History of Nursing in Pacific Canada

The Vancouver Medical Association Bulletin: July, 1930 Vancouver Medical Association Jul 31, 1930

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  Patient Types:
THE EXPECTANT MOTHER
During the anxious period of pregnancy you are "the law and the
prophets" to the woman. Sympathy and understanding incline you to
select a smooth, palatable and comfortable aid to the essential normal
peristalsis.   What better meets such requirements than Petrolagar?
To avoid bowel complications of pregnancy, Petrolagar is prescribed as a harmless routine.
Petrolagar has many advantages in maintaining bowel function. It
is palatable and does not interfere with digestion. It produces normal,
soft-formed fecal consistency, providing real comfort to bowel movement.
Petrolagar is an emulsion of 65% (by volume) mineral oil with the
indigestible emulsifying agent, agar-agar.
Fktrol
agar
Gentlemen:—Send me copy of "HA-
Petrolagar Laboratories fZJ™« &l££movemmt) and
of Canada Ltd. Dr.	
907 Elliott St., Windsor, Ont. Address    —
Dept. V.M.  10. THE   VANCOUVER   MEDICAL   ASSOCIATION
BULLETIN
Published Monthly under the Auspices of  the  Vancouver Medical Association in  the
Interests of the Medical Profession.
Offices:
203 Medical and Dental Building, Georgia Street, Vancouver, B. C.
Editorial Board:
Dr. J. M. Pearson
Dr. J. H. MacDermot Dr. D. E. H. Cleveland
All communications to be addressed to the Editor at the abovs address.
Vol. VI.
JULY,  1930
No.  10
OFFICERS 1929-30
Dr. G. F. Strong Dr. C. Wesley Prowd Dr. T. H. Lennie
President Vice-President Past President
Dr. E. M. Blair Dr. W. T. Lockhart
Hon. Secretary Hon. Treasurer
Additional Members of Executive:—Dr. A. C. Frost; Dr. W. L. Pedlow
Trustees
Dr. W. B. Burnett Dr. W. F. Coy Dr. J. M. Pearson
Auditors:   Messrs. Shaw, Salter & Plommer
SECTIONS
Clinical Section
Dr.   S.  Sievenpiper Chairman
Dr. J. E. Harrison : Secretary
Eye, Ear, Nose and Throat
Dr.  F.  W. Brydone-Jack Chairman
Dr. N. E. McDougall _ Secretary
Pediatric Section
Dr.  C  F.  Covernton Chairman
Dr.  G.  O.  Matthews Secretary
STANDING COMMITTEES
Library Orchestra Summer School
T-.T-.T-n t->ttji->~ Dr. W. T. Ewing
Dr. D. F. Busteed Dr. J. R. Davies ^ „    „   v
„„,.,, t\     ■%  ii -it    t\ Dr- R- F- Kinsman
Dr. D. M. Meekison Dr. J. H. MacDermot n w   T    /-<
'■TX TO-      TT       TT T->T?XTT> DR.      W.     L.     GRAHAM
Dr. W. H. Hatfield Dr. F. N. Robertson t-.     t   „
TX S-.       TT       T, T-NTAO DR.     J.     CHRISTIE
Dr. C. H. Bastin Dr. J. A. Smith _,    >,   „   „
_.     „   TT   ,r Dr.  C. E. Brown
Dr. C. H. Vrooman r.    -r   t   t>
rL    r-   Tf   -a ,, Dr.   T.   L.  BuTTARS
Dr. C. E. Brown Publications
Hospitals
Dr- J- M- Pearson Dr. J. W. Arbuckle
Dmner Dr. j. h. MacDermot Dr. j. a. Gillespie
Dr. L. H. Webster Dr. D. E. H. Cleveland Dr. W. q. Walsh
  Dr. F. W. Lees
Dr. E. E. Day Credentials VQN Advhory Board
T,i r,   ^   -ir j    a Dr. W. S. Turnbull Dr. Isabel Day
Rep. to B. C Mea. Assn.    t^att^t txtttj^
* Dr. A. J. MacLachlan Dr. H. H. Caple
Dr. H. H. Milburn Dr. P. W. Barker Dr. G. O. Matthews
Sickness and Benevolent Fund — The President — The Trustees Day or Night
"Seymour Ten-Fifty" is an easy phone
number to remember when you want service
day or night. Your patients appreciate a service which makes it possible for them to secure
medicine or sick-room necessities any hour of
the night.
Seymour
1050
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pharmacy
Granville at QeortCifcs.
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in cystitis and pyelitis
TRADE
MARK
PYRIDIUM
Phenyl-azo-alpha-alpha-diamino-pyridine hydrochloride
(Manufactured by The Pyridium Corp.)
For oral administration in the specific treatment
of genitO'Urinary and gynecological affections*
Sole distributors in Canada
MERCK & CO. Limited     Montreal
412 St. Sulpice St. EDITOR'S PAGE
We do not know whether any philosopher has ever considered the
question of committees. The committee is frequently a subject of jest,
and sometimes, when a new one is appointed to consider and report on
some vital question, we shrug our shoulders, and feel that the matter
has merely been shelved, and responsibility evaded. But this is a short
sighted, thoughtless view to take. As a matter of fact, the committee is
the indispensable element of self-government. What is Parliament but
a committee? And the Cabinet but a committee elected by Parliament?
The failures of popular government have arisen from the effort to allow
everyone a voice in government, instead of leaving it to committees.
Greece, and the referendum which led to prohibition, are two outstanding
examples.
The committee is really the only solution of the democratic problem. Like the nucleus in the cell, it represents the concentration of
effort and purpose, though, more flexible than the nucleus, it can be
changed from time to time, and may be formed continually from differ-
•ent units in the body politic. Wisely used, it gives opportunity to every
member to render the service that he best, perhaps he alone, can give—
by its concentration and devotion to one subject at a time, it ensures
speedier and more efficient work. It makes for solidarity, for better understanding and the removal of misunderstandings amongst the brethren,
and frequently it acts as a safety valve. It is a testing ground where men
are proved, and many a man first finds his footing and gains recognition
for his sterling worth, through work he has done as a member of a committee. It is a well-known fact that the best cure for the malcontent
(who very often has solid ground for his sense of grievance) is to put
him to work.
Looking back over some years of committee work, one can think
of many solid, enduring pieces of work that have been well and soundly
done by committees. Mjany years ago, one remembers the Milk Committee, with Dr. C. S. McKee as Chairman, which did such excellent
work that today the milk supply of Vancouver stands largely as a
monument to their work. The Summer School Committee, too, is one
of the most hard working and most productive of all we have. Again,
working quietly, steadily and with true devotion, what excellent, lasting
work the Library Committee has accomplished. Nor is this committee
work done as is sometimes carelessly stated, by any one or two men:
each "in his several star" shines more or less brilliantly.
Perhaps the best piece of committee work we have seen lately is
the Report of the Council of the British Medical Association, recently
given, on proposals for a General Medical Service for the Nation. This
is so thorough and so sane a treatment of the whole subject, that it
deserves to be read carefully by every medical man—especially the paragraphs dealing with Hospital Service.    We recommend it to all.
Page 208 NEWS AND NOTES
Dr. H. W. Hill, of the Vancouver General Hospital and the University of British Columbia, and Dr. C. P. Brown, of the Dominion
Quarantine Station at William Head, addressed a meeting of the American
Public Health Association (Western section) in Salt Lake City on June
12 th. Drs. Hill and Brown represented the B. C. Board of Health,
Dr. Hill speaking on the Epidemiology of Tuberculosis, and Dr. Brown
on International Quarantine.
Among the reservations made in Winnipeg for accommodation during the meeting of the British Medical Association in August are those
of the following Vancouver doctors, many of whom are accompanied by
members of their families:
L. H. Appleby
A. W. Bagnall
R. B. Boucher
F. J. Brodie
C. E. Brown
F. J. Buller
W. B. Burnett
A. T. Henry
G. L. Hodgins
A. S. Lamb
L. H. Leeson
A. Lowrie
R. E. McKechnie
A. J. MacLachlan
J. J. Mason
D. M. Meekison
A. S. Monro
A. B. Schinbein
G. E. Seldon
Wallace Wilson
Dr. T. H. Lennie has been away on a two weeks' vacation, part of
which was spent at Craig Lodge.
Dr. J. J. Mason has gone to Europe, and will take in the meeting
it Winnipeg on his return.
Dr. W. B. Burnett recently addressed the Ontario Medical Association at Toronto, and has also been visiting clinics in Philadelphia and
New York.
Dr, F. P. Paterson has reutrned to work after a serious attack of
illness which was happily of short duration.
Latest reports from the Vancouver General Hospital announce that
Dr. Fred Bell is making good progress towards recovery. He is stronger
and able to enjoy a wheel-chair.
Twelve candidates for the license of the Medical Council of Canada
appeared for examination in Vancouver in the month of June.
Page 209 Drs. Colin Graham and Wallace Wilson are expected back in a short
time from a European tour.
Dr. Oliver Large has returned to the city after three months
abroad. He visited Egypt and Palestine and other countries bordering
on the Mediterranean, and spent some weeks in London attending clinics.
Dr. H. H. Boucher of this city was married on June 19th to Miss
Audrey Knox, daughter of Dr. W. J. Knox of Kelowna.
Dr. F. J. Nicholson, who has been seriously ill at St. Paul's Hospital,
is now reported slightly improved.
Dr. R. Grant Lawrence has returned after a three months extensive
post-graduate tour in Europe, where he spent some time in Vienna and
London.
Our congratulations are extended to Dr. Stewart Murray and Mrs.
Murray on the birth of their daughter, June Rykert, who arrived at
Grace Hospital on Monday, June 9 th.
Dr. H. W. Hill, Director of the Vancouver General Hospital
Laboratories, has been appointed Chairman of the Sectional Committee
on Hygiene and Public Health of the Pacific Science Congress, meeting
under the auspices of the National Research Council of Canada, in Vancouver and Victoria, May and June, 1932. The members of the Committee are: Dr. J. A. Amyot, Deputy Minister of Health; Dr. Norman
McL. Harris, Director of the Dominion Laboratories of Hygiene; Dr.
H. E. Young, of Victoria and Dr. F. T. Underhill of Vancouver.
B. C. MEDICAL ASSOCIATION NEWS
Dr. J. Allison Shotton, of Kamloops, has started practice at Blue
River, B. C.
Dr. R. B. Shaw is assisting Dr. L. E. Borden, of Nelson, during the
absence of Dr. D. W. McKay. The latter is recovering slowly from
the accident he sustained last December.
The annual meeting of the No. 6 District Medical Society was held
at Nanaimo on May 22nd. The President, Dr. G. K. McNaughton, was
in the chair and gave an interesting resume of the past years' work,
pointing out the importance of organization and necessity for unity
to further the welfare of the profession.
Page 210 Officers elected for the following year were:
President  - Dr. W. E. J. Ekins, Nanaimo
Vice-President  Dr. T. A. Briggs, Courtenay
Sec-Treasurer  Dr. A. P. Procter, Jr., Nanaimo
Representative on B. C. Medical Ass'n.
Executive,  Dr. G. A. B. Hall, Nanaimo
Executive Committee:
Dr. A. D. Morgan, Alberni.
Dr. H. B. Maxwell, Ladysmith.
Dr. W. F. Drysdale, Nanaimo.
Interesting and instructive addresses were given by:
Dr. A. S. Monro on "Lodge Practice."
Dr. J. H. MacDermot on "Health Insurance."
Dr.  G. L. Hodgins on "Some of the later news on diabetes
mellitus and its treatment.
These addresses were much appreciated by those present.
MEETINGS
A Special General Meeting of the Association was held in the Auditorium of the Medical Dental Building on the evening of June 17 th to
consider plans for the entertainment of Overseas Visitors to the British
Medical Association meeting at Winnipeg and to consider the report of
the Committee on amalgamation with the B. C. Medical Association.
Owing probably to the fact that a mass meeting was being held the same
evening to hear the Conservative leader in the Arena, there was a very
poor attendance.
The President informed the meeting that the Finance Committee of
the City Council had agreed to give a Civic Dinner to the British medical
men on the evening of September 5 th at the Hotel Vancouver, and he
outlined the alternative plans made for their entertainment on Saturday,
Sptember 6th. These plans included visits to a logging camp and lumber mill, canneries, sight seeing in the City and trips round the Harbour,
and golf. Dr. Strong explained that money would be required to make
the visit a success and eventually a motion was carried that members be
asked to contribute each $5.00 or more to a fund for this purpose, a committee to be appointed by the Executive to arrange for' the collection.
The report of the Committee re amalgamation with the B. C.
Medical Association was presented by Dr. H. H. Milburn. Dr. Strong
pointed out that the principle of amalgamation had been passed by a
general meeting of the Association as long ago as 1928 and the Executive
had been empowered to continue negotiations along the lines of the
report presented at that time. There was considerable discussion as to
whether the report should be considered at a meeting with such a poor
attendance but eventually on motion it was decided to consider the
report. On motion duly seconded and carried the meeting went into
Committee of the whole with Dr. Milburn in the Chair and discussed
the report clause by clause. Nearly every member present took part in
the discussion. The report was finally adopted with one slight amendment and the Executive was authorized to inform the B. C. Medical
Association of the terms of the report and proceed with negotiations.
Page 211 INDUCTION OF PREMATURE LABOUR
Dr. W. L. Boulter
Introduction
Mr. President, our very well known and welcome guests and fellow
members, it is with some diffidence that I present this paper for your
consideration this evening.
Induction of labor—the artificial termination of pregnancy before
term but not before the child has become viable (with but a very occasional exception) so far as our present day teaching goes—is but another
example of a procedure, which was well known and practised by the
specialists in medicine in the great Egyptian era. Then Soranus of
Ephesus, in the second Century, mentions it. Apparently it was forgotten again, at least we have no records of its use, till Louise Bourgeois, in
1608, midwife to Mary de Medici, introduced the operation as a therapeutic measure. Smellie did it in 1756, and in 1793 Denman reported
20 cases for contracted pelvis. So we see, gentlemen, that it is an old
procedure that has been forgotten many times, no doubt frequently
abused, as it undoubtedly is, even in our age. It has passed through
many vicissitudes, has been frequently condemned and in unscrupulous
hands is still a dangerous procedure. However, with our present day
knowledge of aseptic technique, it is a procedure that has a great many
advantages over other methods. It is often the method of choice under
certain conditions, and tonight I shall attempt to review the indications
and most approved methods of its application.
Indications
The indications for this procedure are fairly numerous. While we
cannot lay down any hard and fast rules for all conditions due to the
constant progress in the prevention and treatment of disease, nevertheless, the basic reasons may be stated to be:
(a) The safety of the mother.
(b) The interests of the child.
(c) Often the welfare of both is mutually and equally at stake,
but at no time should the consideration of the child eclipse the
maternal preference.
Owing to better prenatal care, therapeutic abortion is less often
required, except in diseases which affect the mother so seriously that it
is problematical as to whether she will survive until term, or that if
allowed to proceed, the resultant strain to her constitution may materially shorten her life.
We may group them somewhat as follows:
1.    Disproportion between passage and passenger.
(a) Pelvic contraction.
(b) Prolonged pregnancy and overgrowth of child.
Read before the Osier Society of Vancouver.
Page 212 2. Diseases incidental to pregnancy. .
3. Diseases accidental to pregnancy.
4. Habitual death of the fetus after viability but either before
term or during labour.
1. Fitzgibbon, Master of the Rotunda Hospital, Dublin, gives it
rs his opinion (and his observations are verified by the majority of the
best obstetricians of all countries) that labour in from 70% to 80% of
contracted pelves terminates with no more difficulty than normal cases
under good care and observation. A normal infant weighs 7 to 7/4 lbs.
and both diameters which engage in the pelvis in spontaneous labour
measure 3% inches. The size of the fetal head can be reduced by pressure.
In cases where there is disproportion the mother should have repeated
weekly examinations for;
(a) Relative sizes of the passenger and the pelvic brim.
(b) Position of child's head.
(c) Shape of the pelvis.
A generally contracted pelvis usually presages an earlier induction
than where there is only flattening present. An examination under
anaesthesia nearly always shows that the amount of disproportion between the head and the brim is not as great as was at first anticipated.
1. When the head engages with reasonable ease induction should
be carried out in two weeks providing the pregnancy has advanced to
35 weeks.
2. Should only a small amount of movement be obtained, induction in one week's time with the same proviso as to the length of gestation.
3. If the head cannot be made to engage at all, but there is no
real overlapping at the upper border of the symphysis pubis, the indication is for immediate induction.
Certain specific points may also be noticed during this complete
examination;
(a) The relation to the position and attitude of the head, e.g., in
dealing with a generally contracted pelvis, if the head is noticed
to be well flexed and in O. A. P., induction may be safely
advised, although manual efforts may not be able to produce
much descent. In a flat pelvis where the sagittal suture is
felt to be definitely nearer the symphysis than the promontory,
and the child's head is more extended than flexed, it is doubtful whether induction should be recommended at all.
Normal Measurements
Between Spines    26 cm.
Between   Crests    29 cm.
Between greater Trochanters  . 31 cm.
Circumference of Pelvis  ^ 90 cm.
External Conjugate  ; 20 cm.
Diagonal  Conjugate     12%   cm.
Page 213 True  Conjugate   10%-H1/-   cm.
The Bi Spinous  (Spines of Ischia)    11  cm.
The Bin-ischial   (Tuberosities of Ischia) 11  cm.
Sacro-pubic (end of Sacrum to Ligamentum arcuatum of
pubis)      lV/2   cm.
Posterior Sagittal (between tuberosity and tip of sacrum)  8 cm.
Contracted Pelvic Measurements
1. Absolutely contracted*
C. V. of 9 cm. in flat and 9/2 cm. in generally contracted,
contracted.
2. Relatively Contracted.
C. V. of 5%-7% cm. in flat and 6-8 cm. in generally contracted.
3. Moderately Contracted.
C. V. of 7l/2-9 cm. in flat and 8-9/4 cm. in generally contracted.
4. Border Line.
C. V. or 9 cm. in flat and 9/4 in generally contracted.
1. Caesarean Section.
2. Caesarean Section unless in upper limits and with a small fetus,
when induction may with discretion be used.
3. Induction  with  a  previous  difficult  labor  under  a  competent
obstetrician.
Contraction of the A. P. diameter is the most important element
influencing the prognosis of delivery. The transverse diameter is usually
ample. Fitzgibbon places little importance on the outlet. He has never
had difficulty in extracting the head after it has reached the outlet. Some
of the American authors have, during the past few years, been laying
considerable stress on contractions at the outlet.
Contracted pelves are often classified as:
1. Symmetrically contracted   (usually hereditary).
2. Small round or transversely contracted.
3. Generally contracted flat pelvis.
4. Small, flat pelvis.
Most authors agree that labour should not be induced before the
36th week of pregnancy, some put it as low as the 32nd. About the
38 th week is prabably the best time.
Induction of Labour is indicated in at least 25% of all pelvic contraction.
2.    Diseases Incidental to Pregnancy.
(a) Eclampsia. Only where this has refused to respond to modern
methods of medical treatment, and where convulsive seizures
are present.     (Stroganoff's treatment correctly applied).
Page 214 (b) Toxaemias. Not responding to medical treatment. (Glucose
fluids, etc.)
(c) Chronic Nephritis. Which in spite of every precaution and
care, becomes progressively worse with advancing pregnancy,
justifies therapeutic abortion. The history of this condition
with previous pregnancies is of assistance in the diagnosis.
Many such pregnancies end prematurely with toxic, poorly
developed children that rarely survive, and then there is the
marked and permanent damage to the mother.
3. Chorea. Development of high fever would indicate termination of pregnancy.
4. Pernicious Vomiting. Occasional malignant forms that will
not respond to treatment and have to be terminated.
5. Pernicious Anaemia.    If not responding to medical treatment.
6. Placent Praevia. Abruptio Placentae.
7. Psychosis.
8. Multiple Neuritis.
9. Impetigo Herpetiformis.
10. Polyhydramnios.
11. Hydatiform Mole, etc. The keynote of treatment is to stop
the gestation at a point before either mother or child, or both,
are in danger, either to life or to health.
12. Abnormal Mechanisms.
(a) Uterine inertia.
(b) A rigid cervix.
1. Elderly Primipara.
2. Result of operation.
Failing to dilate in reasonable time, assistance is then
of importance to both mother and child.
(c) Prolapse of cord—in incomplete dilatation of cervix.
(d) Transverse presentation.    Occasionally face or high
occipito posterior.
Diseases Accidental to Pregnancy.
1. Bright's Disease.
2. Tuberculosis (especially of larynx) in active cases early abortion; if over six months try to carry on and deliver in easiest
way.
3. Pyelitis:—resistive.
(a) Medical treatment.
(b) Lavage by ureteral catheter.
4. Dead Fetus.
5. Diabetes. With use of insulin, practically all cases can be
carried to term.
Page 215 6. Retinitis.
7. Hyperthyroidism with marked toxicity and cardiac changes all
really present; had better be relieved as they are poor obstetrical
risks.
8. Cardiac Lesions.
(a) Fibrillation.
(b) Mitral Stenosis and aortic stenosis.
(c) Myocarditis with dilatation.
If the lesion is pronounced and if the cardiac reserve is poor,
especially if there is a history of repeated breaks in compensation, termination is imperative and the sooner the better. If
gestation is well advanced, beyond the 6th or 7th month, and
no loss of compensation is apparent, then an attempt is made
to carry on to term under strict medical supervision. At labour
every means must be utilized to relieve cardiac strain, e.g.
Caesarean Section. In the advent of a break in compensation, never terminate abruptly, but an attempt must be made
to build up some cardiac reserve. A young patient with valvular disease but with good compensation may pass through
several pregnancies providing they are not too close together,
so long as no signs of failure present themselves.
9. Mental. If a study by experts decides that the pregnant patient has had a puerperal psychosis or has a bad heredity
or is a case of marked mental and nervous instability, interruption might be justifiable.
10. Vesicular Mole.    As soon as it can be diagnosed.
11. A very interesting condition is the habitual death of the child
after viability but before term. In apparently healthy women successive children die either just before labour or directly
after. Sometimes the boys die, the girls live. The causes are
mostly unknown. Syphilis is the most common, and even with
negative sero-reactions of both parents, it is often wise to submit both to mild Hg. treatment, e.g. Hydrarg. Iodidi, rubri.
grs. 1/20—Feri Carbonates gr. III.—acid arseniosi gr. 1/50
t.i.d. during pregnancy.
12. Uterine and ovarian tumours—conservative surgery.
13. Also in prolonged pregnancy and overgrowth of child. Some
women habitually go over the usual period of pregnancy and
not seldom the child dies or suffers so much during delivery
that it succumbs shortly after.
Means of Terminating Pregnancy
The ideal termination of pregnancy is by normal labour which progresses with sufficient rapidity not to exhaust the mother; to give ample
time for dilatation of the maternal soft parts without trauma, after
which the child is spontaneously expelled.
The fact that there are many ways of artificially terminating pregnancy is fairly good evidence that no known method is entirely satis-
Page216 factory. In so far as possible, the means chosen should be those which
offer the greatest safety to the mother and child. They should aim at
sureness, moderate rapidity, ease of accomplishment and with the least
danger of infection.
1. Medical induction.
2. Bougies and pack.
3. Rupture of the membranes.
4. Hydrostatic bag.
1. Medical Induction. In a recent series of 500 consecutive cases
of induction of labour reported by Ralph A. Reis of Chicago, Illinois,
the following results were obtained using six methods:
1. Pituitrin  alone      31%
2. Oleum Ricini      67%
3. Quinine plus Oleum Ricini      75%
4. Oleum Ricini plus pituitrin      80%
5. Oleum Ricini plus pituitrin plus quinine      90%
6. Stripping the membranes increased the percentage of successful
results in each of the above 5 methods. The finger is inserted
through the cervix, and a sweeping motion is made around the
inner circumference of the lower uterine segment to separate
the membrane. This manoeuvre must be done gently to avoid
rupturing the membranes, and is aided, when necessary, by
pressing the head into the pelvis with the abdominal hand.
The criterion of a successful stripping is a blood stain on the
examining finger. There is a slight increase (about 1%) in
morbidity where stripping is carried out. It has no effect
either on increasing the speed of the induction or the length of
labour.    Primiparae reacted as well as multiparae.
Watson, in reporting 276 cases, using his own method of induction,
gives the following table of indications:
1. Prolonged   labour    154
2. Toxaemia      51
3. Disproportion     38
4. Distress  before labour.. 30
5. Haemorrhage   10
Maternal  mortality    0
Fetal   mortality   6%
which in his own clinic is less than
when pituitrin is not used. Watson
method approved widely in this
country, e.g., Titus, Miller, Adair,
Williams, Scott, etc., the latter
two having 80% and 90' < respectively of successful results.
The use of the Watson method in induction of labour is not generally successful before the 8 th month, but becomes increasingly effectual with each ensuing week.
There have been a few cases reported in which pituitrin has been
blamed for causing violent uterine contractions and hence the patients
should be in hospital and under careful constant observation, so that in
case of violent contractions being started up, they can be immediately
controlled by ether.
Page 217 Quinine has also been blamed several times for intra-uterine or
extra-uterine death of the child, but this is not proved.
Bougies and Pack
This is a method that is much in use. In this procedure it is sometimes necessary to give an anaesthetic. It is probably more successful in
all cases than medical induction in that this induction is equally effective
throughout the various stages of pregnancy and is perhaps a faster
method, which occasionally recommends it. On the other hand, when
bougies are used, grave septic infection is not uncommon and the morbidity is considerably higher than with either medical induction or a
normal labour.
It is advised to use pituitrin as well.
Bag Induction
Failures are infrequent (5%). Occasionally this procedure may
lead to malpresentation and accidents to the umbilical cord due to dis-
lodgment of the presenting part. It offers, however, the most certain and
rapid method available for induction. Cord disasters can normally be
avoided if membranes are not ruptured.
Bags are far more satisfactory than version and the bringing down
of a leg in Placenta Praevia, especially of the lateral and marginal varieties, also in Abruptio Placentae. In these cases the bag should be introduced through the membranes, in order to bring direct pressure against
the lower part of the placenta and control hemorrhage. As soon as the
bag is expelled—deliver by version and extraction.
This procedure *very frequently requires an anaesthetic. Then the
cervix has to be dilated and tears can result very easily if the operator
is not careful.
In Reis's series—this procedure increased his morbidity by 27.7%.
No effect on fetal mortality and morbidity.
Podalic Version and Extraction
Indication—with dilated cervix.
In transverse positions; some few cases of brow and face presentations, and occasionally a high occiput-posterior position with poor uterine
contractions and the head high. Some do it for certain cases of Placenta
Praevia, Abruptio Placentae and maternal exhaustion. Complicating
diseases such as T.B. or cardiac failure are, in the absence of gross
contra-indications, frequently most conservatively handled by podalic
version and extraction.
Forceps
When labour has advanced to the 2nd stage, with the cervix fully
dilated and head engaged, then when no further advance is made after
two hours of good contractions with the head in mid pelvis, or after one
hour with the head on the perineum,  forceps carefully applied are of
Page 218 1 illfi!i
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Medical-Dental Building Vancouver great value to mother and child. Before forceps are applied it is often
of advantage to do a manual dilatation (so called ironing out process)
and occasionally an episiotomy.
Caesarean Section
1. True conjugate of less than 7.5 cm. and some cases of marked
funnel deformity.
2. Placenta Praevia—central variety with a tight cervix and free
bleeding.
3. Premature separation of the placenta with marked symptoms.
4. Some elderly primiparae, with rigid cervix, and soft parts previously repaired for extensive laceration.
5. To avoid cardiac strain in presence of broken compensation.
6. For the occasional case where birth canal is obstructed by a
tumour growth; frequently most conservatively handled by
podalic version and extraction.
The Porro-operation is the best for infected cases; for those with
previous frequent vaginal examinations or attempts at delivery from
below.
May I suggest, that in the employment of induction of premature
labour we can obtain evidence of incalculable value as to the capacity of
the particular uterus and pelvis at a certain risk to the child, but we
have the consolation of knowing that we obtain it at a risk to the
patient, one-tenth as great as that involved in Caesarean Section (putting
the mortality of that operation as low as 1.3%), from which we obtain
no knowledge at all of the possibilities of normal delivery.
Once an induction, always an induction is not a true saying, although the same careful supervision is necessary in each ensuing pregnancy.
Conclusion
(1) The wider use of induction of labour in cases of contracted
pelvis should be urged, and that this is especially necessary today in view
of the widespread employment of Caesarean Section.
(2) Should be dependent upon very careful investigation and
frequent examinations.
(3) Affords the only actual test of the power of the uterus under
conditions which imply a reasonable chance of the survival of the baby.
(4) Last, but not least, it is an attempt to procure what is
rightly regarded as the highest aim of the true obstetrician—a natural
parturition.
Page 219 SYNOPTICAL REVIEW   OF   X-RAY   EXAMINATION
OF THE MASTOID
By Dr. H. A. Rawlings
In this paper that important part of the temporal bone known as
the mastoid is to be discussed. There is, however, an important difference between the anatomical mastoid and the area referred to as the
mastoid, considered radiologically. In the latter the temporo-maxillary
joint, the area surrounding the meatus, the bone above the tegmen and
posterior to the mastoid cells, are considered as well as the "thick conical
projection" containing air cells, which is, of course, the mastoid process
proper. Also many clinical points of interest will not be here discussed^
but an attempt will be made to adhere strictly to a description of the
assistance that X-ray may give in the examination of this area.
Anatomically the mastoid is a development of the lateral and posterior portion of the temporal bone; externally it serves by its rough
projection as a point of anchorage for muscles. As usual in the skull, its
interior is canalized and cellularized presumably to secure lightness commensurate with strength. Also, like those other cellular areas, the accessory nasal sinuses, there is a direct and open air-line connection to the
upper respiratory tract and therein lies the weakness of the system, for
through this path infection enters.
A proper radiograph of the mastoid area must be so taken that the
cells of the side under investigation are clearly shown without any of the
haze that results from movement, and of proper density; and so that the
cells of the opposite side are thrown completely out of the field. Such
a film shows in front—first, the articulating process of the mandible
and above it the glenoid fossa; second the canal; third the tegmen;
fourth, if present, the zygomatic cells; fifth, the anterior wall of the
sinus; sixth, the tip of the mastoid process; seventh, the emissary vein
or veins; eighth, the posterior wall of the canal; and ninth, the mastoid
antrum. Just superior and posterior to the auditory canal lies the antrum of the mastoid with its overlying cells. The antrum is bounded in
the radiograph, above by the line of the tegmen, and posteriorly by the
anterior wall of the sinus—in ront the canal itself is the boundary line.
Winding its curved way downwards and forwards to join the jugular
vein is seen the sigmoid sinus. Superiorly, the area where it turns more
or less abruptly downwards, is known as the knee of the sinus. All
cells contained in the area adjoining the above are parts of the mastoid
and that area bounded superiorly by the tegmen, posteriorly by the
anterior sinus wall and anteriorly by the canal constitutes the whole of
the non-cellular mastoid. This type, the non-cellular mastoid, may be
subdivided into:
1. Infantile; 2. Diploetic; and 3. Sclerotic.
Where in addition there are cell masses posterior to the sinus and
downwards into the tip we have a different type—the so-called pneumatic mastoid. These again are arbitrarily divided into three types, viz.
large celled, small celled and mixed.
Page 220 Non-Cellular Types
Infantile. Essentially an infantile mastoid, the one usually found
in early childhood, shows radiologically an auditory canal, posterior wall,
anterior sinus wall and tegmen, small mastoid tip, occasionally the semicircular canals, and, enclosed by these boundary lines, the antrum. The
latter shows a varying degree of small cell formation; sometimes it is so
deeply situated that no cells may be seen. In some individuals this
type persists throughout life.
Diploetic. This type resembles the infantile. The point of difference lies in the fact that in this type there is in addition a very fine network of cells.
Sclerotic. The sclerotic type cannot always be differentiated from
the purely infant type by the X-ray examination. However, with a history of ear trouble and dense bone opacity it is customary to describe
such cases as sclerotic, implying that at one time inflammatory reaction
occurred, leaving as an aftermath sclerosis.
Pneumatic Mastoids
These as noted above may and usually do have many varieties of
cellular structure, small and large, intermediate mixtures, and here and
there very large cells; sometimes a very small number of cells and again
so great a cellularization that they run forward into the zygomatic,
upwards into the squamous or porsteriorly into the occipital bone. Then,
too, the cortex may be dense or thin and the individual cell walls thick
or thin.
In both cellular and non-cellular types the sinus may usually be
seen; since blood is of the same radiological density as air the sinus is
potentially an air tube surrounded by a bony wall, the whole surrounded,
in the pneumatic type, by a collection of air cavities.
Inasmuch as there is no overlying cell structure the sinus in a
normal non-cellular mastoid or in a sclerotic abnormal mastoid shows
more clearly than in the pneumatized types.
Usually mastoids are identical; exceptions do occur. If one side is
normal and the other abnormal, deductions are simple, but if both sides
are diseased one must depend on judgment based on visiual impressions
in order to determine what the normal for that particular individual
should be.
So much for the normal mastoid. Pathologically mastoiditis is
the important subject for consideration. This begins as a simple hyperaemia and is shown by a faint blurring of the cell outlines. Hence the
extreme importance of immobilization of the patient. Later a true inflammatory exudate appears, with greater haziness, and subsequently pus
formation occurs. The latter accumulates in the middle ear, mastoid
antrum and in the cells proper of the mastoid. If adequate drainage is
provided by drum rupture or paracentesis resolution takes place, if pus
drainage is greater than pus formation. If not, pressure occurs, the cell
walls lose their lime salts, soften and break down.    All this is shown by,
Page 221 first, haziness with cell walls still intact and sharp; second, haziness with
cell walls intact but blurred; third, cell walls present but indistinct, and
here and there differentiation from cell content impossible; fourth, cell
walls invisible; fifth, some walls visible but blurred, while some have
disappeared; sixth, here and there small or large dark areas of cell wall
destruction and liquefaction. Finally the small areas of destruction may
become confluent, to produce large dark areas on the film—i.e. gross
abscess formation. If in the early stages resolution occurs, one may see
later in the radiograph only- thickened cell walls, or, if later still, several
cells with walls broken down to make one large irregular cell unlike
those in the same area on the contralateral side. As a rule the breaking
down process begins at or about the sinus, knee. If necrosis continues the
sinus wall may be uncovered and a perisinus abscess produced. This
appears as a large radiolucent area, adjacent to the sinus.,
To recapitulate, a good radiograph should reveal:
1. Mastoid cell hyperaemia.
2. Mild acute mastoiditis.
3. Purulent Mastoiditis.
4. Softening of cell walls.
5. Necrosis of cell walls.
6. Sinus groove exposure.
7. Exposure of the dura.
8. Sclerosis.
In addition to these there are several other conditions which may
be considered by-products, for instance cholesteatoma. This condition
is shown usually in the antrum as a large, dark area often adjoining the
canal. It cannot be distinguished from any other large abscess area
radiologically, but when this is combined with a history of chronicity,
and with the unpleasant odour usually present, the diagnosis is not particularly difficult.
The above describes in a hurried review the general points of interest, radiologically, of the mastoid. It is, of course, not by any means
complete. Yet, if the principles mentioned here, which are universally
accepted, are clearly understood, a better appreciation of the assistance
an X-ray examination may give in the difficult case be had.
Essentially, then, the production of a proper film of the Mastoid and
proper interpretation thereof, require:
1. Correct position of the head.
2. Correct exposure.
3. Absolute immobilization, since movement, however slight, produces haze which renders the film valueless or at least capable
of misinterpretation.
(Great speed of exposure in infants, or others in whom
co-operation cannot be secured, is the poor but compara-
Page222 tively effective alternative where immobilization is impossible) .
4. Knowledge of the minute anatomy of the part and of the
anomalies and variations incident thereto.
5. Knowledge of the radiological appearance of all phases of pathological processes, especially inflammatory reactions which occur
in bone-enclosed air cells and the end results of this—i.e. either
resolution and repair or liquefaction and destruction.
The technical means necessary to secure the perfect radiograph has
not been discussed as this was not considered germane to the paper.
However, it is necessary to add that unless good contrast and films of
high technical excellence are secured, the utmost information available
by this method of examination cannot be obtained. A blurred photograph which is dependent only upon the phenomenon of reflected light
from irregular surfaces would be immediately discarded—how much
more important it is that we demand at least as much from a film portraying living pathology, not only at the surface, but at all depths, and
merging, at times into the boundaries of the microscopic.
VANCOUVER HEALTH DEPARTMENT
STATISTICS, MAY, 1930
Total   Population    (estimated)	
Asiatic   Population   (estimated)	
Total   Deaths L     167
Asiatic   Deaths „       10
Deaths—Residents   only     154
Birth   Registrations     418
Male      213
Female  205
-    240,421
9,335
8.18
12.61
7.54
20.47
infantile mortality—
Deaths under one year of age         5
Death   Rate  per   1000   Births        11.96
Stillbirths   (Not included in above)         8
Cases of Contagious Diseases Reported in City
April, 1930
Cases Deaths
Smallpox     21 0
Scarlet   Fever      25 0
Diphtheria    20 0
Chicken-pox     __ 59 0
Measles    ;     6 0
Mumps      54 0
Whooping-cough       69 0
Typhoid   Fever        0 0
Paratyphoid   B.        4 1
Tuberculosis    -_ 14 21
Poliomyelitis         0 0
Meningococcus   Meningitis        0 0
Erysipelas        7 0
May, 1930
Cases    Deaths
2
13
13
68
2
43
136
2
2
10
0
1
6
0
0
1
0
0
0
0
0
0
19
0
0
0
June 1st
to 15th, 1930 .
Cases    Deaths
0
11
7
32
1
12
46
0
4
0
1
3
Page 223 British Columbia Laboratory Bulletin
Published irregularly in co-operation with the Vancouver Medical Association Bulletin,
in the interests of the Hospital, Clinical and Public Health Laboratories of B. C.
Edited by
A. M. Menzies, M.D., of The Vancouver General Hospital Laboratories
Financed by
The British Columbia Provincial Board of Health
COLLABORATORS: The Laboratories of the Jubilee Hospital and St. Joseph's Hospital,
Victoria; St. Paul's Hospital, Vancouver; Royal Columbian Hospital, New Westminster;
Royal  Inland Hospital,  Kamloops;  Tranquille  Sanatorium;  Kelowna  General  Hospital;
and Vancouver General Hospital.
All communications should be addressed to the Editor as above.   Material for publication
should reach the Editor not later than the seventh day of the month of publication.
Vol. IV.
JULY, 1930
No. 6
PUBLIC HEALTH WORK IN BRITISH COLUMBIA
By A. R. Chisholm, M.D.
Epidemiologist, Provincial Board of Health
Victoria, B. C.
To a great extent Public Health Administration consists, at present,
of a central full-time administration bureau, known as the Provincial
Board of Health. It is, of course, a very necessary part of every Provincial administration, and it is the nucleus from which public health work
should expand and embrace every district of the Province. Obviously,
for the small personnel which constitutes the Health Department, to
personally attend to the numerous wants and problems of every community or district of its administrative area, cannot be expected. Therefore, the Department must depend for the actual exhibition of its principles and objectives, which are largely educational, upon the services
of individuals who reside in the populated areas.
That is, we have the efficient and highly trained central point, with
radiations throughout the country which should terminate in smaller
administrative bodies of one or more members, depending on the area
and population of the latter's jurisdiction. This body should be trained
in Public Health work and be so supported that it could devote its full
time to the improvement of the Public Health in its area. Unfortunately,
and with only a few exceptions, our radiations do not terminate in units
of full-time service. On the contrary, they receive the attention of
volunteer organizations only, or the services of an individual who is
already pushed almost to the limit of endurance in making a livelihood
in some other field. And thus we leave the actual exhibition of Public
Health principles, training, and objective, in the hands of volunteer
organizations or part-time Medical Health Officers.
Because of the very nature of the latter's position, they are expected
to assume the burden and responsibility of enforcing Health Laws, educating  the people of their districts, and,  in fact,  do everything from
Page 224
Vji privy examination to the conducting of medical welfare work, in addition to treating the indigent—and all this gratis or almost so. In general, to efficiently administer Public Health they must so arrange their
practice that they will be at the beck and call of everyone and able
to cope with the many Public Health problems that constantly require
attention and correction. To successfully administer Public Health in
their districts, the part-time Medical Officers or volunteers would be
forced to sacrifice their profession, i.e. their livelihood, and devote their
full time to the problems of State.
The active practitioners are trained in the principles of Curative
Medicine, which in itself is a problem great enough to occupy every
moment of their time and endeavour. In addition, they have already
assumed almost to the limit of their endurance a burden which is technically unjust. An examination of any physician's accounts will quickly
show how much of his time, his experience and knowledge have been
given without remuneration to protect and allay the suffering of mankind. Yet, in addition to this we expect him to cope with a problem,
which from a National standpoint is just as important as Curative Medicine, namely Preventive Medicine.
Such a situation is not only absurd, but it is unjust. It not only
defeats the great good which can confidently be expected from full-time
Public Health Administration, but it lends to' the whole system a picture so grotesque that the general public lose faith in the personal and
national value of Preventive Medicine. They continue to look with confident disinterest upon the ravages of disease in their midst, and lend
only a pre-occupied ear to the simple theories and principles of Preventive
Medicine.
We do not expect the captain or a ship's complement, in addition
to their responsible duties of navigation, etc., to be responsible for the
execution and maintenance of the many lighthouses and other landmarks of navigation that are so essential to that vessel's safety and progress. Imagine if these men, already burdened with a heavy responsibility, were compelled to dash around in their spare time to erect a
lighthouse here, attend to a sunken buoy there, and fix a light or horn
somewhere else—imagine how erratic and unsafe would be the progress
of that vessel's course. Neither then, should we expect the active practising Medical Fraternity to be entirely responsible for the exhibition and
application of principles and objectives that have a national import and
to be effectively done would require full time service.
The remedy is obvious. A full-time service living in the field of its
endeavour is required. Such a service, directly associated with and under
the jurisdiction of the Provincial or central body of administration, will
bring to the people of that field the immediate services of the Provincial
Government, the opinions and advice of all the Preventive centres of
the Universe, and finally a clear-cut progressive Public Health program
could be maintained.
Page 225 First, however, let it be clearly understood and generally accepted
that Public Health Administration requires first, last and all the time,
the sympathetic co-operation and whole-hearted support of the Medical
Fraternity. For it must be accepted without argument that Public
Health or Preventive Medicine is an integral part of the Medical Field,
and as such it should be accorded a position in keeping with the responsibilities it entails. It differs in its method of application, however, from
that of our colleagues of the Curative Field. The latter are primarily
concerned in curing or improving the wrecks of humanity that present
themselves for aid; whereas the Public Health official approaches the
problem from the preventive angle, leaving the field of therapeutics
wide open for his rnore fortunate colleagues.
As this angle of prevention deals largely with mass phenomena and
community life, with hygiene and sanitation and with operating agencies
whose purpose is to improve and protect the health properties of the
body politic, such an endeavour will naturally find its inception in the
central governmental body. But as the general field is over 350,000
square miles in area and one in which many emergencies arise, and also
one which requires constant and personal observation, one Central point
of administration, namely the Provincial Health Department, will not
be sufficient. Consequently, many points of contact with the people
are required. Such contact should be maintained by the full-time service
of small units of Public Health organizations, subsidiaries of the central
body, placed at strategic points about the general field. These units of
Public Health should each embrace in their area of jurisdiction a population of at least 20,000 to 40,000 persons.
To cope, however, with the many activities that are presented in
the accompanying graph, each Public Health Unit should consist of a
personnel of four members—a physician who has had special training
in Preventive Medicine, as director, assisted by a qualified nurse and a
sanitary inspector who have both received special training in Public
Health, and also an office secretary to attend to office duties and correspondence, etc. These units will be the field force of the Central Administration. They will be essentially an aggressive force—the division
that carries the objectives and principles of Preventive Medicine rapidly
forward. And by their unity of effort and constant co-operation with
the physicians in their field, marked progress will be made. The physicians will be relieved of an unfair burden, and the Unit's personnel will
be able to institute efficient measures of Public Health administration.
The advantage will be mutual. The results will be positive, and our
people can confidently expect a higher health level, a lowered death rate,
a lowered incidence of preventable diseases, and an increased production
of wealth due to a higher standard of health. Such an improvement
automatically becomes a national question, and such a question deserves
all the consideration, all the thought and careful analysis that will unify
the forces at our disposal, and in time produce a strong virile citizenship, a higher standard of physical development, and a national consciousness that will assure general prosperity and happiness.
Page 226 ft
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(Antirachitic, antispastic)
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Cod-liver Oil contains more vitamin D than any other natural available
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vitamin.   It is
l|P VIOSTEROL in Oil -100 D
This product has 100 times the vitamin D potency of high-grade cod-liver
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The dose ranges from 10 to 20 drops (3 to 7 minims) a day, or in
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Seymour 4183
Westminster 288
«©«?
TUSiv

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