chlorinated lime) may be U9ed in the
proportion of 30 oz. of chloride of lime per 1000 gals, of water in the well. Ope standard can of chloride of lime contains 12 oz. It is important that the chloride of lime bd
fresh and at full strength. If H.T.H. or Perchloron, or similar high test hypochlorite*;
are used, use only 15 oz. per 1000 gals, of water.
In order, therefore, for one to know the amount of chloride of lime that must be
used, you must first know the amount of water in the well. The formula for finding
the number of gals, of water in a square or rectangular well is as follows:
No. of gals. II Length X Width X Depth of Water X *.25
(Note: All measurements must be in feet.)
If the well is circular, the formula for finding the number of gals, is as follows:
No. of gals. = 0.785 X Diameter X Diameter X Depth X 6.25
When the amount of water in the well is known, the proper amount of chloride of
lime that it required may be determined by the following formula:
30 X No^of Gals.
Ounces of Chloride of Lime Required =	
If H.T.H. is used, use half the amount calculated for chloride of lime.
The chloride of lime or H.T.H. powder is placed in the bottom of a bucket or tub
and water is added slowly, stirring continually, until a good smooth paste is formed
Water may then be added until the bucket or tub is full. Stir thoroughly. This solution
may now be poured into the well. The well should then be left undisturbed for at least
12 hours. The well should then be pumped until no taste of chlorine remains in the
water. i^f
It is important to remember that the above will give a much stronger dose of
chlorine than is used in ordinary chlorination of water. For this reason the well should
be pumped until all taste or odor of chlorine is removed.
If the well to be treated is a sandpoint or drilled well, use one 12 oz. can of chloride
of lime, mixed in a bucket of water. The solution should then be poured down the well.
This should be left for 12 hours. The well should then be pumped until no taste or odor
of chlorine remains.
Page 276
, ■ -_ ; .-■-■ iM,
U* •     %3U0
w w
Campobiol is a therapeutically effective, potent, well tolerated combination of vitamin B
complex factors with liver concentrate and iron. Marketed in easy-to-swallow gelatin
capsules, with a pleasing aromatic odor.
Thiamine hydrochloride (vitamin B.) 2 mg.
Riboflavin (vitamin BJ 2 nig.
Nicotinamide 10 mg.
Funis silfate (anhydrous) 100 mg.
Liver concentrate (11« 20) 200 mg.
Prophylactic dose for adults: 1 capsule daily. Therapeutic dose for adults: 2 or 3 capsules three or more times daily, depending on severity of the anemia.
Braid of
Vitamin   B   COMPLEX   Factors
with LIVER Concentrate and  IRON
New Youc 13/ N. Y.
1019 Elliott Street West, Windsor, Ont.
Windsor, Ont.
423 Ontario Street East, Montreal, P. Q.


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