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■J '?;;■*>'] " i' '"'■;'''' -5''' • '!■'<' 'V-' :' 

if yS"S3'^l;';-;r''' '■ 

■ '■ ' ; ) ■; ' ; r ^ /■ 


Associate Editor 


Senior Assistant Editor 


Assistant Editor (English) 


Assistant Editor (French) 


Circulation Manager 

Canada ond Bermuda: 

6 months, $2.25; one year, $4.00; 

two years, $7.00. 

Student nurses: 

One year, $3.00; three years, $7.00. 

U.S.A. and Foreign: 

One year, $4.50; tvyo years, $8.00. 

Single copies: 50 cents each. 

For the subscribers in Canada, in combi- 
nation with the "American Journal of 
Nursing" or "Nursing Outlook": 1 year, 

Moke cheques or tT.oney orders poyoble to 
The Conodion Nurse. 


Four weeks' notice and the old address 
as well OS the new ore necessory. 

Not responsible for journals lost in mail due 
to errors in address. 

Eiiii m 

A monthly journal for the nurses of Canada 

published in English and French by the 

Canadian Nurses' Association 

1522 Sherbrooke St. W., Montreal 

17 The Crisis of Identity 

18 Am I Emotionally Mature? 
\/z\ Quo Vadis School of Nursing 

22 Recent Developments in Obstetrics 

24 Prenatal Care 

26 Supportive Care 

29 Postpartum Nursing Care 

31 Reaction of Mothers 

33 The Newborn 

35 The Intensive Obstetrical Nursery 

37 A Nursing Refresher Course 

40 The "Servo" Theory 

43 Safety in Hospital Operating Rooms 

January 1965 — Vol. 61, No. 1 

A. I. MacLeod 
H. Creighton and Sister C. Armington 

Sister M. Feliciias 
JR. Tittley 
C. Nucci 
S. M. Cameron 
Sister M. Christine 
A. Pask 
J. Houthuesen 
C. J. Parsons 
Sister M. Rebecca 
S. M. Jourard 
P. J. Sereda 


"The Canadian Nurse" welcomes unsolicited 
articles. All manuscripts should be typed 
double-spaced, on one of unruled paper 
leaving wide margins. Manuscripts ore ac- 
cepted for review for exclusive publication in 
the "Journol". The editor reserves the right to 
make the usual editorial changes. Photographs 
(glossy prints) and graphs and diagrorrs 

drawn in India ink on white paper) ore 
welcomed with such orticles. The editor is 
Tot committed to publish all orticles sent. 

nor to indicate definite dotes of pubhcotion. 

Authorized OS Second-Class Mail by 'he Post 
Office Department, Ottowo, and *<"■ P°V"ien' 
of postage in cosh. Postpaid ot Montreol. 





2 Between Ourselves 

6 Pharmaceuticals and Other 

8 Random Comments 

9 In Memoriam 
46 The World of Nursing 

48 Nursing Profiles 
51 About Books 

53 Employment Opportunities 
65 Educational Opportunities 
67 Index to Advertisers 



single dose 
disposable unit 

Just one second of prep time needed . . . with the 
modern FLEET ENEMA ! Once the full-length pro- 
tective cover has been removed and the prelubricated 
2-inch rectal tube has been inserted, simple manual 
pressure does the rest. And after the enema — 
no scrubbing, no sterilization, no setting up for 
re-use. The complete FLEET ENEMA unit is 
simply discarded! 

why more and more hospitals are using the 

An efficient, economically-priced, safe enema 
requiring far less time than outmoded procedures, 
FLEET ENEMA also avoids the ordeal of injecting 
large quantities of fluid into the bowel. 
Left colon catharsis can be achieved in two to five 
minutes without causing pain or spasm,! while afford- 
ing the same cleansing efficacy as the usual enema of 
one or two pints. Reverse flow and leakage are pre- 
vented and a comfortable flow rate assured by the 
construction of the anatomically correct plastic tube. 

Each Single-Dose Disposable Unif confains, in each 100 cc: 

Sodium acid phosphate USP 1 6 G. 

Sodium phosphate USP 6 G. 

Plastic "squeeze-bottles" of 4'/2 fluid ounces, with prelubri- 
cated tip. 

1. Marks, M.M.: Am. J. Digest. Dis. 18:219, 1951 





the disposable 
injection unit 
with the 
sharpest needle ever 


sterile disposable hypodermic unit 

PLASTIPAK disposable syringes for ail parenteral uses are available 
in a full range of sizes, with or without ultra-sharp YALE disposable 
needles attached. Supplied sterile, pyrogen-free, non-toxic... discarded 
after use to avoid danger of cross-infection. Design of peel-apart pack- 
age for IVz through 10 cc. sizes permits easy detection of accidental 
damage and aseptic removal of contents. Package, syringe plungers, and 
needle hubs are color-coded by needle gauge to simplify identification. 









Indications — Treatment of infections caused by organisms sensitive 
to penicillin and/or sulfonamides and where a liquid oral suspension is 

Description — "Duapen"-Sulfa Suspension contains Benzathine Peni- 
cillin G 500,000 I.U. and Sulfamethazine 0.5 Gm. in 5 cc. A pediatric 
suspension containing one-half the above strength is also available. 
Supplied in bottles of 60 or 100 cc. 

Dosage — One-half to 1 dram (5 cc.) t.i.d. or q.i.d 

Caution — Usual precautions with penicillin or sufo theropy. 





Description — A closed urinary drainage collection unit. The system 
may be suspended from the bed by a plastic strop. The collapsible 
plastic container expands as it fills and is vented for safety overflow. 
The bottle will stand by itself, is marked for easy measuring, and will 
hold up to 2000 cc. The wide mouth permits easy emptying, and the 
unit includes a clip on the tubing which will suspend the cop while the 
container is being emptied. The unit con be stored in a minimum of 




Description — This readily-opened, see-through package contains dis- 
posable metal suture scissors, disposable forceps and o gauze square in 
on inner sheath permitting easy aseptic removal. 

For further information write: Sterilon Corporation, 500 Northland 
Ave., Buffalo, New York 14211. 



Indications — A protozoocide used for the treatment of Trichomonas 
vaginalis, vaginitis, senile, mycotic and mixed infection vaginitis, and 
vaginal pruritis. Floraquin also stimulates postoperative vaginal granula- 
tion, reestablishes normal vaginal acidity, promotes growth of Doder- 
lein bacillus and acts as a vaginal deodorant 

Description — These vaginal tablets contains 7.5% diiodohydroxyquin 
(U.S. P.), plus lactose, dextrose and boric acid. 

Administration — Two moistened toblets are inserted doily info vagi 
nol fornices (applicator supplied). During menstruation, dosage should be 
accompanied by worm acid douches. Treatment for trichomoniasis should 
continue until three monthly smears are negative. 



Indications — Soothes the onnoying pruritus and discomfort of post- 
partum episiotomies and hemorrhoids; also gives soothing, cooling re- 
lief in pruritus oni, vulvitis, diarrhea, hemorrhoids and discomfort fol- 
lowing anorectal surgery. 

Description — A small, disposable, soft, cotton, flannel pad impreg- 
nated with witch hazel (50%) and glycerin (10%); pH is 4.6. Available 
in containers of 40 or 100 pods. 

Administration — As indicated; Tucks may be kept at the bedside and 
used p.r.n. Tucks should be placed in direct contact with the perine- 
orrhaphy or hemorrhoids and may be held in place with o perineal pad 

Literature is available from Winley-Morris Co. Ltd., 2795 Bates Road, 
Montreal 26, P.Q. 

The Journal presents pharmaceuticals for information. Nurses understand that only a physician may prescribe. 




what can 
I take for 
or acid 

The answer— TU MS! These mild, minty 
tablets are so practical to recommend 
because they're fast acting, long lasting 
and safe— made of the finest antacid 
ingredients. They're economical too— 
only a few cents buys enough for several 
doses. And they leave no aftertaste- 
no water or glass needed. 

for the tummy 






> offer delightfuUy ^ 
y^ soothing relief %o local 
^ edema, pain and itching 

when placed undfr the pad 
[ in direct contact wftk the per- 
tteorrhaphy or hemprirhoids. Thd 
\d witch hazel solutjbii is analgesi; 
i cooling, nonocclusive and virtui^y 
noi^sensitizi^g. § t 

TWC^S stfve nursing time and el$^ 
i^te thd" expense and trouble qt -^ 
preparing special dressings.! ; 
TUCK^ can be kept by \J 
the Ibfdside for applica- 
ti^ul whenever their 
s^o4thing, healing 


properties are 

For literature and samples, please write. 


2795 Bates Road, Montreal 26, P.O. 


A successful one-day institute on tuber- 
culosis and respiratory diseases was held 
at Regina General Hospital. Saskatchewan 
in May. 1964. Sponsored jointly by the 
Canadian Tuberculosis Association and the 
Saskatchewan Registered Nurses' Associa- 
tion, this first national institute to be held 
in the West emphasized: changing trends in 
TB control: the role of the nurse; com- 
munity responsibilities: medical, social and 
educational research; and respiratory dis- 
eases today. 

Dr. G. D. Barnett. director of medical 
services and general superintendent of the 
Saskatchewan .\nti-tubercuIosis League, em- 
phasized that the general population is more 
susceptible to tuberculosis today than 20 
or 40 years ago and that infectious cases 
of TB now present greater hazards to the 
community. The importance of detecting 
new, active cases early and the need for 
a vaccine that would increase immunity 
without converting the tuberculin test to 
positive, were also stressed. 

Esther Paulson, director of nursing at 
Pearson Hospital. Vancouver, spoke about 
the changing role of nurses. Today, they are 

more involved in teaching and rehabilitation 
than in bedside care. The nurse needs knowl- 
edge from the past, but must be able to 
adapt this knowledge effectively to new 
developments. New trends, such as the 
shorter hospital stay, early ambulation, and 
leaves of absence, often create obstacles to 
effective nurse-patient relationships. These 
reduce the nurse's time and opportunity for 
teaching the patient, getting to know him. 
and helping with problems. The average 
person who contracts TB today is not always 
receptive to the teaching and supervision 
for which nursing service is responsible. All 
nurses concerned with TB today seem to 
be facing similar problems. 

Miss Hazel Wilson, assistant professor 
at the school of nursing. University of To- 
ronto, stated that the number of persons be- 
ing treated at home is increasing: obviously, 
the public health nurse must use skill in 
analyzing the family health needs and ap- 
praising the family's ability to meet these 
needs. The person with TB is not always 
cooperative, and. as with many ill people, 
may refuse to accept the diagnosis, may 
express hostility and may even hide, some- 

times in another province. After discharge 
from the hospital or sanatorium, supervision 
of continued treatment is difficult. Although 
drug therapy is usually continued for about 
24 months after discharge the patient may 
be able to return to work soon after he 
leaves hospital. This makes it difficult for 
follow-up visit by the nurse. A study of post 
discharge treatment showed that about 25 
per cent of patients fail to complete the rec- 
ommended course of drug therapy. 

Dr. A. J. Bailey, of the Saskatchewan 
Cancer Commission. Regina, presented a 
talk concerning lung cancer and smoking. 
This paper will be published in the April, 
1965 issue of The Canadian Nurse. 

Dr. C. L. N. Robinson, associate profes- 
sor of surgery. University of Saskatchewan, 
Saskatoon, discussed the present patterns of 
respiratory disease. 

The institute was attended by 203 repre- 
sentatives from British Columbia, Alberta. 
Ontario, Yukon Territory and Saskatchewan. 

— Floris E. King, B.Sc.N.. M.P.H., Study 
Consultant. Nurses' Section. Canadian Tu- 
berculosis Association. 


JANUARY ige.? 


Investment in physical capital must be 
balanced with investment in human capital. 
Most educators have taken this for granted 
all along, but they have usually been re- 
luctant to stress the point lest it invite over- 
emphasis on the materialistic aspects of 
education. Quite rightly they have insisted 
that education is not merely an instrument 
of economic growth, but that it also has 
other and perhaps even higher aims .... 
In a host of situations all over the world 
including many developed countries, the 
major bottleneck to development is the 
shortage not of money but of educated 
manpower .... One of the scarcest of re- 

sources is competent manpower for teaching 
which therefore must be utilized with max- 
imum efficiency. Accordingly, there is need 
for a massive search for new technologies 
of education that will enable teachers and 
students alike to be more productive .... 
The basic problems of educational modern- 
ization, common to all nations whatever 
their stage of development, are: the updating 
of curriculum, the improvement of teacher 
supply, the development of more effective 
teaching methods, the strengthening of edu- 
cation's financial base, and the more effi- 
cient utilization of educational resources. 
— Philip H. Conway 


This bottle contains 400 labora- 
tory tests. It gives you 48,000 
possible answers in 100 cc. of 
space. HEMA-COMBISTIX* is 
a dip-and-read test for urinary 
blood, protein, glucose, and pH. 
Ames Company of Canada 
Ltd., Rexdale (Toronto) 

Ontario. •Trademark Reg. CA e9M4 AIVIE 

/^anJm Cmmenis 

Letters to the Editor are welcome. Only 
SIGNED letters will be considered for 
publication. Name will be withheld from 
the published letter at the writer's request. 

Dear Editor: 

I wish to make known to you my strong 
objection to the inclusion in our professional 
Journal of articles such as "The Christian 
Nurse's Role." (Aug., 1964) previously pub- 
lished in The United Church Observer, a 
journal with which I am quite familiar. Had 
I come upon this article in that publication 
I should have considered it appropriate and 
interesting reading. Tlie editors of The Ob- 
server, can justifiably expect that their read- 
ers are Christians and, therefore, would be 
most unlikely to take offence at any of the 
beliefs stated or implied in the article. I 
think you would agree that the editor of a 
professional journal cannot operate upon 
such an assumption regarding the religious 
convictions of its readers. In its present 
form this article expresses a narrow and 
a parochial, if not prejudicial, point of view 
which might have been avoided had it 
been reworded for publication in The Cana- 
dian Nurse. 

Surely if many dignitaries of such an 
old and established religious body as in 
the Roman Catholic Church consider that it 
is time to champion religious freedom, our 
professional Journal should not suggest, even 
by implication, that nurses holding any parti- 
cular set of religious convictions are in a 
better position, through their special brand 
of faith, to help patients than are other 
nurses who hold a different faith. 

North Americans are frequently accused 
of perceiving the world, its problems and 
solutions only in terms of our WASP sys- 
tem of values. I write to you as one white, 
Anglosaxon, protestant, Canadian nurse ex- 
pressing the hope that our professional 
Journal will conscientiously avoid publica- 
tion of material which might confirm this 
damaging accusation. 

Helen Gemeroy, Que. 

Dear Editor: 

I was very interested in the experiences of 
the nurse writing in the September issue 
(Random Comments); her experiences were 
so similar to mine. 

Finding that I had time to spare as my 
family were in their 'teens, I took a re- 
fresher course offered by a local hospital. 
We were invited to fill out forms stating 
the hours we would be available — but 
the only hours they offered were 6:00 p.m. 
to midnight. These are often impossible for 



a wife and mother whose first duty is her 

I was fortunate in getting part-time work 
at a small local hospital whose superinten- 
dent believed that part-time nurses are the 
answer to nursing shortage. She made sev- 
eral of us welcome at times suitable to our 
home routine. However, she was transferred 
to a larger hospital and superintendents who 
followed her were like the interviewers that 
"R.N." met. They ruled against part-time 

I have attended conferences where the cry 
from the hospitals was that so many nurses 
are lost to them through marriage. Again, 
we filled out papers and submitted our 
suggestions. Some suggested that older nurses 
might return to relieve the staff of desk 
work, recording and checking doctors' or- 
ders. TTiis seems preferable to employing a 
non-nurse as ward secretary. 

When women insist upon a good educa- 
tion and training in a chosen profession, 
this training should not be allowed to lie 
unused and become obsolete during the 
years that one's first obligation is to the 
family. Also, it has been shown that work- 
ing women have a fresher, happier outlook 
and more energy to devote to the family. 

All these points seem to me to come 
under the heading of the importance of 
part-time nurses to both hospital and nurse. 

J. D., Ottawa 


<Jn (jHe 


Mary Mavis (Short) Acheson '63. Char- 
lotte County Hospital, St. Stephen, N.B. 

Margaret (Hurd) Aitchison '27, Blanche 
C. (Dynes) Warren '26. St. Joseph's Hos- 
pital, Hamilton, Ont. 

Stephanie Ellenthora BJarnason '28, 
Portage General Hospital. Portage la 
Prairie, Man. 

M. Feme Burdick '23, Grace Hospital, 

Frances Catherine (Cottle) Cooke '26, 
Windsor Grace Hospital. Ont. 

Maude Frances Daley '13. Sister AndrS 
Marie (Andrelene Belanger) '41. Ottawa 
General Hospital, Ont. 

Mary Louise (Glidden) Gravgaard '28. 
Margaret O. (Backman) Kirshaw '28, Win- 
nipeg General Hospital, Man. 

J. Mildred Lower '17, Niagara Falls 
General Hospital, Ont. 

Verna May (Stevens) MacLean '31, Holy 
Cross Hospital, Calgary, Alta. 

Reta L. Nicely '34, Ontario Hospital, 
Whitby, Ont. 

Mildred Irene (Munson) Wensley '30. 
Regina General Hospital, Sask. 

Ethel M. Strueben, St. Luke's Hospital, 
Davenport, Iowa. Miss Strueben was di- 
rector of the American Nurses' Associa- 
tion General Duty Section. 

Today, doctors treating patients suffering 
from pneumonia give them a handful of 
tiny capsules costing 50^ a piece. A pre- 
scription for 20 costs $10. People say 
"How costly it is!" But the difference is 
that they take these capsules and in a day 
or two their temperature is down to normal. 
The doctor reminds the patient that he's 
been threatened by a serious disease and the 
only reason he's doing well is by virtue of 
those truly marvelous drugs. He argues with 
the patient when he wants to go back to 
work in a week or ten days, but lets him 
go back in a couple of weeks. They say 

"Gee, how much it costs." But people live 
where they used to die, and they get well in 
days instead of weeks, and they return to 
work in weeks instead of months. I ask, 
which is more costly, the medicines of our 
earlier days in practice or the medicines 
of today where it costs you more per day 
but you're back as a breadwinner and 
you're back as a wage earner and, of ut- 
most importance, you're back to work in a 
relatively short time. 

Dr. Edward R. Annb, 

Past President, 

American Medical Association. 

lOS STRIPS '^^■1 

Hema- ^' 

D D D D 




tells the story of urinary blood, 
protein, glucose, and pH in half 
a minute, it has to save time. 
P.S. Time is money. D /TTn 
AmesCompany of Canada, \^>>^ 
Ltd., Rexdale (Toronto) Ont. aivies 

*Trade Mark Reg'd. CA88484 



On every ward, when you turn out the lights, some one wakes up . . . and 
wakefulness thrives on minor irritations. Skin discomfort, particularly, can 
disturb your patients during the nighttime hours. But as nurses in thousands 
of hospitals know, a body rub with Dermassage may add that one welcome 
touch of relaxation which tips the balance in favor of rest and sleep. 

Dermassage comforts, cools and soothes tender, sheet-burned skin. It relieves 
dryness, cracking and itching and helps prevent painful bed sores. 

You will like Dermassage for other reasons, too. A body rub with it saves 
your time and energy. Massage is gentle, smooth and fast. You needn't follow- 
up with talcum and there is no greasiness to clean away. It won't stain or 
soil linens or bed-clothes. You can easily make friends with Dermassage — 
send for a sample! 


Now distributed in Canada by Lakeside Laboratories (Canada) Ltd. 

1875 Leslie Street, Don Mills, Ontario 








The TRAVAD system simplifies all aspects of your enema procedures. From Central 
Supply to use "on-the-floor" the TRAVAD system saves personnel time and saves 
the hospital money. Enema administrations are no longer a chore, because all units 
^re completely assembled/completely disposable . . . there's nothing to disassemble, 
tiothing to disinfect afterwards. Whether the need is for a conventional cleansing or 
even a barium enema ... a prefilled unit, or a large volume container . . . the TRAVAD 
system has a specific unit for the specific need. TRAVAD disposable enema units 
are individually packaged . . . flat to save storage space . . . reduce work load. And, 
they cost no more than less convenient units. Is it any wonder, 

"THE TREND IS TO TRAVAD*" (disposable enema units). 

TRAVAD 1500* large volume enema 

container with soap paci^et and 

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TRAVAD' ready-to-use 
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TRAVAD' B.E. large volume 
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Montreol, Canada 












pre-eminent in its field for years 



Complete information for«sage awiiaWe to piiysKians on request. 


It was erroneoLish' reported, in the No- 
vember "World of Nursing." that four 
nurses had shared a Sl.UOO scholarship 
offered by the Saskatchewan Registered 
Nurses' .^ssociation. Each of the four re- 
cipients — Lorna Barker. Eleanor Heieren. 
Shirley .Adams and Donald Brown — re- 
ceived a SI. 000 scholarship from the .As- 


Tasty tests have begun at one London 
hospital to see whether catering methods 
used by BOAC can be applied to offer more 
appetizing food to patients. Fresh frozen 
individual meals, prepared in advance by 
top-line chefs, will be heated in aircraft 
ovens right beside the hospital wards. 

The East Finchley convalescent unit of 
the National Hospital for Nervous Dis- 
eases, in Queen Square. London, has been 
chosen for the experiment. 

— Tlie Horner Sewsleiter 


Right Medicine for Jimmy. . . helping children 
to get well is much easier when they're positively 
identified with Ident-A-Band. It takes only a second 
to be sure the nght Jimmy gets the right medicine. 


In the Good Old Days 

The Canadian Nurse 
January, 1925 

Under new orders issued by the Victoria 
Hospital, London, Ont., student nurses are 
to undergo rigid physical examinations be- 
fore being accepted by the school of nurs- 
ing. This will eliminate those students 
physically incapable of carrying on the ar- 
duous work of a hospital nurse. This step 
has been taken with a view to greater eco- 
nomy as well as in the interest of the stu- 

hiformalion regarding transportation to 
Helsingfors, site of the ICN Congress, July. 
1925: The minimum rate from Montreal 
through to Helsingfors is $175 plus $5 war 
tax. This rate covers third-class rail fare 
across England and a cabin on the North 
Sea steamers, also board and lodging in 
England while awaiting connections. 

Winnipeg Municipal Hospitals have de- 
veloped a program of affiliation for theii 
students in fifteen associated hospitals: Man- 
itoba. 9: Saskatchewan. 4; Ontario, 2. The 
affiliation is deemed advisable for two main 

1 . There are a great many hospitals 
where capacity ranges between 10 and 20 
beds. The patients in these hospitals must 
be nursed and the student nurse has been 
found the most satisfactory person for that 

2. There is a need for affiliation to equip 
the student fully for any and all calls upon 
her knowledge of nursing in its every phase. 
whether they be of an industrial, social 
service, school, public health or hospital 


. XJKoLLisT^B® 


I.C.N. Congress 
Frankfurt June 1965 









Fast, convenient dispensing. All Davis & Geek sutures and suture-needle combinations are 
supplied ready for immediate use, individually packaged in dry, presterilized plastic envelopes- 
transparent and double-labelled for easy identification of contents. 

Maximum ease of handling. Surgeons appreciate Davis & Geek sutures for their excellent hand- 
ling and performance characteristics, assured by meticulous care in processing during every 
phase of manufacture. You will find that the nursing team can function more efficiently with suture 
materials from the broad line of Davis & Geek suture products. 

SP Service Program. This Davis & Geek service completely eliminates the time, expense and 
potential hazards involved in cold resterilization of unused suture packages. Davis & Geek assumes 
all responsibility for repackaging and resterilizing left-over suture packages . . . saving many nurse- 
days each month and providing significant new savings in operating room management. 





3 Montreal, Quebec 

C Vj\ rv A /VI M I» 

©Registered Trademark 

There is only one 

surgical mask tliat 

filters best* 




*For dramatic proof documented from laboratory tests, request DuUetin 337 

I i^TEc;p4iT"y 



SINCE ieo'7 

^ke L^f^ 




The psychologist, Erik Erikson. speaks of the turbulent 
passage from adolescence to adulthood as "'the crisis of 
identity." How well this crisis is met determines how 
successfully and purposefully the individual will function 
through adult life. 

I suggest that the profession of nursing in Canada is 
today grappling with a similar problem of achieving a true 
sense of identity and purpose. As with the individual, if 
we fail we will be left in a chronic state of disorganization 
and dissatisfaction; if we are successful, we will emerge 
with a picture of ourselves as truly a profession, secure in 
the rightness of its chosen goals and confident in its 
ability to attain them. 

To this end, the nursing profession must deal with chal- 
lenges from within and from without. 

From without comes the urgent, continuing demand for 
more and more nursing practitioners qualified to staff the 
expanding health services of our fast-growing communi- 
ties. From without, too, come the stimulating challeiiges 
presented by the great advances being made in medicine. 
With increasing recognition of the psychological and 
sociological factors associated with illness, the nurse's role 
on the health team has become more positive, more 
creative. In addition to her technical skills, she now needs 
skills in helping the patient, the family and the community 
meet, overcome or adjust to the problems of ill health. 

Moreover, the standards of our affluent society often 
give the nurse occasion to make invidious comparisons be- 
tween her own economic status and that of other profes- 

From within the profession comes the question as to 
how we should go about educating a sufficient number of 
fully qualified nurses. Needed first is an agreement within 
our own ranks as to the number of acceptable categories 
of nurses, and as to the role and education of each. If 
we do not soon do this for ourselves, it will be done for us 
from outside. Oearly, the Report of the Royal Commis- 
sion on Health Services, and the report of Dr. Kasper 
Naegele in his assignment for the Canadian Nurses" Asso- 
ciation warn us that we cannot delay action. We must 
exercise the right of self-determination in order to retain 
it. A measure of our professional maturity, however, will 
be the care we show to protect the interests of patients, 
hospitals and colleagues in other professions, while exer- 
cising this right. The national committees of the Cana- 


dian Nurses' Association are now bringing together nur- 
ses with similar interests and experience across the coun- 
try to plan and initiate appropriate action. 

Already there is a consensus that the present two 
categories of nurses with full professional status will be 
needed for a long time to come — the graduate of a 
diploma course, and the nurse with a university degree. 
But changes in nursing education are seen as necessary 
and urgent if we are to turn out graduates sufficient in 
numbers and qualifications to meet the needs of the 

A number of studies have basically agreed in their 
recommendations that: 

1. The diploma nursing course be shortened from three to two 
years without reducing its educational content by freeing the stu- 
dent nurse from a multitude of routine hospital duties: 

2. the schools for the diploma course be separated from and 
mdependent of the hospitals; 

3. more nurses be prepared m the basic university schools 
of nursing. 

There is wide agreement on the need for: 

1. The curricula of the university courses of nursing to be 
so organized that graduates of diploma courses could continue 
their education toward a degree in clinical nursing rather than 
being limited to specialized courses in administration and teach- 

2. the clinical nurse who is trained to provide modern com- 
prehensive nursing being assured status and remuneration com- 
parable to those of the nurse who devotes herself to administra- 
tion or teaching. 

These broad recommendations have a great body of 
support behind them. All that is needed for action now is 
a willingness to give and take on minor details. While the 
responsibility for leadership at this phase lies wath the 
national committees, leadership needs to be broadened 
and strengthened from the membership. 

I suggest that if the profession is to meet its crisis of 
identity successfully, it should now be drawing upon and 
fostering the leadership potential of its younger members. 
Nursing has within itself the power to shape its own 
future. The time for talking and studying is past; the 
time for learning by doing is here. 

A. IsoBEL MacLeod, m.a., 


Canadian Nurses' Association. 




When you received the last evaluation of your nursing performance which indi- 
cated a need for greater emotional maturity, did it bother you a bit? 
Or, as one of our colleagues phrases it, "Where you exercised?" Of 
course you were. Then come the questions: "What is expected of me? 
What should I do that I am not doing or what should I refrain from 
doing in order to be more emotionally mature?" 

Helen Creighton, b.s.n., m.a., j.d. and Sister Catherine Armington, b.s.n.e. 

In childhood the personahty emer- 
ges and becomes socialized against a 
background of love, discipline, and 
freedom. In adolescence that person- 
ality must separate from the security 
of the environmental background and 
become independent. When finally the 
adult emerges from the period of ado- 
lescent struggle and confhct, what do 
we find if development has been suc- 
cessfully accomplished? The emotion- 
ally mature adult is an individual in 
his own right — separate from every- 
one else — alone, in this sense, and 
able to tolerate the isolation that this 
at times brings. She must decide her 
own course in life. She must now be 
responsible for herself. She must form 
her own code of living. She must form 
her own opinions and judgments and, 
where circumstances require, she must 
support herself against others. This 
is one half of the story of "what is 

In addition to being an individual. 

Helen Creighton, R.N., B.S.N. . George- 
town University School of Nursing. M.A.. 
University of Michigan: J. D., George 
Washington University Law School. Dr. 
Creighton is associate professor of nursing. 
University of Southwestern Louisiaua. La- 
fayette, Louisiana and author of numerous 
articles in professional nursing literature. 

Sister Catherine Armington D.C.. R.N.. 
B.S.N.E. Graduated from St. Vincent's Ho.s- 
pital, Indianapolis. Indiana and De Paul 
University, Chicago. Sister Armington is su- 
pervisor of nursing service. T.B. Annex, La- 
fayette Charity Hospital, Lafayette, Louisia- 
na, and author of several articles in pro- 
fessional nursing literature. 

she must live in society. This require- 
ment is also something of a desire. 
None of us can live in a vacuum 
either physically, intellectually or emo- 
tionally, so she must be prepared to 
mamtain her individuality and yet be 
able to adapt to society; to know where 
and when she can maintain her inte- 
grity and yet fit in with others. In place 
of the loud-voiced assertions of ado- 
lescence, impatient with and unable to 
listen to contrary opinions, the adult, 
secure within, can listen and use other 
peoples' ideas and judgments where 
she finds them valuable. Ideally, the 
emotionally mature adult will maintain 
harmony within herself and in relation 
to others. Frankly, none of us com- 
pletely achieves such perfection, just 
as none of us achieves perfect con- 
tinuous physical health, but the meas- 
ure of our emotional maturity is the 
nearest we get to such an ideal. 

Let us consider some of the qualities 
of the emotionally mature person: 

1. If we are emotionally healthy it 
means that we have learned to think 
in long-term goals and to persevere 
with short-term goals. We have learned 
to accept frustration with fair grace 
in order to gain something we desire 
in the future. We have learned to work 
under difficulty, to face problems and 
not resort to "flight or fight." Certain- 
ly, it is easy to run away from criticism 
and reversals as we are tempted to fly 
away from the disagreeable, tedious, 
and whining person. How often, too. 
does our propensity to engage in verb- 
al battle cause a situation to deterior- 
ate rather than improve? The emo- 
tionally mature person has learned to 

work out reasonable compromises so 
that she is neither given to fleeing from 
the situation nor to destroying what 
and whom she cannot master. While 
there is and will be a constant challenge 
of anxiety-producing situations, stami- 
na and skill at work are not inhibited 
by tension and anxiety nor is there 
interference with the enjoyment of 
recreational activities. Also, there will 
be a relative freedom from symptoms 
that are produced by anxiety and ten- 
sion, such as a headache, over-fatigue, 
unreasonableness or illogical thinking. 

2. The emotionally mature person 
is honest with herself. She recognizes 
that she manages conflicts and frus- 
trations by the use t>f psychological 
devices known as defence mechanisms. 
All of us manage conflicts between 
ourselves and reality, between our de- 
sires and our good judgment with these 
weapons. The use of some is neces- 
sary while others are a sign of weak- 
ness and immaturity. Their use is rather 
automatic and habitual so we are sel- 
dom aware of their functioning and 
even less of how they distort reality: 

a. Rationalization is our device for jus- 
tifying ideas and behavior so they seem 
reasonable to us. We often rationalize our 
prejudices: one of a group behaves in such 
and such a way. we generalize, rationalize, 
then say they all behave that way: our pre- 
ferences: the grateful patient or the one 
who has shown improvement under our 
care. We rationalize, and call this one the 
"good patient" or the "cooperative patient." 
Our daily mistakes: errors in charting, in 
iudgment. in overlooking symptoms or 
Ignoring complaints, we rationalize by say- 
mg nobody ever pays any attention to such 




trivia. And maybe, sometimes, we ration- 
alize a dislike for another nurse because we 
are jealous of her. Instead of wasting time 
being jealous, why not emulate her, or even 
surpass her? 

b. Projection defends the personality 
against unacceptable ideas or wishes by 
attributing them to someone else. There are 
people who constantly blame others for their 
own mistakes or shortcomings. They are 
rather quick to read into others the motives 
that secretly they hold themselves. The in- 
dividual who has difficulty relating warmly 
to others suspects that he is being rejected 
by friends and associates. Again, if we are 
honest with ourselves, the faults we see in 
others may be our own. The behavior man- 
ifesting the fault may have a slightly differ- 
ent turn. So let us make sure the pot isn't 
calling the kettle black! 

c. Repression is a spontaneous, irrational 
response of the mind and emotions to 
fearful thoughts, desires, situations, actions. 
Whenever such forbiden subjects or feelings 
confront the individual, whether in fact or 
fantasy, they instantly trigger fear and 
anxiety. The mind responds immediately by 
pushing down the undesirable image. The 
more threatening the image, the more auto- 
matic the pushing down response. Repres- 
sion of one emotion often leads to the 
emergence of another equally undesirable 
emotion. Thus, a woman who is never 
able to permit herself even to feel angry 
may. ease her tension by sly and nasty verbal 
sniping. We can't go around expressing 
angry feelings by childish banging and anti- 
social behavior but we can release these 
feelings by getting busy in a constructive 
way such as: a useful hobby, housecleaning. 
a new hat. thinking through one's problems, 
or an honest appraisal of oneself. We are 
so good at fooling ourselves that the wisdom 
of self-knowledge is not easy to come by. 
However, our ability to recognize our use 
of these devices does improve our emotional 
maturity if we take constructive means for 
self-control. Controlled tension can be valu- 
able in pressuring us to find better solutions 
to the problems that face us. 

3. The emotionally mature person 
is flexible and can defer to time, place 
and circumstances. This quality of be- 
ing adaptable is most important, for liv- 
ing is a series of changes: new experi- 
ences are new opportunities which re- 
quire adaptation. If we are to master 
our daily lives we must continually 
grow, from birth to death. All of us 
are familiar with the person who con- 
tinues to use the same devices that 
were used to solve childhood problems. 
We are familiar, too. with the person 
who is so rigid she cannot change. 
Whether her behavior is described as 
stubborn or firm depends on whether 
we are describing the actions of others 
or our own. Resiliency and flexibility, 
an ability to adapt to change is needed 
if we are to be emotionally mature, no 

matter what our age or position. 

4. The emotionally mature person 
has a capacity to enjoy relationships 

— not only on a one-to-one basis but 
as one who can make a positive con- 
tribution to a group. People vary in 
gregariousness and it is a mistake to 
condemn solitary people as insecure. 
However, relationships should not be 
made painful by awkward silences, 
crude, rude, pushing or stiff behavior. 
While insecure people often say they 
have no need of pleasurable associa- 
tion with others, this is not true. Hon- 
esty compels us to acknowledge that 
we need the approval and acceptance 
of others — but the price of adjustment 
and cooperation seems too high. "My 
way or I won't play." 

In order to contribute one need not 
to be leader in the group. Some peo- 
ple are insecure unless they are in a 
dominating situation which gives them 
the prestige they desire — "This is it — 
it's the way I see it!" With that, the 
discussion is closed and, by the way, 
it's never an opinion — always a firm 
conviction. Others are conspicuous by 
their silence, muttering in undertones, 
or just plain pouting. "Whatever it is 

— I'm agin it." Negativistic behavior 
is destructive to the group. Still others 
are the timid little birds "Oh! My 
opinion? I wouldn't dare to be so 
bold." But she never stops muttering 
and opinions fly in every direction after 
the group has dispersed. Also, in our 
group situations, we have the bland, 
phlegmatic "Whatever you say" (no 
contribution, just there). 

The emotionally mature person en- 
joys the experience of cooperation 
which strengthens the group. She niay 
not agree but she voices her opinion 
and gives her suggestions. Such a per- 
son can work in an organization and 
under authority. How many hours do 
we nurses spend in meetings? And we 
spend these hours — not for self-ag- 
grandizement — but to improve our- 
selves and improve and strengthen our 
group so that we can ultimately best 
serve our patients by meeting their 

5. The emotionally mature person 
can tolerate criticism without break- 
ing down. Criticism naturally arouses 
fear. The immature individual either 
denies the accusation or makes ex- 
cuses or thinks somebody has it "in 
for her." This may even interfere with 
her efficiency. We' would all do well to 
recall the words of a wise man who 
pointed out that our best friends for 
time and eternity are those who tell 
us our mistakes. Once an error is 
known, it can be corrected and elim- 
inated. The problem of how to criti- 
cize subordinates or our friends is a 
delicate one in human relationships. 

that is, how to be constructive and not 
crushing in one's comments. We might 
consider constructive criticism as giv- 
ing money to someone who needs it 
. . . and in this we can follow St. 
Vincent de Paul "It will only be 
through the love you show that the 
poor will forgive you the alms you 
bestow." Dr. Crane, the psychologist, 
has offered the complimentary sand- 
wich: give the person a sincere com- 
pliment (the bread) then add the meat 
(the criticism) and top it off with more 

6. The emotionally mature person 
has a considerable amount of inde- 
pendence. She can size things up and 
make her own decisions. She has a 
goal and the will to achieve that goal. 
The immature person is indecisive and 
unsure. She has trouble making deci- 
sions, misgivings about those she 
makes, and often seems inconsistent 
— or even capricious. This trait not 
only plagues the individual but it is 
frustrating to all who may be depen- 
dent upon her for decisions. Complete 
independence is fullblown lunacy but 
the autonomous woman knows herself, 
works within her limits but up to those 
limits, and knows when to call on 

7. The emotionally mature person 
has the capacity to love. And she can 
love all without exception. She can 
desire that others fulfill their purpose 
in life; she will help them to help 
themselves; she will be persuasive and 
encourage others. She will begin at 
home but not end at home. Although 
we enter the world needing to be on 
the receiving end. as we mature the 
process reverses. No one can really 
live and work harmoniously with 
others unless she is willing to give; and 
the really mature have the quality of 
giving more than is asked or required 
in a given situation. Getting along with 
others requires self-control, vitahty and 
energy, sincerity, fairness, helpfulness, 
willingness to assume responsibility 
and reliability, persuasiveness, consis- 
tency, a sense of humor, the ability to 
win modestly and lose graciously in 
the game of life. The list could go on 
and on. But there is only one impor- 
tant thing to remember when there is 
a breakdown in relations with others: 
the greatest barrier to cooperation with 
others — and we know it if we're 
truly honest with ourselves — is self- 

Having reviewed the qualities of the 
emotionally mature let us put system 
into our attainment of it. Have a goal 
— ■ one that will really appear worth- 
while although involving stick-to-it-ive- 
ness and perseverance. 

Work on some weakness using these 
qualities as yardsticks for a bit of 




healthy introspection. Work one day at 
a time. Try to recognize basic moti- 
vations: "To thine ownself be true." 
To increased insight and awareness of 
personal weaknesses, add a healthy at- 
titude toward the criteria. Growth in 
enwtional maturity wUl be reflected 
in improved interpersonal relationships 
and in other qualities measured by an 
evaluation of our nursing performance. 
Our ability to utilize constructively 
such evaluations of ourselves by others 
will also grow. As individuals we 
live more harmoniously with ourselves 
as our emotional maturity increases. 
As an individual each person must 
live in a society. By choice, profes- 
sionally, you Uve as a nurse. Profes- 
sional nurses exist for the patient and 
his needs. To the extent the patient's 
needs are met, and only to this extent, 
is the quality of nursing good. Each 
of us lives more harmoniously with 
others as our emotional maturity in- 
creases. We can better understand and 
accept the ideas and judgments of 
others and consequentiy find much of 

value to add to our own living and to 
the lives of those whom we touch. 
Look in the mirror, a full-length mir- 
ror. Am I emotionally mature? No, 
there is spmething left to be desired 
in my emotional maturity. But, I do 
know my ideal! I know the qualities 
that will make my ideal a reahty. 
Every day, if it is only by a sixteenth 
of an inch, I move closer to emotional 

If we can admit to the mirror that 
there is a need for growth, we can 
start exercising in the right way. The 
following check list will help with our 
self-evaluation. Find the weakness that 
may have triggered the evaluation and 
more on to emotional maturity. 


Do you feel confident of your ability to 
deal with your own problems? 

Do you patiently listen to people whose 
views differ from yours? 

Do you accept other people and not try 
to mold them into your pattern? 

Do you have confidence in your ability 

so you can welcome the ideas and participa- 
tion of others including your subordinates? 
Do you wilUngly accept responsibility for 
your subordinates' errors? 

Do you graciously share the credit with 
co-workers who assist you? 

Do you accept unfavorable comment 
about yourself? Do you bounce back from 
Ufe's hurts with resiliency and hope? Do 
you respond to difficulty and worry as to a 

Do you volunteer to accept new or added 

Do you try to assemble all available in- 
formation before making a decision? 

Do you make a decision timely despite 
ambiguity? Do you show a willingness to 
take a calculated risk? 

Do you take a stand on controversies in 
accordance with your principles — be they 
popular or unpopular? 

Do you cut yourself off from business 
pressures and enjoy leisure time? Do you 
live a balanced life? 

Do people come to you for assistance? 

Do you utilize your abilities and capabi- 
lities constructively and to good advantage? 

A successful 6th Annual Operating Room 
Conference was held November 17-19, 1964 
in Montreal. Six hundred nurses, the major- 
ity from Quebec and with representation 
from eight other provinces and several 
northern states, registered for some portion 
of the three-day event. 

The Executive Committee planned a very 
full schedule. Professional ethics, O.R. 
scheduling, and interdepartmental relations 
between C.S.R. and O.R. were subjects of 
discussion on the first day. 

The second day, Dr. i. C. Ducharme, 
Miles Francine Bruneau, R.N. and Mar- 
guerite Pedneault, physiotherapist, Ste Jus- 
tine's Hospital, Montreal, discussed "Treat- 
ment of Burns," and Dr. Ian Henderson, 
Montreal General Cancer Clinic, spoke on 
cancer chemotherapy. An interesting sympo- 
sium presented by the operating room staff. 
Montreal General Hospital, described the 
use of visual aids and audio-visual aids 
in the O.R. Five major groups of devices 

can be used as special supplements lo 
learning. An interesting display was used to 
illustrate the discussion. 

On the final day. Dr. Claude Bertrand, 
neurosurgeon. Notre Dame Hospital. Mont- 

Miss M. Kerr with visual aids 

real, used films and slides to illustrate new 
methods of treatment in Parkinson's disease. 
"Exchange Transfusion" was the topic of 
Dr. Leo Stern, Montreal Children's Hospital. 
He was assisted in his presentation by Mrs. 
Janet Thorne, head nurse at Montreal Chil- 
dren's Hospital, who emphasized the role of 
the nurse in preparing the baby and equip- 
ment for transfusions. Dr. Peter RosTn- 
baum. Royal Victoria Hospital. Montreal, 
discussed "Surgical Intervention. Pre- and 
Postoperative Care of Cataract Extraction." 
A stimulating question period followed. Mr. 
Gilles Tremblay, an industrial engineer, de- 
scribed the use of "Methods Study in Nurs- 
ing." The principle of work simplification 
programs is to help the nurse to 'work 
smarter, not harder." 

Many excellent exhibits were assembled 
in the large area adjoining the conference 
room, and free time was _ profitably spent 
viewing the new developments in medical 
and surgical equipment and materials. 




Quo Vadis School of Nursing 

Something new has developed in nursing that is of importance to the profession 
and especially to women between the ages of 30 and 50 years. 

Sister Mary Felicitas, 

Quo Vadis? Where are you going? 
This question was uppermost in the 
minds of the nursing committee of 
the CathoHc Hospital Conference of 
Ontario when, in the fall of 1962, a 
study of current trends in nursing edu- 
cation and nursing service was pro- 
posed. For this reason the study was 
named "The Quo Vadis Project." 

The methods employed in this 
study, the nature of the deliberations 
and their final outcome are not re- 
levant to this article, except insofar 
as they led to the concept of this new 
type of school of nursing. Among 
these was the awareness of an in- 
creasing demand for well-prepared 
nurses, with a corresponding urgent 
need to provide additional facilities for 
their preparation. It seemed feasible 
to build upon the success of indepen- 
dent schools offering two-year pro- 
grams. In exploring community re- 
sources for potential students, it be- 
came apparent that there were a grow- 
ing number of older women in the 
community who might be interested 
in entering a school of nursing specifi- 
cally designed to meet their needs, and 
who might be expected to continue 
in the practice of nursing after gradua- 
tion. It was felt that such a group 
would be a stabilizing influence on a 
profession in which there is a very 
high rate of turn-over. It was also an- 
ticipated that the motivation of such 
students would be high — and there- 
fore the attrition rate might be lower 
than in the traditional schools. 

Miss Catherine D. MacLean. M.Sc, 
coordinator of the project, pursued 
these ideas. Discussions were held 
throughout Ontario among the project 
participants and with representatives 
of various organizations in the health 
field. Women's divisions, social scien- 
ti'its and adult educationists were also 
consulted. There grew the possibility 
of being able to launch a new venture 
which would not only draw upon a 

Sister M. Felicitas is Director of the 
school of nursing at St. Mary's Hospital. 

previously untapped source of students 
for the nursing profession, but would 
also demonstrate a new approach to 
the retraining of older persons. 

Explorations for facilities and meth- 
ods of implementing the idea, were 
begun. Classroom and clinical facili- 
ties of St. Joseph's Hospital, Toronto, 
seemed to be sufficient to accommo- 
date both their present students and an 
additional group of 60 students (30 
per year) in the new program. The 
Board of Directors and other authori- 
ties gave approval, as did the College 
of Nurses of Ontario. 

A well qualified staff was secured. 
Miss Margaret Mackenzie, the director 
of the school, earned her master's de- 
gree at Teachers College, Columbia 
University. Her extensive experience 
in public health included a tour of 
duty in India with WHO where she 
assisted in the organization of courses 
to prepare personnel in nursing in that 
country. Of the instructional staff, two 
have their master's degrees, one has a 
baccalaureate degree and the fourth 
one is currendy completing work on 
such a degree. Miss MacLean re- 
mains as coordinator and research 

When the idea for the new school 
was proposed, it not only seemed 
appropriate to use the name of the 
project which led to its establishment, 
but the phrase itself seemed applicable. 
The school was set up to challenge 
and to channel the energies of those 
who had ability and talent, but who 
were not using it. The school might 
well be saying to its potential appli- 
cants. "What are you doing to realize 
your potential? How are you using 
vour talents? Where are you going?" 

The Quo Vadis School of Nursing 
offers a two-year program which pre- 
pares candidates to write the registra- 
tion examinations of the College of 
Nurses of Ontario and subsequently 
to practise as registered nurses. The 
school is independent and non-secta- 
rian, with authority and responsibility 
vested in its own board of directors. 

The most unique feature of the 

school is its policy of accepting only 
mature students — presently defined 
as those who are over 30 and under 
50 years of age — who have the aca- 
demic qualifications required for ad- 
mission to schools of nursing in On- 
tario, and who have satisfied an Ad- 
missions Committee that they are per- 
sonally suitable and have made ade- 
quate arrangements to undertake the 

It is presumed that the student's ex- 
perience of life is an asset, and a po- 
tential on which both staff and stu- 
dents can build. This implies fullest 
use of adult education methods of 
teaching, and the assigimient to the 
student of as much individual respon- 
sibility for her professional develop- 
ment as she is able to assume. The 
program is also specifically geared to 
the home responsibilities which it was 
anticipated would be of first impor- 
tance in the lives of the majority of 
students. As much as possible the five 
day week is being scheduled from 
9:00 A.M. to 5:00 p.m. There is no 
residence accommodation. A tuition 
fee is charged for each year, and stu- 
dents pay for their uniforms and books. 

Much interest was shown after the 
first publicity release. About 600 in- 
quiries were received. A total of 80 
followed through to the extent of 
paying for their psychological testing, 
and completing other preliminary ap- 
plication forms. The majority of the 
applicants are married and have child- 
ren ranging in age from two to 28. 

The first class includes two grand- 
mothers with an average age of 41 
years. All have the necessary educa- 
tional requirements, and are of suffi- 
ciently high intelligence to undertake 
further studies. 

The profession of nursing needs 
practitioners of this calibre. It appar- 
ently has only to provide the facilities 
for their education in o;-der to attract 
them in large numbers. We watch this 
development wijh interest — and wish 
success to the pioneers who were brave 
enough to go forth into an uncharted 




Recent Developments In Obstetrics 

The past two decades have brought tremendous progress in the field of ob- 
stetrics, as in all other medical specialties. 

J. Rene Tittley, m.d. 

Statistical data from various coun- 
tries show a marked decrease in both 
maternal and neonatal mortality and 
morbidity rates. Several of the factors 
responsible for this are well known. 
However, prematurity, congenital mal- 
formation, and Rh incompatibility still 
prevent the desired lowering of neo- 
natal rates. The hope of early and in- 
teresting results calls for even more 
active research. 

It is noteworthy that the decrease in 
rates lacks uniformity. Figures vary 
from one geographical area to another 
and from one institution to another. 
Inevitably, the private or small region- 
al hospital produces statistics substan- 
tially higher than those of the large, 
well-equipped maternity centre. While 
most specialized institutions report a 
drop to near zero in maternal mortal- 
ity rates, this is not representative of 
the individual province or of the 
country as a whole. 

Can we, as protectors of maternal 
and new born life, assist in reducing 
obstetric mortality and morbidity rates 
in 1965 to the very minimum, even 
in remote districts? 

Physical Facilities 

We must first assess the accom- 
plishments of the large centres in or- 
der to improve methods in regional 
hospitals and plan for the necessary 
facilities in remote areas. 

Socialization and planning tend to 
assume increasing urgency and im- 
portance as the means whereby every- 
one, rich and poor, may have access 
to the best in medical and hospital 
care. This implies that a pregnant wo- 
man in any part of the country will be 
assured of the same advantages as pa- 
tients in large centres. Our concept of 
socialization goes beyond this mini- 
mum. Research centres in greater 
numbers are needed and their discov- 
eries instead of being reserved for a 
privileged few institutions should be 
extended to all. (It should be noted 

Dr. Tittley is an obstetrician on the staff 
of Ste-Justine's Hospital, Montreal. 

in passing that these various benefits, 
available to both private and public 
patients, antedate hospital insurance 
and were, perhaps, provided with 
greater generosity!) 

What are the special advantages 
open to the private patients of ob- 
stetricians on the staff of a large 
centre or the patient attending a pub- 
lic clinic in the same institution? 

Prenatal Clinics 

.Adequate prenatal health care includes 
regular physical examination, usually at 
monthly intervals, from the beginning and 
throughout the course of pregnancy. Fre- 
quency of examination increases toward the 
end of the gestation period or as need 
dictates. There is complete subjective and 
objective evaluation; certain blood and urine 
analyses; possible consultations with other 
medical specialists in such services as car- 
diology, nutrition, and diabetes. With medi- 
cal approval, conditioning for psycho-pro- 
phylactic delivery may be planned. 


Hospital care is available for the treat- 
ment of patients who develop complications 
of pregnancy — for example, pernicious 
vomiting, inevitable spontaneous abortion, 
severe hemorrhage. This is an extremely 
important factor in obstetric care. Naturally, 
postpartum complications receive the same 
attention. Deliveries should be carried out 
in hospital, whether or not it is anticipated 
that they will be normal or abnormal. 

Labor Hooni.i 

On admission, the patient is taken to a 
private labor room. Crowding several wo- 
men in various stages of labor together in 
one room is intolerable. The primipara, 
just starting to have contractions, finds her- 
self side by side with a woman in shock as 
the result of placenta previa: another, un- 
til now, calmly preparing for natural child- 
birth, has as her companion someone who 
tosses about at the slightest contraction and 
begs to be put to sleep, and so on. 

Delivery Rooms 

Spacious, clean, well-lighted, and fully 
equipped rooms are available for the nor- 

mal or the complicated delivery. Supplies in- 
clude the following: 

Ajustable (tilting) delivery tables; 

incubators, heated and ready for use; 

modern anesthetic and suction equip- 

emergency sterilizers; 

a variety of obstetrical forceps; 

adequate instruments — scissors, for- 
ceps, suture materials, etc.; 

emergency drugs and equipment ready 
for using them; 

special sets for cardiac massage, re- 
suscitation of mother or child, etc.; 

sterile linen bundles for draping the pa- 
tient and for clothing personnel: 

movable mirrors — the patient who 

chooses natural childbirth may watch the 

delivery if she desires; if the patient is 

anesthetized, the anesthetist is enabled 

to follow the progress of delivery. 

In addition, one might expect to find 

posters indicating the exact location of 

emergency equipment: intravenous solutions, 


Recovery Rooms 

Generally, the same procedure is followed 
in the care of the anesthetized obstetrical 
patient as in general surgery: she is taken 
to the recovery room for the delivery room. 
All supplies and equipment required for 
adequate observation of vital signs or for 
emergency treatment are on hand. 

Postpartum Room 

A bright, clean room with space for only 
three beds at a maximum is desirable to 
avoid postpartum contamination. The beds 
are adjustable so that treatments can be 
carried out more easily and the patient can 
be postured in certain positions. Each room 
has its own shower, washbasin, dressing 
room, and is suitably furnished. Isolation 
units are available for patients with an in- 
fectious or contagious condition, or who 
require special treatment (for example, the 
patient with a heart condition). 

Postpartum rooms should be reasonably 
close to a nurses' station and connected 
to it by "intercom." 

N iirseries 

Glass-enclosed, isolated rooms with care- 




fully regulated temperature are generally 
available. Many have treatment rooms and 
their own nursing stations. Emergency medi- 
cations and equipment for resuscitation of 
the newborn are on hand. In addition, the 
well-equipped hospital provides separate 
units for premature infants or any new- 
born requiring special care. 

The specific advantages of the large, 
specialized centre also include: labo- 
ratory facilities such as bacteriology, 
pathology, and hematology; a blood 
bank on 24-hour call and prepared 
at all times to supply severad bottles 
of group O, Rh negative blood; radio- 
logical and medical consultation ser- 
vices; a medical records department 
with charts available for reference pur- 
poses on very short notice; teaching 
rooms for interns, nurses and patients; 
and a library, that p)ermits profitable 
use of spare time while waiting for a 
patient to deUver. 


The services of nurses and nursing 
assistants must be available 24 hours 
a day. The delivery room needs as 
large a staff at night as during the day, 
and as many people on Sunday as any 
other day. Student nurses are in the de- 
partment for educational purposes and, 
far from adding to total staff strength, 
their presence necessitates the services 
of clinical instructors. As far as nurs- 
ing aides are concerned, they are what 
their name implies — persons to aid 
others. They should not carry out 
duties that belong rightfully to the 
nurse nor should they be at all in- 
volved in procedures of a purely me- 
dical nature (i.e., administration of 

A profession sets certain standards 
that must be met and the emphasis on 
this is increasing. For example, the 
head nurse or instructor not only 
commands a higher salary but she must 
have specific preparation for her job 
through postgraduate study. In this 
instance, she should be especially pre- 
pared in obstetrics and the care of the 

As far as the medical staff are 
concerned, large centres accept quali- 
fied obstetricians only. At Ste. Jus- 
tine's Hospital, Montreal, in 1963, 
only 10 per cent of obstetrical cases 
were cared for by general practitioners. 
These are required to seek consulta- 
tion at the slightest indication of ab- 

The general staff of the good insti- 
tution is made up of qualified special- 
ists who keep their knowledge up-to- 
date in order to provide satisfactory 
teaching for nurses and medical in- 
terns. Regular staff meetings, prefer- 
ably on a weekly basis, afford an op- 

portunity to study and compare statis- 
tics of the service, discuss problems, 
and revise procedures and regulations. 
On occasion, a member from another 
branch of medicine is invited to ad- 
dress the obstetrical group concerning 
developments in which they have a 
mutual interest. The obstetrician, in 
turn, has a chance to draw to the at- 
tention of other medical personnel the 
demands that will be made upon them 
as the result of new discoveries in 
obstetrics. Finally, discussions of an 
ethical nature, which are becoming so 
common in this era of family plan- 
ning, allow those concerned to ex- 
press their opinion about moralistic or 
legalistic aspects. 

Other factors have also contribu- 
ted to the decrease in maternal and 
neonatal morbidity and mortality rates. 
It would be interesting, however, to 
show the substantial improvements in 
obstetrics as the result of deliveries 
under controlled conditions in a fitting 
environment and under the supervision 
of competent and intelligent staff. In- 
duced delivery under any circumstan- 
ces is hazardous for both mother and 
child. Controlled delivery, under the 
guidance of a professional obstetrician 
and in well-equipped surroundings, of- 
fers security and demonstrates the su- 
periority of human intelligence over 
the elements. 

Teamwork in Obstetrics 

Teamwork, although not specific to 
obstetrics nor originating in this field, 
is important. The elements of emer- 
gency, and of the unforeseen make 
obstetrics one of the most demanding 
fields of practice. In spite of increas- 
ing numbers of controlled deliveries, 
we will always have to plan on having 
a team in readiness 24 hours a day, 
seven days a week, holidays or not. 
All administrative and business per- 
sonnel entrusted with the allocation of 
staff to labor and delivery rooms 
should be required to spend an unin- 
terrupted period of several weeks or 
months on the obstetrical service so 
that they may see at first hand the 
importance of having a full team! 

No one would be so short-sighted 
as to criticize personnel administra- 
tors for keeping a complete team of 
firemen in readiness 24 hours a day, 
7 days a week, whether or not a fire 
is anticipated. No one criticizes the 
firemen for reading, watching tele- 
vision, listening to the radio, or taking 
a nap during the long waiting periods. 
When the alarm rings, everyone is on 
his feet. Their holidays and vacations 
are planned so that the team is always 
at full strength at anytime of the year. 
This is accomplished by extending 
vacation periods over the full year 

instead of the summer only, and in 
addition, a reserve force fills in vacan- 
cies occurring from vacations, statu- 
tory holidays, and illness. 

Why not follow the example of the 
firemen and establish a similar sys- 
tem within the hospital, at least for 
emergency services? A central team 
of reserve nurses and nursing aides 
could be employed to fill in for va- 
cations or holidays in various hos- 
pitals as the need arises. The objec- 
tion will be raised that there is a 
shortage of nurses. Undoubtedly this 
is true, but spreading vacations over 
a longer period of time in the year, and 
predetermining working days and holi- 
days for each employee in advance 
would reduce the shortage during July 
and August and over statutory holi- 

Another objection will be the diffi- 
culty of establishing and maintaining 
this reserve team. Perhaps it could be 
composed of volimteers or of affiliat- 
ing nurses or of new graduates begin- 
ning their careers with experience as 
replacement staff in various hospitals. 
In setting up and maintaining such a 
team, there should be, first of all, 
an assessment of what is need- 
ed. Who is better qualified to do this 
than the doctor? He is ultimately re- 
sponsible for the patient's well being. 
Strangely enough, he is the one person 
who is not consulted. 

By definition, a hospital is a place 
where the sick — be they private or 
public patients — are cared for, with- 
out thought of financial gain. Who is 
responsible for their care? The doctor, 
assisted by nurses and other medical 
and paramedical staff. A poor business 
man. in spite of what the public thinks, 
the doctor continues to rely on lay and 
religious bodies in regard to the finan- 
cial aspects of hospital function. This 
gives rise to a paradoxical state of af- 
fairs. Instead of being under the con- 
trol of its medical personnel, the hos- 
pital is. first of all, the concern of busi- 
ness administration. It is not the doc- 
tor — the chief of a service — who looks 
after the recruitment of a team of 
nurses or nursing aides, according to 
the needs as he knows them. Business 
administration, through its personnel 
office, assumes this responsibility and 
decides what is needed. In the same 
way, the admitting office grants or 
denies hospitalization. 

Finance plays an important part in 
the life of a hospital but money mak- 
ing is not its primary objective. If 
this were so, it would appear that the 
haste to bring about socialized medi- 
cine arises, not from a desire to im- 
prove the health of the population gen- 
erally but from the intent to exploit a 
profitable enterprise. 




Prenatal Care 

One of the main reasons for the decrease in maternal and fetal mortality is better antenatal care 

C. NUCCI, M.D., F.A.C.O.G. 

In Canada, the maternal mortality 
rate has fallen from 50.1 per 10,000 
live births in 1931 to 5.6 in 1958. 
This rate varies from a low of 3.8 in 
one province to a high of 9.4 in an- 
other, the difference being related to 
environmental factors rather than 
those of color or racial background. 
Where the quality of medical care is 
the same, there is little difference in 
the mortality rate. 

The importance of an early first 
visit to the physician's office, two or 
three weeks after the missed period, 
must be stressed by health workers. A 
program, aimed toward a safe and un- 
complicated delivery for both mother 
and fetus, can then be initiated. Ante- 
natal care, although directly concerned 
with the basic requirements of the 
present pregnancy, is varied and broad 
in scope. It affords the physician the 
opportunity to practise preventive 
medicine in the interests of a patient 
— usually in the younger age group — 
who may not have seen a doctor since 
her last childhood disease of measles 
or mumps. 

The first visit to the physician is the 
most important one. At this time, a 
complete history should be taken and 
a thorough physical examination car- 
ried out — including a vaginal exami- 
nation with cytological studies for can- 
cer detection. The usual laboratory 
tests and an x-ray of the chest are or- 
dered and the education of the patient 
for a completely safe and happy del- 
ivery begins. 

The history gives the doctor inform- 
ation regarding possible coincidental 
illnesses which are themselves impor- 
tant and which may have a definite in- 
fluence on the outcome of the preg- 

Dr. Nucci is on the staff of St. Mary's 
Hospital, Montreal, Quebec. 

nancy. Careful questioning should be 
carried out regarding the possibility of 
rheumatic fever or heart disease, kid- 
ney disease, diabetes, allergies, vene- 
real disease, respiratory disorders, thy- 
roid or adrenal gland disorders, as 
well as nervous or psychiatric disor- 
ders. The physician should determine 
whether or not blood transfusions have 
been administered in the past. Previous 
obstetrical history is, of course, of ut- 
most importance and should be care- 
fully taken. From the menstrual his- 
tory, the expected date of delivery is 
calculated and it is wise to warn the 
patient that she may well go 10 days 
or more past this date. Some women 
become unnecessarily concerned when 
they go past their expected date of 
confinement and make their lives mis- 
erable — not to mention the pressures 
which they bring to bear on the obste- 

A thorough physical examination is 
essential to detect and correct any ab- 
normality early. The breasts are exa- 
mined for signs of early cancer; a com- 
plete pelvic examination, mandatory 
for all these patients, is carried out. It 
is amazing how poorly educated most 
women are concerning this essential 
part of good antenatal care. Unfor- 
tunately, some physicians, for reasons 
which are not at all scientific, defer or 
do not perform a pelvic examination; 
and, through ignorance, some women 
feel that this omission is unimportant. 
This simple examination of the pelvic 
organs gives invaluable information re- 
garding possible complications that 
may occur both early in the first three 
months of pregnancy and later in the 
third trimester. Adnexal masses may 
be detected as well as an ectopic preg- 
nancy which is as yet unruptured. The 
examination also gives information as 
to the progress of the pregnancy and 

serves as a baseline for future refer- 
ence. At this time, a smear is taken 
for cytological examination to detect 
any early cellular changes that might 
alert the physician to the possibility of 
a future development of carcinoma of 
the cervix. Although most of these 
smears come back negative because of 
the young age of most patients, a pos- 
sitive one is occasionnally detected. 
However, the important factor is that 
the patient can be taught the value 
of a yearly cytological cervical 
smear. She may get into a habit of 
yearly check-ups that may one day 
prolong her life. 

A pelvic evaluation is carefully made 
to discover any bony structural abnor- 
mality that might impair normal deh- 
very. A rectal examination is also done 
routinely. The usual laboratory exami- 
nations consist of a hemoglobin and 
hematocrit — repeated at 24, 32 and 
36 weeks — as well as blood typing. 
Rh, serology and a chest x-ray. Em- 
phasis is placed on oral hygiene and 
the patient is advised to see a dentist 
as part of her check-up. 

Psychological and emotional sup- 
port which are essential to the patient's 
well-being are provided. The physician 
will save himself and his patient many 
anxieties if he takes the time and trou- 
ble to attain her confidence and trust. 
She should feel that the physician has 
the well-being of both herself and her 
baby foremost in his mind; she should 
feel free to discuss any problem with 
him. A program of education begins 
during this initial visit and is gradually 
increased at each future visit. 

Throughout her pregnancy, the pa- 
tient must maintain optimal physical 
fitness for herself and the baby. The 
need for proper nutritional balance is 
explained to her and the necessity to 
keep weight gain between 15-20 pounds 


JANUARY 196.5 


is emphasized. She is given an iron- 
vitamin-calcium preparation and her 
energy requirements plus body weight 
and stature will dictate her dietary 
needs; frequently, salt intake is re- 
stricted to help prevent the develop- 
ment of toxemia. The patient's behav- 
ior with regard to weight gain and pre- 
vention of toxemia will bear a direct 
relationship to the enthusiasm and in- 
terest of her physician. We do not 
hesitate to bring patients back for 
weekly visits — even early in their 
pregnancy — if we see that they have 
a tendency to gain excessive weight. 
The best way to treat toxemia is to 
prevent it; and prevention should be- 
gin at the first sign of excessive weight 
gain rather than when hypertension or 
proteinuria develops. The patient need 
not be placed on a special diet, but a 
list of foods to be eaten and foods to 
be avoided is provided. Meats, fruits, 
vegetables, cheese, eggs, juices and 
milk are recommended; starchy, high- 
carbohydrate and high salt-content 
foods should be restricted. 

The patient is encouraged to view 

pregnancy as a normal physiological 
state and to lead a normal, healthy 
life. Unfortunately, relatives and friends 
seem to delight in making her an in- 
valid and in filling her with exaggerated 
fears and anxieties about labor and 
pregnancy. The doctor must convince 
the patient that these fears are un- 
founded; he should inspire such con- 
fidence that the patient will seek his 
advice on matters troublesome to her, 
rather than rely on the poor and wrong 
advice of friends and neighbors. The 
doctor builds this confidence with each 
visit and allows time to answer the 
many questions about what she can do 
and cannot do. He should anticipate 
many of the usual questions and answer 
them before they are even asked. The 
patient is given one of the many ex- 
cellent manuals on pregnancy, mother 
and child. 

All primigravidas and most parous 
patients are advised to follow some 
educational program for psychophysi- 
cal training in preparation for child- 
birth. Such a program is of value since 
it gives the young pregnant woman 

contact with women in a similar situa- 
tion; it also helps to prepare her for 

During the last two months, the pa- 
tient and doctor discuss the mode 
of delivery. Various methods of anes- 
thesia, both general and local, are out- 
lined; the patient chooses the one which 
appeals to her. The doctor explains 
that he reserves the right to modify 
this aspect of the delivery should he 
deem it necessary. The patient is told 
what she is to expect when she comes 
into the labor room and what sedation 
she will be given. It is important to 
explain how labor will begin and what 
she is to do if she bleeds, or if her 
membranes rupture. She must feel free 
to call and discuss any problem or fear 
about the initiation of her labor. If she 
feels the concern and interest of her 
doctor she will be much more relaxed 
throughout labor and delivery. 

With proper guidance, preparation 
and enthusiasm during the antenatal 
course, labor and delivery can be a 
most gratifying and rewarding experi- 
ence for the patient. 


The hirth process is a progression from 
intrauterine dependence toward physiolo- 
gical independence. The most profound ad- 
justment to be made by the normal new- 
born is the establishment and maintenance 
of pulmonary respiration. The accompanying 
cardiovascular changes initiated are also 

The .Apgar rating system, developed by 
Dr. Virginia Apgar. professor of anesthesio- 
logy. Columbia University. New York, is a 
means of evaluating the ability of the new- 
born to establish and maintain respiration at 
the all-important moment 60 seconds fol- 
lowing birth. 

The rating is based on five observable 
signs requiring critical appraisal by the at- 
tendants. These are heart rate, respiratory 
effort, muscle tone, reflex irritability and 
color. A score of zero, one or two is given 
for each sign according to the condition 
as indicated on the chart. 

A score of eight, nine or ten indicates 
that the baby is in good condition; a score 
of seven or less indicates a slate of asphyxia 
neonatorum, i.e.. there is an absence of 
established breathing, with or without car- 
diac failure. This immediately alerts the 

Copies of larne charts for coserooms and 
films on resuscitative measures are avail- 
able from Smith. Kline and French Labo- 
ratories, 300 Laiirentian Blvd.. Montreal 9, 

delivery room staff of the impending dan- 
ger; resuscitative measures compatable with 
the condition are initiated immediately. 

The perinatal death rate remains high and 
one of the two most common causes is 
asphyxia. Use of tools such as the Apgar 
rating chart can help reduce neonatal mor- 
tality. However, a tool is only as good as 
those who use it. Nurses must; 

1. Be able to recognize the signs of 

impeding danger to the newborn during 

the birth process and immediately after; 

2. be familiar with the resuscitative 
measures and tools and see that they are 
kept in good working order; 

3. realize the importance of immediate 
and continuing observation in the nursing 
care of the newborn and of maintaining 
pulmonary respiration once it has been 
established. — H. M. Evans, obstetrical 

clinical instructor. Royal Columbian Hos- 
pital. New Westminster. B.C. 






(Below IDO) 

Over 100 










Some Flexion 
of Bxtreinities 





No Response 






Body Pink, 
Extremities Blue 



JANUARY 196.5 



A discussion of the importance of assisting the patient in labor. 

Shirley M. Cameron 

Obstetrics is probably one of the 
most talked about subjects outside the 
hospital. This business of having babies 
is discussed on buses, at luncheons and 
at bridge parties. Partly as a result of 
these discussions, many women come 
to hospital with bizarre ideas of labor 
and are fearful of what is going to hap- 
pen to them. Multiparous patients may 
have had a previous labor experience 
that has left them with some unhappy 
memories; and many women today ex- 
perience added misgivings because of 
a language barrier. 

Many of us have the feeling that 
we are not really nursing unless we 
are doing something physical for the 
patient. Actually, there are not too 
many physical procedures that one can 
do for the patient in labor. True, some 
appreciate having their back rubbed or 
their face and hands washed, but many 
do not want this kind of care when 
they are under stress. 

Are there "good" and "bad" labor 
patients? Who knows how much pain 
a person has or how high or low her 
pain tolerance is? But then, this is not 
really the nurse's problem. She is there 
to help each patient with her individual 
need, and to accept her behavior under 
stress without signs of censorship. 
There are many things to consider in 
caring for the person as an individual. 
Many women come to hospital after a 
week of false labor at home; they have 
been awake each night for several 
hours wondering if they should go to 
the hospital; during the day, they may 
have the responsibility of several small 
children. These women come to us 

Miss Cameron is head nurse in the del- 
ivery room, Victoria Hospital, London, Ont. 
She presented this paper at a refresher 
course in obstetrical nursing held at the 
University of Western Ontario, London. 

tired, emotionally as well as physically; 
they are not as capable of tolerating 
a long labor as someone who is rested. 

The initial greeting of the patient can 
and should lay the foundation for good 
supportive care. Imagine the added 
feeling of insecurity the patient has if 
she overhears the nurse groan, "Not 
another one." How much better for the 
nurse to greet her pleasantiy and show 
genuine interest in her. 

Most patients are admitted to hos- 
pital during the early part of the first 
stage of lai)or. Unless contraindicated 
they should be encouraged to be am- 
bulatory; to visit with their husbands; 
play cards, or read — anything to keep 
them from clock-watching, wondering 
why the last contraction was two min- 
utes late. In countries where women 
are prepared for "home delivery," 
much unnecessary tension is eliminated 
during these early stages. These women 
remain in their own homes and can 
prepare the meal for their family or 
clean the kitchen cupboards if they 

This early stage of labor is also the 
time when the nurse can do her most 
effective teaching. Many nurses feel 
that a multipara does not need to be 
taught. True, she does not need to be 
taught what to expect during labor; 
and if you attempt to do this she may 
look at you sweetly and say — "How 
many babies have you had?" She may, 
however, need to learn how to breathe 
correctly and how to relax. Relax is a 
hospital word and patients need to be 
taught its meaning. The nurse should 
realize that not all primigravida receive 
the same instruction. Many have had 
some teaching, possibly from the Vic- 
torian Order of Nurses or from some 
other health agency. The labor room 
nurse can confuse them by using a new 
or different term. So it is advisable to 

encourage these women to practise the 
type of breathing they were taught, 
rather than to attempt too much new 
teaching. Many young women have 
had no teaching and will benefit from 
the nurse's preview of the signs of 
progress to be expected. 

During the early part of labor, the 
patient may wish to have time to visit 
with her husband alone; but as her la- 
bor progresses, both she and her hus- 
band are reassured to see the nurse 
frequently and for longer periods of 

Although each individual has a right 
to know what is happening to her, the 
nurse should use discretion as to what 
information is given. The well-known 
question that is frequently asked by 
patients and their husbands is "how 
much longer"? The wise nurse does not 
predict because she does not know. If 
she does predict and the labor con- 
tinues past the predicted time, the pa- 
tient may become discouraged and 
possibly apprehensive, feeling certain 
that something is wrong. 

Many women who have taken pre- 
natal courses are interested in knowing 
about the dilatation of their cervix. 
This is their means of measuring pro- 
gress. If a patient insists on this in- 
formation, she should be told; but she 
should also be told about the possibility 
of error and the possibility of discour- 
agement due to slow progress. After 
having experienced three hours of hard 
labor contractions, the patient's cervix 
may still show insignificant change. She 
would be more encouraged if the nurse 
told her that the presenting part had 
come down a little and that the cervix 
was softer and thinner — both im- 
portant signs of progress. The nurse 
may be unaware that the last person 
who examined the patient told her the 
cervix was two fingers dilated; and 




now. after all these hard contractions, 
she tells her it is one and one-half fing- 
ers dilated. This, of course, is ver\ 

Some doctors do not tell their pa- 
tients that the baby is a breech pre- 
sentation because of the added ap- 
prehension it may cause. In such a 
case, the nurse must be careful not to 
give this information. The patient's 
questions should be answered intel- 
ligently and explanations should be 
given in words that help both her and 
her husband to feel informed and en- 
couraged. One of the main sources of 
discouragement seems to be the care- 
less handling of information by the 

Once the patient has been given 
sedation, there should be no more un- 
necessary conversation; she should be 
encouraged to rest between contrac- 
tions to get the maximum effect of the 
drug. The expected effect of the drug 
should be explained to her. otherwise 
she may fight the resultant drowsiness 
for fear of slowing the labor process. At 
this time, the nurse can quietly encour- 
age her to practise what she has been 
taught — slow, even breathing and the 
loosening of all muscles. 

It sometimes is necessary to en- 
courage nurses to spend more time 
with the labor patient. Their seeming 
reluctance may be due to fear of the 
patient in labor because of their own 
inexperience. To sit with the patient 
during her labor, to get to know her 
and to be able to help her through 
what otherwise might be a terrifying 
event can be a very rewarding experi- 
ence. Can I hear you saying "that's 
fine but we don't have time to sit with 
our labor patients"? Time does seem 
to be our enemy; but even when 
we do have the time do we use it 
wisely? I asked earlier whether there 
are good and bad labor patients. Per- 
haps we should ask ourselves the ques- 
tion "are there good and bad labor 
room nurses'"? 

Have you ever heard nurses dis- 
cus.sed by patients? Have you ever 
heard them say "I told that nurse I 
was ready." Do you listen to your pa- 
tients? You may be amazed how much 
they know about their own progress. 
Many nurses place too much emphasis 
on the dilatation of the cervix. This 
is important, but other signs of pro- 
gress should be considered; often the 
"feehng" of the patient and the intui- 
tion of the nurse are factors to heed. 
The picture changes when we think 
of supportive care in the second and 
third stages of labor. The nurse no 
longer has a choice of whether or not 
she will be with the patient. She finds 
that once the second stage has begun, 
the delivery is usually imminent. 


Before we discuss the actual delivery, 
let us consider Mrs. Brown in labor 
room 5. She has just rung her bell. 
The nurse answers and finds that the 
patient's membranes have ruptured and 
she is now "pushing." Imagine the fear 
she experiences as she sees the nurse 
turn again to the door and leave her 
alone! It is true that the nurse has to 
call the doctor, inform the charge nurse 
and make various arrangements. But 
how much better it would be if she 
rang the bell, got some one else to 
come and stayed with her patient! 

An inexperienced nurse who is un- 
able to examine the patient should not 
leave her alone if she is in active labor 
and her membranes are ruptured. 

At this point, some patients may 
quickly enter the second stage of labor. 
The nurse's main duty will be to give 
supportive care to the mother and to 
get the baby up out of the amniotic 
fluid. We all know that a "good" labor 
room nurse dislikes to have the mother 
deliver the baby in bed; but when the 
situation is unavoidable, her manage- 
ment is what counts. This may be the 
first time the patient has had a baby 
without benefit of anesthesia; and when 
the delivery is over she will probably 
be quite pleased with herself. The 
nurse can add to her pleasure by of- 
fering congratulations. 

Some nurses feel that if a patient 
who is in active labor vomits, she is 
entering her second stage of labor. 
This is not necessarily true as some 
women vomit when the contractions 
become harder. The nurse needs to as- 
sure these patients that it is normal to 
vomit at some time during their labor. 
If no explanation is given, they feel 
they must really be sick. Nurses have 

traditionally been taught not to put an 
cmesis basin where the patient can see 
it because it will encourage her to 
vomit. I do not think this is true with 
patients in labor since many experience 
no nausea, just a hard contraction and 
emesis. The husbands, of course, are 
often the ones to find themselves with 
the patient in this frustrating situation 
and many rather unsuitable containers 
are used. How is he to know that we 
keep the emesis basin in a brown bag 
on the bathroom shelf? This could be 
easily corrected by the nurse quietly, 
with no announcement, putting the 
basin near at hand during the admis- 
sion procedure. 

Continuity of patient care should 
be practised. The time of delivery is 
a much less fearful event if the nurse 
known to the patient accompanies her. 
It is also a satisfying experience for 
the nurse, as she is able to continue to 
support the patient and to share with 
her the joy that comes with the birth 
of her baby. 

With the patient's arrival in the del- 
ivery room, the nurse has a few im- 
mediate demands on her time: open- 
ing bundles; tying gowns; washing the 
patient for delivery, etc. She should 
always explain procedures to the pa- 
tient. It is essential to point out that 
her hands are fastened to her side as 
a reminder so that she will not put 
them on the sterile drapes. Otherwise, 
she probably envisions the delivery as 
being such a violent procedure that 
she has to be literally "tied down." 

The nurse must know when the pa- 
tient has a contraction. Each delivery 
varies and. of course, there is also 
variation in the types of anesthetics 
used. In some hospitals, epidural anes- 

JANUARY 1965 27 

thesia is in common use; if the nurse 
is not able to determine contractions 
with her fingers, she will not know 
when to have the patient push. Also, 
many patients become visibly excited 
just by being transferred to the deUvery 
room; they often push when they 
should not and won't push when they 
should. If the presenting part is well 
down, the patient may have a feeling 
of constant pressure and desire to bear 
down. The nurse is able to help all 
these patients by telling them when 
the contraction is starting, how many 
breaths to take, when to push and 
when to relax. 

If the doctor is waiting for the pa- 
tient to bring the presenting part lower, 
it is the nurse's responsibility to note 
the fetal heart rate frequently. The 
doctor will not sit and wait if he 
knows the fetal heart rate is 60, and 
he does not know unless the nurse 
listens. The nurse should give him this 
information quietly, because many wo- 
men know the normal fetal heart rate 
and may become quite apprehensive. 

Once everything is ready for del- 
ivery, the nurse's place is at the side 
of the patient where she can continue 
to give her psychological support. The 
patient may not need such extensive 
supportive care from the nurse at this 
time — because we all know how the 
patient visibly relaxes when her doctor 
arrives — but it is still pleasant for her 
to have the nurse she knows beside 
her, to hold her hand while she goes to 
sleep, or to bend over and help her 
pant as the baby's head crowns — and 
to share her joy as the doctor an- 
nounces "It's a boy!" 

The first hour following the delivery 
of baby and placenta is a critical one. 
It is at this time that the uterus can 
fill with clot and the patient can bleed 
profusely and sometimes dangerously. 
The nurse must be aware of this dan- 
ger; she should check the fundus fre- 
quently and express any clot by gentle 
massage. The patient is tender and 
may resent this frequent checking but 
a httle explanation of the necessity 
usually corrects this attitude. The nurse 
probably has other responsibilities dur- 
ing this hour: to give breast care to 
the mother, to take the babe to the 
nursery, to clean the room. etc. She 
must, however, realize the importance 
of checking the fundus frequently dur- 
ing this first hour. She cannot afford 
to wait until the hour is over and then 
be surprised that the fundus is above 
umbilical level and a hidden postpar- 
tum hemorrhage has been in progress. 
A patient who has had a general anes- 
thetic is not left alone for any reason 
until she is completely conscious. 

The period following the delivery 
is often a pleasant time. The mother 
is happy because they wanted another 
boy — and he is big and healthy and 
even resembles little Johnny, at home. 
Here, the nurse's role is a simple one, 
she just has to listen, smile, and en- 
courage the mother to talk about her 
family and their plans. 

The individualized care given to the 
patient during labor should continue as 
long as she remains in hospital. 

Besides giving good physical care 
to the patient, the ward nurse can do 
much to reassure her. Often, the pa- 
tient worries because her breasts are 

sore; she has afterpains; she has loose 
abdominal muscles; her bowels are not 
functioning normally. The nurse may 
feel that her own hfe consists only of 
listening to minor complaints — breasts, 
bowels and stitches. But she needs to 
remember that those problems do not 
always seem minor to the patient; her 
attention may do much to relieve the 
patient's concerns. This same patient 
not only worries about herself, but also 
about her baby. Does she, or will she 
have enough milk? What are those fun- 
ny white spots on baby's nose? Why 
does she need help to start her baby 
nursing? The nursery nurse can do 
much to answer her questions and allay 
her fears. 

Finally, the long-looked-for day has 
arrived when the patient and her baby 
are going home. For a woman with her 
first baby this can be a very frighten- 
ing, as well as exciting, period. For 
the first time the entire responsibility 
of this little bundle is her's. When the 
community nurse calls in the morning 
to help her bathe the babe, mother is 
weak with rehef and full of questions. 
Her baby only slept for three-hour 
periods; he had two loose yellow stools; 
— is this normal? The baby seemed 
restless, did he get enough to eat? How 
will she know if she has enough milk? 
And so we find that the nurse in the 
community continues with the sup- 
portive care to help the mother adjust 
to her new role. 

The friendly, helpful, interested at- 
titude of the labor room nurse, the 
floor nurse, the nursery nurse and the 
coimnunity nurse should all blend to 
leave happy memories for the patient. 


Childbirth, although it occurs every day 
and is, therefore, not at all unusual, is one 
of the most important and significant ex- 
periences that a woman will have in her life. 
For a married woman it is probably an ex- 
perience that she has been looking forward 
to — albeit with some apprehension. In 
this way it is comparable and takes only 
second place to her wedding ceremony and 
the honeymoon itself. It therefore becomes 
the pleasure and duty of the physician and 
nurse to help her to remember this experi- 
ence with pleasure and contentment — in 
lieu of nightmare. One of the most chal- 
lenging and successful possibiHties toward 
this end is hypnotism. For this reason — and 
being a nurse and expectant mother — I 
decided to investigate, through personal ex- 
perience, the possibilities of hypnosis. 

Almost any expectant mother who believes 
in the success of hypnotism and whose doc- 
tor also believes in its use and is able to 
hypnotize her, can deliver her baby in this 

There are certain advantages of hypnosis 
over other forms of anesthesia: it is unneces- 
sary to administer an analgesic to the mo- 
ther; it is comparatively free of risk; it is 
unaccompanied by nausea and vomiting; it 
is rarely followed by fatigue or postpartum 

The patient should be well rested and 
relaxed since her powers of concentration 
must be alert. A tranquil atmosphere and 
soft music are desirable and conducive to 
relaxation. The delivery room should be 
prepared in advance so that the patient is 
disturbed as little as possible. 

Immediately postpartum, the patient 
should be observed closely for any signs 
of hemorrhage — although there is less 
risk of severe bleeding following hypnosis 
than with other types of anesthesia. Her 
mind should be kept active since she may 
return to a "trance-like" state. Generally, 
she is able to sit up in bed, is free from 
nausea and fatigue and experiences few 
"after-pains" except in the first hour. 

Hypnosis in obstetrics ties in well with 
natural childbirth. Many doctors are in- 
terested in practising it, and nurses should 
acquaint themselves with the procedures in- 
volved. It could change the present concept 
of obstetrical nursing considerably. From a 
patient's point of view, this is a rewarding 

— B. H. McElreavy. R.N. 




Postpartum Nursing Care 

In this period, communication and cooperation between the branches of nursing 
is essential if continuity of care is to be provided. 

Sister Marie Christine 

The puerperium or postpartum 
phase of pregnancy is the period be- 
tween the end of the third stage of 
labor and complete involution and 
healing of pelvic structures. During 
this time, the new mother meets nurses 
from many branches of the profession: 
delivery room and postpartum nurses; 
Victorian Order or public health 
nurses; office or clinic nurses — often 
including those from pediatricians' of- 
fices. No matter from which field the 
nurse may come, the mother will look 
to her for support. The approach 
should, of course, be consistent. 

The complex mental, spiritual, so- 
cial, emotional and physical needs of 
each patient are met through the com- 
bined efforts of all on the nursing team. 

An understanding of these various 
needs is vital. It is important to look 
at each separately even though the 
needs are interactive one with the other 
and a solution for one may ultimately 
aid with a problem of a different na- 
ture. Take, for example, a patient with 
a family problem. Something or some- 
one helps to ease the situation. Invari- 
ably the patient's emotional and physi- 
cal well-being will improve. 

Mental or Infellectual Needs 

Maternity nursing offers a great edu- 
cative and rehabilitative challenge. A 
mother with a new baby, whether it 
be her first or tenth, is undergoing a 
new experience which will require con- 
siderable adjustment. This adjustment 
includes both acquisition of knowledge 
and development of skills. The nurses 
concerned can explain intelligently, yet 
in a simple way, the principles of all 
techniques and procedures used to pro- 
tect, ease and comfort the patient. 
These explanations will help the mo- 
ther to relax, to have confidence in her 

Sister Marie Christine is supervisor of ob- 
stetrical nursing, St. Joseph's Hospital, Lon- 
don. Ont. She gave this address at a re- 
fresher course in obstetrical nursing held at 
the University of Western Ontario. London. 

nurse, and to ask about problems that 
may be upsetting her. 

During her hospital stay, the mother 
should have an opportunity to attend 
classes that include baby bath demon- 
stration and preparation of for- 
mula. It is desirable to permit each 
new mother to bathe her baby at 
least once with supervision before her 
discharge. Although some hospitals do 
this, the majority seem to have prob- 
lems with shortage of staff. 

Informal discussion groups should be 
organized and instructive books and 
pamphlets should be readily available. 
Pamphlets published by both federal 
and provincial departments of health 
may be obtained through the local 
pubhc health agency and make in- 
teresting reading for both parents. In 
some hospitals, the father is encour- 
aged to attend demonstration classes 
with his wife. 

While still in hospital, the mother 
should be interviewed by the V.O.N. 
or pubhc health nurse. This nurse will 
then be aware of the new mother's 
problems. Obviously, communications 
must be excellent between the hospital 
and the visiting nurses. 

The office or clinic nurse will need 
to assume the teaching duties and 
should be aware of what is being car- 
ried on in the hospital and agency 

In attempting to meet the mental 
needs of the patient: 

the personality of the parents, their so- 
cial and cultural backgrounds and traditions, 
their Hfe experience — all these must be 
taken into consideration in teaching parents 
about care of their infant. TTie simplicity 
of the job should receive greater emphasis. 
Every effort should be made to avoid being 
either too technical or too authoritative.* 

Spiritual Needs 

Respect for the patient's beliefs make 

* E. McKerlie and L. Einarson. "The Psy- 
chological Impact of and on the the New 
Arrival," The Canadian Nurse. Vol. ."^O. 
April 1954. p. 262-4. 

it possible for her to practise her reli- 
gion while hospitalized. Clergymen 
should be permitted in the maternity 
unit since they are a source of much 
consolation and joy to the new mother. 
The importance of the administration 
of Baptism to the dying infant must 
not be forgotten. Mothers of many 
faiths find solace in this sacrament. 

Social Needs 

The social needs of the new mother 
most often concern her relationships 
with her immediate family. Some can 
be met with encouragement and a 
sympathetic ear; others can only be 
met by a skilled social worker. In 
either case, the nurse's awareness of 
the needs and her readiness to find 
assistance is vital. Patients have many 
home problems that they try to hide; 
if more nurses were aware of these 
problems perhaps they would not in- 
sist obstetrics is the "happiest service." 

Emotional Needs 

Certain attitudes are common to 
most expectant mothers; that is, a nor- 
mal psychology of pregnancy exists. Af- 
ter the new arrival, change and adjust- 
ment will be necessary. 

Following delivery, the mother's im- 
mediate concern is for the baby and 
his normalcy. Both the doctor and 
the nurse must reassure the patient. 
She should be permitted to see and 
hold her baby if at all possible. 

Later, the mother may have mood 
swings. First elation may be followed 
by a let-down feeling. This may be 
due to both physical and emotional 
factors. Sometimes she is disappointed 
and guilty because she views herself 
as lacking maternal feeHngs. During 
pregnancy, she identified the baby as 
a part of herself; the ending of preg- 
nancy is experienced as a loss of self. 
Often she feels grief at this loss and 
looks on the baby as a stranger. Lack 
of understanding by the nurse may 
aggravate this guilt. When a mother 
turns away from an appealing infant, 
a nurse may experience anger, but she 




must hide it. Maternal feelings are of- 
ten not full-blown at the time of deliv- 
ery but develop as the mother cares 
for her infant. 

Rooming-in may help the mother 
become accustomed to the baby's re- 
actions and routines. Love for her 
baby will grow as she cuddles and 
cares for him. When rooming-in is not 
available the mother and baby should 
be together as often as possible to 
strengthen the relationship. 

Physical Needs 

These are not as nebulous as the 
other needs and are, therefore, gen- 
erally easier to meet. The nurse knows 
that the fundus is a firm contracted 
mass; that the amount of flow is not 
excessive; that the blood pressure re- 
mains within the normal range; that 
the pulse rate is satisfactory. She is 
thus aware of the first signs of post- 
partum hemorrhage. She takes special 
precautions in the care of the peri- 
neum, knowing that a break in tech- 
nique could lead to infection. Through- 
out the postpartum period, the nursing 
team is aware of the two major com- 
plications — hemorrhage and infec- 
tion. Again, communication between 
team members must be established and 
any complication of mother or baby 
must be reported promptly. 

Elaborate procedures, so popular 
10 or 15 years ago, have been simpli- 
fied. The simpler a procedure, the bet- 
ter and more consistent the technique 
will be. 

Early ambulation in the postpartum 

period has modified many procedures, 
but should not be used as an excuse to 
stop procedures! 

The nurse must recognize that the newly- 
delivered mother going to the bathroom 
for the first and second time represents 
more than an opportunity to make an un- 
occupied bed. She needs assistance, teaching 
and someone to stay with her. The fact that 
a mother is able to take a shower does not 
mean that she can be almost ignored. Her 
daily progress must be noted; she must be 
taught and supervised. As she learns the 
happy combination of sitting, walking, or 
lying in bed, the purposes of early ambula- 
tion are accomplished.** 

In some hospitals, perineal and 
breast care are taught to the patient in 
the first 24 hours; thereafter, the pa- 
tient is responsible for this care her- 

In other units, perineal care is given 
once a day, or more often if indicated 
by the nurse who observes the lochia, 
suture line, hemorrhoids, and the height 
and firmness of the fundus. The patient 
is taught to give herself perineal care 
when she goes to the bathroom or 
changes the perineal pad. The teaching 
of perineal care includes good tech- 
nique, proper method of applying pad, 
and the necessity of thorough hand 
washing. Breast care is also given to 
the nursing mothers; fissures and cracks 
are noted and treatment is commenced. 

Care routinely given during the puer- 

** J. F. DeClue. "Early Ambulation in a 
Postpartum Unit," American Journal of 
Niirsin!;. Vol. 54, 1954, p. 295-6. 

perium includes sitz baths, perineal 
lamps. Tucks and sprays for the sore 
perineum and painful hemorrhoids; ice 
bags and binders for engorged breasts; 
analgesics, as ordered, for after pains. 

Visiting, clinic or office nurses con- 
tinue to meet the mother's physical 
needs after discharge. They assist her 
to follow the doctor's instructions. In 
the hospital and later at home, nurses 
play a vital part in directing the course 
of the mother's convalescence. Prob- 
lems arise, and mothers need guidance, 
encouragement and an understanding 
ear. Sometimes the active woman will 
not allow herself time to regain her 
strength and the nurse must persuade 
her to begin her activities gradually; 
other women prolong the sheltered 
stage — perhaps because of fear of 
responsibility — and the nurse helps 
her to develop confidence in her ability. 

Nurses can help or hinder the de- 
velopment of the maternal instinct by 
their care in this postpartum period. 
Future parent-child relationships de- 
pend upon the understanding and sup- 
port that nurses give the mother as she 
becomes accustomed to her new baby. 


Jarrett. Armentia Tripp. "Interviewing Pa- 
tients — An Opportunity for Learning." 
American Journal of Nursini;, 52:833, 
July 1952. 

Robertson, Esther J. "Mental Health and 
Maternity Care." Canadian Nurse, 56: 
219-23, March 1960. 

Strauss. Barbara. "Mental Hygiene in Preg- 
nancy." A.J.N., 56: 314, March 1956. 


During the past year, Canada became 
the 32nd country to be represented in the 
International Planned Parenthood Federation 
— the last major world power (apart from 
China and the Soviet Union) to join the 
I.P.P.F. This event was significant for two 
reasons. First, the long delay in Canada's 
being accepted into the international family 
planning group reflected the confusion which 
surrounds the whole subject of planned 
parenthood in Canada and, second, the ad- 
mission of a Canadian family planning fed- 
eration signified the first faint stirrings of a 
family planning movement in Canada which 
holds promise of national interest and sup- 
port. . . . 

It is possible to detect a variety of mo- 
tives which have prompted the formation 
of birth control groups or organizations. 
One . . . has been an interest in and a 
concern about eugenics. For many years, 
the proponents of family planning included 
those who viewed contraception and steril- 

ization as means of preventing the birth 
of physically and mentally handicapped 
children. This point of view has been ex- 
pounded by scientists who are convinced 
that at least some of the knowledge gained 
by science and used in the development of 
better stock in the animal and plant worlds 
should be drawn upon in the reproduction 
of mankind. 

A second motivation was concern for 
the health of the mother, and this concern 
arose naturally among doctors, nurses and 
social workers in daily contact with women 
who had borne large numbers of children in 
rapid succession and whose health had 
suffered as a result. . . . 

A third motivation was concern for the 
welfare of the child. . . . TTiere should be a 
space between children in a family to permit 
each child to absorb the life-giving elements 
he needs and to sink firm roots into the 
family complex before a sibling arrives to 
demand his share of the available love. 

A fourth motivation has been concern 
for the stability of the family unit .... 
It stems from observation of the effects 
of economic, social, emotional and physical 
stress upon the partners in the marital rela- 
tionship and upon the family as a unit. . . . 
The effect of these stresses, many caused 
by or aggravated by the arrival of too many 
unplanned and unwanted children, is well 
known to everyone in the public health or 
welfare fields. . . . 

A fifth motivation ... is concern for 
women's rif;hts. A number of pioneering 
souls have been . . . concerned ab.ut the 
right of women to determine if and when 
they will become pregnant. . . . 

Finally, the grim facts of the world popu- 
lation explosion have given an added im- 
petus to the planned parenthood movement. 
— Ian Bain. The Development of Family 
Planning in Canada. Canadian Journal of 
Public Health, Vol. 55. No. 8, August. 1964. 
pp. 334-40. 








A report of a survey of the initial childbearing experiences of a cross-section 
of mothers in Yellowknife, N.W.T. 

Anna Pask 

In the past twenty years many chan- 
ges have taken place in the pat- 
terns of maternity care that is avail- 
able to young mothers in all parts of 
our land. In order to study the re- 
actions of mothers to the care they 
had received during and after their 
pregnancies, a questionnaire was pre- 
pared and distributed by the Nurses' 
Association of Yellowknife. No signa- 
ture was required on the replies. This 
report is a condensation of the lengthy 
analysis of the information thus ob- 

A total of 201 questionnaires were 
returned. However, three of the mo- 
thers had failed to answer any of the 
questions so the findings are based 
on the replies of 198. Of these, 19% 
related to births in the 1940's; 33% 
to births in the early 1950's; 24% to 
births between 1957 and 1963; the re- 
maining 21% did not supply any 

The analysts were strongly of the 
opinion that there is a marked cor- 
relation between basic satisfactions in 
childbearing and subsequent parental 
attitudes toward and success in child 
rearing. They recognized as well that 
there is considerable variation in the 
individual endowment of the maternal 
instinct. A small percentage of mo- 
thers have so much of this instinct that 
no matter what happens they are still 
devoted and satisfied. At the other 

Miss Pask is presently nurse-in-charge of 
nursing station at Watson Lake, Yukon, 
along the Alaska Highway. For additional 
information about the study, please write 
to her. 

extreme are those who have so little 
maternal instinct that the most favor- 
able experiences can scarcely provoke 
them into being happy mothers. Be- 
tween these two groups is a vast body 
of women whose potential for satisfy- 
ing motherhood is very vulnerable to 
extrinsic influences which can tip the 
balance one way or another. It was 
especially to the latter group that the 
considerations of the analysis were di- 

In their detailed study of the an- 
swers received, therefore, the analysts 
chosen seven crucial questions to 
which positive answers would indicate 
a favorable obstetrical experience. 
Those giving at least four positive an- 
swers were placed in the "favorable" 
group, less than four were rated as 
"unfavorable." The actual tally show- 
ed 152 favorable, 46 unfavorable. The 
questions on which this scoring was 
based related specifically to the care 
received during the prenatal, delivery 
and postpartum period. Since the ques- 
tions were grouped under these three 
periods the seven key questions were 
scattered throughout as the individual 
numbering reveals: 

3. Did you feel the medical supervision 
included adequate opportunity for your 
questions and/or worries? 

11. Did you feel well attended and sup- 
ported during the delivery? 

12. Was your husband with you (a) dur- 
ing labor? (b) during delivery? (c) imme- 
diately after with the baby? 

14. Did you feel the whole process pro- 
ceeded as anticipated, was better or worse 
than expected? 

17. Did you feel that you saw enough 
of your baby while in hospital? 

20. Did you feel sufficiently prepared to 
care for the baby at home when discharged 
from hospital? 

29. Were you aware of any marked 
emotional satisfactions in giving birth to 
and/or nourishing your firstborn? 

Space in this consideration does not 
permit the inclusion of the wide range 
of comments received to all 39 of the 
questions. However, it will be of spe- 
cial interest to nurses to consider some 
of the remarks made in coimection 
with the above questions. 

Question 3. There were 138 who report- 
ed having had adequate medical supervision 
throughout. Among the 51 who answered 
"no," such statements as: "doctor too busy," 
"doctor always in a hurry," "I was back- 
ward in asking questions and little guidance 
was offered," appeared frequently. 

Interestingly, a following question 
revealed that an astonishingly small 
number of mothers took advantage of 
prenatal classes in their communities, 
though these have been available for 
many years. Fourteen mothers indi- 
cated they had attended such classes, 
compared to 184 who had not. Of the 
latter group, only 12 noted that no 
classes were organized. 

Question 11. These answers are of parti- 
cular interest and value to hospital person- 
nel. It was rather reassuring to learn that 
166 of the mothers felt that they were well 
supported and attended during labor. How- 
ever, some of those who answered "no" 
were quite vehement in their accompanying 
statements: "insufficient staff." "nurses not 
interested," "too much bustling around," 
"guess I'd rather be alone anyway." 




That even one mother should re- 
call her labor with comments such as 
those would be bad enough. That 32 
did certainly indicates there are some 
gaps in our care that should be serious- 
ly considered! 

Question 12. Surprisingly, each of the 
three parts of this question drew largely 
negative answers, even part C. The actual 
tabulation of figures showed: During labor: 
yes-51; no-139; no answer-8. During deliv- 
ery: yes-7; no- 186; no answer-5. With baby: 
yes-79; no-115; no answer-4. A number of 
of the respondents noted that their hus- 
band's absence was unavoidable. One wo- 
man had lost her husband during her 
pregnancy. She noted that her mother was 
with her during labor and when she first 
held her baby. 

What are the hospital regulations 
regarding the husband's presence in 
the labor room? Is the emotional sa- 
tisfaction of the new mother of suffi- 
cient importance to stimulate greater 
concern over this aspect of the whole 
cycle among nurses? 

Question 14. Of the 122 mothers who 
replied favorably to this question, 25 felt 
that they had fared even better than they 
had expected to. However, the negative 
responses from the remainder were accom- 
panied by some bitter comments: "scared 
throughout," "had no idea what was going 
to happen," "fearful and nervous," "al- 
lowed to go too long in a hard labor," 
"nobody told me what to expect." 

Surely this points up the need, 
somehow, for more adequate prenatal 

Question 17. Here, 146 of the mothers 
stated they saw enough of their babies. On- 
ly 50 of these mothers would have liked 
to have the baby rooming-in. However, of 
the 52 who replied in the negative, 40 were 
in favor of the rooming-in pattern. 

Question 20. Readiness for discharge 
from hospital and to assume personal care 
of the infant brought out 146 positive an- 
swers though several admitted there were 
reservations • — "went to my mother's," 
"had help from friends," "with the aid of 
Dr. Spock," "didn't do any housework, 
caring for baby only." Many of the nega- 
tive responses stated they were "afraid to 
handle the infant," "too nervous and tired," 
"depressed," "no preparation," "day fine, 
night awful." 

Replies to a later question revealed 
that utilization of the local visiting 
nursing service is still a rarity among 
Canadian mothers. Experience proves 
that this form of assistance even for 
a couple of days after the young mo- 
ther returns home would make a con- 
siderable difference even to the most 

The analysts felt that the replies to 
the last of the key questions. No. 29, 
was really the heart of the whole 
questionnaire. "Were you aware of 
any marked emotional satisfactions in 
giving birth to and/or nourishing your 

Question 29. One hundred and twenty 
six said "yes." TTieir comments indicated 
their sense of fulfilment: "proud and sa- 
tisfied," "a most wonderful experience," 
"incomparable joy," "a great sense of ac- 
complishment," "pride in having some- 
thing of my own," "especially in nursing 
the baby." 

Although 22 did not reply to this ques- 
tion, among the remainder who gave a 
negative response such comments appeared 
as: "glad when the ordeal was over," "too 
tired," "too nervous," "too ill to care," "no 
real sense of accomplishment but happy 
nevertheless." One woman in particular 
commented: "So often since I have wished 
I could tell doctors and nurses what the pa- 
tient thinks is important; what she really 

Perhaps, even through this conden- 
sation of data, these 198 mothers who 
assisted the Yellowknife association 
have told us nurses some of the things 
we needed to know to be more co- 
operative, more willing to help, more 
conscientious in our care of maternity 

Finally, it may be of interest to 
readers to know how many of these 
198 mothers studied produced more 

Mothers with only one child — 32 

Mothers with two children — 61 
(2 have also adopted) 

Mothers with three children — 41 

Mothers with four or more chil- 
dren — 64 


The increasing importance of diabetes 
mellitus demands the help of nurses in track- 
ing down, treating and educating for better 
control of this disease. According to Per- 
ott's forecast, by 1980 diabetes will rank 
second among the causes of death. 

Degenerative onslaughts caused by this 
disease, such as diabetic retinitis, heart or 
kidney or cerebral complications and dis- 
ease of the arteries in the lower limbs that 
often call for amputations give a rate of 
morbidity no less than nine per 1,000 of 

In Canada, the number of known diabetics 
is 290,000, with another 300,000 persons 
suffering from this disease without knowing 
it. This number presents a challenge to 
diabetic associations, doctors and nurses. 
Early diagnosis and improved treatment of 
diabetes have caused a sensational improve- 
ment in the care of diabetics in the past 30 
years. Yet in spite of sensational discoveries 
in the field of diabetes, how can one explain 
the yearly avalanche of newly diagnosed 

Factors helping to explain this increase: 

1. The longer lifetime among the general 
population and thereby a greater opportunity 
to develop diabetes. Studies show that 80 
per cent of diabetics are over 40 years of 
age and the maximal incidence occurs be- 
tween 65 and 74 years of age. 

2. The survival of diabetic children and 
therefore their reaching the age of pro- 
creation. The heredity blemish thus handed 
down is more largely disseminated. It is 
thought that 25 per cent of all diabetics 
have diabetic antecedents. 

3. The ability of diabetic women to de- 
liver live children thanks to better control 
of diabetes in obstetrics. At present, diabetic 
associations are concentrating their efforts 
on early detection and adequate treatment 
of this disease. 

It is regrettable that nurses take little in- 
terest in the associations in which they could 
play a role of first importance. A nurse 
aware of the symptoms can be of great help 
in tracking down unknown diabetics or in 
directing those who suspect diabetes but 

will not consult a physician for fear of being 
declared diabetic. 

Many diabetics fear the diagnosis of 
diabetes and associate it with a lifetime of 
injections. The treatment of diabetes rests, 
above all, on a diet aimed at maintaining 
the ideal weight of the individual. When 
diet itself is not sufficient for control, the 
physician resorts to other helps: oral agents 
or, if necessary, insuhn. 

Because of its character and of its com- 
plications, diabetes takes on various aspects. 
Its frequency as an isolated disease or as- 
sociated with others makes it the disease 
of the future. Graduate nurses should re- 
vise their notions on the subject; student 
nurses should prepare diligently to help 
diabetics; and nursing schools have a duty 
to instruct their students about this disease 
to enable them to play fully the role that is 
theirs through their profession. — Rosario 
ROBILLARD, M.D., Sacred Heart Hospital, 
editor of Survivre, published by I'Asso- 
ciation du Diabete de la Province de Que- 




Tlie Newborn 

A review of the newborn period — a time of danger and change 

Joan Houthuesen, s.c.m. 

Infancy is generally divided into two 
periods — ■ partunate and neonate. The 
partunate comprises the first 15 to 30 
minutes of Hfe, and includes the time 
during and immediately after birth. 
The infant ceases to be a parasite and 
becomes a separate and distinct indi- 
vidual. The neonatal period consists of 
the first 30 days of life and is charac- 
terized by the making of adjustments 
essential to a life free from the protec- 
tion of the intrauterine environment. 

Physical Development at Birth 

The average newborn weighs 7.5 
pounds and has an average length of 
19.5 inches. Weight ranges from three 
to nine pounds and length from 17 to 
21 inches; male infants are generally 
slightly larger than female infants. In 
the third and subsequent births, weights 
tend to be increased. During the first 
three days, a physiological loss of four 
to eight ounces occurs; the bigger the 
baby, the larger its weight loss. This 
decrease is caused by loss of tissue 
fluid, deficient food and fluid intake, 
and passage of meconium. Usually, 
birth weight is regained by the tenth 

The newborn's head is about one- 
fourth of the entire body length; the 
adult's is about one-seventh. Great dis- 
proportion exists in the head above 
the eyes, i.e., in the cranial region. 
The ration between cranium and face 
is 8:1, while in the adult it is 1:2. The 
face appears broad and short because 
of the lack of teeth, the undeveloped 
condition of the jaws, and the flatness 
of the nose. The arms, legs and trunk 
are small in relation to the head. The 
abdominal trunk is large and bulging, 
and the shoulders are narrow (opposite 
to adult proportions). The eyes are 
are bluish gray; this color gradually 
changes to the permanent color. Al- 
though almost mature in size, the eyes 

Miss Houthuesen is currently enrolled at 
the School of Nursing, University of Ot- 

are uncontrolled and roll in a meaning- 
less fashion without relation to one 
another. Tear glands are inactive and 
no tears accompany crying. The neck 
is so short that it scarcely exists, and 
the skin covering it lies in deep folds 
or creases. A heavy growth of fine- 
textured hair often covers the head. 

The muscles are small, soft and un- 
controlled. Leg and neck muscles are 
less developed than those of the arms 
and hands. Bones are composed chiefly 
of cartilage or grisde and, consequent- 
ly, are soft and flexible. The flesh is 
firm and elastic; the skin is soft, deep 
pink, and often blotchy. A soft downy 
growth of body hair, mostly on the 
back, will soon disappear. In 1:2000 
births, an infant is born with a tooth or 
even two teeth — usually the low 
central incisors. 

Physiological Adjustments at Birth 

Breathing must be established first. 
A lack of oxygen and a corresponding- 
ly high level of carbon dioxide in the 
blood stream stimulates the respiratory 
centre in the medulla and breathing 
starts. Compression of the chest wall 
during birth, the impact of cool air on 
the face, and the handling of the limbs 
and body aid this stimulus. 

When respiration is established, cir- 
culatory changes begin. The solid lungs 
expand and increase their vascular 
field. Blood, which has been passing 
through the ductus arteriosus to the 
aorta, now flows through the pulmon- 
ary arteries to the lungs for oxygena- 
tion. Within five minutes, the ductus 
arteriosus is half closed (it ultimately 
becomes a cardiac ligament). In a very 
small number of babes the ductus ar- 
teriosus remains patent. The increased 
flow of blood to the lungs reduces pres- 
sure in the right side of the heart and 
inreases the tension in the left side, 
causing the valve-like foramen ovale 
to close. If this does not occur, the 
venous blood in the right atrium will 
mix with arterial blood in the left 
atrium. The umbilical vein lying just 

under the abdominal wall thromboses 
and occludes soon after the cord is 
tied. It eventually forms a fibrous 
cord — the ligamentum teres of the 
liver. The ductus venosus becomes the 
ligamentum venosum and helps sup- 
port the attachment of the portal vein 
to the inferior vena cava. The hypo- 
gastric arteries atrophy and form a 
ligament between the bladder and um- 

At birth, the baby is able to suck, 
swallow, digest, absorb food and de- 
fecate. Meconium, present in the in- 
testine from about the 16th week of 
intrauterine life, is the first stool. It is 
composed of bile pigment, fatty acids, 
mucus and epithelial cells and is dark 
green in color. 

Heat regulation in the newborn is 
unstable and because of a low meta- 
bolic rate, heat production is poor. 
The baby leaves an environment of 
100°F and enters one of about 70°F, 
and, being wet, loses heat by evapor- 
ation. He should, therefore, be received 
into a warm towel, dried, wrapped in 
a cotton blanket, and laid into a warm- 
ed cot. A condition in which the tem- 
perature may fall as low as 85 to 90 
degrees results from exposure to cold. 
Rectal thermometers ranging from 85 
to 105 degrees should always be used 
for the newborn to detect these low 

Passive immunity to specific infec- 
tious diseases is inherited from the mo- 
ther, but some weeks elapse before the 
baby produces active immunity to vari- 
ous organisms. Babies have least re- 
sistance to the staphylococcus aureus. 

The number of red cells necessary 
during intrauterine life is more than 
is required after birth; the extra cells 
are broken down and the hemoglobin 
stored bv the liver. The RBC is about 
6,000,000 and the hgb. about 130 
per cent at birth. 

At term, the bladder contains urine, 
which is usually expelled during par- 
turition. The kidneys do not excrete 
fluids or chlorides efficiently during the 




first weeks, and if insufficient fluid is 
given, the urine will be dark yellow in 
color ana may leave a brick-like dust 
deposit resembling blood on the nap- 

The skin is very delicate and easily 
abrased, and infection may easily oc- 
cur. Vemix caseosa, secreted by the 
sebaceous glands, covers the skin at 
birth and acts as a lubricant, protects 
the skin, and helps retain heat. 

The umbilical cord stump shrivels 
by a process of necrosis or dry gan- 
grene and separates from the healthy 
skin after approximately two weeks. 
The umbilical vein inside the abdomen 
becomes thrombosed. 

The newborn expends great energy 
through diffuse activity. This energy 
loss is about two and one-half times as 
great as in the adult when pound to 
pound comparisons are made. Also, in 
crying, the infant uses three times more 
energy than in sleeping. Not all parts 
of the infant's body are equally active. 
Observation of newborn infants dur- 
ing the first ten days of life reveals that 
the greatest amount of movement is in 
the trunk and legs, and least in the 

Specific Activities 

These are divided into two types 
— reflexes and general responses. 

Reflexes present at birth or shortly 
afterward include: pupillary; corneal; 
conjunctival; lip; retrusion tongue; 
chin; Darwinian; Achilles tendon; pat- 
ellar; triceps; biceps; abdominal; cre- 
masteric; plantar; Moro; sucking; knee 
jerk; pharyngeal; sneezing; and Bab- 
inski. Breast-fed infants develop a 
stronger sucking reflex than do in- 
fants fed by bottle. However, they also 
show a slightly poorer appetite for the 
first three days. The Babinski, Moro, 
and Darwinian reflexes appear shortly 
after birth but disappear within the first 

months of life. To test the Moro "em- 
brace" reflex, the infant is placed flat 
on his back, and the mattress is struck. 
The infant throws out his arms in an 
arc movement resembling an embrace. 
The infant's cry may indicate differ- 
ent meanings according to its pitch, in- 
tensity or continuity: 

discomfort — the cry is monotonous in 
pitch, staccato-like and int"rniittent; 

pain — • the cry rises in pitch. If pain is 
accompanied by increasing physical weak- 
ness, piercing tones give way to low moans; 

rage — - the cry is longer, the breath is 
held, the face becomes mottled or purplish. 

Babies may also cry to show hunger, 
or, occasionally, for lack of exercise. 

Observation in the Nursery 

The healthy baby has a clear pink 
skin (often mottled), firm muscles, a 
vigorous kick, and a lusty cry. He 
takes his food eagerly and has a clean 
tongue, normal stools, bright eyes, 
gains in weight and sleeps well. 

The chart should show the following 

respirations — rate and type (most im- 
portant during the first 48 hours). Normal 
rate is about 50 per minute. Flaring of 
nasal alae or indrawing of the chest wall 
should be reported. 

temperature — taken once or twice daily. 

weight — approximately same time each 

feeding time — whether three or four 
hourly or self regulated. 

breast fed or bottled fed — how taken; 
type of formula used. 

medicines — including oxygen if used. 

urine — • first voiding; record once per 
shift following. 

stools — number and character. 

cord — the day on which the cord 

eyes — inspected for discharge. 

mouth — inspected daily for thrush. 

Later Adjustments 

Prenatal environment may influence 
early adjustment of the newborn. In- 
tense and prolonged nervous or emo- 
tional disturbance of the mother during 
the last months of the pregnancy may 
cause a hyperactive state in the fetus. 
This state may persist after birth and 
manifest itself in various ways, such 
as feeding difficulties, gastrointestinal 
dysfunction, sleep problems, hyperacti- 
vity and general irritability. 

The birth process may also affect the 
baby. Difficult births produce more 
damage than easy, spontaneous births. 
This damage may not be apparent at 
once, and it may be temporary or 
permanent. Anoxia, brain or central 
nervous system damage, trauma to 
sense organs and fractures are com- 
mon in difficult delivery, as are motor 
disability, cerebral palsy and low grade 

Studies of children and adolescents 
born with the aid of instruments reveal 
more unfavorable personality charac- 
teristics than in those born spon- 
taneously. General hyperactivity, rest- 
lessness, irritability, anxiety, speech 
defects — ■ especially stuttering — and 
poor concentration have also been re- 
ported. Cesarean babies, by contrast, 
are the quietest, cry less, and make 
better adjustments to their postnatal 
environments. They do, however, ex- 
perience more difficulty in establishing 

The type of birth also affects the at- 
titude of the parent toward the new- 
bom. A baby born with a minimum 
of discomfort to the mother will arouse 
very different emotional reactions on 
the part of both parents than one 
whose birth was accompanied by a 
prolonged and difficult labor. 

Any nurse caring for the newborn 
must be aware of the normal and alert 
for any deviations. 



February 196.'^ 

M. Campbell — Identifying Nursing Problems 
V. Lindabury — Cardiac Arrest Procedure 
M. Street — A key to Nursing Service 

K. Buckland — Nursing of Children 

E. Dobbs — Behavior Interaction Study 

Sister Clare Marie — Intensive Care Unit 




Tlie Intensive Care 
Obstetrical Nursery 

Constant observation is essential in this unit 

CoLEEN J. Parsons 

More and more obstetrical units are 
finding need for larger premature in- 
fant nurseries. Increase in the number 
of premature infants plus frequent re- 
quests from obstetricians and pedia- 
tricians for admittance of full-term in- 
fants requiring intensive care, has re- 
sulted in the change of the name 
"premature nursery" to "intensive care 
obstetrical nursery." 

Admissions to this unit include: 

1. The very immature infant and ill pre- 

2. the normal, healthy premature; 

3. the full-term healthy premature (under 
five pounds eight ounces); 

4. the over five and one half pound 
premature (under 38 weeks gestation); 

5. babies delivered by cesarean section; 

6. babies of diabetic mothers; 

7. difficult deliveries and resuscitations; 

8. placental dysfunction, including post- 

9. babies with respiratory distress syn- 

10. babies with abnormalities. 

Combinations of the above frequent- 
ly occur. It is essential to assess each 
infant individually during his entire 
stay in the nursery. Infants in groups 
five, six and seven are often transferred 
to normal nurseries in 12 to 24 hours. 

Controversial and changing theories 
in the treatment and basic care of these 
infants exist as in other fields in medi- 

cine. Standard routines are set by each 
hospital and include: 

1. Administration of eye drops in delivery 
room. If argyrol or silver nitrate is used, the 
eyes should be thoroughly irrigated to pre- 
vent undesirable reactions. 

2. Cord treatment. This includes tying, 
clamping and the daily apphcation of a 
paint or alcohol. 

3. Administration of vitamin K,. One 
mg. at birth is the usual dosage. 

4. Bathing routines. These vary consider- 
ably, but generally include the use of a 
bacteriostatic agent. 

5. Feeding routines. 

Good general nursing care of these 
infants is imperative. Strong emphasis 
is placed on handwashing and the use 
of sterile equipment. Any abnormal 
discharge from an infant is cultured 
and the infant placed on isolation 
technique. The nurse must recognize 
anything abnormal quickly and report 
it to the physician since a delay in 

Miss Parsons is head nurse in the inten- 
sive care obstetrical nursery. Calgary Gen- 
eral Hospital. Alta 


t In* 



-^ t wA 






A maze oj equipmenr 

communication may mean the death 
of the infant. This apphes particularly 
to infants who develop grunty respira- 
tions with cyanosis, jaundice within 24 
hours, signs of cerebral irritation; it 
also apphes to a previously satisfactory 
"premie" who becomes lethargic or 
"just not his usual self." In the latter 
case, the infant is dangerously ill by 
the time a definite symptom occurs. 

Large hospital facilities are not al- 
ways available. Often one must im- 
provise according to the individual 
situation to the best of one's ability. All 
infants require: 

1. Maintenance of Adequate Re- 
spiration. This initially takes place in 
the delivery room and is maintained 
through suctioning, proper body ahgn- 
ment, oxygen, stimulation and resus- 
citation. Suctioning should be gentle, 
but adequate to remove aU obstructive 
mucus. Oxygen is administered in the 
amount necessary to relieve cyanosis: 
attempts at reduction and discontinua- 
tion should commence as soon as the 
condition permits. Retrolental fibro- 
plasia may occur when a high concen- 
tration of oxygen over the amount ne- 
cessary to relieve cyanosis is admin- 
istered. Frequent stimulation should be 
given only to infants termed "lazy 
breathers" who. with stimulation, ap- 
pear satisfactory. A firm, gentle, but- 
tock-to-head motion along the infant's 
spine usually produces good results. Ill 
babies, incliiding the pallid baby who is 
in shock, should be given minimum 
handling and not stimulated to cry. 




Apnea is frequently relieved by suc- 
tioning and manual stimulation. The 
latter is accomplished by placing the 
hands at the base of the scapula and 
slowly raising and lowering the chest. 
If this is unsuccessful after four at- 
tempts, the "Pulmonator" bag or re- 
suscitator should be used or mouth-to- 
mouth resuscitation commenced. Stim- 
ulant drugs are not recommended. 

2. Prevention of heat loss. Respir- 
atory acidosis may occur through heat 
loss between the time of delivery and 
admittance to an incubator; therefore, 
the transfer should be done as quick- 
ly as possible. Incubator temperatures 
vary from 80° F. for mature infants 
to 92° F. for premature infants. A 
stable environment of heat and humid- 
ity promotes stabilization of the infant's 
temperature. Thermal blankets are 
available for cot babies. If heat loss 
has occurred, a gradual increase in 
incubator temperature up to the desired 
degree is recommended. 

3. Adequate caloric intake. This is 
determined by the pediatrician. The 
trend is towards earlier feedings com- 
mencing with water or sugar solution 
from four to 24 hours, and gradually 
increasing in amount and strength de- 
pending on the infant's contentment 
and weight gain. 

The method of feeding is determined 
by the infant's desire to suck. The 
bottle nipple should be soft with holes 
large enough to produce a stream of 
milk. The softness enables the infant 
to control the rate of flow by raising 
his tongue. The infant is held in an 
upright position and the mouth open- 
ed to be sure the nipple is placed over 
the tongue. Bubbling is offered after 
each one-quarter ounce to one ounce 
depending on the need. Follow- 
ing feeding, the infant is placed on 
his side, supported by a blanket roll. 
Sides are alternated to prevent asym- 
metry of the head. If the infant is not 
able to manage the soft nipple with 
the large hole, he is placed on tube 
feedings intermittently or completely as 
indicated. Permanent gavage tubes, if 
used, are changed every five days and 

I I 




n 1 

' ■ ■< 


,<• LiJ^««_ 


Instructing the mother 

any nasal irritation reported imme- 
diately. One cc. of sterile water is 
given after each feeding to clear the 
tube. Breast milk feedings are encour- 
aged; the mother should pump her 
breasts every four hours at home and 
bring the milk to the formula room 
once a day for sterilization. Infants 
prone to regugitation are fed slowly, 
bubbled more frequently and left with 
the head of the bed elevated. If mucus 
is troublesome, a saline lavage a.c. is 
often helpful. The prevention of aspira- 
tion of feeding cannot be overempha- 
sized as a pneumonia is difficult for 
the infant to overcome. Under-feeding 
is preferable to over-feeding; if neces- 
sary, feed smaller amounts more fre- 
quendy to maintain the necessary cal- 
oric intake. Intravenous therapy, a 
frequent treatment, demands constant 
observation to prevent over-hydration. 
4. Constant supervision. An inten- 
sive care obstetrical nurse must have 

adequate knowledge and be able to 
apply it in an efficient, yet gentle way. 
Acute observation of all infants, at all 
times, is essential. She must have a 
tactful, understanding manner when 
meeting with parents and be able to 
give them a daily report and simple 
explanations of equipment and rou- 
tines that frequently alleviate unneces- 
sary concern. Religious services, such 
as baptism or prayer, should be ar- 
ranged immediately at parents' request. 
When the infant is making satisfac- 
tory progress and is soon to be dis- 
charged, the mother should commence 
feeding him daily under supervision. 
Any questions may be answered dur- 
ing these visits. 

A new father's amazed comment 
"You treat and talk to the babies like 
they were human beings!" suggests a 
popular reaction to the nursery nurse. 
But we do not mind, because we know 
that they really are! 


A successful and interesting con- 
ference was held by the Ontario Pub- 
lic Health Association in Toronto in 
October. Workers from all fields in 
public health attended, although nurs- 
ing comprised the largest section. 

Mrs. Olive David. Director of Area 
Services, Social Planning Council of 
Metropolitan Toronto, spoke on "Nur- 
ses Are Not Alone" and discussed the 
many agencies that welcome cooper- 
ation with the public health nurses. 

Dr. Muriel Uprichard. associate 
professor. University of Toronto 
School of Nursing presented a stimul- 
ating talk on "Public Health Nursing in 
Transition" stressing the challenging 
standards in public health nursing today. 




A Nursing Refresher Course 

A description of a refresher course designed to bring t/ie nurse up-to-date witfiout 

shattering her confidence. 

Sister Marie Rebecca, s.s.m. 

It is no secret that the need for 
registered professional nurses simply 
is not being met by the present ac- 
tive nursing force. Not only does nurs- 
ing meet much competition from other 
fields in recruiting girls into the pro- 
fession, but the percentage of girls 
in a given class that remain in nursing 
decreases at an alarming rate within 
the first few years after graduation. A 
desire for fuller maturity beckons to 
the young woman to depart from the 
active practice of her profession to de- 
velop her potential in marriage and 
child-bearing. For all practical pur- 
poses, the majority of these women 
are lost to nursing during the time that 
they are rearing their children. The 
multitude of demands that are made of 
a woman during these years, plus the 
"home" atmosphere which envelopes 
her if she is fulfilling her wife-mother 
role properly, tend to withdraw her 
from the feeling that she belongs on 
the patient care team. While she is 
homemaking. medicine, hospital or- 
ganization and nursing practice are 
advancing by leaps and bounds so that 
a revisit to the hospital and contact 
with active professional nurses make 
her realize how functions differ from 
those for which she was trained. 
Ten, 15. 20. 25 years may have 

Sister Marie Rebecca, formerly director 
of nursing service, St. Mary's Hospital. 
Madison, Wis., is now assistant administra- 
tor, St. Mary's Hospital, St. Louis, Mo. 
Reprinted with permission from Hospital 
Progress, Sept., 1964. 


passed since the days of her training, 
and though she still has the "heart" 
of a nurse, she has lost her confidence 
in her own ability to practise nursing 
as a professional person. Her lack of 
confidence has some basis in reality, 
and some basis in imagination: it is 
very, very true that nursing simply is 
not what it was 10 to 25 years ago. 
New concepts of a nurse's function 
have evolved due to the changes in 
medical knowledge and practice. Many 
functions formerly considered as the 
sole property of doctors have been 
delegated to nurses. The number of 
people admitted to hospitals has in- 
creased because now many conditions 
arc capable of being diagnosed and 
treated which formerly were consider- 
ed hopeless. Prepayment plans have 
enabled many persons who formerly 
were unable to bear the cost of hos- 
pitalization to take advantage of me- 
dical help. Hence, greater numbers of 
people are receiving newer types of 
treatment in hospitals that are, pro- 
portionately, less adequately staffed 
with trained professional nurses. This 
has forced a changed pattern of nurs- 
ing performance. 

Registered nurses now perform the 
more highly technical tasks. They or- 
ganize and supervise the semi-pro- 
fessional and auxiliary personnel who 
must be employed to carry on those 
functions which do not demand the 
advanced knowledge and skills of 
the professional person. Faced with 
this situation the former graduate 
tends to abandon hope for ever return- 

ing to her career as a registered nurse. 

St. Mary's Hospital (Madison), like 
many U.S. hospitals, sought to augment 
its present supply of nurses. The num- 
ber and quality of its nurse graduates 
of the past 25 years constituted an 
open and unharvested field. 

Why haven't these women returned 
to nursing? The nursing service depart- 
ment considered the question and after 
an informal survey, tentatively con- 
cluded that, even though nursing re- 
fresher courses have been and are be- 
ing conducted across the country, and 
many nonpracticing nurses have ven- 
tured out to attend them, many fre- 
quently found that after the course 
they still had their inhial fear of re- 
turning to the active practice of nurs- 

With the conviction that this 35- 
50 age bracket holds part of the an- 
swer to the shortage of professional 
nursing personnel, we (the nursing ser- 
vice department) attempted to find 
some effective means of recruiting 
these women back into active practice. 
What kind of refresher course could 
be given that would take into con- 
sideration all the factors necessary? If 
lecture, demonstration and return de- 
monstration are put in a test tube, 
what is the catalyst or unknown in- 
gredient which, when added, will in- 
duce the inactive nurse to become a 
working nurse? 

Could it be confidence? If so, what 
type of teaching techniques are need- 
ed to supply it? How can one go about 
calling forth that which can spring 



only from within the individual? How 
can you tell someone: "You can do 
it!" and have her respond affirmative- 
ly and spontaneously? 

We had some theories and decided 
to prove them. First of all we recog- 
nized the importance of giving a cer- 
tain amount of personalized attention, 
if we hoped to receive a personal re- 
sponse. We, therefore, limited the num- 
ber in the course according to our 
ability to accommodate them com- 
fortably diu-ing their practical experi- 
ence. We set the limit tentatively at 
twelve. We did not publicize the 
course; but sent individual notices to 
a limited number of nonpracticing nur- 
ses who had graduated between the 
years 1935 and 1955. We set the cour- 
ses for early Spring with the hope 
that some of these women would re- 
turn to nursing and ease the conven- 
tional summer shortage. We accepted 
women whose applications seemed to 
indicate there would be a sufficient 
amount of "salvageable" qualities pre- 
sent with which to work. We required 
a physical examination and chest x- 
ray. We also requested evidence that 
they were authentic nurses. (Current 
registration being required by the State 
Department of Nurses.) 

Since this was a pilot project, we 
thought it best not to commit our- 
selves to more than a four-week course. 
In accord with our objective of de- 
veloping confidence in the "students" 
we outlined a program which would 
provide as much support as we would 
be able to give. We delegated the pro- 
ject to the inservice coordinator who. 
besides being very capable profession- 
ally, possessed a rich talent for creat- 
ing a relaxed, comfortable, friendly 
atmosphere — to set the stage for 
learning. We emphasized every area 
where we could afford personal con- 
tacts: we scheduled only two three- 
and-a-half hour days of theory and 
three full days of assignment to a 
nursing unit with an rn "partner." 

The course content was as exten- 
sive as possible without sacrificing 
fundamentals. We used supplementary 
teaching aids: films, records, booklets, 
posters, etc. In this area, the medical 
society, the state board of health, 
pharmaceutical representatives, and 
various societies such as the Cancer, 
Heart, Polio, etc., were helpful. We 
scheduled our speakers from the spe- 
cialties a month in advance to allow 
them time to prepare pertinent ma- 
terial. We outlined the content of 
the class and then discussed with them 
their suggestions for additional topics. 
A pharmacist lectured on drugs, but 
the members of our nursing staff lec- 
tured on the majority of disease en- 
tities. We felt that our students would 

be less hesitant to post questions to a 
nurse; we also recalled several respon- 
ses during our preliminary survey: "I 
took a refresher course; it was a won- 
derful course. We were deeply appre- 
ciative to the doctors for taking out so 
much of their time, but we felt that 
their presentations were too technical 
for us; we still did not feel like we 
could go and do it." The coordinator 
of the class remained present during 
all presentations by guest lecturers to 
give a sense of unity and security to 
the group. 

Several weeks before assigning stu- 
dents to the nursing units, we discus- 
sed the plan with the supervisors and 
head nurses. We decided that to rotate 
the specialties would be too bewilder- 
ing because of the rapid advances 
which have occurred in these areas. 
The time which the class was to spend 
in the specialties was limited to a half 
day only. The majority of time was 
scheduled for the general medical-sur- 
gical units on which the students were 
assigned to a specific rn. They were 
to spend three full days each week get- 
ting first hand information "at the 
scene," and, where circumstances per- 
mitted, first hand experience. Each 
participant was exposed to team lead- 
ing with medicines and to desk work 
on the nursing units; we did not en- 
courage bath giving, etc., except where 
necessary to make the student comfort- 
able in the work situation. We attempt- 
ed, rather, to make her aware of the 
necessity of developing more organi- 
zational skills and accepting more re- 
sponsibility for semi- and nonprofes- 
sional help. We assigned each person 
to one unit principally, in order to 
avoid the frustrations of frequent chan- 
ges in surroundings. On the other 
hand, we also recognized the benefit 
which they would derive from rotation 
to the other units; and thus provided 
for a brief stint in pediatrics, obstetrics, 
psychiatry, post-anesthesia room, the 
other medical-surgical units, central 

supply, physical therapy and operat- 
ing room when requested. 

We were careful to select those rn 
"partners" who we felt would minim- 
ize the idea that present day nursing 
is difficult, even impossible. We urged 
the RNs to stress the ease of learning 
situations through patience, calmness 
and clear explanations. We also sought 
to promote a greater sense of security 
and unity by frequent at-the-scene 
visits from the coordinator. 

We developed some side situations 
as further confidence-promoting occa- 
sions: the students had morning coffee 
breaks with the coordinator; they had 
several question-answer-discussion per- 
iods weekly; if they knew any of our 
general duty nurses we arranged con- 
tact with them as much as possible; we 
gave them procedure checldists so they 
could get an over-all picture of where 
they stood in relation to the knowledge 
and technique with which every nurse 
today should be acquainted; we ar- 
ranged for a personal conference per- 
iod for each with the director of nurs- 
ing service. 

As a climax we had a short gradua- 
tion exercise at which the supervisors, 
head nurses and staff nurses who help- 
ed with the course were present. We 
gave each refresher nurse a certificate. 

It was gratifying that of the group, 
five returned to active nursing right 
away: three to our hospital and two to 
hospitals near their residence. Six 
planned to return in the Autumn after 
previous summer commitments were 
were fulfilled. Four were unable to re- 
turn at that time because of home 
responsibilities; however, they indicat- 
ed their desire to return as soon as 

Though the course originally was 
arranged for the benefit of the inactive 
nurses, every member of the group 
seemed to be unusually motivated and 
their enthusiasm served as an over-all 
refresher for all the nursing units on 
which they took their experience. 

What is the catalyst which will 
induce the inactive nurse to 
become a working nurse? 





Course Outline 

1st WEEK 


8:30 Assignment of lockers 
9:00 Welcome 
9-10:30 Introduction to program 
trend in nursing 
10:30-11:30 Tour of hospital 


8:30- 9:45 Review of systems 
9:45-10:00 Break 
10-11:30 Vital signs, diagnostic proce- 
dures, admin, procedures 

8:30-10:30 Intro, of supervisors and head 

Tour of individual units 
Unit assignment 
10:30 Movie: "Fire in Your Hos- 

*8:30- 9:00 Discussion period 

9-10:00 New Medications 

10-10:15 Break 

10:15-11:30 Administration of drugs 


7- 3:30 Unit assignment 

2:00 Movie: "Hypodermic" 

* A 1/2 hour period devoted to unit assign- 

2nd WEEK 


1- 3:30 Unit assignment 

2:00 Movie: "Community Health" 
and "No Margin for Error" 

8:30- 9:00 Discussion period 




7- 3:30 


*8:30- 9:00 



1- 3:30 


Body mechanics and related 



Oxygen therapy 

Set ups and procedures 

Unit assignment 
Movie: "Breath of Life" and 

Discussion period 
Spiritual and psychological 

Pre- and postoperative care 
Discussion of PAR and ad- 
vances in anesthesia 


Unit assignment 

3rd WEEK 

7- 3:30 Unit assignment 


8:30- 9:00 Discussion period 

9-10:00 Care of abdominal surgery 
10-10:15 Break 
10:15-11:00 Care of diabetic 
11-11:30 Nutrition review 

Movie: "Current Trends in 
Clinical Management of 

7- 3:30 Unit assignment 

Movie: "Team Nursing" 

8:30- 9:00 Discussion period 
9-10:00 Diseases of chest 


7- 3:30 


7- 3:30 


8:30- 9:00 




7- 3:30 


8:30- 9:00 






12:30- 1.30 



Chest surgery 

Unit assignment 

Movie: "Closed Chest Cardiac 


"Common Heart Disorders 

and their Causes" 
Rescue breathing 

4th WEEK 

Unit assignment 

Movie: "The Proud Years" 

Discussion period 

Isolation technique 


Orthopedic surgery 

Demonstration of traction 

Unit assignment 
Movie: "Nurse Patient 


"Hospital Sepsis" 


Discussion period 

Panel: OB. Peds.. Psych. 


Movie: "Normal Delivery 
Without Anesthesia" and 
"Breast Feeding" and "C- 
Section Under Hypnosis" 


Movie: "Head Injury" 

Neurological nursing (Med. & 




Coffee hour with presentation 

of certificates 


Adult education was introduced to pro- 
vide a late opportunity for the educationally 
neglected part of the population who. for 
one reason or another, had not attended 
school when young. Education at that time 
was considered as the orderly transmission 
of selected portions of our accumulated 
tradition. What you learned at school dur- 
ing childhood and youth would serve for all 
your days. It would provide the learning 
necessary for conducting your affairs and 
in addition would set you apart from those 
not privileged to have been graduated from 
school. Adult education became a second 
chance to learn the same things in the same 
way as you should have learned when 
young. It has since grown beyond such nar- 
row confines and is now finding its niche 
in the structure of both formal and informal 
education .... 

The argument that ability to learn is 
greatly lessened as youth turns into man- 
hood is seldom raised any more. Its grain 
of truth is probaly best forgotten. 

Opportunities for adult education are 
provided in all provinces of Canada. In 
many cities, evening students may choose 
from a wide variety of academic, vocational, 
cultural and miscellaneous offerings, but 
elsewhere choice may be decidedly limited. 
In 1960, about 40 per cent of evening stu- 
dents were enrolled in vocational courses 
and classes offered by school boards, with 
assistance from the provincial departments, 
or by universities and colleges. About as 
many were enrolled in non-credit courses 
of general cultural value, and the remainder 
attended classes leading to a high school 
diploma or university degree. Some 25 
government departments (Education. Health, 

Agriculture. Forestry. Justice, etc.) support- 
ed such classes, which enrolled almost 
8.000 in elementary and about 70.000 in 
secondary school subjects; 212.000 were en- 
rolled in vocational courses of whom al- 
most 100.000 were taking home economics 
or agriculture. In the general classes, 84,000 
were enrolled in social education. 28,500 
in the fine arts and 20.000 in other re- 
lated courses. 

Public lectures, film shows, exhibits, tours, 
music and drama of an educative nature 
sponsored by various bodies and organiza- 
tions, attracted 600.000. The same sort of 
programs conducted by public libraries re- 
ported an attendance of about 215,000 per- 
sons — Canada. Dominion Bureau of Sta- 
tistics. A Graphic Presentation of Cana- 
dian Education. Ottawa. Queen's Printer. 




The Servo Theory 

A suggested method in evaluation of nursing students 

Sidney M. Jourard, ph.d. 

A nurse is a highly trained and 
skilled person, but unless she is able 
to perform the right skill at the right 
time, her skill is useless. Moreover, 
unless she is able to perform her skills 
in a way that does not jeopardize other 
values, she may do more damage than 

What is a skill? A skill is a means 
of behaving, with or without gadgets, 
in order to produce a desired outcome. 
Examples of the ones which nursing 
students must learn include injection 
of fluids by means of hypodermic 
needles, administering enemas, insert- 
ing catheters, applying and changing 
surgical dressings, cleansing and irri- 
gating colostomies. A nursing student 
might well display smooth, elegant 
prowess in the performance of these 
skills upon a mannikin or an uncon- 
scious patient, under the gaze of her 
clinical instructor. This same student, 
confronted with a conscious, pain-rid- 
den, demanding person and deprived 
of her instructor's support may fall to 
pieces, and be unable to perform. Or, 
by virtue of various mechanisms, she 
may be able to pretend to herself that 
this hving, conscious patient is a man- 
nikin or unconscious body, thereby be- 
coming better able to perform her 
skills. This procedure may offend the 
patient, and has other undesirable con- 
sequences, not the least of which is the 
student's failure to gain competence in 
interpersonal relationships when she 
thus depersonalizes her patients. 

Ideally, a nurse functions in a man- 
ner similar to blood as it circulates 
through the arteries. The blood trans- 
ports all manner of needed substances 
to cells and tissues, and appears to 
drop off at each cell exactly what the 
cell needs to repair itself or to func- 
tion optimally. There is little delay in- 
volved, and the cell is better off after 
the blood has gone by than before. The 

Dr. Jourard is with the Department of 
Psychology, University of Florida. Gaines- 
ville, Fla. 

blood does not become "ratded" or 
"upset" if a cell is demanding, but 
raUier, transmits what is needed and 
goes on to the other cells. There is 
this difference, among others, between 
a nurse and blood. All that the blood 
seems to do is to carry the needed sub- 
stances. It is the cell that seems to 
decide how much and what it will take 
in from the passing fluid. The blood 
does not appear to be obhged to make 
judgments of which cell needs what. 
A nurse, however, is required to assess 
the immediate status of a given patient, 
and to provide what is needed. Of 
course, in many situations, she does 
not perform the assessment, but, ra- 
ther, gives the patient what the phy- 
sician decides is necessary. In such 
situations, when she is in the role of 
executor of the physician's orders, she 
is little more than an extension of the 
latter's arms, and can possibly shut off 
her own observations, feelings, and 

If the nurse is to be more than an 
extra pair of hands and feet for the 
physician, if she is to be a positive 
factor in the promotion of patient well- 
ness, than she must function with more 
of herself than her hands and feet. She 
must, in short, function in a marmer 
more closely similar to blood, or even 
to one of the so-called "servo-mecha- 

Servo-mechanisms are gadgets, me- 
chanical or electrical, that function in 
a manner not too different from peo- 
ple. They have a certain "output" 
which is supposed to produce desired 
or valued outcomes; they have "input" 
of information which "tells" the "com- 
munication centre" what the state of 
affairs is. More important, they have 
"feedback mechanisms" built in so that 
whenever the output is too much, too 
little, or of the wrong kind, this in- 
formation is "fed back" to the con- 
trol-centre, and the output is sensitively 
varied until it is "right." 

It may be offensive to be compared 
to a machine of this sort, but the anal- 

ogy is rather useful in highlighting cer- 
tain aspects of nursing. Let me point 
out the parallels. Corresponding with 
a "servo's" output is the nurse's reper- 
toire of skill — everything that she 
can do of a skilled and unskilled na- 
ture. Corresponding with "input" is the 
information that a nurse secures about 
a patient's present status — the con- 
dition of his dressing, his present state 
of mind, what he needs in order to be 
maximally comfortable and to recuper- 
ate, his wishes, etc. Presumably, the 
better prepared the nurse, the more 
effective will she be in "scanning" the 
patient in order to evaluate his present 
condition and needs. She will employ 
her eyes and ears in scanning the pa- 
tient in his room; she will consult his 
chart; she will check reports from the 
physician and other nurses, and so 
forth, in order to have the means to 
evaluate the patient. Students, it can be 
assumed, are less able to "scan" and 
evaluate than more experienced nurses, 
because they do not always know what 
to look for, nor do they always appre- 
ciate the significance of what they see. 
hear, read, or smell. 

In surveying the situation of the pa- 
tient, it becomes apparent that there 
are many things that need to be done, 
or that could be done in order to foster 
greater wellness. There is certainly a 
hierarchy of importance in all these 
weUness-fostering actions. First things 
must come first. It would be consider- 
ed stupid or criminal if a nurse who 
noticed that a patient was gasping for 
breath, turning blue in the face, and 
had also overturned his bedpan, first 
mopped up the urine with commend- 
able precision and sanitation before 
turning to the problem of strangulation. 
Judgment is required. Again, students 
will differ from more experienced nur- 
ses in this ability to select, from all 
the things that might be done on be- 
half of a patient, those things that are 
the most important and should be done 

Let us consider the nurse's "output" 




— this refers to her repertoire of skills. 
It includes giving medications, injec- 
tions, enemas, back-rubs; it includes 
listening and responding to a patient's 
communications. All of these "outputs" 
undoubtedly are undertaken in the 
hope or wish that they will produce a 
valued outcome. Certainly, an experi- 
enced nurse can be expected to have 
a more varied "output" than a novice 
or a student. She can do more things 
than a student can and do them better 

— or at least this is hoped. She can 
administer medications more skilfully 
than a novice, simply because she has 
had more practice. She is more em- 
pathic with patients than a novice, and 
less painfuUy self-conscious about per- 
forming her skills. The student is more 
preoccupied with her anxieties about 
pleasing her instructor than she is in 
touch with the reaUties of the patient. 

This leads us back for a moment to 
the problem of "skills." Skills are be- 
havior patterns enacted (with or with- 
out apparatus or gadgets) by the nurse, 
in order to do something to or for the 
patient. They are performances that 
the patient usually cannot do himself 
(though sometimes he can be taught, 
as in the case of injections), but which 
need to be done in order to foster re- 
covery to wellness. A skill has no 
meaning outside the context of the in- 
terpersonal relationship between nurse 
and patient. Skills are part and 
parcel of the "personahty" — a way 
of being a person — which the nurse 
brings to her relationship with the pa- 
tient. In a sense, a nurse's skills are 
part of her capacity to love, that is, to 
employ her energies, powers and tal- 
ents in the service of another's well- 
being, growth and happiness. Even 
without special training, everyone who 
can do anything has some power to 
love, or serve. Hopefully, a beginning 
student, aged 18, can do many things 

— walk, talk, listen, carry, etc. She 
can do all these things for another per- 
son and, in all probability, has already 
done much for people about whom 
she cared. All that nursing seems to be, 
from this point of view, is doing things 
for others — • patients — which they 
cannot do by and for themselves. Of 
course, many of the things that must 
be done in order to foster wellness in 
a patient require training and practice. 
How tragic it would be. however, if in 
learning how to give injections, or ad- 
minister suction, a nurse forgot or 
set aside all those human ministrations 
that she learned in growing up. It fre- 
quently appears as if a beginning stu- 
dent is able to do many things for a 
patient that the more experienced 
nurse has forgotten about, or else 
leaves for aides to do. 

Students somehow receive the idea 

that "skills'" are horribly difficult to 
learn; that they are something that can 
be judged, independent of the relation- 
ship with the patient. If a student sees 
a skill simply as another instance of 
something to do for a patient, she loses 
some of her awkwardness and terror of 
needles, gadgets, and so on. Perhaps 
instructors foster the terror of skills by 
underemphasizing the patent fact that 
they represent merely an enhancement 
of a nurse's loving repertoire. 

Now let us consider the role of 
■■feed-back" in the practice of nursing. 
We noted that the feedback mecha- 
nism of a "servo" works by sending 
information back to the "communica- 
tion centre" regarding the effect of the 
output. When the output is not on 
target, hitting the mark or producing 
the desired effect, this information 
serves to modify subsequent output in 
quantity or quality, until the desired 
results are forthcoming. 

In nursing, the nurse does some- 
thing for the patient — this is her 
output — because she beheves, or has 
been told, that this will be helpful. It 
is my impression that much nursing- 
action is not maximally helpful be- 
cause feedback is either not sought, is 
difficult to obtain, or because the nurse 
finds it hard to modify her output on 
the basis of feedback information. Let 
me comment on each of these in turn, 
and then see what the implications are 
for training and practice. 

When "feedback" is not sought: 
Most, if not all that we do is performed 
in order to produce some valued out- 
come. In the ordinary course of events, 
if our action does not yield the desired 
result, we notice this (feedback), and 
then modify our action until we do get 
the desired result. In the case of nurs- 
ing-action, it may happen that the 
nurse does something, such as giving 
an injection, and ignores the impact 
that this has on the patient. She bland- 
ly assumes that she is doing "the right 
thing," and does not seek confirma- 
tion. Much that is rigid and stereo- 
typed in nursing routines probably fol- 
lows from such inattention to feed- 
back — the "bedside manner." stock 
phrases and greetings. 

When "feedback" is difficult to ob- 
tain: A rich source of information 
about the effects and consequences of 
nursing action is the patient's honest 
and spontaneous disclosure of his feel- 
ings, wishes and beliefs. If he is stoical, 
highly repressed or shy. then it can 
happen that while the nurse believes 
she is doing well, and helping her pa- 
tient, she is, in fact, missing the mark 
widely. The silent patient certainly 
makes feedback relatively inaccessible. 
Other kinds of feedback, such as blood 
pressure, pulse, and blood count, are 

difficult to obtain because of the time 
involved in securing such information. 
Often, however, verbal feedback from 
the patient is potentially available, but 
the nurse in some way makes it diffi- 
cult for the patient to express himself. 
When feedback is not acted upon: 
A relatively rigid person generally has 
only a small range of behavior at her 
disposal. What often happens is that 
when one way of behaving does not 
produce the expected outcome, the in- 
dividual does more of the same thing, 
in the hope that if a "little bit didn't 
work, maybe a lot will." In nursing, 
for example, there is the danger that 
the new practitioner, steeped in the 
virtues of talking and listening to pa- 
tients, may overdo it. She may notice, 
for example, that "being with a pa- 
tient," instead of making the patient 
feel more relaxed, understood and 
cared for, irritates him — simply be- 
cause at that time he wants to be alone. 
Instead of taking the hint, she may 
try harder to engage the patient in in- 
teresting and self-reveahng talk, prob- 
ing for deep-seated problems. This is 
characteristic of the nursing studem. 
She may notice that her behavior is not 
producing the desired outcomes, but 
she does not or cannot modify her 
behavior on the basis of such feed- 

Implications of "servo" theory for 
evaluation of students' practice 

We have shown what seem to be 
rather crude analogies between the 
task of the nurse, and the manner in 
which blood and servo-mechanisms 
work. I believe that these may help 
us to see the problem of student evalu- 
ation in a slightly off-beat, but pos- 
sibly sharper perspective: 

We can assess the information accessible 
to, or built into the "communication centre." 
that is. the nursing student herself. This can 
be accomplished in traditional ways with 
quizzes and exams. 

We can assess the students' scanning and 
intake-ahility in a nursing situation. This 
refers to her ability to observe what is 
there, to interpret it. to evaluate it. and to 
make judgments about what needs to be 

We can assess the student's judgment 
about the relative priority of the importance 
of things to be done. This should be com- 
pared with a more mature nurse's ranking 
of the order in which things should be done 
in the best interest of the patient. 

We can assess the nurse's output, both 
in regard to its diversity — the number of 
things that she can do to, with, or for 
patients (perhaps these could actually be 
counted), and also with regard to its ef- 
fectiveness in producing desired effects on 
the patient without jeopardy to other values. 




Thus, we may notice that a given student 
does not know how to administer an injec- 
tion, but she can bathe patients, give back 
care, and irrigate colostomies. Or. she is 
expert at establishing contact with patients, 
and listening to them, making them feel 
understood, but she is inexpert at perform- 
ing douches. 

In such judgments, it is not the dis- 
embodied skill that is being judged, 
but rather the abihty of the student to 
produce the desired result with mini- 
mum jeopardy to other values. Thus, 
student A may have a firm and ac- 

curate mastery of hypodermic injec- 
tion, but she administers the medica- 
tion without noticing how the injection 
siuation may be terrifying the patient. 
Student B is shaky in handling the 
same equipment, but quite observant 
of her patient. In spite of her wobbly 
aim, she succeeds in getting the fluid 
into the patient's arm, and remains in 
interpersonal contact with him. It is 
quite probable that student B is fur- 
ther along in over-all nursing "expert- 
ise" than student A. 

Finally, we can try to determine a 
student's ability to seek and to employ 

feedback, both in the improvement of 
effectiveness in this very situation, and 
also for more general learning. We 
might notice that some students ignore 
feedback, ending their observation 
when they have done what they started 
to do. Others are unskilled in obtaining 
feedback — they do not know what 
kind is most pertinent in abetting more 
effective care. Still others may obtain 
feedback, and may be aware that they 
have not produced desired outcomes, 
but fail for various reasons to qualify 
their action on the basis of this infor- 


Many educators and lay writers have 
commented in recent years upon the serious 
problem of school drop-outs and under- 
achievers. Articles in professional journals 
and on the family pages of general periodi- 
cals are evidence of the widespread concern 
of parents and teachers. 

We think of a "drop-ouf as a .student who 
leaves school before completing a course 
of study which is in harmony with his 
abilities. An "underachiever" is a student 
who does not study up to the peak of his 
natural capacity for learning. What we seek 
is to channel these unfortunate students back 
into the stream so that they may receive the 
education they so vitally need in order 
to cope satisfactorily with life. Sometimes 
a friendly pat on the back will suffice, 
said Orville White in The Educational Re- 
cord, but in many cases a strong push is 

Underachieving students are young peo- 
ple who could do better but will not, in 
spite of being warned, encouraged, punished, 
counselled and tutored. Some are rebels 
who pay lip-service to parental demands 
and go through the motions of classes and 
study, but whose minds are idling. Others 
look upon education as an affliction they 
are compelled to endure. Instead of showing 
lively interest and curiosity, they sit neu- 
trally as an audience and wait in a docile 
way for the teacher to compel them to 
learn .... 

The young person who drops out of 
school before obtaining the best education 
available to him finds that the status of all 
his adult life has been determined and 

fixed on a low level by his action. He is 
likely to be the first to lose his job in a 
slump. Studies show that he will probably 
move down the occupational ladder rather 
than up. His life will be unsatisfying, and 
he is unlikely to make a useful contribution 
to society. 

What is the cause of failure, drop-out and 
and underachievement? Generally speaking, 
the student decides to drop out because 
he has no substantial goal in life. Our 
strong economy, with its blatant display of 
affluence and flight from hard work, fosters 
thoughts of enjoying ease and comfort with- 
out effort. Parents and teachers may not 
openly condone school failure, but they con- 
tribute to it by failing to stress the worth- 
whileness of working toward success. 

Failing students are not necessarily men- 
tally retarded. Some drop-outs have IQ's 
as high, based on standard intelligence 
tests, as those who graduate. For them, 
something has gone wrong. An article in 
School Life says three factors are particu- 
larly influential: a low academic aptitude. 
a slow rate of emotional and social develop- 
ment, and lack of parental interest in edu- 

One reason frequently given for failure 
and drop-out is the distraction of working 
to supplement the family income. Research 
has shown that grades do not necessarily 
suffer because the student is working part 
time. In fact, a survey in Illinois revealed 
that proportionately more among those 
who become graduates hold after school or 
Saturday jobs than do those who op out. 
Some students find that the hours spent 

in gainful employment provide needed re- 
creation and a rest from school work. Their 
mental health is made better by the grati- 
fication of doing socially useful work .... 

What can be done [to lessen failure, 
drop-out and underachievement]? A force- 
ful endeavour should be made by everyone 
who feels concern for children and their 
future to find a positive way of meeting the 
challenge .... Common sense, thoughtful- 
ness. good-heartedness and a little time — 
these are the ingredients of parent help. It 
has been suggested that parents should get 
together at two or three meetings during 
the school year to talk about methods. In 
discussion with teachers and guidance work- 
ers they would learn to give leadership 
without meddling and help without pam- 
pering. They would hear about the danger 
of over-indulgence. Some children are given 
so many possessions and privileges that they 
do not learn the essential connection be- 
tween effort and reward .... 

Our obligation is to impress upon the 
student that he faces certain needs which 
are inescapable. We should show him the 
causes of his failure and the possibility of 
their being removed. We should provide 
him with a program that gives promise of 
successful activity in his educational, voca- 
tional and social future. A whole — heart- 
ed getting together of parents, teachers, 
boards of education and persons interested 
in social services would start the ball rolling. 
This is not a task for the schools alone, but 
one whose successful completion demands 
the co-operative effort of all the community. 
— The Royal Bank of Canada Monthly 




laf ety in Hospital Operatini 

Safety begins with awareness of a fiazard 

P. J. Sereda 

Amid the complexities of hospital 
design and construction the hazards of 
fire and explosion in operating rooms 
may too easily be treated as minor de- 
tails. These hazards, however, must 
not be ignored. The Division of Build- 
ing Research became interested in them 
in 1953 after receiving an inquiry from 
a firm of architects about the durabil- 
ity of static conductive flooring for 
operating rooms. 

Hospital administrators should be 
aware of the special nature of the 
equipment and facilities that can be 
provided. Full advantage of these facil- 
ities can be realized only if the operat- 
ing room staff institute certain proce- 
dures and take certain precautions to 
avoid the sources of ignition of anes- 
thetic gases. 

It may seem strange that in an ac- 
tivity such as surgery, which in itself 
has great risks attached, there is con- 
cern with fires and explosions of anes- 
thetic gases such as ether, cyclopro- 
pane and ethylene in combination with 
oxygen. These accidents occur at a sta- 
tistical frequency of one in 80.000 to 
100,000 anesthesias that use flam- 
mable gases. Statistics, however, do not 
always reveal a true picture of the im- 
portance of some hazards. An explo- 
sion in the operating room has a great 
psychological impact upon the oper- 
ating room staff, the public at large, 
and potential patients, not to speak of 
the liability cf the physician and the 
hospital if such an accident is judged 
as negligence. The presence of a po- 
tential hazard may also add unneces- 
sary stress to personnel already under 
great pressure and thus hinder their ef- 


The potential hazard in operating 
rooms is associated with the mixture 
of anesthetic gases with oxygen or air. 

Mr. Sereda is head of the Inorganic 
Materials Section, National Research Coun- 
cil, Ottawa. This article is reprinted in part 
from the Canadian Building Digest No. 32. 

Extensive field and laboratory investi- 
gations have been carried out, notably 
by the U.S. Bureau of Mines, demon- 
strating conclusively that mixtures of 
oxygen or air with anesthetic gases 
normally used in operating rooms can 
be ignited by very low energy sources. 
Energies in excess of this minimum are 
associated with spark discharges such 
as are produced from electrostatic 
charges built up on equipment and 
personnel in operating rooms. This 
constitutes the chief source of ignition, 
although other sources such as open 
flames, arcs and sparks from non-ex- 
plosion-proof electrical equipment and 
faulty wiring, as well as incandescent 
lamps and endoscopes or high frequen- 
cy cauteries or coagulators have added 
to the hazard. 


Safety begins with awareness of a 
hazard. To achieve it in operating 
rooms one must educate the operating 
room personnel: Demonstrate that the 
hazard exists; what factors contribute 
to it; the action that can be taken to 
reduce to a minimum the chances that 
an accident will occur. 

Safety codes are available to assist in 
the design and construction of equip- 
ment and facilities to eliminate or at 
least reduce the hazard. The National 
Fire Protection Association has pro- 
duced such a document; the Canadian 
Standards Association has also issued 


Open flames and hot surfaces: Open 
flames, Hghted cigarettes, heaters and 
hot plates, hot cauteries, sterilizers, 
lamps and hght fittings, hot instru- 
ments such as hot dental syringes, or 
any surface with a temperature above 
180° C are easily recognized as igni- 
tion sources. These can be controlled 
or eliminated with little effort on the 
part of the staff. Only vigilance and 
cooperation are required. 

Ele rical systems: Both fixed and 
portable electric systems and equip- 

ment provide many sources of electric 
spark ignition. Even normal function- 
ing of such equipment as the brush 
gear of electric motors, switch contacts, 
receptacles, radio-frequency cutting, 
coagulatmg, and diathermy apparatus 
may result in sparking. There is risk 
from faulty connections and short cir- 
cuits on almost all electric apparatus. 
Sparking may even be electrically in- 
duced between objects not directly con- 
nected to electric equipment. There is 
danger of random or diffuse sparking 
in electric apparatus and associated ob- 
jects when radio-frequency equipment 
is used. Hot surfaces can be provided 
by over-heated components such as 
cables in which some of the wire 
strands have broken. 

To ensure safety the wiring system 
and design of electrical equipment 
should comply with the electrical codes 
and should be maintained through re- 
gular inspection and upkeep. The re- 
commended wiring consists of an un- 
grounded system, isolated completely 
from other systems, that can be con- 
tinuously monitored to detect the pre- 
sence of faults. Such a wiring system 
is especially desirable when a static- 
conductive floor is installed, because 
of the increased hazard of electric 
shock. The fact that the system is mon- 
itored by means of a ground hazard 
indicator, to give warning when the 
impedance (consisting of resistance or 
capacitance) of either or each side of 
the line to ground drops below 
120,000 ohms, not only ensures that 
no serious electric shock can be ob- 
tained but also assists in the proper 
maintenance of the system. Faulty elec- 
trical equipment plugged into such a 
system will immediately cause a warn- 
ing to be given by the indicator so 
that the equipment can be taken out 
of use and repaired. 

Electrostatic sparks: Experience in- 
dicates that the most frequent source 
of ignition of flammable anesthetics is 
the electrostatic spark discharge. Sur- 
veys of hospitals indicate that there is 
probably no combination of equipment 




and personnel activity anywhere more 
liable to produce casual, dangerous 
charges of static electricity than that 
found at present in the anesthetizing 
areas of most hospitals. 

Although little is known of the na- 
ture and mechanism of static electrifi- 
cation, a great store of observation and 
experience is available to define condi- 
tions under which this phenomenon oc- 
curs. Generally, any insulating material 
will exhibit the phenomenon of separ- 
ation of charges when separated from 
another insulating or conducting sur- 
face. The higher the specific resistivity 
of the surface and the more intimate 
the contact, as occurs with very smooth 
surfaces or by sliding one surface over 
another, the more pronounced will be 
the separation of charges. 

A charge held by any body or part 
thereof is a product of its capacity and 
the electrostatic voltage. Capacity of 
most objects is small, and the poten- 
tials encountered when there is a sep- 
aration of charges are measured, there- 
fore, in thousands of volts. If the elec- 
trostatic voltage is above 350 volts, 
there is a definite chance of a spark 
discharge through the air to some body 
not similarly charged, provided that 
body is close enough and has the capa- 
city to receive the charge, as by con- 
duction to ground. Any object carry- 
ing a charge can induce one in another 
object or body in close proximity, 
especially if the second object is a con- 
ductor of electricity. Equalization of 
the charge to other objects or to ground 
across a small gap can result in sparks, 
especially if there is a charge on a 
conducting object such as a person. 

To eliminate static electrification it 
is necessary to eliminate from use in 
operating rooms all materials that have 
high specific resistivity and can be 
classed as insulators. All items made 
of ordinary rubber such as sheets, cas- 
ters, shoes; woolen goods such as 
blankets; all items, with the exception 
of undergarments, made of nylon, or- 
lon, dacron, silk, acetate; artificial 
leather and sharkskin, should be elim- 
inated from the operating room and 
replaced by items made of metals, con- 
ductive rubber, conductive plastic or 
cotton. Cotton is safe only when the 
humidity in the room is controlled at a 
value in excess of 50 per cent. By 
virtue of its hygroscopic properties its 
resistance is a function of the relative 
humidity in the air. At values of rela- 
tive humidity in excess of 50 per cent 
the surface conducts electrostatic char- 
ges fast enough to prevent the build- 
up of dangerous voltages. Cotton can 
be rendered non-static-producing at 
low humidity by treatment with antista- 
tic agents. This procedure, however, 
requires regular attention. 

It has been found that resistivity in- 
creases exponentially as the relative 
humidity is decreased to zero. It fol- 
lows that electrostatic charging is at a 
maximum at a relative humidity of 
about 35 per cent, and decreases as the 
relative humidity is decreased below 
this value. Thus there is no advantage, 
and there may be some hazard in pro- 
viding some humidity in the operating 
room during very dry periods, unless it 
is possible to maintain an adequate 
humidity of at least 50 per cent. 

With a relative humidity of 25 to 35 
per cent, clean cotton will charge to a 
higher voltage than synthetic fabrics 
such as nylon, although nylon contin- 
ues to retain its charge, even at a 
humidity of 60 per cent at which 
cotton does not charge at all. It is im- 
portant that all cotton items used in 
operating rooms should be allowed a 
minimum of several hours to come to 
equilibrium with the high humidity be- 
fore they are used. 

Despite efforts to eliminate the pre- 
sence of insulating materials and to 
maintain a high relative humidity, it 
must be conceded that some charge 
may still occur and that a second line 
of defence is required. It has been 
found that the provision of a static 
conductive floor is the most effective 
safeguard against the accumulation of 
dangerous electrostatic charges. Each 
individual must wear some form of 
conductive footwear, however, and all 
objects must make effective electrical 
contact with the floor through static 
conductive casters, metal leg tips or 
other grounding devices. To be com- 
pletely effective everyone and every- 
thing must be electrically intercouoled 
via a static conductive floor at all times 
during the use of flammable anes- 
thetics. This implies constant vigilance, 
inspection (by testing) and a high stand- 
ard of "housekeeping." Wax or dirt 
accumulation on the floor and on 
grounding devices can provide high 
resistance and cancel the effect of 
static conductive flooring. 


The committee on Hospital Oper- 
ating Rooms of the National Fire Pro- 
tection Association has given much 
consideration to the establishment of 
safe limits of resistance for a suitable 
static conductive floor, based on a 
method of test that attempts to sim- 
ulate the contact between a shoe and 
the floor. 

Common flooring materials do not 
usually provide sufficient conductivity 
under conditions of normal indoor use 
to ensure the dissipation of electrostat- 
ic charges. Terrazzo floors with metal 
gridwork may provide high conductivi- 
ty near the grid, leading to the possib- 

ility of electric shock, but may provide 
little conductivity elsewhere. Many 
other flooring materials such as wood, 
linoleum and asphalt act as electrical 
insulators. The problem, therefore, is 
one of finding a suitable material for 
the floor or floor covering that will 
provide an electrical path with a resist- 
ance that can be maintained within 
safe limits. 

Ideally, a static conductive floor for 
use in hospital operating rooms should 
consist of a chemically and physically 
homogeneous semi-conducting material 
that provides resistance within desired 
limits under all conditions of service. 
Flooring materials in common use are 
generally not sufficiently conductive. 
To make them so, it is necessary to 
mix a conductive ingredient into the 
non-conductive body of the flooring 
material. Obviously, the particle size 
and grading of both ingredients should 
be as fine as possible and the disper- 
sion very uniform to achieve satisfac- 
tory results. It is also desirable that all 
the ingredients are free of water-soluble 
salts in order that their conductivity 
is a function of the proportions of the 
conductive to the non-conductive in- 
gredients only and is independent of 
such changing conditions of use as 
moisture content and humidity. 

A number of flooring materials of 
the ccmentitious type owe their elec- 
trical conductivity, in part or in whole, 
to the presence of soluble salts. Oxy- 
chloride flooring is a good example. 
With these floors, the resistance is a 
function of the moisture content of the 
floor. This is governed by humidity in 
the air and water added during wash- 
ing. Since these factors are not nor- 
mally controllable in operating rooms, 
the resistance will fluctuate over wide 
limits. In fact, the lower limit of re- 
sistance can be met only under ideal 
conditions; if any water is spilled on 
such a floor, the resistance drops to a 
very low value. In addition, such 
floors tend to lose their conductivity 
with time because of the washing away 
of soluble salts from their surface. 
These are serious problems that make 
maintenance of resistance within spe- 
cified limits difficult. 

The durability of most static con- 
ductive flooring materials would be 
improved by the use of a preservative 
such as wax. Most waxes, however, 
impair conductivity and cannot be 
safely used. Although the development 
of suitable sealers and waxes to pre- 
serve such floors without affecting their 
conductivity is under study, too little is 
yet known about them to permit any 
specific recommendation. 


The necessity of achieving electrical 




intercoupling between all items and 
persons in the operating room has al- 
ready been discussed. Assuming that a 
satisfactory static conductive flooring 
has been installed, it remains to com- 
plete the circuit to personnel through 
static conducting footwear, and to 
equipment and furniture through 
grounding devices such as static con- 
ductive casters, metal leg tips or drag 

Over the years a variety of static 
conductive footwear has been proposed 
and used. Shoes with static conductive 
soles are reliable but difficult to steri- 
lize. E>evices acting as grounding con- 
tacts attached to shoes are easily dam- 
aged and often do not remain conduc- 
tive because of accumulation of dirt. It 
appears that the most satisfactory so- 
lution to the problem lies in the pro- 
vision of a static conductive bootie or 
slip-on, that makes static conductive 
contact with the ankle of the wearer 
through a static conductive plastic or 
rubber strap and through the sole of 
the bootie with the floor. These booties 
can be washed or sterilized and worn 
over regular shoes. Whatever type of 
static conductive foot wear is used, it 
should be tested each day while worn 
to ensure electrical conductivity in the 
desired range. 

Devices used for grounding equip- 
ment and furniture to static conductive 
flooring, whether static conductive cas- 
ters, metal leg tips or drag chains, must 
"^e kept clean and must be checked to 
oe that they actually do complete the 

electric circuit. This can be done only 
by regular inspection and testing. Such 
testing can readily be carried out by 
placing an electrode (type used for 
flooring test) on the metal part of fur- 
niture or equipment and another elec- 
trode on the static conductive flooring. 
In this way both the equipment and 
flooring may be checked in one oper- 
ation. In checking an anesthesia ma- 
chine one electrode may be placed on 
the face mask of the machine and the 
other on the floor. One ohm-meter 
should be used to test both flooring 
and footwear. Specifications for the 
electrodes and test meters are given in 
the various codes. 


Where safety is involved there 
should not be two sets of standards. 
Those for new hospitals, which must 
now meet the safety requirements of 
codes with regard to electrical wiring 
and equipment, humidity control and 
electrostatic control, and those for old 
hospitals, which were built before such 
standards were defined, must somehow 
agree. Now that standards have been 
set down clearly in the form of regula- 
tions and codes it should be the re- 
sponsibility of hospital administrative 
staffs as well as the various levels of 
government to see that these standards 
are realized in all hospitals as soon as 

Humidity control: The maintenance 
of high humidity in operating rooms 

presents design problems in the severe 
winter climate of Canada. Not only 
must the walls be insulated to prevent 
condensation, but adequate vapor bar- 
riers must also be provided to prevent 
excess moisture from accumulating in 
the walls and causing frost damage. 
Windows present the greatest prob- 
lem from condensation. One solution 
eliminates them from operating rooms 
entirely. These problems can be solved 
during design and construction in new 
hospitals, but in old hospitals the so- 
lution may require considerable adap- 

Housekeeping and equipment main- 
tenance: In discussing the various 
means for eliminating ignition hazards, 
the importance of a high standard of 
housekeeping and maintenance cannot 
be over-emphasized. Such standards 
can be maintained only through fre- 
quent inspection and testing according 
to a schedule. This should include 
checking all precautionary measures, 
and should be the responsibility of one 
person, with the administrative staff 
of hospitals in charge of organizing 
the necessary inspection and testing. 

Education and training: It should be 
the responsibility of the administrative 
staff to organize a program of instruc- 
tion through posters, signs and lectures 
or demonstrations in the safe handling 
and use of anesthetic gases and oxy- 
gen. All efforts to design and construct 
safe equipment and facilities can be 
nullified by one careless or thoughtless 

The Unwed Mother 

The problem of the unwed mother is one 
that the nurse as well as the doctor is fre- 
quently called upon to face. We have much 
to do. not with moral problems but with 
the psychological effect of the circumstances 
upon the individual. Often, by being under- 
standing, we can help to prevent dire re- 
Milts, such as suicide or criminal abortion: 
we can encourage the girl to believe that she 
has not hopelessly destroyed her life, but 
that she may be brought safely through this 
pregnancy without undue publicity, and that 
her child can be well cared for even if she 
is unable to keep it. 

Many girls come to the doctor or nurse 
with the question "What can I do. now?"" 
once they have found out they are preg- 
nant. If marriage cannot be arranged, then 
the girl is often advised to continue to live 
with her parents, to stay with relatives or 
friends, or to seek admission to a home 
for unwed mothers where she can live until 
her time for delivery arrives. Once it has 
been explained to her that she will be look- 
ed after and she is made to see that she is 
not the first and onlv one who has made 

this mistake, she will usually be dissuaded 
from doing anything desperate. In any case, 
the unmarried prospective mother should re- 
ceive good antenatal care — including an 
adequate diet. 

The nurse should remember that the 
patient suffering from her own mistakes 
needs more sympathy and understanding 
than anyone else. None of these patients fit 
into a typical category: each reacts differ- 
ently. Some are apparently indifferent: others 
rather obviously are in a state of panic: 
still others exhibit a kind of silent with- 

In caring for the unmarried mother, the 
nurse should do all in her power to help 
her face the reality of the situation. A warm, 
sympathetic nurse can allay the patient"s 
fears by just maintaining an accepting at- 
titude. If the girl decides to keep her baby, 
the nurse can teach her how to care for it. 
Care of the unmarried mother presents to 
the nurse one of the greatest opportunities 
for the exercise of Christian charily, be- such care does much to restore the 
patient's self-confidence and to as.sure her 

that she has a place in society. 

The handling of the problems of the 
unmarried mother often determines how 
successfully she can return to a productive, 
satisfying life after her baby is born. Often 
the girl is very young and immature. She 
must face a very real problem, the attitude 
of the community in which she lives. The 
father of the unborn child is absent in the 
situation of the unmarried mother, thus 
denying her the emotional support and se- 
curity resulting from the husband-wife rela- 
tionship. The nurse must show confidence 
in the girPs ability to think through the 
problem realistically and to carry out a 
plan for the future. 

Most unwed mothers make arrangements 
for their child to be adopted. Sometimes 
the girl may look upon her baby as a cute, 
cuddley toy to lake home with her and not 
think of the responsibility or problems of 
rearing a child. Since the child's welfare is 
decided by the mother, the nurse must try 
to help the mother make the right choice 
for the child and herself. — Janet Mc- 
Kain. Holy Cross Hospital. Calgary, Alia. 







CNA Sub-committee Holds First 

From the Sub-committee meeting 
of tlie CNA Executive Committee, held 
in Ottawa in September, came these 

Royal Commission on Health Ser- 

It was agreed that there was a 
need for a well organized statement 
by the Canadian Nurses' Association 
on the recommendations of the Report 
of the Royal Commission on Health 
Services relating to nursing. The Sub- 
committees of the three National Com- 
mittees on Nursing Education, Nursing 
Service and Social and Economic Wel- 
fare, together with the chairmen of 
the Committee on Nursing Affairs and 
the Committee on Public Relations 
were called together in November to 
develop a plan of action for the bien- 

Association By-Law Change: 
The Committee on Legislation and 
By-Laws has been requested to give 
consideration to presenting a change 
in By-Laws providing for the nomin- 
ation and election of the representa- 
tives from the Nursing Sisterhoods ac- 
cording to the various regions of the 

Special Studies: 

Dr. Kaspar D. Naegele plans to 
have his report on nursing education 
in Canada completed for presentation 
to the Executive Committee in Febru- 
ary, 1965. Dr. Naegele's presentation 
to the 1964 biennial meeting was a 
summary of his conclusions up to that 

Miss Lillian Campion presented a 
progress report on the Project for the 
Evaluation of the Quality of Nursing 
Service. The surveys are completed 
and the Panel of Review, under the 
chairmanship of Miss Trenna Hun- 
ter, met in Ottawa in October. Miss 

Campion hopes to be able to announce 
the date the report will be completed 
to the Executive Committee in Febru- 

Miss Glenna Rowsell will present 
her final report on the School Im- 
provement Program to the Executive 
Committee in February, 1965. 

Statistical Survey: 

It was agreed that since the statis- 
tical survey undertaken by Mr. Ber- 
nard Blishen is very lengthy and 
comprehensive and based on a 30 per 
cent response that an abstract of the 
survey will be prepared by Mr. Blishen 
for distribution and the full report 
will be available on loan from the 
CNA library. Mr. Blishen is now work- 
ing on the abstract and the report is in 
the hands of the translator. 

Canadian Nurses' Foundation: 
Following study of the financial 
statements of the Canadian Nurses' 
Foundation, concern was expressed 
for the future of this organization. The 
meeting commended the work done by 
the CNF provincial representatives but 
felt that the lack of support by the 
membership of the CNA was due to 
lack of knowledge. It was agreed that 
much more interpretation about the 
CNF and soliciting of financial sup- 
port could be done at the chapter 
and local levels. The CNA was re- 
quested to send a letter to the provin- 
cial boards, through their respective 
executive secretaries, explaining the 
financial conditions of the CNF; ex- 
pressing concern for the future of this 
organization; asking for suggestions 
for financing the Foundation and sol- 
iciting their support in doing so. 

CNA Statements on Nursing 
A collection of policy statements 
and views on nursing have been com- 
piled by the Canadian Nurses' Asso- 
ciation and is being published under 

the title, "On Record." It answers the 
kind of questions that any professional 
nurse is likely to be asked and should 
be able to answer. The document will 
be off the press by the end of January 
and will be available to every interest- 
ed nurse in Canada. 

Publications Recently Received in 
CNA Library 

Most of the material listed below 
is available on loan from the CNA 
library. Requests should be addressed 

The Librarian 

Canadian Nurses' Association 

74 Stanley Avenue 

Ottawa 2, Canada 

Applications for loans should give 
the month in which the publication 
was listed in The Canadian Nurse. 

1. Alberta Association of Registered 
Nurses. Standards of professional nursing 
practice. Edmonton, 1964. 46 p. 

2. American Nurses' Association. De- 
scription of exchange visitor programs for 
nursing administrators. New York, 1963. 
251 p. 

3. American Nurses' Association. Facts 
about nursing: a statistical summary, 1964 
ed. New York, 1964. 264 p. 

4. American Optometric Association. 
White House Conference report on the se- 
nior citizen and optometry. St. Louis, Mo., 
1960. 17 p. 

5. Bachand, Sister Madeleine. A study 
of the nurse auxiliary groups in the pro- 
vince of Quebec. Montreal, 1964. 101 p. 

6. Bradford, Marjorie. Study of the needs 
of older and chronically ill persons in the 
city of Ottawa. Ottawa, Council of The 
Corporation of the City of Ottawa, 1955. 
87 p. 

7. Brazilian Nurses' Association. Survey 
of needs and resources of nursing in Brazil. 
Rio de Janeiro, 1963. 286 p. 

8. Canada, Bureau of Statistics. Hospital 

a) V. 1. Hospital beds. Ottawa, Queen's 




Primer, 1963. 105 p. (D.B.S. 83- 

b) V. 2. Hospital services. Ottawa, 
Queen's Printer, 1964. 117 p. (D.B.S. 

c) V. 7. Hospital indicators. Ottawa, 

Queen's Printer, 1964. 96 p. (D.B.S. 

9. Canada, Bureau of Stalislics. Popula- 
tion estimates by marital status, age and 
sex for Canada and provinces, 1962. Ot- 
tawa, Queen's Printer, 1964. 5 p. 

10. Canada, Bureau of Stalislics. Pro- 
vincial and regional life tables, 1950/52- 
1955/57. 45 p. (D.B.S. 84-512) 

1 1 . Canada, Bureau of Statistics. Statis- 
tics of home nursing services. Victorian 
Order of Nurses for Canada. Ottawa, 
Queen's Printer, 1962. 78 p. (D.B.S. 82- 

12. Canada, Civil Service Commission. 
Specifications, Nurse. Ottawa 1961. 29 p. 

13. Canada, Dept. of Labor. Economics 
and Research Branch. Monthly salary rates 
in hospitals, October 1962. Ottawa, Queen's 
Printer. 1964. 86 p. 

14. Canada. Dept. of Labor. Women's 
Bureau. Collective action by nurses to im- 
prove their salaries and working conditions. 
Ottawa. Queen's Printer, 1964. 12 p. 

15. Canada, Dept. of National Health 
and Welfare. Nursing Counsellor's manual. 
Ottawa. Queen's Printer. 1963. 1 v. 1 1 p. 

16. Canada. E.xternal Aid Office. Hand- 
book for scholars and fellows. Ottawa, 
Queen's Printer, 1964. 30 p. 

17. Canada, Royal Commission on Health 
Services. Report, v. 1. Ottawa, Queen's 
Printer. 1964. 914 p. 

18. Canadian Medical Association. Jour- 
nal. Special supplement to v. 19, no. 1, 
19 September. Toronto, 1964. 48 p. (Report 
of Special Committees on Policy, to Adapt 
the Australian Plan of Medical Services to 
Canadian conditions, and on prepaid medi- 
cal care.) 

19. Canadian Universities Foundation. 
Graduate studies in the humanities and so- 
cial sciences, registered at Canadian univer- 
sities 1963-64. Ottawa. 1964. 1 v. 

20. Chicuf-o. Prcshyterian-St. Luke's Hos- 
pital. Dept. of Patient Care Research Evalu- 
ation of an experimental nursing curriculum. 
Final report. Chicago. I.L.T. Health Re- 
search Centre, 1964. 244 p. 

21. Gt. Brit. Central Office of Informa- 
tion. Reference Division. Social service in 
Britain, rev. 1963. London. H.M.S.O., 1964. 
116 p. 

22. Havener, William H.. William H. 
Saunders and Betty S. Bergersen. Nursing 
care in eye, ear, nose and throat disorders 
Saint Louis, Mo., C.V. Mosby Co., 1964. 
360 p. 

23. '-iternational Labor Office. Effects 
of me^nanization and automation in offices. 
Geneva, 1959. 121 p. 

24. International Labor Office. General 
report to LL.O.. Advisory Committee on 
Salaried Employees and Professional Work- 

ers. 5th Session, Cologne, 1959. Geneva, 
1959. 2 v. 

25. International Labor Office. Prob- 
lems of women non-manual workers. Gen- 
eva, 1959. 83 p. 

26. Kempf, Florence C. and Ruth Hill 
Useem. Psychology: dynamics of behavior 
in nursing. Philadelphia, Saunders, 1964. 
220 p. 

27. Mainland, Donald. Elementary medi- 
cal statistics. 2nd ed. Philadelphia, Saunders 

1963. 381 p. 

28. Merton, Robert K. Issues in the 
growth of a profession. Presented at 41st 
Convention of the American Nurses' Asso- 
ciation, 1958. New York, 1958. 12 p. 

29. Midwives' Seminar, Lagos. 3-7 Feb. 

1964. Report by Adetoun Bailey. Lagos, 
Midwives' Board for Nigeria, 1964. 321 p. 

30. Mullans, Mary Kelly. Self-appraisal 
guide for hospitals, Detroit and Tri-County 
League for Nursing and Greater Detroit 
Area Hospital Council, 1959. 29 p. 

31. National Council of Women Year- 
hook, 1964. Ottawa, 1964. 132 p. 

32. Ontario Cancer Treatment and Re- 
search Foundation. Report, 1962-63. Toron- 
to, 1964. 145 p. 

33. Overseas Institute of Canada. Direc- 
tory of Canadians with services overseas. 
Ottawa, 1964. 268 p. 

34. Parmenter, Morgan D. Success in the 
world of work, 1964-67 ed. Toronto, Guid- 
ance Centre, Ontario College of Education, 
1964. 64 p. 

35. Pelley, Thelma. Nursing; its history, 
trends, philosophy, ethics and ethos. New 
York. Saunders, 1964. 238 p. 

36. Peptau, Hildegarde. Basic principles 
of patient counseling. Extracts from two 
clinical nursing workshops in psychiatric 
hospitals. Philadelphia, Smith, Kline & 
French Laboratories, 1964. 73 p. 

37. Reiter, Frances. Quality of nursing 
care; a report of a field study to establish 
criteria. 1950-54. New York. Medical Col- 
lege, Graduate School of Nursing. 1963. 
138 p. 

"i^. Rockefeller Foundation. Report, 1963. 
New York, 1964. 319 p. 

39. Royal College of Nursing and Na- 
tional Council of Nurses of the United 
Kingdom. A reform of nursing education: 
First report of a special committee. (Chair- 
man: Sir Harry Piatt) London, 1964. 57 p. 

40. Royal College of Nursing. Student 
Nurses' Association. Yearbook. London, 
1964. 20 p. 

41. Rowe, Harold R. and Hessel H. Flit- 
ter. Study on cost of nursing education. Pt. 
1. Cost of basic diploma programs. New 
York, National League for Nursing, 1964. 
101 p. 

42. Saskatchewan. Aged and Long Term 
Illness Survey Committee. Report and re- 
commendations. Regina, Queen's Printer, 
1963. 326 p. Survey of aged persons in 
institutions. Regina, Queen's Printer, 1961. 
71 p. Information and opinion of senior 
citizens. Regina, Queen's Printer, 1962. Ill 

p. Survey of employers. Regina, Queen's 
Printer, 1962. 32 p. 

43. U.S. Dept. of Health, Education and 
Welfare. Class specifications for nursing 
positions; a guide for state and local pub- 
lic health agencies. Washington, U.S. Govt. 
Print. Off. 1964. 18 p. 

44. U.S. Dept. of Health, Education 
and Welfare. Nursing education facilities 
programming considerations and architec- 
tural guide. Report of the Joint Committee 
on Educational Facilities for Nursing of the 
National League for Nursing and the Public 
Health Service. Washington, 1964. 88 p. 

RNAO Plans for Bargaining 

The Registered Nurses' Association 
of Ontario, as authorized by its 1964 
annual meeting last May, is actively 
working on its plans for collective bar- 

The preparation of a brief to be 
presented to the Government of On- 
tario to support legislation for col- 
lective bargaining is in the hands of 
the RNAO's Committee on Legislation 
and By-Laws. RNAO president, Mrs. 
Margaret Page, Port Arthur, reports 
that a working party appointed to un- 
dertake this important assignment and 
under the convenership of Miss E. 
Marie Sewell of Toronto, has met. 
(Toronto Telegram, October 27) 

Nursing School Talks Started 

Negotiations are underway between 
the provincial government and the 
Lion's Gate Hospital for a nurses' 
training school for North Vancouver. 
Hospital administrator J. E. Bragg 
said the school would be set up with 
a short curriculum. The Hall Royal 
Commission Report on Health Services 
recommended a two-year program in- 
stead of the present three year nurses' 
training period. 

Health Minister Martin has said 
there is a shortage of teaching facilities 
in the province and a new nursing 
school would help solve the problem. 
(Vancouver Province, October 13) 

Nurses' Salaries "Miserably Low" 

Criticism of the "miserably low sal- 
aries" paid to nurses was voiced at a 
meeting of the board of management 
of the Halifax County Hospital last 
week. Members felt that the "pittance" 
given to nurses-in-training and the in- 
adequate salaries paid to graduates 
were keeping many young women out 
of the profession, and forcing some 
experienced nurses to leave the pro- 
vince. It was decided that hospital su- 
perintendent E. J. Davies would ar- 
range a meeting with officials of the 
provincial Registered Nurses' Asso- 
ciation to get the full picture of salaries 
being paid to nurses in Nova Scotia. 
Councillor Percy Baker said he 


JANUARY 196.5 


knew of young women who wanted 
to make nursing a career but whose 
responsibilities didn't allow them to 
train for three years, receiving a pit- 
tance of $10 a month or less. He said 
some girls with Grade XII education 
"ended up working as waitresses in 
restaurants because they could not af- 
ford to take nurse's training." (Halifax 
Chronicle-Herald, October 12) 

No Shortage of Girls for Nursing 

Although there is a shortage of 
nurses in Newfoundland there is no 
shortage of young women seeking to 
enter the profession. A survey of the 
three St. John's schools of nursing 
shows each has a heavy waiting list. 
The General Hospital, largest of the 
three accepted 107 students, four of 
whom were men; St. Clare's Mercy 
Hospital accepted 56 out of 227 ap- 
plicants and the Grace Hospital ac- 
cepted 31 students. The Grace has a 
waiting list of 150. Combined, the 
three schools of nursing have 623 
nurses in training. This figure includes 
first, second and third year students. 

If clinical facilities were available in 
this province, officials estimate that 
at least 300 more student nurses could 
be recruited. Although two more 
schools of nursing are in the plan- 
ning stages, one at Grand Falls and 
one at Corner Brook, there still will 
not be enough facilities to take care 
of all the applicants. (Newfoundland 
Herald, October 18) 

American Nurse to Develop New 
Program in Nigeria 

Mrs. Anna T. Howard of Boston 
has been appointed by the World 
Health Organization to head an inter- 
national team of five nurses to develop 
the first university degree program for 
graduate nurses on the African con- 
tinent. The project is currently under- 
way at the University of Ibadan in Ni- 

Supported jointly by the World 
Health Organization and the United 
Nations Children's Fund, a department 
of nursing of the faculty of medicine 
will be established offering a course 
of three academic years for graduate 

nurses leading to a bachelor of science 
degree in nursing. Long range plans 
include a preservice baccalaureate de- 
gree program and a graduate program. 
To head this program, Mrs. Howard 
has taken leave-of-absence from Bos- 
ton University, where she is associate 
professor of nursing. 

Nursing Education Strengthened in 
Costa Rica 

A move to incorporate Costa Rica's 
only school of nursing as part of the 
University of Costa Rica has been an- 
nounced by the Pan American Sanitary 
Bureau, regional office of the World 
Health Organization. The Bureau sign- 
ed an agreement to provide an expert 
in nursing education to work with Cos- 
ta Rican health officials in bringing 
about the change, which will probably 
take place before the end of 1965. 
Students will be offered advanced nurs- 
ing courses, in addition to those in 
midwifery, to strengthen nursing edu- 
cation in the country. The school and 
the university are both located in San 
Jose, the Costa Rican capital. 

Iflursing Profiles 

Marjorie A. Rutherford retired in October, 
1964, after 31 years in public health nurs- 
ing. A native of Mount Forest, Ontario, and 
a graduate of the Victoria Hospital, London, 
Miss Rutherford studied public health nurs- 
ing at the University of Western Ontario in 
1932-33. She was then appointed to the 
staff of the Ontario Department of Health, 
serving with the United Counties of Eastern 
Ontario where the first demonstration 
health unit was organized. Eight years later, 
leave of absence was granted her to join 
the Anned Forces. She spent five years in 
England, Italy, and Belgium with No. 2 
and No. 5 Canadian General Hospitals 
with the ranlc of Major (P/Matron). 

On her return to Ontario, Miss Ruther- 
ford was loaned as supervisor to the newly- 
formed Elgin-St. Thomas Health Unit. In 
1947, she obtained her certificate in ad- 
ministration and supervision at the Univer- 
sity of Toronto. Folowing this, she served 
as regional supervisor with the public 
health nursing branch in south-western On- 
tario. In 1958, she was appointed assistant 
to the director in central office. 

At the annual meeting of the Ontario 
Public Health Association last October, Miss 
Rutherford was granted honorary member- 
ship for her leadership abilities and contribu- 
tion to public health. 

lEoton's Portrait Studio, Montreal) 

Madge McKillop 

Madge McKillop, a graduate of Moose 
Jaw General Hospital and the School for 
Graduate Nurses, McGill University, has 
been appointed assistant director of nursing 
at the University Hospital, Saskatoon, Sas- 

Miss McKillop's professional experience 
includes private and general duty nursing and 
a variety of other positions. From 1941 to 
1945, she served with the Canadian Armed 
Forces in England, North Africa and Wes- 
tern Europe. Following graduation from 
McGill University, she was appointed clini- 
cal instructor at the Royal Edward Lauren- 
tian Hospital, in Montreal, and, later, as- 
sociate director of nursing. Since 1954, she 
has been director of nursing there. In addi- 
tion. Miss McKillop has been active in the 
ANPQ, serving as chairman of the Quebec 
Nursing Service Committee, and as a mem- 
ber of the Quebec Curriculum Committee 
and the Committee on Labour Relations. She 
has also found time to act as chairman of 
the Nursing section, Canadian Tuberculosis 
Association and as a member of the Cana- 
dian Save the Children Fund. 




fCorone* Studio Inc., Montreal) 

Dorothy Sharp 

Dorothy M. Sharp has been appointed 
district director. Victorian Order of Nurses, 
Saint John. New Brunswick, branch. 

Miss Sharp graduated from the Grey 
Nun's Hospital, Regina. Sask., in 1954. 
In 1962, she obtained a diploma in public 
health nursing at McGill University, Mont- 
real, and in 1963, completed her bachelor 
of nursing degree at the same university. 
Miss Sharp's experience includes general 
duty nursing in Saskatchewan, British Co- 
lumbia and Quebec; senior nurse at a pe- 
diatric clinic in New York City; and senior 
nurse with the V.O.N. 

The Charlotte County Hospital. St. Ste- 
phen. New Brunswick, has appointed 
Elizabeth I. Rumsey, a graduate of The 
Montreal General Hospital, as director of 

Miss Rumsey received her diploma in 
teaching and supervision from McGill Uni- 
versity in 1957. and her bachelor of nurs- 
ing degree from the same university in 
1958. She has had experience as both 
head nurse and supervisor at The Montreal 
General Hospital. 

Lillian G. Hiltz has been appointed direc- 
tor of Outpost Hospital and Nursing Ser- 
vice for the British Columbia Division, 
Canadian Red Cross Society. Miss Hiltz is 
a graduate of the Vancouver General Hos- 
pital school of nursing and has worked there 
as a general duty nurse, assistant head nurse 
and head nurse. 

There are eight Red Cross Outpost Hos- 
pitals in B.C., which give emergency ser- 
vices only. Registered nurses provide this 
care until the patient can be sent to the 
nearest general hospital. Nurses travel over 
rugged country to visit patients and use all 
types of transporation from dogsled to 
planes. One of Miss Hiltz's first duties will 
be to visit all of the outpost hospitals in her 

Irene Rlmsey 
volume 61. number 1 

(B.C. Jennings, Vancouver) 

Lillian Hiltz 

M. Laurie McColl, a graduate of McGill 
University, Montreal, has been appointed 
associate director of nursing at the Ortho- 
paedic Hospital, Los Angeles. California. 

A native of Canada. Miss McColl has 
served as supervisor. Saskatchewan De- 
partment of Public Health; program super- 
visor. Saskatchewan Council of Crippled 
Children and Adults: and as nursing secre- 
tary with the Canadian Nurses' Association. 

Vera Ostapovitch, a graduate of Saska- 
toon City Hospital, has been appointed nurs- 
ing .service adviser, Saskatchewan Regis- 
tered Nurses' Association. 

Miss Ostapovitch holds a diploma in 
teaching and supervision, from the Univer- 
sity of Saskatchewan, and a bachelor's and 
master's degree in nursing administration 
from the University of Minnesota. Her 
professional experience includes general staff 
nursing, supervision and administration at 

(Wesf'j Studio, Regina) 

Vera Ostapovitch 

the Yorkton General Hospital, Saskatche- 
wan; supervision at the University Hospital, 
Saskatoon; and administration at the Win- 
nipeg General Hospital. 

Marion Werry has been appointed re- 
gional director, Victorian Order of Nurses, 
in the province of New Brunswick. A grad- 
uate of the Brantford General Hospital 
school of nursing. Miss Werry obtained a 
certificate in public health nursing from 
the University of Toronto in 1945 and a 
certificate in public health administration 
and supervision at the same University in 
1955. In 1964, she graduated with a bach- 
elor of science in nursing degree from the 
University of Western Ontario. 

The new regional director has had con- 
siderable experience with the V.O.N, in 
many parts of Canada. She has served as 
staff nurse with the Belleville branch; nurse- 
in-charge in both Chatham, New Brunswick, 
and Chatham, Ontario; regional director in 
south-western Ontario; acting district direc- 
tor, Winnipeg Branch; and acting district di- 
rector, Windsor, Ontario. Miss Werry com- 
menced her present responsibilities in Sep- 
tember, 1964. 

Marian Werry 



&» a capsvi/© 


Removal of a brain tumor calls for a 
surgeon, with two assistants, a scrub nurse, 
two circulating nurses, an anesthetist and 
an assistant. The patient's prognosis is about 
18 months and the hospital investment is 
tremendous. The birth of a new baby at 
4:00 A.M. more often is attended by one 
physician, no scrub nurse, one circulating 
nurse and inadequate or haphazard anes- 
thetic coverage. The combined prognosis of 
the two patients is over 100 years, but the 
hospital investment is minimal. Reducing 
the fetal hazard inherent in the process of 
birth is not a one-person job, but calls for 
an adequately staffed hospital with appro- 
priate supporting services available. It would 
be a mistake to believe that this protection 
is currently being provided. — Barnes, A. 
Worldwide Abstr. Gen. Med., 6:8, Nov. -Dec, 
1963, as cited in CM. A. J., 91:442, Aug. 


Certain professional and community at- 
titudes add significantly to the problems 
of the unmarried mother. Within the social 
work field, there is a general tendency to 
diagnose in advance, that all unmarried 
mothers are neurotic, acting out in sexual 
behavior unconscious and unresolved con- 
flicts with their parents . . . This kind of 
stereotyped thinking not only is unscientific, 
but has led to popular articles by the 
score, which . . . blame faulty family rela- 
tionships for the predicament .... If [this] 
image is not corrected, the young unmarried 
pregnant woman with considerable emo- 
tional health and ego strength, because of 
her unwilligness to be identified with the 
present stereotype, will refuse to use so- 
cial agency services .... 

It is probably true that each of us, 
whether nurse, physician or social worker, 
may bring to the problem of the unmar- 
ried mother a series of complexities of feel- 
ings, emanating from our own psychological, 
social, cultural and even psycho-sexual 
experiences in growing up ... . There is 
a tendency ... to over-identify with the 
client or patient, and to become so subjec- 
tive that the much-needed help is not forth- 

coming .... The average young, unmar- 
ried mother engages in a grave struggle 
whether to give the baby up or to keep 
him. She is vastly helped if those profes- 
sional persons with whom she has been in 
contact, understand these psychological 
changes in her attitudes. — Montgomery, 
Helen. Excerpts from address "Professional 
and Community Attitudes which Add to the 
Problems of Unmarried Mothers." presented 
at a Conference on OB-G Nursing in New 
York City sponsored by the American Col- 
lege of Obstetricians and Gynecologists. 


Head nurses will not be carrying out 
their proper function until the are pro- 
hibited from acting as nurses — just as 
union foremen are prevented from doing 
manual labor — and begin devoting their 
time to coaching their staff, evaluating work, 
and dealing face to face with medical per- 
sonnel, according to a senior U.S. manage- 
ment consultant. 

Speaking at the recent American Hospi- 
tal Association's mid-summer conference in 
Chicago, Joseph R. Ryan, senior member 
of A. T. Kearney, management consultants, 
offered statistical proof that the head nurse 
is too busy to be a manager; that she works 
below her level of competency; and that she 
interferes with the work of her subordinates. 
He suggested that hospitals re-assess head 
nurse requirements. — Canadian Hospital, 
41:27. Sept. 1964. 


Life may begin at 40 for some people, 
but for Dr. Annie Higbee. at 100 one of 
Canada's oldest physicians, life begins when 
"you can work at what you like." Dr. Hig- 
bee now lives in retirement in Milton, On- 
tario, where nurses say she reads several 
books each week and currently is "brushing 
up on her high school French." 

Born at Port Hope, Ont., Annie Car- 
veth attended Toronto General Hospital 
School of Nursing and now is the school's 
oldest surviving graduate. After receiving a 
medical degree in 1893. the then Dr. Car- 
veth went to California where she met 
Charles Higbee. a high school principal. 
Thev were married and in 1912 went to a 

640-acre Alberta homestead, where Dr. 
Higbee continued practising medicine. Sev- 
en years later, they moved to Toronto, 
where Dr. Higbee worked 10 years at The 
Toronto Western Hospital, which her bro- 
ther — Dr. George Carveth — helped 
to establish. 

After practising another decade at New- 
castle, Ont., Dr. Higbee retired. In 1960, 
she was given the Canadian Medical As- 
sociation's highest honor — a senior mem- 

Dr. Higbee learned to drive a car at 
the age of 70; went by bus to California at 
80; and until she was 98, regularly tra- 
velled by bus alone from her son's home in 
Burlington, Ont.. to shop in Toronto. — Tlie 
Ottawa Journal, Nov. 2. 1964. 


Excerpts from letter written by Dr. Hilde- 
gard Peplau, R.N., well-known nurse edu- 
cator, published in the American Journal of 
Nursing, September, 1964. 

I do wish the Journal would give serious 
thought to an entire issue on women .... 
Registered nurses [seem] largely unaware of 
the extent to which the social image of wo- 
men governs their behavior unwittingly — 
and keeps the profession from moving 
ahead. Most of the lay journals are doing 
many articles on women. Many of the col- 
leges are offering programs to rescue the 
female brains of the country vis-a-vis the 
housewife-who-could-also-be scientist. It 
seems to me that nursing is one profession 
that should prepare women for service in 
the dual roles of housewife (mother) and 
professional worker. The nurse scientists are 
going to be few and far between if the cur- 
rent and future collegiate students are not 
aided to recognize and to become comfort- 
able with their native capacities, if they are 
unwilling to develop and use them fully, 
and get themselves above and beyond the 
current image of women. There is no doubt 
that nursing is anti-intellectual and mean- 
while, there is an explosion of knowledge. 
Unless we begin more vigorously than at 
present, we will indeed never gear the pro- 
fession to keeping in touch with .scientific 
advances in the many even closely re- 
lated sciences. 




;4&<Mt Saa^ 

Outline of Pharmacology and Therapeutics 

by Sister M. Mariel, C.S.A. 297 pages. 
Charles C. Thomas, Publisher, Spring- 
field, 111. 1963. 

Reviewed by Miss Jean Pipher, Clinical 
Coordinator, The Montreal General Hos- 
pital, School of Nursing, Montreal. 
This book was designed as a teaching 
tool for medical and nursing students. The 
outline method of approach is advantageous 
to those members of the medical team 
who have a sound background in pharma- 
cology and therapeutics. Under such cir- 
cumstances the book is a guide to better 
understanding and provides a concise and 
accurate reference to modern drug therapy. 
The author meant the book as a com- 
plement to a pharmacology textbook and 
has used abbreviations freely and provided 
adult dosages only. The abbreviations limit 
the use of the book somewhat; the theory 
that knowledge of "range of dosage is 
gained in clinical experience" has merit. 

The table of contents is more detailed 
than in many textbooks, including such 
subheadings as osmotic diuretics; plasma 
volume expanders; drugs that inhibit tubular 
reabsorption of uric acid; ion-exchange 
resins, etc. 

Each chapter is summarized by an out- 
line of the drugs presented. This provides 
another quick reference to a particular 
system, disease or condition. It further 
pinpoints a drug in relation to other drugs 
with which one is familiar. 

This book would be of assistance to 
nursing instructors and doctors as a refer- 
ence. It demonstrates "the use that drugs 
fulfil and the advance in medicine that 
they represent." 

Practical Approach to Microbiology for 
Nurses by Lida S. White, B.S., R.N. and 
Sr. Sigrid L. Nelson, M.S., M.T., R.N. 
160 pages. F. A. Davis Co.. Phila. Ed. 2. 

The aim of these laboratory exercises is 
to give the student an understanding of the 
effects produced by microorganisms in the 
environment, and to develop insight regard- 
ing their control. 

This is a practical rather than a classical 
approach. The exercises lend themselves to 
varied types of assignment — individual or 
group — and to comparative studies of 
control methods or of different organisms. 

Medical-Surgical Workbook for Practical 
Nurses by Marilyn G. Freedman M.A., 
R.N. and Justine Hannan, M.A., R.N. 
1 54 pages. F. A. Davis Company, Phila. 

Ed. 2. 

In this second edition, new pictures have 
been added as well as more material con- 
cerning drug therapy. Each chapter is con- 
cluded with a list of pertinent articles. At 
the end of the Workbook is a list of text- 
book references. 

Basic Human Biochemistry by Armand J. 

Courchaine, 483 pages. G. P. Putnam's 

Sons, New York. 1963. 

The author's objective was to produce a 
book whose contents could be "understood 
by students who have had limited pre- 
paration in the science of chemistry without 
oversimplification of the subject matter." 
The book is written primarily as a reference 
for students contemplating a career related 
to health and disease. 

Charts and diagrams are used extensively. 
The material is well organized and present- 
ed in clear, logical sequence. A "Questions 
for Study" section, found at the end of 
each chapter, would be a helpful tool in 
testing the student's assimilation of material 

Where possible, the author has included 
information concerning pathologic as well 
as normal states. For example, when dis- 
cussing the pancreatic hormones he has in- 
cluded a section that describes the bio- 
chemical effects of diabetes mellitus. In this 
instance, he also discusses the various types 
of hypoglycemic agents available for treat- 
ing the disease 

This book would he extremely useful 
in a school of nursing library. 

Patient Care and Special Procedures in 
X-ray Technology by Carol H. Vennes. 

R.N.. B.S. and John C. Watson,, R.T. 

228 pages. The C. V. Mosby Company, 

St. Louis. Ed. 2. 1964. 

This textbook is directed to the individual 
who is training to be an x-ray technician. It 
defines the technician's role in the medical 
team caring for the patient; it supplies 
specific information on patient care in many 
diverse situations; it offers practical tech- 
nical help for carrying out many special 
x-ray procedures. 

Chapters such as "Radiography and 
Fluoroscopy — Its Hazards and Special 
Procedures." "Neuroradiography" and "Vas- 
cular Radiography and Fluoroscopy" should 
prove helpful to the nurse in her own 
understanding of x-ray technology, its pur- 
pose and methods. 

.'\ copy of this book should be on hand 
in each department of radiology. It would 
be a valuable asset in a school of nursing 

Aids to Pre- and Postoperative Nursing 

by N. L. Wulfsohn, M.B., B.Ch., D.A.F. 

F.A. 261 pages. Bailliire. Tmdall and 

Cox, London. Ed. 2. 1963. 

The author has intended this pocketbook 
mainly for the student nurse. It contains 
principles of care and explains the com- 
moner problems that the nurse is most 
likely to meet The book is well-illustrated 

The Diabetic ABC by R. D. Lawrence, M.A., 
M.D., F.R.C.P. 91 pages. H. K. Lewis & 
Co. Ltd.. London Ed. 13. 1964. 
This revised edition of Dr. Lawrence's 
handbook contains an index and a com- 
plete rearrangement of material. It should 
be a helpful book for new diabetics. 



A good all-purpose restraint to prevent 
patients from foiling or getting out of bed. 
Porticulorly good for use on femoles as it 
does not irritate busts. Available in Small, 
Medium and Large sizes. Posey "V" Re- 
straint Cat. No. V-956 Price S6.90. (Extra 
heovy construction, w/riveled joints and 
key-lock buckles) Cat. No. VK-95a S19.20. 


A long-sleeved gown made of heavy con 
ton flannel. Loops ot the ends of the sleeves 
permit ottochment to side roil of the bed 
spring. This prevents patient from scratching, 
or removing diaper, cotheter, etc., yet oHov»/5 
comfort and freedom of movement. During 
eating, sleeves moy be rolled up to oilow 
for use fo honds. A sling attached to front 
section of garment moy be used to support 
patient's arms when they ore folded across 
the front, with strops ottoched to loops in 
each sleeve to prevent use of arms. Gown is 
of short-length, waist design for use on in- 
continent patients. Avoiloble in closed or 
open-bock models Small, medium, large o*^ 
extra-large sizes. 

Posey Tidy Gown. Cot No P-755 S19 SO 

And Write for Free iHustroted Posey Catalog 




JANUARY 196.=- 

Located on the 
University cam- 
pus. Cultural, 
edttcational, rec- 
reational facili- 
ties. Metropolitan 
living in "City of 




a friendly place to work 
challenging opportunities for nurses 
excellent patient-care facilities 
wide variety of clinical services 
nurses' residence available 

LPN $304.00 PER MONTH 



B-385-1 Mayo BIdg. 



Minneapolis 14, Minnesota, U.SA 

f Virginia Keating 
first practised anesthesia as a pub- 
lic health nurse. She's been on 
Roosevelt's staff for six years. 

Miss Betfy Jane Smith, C.R.N.A. C-7 

I Course Director, School for Nurse Anesthetists i 

The Roosevelt Hospital 
428 West 59fh St., New York 19, NY. 

' Please tell me about two-year course of study | 
, and role of nurse-onesthetist at Roosevelt. 



American Drug Index 1964 by CO. Wil- 
son, Ph.D. and T.E. Jones, Ph.D. 772 
pages. J. B. Lippincott Co., Montreal 

This Index has been prepared for the 
identification and correlation of the many 
pharmaceuticals available to the medical 
and allied professions. 

The organization is fundamentally al- 
phabetical with extensive cross-indexing. 
Data included are generic and chemical 
names; manufacturer, pharmaceutical forms, 
size, dosage and use. 

This is an excellent book for quick refer- 
ence use. 

Handbook for Nursing Aides published by 
The Hospitals and Charities Commission 
for Nursing Aide Training Schools in 
Victoria, Australia. 333 pages. City Serv- 
ice Press, 103 — 5 Longsdale St., Mel- 
bourne, Victoria, Australia. Ed. 2. 1963. 
This text covers the curriculum required 

by the Victorian Nursing Council. It 

provides instruction for basic bedside 

nursing care. 

Going into Nursing by D. Hubert Thomas, 

M.A., Ph.D. 52 pages. The Epworth 

Press, London. 1964. 

This small pocketbook attempts to give 

a candid picture of nursing to those who 

are considering nursing as a career. The 

author believes that only the Christian 

faith will provide both the idealism and the 

practical virtues which are indispensable 

to the true nurse. 

On Becoming an Educated Person by Vir- 
ginia Voeks, Ph.D. 206 pages. W. B. 
Saunders Co., Phila. Ed. 2. 1964 
This paperback book is directed to 
students at the university and college levels. 
It should also be helpful to nursing students. 
Topics such as "Choosing a Place to Study," 
"The Use of Books for Becoming Educat- 
ed," and "Taking Examinations with Skill 
and Freedom from Terror," make interest- 
ing and profitable reading for any student. 
This second edition includes sections con- 
cerning creativity, educational television and 
teaching machines. Material has been revis- 
ed throughout. 

Handbook of Dietetics for Nurses by Cathe- 
rine F. Harris, S.R.N., Dipl. Diet., R.C.N. 
232 pages. Bailliere, Tindall and Cox, 
London. Ed. 2. 1963. 
The object of this book is "to point out 
the essential link between good health and 
correct feeding, and to emphasize the im- 
portance of this link not only in the main- 
tenance of good health, but in the treat- 
ment of certain diseases." 

The first section deals with normal nutri- 
tion, digestion, absorption and metabolism 
of food, infant feeding, food hygiene, etc.; 
the second section is devoted to diet therapy 
in specific diseases. 

The Long White Line by Herman Kogan. 

309 pages. Random House, New York. 


This is an informal narrative about the 
Abbott Laboratories. Its purpose is to con- 
vey to the general reader an interesting 
account of important achievement by relat- 
ing the events that have shaped Abbott 
Laboratories' first 75 years. 

Midwifery for Nurses by Elliot E. Philipp 

F.R.C.S. and Eva Crisp S.R.N., S.C.M. 

115 pages. H. K. Lewis & Co., Ltd., 

London. Ed. 2. 1964. 

This book is designed as an introduction 
to the three-month preliminary midwifery 
training course offered by training schools 
in Great Britain. It is planned to instruct 
according to the syllabus approved by the 
General Nursing Council and the Central 
Midwives' Board. 

Laboratory Manual and Workbook for In- 
tegrated Basic Science by Stewart M. 
Brooks. 331 pages. The C. V. Mosby 
Company, Saint Louis, 1964. 
This well-illustrated manual and work- 
book includes the essence of chemistry, 
microbiology, and human biology as an in- 
terrelated and integrated body of knowl- 
edge. It also includes 13 selected exercises in 
basic physics and several experiments deal- 
ing with the action of drugs. 

Nursing Studies Index. Vol. IV (1957- 
1959) prepared by Yale University 
School of Nursing Index Staff, under 
the direction of Virginia Henderson, R.N., 
M.A. 281 pages. J. B. Lippincott Com- 
pany, Montreal. 1963. 
This is to be an annotated guide to 
reported studies, research in progress, re- 
search methods and historical materials in 
periodicals, books and pamphlets published 
in English from 1900 through 1959. It is 
intended to serve the interests of all ele- 
ments of the nursing occupation and persons 
outside the occupation seeking information 
on nursing or nurses. It is a must for all 
school of nursing libraries. Volumes III, II 
and I are to be published at a later date. 

Laboratory Manual and Workbook in Micro- 
biology by L. Sommermeyer, R.N., B.S., 
Ed. M. 171 pages. W. B. Saunders Co., 
Phila. Ed. 3. 1964. 

This manual was written to accompany 
the 1 1 th edition of Microbiology for Nurses 
by Frobisher, Sommermeyer and Blaustein. 
The author points out that its effectiveness 
is not, however, limited to users of any 
specific text. The organization of the 
manual proceeds from introductory material 
on the microscope, morphology and staining 
of microorganisms to disinfection and 
sterilization, sanitation, immunity and patho- 
genic microorganisms. 

Cooking for Special Diets by Bee Nilson. 
446 pages. Penguin Books, Distributed by 
Longmans Canada Ltd., Paperback Divi- 
sion, 55 Barber Greene Rd., Don Mills, 
Ontario. 1964. 

The purpose of this pocketbook is to 
help persons who are preparing special 
diets for patients in the home. The author 
believes that it is often difficult for the 
home cook to translate the doctor's instruc- 
tions into acceptable and varied meals. This 
is a book to help cope with such a situation. 
Each chapter carries a brief description of 
the diseases being discussed and indicates 
why special diets are a necessary part of 
the treatment. 

A meal-pattern, based on the good, 
normal diet of average eating habits in 
Great Britain is included. 

The human species, according to the 
best theory I can form of it, is composed 
of two distinct races, the men who borrow 
and the men who lend. 

— Charles Lamb 






Associate Editor 


Senior Assistant Editor 


Assistant Editor (English) 


Assistant Editor (French) 


Circulation Manager 

Canada and Bermuda: 

6 months, $2.25; one year, $4.00; 

two yeors, $7.00. 

Student nurses: 

One year, $3.00; three years, $7.00. 

U.S.A. and Foreign: 

One year, $4.50; two years, $8.00. 
Single copies: 50 cents each. 

For the subscribers in Canoda, in combi- 
nation with the "American Journal of 
Nursing" or "Nursing Outlook": 1 yeor, 

Vake cheques or money orders payoble to 
The Canadian Nurse. 


Four weeks' notice and the old address 
as well as the new are necessary. 

Not responsible for iournals lost in moil due 
to errors in address. 


"The Conadion Nurse" welcomes unsolicited 
articles. All manuscripts should be typed, 
double-spaced, on one side of unruled paper 
leaving wide margins. Manuscripts are ac- 
cepted for review for exclusive publication in 
the "Journal". The editor reserves the right to 
moke the usual editorial changes. Photographs 
(glossy prints) and graphs ond diagrams 
(drown in India ink on white paper) are 
welcomed with such articles. The editor is 
not committed to publish all articles sent, 
nor to indicate definite dotes of publication. 

Authorized as Second-Class Mail by the Post 
Office Deportment, Ottawa, ond for payment 
of postage in cosh. Postpaid at Montreal. 



W Ellll 11 

A monthly journal for the nurses of Canada 

published in English and French by the 

Canadian Nurses' Association 

1522 Sherbrooke St. W., Montreal 

February 1965 — Vol. 61, No. 2 

91 Staffing Problems in Nursing Service 

94 Development of Human Resources 

96 Identifying Nursing Problems 

100 Behavior-Centred Study 

109 Nursing of Children 

1 1 2 Intensive Care Unit 

1 1 4 Cardiac Arrest 

M. M. Street 

J. P. Villeneuve 

M.A. Campbell 

E. Dobbs 

K. Buckland 

Sister C. Marie 


70 Between Ourselves 

72 Random Comments 

111 In A Capsule 

119 Thu World of Nursing 

74 Ph.^rmaceutical and Other 123 Employment Opportunities 

80 About Books 
88 In Memoriam 


136 Educational Opportunities 

139 Table of Contents 

FEBRUARY 1965 71 

r^anJ&m C^mmenis 

Letters to the Editor are weUomc. Only 
SIGNED letters will be considered for 
publication. Name will be withheld from 
the published letter at the writer's request. 
Dear Editor: 

Increasing research has been done in the 
field of nursing education during the last 
decade. Mr. Justice Emmett Hall, Myrtle 
Brown, and Helen Mussallem, to mention 
but a few, have all focused attention on the 
complexity of modern nursing education 

and have proposed changes. Consideration 
is being given to the pressing need for the 
upgrading of the standards of education 
throughout the profession. Many of our top 
educators are striving toward this goal. 

Numerous hurdles must be overcome if 
this is to be accomplished smoothly and ef- 

The shortage of qualified personnel to 
teach at university, collegiate, and diplo- 
ma school levels; 

the financial fiasco where education is 
under the apprenticeship system and is 
financed through hospital budgets and 
few bursaries are available at this time; 

begins with 
weight watching! 

Weight control and general well-being 
depend on avoiding extra calories. 

Using Sucaryl means you can keep 
an attractive silhouette, maintain your 
ideal weight— yet go right on enjoying 
fully sweetened, natural-tasting foods 
and beverages. 

Sucaryl Sweetens 
Without Calories! 

Sucaryl contains no calories at all. 
Whether you are just watching your 
weight, or are on a prescribed low- 
sugar diet, you can use Sucaryl in 
tablet, liquid or granulated form in 
cooking, freezing or canning, as well 
as in coffee and tea. It is not affected 
by heat or cold, has no bitter taste or 

Look for Sucary/ at you r 
drug store— and ask 
for your free copy of 
the 32-page colour 
booklet, "Calorie- 
Saving Recipes with 


Non-caloric Sweetenet 

'Trade Mark Registered 


Halifa* • Montreal • Toronto • Winnipeg • Vancouver 

curricula as varied as the colors in a 
prism with two year programs, two 
years plus one programs, three year 
programs, four year basic baccalaureate 
programs, five, six and seven year pro- 
grams leading to multiple degrees. 

It is concerning curricula that I wish to 
direct attention. If we wait until our insti- 
tutes of higher learning have prepared a 
sufficient number of teachers to adequately 
staff schools of nursing at every level, then 
I am afraid that we are doomed to early 
failure in our quest to attain professional 

It is well-known fact that schools of 
nursing are not able presently to recruit 
qualified staff in sufficient numbers, there- 
fore, I would like to suggest an interim sub- 
stitute, based on personal experience with 
taped lectures. 

It occurred to me — why could not the 
Canadian Nurses' Association library con- 
tain a section of taped lectures prepared by 
broadly experienced nurse educators dealing 
with many facets of core curricula content? 

A committee of consultants could decide 
on suitable topics for taping, select teachers 
to prepare the tapes, select schools of nurs- 
ing for experimentation, evaluate this media 
as a teaching aid. and organize a lending 

Advantages would be: 

Continuity in teaching, specialists pre- 
paring tapes, basic nursing education top- 
ics available to all schools, regardless of 
size and location, opportunity for the 
home teacher to review tapes prior to 
presentation, tapes could be played back 
as often as desired, time saved in prepar- 
ing lectures. 

Disadvantages would be: 

Student attention may not be main- 
tained, inconvenience of having to indent 
for the tapes, tapes may not be available 
when required, initial expense of tape 
recorders for the nursing schools. 

If such a media proved to be advantage- 
ous, it could be implemented in schools of 
nursing from coast to coast, resulting in a 
more uniform basic nursing educational 
program and raised standards. 

George Dawson-North, R.N.. Ont. 


An experimental program being carried 
out at the Regina Grey Nuns' School of 
Nursing in Saskatchewan held graduation 
exercises in November, 1964, for the first 
group of students. The sixteen students of 
this program were successful in their 
examinations, and therefore received their 
registration with their diplomas. The cere- 
mony marked the completion of this twenty- 
two month course. 





Caps have an honorable place in our 
society. Jesters have always worn them, and 
the expression "cap and bells'" stands for 
fun and fooling to all of us; judges wear 
caps on solemn occasions; revolutionaries 
have exalted their cap into a symbol of li- 
berty; thinkers are said to wear a cap when 
they are doing their work. I found, by 
searching in old books, that queens and 
l^otklesses are always pictured as well-cap- 
ped. Any of the caps I have mentioned may 
fit you. 

Never underestimate the jester's cap and 
bells! Nurses need it. to keep their own. 
and their patients' tempers sweet. A joke, a 
smile, an encouraging word will make your 
company and assistance welcome in the 
wards. I shall never forget an incident that 
happened in a military hospital years ago 
when, as a soldier. I contracted that least 
military of diseases — the measles. A sedate 
nun had been squirting fly spray about the 
room in her calm and dispassionate way. 
Just as she finished, a young soldier, dressed 
only in his short nightgown, passed along 
between the beds. Quick as a flash, the nun 
turned and squirted his bare legs with her 
fill gun. and then dashed out the door. 

laughing hilariously as she went! She knew 
the value of the jester's cap. Remember, 
when you don yours, that a little of the 
jesting spirit sits in its crown. 

A judge's cap is no joking matter and 
may have very serious implications. Good 
judgment is part of your daily work. There 
will be times when you will find yourself 
alone, with no help at hand, in an emer- 
gency. Good judgment may then save a life. 

The cap of liberty, often worn in man's 
long history, suggests the nurse's adaptabil- 
ity to change. Nursing can never be static, 
any more than medicine. Your cap is that 
of a revolutionary, although it is a more 
attractive color than red! 

The "cap of thought" suits any line of 
life. "Put on your thinking cap!" is an old 
saying, worthy of our attention. One can, 
of course, slip through life without doing 
much thinking. A hospital or a sick room 
is no place for thoughtlessness. The nurse's 
cap must be a thinking cap! 

Queens have worn caps throughout his- 
tory from the Egyptian Queen Nefertiti to 
our own Queen Elizabeth in her "Cap of 
Maintenance" before the Coronation. There 
is also something royal in the nurse's cap: 

to the patient, his nurse is a queen, or at 
least a fairy princess, with magic in her 
cool fingers, and music in the tap of her 
heels in the corridor. She rules the patient 
in his own best interest (under the doctor's 
orders), and the patient recognizes her regal 
quality. A cap is a linen crown. 

The cap is not very practical; but neither 
are many other attractive things. What, 
then, is its significance? 

First, it symbolizes order. Routine and 
discipline are indispensable in the Temple 
of Aesculapius. Otherwise, the work would 
never get done, and the patient might never 
get better. It signifies cleanliness. And that, 
we are assured, is next to godliness. It 
stands for dependability. This quality has 
to be learned through experience, for none 
of us was born with it. It signifies skill. And 
this comes from learning and from the 
daily application of what has been learned. 

It may be that you who don the cap will 
some day add such lustre to this linen 
crown, that the long list of great and good 
nurses will lengthen to still another page 
in the annals of your chosen profession. — 
Hume Wilkins, assistant principal. Colle- 
giate and Vocational School. Cornwall, Ont. 




(maiden name, if recently married) 





Mail this to: 


1522 Sherbrooke St. W., Montreal 25, P.Q. 








Indications — For emergency splinting of broken or badly-burned 
limbs. This new balloon splint exerts an even pressure and helps stop 
bleeding or escape of body fluids and keeps the limb immobile in an 
extended position. It can also be used to hold limbs in place following 
surgery until a plaster cast can be applied. 

Description — A lightweight inflatable balloon splint made of Capran 
nylon film. It is available as a sterilized, loose-fitting tubular splint that 
con be used directly over clothing or next to the skin. Air is blown 
into the splint after application. 



Indications — For effective and thorough cleaning of surgical, ward 
and laboratory instruments, glassware and equipment. 

Description — An instantly soluble, stable, non-toxic liquid detergent, 
Liqui-nox works well in hard or soft water and is mild to hands. 
Special blood and fat dissolving ingredients eliminate the necessity for 
use of additives. Liqui-nox con be decomposed by present sewage treat- 
ment methods and thus does not contribute to seepage or pollution 



Indications — For treatment of depressive states — especially de- 
pressed mood, depressed psychomotor activity, reduction of drive and 
initiative, listlessness and fatigue. Perfofrone is described as producing 
an increased ability to concentrate and communicate, a brightening of 
outlook and on increase in psychomotor activity. 

Description — Mechanism of action is not clearly established. Each 
beige-colored, sugar-coated tablet contains 25 mg. Pertofrone (desipro- 
mine hydrochloride) and is rapid-acting, well tolerated, and compatoble 
with most other therapies. Supplied in bottles of 50 and 500. 

Dosage — Mild cases: 1 tab. b.i.d. or t.i.d.; severe cases: require 
daily dosage of 100-150 mg. doily. Maintenance dosage after initial 
therapy should be individualized. 



Description — A fine crystalline concentrate which con be applied 
to carpets and upholstery to prevent static shock is available for doctors' 
offices and institutions using large omounts of carpeting. The electrical 
chorges encountered on dry wintery days — generated chiefly through 
walking on carpeting — ore eliminated for up to one year through one 

Information available: Shock Proof Co., P.O Box 4455, Fort Lauder- 
dale, Flo. 



Indications — To relieve pain and muscle spasm of sprains, strains 
and troumotic injuries and for neuralgia, headache, dysmenorrhea, and 
conditions in which pain, fever and tension are symptoms. 

Description — Muscle relaxant and analgesic. Each scored, corol- 
colored tablet contains Carisopordol 200 mg., Acetophenetidin 160 mg., 
caffeine 32 mg. Supplied in bottles of 25 and 250 tobs. 

Dosage — Adult: 1 to 2 tabs, q.i.d. 

Caution — Appearance of skin rash or other symptoms indicates that 
Soma Compound should be discontinued. 



Description — This Lifter is designed for in and out of cor movement 
and motel use. The device fits easily into auto trunk space, and was 
designed specifically for cor travel. The Travel Lifter folds for storage 
into pieces 6 inches in width, 30 pounds in weight. Safety design en- 
ables it to roll easily beneath cars and motel beds. Base width con be 
adjusted readily between 23 and 29 inches while the unit is occupied, 
allowing possage through narrow doors. Lifting capacity is 300 pounds 
over a 25'/2-inch range. The jock controlling up and down movement is 
available in hydraulic or mechanical models. 



Description — A new electrode cream for use in ECG, EEG, and EMG 
studies. It contains a maximum of electrolytes and has an extremely 
high level of conductivity. Hi-Con is completely water soluble and 
washes easily from ikin, linen, clothing, etc. Available in unbreakable 
plastic bottles. 



Indications — A prolonged action ataractic given to alleviate agita- 
tion, apprehension and anxiety; to control withdrawal symptoms of 
alcoholism and drug addiction; for prophylaxis and therapy of nausea 
and vomiting; to potentiate action of barbiturates and analgesics. 

Description — Each capsule contains 75 mg. promazine hydrochloride. 
The therapeutic effect is believed to lost for 10-12 hours in the average 
patient. Promazine is now regarded as on inermediate ataractic, being 
more potent than meprobomote and one-holf to two-thirds as potent as 

Caution — Promazine should be used with caution in patients with 
coronary heart disease. Since Promazine potentiates barbiturates and 
analgesics, the dosage of these should be reduced accordingly. 



Indications — For the suppression of lactation, the control of the 
symptoms of physiologic and artificial menopause, post-menopousal vo- 
ginitis, and the pain of post-menopausol osteoporosis and osseous metas- 
tases of prostatic cancer. 

Description — Vallestril is a synthetic estrogen and is available as 
tablets of 3 mg. and of 20 mg. for oral use. 

Administration — Menopausal syndrome: 6 mg. daily for 3 wks., then 
3 mg. doily for as long as required; lactation suppression: 40 mg. doily 
for 5 days; post-menopausol vaginitis: 6 mg. doily for 4 wks.; post- 
menopausal osteoporisis: 9 mg. daily for 2 wks., then 3 mg. doily as 
maintenance therapy; prostatic carcinoma: 20 mg. daily, reduced if 
possible after the original manifestations are controlled. 

Caution — Vallestril should be given with caution, if at all, to patients 
with a history of genital carcinoma. 

The Journal presents pharmaceuticals for information. Nurses understand that only a physician may prescribe. 





Registered Staff Nurses required for a new Regional 
Neurological centre of 72 beds to be opened in 
July 1965 at Southampton, U.K. Certificate awarded 
on successful connpletion of one year's course. Centre 
comprises neurosurgical and neurological beds, X- 
ray and Out-patient Department, and Operating 
Theatres. Southampton is near the sea. New Forest 
and within easy reach of London. 

For further details apply: 
The Matron 


Tremona Road, Southampton, England, U.K. 

-fim-t^if up^et ( 

The answer: TU MS! 

These mild, minty- 

flavoured tablets will give fast relief 

from heartburn, gas and the 

other discomforts of acid indigestion. 

Keep TUMS in mind when 

your patients ask this question. 

Remember TUMS bring fast, long 

lasting, safe relief . . . and they 

cost so little too. 

for the tummy 

.\n improved sling support for the 
eak. flaccid or injured arm has been devel- 
oped at the Riverview Hospital. Windsor. 

Designed by the staff of the rehabilitation 

Mnit with the cooperation and assistance of 

le ph\siotherapy department, the Classic 

\imsling is simple to make, easy to apply, 


and convenient to clean and store. 

The sling consists of an envelope type of 
support with straps that cross at the back 
and distribute the weight of the affected 
limb to both shoulders. Pressure on the sev- 
enth cervical vertebra, common in the con- 
ventional armsling. is eliminated. The posi- 
tioning of the arm prevents ulnar deviation 

and contracture of the wrist and fingers. 
The sling can be adjusted to the length of 
the arm from elbow to knuckle ioint and 
the fingers may be left free. 

Further information can be obtained by 
writing to; Mrs. B. Murtaugh. Reg.N.. Ri- 
verview Hospital, Windsor. Ont. 

I rant view 

VOl^UME 61. NXraJBER 2 

Back view 
FEBRUARY 196.=i 


Much has been written concerning the 
care of patients in the radiology depart- 
ment. However, from time to time a re- 
minder concerning interpersonal relations is 
essential since there is danger that the work 
may become simply routine. 

The patient leaves behind all the things 
that are familiar to him — family, home, 
acquaintances and possessions. He finds 
himself thrust into an unfamiliar environ- 
ment, where he is surrounded by strangers 
and subjected to treatments and examina- 
tions that he does not understand — espe- 
cially if this is a first illness. His private 
problems, anxieties and sorrows come to 
hospital with him and, in addition, there 
are those arising from his illness: What re- 
sults will the test bring? Will treatment help 
him? How long will he be hospitalized? 
How much time will be required for con- 
valescence? For many there is the worry of 
making ends meet financially after the un- 
expected expense. 

We are very much aware of the hectic 
activity that exists in a radiology service 
on certain days. The patient who may find 
himself waiting nearly an hour for attention 
is more bewildered. The personnel of the 
department must take responsibility for 

creating a relaxed environment — a diffi- 
cult task. Every effort must be made to 
avoid the impression that the patient is 
just a number, a stomach, a gall bladder or 
a cranium. Greeting him by name when he 
arrives in the department; receiving him 
respectfully and with kindness; considering 
his comfort; showing interest in and sym- 
pathy for him help to give him the pleasant 
feeling that he is the one with whom you 
are particularly concerned at the moment, 
even if others are waiting. 

The patient's cooperation is a very im- 
portant factor in achieving a good radio- 
graphic film. We cannot hope to obtain it 
unless we give the impression of knowing 
our business. Professional dignity and a 
calm, assured manner inspire confidence 
and gain cooperation; technical skill helps 
to eliminate doubt. 

Any intelligent person likes to know what 
is going to be done and why. If he knows 
what is in store for him, he will be less 
anxious, less fearful, and ready to cooper- 
ate more effectively. Explain the porcedure, 
the positions necessary and the patient's 
role. Even the very intelligent person is 
likely to react in unexpected ways if he 
finds himself in a situation that he does 

not understand. If possible, a brief demon- 
stration for the patient before the actual 
films are taken and a request to have him 
repeat the instructions given to him will 
confirm whether or not he really under- 
stands thoroughly. Some examinations such 
as x-ray of the gastric tract and gall blad- 
der, pyelogram and myelogram require a 
high degree of patient cooperation. A writ- 
ten explanation accompanied by illustra- 
tions, of the examination in question is 
very effective. The patient understands why 
he must neither eat nor drink, and why, 
for example, castor oil is a necessity! 

Following a period of fasting, the patient 
will be grateful if the examination is car- 
ried out promptly. As soon as it is com- 
pleted he should be returned to his ward 
with a note indicating permis.sion to eat. 
His meal can then be brought to him. 

//. al times, you meet someone who can- 
not give you the smile that you deserve, be 
generous and give him yours. No one has 
as much need of a smile as the one who 
cannot give it to others. — Jean Folio. — 
Therese Bernard, radiological technician 
with the radiology department of St. Vin- 
cent de Paul General Hospital. Sherbrooke, 


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On every ward, when you turn out the lights, some one wakes up . . . and wakefulness thrives 
on minor irritations. Skin discomfort, particularly, can disturb your patients during the night- 
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You will like Dermossage for other reasons, too. A body rub with it saves your time and energy. 
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INDEX for 1964 

Subscribers wishing to receive a copy of this Index, 
free of charge, are requested to complete the form 
below and mail it to the Journal office. 

Many individuals, associations, libraries, etc., are on 
our "permanent" list. Any subscriber wishing to secure 
an Index each year, automatically, please check 
here. □ 




Zone No. 


Number of copies desired 


Regulations made under the authority of 
the Food and Drugs Act contain require- 
ments that if certain types of claims are 
made for a food, either on a label or in an 
advertisement, such claims shall be made in 
a specified manner.... [Certain] regulations 
apply to food to which no vitamins have 
been added; other requirements apply to 
foods with added vitamins. 

These regulations can be interpreted in 
ordinary language to mean that labels or 
advertisements on foods to which no addi- 
tional vitamins have been added, may bear 
no statement with respect to vitamin con- 
tent other than that the food is "an excel- 
lent dietary source" or "a good dietary 
source" of any vitamins that may be men- 
tioned. Furthermore, these statements may 
be made only if the food contains at least 
the minimum amounts of the vitamins listed 
in the appropriate sections [of the Food and 
Drug regulations]. For example, a food that 
contains, without any addition by the man- 
ufacturer, at least 15 milligrams of vitamin 
C (ascorbic acid) in a reasonable daily in- 
take mav be advertised and labelled as "an 

excellent dietary source" of vitamin C. Like- 
wise, a food containing 7.5 milligrams of 
vitamin C may be advertised and labelled 
as "a good dietary source" of vitamin C. 
The manufacturer may not, however, indi- 
cate the actual amount of vitamin C present 
in milligrams per 100 grams. Thus the 
terms "good dietary source" and "excellent 
dietary source" serve as a guarantee of 
mininum potency .... 

As an example of the application of these 
regulations, orange juice may be labelled or 
advertised as "an excellent dietary source" 
of vitamin C since a four-ounce glass of 
orange juice, which is considered to be a 
reasonable daily intake of this food, con- 
tains at least 15 milligrams of vitamin C. 

Towards the end of 1963, the Consumer 
Division of the Food and Drug Directorate 
undertook a survey to determine the con- 
sumers' understanding of these permitted 
claims for the vitamin content of food. The 
survey was conducted by telephone, among 
a random selection of 500 householders 
listed in the Ottawa-Hull and District tele- 
phone directory. 

The following results were obtained: 

1. A percentage of 63.6 . . . had seen the 
phrase "an excellent dietary source" in re- 
ference to vitamins on a label or in adver- 
tising, while only 37.4 per cent had seen 
the phrase "a good dietary source" used; 

2. 50 per cent said there is a difference 
between the products so described and 25.9 
per cent said there is no difference; 

3. of those who said there is a differ- 
ence, 75.4 per cent gave as their reason for 
saying so the fact that the word "excellent" 
means better than "good" . . . 

4. only 35.2 per cent said they were in- 
fluenced in their buying by seeing the terms 
used in labelling or advertising; 

5. finally, 50 per cent said they thought 
the government controlled the use of the 
terms and only 15.6 per cent thought the 
manufacturer could use the terms as he 
liked. — Ordway. Eleanor M. The Con- 
sumer's Understanding of some Permitted 
Claims for the Vitamin Content of Foods. 
Canadian Home Economics Journal, Sept. 





The XIII Quadrennial Congress of the International Council 
of Nurses is being held in June, 1965 in Frankfurt am Main, 
Germany. This is a ten-day congress to which nursing organi- 
zations, hospitals, and other health agencies all over the world 
send representatives. During these ten days, many aspects of 
nursing are reviewed and discussed. Delegates have an excellent 
opportunity to learn about nursing in other countries and to 
meet and become acquainted with people of other races and 
ethnic groups. 

Three years ago. the student nurses of The Montreal General 
Hospital began to make plans to raise sufficient money to send 
a large student representation to this Congress. The students' 
council decided to hold a bazaar, open to the public, in April. 
1963. Work began on this rather industrious project in the fall 
of 1962. Several of the students' mothers kindly devoted a few 
of their evenings to "bazaar bees," where they assisted with 
sewing and knitting problems. All articles were made by the 
students or their families and friends. The bazaar was a great 
success, and a profit of $1,700 was obtained. 

Last year, the executive of the council, with the approval of 
membership, decided to attempt something slightly different. 
This project took the form of a raffle and Scandinavian Air- 
ways donated a return trip ticket to Copenhagen. Each student 
was assigned a book of ten tickets to sell to friends, relatives, 
nurses, and doctors; volunteers went from ward to ward through- 
out the hospital selling tickets to be staff. Mrs. Isobel MacLeod, 
director of nursing, drew the winners name at the general student 
council meeting in April. 1964. This exciting prize was won by a 
former patient. Our LC.N. fund was $1,200 richer. 

This year we are planning to hold another bazaar in the early 
spring. With $2,000 presently in our LC.N. fund, we must raise 
at least another $1,000 to send our five student representatives 
to Germany. The selection of students who will represent the 
School at the Congress took place in September. Fifteen girls, 
nine from the senior class and six from the intermediate class 
were nominated by the teaching staff and students; the nommees 
were subsequently voted upon by staff and students. Charlotte 
Rutherford, president of the Student Council. Ruth Rowan, 
secretary-treasurer of the bazaar, and Heather Campbell, director 
of the "Pyramid" were chosen from the class of 1965: Cristma 
Seibert and Ann Pink will represent the class of 1966. 

Plans for this year's April bazaar are well under way. Many 
students have started work early on hand-knitted and sewn 
articles, and are growing plants, making preserves, etc. Letters 
have been sent out to all parents, informing them of the bazaar. 


fast, lasting relief 
no acid rebound 
contains no laxative 


Charlotte Rutherford and Faith Detchon 


asking for suggestions and donations, and urging them to start 
wort too. The following booths have been proposed: knitting, 
sewing, handicrafts, parcel post, fish pond, plant sale, white 
elephant, and baked goods. We also plan to serve tea and to 
provide a baby-sitting service. 

Our objective of $2.000-$2.500. although rather high, is not 
unattainable. However, every student, parent, friend, and graduate 
of The Montreal General Hospital School of Nursing must feel 
that it is her bazaar. Without each person's assistance and support, 
it will not be a success. We extend a cordial invitation to each 
nurse living within the Montreal area to attend our bazaar which 
will be held April 3, 1965, from 2:00 to 5:00 p.m. in Livingston 
Hall. You will be very welcome. — Faith Detchon. Chairman 
of Program Committee. The Montreal General Hospital, Quebec. 


A two-year college-training program for nurses, conceived 
and developed by Professor Mildred L. Montag of the Depart- 
ment of Nursing Education, Teachers College New York, has 
proved so effective that the number of institutions offering it 
has grown from one to 103 in all parts of the United States 
in the past 12 years. Many graduates have proved as good as. or 
better than, graduates of regular three year hospital diploma 
courses. The two-year training program, leading to an Associate 
Degree, was begun at Teachers College in 1952 to meet a growing 
demand for nurses. Dr. Montag said the program not only has 
the advantage of facter training, but emphasizes the academic 
over the service aspects. It has been felt by many nursing edu- 
cators, Dr. Montag said, that the four-year academic program 
was unnecessary for those who were not planning administrative 
or teaching careers in nursing, and that the three-year hospital 
program, which emphasizes hospital service during training, 
might not produce nurses with a well-rounded education. — 
TC Topics, vol. 12, no. 4, Summer 1964. 



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appreciated the gentle effective 
action of NEO-SYNEPHRINE to 
unstuff his peerless proboscis. 

gives prompt, dependable decon- 
gestion of the nasal membranes for 
the fast symptomatic relief of hay 
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first spray shrinks the turbinates, re- 
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%% SOLUTION in 20 ml. plastic sprays 
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Marriage and Family Living as Self-Other 
Fulfillment by Austin L. Porterfield. 408 
pages. F. A. Davis Co., Phila. 1962. 
Reviewed by Mrs. Hester J. Kernen, As- 
sociate Professor in Public Health Nurs- 
ing, School of Nursing, University of 

The author's objective is to promote 
greater understanding of the principles of 
social psychology as these apply to the re- 
lationships of marriage and family life. He 
points out that decisions must be made in 
all phases of the life cycle of the family 
and that, in a constantly changing society, 
the wisdom of tradition is no longer ade- 
quate. A new wisdom, based on knowledge 
of social psychology, can be applied in all 
human relations but could be of particular 
value in making the decisions and manag- 
ing interpersonal relations within the fam- 
ily. TTie author is chairman. Department of 
Sociology and Anthropology. Texan Chris- 
tian University and it seems likely that the 
book was designed for use as a text in a 
university course on the subject. He ad- 
dresses himself to college-age young people 
and assumes interest in and some familiar- 
ity with the language and concepts of psy- 
chology and sociology. 

Strong disagreement is voiced toward 
existential philosophy and psychology with 
its concept of the individual as essentially 
seeking only self-realization, finding little 
help from others and struggling for freedom 
by himself. Instead "the emphases is on the 
self-other relationship as the basic unit of 
meaningful existence." He takes the point 
of view that the self cannot achieve signi- 
ficance without significant others, especially 
in the family, and that freedom will be 
gained through mutually supportive relation- 
ships with others. Fulfillment is seen as the 
achievement of goals sought by the indivi- 
dual in relation to goals sought by others 
and therefore must be a socialized pursuit 
rather than an egocentric one. 

The focus is on the interaction of the 
marital partners in the immediate context 
of the successive stages of the family cycle 
more than on parent-child interaction. How- 
ever the first section is devoted to a dis- 
cussion of family function and to the fun- 
damental influence on personality develop- 
ment of the child's experiences within the 
family. This illustrates the complexity of 
stimulation and response within a family 
group and the variety of roles involved. It 
also emphasizes that each person brings to 
his own marriage attitudes and values learn- 
ed in a unique family setting. Although the 
author explicitly states that he offers prin- 
ciples for the young reader rather than 
practical procedures, many of the topics are 
presented in a way that would aid a young 
reader in making applications to his own 

situation. One example is the chapter en- 
titled "On Being Qualified to Marry." Con- 
siderable use is made of examples taken 
from well-known works of fiction, drama 
and poetry, and from "own-stories" written 
by former students in the author's class. 
These illustrate vividly the relevance of the 
principles to real-life situations. 

This is a book with much value for the 
reader who will spend some time becoming 
familiar with the vocabulary used and the 
concepts presented. The nurse who works 
closely with families or who feels concerned 
about patients with family difficulties is 
likely to find the latter sections especially 
pertinent. For example in the chapter titled 
"Health Values in Family Interaction," the 
comment is made that when a patient seeks 
psychiatric treatment "the core problem . . . 
seems to be one that his whole family has 
worked to solve for an extended period." 
Therefore, the family needs help in becom- 
ing a more effective problem-solving unit. 
A chapter dealing with transition of the 
family from farm to city contains an in- 
teresting explanation of this in terms of the 
change from a folk-sacred community to a 
secular one and discusses family mobility as 
an index of secularization. In discussing 
religious values in family interaction, the 
author notes that disagreements over reli- 
gion are hard to isolate from other interests 
partly because the liturgical aspects of reli- 
gion are expressed not only in the form of 
church services but also embedded in fam- 
ily rituals. Thus religious differences can 
become factors in other lines of conflict. 

Throughout the book the author supports 
his point of view with evidence drawn from 
a wide range of resources including the 
concepts developed by Freud, Fromm, Erik- 
son and other behavioral scientists, the in- 
sights gained from the work of cultural an- 
thropologists such as Linton and Benedict, 
and the findings from research studies of 
social and behavioral problems carried on 
by many psychologists and .sociologists in- 
cluding the author himself. Frequent refer- 
ences are also made to such well-known 
writers on the family as Burgess and Wal- 
ler. In addition to the usual footnotes and 
suggestions for further reading at the end 
of each chapter, a substantial index of au- 
thors is available. 

Newer Dimensions of Patient Care by Esther 
Lucile Brown, Ph.D. 163 pages. Russell 
Sage Foundation, N.Y. 1964. 
Reviewed by Sister Jane Frances, Direc- 
tor of Nursing, Holy Family Hospital, 
Prince Albert, Saskatchewan. 

The third monograph in this series is 
subtitled "Patients as People," and should 
be in the hands not only of nurses in hos- 




pital and public health agencies, but also of 
administrators, social workers, dietitians, 
doctors and all members of the health team. 
The author seems to "have kept the best 
wine to the last," as she develops the main 
theme by emphasizing the importance of 
knowledge about the psychosocial and cul- 
tural characteristics of patients and of the 
use of such knowledge as a tool in the 
therapeutic situation. 

Admitting clerks supply us with consid- 
erable data which are not sufficiently used 
by personnel planning total care of the pa- 
tient. Such data can be of value in predict- 
ing how patients are likely to respond to 
illness; how patient care plans could be 
fashioned accordingly; and how staff might 
initiate interpersonal relations with fewer 
errors. The author states that "attempts are 
too rarely made to scrutinize the validity of 
generalization or to explore what helpful 
data are available in the social sciences." 

A list of data outlines a profile of a pa- 
tient in a psychosocial and cultural frame 
of reference. The information systematically 
obtained, provides the members of the 
health team with an appreciable pen-sketch 
of the patient as a person. Used in the right 
way, this tool initiates with ease, meaningful 
conversations with the patient. The informa- 
tion so readily available helps us understand 
and help the people with whom we work. 

Dr. Brown states that "health personnel 
often seem lacking in the sensitivity needed 
to recognize that there continue to be psy- 
chocultural differences with possible accom- 
panying stresses that require attention." Her 
third monograph skilfully presents the need 
for an awareness of this dimension of pa- 
tient care. 

Although the examples given are of vari- 
ous ethnic groups found largerly in the 
U.S.A.. the basic principles can be of value 
in any area. The author has given us a very 
practical guide in total care. It should be 
useful not only to the professional, but also 
to the undergraduate as reference material 
to be used in conjunction with her studies 
of the social sciences. 

Essentials of Pediatric Nursing, 7th ed., by 
Florence G. Blake, R.N., M.A. and F. 
Howell Wright, B.S., M.D. 815 pages. 
J. B. Lippincott Company, 4865 Western 
Ave.. Montreal 6, P.Q. 1963. 

This well-known text formerly appeared 
under the title "Essentials of Pediatrics" 
with Philip C. Jeans as senior author. It 
has been completely revised and includes 
units dealing with the newborn, infant, tod- 
dler, pre-schooler, school aged child and 
adolescent. Information concerning growth 
and development has been added; diseases 
and nursing care have been placed in the 
particular age group in which they are most 
frequently seen; an extensive bibliography 
is given at the end of each chapter. 

This well-illustrated text should be use- 
ful for the student or graduate in the pedi- 
atric department. 

The Nursing Care of Children, 2nd ed., by 
Inez L. Armstrong, R.N., M.S. and Jane 
J. Browder, R.N., M.N. 699 pages. The 
Ryerson Press, 299 Queen St. W., To- 
ronto, 2B. 1964. 

Material in this edition has been rear- 
ranged and revised considerably. Growth 
and development, along with some behavior 
problems, have been included in sections 
dealing with the various age levels; discus- 
sion concerning the adolescent is now in a 
separate chapter; new material relating to 
pre- and post-natal disturbances of children 
has been added. The presentation of specific 
illnesses by systems remains, for the most 
part, unchanged. 

Very little information concerning hu- 
man genetics and heredity is to be found 
in this text. Also, it seems to this reviewer 
that inclusion of all the main principles of 
development, in point form, would be lo- 
gical before the discussion of specific de- 
velopment at various age levels. Chapters 
dealing with the various age groups are 
more comprehensive than those usually 
found in a pediatric text; the photographs, 
illustrations and charts in these sections are 

This text should be very helpful to the 
pediatric instructor who stresses growth and 
development in her course; it should also be 
a valuable reference for the nursing student. 


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Simplified Drugs and SoluHons for Nurses, 

3rd ed., by Minette Nast, R.N., M.S. 72 
pages. The C. V. Mosby Company, St. 
Louis. 1964. 

This third edition remains essentially the 
same as the second. Newer drugs have been 
used as examples in the exercises; in several 
places, the material has been rearranged to 
achieve greater clarity. 

This handbook should be useful as a 
concise teaching aid for students. 

Some Clinical Approaches to Psychiatric 
Nursing, edited by Shirley F. Burd. B.S., 
M.S., R.N. and Margaret A. Marshall. 
B.S., M.S., R.N. 379 pages. Collier-Mac- 
Millan Canada, Ltd., Gait, Ont. 1963. 
Reviewed by Miss Leith Nance, B.N., for- 
merly Instructor, Psychiatric Unit, Mont- 
real General Hospital. 

Dedicated to the "Renaissance of Clinical 
Practice of Nursing," this volume will be of 
interest to any nurse who feels that study 
at the university level has led her away 
from the patient. It is, essentially, "a com- 
pilation of clinical papers, research reports, 
and conceptual frameworks" concerned with 
the study of problems of communication be- 
tween patients and nurses. It exemplifies the 
concept that nursing is an educative process 
in which the nurse and the patient are 
interdependent participants. The influence 
of Hildegard Peplau is reflected in a num- 
ber of chapters as well as by virtue of the 
two chapters and forward which she has 

The editors address themselves, primarily, 
to directors of diploma schools of nursing 
and deans of collegiate schools of nursing. 
It is an appeal to them to identify the 
significance of interpersonal problems, and 
to encourage the study of them in a scien- 
tific manner. Several different models for 
reporting results of study of such problems 
are provided. 

This volume — the work of two senior 
participants, assisted by 24 others — is 
made up of 45 chapters, some of which 
are exceedingly brief. In general, the brevity 
enables the reader to grasp the central idea 
and think about it without being encum- 
bered by limitless detail; at times, however, 
brevity takes precedence over clarity. That 
the volume lacks a degree of sophistication 
which would make it read more smoothly 
is illustrated by the fact that some of the 
headings are unrelated and uninformative: 
some of the footnotes are incorrect: and 
quotations are altered. 

The reader might find it helpful to begin 
with chapters one and two. normal and 
abnormal thought processes, proceed to 
chapters 42. 43. and 44 which deal with 
definitions, the learning process and theme 
abstraction, then return to chapter three and 
read the remaining chapters in order. The 
rationale behind such an approach is that 
a good many of the contributors have 
utilized a particular conceptual framework 
in their research. Indubitably, these tech- 
niques are significant and important, parti- 
cularly to those who wish to critically eval- 
uate the methods and the findings. On the 
other hand, some readers may find section 
four. "Conceptual Frameworks" a little 

The studies presented do not offer a pat 
solution to the application of the problem- 
solving approach in nursing: they do, how- 
ever, affirm that studies of this nature can 
lead to a more satisfactory understanding 
of the nurse-patient relationship. Two of 
the most salient aspects of the volume are. 



first, the fact that the questions raised can 
serve in provoking further study of the 
inter-personal process and, second, the ex- 
cellent bibliography. 

This volume, apart from providing in- 
teresting reading, should prove to be valu- 
able to nurse educators in general and to 
those in the field of psychiatry in particular. 

The Psychiatric Aide, 3rd ed., by Alice M 
Robinson. R.N., M.S. 226 pages. I. B. 
Lippincott Company, Montreal. Que 
1964. ^ 

This book describes "the role and func- 
tion of the aide in working with the men- 
tally ill patient. Attitudes rather than pro- 
cedures and technics are emphasized . . . ." 
In this edition, material concerning the vari- 
ous behavior problems, ataraxic drugs, etc. 
has been expanded. 

The Psychiatric Aide is available in paper- 
back or clothbound form. 

A Nurse's Guide to Anaesthetics, Resuscita- 
tion and Intensive Care by W. Norris 
M.D., F.F.A.R.C.S. and D. CampbelL 
F.F.A.R.C.S. 116 pages. E. & S. Living- 
stone Ltd., Edinburgh and London. 1964. 

The authors describe some of the methods 
used by present-day anesthetists and the 
accompanying nursing care. The routine 
pre-anesthetic preparation and supervision 
of the patient is discussed and illustrated; 
a description of techniques used in recovery 
rooms and intensive care units is presented; 
modern techniques of resuscitation are also 

Most of the material in this text can be 
found in surgical nursing texts used in 
Canadian schools of nursing. 

Structure and Function of the Body, 2nd ed.. 
by Catherine Parker Anthony, R.N., B.A 
M.S. 158 pages. The C. V. Mosby Com- 
pany, Saint Louis. 1964. 

The author states that this is a textbook 
— not a reference book — and is limited to 
basic information concerning both struc- 
ture and function. It is written primarily 
for students in practical nursing programs. 
In this second edition, new information 
can be found concerning cells, the hypothal- 
amus, automatic nervous system, the pit- 
uitary and adrenal glands, and various hor- 
mones. The nervous system is presented 
much earlier than in the first edition: more 
emphasis is given to principles of body func- 
tions and the relationship between struc- 
ture and function. 

For some reason, the author has chosen 
to use the second and third person through- 
out the text. e.g. "If you were asked to name 
the sense organs, what organs would you 
name?" "When He look at a person's eyes, 
we see only the surface . . ." (italics ours). 
This "personalized" approach is irritating 
to this reviewer, perhaps because it is gen- 
erally associated with children's books. 

The presentation is clear, concise and 
informative; diagrams are good. This book 
should be of considerable value to students 
in nursing assistant programs. 


Basic Physiology and Anatomy by Ellen E. 

Chaffee, R.N.. B.S., M.N. and Esther M. 

Greisheimer, Ph.D., M.D. 656 pages. J. B. 

Lippincott Co. of Canada. Ltd., 4865 

Western Ave., Montreal 6, P,Q. 1964. 

Reviewed by Mrs. Dzidra Steinbergs, 

B.Ed.M.. Hamilton, Ont. 

This book is a basic text consisting of 
21 chapters for nursing students. The 
first chapter offers hints for successful 
study including "dissection" of scientific 
terms. Listing of common combining 
forms, prefixes, and suffixes is appended. 
Subject matter is approached on the 
basis of body systems. The concept of ho- 
meostasis is introduced early and developed 
further with each new chapter. The endo- 
crine system is contained within the last 
chapter, but the specific hormones influenc- 
ing the functions of a system are included 
briefly within the pertinent discussion. 

Common abnormalities and practical ap- 
plications are meaningfully woven into the 
text and are not singled out at the end of 
each chapter. Description and uses of the 
latest equipment (e.g. artificial kidney), tests, 
diagnostic procedures, commonly used drugs 
and their physiological effects are also in- 
cluded. The authors frequently relate the 
characteristics of a structure and its func- 
tions to nursing problems and care. 

Chemistry is presented in a meaningful 
manner and quantity. The inclusion of mi- 
crobiology principles is very limited. 

Each chapter concludes with questions 
and practical problems useful to both stu- 
dents and teachers. 

The authors have successfully eliminated 
information superfluous to a basic nursing 
text. It should prove a valuable book when 
used in conjunction with advanced refer- 

Fundamentals of First Aid, 2nd ed., by Ro- 
bert A. Mustard, M.D., F.R.C.S.(C.). 119 
pages. Issued by Porcupine Publications 
Ltd. of Montreal by special arrangement 
with St. John Ambulance, Canada. 1964. 

This completely revised edition is written 
for the layman. It avoids highly technical 
language, discards some traditional practices 
which are either unnecessary, ineffective or 
impractical and introduces some new sub- 
jects such as oral resuscitation, external 
heart massage, etc. It is well illustrated. 

The Student Nurse in the Operating Theatre 

by E. Philipp. F.R.C.O.G., and K, L. 
Gearing S.R.N. 62 pages. E. & S. Living- 
stone Ltd.. Edinburgh & London. 1964. 

This handbook is divided into two sec- 
lions, the first for "outsiders" who only 
occasionally go to an operating room, and 
the second for those who are commencing 
their apprenticeship as "insiders." 

Section 1 is subdivided into chapters con- 
cerning the aims of preoperative prepara- 
tion, and how these are fulfilled. The chap- 
ters in Section II describe the functions of 
such member of the operating room team 
as well as usual O.R. equipment and its 


Workbook for Practical Nurses, 2nd ed., by 
Audrey Latshaw Sutton, R.N. 421 pages. 
A W. B. Saunder's publication, available 
in Canada through McAinsh of Toronto 
and Vancouver. 1964. 
This book is "keyed for use with all the 
current practical nurse textbooks , . ." In 
this edition, two new chapters have been 
added concerning personal and vocational 
relationships; new exercises concerning vo- 
cabulary study have been included in the 
section "Structure and Function of the 
Body;" other parts have been completely 
rewritten and expanded. A unit relating to 
the mentally ill patient appears for the first 

Basic Statistics: A Primer for the Biomedical 

Sciences by Olive Jean Dunn. 184 pages. 

John Wiley & Sons, Inc., 605 Third Ave,. 

New York, N.Y. 10016. 1964. 

This book was designed "to serve as a 
textbook for a one-semester course in statis- 
tics for students in the biomedical fields." 
The author expresses the hope that it will be 
useful to physicians, nurses, etc. who are 
involved with research projects. 

Contents include: populations and sam- 
ples; description of a sample — frequency 
tables and their graphs, measures of loca- 
tion, and measures of variability; normal 
distribution; estimation of population means 
— ■ confidence intervals; variances — estima- 
tion and tests; regression and correlation. 
Exercises for self-testing are given at the 
end of each chapter and some of the an- 
swers are provided at the back of the text. 

Clinical Nursing: A Helping Art by Ernes- 
tine Wiedenbach, R.N., M.A. 118 pages. 
Springer Publishing Company, Inc.. New 
York. 1964. 

This book concerns the professional dis- 
cipline of nursing, specifically clinical nurs- 
ing, which it recognizes as a helping art ... . 
The principal character in the book is 
the nurse who is caring for a patient. The 
elements of her practice are examined and 
the process which determines it is exposed 
.... The book also identifies theory under- 
lying clinical practice. 

Introduction to Human Anatomy, 4th ed., 
by Carl C. Francis, A.B., M.D. 478 pa- 
ges. The C, V. Mosby Company, Saint 
Louis. 1964. 

The author's objective is to "present in 
the smallest possible compass the essential 
facts of human anatomy." He puts stress 
on the function of each part and on the 
integration of each tissue and organ of the 

In this edition, more coverage has been 
given to certain areas of the body. Three 
hundred and twenty-five illustrations and 25 
color plates help to clarify the text. Many 
of these are detailed to an extent not found 
in books that include extensive physiological 
description as well as anatomy. For these 
reasons, this book should be a welcome ad- 
dition to any school of nursing library; it 
would also be a helpful reference for nurs- 
ing instructors. 



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the front, with straps attached to loops in 
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Travel is always pleasant, and for the 
wise traveler, perfectly healthful. If you are 
planning on going abroad this winter, be 
sure you are protected. 

A smallpox vaccination within the last 
three years is required to enter most coun- 
tries (including return to Canada). Moreover, 
If you are traveling in countries where yel- 
low fever or cholera are prevalent, vaccina- 
tions for these diseases are advised. Yellow 
fever vaccination is good for six years, but 

cholera should be renewed annually. 

Immunization against typhoid and para- 
typhoid are also recommended for foreign 
travel; protection lasts one to two years. This 
Is also a good time to be sure that your 
Immunizations to tetanus, diphtheria and 
poliomyelitis are up-to-date; boosters are 
necessary every five years. 

Vaccinations must be recorded on an In- 
ternational Certificate of Vaccination docu- 
ment (available at public health agencies, or 

through your travel agent) and must be 
validated with the stamp of the local health 
department or other stamp approved by the 
public health service. Health leaflets for 
prospective travelers entitled "So You're 
Going Abroad" and "Immunization Infor- 
mation for International Travel" can be 
purchased at five cents a copy from the 
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Toronto, Ontario 



84 FEBRUARY 1965 


MAY 31 -JUNE 3. 1965 







JUNE 2-4, 1965 




(Grad'jates who have not received 
notice of the reunion should send 
their address to the Alumnae Office. 
Nurses' Residence, Hamilton General 

MARCH 14-20. 1965 


Canada's 21sf Annual 
National Health Week 


' CANADA 19G5 

ii rm^ 

Like any other child, the crippled 
youngster enjoys the things of nature. 
Your Easter Seal contribution helps 
this little girl live as normal a life as 


Now - the history of nursing in Canada surveyed 

in a completely new section added 

. 1 ,, I ,, if to this popular text 

Consider this new edition 

for your "History of Nursing" 

course next semester 

Eighteenth century hospital. One of 43 illustrations in this new edition. 

New 5th Edition! 


Several new features, including a unit on "Nursing in Canada", 
have been incorporated in the new edition of this popular his- 
tory of nursing textbook in order to make it truly comprehensive 
and to show the relationship of Canadian nursing with nursing 
in the United States. This unit, written by Mary B. MUlman. 
R.N,. B.A., presents the history of nursing in Canada, modern 
curriculum procedures in the country and the relation of Cana- 
dian university and nursing education. 

If you teach "History of Nursing", you will want to consider 
adopting this new edition as your required text. For more 
thorough understanding, it has been extensively revised and up- 
dated and has more interpretive discussion than previous editions 
had. It not only reports trends and events in history but also 
translates the significance of these events into their relation with 
up-to-date methods in today's expanding medical research. 



Updated discussions deal with: D the overall place of nursing 
in relation to the increasing growth of medical research and 
clinical experience; Q different types of nursing programs and 
the expanding opportunities for the graduate nurse; i_^ legal 
aspects of nursing; and Q international advances of nursing. 

The organization of this text, with individual sections created 
independent of each other, allows you to teach without following 
a strict progressive sequence. The directness, simplicity and un- 
derstanding which was apparent in the original edition written 
by the renowned educator. Deborah MacLurg Jensen, remain 
throughout this new edition. 

GRIFFIN R N , B.S., M.A. With a special unit on legal aspects of nursing 
bv EIWYN I. CADY, Jr., IL.B., B.S. Med., and a special unit on Canadian 
nursing by MARY B. MILIMAN, R.N., B.A., formerly Professor of Nursing, 
Snversity of Toronto, Toronto, Ontario, Canada. Publication date: Januonr. 
1965 5th edition. 5ra pages, 6V2" x 9V2". 43 illustrofons Price S6.75 

.4 New Book! 


A Programmed Presentation 

This programmed text-workbook is designed especially to help 
student nurses in "Dosage and Solutions" courses recall mathe- 
matical procedures and systems and to develop greater skill in 
this often difficult area — individually or with little or no class 
lime instruction. It presents ratio and proportion, percentage 
and all other systems and procedures students will need to know 

m preparing drug dosages and solutions. Principles in each 
frame are demonstrated through model examples. Answers to 
exercises are provided immediately to reinforce the learning 

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CI M r^ c I Q (~» -7 

Answering your questions about 


Which Armed Service may I join? 

A nurse may enrol in the Navy, Army 
or Air Force, but she is assigned for 
duty with the Canadian Forces Medi- 
cal Service. 

What is the Canadian Forces 
Medical Service? 

The CFMS incorporates all medical 
personnel of the three Armed Serv- 
ices and is responsible for the health 
and medical care of all military per- 

Where would I serve? 

A CFMS nurse may be sent to a 
Canadian military installation any- 
where in the world although nor- 
mally her service is restricted to 
Canada and Europe. 

What types of nursing duties are 

Nursing includes service in CFMS 
hospitals, including operating room 
and out-patient departments, public 

health nursing, flight nursing and 

How am I trained? 

On enrolment CFMS nurses are 
taught the responsibilities of an offi- 
cer and oriented to military nursing 
at the Canadian Forces Medical Serv- 
ice Training Centre. 

How can I qualify? 

You must be a registered nurse and 
a current member of a Provincial 
Registered Nurses' Association, 
single, under 35 years of age and a 
Canadian citizen or other British 
subject with the status of "landed 

Where can I obtain further infor- 

Write, visit or call your nearest 
Canadian Armed Forces Recruiting 
Centre or write to: 





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Anderson -BASIC patient care 

Here are step-by-step programed instructions in 
the basic nursing techniques all students must 
master. From material introducing the student to 
her role in care of the patient . . . through pro- 
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frames". They lead the student firmly and stead- 
ily through; how to make beds, move patients, 
serve meals, preserve privacy, avoid unnecessary 
strain, etc. Each new fact is introduced as a 
separate and distinct step. The student is required 
to write the correct answer to a pertinent question 
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This is a complete handbook, geared for use as a 
text in an in-service training program, and also as 
a personal review guide for the aide. It covers vir- 
tually every clinical hospital procedure an aide 
might be called upon to perform. Miss Abdallah 
gives specific, step-by-step directions on: hed-nwkin.w 
— taking lite pulse, temperature and respiration- 
moving and lifting patients — sterile technique^ 
assisting with gastric suction, lavage, and feeding 

care of the immobilized patient, the chronically 

ill, the terminal case, the child — etc. This text 
material has been tested extensively, proving itself 
both in the classroom and in the hospital. The 
author also provides an introductory section on 
orientation and hospital ethics which acquaints 


The confusion surrounding "Drugs and Solu- 
tions" will be immeasurably clarified for the 
student nurse using this programed text. It is 
organized in short, easy steps, proceeding from 
simple to complex material in a logical manner. 
The authors teach the student a simple, easier 
to understand Ra'io and Proportion method for 
calculating dosages and preparing solutions. This 
system clears away the tangle of difficult mathe- 
matical formulas which impede the progress of 
so many students. Once the proportional method 
is grasped, the student can solve any problem. 
Programing this material has made it even more 
accessible "and clearly understandable. Kach new 

that imprints important facts firmly in the mind. 
The student proceeds at her own only 
by her understanding of the material as it is pre- 
sented. This unique program has been extensively 
tested at nursing schools with varied curricula. It 
provides sufficient detail to allow the student to 
function in a real situation once she has com- 
pleted the text. Each unit has a vocabulary list of 
new words, tear-out test sheets and instructor's 

By MAJA C. ANDERSON, M.N., Director, School of Nursing, 
Stole University of New Yorlc, Upstote Medicol Center, 
Syrocuse, New York. 234 pages, 7'4" x 10>4", illustrated 
About S3. 55 New— Ready February, 1965 

the student with training requirements, correct 
appearance and behavior, hospital etiquette, etc. 
.\ well-organized section presents basic human 
anatomy geared to the aide's level and arranged 
according to major body systems. This compre- 
hensive text not only clearly shows the nurse's 
aide exactly how to perform her duties, it also 
gives her a clear insight into her essential part in 
patient care. A large teaching guide is also avail- 
able, which gives basic outlines to follow and 
answers to questions posed in the text. 

By MARY C. ABDAllAH, R.N., Formerly In-Service Director 
of Nurses, St. John's Hospital, Oxnord, California. About 
180 pages, TV x lO'i", illustrated. About S3.05. 

New — Ready ionuory S, 1965 

fact is presented in a sequential step. The correct 
answer must be written, before proceeding to the 
next frame. The student thus gets prompt feed- 
back on her understanding, plus a reinforcing 
effect that fixes important facts firmly in mind, 
■you'll find the topics embrace the content of the 
typical Drugs .aiul Solutions (Pharmacology I) 
course, from material on Apothecaries' and Met- 
ric Systems, to Preparing Large Amounts of Solu- 
tions for Treatments. 


both of the Athens General Hospital, Athens, Georgio. \'ii 
pages, 5Vt" x 7'/,", About $3.05. 

New — Ready January, 1965. 

PeLLEY — NURSING Its History, Trends, Philosophy, Ethics, Ethos 

This text closely follows Canadian nursing school 
curricula. It developed from the author's class- 
room lectures at Port Arthur General Hospital. 
Miss Pelley skillfully combines both nursing his- 
tory and professional adjustments in this compact 
volume. She begins with a concise account of the 
development of nursing from earliest times to the 
present. The remaining pages are devoted to clear 
and practical discussions designed to help the 
Canadian nursing instructor prepare her students 
for a nursing career by today's standards. 'Vou'll 
find a wide scope of interesting topics, ranging 
from patterns of nursing activity in medieval 

Europe to the responsibility involved in being a 
registered nurse. Chapters are devoted to Meeting 
the Spiritual Needs of the Patient — Economic 
Welfare and Budgeting — Legal Aspects of 
\ursing — Careers in Nursing — etc. With this 
vital classroom aid the student will gain a fuller 
understanding of the trends which have resulted 
in modern nursing — and a solid background for 
the transition to the graduate nurse's duties and 
place in her profession. 

By THEIMA PEllEY, R.N., Director of Nursing, Stortford 
Generol Hospitol, Stratford, Ontorio, Conado. 319 pages. 
5U' X TV.-. $3.80. Nawl 

Gladly sent to teachers on approval 


West Washington Square, Phila., Pa. 19105 

Canadian Representative: 

McAinsh and Co. Ltd. 

1835 Yonge St., Toronto 7 




The need to care for others 

Always ready to understand, to help— the nurse is 
imbued with the patience and warmth demanded 
of those who aid the sick, the helpless, the very 
young. We are all indebted to the nursing pro- 
fession for its devotion to the needs of others. 





J^tal^hna l^yobiemd 


r/urdina S^eruLce 


// a key lo the intricacies of staffing exists, it will be found 
in the identification of patient needs and the kinds and 
amount of nursing care required to meet these needs. 

Margaret M. Street, m.a. 

Staffing of hospital nursing service 
IS an area of great concern to directors 
of nursing and to all who share the res- 
ponsibility for providing safe and ef- 
fective patient care — hospital boards, 
administrators, government, and mem- 
bers of other health professions. The 
hospital has a moral and a legal res- 
ponsibility to provide safe patient care 
and to maintain good standards of ser- 
vice. To accomplish this, an adequate 
number of qualified nursing service 
personnel must be in attendance. 

The nursing staff of any hospital ac- 
counts for 60-65 per cent of the total 
personnel; and salaries for this group 
are by far the most substantial item in 
the hospital budget. This, plus the fact 
that hospital costs are on the increase 
and hospitals have to compete with 
other essential public services for a 
share of the tax dollar result in careful 
scrutiny of staffing by those responsible 
for hospital financing. The implica- 
tions for nursing service are clear. 
Murse administrators must try to assess 
staffing needs accurately and soundly; 
to prepare and justify the budgetary re- 
quest for nursing service personnel; to 
administer the personnel resources wi- 
sely and economically; and to evaluate 
the adequacy of personnel to meet the 
nursing needs of the patients effective- 
ly. It is in the areas of assessing and in- 

Miss Street is assistant professor. School 
of Nursing. University of B.C. This address 
was presented at a meeting for directors of 
nursing at the AARN convention in 1964 


lerpreting staffing needs and evaluating 
the adequacy of staffing that most dif- 
ficulty has been encountered. 

"Necessary Nursing Service" 

Under the Federal Hospital Insur- 
ance and Diagnostic Services Act, as- 
sented to on April 12, 1957, provision 
was made for coverage of "necessary 
nursing service." In the seven years that 
have elapsed since the inaugiiration of 
the Federal-Provincial Hospital Insti- 
rance Program, no satisfactory defini- 
tion of necessary nursing service has 
been forthcoming. This is one of the 
most crucial questions currently con- 
fronting the nursing profession. To 
whom can government bodies, hospital 
boards, and administrators turn for an 
answer to this question, if not to us, 
the members of the nursing profession? 
And what sources may we tap in an ef- 
fort to find the answer? I believe the 
following to be rich reservoirs upon 
which we can draw: 

1. Official pronouncements of the orga- 
nized nursing profession, national and pro- 

2. nursing service literature and research; 

3. the day-to-day experience of depart- 
ments of hospital nursing service. 

Official Pronouncements 

Official pronouncements of national 
and provincial nursing associations in 
Canada offer considerable guidance in 
staffing and administering the hospital 
nursing service. Statements of belief 
have been made about nursing, nursing 

care and nursing service; the role of 
the professional nurse; the role of the 
auxiliary nursing worker; principles in 
the utilization of nursing service per- 
sonnel; the role of the nursing student; 
recommended policies and practices in 
nursing service; current nursing servi- 
ce problems and recommended ap- 
proaches to their solution; present and 
anticipated future needs for nursing 
service; and personnel resources requi- 
red to meet these needs. Surely from 
this rich storehouse of nursing exper- 
ience and wisdom, guidelines could be 
drawn for staffing and evaluating the 
hospital nursing service. 

Because of the uniqueness of the si- 
tuation and the staffing needs of each 
hospital, it is neither realistic nor sound 
for the nursing profession to recom- 
mend quantitative staffing standards 
which would apply to all institutions. 
But it seems both realistic and desira- 
ble that the organized nursing profes- 
sion supply a set of guiding principles. 
Staffing patterns for nursing units could 
then be drawn up within this general 
framework, in relation to the needs of 
each hospital. Would not the develop- 
ment of such a statement of principles 
be a worthy project for committees on 
nursing service, national and/or pro- 

There is abundant evidence that our 
nursing organizations have not been 
apathetic or lacking in a vigorous ap- 
proach to the problems of staffing. But 
the extreme complexity of the subject, 
the uniqueness of each patient's needs 
and of each staffing situation, and the 

FEBRUARY 196.=i 


limited research in this area — parti- 
cularly in Canada — are in large mea- 
sure responsible for the continuing con- 
fusion surrounding the vitally-impor- 
tant question, "What is necessary nur- 
sing service?" 

Literature and Research 

Nursing service literature and re- 
search can help the nurse administra- 
tor to assess the staffing needs of the 
hospital nursing service, interpret the- 
se needs, and evaluate the nursing ser- 

A steadily growing amount of litera- 
ture can be found concerning nursing 
service administration and staffing as- 
pects. During the past two years, a 
Task Committee of the Committee on 
Nursing Service of the Canadian Nur- 
ses' Association has been engaged in a 
review of the literature on staffing the 
hospital nursing service. It is hoped 
that this study may reveal trends in ap- 
proaches to staffing and a composite 
picture of the findings of research. 

Nursing service research in Canada 
has been relatively limited to date whe- 
reas in the United States the volume of 
research in this field has increased 
steadily over the past twenty-five years. 

Research in U.S.A. 

1925-50: In this quarter century, re- 
search related to hospital nursing ser- 
vice centred largely around the deter- 
mination of quantitative standards of 
staffing, expressed in terms of average 
hours of general nursing care per day 
for patients in various clinical services, 
and optimum ratios of supervisors, 
head nurses, and orderlies. Generally 
speaking, standards were derived from 
surveys of existing staff patterns in de- 
partments of nursing of selected hospi- 
tals recognized as giving quality pa- 
tient care. Yet, as early as 1937, it was 
recognized that staffing standards 
should be based on assessment of pa- 
tients' needs rather than on current 
practice. In a research report published 
in that year, the recommendation was 
made that the average bedside nursing 
hours provided for patients in the me- 
dian hospitals surveyed be adopted as 
a minimum standard. This recommen- 
dation was accompanied by the follow- 
ing statement: 

The fact that stands out clearly, however, 
is the need for information based upon 
sound investigation of the factors essential 
for organizing and evaluating hospital nur- 
sing service. The recommendation that all 
hospitals provide at least the average num- 
ber of hours of bedside nursing found to 
be available on the median or typical ward 
units is submitted, not because they are 
known to be right, but because from the in- 
formation offered by this study it would ap- 
pear to be a practicable recommendation for 

the present. The next step is to determine 
what the right number of hours of nursing 
care for various categories of ward patients 
should be. * 

Recommendations were made for 
further studies; 

To determine the average number of bed- 
side nursing hours required for the good 
care of patients on at least the four major 
services: medical, surgical, pediatric, and 
obstetric, in acute general hospitals. 

To determine the kind and amount of 
nursing required by the different types of 
patients with prolonged illnesses. * 

It is significant that the soundness 
of establishing staffing patterns by 
assessment of patients' needs rather 
than basing standards on current prac- 
tice is recognized by many; yet relati- 
vely little progress has been made in 
this direction. 

Gradually, during this 1925-50 pe- 
riod, the emphasis shifted from a re- 
commendation of set quantitative stan- 
dards of staffing for all hospital depart- 
ments of nursing to a recognition of 
the multiplicity of factors that make 
each department and each hospital 
unique in its staffing needs. The 1950 
Hospital Nursing Service Manual ad- 
vocated that each hospital, depending 
on the factors influencing staffing 
which were inherent in its own situa- 
tion, adopt policies and measures to 
govern its staffing of nursing personnel, 
with particular reference to average gen- 
eral nursing hours required by each 
patient. ** 

1950-64: Main areas of hospital nur- 
sing research in the U.S.A. during the 
past fourteen years are: 

1. Organization of the hospital nursing 

a. Research in team nursing; 

b. research in progressive patient care 
and its implications for nursing service, 
patient care. etc. 

2. Utilization of nursing service person- 

a. Studies of functions, standards and 
qualifications of nursing personnel, pro- 
fessional and non-professional: 

b. activity studies; 

c. studies of the use of floor managers, 
ward clerks. 

3. Staffing: 

a. Studies to determine staffing stan- 

* Committee on Studies, National League 
of Nursing Education, A Study of the Nurs- 
;>!j? Service in Fifty Selected Hospitals. Re- 
printed from Hospital Survey for New York, 
2:355-429. Published by the United Hospital 
Fund of New York, 1937. 

** Committee of the American Hospital 
Association and the National League of 
Nursing Education, Hospital Nursinf; Serv- 
ice Manual, New York. National League of 
Nursing Education, 1950. 

dards according to needs of patients in 
various categories according to acuity of 
illness and dependency. 

b. studies to determine the effectiveness 
of various staffing patterns in nursing 

c. studies of factors in selected institu- 
tions affecting the numbers of nursing 
personnel required; 

d. studies of job satisfaction, turnover, 
and so forth. 

4. Evaluation of Nursing Service: 
Studies to develop criteria by which to 

evaluate the quality of nursing service ad- 

5. Nursing Care: 

Studies to develop approaches to identifi- 
cation of the needs and nursing problems 
of patients. 

A highly significant research project 
in nurse staffing was carried out at the 
Johns Hopkins Hospital, Baltimore, 
Md. and reported in the May 1, 1961 
issue of Hospitals. An article by Ruth 
Preston, a nurse member of the re- 
search team, appeared in the July, 
1962, issue of Nursing Outlook, under 
the title, "Add Meaning to Your Hos- 
pital Census." The purpose of the stu- 
dy was to investigate ways and means 
of matching personnel (and other) re- 
sources to patient needs. In the cour- 
se of the study, much work was done 
in the development of a guide to be 
used by head nurses in classifying pa- 
tients into categories. A checklist was 
also prepared for the daily use of head 
nurses in indicating the components of 
nursing care for individual patients, 
which in turn could be used in their 

Research in Canada 

1945-50: Studies of nursing needs 
and resources were carried out as part 
of provincial health surveys, prepara- 
tory to the establishment of the National 
Health Grant Program. Outstanding 
among these nursing surveys was that 
directed by Rae Chittick in Alberta. 

1950-64: Formal research projects 
and other nursing service studies car- 
ried out in Canada during this period 

I . A ctivity Studies 

a. A study of the functions and activities 
of head nurses in a general hospital was 
carried out by the Research Division of the 
Department of National Health and Welfare 
at the request of the Canadian Nurses' Asso- 
ciation and published in 1954. 

b. Research into better patient care and 
nursing activities was conducted at the No- 
tre-Dame Hospital. Montreal, under the 
direction of J. W. Willard, Director of Re- 
search Division, Department of National 
Health and Welfare. The report appeared in 
Tlie Canadian Nurse in French, October, 
1957, and in English. December. 1958. 




c. A time and activity analysis of the nur- 
ng personnel on eleven patient units of the 

University Hospital. Saskatoon, was made 
under the direction of Dorothy Hibbert. The 
report was published in 1963. 

d. Nursing activity studies have been and 
re currently being conducted at the request 

of individual hospitals in Ontario by the 
nursing consultants of the Ontario Hospital 
Services Commission. .\n interim report ap- 
peared in the March. 196?. issue of Cana- 
lian Hospital. 
2. Studies by Individual Hospitals 

a. A three-year study of staffing in rela- 
tion to patient needs was made at the Mont- 
real Neurological Institute. This was report- 
ed by E. Flanagan and I. Herdan. in The 
Canadian Nurse, November. 1955. 

b. A survey of nursing service at the Cal- 
gary General Hospital was carried out over 
a period of one and one-half years, and was 
reported in an article by G. M. Hall and 
Vf. Street, in The International Nursing Re- 
view. October. 1959. 

c. A study was made at the Pearson Hos- 
pital. Vancouver, of the nursing care requi- 
rements for a poliomyelitis unit. It was re- 
ported by E. Paulson and associates, in the 
July, 1963 issue of The Canadian Nurse. 

d. A study was carried out by the nurs- 
ng personnel at the Provincial Mental In- 
titute, Edmonton. January 2-15, 1964, of 
ne nursing needs of 529 patients in eight 
emale wards. Although the report of this 
xcellent study has not been published to 

date, the writer has been privileged to read 

it and considers it a study of real value, 

particularly because of the attempt made 

to identify the triple level of functioning 

•nd consequently the nursing problems and 

leeds of this very large group of patients. 

?. Studies of Nursing Care 

.\ well-known study in the area of nurs- 

ng care was that of the experience of eight 

.ardiac patients during a period of hospi- 

alization. This was conducted by Margaret 

\llemang. University of Toronto School of 

Nursing, and reported in The Canadian 

S'urse. August. 1959. 

4. Evaluation of Nursing Service 

.\s you are well aware, a major research 
project is currently under way. conducted 
^y Lillian Campion, Canadian Nurses' As- 
sociation. The report of this study on eval- 
uation of the quality of nursing service, 
is awaited eagerly by those responsible 
for administration of the hospital nursing 

5. Provincial Surveys 

Since implementation of the Hospital In- 
surance Program, in 1957. studies or sur- 
veys of hospital nursing services have been 
made under government auspices in Alber- 
ta and in Saskatchewan. Currently, the Reg- 
istered Nurses' Association of British Co- 
lumbia and the B.C. Hospital Association 
:ire exploring the possibility of a research 
project in relation to staffing of nursing de- 
partments in hospitals of the province. 
From this verv brief overview of 

nursing service research in the U.S.A. 
and Canada, it can be seen that a fair- 
ly intensive attack has been waged on 
some nursing service problems related 
to staffing. An encouraging beginning 
has been made, both in formal re- 
search and in studies launched by in- 
dividual hospitals, in regard to assess- 
ment of patients' needs and nursing 
problems as a starting point in staffing 
estimations. Our national association 
has developed and is now testing cri- 
teria by which to evaluate the quality 
of nursing service. It must be remem- 
bered that it is a responsibility of a 
professional group — and a mark of 
professionalism — to engage in re- 
search in an attempt to enlarge its 
body of knowledge. We must recog- 
nize, also, that research, by its very 
nature, is slow and painstaking. It is 
also very costly in terms of human ef- 
fort, time and money and must be 
planned with great care and a clear- 
cut purpose. Meantime, nursing serv- 
ice problems are acute and pressing. 
We are still in urgent need of an an- 
swer to the question, "What is neces- 
sary nursing care?" 

Day-fo-day Experience 

A valuable source of information on 
which to base assessment of staffing 
needs and evaluation of the adequacy 
of staffing is, of course, the day-to-day 
experience in the nursing units. This 
necessitates continuous round-the-clock 
supervision and evaluation of the qual- 
ity of nursing service and patient care. 
It necessitates a systematic, continuing 
analysis of problems related to staffing 
and the nursing care of patients. It 
also means that records of this daily 
experience need to be kept consistent- 
ly and analyzed. Since recording is 
time-consuming, and time is a precious 
commodity in nursing service admin- 
istration, careful planning must be 
done by the director of nursing with 
her supervisors and head nurses to de- 
cide the type of data required, and 
how, when, and by whom they will be 
gathered and recorded. The use to 
which such information will be put 
must be pre-determined. 

In many departments of nursing 
service, it is customary to keep a daily 
record of the patient census and aver- 
age nursing hours given to patients in 
each nursing unit. Hours of care may 
be broken down into those given by 
professional and those by non-profes- 
sional nursing service personnel. Pro- 
fessional hotirs may be divided into 
those given by registered nurses and 
those contributed by nursing students; 
numbers of private duty nurses on 
each unit are noted. Limitations in this 
kind of recording are that it often 
makes no provision for indicating the 

acuity ot patients" illnesses nor the 
kind and amount of care required by 
the patients in a given unit on that 
day. This kind of information is, of 
course, available through reports from 
nursing unit and supervisory rounds. 
Thus the record of average hoxirs of 
nursing care becomes very meaningful 
from the point of view of day-to-day 
administration of the nursing depart- 
ment. However, unless provision is 
made for including data about the 
nursing needs of patients and related 
activities of nursmg staff in the rec- 
ord, it may fail to serve a useful pur- 
pose from the point of view of evaluat- 
ing the adequacy of the staffing pat- 
tern in a unit, and preparing and in- 
terpreting the budgetary request for 

Another limitation that has been ob- 
served in the recording of average 
hours of nursing care is the lack of 
uniformity from one hospital or de- 
partment of nursing to the other with 
regard to what is included in these 
hours. Such lack of uniformity may 
not be directly detrimental to the in- 
dividual hospital; but it may well pre- 
sent a handicap in statistical studies, 
and in nursing service research. 

Mention was made of the staffing 
research carried out at Johns Hopkins 
Hospital. The writer is impressed with 
the excellence and practical value of 
the tool developed in the study to as- 
sist in identification of patients' nurs- 
ing needs and classification of patients 
on this basis. A checklist of this kind, 
if kept daily by each head nurse and 
analyzed by the supervisor, should re- 
veal a pattern of ward dynamics and 
patterns of patient needs that would 
have definite usefulness in predicting 
staffing requirements on both short- 
range and long-term bases. The value 
of this kind of information in inter- 
preting and justifying the staffing re- 
quests can scarcely be over-estimated. 
Perhaps the consistent gathering and 
analysis of data about patients' needs 
would ultimately make it possible for 
the nursing profession to give realistic 
guidance to those responsible for hos- 
pital financing in this country as to 
what constitutes "necessary nursing 

Through the diligent use of the vari- 
ous sources considered in this paper, 
and through the pooling of experiences 
and probfems by those who are re- 
sponsible for administering hospital 
nursing services, progress will be made 
toward the goal which we all cherish 
— "the unsurpassably excellent care 
of the patient."! 

t Herman Finer. Administration and the 
Nursing Services, New York. The Macmil- 
lan Company. 1952. p. 26. 





The ability to continuously motivate individuals to maximum per- 
formance is an essential characteristic of a manager or anyone 
aspiring to such a role. 

Jacques P. Villeneuve 

The Resources of an Organization 

Any organization, regardless of its 
nature — industrial, commercial, gov- 
ernmental, hospital or otherwise — 
has five basic resources. The role of 
management — supervisors, managers, 
and senior executives — is to use ef- 
ficiently resources to achieve the aims 
and objectives of the organization. The 
five resources are: 
Financial resources; 
material resources (for example, the hospital 

itself, its equipment, its raw material); 
human resources; 
ideas; and 

The first four are obvious. The fifth 
when applied to the hospital really 
refers to the patients. This may seem 
to be a rather harsh statement, how- 
ever, the hospital does exist for the 
care of patients and, consequently, the 
sick do constitute the hospital's mar- 
ket. In other words, it can be said 
that the care and cure of illness is of 
course, the first objective of the hos- 

The point to keep in mind here is 
that neglect of attention to or lack of 
success with any one of these five 
resources will, in the long run, hinder 
the hospital or any other organization 
in the attainment of its objectives. One 
weak functional area or one weak re- 
source weakens all others; that is, a 
chain is only as strong as its weakest 

Of all the resources at our disposal 
the one requiring most attention and 
greatest skill in handling is the human 
resource. The human resources of any 

Mr. Villeneuve is vice-president, person- 
nel. Johnson and Johnson Limited, Mont- 
real. This article is adapted from an address 
to the Association of Nurses of the Province 
of Quebec. 

enterprise include all employees, re- 
gardless of their respective positions 
in the organization. Efficient manage- 
ment is first and foremost the manage- 
ment and development of human be- 
ings and not the direction of things. 
Direction of an organization re- 
volves around and includes the human 
element. This does not mean that the 
attention of the supervisor, manager, 
or senior executive should be concen- 
trated exclusively on people. It simply 
implies that the development of human 
resources requires: that both manage- 
ment and employees accept certain 
basic concepts; that there is under- 
standing and application of a method 
or course of action that encourages 
the development of individual talents 
at work; that this plan is carried out 
steadfastly and with sincerity. If prop- 
erly implemented, the end result will 
be a sharp upward curve in the effi- 
ciency of the organization. 

Basic Concepts 

In order to consider human rela- 
tions or the development of human 
resources in its proper perspective and 
to recognize its contribution to the 
success of an organization, it is neces- 
sary to understand some of the under- 
lying concepts. 

1. Good human relations does not 
imply paternalism or universal happi- 
ness. There must be understanding of 
the needs — physical, psychological, 
intellectual and moral — of individuals 
at all levels. The manager must be 
able to furnish the leadership required 
for fulfillment of the aims and objec- 
tives of the organization. The em- 
ployee, in turn, must appreciate the 
problems of management and assist in 
their solution to the best of his ability. 

2. There is no real conflict between 
acceptance of this first concept and 

the need to be firm, to maintain and 
demand the highest standards of work 
performance, and to make practical, 
realistic decisions. 

3. Probably the most important fac- 
tor in an individual's efficiency is his 
mental attitude toward his immediate 
superior. The latter is responsible 
for the creation of on-the-job condi- 
tions conducive to the personal growth 
of the people under his supervision. 
This includes developing in the em- 
ployee a sense of responsibility; initia- 
tive; a desire to excel. It is almost im- 
possible to contribute to the personal 
development of someone unless there 
is a certain feeling of friendship for 

Having stated these basic concepts 
— and there are several others that 
could be added — we must now clarify 
the method, philosophy, or strategy 
which, when used effectively, permits 
the fullest expression of individual 
talents on the job. 

The Plan of Action 

The creation of an atmosphere with- 
in an organization or department that 
is conducive to personal growth and de- 
velopment is contingent upon certain 

I . Clarification of position or func- 
tion. The most important segments of 
a job should be stated in writing. The 
typical description of duties prepared 
by the supervisor himself or an out- 
side consultant is not sufficient. The 
employee and his superior must sit 
down together and analyze functions to 
be performed. Communication of this 
type helps the employee to visualize 
much more clearly his role within the 
department and the organization as a 
whole. He begins to realize that the 
responsibility for his development rests 
squarely on his own shoulders. He be- 




• f Human Resources 

gins to show initiative and a sense of 
responsibility previously foreign to him. 

2. Establishment of criteria and 
standards of performance. How well do 
you expect the employee to carry out 
his duties? Have him determine his 
plans or objectives for the year, both 
for his department and for his own 
personal development. Realistically, try 
to set up both qualitative and quan- 
titative standards. 

This intellectual exercise offers de- 
finite advantages. It challenges the 
employee to efficiency and stimulates 
the development of personal talents. 
This challenge is continual. The em- 
ployee knows exactly what is expected 
of him and is free to use his own in- 
itiative. He experiences a great sense 
of satisfaction and tends to set very 
high standards of performance for him- 
self. Finally, he develops an apprecia- 
tion of the principles of professional 
management: planning, organization, 
actuation, and control of his activities. 

3. Provision of an opportunity for 
action. In the interval between the es- 
tablishment of objectives and standards 
of performance and the evaluation of 
progress made, the role of the manager 
assumes prime importance. He should 
not expect too much too quickly. He 
must be intelligent enough to realize 
that mistakes will be made and that 
these should be accepted with good 
grace unless they are obviously stupid. 
Experience has proven that an indivi- 
dual learns much from his errors. 

The manager must show confidence 
in the employee. He must be ready to 
offer encouragement and guidance. At 
the same time he must require high 
levels of performance both qualitative- 
ly and quantitatively. He must insist 
upon the employee making his own 
decisions and allow him considerable 
freedom of action in the carrying out 
of duties. 

The manager should not assimie du- 
ties that rightfully belong to his sub- 
ordinates. Once having delegated au- 
thority, he should keep his distance. 
He should concentrate on results ob- 
tained and not become preoccupied 
with details of function. Again, you 
cannot help to develop an individual 
as a person unless you hold him in 
high regard. 

4. Evaluation of progress. Perfor- 
mance should be evaluated periodical- 
ly throughout the year in terms of the 
predetermined objectives. Objectives 
should be revised as necessary. At the 
end of the year, evaluation should be 
based on results obtained. 

This method has specific advantages. 
In review of past performance, the 
individual justifies what he has accom- 
plished to date and what remains to 
be done; obtains a more intimate un- 
derstanding of his strengths and his 
weaknesses — something he may never 
have possessed previously; seeks means 
of self-development rather than sub- 
mitting to imposed methods of train- 

The manager has the opportunity to 
act as a true leader instead of making 
rash judgments on the good and bad 
qualities of his staff. 

5. Improvement of individual per- 
formance. Should the employee be 
transferred to another type of work? 
Is there a need for a salary adjust- 
ment? Should he be given more en- 
couragement? Should he be given more 

6. Determination of sources of ac- 
tion. This should be done in consuha- 
tion with the employee. Are you the 
one who can help him or should it 
be someone from outside? Is there a 
specialist within the organization who 
can be approached? Should he not 
perhaps help himself? 

7. Provision of incentives and re- 

wards. How much are you willing to 
pay him or in what way are you pre- 
pared to recognize improvement in the 
quality of his work? Whatever the in- 
centive provided it must be in direct 
relationship to the results accomplished 
on the job. Results are obained by 
putting emphasis on incentives. 

8. Timing. When are you prepared 
to help him? When are you going to 
take action to improve his perfor- 

The concepts and strategy outlined 
have proven extremely beneficial in a 
number of organizations because they 
are based on a logical conception of 
work and on a healthy philosophy in 
regard to communication between su- 
pervisors and those supervised. Imple- 
mentation of this method calls for time 
on the manager's part, and intellectual 
maturity on the part of the employee. 
It does offer a solution to 75 per cent 
of the human problems in large enter- 
prises. It produces the finest form of 
communication between supervisor and 
subordinate since it permits the form- 
er to realize departmental aims and 
objectives, and the latter to prepare 
himself for positions of greater respon- 
sibility. The best monument that a 
manager can erect to himself and his 
organization is a well-prepared suc- 
cessor (or successors) to replace him 
and carry on his work. 

The development of human re- 
sources, then, is the application of a 
planned attitude or strategy on the part 
of top management. Top management 
must believe in individual, on-the-job 
development rather than a mass pro- 
gram. It is the integration of indivi- 
duals within the work situation in such 
a way that they are productively con- 
tributing to the organization's goals 
and at the same time are provided the 
climate in which they will find satis- 
faction of their personal needs. 




Identifying Nursing Problems 

An aproach designed to help the student plan and provide comprehensive nursing 


Margaret A. Campbell, m.s.n. 

"Ne'er look for birds of this year in 
the nests of the last." This is the way 
Cervantes, in the novel Don Quixote, 
referred to change. The faculty of the 
University of British Columbia School 
of Nursing can justly echo this state- 
ment since its members are well aware 
of the dynamic state of its basic degree 
program and of the many changes that 
have been made to mould it to its 
present form. They are very conscious 
of the persistent need to re-examine its 
offerings and to make necessary ad- 
justments and modifications. 

In 1958. a significant change was 
made when the University accepted 
full responsibility for the educational 
program provided by the School for 
the basic preparation of professional 
nurses. With this acceptance came a 
reorganization of the curriculum and 
the need for the School to plan and 
provide instruction and experience in 
clinical nursing; previously, such in- 
struction and experience had been 
primarily the responsibility of the hos- 
pital school with which the U.B.C. 
School of Nursing was associated. To 
meet this need, the University em- 
ployed additional faculty members 
whose major functions were in rela- 
tion to the clinical nursing courses 
offered during the second and third 
years of the program. As these instruc- 
tors guided the first class of students 
through the selected learning experi- 
ences, they encountered a common 
problem in their respective clinical 
areas: how could the^ help students 
plan for the provision 'of comprehen- 
sive nursing care? Attempts to solve 

Miss Campbell is assistant professor, 
School of Nursing, University of British 
Columbia, Vancouver, B.C. She presented 
this address at the Canadian Conference 
of University Schools of Nursing held in 
Charlottetown. P.E.I.. in 1964. 

this have culminated in an approach 
which is now being used to help stu- 
dents identify nursing problems. 

With the inception of the revised 
program six years ago, the faculty 
reconfirmed its belief that nursing care 
plans are a vital tool in the provision 
of comprehensive nursing care. The 
problem arose in helping the students 
develop their plans of care. It was 
decided to try an approach that had 
been used with only spasmodic suc- 
cess with graduate nurse students en- 
rolled in other programs in the School. 
The instructors suggested that the stu- 
dents think in terms of three aspects 
of the patient's care: general, specific, 
and individual. General nursing care 
included the care provided under 
stated policies and standards for any 
patient. It was designed to meet basic 
physiological needs — rest, exercise, 
cleanliness, food, and hydration. The 
objective of specific nursing care was 
to meet the requirements of the patient 
as determined by his diagnosis. It in- 
cluded specific therapies pertaining to 
the control or cure of the patient's 
condition and the nursing measures 
related to the therapy. Individual nurs- 
ing care was the adaptation of care 
to fit the patient as an individual. This 
approach gave consideration to the 
patient's level of education, culture, 
interests, likes and dislikes, and his 
special needs as a unique individual. 

At first, no single form for the 
nursing care plan was recommended. 
It was suggested that each student 
experiment with format until she found 
one most suited to help her provide 
the best possible care for her patients. 
Soon it was recognized that a prescrib- 
ed form would be helpful. One was 
devised in which the upper half of the 
page was devoted to an indication of 
the general, specific, and individual 
needs of the patient and the problems 

and approach in relation to each need. 
The lower half of the page provided 
for the essential identifying informa- 
tion relating to the patient and for the 
listing of the prescribed medications, 
treatments, and procedures. 

Several difficulties became evident 
as the students worked with these 
plans. By suggesting that the care of 
patients be viewed in three different 
ways, the instructors were, in effect, 
forcing students to compartmentalize 
their care. The average students met 
the expectations of the instructors fair- 
ly well; but the more alert student 
found it difficult to separate the three 
aspects in terms of comprehensive 
nursing care. It was also noted that 
each instructor interpreted each as- 
pect to the students in a slightly dif- 
ferent way, even though the areas were 
carefully defined. Furthermore, some 
instructors were requiring students to 
complete a certain number of nursing 
care plans as assignments, thus utiliz- 
ing the plan more as a nursing care 
study than as a tool to provide con- 
sistent care. Although the students 
were required to list the needs of pa- 
tients — general, specific, and indivi- 
dual — there was no clarification of 
how they might determine these needs: 
nor was there any suggested way to 
identify the nursing problems. In addi- 
tion, the students were confused as to 
the difference between an identified 
need and a nursing problem. It soon 
became apparent that the instructors 
had to clarify their own thinking with 
respect to nursing care plans before 
they could formulate a method which 
would be of assistance to students. 

In the early stages of the develop- 
ment of the revised program, the in- 
structors were faced with other de- 
mands which took precedence over the 
nursing care plans. One instructor, 
however, was persistent in her attempts 




to help solve the problem. After work- 
ing for some time on her own, she 
enlisted the support of a small group 
of faculty members. After a number 
of seemingly non-productive meetings 
in which the discussions were circular 
in direction, always returning to the 
starting point instead of being linear 
to a decision, the intangible and elu- 
sive came into view and it became 
possible to enunciate an approach. 
The following assumptions evolved: 

1. AM human beings have basic needs; 

2. certain factors will influence the extent 
to which the individual is able to meet each 

3. certain sources of data can be used 
to assess the ability of the individual to 
meet each of his needs; 

4. if he is unable to meet a basic need, 
a nursing problem results; 

5. with the nursing problem defined, 
the nurse uses her personal and profes- 
sional resources to plan the approach to 
solve the problem. 

It was recognized that human needs 
can be stated in many ways. To sa- 
tisfy the requirements of this approach, 
the group selected the following needs 
as those which are basic to every 
human being: exercise; rest; sleep; oxy- 
gen; food and water; elimination; pro- 
tection from the environment; sexual 
activity; coordination of body proces- 
ses; affection; achievement; security; 
and relationships. The modifying fac- 
tors in the life situation which would 
influence an individual's ability to meet 
his basic needs were identified as: age; 
culture; emotions; environment; intel- 
lectual capacity; physical capacity; 
pregnancy; sex; and stress. The sources 
of data available for assessing needs 
of patients, in relation to both the 
significant influencing factors and the 
ability of the patient to meet his basic 
needs comprise: the patient's chart, 
particularly the admission information, 
nurses' notes, progress notes, and 
the history record; observation of and 
conversation with the patient and his 
relatives; and the nurse's understand- 
ing of concepts related to the patient's 
stress. The group chose to use Ab- 
dellah's definition of a nursing prob- 
lem* " . . .a condition or situa- 
tion faced by the patient or his 
family which the nurse can assist him 
to meet through the performance of 
her professional functions." The ap- 
proach to the solution of each nursing 
problem provides opportunity for the 
nurse to be creative in planning the 
care, which, by the very nature of this 
analytical process, becomes individual- 

*F. G. Abdellah, I. L. Beland, A. Mar- 
tin, and R. V. Matheney. Patient-Centered 
Approaches to Nursing. New York. Mac- 
millan. 1961. 

ized to meet the nursing problems pre- 
sent because of the unmet needs of the 

With the basic assumptions stated 
and clarified, the next stage was to 
decide how and when this approach 
could be introduced to students. It was 
recognized that it would be helpful 
to have students thinking about human 
needs from the beginning of their first 
year in the program. The course in 
anatomy and physiology, which is 
taught by a member of the School 
faculty, was suggested as a possible 
starting point. The traditional body- 
system approach was reorganized to 
meet the requirements of this new 
method. It was exciting to see how the 
course could be developed to help the 
students increase their understanding 
of the physical needs of the normal hu- 
man body and the structural and func- 
tional ways in which these needs are 
fulfilled by the body. 

Following a unit on "The body as 
a whole," in which the students are 
introduced to a review of cell and 
tissue structure and physiology, the 
course is divided into eight units. 

1. The body's need for exercise, rest, and 
sleep. This include a study of the essentials 
of body movement: skeletal support, skeletal 
muscle activity, and nervous activity. 

2. The body's need for oxygen. The stu- 
dents study the acquisition of oxygen by 
means of the respiratory organs and its 
transport via the circulation of blood; all 
major aspects of respiratory and circula- 
tory functions are included. 

3. The body's need for food and water. 
This examines the provision of nutrients 
to body tissues through the processes of 
digestion, absorption, and metabolism. 

4. The body's need for elimination. This 
includes consideration of the formation of 
waste products as the result of digestive 
processes and catabolic metabolism and 
their means of elimination. 

5. The body's need for sexual activity. 
This is limited to a study of the ways in 

which the male and female are structurally 
and functionally equipped to meet their need 
for reproduction. 

6. The body's need for protection from 
the environment. Consideration is given to 
the protective mechanisms: the skin, tem- 
perature control, the special senses-, and 
the body's defense mechanisms. 

7. The body's need for coordination of 
its processes. This includes a brief mention 
of previously studied concepts related to 
the integrative functions of the nervous 
system. The emphasis in this unit is on 
the humoral system of communication and 

8. The results of coordination. This in- 
cludes the homeostatic mechanisms involved 
in the maintenance of fluid and electrolyte 
balance and acid-base balance. 

Students are encouraged to identify 

physiological principles applicable to 
the provision of each basic physical 
need. This plan for the teaching of 
anatomy and physiology has been fol- 
lowed for the past three years, with 
each successive class benefiting in 
terms of depth and breadth because of 
the instructor's experience with the 

Since the beginning of this approach 
to basic human needs, the instructors 
have evolved a plan, based upon the 
basic assumptions, to help students 
identify nursing problems and provide 
for their solution. In the "introduction 
to nursing" course, which is given 
concurrently with anatomy and physio- 
logy, the students have an opportunity 
to consider the psychosocial needs of 
patients and some of the symptoms 
that may be provoked if these needs 
are unmet: anxiety, depression, and de- 
pendency, and ways in which these 
may be manifested. In the laboratory 
practices correlated with the introduc- 
tory course in nursing, the students are 
encouraged to apply the principles re- 
lated to the provision of basic human 
needs to their practice of fundamentals 
of nursing care. As a summary, they 
evaluate their present level of nursing 
ability in the light of the needs that 
the seriously ill patient is unable to 
meet for himself. Through discussion, 
they are helped to correlate previous 
learnings from classes and laboratory 
practices to the demands of anticipated 
experiences in the hospital setting. 

Following the academic portion of 
the first year, the students participate 
in a nine-week course "orientation to 
nursing in hospital." With the excep- 
tion of three or four three-hour labo- 
ratory periods spent at the hospital 
during the academic year, this is the 
students initial contact with patients 
in hospital. During the first week of 
this initial clinical nursing experience, 
the first-year students are introduced, 
in a two-hour class period, to the 
analytical approach to the identifica- 
tion of nursing problems. They are 
asked to recall the basic needs of all 
human beings; then they are asked 
to contribute their ideas about factors 
that might influence the ability of a hu- 
man being to meet his needs. Knowing 
that there are many factors which will 
modify an individual's ability to meet 
his needs, the students are encouraged 
to indicate the sources of data avail- 
able in hospital to help the nurse know 
more about the influencing factors and 
the extent to which a patient is able 
to meet his basic human needs. With 
these data she can thus assess the 
needs of her patients. Time is spent 
considering the observations that a 
nurse could make in relation to spe- 
cific needs. This is time profitably 




spent as it not only permits students to 
recognize what they already know and 
how they can apply scientific principles 
but it also reinforces the value of de- 
veloping skill in observation. To assist 
them further in developing observa- 
tional skills, the students are provided 
with mimeographed material which in- 
cludes a list of the physical, psycho- 
social, and biopsychosocial needs, the 
factors influencing the attainment of 
each need, and suggested observations 
that could be made in their assess- 
ment. The students then proceed to 
the identification of nursing problems 
and the preparation of a plan of care. 
The nursing care plan presently in use 
provides space for indicating the essen- 
tial identifying information related to 
the patient and a definition of the ob- 
jective of nursing care. In the three 
columns headed need, problem, and 
approach, the student notes the pa- 
tient's unmet needs, the resulting nurs- 
ing problems, and a suitable approach 

to the solution of each problem. The 
approach includes, in addition to nurs- 
ing care, any medications, treatments, 
and procedures designed to alleviate 
the nursing problem. 

One method that has been found 
useful in helping students develop the 
concept of nursing problems is to 
have them make up a nursing care 
plan for a hypothetical patient. By 
letting them contribute the necessary 
information related to a newly ad- 
mitted patient assigned to their care, 
and by finding out where they would 
seek the data, the instructor is rein- 
forcing their learning in relation to 
influencing factors and sources of data. 
With the information they would re- 
quire to formulate a plan of care, they 
are then able to take each human need, 
decide whether it may or may not 
be met by the hypothetical patient and, 
if it cannot be met, what the nursing 
problem would be and what approach 
they would use. 

University of British Colirabia School of Nursing 


Name: ffrs. Join SntifA Age: 32 Admitted: •f/zt./if Doetori U- Srou>n 

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a I ' children 

Diagnosist OroncnopneurKonii Surgerj: Date: 

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Such a hypothetical patient might be a 
32-year-oId mother of three children who 
has been admitted to hospital with a diag- 
nosis of "bronchopneumonia." Knowing this 
patient's stress factor and the clinical mani- 
festations it would produce, and knowing 
the family constellation of the patient, one 
would anticipate that she would have dif- 
ficulty meeting her need for rest. Two 
nursing problems would be "cough" and 
"anxiety related to her family." Further 
contact with the patient would confirm or 
change this assessment of the need for rest 
The approach to be used in nursing care 
would include measures to allay her anxiety 
and to reduce the irritation from the cough, 
while at the same time assisting with ex- 
pectoration of sputum. It would be anti- 
cipated that in relation to the need for oxy- 
gen, the patient's nursing problems would 
include "pain on inspiration" and "dyspnea 
aggravated by exertion." Therefore, in plan- 
ning nursing care, the nurse would provide 
splinting of the chest wall to ease the pain 
while coughing. She would note the best 
position for the patient and would suggest 
that activity and conversation be limited 
Two nursing problems one would expect tn 
be associated with the need for protection 
would be "dry mouth and lips" and "di- 
aphoresis." On the nursing care plan, the 
approach to the first problem would in- 
clude: frequent mouth wash; lubricant to 
lips (indicatirg the patient's preference): 
and encouragement of fluid intake, again 
indicating the patient's likes and dislikes 
with respect to fluids. The second problem 
could be met by noting the specific nursing 
care required to protect the patient from 

Thus the first year students, equip- 
ped with some knowledge of a scien- 
tific method of assessing patients' needs 
to identify nursing problems, are ready 
to develop those skills which are basic 
to the planning and provision of com- 
prehensive nursing care. 

During the clinical nursing courses 
that make up the second and third 
years, guidance is provided to in- 
crease students" skills in assessing 
needs and to help them incorporate 
into plans of care, approaches which 
connote their enlarging concepts of 
nursing care. During the second year, 
they are required to use the School's 
form for a nursing care plan to en- 
courage a scientific approach to the 
identification and solution of nursing 
problems and thus ensure that the 
more subtle as well as the obvious 
problems will be identified. By the 
third year, less emphasis is placed on 
the form itself: students are assisted 
in adapting their plans to the particu- 
lar form utilized by the ward and 
usually incorporated in the team Kar- 

And now to the future. The instruc- 
tors who are responsible for the clini- 




cal nursing courses realize that they 
have only begun the exciting explora- 
tions that can help them guide stu- 
dents toward the identification and 
solution of nursing problems. Certain 
areas, where there is duplication or 
where there are obvious gaps, require 
further study. One omission relates to 
spiritual needs. The guide prepared to 
help students assess the needs of pa- 
tients outlines the physical, psychoso- 
cial, and biopsychosocial needs of pa- 
tients but does not mention spiritual 
needs. When planning nursing care, 
students are reminded that they should 
consider and try to meet these needs 
also. Their studies of patients from 
varous cultures have helped to increase 
their appreciation of different religions 
and of the tenets and rituals that pro- 
vide solace and security to members 
of many religious faiths. No attempt 
has been made to define in writing 
what is meant by spiritual needs nor 
what observations would suggest that 

these needs have not been met. Per- 
haps it might be wiser to avoid com- 
partmentalizing human needs into phy- 
sical, psychological, biopsychosocial, 
and spiritual and to think of them all 
as basic human needs. In this context 
one could think of spiritual needs as 
being an integral part of all human 
needs, as permeating the basic needs 
of human beings and as being mani- 
fested in varying degrees of intensity 
by different individuals and in differ- 
ing circumstances. As each basic need 
is being met, the extent to which con- 
sideration has been given to its spirit- 
ual aspect will make the difference 
between a partially and a wholly sa- 
tisfied person, recognizing the totality 
of the individual. Further study is ne- 
cessary to test this hypothesis in order 
to determine if this is a valid approach 
to the realm of spiritual needs in the 
context of nursing care or merely a 
way of evading a problem which has 
not received its merited attention and 

which therefore demands careful and 
direct consideration to ensure more 
than lip service to this essential aspect 
of nursing care. 

This has been a description of one 
approach to the identification of nurs- 
ing problems. Probably the major 
achievement directly related to the use 
of this approach has been the students' 
growth in their ability to plan com- 
prehensive nursing care. It has been 
encouraging to watch them integrate 
their previous learnings as they de- 
velop skills in observation. It has been 
rewarding to see them become more 
critically analytical in their treatment 
of data. It has been exciting to observe 
the emergence of creativity in their 
approaches to nursing care. For the 
faculty working with these students 
there has also been evidence of growth, 
with each successive class providing 
the stimulus for further exploration 
and refinement of this approach to the 
identification of nursing problems. 


In order to start any argument among a 
group of people, the topic of married work- 
ing women only needs to be mentioned to 
let out a flood of contradictions, prejudices, 
falsehoods, and stereotyped arguments for 
"bringing the women back to the home, to 
toil in front of the stove and mind the 
kids." What are the facts? What is the pres- 
ent trend in Canada? 

In 1963. 1.858,000 women were in the 
labor force, comprising 28 per cent of our 
total labor force. Of these women roughly 
half were married. 40 per cent single, and 
10 per cent were widowed, separated or 
divorced . . . The majority . . . worked in 
five broad occupational groups: I. clerical 
work — 30%; 2, personal services — 23%; 
3. professional services — 15%; 4. manu- 
facturing — 11%; 5. commercial occupa- 
tions — 10%. TTie balance were scattered 
among other occupational groups .... 

Canada falls a little below the average 
of employed women compared to other in- 
dustrialized countries. Its percentage is 
lower than in the United States, and in four 
European countries. 

Women work for many reasons : for 
money, prestige, the chance to serve the 
community, the desire to broaden their hori- 
zons; out of boredom or dislike for house- 
keeping; to reach long-range goals; even for 
a sense of power. Some women, especially 
professional people, have a sense of doing 
something important, eithe for themselves 
or for others. Some women gain deep emo- 
tional satisfaction from their work in terms 
of glamor or excitement, or perhaps merely 
in terms of escape from the routine of 

The working wife, despite her numbers, 
is a relatively new social phenomenon and 
still in the minority. About three times as 
many North American wives do not work. 
-And they tend to be sharply critical of their 
lob-holding sisters. 

Researchers gave 250 housewives, mostly 
between [the ages of] 25 and 44 and of 
whom one-third held jobs, a list of 16 rea- 
sons for wives working. The reasons ranged 
from "for the categories of life" to "dislike 
housekeeping." Four categories were set up: 
women with no children, with preschool, 
grade school and high school children. 

Women approved of a wife's working if: 
1. her husband agreed; 2. she had no young 
children; 3. she was working to contribute 
to family needs or goals rather than for 
purely personal reasons. Ranked highest as 
family goals were: improved living stand- 
ards, payment of debts, buying and furnish- 
ing a home, helping to support elderly 
relatives. Ranked lowest as reasons in every 
category were a woman's desire to use. her 
education and her dislike for housekeeping. 
When a wife had preschoolers, the only 
reasons a majority accepted for her working 
were: to buy necessities, to pay off debts 
and to help her husband complete his edu- 
cation. Only about 40 per cent . . . thought 
a women had a right to work for personal 
desires even when her children were of high 
school age. 

In a historic study of 1.000 children. 
Sheldon and Glueck, experts in delinquency, 
found there was just as high a proportion 
of juvenile delinquents in the families of 
nonworking mothers as of working mothers. 
The largest percentage of delinquents came 

from families where the mother worked ir- 
regularly. Children whose mothers worked 
part time made better adjustments than 
children whose mothers worked either full 
time or not at all. This was especially true 
of middle class families. A mother's em- 
ployment has no direct effect on her child's 
love for her, on his schoolwork or on his 
health .... 

Why isn't the raising of a family enough 
to give direction and purpose to many wo- 
men's lives? 

1. Raising a family takes a very small 
proportion of a woman's adult life. A large 
percentage of North American women are 
through with child-bearing before their 
thirties. Say ten years, from early twenties 
to early thirties, will see the last of three 
children in school. One's working life is 
45 years plus. What of the rest of these 
years with 25 working years ahead of her? 

2. Woman's maternal role is of course an 
important factor in her life and personality 
and work. But it is one part of her life. 

3. By concentrating all her efforts on her 
husband, children and domestic work, a 
mother may actually be more likely to fail 
as wife and mother than if she also had a 
life as a human being in her own right .... 

If a woman knows why she wants to 
work and has . . . decided that the advan- 
tages outweigh the disadvantages, then she 
should be able to work without the burden 
of guilt that afflicts so many working wives 
and mothers. — BENjAMrN Schlesinger. 
assistant professor. School of Social Work. 
University of Toronto. Excerpts from an 
article published in Canada's Health and 
ly el fare. Sept. and Oct. issues. 1964. 




i5ekauior - L^entred 



Elizabeth Dobbs 

Acceptance of the individual and her 
behavior is the key to successful nursing of 
a patient with a manic depressive reaction. 

Mrs. Paul, forty-one years of age, 
was admitted to the psychiatric unit 
with a diagnosis of manic depression. 
I met her shortly after my rotation 
to the ward and felt rather unnerved 
by her appearance: She was a striking- 
looking woman, tall, with glossy black 
hair and aristocratic features. Her eyes 
appeared large, dark and fearful, and 
flitted constantly from obect to object. 
I was reminded of a hunted animal 
searching desperately for a place to 
hide from its pursuers. 

I was drawn to this patient imme- 
diately, because I felt sorry that any 
human being could feel so miserable, 
and partly because I wanted to help 
her in some way. How? I did not know. 

Mrs. Paul was not often assigned 
as my patient, but 1 made a point of 
visiting her frequently. She presented 
a classic example of manic depression. 
She was extremely depressed and 
tense; she exhibited marked slowing 
of psychological and physiological 
functions; any physical effort caused 
her to become fatigued. She lay on her 
bed most of the day, seemingly too ex- 
hausted to even lift her head. Other 
signs of her depression were anorexia 
and insomnia. 

The fatigue of a severely depressed 
patient is an expression of her mood, 
i.e., it does not have physiological 
causes. This fatigue reduces the pa- 
tient's ability to perform even minor 
tasks. Feelings of guilt and worthless- 
ness are part of all depressions and 
being unable to cope with everyday 
activities increases their intensity. Mrs. 
Paul did not actually verbalize such 
feelings to me since she had difficulty 
relating with others and expressing her- 
self while in this depressed state. Be- 
cause the world appears such a dark, 
hopeless place in the eyes of a de- 
pressed patient, the risk of suicide is 

Miss Dobbs was a second-year student 
at The Montreal General Hospital School 
of Nursing when she wrote thi this study. 

100 FEBRUARY 1965 


always present. The nursing staff was 
warned by the psychiatrist that Mrs. 
Paul did have suicidal thoughts. 

My relationship with Mrs. Paul was 
not progressing according to plan. My 
attempts to be understanding, em- 
pathetic, and a good listener did not 
appear to be doing either of us much 
good. She did not talk to me, beyond 
brief, extremely polite replies to ques- 
tions I ventured. I was quite discour- 
aged. Looking back, I see now that 
this siutation was largely due to her 
extreme difficulty in relating to others, 
a symptom of her depressed state. She 
smiled almost continuously but it was 
a forced, unnatural smile. Her eyes 
gave her away, making the smile more 
of a grimace. Because of her exhaus- 
tion, the doctor recommended that she 
be allowed to remain in bed. She slept 
very little, just lay on the bed looking 
tense and preoccupied with her 
thoughts. I often had the feeling that 
she resented my intrusion upon her 

The following interaction, occurring 
about ten days after our first meeting, 
is typical of our conversations during 
her depressed period. 

Patient is lying in bed with covers 
pulled around her. She smiles brightly, 
but falsely; her eyes dart about with- 
out focusing on me. I enter the room 
quietly with what I hope is a kind, 
understanding expression on my face. 

Hello, Mrs. Paul. 

I say this in a confident tone of 
voice, refraining from saying "good 
morning" as I am certain there is no- 
thing good about it to her. 

The patient returns my greetings in 
a barely audible voice. She is twisting 
the sheets and moving her hands pur- 
poselessly. Every now and then our 
glances meet and she immediately looks 
away. I remain silent, conscious that 
she is ill at ease. Her obvious tension 
is making me anxious because I won- 
der what there is about me that brings 
forth this reaction. The silence persists. 
[ begin to feel that the patient lacks 
confidence in me because I am a stu- 
dent. Finally, 1 break the silence. 

How are things going today? 

I thought I should say something 
to help put her at ease and to show 
my interest. I believed this question 
was preferable to "how are you?" 

Oh. the same. Tm very tired. 

She stops talking and an almost 
frightening smile appears on her face. 
1 nod sympathetically. The smile both- 
ers me but I smile back because I don't 
know what else to do. I try to let her 
know that I accept and understand her 
behaviof — but do I really? 


By repeating her remark, I hope 

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Nursing plan for patient while in depressive stage 

to encourage her to elaborate her feel- 
ings without seeming to pry. She con- 
tinues to affect "nervous" mannerisms. 
Finally, she states, rather apologetical- 

Yes. I just cannot sleep. I find it an 
effort to even get out of bed. Maybe I'll 
get up and go to the cafeteria to-morrow. 

I detect this apologetic tone and 
feel guilty. Am 1 the cause of this? 
Perhaps, unconsciously, I feel that she 
is just being lazy — and this feeling 
is being transmitted to her by my man- 
ner. By saying "maybe I'll get up and 
go to the cafeteria to-morrow," Mrs. 
Paul is, in a way, atoning. Trying to 
be gently encouraging, I reply: 

That would be nice for you, Mrs. Paul, 
if you feel up to it. 

Mrs. Paul remains silent. She is be- 
coming more and more agitated by my 
presence. I feel very tense myself and 
I realize that she must be aware of 
this. Now / am looking everywhere. 
Finally, after a silence that seems to 
last forever, I ask: 

Can I get you more juice, Mrs. Paul? 

This is probably not the best thing 
to say, even though I know she is to 
be encouraged to "push fluids." By 
asking her if I can get her juice, \ 
am anticipating her needs. I knew she 
disliked asking for anything, but per- 
haps it would have been wiser to have 
encouraged her to verbalize her needs. 
Mrs. Paul looks directly at me. 

Yes. thank you — if its not too much 
trouble. Don't do it if its not your job. 

This remark tells me that she feels 
unimportant and worthless and does 
not want to bother anyone. 

I'll be glad to get you some. 

By getting juice for the patient, I 
feel more comfortable — because I'm 
actually doing something for her. I re- 
turn with the juice but am still reluc- 
tant to leave. She is making me feel 
inadequate because I can't meet my 
own needs by meeting hers. Finally. 
she asks: 

Will you please leave now. Miss Dobbs? 
I think I'll nap. 

She turns in bed so that her back 
is to me. 

All right, Mrs. Paul. I'll be back to 
see you after your nap. 

I leave the room, feeling dissatisfied 
with the situation. I was not surprised 
by her request, since she had reported- 
ly asked many nurses to leave the 
room. Still, it is an obvious dismissal 
and I feel hurt. At the same time, I 
am relieved that I can leave. 

I should not be hurt by this dis- 
missal. My feelings indicate that I am 
not really accepting her behavior as 
part of her illness. Also, I am concen- 
trating too much on my own, rather 
than on the patient's discomfort. To 
compensate for these negative feelings, 
I try to show that I do not reject her 
by stating that I will return. 




Gradually, Mrs. Paul emerged from 
her depression. Her fatigue decreased 
and she began taking short walks up 
and down the corridor and, finally, to 
the cafeteria. She found a companion 
in Mrs. Smith, another patient on the 
ward, and the two of them spent long 
hours in conversation. I often joined 
them in somewhat superficial discus- 
sions about clothes, travel, and books, 
and the atmosphere was a relaxed, 
congenial one. I was encouraged by 
subsequent conversations with Mrs. 
Paul as she was beginning to discuss 
some of her feelings with me when we 
were alone. She spoke intelligently and 
1 found her to be a gracious and charm- 
ing person and believed that she was 
progressmg well. 

About this time, I had five days 
off duty, so 1 was out of contact with 
her. 1 returned to learn that she had 
passed through the phase of "normal- 
cy" and was now manic. I was as- 
tounded by the change: She was very 
hyperactive, physically and mentally; 
she was continuously on the move, 
surrounding herself with all kinds of 
projects and loud music; her room 
had become an unbelievable clutter 
of half-completed projects, scattered 
newspapers, clothes and dishes. She 
seemed typical of a manic depressive 
patient in a manic phase. She gave 
the impression of being very happy, 
almost exuberant at times; however, 
she was easily irritated by relatively 
minor incidents, often becoming rude 
and abusive. 

At first glance, she seemed to be 
productive; but, on closer observa- 
tion, I noticed that she was unable to 
complete one project or task. This 
"flight of ideas."' a characteristic of 
manic reaction, certainly applied to 
Mrs. Paul. She talked about seemingly 
unrelated topics; she would begin to 
ask a question, then one word would 
suggest another idea and launch her on 
to another subject, only tenuously con- 
nected with the first. 

She had little sleep, often awakening 
in the middle of the night to play re- 
cords, sing and to carry on a number 
of other inappropriate early a.m. acti- 
vities. She did imusual things, such as 
smoking cigars and pipes and ordering 
eight dollars worth of chicken in the 
middle of the night. She had expansive 
ideas about organizing a musical pro- 
duction for the other patients. All these 
activities are typical of those exhibited 
by the manic patient. 

The following interaction occurred 
while I was working on the night shift. 
Mrs. Paul was scheduled to have elec- 
troconvulsive therapy the next morning. 
I was making rounds about 3:00 a.m. 
and as I walked into her room, flash- 
light in hand, I was surprised to see 

her preparing a cup of tea — having 
boiled the water with an electric im- 

Mrs. Paul! What are you doing? 

(I had a good idea.) 

Patient looks up, startled. 

Oh, Miss Dobbs, I'm sorry — I forgot. 
Here, we'll throw it away! 

She dashes to sink and throws con- 
coction away. 

Do you like Harry Belafonte? 

She puts record on turn-table, bursts 
into song, lights cigarette and com- 
mences to rearrange papers scattered 
on the bed. 

I was surprised and slightly annoyed, 
since I had reminded her, half an hour 
before, not to eat or drink and had 
explained why. I pick up immerser. 

Do you mind if I take this and return 
it to you after your treatment? 

1 dislike having to remove the im- 
merser since it seems dictatorial — 
and I hate to treat her like a child. 

You don't trust me. Everyone here thinks 
I'm a nut just because I like people and 
smile and laugh. I'm a very happy person. 

It is true — I do not trust her. I 
fear she might eat and drink if she 
has the opportunity so that she will not 
have to receive E.C.T. — which she 
fears, i do not want her to feel that I 
distrust her, so I remind her that she 
has received sedation earlier that eve- 
ning and might forget that she is not to 
eat or drink. She interrupts me without 
seeming to notice what I have said. 

No one understands me. It's not your 
fault. Dr. Murray shouldn't have removed 
my phone. I have an important call to make 
now. Will you please get my phone? 

She is becoming more and more ex- 
cited (and I am feeling a bit "hyper" 

myself, just being with her). I feel an- 
noyed, but struggle to remain calm. I 
say, firmly: 

No, Mrs. Paul, you cannot phone anyone 
at 3:00 a.m. Please get into bed and I'll 
give you a backrub. 

I figure you can never go wrong 
with a backrub! 

Mrs. Paul ignores my remarks, picks 
up her record albums and starts toward 
the door. 

I'm going to take these records to Mrs. 

I feel I have lost control of the situa- 
tion and am angry with the patient for 
putting me in this position. I am trying 
to suppress these feelings when I 
should realize that they are quite na- 
tural and accept them. Again, 1 am 
losing sight of the fact that this be- 
havior is part of her illness. 

I gently guide her back to bed, ex- 
plaining that her friend Mrs. Smith 
is asleep. She raises no objections, hops 
into bed, face down, in the midst of all 
the records, books and papers. I pro- 
ceed to rub her back. 
I love this music. 

With this remark, she reaches over 
and turns the volume higher. I turn 
the volume low, but she doesn't seem 
to notice. 

I feel relieved and less tense. While 
giving the backrub, I have dme to iden- 
tify my feelings. Mrs. Paul has become 
quiet — also a relief. 

After the backrub, I say "goodnight" 
to the patient, assuring her that I will 
look in on her later. I pick up the im- 
merser and leave the room. 

Blind Spots 

1. I had a blind spot in my inter- 
action with Mrs. Paul because I did 


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Nursing plan for patient in manic stage 




not really accept the principle all be- 
havior is meaningful. I kept waiting 
for the patient to make me her con- 
fidante, thus overlooking smaller in- 
cidents which were nonetheless mean- 

2. A blind spot was in the form 
of my anxiety. In every interaction 
with this patient. I was conscious of 
remembering what was said, how she 
reacted, how I reacted. This reduced 
the spontaneity and may have been 
conveyed to her. 

3. Initially. I had a blind spot in my 
whole attitude toward mental illness. 
I thought that to be mentally ill was to 
be weak-willed; that a person should 
be able to prevent mental illness just 
by '"putting their mind to it." I have 
since changed my opinion about this. 

4. While Mrs. Paul was in the man- 
ic phase, I heard a report that she was 
doing bizarre things and being difficult. 
I looked for these things instead of 
observing, then deciding for myself. 

5. I was concentrating too much 
on my own needs. 

Nursing Care 

Acceptance of the patient and her 
behavior is. of course, the key to suc- 
cessful nursing in both the depressed 
and manic phases of this illness. 

In the Depressed Stage 

Nursing care can be planned ac- 
cording to Maslow's hierarchy of needs. 
Mrs. Paul was so depressed that she 
could not meet her own basic physio- 
logical needs. It was thus necessary for 
the nurse to stay with her as much as 
possible during meal time to encourage 
her to eat. It is rather unpleasant to eat 
alone at the best of times so the need 
for this patient to have company is ev- 
ident. Providing between-meal snacks, 
such as high protein milkshakes, also 
helped to maintain the patient's nu- 
tritional requirements. 

The doctor advised the nursing staff 
to allow Mrs. Paul to remain in bed. 
if she wished, because of her exhaus- 
tion. Nembutal gr. li/oQ-h-s. was or- 
dered to induce sleep. Basic nursing 
measures, such as giving backrubs and 
providing a quiet environment conduc- 
ive to sleep, were employed at night. 

Because the patient was almost im- 
mobile, plus the fact that muscle tone 
is often decreased in depression, she 
tended to be constipated. For this 
reason it was necessary to provide 
fluids that she liked and to encourage 
her to drink. 

Mrs. Paul had to be encouraged to 
maintain her hygienic standards during 
this depressed stage. Although this 
is not a basic physiological need, it is 
important. If a person feels unclean 
and unkept, she will find it difficult 

to have self-respect. Although self- 
respect is high on the hierarchical lad- 
der it is necessary to start somewhere 
in restoring this. 

The next step to consider is security. 
The nurse must keep in mind, at all 
times, the suicidal risk for the depres- 
sed patient. We were informed that 
Mrs. Paul had suicidal thoughts so we 
had to watch her as unobtrusively as 
possible. She was on "special observa- 
tion" which meant that her nurse 
would visit her every 15 minutes. This 
protected her from herself. It was es- 
sential for the patient to feel that she 
was in safe, consistent environment. A 
reasonably strict routine set by the 
nurses helped Mrs. Paul feel more 
secure in that she knew what to expect. 

The next goal is love — in this case 
meaning belonging and acceptance. The 
nurse must first identify and examine 
her own feelings before she can gen- 
uinely accept any patient. Mrs. Paul 
desperately needed to be liked and ac- 
cepted on her own terms. This need 
was best met by the nurse visiting her 
frequently and allowing her to be her- 
self. The patient should never feel that 
she has to make conversation merely 
to please the nurse or make her more 

Although Mrs. Paul appeared indif- 
ferent to the nurse's presence, the lat- 
ter should not have felt discouraged. 
Eventually, the patient would feel that 
perhaps she "wasn't so bad after all" 
if the nurse was interested enough to 
keep visiting her. It was important to 
remember that Mrs. Paul already felt 
worthless and was sensitive to further 

Gradually, at the nurse's discretion, 
Mrs. Paul was encouraged to further 
activity: first, a walk with the nurse 
in the corridor; then, eating in the 
cafeteria. It was important that this 
patient be allowed to progress socially 
at her own pace. 

In the Manic Stage 

When Mrs. Paul emerged from her 
depression and went into the manic 
phase, her nursing care had to be re- 
vised. If unrestricted, she would have 
worn herself out, physically, in a mat- 
ter of days. To prevent this, her doctor 
ordered that she be confined to her 
room. At first this was difficult to en- 
force since she was so hyperactive 
that she just could not remember. The 
nurses had to adopt a kind but firm 
approach in reminding her of this re- 
striction. It was important that all the 
nursing staff be aware of this and con- 
sistent in enforcing it. 

The nurses had to set limits for Mrs. 
Paul and stick to them. Because she 
phoned people at all hours, her tele- 
phone privileges were limited to two 

hours a day. She accepted this quite 
well but became reluctant and hostile 
about giving up the telephone if she 
sensed hesitancy in the nurse who 
came to remove it 

Because of her hyperactivity, the 
patient had to be firmly persuaded to 
eat her meals. Persuasion was also 
necessary for retirement at night. Be- 
cause of this mental and physical hy- 
peractivity, stimulating situations had 
to be avoided. For example, the nurses 
refrained from mentioning subjects that 
the patient was known to become ex- 
cited about. At the same time she had 
to be allowed to express her feelings 
since a deep-seated feeling of inade- 
quacy and worthlessness was at the 
bottom of this euphoria. Even though 
the patient was hyperactive, it was es- 
sential that the nurse remain calm and 
cool. It was better to leave her, saying 
you would return within a specified 
time, than to stay if you became ex- 
cited yourself. 

To help control Mrs. Paul's over- 
active behavior, she was given 600 
mg. of Largactil daily plus 250 mg. 
of Nozinan. On such large doses of 
Largactil, constipation and dryness of 
the mouth are often side effects. For 
this reason, the patient required a high 
fluid intake. 

During this phase, Mrs. Paul was un- 
commonly sensitive to how the nurse 
reacted to her. It was most important 
for the staff to avoid showing any 
feelings of annoyance. Acceptance of 
the fact that it was her illness that 
made her somewhat obnoxious and 
difficult to control, made it easier to 
care for her. 

A nursing care plan for Mrs. Paul 
helped to provide consistency of ap- 
proach. A good plan acts as a guide 
and is a means of communication be- 
tween doctor and nurse as to how the 
doctor wishes the patient to be treated. 
For example, it may be beneficial to 
encourage one patient to socialize, but 
it could be harmful for others. With- 
out some means of deciding, the nurse 
would be at a loss. There would be a 
tendency to take the same approach 
with all patients. A nursing plan, de- 
vised for each individual, eliminates 
this possibility since it provides clues 
to the person's individual likes, dis- 
likes and needs. 


English. O. S. and Finch. S. M. In- 
iroditction to Psychiatry. New York, W. W. 
Norton and Co.. 1957. 

Matheney. R. V. and Topalis. M. Psy- 
chiatric Nursing. St. Louis. C. V. Mosby 
Co.. 1961. 

Noyes. A. P.. and Klob, L. C. Modern 
Clinical Psychiatry. Philadelphia. W. B. 
Saunders Co.. 1963. 




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An outline of a pediatric program. 


Students of The Vancouver General 
Hospital school of nursing diploma 
program receive theory and practice 
concurrently throughout the three-year 
course. A 15-week experience "nurs- 
ing of children" is included during 
the latter half of the second year. Be- 
fore entering the pediatric department, 
students receive experience in general 
medical and surgical nursing, operat- 
ing room, and normal maternal and 
newborn care. 

The Health Centre for Children in 
this hospital contains 210 beds for the 
care of acutely ill children. Children 
up to the age of 16 years are admitted 
from all parts of the province because 
of the available facilities. Students are 
able to care for or observe children 
with a majority of the childhood con- 
ditions and diseases. 

The objectives of the program are 
based on the premise that knowledge 
of the well child is preliminary to car- 
ing for the sick child; that the patient 
is primarily a child and only second- 
arily, a sick child. By the completion 

Mrs. Buckland is pediatric instructor. The 
Vancouver General Hospital School of 
Nursing. B.C. 


of the program, the student should 

1. Developed an understanding of the 
growth and development of the normal 
child from birth to 16 years; 

2. developed an understanding of the 
sick child through an appreciation of the 
effects of illness on the child and a knowl- 
edge of the common childhood illnesses; 

3. developed basic skills in observing and 
nursing the sick child; 

4. gained an understanding of the im- 
portance of the development of good phy- 
sical and mental health habits in childhood; 

5. increased her skill in communication 
and health teaching by working with the 
child and his family. 

To accomplish these objectives, each 
student receives 12 weeks' experience 
in the Health Centre for Children — 
eight weeks with children under and 
four weeks with children over six years 
of age — usually in both a medical 
and a surgical area. Later, in the same 
term, she receives three weeks' experi- 
ence with children during a community 
health assignment that includes: a 
week with children in a nursey school; 
a week with a public health nurse of 
the Metropolitan Health Committee 
of Greater Vancouver spent visiting 

schools, child health centres, prenatal 
classes, and school or postnatal home 
visits; and a week in the children's and 
women's outpatient clinics. During one 
of her rotations, she spends several 
days in the play therapy department 
of the Health Centre for Children. 

Theory during the 15 weeks is pre- 
sented in formal classes, through dis- 
cussion groups, and by films, for four 
hours each week. The community 
health classes cover three main topics: 
play therapy and the use of play by 
the child; the handicapped child, his 
adjustments to family and community, 
and community agencies available; and 
pre- and postnatal teaching for new 
mothers, including the services avail- 
able in these fields. Films used in con- 
junction with these classes include: 
"A Study in Maternal Attitudes," 
"Community Health in Action," and 
"A Long Time to Grow" (Parts I 
and II). 

Field trips to community agencies 
usually include: the Cerebral Palsy 
Centre for Children; Sunny Hospital 
for Children, chronic care; Jericho Hill 
School, for blind and deaf children; 
Woodlands School, for the mentally 




Theoretical teaching in the program 
follows the growth and development 
of a child from birth to adulthood, 
with physical, mental, emotional and 
social patterns in the different stages 
and the common illnesses of each age 
group presented. When conditions 
have been covered in other courses, 
the student is encouraged to draw on 
and enhance her knowledge; specific 
differences occurring in childhood are 

The basic physical and social scien- 
ces are used extensively to further the 
student's understanding of nursing of 
children. The subject matter is divided 
into six units: newborn, infant, toddler, 
preschooler, school age and adoles- 
cent. Nursing care is included with 
each condition as necessary. 



1. Characteristics of growth and develop- 

2. Signs and symptoms of the ill child. 

3. Admission of children to and discharge 
from hospital. 

I 'nit I: Newborn 

1. Review characteristics of the normal 

2. Surgical emergencies of the newborn: 
tracheoesophageal fistula; imperforate anus: 
omphalocele; intestinal obstructions. 

3. Congenital orthopedic conditions: club 
feet; con'i^enital dislocation of the hip. 

4. Congenital cardiac conditions: tetral- 
ogy of Fallot: septal defect; patient ductus 
arteriosus; coarctation of the aorta. 

5. Congenital central nervous system con- 
ditions: spina bifida; hydrocephalus; men- 

Unit II: Infant 

1. Growth and development of the infant 
(2 weeks- 1 year). Film: "Life with Baby." 

2. Infant feeding. 

3. Gastrointestinal surgical conditions: 
pyloric stenosis; intussusception; Hirsch- 
sprung's disease; hernia. 

4. Respiratory conditions in the infant: 
Nasopharyngitis; otitis media; bronchiolitis; 
aspiration pneumonia. 

5. Nutritional disorders: dehydration; mal- 
nutrition; rickets; tetany; scurvy; anemia. 

6. Cleft lip and palate. 

Unit III: Toddler 

1. Growth and development of the todd- 
ler (1-3 years). Film: "Terrible Two's and 
Trusting Three's." 

2. Safety and accidents: poison; foreign 
bodies; fractures. 

3. Respiratory conditions: croup; epiglot- 
titis; laryngotracheobronchitis. 

4. Celiac syndrome: celiac disease; cystic 
fibrosis. Film: "Cystic Fibrosis." 

5. Kidney conditions: pyelonephritis; 
nephrosis; glomerulonephritis. 

Unit IV: Preschooler 

1. Growth and development of the pre- 
schooler (4-6 years). Film: "Frustrating 
Four's and Fascinating Five's." 

2. Blood dyscrasias: leukemia; hemophi- 
lia; purpura. 

3. Other conditions: epilepsy; asthma; 
intestinal parasites. 

Unit V: School age 

1. Growth and development of the school 
child (6-9 years). Film: "Sociable Sixes to 
Noisy Nine's." 

2. Rheumatic fever. 

3. Other conditions: diabetes; brain tu- 
mors; Legg-Calve-Perthes disease; burns; 

Unit VI: Adolescent 

1. Growth and development of puberty 
and adolescence. Films: "Ten's to Twelve's" 
and "Age of Turmoil." 

2. Conditions of the teenager: fatigue; 
postural problems; acne; anemia; obesity; 
menstrual irregularities; scoliosis. 

3. Emotional problems of the school 
child and teenager. 

4. Nursing care studies — student pres- 

Theory assignments include com- 
parison studies of the hospitalized 
child with the "hypothetically average" 
child of the textbooks, short nursing 
care studies on children with various 
conditions and in different age groups, 
and interaction studies. 

Orientation classes cover safety 
measures, emergency situations, diet- 
ary regimes for children, and admin- 
istration of medications and parenteral 
fluids. Orientation to individual nurs- 
ing units is given the first morning the 
student arrives on a new area. Three 
weeks of afternoon shift are planned 
for each student to give her a better 
understanding of children by assuming 
responsibility for their evening care 
and through dealing with visiting par- 
ents. Ward classes each weekday en- 
able the student to present and dis- 
cuss the children with whom she is 
working and help her to gain an un- 
derstanding of the management of the 
sick child. 



March 1965 

Series on Neurology and Neurosurgery 

P. Robb — Epilepsy and Its Medical Treatment 

W.M. Lougheed — Intracranial Berry Aneurysms 

R.R. Tasker — Increased Intracranial Pressure 
C. Bertrand — Parkinson's Disease 

and others 




S^ a caps^'©. 


Legal counsel for the California Hospital 
Association recently cautioned: 

It is serious morally, legally, and me- 
dically "to ask a nurse to decide whether 
the patient has a condition that contra- 
indicates closed chest cardiac massage. 
On the other hand, if the nurse has been 
trained and the hospital has rules permit- 
ting nurses to do this procedure, the nurse 
may be in legal trouble if she fails to try 
to resuscitate a patient; she may be 
wrong if she does and wrong if she 
doesn't. — A.J.N.. 64:24. 1964. 


A hospital administrator is quoted in 
Canadian Hospital as saying that the basic 
cause of the shortage of nurses in Metro 
Toronto is the shortage of training hospitals. 
He also claims that "These girls don't go 
to the States because they can make more 
money. They go because they want to see 
some of the world or are looking for 
their Prince Charmings. But they soon come 

It is a constant source of amazement to 
us how some hospital administrators be- 
lieve they "know" so much about the 
motivations of nurses, how they should be 
educated, etc. They expound their beliefs 
about our profession and what is best for us 
on platforms and in various professional 
journals ad infinitum. Perhaps they are 
encouraged to do this because of the re- 
luctance of nurses to speak out for them- 

The answer does not lie in treating us 
as "girls" who are looking for adventure. 
In fact, it is precisely this "pat them on the 
head, but don't treat them as professionals" 
attitude that is partly responsible for driv- 
mg nurses from one hospital or country to 

We do not deny that travel, and an 
opportunity to "see some of the world" is 
appealing. But it is not mere coincidence 
that the hospitals chosen by most nurses 
crossing the border are those in states 
which offer the highest salaries. Also, if 


travel is the main motivation, why is it 
that so few nurses from the U.S.A. come 
to Canada? 

We cannot help but wonder what would 
happen if the average salary of an ad- 
ministrator was $350 monthly. Would he 
not be inclined to pack up his skills and 
move them elsewhere? 


Noise affects the hospital and its opera- 
tions in four ways: it retards patient recu- 
peration; generates a fear reaction in pa- 
tients; impairs employee relations: contribu- 
tes to a poor public relations image. In a 
"noise study." undertaken at six hospitals in 
Massachusetts, questionnaires completed by 
a sampling of patients revealed that a direct 
relationship was shown between the fre- 
quency of the noise and its annoyance to 
patients. In most cases, the noon hour was 
the noisiest time of day. 

What makes noise "noisy"? 1. The fre- 
quency of noise; 2. The time a noise occurs, 
e.g.. a telephone ring during the day is not 
as disturbing as the same noise occurring at 
night; 3. Personal association with the noise. 
Patients themselves turned out to be the 
greatest source of annoyance to their fellow 
patients. Some of the complaints with re- 
gard to other patients were made on the 
basis of sentiment and emotional associa- 
tions as well as sonic stimulation. For exam- 
ple, a patient moaning may not necessarily 
be a loud phenomenon or limited to any 
specific time in the day but. generally, 
moaning and like sounds are disturbing to 
patients because they associate pain and dis- 
tress with a moan. Verbal paging systems 
are also disturbing. These systems should be 
replaced by the newer, individual portable 
paging sy.stem. 

Recommendations to lessen noise in- 
clude: 1. The establishment of an emergency 
(or night) admission area: 2. A "special 
care" unit for critically ill patients with a 
proper waiting room for late night or odd- 
hour visitors; 3. Emphasis on anti-noise 
features when purchasing equipment; 4. Re- 
placement of the harrassing telephone ring 

10 a more "sonically" attractive chime or to 
a visual signal; 5. An investigation of the 
relationship between light, color and sound; 
6. Programs to make each employee noise 
conscious. — Snook. I. D. Noise That An- 
noys. Nursing Outlook. 12:33-35. July. 1964 


Illnesses of the great hold an unending 
fascination for later generations. Jane Aus- 
ten, who died nearly 150 years ago. now 
appears on medical evidence produced by 
Sir Zachary Cope (British Medical Journal. 
July 18. 1964) to have died of Addison's 

Her last illness, to which she refers in 
numerous letters, was characterized by "in- 
creasing languor and a pain in the back, 
progressing steadily with yet periods of in- 
termission, and attended by critical attacks 
of faintness and gastrointestinal disturb- 
ance." With all this, her own description of 
her altered complexion "black and white and 
every wrong colour" suggests the charac- 
teristic pigmentation of adrenal gland tuber- 
culosis. This account, says Sir Zachary, cor- 
responds well with Thomas .Addison's own 
description of one of the diseases which 
bears his name (the other is. of course. 
Addisonian or pernicious anemia) and it is 
interesting to note that, in addition to writ- 
ing her novels, she has the distinction of 
describing "the first recorded case of Ad- 
dison's of the adrenal bodies." 

— News in Medicine. Niirsin.w Mirror. 
[ l!i:487. .August. 1964 

The management of the menopausal pa- 
tient should be individualized Most pa- 
tients will require nothing more than re- 
assurance and psychological support. A few 
will require mild sedation. The depressed pa- 
tient may require one of the antidepressant 
drugs, and estrogen is specific for the relief 
of the vasomotor symptoms. Estrogen should 
not be given continuously. Oral, rather than 
iniectable preparations are preferred. 

— Brown. A. B. Menopausal Drugs. 
C..M.4.J.. 91:561. Sept. 5. 1964. 




Constant, supervised care for critically ill patients is provided in this unit. 

Sister Clare Marie 

Generally, every new invention is 
born out of an emergency situation. 
Scarcity of trained personnel and the 
desire to provide continuing improve- 
ment of services without unduly in- 
creasing costs, were the factors that 
forced our intensive care unit into 

An intensive care unit is designed to 
provide high level nursing care for 
critically ill patients who require con- 
tinuous, comprehensive observation 
and care regardless of category — 
medical, surgical, obstetrical, etc. 

This unit is one phase of the "pro- 
gressive patient care" program that has 
been set up in many hospitals. 

The intensive care unit is an out- 
growth of the recovery room. Since 
World War II, the recovery room has 
been an integral part of postoperative 
nursing service. Due to shortage of 
qualified personnel during the war, 
some means had to be found for giv- 
ing care to the unconscious, anesthe- 
tized patient. To meet this need, re- 
covery rooms were set up in close 
proximity to the operating rooms in 
many hospitals. They have proved suc- 
cessful in giving continuous, adequate 
care to the patient who is recovering 
from anesthesia. Emergency equipment 
is instantly available; drugs, parenteral 
therapy, and blood transfusions are 
immediately attended to without neg- 
lect to any other patient. A nurse in a 
recovery room situation can look after 
six patients with the help of one auxi- 
liary assistant. 

Some hospitals further experimented 
by adding an extension to their recov- 
ery room. Immediately adjoining it, 
they set up a unit which could care 
for six to eight patients who required 
constant, supervised care over a three 
to four-day period. The intensive care 
unit for every category of critically ill 

This material was presented in panel form 
at the annual meeting of the RNANS. Par- 
ticipants were: Chairman, Sister Clare Ma- 
rie, (formerly director of nursing): Shelagh 
Molloy; Loyola Floyd: and Jeanne Gou- 
gere. all of St. Martha's staff. 

patient thus came into existence. 


We had certain objectives in mind 
when planning our unit: 

1. To provide a nursing unit especially 
designed to incorporate many features in- 
tended to save time and to conserve nursing 

2. to maintain a maximum number of 
fully qualified professional nurses who have 
demonstrated ability to interpret patients' 
needs and to initiate the types and kinds of 
nursing care to meet these needs; 

3. to provide the necessary supplies and 
equipment, either "built in" or easily ac- 

4. to identify and admit to the special 
care unit only those patients who will benefit 
from this type of care and to discharge 
patients from the unit as soon as the need 
for this type of care no longer exists; 

5. to save life, reduce the length of the 
critical period and to prepare the patient 
for his convalescence and eventual attain- 
ment of optimum health. 

There are no hard and fast rules 
governing the selection of patients for 
the intensive care unit. Each hospital 
determines its own criteria. In general, 
the selection is based on the patient's 
specific needs rather than on diag- 
noses. The nursing needs considered 
most critical and deserving of special 
care are: 

1. shock; 2. hemorrhage; 3. respiratory 
embarrassment; 4. convulsions and/or coma; 
5. fluid and electrolyte problems; 6. circula- 
tory distress; 7. complicated drainage prob- 

Intensive care units are not intended 
to replace recovery rooms. These still 
exist, although they generally operate 
on an eight-hour basis, whereas the in- 
tensive care unit carries on for 24 


The physical planning of the unit is 
governed by whether or not renova- 
tions have to be made to erect it, if it 
is being built as part of a new exten- 
sion to a hospital or if it is to be built 
within a new hospital. When possible. 

it should be located near important 
departments of the hospital — operat- 
ing room, x-ray, central supply, etc. 
Certain factors should be considered 
in the planning: 

1. Multiple or ward arrangements 
are deemed preferable to single ac- 
commodations to obtain the most effi- 
cient use of the space and the oppor- 
tunity for constant observation. Some 
units are designed so as to resemble 
one big ward with the nurses' station 
centrally located and utility room facil- 
ities and medicine cupboard within the 
ward. Other units are constructed with 
individual sub-units of two, three and 
four beds — generally to a maximum 
of 10 beds. These are not as service- 
able as they do not allow instant vision 
of all patients. 

2. In the multiple-bed arrangement, 
at least one private room should be 
available for care of patients with cer- 
tain kinds of illness, particularly those 
of an infectious nature. 

3. The unit is generally designed to 
care for both sexes. Even though pri- 
vacy is provided by cubicles or drawn 
curtains, this is the most questionable 
factor of the whole set-up. 

4. The unit is for all types of illness, 
providing the patients meet the previ- 
ously-mentioned criteria. 

5. The nursing station should be lo- 
cated so as to assure the possibility of 
constant observation of all patients. 

6. The patient area should be situ- 
ated so as to assure the shortest possi- 
ble distance between the nursing sta- 
tion and all beds. 

7. It would be desirable to design 
the unit to permit flexibility — for ex- 
pansion when demand is high, concen- 
tration when low. 

8. The unit should be completely 

9. To the greatest degree possible, 
all equipment should be "built in" and 
available for each bed. This would in- 
clude suspended intravenous hangers, 
ceiling spotlights, piped oxygen and 
suction and other wall-mounted appa- 

10. An emergency call system, both 




from bed to station and from special 
care station to a nearby general nurs- 
ing station, is desirable. 

1 1 . The assurance of adequate sound 
control is of particular importance, al- 
though difficult to attain within mul- 
tiple-bed accommodations. 

12. The provision of both 110 and 
220 volt electrical outlets is essential. 

13. Mechanically operated beds, ad- 
justable as to height, are desirable. 

14. Provision should be made for 
the immediate availability of ernergen- 
cy medication, essential equipment, 
and instruments, e.g., those needed for 
heart massage, intratracheal emergen- 
cies, etc. 

15. Usual bedside "niceties," e.g., 
chairs and dressers, are eliminated. 


The main purpose of an intensive 
care unit would be defeated if it were 
left inadequately staffed. The number 
of staff required depends on the size 
of the unit and the physical planning. 
Where the unit has been constructed 
on the open-ward style, care can be 
given with fewer nurses than would be 
the case with the sub-unit type of ar- 

Hospital A has a 27-bed unit divided into 
four sub-units. Two of these sub-units con- 
sist of a four-bed room plus an adjacent 
single room; one consists of a four-bed 
room, a two-bed room and a single room; 
the remaining unit consists of five two-bed 
rooms. A nursing team is provided for each 
sub-unit. One professional nurse is assigned 
to each of the four units for each tour of 
duty — a total of 12 professional nurses in 
24 hours. The remaining staff is made up of 
licensed practical nurses or certified nursing 

assistants, one or two per team for each 
tour of duty. 

Hospital B has an intensive care unit of 
10 beds. The staffing quota is five registered 
nurses and five nursing assistants for the 
7:00 a.m.-3:00 p.m. and 3:00 p.m.-l 1:00 p.m. 
shifts and one registered nurse and one 
nursing assistant for the 1 1:00 p.m. -7:00 a.m. 
period. Student nurses are given some ex- 
perience in this unit, mostly on an observa- 
tion basis. 

The intensive care unit in Hospital C 
has 10 beds. By means of an accordion fold- 
ing door, the capacity can be enlarged to 
14 beds or decreased to six. The set-up is 
such that the nurses' station is in the centre 
of the room. It resembles a glassed-in island 
and encloses the medicine cupboard. Patient 
rooms closely encircle the "island" permit- 
ting close observation. The staff consists of 
the head nurse, two registered nurses, two 
licensed practical nurses and a ward clerk, 
7:00 a.m. to 3:00 p.m.; two registered nurses 
and two practical nurses. 3:00 to 11:00 p.m.; 
one registered nurse and three practical nur- 
ses, 11:00 p.m. to 7:00 a.m. Private duty 
nurses are not employed in this unit. 

Hospital C reports that and average of 
17.7 hours of nursing service per patient is 
given in a 24-hour period. In comparison, 
patients in the remaining portion of the hos- 
pital average 4.3 hours. 

Persons chosen to work in this area 
must be of a very high calibre. They 
must be skilled, intelligent, conscienti- 
ous, enthusiastic, energetic and emo- 
tionally stable. 

Nurses tend to become fatigued easi- 
ly when faced with the strenuous care 
of critcally ill patients over a prolonged 
period of time; on the other hand, if 

the patient load lessens, they feel that 
their skills are not being used. Most 
hospitals using the units have policies 
that allow for reallocation of personnel 
should there be a low patient census 
for any length of time. Thorough orien- 
tation programs are a "must" in the 
development of techniques essential in 
emergency nursing. 


The major advantage of the unit is 
the giving of comprehensive, special- 
ized care to the critically ill, many 
times resulting in the saving of a life, 
by making the best use of medical and 
nursing personnel — and all this with- 
out additional cost to the patient. 

The disadvantages are: The diffi- 
culty in maintaining optimum occu- 
pancy, particularly when the unit is 
established in a small hospital; the 
problem of staff turn-over, possibly due 
to the depressing effect of caring only 
for critically ill patients necessitating 
frequent in-service training programs: 
the higher cost to the hospital; the 
difficulty for some patients to be- 
come accustomed to general care af- 
ter being on the intensive care unit: 
the attitudes of some doctors who ad- 
mit patients to the unit even though 
they do not require special care; the 
attitude of some nurses on other units 
who believe that patients who are in 
the terminal stage of illness should be 
transferred to the intensive care unit. 

One of the important features of this 
unit is that the medical condition and 
nursing needs of each patient must be 
reviewed daily by the head nurse with 
the physician so that the patient may 
be transferred from the unit as soon as 
his needs can be met elsewhere. 


The operating room of a cancer research 
hospital . . . differs from other surgical 
suites primarily because the majority of 
operations involve radical or extended pro- 
cedures and because one or several research 
projects may be concerned with each pa- 
tient. New techniques, instruments, and ma- 
terials are continually being evaluated. Re- 
search projects require sampling of many 
different body fluids for cancer cells, col- 
lecting of tissue specimens for cell cul- 
ture, and of tumor specimens for trans- 
plantation, virology, and chromosomal stu- 
dies. Frequently, adjuvant chemotherapeutic 
drugs are administered during surgery. Ra- 
dioactive materials are studied clinically 
and given therapeutically .... 

The operating room "preps" differ and 
change often as new products are tested. 
Any substance that must be massaged over 
a tumor site is contraindicated. Effective- 

ness of the prep is checked by a culture 
after the prep, followed by a second culture 
at the same site following a long procedure. 
If there are several areas to prepare, each 
is allotted a separate preparation setup .... 

[The] average major procedure last four 
hours, but many require up to 10 hours. 
If the operation is preceded by a frozen 
section, all material is removed and a fresh 
preparation setup, linen, and instrument 
pack are used to avoid spreading cancer 
cells. When a patient is to have more than 
one incision, clean instruments are provided 
for each .... 

Special tumor kits may be employed to 
transplant a tumor. Transplantation is done 
to determine whether the patient's body 
will accept the transplant or manufacture 
antibodies and reject the tissue. Later, some 
of these patients will be treated with drug 
vaccines or irradiation. Various types of tub- 

ing must be ready for cannulation during 
the operative procedure to administer a 
chemotherapeutic agent. For some patients, 
intravenous or intra-arterial tubing may be 
left in place for infusion .... 

Saline washings of the peritoneal and 
thoracic cavities are taken before and after 
tumor manipulation. Blood specimens drawn 
from regional veins draining the tumor 
area serve the same purpose. For instance, 
in studying breast cancer, blood is obtained 
from the arm of the patient's affected side 
periodically during the procedure. From one 
to 20 frozen sections may be taken during 
a single operation to confirm the presence 
or absence of distant metastases or to de- 
termine whether the margin of the tumor 
was adequately circumscribed. — Connell. 
Alice. Cancer Research O.R. American Jour- 
nal of Nursing. 64:110-111, October, 1964. 





Procedures being used io combat sudden cessation of the heartbeat. 

Four minutes. A short time in 
which to do anything — let alone save 
a life. And yet four minutes is the 
maximum time allotted by nature if a 
patient in cardiac arrest is to be saved 
and irreparable brain damage pre- 

Obviously, therapy must be initiated 
by those at hand immediately. Certain 
procedures, when carried out in the in- 
terval between discovery of the arrest 
and arrival of the "emergency team" 
with special equipment, can be and 
frequently are life-saving. 

To determine the procedures cur- 
rently being taught and followed, the 
editorial staff of the Journal sent the 
following questionnaire to directors of 
nursing in 17 Canadian hospitals: 

1. Do you have a written emergency pro- 
cedure in your hospital for the treatment of 
cardiac arrest? If so, please describe. 

2. Are staff nurses taught what to do be- 
fore the "emergency team" arrives? De- 
scribe what is taught and by whom. 

3. Are external cardiac massage and 
mouth-to-mouth resuscitation taught to 
nursing students? When is the student taught 
these procedures? 

4. Has this emergency procedure been ef- 
fective in saving lives? Please comment. 

We express our appreciation to the mem- 
bers of staff in the following hospitals 
who participated in this study: The Regina 
Grey Nuns' Hospital, Regina. Sask.; The 
Vancouver General Hospital. B.C.; Saint 
Mary's Hospital. New Westminster. B.C.: 
The Montreal General Hospital, P.Q.; H6- 
tel-Dieu St-Vallier, Chicoutimi, P.Q.; Uni- 
versity Hospital, Saskatoon, Sask.; Calgary 
General Hospital, Alta.; St. Mary's Hospital. 
Montreal, P.Q.; General Hospital. St. John's. 
Nfld.; The Victoria General Hospital, Hali- 
fax. N.S.: St. Michael's Hospital. Toronto. 
Ont.; McKellar General Hospital. Fort Wil- 
liam. Ont.; Hamilton General Hospital. Ont. 


Thirteen of the 17 hospitals con- 
tacted returned their completed ques- 
tionnaire. Five respondents stated that 
a pre-arranged code is announced over 
the public address system to alert per- 
sonnel to a cardiac arrest. The code 
most commonly used is "99" (e.g., 99, 
3rd. floor, room 8). Others reported 
that the switchboard operator notifies 
the person(s) concerned — anesthe- 
tist, resident or staff doctors — di- 
rectly or through "locating." 

In all but one hospital, student and 
graduate nurses are expected to com- 
mence mouth-to-mouth (or mouth-to- 
airway) breathing and closed-chest (ex- 
ternal) cardiac massage, before the 
emergency team arrives. In one hospi- 
tal, the nurse is not permitted to give 
closed-chest cardiac massage — • this 
remains a doctor's responsibility. 

Six of the 1 3 hospitals make use of 
the Brook Airway during the critical 
four-minute period. At least two hos- 
pitals keep one of these airways on 
each nursing unit as well as on the 
portable cardiac arrest cart. One re- 
spondent stated that direct mouth-to- 
mouth resuscitation is not advocated in 
hospital because of the danger of in- 
fection to the person giving it. 

Eight hospitals keep their emergen- 
cy equipment on a "cardiac arrest 
cart" that can be wheeled from its lo- 
cation (usually one is kept in the oper- 
ating room and one in the recovery 
room) to any point in the hospital 
within minutes. As well as this, most 
hospitals have a "cardiac arrest set" 
on each nursing unit and on the port- 
able cardiac arrest cart. Oxygen and 
suction equipment are also available 
on each unit. 

Equipment Kept on Portable Cart 
This varies from one hospital to 

another. Equipment generally men- 
tioned includes: 

1. Brook Airway 

2. Pacemaker and monitor 

3. Portable cardiac defibrillator 

4. Resuscitation kit containing laryngo- 
scope, intubation tubes, Om masks, 
tongue forceps, etc. 

5. Intermittent positive pressure breath- 
ing apparatus (IPPB) 

6. Sterile chest retractor 

7. Underwater chest drainage apparatus 

8. Tracheotomy tray 

9. I.V. cutdown tray and I.V. solutions 
10. Cardiac arrest set. 

Equipment Kept 
on Cardiac Arrest Set 

1. Brook Airway 

2. Ambu resuscitator 

3. Stethoscope and sphygmomanometer 

4. Tourniquets 

5. Bottle of "prep" solution 

6. Adhesive tape 

7. Sterile tray containing: 

a. disposable scalpels and blades 

b. syringes and needles 

c. medicine glass 

d. cotton balls and gauze squares 

e. hemostats 

f. thumb and tissue forceps 

g. Mayo scissors 

h. suture equipment 

8. Emergency drugs. 

Emergency Drugs 
As previously mentioned, these 
drugs are generally kept on the cardiac 
arrest set: 

1. Adrenalin 1:1000 

2. Aminophylline 

3. Metaraminal bitartrate (Aramine) 

4. Atropine sulphate 

5. Calcium chloride 

6. Diphenylhydantoin sodium (Dilantin) 

7. Isuproterenerol hydrochloride (Isuprel) 

8. Digoxin (Lanoxin) 








Flash bedside signal light. 
Patient supine. 
Remove pillows. Extend neck. 
Head to side. Clear airway. 


Hands over lower sternum. 

Push firmly, release quickly 

40 — 60 times per minute. 

Arms straight. 

Desirable to 

raise legs and 

place board under mattress 



Insert airway over tongue. 
Raise jaw. Occlude nostrils. 
Blow into airway. 
Expand chest 1 2—16 times 
per minute. 







Luxo Light 

B.P. Cuff 




ECG Jelly 


Electric Cables 

ectric Outlet (4) 




ECG Coble 
EEG Coble 
and Needles 

Sterile Internal 



ver Tracheotomy 

Front view of resuscitation cart designed and used in the hospitals of the Upstate Medical Centre, Syracuse, N.Y. (Israel, J.S., McCulla. 
K. and Dobkin, A.B. A Cart for Cardiopulmonary Resuscitation. CM. A. J. 89: 1284-89. Dec. 1963.) 

9. Levarterenol bitartrate (Levophed) 

10. Phenylephrine hydrochloride (Neo- 

11. Procainamide hydrochloride (Prones- 


12. Sodium bicarbonate 


Graduate and student nurses (and, 
in some hospitals, orderlies) are taught 
a procedure similar to the one de- 

1 . The first person to discover the 
patient notes the exact time of the ar- 
rest, stays with the patient and alerts 
other staff members who notify switch- 

board. The emergency team is called. 

2. In the absence of the resident 
physician, the nurse attempts to re- 
store the heart beat by several sharp 
blows over the precordium. (Only two 
hospitals mentioned this in their pro- 
cedure.) If this is unsuccessful, she 
commences mouth-to-mouth or mouth- 
to-airway breathing. 

3. Another member of staff applies 
closed-chest cardiac massage. 

4. A third person assembles equip- 
ment from the cardiac arrest set while 
awaiting the arrival of the portable 
cardiac arrest cart and the resuscita- 
tion team. 

Closed-Chest Cardiac Massage 
The principle is to force blood 
out of the heart by compressing the 
heart between the sternum and the 

1. Place patient in supine position 
on a firm surface such as the floor if 
there is no board under the bed mat- 

2. Kneel beside patient; locate xi- 
phoid process and place heel of one 
hand over it. Place heel of second 
hand over heel of lower hand. (For 
children one to 12 years of age, use 
only one hand, placed slightly above 
base of sternum to prevent liver dam- 




Mayo Tray 

Ambu Bag and Mask 

Labeled Plastic 
Drawers containing 
Emergency Drugs 

Clip Board with 
Evaluation Protocol 

f I.V. Giving Sets 
> Pediatric Drip Sets 
^^ Blood Pump 

Fibreboard Troy 

I.V. Solutions 

Electric Cable 


Back view of resuscitation cart designed and used in the hospitals of the Upstate Medical 
Centre Syracuse, N.Y. (Isr.ael, J.S., McCulla. K. and Dobkin, A.B. A cart for 
Cardiopulmonary Resuscitation. CM. A. J. 89: 1284-89, Dec. 1963). 

age; for infants up to one year, use 
two thmnbs only, placed midway on 

3. Using the weight of your body, 
push sharply downwards with suffi- 
cient pressure to depress sternum one 
to two inches (less for infants and 

4. Immediately release pressure. Re- 
peat cycle 50 to 60 times a minute. 
Continue until other therapy is insti- 

5. If extra help is available, the pa- 
tient's legs should be elevated to an 
angle of about 30°. 

One of the written procedures sub- 


mitted slated the possible complica- 
tions of closed cardiac massage; rib 
fractures, liver injury, hemothorax, 
hemopericardium and marrow emboli. 


1. With patient in supine position, 
remove any foreign matter from mouth 
and pharynx. 

2. Insert airway, if available, over 
tongue and blow forcefully (gently for 
children). If airway is not immediately 
available, lift up the patient's jaw so 
that it "juts out." tilt his head back- 
wards; take a deep breath, open your 
mouth widely and place over patient's 

mouth; occlude his nostrils with your 
hands; blow forcefully, using sufficient 
pressure to cause visible expansion of 
his chest. 

3. Allow the patient to exhale pas- 

4. Repeat procedure 12-20 times 
per minute. Continue until equipnient 
for providing oxygen under positive 
pressure has arrived. 


Cardiac arrest procedures are gen- 
erally taught to the graduate nursing 
staff by a cardiologist or an anesthetist. 
At least two hospitals present a three- 



day program conducted by a pharma- 
ceutical company. Three respondents 
mentioned that films concerning ex- 
ternal cardiac massage and mouth-to- 
mouth breathing are shown.* Two hos- 

* The film "External Cardiac Massage" 
IS available on loan from Smith. Kline and 
French Laboratories, .^00 Laurentian Blvd., 
.Montreal. Que. On request, this company 
will send a representative who uses an 
adult-size doll to demonstrate external car- 
diac massage and moulh-to-mouth resusci- 

pitals make use of an adult-size doll 
for demonstration and practice pur- 
poses. One hospital which does not 
have resident doctors, teaches its nurs- 
ing staff how to administer inhalation 
therapy with the IPPB machine. 

Nine of the twelve hospitals having 
schools of nursing reported that stu- 
dents learn mouth-to-mouth breath- 
ing and closed cardiac massage during 
their first year. In most instances, stu- 
dents are taught by a Red Cross or 
a St. John Ambulance First Aid in- 
structor. These procedures are appar- 


To help physicians m teaching external cardiac massage and cardiopulmonary resuscitation 
to medical audiences and physician-directed rescue groups. Smith Kline & French provides 
■Resusci-Anne', a life-size training manikin. 'Resusci-Anne' is available through SK & F 
representatives for use with the teaching films "External Cardiac Massage" and "Life in 
Your Hands." 

ently reviewed in the student's second 
or third year in a "disaster nursing" 
course or in the emergency or medical- 
surgical departments. 


Has this procedure helped to save 
the lives of persons in cardiac arrest? 
All respondents, except one, stated 
"yes." In this one case, no cardiac 
arrests had occurred since their plan 
went into effect. 

One hospital, in a five-month per- 
iod, successfully treated six patients 
who were in cardiac arrest; others re- 
ported they had no statistics concern- 
ing the number of patients who had 


Of 1 7 hospitals surveyed, 1 3 replied 
stating that they had a written proce- 
dure for the emergency treatment of 
cardiac arrest. In all but one hospital, 
students and nursing staff are taught 
how to give both mouth-to-mouth 
or mouth-to-airway resuscitation and 
closed-chest cardiac massage. Almost 
50 per cent of the respondents claim 
they use the Brook Airway rather 
than direct mouth-to-mouth breathing. 

The twelve hospitals who have used 
this procedure state that it has been 
successful in either prolonging or sav- 
ing lives. 



The art of medicine is not an exact 
science. One of the main charges leveled 
at modern medicine is that we treat the 
disease mstead of the patient. Progressive 
patient care has once again allowed us to 
go back to the patient as an entity and 
treat each person according to his medical 
needs. Flexibility, both as to method and 
as to degree of cure, is possible and ben- 
eficial to both patient and physician. The 
patient is allowed to retain his individual 
dignity. The vast majority of patients enter, 
remain, and go home from the initial unit 
of admission. Other patients, however, do 
move from one unit to another as the 
physician deems necessary. 

[For example], one surgical patient ad- 
mitted to the self-service unit [at Manches- 
ter Memorial Hospital. Conn.] had his diag- 
nostic studies performed there, moved to the 
special care unit the night before surgery 
and received his preoperative preparation, 
went to surgery, recovery room, back to the 
special care unit for a few days, then down 
to the intermediate care unit . . . back to the 
self-service unit once again before he went 

home. As another mstance, a patient with 
diabetic coma was cared for in the special 
care unit and, as the diabetes and intercur- 
rent complications were corrected, moved 
through the various phases of care to the 
self-service unit, where he completed his 
hospital stay .... These two brief examples 
point out the potentialities and flexibility of 
progressive patient care which answer the 
patient's needs .... 

Most patients will accept new ideas if 
they are adequately explained by their per- 
sonal physicians. Patients say they feel pro- 
moted as they moved from the special care 
unit to the intermediate care unit to the 
.self-service unit and home. The physical 
progress becomes a symbol of their medical 
progress in overcoming disease. One can see 
that a patient normally faces a series of 
psychological adjustments during hospital- 
ization. As a "sick" man, he resigns his own 
will and allows others to make decisions for 
him. Later, he gradually sloughs off this 
dependency state, becomes convalescent, and 
finally resumes the responsibility of his own 
care. The physical movement of the patient 

from nursing unit to nursing unit within 
progressive patient care acts as a stimulus to 
these psychological adjustments. It symbol- 
izes to all concerned — doctor, nurse, fam- 
ily, and patient — that the patient's status 
is now changed and it is easier for him to 
overcome his former dependency and take 
the next step forward. 

From the nurse's standpoint, progressive 
patient care allows her to work in the area 
for which she is best qualified. The nurse 
who enjoys the challenge of the life-and- 
death tension of the special care unit may 
welcome such an assignment. The nurse 
who enjoys teaching and talking with people 
might be happy on the self-service unit. The 
nurse who loves to mother and care for the 
long-term patient finds her niche in the 
continuation care unit, while the interme- 
diate care unit offers a variety of care for 
the nurse who likes change . . . The nurses 
have been more content with the knowl- 
edge that their individual abilities are being 
utilized. — Lockward, J. L.. Gidding, L. 
and Thorns. E. Progressive Patient Care. 
l.A.M.A. 172: 132-37. 







Federal-Provincial Conference on 
Menial Retardation 

This four-day Conference, conven- 
ed by the Minister of National Health 
& Welfare in Ottawa in October, 
brought together approximately 150 
delegates with special interests and re- 
sponsibilities in retardation, and in- 
cluded CNA's president, Mrs. A. Iso- 
bel MacLeod, who presented a state- 
ment from the Canadian Nurses' As- 
sociation setting forth some observa- 
tions and suggestions. The statement 
follows at the end of this report. 

Through panel and group sessions, 
obstetricians, pediatricians, psychia- 
trists, psychologists, social workers, 
nurses, research workers, educators, 
mental health workers, vocational guid- 
ance representatives, rehabilitation ex- 
perts and members of government de- 
partments discussed the educational, 
health, welfare and vocational aspects 
of retardation and endeavored to cla- 
rify the roles and responsibilities of 
the various agencies and workers in 
this challenging field. 

Dr. R. O. Jones, professor of psy- 
chiatry at Dalhousie University, in his 
summation of the conference, stated 
that a multidisciplinary approach is 
needed to meet the large and complex 
problem of mental retardation. He 
broke his summation down under four 
headings — Prevention; Detection, As- 
sessment and Counseling; Care; Im- 
plementation, Coordination and Inte- 
gration of Services - — and drew these 

1 . There is a need for better education 
in the undergraduate courses, in post- 
graduate courses and in in-service edu- 
cation programs to ensure doctors and 
nurses are in a position to play their 
proper role in detection and treatment 
of the mentally retarded. 

2. Some of the knowledge already gained 
demands change in social attitudes, 
such as attitudes regarding family plan- 
ning and marriage laws. 

V There is a great need to coordinate 
facilities to serve the mentally retard- 
ed and also for good facilitie«; for the 

mentally retarded in their own com- 

4. Home care is preferable to institution- 
al care. Institutional care should be 
used only when necessary and for a 
short time. Institutions should be com- 
munity-based and community-linked. 

5. There is a need for a spectrum of ser- 
vices for the retarded over their whole 
life span, such a sheltered workshops, 
leisure activities, etc. 

6. The emotional factors in the parents 
and in professional people need to be 
recognized and dealt with to avoid re- 
jection and allow the full intellectual 
development of the retarded. 

7. There is a need to stimulate recruit- 
ment of well-qualified people to work 
with the mentally retarded. 

8. There is a need to do away with mter- 
professional rivalry and to work toge- 

Statement on Mental Retardation 

This brief statement, submitted by 
the Canadian Nurses' Association for 
the Federal-Provincial Conference on 
Mental Retardation, sets forth some 
observations and suggestions which, 
it is hoped, might be useful to the 
general purpose of the Conference 


The Canadian Nurses' Association, 
with a membership of over 77,000 re- 
gistered nurses, is a federation of the 
ten provincial nurses' associations and 
has as its primary purpose the im- 
provement of nursing practice in ac- 
cordance with the health needs of the 
nation. The promotion of maximum 
health is the basis of the profession's 
concept of nursing care. 

The Association beheves that the 
promotion of maximum health can 
best be achieved as a cooperative ven- 
ture through coordinated planning with 
other health groups and community 
services. Thus, there is a need for 
the nurse to be consistently active in 
planning with other groups for the 
best care of all individuals, including 
those who are mental) v retarded 

The significance of the nurses' con- 
tribution to the health field is recog- 
nized by the World Health Organiza- 
tion in this statement: "In many coun- 
tries where medicine is highly develop- 
ed and nursing is not, the health status 
of the people does not reflect the ad- 
vanced stage of medicine." 


Over the years nurses have been 
involved with the care of the mentally 
retarded both in the hospital and in 
the community. These nurses recog- 
nize the need for coordinating their 
program between hospital and com- 
munity through a comprehensive re- 
ferral system. 

(a) Role of the Public Health Nurse 
Since a large proportion of the mentally 

retarded remain in the community, the pub- 
lic health nurse can play — and has 
played — a significant part in planning with 
families and others for the welfare of the 
mentally retarded. She has long recognized 
these children in her caseload, and has as- 
sisted them and their families in making the 
necessary adjustments to home care. Her 
work has become more effective as varied 
services in the community have become 
available and as alternatives to institution- 
alization continue to improve she can, with 
other community personnel, plan for com- 
prehensive services which will permit the 
retarded to live more productively within 
the community. 

(b) Role of the Hospital Nurse 

About a decade or more ago. the care 
given by the nurse for the mentally re- 
tarded was limited to providing services 
for the patient in the ward area. With 
increasing awareness of and concern for 
the mentally retarded and with the advances 
in health sciences and the changes in insti- 
tutional care, the hospital nurse is provided 
with new opportunities for giving improved 
patient care and is becoming a participant in 
the health team which plans for the pa 
tient's total care. In some institutional set- 
tings she functions as a coordinator of 
services for children in ward units At all 


FEBRUARY 1 96.5 


times she serves as a friend and counsellor 
of the patient. With members of the health 
team she works with and phms for the 
rehabilitation of the patient. 

(c) Role in Research 

As various research projects are develop- 
ed in mental and general hospitals and in 
public health agencies, the nurse with the 
necessary preparation will make a significant 


Although nurses have participated 
in the care of the mentally retarded, 
there is a need for all nurses to have 
better preparation in this area of health 
care. It is suggested that the concepts 
related to mental retardation be inte- 
grated into the nurses' basic curricu- 
lum. There is also a need for some 
nurses to have specialized post-basic 
preparation in this area, so that they 
may give the necessary nursing lead- 
ership in this field. 


Nurses in the public health field 
and in general and mental hospitals 
are playing an important role in the 
care of the mentally retarded. The pub- 
lic health nurse plays an essential role 
in case finding, referral and follow-up. 
She acts as friend and counsellor to 
the mentally retarded and their fam- 
ilies. The nurse recognizes that the 
care of the mentally retarded is a 
cooperative venture, and works with 
other groups to achieve the most ef- 
fective plan for this care. Nurses in 
institutions have developed nursing 
care programs for the mentally re- 
tarded, and have cooperated with other 
disciplines in rehabilitation programs. 

It is vital that all nurses have bet- 
ter preparation in this field so that 
they may make a greater contribution. 
Canadian Nurses' Association 

Canadian Nurses Attend Conference 

Eleven Canadian nurses were among 
325 delegates who attended a cardiac 
nursing conference in Portland, Ore- 
gon in November. The three-day meet- 
ing, sponsored by the American Nur- 
ses' Association and the American 
Heart Association, was focused on new 
techniques in nursing care of cardiac 

Among the roster of speakers were: 
Dr. Frederick P. Haugen, professor and 
head of the Division of Anesthesiology 
at the University of Oregon Medical 
School; Miss Dorothy Cahill, auxilia- 
ry personnel supervisor. University of 
Oregon Medical School Hospital; Dr. 
Herbert J. Semler, cardiologist and di- 
rector of the Cardiac Telemetry Sta- 
tion at St. Vincent Hospital, Portland; 
Miss Joanna DeMeyer, assistant pro- 


Canadian nurses attending the clinical conference on "Nursing Care of the 

Cardiac Patient" held at Portland, Ore., Nov. 11-13 take a break between 

clinical sessions to pose for the photographer. 

L to R seated are: Phillis R. Calvert, Victoria, B.C.; Alice J. Baumgart, 

Vancouver, B. C; Mrs. Sheila MacPhail, Victoria. B.C.: Sheila Hunter, 

Calagry, Alberta. 

L to R standing are: Mrs. Valeria Nicholson, Calgary, Alberta: Mona 

Farmer, Victoria, B.C.: Gertrude F. Shaw, Calgary, Alberta; Sister Mary 

ScHAUM, Vancouver, B.C.; Sister Margaret Mary, Gaspe Quebec: Sister 

Ann Elizabeth, Vancoidver, B.C.; Glenora Erb, Vancouver, B.C. 

The national conference was sponsored by the American Nurses' Association 

and the American Heart Association. 

fessor of nursing at the University of 
Oregon School of Nursing; Dr. George 
E. Wakerlin, medical director of the 
American Heart Association; Mrs. 
Harriet Coston Moidel, associate pro- 
fessor of nursing at the University of 
California at Los Angeles, and Mrs. 
Judith G. Whitaker, executive director 
of the American Nurses' Association. 

Cannot Indulge in Smugness 

Organized nursing must come to 
grips with a number of critical prob- 
lems if the profession is to maintain 
its place in the provision of health care 
for the people of Canada, delegates to 
the recent Conference of Directors of 
Schools of Nursing were told by the 
Canadian Nurses' Association executive 

"Among the problems facing nurses, 
the largest group in the field of health 
care, are the supply of nurses, recruit- 
ment, organization, nursing education 
and nursing research," said Dr. Helen 
Mussallem. "The profession must cea- 
selessly press for higher standards for 
nurses and for better education and 
welfare services for them." 

The report of the Royal Commission 
on Health Services may have over- 
whelmed many persons and caused 
them to conclude there is not much 

that can be done. Dr. Mussallem said, 
but there is much that each one can 

Let us not perpetuate our indecisions of 
the past. We cannot indulge in the luxury 
of doing nothing any more. It is just as pre- 
sumptuous to think that you can do nothing 
as to think you can do everything. We may 
never indulge in smugness which assumes 
that everything possible has been attained. 
We are committed to search for better ways 
of performing our tasks. 

Dr. Mussallem told the delegates no 
government or national association 
would move the profession toward 
health goals without the action of key 
personnel in nursing. 

Invitation to Switzerland 

The Swiss Association of Graduate 
Nurses has invited members of the Ca- 
nadian Nurses' Association to visit 
Switzerland in connection with their 
participation in the ICN Congress in 
Frankfurt next June. 

Miss Erika Eichenberger, General 
Secretary, advises that study programs 
will be arranged in the fields of visi- 
tor's interests and recommends visits 
to the headquarters in Geneva of the 
International Committee of the Red 
Cross, the League of Red Cross Socie- 
ties and the World Health Organiza- 




tion. June 28th to 30th have been re- 
served for these visits. Interested nur- 
ses should advise the Swiss Association 
of Graduate Nurses. Choisystrasse 1. 
Berne, not later than March 31. 1965. 
giving the following information: 
Name and home address 
Fields of interest 
Language understood and spoken 
Exact dates of duty programs in Swit- 
zerland (no visits can be arranged on 
Saturdays or Sundays) 
Address in Switzerland 

RNAO Appoints Program Director 

The president of the Registered Nur- 
ses' Association of Ontario has an- 
nounced the appointment of Lloyd B. 
Sharpe, Toronto, as the Association's 
Employment Relations director. 

Bom in Calgary, Mr. Sharpe re- 
ceived his Bachelor of Science degree 
from the University of Manitoba. He 
also attended Queen's University stu- 
dying labor law and Bethel University 
where he studied human dynamics. 
For a number of years he was with Im- 
perial Oil Limited. When he left there 
in 1955 he was head of Imperial's la- 
bor relations and research division. 

An interim committee on collective 
bargaining has also been appointed by 
the RNAO's Board of Directors. The 
Association's 12 districts, representing 
every part of the province, were asked 
to submit names of members who 
would be willing to serve on this com- 

The Association, as authorized by its 
1964 annual meeting, is actively work- 
ing on its plans for collective bargain- 
ing. (Burlington Gazette, November 
19. 1964). 

Nursing Students Need More Freedom 

Nursing students should be allowed 
more freedom if student shortages are 
to be overcome, an Ontario Department 
of Labor official has suggested. 

Nursing must offer programs which 
permit freedom to students similar to 
that of university undergraduates, said 
Ethel McLellan. director of the Wo- 
men's Bureau of the Labor Depart- 
ment. She was speaking at a five-day 
conference of directors of Ontario nur- 
sing schools. 

A second method of encouraging 
greater numbers of women to enter the 
nursing field is to develop a program 
for older applicants, she said. (Ottawa 
Journal. November 16, 1964). 

'Scattergun' Training of Nurses Hit 

The training of nurses too often 
tends toward scattergun teaching of 
skills without organized progress to a 
present goal, an American educationist 
has suggested. 

Dr. Margaret Lindsey. professor of 

education at Columbia University Tea- 
chers College in New York City, said 
training programs for nurses should be 
built around a central theme that in- 
volves ""a total concept of nursing." 

Speaking to a conference of direc- 
tors of Ontario nursing schools about 
the content of training programs. Dr. 
Lindsey said there should be a clear 
conception of the ultimate goal of 
training. The nursing profession's at- 
tempt to define what skills a nurse re- 
quires "up to this date have been done 
very inadequately," she said. 

Dr. Lindsey called for research that 
will produce tested information on 
"exactly what the behavior of the nurse 
must be to accomplish the goals the 
nurse is trying to achieve." (Kitchener- 
Waterloo Record, November 13.1 964). 

Publications Received in CNA Library 

Most of the material listed below is 
available on loan from the CNA Libra- 
ry. Requests should be addressed to: 

The Librarian 

Canadian Nurses' Association 
74 Stanley Avenue 
Ottawa 2, Canada 

Applications for loans should give 
the month in which the publication 
was listed in The Canadian Nurse. 
1 American Nurses' Association. Manu- 
al for an economic security program. 
Rev. 1963. New York, 1963. 85 1. 

2. American Nurses' Association. Using 
and improving the keys to knowledge. 
New York, 1964. 20 p. 

3. American Nurses' Association. Work 
conference on the implementation of 
recommendations of the sub-commit- 
tee on the preparation of educational 
standards. New York, 1964. 84 p. 

4. American Nurses' Association. Pre- 
paring an economic brief for public 
health nurses. New York. 1959. 12 1. 

5. Association of Registered Nurses of 
Quebec. Reports presented during 44th 
annual meeting. Montreal. 1964. 25 p 

6. Canada. Bureau of Statistics. Census of 
Canada, 1961. Ottawa, Queen's Printer. 
1963-64. 3 V. 

(a) v.l population 

(b) v. 3 labor face 

(c) V.7 general review 

7. Canada. Bureau of Statistics. Hospital 
statistics 1963. Ottawa. Queen's Printer. 
1964. 21 p. (D.B.S. 83-217). 

8. Canada. Bureau of Statistics. Review 
of employment and payrolls. 1963. Ot- 
tawa. Queen's Printer. 1964. 72 p 
(D.B.S. 72-202). 

9. Canada. Bureau of Statistics. Survey of 
adult education 1961-62. Ottawa. 
Queen's Printer. 1964. 55 p. (D.B.S. 

10. Canada. Dept. of Labour. Labour or- 
ganization in Canada. 1963. Ottawa. 
Queen's Printer. 1964. 100 p 

1 1 Canada. Dept. of National Health and 
Welfare. The Canada pension plan. 
Ottawa, Queen's Printer. 1964. 11 p. 

1 2. Canada. Dept. of Public Printing and 
Stationery. Organization of the Go- 
vernment of Canada. Rev. ed. 1963. 
Ottawa. Queen's Printer, 1964. 416 p. 

13. Canada. External Aid Office. Admi- 
nistrative guide. Commonwealth scho- 
larship and fellowship plan. Ottawa. 
Queen's Printer, 1964. 28 p. 

14. Canadian Association for Adult Edu- 
cation. Joint Planning Commission. 
Meeting 10 April, 1964. Toronto. Pro- 
ceedings. 16 1. 

15. Canadian Library Association. General 
inter-library loan code 1952. Rev. 1956. 
Ottawa, 1964. 13 p. (Its occasional pa- 
per no. 43). 

16. Canadian Tuberculosis Association. 
Nurses study report by Floris E. King. 
Ottawa, 1964. 16 1. 

17. Canadian Welfare Council. Computers 
and public welfare administration. Ot- 
tawa, 1964. 8 p. (Canadian Public Wel- 
fare Supp.). 

18. Health Information Foundation. An in- 
ventory of social and economic re- 
search in health. 13th ed. Chicago. 
1964. 94 p. 

19. Kruger, Daniel H. The economic se- 
curity program: an approach to im- 
proving economic and professional sta- 
tus of professional nurses. Lansing. 
Mich., School of Labor and Industrial 
Relations, College of Social Science. 
Michigan State University, 1963. 13 1. 

20. McCreary, John. Education of health 
personnel, Toronto. Can. J. Public 
Health, 55: 424-434. Nov. 1964. Re- 

2 1 MacKinnon, Frank. The politics of 
education, a study of the political ad- 
ministration of the public schools. To- 
ronto, Univ. of Toronto Press. I960. 
187 p. 

22. Matheney, Ruth V. et al. Fundamentals 
of patient-centered nursing. Saint 
Louis, Mo. Mosby. 1964. 345 p. 

2v National League for Nursing. Bacca- 
laureate and higher degree programs in 
nursing education. New York. 1959-63. 
1 V. (Collection of documents issued 
by NLN). 

24. National League for Nursing. College 
controlled programs in nurse education 
leading to an Associate degree. New 
York, 1958-63. 1 v. (Collection of do- 
cuments issued by NLN). 

25. National League for Nursing. Educa- 
tional programs in nursing leading to a 
diploma. New York. 1957-63. 1 v. 
(Collection of documents issued by 

26 National League for Nursing. Expand- 
mg horizons of patient care: NLN 
spotlights the way. New York. 1964. 
18 p. 

27 National League for Nursing. Guide 
for the development of libraries in 



schools of nursing. 2nd ed. New York, 
1964. 19 I. 

28. National League for Nursing. Health 
issues of the day; report of symposia 
of the National League for Nursing 
1963 convention. New York, 1963. 55 


29. National League for Nursing. The li- 
brary - a force for better nursing care. 
Papers presented at the program meet- 
ing of the Inter-agency Council on Li- 
brary Tools for Nursing of the 1963 
convention of the National League for 
Nursing. New York, 1964. 34 1. 

30. National League for Nursing. Roles 
and relationships in nursing education. 
New York, 1959. 142 p. 

3 1 . National League for Nursing. Schools 
of professional nursing, 1964. New 
York, 1964. 39 p. 

32. National League for Nursing. Dept. of 
Baccalaureate and Higher Degree Pro- 
grams. Some statistics on nursing edu- 
cation, 1962. New York, 1963. 9 1. 

33. National League for Nursing. Dept. of 
Diploma and Associate Degree Pro- 
grams. Guiding principles for the es- 
tablishment of co-operative relation- 
ships between hospital schools of nur- 
sing and colleges and universities. New 
York, 1962. 3 1. 

34. National League for Nursing. Dept. of 
Diploma and Associate Degree Pro- 
grams. A new look at the why and 
how of clinical laboratory experience. 
New York, 1964. 23 p. 

35. National League for Nursing. Dept. of 

Hospital Nursing. Self-evaluation guide 
for nursing service personnel programs. 
New York, 1957. 27 I. 

36. National League for Nursing. Dept. of 
Hospital Nursing. Self-evaluation gui- 
de for nursing service: preparation of 
the budget. New York, 1957. 8 1. 

37. National League for Nursing. Dept. of 
Public Health Nursing. How to organi- 
ze and extend community nursing ser- 
vice for the care of the sick at home. 
New York, 1962. 96 p. 

38. National League for Nursing. Dept. of 
Public Health Nursing. Proceedings of 
a conference on role definition in ad- 
ministration of a combination public 
health nursing service. New York, 
1963. 47 p. 

39. National League for Nursing. Dept. of 
Public Health Nursing. Guide on per- 
sonnel policies for employers of public 
health nurses. New York, 1957. 72 p. 

40. National League for Nursing. Dept. of 
Public Health Nursing. Statistical re- 
porting in public health nursing. New 
York, 1962. 42 p. 

4 1 . National League for Nursing. Mental 
Health and Psychiatric Nursing Advi- 
sory Service. Education and supervision 
in mental health and psychiatric nur- 
sing. New York, 1963. 

42. National League for Nursing. Research 
and Studies Service. A method for ra- 
ting the proficiency of the hospital ge- 
neral staff nurse; a manual of direc- 
tions. New York, 1964. 28 p. 

43. National League for Nursing. Research 

and Studies Service. State approved 
schools of professional nursing. 1963 
New York. 1963. 88 p. 

44. National League for Nursing. Special 
Committee on Practical Nursing. State- 
ments regarding practical nursing and 
practical nursing education. New York. 
1962. 18 p. 

45. National Research Council of Canada. 
General instructions, university support 
program. Grants in aid of research. 
scholarships, fellowships. Ottawa. 1961. 
28 p. 

46. National Research Council of Canada. 
Students registered in the graduate 
schools of Canadian universities 1963- 
64. Ottawa, 1963. 4 v. 

47. Ontario, Hospital Services Commission. 
Report 1963 and statistical supple- 
ment. Toronto, Queen's Printer. 1964. 

48. Preston, Ruth A. et al. Patient care 
classification as a basis for estimating 
graded inpatient hospital facilities. New 
York, J. Chron. Disease. 17: 761-762 
1964. Reprint. 

49. Ritchie, Ronald S. A philosophy of ma- 
nagement. Ottawa, Canadian Welfare 
Council, 1964. 6 p. (Canadian Public 
Welfare, supp. no. 2). 

50. Simon, Beatrice V. Library support of 
medical education and research in Ca- 
nada. Ottawa, Association of Canadian 
Medical Colleges, 1964. 132 p. 

51. U. S. Dept. of Health, Education and 
Welfare. National Library of Medicine 
classification schedule. Washington. 
Govt. Print. Off., 1964. 286 p. 

<Jn (jHemo/iiam 

Genevieve H. Johnson '26, University 
of Nebraska, Lincoln, Neb. who had 
worked in Alberta for many years. 

Isobel (Angus) Abercrombie '51, Rhonda 
(Stentiford) Leonard '15, Vancouver Gen- 
eral Hospital, B.C. 

Pierrette (Lee) Bergeron '59, Hopital 
Notre-Dame, Montreal. 

Mary Ogilvie Berry '28, Queen Eliz- 
abeth Hospital, Montreal. 

Thamer M. Brose '43, Pembroke General 
Hospital, Ont. 

Russel Earl Dagenais '54, St. Elizabeth 
Hospital, Humboldt, Sask. 

Mary Dinning '23, Strathroy General 
Hospital, Ont. 

Alda Bell (Holiday) FItzslmmons '37, 
Stratford General Hospital, Ont. 

Dorothy (Wade) Fraser '23, Royal Vic- 
toria Hospital, Montreal. 

Margaret Fraser '19, Royal Alexandra 
Hospital, Edmonton, Alta. 

Beulah (Andrews) Gorham '13. Iris 

Cecilia (Pike) Wells '32, St. Joseph's Hos- 
pital, Victoria, B.C. 

Elizabeth Hannant '04, Annie Maud 
Sterling '05, Toronto General Hospital, 

Joyce Harasem '65 (student), Eleanor 
Ruth (Lomas) Reid '54, University of Al- 
berta Hospital, Edmonton. 

Velma Viola (Stinson) Harrison '35, 
Chatham Public General Hospital, Ont. 

Marjorle Alberta (Burtch) Johnson '37, 
Edmonton General Hospital, Alta. 

Geraldlne (Crackel) Lunney '32, Vic- 
toria General Hospital, Winnipeg, Man. 

Isobel Craigle (Nicolson) McQueen '29, 
Victoria Memorial Hospital. North Bay, 

Kathleen Mary (Doupe) Mutch '32, Mc- 
Kellar General Hospital, Fort William, 

Caroline V. Navid '43, St. Boniface Gen- 
eral Hospital, Man. 

Christina Parker '17. Lillian Hester 

(Lavi/rence) Reykdal '27, Winnipeg Gen- 
eral Hospital, Man. 

Eleanor Jane (Edwards) Paulson '49. 
Belleville General Hospital, Ont. 

Mary Maude (MacNish) Taylor '18, 
Brockville General Hospital, Ont. 

Silla Marguerite Carr-Harris, R.R.C.. 
died in December, 1964 in hospital in 
Montreal. She was 85. Born in Ottawa, 
she received her nursing education at 
Presbyterian General Hospital, New York. 
Following graduation, she worked at Dr. 
Grenfell's Labrador Mission and was 
among the group to greet Commander 
Robert Perry following the discovery of 
the North Pole in 1909. Miss Carr-Harris 
served overseas in World War I and was 
decorated for her heroism in evacuating 
wounded from a military hospital during 
a bombing raid. She later worked as a 
public health nurse for the Ontario Dept. 
of Health in the far north. Following her 
retirement she lived in Montreal. 





Associate Editor 


Senior Assistant Editor 


Assistant Editor (English) 


Assistant Editor (French) 


Circulation Manager 

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two years, $7.00. 

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One year, $4.50; two years, $8.00- 
Single copies: 50 cents each. 

^or the subscribers in Canada, in combi- 
nation with the "American Journol of 
Nursing" or "Nursing Outlook": 1 year, 

^^aVe cheques or money orders poyoble to 
The Canadian Nurse. 


four weeks' notice and the old address 
OS well OS the new are necessary. 

>ioi responsible for journals lost in mail due 
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'The Canadian Nurse" welcomes unsolicited 
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nor to indicate definite dotes of publication. 

Authorized as Second-Class Mail by the Post 
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of postage in cash. Postpaid ot Montreol. 



11 11 

A monthly journal for the nurses of Canada 

published in English and French by the 

Canadian Nurses' Association 

1522 Sherbrooke St. W., Montreal 

March 1965 — Vol. 61, No. 3 

167 The Permanence of Humanism 

170 Epilepsy Today 

171 Epilepsy and Its Medical Treatment 
174 Surgical Treatment of Epilepsy 
177 Nursing an Adolescent with Seizures 
185 Social Factors in Epilepsy 
188 Parkinson's Disease 

199 Care of Parkinsonian Patients 

200 Herniated Discs 

P. Pirloi 

T. Rasmussen 

P. Robb 

C. Branch 

C. Robertson and P. Murray 

C. Griffin 

C. Berirand and S. N. Martinez 

L. Moody 

C. Bertrand and S. N. Martinez 

204 Nursing Care : Patients with Herniated Discs 

207 Increased Intracranial Pressure 

209 Recognition, Recording and Significance of the 
Signs of Increased Intracranial Pressure 

213 Intracranial Berry Aneurysms 

215 Nursing Care: Ruptured Cerebral Aneurysms 

222 Frankfurt Am Main 

L. Moody 
R. R. Tasker 

J. F. Young 

W. M. Lougheed 

J. F. Young 


142 Between Ourselves 

148 Pharmaceuticals and 
Other Products 

150 Random Comments 

154 About Books 

158 In Memoriam 

158 Dates to Remember 

219 The World of Nursing 

224 In a Capsule 

225 Employment Opportunities 
242 Educational Opportunities 

245 Index to Advertisers 

246 Official Directory 


MARCH 1965 



Send for this informative booklet, which outlines the nursing and 
career opportunities in the Canadian Forces Medical Service. Visit, 
write or call your nearest Canadian Armed Forces Recruiting Centre 


MARCH 1965 


A New Industry for Canada 



If II !? » ?^ I TTTI 

.'ftW«ilflTlHmilllW)!IB!lit'i>:iimil.V:«ttfllli«IHM'l«T-l>iM':i.'r.T lan-j 

Equipped with Canada's first commercial Cobalt 60 sterilizi 

(Photograph ot Administration Building) 

Trade Maik Rog'd. 


Ethicon Sutures Ltd., Peterborough, Ontario 




with "^k -l ^S^ ' 


single dose 
disposable unit 

Just one second of prep time needed . . . with the 
modern FLEET ENEMA! Once the full-length pro- 
tective cover has been removed and the prelubricated 
2-inch rectal tube has been inserted, simple manual 
pressure does the rest. And after the enema — 
no scrubbing, no sterilization, no setting up for 
re-use. The complete FLEET ENEMA unit is 
simply discarded! 

why more and more hospitals are using the 

An efficient, economically-priced, safe enema 
requiring far less time than outmoded procedures, 
FLEET ENEMA also avoids the ordeal of injecting 
large quantities of fluid into the bowel. 

Left colon catharsis can be achieved in two to five 
minutes without causing pain or spasm,' while afford- 
ing the same cleansing efficacy as the usual enema of 
one or two pints. Reverse flow and leakage are pre- 
vented and a comfortable flow rate assured by the 
construction of the anatomically correct plastic tube. 

Each S/ng/e-Dose Disposable Unii contains, in each 100 cc.« 

Sodium acid phosphote USP 1 6 G. 

Sodium phosphote USP 6 G. 

Plastic "squeeze-bottles" of 4'/^ fluid ounces, with prelubri- 
cated tip. 

1. Marks, M.M.s Am. J. Digest. Dis. 18:219, 1951 





MARCH 1965 







Fast, convenient dispensing. All Davis & Geek sutures and suture-needle combinations are 
supplied ready for immediate use, individually packaged in dry, presterilized plastic envelopes- 
transparent and double-labelled for easy identification of contents. 

Maximum ease of handling. Surgeons appreciate Davis & Geek sutures for ttieir excellent hand- 
ling and performance characteristics, assured by meticulous care in processing dunng every 
phase of manufacture. You will find that the nursing team can function more efficiently with suture 
materials from the broad line of Davis & Geek suture products. 

SP Service Program. This Davis & Geek service completely eliminates the time, expense and 
potential hazards involved in cold resteriiization of unused suture packages. Davis & Geek assumes 
all responsibility for repackagingand resterilizing left-over suture packages . . . saving many nurse- 
days each month and providing significant new savings in operating room management. 






C V A. !St A. 1\-M I r> 

Montreal, Quebec 

©Registered Trademark 




Indications — A dietary salt-substitute for use in sodium restricted 

Description — A pleasant tasting seasoning containing herbs, spices, 
potassium monoglutamote, glutamic acid, potassium chloride. Whereas 
many salt substitutes are loitter tasting. Amplify gives a zestful and 
appetizing flavor. 

Uses — For sodium restricted diets. Use as seasoning before, during 
or ofter cooking. 



Indications — A vitamin supplement for the diet of children and 
adults; to prevent and treat rickets. 

Description — Each red gelatin capsule contains 5000 I.U. of vitamin 
A, 400 I.U. of vitomin D and 75 mg. of vitamin C in a cherry-flavored 

Dosage — One capsule doily. Both capsule and contents are flavored, 
and may be chewed or swallowed whole. 



Description — A new disposable hospital mask made of layers of 
wet strength cellulose with an inner core of activited carbon. Activated 
carbon is highly effective in bacterial filtration and also helps control 
toxic odors, absorb irritating vapors and purify air. 

A form-fitting nose bridge adjusts the mask to facial contours and 
helps prevent fogging of glasses. Masks are available with string ties 
or elastic ear loops. 

Further information available from Busse Hospital Disposables, Inc., 
Greet Neck, N.Y. 11021. 



Indications — For relief of onxiety and mild to moderate depression, 
without insomnia or anorexia; reduces excessive emotional responses to 
disturbing stimuli. 

Description — A pink, scored tablet containing benactyzine 1 mg. 
and meprobomate, 400 mg. Side effects such as dry mouth and drow- 
siness are relotively rare and usually controlled by reducing dosage. 

Dosage — ■ 1 tab. q.i.d. 

Caution — Daily dose of meprobomate above 2400 mg. is not 
recommended. High dosage and prolonged use may cause dependence. 
Do not use in presence of glaucoma. 



Description — A safe, efficient, and complete (except for water) 
single-use unit for enema administration. Unit contains a 2000 cc. 
plastic bag with handle grip ond 5 foot integral enema tube and 
clomp; plastic lined underpod; sterile costile soap; sterile lubricating 
jelly; all enclosed in a clear, easily-opened plastic bog. 



Indications — For treatment of kidney and urinary tract infections 
and some G.I. infections. Penbritin gives high urine concentrations and 
is effective against strains of E. coli. Strep, fecalis, P. mirobilis, and 
P. vulgaris. Also produces high concentrations in bile and is effective 
against salmonella, shigella, and other "food poisoning" bacteria. 

Description — Black and red capsules containing 500 mg. ompicillin. 

Dosage — Kidney and urinary tract infections: I cap. q. 8 h.; G. I. 
infections: 1 to 2 cops. q. 8 h. 

Contraindications — Allergy to penicillin, and in infections caused 
by penicillin-resistant staphylococci. 



Indications — For treatment of ulcerative colitis, and for colitis other 
than that caused by putrefactive bacteria or omeboe. 

Description — ■ Each tablet contains 0.5 Gm. of solicylazosulpha- 
pyridine. Salazopyrin is an acid azo-compound of sulphapyridine and 
salicylic acid. Clinical studies show remission or considerable improve- 
ment in 70-80% of coses treated. 

Dosage — Two tablets q.4-6 h. Severe coses: up to 16-18 tabs, per 
24 hr. period. Children over 7 years: 1-2 tabs, q.6-8 h.; children 5-7 yrs.: 
1/2-1 tab. q.6-8 h. In cose of nausea, dosage is reduced or treatment 
stopped for 2 days. Maintenance dosage: 3 tabs, per day. Recommended 
course of treatment: two weeks followed by one week's rest. 

Caution — Precautions and supervision as for any sulphonomide. 





Description — • An entirely new version of the moveable bedside 
screen with a spring-loaded pole which will fit between the floor and 
any ceiling up to 11 feet. When the six foot curtain rod is raised it 
outomaticolly locks rigidly into horizontal position. Pressing a trigger 
allows it to return to vertical for storage. 

Once adjusted to the ceiling height in a given hospital, the screen 
may be sprung in and out of place anywhere. It weights only 6 lbs., 
takes practically no bedside floor space, and will not tip over. Curtain 
available in regular or flame-proof white cloth, 6 feet wide and 5 feet 

Brewster Corp., Old Lyme, Conn, will supply further information. 

TAe Journal presents pharmaceuticals for information. Nurses understand that only a physician may prescribe. 


MARCH 1965 




Trained nurses who wish to gain post-graduate experience 
find opportunity of furthering their career at the 


St. Helier 
Group of Hospitals 

Situated within eosy reach of London and south coast. Experience 
available in the following Departments: General Medicine, General 
Surgery Operating Room, Accident Unit, Psychiotry, Maternity, 
Thorocic, Ear Nose and Throat, Paediatrics, Geriatrics, Orthopae- 
dics, Ophthalmic. 

Salary: £618 - £773 less £206 if resident. Starting point depends 
on previous experience. Residential accommodation is available if 
desired; uniform provided; 5 weeks annual leave. Applications 
stating training, experience and specialties in which interested 
and names of two referees to: 

Deputy Group Secretary, St. Helier Group 

Management Committee, St. Helier Hospital, 

Carshalton, Surrey, England. 


what can 
I take for 
or acid 

The answer-TUMS! These mild, minty 
tablets are so practical to recommend 
because they're fast acting, long lasting 
and safe — made of the finest antacid 
ingredients. They're economical too- 
only a few cents buys enough for several 
doses. And they leave no aftertaste- 
no water or glass needed. 

for the tummy 


Psychiatric Nursing: The Nurse-Patient 
Relationship is available to interested 
health groups. This 34-niinute. black and 
white sound film was produced by the 
ANA-NLN Film Service and the Medical 
Film Center, Smith, Kline and French 

It portrays a nurse working in a large 
mental hospital. While illustrating many 
facets of her work, it was prepared to show 
aspects of the nurse-patient relationship as 
the core of nursing practice. 

Students on all levels, as well as gradua- 
te nurses working in the psychiatric setting, 
will benefit from a review of the film; it 
is also suitable for other professional and 
lay groups. 

An Instructor's Guide, prepared by Hil- 
degard Peplau and Laetitia Roe is available 
to assist in the presentation of the film. 

The film is available from Smith. Kline 
and French Laboratories, 300 Laurentian 
Blvd., Montreal 9. 

Initial Care of Burns, a 29-minute, color 
and sound film released in 1963, is an 
excellent audio-visual aid for nurses. The 
film received a medical education award 

in 1962. It depicts five typical 2nd or 
3rd degree burns and follows the care of 
the patient from his admission until he is 
ready for skin graft. It illustrates and eva- 
luates both the closed and exposure me- 
thods as means of local care. 

The film is recommended for all levels 
of nurses and for showing to interested 
health profession groups. It is available 
from the Surgical Film Library, Cyanamid 
of Canada Limited, 5550 Royalmount Ave., 
Town of Mount Royal, Quebec. 

Stereotatic Procedures for Parkinson's 
Disease, a 25-minute, color, sound film, 
was made in Canada under the direction 
of Dr. Claude Bertrand. This excellent 
film was one of five chosen to represent 
Canadian medical education aids at a con- 
ference in Italy. The film illustrates new 
techniques in brain surgery and the me- 
thods for exactly locating the area requir- 
ing electro or knife therapy. Although high- 
ly technical, the film is recommended for 
operating room nurses, for nurses especial- 
ly interested in neurosurgery, and as an 
extra film in schools of nursing where it 
can be used to illustrate very new operat- 

ing methods being used in brain surgery. 

The film is available with either English 
or French soundtrack, from Cyanamid of 
Canada Ltd., 5550 Royalmount Ave., Mount 
Royal, Quebec. 

Essentials of the Neurological Examina- 
tion shows the performance of a thorough 
examination as carried out in a doctor's 
office or at the patient's bedside. The pre- 
liminary history, the purpose and order of 
the examination are discus.sed. The tests 
for cerebral function; cranial nerves; cere- 
bellar functions, the motor system; the sen- 
sory system; and deep and superficial re- 
flexes are describes step-by-step. A diagra- 
matic representation of the underlying ana- 
tomy accompanies the examination. The 
testing of an actual patient is shown. 

An excellent booklet is available for use 
with the film. 

This 50-minute, sound, color film is suit- 
able for graduate groups, and although rat- 
her long, it is recommended as an aid in 
teaching neurology to student nurses. 

The film is available from Smith, Kline 
and French, 300 Laurentian Boulevard, 
Montreal 9, Que. 


MARCH 1965 



Canada ranks sixth in mortality from 
diabetes, according to Metropolitan Life 
Insurance Company statisticians. The age- 
adjusted death rate from diabetes was 10.8 
per 100,000 of population in 1958-60. This 
compared with 15.5 in Ceylon and 14.0 
in Belgium. The United States ranked third. 
Israel and Japan had the lowest rate; 3.7 
per 100,000. Rates are adjusted to allow 
for differences between countries with res- 
pect to the age distribution of their po- 

In 15 of the 17 countries the death rate 
from diabetes is higher for females than 

for males at all ages combined. The greatest 
excess occurs in the Netherlands, where 
the rate for females is almost twice that 
for males. In England and Wales the ratio 
of the death rates is nearly 11/2 to 1, and 
in the United States and Canada it is \[u 
to 1. 

The disease is somewhat more prevalent 
in urban than in rural areas, although the 
difference is not as great as it was in earlier 
studies. Variations according to social class 
and occupation also appear to be levelling 
off and becoming less meaningful. 

— Metropolitan Life Insurance Company 


This bottle contains 400 labora- 
tory tests. It gives you 48,000 
possible answers in 100 cc. of 
space. HEMA-COMBISTIX* is 
a dip-and-read test for urinary 
blood, protein, glucose, and pH. 
Ames Company of Canada /7^ 
Ltd., Rexdale (Toronto) v^^ 

Ontario. •Trademark Reg. CA g9H4 /VIVIES 

Letters to the Editor are welcome. Only 
SIGNED letters will he considered loi 
publication. Name will he withheld from 
the published letter at the writer's request 

Dear Editor: 

Having been away from hospital nursint: 
for several years. I find it interesting and 
helpful to discuss new nursing procedures 
with some of my hospital-employed col- 

I recently learned that the use of linseed 
poultices to relieve postoperative abdomi- 
nal distention has fallen into disuse. Appa- 
rently this procedure is no longer taught in 
many schools of nursing since it is seldom 
ordered by the attending physician. In its 
place, neostigmine is administered intra- 
muscularly to stimulate peristalsis and to 
help the patient expel flatus. 

I have cared for patients whose doctors 
ordered this drug and for others whose doc- 
tors ordered the poultice. Those in the latter 
group received much more relief. This is 
one instance where a nursing procedure, al- 
though time-consuming, is more effective 
than the administration of a drug. 

When a nurse knows that a certain pro- 
cedure offers comfort and physiological re- 
lief she shou'd relay this information to 
the physician who, in this modern era of 
"wonder drugs", has probably never heard 
about it. I am certain that patients having 
abdominal surgery will be appreciative. 
T. N., R.N., Quebec 

Open letter from a Night Nurse 

Night shift is a glorious challenge. It is 
a great honor to be entrusted with the well- 
being of your fellowman. 

A good night nurse not only does the 
expected patient care (keeping an eye on 
irrational patients, checking an unstable 
blood pressure or temperature, watching an 
I. v.), but also does the little extras. Espe- 
cially at night, when sleeplessness, and les- 
ser aches and pains are bothersome: when 
home and personal problems come to the 
foreground of the mind, there is ample 
opportunity to give of yourself and your 
time to make the night bearable and less 
long. Unspoken fears might be a little 
eased by a talk, a cup of tea or a glass 
of milk, a joke, or a pat on the back. 

Whatever you do, it is important to do 
it as well as you know how — writing 
clearly and neatly, spelling well, dating the 
chart (not upside down or crooked), making 
out the necessary requisitions, answering 
signal lights promptly, keeping the office 
tidy, putting things away clean — and 
especially charting immediately. All these 
little things help your work to go smoothly 
and give you the inner satisfaction that 
comes from doing your best. 

Another important factor is your .il- 
titude toward your auxiliary staff. The night 


MARCH 1965 


nurse should give her aide a complete re- 
port on the patients. This way she will 
know what to expect, and can be of more 
help. Never give orders, but rather ask! 
Orders create a feeling of ill will, and des- 
troy the feeling of teamwork. 

A night float often drops by, asking . . . 
"Hello, need any help?" There are always 
things to do; the attitude of the true "hel- 
per" is more apparent. She takes a flash- 
light and makes a quick round — without 
being asked to do so • — and reports un- 
usual findings, tells who is awake and 
why, gives a pan or a drink where needed. 
She is there to help with the turning of 
very sick patients, and notes condition, co- 
lor, skin, and so on. A really interested 
nurse will ask about the patient before she 
starts. She also helps with that everlasting 
problem — • intakes and outputs. 

The night supervisor is the key member 
of the team and is there to discuss any 
problems if you are in doubt as to what 
to do. 

It is said that one pound of learning 
requires ten pounds of common sense. 
Even though you do the right thing, do you 
do it the right way ? A patient should be 
turned q. 3 h.: you turn her at midnight 
and she is awake at 2. Common sense 
should tell you to turn her again. If her 
injection for pain is due at 4, will you let 
her sleep until she wakes up and then give 
the injection? 

Visualize the well-being of the patients 
over 24 hours, and not only on your 8-hour 
shift. Just think how pleased you are to 
have something done for you by the pre- 
vious shift. We are all working together for 
one purpose — to help the patient. 

The night shift is a lonely but also a 
most gratifying shift. 

Mrs. Gehrer. R.N., permanent 11-7 night 

Dear Editor: 

I must tell you that I have enjoyed the 
article on nursing in the December Journal 
more than any that have appeared before. 
They were to the point, logical, and dealt 
with facts. No wishy-washy generalities 
about the changing role of nursing in a 
changing society. 

However, I do take exception to one sta- 
tement in Rae Chittick's article "What 
Have you to Declare". She says: "We are 
only human and we expect to be paid for 
our abilities." I agree — naturally we are 
human. We are proud to be human. And 
most certainly do we expect to be paid 
for our abilities. But are we? Adequately? 
Right there creeps into the otherwise won- 
derful and brilliantly written article a note 
of apology for our shortcomings, as if 
we were apologizing for the fact that we 
just aren't big enough to work as nurses 
out of sheer love for our fellow men alone. 
Every nurse has to have a great deal 
of dedication and love for her fellow men 
anyway, even with much higher wages than 


we are now getting, to remain a nurse, even 
after she marries and does not "have to 
work". There are so many unpleasant du- 
ties, so many soul-shattering experiences, so 
many frustrations, so many personal con- 
flicts that a person has to be strongly 
motivated to remain in nursing for life. 
As long as a semi-skilled worker gets 
the same amount of money that a Regist- 
ered Nurse makes — or more — just be- 
cause he belongs to a strong union and 
everybody is afraid of a strike, as long 
will our hospitals be understaffed and our 
nurses overworked — resulting in less-than- 
perfect patient care. 

Mrs. Maria-E. Meuller, R.N., Sask. 


Careless handling of doctors' appoint- 
ments by office nurses can stir up legal 
trouble as well as ill feeling, warns Provi- 
dence attorney, William A. Regan. 

He tells of a New York radiologist who 
examined a woman at a city out-patient 
clinic. Later, the woman feared she had 
cancer and called the doctor's private office 
for a Wednesday afternoon appointment. 
His nurse told her the doctor didn't see 
patients at that time and hung up. 

Rebuffed, the woman neglected her con- 
dition and eventually required surgery. She 
sued the radiologist for abandoiunent. 

— The Horner Newsletter 



tells the story of urinary blood, 
protein, glucose, and pH in half 
a minute, it has to save time. 
P.S. Time is money. D 
Ames Company of Canada, ^ 
Ltd., Rexdale (Toronto) Ont. ajvi 

•Trade Mark Reo'd. CA6»484 

MARCH 1965 




Dept, CN, 2222 Minnesota St., Oshkosh, Wis. 

INDEX for 1964 

Subscribers wishing to receive a copy of this Index, 
free of charge, are requested to complete the form 
below and mail it to the Journal office. 

Many individuals, associations, libraries, etc., are on 
our "permanent" list. Any subscriber wishing to secure 
an Index each year, automatically, please check 
here. □ 




Zone No. 


Number of copies desired 

Registrants at conference held by the 

Association of Non-Profit Homes and 

Hospitals for the Aging of the Province 
of Quebec. 

If enthusiasm is contagious and helps to motivate others — • 
and we are convinced it is, and does, after attending this con- 
ference — the Association of Non-Profit Homes and Hospitals for 
the Aging of the Province of Quebec will meet its objective: to 
foster the welfare of aged people living in such facilities. 

Believing that a need existed in the province for adequate 
geriatric long-term care facilities, a small group of administrators 
of homes for the aged founded the Association three years ago. 
It now has a membership of 18 homes and hospitals containing 
over 2,000 beds. Members meet regularly to share ideas and to 
discuss ways and means of improving standards. The Association 
welcomes government standards that have been set up to ensure 
adequate care for older persons living in such homes or hospitals; 
but its members believe that they can assist the government in 
the development of these standards. 

The Association's first conference, held January 28, 1965, at 
the new Maimonides Hospital and Home for the Aged in Mont- 
real, concentrated on long-term care facilities for the aged. Dr. W. 
J. Klinck, Lennoxville, Quebec, was Conference Chairman. 

The first speaker. Dr. Raymond Hebert, Medical Adviser, 
Montreal Department of Social Welfare, stated that few efforts 
are made in our society to allow the elderly person to remain 
in his own home. "Many persons could be cared for in their 
homes if special geriatric clinics were provided by general hospi- 
tals and if home care programs — that would include medical, 
nursing, social and homemaker services — were provided." Ac- 
cording to Dr. Hebert, the cost of such services would be less 
than that of our present system of institutional care. Persons who 
required more extensive care, or for some reason could not remain 
in their homes, would then be transferred to a well-equipped hos- 
pital or nursing home. 

Considerable audience participation followed Dr. Hebert's dis- 
cussion. One question concerned the basic criteria necessary for 
a home which cared for the elderly sick. He replied: 

1 . A good physical plan is essential, e.g.. the building 
should be protected against fire hazards. 

2. The medical set-up should permit the institution 
to cope with any emergency. Registered nurses should 
be in attendance day and night. 


MARCH 1965 


Dr. Hebert pointed out that in some nursing homes, nurses were 
only available eight out of 24 hours. 

According to Dr. Hebert, any aged person who requires 
constant medical attention should be covered financially by 
Quebec Hospital Insurance; if he needs only a place to live, he 
should come under the auspices of the city's Department of 
Welfare. At present, the decision of whether an aged person 
should be financially covered by hospital insurance or by the 
department of welfare is determined by the intensity of care 
he requires — a very difficult, if not impossible, factor to assess. 

Following lunch, a tour of the ultra-modern Maimonides Hos- 
pital and Home was conducted by members of the Women's 
Auxiliary. Mr. Louis Novick. executive director of the Hospital 
and president of the Association, explained the many activities 
and projects carried on by the persons who lived there. His phil- 
osophy — and that of the staff — is that patients should have 
an opportunity to participate in the running of their hospital. The 
patients at Maimonides have an active "patieat council" — com- 
plete with elected executive — who meet regularly with the staff. 
Various problems and suggestions are discussed and, frequently, 
acted upon. Individual attention is given to each patient to en- 
courage him to contribute — and develop, if he has regressed • — 
to his highest potential. 

Dr. J. Ronald Bayne. Head of the Geriatric Service at the 
Department of "Veterans' Affairs, Montreal emphasized that treat- 
ment for the aged must be vigorous, enthusiastic and complete. 
The staff and the patient should work together since the out- 
come of any treatment depends on the patient's understanding 
and acceptance of it. The old concept that the "indigent" patient 
should be grateful for all services rendered, still exists in the 
minds of some personnel. This altitude must change. 

Dr. Bayne pointed out that the elderly person should be re- 
sponsible for himself, as far as possible. "If treated like a child, 
he will become childish, and let others 'do' for him. We act as 
we are expected to act — and the patient is no exception to this." 

In response to the question: Is it a good idea to place the sick 
individual with the well. Dr. Bayne replied: "It is not wise to mix 
the severely handicapped with well persons. This is done in some 
hospitals in the U.S.A., where they have a "buddy system," with 
a well person responsible, in part, for a handicapped person. The 
main drawback is that it utilizes abilities which could be used 
by the well man to develop himself." 

Mr. Novick expressed a truism when he stated that even though 
an individual may have a short time to live, he can always con- 
tribute to society — after all, we all have a short time to live! 
Age is relative: a person 40 years of age appears old to the 17- 
year-old and 80 appears old to the 40-year-old. 

The resolutions arising from this one-day conference w«re: 

1. That coordinated home care programs be set up in the 
Province of Quebec to keep people out of hospital and in their 

2. That geriatric clinics of a high calibre be established to 
treat the elderly sick as outpatients. 

3. That adequate housing programs be established throughout 
the province for the aged who do not require medical attention. 

4. That medical care required for aged persons be provided by 
the provincial Department of Health. 

5. That adequate financial support be provided by the govern- 
ment to ensure complete nursing, rehabilitation, etc. programs to 
meet the needs of geriatric patients. 

6. That further efforts be taken to interest and train staff for 
all categories of geriatric care. 

7. That steps be taken to institute and improve the care of 
the aged presently living in institutions in the Province of Que- 

The members of this Association accomplished a great deal in 
one day. It was refreshing to attend a conference where the focus 
was, at all times, on the patient • — and the improvement of his 

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MARCH 1965 


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Rehabilitation, A Manual for the Care of 
the Disabled and Elderly by G. G. Hirsch- 
berg. M.D., F.A.C.P.. Leon Lewis, M.D., 
F.A.C.P., and Dorothy Thomas, R.N., 
B.S. 377 pages. J. B. Lippincott Com- 
pany, 4865 Western Ave., Montreal 6, 
P.Q., 1964. 

Reviewed by Miss M. E. Smith, Con- 
sultant in Rehabilitation, Victorian Or- 
der of Nurses, Vancouver, B.C. 

This is a most comprehensive book on 
rehabilitation and would be a valuable ad- 
dition to any nursing library. The authors 
set out to present a common knowledge of 
management of disabling conditions to unify 
the approach of the many disciplines in- 
volved, which thus far have tended to be 
fragmented with loss of continuity of care. 
Necessarily, in this approach there is sim- 
plification. Physiotherapy is not well inter- 
preted as there is no outline or apprecia- 
tion of the benefits of these techniques in 
the conditions covered; this also is true 
of the omission of physical and psycholo- 
gical strengths gained from therapeutic 
occupation. These omissions are, however, 
offset by showing that much rehabilitation 
can be accomplished with simple techniques 
when there is a real appreciation of the 

The first part is an introduction to ensure 
understanding of the goals of rehabilitation, 
causes of disability (which includes thought- 
less nursing care), and necessary environ- 
ment for activation which is not necessarily 
elaborate. The authors emphasize that 
nursing homes should add inexpensive 
measures to their programs to add life 
and to decrease care for their patients. This 
section also goes into some detail on nu- 
trition and elimination, plus the handling 
of obesity. Psycho-social factors are dis- 
cussed briefly. Canadian readers should 
realize that various Acts and aids wijth 
which anyone helping the disabled needs 
to be familiar exist in this country. This 
book outlines the applicable social wel- 
fare measures in the United States. 

The second section concerning self-care, 
gives useful advice. More specific detail 
can be found under each conditions later 
in the book. It would have been helpful 
to have references listed for activities of 
daily living at the end of this chapter. 
Some pointers are given for helping pa- 
tients with communication difficulties, but 
this section is not as detailed as one would 

The third part varies in the amount of 
detail given in the rehabilitation of specific 
disabilities. Material on the simple hemi- 
plegic, paraplegic, self-care for quadri- 
plegic, is good; the authors go into great 
detail for patients needing respiratory 
mechanical aids, presumably because there 
is little literature on this subject. A bowel 

and bladder training program is included. 
The general outline for rheumatoid and 
osteo-arthritis care is not detailed enough. 
One of the most helpful measures for 
these people is muscle tensing without joint 
movement, and this is not mentioned. The 
chapter on hip fracture is useful; a section 
on proper bandaging of lower limb stump 
would have been valuable, rather than so 
much detail about the pylon which takes 
time and skill to fashion correctly. There 
is not enough detail concerning the physio- 
therapy of respiratory ailments even though 
simple but proper breathing techniques, 
drainage positions and vibrations can help 
the patient with bronchiectasis and emphy- 
sema to a much more comfortable life. This 
book would also be more valuable if it 
included a possible daily schedule for 
the nursing home care of chronically ill. 
rather than just suggesting stimulation and 

Other books and pamphlets exist that 
give more detail on specific disabilities but 
these are, by and large, written for their 
own professional groups. This should be a 
handy reference manual for nurses in- 
terested in caring for disabled persons. 

No Language But a Cry by Bert Kruger 
Smith. 170 pages. Boston, Beacon Press. 

Reviewed by Dr. S. R. Laycock, formerly 
Dean of Education, University of Sas- 

This book was written by a mental health 
specialist of the Hogg Foundation for 
Mental Health (University of Texas) and 
carries a foreword by Dr. Robert H. Felix. 
Director, National Institute of Mental 
Health, Bethesda. Maryland. It is a warm, 
sympathetic account of the characteristics 
and problems of seriously emotionally dis- 
turbed children together with a description 
of the types of facilities needed for their 
treatment and education. Visits to three out- 
standing treatment centres are described — 
The League School, Brooklyn, The Sonia 
Shankman Orthogenic School, Chicago, and 
The Hawthorne Centre, Northville, Michi- 
gan. The final chapter makes specific 
recommendations as to what can be done. 

This book is of value to practising nurses, 
especially public health nurses, who deal 
regularly with various types of emotionally 
disturbed children. While it deals with the 
situation in the United States, there is abun- 
dant evidence that there is a serious lack 
of facilities for emotionally disturbed chil- 
drne in Canada. Many of these youngsters 
aer wrongly diagnosed as mentally retard- 
ed, deaf, or delinquent. 

This book can be read with profit by 
laymen — • particularly by community lead- 
ers in health education and welfare. 


MARCH 1965 


Nursing: Ifs History, Trends, Philosophy, 
Ethics and Ethos by Thelma Pelley, R.N., 
B.A., B.Sc.N. 238 pages. A. W. B. Saun- 
ders publication, available in Canada 
from McAinsh of Toronto and Vancou- 
ver. 1964. 

Reviewed by Sister Mary Felicitas, R.N., 
M.Sc.. Director, School of Nursing, St. 
Mary's Hospital, Montreal. 
The author states that this book was 
written "as an attempt to interpret some of 
the interrelated historical facts in a per- 
spective that may help explain nursing as 
it is today, and to help to create an aware- 
ness that not only are we a part of all that 
has been, but we are also a part of history 
in the making, and the makers of history." 
She specifies that no attempt has been made 
to present a detailed history of all. nor 
even the most important events which have 
occurred in the history of nursing. The idea 
of presenting historical values was conceived 
when first year students showed great en- 
thusiasm, yet senior students protested the 
further study of history and trends in 
nursing. She further states: "There is a 
philosophical concept which affirms that 
an awareness of a need constitutes an im- 
plicit moral obligation to do something to 
meet that need . . . this explains in part 
the raison d'etre for the writing of this 

Most of the 18 chapters are introduced 
with inspiring quotations that tempt one 
into further reading. The first eight chap- 
ters deal with various eras of history of 
nursing, and interpretation of certain details 
of these eras. There is some chronological 
order, but considerable "back-tracking" im- 
pairs logical sequence of thought. Frequent- 
ly, conclusions are drawn which lead one 
to question their accuracy or validity, e.g., 
"Unfortunately the purity and simplicity 
of early Christian concepts and practices 
were marred by the influences of prevailing 
pagan beliefs and practices, such as the 
cult of virginity and a belief in the virtue 
attained by the practice of ascetism." Few 
students of history or philosophy would 
concede that the examples cited were 
"prevailing pagan beliefs and practices." 

Chapters 9 to 18 deal more specifically 
with nursing of today and tomorrow. There 
are some thought-provoking and challeng- 
ing statements, if one can sift them out 
of the lengthy and involved sentence struc- 
ture. Much excellent material is found in 
the discussions of professionalism, econo- 
mic welfare, legal responsibility and nursing 
leadership. This reviewer was a little puz- 
zled at the description of affiliations and 
especially the reason given for "planned 
affiliation experiences." The confusion ex- 
tends to a common one existing today: is 
the student nurse a learner or a practi- 
tioner? The terminology "affiliation ser- 
vice" used in the text adds to this per- 
plexity. The useful chapter on spiritual 
care of the patient is marred by the defini- 
tion of health in the first paragraph where 
"emotional" is used as a synonym for 

Appendix I contains an excellent summa- 
ry of "Milestones in the History of Or- 
ganized Nursing in Canada," providing a 
concise and up-to-date reference of the 
development and progress of the nursing 
associations of this country. Appendix II. 
"Something to Think About and Something 
to Do" is precisely this, and could be used 
for various types of assignments. Appendix 
in gives 18 brief "Biographical Sketches of 
Representative Leaders and Makers of 
Nursing History." A few Canadians are 
here included. 

No doubt the class presentation of this 
material was inspiring, and it probably 
served the author in her efforts to "re-clothe 
the dry bones of historical fact" for her 
students. However, one would question the 
value of seemingly random gleanings of 
"history" with which the first eight chapters 
are filled, especially when such material is 
found with greater precision, sequence and 
accuracy in other readily available books. 
The author states she has not always se- 
lected the most significant incidents. On 
what basis then, was the choice made? 

The title and five sub-titles are too all- 
embracing and. therefore, might be some- 
what misleading to the prospective reader. 
Portions of this little volume will be useful 
as reference. It is not always possible to 
agree with the author's interpretation of 
factors and events, but perhaps some of 
its value lies in this very disagreement. It 
should send students and teachers to more 
complete sources of history and philosophy 
to search out the rationale of occurrences 
that influence change in nursing. 

Nursing Research, a Survey and Assessment 

by Leo W. Simmons, Ph.D. and Virginia 
Henderson, R.N., M.A. 461 pages. 
Appleton-Century-Crofts. A Division of 
Meredith Publishing Company, 34 West 
33rd St.. New York 1, N.Y. 1964. 

Reviewed by Mr. Albert Wedgery, 
Assistant Director, College of Nurses of 

When two people who can write fake up 
a subject which they know and in which 
they obviously share a deep interest and 
respect, the result cannot help but be worth 
reading. In this case, to our pleasure and 
relief, we find that the writers have suc- 
ceeded in making a still somewhat intimi- 
dating topic to most nurses both palatable 
and rewarding. Of course, the authors' 
qualifications to undertake the task are 
impeccable. Both have earned well-deserved 
reputations in their respective bailliwicks: 
Dr. Simmons in the field of education. Miss 
Henderson in the world of nursing. Their 
collaboration, combining scholarship with 
literary grace, should help to convince any 
skeptical members of the profession that 
putting research to work for nursing is the 
way out of many of the dilemmas facing 
us today. 

Though we live in a world that is at 
times oppressively scientific, due largely 
to the widespread use of research as a 
means of solving man's problems, relatively 



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MARCH 1965 


few nurses, despite their ability to apply 
new knowledge to the health field, are 
research-minded. Yet nursing today is a 
potential laboratory for the study of con- 
tinual changes that bring confusion and 
frustration with respect to the nurse's own 
responsabilities within the widening circle 
of special services to the patient. "This 
situation," comments Miss Henderson, "has 
evoked a growing concern for independent 
research by nurses themselves on problems 
related to their traditional and developing 
roles on the health team." Thus, we can 
appreciate at once the necessity for estab- 
lishing or refining a research technique 
that will be suited to the study of the 

occupation of nursing. 

This recent publication, presenting new 
material reliably grafted onto what was 
known previously, is a comprehensive guide 
to nursing studies in the United States and 
underlines those areas where fresh or ad- 
ditional research is indicated. The review 
and assessment of such concerns as occupa- 
tional orientation, career dynamics, and 
nursing care, suggest a variety of projects 
urgently awaiting the attention of nurses 
skilled in research methodology. Reports 
of studies, doctoral dissertations, masters' 
theses, and contemporary research projects 
show the extent to which the changing face 
of nursing service will continue to provide 



Dr. Bowman 





mmm >- 






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Line-O-Vision Sign is easy to see, whether it's placed high on a 
wall or door, or low on a bed. Signs are available with any number 
of slots, from one to five. One of these holds the patient's name, 
and the others are used for Reminder Cards which concern the 
patient's care. Each slot has a clear covering to protect its card 
from dust, damage or tampering. More than 120 printed Reminder 
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an increasing impetus for scientific analy- 
sis. That nurses must recognize also the 
need of research in instituting further 
changes to keep pace with new knowledge 
and practices in the health field is a major 
premise of the book. 

It is safe to assume that research will 
be used more and more to alter present pat- 
terns of nursing and contribute to its 
stabilization. More nurses must learn how 
to go to the source for facts in order to 
make nursing more satisfying to the prac- 
titioner and more beneficial to the patient. 
"With the development of research skills 
among clinical nurses, and with their ac- 
ceptance of responsability for research." 
asserts Dr. Simmons, "the volume and qual- 
ity of agency-sponsored, patient-centred re- 
search will almost certainly outweigh most 
other types." When that day arrives, it 
will be a sign of true professional maturity. 
One can only hope, however, that such 
research in nursing will not. under the 
cold eye of scientific scrutiny, overwhelm 
its subjects and alienate its victims. 

The individual nurse interested in re- 
search as a possible field of activity can 
learn a great deal from a careful study 
of this volume. As for the general nursing 
community, apt to shy away from such an 
esoteric domain, they will be depriving 
themselves of an easy introduction to the 
subject and its possibilities for profes- 
sional improvement if they fail to read it. 

Fundamenl-als of Nursing, Ed. 3 by Elinor 
V. Fuerst, R.N., M.A. and LuVerne 
Wolff, R.N., M.A. 661 pages. J. B. Lippin- 
cott Co., Montreal. 1964. 
Reviewed by Miss M. Forrester, Nursing 
Arts Instructor, St. Mary's Hospital 
School of Nursing, Montreal, Que. 
This text, a familiar one in nursing 
circles, deals with the application of 
principles drawn from the sciences and the 
humanities in the basic nursing care of the 

The current edition, as in the previous 
one, begins with a consideration of nursing, 
the nurse, the patient and the health agency 
before introducing concepts and principles 
underlying all nursing practice. Attention 
is given to specific aspects of care, such as 
the bed bath and oxygen therapy, which 
are discussed in terms of principles and 
related actions for the purpose of indicating 
the "why's" behind the "how's." 

The book has undergone some reorganiz- 
ation, addition, subtraction and develop- 
ment. For example, the psychological, socio- 
logical and spiritual needs of patients have 
been emphasized by being presented in a 
unit titled "Developing a Therapeutic 
Relationship with Patients," and the new 
ventrogluteal site intramuscular injection is 
described and illustrated. 

The updating of this text ensures that 
it will continue to be used either as a 
prime source or as an additional source of 
learning of fundamental nursing care for 
both teachers and students. 


MARCH 1965 


Bedside Nursing Techniques in Medicine and 
Surgery by Audrey Latshaw Sutton. R.N. 
374 pages. A W.B. Saunders Publication 
available in Canada through McAinsh & 
Co., Ltd. of Toronto and Vancouver. 

Reviewed by Miss M. Crawford, Dir- 
ector of Clinical Education, School of 
Nursing, University of Saskatchewan, 

This book is dedicated to "the nurse 
whose career is interrupted by those some- 
times joyful and sometimes distressing 
events which accompany being a wife and 
mother." It will be very useful to nurses 
in this group who are returning to a 
nursing careers, but it will also be very 
helpful to those who may be changing from 
one field of clinical specialization to 
another. It is designed "to serve as a hand- 
book of practical information for the bed- 
side nurse." In contrast to many books 
published, particularly those dealing with 
nursing procedures, this one is intended 
for the graduate nurse rather than for the 
beginning student. It is particularly helpful 
to have such a reference available as it 
becomes more and more difficult to keep 
up with new equipment and new treatments 
as nurses work in more highly specialized 
units. One excellent feature of the book 
is the abundance of illustrations (mostly 
drawings) which are in very close proximity 
to the text describing them. The drawings 
are clear and well-labelled but are not 
cluttered bv extraneous detail. 




"The History of the School" is 

ready for publication! 

We need the addresses of all 
the Alumnae members and all 
graduates in order to send you 
order forms. We trust that every 
member and graduate will res- 
pond by ordering at least one 
copy so that we con finance the 

Please send address 


3506 University Street, 
Montreal, P.O. 

Part I deals with general nursing tech- 
niques. This will be very helpful to the 
nurse who is returning to nursing practice 
after a period of retirement or of doing 
some other type of work. 

Part II deals with special nursing tech- 
niques. This part is divided into chapters 
relating to the various systems of the body. 
Each chapter has five major headings: 
Diagnostic Procedures; Therapeutic and 
Rehabilitative Procedures; Diets to Review; 
Medications to Review and Bibliography. 
Any nurse interested in giving better nursing 
care will find much to help her in these 
chapters. Nurses who are doing clinical 
teaching to students would be well advised 
to look into these chapters as a handy 
reference in the preparation of lectures 
and demonstrations. 

This publication adds another dimension 
to the type of book available on the sub- 
ject of bedside nursing techniques. It is 
hoped that the publishers will make every 
efforts to keep the book up-to-date by fre- 
quent revisions or by publishing supplements 
at intervals. The first edition has been 
well-produced. The paper is of good quality 
and the print is set up in the easy-to-read 
form of two columns to a page. The size 
has been kept down so that it is easy to 
handle and carry around. These features as 
well as the quality of the content should 
make it popular in nurses' libraries. 

Up and Around. U.S. Department of Health. 
Education and Welfare, Washington, 
D.C., Feb. 1964. 

This small booklet clearly outlines a 
program in the rehabilitation of the patient 
following a cerebrovascular accident. It 
teaches a patient with one-sided hemiplegia 
how to perform his daily activities indepen- 
dently. Clear diagrams and a step-by-step 
text help the reader to clearly understand 
each part of the planned program. 

This booklet will be of value to all 
members of the health team, and an ex- 
cellent tool for those working in rehabi- 
litative or convalescent units. It is also 
recommended for the family of a patient 
with a stroke. 




full information available on request. 


A good all'purpose resTrainr io prevent 
potients from falling or getting out of bed. 
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does not irritate busts. Avoilable in Small, 
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straint Cat. No. V-958. Price $6.90. (Extra 
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the front, with straps ottached to loops in 
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MARCH 1965 



Ontario Hospitol, London 

There will be a reunion of all graduates 
in the summer of 1965. Anyone knowing 
the addresses of former members, or any- 
one wishing to attend, please get in touch 

Mrs. Lois Scott. Reg. N. 

Hyde Park Sideroad 

London. Ont. 

Dauphin General Hospital 

Nurses' Reunion 
June 23-24, 1965 

For further information, contact: 

Mrs. B. E. Haywood, (Convenor) 
258 Ethelbert St. 
Sudbury, Ontario. 

Jn (/Mc 



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Halifax • Montreal • Toronto • Winnipeg • Vancouver 

Isobel Elizabeth (Angus) Abercrombie 
'51, Vancouver General Hospital, B.C. 

Esther Arietta (Greig) Ashley '35, St. 
Joseph's Hospital, Toronto, Ont. 

Marjorie Buckley '25, The Moncton 
Hospital, N.B. 

Agnes Lucy Mae Crandell '34, Ontario 
Hospital, Hamilton, Ont. 

Jennie (Cougle) Dickson '15, Victoria 
Public Hospital, Fredericton, N.B. 

Eleanor (Blaker) Dunning '37, Oshawa 
General Hospital, Ont. 

Mary Geraldine Fluelling '48. Effie M. 
(Bennett) Kennedy '34, St. Joseph's Hos- 
pital, London, Ont. 

Margaret E. (Berst) Hall '31, Woodstock 
General Hospital, Ont. 

Muriel 0. Harman '20, Margaret A. 
(Henderson) Savery '26, Royal Jubilee 
Hospital, Victoria, B.C. 

Ida Mabel (Jacobs) Jacobs '09, Marjorie 
Bell Reyner '19, Montreal General Hos- 
pital, Que. 

Edna Winnifred (Leonard) Jardine '27, 
Medicine Hat Municipal Hospital, Alta. 

Flora B. MacLean '15, City Hospital, 
Saskatoon, Sask. 

Reverend Sister Frances Sanford '23, 
Hotel Dieu Hospital, Chatham, N.B. 

Pierrette (Laberge) Tlsseur, Hopital 
St-Joseph de Lachine, Que. 


A new word, "tegleg," is being used to 
identify a new light-weight artificial leg. 
The word was coined from the initials of 
the Toronto East General Hospital where 
the leg was developed in a joint project 
with the University of Toronto. So far, 
the leg is experimental. It is made in 
workshops at The Wellesley Hospital, To- 
ronto, and has been fitted to four elderly 
patients at the East General. 

The tegleg has many advantages, espe- 
cially for older people: Light weight — 
only five and a half pounds, compared 
with up to 15 pounds for a standard artifi- 
cial leg including fittings; inexpensive — 
a cost of about $60, compared to $400 or 
$500 for models commonly used; fittings 
require only a couple of days instead of 
three to four weeks, the usual waiting 
period for other types. 

Tegleg is of most use indoors because a 
light leg might t>e blown by the wind out- 
doors and the wearer would have trouble 
keeping his balance. However, it should 
be most advantageous to elderly people 
who spend more time indoors than out- 
doors and who have trouble wearing a 
heavy leg. 

Once the leg has been thoroughly proved 
in clinical tests its design will be made 
available to manufacturers. 


MARCH 1965 


Menley and James. You know — they're a 
division of Smith Kline & French. 

Oh — Menley and James; the ones who make 

That's right. Remember how it cleared up 
my last cold? 

Did yon know there are CONTAC* antiseptic 
throat lozenges and nasal spray now as well? 

Yes, I've heard they're as good as the 
capsules, too. 

You mean you haven't tried them yet? 

*Reg.Can.T. M.Off. 


Eh (A Division of Smith Kline & French, Montreal 9. Quebec) 
\J 'Proprietary Pharmaceuticals Made to Ethical Standards' 

with medicated 


skin refreshant and body rub 

On every ward, when you turn out the lights, some one wakes up . . . and wakefulness thrives 
on minor irritations. Skin discomfort, particularly, can disturb your patients during the night- 
time hours. But as nurses in thousands of hospitals know, a body rub with Dermassage may 
add that one welcome touch of relaxation which tips the balance in favor of rest and sleep. 

Dermassage comforts, cools and soothes tender, sheet-burned skin. It relieves dryness, cracking 
and itching and helps prevent painful bed sores. 

You will like Dermassage for other reasons, too. A body rub with it saves your time and energy. 
Massage is gentle, smooth and fast. You needn't follow-up with talcum and there is no greasiness 
to clean away. It won't stain or soil linens or bed-clothes. You can easily make friends with 
Dermassage — send for a sample! 


Now distributed in Canada by Lakeside Laboratories (Canada) Ltd. 

'trademaric 1875 Leslie Street, Don Mills, Ontario 





Sterilon Cath -Trays with Plastic Catlieter 

No. 801 Cath -Tray Includes: 

• 16 Fr. Plastic Robinson Catlieter 

• 1500 cc Spillproof collection bag with 
clamp and catheter adapter 

• 3 oz. specimen container and label 

• Sterile overwrap to provide sterile field 

• Waterproof paper tray — 900 cc capacity 

• Disposable ambidextrous Tru-Touch* 
plastic gloves 

• Waterproof underpad 

• Fenestrated drape 

• Benzalkonium Chloride (1:750) 30 cc's 

• Five rayon balls in plastic cup 

• Bursak lubricant 

No. 802 Cath-Tray — Same as 801 but with 
18 French Robinson Catheter 

No. 800 Cath-Tray — Same as 801 but with- 
out catheter 


Cath -Trays 





(Camel CathTM) 

Sterilon's exclusive sealed res- ^ 
ervoir guarantees correct reten- 
tion balloon shape and capacity, 
absolutely no reservoir seepage! 


Trays contain all components of No. 801 
shown above except Robinson Catheter, col- 
lection bag and specimen container are re- 
placed by Sterilon's Self-Inflating Balloon 
Catheter (Camel Cath^^) which carries its own 
water supply. 

No. 901 • Tray with 18 Fr. — 5 cc Catheter 

No. 902 • Tray with 16 Fr. — 5 cc Catheter 

No. 900 • Tray without Catheter 

(No. 900 Tray may also be used as a urethral 
catheterization tray with a specimen con- 
tainer or collection bag from hospital stock.) 

"t.m. Becton, Dickinson & Co. 



Buffalo, New York Fayette. Alabama 


MARCH 1965 


In the Good Old Days 

The Canadian Nurse 
March, 1925 

Brandon General Hospital has instiluted 
a "Scout Nurse." The aim of this nurse is 
to eliminate waste — the unnecessary 
burning of lights, running of taps, careless 
use of cleansing material, food allowed to 
deteriorate, and the thoughtless and impro- 
per use and care of linen. 

She inspects the nurses' dining room 
each morning, and frequently after meals 
to discover if there is any particular food 

that is unpopular, and therefore, is being 

She may save unnescessary expense on 
the wards by turning off lights in corridors 
and empty rooms. And the number of ti- 
mes a tap is left running when it could 
be shut off by a little extra twist is cer- 
tainly surprising. Until a nurse has seen 
these things for herself she can scarcely 
credit the wastage. 

;i< * * 

In a survey of school children in Winni- 
peg, many instances of enlargement of the 
thyroid gland were found. Six per cent of 
those examined had moderate enlargement 
and 36 per cent slight enlargement — a 




._,',- .-.;',., *fe 

answer feminine hygiene problems 

• safely 

• effectively 

• discreetly 

Soothes, deodorizes, removes vaginal dis- 
charge in leukorrhea, trichomoniasis and 
other forms of vaginitis. Mucosolvent action 
of the fruit ferment "Caroid" assures rapid, 
effective action. Easy to use — pleasantly fra- 
grant. Recommend with confidence for 
routine feminine hygiene. 

Contains the ferment-cleanser Caroid 
(brand of Papain) with Boric Acid, Sodium 
Borate (dried), Zinc-Phenolsulfonate 
(dried), plus excipients, antiseptic deo- 
dorant and soothing oils with a pleasant 

CAROFEM Powder available in box of 12 
individual douche packets or 8 oz. container. 

total of 4.^ per cent showing some enlar- 

New evidence enhances the belief that the 
chief cause of such enlargement is iodine 
starvation. The iodine content in water sup- 
plies and food varies greatly in different 
districts. In some parts of British Colum- 
bia, for instances, the local deficiency in 
iodine is so marked that domestic animals, 
unless fed a certain amount of this food 
element, cannot produce healthy offspring, 
nor indeed, offspring that will survive. 

In the Winnipeg survey, as in others, 
enlargement was more common at the older 
ages and more in girls than in boys. It 
was not found to be definitely linked with 
any other abnormal condition, except to 
some extent with mental deficiency. — 
From a report by Dr. D. Stewart, Ninette 
Sanatorium, Ninette, Man. 

[Iodized salt was first introduced about 
1925; Canadian legislation requiring all 
table salt to be iodized passed on May 7. 
1949. — Ed.], 

By 15 years of age 75% or more of all 
children have had a primary tuberculosis 
infection. It is well to remember that signs 
in children are much less apparent. The 
earliest and most common symptom is 
fatigue. Following this listlessness there is 
usually anorexia and failure to gain weight 
or weight loss. 

Control of a tuberculous infection at an 
early stage in the child is so vital that it is 
advisable to institute treatment even when 
in doubt — because at this stage the prog- 
nosis is good. Delay permits the lesion to 
develop into the parenchymatous type of 
lesion in which the prognosis is anything 
but favorable, — Excerpts from "Early 
Tuberculosis in Children" by W. J. Dobbie, 
physician-in-chief, Toronto Free Hospital, 
Weston, Ont. 

1910 death rate: 130 per 100,000 popula- 

1923 death rate: 65 per 100.00 popula- 

[1963 death rate: 4.0 per 100.000 pop- 
ulation — Ed.l 



Easter Seals Help Crippled Children 

Camping activities present some special 
problems in the care of crippled children. 
The flag-raising, the wiener roast, the joy 
of the first fish biting are theirs with the 
help of your Easter Seal contribution. 


MARCH 1965 


precision from B/iXTER 
the FLO'TROL clamp 

—one of many taken -for-granted exclusives 

on PLEXITRON sets 

In giving parenteral fluids, you can be confident that your FLO-TROL clamp settings 
will be maintained. The wheel of the clamp can be rolled on the tubing from wide-open 
to shut-off position ... yet it will remain precisely fixed on the tubing at any desired 
point in between. And the FLO-TROL clamp permits you to stop, change bottles, and 
start administration again ... without disturbing the original setting or "flow rate. We 
hope you continue to take it for granted! 

Manufacturing Ethical Pharnnaceuticats in Canada Since 1938 



MARCH 1965 


Provide your students with the insight and dedication modern nursing demands 
with the aid of the completely redesigned and reorganized new edition of 
the most popular textbook available for courses in "Professional Adjustments" 

to professional nursing i V 

Text and Workbook for Student Nurses 

How can a textbook which is already the most popular and 
widely adopted text in its subject area be improved? Examine 
a copy of the new 4th edition of this outstanding text-work- 
book and see for yourself how this can be done. You will 
find this new edition has been updated extensively to keep 
pace with rapid professional advances and current thinking 
in the field. The physical format has been changed completely 
to make it more readable and appealing. The content has 
been revised to better assist the student in acquiring a more 
solid foundation for the profession she is about to enter. And 
suggestions of instructors who have used this text in their 
classrooms have been incorporated throughout this new 
4th edition. 

Combines the best features of a text and a workbook 
This new 4th edition can provide your students with both a 
text and a workbook in one comprehensive volume. Based 
on the premise that "nothing is more important than the pa- 
tient", it provides the student with a wealth of basic informa- 
tion, always with emphasis on her responsibilities as she 
learns the art of nursing. This text-workbook effectively and 
maturely stresses the "why" and the "how" of the adjust- 
ments a student must make while becoming a professional 
nurse. The workbook portion includes 64 two-color perfor- 
ated and punched worksheets bound into the back of the 
book. On the inside back cover is a triangular pocket where 

the student may securely keep the worksheets for future 

This new 4th edition includes these important features: 
D three new chapters on history of nursing; D new discus- 
sions of communications, leadership and challenges to be 
met; D descriptions of social influences upon nursing; D dis- 
cussions of the nurse's legal responsibilities; D discussions of 
the importance of appreciating the worthwhile things and of 
using leisure time to develop well-rounded professional rela- 
tionships; n aids to strengthen the nurse's ability to give spir- 
itual and emotional support to the patient; D discussions of 
the need for flexibility and adjustments and of some possible 
future adjustments. 

Features a complete change in format 

Notice the dynamic change in the physical appearance of 
this edition. Now a hard-bound volume with a full-color 
cover, this new edition's more than 450 pages are printed in 
two colors for increased readability. For the first time in a 
text of this type, a 32-page section of 64 full-color illustra- 
tions relates specifically to portions of the text and greatly 
aids student understanding. In addition, more than 70 other 
illustrations add to this edition's value by being strategically 
placed where they will enhance comprehension of the dis- 
cussions and stimulate student thought. All charts and tables 
have been brought completely up to date. 

By LUELLA J. MORISON, R.N., M.A., Nurse Specialist, Ohio Department of 
Health, Columbus, Ohio. Publication date: Febuary, 1965. 4th edition, 464 pages, 
8ii" X ^0h", with 74 photographs and line drawings and 64 Illustrations in full 
color. Price, $7.25. 

Available in Canada through: 
1835 Yonge Street 
Toronto, Ontario 

THE C. V. 


3207 Washington Boulevard 



St. Louis, Mo. 63103 


MARCH 1965 


To save you time 

in answering 

questions about menstruation 

When girls bring their questions to you, you 
may not always have as much time as you'd like 
to spend talking with them. As a timesaver for 
you, we have prepared a 24-page booklet called 
"Accent on You" which answers many of the 
questions young girls ask — or would like to ask 
— about menstruation. All these questions have 

actually been asked of Tampax educational con- 
sultants, and they reflect the lack of information 
and genuine concern young girls have about 

Also available for your instructional use is a 
set of the classic anatomical charts in color by 
R. L. Dickinson, M.D. illustrating the female repro- 
ductive system. These are laminated in plastic for 
permanence; suitable for grease-pencil use and 
erasure. A second booklet, "It's Time You Knew," 

tells, in terms the more mature girl understands, 
why menstruation is part of a woman's life. 

We will be happy to provide you with a free set 
of the anatomical charts and samples of the book- 
lets for your evaluation. You may then order as 
many free booklets as you need. Return the cou- 
pon on this page for your requirements. 

Tampax vaginal tampons themselves solve 
many of the problems a young girl experiences 
during menstruation. Tampax is so comfortable to 
wear that she will be unaware of its presence once 
it is properly in place. She'll feel cool, clean and 
fresh all during the menstrual period, too, be- 
cause Tampax, placed internally, allows no odor 
to form and it is hygienic. A young girl will also 
appreciate the freedom that comes from wearing 
Tampax. Sitting, walking— all activities are made 
as comfortable during menstruation as at any 
other time of the month. 

Tampax is available in Super, Regular, and 
Junior absorbencies. Explicit directions for inser- 
tion are enclosed in each package. 


Internal sanitary protection for better menstrual hygiene 

Canadian Tampax Corporation Limited. 
P.O. Box 627. Barrie, Ont. 

Please send me a free set of the laminated Dickinson 
anatomical charts, and samples of the two booklets along 
with an order card for easy reordering. 


Address . 


MARCH 1965 






(Gastric Sump Model) 

for continuous aspiration 
of gastric secretions. 


for continuous monitoring 
of venous pressure. 



^?ii|<-=: BEDSIDE BAGS 
for urinary 
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.v> for ambulatory 

collection of urine. 




* / s"^ for venous infusion via 
a soft pliant cannula. 


For complete information request Brochure on Bardic Products for Patient Care 






Are there reasons to doubt the continuation in the present or the survival in the 
future of y/hat appears to have been for more than two thousand years an 
undeniable ideal? 

Paul Pirlot,, ph.d. 

Is there or is there not a problem 
of humanism? If humanism was first 
defined by the Greeks, it has neverthe- 
less been resubmitted to varying defini- 
tions during the ensuing centuries. This 
is natural since history is not a per- 
petual re-beginning. Time proceeds in 
one direction and no two eras can 
ever be identical. A human ideal 
therefore, while it retains its essen- 
tial structure and its basic skeleton 
intact, would require subtle revisions 
in each successive historical context. 
These revisions are particularly im- 
portant as truth often lies in slight 
shades of meaning. Periodically, there- 
fore, the problem of redefining hu- 
manism arises. 

At the present time the words 
"humanism" and "humanities" are 
used much less than they were even a 
few years ago. On the other hand, the 
expression "human sciences" is crop- 
ping up everywhere. Human science is 
made up of disciplines pertaining to 
biology, psychology and sociology; 
man is the common objective of these 

Professor Pirlot is in the Faculty of 
.Sciences at the University of Montreal. He 
gave this address to the graduates of the 
Institut Marguerite d'Youville at Convoca- 
tion ceremonies in May, 1964. 

Studies. Is it possible that this scien- 
tific study of man will turn out to be 
the contemporary form of humanism? 

Everyone has some concept of the 
humanist ideal, but it is usually ex- 
tremely vague. It is not easy to define 
or to delineate this concept — it is 
vaguely synonymous with the idea of 
culture. The essential feature of cul- 
ture, lacking a proper definition, is 
given as: 

a refinement, within the individual, of the 
mind and the heart through which those 
persons capable of so doing accept and 
appreciate the totality of intellectual and 
moral values which constitute the highest 
achievent of the human adventure. In the 
community, it is an atmosphere which 
permeates its surroundings and which even 
the least enlightened layman is forced to 
take in. 

The extent of this cultural or hu- 
manist ideal is impressive. To know 
and to comprehend sufficiently the 
great exploits of human knowledge 
and generosity so we may admire them 
all is indeed a formidable program. 
More so, because this heritage in- 
creases and becomes wealthier from 
geaeration to generation, following the 
upward trend of evolution. 

In the Hellenic worid, it was 
relatively easy to know all that was 

to be known at that time. This is 
proven by the omniscience often ac- 
companying the great wisdom of cer- 
tain scholars of antiquity. From the 
Renaissance onward, however, om- 
niscience became an ideal beyond the 
reach of man. Knowledge increased at 
such a rate that mastery of it became 
impossible during the lifetime of any 
one individual. The equation between 
culture and universal knowledge was 
therefore destroyed. It was temporarily 
replaced by a concept of humanist 
culture in which the latter was reduced 
to a thorough knowledge of the lit- 
erature and the arts from antiquity to 
modem times. This concept still exists, 
floating about like a fog, in some 
Arts and Letters faculties. A last trace 
of it is still to be found in universities 
that have faculties of Humanities. This 
fog is lifting by degree before the 
illuminating triumphs of the contem- 
porary positive sciences. Science, art 
and literature, and an individual con- 
cept of man are the necessary compo- 
nents of humanity today. 

IRST, it is no longer possible to 
be a cultured person or a humanist 
without knowing something of scien- 
tific developments, besides being ac- 


MARCH 1965 


quainted with the evolution of arts 
and literature. Scientific developments 
and their technical application cons- 
titute unquestionable human achieve- 
ments. But what must be known about 
them in order to be a cultured person, 
to be of our time? To absorb more 
than a fraction of what is published 
in scientific books and journals is im- 
possible. Moreover, these publications 
are usually specific in scope since the 
authors are often specialists and there- 
fore may be also more or less limited 
in their intellectual outlook. 

Thus, the nourishment offered to 
satisfy our cultural appetite is pre- 
sented as a mass of fragmentary in- 
formation on all manner of subjects. 
Even the popular treatises are often 
a mere accumulation of various ele- 
mentary "exposes." isolated from a 
vast background without a connecting 
link of any kind — in particular, those 
magazines made up of a mixture of 
disjointed articles about anything and 
everything and often about nothing, 
written by entirely unknown authors. 
This is not to condemn the populariz- 
ation of scientific knowledge, which is 
an excellent thing in itself as it helps 
to spread knowledge. However, we 
should be wary of the easy, super- 
ficial pulps flooding the publication 
market for the information provided 
is often mistaken for authentic basic 
education. This is the danger point. 

Basic education is altogether dif- 
ferent from the acquisition of informa- 
tion. Education can be compared to 
good digestion, an assimilation provid- 
ing the body with the elements from 
which the organism will build its vital, 
personal and unique substance. It is 
essentially a well-balanced process, 
characterized by bonds which connect 
the various elements one to another: 
science, philosophy, religion, esthetics, 
and so on. At its very core is a per- 
sonal synthesis, an orderly and re- 
warding synthesis. Conversely, plain 
unintegrated information is mere 
chaos, an accumulation of intellectual 
bric-a-brac; it is made up of splinters 
of superficial concepts, completely un- 


HE scientific ingredients of culture 
(in the sense of natural sciences) have 
been mentioned. A similar situation 
exists in the artistic and literary field 
— the second cultural panel. Formerly, 
the Mediterranean and Western Euro- 
pean masterpieces have constituted the 
whole of our esthetic heritage. Europe 
emigrated, taking with it its artists and 
its writers, who planted their roots in 
distant lands. Now, in unknown and 
far-away continents, we have encoun- 
tered ancient civilizations, living or 

dead, which are obviously interesting 
in themselves. Rapid transportation 
has permitted even the earth's remotest 
corners to be explored from a cultural 
point of view. In our day and age, it is 
unthinkable that an introduction to 
general culture should ignore the exis- 
tence of the temples of Asia, the 
philosophy of the Upanishads, the 
customs of the Incas, the statues of 
Easter Island, the majesty of the Bali 
dancers, the music of the Balubas of 
the Congo, and other artistic ex- 
periences. There sometimes appears to 
be a certain amount of snobbishness 
involved in a puerile enthusiasm for 
certain civilizations which are limited 
in their scope and duration. People 
claim to understand the language of 
the tom-toms but listen to Beethoven 
with disdain; appear to value the 
basket-weaving of the Orinoco Indians 
more highly than the marbles of 
Michelangelo. Be that as it may, in 
esthetics, as in the sciences, horizons 
have broadened and cultural know- 
ledge has been greatly extended. This 
knowledge, too, may be presented to 
us in a chaotic fashion — a compila- 
tion of isolated facts rather than a 
body of cultural knowledge of educa- 
tional value. 

It was inevitable that such a re- 
warding and enriching evolution should 
bring about a heavier scholastic cur- 
riculum. Since the last war, it was 
necessary to integrate into the curri- 
culum subject matter that had pre- 
viously been ignored altogether or that 
had barely been touched upon. Even 
before the background data could be 
synthesized, a reasonable number of 
hours allotted, it was in the course 
outline! A glance at any university 
syllabus demonstrates the legitimate 
desire to offer as complete a nursing 
program as possible. Indeed, a well- 
balanced program seems to offer sub- 
ject matter that is practical and im- 
mediately applicable and also subject 
matter that would appear to have no 
practical purpose. Although not a 
"pay-load," this latter may well be the 
most valuable part of the course (the 
eternal conflict of Martha and Mary). 

When we complete our formal edu- 
cation, and as we close our last note- 
book, we are not ending the study of 
the world around us, nor our humanist 
training. On the contrary, we are 
making a new beginning. Faced with 
the incredible richness of human ac- 
complishments of all kinds and with 
the difficulties in discerning and 
classifying human values, it is impor- 
tant to pursue learning relentlessly so 
that appreciation may continue un- 
abated. Our very existence is a 
continuous progress in personal cul- 

We will encounter the practical con- 
flict mentioned earlier — the antithesis 
that exists between basic education and 
mere information. There is no easy 
solution of the problem. What to read, 
what to listen to and what to reject 
amid this avalanche of information 
transmitted by radio, television, books, 
newspapers and magazines depends, 
but only partially, on personal prefe- 
rences. Two sound words of advice 

To acquire a basic education rather 
than to accumulate mere information, 
we should seek, in the various fields, 
those publications that present a syn- 
thesis of knowledge. They may not be 
numerous but they exist and they are 
usually written by the best minds of 
our time (for example, the writings of 
Erwin Schrodinger in physics, of Ju- 
lian Huxley in biology, of Rene Huy- 
ghe in art criticism, as well as some 
good biographies). 

Interest in current matters that have 
not yet shown any indications of per- 
manency (the latest literary fad. the 
latest word in painting and sculpture, 
the latest philosophical or anti-philo- 
sophical mouthings or even the bizarre 
Beatlemania) need not be ignored. 
However, we must acquire the habit of 
basing judgment and taste on broad 
and firm studies; then it is easier to 
place all the little nonsenses where 
they really belong in the cultural pan- 
orama. These eruptions of exacerbated 
peculiarities are not lacking in signi- 
ficance, but usually represent little 
more than measles accompanied by the 

Synthetic works are hard to find. 
They attract litde attention because 
they are not widely advertised. 
Yet, the more people become in- 
terested in them, the more will 
publishers place them on the market 
since the wise buyer has a favorable 
effect on production. 

The second word of advice concerns 
mental discipline. Be wary of super- 
ficiality engendered by haste. Most 
people read a great deal and read 
rapidly. During a single week, they 
may attend three or four plays, or 
concerts or exhibitions but. because of 
lack of time, they do not reflect on 
what was seen or read; they have no 
time to ruminate what was swallowed 
whole. Our ancestors had time to med- 
itate while they traveled in a stage- 
coach; in the jet age, the faculty for 
meditation, with its attendant rewards, 
has largely disappeared. This faculty 
returns at times when one is in the 
far north or in the tropics and a break- 
down of a car or plane forces the 
traveler to remain for three days in 
the jungle or on the tundra. And yet, 
meditation appears to be the sine qua 


MARCH 1965 


non of all personal synthesis and 
therefore of all authentic culture. In 
our feverish world the benefits of 
meditation become more and more 
difficult to acquire. We have become 
mass-minded, according to the philo- 
sopher Ortega; we are persons from 
whom society has withdrawn solitude 
to such an extent that we can no 
longer bear it. Too few of us wish to 
withdraw within ourselves to examine 
in depth, to integrate and to balance 
the elements of our inner life, and 
still fewer of us could if we would. 
Shortly, in order to find solitude and 
meditation, it will be necessary to do 
one of two things: enter a monastery 
(of Trappists, preferably), or take off 
in a space capsule (without a radio). 


NLY two of the panels of the tryp- 
tic which humanism or culture com- 
prises — that is, scientific knowledge 
and esthetic enjoyment — have been 
observed. The third panel is a thou- 
sand times more important. An ade- 
quate description of it would require 
too much space and thus only one 
or two of its principal traits are out- 
lined here. This third aspect of hu- 
manism concerns the conception of 
man's place in the cosmos. It is preci- 
sely one of the characteristics of a 
cultured individual that he has a per- 
.sonal opinion on this subject while 
others are satisfied with the smug 
complacency of their newspaper, or 
with living vicariously the lives of their 
neighbors. Reflection on this matter 
may be naturally subdivided into two 
parts: individual destiny, and one's 
relationship with other individuals. 
Both of these are intimately related. 
All the philosophies and the sciences 
of man can provide food for thought 
on this matter. 

In reality, in individual destiny, on- 
ly two attitudes confront one another, 
two humanisms which are irreconcil- 
able. The first examines biological 
man. In this perspective, stress is 
placed, first and foremost, on the zoo- 
logical continuity of the human species 
— a scientific fact that it would be as 
foolish as it would be dangerous to 
attempt to deny. However, accepting 
this awareness as a starting point, 
most of the minds of our time, even 
the most brilliant, have come to the 
conclusion that the activities of the 
mind and moral attitudes can be re- 
duced to manifestations of unadul- 
terated, vital energy based on the 
needs of a biological balance which 
evolution appears to automate more 
and more as time goes on. It would 
indeed be naive to believe that this 
is not the outlook, conscious or un- 
conscious, of the majority of our con- 

temporaries. Take a good look around 
you and you will see to what extent 
most people automatically reduce 
psychic activities to biological activi- 
ties, success in life to a strictly pro- 
fessional efficiency and welfare, hap- 
piness to the harmony of cerebral and 
sentient functions and suffering to be 
no longer only an ordeal but a dis- 
grace. Even among the active advo- 
cates of education for the masses, this 
mentality predominates among the 
intellectuals. Thus, the dream of our 
society becomes a way of life which 
approximates Aldous Huxley's Brave 
New World, a dream that is less 
whimsical than it appears on the sur- 
face and that can, in part, become 

This ideal is only a devaluated hu- 
manism because it has forgotten to 
take into account man's power of 
thought. This power of cogitation, 
however, can be anesthetized, if not 
killed outright, and this is being done 
to a great degree in our western world. 
The metaphysical problem is simply 
eliminated among a very large num- 
ber of persons, particularly in the af- 
fluent societies. Thus, whole commu- 
nities have been able to accept, with- 
out turning a hair, such monstrous 
measures as euthanasia or genocide. 
It is, therefore, absolutely imperative 
that we set up against this attitude 
another type of humanism; to see to 
it that the metabiological concern re- 
garding the whole man should not be 
destroyed; and to maintain the trans- 
cendency of the mind above the mere 
boundaries of comfort. The problem 
of the destiny of man is not solved by 
social security nor by the economic 
world balance under an international 

The second reflection on the place 
occupied by man in the universe must 
lead to a definite yet varied concept 
of harmonious human relationships. 
This is more an art than a science. 
During the past few years, the ideal 
suggested in this field appears to have 
been a bland philanthropy sometimes 
tinged with missionary zeal; a parody 
of charity aiming to make others bio- 
logically happy in order that life with 
everyone will be made easy. This at- 
titude is basically a mere calculated 
egoism. Once again, a genuine interest 
in the real destiny of the community 
is not involved. This interest is, none- 
theless, the very axis of an authentic 
humanism. Its absence is particularly 
unacceptable among men who are 
otherwise cultured. A personal culture 
that is nothing but an egotistical dilet- 
tantism is also unacceptable. Real cul- 
ture implies dynamics and a wish to 
communicate at the highest level. 
Nothing is more odious, because noth- 

ing is more responsible and at the 
same time less dependable, than a man 
who is outstanding in his knowledge 
or his art who is unable to appreciate 
the value of the persons around him; 
who is unable to respect others and 
their individual liberty; who refuses to 
transmit to others the abundance of 
his knowledge and his talent. 

Formerly, the art of living with 
others and for the greatest good of all 
was only learned at the price of ex- 
perience. The only scholastic part of 
this apprenticeship consisted in the 
reading of epics, biographies and dry 
texts on general morality, that it is 
difficult to relate to the conditions 
which obtain in the present day and 
age. Today, as our curricula indicate, 
human relationships are studied speci- 
fically: psychology, psychiatry, socio- 
logy, labor and family legislation, etc. 
These constitute fields of research and 
subject matter for academic courses. 
Their data are gradually integrated 
into the framework of contemporary 
humanism, which progresses at the 
same rhythm, benefitting from an in- 
tegration which is scientific in the 
widest meaning of the word. But here 
again, more than elsewhere, informa- 
tion does not constitute basic educa- 
tion. What is missing is the testing 
through experience. Whatever may be 
our professional future, this test always 
is at hand. 


UR conclusion is, as in every 
period of history, there exists a 
nowadays a problem of humanism. 
If humanism is to be permanent, 
even today, wisdom must have the 
last word. Wisdom erroneously brings 
to mind a head of white hair 
and senile maunderings; wisdom be- 
longs to every age, particularly 
Christian wisdom, which culminates 
in charity — and charity belongs first 
of all to youth since it implies gene- 
rosity. Real humanist wisdom is not 
acquired through successful examina- 
tions. Of course, it requires more and 
more knowledge but it also requires 
the precise and sincere adjustment of 
action to this knowledge and a more 
than Socratic ideal. This ideal goes be- 
yond plain intellectualism and the sim- 
ple accumulation of smatterings of no- 
tions; it requires a personal integra- 
tion, a synthesis within the mind — 
and the mind is something quite dif- 
ferent from mere intelligence. 

This integration is an ideal worthy 
of a lifetime of pursuit. Just as Her- 
riot said that culture is what is left 
after everything has been forgot- 
ten, so would I say in conclusion: We 
will forget much, but may this ideal, 
at least, remain with us. 


MARCH 1965 


Epilepsy Today 

Theodore Rasmussen, m.b., m.d., m.s., f.r.c.s.(c) 

An introduction to the articles concerning epilepsy 

Epilepsy, or recurring seizures, af- 
flicts one out of every 200 persons 
on this continent and is thus one of 
the common ailments that brings pa- 
tients to physicians. It is often a par- 
ticularly distressing condition because 
the great majority of patients with 
epilepsy are otherwise completely nor- 
mal and potentially productive mem- 
bers of society except for the tiny 
fraction of the week, month, or year 
occupied by the attack itself. Thus 
a two-or three-minute day-time attack 
occurring once or twice a month often 
constitutes a severe handicap to an 
individual in holding a job or leading 
a normal life in the community. 

Epilepsy, like headache, is a symp- 
tom rather than a true disease, and 
is a symptom that is usually due to 
something wrong in the brain. Like 
headache, epilepsy sometimes indicates 
the presence of a serious lesion of 
the brain, such as a tumor or vascular 
malformation, that requires treatment 
for its own sake. More often, however, 
like headache, the epilepsy is due to 
some lesion, such as an area of scar- 
ring or atrophy, which requires no 
specific treatment, or is due to some 
lesion we are as yet unable to detect. 
In the latter instance, we classify the 
epilepsy as idiopathic, cryptogenic or 
primary. When the causative brain 
lesion can be demonstrated, the epi- 
lepsy is classified as symptomatic or 
secondary. The attacks are often focal, 
showing evidence of starting in a res- 
tricted region of the brain. 

Once proper investigation has shown 
that the epilepsy is not due to a 

Dr. Rasmussen is Director. Montreal 
Neurological Institute and Hospital, and 
Professor of Neurology and Neurosurgery. 
McGill University, Montreal. Que. 

serious brain lesion which requires 
specific and definitive treatment itself, 
it is then necessary to treat the symp- 
tom, the epilepsy or seizures just as 
headaches often must be treated symp- 
tomatically with analgesics, etc., be- 
cause the underlying cause is un- 
known, cannot be treated, or requires 
no specific treatment. 

Although epilepsy has been a prom- 
inent ailment of mankind since the 
beginning of recorded history, modem 
study of the condition began barely 
100 years ago. The first truly effective 
treatment only recently passed its 50th 
birthday, and it is barely 30 years 
since the electroencephalogram began 
making its important contributions to 
our understanding of seizure mecha- 
nisms and varieties of epilepsy. The 
basic physico-chemical abnormalities in 
the brain that are actually responsible 
for the seizures are still unknown, but 
will certainly yield to the rapidly ad- 
vancing knowledge in the fields of 
neurophysiology and neurochemistry 
before many more decades have pass- 

Although we lack the basic know- 
ledge to produce a definitive agent 
for controlling epilepsy, on an empir- 
ical basis a large number of anticon- 
vulsant drugs have been developed and 
investigated since the introduction of 
Dilantin (diphenylhydantoin) in 1937 
rekindled the chemist's interest in this 
field. As Dr. Preston Robb points out 
in his discussion of "Epilepsy and its 
Medical Treatment," 20 of these drugs 
have earned places in the physician's 
present armamentarium of anticonvul- 
sant medications. With a thorough and 
systematic trial of various combina- 
tions of these drugs, between a third 
and a half of all epileptic patients can 
be kept essentially seizure-free. An- 

other fourth or third will show fairly 
satisfactory seizure control. 

A certain percentage of patients 
whose seizures cannot be adequately 
controlled with anticonvulsant medica- 
tions and whose seizures are focal in 
nature can be helped by surgical 
therapy, a field pioneered by Dr. 
Wilder Penfield, the founder and first 
director of the Montreal Neurological 
Institute, and a field of continued and 
expanding interest of the present Ins- 
titute staff. This aspect is discussed by 
Dr. Charles Branch in the second 
paper of this series, "Surgical Treat- 
ment of Epilepsy." 

The nursing staff of the Institute, 
under Miss Eileen Flanagan, nursing 
supervisor until 1960, and her associ- 
ate and successor. Miss Bertha Came- 
ron, have likewise had a special in- 
terest in the many problems of the 
epileptic patient and have developed 
nursing techniques designed to provide 
maximum safety and comfort for the 
patient undergoing a complete study 
of his epileptic problem and facing the 
special problems incident to surgical 
therapy when this is indicated. Miss 
Robertson and Miss Murray describe 
these in the report "Nursing an 
Adolescent with Seizures," which is 
built around a boy with a difficult 
seizure problem being operated upon 
for a second time in an effort to 
relieve his focal temporal lobe seizures. 

Public understanding of the epileptic 
has improved considerably during the 
past 20-30 years but still lags far 
behind the medical advances. The 
principal problems of the epileptic in 
relation to his family and the commu- 
nity are discussed by Miss Cynthia 
Griffin, director of Social Service, in 
the final paper of this series, "Social 
Factor in Epilepsy." 


MARCH 196.5 


Epilepsy and Its 
Medical Treatraent 

Most patients with epilepsy can be treated successfully. 
Preston Robb,, m.d., cm. 

Epilepsy has been defined as a 
group of conditions characterized by 
recurring convulsions. From the time 
that records have been made on the 
illnesses of man, epilepsy has formed 
a prominent part. The early history 
of "The Falling Sickness," as recorded 
by Temkini, Lennox- and others, is an 
interesting story; but it has contributed 
little to an understanding of the true 
nature of the disorder. The theories of 
its origin were a mixture of magic and 
religious fantasy and, according to 
Thomas Willis, in 1684, the early 
approaches to treatment frequently did 
more harm than good. 

In the Hippocratic collection of 
medical papers'', written about 400 
B.C., a physician hinted at the truth 
when he wrote of epilepsy: "Its origin 
is hereditary like that of other dis- 
eases." He recognized that the seat of 
the trouble was in the brain and ex- 
pressed the opinion that the precip- 
itating factors of the attack were cold, 
sun, and winds which changed the 
consistency of the brain. He considered 
these cosmic phenomena divine; thus, 
since they influenced all diseases, all 
diseases were divine. At the same time, 
they were human because of their phy- 
siological substratum. Epilepsy, there- 
fore, should not be treated by magic, 
he suggested, but rather by diet and 

The first ray of hope for the 

Dr. Robb is Deputy Director of Hospital- 
ization. Montreal Neurological Hospital, 
and Associate Professor of Neurology. 
McGill University. Montreal. Quebec. 

patient came in 1857 when Sir Charles 
Locock reported the successful use of 
bromides in the treatment of hystero- 
epilepsy. It was not until 1912, when 
Alfred Hauptmann^ published "Die 
Behandlung bei Epilepsie mit Lu- 
minal," that seizures were first treated 
with any degree of success and safety. 
In 1937, Merritt and Putnam"' discov- 
ered diphenylhydantoin while testing 
the ability of drugs to prevent elec- 
trically induced convulsions in cats. 
The drug was found to be effective 
without serious side effects. The fol- 
lowing year, these investigators re- 
ported its successful use in humans. 

Phenobarbital and diphenylhydan- 
toin continue to be the core of treat- 
ment for most patients having epilepsy 
although many other drugs have been 
developed, some of which are remark- 
ably effective. Outstanding among these 
are trimethadione. used in the treat- 
ment of petit mal, and primidone and 
Mesantoin, used in the more general- 
ized convulsive disorders. 

Although the convulsive seizure 
represents the popular conception of 
epilepsy, it is only a part of the 
problem. The epilepsies compose a 
group of disorders in which the com- 
mon factor is paroxysmal, excessive, 
neuronal discharge within the brain. It 
is accompanied by a sudden disturb- 
ance of function of the body or mind. 
The disturbance, whether it is loss of 
consciousness, disturbance of the mind, 
excess or loss of muscle tone or move- 
ment, disorders of sensation or special 
senses or disturbances of the automatic 
functions of the body, is subservient 
to the part of the brain involved. 

Many different types of seizures 
occur. As yet, no classification has 
been universally accepted. The attack 
may be a tonic-clonic type of seizure 
with loss of consciousness and a post- 
ictal confusion state much like that 
described by St. Mark. This is gener- 
ally referred to as a grand mal attack. 
On the other hand, the attack may be 
a transitory pause, "absence," or loss 
of consciousness, lasting only a few 
seconds. This is called a petit inal 
seizure. The attack may originate in 
any one part of the brain, and begin 
with a motor or sensory aura. It may 
manifest itself with automatisms, delu- 
sions, or hallucinations. There is a 
different type of attack for every region 
of the brain involved. In addition to 
the actual seizure itself, certain behavi- 
oral disorders associated with epilepsy 
are frequently more disabling than the 
attacks themselves. 

A careful history and physical 
examination constitute a most impor- 
tant aspect in diagnosis and evalua- 
tion of epilepsy. Modern techniques 
of x-ray and electroencephalography, 
biochemistry and psychology have done 
much to elucidate our understanding 
of these conditions. 

The causes of epilepsy are multiple. 
The seizure itself is a symptom of an 
underiying disorder of the brain which 
may be structural, chemical, physiolog- 
ical or a combination of all three. 
The basic physico-chemical phenomena 
that takes place may be common to 
all seizures, but the cause varies from 
patient to patient. It is preferable to 
refer to them as "the epilepsies." A 
strong family history may indicate that 


MARCH 1965 


it is truly a genetic disorder. Tliere 
may be a history of a difficult birth, 
postnatal head trauma, a nutritional or 
toxic disorder, tumor etc. Frequently, 
one has to consider the possibility of 
many causes that lower the threshold 
and induce seizures. 

The most direct approach one can 
make toward the successful treatment 
of the epilepsies, is to determine and 
treat, when possible, the primary, 
underlying cause of the attack. The 
second approach is to control or pre- 
vent the symptomatic seizures by the 
use of anticonvulsants and other drugs 
and, occasionally, by surgery. The 
third major aspect is to understand 
the total problem of the patient as a 
person, his emotional life, and his 
relationship to his environment. 

Seizures are, in a sense, a physiolog- 
ical disturbance. They can be elicited 
in the normal brain by chemical or 
electrical stimulation. As a rule, the 
threshold for seizures is lower in ab- 
normal brain tissue, and attacks are 
more readily produced by chemical or 
electrical stimulation. In the normal 
brain, a certain stability exists between 
the processes of excitation and inhibi- 
tion. When a seizure occurs, it is 
generally considered that the balance 
is lost in favor of excitation. Current 
investigation suggests that convulsive 
activity is not an enhancement of the 
normal excitation of neurons, but a 
partial or complete block of normal 
inhibition. A biological abnormality 
of some neurons is thought to underlie 
the initiation of a gradually increasing 
depolarization in their dendritic fields, 
so that minimal stimuli may initiate 
a seizure discharge. In any case, 
therapy is directed at increasing the 
stability of the neuronal tissue. A 
seizure originating in an area of 
abnormal cerebral tissue may remain 
localized or it may spread to involve 
normal brain cells. If the spreading 
electrical activity is sufficiently ex- 
tensive, the whole brain and spinal 
cord become involved and a tonic- 
clonic seizure ensues. 

Factors such as blood sugar level, 
blood gas concentration, body fluid, 
plasma. pH. body temperature, endo- 
crine disturbances, nutritional deficien- 
cies, specific metabolic disorders, etc.. 
are known to influence the develop- 
ment and spread of a seizure. 

Other factors such as hyperventila- 
tion, flickering lights, sudden noises, 
pain, and even emotional disturbances 
may precipitate an attack. When 
planning treatment, these factors and 
indeed, the whole patient and his 
environment are considered. 


The ideal anticonvulsant druc 

should be capable of preventing an 
epileptic discharge, regardless of its 
pathological or neurochemical back- 
ground. The drug should develop the 
stability of cerebral tissue to with- 
stand the normal provoking factors 
and be effective in all locations in the 
nervous system. It should be non- 
sedative, well tolerated, and devoid 
of untoward effects on vital organs 
and functions. When taken orally, its 
effect should be of long duration to 
maintain a fairly stable level in the 
body. It is no secret that such a 
compound does not exist; thus, the 
search for new compounds must con- 

The anticonvulsant compounds are 
the backbone of treatment of the 
epilepsies, and of the prevention of 
convulsions. The decision of when to 
start a patient on medication is an 
individual one. It will depend on the 
circumstance and the results of the 
investigation. A child who has had 
one seizure associated with a febrile 
illness and who has a normal electro- 
encephalogram, may be observed in- 
stead of being given immediate medi- 
cation. On the other hand, if there is 
a positive family history or some 
positive signs of post-ictal paralysis, 
drug therapy should be started. In an 
older person, a single seizure may 
herald a tumor. Complete investiga- 
tion is indicated, and prophylactic 
anticonvulsants are a wise precaution. 

Although 15 to 20 anticonvulsants 
have proven useful, the majority of 
patients are treated with some combin- 
ation of phenobarbital, diphenylhydan- 
toin. primidone, and trimethadione. 
Probably 75-80 per cent of patients 
are well controlled with these drugs 

Treatment is generally started with 
one drug with the dosage slowly 
increased until the seizures are con- 
trolled or toxic symptoms develop. If 
the patient is admitted in status 
epilepticus or has had a prolonged 
seizure, he is given large doses of 
intramuscular phenobarbital immedi- 
ately. Oral phenobarbital and diphe- 
nylhydantoin are substituted as soon 
as possible. As the seizures come under 
control, the phenobarbital can be 
reduced. In such a case, the physician 
is likely to continue both drugs and 
regulate them slowly. Most patients 
require a combination of drugs. 

The time the drugs are taken is 
also important. It is easier and more 
convenient to take them at meal times 
and at bedtime. Ordering medication 
at odd hours is inadvisable since it 
is too easy for the patient to forget 
to take them. It is probable that drugs 
which are absorbed and excreted slow- 
ly and which do not show a great 

fluctuation in blood level could be 
given twice a day; however, the general 
tendency is to order them with meals, 
and to add a drug with a greater 
sedative effect, such as phenobarbital, 
at bedtime. 

Unless there is a toxic or allergic 
reaction to a drug, it should not be 
discarded until proven to be of no 
benefit in maximal tolerable doses. The 
tendency to switch from one drug to 
another, before the first one has been 
tested adequately, should be avoided. 

The importance of taking medica- 
tion regularly and the dangers of 
precipitating continuous seizures by 
sudden withdrawal should be stressed 
to the patient or his parents. 

The decision of when to stop 
medication is a difficult one. As a 
general rule, medication should be 
continued for one to three years after 
the last seizure. Older patients who 
have one or two seizures after stop- 
ping medication following a long 
seizure-free period should probably 
continue medication indefinitely. In 
the case of younger children who are 
taking a toxic drug, especially those 
with petit mal, the physician may wish 
to try discontinuing medication even 
before a seizure-free year has passed. 
The length of time the child had the 
attacks and the EEG influence the 
decision. In patients approaching pu- 
berty, it is better to continue medica- 
tion until this period is completed. 

The possibility of the development 
of blood dyscrasia, hepatitis or ne- 
phrosis should be considered in 
patients receiving trimethadione. para- 
methadione. Mesantoin, Phenurone, 
and ethosuximide. To detect and pre- 
vent serious suppression of hemopoie- 
sis, white blood counts should be 
made before starting treatment and 
again every two weeks until mainte- 
nance dosage is established. Such 
counts should be repeated monthly for 
one year, and every three months for 
the balance of treatment. If neutrophils 
drop to between 2500 and 1600 per 
cu. mm., counts should be made every 
two weeks. Medication should bo 
stopped if the count goes below 1600. 

Some of the most commonly used 
anticonvulsants are: 

nielhsuximide fCelontin) 

methamphetamine hydrochloride 

dextro amphetamine (Dexedrine) 

acetazolamide (Diamox) 

diphenylhydantoin (Dilantin) 

amino-glutethimide (Elipten) 

metharbital (Gemonil) 

chlordiazepoxide (Librium) 

mephoharbital (Mebaral) 

meprobamate (Equanil) 

3-methyl-5-5-ethyl-phenyl hydantoin 


MARCH 1965 


phensuximide (Milontin) 

primidone (Mysoline) 

paramelhadione (Paradione) 


ethyl-phenyl-barbituric acid 

ethotoin (Peganone) 

phenaceniide (Phenurone) 

trimethadione (Tridione) 

ethosuximide (Zarontin) 

Many other drugs have been dis- 
covered and tested clinically, but for 
reasons of their sedative effects, toxi- 
city, or their poor abilities to control 
seizures, their use has been discontin- 
ued. Some reached the stage of being 
assigned names; others were merely 
given numbers. 


The acute psychosis and severe, 
repulsive pustules seen on the skin 
of patients taking prolonged overdos- 
age of bromides made the advent of 
phenobarbital a welcome event. How- 
ever, many physicians today still 
resort to bromides when all other 
measures fail. Phenobarbital has prov- 
en an excellent anticonvulsant, and 
is still the most useful and safest 
known. Many patients prefer not to 
take it during the day because of its 
sedative effect; parents welcome a 
change from phenobarbital since it 
tends to produce hyperactivity and 
behavior disorders in children. Over- 
dosage will cause ataxia, but this is 
easily remedied by adjusting the dose. 
There is considerable danger of pre- 
cipitating status epilepticus by sudden 
withdrawal of phenobarbital in a pa- 
tient who has been receiving it for a 
long time. If the drug is to be stopped, 
if should be done slowly. Severe and 
fatal exfoliative dermatitis has been 
reported, but this is unusual consider- 
ing the tons of phenobarbital con- 
sumed annually. The most common 
cause of death from phenobarbital is 
a suicidal overdose. The most serious 
toxic effect from the newer anticon- 
vulsants is suppression of bone marrow 

Other undesirable, but not fatal, side 
effects have been reported with diph- 
enylhydantoin and mcthyl-ethyl-phenyl- 
hydantoin (Mesantoin). These include 
hypertrophy of the gums, hirsutism, 
lymphadenopathy simulating Hodgkin's 
disease, and a syndrome simulating 
lymphosarcoma. Toxic effects on the 
kidney by anticonvulsants, particularly 
trimethadione and paramethadione. 
have been reported. 

Other undesirable side effects of an- 
ticon\ulsants may be: dizziness, photo- 
phobia, drowsiness, and rashes which 
occur usually with the initiation of 
treatment. Often, they can be con- 
trolled by starting with small doses 


and gradually increasing until a ther- 
apeutic level is reached. 

Variable reports have been made on 
the value of such drugs as reserpine, 
the phenothiazines (chlorpromazine, 
promazine, prochlorperazine, perphen- 
azine, mepazine) and other ataractic 
drugs in epilepsy. Some authors report 
increased incidence and others a de- 
creased incidence of seizures. It is the 
general experience that they are not 
very effective as anticonvulsants, but 
in some instances are useful to control 
associated behavior disorders." 

Adrenocorticotropic hormones 
(ACTH) and cortisone have proven 
to be useful in the treatment of myo- 
clonic seizures of infancy and occa- 
sionally in "absence" attacks. The 
effectiveness seems to be related to 
the age of the child, the degree of 
maturation of the brain, and the type 
of seizure. Children in the younger age 
group, regardless of the pathology — 
phenylketonuria, inclusion body ence- 
phalitis or cause unknown — have 
responded to such treatment and 
seizures have been controlled. All 
authors emphasize that this type of 
treatment does not have any effect 
on the mental retardation associated 
with these disorders. 

In the Hippocratic collection of 
medical writings, it is suggested that 
epilepsy be treated, not by magic but 
by diet and drugs. From that time 
until the present, diet has played a 
role in the treatment of epilepsy, even 
though, for the most part, there was 
little rationale. Because of the noted 
effect of fasting on epilepsy. Wilder," 
in 1921, suggested that ketone bodies, 
produced during starvation, might be 
anticonvulsant; he then proceeded to 
develop a diet which would produce 
ketosis. Since then, others have used 
this ketogenic diet in certain types of 
epilepsy and reported considerable 
success. Dietary treatment must be 
reserved for patients who do not res- 
pond to regular drug therapy since the 
difficulty in preparing the diet, the 
cost, and the natural dislike for the 
diet on the part of the patient, make 
it extremely difficult to carry through 
with any degree of success. 


John Hughlings Jackson's concept 
that epileptic attacks originate in 
nerve cells of the brain, and that the 
pattern of the seizure depends on the 
anatomic location of these cells, led 
Sir Victor Horsley. on May 25, 1886. 
to operate on a young Scot. The pa- 
tient was 22 years old and, since the 
age of 15, had been having focal 
seizures resulting from a compound 
fracture of the skull when he was 
seven. The scar was removed, the 

wound healed, and the seizures ceased. 

Other operations followed. In mod- 
ern medicine, the surgical treatment of 
epilepsy has helped many hundreds 
of patients whose seizures had not 
responded to medication. The histori- 
cal development of this form of therapy 
is completely covered by Penfield and 
Jasper** in their classical volume 
Epilepsy and the Functional Anatomy 
of the Human Brain. Indeed, no one 
has done more than these two col- 
leagues to develop the surgical treat- 
ment of epilepsy to the fine point it is 
at today. Penfield's object was to 
eliminate the seizures, but he took 
advantage of the opportunity to study 
the human brain. 

It is recognized that some patients 
with epilepsy do not respond to medi- 
cation. If, after adequate trials on 
medication and careful diagnostic 
evaluation, the patient meets the 
necessary criteria, then surgical ex- 
ploration should be offered to him. 
The amount of the brain to be removed 
depends on the degree of abnormality, 
as evaluated preoperatively, and the 
findings by electrocorticography on 
exposure of the cortex. The removal 
may be small and localized; it may be 
a whole lobe or. in exceptional cir- 
cumstances, a whole hemisphere. Not 
every patient who fails to respond to 
medical therapy is a candidate for 
surgery; indeed, relatively few are. 

In conclusion, it should be em- 
phasized that most patients with 
epilepsy can be successfully treated. 
In each case, we do not rest until a 
complete investigation has been carried 
out, and the most modern forms of 
therapy have been made available. 


1. Temkin. O. The FaUint; Sickness. Bal- 
timore. The Johns Hopkins Press, 1945. 

2. Lennox. W.G. Epilepsy and Related 
Disorders. Boston. Little, Brown & Co.. 

3. Hippocrates. The Genuine Works of 
Hippocrates, Vol. I and II. Francis 
Adams Translation. London. The Syden- 
ham Society, 1849. 

4. Hauptmann, A. Luminal bei Epilepsie. 
Miiench. Med. Wschr. 59:1907, 1912. 

5. Putnam, T. J., Merrett. H. H. F.x- 
perimental Determination of anticonvul- 
sant properties of some phenyl deriva- 
tives. Science 85:525, 1937. 

6. Gunn, C. G.. Gogerty. J.. Wolf. S. 
Clinical pharmacology of anticonvulsant 
Compounds. Clin. Pharm. and Therap. 
2:733. 1961. 

7. Wilder. R. M. The effect of ketonemia 
on course of epilepsy. Mayo Clin. Bull. 
2:307. 1921. 

8. Penfield. W.. Jasper, H. H. Epilepsy 
and Functional Anatomy of the Human 
Brain. Boston. Little, Brown & Co.. 1954. 

MARCH 1965 


Surgical Treatment of Epilepsy 

Two-thirds of patients who have been operated on for non-neoplastic epilepsy are 
rendered seizure-free or have a marked reduction in seizure tendency. 

Charles Branch, m.d.,, f.a.c.s. 

The neurosurgeon's interest in epi- 
lepsy is aroused by the opportunity 
afforded for study of the human brain, 
the technical challenge of finding and 
eradicating an offending lesion and 
most important of all, the humanitar- 
ian goal of trying to give new life to 
victims of this distressing illness. 
Victor Horsley in England, Otto Foers- 
ter in Germany and other pioneers 
neurosurgeons performed operations on 
epileptic patients; however, it was Dr. 
Wilder Penfield who developed the 
techniques necessary to make surgery 
a truly useful addition to the physic- 
ian's armamentarium in the treatment 
of epileptic patients. ' Surgery is re- 
stricted to those patients who have 
focal, as opposed to non-focal or 
generalized epilepsy, and is an excel- 
lent example of the team-effort ap- 
proach to the solution of a challenging 
medical problem. 

Patients are considered candidates 
for surgery only if they meet the 
following criteria: 

1. Have focal cerebral seizures, that is 
the seizure discharge always begins in the 
same restricted area of the cortex of the 

2. the involved area of cerebral cortex 
can be removed without producing paralysis 
or other serious neurological disability; 

3. their seizures have not been satisfac- 
torily controlled by an adequate trial of 
anti-epileptic drugs; 

4. they are properly motivated. 

To determine whether or not a 
patient's epilepsy is focal in nature, 
it is necessary to proceed, step by 
step, through an exhaustive work-up 
that begins with a careful history of 
the patient's illness from birth to the 
present time. A search for clues to 

Dr. Branch is Associate Neurosurgeon. 
Montreal Neurological Institute and Hos- 
pital, and Assistant Professor of Neuro- 
surgery, McGill University, Montreal. Que. 

pathology, such as birth injury, anoxia, 
encephalitis, meningitis, head injury, 
vascular disease or neoplasm, must be 
made and the seizure pattern, begin- 
ning with any initial aura or warning, 
must be carefully documented. Other 
causes for episodic unconsciousness, 
such as diabetes mellitus, heart dis- 
ease, vascular instability and islet cell 
tumors of the pancreas, must be ex- 
cluded by general medical examina- 
tion and appropriate special investi- 
gation. After a thorough neurological 
examination, the patient is placed 
under the constant observation of 
nurses and house doctors who are 
specially trained to observe and record 
the pattern of attacks which may occur 
in the hospital, so that they may be 
compared with descriptions of attack- 
patterns obtained from family members 
and the patient. Detailed knowledge 
of the patient's attack-pattern or 
patterns provides important clues as to 
the regions of the brain involved in 
his seizure process.- 

The special examinations most help- 
ful in locating regions of cerebral 
damage and the site of origin of 
cerebral seizures, are: 

1. visual field charting; 

2. skull x-ray; 

3. pneumoencephalogram: 

4. cerebral angiography in selected cases; 

5. mutiple electroencephalograms, when 
patient is off medication, if possible: 

6. psychological study; 

7. lateralization of cerebral dominance 
for speech by intracarotid sodium amytal 
when this lateralization is in question, as 
in left-handed or ambidextrous patients.-' 

If this Study demonstrates a focal 
seizure process in a portion of the 
brain which can be removed with im- 
punity, surgery can be considered.^-' 

Patients are not usually admitted 
to hospital for the above study unless 
their referring physician feels that they 
have not been adequately controlled 

by medication. The definition of ade- 
quate control is not the same for all 
patients, and must be carefully re- 
viewed by the neurologist and neuro- 
surgeon before a recommendation for 
surgical intervention is made. Thus, 
frequent minor seizures may not be a 
handicap to a retarded child living 
under sheltered conditions, whereas an 
occasional seizure may be devastating 
to a family bread-winner if each 
seizure results in the loss of employ- 
ment. If the patient, the family, and 
the physician agree that an adequate 
trial of medical management has 
achieved less than satisfactory con- 
trol of the seizures for this particular 
patient, surgical intervention can be 

During the study of such a patient, 
the surgeon has the opportunity to 
evaluate the patient's motivation. He 
must be certain it is the patient who 
wants relief and not the family or 
some other person, such as school 
teacher, fiancee or family physician. 
Most patients are well-motivated and 
will cooperate in the various phases 
of the study and therapy; however, if 
they are not, it is best to postpone 
surgery until they are. 


To make the most accurate excision 
of epileptic brain tissue with maximum 
safety, the operation is performed 
under local anesthesia (Figure 1). This 
prevents distortion of the brain waves 
by anesthetic drugs and provides 
opportunity for accurate brain mapping 
by electrical stimulation (Figure 2). 
Thus a removal of epileptic cortex can 
be carried up to, but not into, vital 
areas such as those which subserve 
speech, vision or locomotion." 

Once the initial removal has been 
completed, another electrical record- 
ing from the brain surface is carried 
out. This checks on the completeness 


MARCH 1965 






fig. 1. Patient under local anesthesia undergoing surgical cortical excision for focal epilepsy. (From Penfield, W. and Jasper. H. 
Epilepsy anil the functional anatomy of the human brain. Boston. & Co.. 1954). Fig. 2. EEG recording from surface of the brain. 
Letters indicate areas of maximum epileptic activity. 

of the removal of the epileptogenic 
cortex, and sometimes indicates further 
removal to provide the best possibility 
of stopping the patient's attacks. A 
post-excision corticogram free of epi- 
leptogenic activity is an encouraging 
sign; however, it is not a guarantee 
of a successful operation." When the 
surgeon is satisfied that the removal 
has been completed, the patient is 
allowed to sleep during the closure. 

Corticosteroid therapy during the 
first ten postoperative days has les- 
sened the effects of cerebral edema 
and made the postoperative course 
uneventful in most cases." The patient 
usually takes nourishment during the 
first postoperative day, gets out of 
bed on the third or fourth day and 
begins the postoperative EEG. x-ray 
and psychological testing at the end 
of the second postoperative week. 

Near the end of the third postoper- 
ative week, the patient is discharged 
home to the care of the referring 
physician, with a recommendation to 
allow two months for recovery before 
undertaking heavy physical or mental 
activity, and to avoid excessive fa- 
tigue, alcohol and emotional distress. 

All patients are placed on a regimen 
of anticonvulsant drugs in moderate 
dosage, and advised to take this 
medication regularly for at least one 
year. If, at the end of this first post- 
operative year, they have had no 
attacks and if a follow-up EEG is 
free of epileptogenic activity, the 
family physician will begin gradual 
withdrawal of the medication. 


The surgical treatment of epilepsy 

was first begun in Montreal by Dr. 
Penfield in 1928, and has continued 
at an increasing rate at the Montreal 
Neurological Institute until the present 
time. An attempt is made to maintain 
accurate follow-up information on all 
of these patients so that the results 
can be reviewed from time to time." 
For this type of surgery to be success- 
ful, it must be carried out in a centre 
where a team of experts is available 
to work together on these problems 
and where special equipment, such as 
that necessary for electrocorticograms 
(surface EEG during surgery) and 
depth recording from the brain, is 

In general, this work has been very 
rewarding to both patient and surgeon. 
When one considers that many of 
these patients have had recurring 
seizures for many years in spite of 
expert medical care, any sizeable 
reduction in their seizure tendency is 
greatly appreciated. For this reason, 
patients and their families may report 
a higher success-rate than is justified 
by a more scientific assessment. 

About one-third of the patients who 
have been op)erated on for non-neo- 
plastic epileptic lesions have been 
rendered seizure-free; another third 
have had a marked but not quite com- 
plete reduction in seizure-tendency. 
Thus, there has been a satisfactory 
result in two-thirds of the cases. In 
the remaining third, the actual reduc- 
tion in number of attacks does not 
justify a rating of worthwhile result 
from the scientific standpoint; how- 
ever, in many of these cases the patient 
and family report gratifying improve- 
ment following operation. Tables 1, 2 

and 3 summarize the findings in the 
most recent surveys of postoperative 
results, in cases operated upon at the 

Montreal Neurological Institute. " '"' 


These results compare favorably 
with other reported results from cen- 
tres where a team effort, similar to 
that described above, is employed.'- " 


Serious complications following sur- 
gical excision of non-neoplastic epilep- 
tic lesions are rare. There has been a 
mortality rate of about one per cent 
in the total series of 1600 patients, 
with, however, no deaths in over 600 
patients operated upon in the last 10 
years. Serious postoperative neurolo- 
gical disability, such as hemiparesis or 
aphasia, has occurred in one to two 
per cent of patients, but has also been 
much less frequent in the past 10 

Case History 

R. D.. aged 12. was first seen at the 
M.N.I, in 1958 for evaluation of his seizure 
problem. He was the second child in a 
family with no history of epilepsy. Delivery 
was at home, without difficulty in spite 
of a birth weight of 9 lb. Development 
and schooling had been normal. He had a 
mild head injury without skull fracture or 
loss of consciousness at age 5 years, but no 
other serious illness. 

His seizures began at the age of 7 and 
had gradually increased in frequency from 
3 per year to 3-5 or more per month, in 
spite of a variety of anticonvulsant medica- 
tion that included Dilantin. Milontin and 
Paradione. Neurological examination in 
1958 was normal and the EEG revealed an 


MARCH 1965 




Results of Surgical Therapy 





Results of Surgical Therapy 

1929 - 60 

No. of patients 


No attacks since discharge from hospital 106 (27%) 

Early attaclcs then seizure free 61 (16%) 

Marked reduction in seizure-tendency 99 (25%) 

Unsatisfactory results 123 (32%) 

Total patient followed-up, 1-25 years 389 

(Total series of 413 patients reduced by 7 postoperative deaths 
and 17 with inadequate follow-up data.) 

No. of patients 

No attacks since discharge from hospital 27 

Early attacks then seizure free 28 

Marked reduction in seizure-tendency 53 

Unsatisfactory results 60 

Total patients followed-up, 1-31 years 168 

(Total series of 183 patients reduced by 3 postoperative deaths 
and 12 with inadequate foUov-up data.) 




Results of Surgical Therapy 

1930 - 60 

Results No. of patients 

No attacks since discharge from hospital 31 (36%) 

Early attacks then seizure free 8 ( 9%) 

Marked reduction in seizure-tendency 24 (28%) 

Unsatisfactory results 22 (26%) 

Total patients followed-up, 1-24 years 85 

(Total series of 88 patients reduced by 2 postoperative deaths 
and 1 with inadequate follow-up data.) 

epileptogenic focus in the right temporal 
lobe. It was decided to give him a further 
trial of medication and he was sent home 
on a combination of Dilantin and pheno- 

The patient continued to have clusters 
of 2 to 5 attacks each month and was 
readmitted for further study on July 7, 
1960, at which time he was 14. Again, the 
general and neurological examinations were 
normal and it was noted that he was left- 
handed. His seiziu-es began with an aura 
or warning of fear and a sensation of 
pressure in his chest. He then lost contact 
and was observed to have a blank stare with 
lip-smacking, swallowing, and automatic 
patting or searching movements of his right 
hand, accompanied by efforts to sit, stand, 
or walk about. These attacks usually lasted 
about a minute and were followed by a 
period of rest for 20 to 30 minutes. The 
family reported no post-ictal weakness or 
dysphasia; however, in hospital he had 
some difficulty naming objects after one of 
his habitual attacks. 

Skull x-rays and pneumoencephalogram 
revealed smallness of the right cerebral 
hemisphere dating from birth or early life. 
and visual-field examinations were within 
normal limits. EEG studies again demon- 
strated a right temporal epileptic focus, 
with a small amount of independent epilep- 
tic activity seen over the left temporal lobe 
area. Psychological studies showed that he 
was a bright boy with an I.Q. of 113, 
but with obvious impairment of perceptual 
skills and pictorial comprehension suggesting 
a lesion in the non-dominant temporal lobe. 
Since he was left-handed, it was not certain 
whether the right or the left cerebral 
hemisphere contained his speech mechan- 
isms; therefore, a bilateral intracarotid 
sodium amytal test was carried out to 
determine the lateralization of cerebral 

speech dominance. Following the right-sided 
injection, he had a transient left hemiparesis 
without speech arrest or dysphasia. When 
the left carotid was injected, there was a 
transient right hemiparesis and a complete 
arrest of speech for 2 minutes, followed by 
obvious dysphasia for 6 minutes. Speech 
was thus clearly subserved by the left 
cerebral hemisphere. 

On July 21, 1960, a right temporal 
craniotomy was performed under local 
anesthesia, and electrical recordings carried 
out from the surface of the brain and from 
an electrode placed in the depth of the 
temporal lobe (Figure 3). Epileptic activity 
in the form of high-voltage spikes was 
recorded from the lateral surface of the 
anterior 5 cm. of the temporal lobe and 
from the depth electrode as well. 

During removal of the anterior 5.5 cm. 
of the temporal lobe, it was obvious that 
there was extensive scarring in the first 
temporal convolution and in the mesial 
portions of the temporal lobe (Figure 4). 

This was felt to be a typical example of 
"incisural sclerosis" in which the portion 
of the brain near the incisura of the ten- 
torium was grossly scarred and epilepto- 
genic, probably due to an unrecognized 
birth injury.^ 

Postoperatively, he received cortisone 
acetate for 10 days, for protection against 
cerebral edema, and the usual anticonvul- 
sant medical regime of Dilantin and pheno- 
barbital. No seizures were observed and 
his postoperative course was smooth and 
uneventful. Prior to discharge, an EEG 
revealed only very minimal traces of 
potentially epileptogenic activity. 

In the 4'/2 years since operation, he has 
had only one seizure which occurred during 
1961, at the end of a long, hot, bicycle 
ride after receiving news of the sudden 
death of a close friend. Since 1961 he has 
had no further attacks in spite of a gradual 
withdrawal of medication during the period 
from 1961 to 1963. The last EEG taken 
in 1963 revealed no epileptogenic activity. 

Fig. 3. Operation photo of patient R.D. showing epileptogenic area of right temporal 
lobe to be excised outlined with white thread and bearing letters indicating areas of maxi- 
mum epileptic activity recorded in the cortical EEG. Numbers above indicate normal motor 
and sensory responses to electrical stimulation. Fig. 4. Operation photo of patient R.D. 
showing excision of anterior 5.5 cm. of right temporal lobe. 


MARCH 1965 


Follow-up psychological tests on October 2, 
1961 demonstrated a remarkable improve- 
ment in performance, with a rise in I.Q. 
from the preoperative level of 113 to 129. 
He has completed high school, is now 
successfully employed as a clerical worker, 
and participates in a variety of sports. 


1. Penfield, W. and Jasper, H. Epilepsy 
and the Functional Anatomy of the Human 
Brain. Boston, Little, Brown & Co., 1954. 

2. Penfield, W. and Erickson, T.C. Epi- 
lepsy and Cerebral Localization. Springfield, 
Illinois, Charles C. Thomas, 1941. 

3. Branch, C, Milner, B. and Rasmussen, 
T. Intracarotid Sodium Amytal for the 
Lateralization of Cerebral Speech Domin- 
ance, y. Neuro-Surg., 21:399-405, 1964. 

4. Penfield, W. and Steelman, H. The 
Treatment of Focal Epilepsy by Cortical 

Excision. Ann. Surg., 126:740-762, 1947. 

5. Rasmussen, T. and Jasper, H. Tem- 
poral Lobe Epilepsy: Indications for Opera- 
tion and Surgical Technique. Second 
International Colloquium on Temporal Lobe 
Epilepsy. Springfield, Ilhnois, Charles C. 
Thomas, pp. 440-460, 1958. 

6. Rasmussen, T. and Branch, C. Tem- 
poral Lobe Epilepsy. Postgrad. Med. J., 
31:9-14, 1962. 

7. Jasper, H., Arfel-Capdeville, G. and 
Rasmussen, T. Evaluation of EEG and 
Cortical Electrographic Studies for Progno- 
sis of Seizures following Surgical Excision 
of Epileptogenic Lesions. Epilepsia, 2:130- 
137, 1961. 

8. Rasmussen, T. and Gulati, D. R. 
Cortisone in the Treatment of Postoperative 
Cerebral Edema. J. Neuro-Surg., 19:535-544, 

9. Penfield, W. and Paine, K. Results 

of Surgical Therapy for Focal Epileptic 
Seizures. C.M.A.J. 73:515-531, 1955. 

10. Rasmussen, T. Surgical Therapy of 
Frontal Lobe Epilepsy. Epilepsia, 4:181-198, 

11. Rasmussen, T. and Gossman, H. Epi- 
lepsy Due to Gross Destructive Brain 
Lesions: Results of Surgical Therapy. Neu- 
rology (Minneap.), 13:659-669, 1963. 

12. Falconer, M. A., Serafetinides, E. A. 
and Corsellis, J. A. N. Etiology and Patho- 
genesis of Temporal Lobe Epilepsy. Arch. 
Neurol., 10:233-248, 1964. 

13. Green, J. R. and Schutz, D. Surgery 
of Epileptogenic Lesions of the Temporal 
Lobe. Arch. Neurol., 10:135-148, 1964. 

14. Earle, E. M., Baldwin, M. and Pen- 
field, W. Incisural Schlerosis and Temporal 
Lobe Seizures Produced by Hippocampal 
Herniation at Birth. A.M.A. Arch. Neurol, 
and Psychiat., 69:27-42, 1953. 

Nursing an Adolescent 
with Seizures 

A detailed description of the essential nursing care in the pre- 
and postoperative phases of surgery for epilepsy. 

Caroline Robertson, r.n., b.n. and Patricia Murray, r.n., b.n. 


Epilepsy is the tendency to recur- 
ring epOeptic seizures.^ It is a symp- 
tom of disorder or disease in the brain, 
but it is not a disease in itself. Seizures 
may be caused by various brain 
lesions such as neoplasm, trauma and 
post-traumatic scarring, congenital ab- 
normalities, inflammation, circulatory 
disturbances, metabolic and degenera- 
tive processes. When the underlying 
cause caimot be eradicated, it becomes 
necessary to treat the symptom, the 

Just as diabetes can usually be con- 
trolled by insulin and diet, epileptic 
seizures can often be controlled by 
anticonvulsant drugs and regular living 
habits. That is, the cause is not elimin- 
ated but the symptom is controlled. It 
is estimated that 30 per cent of persons 

with seizures can be freed of attacks 
indefinitely.^ With treatment, 80 per 
cent can be helped to lead normal lives 
// society will let them.* Yet the public 
continues to treat an epileptic person 
as socially imdesirable. 

Seizures are disrupting and disturb- 
ing both to the person subject to them 
and to the on-looker. Knowledge and 
understanding of the disorder alleviate 
the fear and anxiety that are usually 
experienced. The nurse who has in- 
sight will be able to overcome her own 
panic so that she can aid the person 
involved. She will reassure others 
through her calm organized actions. 

This study is about Bill, a 16-year- 
old boy, who was treated both medical- 
ly and surgically for seizures caused 

Miss Robertson is clinical coordinator, 
and Miss Murray is operating room super- 
visor and instructor. Montreal Neurological 
Hospital, Quebec. 

* Modem Concepts of Epilepsy A 16- 
mm. sound film produced by Georgetown 
University School of Medicine, Washington, 
D.C. Available on loan from Ayerst, Mc- 
Kenna & Harrison Ltd., 1025 Laurenfian 
Blvd.. St. Laurent, P.Q. 

by scar tissue in the brain as a result 
of trauma. His example illustrates 
clearly the importance of understand- 
ing seizures in relation to the person 
who has them. Generally he received 
the same care that would be given 
to a more mature person or to a 
child. His specific needs, however, 
were those of an adolescent. 

Essentially, the objective of nursing 
care is to provide for the basic needs 
of the patient only when he cannot 
do so himself — i.e., when he is 
having a seizure — and to help him 
gain independence as quickly as pos- 

Much of the nursing care was di- 
rected toward increasing Bill's under- 
standing and acceptance of his condi- 
tion. Understanding and acceptance 
does not come magically overnight. 
Its nurturing begins at the moment 
of contact with the first member of 
the hospital team — the doctor, in 
his office or at the clinic. 

Bill was first referred to a neuro- 


MARCH 1965 


logist in 1954 when, at the age of six, 
he had his first seizure. He was hos- 
pitalized for a month for examinations 
that revealed atrophy of the left tem- 
poral parietal region of the brain, pro- 
bably the result of head injury sus- 
tained in a fall from a pony at the 
age of five and a half. In 1955, the 
anterior portion of his left temporal 
lobe was excised in an effort to con- 
trol his seizures. The attacks continu- 
ed, however, despite the operation and 
the use of various anticonvulsant 
drugs. They increased in frequency so 
that in 1964 he was readmitted to the 
hospital for investigation as to the 
advisability of further surgical therapy. 

The realization that waiting causes 
anxiety and that anxiety can precipi- 
tate a seizure encourages the admit- 
ting secretaries in our hospital to ob- 
tain essential information from the 
patient quickly. The nursing staff teach 
the secretaries to know what to expect 
and what to do if a seizure should 
occur. Courtesy and friendliness are 
emphasized because first impressions 
are vital to rapport. 

Bill arrived on the ward protected 
on either side by his parents. Before 
his arrival on the unit, the admitting 
nurse had obtained pertinent informa- 
tion about him from the doctor's notes. 
Bill's grin and "Remember me ?" was 
a good beginning to their relationship. 



Bill's room overlooked the football 
stadium and, apart from its high-low 
bed and indented wall outlets for oxy- 
gen and suction, could have passed 
for a hotel room. The bed was posi- 
tioned so that the occupant's head 
could be seen from the glass-enclosed 
nursing station opposite. The nurse 
suggested that Bill get into bed. even 
though it was afternoon. He was not 
particularly happy about this, but he 
realized that it was necessary when he 
was "off medication." 

As she proceeded with the tasks of 
admission, the nurse impressed upon 
Bill and his parents the importance of 
taking the other "seizure precautions." 
Bill recited them jokingly, but mean- 

I must use a small, firm pillow (I do 
that at home, too): stay in bed with the 
bedsides up while off medication (although 
I can, if accompanied, go to the bath- 
room). I must drink through a paper rather 
than a glass straw, and I must have my 
temperature taken rectally, rather than 
orally. Luckily, I don't smoke; if I did I'd 
have to have someone with me so that I 
wouldn't set the place on fire if I dropped 
my cigarette. 

Knowing that much of his time 

would be spent in bed, Bill brought 
a checker board, a book of puzzles, 
and various science thrillers with him. 
Staying in bed as a seizure precaution 
does not mean complete bed rest ! 

The nurse attached two wooden 
spatulas padded by a few layers of 
adhesive to the head of Bill's bed. if 
he had a seizure, the padded end 
would be inserted between his molars 
to prevent him biting his tongue. A 
spatula wrapped in a fold of paper is 
also kept in each nurse's pocket ready 
for use. Bill was instructed to use the 
call bell if he felt that an attack was 

While the parents signed their son's 
admittance consent, the nurse com- 
pleted the hospital forms and checked 
Bill's vital signs (see chart page 000). 
She made note of his appearance and 

Bill's face is pale. There are small pus- 
tules and a sprinkling of reddened irrita- 
tion on his lower face and several large 
pustules on his neck and upper back. His 
gums are hypertrophied (from the con- 
tinuous use of Dilantin Sodium). He uses 
his left hand more than his right. He 
could not stand on one foot when he took 
off his shoe; he had to sit down. His speech 
is slow and the words are slurred. 

The nurse asked Bill and his parents 
several questions concerning his activi- 
ties. Direct questions about his high 
school record would have embarrassed 
him since he was achieving slowly but 
with determination. (Later, his father 
admitted that Bill was having difficul- 
ties with school work.) Active partici- 
pation in competitive sports did not 
interest him; he preferred to collect 
stamps and phonograph records. Spe- 
cific information concerning his sei- 
zures was obtained, so that the staff 
would know what to expect. Bill re- 
ported that he was having about one 
"blackout" per week. 

His need to be like others prevented 
him from calling his problem, "sei- 
zures." Any one can have a "blackout" 
but seizures are not "normal." If an 
adolescent deviates from the norm he 
is without one of his greatest sources 
of security. Realizing this adolescent 
need, the nurse gained her informa- 
tion without probing and was able to 
develop rapport with Bill and his 

Nursing Care 

As well as listening to the family's 
description of Bill's seizures and read- 
ing his medical history, the nurse made 
her own assessment of his needs. Her 
basic knowledge of neuroanatomy and 
physiology increased her understand- 

The position of the bed was impor- 

tant. Bill was in a single room, but 
the head of the bed could be seen 
easily by the nurse in the corridor or 
in the nurse's station. His door was 
left open unless someone was in the 
room with him. The staff and patients 
were told what to expect and were 
asked to call the nurse immediately if 
Bill had a seizure. Probably no one 
is ever totally prepared to witness a 
severe generalized seizure. Those who 
have observed many seizures still feel 
disturbed; but the nurse who has pre- 
pared herself and others will reduce 
the tension considerably. 

Finding out if the patient has an 
aura (a warning sensation) is impor- 
tant. As a child, Bill had experienced 
a "stomach ache" or a feeling of 
'deadness" in his right hand for a few 
seconds just before a seizure; as he 
grew up these epigastric and parasthe- 
tic auras disappeared. Persons having 
other types of seizures often report 
visual, olfactory, taste or auditory dis- 
turbances as warnings. If the patient 
is able to communicate in the aura 
stage, the nurse, thus alerted, by 
answering the call immediately, may 
be able to witness the attack from the 
beginning. It is the beginning of the 
attack that gives the most important 
information as to the part of the brain 
giving rise to the seizure. 

Since Bill now had no warning be- 
fore his attacks, the nurse looked in 
on him more frequently. When sum- 
moned to his bedside because of a sei- 
zure, she used the call-bell to notify 
another staff member to telephone the 
doctor, and to come to her assistance. 
She shut the door for privacy, checked 
to make certain that his airway was 
unobstructed, and inserted the spatula 
between the molars. (If the teeth are 
already clamped shut, forcing the jaw 
open to insert the spatula may damage 
them. By this time, the tongue will 
already have been bitten.) 

Behavior at the onset of the "ictus" 
or seizure may give important clues as 
to the location of the epileptogenic fo- 
cus in the brain. Pulling the bed 
clothes down to the foot of the bed. 
the nurse noted Bill's position and the 
first movement she saw; then she 
mentally recorded all his behavior in 
chronological order. All behavior is 
significant. Every movement such as 
blinking the eyelids and swallowing 
may help to localize the focus. The 
progress of the seizure may be more 
easily observed if the face and body 
are mentally divided into four 
quadrants — left and right, upper and 

The end of the seizure is also impor- 
tant since the last movements may also 
give evidence as to the brain regions 
involved in the seizure. After his sei- 


MARCH 1965 





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zure, Bill had difficulty naming fami- 
liar objects. He would state what they 
were used for instead of the name. 
This nominal dysphasia showed that 
his speech area was involved in the 
seizure discharge. 

The length of the seizure was noted 
as well as the post-ictal effects. 
Pupillary size and reaction and other 
vital signs including motor ability 
were checked. If he had become 
drowsy after the hard labor of the 
seizure, he would have been roused 
to make certain he was alert and 
oriented to time, place and person 
before he was allowed "to sleep it off." 

The calm, accepting manner of the 
nurse and her example to others, help- 
ed to reassure him. 


Each seizure is described in detail 
by the person who observed it. The 
observer describes in basic, simple, but 
descriptive terms, what has been seen. 
At no time does she offer her opinions, 
conclusions or interpretation of the 
events; nor does she include the opin- 
ions of others. A truthful, accurate, 
objective account of every happening, 
in chronological order, is needed. 

The account is written in the first 
person. Technical terms are avoided. 
For example, the nurse knows the dif- 
ference between tonic and clonic 
motion, but she describes these as 
stiffening or jerking movements instead 
of naming them; she differentiates bet- 
ween "gross jerking movements" and 
"tremors" when she describes move- 
ment; she notes the absence of some 
happenings, e.g., when there is no ini- 
tial cry or incontinence. She knows 
what is significant, but does not allow 
this to cloud her objective account. 

Included in the recorded observa- 
tions are : the date and time of seiz- 
ure; whether or not the onset and the 
entire seizure were observed; the dura- 
tion from the known onset to the end; 
the nurse's signature; the name of the 
doctor and the time he was notified. 
The recorder should admit when she 
is uncertain about any part of the 
event rather than to make statements 
that are Questionable. 

The following is the descriotion of 
the seizure recorded when Bill was 
"off medication" : 

Oct. 6, 1964 Seizure: partly observed 
2:15 p.m. Onset: not observed 

Duration: approximately 
eight minutes. 
I was in the nursing station when I 
heard a bedside rattling. I immediately 
went to Bill's room and found him lying on 
his right side. His eyes were open with the 
pupils turned up and to the right. His pu- 
pils were equally dilated. His mouth was 

turned up and to the right and his hps 
were twitching. There was a moderate 
amount of frothy mucus about his mouth. 
He became slightly cyanosed so I suction- 
ed once and obtained a moderate amount 
of mucus. His legs and arms were stiff 
and his fists were clenched; both thumbs 
were held between his fingers. His whole 
body was jerking when I arrived and this 
lasted approximately four minutes. His 
right hand was the last to move when he 
unclenched it. 

He responded to painful stimuli in about 
six minutes. When I called to him a 
minute later, he opened his eyes and made 
swallowing movements. He moved his right 
hand better than his left. When asked to 
identify objects, he responded slowly; but 
he replied "quarter to nine," when asked 
to identify my watch. His hand grips were 
equal and strong in about eight minutes. 
At this time he could also name objects 
and was oriented to time, place, and 
person. When asked what had happened 
to him he replied: "I had another black- 

Jean Gray, R.N. 


Many diagnostic procedures includ- 
ing skull x-rays and several special 
electroencephalograms were required 
to make the decision whether or not 
further operation in the left temporal 
region was advisable. The care Bill 
received before, during and after these 
procedures built up a base of confi- 
dence so that he knew he would be 
supported through more difficult pro- 
cedures. One of these was the proce- 
dure of injecting Sodium Amytal into 
the common carotid artery to deter- 
mine which cerebral hemisphere con- 
tained his speech mechanisms. Al- 
though right-handed people almost al- 
ways have their speech representation 
in the left cerebral hemisphere, in 
left banders it is sometimes in the 
left and sometimes in the right. Since 
Bill was left handed, preoperative 
determination of the lateralization of 
his cerebral speech representation was 
important in safeguarding his speech 
functions during the proposed reoper- 
ation in the left temporal region. 

Injection into the left carotid artery 
produced a temporarv right hemiplegia 
with inability to talk for 2 minutes 
and. as the hemiplegia disappeared 
during the next 3 minutes, his speech 
returned with dysphasic responses 
such as misnaming and perseveration 
(involuntary continued repetition of 
words). Speech was thus clearly rep- 
resented in the left side of the brain. 
This was verified the following day 
when a similar injection of amytal into 
the right carotid artery produced a 
temporary left hemiplegia without in- 
terfering with his ability to speak. 


Although Bill was apprehensive 
about the impending surgery he ex- 
pressed relief that "'something more 
was being done" for his seizures. The 
doctor talked to him the evening be- 
fore, reminding him that he would 
be awake when the brain was exposed, 
so that he could be questioned during 
the electroencephalographic recording 
that is taken directly from the cortex. 
The anesthetist examined him to re- 
check his ability to withstand the long 
procedure and the anesthesia used at 
the opening and closing of surgery. 
The minister visited him the day prior 
to surgery and talked with his parents. 
He planned to come back to be with 
them during the long waiting period. 

Bill had conversed with another 
young patient who had given a blow- 
by-blow account of how he had come 
through his surgery; thus he was ex- 
pecting much the same treatment as 
his pal. "I suppose you'll wake me 
up every hour to take my vital signs!" 
The nuisance factor of this observation 
is outweighed by the unspoken plea 
"you'll give me the same attention as 
you did my friend, won't you?" 

The evening before operation, the 
resident cut Bill's hair with clippers 
and inspected the scalp for any abras- 
ion or pustule. Surgery is cancelled 
if there is any break in the skin. A 
disposable bed protector was used for 
this procedure instead of a towel since 
hair left on a towel is another possible 
source of infection. If the patient had 
been female, her hair would have been 
saved for cosmetic reasons. 

The patient's scalp was shampooed 
and he was given a cotton cap to wear 
for warmth — and dignity. With the 
popularity of the Beatles, the young 
male who loses his hair may be as 
upset as the female. Here, again, 
consent and cooperation are necessary 
before the procedure. 

Bill's problem of adolescent acne, 
probably aggravated by his Dilantin 
therapy, had been solved by pHisoHex 

Another of Bill's basic needs — 
bowel elimination — had been checked 
daily. Prune juice taken daily at break- 
fast was usually adequate for regularity. 

After his shampoo and pHisoHex 
bath, he was given a bedtime snack 
of toasted egg sandwich and milk, 
then his medication, phenobarbital 60 
mg. and Dilantin 100 mg. These were 
given for their sedative and anticonvul- 
sant effects. A "nothing by mouth" 
sign was placed on his bed and he was 
requested to refrain from eating and 

At six A.M. Bill was wakened from 
a sound sleep. To provide a base re- 
cording for the anesthetist, he was 


MARCH 1965 


weighed and his vital signs were 
checked. A record of his premedication 
was sent to the operating room in ad- 
vance. The operating room attendant 
came to the unit and shaved the 
patient's entire scalp to avoid entrance 
of bacteria or hair at craniotomy. A 
clean cap was applied. 

The nurse in the unit collected 
the medications that would be needed 
during surgery: intravenous Dilantin 
250 mg.. sodium luminal 100 mg. and 
Solucortef 100 mg. 

After his parents had visited, Bil! 
was taken to the anesthetic room 
where he was introduced to the staff 
by the nurse who had accompanied 


In some ways, seizure surgery dif- 
fers from general surgery and poses 
certain unique problems for the sur- 
gical team. The operation is long, 
usually eight hours or more; thus care 
must be taken to ensure that the skin 
is well prepared and that drapes and 
instruments are well placed for com- 
fort and convenience. Since the in- 
fection hazard is great, because of the 
long exposure, techniques must be well 
thought out and rigidly observed. 

The patient is awake, or almost 
awake, for the greater part of the 
operation so that he can answer ques- 
tions and obey commands. We must 
try to keep him from suffering pain 
and from becoming too bored or rest- 
less; we must protect his body from 
pressure areas, or other injury. He 
may have a seizure during the opera- 
tion, so he has to be firmly fastened 
to the table, yet not conscious of too 
much restriction of his movements. He 
must not be able to harm himself 
during an attack, dislodge the drapes, 
or contaminate the instruments. 

During the operation, the surgeon 
is concerned with the patient's ability 
to respond, speak, move, and obey 
commands. He is also vitally interested 
in his responses to the electrical stim- 
ulation of the cortex. One member of 
the surgical team has to be able to 
see the patient's whole body clearly — 
face, hands, arms and legs — so that 
the various responses may be accu- 
rately reported and the progress of an 
attack noted. 

Much of the care given by the 
nursing staff in the operating room is 
indirect: in other words, our tasks are 
performed for the patient, but do not 
involve direct care. Most of this is 
given by the anesthetists and surgeons. 

As members of the surgical team, 
nurses are concerned with three as- 
pects of patient care: 

! . reassurance and support: 

2. safety — from direct physical injury. 
























from fire and explosion, and from infection; 

3. comfort. 

To assure patient safety and com- 
fort, we must have on hand instru- 
ments and equipment that are in good 
working condition and properly pre- 
pared or sterilized. We must have the 
right instrument at the right time. 

The patient's emotional state is very 
important since the doctors depend on 
his cooperation during certain stages 
of the operation. It is also important 
to the patient himself, since it will 
affect his postoperative course in 
hospital. 5 

When the patient is brought to our 
care, we let him know that we are in- 
terested in him, concerned about his 
fears and needs and that we are com- 
petent to care for him. To avoid 
alarming him unduly, we bring him 
to the operating room in his own bed, 
rather than on a stretcher. He is 
brought into the room only when the 
anesthetic team is ready. 

While Bill was being prepared, the 
staff made certain that their conversa- 
tion included him, or was confined to 
professional details of the work at 
hand. If he could not see. or did not 
understand what was happening, it was 
explained to him. Patients sometimes 
complain about a feeling of blood 
trickling down their forehead — 
caused by a drop of local anesthetic 

escaping from the needle. This and 
other fears are anticipated and ex- 
plained so that the patient is not left 
to worry. He is at aJl times reminded 
of the fact that we are thinking of 

Bill was drowsy during his opera- 
tion, due to the administration of a 
neuroleptanalgesic drug that gave him 
relief from pain, and acted as a tran- 
quilizer. He could be roused easily to 
answer questions and obey commands, 
but for a large part of the operation 
he simply dozed. This type of drug 
depresses the E,E,G, record, but does 
not obscure the epileptic pattern. 

As protection against physical in- 
jury. Bill was strapped to the table 
on an alternating air pressure mattress; 
he was then covered with a large frame 
which held the drapes away to allow 
the anesthetist a full view at all times. 
This frame, which also supported the 
nurse's instrument trays, was padded 
with pillows at the patient's back and 
front so that he could not hurt him- 
self if he had had a seizure. He was 
given as much freedom to move as 
possible but was restrained to protect 
the incision area, and the intravenous. 
One arm was loosely tied so that he 
could not put his hand up to the 
incision area. He could move his legs 
quite freely. 

A cautery pad was placed on a mus- 


MARCH 1965 


cular part of his leg; the wires and 
grounds to the cautery were carefull) 
checked to see that they were working. 
Conductive mattress, castors, flooring, 
60 per cent humidity in the operating 
room — all are measures taken to pre- 
vent explosion. The constant use of 
electrical cautery makes the use of 
explosive anesthetic gases hazardous. 

The danger of infection is great 
because of the long exposure ot the 
brain. Care must be exercised to keep 
the air as free as possible from pa- 
thogenic organisms. Glassed-in galleries 
allow the electroencephalographers. 
secretaries, pathologists, photographers 
and students to do their part of the 
team work without actually entering 
the room. Ultraviolet light is used in 
high concentrations at the beginning 
of the procedure when people are 
moving about a great deal, and while 
the drapes are being placed; as the 
more delicate tissues are exposed, this 
concentration is lessened. High humid- 
ity in the room helps to keep down 
dust; filtered air is delivered through 
the air-conditioning systems. 

The preparation of instruments and 
drapes is the scrub nurse's responsi- 
bility. She is required to make notes 
about each operation, and to write a 
full report if infection occurs. We 
believe that this report helps the 
staff recognize a situation that needs 
attention and take an interest in cor- 
recting it. 

To reduce the possibility of infec- 
tion, a second pHisoHex scrub of the 
patient's scalp is given in the anes- 
thetic room; in the theatre, alcohol, 
ether, and tincture of iodine, two and 
one-half per cent are applied slowly 
and carefully. The drapes are sutured 
close to the line of incision so that they 
will not be disturbed if he moves his 
head or has a seizure on the table. 

Bill's comfort was, in part, a re- 
sult of measures taken to prevent phy- 
sical injury, since pressure areas give 
pain and reduce comfort. He lay on 
his right side with an intravenous in 
his right arm. His head was placed 
on a head rest in good alignment with 
his body (this is important to maintain 
a good airway, a good position for the 
surgeon, and comfort). He could move 
his head, from time to time, during the 
of)eration with the support of the sur- 
geon and the anesthetist. He had 
pillows at his back to keep his body 
from pressing against the hard metal 
of the over-table frame. He also had 
a pillow under his upper knees, and 
one in front of his body under his left 
arm. If he became thirsty, he could 
have ice chips to suck; and provision 
was made for him to void if necessary. 
He could see and speak to the anesthe- 
tist who sat near him during the 





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Illustrative chart showing changes in mental state (conscious level), pupils, blood pressure, 
pulse rate, respiration rate and temperature before and after the onset of fatal increase of 
intracranial pressure (Wilder Penfield, Canadian Army Manual of Military Neurosurgery. 
Ottawa. H. M. Printing Bureau, 1941. p. 61.) 

procedure and who constantly checked 
his vital signs and, during the reinoval 
of the diseased cortex, his arm and leg 
movements, and his ability to speak. 

The local anesthetic used on the 
scalp was injected slowly and carefully 
so that every nerve fibre in the vicinity 
of the incision or the drape sutures 
was anesthetized. A solution with a 
slow absorption rate and long lasting 
effect is needed. The drug of choice 
is nupercaine 1:1500 with 1 cc. of 
adrenalin 1:1000 added. Sensitive areas 
of the dura are also injected with 
nupercaine. This local anesthetic, plus 
the neuroleptanalgesic drug, kept Bill 
from suffering too much discomfort 
or apprehension during the procedure. 


After eight hours in surgery. Bill 
was returned, almost awake, to his 
room. At this point, he needed the 
attention of a nurse who knew him 
and cou'd help him adjust to the 
postoperative discomfort and other 
temporary neurological problems, such 
as the temporary speech difficulty to 
be expected during the first post- 
operative week and the neighborhood 
seizures that often occur during this 
same period. 

Equipment placed in the room be- 
fore his return was designed to main- 
tain an adequate airway, to observe 
for rising intracranial pressure and 
seizures; to prevent postoperative hem- 
orrhage and to avoid edema; to prevent 
invasion of bacteria; to provide skin 

care; and to maintain comfort. 

Although the patient was nearly 
awake, the nurse stayed with him 
during the first postoperative hour. His 
respirations were checked for rate and 
quality; his skin and nailbeds were 
noted to be pale, but not cyanotic; 
nasal oxygen was ready but not used. 
He was lying on his side, his head on 
a small pillow with his chin up to 
prevent any kink in his trachea. If he 
had much mucus, the nurse would 
have turned him semi-prone over a 
pillow to allow drainage. Suction was 
available to remove secretions. 

Trauma, even though it is incident 
to surgery, causes tissue and blood 
vessel disturbance and resulting cere- 
bral edema. Because of the danger of 
rising intracranial pressure from this 
edema or postoperative hemorrhage. 
Bill's vital signs were checked and 
compared with the signs of early rising 
pressure on the "clinical correlates" 
chart. A change in his conscious level 
may be the easiest sign for the nurse to 
miss. On return to the ward he was 
drowsy due to the anesthetic used in 
closing. After about an hour he was 
more alert and oriented to time, place 
and person. He recognized his parents, 
and the nurse, knew he was back in 
his own room, and knew it was late 

If he had become drowsy again, the 
nurse would have roused and ques- 
tioned him to prevent his lapsing into 
an unresponsive state. The patient who 
becomes restless is also watched care- 


MARCH 1965 


fully. He is not restrained because 
straining can cause a rise in intra- 
cranial pressure. 

Intracranial pressure will also ele- 
vate the pulse pressure (difference be- 
tween the systolic and diastolic blood 
pressures) and slow the pulse and 
respirations. Although the pulse is 
slow, it is bounding and full. These 
signs are checked every 15 minutes 
for one hour; then, if there is 
no change, half-hourly and hourly. 
Changes are reported immediately so 
that the surgeon can evaluate their 
significance and carry out the necessary 
treatment promptly. 

The pupils of Bill's eyes were 
checked for size and reaction to light. 
If the left pupil had increased in size, 
in comparison to the right, and had 
become sluggish in reaction it would 
have indicated rising intracranial press- 
ure. When the uncus of the temporal 
lobe herniates through the incisura of 
the tentorium from pressure above, the 
oculomotor nerve is stretched. Con- 
striction of the pupil is not as possible 
and the pupil dilates on the same side 
as the pressure. 6 BiH's pupils re- 
mained equal and reacting, although 
his left eye was closed because of 

The patient's motor ability was 
checked by handgrips and leg move- 
ments. With surgery performed on the 
left side of the brain, pressure might 
cause his right side to be weak. Several 
times the nurses reported a shght weak- 
ness of the handgrip on the right, as 
compared to the left. This quickly 
cleared up. 

Bill's ability to use language was 
a concern since the surgery had been 
in his dominant hemisphere. At first, 
his speech was hesitant and slurred 
when he was asked to name various 
objects; sometimes he repeated the 
same word in response to a different 
question. On the fifth day. both his 
mother and the nurses felt that his 
speech was the same as before the 

Careful regulation of the fluid bal- 
ance is important in minimizing post- 
operative cerebral edema. The two 
pints of blood given in the operating 
room were used to replace blood loss. 
The intravenous and oral fluids were 
regulated so that only 1500 cc. were 
administrated in 24 hours. When Bill 
was thirsty, ice chips were given; but 
even this amount of fluid had to be 
estimated and recorded. Excessive 
vomiting and elimination have to be 
considered and the intravenous ad- 
justed accordingly. Bill was given a 
Gravol suppository for nausea. He did 
not vomit and voided 400 cc. four 
hours after his return from surgery. 
Cortisone was administered prior to, 

during, and after surgery because its 
anti-edema effect has proven valuable 
in protecting against postoperative 
cerebral edema. 

Bill's left eyelid appeared puffy two 
hours after surgery. Using a piece of 
pliofilm to protect the area of the head 
dressing near the eye, the nurse folded 
a pliofilm bag around an ice cube and 
taped it over the vaseline-protected 
eyelid to reduce swelling. Normal sa- 
line was used to irrigate the eye. 
Sterile liquid paraffin drops were in- 
stilled to lubricate the eye and to 
prevent a corneal ulcer from forming 
due to dryness and irritation. 

In one hour. Bill's systolic blood 
pressure had returned to its preop- 
erative level. The head of the bed was 
then elevated 15 degrees to prevent 
stasis of blood and to help avoid 
edema. When moving Bill's head, the 
nurses used the palms of their hands 
rather than their finger tips to avoid 
digging into the wound or pressing on 
the bone-flap. 

In spite of this care, Bill had a 
seizure on the third postoperative day. 
His right arm jerked when he was 
holding a cup, causing him to fling the 
cup away from him. Apparently, 
edema had caused sufficient irritation 
of the neurons in the vicinity of the 
removal thus acting like the former 
seizure focus. 

Bill became quite apprehensive after 
his seizure although he had been in- 
formed of the possibility of having one 
during the period of edema. Realizing 
his feelings of insecurity and of fear, 
the nurses tried to anticipate his needs; 
slowly they encouraged him to be more 
active after the edema had subsided. 
When they had to leave him they told 
him when they would return. Almost 
as soon as he woke up he demanded 
his watch, and told the nurse if she 
was a minute late. The staff realized 
the importance of listening intently 
to Bill's slow hesitant speech, inter- 
preting his words and taking the time 
to understand him. The nurse whose 
motions were deliberate and who did 
not appear to be hurried gained most 
of his confidence. 

A subdural drain had been left in 
place at the time of surgery. The nurse 
checked the head dressing frequently 
for drainage of blood and cerebrospin- 
al fluid. The drain provides entryway 
for infection and the protein fluids 
are excellent media for the growth of 
bacteria. Therefore, as soon as drain- 
age appeared on the head dressing, it 
had to be reinforced. 

This was done four times during 
Bill's first postoperative night. Each 
time, one nurse cut off the old rein- 
forcement, while the other raised his 
head. Holding one hand at the back of 

his neck, for support, the second nurse 
eased his head in its original dressing 
down onto a sterile towel. Had the wet 
dressing been jillowed to lie on the bed, 
bacteria from the bedclothes could 
easily have entered. Sterile absorbent 
was wrapped about the head, starting 
low at the nape of the neck. Usually 
two wide pieces will cover each side, 
but it is sometimes necessary to put 
an extra piece over the operative site. 
The absorbent is held in place with 
roller bandage and adhesive, applied 
in the same manner as for a head 
dressing. Later, when the dressing has 
been removed, vaseline is used to 
massage the incision and daily sham- 
poos are given. 

Since a second craniotomy carries 
more risk of infection than a first. 
Procaine Penicillin and Erythromycin 
were given prophylactically. The pre- 
vention of infection also involves 
frequent washing of the nurses' hands 
with pHisoHex and the good health of 
all staff. 

Bill's temperature curve was watch- 
ed, particularly in the first 48 hours 
after surgery. Since disturbance of the 
meninges causes irritation, an aseptic 
meningitis can arise. This may result 
in a rising fever and even a stiff neck. 
Cool sponges and rectal or oral aspirin 
can be used to treat this type of fever. 

Because of the length of Bill's 
operation, the care of his skin was 
important both pre- and postopera- 
tively to prevent pressure areas. Until 
he moved easily by himself. Bill was 
turned by the nurses hourly to increase 

Mouth and eye care were necessary 
because of a reduced fluid intake. 

Disturbance of the dura during 
surgery can cause headache from the 
pull on blood vessels even though 
there are no sensory pain endings in 
brain matter. The nurses were careful 
to avoid jarring the bed. Periods of 
rest were arranged although these had 
to be interrupted hourly for turnings 
and checking of vital signs. When Bill 
had a headache, he stroked his head 
dressing over the frontal or left tem- 
poral area; he became restless and 
moaned though he did not complain. 
Aspirin relieved the headache and was 
given every four hours as necessary. 
When he was nauseated, the aspirin 
was given rectally. It is important to 
remember that phenobarbital will not 
have its sedative effect in the presence 
of pain. 

In the two weeks following surgery 
Bill met all the milestones easily. He 
was allowed up on the fourth day 
after "dangling" on the edge of the bed 
the previous day. He was soon allowed 
to walk in the corridor with the nurse 
or his parents. 


MARCH 1965 


Postoperative x-rays, an electroen- 
cephalogram and psychological testing 
were carried out prior to discharge. 

Seventeen days passed. Bill's dis- 
charge examinations demonstrated that 
his neurological status was essentially 
unchanged. The improvement in the 
EEG was encouraging as to the long 
range prognosis, but it is only after 
one to two years have elapsed that it 
can be estimated with accuracy to 
what extent the seizure tendency has 
been reduced to normal. About 40% 
of patients like Bill become seizure- 
free after operation and an additional 
35% show a marked but not quite 
complete reduction in seizure tenden- 
cy. 7 Reports from all departments 
concerned with Bill's care were for- 
warded to his family doctor for his 
future management. 

The physician ordered sufficient 
medication to cover Bill's daily dosage 
until he reached home and could have 
his family doctor prescribe further. 
Bill understood he must continue his 
Dilantin and phenobarbital for at least 
a year. His family realized the impor- 
tance of keeping a supply of medica- 
tions on hand. 

General health measures are also 
necessary to control seizures. Rest and 
work periods that are interspersed with 
relaxation and avoidance of emotional 
upsets are desirable. 

Bill's hair was growing apace but 
was still short, so he wore a peaked 
cap when leaving hospital. The nurse 
can make suggestions for suitable head 
coverings. A turban with a few artifi- 
cial curls can be comfortable and chic 

for a woman. Wigs are not usually 
necessary and may irritate the incision. 

Bill's parents worry about the 
future. They are especially concerned 
about his work and the possibility of 
marriage. The doctor discussed these 
problems with the family. 

Bill loves swimming. Together, the 
family have worked out a "buddy 
system" so that Bill will always be 
accompanied when swimming. He was 
eager to learn to drive his father's car 
but he had a realistic approach that he 
would regret injuring others. His aura 
is not dependable so he decided not 
to attempt to obtain a driver's license. 

Some planned study at home will 
have to take the place of finishing this 
year at school. He is fortunate that 
he will be able to work with his father 
who has a small furrier's business. He 
is interested in fur blocking and should 
do well at a supervised, routine job. 

His record and stamp collection 
have helped him in social contacts with 
his peers. These attachments may 
someday lead to marriage. He knows 
that his tendency to seizures will not 
be passed on to any children he might 
have since his condition was caused 
by trauma. If his seizures had an 
hereditary tendency there would be a 
1:40 chance of his children having 
seizures; the probability would be 1:4 
if his wife had seizures as well. 8 
Prevalence of seizures among the gen- 
eral population is 1:200. 

Bill's life will be affected by the 
prevailing community attitudes. Nurses 
are in a strategic position in hospitals, 
in public health agencies, in industry 

and in the community to improve the 
public concept of this disorder. 

Over 2,000 years ago Hippocratic 
writings explained this disorder. They 
criticized the popular belief that an 
epileptic was possessed by a spirit. 

And they who first referred this disease 
to the gods . . . using the divinity as a 
pretext and screen of their own inability to 
afford any assistance, have given out that 
the disease is sacred . . . and have institu- 
ted a mode of treatment which is safe for 
themselves . . . purifications and incantat- 

Today, in spite of modern therapy, 
the person who has seizures continues 
to need our understanding and help. 


1. Penfield, Wilder and Erickson, Theodore. 
Epilepsy and Cerebral Localization. Bal- 
timore, Charles C. Thomas, 1941, p. 12. 

2. Brain, W. Russell. Disease of the Ner- 
vous System. 6th ed. London, Oxford 
University Press, 1962, p. 797. 

3. Harmer, Bertha and Henderson, Virginia. 
Textbook of the Principles and Prac- 
tices of Nursing. 5th ed. New York. 
Macmillan. 1955, pp. 4-5. 

4. Pinnie, F.A. and Baldwin, M. Observing 
Cerebral Seizures. Amer. J. Nurs. 59: 
367, March 1959. 

5. Ciller, D.W. Some Psychological Factors 
in Recovery from Surgery. Hospital 
Topics. July 1963, p. 83. 

6. Mullan, Sean. Essentials of Neurosurgery. 
New York. Springer. 1961. p. 79. 

7. Chao. Dora et al. Convulsive Disorders 
of Children. London. W.B. Saunders, 
1958, p. 129. 

8. Ibid., p. 130. 



This method of bathing is used for 
patients who cannot sit or stand for the 
usual tub bath or shower. The spray 
washes away bacteria from the skin, helping 
to avoid skin infections. The large amount 
of warm water increases circulation. 

The equipment consists of a large tub 
overlaid by a sloping bakelite board, a 
water temperature regulation gauge and a 
connecting hose with a spray nozzle. The 
patient is hfted manually or by a Hoyer 
Lift on to the board which is covered by a 
flannelette sheet. TTie patient's head, if 
bandages, can be kept dry; or shampoos can 
be given. One nurse remains with the 
patient to protect him from falling and to 
give the bath. Meanwhile, another staff 
member makes up the bed. 


MARCH 1965 


Social Factors In Epilepsy 

Cynthia Griffin, b.a., m.s.w. 

How social factors and problems affect the lives of patients, their families and 
communities and ways in w/i/'c/i some of tfiese problems can be alleviated. 

An interdependence exists among 
professional people, as it does among 
members of a family. This implies 
sharing observations and information 
about the patient and his environment, 
and joint participation in assessing 
and carrying out the help required for 
the immediate and long-term future. 
Of all professional groups, nurses have 
the greatest opportunity to become 
familiar with the hour-to-hour and 
day-to-day reactions and attitudes of 
in-patients toward the hospital, the 
care given, and those caring for them. 
This paper will deal more specifically 
with the patient in relation to his life 
and associations outside the hospital. 

In a parent group discussion, the 
father of a seizure patient asked the 
questions "What do we want for our 
children? What are our goals for 
them? and went on, "The same as for 
any children, that is, happiness, as 
normal a life as posible, acceptance by 
family, school and companions and, 
later, by employers and others." The 
areas mentioned as being related to 
happiness are, unfortunately, those in 
which one frequently finds psycho- 
logical and social adaptation problems. 
This is true in relatively healthy 
families and is much more likely to be 
true where illness or disability be- 
comes a major factor in critical periods 
of patients' and families' lives. When 
the diagnosis is epilepsy, the problems 
are compounded. 


The patient is an individual with 
the physical, psychological and en- 
vironmental needs common to all. 
With deprivations in these areas, he 
will have difficulty moving through 
the stages of development to maturity. 
Thus, he will have poor preparation 
for acquiring the strength to partici- 
pate successfully in the drama of life. 
As noted by Thomas and Davidson: 

Early life experiences with parents and 

Miss Griffin is Director of Social Ser- 
vice, Montreal Neurological Hospital, Mont- 
real. Que. 

the ensuing relationships are recognized as 
vitally important. They set the pattern for 
a person's later responses to other people, 
his attitude to life and his ability to meet 
situations. Thus, what happens to children 
in their early formative years is of prime 

For the individual with seizures, 
early relationships and life experiences 
can, as Liebich- points out, "either 
give him the courage to accept and to 
overcome his physical handicap, or can 
instil in him a complex of fearful self- 
consciousness and inferiority and a 
self-image of a social outcast." She 
points to a second vital factor in the 
personal and social adjustment of the 
seizure patient: 

Environmental and social attitudes which 
basically are still impregnated with prejudice, 
fear and discrimination stemming from 
the lack of correct information regarding 
the nature and the meaning of the disease. 

The child who has seizures may 
meet rejection by and lack of affection 
from his parents, or the masking of 
rejection through over-protection. Even 
when the parents are merely according 
the handicapped child the special at- 
tention he requires, this may be in- 
terpreted by the well children as 
favoritism and can result in increased 
sibling rivalry. Thus the ill child can 
also become the butt of rejection or 
hostility by his siblings. The seizures, 
even when controlled, set the child 
apart from others since he is required 
to take medication regularly. He soon 
learns that he is different, a concept 
painful to any child. His self-image 
may be seriously affected and he may 
develop feelings of unworthiness and 
inferiority. It is our experience that 
the feelings of "being different" and/or 
"being unwanted" are frequently un- 
related to the degree of physical handi- 
cap; they are, however, vital factors 
in the social adaptation problems of 
the seizure patient. Indeed, it may 
be said that "the disability of epilepsy 
may be more social than physical."'* 

When the child goes to school he 
is on his own for the first time. He 
encounters a new set of adults and of 

children with whom he must learn to 
live. When possible, it is better for 
him to attend regular school; but too 
often, after one seizure in school, 
problems arise, due, in large part, to 
fear and lack of understanding by the 
teachers and school authorities. This 
fear is then transmitted to the other 
pupils who, in turn, tend to shun the 
child. The attitude of the authorities 
sometimes results in the request for 
removal of the child from school, often 
another indication of rejection to him. 
With a simple explanation to the pupils 
and the example of acceptance of the 
situation by the teacher, the children 
will usually accept it. If handled 
properly, this can be a valuable learn- 
ing experience for both teachers and 
students. If, however, the seizures are 
uncontrolled or if there are other 
factors such as severe mental retarda- 
tion, regular schools are usually unable 
to include the child in their classes 
and special schools must be sought. 

Even when the childhood years 
have passed fairly successfully, the 
existence, and sometimes the onset, of 
seizures can create hazards for the 
boys and girls during the normally 
stormy years of adolescence. The usual 
questions and strivings of the teen- 
ager are likely to have a greater impact 
upon the seizure patient. But if seizures 
are under medical control and if past 
experiences with his family and with 
the community have been positive, the 
adolescent can move relatively smooth- 
ly into adulthood. 

Since "the child is father of the 
man" the path is less rough for the 
adult patient if he has had the kind 
of nature and nurture which will help 
him to accept himself and the limita- 
tions of his illness. Employment, family 
life and leisure time activities are areas 
of life in which he will seek happiness 
and achievement. 


"To most normal adults the signifi- 
cance of satisfactory employment lies 
not only in the material support it 
provides but also in the moral satis- 


MARCH 1965 


faction which plays such an essential 
role in the person's feelings of self- 
worth and self-esteem."* Ideally, a 
patient whose seizures are well-con- 
trolled should be able to compete 
successfully in the open labor market. 
There are a few "enlightened" em- 
ployers who will "not blink at the 
word epilepsy" — a patient's descrip- 
tion — and who will give employment 
to individuals known to have had 
seizures, if the job is not hazardous 
and the applicant is qualified in all 
other respects. However, there are 
many companies with regulations pro- 
hibiting the employment of "epileptics" 
regardless of the kind or degree of 
control of seizures or of the type of 
employment. This leads to concealment 
of a seizure history by those seeking 
employment, and generates constant 
fear that their secret will be discovered. 
The easing of such restrictive regu- 
lations is dependent upon better un- 
derstanding by employers. As a per- 
sonnel officer remarked, it is not only 
the employers who must understand 
and accept the seizure which may 
occur at work, but also the fellow em- 
ployees. A sudden misunderstood seiz- 
ure has been known to shock the ob- 
server into self-injury. The need for 
education and interpretation is clear. 
Just as there are children who can- 
not fit into the regular school system, 
so there will always be adults who, 
because of insufficiently controlled 
seizures or other reasons, are unable 
to work full-time in regular employ- 
ment. For these, a sheltered workshop 
placement can be invaluable. For 
some, the experience is a form of 
vocational rehabilitation leading to 
regular employment; for others, a 
workshop experience of a more per- 
manent nature is required. 


For many who work regularly, 
finances do not create a major prob- 
lem. For others, however, there is the 
continuous burden of paying for med- 
ical care, particularly for medication, 
besides the actual lack of sufficient 
income or fear of its lack due to 
employment difficulties. For a family 
on a marginal income, this can be a 
constant source of anxiety, especially 
when the patient's doctor has im- 
pressed upon him the necessity of 
taking his medication regularly. For 
those who are unable to earn a living 
and who have no legally responsible 
relatives to provide for them, it is 
necessary to seek financial assistance 
from social welfare resources, accord- 
ing to their availability in the various 
localities. In our North American 
culture, with its emphasis on work 
and self-support, such dependence 

on other members of the family or on 
the community has a demoralizing 
effect. For example, if the patient is 
a man with a wife and children, his 
role as husband and father will be 
affected, with resulting strains on 
family relationships. 


Many of the problems encountered 
by families were implied in the para- 
graphs dealing with problems to the 
patient, although the impact on the 
family members differs somewhat. 
There is, first, the psychological prob- 
lem, determined partly by the parents' 
and other relatives' own life experi- 
ences and personality development. 
Some parents are unable to accept the 
"less than perfect child," and some 
develop self-pity, asking "why did this 
happen to us? Is it punishment?" 
(perhaps for an actual or imagined 
misdeed or shortcoming). Such feel- 
ings of guilt and frustration, of resent- 
ment and hostility, make normal rela- 
tionships between parent and child 
difficult and tend toward rejection or 
over-protection. When one parent can 
accept and give support to the handi- 
capped child and the other cannot, an 
added burden falls upon the accepting 
parent. This can cause dissension in 
the marriage, thus further increasing 
the tension in the home. Relatives, 
friends, neighbors and the general 
public who are afraid and do not 
understand can add to the difficulties 
by avoiding not only the child but the 
parents as well. The strengths of the 
parents are sorely taxed by the efforts 
necsssary to carry on family life and 
activities in a manner as nearly normal 
as possible for all members when a 
sick child is in the home. Their degree 
of success will depend upon many 
factors: the severity and frequency of 
seizures; the age of onset; the degree 
of control and other factors, such 
as mental retardation; the relative 
strengths and weaknesses of the in- 
dividual members and the quality of 
the family interrelationships; and the 
kind and amount of support available 
from outside the immediate family 
circle, e.g., from other relatives and 
friends, from the schools, in employ- 
ment, in religious groups, in recrea- 
tional and special interest groups, and 
in social and other community agen- 


On day, in the elevator of a 
public building, a little boy in his 
mother's arms screamed throughout 
the ride. The mother explained "He is 
afraid because he doesn't understand. 
She expressed one of the greatest, 
most widespread problems for the 

seizure patient today, i.e., fear of the 
unknown, fear of what we do not 
understand. The reaction to epilepsy 
by the majority in the community can 
be compared with that of the little 
boy to the mysterious elevator. 

Impressions of many about epilepsy 
are based on biblical references and 
folklore, on dramatic episodes on the 
stage or screen or in ancient and 
modern fact and fiction, on hushed 
reports of colleagues, or on the unex- 
pected spectacle of a major seizure. 
Many, with preconceived ideas, are 
inclined to equate all seizures with 
the most extreme situations. They 
think of "an epileptic" rather than of 
an individual who happens to have 
seizures, and who also has the emo- 
tions and aspirations of those without 
seizures. Ask a group of a dozen 
people — yes, even a group of nurses 
or social workers — what the word 
epilepsy conveys to them, whether they 
have ever seen a seizure or whether 
they have known anyone with seizures. 
Surprisingly, few will be able to reply 
in other than vague terms. 

We have discussed some of the 
results of community attitudes on the 
patient and on his family; but all 
illness and social breakdown effect 
the community as well. In Epilepsy 
and Related Disorders^ the authors 
refer to the "extravagant folly" of 
the public attitude that deprives the 
community of qualified workers be- 
cause they must miss a few hours or 
days of work out of the year. Through 
fear of rejection by employers, some 
patients feel compelled to try to keep 
their seizures a secret and accept 
work which may be hazardous to them- 
selves, to members of the community 
and to property. Other patients, who 
are potential contributors to the hap- 
piness and prosperity of the commu- 
nity, are without work, are subject 
to the multitude of problems related 
to epilepsy and, thus, are themselves 
in need of help. The financial impact 
on the community is two-fold; 1. In 
the actual expenditure of funds for 
basic maintenance, medical care and 
other community services; and 2. in 
the loss of income to the community 
in the form of taxes and other contri- 
butions, and of purchases of services 
and supplies. The loss in terms of 
non-purchasable services and of human 
values is less easily assessed. 


What are the various resources 
required to help alleviate the social 
functioning problems related to the 
diagnosis of epilepsy? The thought 
recurs that the seizure patient should 
not be set apart and, when possible, 
should take advantage of the commu- 


MARCH 196.T 


nity facilities available to the general 
population (e.g., schools, employment, 
recreation). Nevertheless, we must 
take cognizance of the fact that special 
services are necessary in individual 
cases: these may take the form of 
schools and training facilities; centres 
for vocational assessment and counsel- 
ing toward placement in appropriate 
employment; sheltered workshops; aids 
to home care such as specially prepar- 
ed "sitters"; financial assistance on a 
temporary or permanent basis; centres 
that provide custodial care; and 
guidance in obtaining medical (includ- 
ing psychiatric) care. 

To help the patient make maximum 
use of available resources and to help 
with personal and family problems that 
are interfering with his adjustment in 
one or more areas of social function- 
ing, professional counseling is re- 
quired. Among those providing such 

services are professional social workers, 
found in medical centres and in 
community agencies. The members of 
this profession, through individual or 
group counseling methods, assist the 
patient and his family to work through 
some of the problems impeding ad- 
justment. They also participate in 
community programs to disseminate 
information about epilepsy and to 
mobilize resources for seizure patients. 
Many social workers are actively en- 
gaged in research to obtain additional 
information about the social problems 
of these patients. 

As the attitudes of the community, 
the family and the patient react upon 
one another, there is a spiraling, cres- 
cendo effect. This should be reversed 
with greater public understanding and 
acceptance of seizures and seizure pa- 
tients, with expanded resources, and 
with continued joint efforts in their 

behalf by all members of the health 


1. Thomas, Joan C. and Davidson, Elabel 
McL. Social Problems of the Epileptic 
Patient. Published by the Montreal Neuro- 
logical Institute, 1949. 

2. Liebich, I. Teamwork Approach in the 
Treatment of Epileptics. Unpublished 
Paper, McGill University School of So- 
cial Work. 1964, p. 11. 

3. Lennox, Wm. and Lennox, M. A. Ep- 
lipsy and Related Disorders. Toronto, 
Little, Brown & Co., 1960. 

4. Liebich, L Teamwork Approach in the 
Treatment of Epileptics. Unpublished 
Paper, McGill University School of Social 
Work, 1964. 

5. Lennox, Wm. G. and Lennox, M. A. 
Epilepsy and Related Disorders. Toronto, 
Little, Brown & Co.. 1960. 


Probably the most frequent misconception 
concerning the epileptic is that he has an 
inferior intellect. This is a gross error 
. . . Epileptics vary in their intellectual 
ratings in the same way as do people with- 
out this handicap. In the past, many 
epileptics functioned as if they were of 
limited mentality. This was due to the 
fact that the medication then used to 
control the seizures made them drowsy. 
With the [introduction] of the newer drugs, 
the seizures are not only decreased in 
number but, in most instances, the unfor- 
tunate sedative effects are markedly reduced. 

In those case where seizures arise from 
injury to, or disorder of the brain, the 
individual may tend to become more rigid 
and concrete in his thinking. Since, as a 
result of injury, he is less flexible and 
less able to think abstractly, he may com- 
pensate by efforts to be overly precise 
and maintain his surroundings in a well- 
ordered fashion. He may have difficulty in 
adjusting to change and complexity. In job 
placement, consideration must be given to 
these traits. Such individuals can frequently 
make a satisfactory adjustment in a situation 
which demands simple, meticulous order 
and a regular routine. 

Many investigations have been conducted 
in an attempt to describe the personality 
characteristics of epileptics. Although these 
researches have been extensive, they have 
not been satisfactory because so many were 
conducted on epileptics sufficiently hand- 
icapped to be institutionalized. As a result, 
the studies do not present the personality 
of the epileptic as industry would en- 
counter it but, rather, depict only the very 

seriously ill individuals. As a consequence, 
much misinformation about the "epileptic 
personality" is prevalent. Review of the 
studies with a correction for the biased 
sample on which they were done indicates 
that the majority of epileptics show no 
gross evidence of a peculiar personality or 
of unusual behavior. 

The picture is not, however, always this 
simple since, as with other handicaps, 
emotional reactions to the handicap may 
confuse the picture. There is perhaps an 
additional complicating factor in epilepsy 
that arises by virtue of its being a con- 
cealable condition in the interval between 
seizures. The epileptic's handicap is not 
immediately apparent. Reactions to this 
existing, but for prolonged periods hidden 
disability vary with the personality structure 
of the individual. For example, a person 
who is basically optimistic, emphasizes [the] 
relative infrequency [of his seizures] and 
his normal physical appearance. He strives 
to asure himself and others that it is not 
a serious problem. Some of these individuals 
may not only reject the diagnosis of epilepsy 
and refuse to go along with a treatment 
program, but they may also ultimately 
refuse to have anything to do with the 
physician. People with this type of reaction 
are generally unemployable since it is a 
prerequisite in rehabilitation that the patient 
must accept his handicap realistically. In 
general, the epileptic is subject to all of 
the neurotic traits found in any other group 
and these traits, when present, must be 
handled in essentially the same way as in 
the non-epileptic. 

All handicapped persons quite naturally 

have feelings about being handicapped. A 
sense of inadequacy and incompleteness 
often plagues them. Some are driven by 
these feelings to overcompensate for the 
loss. Others are left with feelings of re- 
sentment and hostility. More than others 
who are handicapped, the epileptic suffers 
from rejection by community and family 
discrimination in employment, legal barriers 
and social ostracism. These severe pres- 
sures are sometimes met by reactions on the 
part of the individual that color his whole 
personality. With patience and acceptance, 
such people can be helped to make a satis- 
factory adjustment to the job. 

It may wtW be that the epileptic, because 
of his being handicapped, is actually a 
more conscientious and steady worker. In 
this regard, a statement made to the British 
Epileptic Association points out: 

It is the universal experience in the 
industrial rehabilitation unit that, handled 
with understanding, the epileptic readily 
settles down to work and can acquit 
himself as well as the best. Once he 
realizes that a seizure is not going to 
cause consternation to anyone, a steady 
improvement sets in, and the frequency 
and duration of the seizures diminish. 
With many, the seizures disappear im- 

— Taylor, Graham C. Personality factors 
in epileptics. Excerpts from a report for- 
mulated by the Committee on Psychiatry in 
Industry and Group for the Advancement 
of Psychiatry, Allan Memorial Institute, 
Montreal, as cited in Institute on Rehabilita- 
tion of Seizure Patients, published by Mont- 
real Council of Social Agencies. 


MARCH 1965 



inson s 


C. Bertrand, M.D., F.R.c.s.(c), F.A.c.s. and S. N. Martinez, m.d., f.r.c.s.(c) 

With the prolongation of the hfe- 
span of the individual, Parkinson's 
disease is increasingly frequent. Ac- 
cording to the statistics of Kurkland,' 
one person in 50 would be affected 
after 60 years of age. It would seem 
that it involves one per cent of the 
population over 50, and approximately 
1 per 1000 of the general population, 
being more prevalent in men than in 

The attention of the medical pro- 
fession was originally aroused by the 
brilliant description of James Parkin- 
son in 18 17^ entitled "Paralysis ag- 
itans." The symptoms have been 
studied in detail during the posten- 
cephalitic manifestations encountered 
following the influenza epidemic of 
1918. The surgical era really started 
after the work of Myers'' on the basal 
ganglia, and the beginning of human 
stereotaxis, that is, the possibility of 
obtaining precise localization deep 
within the human brain under local 
anesthesia, with Speigel* and Wycis, 
and Talairach. Various techniques, in- 
cluding ours, have made possible 
effective relief of symptoms with a 
maximum of safety and efficiency. 

For more than 10 years, our group^" 

Dr. Bertrand is Chief of the Neurosurgical 
Service. Notre Dame Hospital, Montreal, 
and Professor of Neurosurgery, University 
of Montreal. Dr. Martinez is Assistant. 
Neurosurgical Service, Notre Dame Hos- 
pital, Montreal, and Assistant in clinical 
research. University of Montreal. 

has been particularly interested in 
the study of Parkinson's disease, yet 
it is still difficult for us to describe 
it both concisely and accurately Be- 
sides being a syndrome its manifes- 
tations are extremely varied and many 
of its basic mechanisms are still 
unknown. There are great differences 
of opinion on its ideology and even on 
the classification of its various forms. 
As in many other fields, the numerous 
investigations which have been made 
have mostly brought out the com- 
plexity of Parkinson's disease and 
there is a tendency to abandon the 
classical division in an idiopathic and 
arteriosclerotic and a postencephalitic 
form. Only a small percentage of cases 
with a definite history and a charac- 
teristic evolution of symptoms can be 
ascertained as postencephalitic. 

While it is known that the patho- 
logical manifestations involve mostly 
the basal ganglia (especially the globus 
pallidus and the putamen) and the 
mesencephalon (particularly substantia 
nigra), some authors like Denny-Brown 
believe that the lesions of the basal 
ganglia are more important for the 
symptoms, while most workers think 
that the alterations of the substantia 
nigra are determinant. The favorable 
results produced by lesions within the 
basal ganglia on certain symptoms 
such as: tremor and rigidity, (more 
than 700 in our series) and the lack 
of aggravation following thousands of 
these lesions, are in favor of the latter 
hypothesis. Moreover, it has been 

possible in the laboratory of Doctor 
Louis Poirier, of the Universite de 
Montreal, to produce tremor at rest 
very much like that of Parkinson's 
disease, in macaques by interrupting 
the efferent fibres of the substantia 
nigra within the mesencephalon. 

It seems fairly definite that in the 
postencephalitic forms there are cer- 
tain characteristics, such as the intra- 
cellular inclusions in the substantia 
nigra, which are not found in other 
cases. In the great majority of cases 
a history of encephalitis cannot be 
ascertained, and it is equally difficult 
to relate them conclusively to arte- 
riosclerosis or to other etiological 


The main symptoms of Parkinson's 
disease are essentially motor: tremor, 
rigidity and bradykinesia; this word 
is used to describe a diminution or a 
loss of spontaneous or associated 
movements. There is no obvious in- 
volvement of the main motor pathway 
(pyramidal or cortico-spinal), reflexes 
are usually equal, there is no Babinski 
sign, initially motor power is not 
altered. An insidious onset and a slow 
progression are typical of the disease. 
In certain cases it progresses much 
more rapidly in a few years, especially 
in the akinetic form. These three 
symptoms: tremor, rigidity and brady- 
kinesia may be present separately or 
in all possible combinations and 


MARCH 1965 


Tremor is usually a fine tremor at 
rest, at 3 to 7 per second which is 
stopped by voluntary movement. Pa- 
tients use this to suppress it tempo- 
rarily. In rare cases of isolated tremor, 
this tremor may reach a very large 
amplitude and the patient is constantly 
agitated from head to foot. 

Rigidity is particularly evident when 
one attempts to move the limbs of the 
patient passively, which may give 
rise to the cogwheel phenomenon, that 
is flexion or extension in successive 
jerks due to a lack of synergism be- 
tween the contracting protagonistic and 
the relaxing antagonistic muscles. Oc- 
casionally, rigidity can be fairly 
marked, yet the patient may move 
quite easily although in general it goes 
hand in hand with difficulty in moving 
the limbs, particularly in accomplish- 
ing fine or rapidly alternating move- 
ments, that is, bradykinesia. As men- 
tioned previously, there are certain 
akinetic forms of the disease when the 
patient can hardly begin even very 
simple movements or stop them once 
they have been initiated, and where 
rigidity is hardly detectable. Such 
forms are the least favorable for 
surgical treatment. They may progress 
quite rapidly and may be accompanied 
by mental sluggishness, and occasion- 
ally transitory confusional states. As 
a rule, mental alterations are very 
slight in parkinsonians, while the 
masked facies and the lack of means 
of expressing themselves suggest a 
much more severe psychic involvement. 
Difficulty in moving gradually prod- 
uces a loss of associated movements, 
such as the natural swinging of the 
arm while walking and trouble in 
changing one's positions: the patient 
may be caught in a comer or near a 
door and be unable to start moving. 
Once walking has been initiated, the 
tendency to fall forward, which is not 
corrected by normal postural tone, may 
produce the typical "demarche a petits 
pas," steps becoming smaller and faster 
as walking proceeds with a tendency 
to fall forward (propulsion), or, when 
the patient is standing, to fall back- 
wards (retropulsion). Writing is al- 
tered, becomes shaky with successive 
words getting smaller and smaller. 
There is increasing difficulty in speak- 
ing or even in swallowing, and a 
marked diminution in respiratory ex- 
cursion. Automatic functions may also 
be involved with excessive salivation, 
dryness of the skin, cold extremities. 
Oculogyric crises which bring the eyes 
to one side and usually upwards against 
the patient's will, are very rare and 
postencephalitic in origin. On the other 
hand, blepharospasm or tonic closure 
of the eyelids is slightly more frequent. 


In an ordinary case of Parkinson's 
disease, one may think of an insidious 
and slowly progressive involvement of 
motor functions which the patient will 
frequently ascribe at first to arthritis. 
In a more advanced form, diagnosis 
is usually very easy and most other 
illnesses which alter normal movements 
or produce abnormal movements, such 
as choreathetosis and cerebral palsy or 
dystonia musculorum deformans, are 
found early in life. Even familial 
tremor is usually evident when the 
patient is still young and this is not 
a tremor at rest but a tremor during 
intentional movements which may be 
of rather wide amplitude. It progresses 
very little during ensuing years. There 
is no rigidity nor bradykinesia; it is 
only occasionally severe enough to 
demand a surgical procedure. Cere- 
bellar tremor, such as that of multiple 
sclerosis, is usually accompanied by 
other symptoms which facilitate diag- 
nosis. If these various forms of tremor 
are too inconvenient to the patient, 
they are also quite amenable to 


A therapeutic triad is a classical 
expression, but it applies quite well 
to treatment of Parkinson's disease, 
the three essential phases of which 
are: medical treatment; physiotherapy; 
surgical treatment. The renewal of 
interest aroused by surgery has created 
a favorable atmosphere for more vigor- 
ous conservative therapy so that one 
now rarely sees cases with completely 
fixed joints, tragically unable to move 
in any way. Alkaloids were the 

favorite drugs for a long time, par- 
ticularly belladonna, atropine and 
stramonium. Many drugs now give ap- 
preciable relief to the patient, at least 
temporarily, even though this may be 
difficult to establish statistically. One 
must try to find the drug which is 
best suited to the patient. Those most 
frequently used are: Artane, Kemadrin, 
Pagitane, Cogentin, Phenoxene, to 
which are added Disipal and Benadryl. 
Sometimes these drugs are more ef- 
fective when they are changed peri- 
odically. These patients are often 
depressed and they need the help of 
their kinfolk. This depressive state 
may be accompanied by a certain 
amount of indifference and they must 
be constantly encouraged to action so 
as to avoid ankylosis. Besides their 
arthritic pain, these patients may also 
experience pain of an indefinite nature 
in the epigastrium or along their limbs. 
Pain seems to be related to rigidity 
since that occurring in the limbs is 
often partially relieved by doing 

Physiotherapy is of paramount im- 
portance. A group of well-defined 
exercises will help the patient main- 
tain a certain degree of agility and 
even increase the ease, number and 
efficiency of his movements. The nurse 
can be of great help in rehabilitating 
these patients since she is in intimate 
contact with them at least during their 
stay in hospital. 

If the symptoms are such that a 
patient becomes unable to perform 
simple things such as dressing himself, 
eating or turning in bed, or if he is 
on the verge of losing his job because 
it is difficult for him to do his daily 

Fig. 1 


MARCH 1965 


work, surgery must be contemplated. 
In younger patients it should be 
thought of earlier in the disease so 
that they may keep on with their ac- 
tivities. If surgery gives only moderate 
results for bradykinesia it is quite 
effective in relieving tremor and rigid- 
ity. Frequently, this relief will not be 
complete but the marked improvement 
of functions is greatly appreciated by 
these patients who suddenly feel a 
relaxation on one side. Surgery prod- 
uces a lesion which restores to the 
contralateral limbs part or most of 
their mobility and abolishes or dimin- 
ishes tremor by liberating certain 
centres through a lesion of the basal 
ganglia, more specifically in the ventro- 
lateral part of the thalamus. There is 
no age limit for this type of surgery. 
Many of our patients were over 70 
years of age, one actually 77, though 
admittedly one is more conservative 
with older persons. As mentioned 
previously, surgical treatment is rarely 
indicated in the less frequent form 
where akinesia predominates with 

very little rigidity. Surgical therapy 
should be avoided in cases presenting 
definite mental alteration' particularly 
hallucinations and a tendency to mental 
confusion. Such patients are a bad 
risk for any kind of surgery. Diabetes 
and cardiac lesions are not a con- 
traindication unless they are severe. 

Surgery is done under local anes- 
thesia. In our own experience, the 
surgical risk is well below one-half 
of one per cent. Our method allows 
rapid and precise localization of the 
structures of the base of the brain with 
verification of visual localization 
through electrical stimulation {Figure 
1), and through recording with micro- 
electrodes through which the various 
nuclei of the ventro-lateral portion of 
the thalamus may be identified before 
producing a lesion. Much has been 
written on the way in which a lesion 
can be produced but it is most impor- 
tant to localize this lesion very 
accurately. Many physical agents and 
mechanical means are now available to 
produce a satisfactory lesion. It seems 



RESULTS OF 38 CASES FROM 3mm to 7 mm behind Monro 
























RESULTS OF 48 CASES FROM 8mm to 12 mm behind Monro 
























RESULTS OF 264 CASES FROM 13 mm to 19mm behind Monro 




























Fig. 2 

to us that mechanical severance of the 
desired region with a fine blunt wire 
(leukotome) which is being used in- 
creasingly, is still the safest. In certain 
centres, ultrasounds, high frequency 
coagulation, extreme heat or cold 
(cryosurgery), proton beams, betatron 
and various radioactive substances 
have been used, but the secondary 
effects of some of these methods seem 
more difficult to control. The micro- 
electrode allows one to define the 
limits of the thalamus within a fraction 
of a millimeter. 

If a procedure on the other side 
becomes imperative, it is usually 
performed three to six months later 
to allow time to evaluate the final 
result of the first section. As shown 
by the accompanying figure (Figure 
2), although there is not a total disap- 
pearance of symptoms in most cases, 
it is unusual indeed for a well-localized 
lesion not to produce a definite im- 
provement in the rigidity and tremor. 
It is obvious that the appraisal of the 
result is still imprecise, since it is 
difficult to grade improvement in 
motor signs, but the relief of symptoms 
is quite definite. Most of this im- 
provements will be maintained over 
the years as has been shown by patients 
followed for more than five years. 
When there is a recurrence it is pos- 
sible to enlarge the lesion since, in its 
present location, it does not produce 
any appreciable drowsiness in most 
patients being far enough from centres 
having to do with psychic functions. 

The innocuousness of this form of 
treatment is now well established. It 
allows certain patients to return to 
work. For the others, it makes life 
much more pleasant since it restores 
at least part of their independence. 


1 . Kurkland. L.T. Epidemiolof;y, Incidence, 
Geographic Distribution and Genetic 
Considerations. Springfield. Ch. C. Tho- 
mas, 1958. 

2. Parkinson, i. An Essay on the Shaking 
Palsy. London, Sherwood, Neely and 
Jones, 1817. 

3. Meyers, R. A. Surgical Procedure for 
Post-encephalitic Tremor with Notes on 
the Physiology of the Premotor Fibers. 
Arch. Neurol. & Psychiat. 44:455, 1940. 

4. Spiegel, E. A., Wycis, H. T., Marks, M. 
and Lee, A. J. Stereotaxic Apparatus 
for Operations on the Human Brain. 
Science. 106:349, 1946. 

5. Bertrand, C, Poirier, L., Martinez, N. 
and Gauthier, C. Pneumotaxic Technique 
for Producing Localized Cerebral Lesions 
and Its Use in the Treatment of Parkin- 
son's Disease. J. Neurosurg. 15:251-264. 

6. Bertrand, C. Martinez, N. Surgical 
Treatment of Parkinsonism, Modern 
Medicine of Canada. 18:47-58, 1963. 


MARCH 1965 




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for the best Canadian-made 
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out. J & J's purchasing phi- 
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Johnson & Johnson's elite 
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the Development Engineer- 
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Care of Parkinsonian Patients 

LisE Moody, r.n. 

A patient suffering from Parkin- 
son's disease, or paralysis agitans, 
presents special problems from the 
nurses' point of view; he requires much 
devotion and sympathy. At first glance, 
this patient would seem totally indif- 
ferent to his surroundings and unable 
to experience emotions. However, the 
masked facies usually hides an intact 
mind and one need only look at the 
eyes of the patient to understand that 
he is fully aware of everything and 
possibly oversensitive to manifestations 
of affection or impatience. 

Upon his arrival, the nurse should 
try to put him at ease without paying 
too much attention to his slow reac- 
tions and his tremor which is increased 
by shyness and emotion. She should 
inquire about his habits from his 
family: Is he able to eat on his own? 
What are his favorite dishes? Can he 
turn in bed? Does he need to be taken 
to the bathroom? 

At least during the first few days, 
the nurse should try to isolate the 
patient behind his curtains during 
meals so that he feels more at ease. 
If he spills too much of his food, he 
may be offered help, particularly with 
liquids, but he should be encouraged 
to do as much as possible for himself, 
while being sure that he is well fed. 
His clothes should be protected with 
a napkin tied around his neck. He 
should take frequent walks so the 
nurse may show him around the ward 
when time permits; thus he will get 
used to his new surroundings more 
rapidly. Usually these patients have 
a rapid shuffling gait (demarche a 
petits pas), with the head leaning for- 
ward; they usually need help to go to 
the bathroom. It is very difficult for 
them to get up when they fall which 
makes it even more essential that they 
should be accompanied. In the more 
severe forms, the patient may have 
marked dysarthria and his speech may 
be almost unintelligible. The nurse 
must therefore be very patient and 
never hurry him if he is to be un- 
derstood. It is almost impossible for 
him to write; by the time he comes 
to hospital his writing is usually fine, 
hesitant and unreadable. Often, he 
can hardiv sign his name. He should 

Miss Moody is assistant head nurse. 
Neurosurgical Unit. Notre Dame Hospital, 

have a sponge bath every morning, 
and if necessary, his glasses and 
dentures should be cleaned; it would 
be too risky for him to do this himself. 
The night staff should be told to turn 
the patient every two hours, if he is 
unable to turn himself. He should be 
sent to physiotherapy every day. Pas- 
sive exercises are very important; 
since voluntary movements are very 
difficult because of hypertonia and 
rigidity, there is danger of progressive 
contracture and fixation of the joints. 
These people should never remain in- 
active. When he arrives at the hospital 
he must keep on his usual medication 
until it is modified by the physician; 
barbiturates and tranquilizers should 
be stopped three days before the EEG 
prior to operation. The routine pre- 
operative tests and the preoperative 
movie should all be done. 

Thalamic section is performed un- 
der local anesthesia. The burr hole 
may be done previously or at the time 
of the section. This burr hole is 
situated in the frontal parasagittal 
region and shaving, which is done in 
the operating room, will involve only 
the region about the actual site. 

On the night prior to operation, a 
shampoo with hexachlorophene is 
given. The surgeon will have explained 
to the patient what he is to do so 
that he will have his collaboration 
during the entire procedure. The nurse 
should answer all questions that the 
patient will ask, so that he will not 
feel anxious. If the procedure is to 
be performed in the afternoon, the 
patient may have a liquid breakfast; 
if it is done in the morning, he will 
usually be fasting. Prior to surgery, 
the patient is given a light pre-medica- 
tion but no alkaloid and no barbiturate 
so as not to mask the symptoms nor 
alter recording with the microelectrode. 
A 5 per cent glucose solution contain- 
ing 1 ampoule of Gravol is available 
during the procedure in case the pa- 
tient should feel nauseated, since he is 
operated upon in the supine position. 

When the patient returns to his 
room he should be placed in a semi- 
supine, semi-sitting position to avoid 
cerebral edema. The nurse will note 
if tremor has been suppressed on one 
side of the body. The patient is fre- 
quently tired and he may have a 
tendency to doze. He should be aroused 
every half hour during the first few 

hours to verify his state of conscious- 
ness. The physician is warned imme- 
diately if the patient becomes som- 
nolent or if he reacts poorly to stimuli. 

Vital signs will be verified every 
half hour or every hour, according to 
the prescription. The nurse should 
check the reactions of the pupils with 
a flashlight and warn the physician if 
one of them is enlarged or responds 
poorly. Like increased drowsiness, this 
might signal a subdural hematoma, 
although this is a rare eventually — 
perhaps 1 per cent. Likewise, vomiting, 
especially projectile vomiting, will in- 
dicate intracranial hypertension. There 
should be suction apparatus, a Mayo 
tube, a padded tongue depressor in 
case of a seizure (less than one-half 
of 1 per cent. Dilantin should be given 
as prescribed either by mouth or rec- 
tally as necessary. At first, prothrom- 
bin time is verified every 12 hours; if 
is falls below 70 per cent, an ampoule 
of vitamin K is given intramuscularly. 
The patient should have breathing 
exercises all the time he is in bed to 
avoid bronchopneumonia which is a 
possibility in the aged. 

Intake and output should be meas- 
ured to be sure that the patient is 
not becoming dehydrated. A liquid 
diet is usually given for the first day 
with a progressively increasing diet. 
As soon as the patient can get up. 
usually on the day after the procedure, 
he will walk with the help of the 
orderly so that he can get to the 
bathroom. He must be watched at first 
because of the hypotonia on the oper- 
ated side in contrast to the rigidity 
on the nonoperated side. The nurse 
should at once start passive movements 
of all four limbs to avoid contrac- 
tures. Note any sign of confusion. 

The stitches are usually removed 
after 5 days and a shampoo given on 
the 7th day if the wound is sufficient- 
ly healed. Female patients usually like 
to wear a cap during the postoperative 
period unless the hair can be brought 
over the shaven area. 

The results of this procedure are 
extremely striking. A patient who yes- 
terday was shaking all over and who 
was totally disabled regains a taste 
for life. With the help of good post- 
operative care, he soon learns to be- 
come independent and may pursue an 
active, even a useful life rather than 
becoming immobile and helpless. 


MARCH 1965 


Herniated Discs 

C. Bertrand, M.D., F.R.c.s.(c), F.A.c.s and S. N. Martinez, m.d., f.r.c.s.(c) 

Sciatica or lumbago were formerly 
considered medical diseases. Surgical 
approach to this problem followed the 
work of SchmorP in 1928 on the 
anatomy of the nucleus pulposus of the 
intervertebral spaces. In the same year, 
Alajouanine and Petit-Dutaillis- dis- 
cussed a case of chronic sciatica in 
which they found a compression from 
a herniated intervertebral disc. At first 
they did not suspect the importance 
of this finding, but in 1930 they en- 
countered another case which made 
them realize the relationship between 
compression of the nerve root and 
the herniation described by Schmorl 
in his work. Goldwaith and Dandy in 
1924 had suspected the importance of 
herniated discs in lumbago and sciatica, 
and reported two cases operated on for 
root compression. However, it is the 
work of Mixter and Barr* in 1934 
with neurological radiographic and 
operative verification which brought to 
the fore the importance of surgical 
treatment for this syndrome. 

Following these reports, lumbago 
and sciatica have ceased to be thought 
of as inflammatory diseases and, in 
most cases, have been recognized as 
resulting from mechanical compression 
of the root at the level of the inter- 
vertebral discs. A similar pathology 
exists in the cervical region, and it 
can be said that most disc herniations 
occur between the fourth and the fifth 
lumbar and between the fifth lumbar 
and the first sacral vertebrae, or in the 
cervical region between the fifth and 
sixth or the sixth and seventh cervical 

Dr. Bertrand is Chief of the Neurosurgi- 
cal Service, Notre Dame Hospital, Montreal, 
and Professor of Neurosurgery, University 
of Montreal. Dr. Martinez is Assistant, 
Neurosurgical .Service, Notre Dame Hos- 
pital, Montreal, and Assistant in clinical 
research. University of Montreal. 


The lumbar and cervical regions 
being the two most mobile points of 
the spine, it is easy to understand 
that most herniations occur in these 
regions of maximum flexion and exten- 
sion by rupture of the ligaments which 
surround the intervertebral discs. 

As described by Sicard,^ a herniated 
disc goes through a series of stages 
each with itS clinical manifestations. 
During flexion, the nucleus pulposus 
which forms the centre of the inter- 
vertebral disc is compressed backward 
and its pressure on the surrounding 
annulus fibrosus is contained by the 
posterior vertebral ligament. If a 
herniation is produced but it is not 
sufficient to touch the nerve root, the 
patient experiences lumbago. When the 
nerve root is finally reached, sciatic 
pain is produced. At that stage the 
phenomenon is still reversible, but 
fibrocartilaginous necrosis is already 

In the first stage, the annulus 
fibrosus is defective but the posterior 
vertebral ligament is still intact; as 
the tissue is liberated outside the in- 
tervertebral space, the hernia becomes 
irreversible with persistent sciatic pain. 
However, if the disc becomes com- 
pletely excluded the lumbar pain will 
subside while sciatic pain will be in- 


Disc herniations are frequently trau- 
matic in origin. This trauma may be 
a simple sudden flexion, or it may be 
the act of lifting a weight with the 
spine in flexion, or more rarely it may 
be a fall. In cervical disc, a sudden 
stop with a brutal flexion or extension 
of the neck (whiplash) may produce 
marked ligamental strain. 


Clinical history if of paramount 

importance in the diagnosis of a 
herniated intervertebral disc. The car- 
dinal symptom is radicular pain, re- 
curring constantly in the same region. 
A history of trauma is not always 
evident; on the contrary in certain 
compensation cases it may be over- 
done. There may have been a few 
transitory episodes of lumbago and a 
vague malaise in between the attacks; 
however, if this is accompanied by 
unilateral radicular pain, the diagnosis 
of a herniated lumbar disc is probable. 

One must look for a Lasegue sign 
(exaggeration of pain on straight leg 
raising); increasing pain on straining 
or coughing; diminution of forward 
flexion of the spine with muscle spasm 
in the lumbar region, sometimes with 
antalgic muscle scoliosis. Localized 
tenderness at one interspinous space 
is particularly significant. 

There are localizing signs in each 
instance. A herniated disc between 
L-5 and S-1 is accompanied by pain 
radiating toward the heel of the foot 
and even on to the little toe. There 
may be numbness or tingling in that 
region. The Achilles tendon jerk may 
be diminished or abolished. Hypotonia 
will be found in the calf. 

A herniated disc between L-4 and 
L-5 will cause radiation down to the 
dorsal surface of the foot toward the 
big toe, and possibly numbness in this 
area. There may be diminution of 
dorsiflexion of the big toe in compari- 
son to the opposite side and atrophy 
will predominate in the anterior tibial 

In the cervical region, there may 
be pain in the neck and in the adjoin- 
ing portion of the scapula at first, 
and then, gradually, irradiation along 
the upper limb. There may be muscle 
spasm with difficulty in turning the 
neck (torticollis). A lateral herniation 
will be situated at C-5, C-6 or at C-6, 
C-7 in 95 per cent of the cases. 


MARCH 1965 


Fig. 1. Cervical x-ray showing narrowing at C-5, C-6 and C-7. Fig. 2. Lateral x-ray of the lumbar spine showing a marked narrowing of 
the disc between the fourth and the fifth lumbar vertebrae. 

During clinical examination, move- 
ments of the head (particularly in 
flexion) will increase the pain, while 
traction along the axis of the cervical 
spine will usually relieve it — unless 
the disc is completely herniated in 
the canal. There is localized tender- 

If the herniation is between C-5, 
C-6 with compression of the 6th 
cervical root, there may be numbness 
or tingling in the thumb and on the 
radial side of the hand, weakness of 
the biceps, and diminution or abolition 
of the bicipital reflex with weakness 
and even fasciculations of the biceps. 

If the herniation is situated at C-6, 
C-7 with compression of the 7th 
cervical root, numbness and tingling 
will be found mostly in the index and 
medius with weakness, atrophy or fas- 
ciculations in the triceps and diminu- 
tion or abolition of the tricipital reflex. 

In the event of a midline cervical 
herniation, there may or may not be 
bilateral cervical root signs together 
with compression of the spinal cord 

with weakness and increased reflexes 
in the lower limb resulting from 
compression of the pyramidal tract; 
this may progress to paraplegia if the 
cord is not decompressed. 


Plain x-rays may show a diminution 
of the intervertebral space — some- 
times with arthrosis (Figures 1 and 2). 
One may see evidence of antalgic 
muscle spasm with scoliosis or, at least, 
straightening of the spine. 

Negative plain x-rays do not rule 
out a herniated disc. If necessary, a 
contrast medium will be used; this is 
most frequently done by myelography 
(Figures 3 and 4). This is a valuable 
examination, since it is very impor- 
tant to localize precisely the level at 
which the root is compressed. A com- 
pletely extruded disc may be com- 
pressing the root above or below the 
point of herniation. Other methods, 
such as discography in which the 
nucleus pulposus is injected directly, 
and spinography in which the veins of 

the vertebral canal are injected, are 
used much less frequently in most 


In the cervical region, one must 
consider the possibility of an inflam- 
mator>' process in the shoulder joint, 
such as bursitis or fibrositis with 
ankylosis of the shoulder. Local 
limitation in certain movements of the 
shoulder causing local pain will sug- 
gest this diagnosis, and it may be 
confirmed by calcification of the bursa 
on x-ray. Pain due to a scalenus an- 
ticus syndrome will radiate mostly 
toward the little finger with atrophy 
in that region, and plain x-rays may 
show an accompanying cervical rib. 
Certain forms of angina pectoris may 
lend to confusion. Certain tumors of 
the apex of the lung (Pancoast tumor) 
may compress cervical roots and give 
rise to brachial pain, but there is 
usually a narrowed palpebral fissure 
on that side due to a Claude Bernard- 
Homer syndrome. Benign tumors of 


MARCH 1965 


Fig. 3. Myelogram showing a lateral disc at C-6, C-7 with a moderate midline disc 
at C-5, C-6. Fig. 4. Myelogram showing a completely extruded disc in the canal at L-4, 
L-5 on the left. 

the cervical roots will usually produce 
an enlargement of the intervertebral 
foramen which will be seen readily on 

In the lumbar region, lumbago may 
result from muscle spasm due to ner- 
vous tension, and this will be brought 
forward by the clinical history and 
the examination of the patient. Sacrali- 
zation of the fifth lumbar vertebra 
which may be found on simple x-ray 
is often present without symptoms and 
one way suspect that the disc above 
is diseased. On the other hand, spon- 
dylolisthesis or slipping of one vertebra 
upon another (usually the 5th lumbar 
vertebra on the 1st sacral vertebra) 
may give rise to pain, but this pain 
is usually less intense and more con- 
stant and x-rays are revealing. Tumors 
of the bone may also cause lumbar 
pain, but these pains are usually in- 
creased when the patient is lying down. 

They may precede radiological evidence 
of destruction for many months. Pain 
from a benign tumor of a nerve root is 
also quite constant and not increased 
by straining. Lumbar pain may also 
result from osteoporosis, which will 
be evident on x-ray, and from an 
unstable lumbar spine. 

Occasionally, sciatica may result 
from a neuritis, of which the most 
frequent type is diabetic neuritis. This 
usually produces more diffuse symp- 
toms with abolition of vibration and 
diminution of tendon reflexes in the 
lower limbs. Sciatica from direct com- 
pression of the sciatic nerve by a 
tumor in the pelvis is quite rare and 
an examination, particularly rectal 
examination, will help to clarify the 
diagnosis. Vascular pains, such as in- 
termittent claudication, that is pain in 
the calves on walking, is usually ac- 
companied by signs of circulatory 

insufficiency and diminution or absence 
of the dorsalis pedis pulse. 


Unless neurological signs are very 
marked, or pain is very intense, early 
treatment of a herniated disc must 
always be conservative. We use: 

1. Rest with immobilization in a stable 
position of the cervical or the lumbar seg- 
ment with a felt collar for the cervical 
region, and by rest on a hard bed for the 
lumbar region. 2. relaxing and antalgic 
drugs to diminish pain, lumbar spasm, and 
also the anxiety of the patient toward his 
pain which may increase muscle spasm. 3. 
mechanical treatment with continuous or 
intermittent traction. In the lumbar region 
one uses pelvic traction or preferably 
traction on both legs with a total weight 
of 20 to 30 pounds if using continuous 
traction, or much more weight if one uses 
intermittent traction. In the cervical region 
one ordinarily uses intermittent traction of 
one-half hour with weights of 10 to 15 
pounds, according to the tolerance of the 
patient. Between tractions the patient wears 
a felt collar. When the cord is compressed, 
one may use tong-traction with up to 25 
— 30 pounds weight both before and during 

Manipulations, like massage, may 
diminish muscle spasm if they are done 
cautiously; severe or uncontrolled 
manipulation of the spine may rupture 
the disc completely, and in the cervi- 
cal region compression of the cord 
with paraplegia may ensue. Heat and 
physical agents may also be of help. 
Local infiltration is rarely used. After 
the acute stage, graduated exercises, 
particularly graduated flexion of the 
hips on the abdomen, may help re- 
covery; tension exercises may strength- 
en muscular support. Postural exercises 
are of help and the patient should 
avoid sudden oblique flexion or exten- 
sion of the spine, and especially torsion 
of the spine. 


If medical treatment is ineffective 
or if recurrences are too frequent, one 
must consider surgical therapy. As 
this is usually an elective operation, 
the ultimate decision will come from 
the patient after the situation has been 
carefully explained to him. Although 
it is a benign operation, one must 
foresee a convalescence of six to ten 
weeks, but this may be preferable to 
frequent interruption of work from 
recurrent attacks. We operate on these 
patients in the genupectoris position^ 
for the lumbar region; cervical discs 
are operated on in a sitting position, 
except when an anterior approach is 
used in which case the patient is lying 
on his back. 

In the lumbar region, we usually do 


MARCH 1965 


a radical bilateral discoidectomy so 
as to obtain a stable intervertebral 
space; for that reason also the disc 
at L-5, S-1 is usually removed when 
the herniated disc is at L-4, L-5; both 
levels are usually explored routinely. 
Immediately after operation, the pa- 
tient lies in a semiprone position until 
he is fully awake so as to avoid 
bronchial aspiration in the event of 
vomiting. (For further pre- and post- 
operative care, see nursing care article, 
page .) 

As a rule, the patient should be 
up on the third or fourth postoperative 
day, and for the first few weeks he 
should avoid all flexion of the spine; 
the patient should be lying down flat 
or sitting up straight or standing. He 
may leave the hospital 8 to 10 days 
after operation. Spinal fusion is used 
only if there is an anomaly of the 
spine or if there is very great mobil- 
ity of the lumbar segment; it will be 
done jointly with the orthopedic de- 
partment. With radical disc removal, 
spinal fusion seems to be necessary in 
a very small number of cases, although 
the currently-used latero-lateral graft 
with spongy tissue from the iliac crest 
does not keep the patient in bed much 

Cervical lateral disc herniation with 
radicular pain is usually amenable to 
conservative therapy, but in very acute 
or irreducible cases surgical treatment 

will be necessary. This is usually done 
in a sitting position through a posterior 
approach by a small laminectomy and 
in this region the involved herniated 
disc is removed unilaterally, since the 
problems of weight bearing are dif- 
ferent from the lumbar region. 

In cases of midline cervical her- 
niated disc with compression of the 
cord, especially if the disc is calcified, 
the anterior approach of Cloward* will 
be used. This operation is done just 
outside the trachea and a special per- 
forator allows one to remove a half 
circle of the vertebral body above and 
below the disc. The disc is then 
removed completely until the anterior 
surface of the cord is free and the 
two bodies are joined by a bone 
button taken from the iliac crest. If 
these midline discs are multiple or 
highly situated, the posterior approach 
may be preferable. 


Lumbar pain with radiation along 
the sciatic nerve, and cervical pain 
with brachial radiation are usually due 
to herniated discs with compression 
of lumbar or cervical roots. Rest, 
relaxing drugs, traction, physical agents 
are usually sufficient to obtain a re- 
gression of the symptoms. In very 
acute or jjersistent cases or in the 
event of multiple recurrences, dis- 
coidectomy should be resorted to and 

its object should be not only to re- 
lieve root compression, but also to 
produce a stable spine. The patient 
should be able to resume his normal 


1. Schmorl, G. Uber Chordoreste in den 
Wirbelkorpem. Zbl. f. Chir. 55:2305. 

2. Alajouanine. T., and Petit-Dutaillis. D. 
Compression de la cheval par une tumeur 
du disque intervertebral; Operation; Gue- 
rison. Bull, ct Mem. Soc. Nat. de Chir. 
54:1452, 1928. 

3. Mixter, W.J. and Barr, J.S. Rupture of 
the Intervertebral Discs with involve- 
ment of the Spinal Canal. New England 
J. Med. 211: 210-215, 1934. 

4. Sicard, A. Chimrgie du Rachis. Paris, 
Masson & Fils, ed., 1959. 

5. Bertrand, C. Les disques intervertebraux 
physiopathologie et notions cliniques ac- 
tuelles. Union Medic, du Canada. 74: 
1196-1204. 1945. 

6 Cloward, R.B. TTie Anterior Approach 
for Removal of Ruptured Cervical Discs. 
J. Neurosurg. 15: 602-617, 1958. 


Semmes. R.E. Rupture of the Lumbar Inter- 
vertebral Discs — The Mechanism, Di- 
agnosis and Treatment. Springfield, Char- 
les C. Thomas, 1964. 

Spurling, R. G. Lesions of the Lumbar Inter- 
vertebral Discs. Springfield, Charles C. 
Thomas, 1953. 


In aphasia, the patient's difficulty lies 
not in producing sound or in pronouncing 
syllables, but in finding the appropriate 
words to use. It is thus a disturbance of 
language. In this broadest sense, the term 
aphasia implies an inability to express ideas 
in the symbols of the language, whether 
spoken or written; sometimes there is in- 
ability to understand what is said or to 
read what is written. These disabilities 
result from interference with the brain 
mechanisms concerned with language and 
they are not merely the indirect result of 
some other condition such as mental con- 
fusion, blindness or deafness. We are con- 
cerned here only with the loss of vocal 
speech for which the terms aphasia (loss 
of speech) and dysphasia (disturbance of 
speech) are often used interchangeably. 

Dysphasia may be slight or severe and 
may take several forms. Nominal dysphasia 
is an inability to name objects; the patient 
can recognize things shown to him and 
can describe and demonstrate their use, but 
he cannot put names to them. This is very 

frustrating for him but he usually recog- 
nizes and can repeat the name if it is 
spoken to him ... It is noticeable, how- 
ever, in many cases of severe dysphasia 
that although the patient is quite unable to 
express original thoughts or ideas in speech 
... he can give vent to more emotional 
or semi-automatic phrases. He may have 
little or no difficulty, for instance, in re- 
turning greetings, singing songs, reciting 
poetry or swearing. 

Perseveration, which is a feature of 
some cases of dyphasia. means that the 
patient tends to repeat out of context a 
word or phrase which he has just used. It 
is as if he gets stuck in a groove. When 
asked to name a certain object, he may 
eventually succeed in doing so but there- 
after he continues to use the same word 
when asked to name other objects ... In 
jargon dysphasia there is a complete loss 
of ability to communicate ideas in language; 
grammar disintegrates, words are put to- 
gether in a meaningless way and bizarre, 
non-existent words are used freely. Patients 

with jargon dysphasia are generally loqua- 
cious and unperturbed; they seem unaware 
that their speech is like a foreign tongue 
and quite meaningless. 

Aphasia is usually caused by disease or 
damage involving certain parts of the left 
side of the brain. It is not surprising, there- 
fore, that aphasia is often accompanied by 
right hemiplegia, or other evidence of a 
lesion of the left cerebral hemisphere. The 
loss of speech and the loss of power on 
the right side may develop slowly or 
suddenly and may be partial or complete. 

If a slight "stroke" due to a cerebro- 
vascular lesion occurs while the patient is 
awake, there may be temporary loss of 
consciousness with subsequent dysphasia. 
A left-sided cerebral tumor may result in 
the more gradual development of dysphasia 
and other signs. Dysphasia may, in fact, 
be the consequence of any disease process 
which involves the so-called speech centres 
of the brain. — Jewesbury, Eric. C. Dis- 
turbances of speech in neurological disease. 
Nursing Times, 58:1100-02, Aug. 1962. 


MARCH 1965 


Nursing Care : 

Patients with Herniated Discs 

LisE Moody, r.n. 


When told that a patient suffering 
from a herniated disc is to be admitted, 
the nurse should make certain that the 
mattress of the bed assigned to him 
is firm and even. A mattress of this 
type will favor better muscle relaxa- 

If conservative therapy fails, the 
patient with a herniated disc may be 
submitted to a myelogram. Myelo- 
graphy is performed under the fluoros- 
copic screen, many x-rays being taken 
after injecting a contrast medium into 
the spinal canal through a lumbar 
puncture. The nurse must tell the 
patient what the tests consist of, and 
stress the importance of being com- 
pletely relaxed. The word "lumbar 
puncture" should be avoided, since it 
may be a cause of anxiety because of 
its association in the patient's mind to 
Tieningitis and pain. On the morninp 
of the myelogram, the prescribed pre- 
medication will be given on call. Or- 
dinarily, the patient will not be kept 
fasting since myelography is performed 
under local anesthesia. 

Upon return from the x-ray depart- 
ment, the patient should be kept in a 
horizontal position for 24 hours to 
avoid a possible post-puncture head- 
ache because of the loss of spinal 
fluid. In such a case the nurse should 
ask the patient to drink as much as 
possible and should give him analgesics 
every four hour as necessary. 

The tubes containing the spinal 
fluid should be sent to the laboratory 
as soon as possible. The following 
analyses are usually required: 

1. Pandy's test and cells; 

2. glucose, chlorides, proteins; 

3. Wassermann and colloidal gold 


Care upon arrival: 

As soon as the medical examination 
has been completed, the nurse should 
measure the patient's neck to fit him 
with a felt collar, which he will keep 
on all the time. The measurements are 

taken from the head of the clavicle 
to the chin, with the head in very 
slight extension so as to estimate the 
width of the collar. The length of 
the collar should be that of the cir- 
cumference of the neck plus three 
inches. Its purpose is to avoid flexion 
of the head, which would increase 
painful compression of the nerve root. 
The patient may be allowed to sit 
up or to be in a semi-sitting position 
in bed. He should have at least two 
pillows when going to sleep so that if 
he turns on his side during the night 
there will not be undue lateral flexion 
of the neck because of the head falling 
towards the shoulder. If the patient 
suffers a great deal, analgesics are 
given every four hours and a barbitur- 
ate is added at that time. Antispas- 
modic drugs will also be prescribed. 
As a rule, the patient will be allowed 
to get out of bed. Cervical tractions 
are the mainstay of the treatment. 


Cervical traction: 

The aim of cervical traction is to 
allow the herniated disc to fall back 
in place by increasing the interverte- 
bral space; this, in turn, will diminish 
root compression and alleviate pain. 
Traction may be performed in bed, 
with the patient in a semi-sitting posi- 
tion. More frequently, it is done with 
the patient sitting on a straight chair 
at the foot of the bed (Figure 1). With 
a rope and pulleys, a traction of 8-15 
pounds may be applied during 20 to 
30 minutes, at least four times a day. 
If the patient is to receive a glucose 
solution with an antispasmodic drug 
(Robaxin), this should be administered 
just before the onset of traction so 
as to obtain maximum muscle relaxa- 
tion. When traction is removed, the 
felt collar is put back in place. Certain 
points must be observed while applying 
cervical traction: 

1. The patient should be sitting on the 

Miss Moody is assistant head nurse, 
Neurological Unit. Notre Dame Hospital. 




Traction -^ , ,- 
collar IH >'/ 



Fig. \ 


MARCH 1965 


chair so that his back is absolutely 

2. The neck must be in line with the 
overhead pulley and the rope. 

3. The traction collar should be ad- 
justed so that the rings are at the same 
level on either side. TTiis collar must be 
fitted snugly, but comfortably. 

4. If traction is painful, the physician 
should be notified. Sometimes pain results 
from compression of the jaws, and this 
may be avoided by placing a mouthpiece 
between the patient's teeth. 

5. The patient should be as comfortable 
as possible so as to be able to undergo a 
long session of traction. If he is not 
relieved, which is unusual, a cervical 
discoidectomy may be recommended. 


Preoperative core: 

On the day prior to surgery, a 
hexachlorophene bath and a shainpoo 
are given to prepare the operative 
field. Shaving is usually done in the 
operating room, immediately prior to 
operation. Before his bath, the patient 
may be given an enema if necessary. 
The nurse should try to answer his 
questions about the operation to relieve 
his anxiety, so that he may get a good 
night's sleep. If he desires, he may be 
seen by the chaplain. 

On the morning of the operation, 
the patient is given the prescribed 
premedication and is taken to the 
operating room with his felt collar on. 
A male patient's face should be shaven 
prior to these procedures. 

Postoperative care: 

On returning to the department, the 
patient will be transferred from the 
stretcher to his bed by four attendants: 
one standing at the head, one at the 
feet of the patient, and one on each 
side of the stretcher and the bed, which 
are placed close together. The sheets 
are held firmly by the four attendants 
and the patient is transferred gently. 
These sheets will also be used to hoist 
the patient up in his bed and to put 
him in semisupination until he is 
awake, and then in a semi-sitting 
position. His position is changed every 
two hours from semisupine to supine, 
the semiprone position being avoided 
so as not to strain his neck. A small 
pillow is placed under his head, to 
maintain good alignment of the spine. 

Alcohol rubs are soothing, but tal- 
cum is to be avoided since it could 
penetrate under the dressing and cause 
local irritation. 

If the patient has been unable to 
void eight hours after operation, the 
intern should be called to determine 
whether catheterization is indicated. 

A liquid diet is given on the first 
night. If the patient in nauseated, a 

Small board 
Air foam 




Fig. 2 

glucose solution with Gravol is given 
intravenously. Diet is increased the 
following day. 

Vital signs are checked every hour, 
as prescribed, for the first 24 hours, 
and every 3 hours afterwards. Daily 
intake and output is measured for 3 
days. Demerol or Dilaudid or another 
analgesic is usually prescribed every 
4 hours if needed, since the patient 
may be suffering in the immediate 
postoperative period. He may be up 
on the first or second postoperative 

Stitches are removed 7 days after 
surgery. In the meantime, the patient 
is given physiotherapy if the herniated 
disc had produced paresis in one of 
his upper limbs. He is usually dis- 
charged 8 to 10 days after operation, 
and wears a collar whenever he gets 
up from the time of operation. 

Core upon arrival: 

Certain routine precautions are 
taken when a patient with an acute 
lumbar disc herniation is admitted. His 
bed is provided with a board extending 
the entire length of the orthopedic 
mattress. This board will increase the 
rigidity of the mattress and will provide 
better support and relaxation for his 
back. The nurses will tell this patient 
to stay in bed and to get up only for 
meals or when he goes to the bath- 
room. He should avoid easy chairs 
and always choose a hard chair with 
a straight back. He must not bend 
under any circumstance. The bed will 
always be kept straight so as to avoid 
faulty posture in the lumbar region 
and the board is also used to ensure 

An ordinary bedpan should never 
be used; instead, an orthopedic type 
of bedpan which can be easily inserted 
without appreciably raising the pa- 
tient's hips is used. The medication 
is the same as for a herniated cervical 
disc. Lumbar tractions is usually 

Lumbar traction: 

The aim of lumbar traction is the 
same as that of cervical traction, that 
is, to help reduce the herniation of 
the disc and thus relieve root irritation. 
Traction is usually done in bed with 
the patient in the reclining position. 
Wooden blocks are inserted under the 
foot of the bed on each side so as 
to raise it approximately five inches. 
This increases the efficiency of trac- 
tion and prevents the patient from 
being pulled down in his bed. Weights 
of 10 to 15 pounds are fixed to either 
leg, with bands of airfoam maintained 
by elastocrepe bandage (Figure 2). 
The nurse should verify the following 

1. The patient must be lying on his 
back in the centre of the bed with a 
single pillow under his head. 

2. The lower limbs should be in line 
with the pulleys. 

3. The small square wooden boards 
to which the ropes are tied at the base 
of the airfoam bands must not be too 
close to the sole of the foot. To avoid 
pressure and for comfort, there should 
be at least V/2 inches between the board 
and the patient's foot. 

4. The bandages must not be too tight, 
so as not to impair circulation: but they 
must be snug enough to avoid slipping. 

5. One should verify that the weights 
used on either side are equal. 

6. When a solution containing an anti- 
spasmodic drug, such as Robaxin, is 
prescribed, it should be given just before 
traction so as to obtain maximum relaxa- 

7. The patient must not sit up with 
his traction on. The traction should be 
maintained as long as possible. When 
the patient is tired, the weights are re- 
moved for half an hour and then they 
are put on again. If traction increases 
the patient's pain, it should be stopped 
and the physician informed; however, it 
is not unusual for traction to cause some 
discomfort in the groins. 

The patient must learn to sit on 


MARCH 1965 


Semi Supine 

Semi Prone 

Fig. 3 

the side of his bed in one movement. 
To do this, he must first He on his 
side near the edge of the bed, then let 
his legs fall down as he pushes himself 
up from the bed with his hands, with 
little or no bending of the spine. 

Preoperative care: 

On the night prior to surgery, the 
nurse should teach the patient the 
best way to change position, that is 
to move from the semisupine position 
on one side to a prone position, and 
then to a semisupine position on the 
other. This will allow him to turn 
himself and to avoid the pain which 
might result from being moved by less 
trained personnel. The nurse will help 
mostly by her suggestions, or in helping 
with a limb or the hips as the case 
may be. The patient must avoid bend- 
ing the spine in the lumbar region. 

Before taking his bath, the patient 
is given an enema; afterwards, he is 
scrubbed with hexachlorophene. The 
operative field is usually shaved in the 
morning, immediately prior to sug- 
gery. (For other details, see: cervical 

Postoperat'iye care: 

The patient is transferred from the 

stretcher to his bed with the sheets, 
as described after cervical discoidec- 
tomy; but he Ues in a horizontal posi- 
tion, semisupine with a single pillow 
under his head. The nurse should see 
that his back is straight. His position 
must be changed every two hours from 
semisupine to semiprone, and from 
side to side (Figure 3), so that his hips 
do not become too tender. Occa- 
sionally, when a graft has been done, 
he may be kept on his back for 24 
hours. The patient's hospital gown is 
removed, so that it will not bunch up 
under him and he can be moved more 

Vital signs are checked every hour 
until they are stabilized, and, after- 
wards, every three hours. 

If the dressings become soiled, the 
intern should be called to change them, 
so as to avoid contamination of the 
operative wound. Talcum powder 
should again be avoided. Bedpans are 
not used in the first postoperative 
days. For women, a special urinal or 
towels are used. (For other details. 
see: cervical discoidectomy.) 


The patient will start sitting up 
three to four days after operation, in 
the manner already mentioned, but the 

nurse should not put pillows in his 
back to hold him up. They give a 
false sense of security and will pre- 
vent the patient from maintaining a 
perfectly straight position. The first 
few times that he sits up, he should 
be helped by holding his shoulders 
after he has turned on his side. He 
must be lifted quickly in an unin- 
terrupted movement to avoid any pain- 
ful muscle contraction. Whether sitting 
or standing, his back must always be 
straight. He will use the same method 
to lie back in bed. He should avoid 
walking with a chair or table in front 
of him, since this will make him stoop 
slightly forward. He should not walk 
while holding one person by the shoul- 
der, because this may bend his back 
laterally. If he needs help to take his 
first steps, he should be held by the 
forearms. He should be encouraged 
to walk as much as possible so as to 
regain good muscle tone. If he has to 
bend to pick up an object, he must be 
taught to do it by bending his knees 
and crouching, without bending his 
back. He should avoid flexion of his 
spine for a few weeks and then pro- 
gressive flexion and tension exercises 
may be taught. As a rule, after a few 
days the patient is greatly relieved 
following surgery. 



April 1965 

H. Peplau — Interpersonal Relations A. J. Bailey — Smoking and Lung Cancer 

V. Wood — Understanding Psychometric Tests L. Turner — Counseling 

G. Camming and L. Young — Physical Fitness in Nurses 


Prompt recognition 0/ this abnormality is imperative. 

R. R. TaSKER, M.D., F.R.C.S.(C) 

The cranial cavity is unique because 
of its rigidity, whicli prevents accom- 
modation to more than minor increases 
in the volume of its contents. Even 
before the sutures close, the infant 
skull can compensate only partially for 
increased pressure by means of enlar- 

Obviously, cerebral edema, abnor- 
mal masses, excessive cerebrospinal 
fluid (hydrocephalus) and venous en- 
gorgement, all lead to increased intra- 
cranial pressure with compression of 
brain cells. Since compressed nerve 
cells cease functioning, unresolved 
intracranial hypertension is incom- 
patible with normal life. As much of 
the practice of neurosurgery consists 
of correcting this abnormality before 
irreversible damage is done, one of 
the prime functions of the neurosurgi- 
cal nurse is its prompt recognition. 
The events may be dramatic and 
obvious, even to the novice, as in acute 
extradural hematoma ; on the other 
hand, they may be subtle, gradual, and 
difficult to detect. 

Clinical Manifestations 

Whatever the cause and rate of pro- 
gression, increasing intracranial pres- 
sure may be recognized by one or 
more of the following criteria : 

1. Progressive enlargement of the head 
in the baby ; 

2. progressive bulging of the post-cranio- 
tomy decompression if the dura remains 
open ; 

3. failing consciousness ; 

4. rising blood pressure : 

5. falling pulse rate : 

6. progressive enlargement and failing 
reaction to light of one or both pupils : 

Dr. Tasker is from the Department of 
Surgery. University of Toronto and the 
Division of Neurosurgery. Toronto General 
Hospital, Toronto, Ont. 

7. progressive loss of function of limbs : 

8. progressive difficulty in speech ; 

9. alteration in respirations ; 

10. certain other features such as increas- 
ing headache, nausea and vomiting, decreas- 
ing vision, double vision, loss of sensation. 

Level of Consciousness 

An understanding of the mechanism 
01 these changes will, perhaps, aid in 
their interpretation. The enlarging 
head and bulging decompression are 
mechanical matters. Deterioration of 
the level of consciousness is, however, 
more obscure. Consciousness depends 
upon the integrity of function of a 
certain portion of the cerebral cortex 
and of nerve cells scattered through 
the brainstem known as the reticular 
system. Impairment of function of 
these structures by compression and, 
later, ischemia, induces the varying 
degrees of unconsciousness. 

Blood Pressure and Pulse 

Pulse and blood pressure changes 
are attempts to preserve brain func- 
tion in the face of rising pressure. 
First, venous flow slows, veins and 
arteries dilate, cerebral blood flow 
falls. But cerebral vasoconstriction 
compensates for this temporarily, after 
which failing oxygen supply stimulates 
the vasomotor centre to elevate the 
blood pressure with reflex fall in 

Pupillary Signs 

The site of compression which ex- 
plains the pupillary signs is the oculo- 
motor or third cranial nerve at the 
tentorial notch or incisura. Through 
this passage between the posterior 
fossa and the supratentorial space 
passes the midbrain with associated 
vessels and nerves including the third. 
In the event of unilateral compression 
from above the uncus, a portion of 

the temporal lobe, which normally lies 
just above the incisura, is gradually 
forced into the slit between the mid- 
brain and the tentorial edge on the 
side of the compression until it pouts 
into the posterior fossa. This gradual- 
ly compresses and flattens the third 
nerve, until the latter ceases to con- 
duct. Since its parasympathetic fibres 
cause the iris to contract, paralysis 
results in pupillary dilation and loss of 
the light reflex (fixation) on the side 
of the compression. This mechanism, 
if allowed to progress, leads eventu- 
ally to compression of the opposite 
third nerve, dilation and fixation of 
the opposite pupil, together with com- 
pression of the midbrain itself. Here. 
pressure on the pyramidal tracts pro- 
duces hemiplegia, while compression 
of the reticular formation induces 
failing consciousness. Further distor- 
tion of the shape of the brainstem 
ruptures small arteries causing "pres- 
sure" hemorrhages and irreversible 

In rising pressure due to infra- 
tentorial or bilaterial supratentorial 
causes, this clear-cut sequence of 
events is not seen, though coma and 
bilaterally fixed dilated pupils eventual- 
ly supervene. 

Movement of Limbs 

Loss of control of arms and legs 
— usually in the form of a progres- 
sive hemiplegia (often associated with 
progressive "speech disturbance or 
dysphasia if the dominant side is 
involved) — may be explained by 
direct compression of the opposite 
cerebral cortex and/or its connections, 
suggesting an expanding lesion. How- 
ever, hemiplegia may also result from 
Kemohan"s notching, and from com- 
pression of the pyramidal tracts else- 
where within the brainstem. With 
rising pressure, paralysis gives way to 


MARCH 1965 


"extensor spasms" and "extensor rigid- 
ity." The musculature of the body 
passes into a rigid state of universal 
extension, either intermittently in 
"spasms" especially on stimulation, or 
for longer periods. This is due to 
excessive stimulation of muscle 
spindles (tiny organs in skeletal mus- 
cle designed to regulate tone) because 
of compressive suppression of normal 
inhibitory systems. 


Experience is required to detect the 
difference between the quiet respira- 
tions of sleep and the stertorous or 
snoring breathing of stupor and coma. 
As intracranial pressure rises, however, 
periodic or Cheyne-Stokes respirations 
supervenes. This ominous sign is a 
manifestation of medullary ischemia. 

Other Symptoms and Signs 

Headache is probably due to dis- 
tortion of nerve endings in the intra- 

cranial vasculature ; vomiting results 
from direct pressure on the medullary 
vomiting "centre", decreased vision, 
diplopia, and other neurological symp- 
toms are due to compression of the 
appropriate structures. Since the eyes 
and optic nerves are really part of the 
brain and share the latter's structure, 
increased intracranial pressure is trans- 
mitted to these organs where, under 
certain conditions, it may be recognized 
as papilledema. 

Though not strictly part of the "in- 
creased intracranial pressure syn- 
drome," certain other features require 
consideration. Alterations in temper- 
ature, particularly hyperthermia, are 
frequently seen in patients with intra- 
cranial hypertension. Though it may be 
due to loss of thermo-regulation or 
to blood or infection in the cerebro- 
spinal fluid, an elevated temperature 
is more often due to respiratory or 
urinary causes. Whatever the source, 
it must be controlled since it raises 

the metabolic needs of nerve cells 
already prejudiced. 

Also completely unacceptable in 
patients with raised pressure is any 
interference with respiration. Preser- 
vation of the clear airway is perhaps 
the most vital function of the neuro- 
surgical nurse. Respiratory distress 
results not only in interference with 
oxygen supply, but also in venous 
engorgement and increased intracranial 
pressure — both by mechanical means 
and by vasodilation due to the action 
of retained carbon dioxide. 


The effective neurosurgical nurse 
should be able to recognize promptly 
changes indicative of rising intracranial 
pressure — such as in the post-trau- 
matic postoperative patient who may 
have a clot, or in the tumor patient 
who is "going bad." She will com- 
prehend what these changes signify, 
and take appropriate action. 


The following discussion of nursing res- 
ponsibilities will be mainly concerned with 
the care of the patient receiving external 
hypothermia. The same underlying physio- 
logic considerations apply, however, to the 
nursing care of any hypothermic patient, 
regardless of the method employed. 

Just before hypothermia is to be initiated, 
a complete bath, if indicated, may be given 
to the patient. Once the temperature has 
been reduced, only partial baths are usually 
necessary. In some hospitals, a mixture of 
lanolin, mineral oil. or cold cream is applied 
lightly to the entire body before hypothermic 
induction to protect the skin against dryness 
and to maintain skin integrity. A thin coat 
of oil or lanolin will tend to protect the 
skin from direct prolonged exposure to 
any ice that may form on the blanket from 
condensation and will decrease the possi- 
bility of frost bite. It tends to allow better 
contact of the skin with the cooling 
blankets and decreases the insulating air on 
the skin surface, allowing more rapid cool- 
ing. Once the desired hypothermic temper- 
ature is reached, oil to the skin, massage, 
and partial baths, plus turning the patient 
at least every two hours, will usually 
protect the integumentary system. 

An indwelling catheter is usually inserted 
before hypothermia is initiated. The pa- 
tient's decreased level of consciousness — 
resulting either from his disease condition 
(often a neurologic one) or the hypothermia 
itself — may lead to loss of voluntary 
control of voiding. As hypothermia pro- 
gresses, renal blood flow and the glomerular 
filtration rate are depressed (30 per cent 
of normal at temperatures of 77°-80° F. 
with no equivalent fall in sodium excretion 
or urine volume). Urinary output becomes 
dilute and of low specific gravity possibly 
because the antidiuretic hormone is de- 
pressed or because the renal tubules are 
less sensitive to the effects of the latter. 
Intake and output records are indicated, and 
specific gravity readings may be taken as 
often as every two hours. Renal blood flow 
and filtration rate are about two thirds of 
normal following rewarming. They return 
to normal in about 24 hours. 

Pulse, respiratory rate, and blood pressure 
are taken and recorded before treatment is 
begun. In fact, vital signs should be taken 
several times prior to hypothermic induc- 
tion so that a baseline blood pressure read- 
ing can be established. 

If the patient is conscious prior to induc- 

tion of hypothermia, the procedure should 
be explained to him. His family is usually 
informed of the treatment by the physician. 

Prior to hypothermic induction, the nurse 
should observe the patient closely and 
record her observations, including presence 
and severity of shivering, evidence of accu- 
mulation of secretions in the respiratory 
tract, regularity of heart rate, presence or 
absence of edema, skin condition, pupillary 
reactions, and extremity movement (normal, 
flaccid, or spastic). If possible she should 
elicit any information that might affect the 
patient, directly or indirectly, during the 
treatment (such as religion or psychosocial 

Following these procedures, the patient is 
placed, usually in a supine position, on the 
uncovered hypothermic blanket: a hypother- 
mic blanket may also be placed on top of 
the patient. He is usually covered only in 
the pubic area. The rectal thermocouple or 
thermistor is then inserted, the physician 
sets the gauge at the desired level and 
turns on the machine, and the induction 
process is under way. — Mary Catherine 
Hickey. Hypothermia. American Journal of 
Nursing. 65: 116-122. January 1965. 


MARCH 1965 


Recognition, Recording and Significance 

of the Signs of 
Increased Intracranial Pressure 

The nurse responsible for the care of neurosurgical patients must be coristantly vigil- 
ant, must make intellingent observations, and must have the ability to in- 
terpret and record these observations. She must understand the neuro-pbysio- 
logical basis for the symptoms and be aware of the need to rapidly institute 
nursing and medical measures if life is to be preserved. 

Jessie F. Young, reg.n., b.a. 

"Watch the patient closely !" How 
often have you, as a nurse, been told 
to do this ? From this statement two 
questions immediately arise : 

Why should I watch the patient closely ? 

What should I watch for, and what 

should these observations mean to me ? 

An explanation of the mechanisms 
underlying the symptoms and signs of 
raised intracranial pressure is given in 
the accompanying article by Dr. R. R. 
Tasker. The nurse, by understanding 
the significance of her observations, 
need waste no time in consulting her 
medical colleagues as to the appropri- 
ate treatment. 

A method of testing and recording 
observations has been developed at the 
Toronto General Hospital, and is used 
routinely in evaluating neurosurgical 
patients. This method consists of as- 
sessing the patient's clinical state when 
he first comes under observation, and 
comparing his subsequent condition 
with this in order to detect changes 
indicative of increasing intracranial 
pressure, should they arise. (Figure 1 .) 

A man of 40 was involved in a car 
accident at 2:00 a.m. and was rendered 
unconscious. On arrival in the neurosurgical 
unit he was placed under observation. As 
the record shows, entries of his condition 
were made at half-hourly intervals 
throughout the night. {Figure 2.) He con- 
tinued to improve until 7:30 a.m. At this 
time it was noticed that there was a lower- 
ing in his level of consciousness, and at 
8:00 a.m. the right pupil became dilated 
and fixed to light. The left arm and leg. 

Miss Young is nursing supervisor, Divi- 
sion of Neurosurgery, Toronto General Hos- 
pital, Toronto, Ont. 

which had been weaker than the right, were 
rigid ; the blood pressure, pulse, and res- 
pirations changed rapidly with increasing 
intracranial pressure. Ttie patient was taken 
to the operating room and a right subdural 
hematoma was removed. 

This record demonstrates the speed 
with which deterioration can occur. It 
is highly desirable to institute treat- 
ment if possible before such grave 
signs as pupillary fixation and spastic 
hemiplegia develop. 

The frequency of craniocerebral 
testing is ordered by the doctor. It 
varies from half-hourly to four-hourly. 
In the event of an abnormal symptom 
arising, the testing should be repeated 
more frequently, irrespective of the 
order. For example, a patient who is 
on four-hourly testing may become 
difficult to rouse and show a slight 
rise in blood pressure ; the frequency 
of testing of the abnormal symptoms 
should be increased. Change in a 
patient's condition may occur over a 
period of days, in a few hours, or even 
in a few minutes (as in the patient 
mentioned above). The nurse observing 
the patient must constantly evaluate 
the present testing in terms of the 
previous testing. Both the patient 
and the family should realize that 
testing is done routinely. If they 
understand the reason for these fre- 
quent interruptions they are reassured; 
if they do not, it is natural that they 
should ascribe the intensive nursing 
activity to a deteriorating condition of 
the patient. 

Frequently, the onset of deterior- 
ation is quite subtle: irritability, leth- 
argy, failure to eat, difficulty in swal- 
lowing, incontinence, may precede the 
symptoms as outlined in the cranio- 

cerebral testing chart. Only through 
her knowledge of the patient can the 
nurse detect these changes early. The 
head nurse and the surgeon should 
never minimize the nurse's observa- 

Records should be neat, concise, 
and factual. State observations clearly. 
The doctor is responsible for the 
diagnosis, but his decision is frequent- 
ly based on your observations. All 
records should be signed, since 
further discussion or explanation may 
be required. 

Levels of Consciousness 

The patient's level of consciousness 
is assigned to one of five categories — 
alert, drowsy, stuporous, semi-conia- 
tose, or comatose. The exact rneaning 
of these terms when used consistently, 
is understood by both medical and 
nursing staff working closely together. 
The term "unconscious" is not used, 
as it is too vague for accurate descrip- 
tion. Some common observations on 
which the choice of category is based 
are these: 

1. Conversational ability (questioning as 
to name, day, time, place, etc.). 

2. Ability to obey simple commands, 
such as "Raise your right arm. Touch 
your left ear with your right hand." 

3. Response to painful stimuli (used in 
testing if the level is stuporous or lower). 
The amount of pressure required — light, 
moderate or severe — will, of course, vary 
with the level of consciousness, and only 
the minimum stimulation needed to evoque 
a response should be applied. To test for 
pain, hold the patient's finger tip between 
your thumb and first finger. Apply pres- 
sure to the sides of the finger tip. (If the 
hands are covered and cannot be used for 


MARCH 1965 


_ ri O * 


MARCH 1966 


testing, apply pressure to the Achilles 
tendon or to the tip of the little toe, 
using the same method for the finger.) Do 
not test for pain by pinching or scratching 
with a sharp object in such a way that 
bruises or marks occur ; these are signs of 
poor patient care. 

The type of response to pain is also 
significant : purposeful resistance and with- 
drawal, or purposeless extensor spasm — 
the latter type of response signifies that 
the patient is functioning at a lower level 
of consciousness than the former. 

A lowering of the level of consciousness 
without any noticeable change in the other 
vital signs is important, and should be 
reported at once. 

Accurate evaluation rests on many 
factors other than those specifically 
mentioned here, and the experienced 
nurse knows that these must not be 
ignored. Ill patients admitted from 
another hospital, on being asked where 
they are, will usually name the hospi- 
tal from which they were transferred. 
Answers may be delayed ; patience 
and persistence are required. The nur- 
sing staff responsible for the patient's 
care is often more successful in elicit- 
ing verbal responses than the neuro- 
surgeon as he makes rounds. 

Blood Pressure and Pulse Rate 

It is convenient to observe and 
record the vital signs in the order in 
which they change during deterioration. 
A lowering in level of consciousness 
due to increasing intracranial pressure 
is usually followed by a rise in blood 
pressure and a lowering in pulse rate. 
The rise may be transitory, gradual or 
sudden. The clinical picture must not 
be confused with cardiovascular 
shock, in which the blood pressure 
falls and the pulse rate rises. The 
characteristics of the pulse should 
also be recorded; rate, rhythm, vol- 
ume. Postoperatively, observations 
should be compared with those made 
during surgery and in the recovery 

Important as these observations are, 
it should be remembered that, as a 
rule, a rising blood pressure and a 
falling pulse rate are signs of in- 
creasing intracranial pressure that dev- 
elop after the level of consciousness has 
already begun to sink. 

Pupillary Reaction 

Firstly, compare and record the size 
and shape of the pupils. Secondly, 
light is directed into the eye under 
examination, while the other eye is 
covered ; the pupil constricts if the 
reflex pathways have not been damag- 
ed. The presence or absence of res- 
ponse is most important. Normally, the 
pupil responds by rapidly constricting 

to light. In the early stages of oculo- 
motor nerve impairment due to the 
effects of raised intracranial pressure, 
the contraction is slower and less in 
extent than in the opposite eye. At the 
same time the affected pupil is slight- 
ly larger. When paralysis is advanced, 
the pupil is widely dilated and fails 
to constrict when the retina is stimulat- 
ed by light. 

Restless patients are frequently 
resistive to testing, and assistance may 
be required for proper evaluation. 
The method of recording pupillary 
reaction is shown in Figure 1. 

Movement of Arms and Legs 

During routine care, as well as 
during craniocerebral testing, the 
movement of the arms and legs should 
be observed. The movements may be 
described as being under voluntary 
control, spontaneous, or in response 
to command. A comparison is made 
between the right and left sides. Hand 
grips are tested simultaneously as to 
equality, strength of grip and release. 
The ability to move the legs to com- 
mand and any evidence of loss of 
motor power is recorded. Both legs 
are tested and compared. If the patient 
is not obeying commands, the m.ove- 
ment of the arms and legs is evaluated 
in response to painful stimuli — light, 
moderate or severe. At the lowest level 
of consciousness the limbs adopt a 
posture of extension and rigidity in 
response to painful stimulation. 

Temperature Control 

The temperature is taken rectally 
at specified times. Frequency of 
testing will be increased if a marked 
change is noted. With an elevation of 
temperature the possibility of any in- 
fection should be considered; the com- 
mon sites of infection are the chest, 
urinary tract, skin or wound. 

Sometimes the temperature rises 
with the advent of raised intracranial 
pressure. The elevation varies with the 
suddenness and the severity of the 
rise in pressure, but this is usually 
not one of the early changes observed. 
Nursing measures to reduce the raised 
temperature must be started as soon 
as an elevation is observed, and con- 
tinued until the temperature returns 
and remains within normal limits. (For 
nursing measures see the following ar- 
ticle, "Nursing Care of Patients with 
Ruptured Cerebral Aneurysms.") It 
may not be desirable to reduce a fever 
due to inflammatory causes, as in these 
cases the fever is part of the body's 
reaction and defence against the in- 
vading organism. 


Maintenance of a clear airway is 

imperative. A lowering of the level of 
consciousness may be caused by a 
blocked airway because it aggravates 
raised intracranial pressure. In observ- 
ing respirations, the nurse should re- 
cord the rate, regularity, and type of 
respiration (e.g. shallow, stertorous, 
periodic and whether accompanied by 

If positioning and suctioning do not 
relieve respiratory distress, a tracheo- 
tomy may be necessary. The observa- 
tions will then include the appearance 
of the tracheotomy site, the amount 
and type of secretions, any difficulty 
in suctioning, and how the patient is 


Do not panic or leave the patient. 
You cannot prevent the seizure run- 
ning its full course. Put the patient on 
his side to prevent him suffocating 
from airway obstruction, due to the 
tongue falling back. At the same time 
watch the seizure develop and then 
record your observations accurately. 
The diagnosis of the condition often 
depends mainly on the nurse's word. 
Have someone notify the doctor.* Ob- 
servations will include the onset of 
the seizure, the sites involved, to 
which side the head and eyes turned, 
the level of consciousness, incontin- 
ence, duration, and the condition of 
the patient after the seizure and his 
ability to recall details. 

Other symptoms include : 

headache, nausea and vomiting, 
ptosis, difficulty of speech, and diz- 
ziness. All are significant and should 
be recorded. 

Recognition, interpretation and re- 
cording of the signs associated with 
increased intracranial pressure is the 
responsibility of the nurse. The man- 
agement of the patient will vary with 
the cause. No matter what treatment 
is carried out, the craniocerebral test- 
ing must be continued until a normal 
level is established and maintained. 

In nursing neurosurgical patients 
the nurse must be familiar with the 
doctor's findings and his provisional 
diagnosis. She must determine the 
patient's base line. By constant moni- 
toring of the signs and symptoms, the 
patient's condition is constantly com- 
pared with the base line already estab- 
lished — any deviations from it are 
reported at once. Effective action may 
depend on the promptness with which 
the nurse recognizes abnormal symp- 
toms and informs the doctor. 

* It will be noted that the use of a gag 
or any other device to hold the jaws 
apart is not recommended. The nurse 
may damage the teeth, gums or tongue, 
yet do nothing to improve the airway. 


MARCH 1965 


Intracranial Berry Aneurysms 

Early diagnosis and surgical intervention have helped to reduce the mortality rate. 

W. M. LX)UGHEED, M.D., F.R.C.S.(C) 

The intracranial berry aneurysm is 
an out-pouching or diverticulum of 
the wall of a cerebral blood vessel. A 
developmental weakness in the blood 
vessel, due to absence of the medial 
coat of the artery, is responsible for 
the subsequent development of a 
pouch-like swelling. Hence, aneurysms 
have a very thin wall composed only 
of adventitia and intima. Although the 
defect in the artery is present at birth, 
many years are required for the crea- 
tion of a berry aneurysm. This ex- 
plains the rarity of the condition under 
the age of 20. The distribution of 
aneurysms in the succeeding decades 
is equal. 

Fig. 1 . Internal carotid artery; 2. anterior 
communicating; 3. middle cerebral; 4. ba- 
silar; 5. basilar; 6. vertebral; 7. posterior 
cerebral. Distribution of aneurysms located 
on the circle of Willis. Above the double 
line, 90% occur; in the posterior half of the 
circle of Willis (below the double line) 
10% occur. 

Aneurysms are found on the circle 
of Willis and its major branches. They 
always occur at sites where a vessel 
bifurcates or gives off a branch. The 
common sites are: the internal carotid 
artery at the origin of the posterior 
communicating arteries; the anterior 
cerebral at the origin of the anterior 
communicating artery; the middle ce- 
rebral at the site of its major division. 
Only 10 per cent arise from the poste- 
rior part of the circle of Willis (basi- 
lar artery and related branches). See 
Figures 1 and 2. 

Mode of Presentation 

An aneurysm may make its presen- 
ce known either by rupture, expan- 
sion, or local pressure on adjacent im- 
portant structures. The most common 
and classical picture is produced 
when the rupture occurs into the sub- 
arachnoid space. Immediately the pa- 
tient experiences headache of such se- 
verity that it wou'd seem his head 
were about to burst. Some patients 
become unconscious temporarily, and 
then improve. The patient may com- 
plain of photophobia and stiff neck. 
These symptoms, in conjunction with 
the characteristic suddenness of onset, 
are sufficient to allow a presumptive 
diagnosis of a spontaneous subarach- 



in media 

Dr. Lougheed is from the Department of 
Surgery, University of Toronto, and surgeon. 
Division of Neurosurgery, Toronto General 
Hospital. Toronto. Ont. 

Fig. 2. Schema indicating the medical de- 
fect responsible for the inherent weakness in 
the wall, which later forms the saccular 
dilatation or aneurysm. 

noid hemorrhage, of which the ruptur- 
ed berry aneurysm is the most com- 
mon etiologiccd agent. Headache 
usually jjersists for several days; in 
some instances, where the hemorrhage 
has been severe or recurrent, it may 
continue for many weeks. 

An aneurysm may rupture into the 
cerebral substance. If rupture is se- 
vere, death usually follows immediate- 
ly. Patients who survive the initial in- 
tracerebral bleeding may demonstrate 
signs of subarachnoid hemorrhage, lo- 
cal neurologic disturbance (eg., hemi- 
paresis, hemiplegia, third nerve paraly- 
sis, 6th nerve palsy, etc.), and signs 
of increased intracranial pressure. It is, 
therefore, important to recognize that 
a sudden stroke in the presence of se- 
vere headache and stiff neck probably 
indicates the rupture of a berry aneu- 

On examination, photophobia and 
the complaint of severe headache are 
often quite striking. The patient may 
choose to lie on the side, with the head 
and eyes turned away from the light. 
Irritability, mental confusion and 
drowsiness are frequently present. In 
more severe cases, coma and focal 
neurologic disturbance (hemiparesis, 
hemiplegia, quadriplegia, aphasia, aki- 
netic mutism) will predominate. A 
stiff neck indicates meningeal irrita- 
tion due to blood in the subarachnoid 


The diagnosis can be established by 
lumbar puncture, which will reveal the 
presence of blood or xanthochromia. 
Angiograms of both carotid systems 
are carried out as soon as possible to 
demonstrate the site of the aneurysm 
(Figure 3). Should these x-rays fail 
to demonstrate the source of bleeding, 
vertebral angiography is carried out. 
In some patients, the site of bleeding 


MARCH 1965 


^aneurysm on 

'^T"'!...!.."'.;' int. carotid 




aneurysms on mid. and 
ant. cerebral a 



Fig. 3. A. Depicts aneurysm arising from the internal carotid artery, as would be visualized by arteriography. B. Shows the frontal 
lobe bemg elevated at operation, allowing exposure of the internal carotid artery and the aneurysm below it. C. Demonstrates the 
angiographic appearance of both middle cerebral and anterior cerebral aneurysm, as seen in the anterio-posterior view. The anterior 
cerebral is represented by the black dot in the midline. D. Shows the frontal portions of both anterior lobes being elevated to gain 
exposure to the anterior cerebral aneurysm which rises immediately above the optic nerves and chiasm. The optic nerves are seen 
in this diagram in the midline of the picture immediately above the root of the nose. 

is never localized. It may thus be pre- 
sumed that nature has sealed off the 
bleeding point and that the prognosis 
is excellent. 


There is general agreement in medi- 
cal literature that approximately one 
half of all patients with subarachnoid 
hemorrhage will die within six weeks 
from the onset of bleeding if treated by 
bed rest alone. Of the survivors, a 
further percentage (the total of which 
is unknown) will subsequently die 
from current hemorrhage. Early treat- 
ment is essential to prevent death from 
recurrent hemorrhage, intracerebral 
clots, and hydrocephalus. 

Once angiography is completed, 
those patients in whom no source of 
bleeding has been found can safely be 
managed with three weeks' bed rest. 

If an aneurysm is demonstrated, 
plans are made to obliterate the weak 
area surgically as soon as the clinical 
state of the patient will permit. Intra- 
cerebral clots and subdural hemato- 
mas, when present and producing in- 
creasing intracranial pressure, are 
promptly evacuated and the aneurysm 
clipped at the same operation if the 
state of the brain allows this. 

Hypothermia is used to facilitate the 
repair of the ruptured berry aneurysm. 
After the patient has been anesthetiz- 

Fig. 4. The hypothernia blanket in use. 
214 MARCH 1965 

ed, the body temperature is lowered to 
29° C. by surface cooling (Figure 4). 
The carotid arteries are dissected in 
the neck and tiny blood pressure cuffs 
are applied to the common carotid ar- 
teries. The tubes from the cuffs are 
led to the anesthetic stand, so that 
when arrest of the cerebral circulation 
is desired this can be accomplished by 
the anesthetist. A craniotomy is per- 
formed and the aneurysm exposed. 
Hypothermia is useful at this stage as 
it allows the cerebral circulation to be 
shut off for longer periods of time 
than is possible at normal body tem- 
perature. When the cerebral circula- 
tion is shut off, the aneurysm can be 

clipped, ligated, or wrapped with 
gauze more safely (Figure 5). Should 
rupture of the aneurysm occur during 
dissection, occlusion of the cerebral 
circulation facilitates the repair. 

Surgical management of angiogra- 
phically-proven berry aneurysms has 
reduced the mortality rate in those pa- 
tients where surgery was possible from 
50 to 23.8 per cent. In patients who 
were conscious without focal neurologic 
signs, the mortality was substantially 
lower than 23.8 per cent. It is essential 
to establish the diagnosis early, and in- 
tervene surgically, prior to recurrent 
hemorrhage, to save the greatest num- 
ber of people. 

^^-^ ^^-^ on n 



e on 

Trapping — ^J- ^^^J^y, 



Fig. 5. Various methods of removing the weak part of the 
vessel from the circulation. 


Nursing Care: 
Ruptured Cerebral Aneurysms 

Continuous and close observation is required and is best provided in an area 
where nursing services can be concentrated — that is, in an intensive care unit. 

Jessie F. Young, reg. n.. b.a. 

Rupture of a cerebral aneurysm 
produces immediate hemorrhage. The 
effect on the patient depends on the 
severity and the site of bleeding, 
therefore the clinical condition varies 
greatly and nursing care must be 
adapted accordingly. 

The onset of hemorrhage is sudden 
and the patient and his family are 
totally unprepared for his illness. Their 
expressions of fear and bewilderment 
make quite apparent the need for an 
under standing staff. Reassurance that 
everything is being done for the 
patient's care and safety is essential. 
A warm, understanding attitude must 
be combined with efficiency. Diagnos- 
tic tests, procedures and craniocer- 
ebral testing are puzzling to the patient, 
and need to be explained both to him 
and to the family. Fear and anxiety 
can be lessened if medical and nursing 
staff take the time to talk. Explana- 
tions, support and encouragement form 
an essential part of the patient's care 
from the time he is admitted until he 
is discharged. 

The staff in a neurosurgical unit 
must be specially trained. New staff 
should have a period of orientation; 
this will vary with the nurse's pre- 
vious experience. During this time the 
nurse should not be responsible for 
a patient assignment but should work 
with one of the regular staff. Lecture- 
demonstrations should be given on 
neurosurgical nursing, charting, tests 
and special procedures. This orienta- 

Miss Young is Supervisor. Division of 
Neurosurgery. Toronto General Hospital. 
Toronto. Ont. 

tion period allows the nurse to adjust 
to a specialized type of nursing and 
helps to resolve fears of inadequacy 
that she may have if this is her first 
contact with neurosurgical nursing. 

An in-service program with regular 
and frequent lectures by doctors as 
well as by nurses will provide an 
opportunity for the staff to acquire 
a knowledge of neurophysiology - — 
necessary if intelligent care is to be 
given. To make these lectures inter- 
esting as well as informative, case 
presentations taken from the existing 
patient population should be used. 

On admission, the patient's ap- 
pearance, level of consciousness, com- 
prehension, motor power and vital 
signs are assessed. Subsequent nursing 
care must be planned on the basis of 
these observations: the restless patient 
will need side rails in position at 
all times; the acutely ill patient will 
be positioned so he will have a clear 
airway. The nurse quickly learns to 
determine the "base line" from her 
own observations and from informa- 
tion supplied by the doctor. On ad- 
mission, craniocerebral testing is 
carried out half-hourly, and results are 
compared with the base line. (For an 
explanation of craniocerebral testing 
the reader is referred to the article; 
Recognition, Recording and Signifi- 
cance of the Signs of Increased Intra- 
cranial Pressure.) 

A lumbar puncture is often per- 
formed to confirm the presence of 
blood in the spinal fluid. The cause 
(usually an aneurysm) and site of 
bleeding is detemiined by arteriogra- 
phy. Craniocerebral testing is contin- 
ued following arteriography to detect 

any evidence of neurological impair- 
ment (asphasia. loss of motor power) 
or bleeding from the site of injection of 
the radio-opaque material. 

A number of laboratory and other 
tests will be done as necessary pre- 
liminaries to operation. These include 
tests to evaluate kidney function, 
blood coagulation, blood chemistr>\ 
blood typing, electrocardiogram, and 
x-rays of chest and skull. 

Not all patients with a ruptured 
cerebral aneurysm can be treated surgi- 
cally — the decision rests with the 


The nursing care plan for patients 
not suitable for surgical treatment is 
based on the assumption that a rise in 
blood pressure is one of the predis- 
posing causes of a recurrent hemor- 
rhage from an aneurysm and this must 
be prevented. Therefore, plan of rest 
together with a controlled amount of 
activity is instituted. Nursing care will 
var>- with the severity of the symptoms 
and the level of consciousness. Ab- 
solute rest is ordered routinely on 
admission; this necessitates complete 
nursing care. The reason for this 
complete rest must be explained to 
the patient in order to gain his coop- 

When free from headache, he may 
have the head of the bed elevated, he 
may sit up in bed, he may feed him- 
self. These activities are increased only 
if favorable progress is made. If a 
headache or any other abnormal symp- 
toms occur, his activity is reduced. At 
the next level of activity he is allowed 
to sit on the side of the bed, then 


MARCH 1965 


to sit in a bedside chair, then to be 
taken to the bathroom in a commode 
chair and, finally, to enjoy accompa- 
nied walks. The plan is quite flexible, 
and activity is increased or decreased 
as indicated by the patient's responses. 
The stages of activity are only in- 
creased with the doctor's approval. 

Constipation is avoided by giving 
mineral oil on a regular schedule, or 
an oil enema may be ordered. Strain- 
ing on defecation is thus prevented. 

Reading and other quiet pastimes 
are encouraged as they help the pa- 
tient to accept inactivy and to divert 
his attention from his illness. Visitors 
should be kept to a minimum but a 
patient may be more content if a mem- 
ber of his immediate family is nearby. 
Mild sedatives may be ordered if the 
patient is anxious or restles. 

This plan of gradually increased 
activity usually lasts three to six 
weeks. On the doctor's decision, ar- 
rangements are made with the family 
for rehabilitation at home. The doctor 
will talk with the patient and his 
family, advising when he may expect 
to be able to return to work, drive 
his car and to carry out the other 
essential occupations of daily living. 
These directions must be known to the 
nurse so that conflicting advice will 
not be offered. 

Preoperative care 

To avoid delay should emergency 
surgery be necessary, many preoper- 
ative tests are performed on admission. 
The hair is shampooed with pHisoHex 
in the afternoon, and again in the 
evening of the day before surgery. 
The purpose is to ensure ordinary 
social cleanliness of hair and scalp, 
not surgical sterility. 

Preoperative sedation and special 
orders are carried out. The preoper- 
ative shave will be done by the 
operating room staff immediately be- 
fore surgery. 

The patient and family are usually 
apprehensive before any surgery, and 
particularly so when confronted with 
a neurosurgical procedure. To talk 
with them and to listen as they ex- 
press their fears will lessen their 
apprehension, and is an important part 
of good nursing care. 

Posioperotiye care 
Once the surgical procedure has 
been performed, the operative findings 
and the postoperative condition of the 
patient will influence the plan of care. 
A brief written report on the opera- 
tion performed must be provided by 
one of the operating doctors and sent 
with the patient to the recovery room 
and intensive care area so that the 

nursing staff can assess the patient 
intelligendy. The staff should also 
be advised of any neurological deficits. 
Postoperative orders guide the nurses 
in planning the patient's care. 

The nursing care measures, in order 
of importance, are: 

1 . Positioning. The patient is placed 
in the semi-prone or lateral position 
with the head on a small pillow so 
that the mouth is at the edge of the 
pillow and the chin is pointing down- 
ward. This allows drainage of oral 
secretions, and prevents the tongue 
from obstructing the airway. The pa- 
tient is repositioned every two hours. 
Deformity of the arms and legs is 
prevented by passive exercise. 

2. Maintaining a clear airway. 
Watch for any evidence of respiratory 
distress, dyspnea or cyanosis. To check 
whether an airway is clear, elevate the 
patient's chin and make sure the 
tongue is not blocking the airway. 

Listen for the quiet passage of air 
and watch for the natural movements 
of the chest. Do not be deceived by 
chest movements into assuming that 
the patient is breathing; you may be 
observing respiratory movements strug- 
gling against a blocked airway. 

The patient must be taught to 
breathe deeply and to cough properly. 
The physiotherapist assists the staff in 
planning a chest routine and in teach- 
ing the breathing exercises. 

When the level of consciousness is 
depressed, it may be necessary to 
remove secretions from the nose and 
mouth using a straight catheter and 

A tracheotomy may be performed if 
the patient is having respiratory dis- 
tress and the lungs are becoming filled 
with secretions. Secretions can then 
be removed by inserting a suction 
catheter* into the trachea and bron- 
chus. The depth of suctioning varies 
with the patient's condition. If shallow 
suctioning stimulates coughing, this 
may clear the airway sufficiently. If 
the patient is unable to cough, the 
catheter is inserted as far as it will go. 
No suction is applied while the catheter 
is being inserted to prevent damage 
to the mucous membrane lining. In- 
termittent suction is applied to the 
Y-connector as the catheter is slowly 
withdrawn. The manoeuvre must be 
thorough, yet gentle; bleeding from 
the mucous membrane (indicating that 
the procedure has been done roughly) 
is dangerous because the bronchia! 
tree may be further obstructed by 
blood clots. The catheter should be 

* A no. 16 Toronto endobronchial 
catheter is recommended. These have an 
angle tip with two side holes and a terminal 

cleared with water and wiped clean 
between each passage and the proce- 
dure repeated until the airway sounds 
clear. The presence of abnormal se- 
cretions or difficulty in suctioning 
should be reported at once. 

A Puritan Nebulizer is frequently i 
ordered. This provides a flow of moist, 
warm or cold oxygenated air across 
the opening of the tracheotomy. Se- , 
cretions are softened, making it easier 
to clear the bronchi and trachea. 

3. Craniocerebral testing begins in 
the recovery room. A base line is 
again established and subsequent test- 
ings are evaluted in terms of this. 
A postoperative increase of intracran- 
ial pressure is usually due to either 
bleeding or cerebral edema. Frequency j 
and duration of testing is ordered by 
the doctor. 

4. Diets and fluids are given orally 
if the patient has no difficulty swal- \ 
lowing. Usually patients quickly pro- 
gress from a fluid diet to a soft or 
ordinary diet. Naso-gastric feedings are ' 
given every three hours if the patient ' 
has difficulty swallowing or is semi- 
comatose; a specially balanced diet of 
1200 calories in 2400 cc. is used. 

5. Head dressings are closely ob- 
served for any discharge, bleeding or 
discomfort. The dressing remains in 
place for approximately five days and 
is removed by the doctor; the head 
is cleansed thoroughly with Cetavlon 
and the shaved portion of the scalp 
lubricated with corn oil. No nev\ 
dressings are applied. The area sui 
rounding the incision is cleansed with 
Cetavlon daily and corn oil applied. 
Stitches are removed as ordered b\ 
the doctor. 

6. Cleanliness. Special attention 
should be given to the mouth, teeth, 
skin and eyes. As soon as the patient 
is able, he should be encouraged to 
bathe himself. 

7. Restlessness. A patient with a 
ruptured cerebral aneurysm may be 
restless and difficult to control. This 
is usually due to cerebral causes but 
may also be caused by a full bladder, 
irritation from a catheter or the desire 
to defecate. Side rails are kept in 
position, or someone may need to 
remain with the patient. No restraints 
other than mitts are used as arm or 
leg restraints generally increase rather 
than decrease restlessness. Mitts allow 
the patient to move his arms and 
hands but prevent him from removing 
dressings and tubes. Mitts must be 
changed daily, the hands washed and 
the fingers exercised (Figure 1). 

8. Elimination. While the patient 
remains incontinent of urine, straight 
drainage of the bladder with an in- 
dwelling catheter (or, in the male, 
condom drainage) is established. Tn the 


MARCH 196.5 


Fig. 1 Application of Restraint Mitts. Slep 1. Weave dressing pad through fingers making sure thumb and first finger are covered 
and held secure. Fingers are flexed over a rolled-up pad which covers the palm of the hand. Place a third pad over the fingers. Step 2. 
Apply a mitten-type bandage over the padding using a 3" bias cut flannelette bandage. Slep 3. Secure the end of a twelve inch 
length of tubular stockinette. Draw stockinette up over bandage. Step 4. Secure stockinette at wrist with 1" adhesive tape. Turn back 
cuff and hold in place with adhesive tape. Correct tightness at wrist allows a testing finger to be slipped inside the mitt. 

older male, prostatic obstruction may 
complicate tlie picture and retention, 
rather tlian incontinence, may occur. 
Such retention may be followed by 
incontinence once the bladder becomes 
over-distended (retention with over- 
flow). The nurse should be able to 
recognise bladder distention by pal- 
pating and percussing the abdomen. 
Constipation is avoided by the routine 

administration of mineral oil. but if 
this is ineffective, an oil enema 
followed by a cleansing enema may be 

9. Medications. Anticonvulsant 

drugs are frequently ordered following 
an intracranial procedure. Sedatives, 
analgesics and narcotics are avoided 
because they mask a fall in conscious 
level due to cerebral causes, and be- 

Fig. 2 Hypolheiiiiiu blanket with ice water circulating through the coils is used for 
surface cooling. This is a corner of the intensive care unit. Special equipment includes 
piped-in oxygen, wall suction, wall mounted spot lights and wall model sphygmomano- 

cause they may effect the vital signs. 
If headache or discomfort persists, 
mild analgesics are given as ordered 
by the doctor. 

10. Maintenance of nomial temper- 
ature. By the time the patient arrives 
in the intensive care area following 
surgery under hypothemia. the temper- 
ature has usually reached normal 
(99.6 rectally) but it tends to rise 
thereafter. Nursing care is planned 
toward maintaining the temperature at 
near normal levels. 

When the body temperature is 

a. cool the room; air conditioning set 
at eS" - 68°. 

b. cover the patient with a cotton sheet 
and spread: flannelette sheets and blankets 
tend to raise the temperature. 

When the body temperature rises 
above 100° F (rectal): 

a. set room temperature at 65°. 

b. aspirin gr. XX by suppository. 

If the temperature continues to rise, 
additional measures are taken: 

a. alcohol sponging using 65% alcohol. 
Ice is sometimes added to the alcohol. 
Surface cooling can be speeded up by 
playing a fan on the patient. 

b. ice caps and plastic bags of ice 
placed in the axilla, groin and against 
the trunk. 

Special cooling techniques may be 
used if these measures do not reduce 
the temperature: 

a. hvpolhermia blanket with ice water 
circulating through Ihe coils placed un- 
der the patient and. if necessary, an 
additional hypothermia blanket placed 
over Ihe patient (Figure 2). 


MARCH 1965 


h. the covered blanket must be in 
contact with the patient's skin for effect- 
ive cooling. 

c. the generation of muscle heat by 
shivering or extreme restlessness must 
be reduced by drugs ordered by the 

Turn and position the patient hourly. 
Special attention is directed to tlie 
areas of skin in contact with the cool- 
ing blankets. Special cooling measures 
are necessary until the temperature is 
reduced to near normal values. 

1 1 . Personal appearance is an im- 
portant consideration, particularly for 
female patients. By assisting the patient 
with her appearance the nurse is en- 
couraging not only the postoperative 
patient but also the patient who has 
yet to undergo surgery. If the services 
of a beautician are available, she may 
assist with the patient's hair styling 
under the guidance of the nurse. 
Boudoir caps made up with ribbon 
drawstrings, rather than elastic, are 
worn after dressings are removed 
(Figure 3). The patient is urged to 

take an interest in her appearance. 

12. Mobilization. Usually the pa- 
tient is out of bed the day after 
operation. Watch for any abnormal 
symptoms or signs, such as headache, 
dizziness or a rise or fall in blood 
pressure. Activity is increased as rapid- 
ly as possible. 

13. Rehabilitation. This is a contin- 
uous process beginning on admission 
and continuing until the patient is 
restored to normal living. In the 
intensive care area, the patient is 
dependent on the nursing staff, but as 
early as possible he must be encour- 
aged to help himself. To become inde- 
pendent he must be taught to master 
the activities of daily living. The 
rehabilitation team consists of the doc- 
tor, nurse, physiotherapist, occupatio- 
nal therapist, speech therapist, social 
worker and relatives. 

As the time approaches for the 
patient's discharge, the family must be 
made aware of his limitations and, 
more important, his capabilities. 

The transfer to hospital at the onset 

Fig. 3 Frilled nylon caps in pastel colors 
improve patient's appearance following re- 
moval of head dressing. 

of a sudden and severe illness calls 
for a spirit of resignation and trust 
from the patient. The readmission to 
his home after the hospital interlude 
demands determination and assurance, 
not only from the patient but also from 
those around him. 


There are probably many nurses . . . 
who have exfverienced dismay when con- 
fronted with an electroencephalogram (EEG) 
report, such as: 

The EEG is normal. The alpha rhythm 
of 10-a-second is prominent on the right, 
but suppressed on the left. A rhythm of 
5.5-a-second in the central areas is dis- 
turbed by a 3-a-second wave and spike 

What is an EEG? In the brain, minute 
electrical charges are produced. Activity 
of this nature was first mentioned as early 
as 1875 by Canton, an Englishman. Later, 
in a work published in 1929. Hans Berger, 
a German, described this activity as a 
brain rhythm dominant in the occipital 
region of normal subjects, with eyes closed. 
When recorded as a graph, this rhythm 
appeared as wave forms occurring ten times 
each second. It disappeared when the sub- 
ject concentrated upon a problem or upon 
opening the eyes. Berger called this rhythm 
alpha (= the first). With eyes opened, the 
dominant rhythm became one of 18-20 
cycles per second — the beta rhythm. 

The alpha, found mainly in the occipital 
and parietal areas, is symmetrical in volt- 
age and distribution in both hemispheres. 
The beta rhythm, which occurs mainly in 

the frontal and temporal areas, occasionally 
in all areas, has a lower voltage than the 
alpha — sometimes so low that the EEG 
tracing will appear almost flat. The actual 
patterns of these normal rhythms are as 
characteristic of the individual as are hair 
and eye coloring, and usually remain con- 
stant throughout normal life. 

The EEG machine ... is designed to 
pick up this minute electrical activity from 
the brain by means of electrodes placed on 
the scalp. It then amplifies this activity and 
the rhythmical wavy forms, which have 
come to be recognized and named, are 
recorded by pens upon moving paper. In 
practice. 21 electrodes are placed on the 
subject's head in various anatomical posi- 
tions. Of these, 10 or more at a time form 
eight circuits which are connected to the 
eight pens of the EEG machine. 

An EEG recording is a laboratory test 
and, in common with many such tests, is 
not always able to pinpoint a specific con- 
dition. Although specific abnormalities may 
be demonstrated ... a record is usually 
considered as an aid to diagnosis rather 
than the final answer. 

During recording, an EEG tracing may 
be disturbed by artifacts. These are wave 
forms which can be the product of the ap- 
paratus (interference) or, more often, un- 
wanted activity from the subject. TTiese 

include the artifacts of a pulse, perspiration, 
muscle activity . . . and excessive blinking. 
Muscle activity can completely overshadow 
any cerebral rhythm and is often found in 
tense subjects. The accompanying mental 
anxiety of these patients may eliminate the 
alpha rhythm completely, the resultant 
record being of little clinical value. 

A successful EEG recording depends a 
great deal upon the subject's capacity to 
relax, but he is unable to do this if he 
arrives at the laboratory anxious and ap- 

Why should a subject be apprehensive? 
Frequently, a patient arrives at the EEG 
laboratory with no idea of the procedure or 
the reason for his being there, often re- 
garding [the procedure] as a treatment, not 
a laboratory test . . . This misunderstand- 
ing is most probably due to an inadequate 
reply to his question "What is an EEG?" 
It is here that the nurse can be of the 
utmost value ... A vague answer to this 
question may be mistaken for a guarded 
reply; thus the seeds of anxiety are sown 
... It is no exaggeration to say that a 
successful EEG depends upon a relaxed 
patient, and the production of this tran- 
quil state is in the hands of the nurse. 
— - Gill. Leslie A. The E.E.G. and the 
nurse. Nursing Mirror. 111:6-7. Nov. II, 


MARCH 1965 





Canadian Nurses on Assignment 
with CUSO 

Nineteen Canadian nurses are pre- 
sently serving under the banner of Can- 
adian University Service Overseas in 
the West Indies. India, Sarawak. 
Rwanda. Nigeria. Tanganyika. Zam- 
bia and Peru. They are among 130 
young Canadian men and women 
working on the frontiers of develop- 
ment — • educational, economic and 
social — in 1 6 countries of Asia. Africa 
and the Caribbean. 

Recruited through local committees 
at 44 universities and colleges across 
the nation, these volunteers are post- 
poning careers in Canada to serve 
abroad. They live and work for the 
same wages and under the same con- 
ditions as their counterparts in the 
country to which they are assigned. 

Reporting on the activities of 21- 
\ear-oId Sharron MacLean at the 
kondhawa Leprosy Hospital in India, 
the coordinator from New Delhi says: 

Sharron has landed firmly on her feet. 
She has a big job and is managing well. 
She does operating theatre nursing when 
special doctors come out to do surgery 
and is really the person in charge for the 
routine medical things. She may be able 
to take a month's training course in lepro- 
s\ surgery in Bombay which I felt would 
He helpful and gave it my blessing. She does 
her own cooking, although people at the 
hospital get most of her supplies and they 
have given her a gas two-plate burner, Shar- 
ron has been given a scooter, but until she 
learns to drive she is happily using the bul- 
lock cart and local bus. She is seven miles 
from Poona. but the hospital is in an isola- 
ted place. She doesn't seem to mind the 
isolation and takes the patients' deformities 
and pathetic conditions in her stride. Both 
doctors have written to me to thank CUSO 
f<ir sending Sharron. 

The selection and assignment of 
f'USO volunteers require care and ex- 
perience. Applicants are interviewed 
and screened on their academic re- 
cord, personality, character and health. 

Those finally recommended by 
CUSO are referred to representatives 
of the countries requesting their service. 
These representatives make the final 

decision concerning the acceptance 
and assignment of volunteers. Prior to 
undertaking their actual assignments, 
the volunteers receive orientation cour- 
ses to prepare them for problems and 
conditions they will confront in their 
new positions in a strange environ- 

Most of the CUSO assignments are 
for two years. As these young volun- 
teers "serve and learn" in the develop- 
ing countries of the world, they are 
accumulating knowledge and building 
values which will be of lasting benefit 
to Canada. 

Ontario Hospitals Solve Training 

"Two of the biggest teaching prob- 
lems facing Canadian schools of nurs- 
ing seem to have been solved at Fort 
William and Port Arthur," reports the 
December RNAO News Bulletin. These 

Upgrading standards of nursing edu- 
cational programs. 

Finding qualified teachers. 

The Bulletin points out that the 
three teaching hospitals in the Lake- 
head cities have evolved a system by 
which they make use of university 
facilities in their area to better educate 
students and to cut down on the re- 
quired number of teachers. First year 
nursing students take courses two 
days a week at Lakehead College stu- 
dying anatomy, physiology, chemistry, 
microbiology, psychology and English. 
These courses are taken by regular col- 
lege students and nursing students are 
granted degree credits for them. 

Sister Ste. Catherine, associate di- 
rector of education at St. Joseph's Hos- 
pital School of Nursing in Port Ar- 
thur, says, "We are starting the fourth 
year in this program now. We have 
already graduated one group of stu- 

Although she feels it is too early to 
know the true worth of the program 
through the graduates, she thinks it is 
proving itself. "They are very well 
prepared." Sister Ste. Catherine feels 
the program is a perfect example of 
what can be done through hospitals 

sharing and pooling their resources. 
The three schools developed the plan 
and formulated the curriculum toget- 

At present, the cost of the college 
training is born by the nursing school, 
although the students buy their own 
books. This might change and the nur- 
ses bear some of the tuition cost. 

Legislation Enacted 

Practical nurses in British Colum- 
bia have been given separate status 
and formal organization. Legislation 
was enacted in December implement- 
ing regulations set up in the Practical 
Nurses Act of 1951. No one who is 
not registered may call herself a 
practical nurse or a licensed practical 

The new regulations deal with esta- 
blishment, maintenance and conduct 
of training schools, requirements for 
admission, examinations, licensing of 
graduates, and the services a practical 
nurse may give to patients. 

A 10-member council will be ap- 
pointed to administer the regulations 
under the act. 

Alberta Proclaims "Nursing Week" 

April 10 to 24. 1965 has been desi- ' 
gnated "Nursing Week" in Alberta by 
Premier Ernest C. Manning in an en- 
deavor to promote the interests of 
nursing in all its phases. Hospitals 
throughout the province will hold 
"Open House". The week will be offi- 
cially opened by the Hon. J. Dono- 
van Ross. Minister of Health. 

Foothills Hospital School of Nursing 
Ready in September 

Alberta's thirteenth hospital school 
of nursing will open its doors Septem- 
ber 7. 1965, reports the December 
AARN News Letter. The report, des- 
cribing the facilities of the school, says 
the educational program of the three- 
year course will be divided into five 
terms. Basic theory will be taught dur- 
ing the first term of 22 weeks. Early 
in this term the student will be intro- 
duced to the hospital environment. At 
Christmas there will be a two-week 


MARCH 1965 


vacation break. The second term of 20 
weeks will introduce disease and relat- 
ed medical and surgical aspects into 
the curriculum and the students' expe- 
rience in the hospital will gradually in- 
crease in time and depth of experien- 
ce. A third term of ten weeks is design- 
ed to acquaint the student with the 
central supply and to further the medi- 
cal-surgical practice. A two-week va- 
cation will follow. The fourth term will 
be 56 weeks in length and will com- 
mence the students' second year. It will 
be divided into six 8-week periods for 
concurrent study and experience in 
obstetrics, pediatrics, psychiatry, oper- 
ating and recovery room, medicine and 
surgery; the seventh 8-week division 
permits four weeks in diet therapy and 
a four-week vacation. The fifth term 
of 48 weeks will begin with a four- 
week block in ward administration al- 
lowing for concurrent practice. Follow- 
ing this the student will progress to 
ten 4-week periods of more advanced 
learning experience demanding greater 
responsibility and skill. The fifth term 
will have a four-week vacation. 

Executive Director in Saskatchewan 

Dr. Helen K. Mussallem spent the 
week of December 14th in Saskatoon 
assisting in the evaluation of programs 
at the University School of Nursing. 
The philosophy of the degree, diploma 
and graduate programs and their im- 
plementation were observed and the 
organization, finances and curriculum 
were surveyed. 

The survey was requested by the 

Dr. Mussallem, who believes that 
universities have the responsibility of 
preparing the future teachers and lea- 
ders of the profession, hopes her re- 
commendations will assist the faculty 
to identify areas where changes are 
needed to better prepare students for 
leadership roles. 

"Sifter Service" Studied 

Day nursery schools may soon be 
provided in Winnipeg General Hospi- 
tal for the children of married register- 
ed nurses who wish to return to their 

"It could solve our problem," said 
Dr. L. O. Bradley, executive director 
of the hospital. 

A shortage of registered nurses and 
other personnel is posing a threat to 
services in many Greater Winnipeg 
hospitals. The most seriously affected 
is said to be Winnipeg General Hospi- 

Day nursery schools for the children 
of married nurses are provided in se- 
veral hospitals in Canada, the United 
States and Great Britain. 

"Until now, the cost of such a ven- 

ture has slowed us down, but we have 
explored the idea fully," said Dr. 

At present, at least 20 qualified re- 
gistered nurses are needed. Another 88 
would likely be needed shortly when 
the new intensive care wing is complet- 

The nursery schools "may be the 
only answer and before spring is out 
we will have to reconsider it seriously," 
Dr. Bradley said. "I can't predict how 
many more nurses it would give us 
but it just might do it." 

Dr. Bradley said that many married 
nurses with young children wished to 
return to work but could not because 
of the prohibitive cost of good baby 
sitters. Such day nursery schools are 
usually operated by qualified hospital 
personnel and are for children from 
three months to six years. 

Children are provied with lunch 
and a token charge of $2.50 each day 
is collected. Comparable services from 
baby sitting agencies range from $5.00 
to $7.00 daily. 

Solutions to three problems must be 
found by hospital officials before such 
a scheme could be implemented : lack 
of space, lack of personnel, and cost. 
(Winnipeg Free Press, December 17, 

Nursing Examiners' Board 

The government has named the 
members of a board of examiners set 
up under the Newfoundland Register- 
ed Nurses' Act. Names of the members 
are: A. W. Parsons, Director of Pu- 
blic Exams, Department of Education; 
Miss Janet Storey, R.N., B.N., director 
of nursing at the General Hospital; 
Major Mary Lydall, R.N., administra- 
tor of the Salvation Army Grace Hos- 
pital; Sister Mary Xaverius, R.N., B.N.. 
director of nursing, St. Clare's Mercy 
Hospital; Miss Jean Lewis. S.R.N., 
director of nursing services, De- 
partment of Health, and Dr. Leonard 
Miller, Deputy Minister of Health. (St. 
John's Telegram, December 9, 1964). 

Renovations Discussed 

Renovations to new headquarters 
for the Registered Nurses' Association 
of Nova Scotia were discussed by its 
executive members at a meeting in Ha- 

The association has purchased pro- 
perty at 6035 Coburg Road and will 
occupy the new quarters soon. The 
new headquarters will have general 
offices, an executive suite, a library 
and private offices for Miss Nancy H. 
Watson, R.N., the association's exe- 
cutive secretary and Mrs. Jean New- 
ton, secretary for nursing education. 
(Haliiax Chronicle-Herald, December 

NLN Named as Accrediting Agency 

The December issue of NLN News 
announces that the National League 
for Nursing has been named the ac- 
crediting agency for provision of the 
Nurse Training Act of 1964. Francis 
Keppel, Commissioner of Education, 
made the designation and the Division 
of Nursing, Public Health Service, has 
sent instructions to all programs in 
nursing about steps which they must 
take to meet the accreditation quali- 
fication for federal funds. 

Because only a few associate degree 
programs in nursing are nationally ac- 
credited, the Commissioner has reserv- 
ed the right to name additional bodies at 
a later date if necessary. 

For new programs or for others not 
yet accredited, a plan for reasonable 
assurance of meeting accreditation 
standards has been proposed by NLN 
and approved by the Commissioner of 
Education, who is charged with the 
responsibility of making the findings. 

The Nurse Training Act of 1964 
authorized the appropriation of $287 
million over a five-year period for 
construction, professional nurse trai- 
neeships, grants to assist with the costs 
of diploma programs, grants to impro- 
ve, strengthen or expand teaching pro- 
grams, and loans to students. 

World Federation for Mental Health 

"Mental Health and Education" will 
be the theme of the 18th Annual 
Meeting of the World Federation for 
Mental Health to be held in Bangkok, 
Thailand, November 15-19, 1965. The 
meeting is open to professional wor- 
kers in psychiatry, psychology, edu- 
cation, nursing, social work, public 
health administration and allied fields; 
and to non-professional people inte- 
rested in the promotion of mental 
health and human relations throughout 
the world. 

The program will include four plen- 
ary sessions and a number of technical 
sections on topics closely related to 
the principal theme. 

Further information is available 
from the Director-General of WFMH, 
1 rue Gevray, Geneva, Switzerland. 

Publications Recently Received in 
CNA Library 

Most of the material listed below 
is available on loan from the CNA 
Library. Requests should be addres- 
sed to: 

TTie Librarian 

Canadian Nurses' Association 

74 Stanley Avenue 

Ottawa 2. Canada 

Applications for loans should give 
the month in which the publication was 
listed in the Canadian nurse. 

1. Blishen, Bernard R. Survey of nurses, 


MARCH 196.'5 


Ottawa. Canadian Nurses' Association. 
1964. 25 1. 

2. Canada. Civil Service Commission. 
The analysis of organization in the go- 
vernment of Canada. Ottawa, Queen's 
Printer, 1964. 70 p. 

3. Canada. Commission dii Ccntenaire. 
.Ainsi naquit la Confederation. Ottawa, Im- 
primeur de la Reine. 1964. 

4. Canada. Conseil dii Ccntenaire de la 
Confederation. Rapport. 1964. Ottawa. Im- 
primeur de la Reine, 1964. 38 p. 

.">. Canada. Dept. of Labour. Women's 
Bureau. National women's organizations in 
Canada. 1964-65. Ottawa, Queen's Printer. 
1964. 115 p. (English and French). 

6. Canada. Dominion Bureau of Statis- 
tics. List of Canadian hospitals and related 
institutions and facilities. Ottawa, Queen's 
Printer, 1964. 63 p. 

7. Canada. Dominion Bureau of Statis- 
tics. Trusted pension plans, financial statis- 
tics. Ottawa. Queen's Printer. 1964. 25 p. 

5. Conant. James B. TTie education of 
American teachers. New York. McGraw- 
Hill. 1963. 275 p. 

9. Davis. Fred and Virginia L. Olesen. 
Initiation into a women's profession: iden- 
tity problems in the status transition of 
coed to student nurse. Sociometry 26:1. 
March, 1964. (Reprint). 

10. Griffin. Amy Elizabeth. The improve- 
ment of the educational preparation of 

instrutors in preservice programs in nurs- 
ing in Ontario. New York, Teachers Colle- 
ge, Columbia University. 1963. 362 p. 

1 1 . Gruneau Research Limited. Study of 
attitudes of registered nurses in Ontario. To- 
ronto, 1964. 45 p. 

12. Hart, Margaret Elder. Needs and re- 
sources for graduate education in nursing 
in Canada. New York, Teachers College. 
Columbia University. 1962. 273 p. 

13. Henderson. Virginia. Nursing stu- 
dies index: an annotated guide to reported 
studies, research in progress, research me- 
thods and historical material in periodicals, 
books and pamphlets published in English. 
V. 4. Philadelphia. Lippincott, 1963. 

14. Leadership Resources Inc. Looking 
into leadership, monographs. Washington. 
1961. 1 V. 

15. Massachusetts. Dept. of Health. 
Practical Nurse Research Project. Report. 
Boston. 1960-64. 4 v. 

16. Montreal. Service de sante. Rapport. 
1963. Montreal, 1964. 164 p. 

17. National League for Nursing. A study 
of the NLN pre-nursing and guidance exa- 
mination in schools of practical nursing. 
New York, 1964. 7 p. 

18. Newman, Dorothy M. and Jean P. 
Newman. Canadian Business Handbook, 
New York, McGraw-Hill, 1964. 624 p. 

19. Royal College of Nursing and Na- 
tional Council of Nurses of the United 

Kingdom. Report 1963. London. 1964. 58 p. 

20. Steering Committee on Negotiation 
Rights for Professional Staffs. Negotiation 
rights for professional staffs. Toronto. 
1964. 8 p. 

21. U.S. Dept. Health. Education and 
Welfare. Class specifications for nursing 
positions: a guide for state and local public 
health agecies. Washington. U.S. Govt. 
Print. Office, 1964. 18 p. 

22. U.S. Dept. of Health, Education and 
Welfare. Public Health Service. Bureau of 
State Services. Research in community 
health. A report to the Sub-committee on 
the Depts. of Labor and Health. Educa- 
tion, and Welfare and Related Agencies of 
the Committee on Appropriations. U.S. 
House of Representatives. Washington. 
1964. 50 p. 

23. U.S. Laws, statutes, etc. Summary 
of provisions of the Nurse Training Act of 
1964. Washington, Div. of Nursing, Public 
Health Service. Dept. of Health, Education 
and Welfare, 1964. 12 p. 

24. Whittaker, Elvi. The faces of Floren- 
ce Nightingale: functions of the heroine le- 
gend in an occupational sub-culture. Human 
Organization. 23:2, Summer. 1964. (Re- 

25. Young, John P. A method for alloca- 
tion of nursing personnel to meet inpatient 
care needs. Baltimore. Operations Research 
Division. The Johns Hopkins Hospital. 1962. 


The year 1965 begins for nurses with 
,1 happy outlook: that of an international 

Our thoughts and our wishes go very 
specially to those who are engaged in the 
preparation of the Congress: first of all 
to our hosts: the President and the members 
of the German Nurses' Federation. May 
they find joy in their heavy and difficult 
task, and be encouraged by the thought of 
the enthusiam with which the nurses of so 
many countries are preparing to go to 

Our wishes also go to the members of 
staff of the International Council of Nurses: 
each of them puts all the resources of 

heart and spirit into achieving the tasks 
that have been entrusted to them; to the 
Chairman and members of the Standing and 
Special Committees who have produced 
work, the importance of which you shall 
appreciate when you listen to their reports: 
to the editors of nursing journals who en- 
deavor to make their journals a means of 
"communication" always more efficient; and 
to all the nurses who are preparing to go 
to Frankfurt, in June 1965. 

But if a great number of nurses can be 
reunited, all may not he present: the care 
of the sick must be assured with continuity, 
the teaching of the students must go on, 
the public health services must not be 
interrupted. Circumstances of private or 

general character can make traveling im- 

To all who will be unable to come, we 
address a very special thought, and we 
assure them that by their personal partici- 
pation to the preparation of the Congress 
discussions, by their contact with the nurses 
who will attend the Congress, they can 
make a valuable contribution to its success. 

To all nurses, we wish to say how much 
we rely on them. May every nurse through- 
out the world believe in her profession: 
may she be deeply convinced that the effort 
of each one is nec-essary to make it strong, 
efficient. May every nurse realize that she 
has a personal responsability for the future 
of her profession. — from I.C.N. Staff 
News Letter. Jan. 1965. 


MARCH 1965 





A description of the host city for the ICN Congress 
the "arm-chair traveler." 

for both the delegate and 

Frankfurt am Main, a delightful 
young-old city, will welcome nurses 
from 58 countries this June. The city 
is host to the 13th Quadrennial Con- 
gress of the International Council of 
Nurses. This prosperous and progres- 
sive city, which has a population of 
700,000, is an industrial, trade and 
banking centre. 

The hospitality of Frankfurt is a 
tradition stretching back over hundreds 
of years; visitors are warmly welcomed. 
.Situated on the Main River, 15 miles 
up-stream from the Rhine Valley, 
Frankfurt is easily reached by a va- 
riety of routes from other European 
capitals. Two main autoroutes (Auto- 
bahn or motor speedways) cross just 
outside the city. An international air- 
port and a main railway line help make 
it easily accessible to the international 
traveler. German is the principal lan- 
guage, but English and French are also 
spoken by many citizens. 

Although the convention time-table 
will be crowded, there is much to see 
and do in Frankfurt. Only a few of 
the many interesting places can be 

Pictures supplied courtesy of German 
Tourist Information Office, Montreal. 

Shiny neoteric sky-scrapers have 
mushroomed up amid the stately and 
elegant architecture of the past. Tree- 
lined streets and boulevards help blend 
ancient and modem and an interesting 
and charming city results. The citizens 
show a great affection and pride for 
their city. 

The Romer, reconstructed since the 
war, is the historic City Hall with its 
Emperor's Hall (Kaisersaal). Situated 
in the old city Central Square (Romer- 
berg), where in other days imperial 
coronation ceremonies and lordly re- 
ceptions were presented, it is held in 
high esteem by the citizens who affec- 
tionately call it their "parlor." 

St. Bartholomew's Cathedral (built 
1315-53) is within easy walking 
distance of the Romer. This quiet, 
beautiful cathedral stands amid a 
newly-built modern residential area. 

The birthplace of Johann Wolfgang 
von Goethe, poet and novelist (most 
famous work: Faust) is preserved as a 
memorial to Frankfurt's famous son. 
Goethe House, open to visitors, con- 
tains many splendid furnishings and 
works of art. 

The Hauptwache or modern Central 
Square is surrounded by large, glass- 
fronted, modern buildings. Standing 

at attention at the bustling inter- 
section, the time-honored Main-Guard 
House preserves the dignity of a time 
of carriages and kings. 

In the evenings, fine ballet and 
opera performances are held in the 
modem Stiidtischen BUhnen, or at the 
Ziirichhaus in Opera Square. 

The Festival Hall, where the ICN 
Congress will be held, is situated on 
the western side of Frankfurt in the 
Exhibition Grounds. Within short 
walking distance are the University, 
the Senckenberg Museum of Natural 

Night view showing the Bridge, 
Cathedral and St. Nicholas Church. 


MARCH 1965 


-listory and, a bit farther on, the 
^almengarten or Botanical Garden 
A'here many exotic tropical orchids, 
:acti, succulents and other plants are 

Frankfurt is a green city, dotted 
-vith manicured parks. Besides the 
Palmengarten, there are many more 
arge and beautiful ones — Griineburg- 
3ark, Holzhausenpark (and the Mu- 
seum there), Gunthersburgpark, and, 
jf course, the Zoologischer Garten 
yith an excellent zoo). The banks of 
:he Main are lined on both sides with 
lovely parkways — interesting both 
in the day time, and in the evening 
when the lights are reflected in the 
quiet waters. 

For serious walkers, strolls over the 
Dridges to Sachsenhausen, and visits 
to the Henninger Tower with the 
revolving restaurant on top, and to 
the famous apple wine restaurants are 

One of the joys of traveling per- 
tains to eating. Many meat and fish 
dishes, vegetables and spicy sausages 
will be new, but should be sampled. 
(Larger hotels and restaurants will 
serve familiar dishes.) Try also the 
local drinks — wine (not only Rhine, 
but other German varieties), beer, 
gin and brandy. German beers are 

The Main River showing parks. The Cathedral (left) was the elect- 
oral church of the German Emperors. 


"An der Hauptwache" Square with 
the \fain Guard Building. 

famous — and you can have one in a 
famous lidded stein in an outdoor 

Frankfurt serves as a good base 
point for further travel in Germany 
following the Convention. The Wester- 
wald-Seig-Lahn-Taunus region, with 
its woods and hills, rivers and streams, 
typifies the secluded, peaceful country- 
side and is reached by a short train 
or bus ride. This area, about 35 miles 
north-west of Frankfurt, is mainly 
rolling forested plateau, with hospitable 
hamlets, quiet country inns and lovely 
Rhine castles. 

River-boating provides a wonder- 
fully relaxing way to tour. Boat trips 
down the Main from Frankfurt, and 
along the romantic Rhine can be 
readily arranged. Food and accom- 

modations on the steamers are des- 
cribed as excellent, and wine from the 
local vineyards is available. 

You will also be able to plan your 
trip to or from Frankfurt through 
several other countries. Remember, 
travel time in Europe is counted in 
hours, not days. 

Germany is warm in June, with day 
time temperatures ranging from 61° 
to 86°. Evening and nights are cooler, 
and rain is to be anticipated. Light- 
weight suits and summer dresses will 
be most useful for convention atten- 
dance and for sight-seeing. (Shorts and 
slacks. are not suitable for European 
cities.) Comfortable shoes are a must. 
Don't forget your camera — and 
-happy traveling ! 

G. Z. 


It has been demonstrated conclusively 
that eggs used in the production of viral 
vaccines contain Avian Leukosis viruses. By 
the selection of flocks free from Avian 
Leukosis it has been possible to produce 
vaccines free of this agent. An example 
of this is live measles vaccines. However, to 
our knowledge, no effort has been made by 
manufacturers to produce other egg viral 
vaccines free of this agent. TTiis includes 
vaccines such as those for influenza and 

yellow fever. 

Manufacturers who hold Canadian Bio- 
logics Licenses for these products are 
therefore requested to make every effort 
to begin their production with Avian Leu- 
kosis free eggs. It is appreciated that this 
may take some considerable time, but it 
can be expected that within a forseeable 
period it will be a requirement that all such 
vaccines sold in Canada will be made from 
eggs free from Avian Leukosis. In the in- 

terim period Canadian licenses for influen- 
za vaccines will be required to carry out 
control tests for the presence of Avian 
Leukosis (R.I.F. test). 

As of November 2. 1964, no lot of in- 
fluenza vaccine may be sold in Canada, 
unless it has been tested for th presence of 
Avian Leukosis viruses, and has been shown 
to be free therefrom. — C.A. Morrell, 
Director, Food and Drug Directorate. Dept. 
of National Health and Welfare. Ottawa. 


MARCH 1965 



Letter to the Editor of the Canadian 
Medical Association Journal: 

Recently there seems to be an epidemic 
of shifts among the nursing profession. To- 
day, if one were unfamiliar with a hospital 
he might think he was in the obstetrical 
department, as a covey of nurses flutter 
by for coffee. 

I can think of nothing . . . more be- 
coming than a well-cut, starched nurse's 
uniform and I can think of nothing more 
hideous than a wrinkled flour sack, with 
arm holes and neck hole, on a nice-looking 

So much time is spent on the importance 
of public relations in hospitals; certainly 
wrinkled shifts are no improvement on the 
well-starched white uniform that we have 
over the years become accustomed to. 
Hospitals today are so fussy about rules of 
behavior; perhaps untidy shifts might be 
prohibited for the nursing and reception 
staff. — F. B. Bowman, M.D., F.R.C.P. 

[We agree. Shifts are almost as hideous 
as the "teddy-bear" outfits worn by many 
resident physicians when making rounds in 
hospital wards. — Ed., the Canadian nurse.] 


The continuous increases in U.S. leu- 
kemia mortality since 1921 were found in 
[a] study to be associated with sex ratios 
(male-to-female death rates) which have 
declined among children and increased 
among adults. The shifts in sex ratio oc- 
curred only in the white population and 
were demonstration in leukemia statistics 
for England and Wales. To evaluate these 
changes, a comparison was made of U.S. 
white males and females according to the 
"relative" and "absolute" increases that 
have occurred in age-specific leukemia death 
rates. In each age group the direction of 
the changing sex ratios reflected the excess 
contributed by either females (in children) 
or males (in adults) to the relative or 
percentage increases in mortality. Of 
greater significance were trends produced 
by the absolute increments, which contained 
an approximately equal number of males 
and females in the childhood age groups 
and an increasing preponderance of males 
in each adult category. These trends suggest 
that (a) the rise in mortality from childhood 



leukemia has been caused either by leukem- 
ogenic factors introduced into the environ- 
ment since 1921 and affecting both sexes 
equally, or by improvements in diagnosis 
of the disease; and (b) the rise in leukemia 
among adults has been real and not prima- 
rily related to improved ascertainment, with 
males selectively affected by increasing 
leukemogens in the environment. — Frau- 
meni, J. and Wagoner, J. Changing sex 
differentials in leukemia. Public Health 
Reports, 79:1093-1100. Dec. 1964. 


Despite what some physicians think and 
many fat people either believe or have been 
led to believe . . . obesity is due to one 
sole cause: an excess of caloric intake 
over caloric output — in other words, 
eating too much. Many factors contribute 
to this trenchman state — none of them 
directly causal. Some of these are social 
custom, family eating habits. lack of 
exercise . . . and the economic status of 
the population. Endocrine factors have been 
suggested as etiologic agents, but it can 
be said with assurance that no alteration 
in internal secretion has been shown to 
alter metabolism to such an extent that 
obesity develops, unless calorie intake 
exceeds calorie output. In recent years the 
possibility that the obese state is a re- 
flection of personality disturbance has 
gained increasing credence. 

It is obvious that drug therapy in 
obesity is unlikely to be of any more than 
purely ancillary value and . . . unlikely to 
have more than a fleeting benefit. The 
placebo effect of taking any medicine which 
the doctor says is "good" can never be 
ruled out. 

The drugs alleged to be helpful in 
weight reduction belong mainly to the 
amphetamine family. All of the commer- 
cially available compounds are alleged to 
suppress appetite without producing other 
central nervous system effects, such as 
insomnia and . . . euphoria. Actually few 
convincing placebo-controlled trials have 
been carried out. 

The combination of amphetamines with 
thyroid extract does not rest on sound 
physiologic grounds. The claim that hypo- 
thyroidism is a frequent cause of obesity 
has long since been invalidated and the 
rationale of the hypothesis that thyroid 

accelerates the metabolic rate to the point 
where calorie expenditure exceeds intake 
does not hold, since the dosages involved 
are not physiological and, at best, can 
only fractionally suppress normal thyroid 

A sound weight-reduction program must 
include an explanation to the patient of 
the factors contributing to excessive ap- 
petite, and [the physician's] willingness to 
take part in a long-range program to help 
the patient regain normal weight . . . 
Results are poor in those who have devel- 
oped excessive appetites as a compensatory 
mechanism, or as an adjustment to serious 
personality or environmental problems. — 
Wilson, D. R. Drugs for Obesity. CM. A. J. 
91:1369, Dec. 26, 1964. 


We knew it. We knew there had to be a 
scientific reason for our dislike of rising 
early each morning and for our non-func- 
tioning-until-10:30 a.m. brain neurons. 

Now, at last, what all we late-sleepers 
have been longing to hear from the world 
of research, has been announced. A McGill 
University professor states that nature has 
installed in each of us, a cyclic system 
which produces highest efficiency at vary- 
ing times of the day. While he has been a 
able to determine why such differences 
exist, he declines to publish his findings 
or to comment — • even to the newspapers 
— on whether or not he has found a cure 
that would enable early morning people 
to put up with evening people and vice 

We do wish that the professor would 
publish his findings so that we could obtain 
reprints. A sheet containing this infor- 
mation could be carried in one's wallet and 
presented to employers, etc., the same as 
one's birth certificate or social security 
card. After all. it is unfair that we late 
rousers should have to go on being labelled 
"lazy" by our eccentric colleagues who like 
to rise early. Also, it is detrimental to 
one's mental health to hear these same 
people make the comment that people who 
cannot wake up when the alarm rings are 
"dependent." do not enjoy their daily work, 
are basically unhappy, etc. 

By the way, please don't wake us tomor- 
row morning. We want to lie in bed and 
contemplate these new findings. 


MARCH 1965 



Associate Editor 


Senior Assistant Editor 


Assistant Editor (English) 


Assistant Editors (French) 



Circulation Manager 

Canada and Bermuda: 

6 months, $2.25; one year, $4.00, 

two years, $7.00, 

Student nurses: 

One year, $3.00; three years, $7.00. 

U.S.A. and Foreign: 

One year, $4.50; two years, $8.00. 
Single copies: 50 cents each. 

for the subscribers in Canada, in combi- 
nation with the "American Journal of 
Nursing" or "Nursing Outlook": 1 year, 

Moke cheques or money orders payable to 
The Canadian Nurse. 


Four weeks' notice and the old address 
as well OS the new are necessary. 

Not responsible for iournols lost in moil due 
to errors in address. 


"The Conodian Nurse" welcomes unsolicited 
articles. All manuscripts should be typed, 
double-spoced, on one side of unruled paper 
leaving wide margins. Manuscripts ore ac- 
cepted for review for exclusive publication in 
the "Journal". The editor reserves the right to 
make the usual editorial changes. Photogrophs 
{glossy prints) and graphs and diagrams 
(drown in india ink on white paper) ore 
welcomed with such articles. The editor is 
not committed to publish all articles sent, 
nor to Indicote definite dotes of publication. 

Authorized as Second-Class Mail by the Post 
Office Department, Ottawa, and for payment 
of postage in cosh. Postpaid at Montreol. 




11 11 

A monthly journal for the nurses of Canada 

published in English and French by the 

Canadian Nurses' Association 

1522 Sherbrooke St. W. Montreal 

April 1965 — Vol. 61, No. 4 

273 The Heart of Nursing: Interpersonal Relations Hildegard E. Peplau 
276 Quebec Nurses Search for Economic Security Margaret M. Wheeler 
279 Understanding Psychometric Tests — Part I Vivian Wood 

283 The First Line Supervisor and Human Relations Annabel C. Sells 
285 Lung Cancer and Smoking A. J. Bailey 

287 Counseling in Nursing Letlie Turner 

289 Physical Fitness of Nurses G. R. Gumming and L. Young 

292 A Hospital Summer Course Joyce Nevitt 

294 Emotionally Disturbed Children A. N. McTaggart 

297 Dilemma of the Nursing Assistant Ann Ford 

300 Nosological Trafficking: Utile or Futile? John M. Binas 

303 A Major Adjustment Joan Fedak and Nellie Babaian 


248 Between Ourselves 

252 Pharmaceuticals and 
Other Products 

256 Random Comments 
258 In Memoriam 
260 About Books 

266 Dates to Remember 

305 Nursing Profiles 

306 World of Nursing 

309 Employment Opportunities 
327 Educational Opportunities 
330 Index to Advertisers 

APRIL 1965 




Oiier up-to-date, effective professional 
guidance toward better nursing practice 

New (3rd) Edition! An easily understood presentation of modern nursing concepts 


Here is a popular nursing arts text that will heighten 
the student's enthusiasm for her career and for her in- 
dividual role as a vital instrument in caring for the sick. 
Every modern concept of nursing is included — facts, 
principles, scientific correlation — and all are complete- 
ly in line with today's curriculum needs and require- 

Extensively reviewed and rewritten, this New (3rd) Edi- 
tion contains revised material on the development of 
nursing; the nursing school; student orientation; and 

care and use of hospital equipment. Two new chapters 
— Scientific Principles of Nursing and Legal Respon- 
sibilities of the Nurse — have been added. Topic out- 
lines, vocabularies, and suggested reference assignments 
are provided for each chapter. A revised Teachers 
Guide, containing nursing procedures and situation 
problems, is also available. 

By ALICE L. PRICE, KM., M.A., Formerly Counselor, School of Nursing, 
Presbyterian Hospitol, Chicago; Nurse Consultant, Hill-Rom Company, Inc., 
Batesville, Indiana. About 700 pages, 6%" x 9y/', with about 260 illustra- 
tions. About $700. New (3rd) Edition — Just Ready! 

New (2nd) Edition! Provides a wealth of basic information on pediatric care 


This leading pediatrics text is now available in a spark- 
ling New (2nd) Edition. It comprehensively covers the 
care of children in health and disease from birth through 
to adolescence — emphasizing normal growth and de- 
velopment. An easy-to-follow format of units is pre- 
sented covering each successive age group (the new- 
bom, the infant, the toddler, etc.). 

For each age group discussed, the author provides: up- 
to-date concepts concerning normal growth, develop- 

ment, and care of the child - — Latest socio-psychologic 
thinking on the effect of illness upon the child — 
Current information on immediate and long-term care 
of illnesses peculiar to each particular age. Full atten- 
tion is given to presenting the most uf)-to-date aspects 
of nutrition, mental health, prevention of illness, rehabi- 
litation, and public health as applied to children. 

By DOROTHY R. MARLOW, R.N., Ed.D., Associate Professor of Pediatric 
Nursing, University of Pennsylvania School of hlursing, Philadelphia. About 
750 pages, 7'^" x 10'^", with about 290 illustrations. About $8.25 

New (2nd) Edition — Just Ready! 

New! A lavishly illustrated presentation of introductory anatomy and physiology 


Ideally suited for the beginning nursing student, this 
new, magnificently illustrated book clearly presents ana- 
tomy and physiology as one integrated subject. The 
anatomy of the entire body is outstandingly illuminated, 
using a regional approach. Over 400 original and 
beautiful illustrations are accompanied by easily-un- 
derstood clinical material on varied disease entities and 
typical pathological states. A brief incisive survey of 
each organ system is given. Each chapter includes a 
short outline of its content, a comprehensive summary, 
and practical study questions for assignment and review. 

Latest Nomina Anatomica terminology is used through- 

As an additional teaching aid, 10 units of illustrations from 
the book are being prepared for overhead projection. These 
transparencies with multiple overlays (a number in color) per- 
mit easier classroom instruction and can be used for testing. 
The set of Technofax Projectuals will be available at approxi- 
mately $50.00. 

By CTANLEY W. JACOB, M.D., F.A.C.S. Associate Professor of Surgery, Uni- 
versity of Oregon Medical School; Lecturer in Anatomy, University of Oregon 
School of Nursing; and CLARICE ASHWORTH FRANCONE, Medical Illustra- 
tor, Head of the Department of Medical Illustrations, University of Oregon 
Medical School. About 600 pages, 7'^" x lO'/i", with about 425 illustrations 
(some in color). About $8.00. New — Just Ready! 

Texts gladly sent to teachers on approval 


West Washington Square, Philadelphia, Pa. 19105 

Canadian Representative: 

McAinsh and Co. Ltd. 

1 835 Yonge Street, Toronto 7 


APRIL 1965 


...take the needle 
out of the patient! 


INTRACATH®. . . places a pliable catheter into 
the vein. Radiopaque with stylet or plain, 
8" to 36" lengths. 

ANGIOCATH^*^. . . places a pliant cannula into 
the vein. 21/4" length. 

CUT-DOWN CATHETERS ... 13 to 22 gauge, 
8" to 36" lengths. 

All of these Bardic^^ Deseret products are 
pyrogen-free, supplied in a Steril-Peel® 
package that is easy to open, aseptically. 

only BARD has all three 

I nth: ORI TTT 




sii^ice: ioo'7 


'P^at^HCi^cuticajU ci^ Ot^en. ^%odutU 



Description — A new improved version of the electronic artificial 
larynx. The new device resembles previous models except for the head 
and diaphragm which ore smaller, actually measuring one inch in 
width. This smaller head fits more snugly against the throat permitting 
sound waves to pass more readily into the throat cavity. This 
innovation will extend use of the larynx to people who, because of 
the size and shape of neck or because of scar tissue, may hove been 
unable to use other units effectively. 

The artificial larynx is small, similar in appearance to an electric 
razor, and contoured in shape to fit the hand comfortably. When the 
head is pressed against the throat and the control lever depressed, 
vibrations ore transmitted through the flesh of the throat into the 
pharynx. These vibrations are formed into voice sounds by the use 
of tongue, lips and teeth in the same manner that the normal talker 
reproduces speech sounds. 

Most medical authorities regard esophageal speech as the most 
effective means of vocal communications for laryngectomized persons. 
However, the company hopes the artificial larynx may help those who 
ore unable to master that method. 

The new unit comes in two models : one high-pitched to simulate 
the female voice, and the other with a lower pitch for men. Priced 
at $45, it is distributed by Bell Telephone Company as a public service, 
on a non-profit basis. Doctor approval is a condition of sale. 

Complete information may be obtained at any Bell business office 
in Ontario and Quebec, and from the major telephone companies 
operating in the other provinces. 



Indications — An antidepressant drug useful in treotment of true 
or atypical melancholic depressions, depressive psychoses, obsessional 

Description — Tablets containing 25 and 100 mg. Trimipromine ; 
2 cc. ampoules containing 25 mg. (12.5 mg./cc.) for I.M. injection. 

Dosage — Must be carefully regulated and supervised by physician 
on an individual basis. Patients on I.M. therapy must be kept in bed 
during the first few days. 

Caution — Side effects generally respond to reduction of dosage. 
Three types of side effects occur : functional (vertigo, weakness, 
drowsiness, dryness of mouth, palpitations) ; neurological (mixed type 
trembling, convulsive seizures); psychiatric (inversion of mood, confusion 
in aged patients, anxiety manifestations). Utmost caution in arterios- 
clerotic, hypertensive or oged patients is recommended, and parenteral 
route therapy is generally contraindicated. Collapse is rare, but if it 
occurs should be treated with nor-epinephrine-like drugs, not epinephrine- 
like. The safety of this drug in pregnancy is not yet established. 

For drug cards and further information write : Poulenc Ltd., 8580 
Esplanade, Montreal 11, P.O. 

Gastric Sump Tube 



Description — An individually packaged, clear, non-toxic, vinyl plastic 
tube designed for the continuous suction of fluids from the stomach. 

This double-lumen tube is available in adult and pediatric sizes. It 
can be passed tronsnasolly. The tube con be connected to any low 
vacuum aspirator. The double lumen tube allows for easy irrigation ; 
the smaller tube may be connected to a bottle into which saline is 
slowly dripped to provide automatic irrigation. 

A longer tube with a mercury-weighted-tip is available for sump 
drainage in the lower intestine. 

Samples and prices ore available from Busse Plastics, Great Neck, 
N. Y. 11021. 



Description — Foley balloon catheter with a new automatic valve. 
A standard syringe tip is inserted into the valve and the sterile water 
injected. To deflate the balloon, the tip of the empty syringe is inserted 

This opens the valve and the 

sterile "Stripseal" container of 
accidental contamination and 

into the valve with a slight pressure 
balloon deflates automatically. 

The new catheter is packed in the 
unbreakable plastic which prevents 
provides convenient ospetic handling. 

The company states that the new catheter is made by the multiple 
dipping process with a separately made balloon for exceptional 
dependability. It is available with 5 cc. or 30 cc. balloons in sizes 
12 to 30 French. Sterilization is accomplished by electron beam 
irradiation and checked by bacteriological testing. 

Additional information is obtainable from Rusch Incorporated, 25 
Grenville Street, Toronto 5, Ont. 

The Journal presents pharmaceuticals for information. Nurses understand that only a physician may prescr/te. 


APRIL 1965 




Description — A disposable dermatologicol wet dressing thoroughly 
saturated with Burow's solution diluted 1:20. The problem of mixing and 
diluting Burow's Solution is elimited with Burowets. One dressing con 
oe conveniently applied and used for 15 to 30 minutes. 

The new product was designed for use as a soothing and astringent 
wet dressing for the relief of inflammatory conditions of the skin 
arising from swelling, bruises, athlete's foot, insect bites, poison ivy, 
allergic or other environmental skin conditions. For external use only. 

Each Burowet measures 7'/2" x ^'/j" and is made of absorbent 
non-woven fabric and con be easily folded for application on any area 
of the body. They are individually pocketed in laminated foil ond ore 
available in boxes of 12. 

Further information can be obtained by writing to Ponroy, division 
of Ormont Drug and Chemical Co. Inc., 223 South Dean Street, 
Englewood, New Jersey. 



Indications — For diet supplementation in pregnancy and lactation 
to provide basic vitamin-mineral support for the mother's diet, and 
supplemental nutritional elements (including fluoride) to contribute to 
sound tooth development in the unborn child. To be used when the 
fluoride content of the mother's water supply does not exceed 
0.7 p. p.m. 

Description — Each tablet supplies 1 mg. fluoride (from 4,94 mg. 
potassium fluoride); 132 mg. ferrous fumorate (equivalent to 200 mg. 
ferrous sulphate or 40 mg. elemental iron) ; 250 mg. calcium (from 
650mg. calcium carbonate); 100 mg. ascorbic acid; 400 I.U. Vitamin D. 
Formulation is phosphorus-free. 

Dosage — 1 tablet doily. 

Contraindications — Obelins with Fluoride tablets should not be used 
when the patient's water supply has a fluoride content exceeding 
0.7 p.p m. Before prescribing, the physician should ascertain that the 
wnter consumed is of known, low fluoride content. 



Indications — For the relief of mild to moderate poin where on 
alternative to established analgesics is desired. 

Description — • Each film-coated tablet contains : Propoxyphene HCl 
65 mg. (1 gr.) ; acetylsolicylic acid 225 mg. (3'/2 gr.) ; phenacetin 
160 mg. (2'/2 gr.) caffeine 32 mg. ('/2 gr-)- 

One grain of propoxyphene in combination with acetylsolicylic acid, 
phenacetin and caffeine provides analgesia which approximates that 
of '/2 groin of codeine in combination with the same ingredients, e.g., 
"292" tablets. 

Dosage — One tablet t.i.d. or q.i.d. 

Caution — Nausea and drowsiness have occasionally been noted as 
well OS dizziness in ambulant patients. Skin rashes, itching and g.i. 
disturbances (including constipation) hove been observed. Propoxyphene 
has very little addicting liability although one case has been reported. 



Description — A barrier towel-drape for use in ony minor surgical 
or theropeutic procedure requiring a sterile field or positive bacterial 
barrier. This new three-layered towel is disposable, moisture proof, 
lint-free ond absorbent. Constructed with an impervious plastic film 
liner, it completely prevents "flow through" of air, liquids, exudates 
and microorganisms. It is impossible for pathogens to poss through the 
towel from one surface to the other. The 17" x 30" towel-drape is 
pockoged in flot, easy to handle individual sterile packages or is 
available in bulk form designed for inclusion in hospital packs. 

The new towel, used in place of a woven cotton towel, has 
applications in hospital obstetrical departments, laboratories, outpotient 
departments, emergency rooms and medical-surgical floors, wherever o 
sterile field or sterile drape is desired, and in doctors' offices , industrial 
first aid stations, nursing homes, and by visiting nurses for procedures 
requiring a sterile field. 



Description — A sterile, disposable, efficiently-pockoged, voginol 
irrigation troy. Pockoged in o poper-wrapped plastic boot, the unit 
contains a 1500 cc. plastic bag with integral tubing (with clamp) ond 
douche nozzle; plastic-coated, water-proof treatment pod; fenestrated 
drape; gloves; bacteriostatic cleansing agent and rayon sponges; towel. 
A plastic protective covering for the douche tip is also included. 

For further information write to: Boxter Laboratories of Conodo Ltd., 
Alliston, Ontario. 


I^HI^BI The answer : TUMS ! 

These mild, minty- 

flavoured tablets will give fast relief 

from heartburn, gas and the 

other discomforts of acid indigestion. 

Keep TUMS in mind when 

your patients ask this question. 

Remember TUMS bring fast, long 

lasting, safe relief . . . and they 

cost so little too. 

for the tummy 



Description — A new plastic shroud sheet for hospital use. This 
plastic shroud sheet is sold at the low cost of a paper sheet. It 
combines the strength of cotton with the price of a disposable. Size is 
60" X 90", individually folded for ease in storing and handling. It 
is on opaque milk white, with a grained finish. 



Description — A protective shield especiolly designed to maintain 
onol, perional or sacral dressings comfortably in place without binding 
and without use of tope. Styled on undergarment lines, the shield is 
made of a soft cotton fabric, rubberized to prevent soiling or staining of 
clothing or bed linens. Other dressings ore easily secured in place 
with o single safety pin. It is fitted with on adjustable elastic waistband 
and held in ploce with two front topes. While the post-operative area is 
completely protected, there is no interference with urination. Winley- 
Morris Co. Ltd. 2795 Bates Rood, Montreol 26, P.Q., will supply further 

APRIL 1965 





The Memorial Hospital of Long Island 
has prepared a booklet The Communicator 
and Translator to aid hospital personnel in 
communicating with persons of many na- 

Sentences expressing various needs, com- 
monly uttered by hospitalized patients, are 
translated into twelve different languages. 
The foreign-speaking patient can point to 
the appropriate line of type in his language 
and the nurse (or doctor) can read the Eng- 

lish translation of the phrase. 

Example: Italian 
I want a glass of water. Desidero un bic- 
chiere d'acqua. 

I want to get up. Desidero alzarmi. 
I am too hot. Sento ptroppo caldo. 

In limited quantities, the books cost one 
dollar each (U.S. funds). Checks should be 
made payable to the Department of Pastoral 
Care, Memorial Hospital of Long Beach, 
Long Beach, California. 

For more efficient oral 

hygiene Steri/sol ...the professional 

therapeutic mouth wash and gargle 

New levels of achievement in the main- 
tenance of oral hygiene are now pos- 
sible due to the natural affinity of 
Steri/sol's active ingredient, hexeti- 
dlne, for mouth tissues. Relatively 
unaffected by food and drink, Steri/sol 
maintains bactericidal and bacterio- 
static activity for hours. 
For bad breath, sore gums, minor oral 
infections or for sore throats due to 

colds, rinse and gargle with full 
strength Steri/sol. For prophylaxis and 
maintenance of a constant high level 
of oral hygiene, use Steri/sol night and 


Toronto. Ontario 



There is no substitute for whole blood. 
When an individual loses great quantities 
of his own blood through an injury or 
surgery, transfusion of whole blood or 
blood products is the only answer. Last 
year in Canada, one person in 66 required 
a transfusion of two or more units of 
whole blood. One person in 427 needed 
a transfusion of blood products. These 
needs were met because Canadians volunta- 
rily donated their blood through the Blood 
Transfusion Service of the Canadian Red 
Cross. Blood is available free of charge 
to anyone in hospital who needs it. Be- 
cause it is free, sick and injured Canadians 
saved more than $25 1/2 million last year. 

This money-saving angle, however, is 
not to be most important part of the Red 
Cross free Blood Transfusion Service. What 
is important is that through this service. 
an individual's most basic right — life — 
can be preserved by his fellow men. 

The Canadian blood transfusion service 
is unique among similar services in the 
world. Recent observations have shown tha! 
the laboratory standards maintained by 
the Canadian Red Cross are second to 
none. Societies around the world constantly 
seek the advice of Canadians for the oper- 
ation of their own transfusion services. 

The Canadian Red Cross continues its 
search for ways to improve its already high 
standards, and to play a more imporlani 
role in the blood research projects carried 
on by doctors and research chemists. At 
present. Red Cross research laboratories 
are concerned with certain blood plasma 
proteins, their isolation and refinement. 
The purpose of this research is to purify 
plasma proteins. Research also includes 
the application of the latest developments 
in chemistry to problems associated with 
routine blood banking in order to increase 
the score and precision of testing in theii 
blood depots across Canada. 

Diagnostic services are supplied to 
hospital laboratories that are not equipped 
to make certain detailed investigations of 
blood. Also, new methods of operation are 
constantly being assessed with a view toward 
more economical operation of the blood 
transfusion service as well as its general 

Canadians can be justly proud of their 
Red Cross blood transfusion service and 
blood research program for they are res- 
pected by many the world over. 






APRIL 1965 



AMSCO-GRAYdiverter valve 

Simple, clean, modern and effective. That describes AMSCO's popular 
Gray Diverter Valve. This chromed hoseless bedpan-emesis basin rinser is 
easily installed as part of the water closet. Both hands are free to hold 
the bedpan. The water closet flushes normally with the added feature of 
being equipped to spray-rinse patient utensils as soon as they become 
soiled. This immediate rinsing of each patient's utensil in the 
patient's room minimizes the possibility of cross contamination. 
In existing or new construction, installation takes only minutes 
and is accepted under the most rigid plumbing codes. 
There is no cleaner and safer way to rinse patient utensils. 
Write for brochure SC-367R 






,\ , 

^^■^^ 'if SPRAY ARM 

""^f ^^»^^>' 



Catalog number 7-C, 
type 2. 









Handom Cmmenis 


Patent Pending 

The Posey Heel Protector serves to protect 
the heel of the foot and prevents irritation 
from rubbing. Permits patient to move his 
feet in bed with comfort and freedom. Cons- 
tructed of slick, pliable plastic, lined with 
Polyether foam to prevent pressure points. 
Designed with self-sizing open heel for com- 
fort and air circulation. Fitted with heavy, 
self -sizing liner which may be removed and 
laundered. Posey Heel Protector, Cot, No. 
HP-63, $3.75. Cotton Liner For Above, Cat. 
No. HI-63, $0.45 ea., $4.80 doz. 

NO. 66 

Patent Pending 

KucU« undar b«d 
ou< of potiantt 

This new 
Posey Belt 
provides safe- 
ty to a bed 
patient yet 
permits him 
to turn from side to 
side. Also allows sitting 
up, if belt is slackened. 
Made of strong, rein- 
forced white cotton webbing; with flannel- 
lined canvas reinforced insert. Strap passes 
under bed after a turn around spring rail to 
anchor. Friction-type buckles. Buckle is un- 
der side of bed of patient's sight and 
reach. Also ovoilable in Key-Lock model 
which attaches to each side of bed. Small, 
medium and large sizes. Posey Belt, Cat. No. 
66. $7.80. Posey Key-Lock Belt, Cat. No. 
K66, $13.65. 



Allows maximum freedom with safe re- 
straint. An improvement over sideboards, 
the Posey belt is designed to be under the 
patient and out of the way. Belt and bed 
strop ore of heavy white cotton webbing; 
loop and pad of cotton flannel. Friction-type, 
rust-resistont buckles. Small, Medium and 
Large sizes. Posey Safety Belt, Cot. No. 
S-141, $6.45. (Extra heavy construction with 
key-lock buckles, Cot. P-453, $19.50) 


39 S. Santa Anita Avenue, 

Dept. CNJ 

Pasadena, California 91107 

Letters to the Editor arc welcome. Only 
SIGNED letters will he considered for 
puhlication. Name will he withheld from 
the published letter at the writer's request 


I would like to take this opportunity to 
congratulate you and your staff on the 
"new look" of The Canadian Nurse. The 
timing of the changed appearance to coin- 
cide with the Diamond Jubilee of publication 
seems most appropriate. 

You have chosen a distinctive cover 
design, and with the simple functional 
format the total effect is extremely pleasing 
and professional. All Canadian nurses 
should be justly proud of their magazine. 
It is always read with much enjoyment at 
ICN headquarters. 

Valerie O'Connor, Acting Editor, In- 
ternational Nursing Review. 

I think the "new dress" of the Journal 
is attractive and dignified. I feel sure you 
will receive many complimentary comments 
from the nurses and others. 
A. Isobel MacLeod, President, C.N.A. 

Congratulations to The Canadian Nurse 
for its beautiful new look ! The cover 
design is indeed attractive as is the way in 
which the editorial material and advertising 
is handled. 

Best wishes on your sixtieth anniversary 
and for many, many more years of success. 

Lucille E. Notter. Editor, Nursing 


Congratulations on the new appearance 
of the Journal. It is most attractive and 
I do think the articles are easier to read. 

Doris E. Gibney. Assistant Executive 

Secretary, RNAO. 

May I add my word of congratulations 
to the many I am certain you are receiving 
regarding the new format. 

Though I am among those who found the 
previous style such a convenient size to 
hold, especially for night reading, I must 
agree that this one looks very professional. 
At first glance it looked bare, but its 
simplicity is growing on me. I believe it 
will become increasingly distinctive as we 
see succeeding copies. 

Margaret M. Wheeler, Nursing Consul- 
tant, Division of Industrial Hygiene, Quebec. 

There are some shocks in life that have 
pleasant repercussions and encountering the 
new design for the first time has had this 
effect for me. Even the best intentioned 
of us are apt to look upon changes with 
a little skepticism, but there is little doubt 

in my mind that the larger-sized edition will 
enable our national Journal to make a 
still greater contribution to the development 
of nursing in Canada. 

Albert W. Wedgery, Reg.N.. Assistant 

Director, College of Nurses of Ontario. 

Congratulations on the new layout of 
the Journal. Looks "very classy !" 

Vivian Wood, Faculty, The University 

of Western Ontario School of Nursing. 
London, Ont. 

January issue of the Journal has just 
arrived — \ do like the new format. looks 
as if we were really growing up ! 

C. Aitkenhead, Director of Nursing. 

Sherbrooke Hospital. Que. 

The new edition of The Canadian Nurse 
is a credit to our profession. 

Sister Barbara. St. Joseph's Hospital. 

London. Ont. 

What an eye-catcher our January issue 
of The Canadian Nurse ! The effect of the 
contents is more readable, too. What 
strides the Journal has made over the 
years ! You are all to be congratulated on 
the high standard of information given. 
What a far cry to earlier days ! It is keeping 
step with the nuclear age. 

To all participants in the production of 
our Canadian nurses' magazine, please 
accept our gratitude ; your success and a 
continuation of progress are assured. 

In discussing the new look with some 
of our nursing staff, we all agreed that 
The Canadian Nurse should have a more 
prominent place on the cover, and our 
name and address labels not so conspicuous. 
We shall miss the colored scheme too. 

Every good wish to you all. 

Ella M. Roulston, Director of Nursing. 

Lady Willingdon Hospital, Ohsweken, Ont. 

Congratulations on the new format of 
the Journal. As a sample of "things to 
come" it is taking its place with the better 
professional publications. 
Sister Damian, Administrator. Provi- 
dence Hosp., High Prairie, Alta. 

Best wishes for your "New Dress" to the 
C. Nucci. M.D., Montreal. 

Thank you for sending me a copy of 
The Canadian Nurse, January issue, with 
my article in it. The new cover is attractive, 
but I think it will take a few issues to 
get used to it as well as to the new 
format. I am ready to accept it, however. 

Sister M. Felicitas, Director, School 

of Nursing, St. Mary's Hospital, Montreal. 


APRIL 1965 


I was most favorably impressed with the 
new format. 
C. J. Parsons. R. N., Alberta. 

What a delightful surprise to receive 
the new version of The Canadian Nurse 
this month. The Journal Board is to be 
congratulated on the selection of this new 
format and cover style. 

The cover is simple and distintive, and 
the copy very readable and easy to follow. 
All in all. it is indeed a more professional 
looking publication — perhaps befitting 
the changing status of the modem nurse. 

Sister Mary Grace, Administrator, St. 

Joseph's Hosp.. JJamilton, Ont. 

Congratulations on the January edition 
of our professional magazine The Canadian 

This new format is both distinctive and 
dignified and certainly does "eye justice" 
to the excellent material which lies between 
its covers. I am sure you would find the 
delighted response of the nurses on our 
nursing service and nursing education staff 
some small source of encouragement for 
all your efforts to bring The Canadi.\n 
Nurse to its present state. 

Sister M. Celestine, M.Sc.N.. Director 

of Nursing, St. Joseph's Hosp., Hamilton, 

Congratulations on the appearance of our 
new Journal. 

Our entire staff has read each article, 
advertisement and suggestion with renewed 
faith that you can and will bring new 
methods and ideas to those of us who are 
still engaged in nursing, but lack the 
opportunity of attending classroom sessions 
or other postgraduate activities. 

Keep up the Good Work ! 

Hotel Dieu of Saint Joseph, Nursing 

Staff, Perth. N.B. 

The cover selected has added a new 
dimension to The Canadian NinjsE in more 
ways than one. Congratulations to all 

C. Lewis Gould. Uniforms Registered, 

Toronto, Ont. 

May I take this opportunity to congra- 
tulate the editorial staff on the format of 
the January edition. The new size and 
layout seems a definite step toward a 
professional journal and is most acceptable 
as an aid in our attempts to reach such 
Margaret F. Munro, Saskatoon, Sask. 

Well, I received the new Journal today 
as did many others in our office. I was 
quite interested in the reaction of the girls 
to the new format. I think most of them 
were quite plea.sed about the change, but 
there were others who were rather disap- 
pointed in the plain cover. Several remarked 
on the fact that the name and address 
being placed in the centre of the book 

looked a little out of place. My opinion 
was that this placement was not intentional 
or permanent, and I voiced this opinion to 
some of the girls. Am I correct in this 
assupmtion ? 

Personally, I think the magazine has 
improved considerably with the new arrange- 
ment of articles and the size of the book, 
etc. I like it very much — except for the 
placement of the address label in the centre 
of the cover. 

■ Ruby Harnett, Associate Director, Dept. 

of Nursing Service, Dept. of Health, St. 
John's, Nfld. 

It was with eagerness and anticipation 
that I awaited our first 1965 Journal 
expecting, since a contest had been held 
and many entries sent in, a brilliant if not 
artistic cover. Yes, I do like the simplicity 
and dignity, the distinctiveness and truly 
professional appearance of this the Joltrnal 
of all the nurses of Canada. However, to 
have these qualities alone representing us 
is, in my mind, to say that the nurses of 
Canada lack creativeness, imagination and 
feeling. How nice it would have been to 
see a bit of the human element around 
which our work and our hearts evolve, on 
our cover to represent us. 

In disappointment and sincerity. 
Registered Nurse, Shawbridge, Que. 


I read with interest the letter by Helen 
Gemeroy of Quebec in the January issue, 
in regard to her opposition to the article 
"The Christian Nurse's Role." (Aug., 1964). 

I did not get the feeling from the 
inclusion of the article that the Journal 
is making an assumption regarding the 
religious convictions of its readers. There 
are practicing nurses who do feel that a 
Christian belief has a definite part in their 
life. Let them express it. Is this not the 
purpose of the Journal ? In the January 
issue the main theme is obstetrical care. 
Of course this is not going to appeal to 
every nurse but it expresses the authors' 
experience and study. The articles will be 
read by those who are interested in this 

From my own experience I have never 
found my own convictions about religion 
damaging to any relationship with any 
patient. It has been on the contrary. 

Thank God for nurses who will stand up 
for what they see to be right. How can 
anyone perceive and measure the world 
and themselves, the problems and solutions, 
unless they have a system of values that is 
a yardstick to measure by ? 

I am glad to see that The Canadian 
Nurse does not have a policy of censor- 
ship. We need more articles about the 
convictions of nurses who are nursing in 
this rapidly moving age. There are two sides 
of this coin called "profession". 

— Barbara Surbeck, R.N„ Edmonton. 

This Spring 
From Appieton 

Drugs and 
Nursing Implications 

with Faye Clark Berzon, M.S. 
and Marilyn Bellini Fall, B.S. 

This new handbook is specif- 
ically designed as a nurse's 
guide to the intelligent admin- 
istration of drugs. All drugs are 
presented in logical and stand- 
ard sequence: U.S.P. Name, 
Trade Name, Drug Group, Ac- 
tion, Uses, Route, Dosage, Con- 
traindications, Toxicity, and Side 

For the nurse, the invaluable 
feature of this book is the de- 
tailed discussion of Nursing Im- 
plications v\/hich is part of the 
coverage of each drug. Here 
the nurse is advised of pertinent 
clinical, emergency, and reha- 
bilitative aspects. With Acet- 
azolamide (Diamox), for ex- 
ample, she is told: (1) intake 
and output, (2) daily weight, 
(3) the diuretic effect usually 
lasts for 2 to 3 days only; for 
this reason the drug is generally 
given on alternate days. 

Based on a thorough and pains- 
taking study of the pharmaco- 
logic action of each drug and 
the physiologic changes which 
imply nursing responsibilities, 
this handbook is a valuable aid 
to the experienced nurse and 
an invaluable text for the 

1965. Approximately 350 pages. 
Flexible Cover $4.95 

Order at your local bookstore 
or directly from : 


Division of Meredith Publishing Company 

440 Park Avenue South 

New York, New York 10016 


APRIL 1965 


RANDOM COMMENTS . . . (con't.) 

I was deeply touched by your article 
(Aug. 19664) 'The Christian Nurse's Role," 
and passed it on — as I feel it is a much 
needed dimension in nursing. 

I too cast my vote for part-time nursing. 

Alice Anne MacKenzie, R.N., Rock- 

cliffe Park. Ont. 

I wonder if I might ask you to make a 
correction in the recent "Nursing Profile" 
you published about me. In it, I was 
described as Assistant Director of Nursing 
at University Hospital, Saskatoon. Actually 

my position is Assistant Director of the 
Hospital and Director of Nursing. 

Many thanks for the very nice biography. 

Madge McKillop, Saskatoon, Sask. 

[Our apologies for the error — Ed.] 

The advance notice of the neurosurgical 
and neurological articles due to appear in 
the March issue of the Journal (Feb. 1965, 
p. 110) advertises only those written by 
doctors. But there are also articles on 
neurosurgical nursing to which the me- 
dical articles are complimentary. Although 
these are written by nurses who are autho- 

rities on neurosurgical nursing, there is no 
mention of them in the editorial advertise- 

The editors presumably believe that first 
class nursing articles are less attractive to 
their readers than some background inform- 
ation from the pens of doctors. Such false 
modesty is the curse of a profession accused 
of not having a mind of its own. 

Are any contributions more important 
than clinical articles written by nurses who 
know what they are talking about? 

— T. P. Merely, F.R.C.S. (C), Toronto 
General Hospital, Toronto, Ontario. 

begins with 
weight watching! 

Weight control and general well-being 
depend on avoiding extra calories. 

Using Sucaryl means you can keep 
an attractive silhouette, maintain your 
ideal weight— yet go right on enjoying 
fully sweetened, natural -tasting foods 
and beverages. 

Sucaryl Sweetens 
Without Calories! 

Sucaryl contains no calories at all. 
Whether you are just watching your 
weight, or are on a prescribed low- 
sugar diet, you can use Sucaryl In 
tablet, liquid or granulated form in 
cooking, freezing or canning, as well 
as In coffee and tea. It Is not affected 
by heat or cold, has no bitter taste or 

Look for Si/cary/ at your 
drug store— and ask 
for your free copy of 
the 32-page colour 
booklet, "Calorie- 
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■Trade Mark Reoislered 


Hallfai • Montreal • Toronto • Winnipeg • Vancouver 

J^ ^ 


It is with regret that we report the 
death of Dr. George Stewart Cameron in 
Peterborough, Ont. Dr. Cameron was 
named an honorary member of the CNA 
in 1962 as a tribute to his work on behalf 
of Canadian nursing. He was chairman of 
the Joint Committee of the Canadian 
Medical and Nurses' Associations which 
sponsored the Weir Report in 1929. He 
retained a strong interest in nursing and 
contributed in many ways to its growth. 

Nurses across Canada were saddened 
to hear of the death of Dr. Kasper Nae- 
gele of Vancouver. Dr. Naegele had 
worked closely with nursing for many 
years. In 1961 he was asked by the Can- 
adian Nurses' Association to direct a 
Study of Nursing Education in Canada. 
He presented his report to the Biennial 
Convention in St. John's, Nfld. this past 
summer. Dr. Naegele was Dean, Faculty 
of Arts, University of British Columbia. 
He was a wise and courageous man and 
he will be sadly missed. 

Bernadine (Mancuso) Adams '30, On- 
tario Hospital, Mimico. Ont. 

Sarah Archard '14, Victoria General 
Hospital, Halifax, N.S. 

Orphy (Brisbin) Austin '41, Frankie 
Eileen (Duffield) Bullen '18, Jean Leish- 
man '08, Margaret (Keyes) Rhuland '33 
Laura Rowan '20, Viola (Copp) Van de 
Weil '32, Marie (D'Altry) Willows '19, 
Toronto General Hospital, Ont. 

Eila Terttu (Haahtl) Dicker '54, St. 
Paul's Hospital, Vancouver, B.C. 

Muriel Frances Maud Frampton, '15, 
Emily Florence (Dowker) Gordon '34, 


APRIL 1965 


Royal Jubilee Hospital, Victoria, B.C. 

Eleanor Smyth (Moffat) Hutchins '31, 
Victoria Hospital, Prince Albert, Sask. 

Helen Jubinvllle '61, St. Boniface Hos- 
pital, Manitoba. 

Grace Dorothy (Maclnnes) Kerfoot 
'27. Brockville General Hospital, Ont. 

Marguerite (Mercier) Labelle '46, Hopi- 
tal Ste-Justine, Montreal. 

Jeanne Labrosse '24, Olivette (Belaln- 
sky Phaneuf '44, Hopital Notre-Dame, 

Lillian Jeane (Stevens) Mcintosh '20, 
Inez Harriet (Ketchum) Robson '37, Vcin- 
couver General Hospital, B.C. 

Janet (Cameron) MacNeiil '32, Salem 
General Hospital, Salem, Mass. Mrs. Mac- 
Neiil worked in Antigonish, N.S. for se- 
veral years. 

Elizabeth (Atwood) Outerbridge '55, 
King Edward VII Memorial Hospital, 

Mary- Ann Pacey '27, Plummer Memo- 
rial Hospital, Sault Ste. Marie, Ont. 

Helen Harriet Tyler, Grant Hospital, 
Columbus, Ohio. Miss Tyler had worked 
in St. Catherines, Ont. for many years. 

In the Good Old Days 

(The Canadian Nurse April 1925) 

It is told of Ruskin, the great Victorian 
art critic, that he was much annoyed by 
the muddy state of the road in which he 
lived at Heme Hill. He could scarcely 
venture abroad without his boots being 
splashed with mud from the wheels of a 
passing vehicle. 

In his eccentric way, he sent a sample 
of this road mud to a friend who was a 
famous analytical chemist, desiring him 
to analyse it. and tell him of what it was 

The reply duly came. The chemist 
reported that the mud contained four in- 
gredients, viz., sand, clay, soot, and water. 
TTiis set Ruskin thinking, and presently the 
poet, artist, and idealist in him got the 
better of the grumbler and enabled him to 
look at the matter from a new viewpoint. 

"Sand ?" said he. "Why, sand is only 
the crude form of the opal, one of the 
purest and loveliest of gems. Clay ? The 
metamorphosis of clay is the sapphire, and 
all the loveliest porcelain in the world, 
wrought by the masters of handicraft, was 
just common clay once, dug out of the 
bowels of the earth. Soot ? What is soot 
but carbon, and what is the diamond but 
pure carbon ? Water ? " 

And at that word his imagination pictur- 
ed the myriad dewdrops, Nature's jewelry, 
sparkling in the rays of the morning sun. 

"Dear, dear !" said he. "All this time 
I have simply been splashed with jewels, 
and I did not realize it !" 


A new publication. Research Project 
Summaries, describing selected research 
studies in the area of mental health has 
been issued by the Public Health Service 
of the U.S. Department of Health, Educa- 
tion and Welfare. Among the projects 
described are a number dealing with various 
aspects of schizophrenia, most prevalent 
of the mental illnesses; research into the 
working of the brain, both chemical and 
psychological in nature; studies of dream- 
ing and sleep ; an investigation into the 

use of hypnosis ; and studies on learning, 
emotions, sensory experiences, effects of 
drugs, and a variety of others. 

Purpose of the pamplet is to present 
detailed information on a selected number 
of projects in the biological, medical, 
psychological, and social sciences. 

Single copies of Research Project Sum- 
maries, Public Health Service Pubhcation 
No. 1208, can be obtained free from the 
Public Health Service, Washington, D. C. 

There is only one Sterling-Quality ... the extra care pin that you wear 
with pride. And at so little cost that everyone should be "pinned" by 
Sterling! These plastic pins can be any color except gold or silver, lettered 
in any color including gold or silver. Sizes are as shown below, the length 
selected to suit your name! Supplied with standard pin back and safety 
clasp and lettered in blue on white plastic unless you specify another color 
combination. Need two name pins exactly alike? The second is half price! 


White Pearl- 
or-color like 

Single line .60 .65 

Double line .90 .95 



Supervisor of Nurses 

Please send correct amount with your order. Guaranteed; any Sterling- 
quality name pin that becomes defective for any reason whatsoever will 
be replaced free of charge. These are pins, not name tapes, which we also 
supply in great variety. 


365 Depot St.. Winsted. Connecticut 


APRIL 1965 



Here, in friendly Connecticut, you will 
find opportunity for advancement at Ttie 
Stamford Hospital . . .' known as "the 
fiospital with a heart". We can offer you a 
choice of services . . . educational assist- 
ance programs . . . health benefits, a 
retirement program and salary to match 
your ability and experience. Exciting New 
York City is only an hour away by train 
or car. Recent registration in 
most Provinces is acceptable 
when applying for Connecti- 
cut registration by reciprocity. 

Write today for our 

descriptive bool<let: 

"Your Future at Stamford" 

Miss Beatrice Stanley, R.N. 

Director of Nursing 


Stamford, Conn. 

;46^(Mt Saa^ 

Driving in Europe ? 


Write for a free brochure to : 


Suite 1002, 62 Richmond St. W. 
Toronto 1 , Ont. 

Phone 366-2413 

Smoking and Health, Reference Book (Can- 
ada). 171 pages. Queen's Printer, Ottawa. 

This handbook presents Icnowledge de- 
rived from research conducted in Canada 
and elsewhere concerning smoking and dis- 

It should be particularly useful to those 
who are health workers in the community 
as well as to persons who are trying to give 
up the smoking habit. 

Prevention of Hospital Infection — The 
Personnel Factor by Sir George Godber, 
R. E. M. Thompson, C. W. Walter, et 
al. 68 pages. The Royal Society of 
Health. 90 Buckingham Place Rd., Lon- 
don, S.W.I, England. 1963. 
Reviewed by Mile Victoire Audet, Hd- 
pital Notre-Dame de I'Esperance, Ville 
St-Laurent, Quebec. 

This is a report of a meeting in London 
in 1963, concerning the prevention of in- 
fection within hospital. The meeting was 
attended by health department representa- 
tives, two bacteriologists, a professor of 
surgery, a supervisor of a central steriliza- 
tion department, and a urologist. 

One notices with satisfaction that the 
discussions centred around the human 
factor. Antibiotics, sterilizers and new 
equipment were reviewed, but each lecturer 
emphasized, in particular, the role of the 
individual in carrying out present-day tech- 

In his opening address. Sir George God- 
ber reminded the audience that the problem 
of infection is ancient. Its present acuteness. 
however, is dependent upon several factors: 

1. The unjustified use of antibiotics, as- 
sociated with the belief that antibiotics can 
replace aseptic technique. Sir George il- 
lustrated this by quoting a urologist who 
said that there was so much infection in 
his department that he would soon have 
to return to asepsis! 

2. the undue attention given to equip- 
ment and services in comparison with the 
lack of interest shown in persons who 
handle this equipment and manage the 

3. the absence of constant attention to 
details which is the only guarantee of sure 
aseptic technique. 

Dr. Thompson, a bacteriologist, stated 
that one can still find nurseries, even in 
our modem world, where 90 per cent of 
the babies harbor staphylococci. The fact 
that this situation is considered inevitable 
and normal is alarming. Dr. Thompson 
believes that the administration of anti- 
biotics to prevent infection is often the 
first step in using them to cover up an 
error in technique. This kind of usage 
eventually leads to substitution of anti- 
biotics for technique. He thinks that aseptic 
technique has deteriorated at all levels — 
in the operating room and at the bedside. 
Nurses are not trained as well as they 
used to be; they are no longer familiar 
with aseptic technique; today one can 
find only a few surgeons who can carry 
out aseptic technique without error. 

Hospital housekeeping is a major problem 
due to an increase in the number of pa- 
tients, a lessening of the number of 

cleaning personnel, together with lack of 
supervision. As a rule, hospitals are dirty. 
It is easy to check this statement simply 
by rubbing your hand against the radiators. 
Operating rooms are occupied so many 
hours every day that it has become im- 
possible to keep them clean. 

No reduction of infection has been 
noticed where central sterilization exists. 
Germs have not become virulent by ma- 
gic, but the persons who handle the steril- 
ized material do not understand the mean- 
ing of the word "asepsis." Lack of basic 
knowledge, lack of training, together with a 
false appreciation of antibiotics can be 
blamed for this situation. 

Another bacteriologist. Dr. Lowbury, 
provided statistics showing that a large 
number of infections are passed on by 
the hands of the operator. He described 
various methods of culturing organisms, 
and the effects of scrubbing the hands with 
soap and water. He also discussed the 
effects of antibiotics on the skin. 

Dr. Carl Walter is of the opinion that 
infection is the result of a number of 
factors: lack of hygiene; and inadequate 
distribution of personnel on various shifts; 
ignorance; inadequate means of diagnosis 
in infection cases. 

A report published in 1951. by the 
Medical Research Council, states that con- 
trol of infection depends upon good isola- 
tion technique, perfect sterilization, ade- 
quate disinfection of equipment, and suf- 
ficient, well-trained personnel. According 
to Miss Parker, supervisor of a central 
sterilization department, these recom- 
mendations still hold true. Aseptic tech- 
niques and sterilization remain the two 
essential factors to the safety of the patient. 

With the coming of new techniques and 
new equipment, central sterilization is 
faced with multiple problems. If a new piece 
of equipment cannot be cleaned, it must be 
used only once. Can it be wrapped and 
sterilized in the sterilizer? Sudmitted to 
Cobalt 60? Should it be handled with 
care? This information must be supplied by 
the manufacturer. 

Miss Parker adds that it is not enough 
to supply sterile equipment. The supervisor 
must also be concerned with the way 
it is handled by the technician, by the 
physician, and by the nurse. It is essential 
that everyone know how to handle sterilized 
material correctly. 

Anyone who is interested in the problem 
of infection will find, in this volume, a 
wealth of scientific information, together 
with an appropriate reminder of the fun- 
damental rules of aseptic technique. 


APRIL 1965 


Evaluating Student Progress in Learning the 
Practice of Nursing (Nursing Education 
Monographs No. 5), by Alice R. Rines, 
76 pages. New York, Bureau of Publica- 
tions, Teachers College, Columbia Univ- 
ersity, 1963. Available from J. B. 
Lippincott Co., 4865 Western Avenue, 
Montreal 6, P.Q. 

Reviewed by Mrs. Vivian Wood, Lecturer, 
School of Nursing, University of Western 
Ontario, London, Ont. 

A significant part of today's and tomor- 
row's nursing education will take the form 
of work in the clinical areas. As much as 
in lecture-based courses, evaluation of stu- 
dent progress is a necessary and difficult 
task. Unlike the lecture-based courses, how- 
ever, pencil and paper tests are not suitable 
evaluation tools for assessing progress in 
the practice of nursing. In the past and in 
the immediate future, observational tech- 
niques have been and will be used. 

Unfortunately, little information is 
available about the use of observational 
techniques of evaluation in nursing educa- 
tion. Some general guides are available but 
have little relevance for the particular 
problems of nursing. 

Miss Rines' study, undertaken as part of 
her doctoral work, sheds some light on the 
way that observational techniques are used 
and proposes some changes that appear to 
have promise. She suggests that the stan- 
dards for which the student should be 
evaluated are the objectives of the course 
and the behaviors that can reasonably be 
expected of the student at her particular 
stage of learning. She then puts forward a 
planned program that combines various 
observational techniques. 

In this brief, but informative study, the 
author identifies and discusses the princi- 
ples of learning and evaluation and at- 
tempts to show the relationships between 
the concepts of learning and evaluation. 
These are applied to the evaluation of 
nursing practice. She emphasizes the need 
for a planned program of evaluation in 
the clinical situation. 

This concise study is of value for teach- 
ers of nursing who are responsible for 
the evaluation of a student nurse in the 
clinical area. Although the solution to the 
problems in perfecting evaluation forms 
may never be found, the author attempts 
to develop more efficient methods of 
evaluating student performance. The pro- 
ject was primarily written for the benefit 
of the nursing teacher. However, the fun- 
damentals and tools of evaluation that are 
discussed would be of value to any per- 
son who is responsible for evaluation. 

The study has six chapters and begins 
with a discussion of: terminology, concep- 
tual framework of principles, and purposes 
of evaluation. Many of the thoughts and 
considerations can be found in educational 
and psychological texts, but the author has 
conveniently stated them and then applied 
them to nursing situations. 

Four main techniques for obtaining data 

about student learning behaviors are des- 
cribed concisely and clearly. However, 
this section is dealt with too briefly for 
the teacher who wishes to gain some 
understanding of the evaluation tools. Her 
treatment of rating scales is an example. 
The interested reader would not find suf- 
ficient depth in this study to satisfy more 
than superficial curiosity. 

Very little was said about student self- 
evaluations. In relation to this, the author 
did state that "in some cases, this type of 
evaluation seems highly over-rated." No 
reference is made to Miss Palmer's study 
in which she analyzed the results of self- 
evaluation of nursing performance based 
on clinical practice objectives. Unlike Miss 
Rines, Miss Palmer found that student self- 
evaluations are an effective tool for eva- 

The fourth chapter is a description of 
learning concepts and their relationships to 
the student-learning process. Most of these 
concepts were selected from the fields of 
general education, education in psychology 
and nursing education. 

In her study, the author has implemented 
the above through data collected through 
interviews of nursing instructors who were 
faculty members in the colleges that partici- 
pated in the Cooperative Research Project 
in Junior and Community College Educa- 
tion for Nursing. The instructors described 
their own observational techniques of 
evaluation. Also, data were collected on how 
instructors reported on student behavior in 
learning nursing practice. 

A comprehensive evaluation program is 
outlined in the fifth chapter. Expected 
student behavior is measured in accordance 
with the learning pattern of students within 
the various clinical areas. In the final 
analysis, five guidelines are suggested. 
These concepts have embodied curriculum 
development, the learning process of stu- 
dents and teaching effectiveness. 

Some of the shortcomings of this study 
must be mentioned. First, evaluation tools 
were discussed in a superficial manner and 
appear to be written for the beginning 
reader in this area. Second, the author's 
very limited sampling of learning concepts 
presents a rather narrow view and can be 
rather misleading. In addition, the sporadic 
method in which the data were dispersed 
throughout the book interrupted its conti- 
nuity and flow. As a research study, the 
project leaned toward a descriptive study. 
One was looking for assumptions and 
hypotheses and limitations to be stated 
within the study. And, finally, although the 
bibliography listed is lengthy and varied, 
many current articles and texts regarding 
evaluation seem to be omitted. Neverthe- 
less, the study provides information where 
little has been previously available. Nurse 
educators who must evaluate using obser- 
vational techniques will find that this 
work provides some useful ways of think- 
ing about their task. 


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A Path to Quality by Helen K. Mussallem, 
Ed.D. 208 pages. The Canadian Nurses' 
Association, Ottawa, Ont. 1964. 

The material in this manual, prepared by 
the author when she was a candidate for 
the doctoral degree, provides a plan for the 
development of nursing education programs 
within the general educational system of 
Canada. The study can be obtained at $2.50 
per copy from CNA, 74 Stanley Ave., Ot- 
tawa, Ont. 


APRIL 1965 





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Le Sueur's, The Home of Nurses Uniforms, 
carries the largest stock and range of styles 
and sizes in Canada. If you would like a 
uniform with all the individuality and high 
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Dept. CNI, 209 Wellington St. S., LONDON, Ont. 

Psychology, Dynamics of Behavior in Nursing 

by Florence C. Kempf, R.N., B.S., 
A.M. and Ruth Hill Useem, Ph.D. 220 
pages. A W. B. Saunders Publication, 
available in Canada through McAinsh & 
Co., Ltd. of Toronto and Vancouver. 

Reviewed by Miss Roberta Smith, Psy- 
chologist, Mental Health Clinic, Ontario 
Hospital, Brockville, Ont. 

The preface to this book makes the 
statement that vocational competence and 
professional skill in a technical sense cannot 
be regarded as sufficient for the nurse of 
today; it is also necessary that she under- 
stand the concepts and principles under- 
lying human behavior. 

The writers have taken a novel approach 
to the study of psychology by nurses. The 
scheme of introducing the student to her- 
self, having her introduce a classmate and 
finally introducing the subject to the 
student is a sound one and likely to catch 
interest right at the start. 

The psychological concepts used through- 
out the book are sound and are presented 
in a rational order. TTie age divisions con- 
sidered seem valid and should be readily 
accepted by the student nurse. The suc- 
ceeding sections "Individual Personality" 
and "Group Relationships" follow in logical 

As outside reading, this book could be 

very illuminating but as a basic text it 
seems to assume a wider knowledge of the 
fundamental concepts of psychology than 
the average beginning student of nursing 
is apt to possess. Herein lies a danger that 
the student may attempt to put into practice 
ideas that are inadequately founded or 
imperfectly understood. 

Communicable and Infectious Diseases, 5th 

ed., by Franklin H. Top, M.D,. M.P.H., 
and Collaborators. 902 pages. The C. V. 
Mosby Company, Saint Louis. 1964. 

This book is intended "as a text or handy 
reference for all persons whose professional 
duties necessitate contact with certain com- 
municable diseases or infestations." In this 
edition, many of the chapters have been 
revised or rewritten to up-date material. 

Two of the contributors are nurses. They 
describe specific nursing measures for each 
major disease as it appears in the text. 

One hundred and thirty-three illustrations 
and 15 color plates are found throughout 
the text. Material is presented concisely and 
clearly, usually under the headings: syn- 
onym; definition; history; infectious agent; 
epidemiology; immunity; pathology; symp- 
toms; complications; differential diagnosis; 
prognosis; treatment: nursing care; preven- 
tion and control. Reference lists and a glos- 
sary are included. 

This text is highly recommended as a 

valuable reference text for ward libraries, 
school of nursing libraries and for public 
health nurses. 

Pediatric Nursing, 5th ed., by Gladys S. 
Benz, R.N., M.A. 547 pages. The C. V. 
Mosby Company, Saint Louis. 1964. 

In this edition, the author has attempted 
to give the reader a broad, universal picture 
of child health, disease, and treatment. The 
book continues to "focus on the individual 
child as a family and community member 
and to delineate the role of the nurse in a 
variety of settings." 

This text is one of the few that presents 
basic material concerning human genetics, 
heredity, etc. Since much emphasis is placed 
on human growth and development in this 
book — and in other pediatric books — it 
seems logical that this kind of information 
be included. 

Certain sections, e.g., principles of de- 
velopment, have been presented in this edi- 
tion in a way which lends itself to greater 
clarity. The format it,self has changed from 
a page-width to a two-column set-up and 
makes for easier reading. Some new illustra- 
tions have added and the general layout of 
the book improved. 

This book should be very useful to both 
students and graduates studying and work- 
ing in a pediatric setting. 


APRIL 1965 


when selecting 
textbooks for 
next semester. . . 

. . . look to these authoritative 
up-to-date texts to meet 
you7' expectations in all areas 
of your nursing curriculum 

New ith Edition! MoriSOn 

Text and Workbook for Student Nurses 

Completely revised and reorganized new edition of the most 
popular and widely adopted text in "Professional Adjustments." 
Can provide your students with a wealth of basic information, 
always with emphasis on their responsibilities as they learn the 
art of nursing. Effectively and maturely stresses the "why" and 
the "how" of the adjustments the student must make while be- 
coming a professional nurse. Content has been completely re- 
vised to provide your students with a firm foundation for nurs- 
ing. Provides both a text and workbook in one comprehensive 
volume. Includes 64 perforated and punched worksheets bound 
into the back of the book. Now a hard-bound volume with a full- 
color cover, printed in two colors throughout for added reada- 
bility. Superbly illustrated, including a 32-page section of 64 
full-color illustrations which greatly aid student understanding. 

By LUELIA J. MORISON, R.N., M.A., Nurse Specialist, Ohio Department of Health, 
Columhus, Ohio. Publication date: Februanr. 1965. 4th edition, 464 pages »Vft 
10%", with 74 photographs and line drawings and 64 illustrations in full color. 
Price, '»7. 25. 


SI Louis, Mo. 63103 


APRIL 196.1 


New 5th Edition ! Smith 


Completely updated and revised new edition of 
the most extensively used microbiology text in 
Schools of Professional Nursing. Comprehen- 
sively presents basic principles for the beginning 
nursing student. Can help her clearly see how to 
apply these principles to the nursing situation 
in a practical way. Presents the latest scientific 
thinking, discussing in detail new developments 
such as those in virology and bacterial genetics 
and those in preventive medicine and newly dis- 
covered diseases. Organized in an easy-to-teach 
six-unit format which includes laboratory exer- 
cises for schools with limited laboratory facili- 
ties. Superbly illustrated throughout. Makes ex- 
tensive use of tables and charts. Scientific names 
of microbes have been taken from Bergey's 
IOLOGY and other accepted authorities. In- 
cludes comprehensive glossary. 

ciate Professor of Pathology, Ttie University of Texas South- 
western Medical School, Dallas, Tex.; Assistant Professor of 
Microbiology, Department of Nursing, Sacred Heart Dominican 
College and St. Joseph's Hospital, Houston, Tex.; formerly In- 
structor in Microbiology and Pathology, Parkland Memorial Hos- 
pital School of Nursing, Dallas, Tex. Publication date: May, 1965. 
Sth edition, 624 pages, 6Wx 9W, with 194 illustrations. 
About $7.50. 

A New Manual ! Smith 


Entirely new laboratory manual and workbook 
includes 29 practical, effective exercises designed 
to demonstrate diagnosis, the prevention of di- 
sease, and to show how microbiology is of prac- 
tical help in treatment. Helps the student build a 
body of knowledge that will be a component of 
the nursing structure and helps her understand 
the place of microbiology in the overall health 

cation date: April, 1965. Approx. 14S pages, 1DV2"x7V4", with 
5 illustrations. About $3.00. 

264 APRIL 1965 

meeting your expectations 

New Sth Edition ! Griffin-Griffin 


Completely revised and updated new Sth edition of the most widely 
adopted text in its subject area comprehensively analyzes and interprets 
significant historical events in their relation with current methods and 
thinking in modern nursing, while examining the place of nursing and the 
nurse in today's expanding medical research. Includes entirely new sec- 
tion on "Nursing in Canada." 

By GERALD JOSEPH GRIFFIN, R.N., B.S., M.A., Head, Department of Nursing, Bronx Community 
College of the City University of New Yorit, Bronx, N.Y.; and H. JOANNE KING GRIFFIN, R.N., B.S., 
M.A., Lecturer, Nursing Science, Department of Nursing, Bronx Community College of the City 
University of New York. With a special unit on Legal Aspects by ELWYN L. CADY, Jr., LL.B. 
B.S. Med., and a special unit on Nursing in Canada by MARY B. MILLMAN, R.N., B.A. Publication 
date; Januanf, 1965. Sth edition, 503 pages, 6V2"x 9Vi", 43 illustrations. Price, $6.75. 



A Programmed Presentation 

Completely new text-workbook saves you valuable class time in courses 
in "Solutions and Dosage" by providing a method of programmed in- 
struction by which students can review fundamental arithmetic proce- 
dures individually and at their own rate of speed. Programs written to 
ensure that practically all students get 95% of the answers correct. 

By LAURA K. HART, R.N., B.S., M.Ed., Instructor in Nursing, State University of Iowa College of 
Nursing, Iowa City, Iowa. Publication date; January, 1965. 71 pages, 7"x10". Price, $2.50. 

New 3rd Edition ! Gebhardt-Anderson 


Well-illustrated new edition presents an easily understood, well-balanced 
survey of fundamental microbiology, immunology and applied microbi- 
ology. Exemplifies the current interest in the mechanisms of the life pro- 
cesses on the molecular rather than the cellular level. Incorporates vir- 
tually all recent advances in the field. 

By LOUIS p. GEBHAROT, M.D., Ph.D., Professor and Head. Department of Microbiology, University 
of Utah College of Medicine, Salt Lake City, Utah; and DEAN A. ANDERSON. M.S., Ph.D., Professor 
of Microbiology and Public Health, California State College at Los Angeles, Los Angeles, Calif. 
Publication date: February, 1965. 488 pages, 6V2"x 9V2", with 90 illustrations. Price, $7.75. 

New 3rd Edition! Gebhardt-Anderson 


Revised new edition presents 72 experiments which include not only stan- 
dard exercises, but a number of unique new ones related to molecular 
biology, such as the IMViC test and microbial genetics experiments. 

By LOUIS p. GEBHARDT, M.D., Ph.D.; and DEAN A. ANDERSON, M.S., Ph.D. Publication date: Febru- 
anr, 1965. 3rd edition, 335 pages, 7V4"x lOV:", IS illustrations. Price, $4.25. 


with a complete line of up-to-date textbooks that effectively 

fill the requirements of your modern nursing curriculum 

New 3rd Edition! Shafer-Sawyer-McCluskey-Beck 


New 3rd edition has been updated and perfected through classroom use 
to meet all your current course requirements in "Medical-Surgical Nurs- 
ing". Provides the latest information on current thinking and preferred 
procedures for effective nursing care in all medical-surgical cases. 
Superbly illustrated and printed in two colors throughout for added 
readability. Includes revised chapters on: cancer, including radiation 
therapy; personality disorders, including alcoholism and drug addiction: 
endocrine disorders, including nursing care related to the use of steroids. 

By KATHLEEN NEWTON SHAFER, R.N.. M.A., formerly Associate Professor in Out-Patrent Nursing, 
Cornell University-New York Hospital School of Nursing, New York, N.Y.; JANET R. SAWYER, R.N., 
A.M., Instructor, School of Education, Department of Nurse Education, New York University, New 
York, N.Y.: AUDREY M. McCLUSKEY, R.N., M.A., Sc.M.Hyg., Supervisor, Hamden Public Health 
and Visiting Nurse Association, Inc., Hamden, Conn.; and EDNA LIFGREN BECK, R.N., M.A., 
formerly Associate Director of Nursing Education, Muhlenberg Hospital School of Nursing, Plain- 
field, N.J. Publication date: May, 1964. 3rd edition, 889 pages, 7"x10", with 192 figures. 
Price, $9.00. 

Koch-Puras-Pugh -Carter-Joel -Savich-Beyers 

Completely new workbook and study guide provides you with a valuable 
teaching tool to help your students in "Medical-Surgical Nursing" de- 
velop problem-solving techniques, communication skills and the moti- 
vation to study. Presents 22 patient-centered, problem-solving case stu- 
dies. Text is correlated with subject matter of Shafer et al, MEDICAL- 

MARJORIE BEYERS, R.N., B.S., M.S., all of the Evanston Hospital School of Nursing, Evanston, III. 
Publication date: June, 1965. Approx. 248 pages, ^Vi"t^0V2", illustrated. 

Netv 6th Edition ! 



A revised and updated new edition of the outstanding text which for 
more than 20 years has set the standard for teaching the nursing of pa- 
tients with abnormalities of the skeletal system. New edition is the most 
up-to-date and profusely illustrated text in the field. Provides a compre- 
hensive, up-to-date presentation of the complete medical and surgical 
nursing care of the patient with orthopedic conditions. Includes all new 
methods of treatment, new techniques and new equipment for nurs- 
ing care. 

By CARROLL B. LARSON, M.D., F.A.C.S., Professor of Orthopedic Surgenf and Chairman of the 
Department of Orthopedic Surgenf, State University of Iowa, Iowa City, Iowa; and MARJORIE 
GOULD, R.N., B.S., M.S., Supervisor of Orthopedic Nursing, State University of Iowa, Iowa City, 
Iowa. Publication date: May, 1965. 6th edition, approx. 580 pages, 6Wx 9V2", with 359 
figures. About $7.75. 



The only comprehensive, up-to-date workbook in maternity nursing 
available today. Written specifically to help students thoroughly under- 
stand the theory of obstetrics, the art of maternity nursing and infant 
care and the important facts involved in conception and birth. 
By CONSTANCE LERCH, R.N., B.S.Ed., Philadelphia, Pa. Publication date: March, 1965. 272 pages, 
7y4"x10yy', 27 illustrations. Price, $4.25. 

THE C. V. 


3207 Washington Boulevard 

New Ath Edition ! 
deGutlerrez-Mahoney and CarinI 

Completely revised, profusely illustrated new 
edition of the most widely adopted text in this 
field. Presents the basic principles of nursing 
care for patients with diseases of the nervous 
system. Provides an up-to-date guide to the pre- 
vention of complications, both physical and psy- 
chological, in any patient with a chronic, disabl- 
ing disease. Most comprehensive book in print 
on symptomatology, treatment and nursing care 
of neurologic difficulties. Organized on a disease- 
entity basis. Emphasizes the responsibility of the 
nurse in the recognition and prevention of com- 
plications. Incorporates only those diagnostic 
procedures, new or modified, which are univer- 
sally accepted. 

By C. G. deGUTIERREZ-MAHONEY, M.D., Director, Department of 
Neurology and Neurosurgery, St. Vincent's Hospital and Medical 
Center, New York, N.Y.; Clinical Professor of Neurosurgery, New 
York University PostGraduate Medical School, New York, N.Y.; 
and ESTA CARINI, R.N., Ph.D., Chief, Nursing Services, SUte of 
Connecticut Department of Mental Health, Hartford, Conn.; 
formerly Department Head of the Neurological Division and 
Instructor of Neurological and Neurosurgical Nursing, St. Vin- 
cent's Hospital. New York, N.Y. Publication date: April, 1965. 
4th edition, approx. 424 pages, 6%"x 9y2", with 95 illustrations, 
including 2 in color. About $7.50. 

New m Edition ! Matheney-Topalls 


Expanded, updated new 4th edition helps your 
students to clearly see how to apply basic princi- 
ples of psychiatric nursing and to utilize inter- 
personal skills in any clinical area of nursing. 
Effectively shifts the emphasis from understand- 
ing psychiatry to understanding the patient, pre- 
senting this vital information in a clear, easily 
understood manner at a basic level. Completely 
revised and expanded to include all the latest 
information. Includes five entirely new chapters 
to provide increased, more effective coverage 
of the subject. 

By RUTH V. MATHENEY, R.N., Ed.D., Professor and Chairman, 
Department of Nursing, Nassau Community College, Garden City, 
N.Y.; and MARY TOPALIS, R.N., B.S.. M.A.. Chairman, Department 
of Nursing, Fairleigh Dickinson University, Rutherford. N.J. 
Publication date: May, 1965. 4th edition, approx. 280 pages, 
6V2"x 9V2", 46 illustrations. About $4.50. 


St. Louis, Mo. 63103 


APRIL 1965 


^€ite^ ta ^ctHC^Hjiex 

April 29 - May 1, 1965 






* * * 

May 3-7, 1965 





Theme : Commitment to Action. 

May 15, 1965 

On May 15, 1915 No. 4 Canadian Gen- 
eral Hospital (University of Toronto) 
C.A.M.C. left Canada for active service. To 
celebrate the 50th Anniversary of that event 
a Reunion of personnel will be held at Rose- 
dale Golf Club, Toronto. 

Anyone who has not received notice of 
should get in touch 

the Reunion 
with : 



504, 7 






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May 26-28, 1965 


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Sponsored by the Operating Room Nurses 

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May 31 - June 3, 1965 






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Mrs. B. Ebert, Chairman, 
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* * * 

May 31 - June 11, 1965 





* * * 

May 31 - June 18, 1965 





APRIL 1965 



A highly successful five-day institute was 
held by the Canadian Conference of Catho- 
lic Schools of Nursing at L'Esterel, Quebec, 
in January. 

The theme of the educational conference 
was S.O.S. for Action and nearly 250 
delegates from all 10 provinces enthusiasti- 
cally prepared to meet the challenge. 

Miss Noella Bertrand, director of the 
school of nursing science at Laval Univer- 
sity, Quebec City, opened the conference 
with an address demanding that we be no 
longer passive. "We have studied and dis- 
cussed," she said, "now we must act." 

Reporting progress rather than just 
promise, a panel of nurse educators spoke 
on the shortened programs for hospital 
schools of nursing now in effect. Sister 
Mary Fanchea, director of nursing of 
Providence Hospital. Moose Jaw, Sask., 
described the 29-month program that has 
been developed there. Stressing the inherent 
needs of Providence Hospital and the 
proven value of a truly educational 24- 
month program, she set forth their plan 
to gradually change from a 36 to 24 month 
course. Although the students are still 
required to supplement service needs. 
Providence Hospital School is able to 
foresee the probability of this improved 
program being in effect by September, 1966. 

Sister Therese Castonguay, director of 
the school of nursing, Regina Grey Nuns' 
Hospital told of the educational program 
initiated there in 1962. Explaining the 
background aspects. Sister emphasized that 
the program was on a research basis, but 
this experiment was again showing that 
in a controlled program nurses can be 
well prepared for first level positions in 
the two-year period. 

A report on the Quo Vadis program 
was given by Miss Margaret MacKenzie. 
The special problems of this experimental 
Toronto school for older women as student 
nurses were outlined and the objectives and 
aims explained. 

A brisk question period followed the 
report, and many questions concerning the 
financing of such programs ; the acceptance 
of the students in parent hospital and else- 
where following graduation : the available 
facilities; provincial registration were an- 
swered by the panel members. 

An interesting workshop was planned for 
the second and third days by Dr. Edith M. 

McDowell, Special Advisor to the C.C.C.- 
N.S., and by Miss Phyllis Conway, Execu- 
tive Secretary. Following each of the four 
addresses on aspects of the changing scenes 
of nursing education, the delegates were 
divided into groups for discussion concern- 
ing that aspect. Dr. McDowell spoke on : 
Organization and principles of faculty func- 
tioning in curriculum development ; objec- 
tives and aims and their definitions; cur- 
riculum pattern and structure ; and 
imprementation and evaluation. 

Dr. McDowell cleverly directed her 
remarks toward demands for action in oiir 
schools and offered many concrete pro- 
posals that could be implemented by 
faculties at once. She requested we stop 
educating for obsolescence and keep pace 
with the times. With the increasing social 
emphasis on education, she pointed out, we 
could now make senior matriculation a 
requirement to enter diploma programs. 
Another topic that afforded much group 
discussion was the establishment of faculty 
libraries and faculty continuing education 

The Executive Committee wisely realized 
that too much work, however stimulating, 
would soon dull the intellect, and planned 
an early finish for the Wednesday. L'Esterel 
is a beautiful winter resort in the Lauren- 
tians, and the hotel provided transportation 
to the ski slopes for those anxious to try 
this sport. Other delegates tried Ski-doo-ing 
over the frozen lake or went sleigh-riding, 
skating or hiking. Much excitement and 
fun was afforded by run-away horses, 
ski-doos that got stuck in the middle of 
the lake and Sisters flying downhill on skis. 
The annual dinner held that evening was 
a relaxed, informal occasion with group 
singing and much laughter. 

The institute returned to business 
Thursday morning with a symposium pre- 
sentation on the expectations and responsi- 
bilities of nursing service to the young 
graduates. Miles M. Hebert, T. Aubry and 
Mme O. Sarrazin-Robitaille provided in- 
teresting points of views. 

The annual meeting of the C.C.C.N.S. 

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\j\J OttOKATOHliS I 



APRIL 1965 


S.O.S. Reports (con't.) 

and the committee reports occupied the 
remainder of Thursday and part of Friday 
morning. Miss R. Dussault gave the closing 
address; she outhned the responsibiUties 
of Cathohc nurse educators. 

The enthusiastic participation of the 
delegates in the conference and their desire 
to utilize the resolutions of the conference 
in their own schools indicates that the 
theme — S.O.S. for Action — will lead to 
an active year in Catholic nursing schools 
across Canada. 

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The special collection of books and 
periodicals about nurses and nursing estab- 
lished in the New Westminster Public 
Library by the local Chapter of the 
R.N.A.B.C. in 1962 — and reported on 
by Monica Angus in the April, 1964 issue 
of this Journal — continues to be a source 
of satisfaction not only to the nurses 
of the area, but to the Public Library as 

From the point of view of the public 
librarian, this sort of project is a most 
valuable one. The book-budget of our 
public institutions must be stretched to 
cover the broadest possible area since it 
must supply materials to appeal to all 
the taxpayers who provide its funds. For 
this reason, the development in depth of a 
collection of books on one special field 
of knowledge, such as nursing science, can 
rarely be attempted — or even justified. 

When the New Westminster Chapter 
of the R.N.A.B.C. approached us with the 
offer to establish and maintain a special 
collection, we welcomed the opportunity 
to develop our resources in this field. Since 
its inception three years ago $1,000 has 
been given by the nurses' group. The 
whole of this amount has been devoted 
to the purchase of books and periodicals 
and to the binding of the latter, for the 
Library makes no charge against this fund 
for cataloguing and processing the books. 

In selecting the books for puchase, the 
Library has been pleased to be able to 
utilize the professional knowledge of the 
nurses themselves. The collection acquired 
so far numbers 175 volumes. These may 
be borrowed by the general public as well 
as by the R.N.A.B.C. members and are 
obviously being very well used. Eight 
journals are subscribed to on a regular 
basis and back files of these are bound 
for reference use. 

Canadian Library Week, 1962. seemed 
to us an appropriate time to inaugurate this 
fine cooperative venture — and Canadian 
Library Week, 1965 seems an equally 
appropriate time to report that "Project 
X", three years later, is pleasing hoi/} its 
sponsors as well as those who use its 
facilities! — Amy M. Hutcheson. Librerian. 
New Westminster Public Library. 




Anyone knowing or having information 
concerning the whereabouts of Elizabeth 
Catherine Andrews, who resigned from em- 
ployment at the Vancouver General Hos- 
pital, in 1950, is asked to contact the Jour- 
nal editorial staff. Information of value will 
be made available to the above-named 


APRIL 1965 


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APRIL 1965 


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APRIL 1965 




i i\ elation 6 


The central focus of nursing can 
be thought of as the "heart of nursing." 
What is the central characteristic of 
nursing practice? What feature does 
the profession of nursing want to 
emphasize as the core focus of its 
work? The practice of nursing is in- 
deed diverse. A number of important 
characteristics could be placed at the 
centre. This paper will explore some 
of the possibilities and make the sug- 
gestion that interpersonal relations be 
considered as the "heart of nursing." 

The profession of nursing is an 
organism of humans rather than a 
human organism. The profession is a 
collectivity of individual nurses — each 
a human being — each a practitioner 
from a particular standpoint, chosen 
according to his or her particular bent. 
This fact is represented through struc- 
tures such as provincial nursing asso- 
ciations. A nurses' association speaks 
with one voice; it states and supports 
the common aims of many nurses 
who join their organization. However, 
nurses as persons must first have in- 
dividual opinions; in time, these al- 

Dr. Peplau is Chairman, Graduate Depart- 
ment of Psychiatric Nursing, Rutgers, The 
State University College of Nursing, New 
Jersey, U.S.A. She presented this address in 
May. 1964, at the NBARN Annual Meeting. 
It is reprinted, with permission, from the 
NBARN News Bulletin . 


ternatives are the base from which 
the common aims of the group will be 
chosen. The same is true of the "heart 
of nursing." Individual nurse opinions 
as to the hub of the profession's work 
are at this time very diverse; a broad 
spectrum of choices is open for the 
selection of the central characteristic 
of nursing. 

The heart of nursing can be selected 
as the hub from which all else radiates 
outward and around which other 
features of nursing revolve. In the 
human organism, the heart is indeed 
a central organ; when it stops working 
the individual dies — life is ended. If 
the "heart," as the symbol of the 
central feature of nursing, is to be 
given similar value, then whatever is 
chosen as the core — the central 
force in the nursing profession — 
must indeed have the faculty of sustain- 
ing the life of the profession. Thus, 
the heart of nursing would be the most 
cherished, the most studied and under- 
stood aspect of practice. It would be 
the last part of the professional work- 
role that would be given away. Nursing 
has either established or aided in 
setting up many of the other more 
recent disciplines in the health field — 
dietetics, social work, occupational 
therapy, more recently practical nurses. 
Some nurses refer to this tendency as 
a "giveway program,'" a program of 
greater proportion than some political 

give-away programs that reach the 
newspapers. The "heart" of nursing 
would be the last aspect to be given 
away. Sociologists speak of the "dirty 
work" of a profession which consists 
of the chores which are given to 
another less well-educated worker. 
These aspects are at the shedding end 
of the profession — the practices that 
are peeled off and taught to others and 
in time cease to be an important part 
of the professional work-role. But, the 
heart of a profession — its core — 
would be the last to be "given away" 
and, when it was abdicated or passed 
on to another group, the profession 
would, in essence, figuratively speak- 
ing, die. The heart of nursing, seen 
in this sense, demands the attention of 
every nurse for it stands for that which 
assures the on-going life of the pro- 
fession. It is the most meaningful, the 
point at which nursing as a social force 
for the improvement of mankind 
makes its most telling impact upon its 
clients. What shall we put at the core 
of nursing and endow with this impor- 
tant life-giving meaning? 

The choices are many. Carefully, 
we must consider them if the choice 
among alternatives is to be a useful 
one. A useful choice meets the ulti- 
mate test — the life of the profession 
is assured. We must not settle for a 
popular cliche! A lofty principle might 
be a fundamental factor in nursing and 

APRIL 1965 


yet not serve as an instrument to evoke 
concern of nurses in sustaining the life 
of the nursing profession. A ghbly 
stated objective might serve only for 
a generation and then lose its rallying 
force. (My personal view is that "the 
needs of the people" is one such ob- 

Each nurse has her own general 
notion of what should be central and 
seen as the heart of nursing. 

Some nurses would put warmth, 
sympathy, tender-loving-care, at the 
centre of nursing. Indeed, this choice 
might be a very good one for the 
acutely ill medical patient. However, 
with increasing knowledge about psy- 
chiatric patients there is also enlarged 
awareness that somehow the mentally 
ill. in many instances, are helped 
toward chronicity by evoking and 
using mere sympathy as a way of 
maintaining their pathology. More 
than TLC, man needs to have oppor- 
tunity to use and develop his intelli- 
gence; and he needs help in gaining 
useful explanations of his experience, 
especially during illness. To sympa- 
thize with the traumatic circumstances 
in the life of a psychiatric patient is 
often to preclude requiring the patient 
to look at his participation in these 
events, at useful alternatives that were 
indeed open to him, and requiring him 
to recognize his reasons for not 
choosing health-provoking experiences 
that were available. Warmth extended 
to a patient who has an automatic 
reaction of abhorrence to closeness of 
any kind, initially at least, may in- 
crease rather than decrease the dif- 
ficulties of the patient. Tenderness is 
only one feature of a larger core 
phenomenon; the meaning of experi- 
ence is more important in the psychic 
health of a person than is warmth or 

Some psychiatric nurses would put 
perceptive observation and intelligent 
interpretation at the heart of nursing. 
With psychiatric patients — if not 
with all patients — these ingredients 
in the nurse practitioner are absolutely 
essential. Without them, inept patterns 
of living, or organic dysfuctioning that 
requires heroic emergency measures, 
may not be recognized and life saving 
intervention may then not be instituted. 
But these intellectual competencies are 
intra-personal ; as stated, they do not 
require of the nurse other important 
atributes, such as self-awareness, re- 
flection, and introspection — which 
also influence nursing practices and 
are necessary to the growth of the 

Intellectual competence of the nurse, 
to use the broad range of scientific 
knowledge, is an extremely important 
factor in professional nursing. But, it 

too, is but one facet of interpersonal 

Some surgical nurses would make 
courage the heart of nursing. They 
know the importance of this trait in 
the nurse — so that she may withstand 
daily the reactions of patients to 
mutilating surgery, disfigurement from 
unexpected accidents, and the defects 
of birth that surgery attempts to 
correct. Indeed, courage is a desir- 
able ingredient — it requires the nurse 
to have a conscience, to know how 
to show concern, to determine inter- 
ventions in light of the fact that she 
cares. But, should this trait be central 
to all nursing? 

Some nurses, particularly adminis- 
trators and educators, would make 
leadership the central feature. But 
leadership is an elusive matter; it is 
both role and function. The role of 
leader can be thrust upon an individual 
by circumstances and it is indeed dif- 
ficult to teach. The function of leader- 
ship goes on in any group of humans 
— whether we like it that way or not. 
Given a difficult situation, leadership, 
as a function, will emerge; some indi- 
vidual will seize the opportunity, then, 
like as not, set it aside once the crisis 
is dealt with. Moreover, the kind of 
leadership that is needed in a profes- 
sion such as nursing changes. From 
the beginning of nursing and almost 
to the present time, the leaders that 
nursing needed and had were the kind 
that made pronouncements. There 
were two major types. The very earliest 
leaders were of an inspirational sort; 
they saw it as their major task to 
inspire lofty ideals in the minds of 
students nurses. There also were the 
persuaders — the nurse leaders who 
took as a major task the persuasion of 
other professionals and the public of 
the need for nursing services. Their 
message was that nursing services 
were worth having; that they made a 
difference in terms of health of people. 
They had to persuade college adminis- 
trators to take nurses into academic 
institutions for purposes of scientific 
development and academic study of 

These leaders spent enormous 
amounts of time — usually their 
personal time — persuading, inspiring, 
and "seeding the clouds" so that the 
future of nursing was ensured. I would 
not want to be misunderstood on this 
point: the great nurse leaders of the 
past and many in the present were 
dedicated workers. As leaders, their 
work, however, was mainly that of 
inspiring and persuading. Leaders of 
the early days were catalysts who in- 
spired others to concern themselves 
with providing opportunities for nurses 
to render nursing services and to im- 

prove the implementation of services. 

A second major type may be called 
the diagnosers. These are the nursing 
leaders who tell us what is wrong 
with nursing, who pinpoint the issues 
and problems and dilemmas. There is 
a shade of difference between these 
diagnosers and the inspirational lead- 
ers: the latter speak in terms of what 
nursing should do, ought to do, must 
do; the diagnosers try to formulate 
what is at fault, to locate the difficulty. 
There are, for example, those who 
diagnose the problem as "disunity 
among nurses" or "anti-intellectualism" 
among nurses. 

A third and new type of leader is 
in the making and is sorely needed 
if nursing is to keep pace with the 
knowledge explosion and to advance 
with other scientific disciplines and 
professions. These leaders are the nurse 
scientists — the ones who dig out hard 
facts, who evolve explanatory theories, 
and who help underpin nursing prac- 
tices with the results of sensitive ob- 
servation, perceptive analysis, and 
systematic researches. In short, while 
there is still need for inspirational and 
persuading leaders, there is even 
greater need to move from the preach- 
ing stage to the point where our 
pronouncements are investigated and 
our practices refined by disciplined 
application of scientific knowledge and 
research. A nursing science is in the 
making and nurse scientists in greater 
numbers are needed to help formulate 
the key concepts of this science and to 
show its relationship to nursing prac- 
tices and nursing research. While these 
new leaders are vital to the future of 
the profession, shall we make them 
central, the heart of nursing? More- 
over, while research is vital to the 
future of the profession, it will not in- 
volve the large majority of nurses and 
we must not make central that which 
concerns only the avant-garde nurses. 

It seems to me that interpersonal 
relations is the core of nursing. Basic- 
ally, nursing practice always involves 
a relationship between at least two 
real people — a nurse and a patient. 
The relationship serves as the vehicle 
within which a nurse carries on many 
important sub-roles in her work-role 
— - mother surrogate, technician, man- 
ager of the environment of the patient, 
health teacher, socializing agent, or 
counselor. Any of these roles go on 
when the nurse is in contact with a 
patient and his family. The way in 
which she produces the effects of her 
teaching or of the application of a 
technical procedure has a good deal to 
do with the interaction between nurse 
and patient. The development of a 
science of interpersonal relations is 
currently being speeded up. There are 


APRIL 1965 


many researches underway that prom- 
ise more definitive scientific knowledge 
about the impact of one human being 
upon another. These research findings 
suggest that a professional relationship, 
as between a nurse and a patient, can 
be a growth-provoking one or it can be 
one that reinforces and makes more 
definite the socio-psychological diffi- 
culties of the patient. 

When interpersonal relations is 
taken as "the heart of nursing" a 
dynamic core is selected. When the 
relationship of nurse to patient(s) is 
studied, and new scientific findings are 
utilized, then changes in nursing 
education are suggested. As the indi- 
vidual nurse gains insight into inter- 

active phenomena, as these influence 
her relationships with patients, her 
professional work improves. No fixed 
formula exists for IPR — they depend 
upon ability to recognize changes in 
self and others and in situ to prevent 
disruption and severe anxiety concern- 
ing the unknown. As a nursing service 
staff develops consciousness of its in- 
terpersonal practices, services to pa- 
tients improve. The behavior of nurses 
in relation to patients having different 
kinds of health problems provides an 
area for research into nursing prac- 
tices and from this a science of nurs- 
ing will develop. And, as the nurse 
sees herself as a participant in an 
interactive situation with a patient she 

takes more responsibility for what she 

Interpersonal relations provides a 
dynamic centre for the study and im- 
provement of nursing care and for the 
growth of nursing in the process. If we 
take this core, we shall be forced to 
look at our relationships not only with 
patients but with other disciplines. We 
shall be forced to grow up — ■ to strive 
for colleague relationships with doc- 
tors, social workers, and others. We 
shall seek to establish professional 
nursing as a vital career for the intelli- 
gent, college-bound young girl, and 
use our energies for full development 
of nursing as a social force that pro- 
motes health and growth in others. 


Teaching hospitals are an integral part 
of the education of medical students and of 
the continuing education of medical faculty 
and practitioners. A medical hierarchy in 
the functional structure of the teaching 
hospital, based on knowledge and skill in 
dealing with the medical problems of pa- 
tients, includes the various levels of house 
staff, the medical students, and the clinical 
medical faculty. These form a cohesive 
learning-teaching service group and apply 
knowledge and skill to solving of patients' 
medical problems. Staff, students, and fa- 
culty ask questions of one another. They 
are scientific investigators — some with 
much knowledge and skill, some with little. 

It is not always as obvious, however, 
that a teaching hospital is a place where 
investigation in nursing is going on — 
where each patient's nursing problems are 
investigated, questioned, and studied by a 
similar nursing hierarchy of students, clinic- 
al faculty, and house staff. More frequently, 
the faculty, not always expert clinicians 
themselves, enter the hospital at specified 
times to supervise students. The students 
frequently, even in programs purporting to 
be "professional" by virtue of their inclu- 
sions in senior colleges or universities, are 
not practising problem-solving, decision- 
making, or nursing management in relation 
to patient's nursing problems. Rather, they 
are engaged in repeating certain procedures 
that characterize the more technical aspects 
of nursing — those that have already been 
delegated to less extensively prepared mem- 
bers of the nursing team .... 

In the teaching hospital, there has been 
little evidence that a method of learning 
that will continue throughout the practising 
life of the nurse is being demonstrated, or 
that the patients' nursing problems have 
been used as the stimulus for this continued 
learning. Rather, it frequently appears that 

the faculty, examinations, ward progress or 
proficiency reports are seen as stimuli for 
learning, and these of course disappear at 

Has nursing ever had an apprenticeship 
system of education to parallel that of other 
professions ? In law and medicine, for 
example, the apprentice learned from am 
independent practitioner — usually in a 
one-to-one relationship — and read the 
books . . . available in the field. Nursing 
has not had a large number of competent 
independent practitioners to whom students 
were assigned on a one-to-one basis. In 
nursing's early history there were private 
duty nurses who were independent pract- 
itioners — many of whom were undoubted- 
ly competent — but students were generally 
not assigned to these "masters" as apprent- 
ices. Rather, students seemed to be ap- 
prenticed to hospitals, to physicians, to 
patients, rather than in any way to master 
nurse-practitioners. It well may be, incred- 
ible as it seems, that nursing has not yet 
had its true form of apprenticeship edu- 
cation and what now is needed is to provide 
this apprenticeship, assuredly in a modified 
form, before advancing to truly profession- 
al education. 

The present stage in nursing — with 
its rapid increase of nursing textbooks 
(rather than watered-down medical text- 
books), nursing journals, and descriptive 
nursing case histories and with the definite 
emphasis on the preparation of master 
nurse-clinicians, both in the faculty and in 
the practice settings — may be more akin 
to classical apprenticeships than would be 
the period immediately past. If the nurse 
training .system has been mor^e of an appren- 
ticeship to hospitals and physicians, this 
might partially explain why nurses have 
gravitated so readily into hospital adminis- 
trative duties and into medical technical 

duties, since so few really ever had the 
experience of being apprenticed to a master 
nurse-clinician in any organized, consistent, 
and continuing way .... 

Schools do not belong in service agen- 
cies and it is well to note here that the 
first modern school of nursing — that 
founded by Florence Nightingale — was, 
in fact, an autonomous school with its own 
budget, which used St. Thomas's Hospital 
in its teaching program. This pattern, how- 
ever, was not carried on in [North Ame- 
rical. Attempts to get nursing schools on a 
sound basis have resulted in considerable 
disunity between those nurses who practice 
in the clinical settings and those nurses who 
teach nursing, and it has sometimes seemed 
that hospitals and physicians have encour- 
aged this disunity to the disadvantage of 
nursing in general. The inevitable conflicts, 
disagreements, and tensions that occur 
among the practitioners and educators of 
all occupations and professions are healthy 
and serve a useful purpose in growth so 
long as communication remains open and 
so long as each group feels some identity 
in the occupation or profession as an entity 
or whole. In nursing, however, for many 
reasons, this identity state has not been 
strong in all instances, and communication 
has not always been open. 

Disunity seems to have resulted in nursing 
getting its cues for action (in practice, edu- 
cation, and research) from physicians, hos- 
pitals, educators, social scientists, and others 
rather than from the society it purports to 
serve. This disunity also seems to activate 
crises situations and expedient short-term 
solutions — perhaps because of the at- 
tempt by nursing to serve too many masters. 
— Smith, Dorothy M. Nursing Education 
and Nursing Service. Journal of the Ameri- 
can Mctlical Association. 191: 416-18. 
February 1965. 


APRIL 1965 


Quebec Nurses 

Search for 

Economic Security 

Today's emphasis on social and economic welfare has captured the attention of 

nurses as it has all other members of society. Like their colleagues throughout 

Canada, nurses in la Belle Province have taken a very active part in improving 

the economic status of members of their profession. 

Margaret M. Wheeler 

Thousands upon thousands of words 
have been written and spoken about 
labor relations. It is a subject that 
many members of the nursing profes- 
sion find almost impossible to re- 
concile with their concept of "profes- 
sionalism" ; yet it is a topic of utmost 
importance to nurses today and will 
continue to be in the future. 

In recent years, several of the 
provincial nurses" associations in our 
country have devoted increasing atten- 
tion to the labor relations problems 
of their members, not the least of 
which has been the Association of 
Nurses of the Province of Quebec. 
Due to considerable publicity being 
directed to the situation in our prov- 
ince during the past year, many nurses 
across Canada undoubtedly are asking: 
"Have the Quebec nurses yet reached 
a solution to their problems ? What 
are the problems ? What will be the 
solution ?"' 

Many reports — not all accurate — 
have caused confusion and, as a result, 
misunderstanding. We will attempt to 
answer these questions, insofar as 
possible, and, from the point of view 
of the professional association, set 
the record straight. 

Miss Wheeler is Nursing Consultant, Div- 
ision of Industrial Hygiene, Quebec Ministry 
of Health, and Assistant Co-chairman, 
Committee on Labor Relations, ANPQ. 


As is true of all spheres of activity, 
history is important to an understand- 
ing of the subject at hand. The fol- 
lowing quotation puts the historical 
fact into perspective : 

From the days of Jeanne Mance and, 
later, Florence Nightingale, the training of 
nurses has stressed dedication to service, 
self-sacrifice, loyalty to the hospital and 
unquestioning obedience to those in author- 
ity. This tradition of service is strengthened 
by the public's expectation of the nurse. 
As a result, the profession itself and the 
public also, have tended to view as some- 
what unethical any forthright effort on 
the part of nurses to improve their working 

Coupled with this is the fact that 
nursing arose as a religious service 
and, from this "we see the origin of 
the tradition of nurses as unpaid or 
underpaid workers."- In addition, lay 
nurses from their origin until as late 
as the 1920's and even 1930's, lived 
in residence. Since room and board 
were provided, it was generally consi- 
dered unnecessary for them to have 
very much money. 

The decade of the '40's saw nurses 
begin to "live out" in fairly large 
numbers. They now were required to 
meet expenses directly — as did all 
other citizens — for rent, food, light, 
heat, telephone, transportation, etc. 
Assuredly, they were not offered 
"charitable" reductions in these costs 

just because they were nurses and 
working for low salaries ! This, then, 
led nurses to the realistic need of 
having to give voice to the hitherto 
traditionally-forbidden topic — money. 

Small successes were achieved by 
nurses in their early efforts to improve 
their working conditions : but it was a 
difficult and slow procedure. Exces- 
sively high hospital budget deficits 
became constant immovable objects in 
the path of salary adjustments up- 
wards. It must be remembered that 
the depression years were not long 
past. During those years, many nurses 
had been glad to accept work in 
hospitals for room and board because 
of the high rate of unemployment. 
Hospitals had tried to relieve the 
situation by employing graduate nur- 
ses in greater numbers. This, however, 
did not obviate the need to discontinue 
perpetuation of such conditions in 
post-depression years. 

Because of the consistent difficulties 
being encountered by nurses in their 
efforts to improve working conditions, 
the professional nursing associations 
recognized the need to give direct 
assistance. In 1944, the Canadian 
Nurses' Association went on record 
as approving the principal of collective 
action for registered nurses. It also 
encouraged provincial associations to 
set up committees to study and deal 
with these problems. In the '40's, many 
of these associations — including the 


APRIL 1965 




established such a coni- 


At the outset, the Labor Relations 
Committee of our province, like most 
of the others, directed its efforts 
toward counseling members and giving 
them assistance, individually or in 
groups, concerning labor relations 
problems. Frequently, contact was 
made with employer groups in an at- 
tempt to solve particular problems. 

At the end of the decade, our 
.•\ssociation, began to prepare and 
publish recommandations regarding 
salaries and personnel policies. Fol- 
lowing intensive study of nurses' 
salaries and working conditions across 
the country, in neighboring American 
states and in related professions and 
competitive occupations, these recom- 
mendations were reviewed and revised 
regularly, usually once a year. After 
each revision, copies of the recom- 
mended scale were sent to all employ- 
ers of nurses and to each member of 
the Association. Also, meetings were 
held at least once a year with hospital 
association and government authorities 
for purposes of interpretation and to 
solicit support in having the recom- 
mendations put into effect. This prac- 
tice continues to the present day. 
Since the majority of nurses work in 
hospitals, their salaries had a direct 
effect on the salaries of the large 
number of nurses working in other 

Due to the traditions mentionel 
earlier, the first salary recommenda- 
tions were essentially lower than they 
should have been — a factor respon- 
sible for the slow progress of many 
years. However, the discrepancy bet- 
ween what existed and what would 
have been a satisfactory level was so 
great, that appropriate recommenda- 
tions would have been totally disre- 
garded by employer groups. Many of 
today's impatient nurses fail to under- 
stand how essential it was to gain the 
cooperation and support of employers 
in recognizing and accepting the re- 
commended salary scale ; indeed, to 
get them to even recognize the role 
of the Association in this matter, as 
well as the need for such a role. 

Any improvement was a major step 
forward. Always to be reckoned with 
were the inevitable hospital budget 
deficits. Hospitals were operating on 
funds drawn from public subscriptions, 
many of them having no endowment 
funds. A salary increase to any one 
group of employees in a hospital would 
automatically require similar conside- . 
ration for all other employees : this, 
in turn, would drastically affect the 
budget and result in even higher defi- 

cits. Nevertheless, slow but steady 
improvement was achieved to the ex- 
tent that the Association leaders deem- 
ed it wise, in those early years, to 
keep the annual recommended in- 
creases at a constant level rather than 
bring them truly "into line" and risk 
losing the goodwill and support that 
had been gained. 

Gradually, most of the English- 
language hospitals and some of the 
French-language hospitals did accept 
and adopt these recommendations. 
They did not always put them into 
effect immediately, but usually did 
so within a few months after receiving 
each new set of recommendations. 

In late 1950's, due to considerable 
unrest among the nurses in the prov- 
ince and to their justifiable impatience, 
the recommended salary scale was in- 
creased quite drastically to bring it 
to the proper level more rapidly. The 
hospitals, of course, expressed inability 
to put the total increase into effect 
immediately ; however many did so 
within a nine-month period. 

In the meantime, other hospital 
workers were having their needs met 
through collective bargaining. Unions 
had succeeded in interpreting the con- 
cept that hospital workers were entitled 
to salaries comparable to workers in 
other fields. Accordingly, unions for 
non-professional workers in hospitals 
became quite prevalent. 

Because large numbers of nurses 
in many hospitals were receiving lower 
salaries than their colleagues in other 
institutions (salaries very much below 
the recommendations of the Associa- 
tion) they too accepted the invitation 
of unions to join their ranks. Many 
nurses outside the Montreal area join- 
ed professional syndicates. These syndi- 
cats, originated by a Catholic nurses' 
association, are presently independent 
and known as SPIC (Syndicats profes- 
sionnels des Infirmieres Catholiques). 
Many other French-language nurses 
in Montreal and in some outlying 
areas joined V Alliance des Infirmieres. 
an affiliate of the Confederation of 
National Trade Unions fCNTU). These 
groups also achieved limited, but 
steady success. 

The advent of hospital insurance 
brought many changes, but by no 
means eliminated all the problems. 
The new concept of health care being 
the responsibility of governments re- 
moved the former charitable characte- 
ristic of hospital care. Hospitals were 
now being financed by tax monies to 
which, incidentally, nurses contribute 
on an equal basis with other citizens. 
From the outset of this new develop- 
ment, the ANPO made repeated and 
persistent advances to govememental 
authorities to insist on proper salaries 

for nurses. Contrary to accusations 
made against the Association to the 
effect that it had "generously colla- 
borated" with the Quebec Hospital 
Insurance Service, it never generously 
collaborated. It collaborated to the 
degress that should be expected of a 
mature, professional organization, de- 
dicated to service of the public, during 
a period of adjustment. Prior to the 
institution of hospital insurance, the 
Association made an insistent request 
for its recommended salary scale to 
be paid from the outset. The reply 
was that this was impossible, but the 
government promised to adopt the 
basic salary recommendation in three 
stages within the year. The promise 
was kept. This pattern has been 
repeated three times. 

The Quebec Hospital Insurance 
Service has repeatedly said that if 
hospitals would include the ANPQ'S 
recommended salaries in their bud- 
gets, duly justified, they would be 
accepted and paid. This also has 
proven to be true. 

A few years ago, a Joint Hospital 
Committee was formed in the province, 
comprised of representatives of the 
Quebec Hospital Association and the 
Catholic Hospital Association. This 
Committee proceeded to recommend 
salaries for nurses but not in accord 
with the Nurses' Association recom- 
mendations. Our Association protested 
stenuously. We are confident that had 
this Committee supported our recom- 
mendation, as they had previously, 
and encouraged their member hospitals 
to include these recommendations in 
their budgets, the problems of the past 
few years would have been avoided. 


In the Province of Quebec, there are 
approxibately 6.000 nurses in unions. 
The recommended salary scale of the 
ANPO has usually been used as a basis 
for their negotiations. Indeed, on fre- 
quent occasions, representatives of 
the Association have been requested 
to attend arbitration hearings to sup- 
port the requests of the nurses — in 
unions — and they have done so 
willingly. Many nurses in unions have 
been assisted, individually or in groups, 
by our Labor Relations Committee. 

Mistakenly, many nurses in the 
province believe that their professional 
association is against the principal of 
unionism. This, of course, is indisput- 
ably false. The Quebec Nurses' Act 
contains a clause that permits the 
district associations to bargain on 
behalf of their members.'' Clause 1 7 
states : 

Each local association may negotiate, 
conclude and sign as agent and proxy in 
the name of any group of members of the 


APRIL 196,T 


local association residing and practising in 
the territorial jurisdiction of the said local 
association who shall have requested them 
to do so, collective contracts or agreements 
with any category of employers. 

If the Association had been opposed 
to such a principle, it would not have 
asked for the inclusion of this clause 
in its Act. There are eleven districts 
and none was ever asked to bargain 
for any of its members. 

The nurses in unions encounter a 
problem that does not affect other 
nurses. Under the Labor Code, the 
province is divided into two zones : 
The Montreal area is Zone I and the 
remainder of the province is Zone II. 
Generally speaking, the salaries in 
Zone II are lower than those in Zone 
I. Consequently, nurses in contracts in 
Zone II, being subject to this system, 
are usually accorded lower salaries in 
their contracts. The Association went 
on record asking that nurses be ex- 
cluded from the zoning system. It 
continues to protest this policy. 

There remain some 17,000 nurses 
who are not in unions. Approximately 
600 of these are employed in the 
Provincial Civil Service and continue 
to be underpaid. Efforts by the ANPQ 
to have their salaries increased have 
resulted in some improvement ; but 
they are still far from satisfactory. This 
fact, coupled with the continued lack 
of support by many hospital autho- 
rities and some other employer groups, 
has led the Association to believe that 
perhaps collective bargaining is the 
best method of regulating working 
conditions for all its members. 

In those institutions and organiz- 
ations that pay the salaries recom- 
mended by the Association and adhere 
to the general policies, the nurses 
seem satisfied. The great dissatisfaction 
exists, mainly, among nurses in 
hospitals and government service that 
do not follow this practice. Since these 
organizations are all financed by public 
funds, it is difficult to understand why 
this situation continues to exist. 

Satisfied persons seldom understand 
or concern themselves with the pro- 
blems of the dissatified. Nurses are 
typical in that sense. Our justifiably 
dissatisfied nurses have become more 
and more vocal about their unhappy 
state. Increasingly, large numbers have 
asked for some kind of collective 
action to overcome their problems. 

To thoroughly acquaint its members 
with all aspects of collective bargaining 
and with various legislative Acts that 
affect nurses, the Association has held 
five study days throughout the pro- 
vince during the past year. Experts in 
collective bargaining, legislation and 
labor law attended and discussed these 
topics at length. Though many nurses 

find professonalism and unionism dif- 
ficult to reconcile, the majority recog- 
nize that they are not incompatible. 


At the Annual Meeting in October, 
1964, a large number of nurses re- 
quested the establishment of collective 
bargaining by the Association of Nur- 
ses. The following resolution was pass- 
ed: "That the Association of Nurses 
of the Province of Quebec take steps 
now to examine the measures which 
would be necessary to provide for col- 
lective bargaining in the interest of its 

Though the district associations have 
the power to bargain, if collective bar- 
gaining is to be done by the profes- 
sional association, we now believe that 
it would be preferable for it to be done 
by the parent body. This would re- 
quire a change in our Act. 

The Association of Nurses of the 
Province of Quebec is a mandatory 
body, with the equivalent powers of 
the College of Physicians and Sur- 
geons or the Bar over its members. 
The Labor Code of the province re- 
quires that individuals have the right 
of "free association"; also, it requires 
that an "association" (bargaining unit) 
be composed either of employees or 
employers; both groups cannot be in- 
cluded in the same unit. Employers 
in this context are considered to in- 
clude management representatives such 
as head nurses, supervisors or ad- 
ministrators. Therefore, in the philo- 
sophy of Labor Relations, the Nurses' 
Association, in its present structure, is 
considered by the unions to be in- 
eligible as a bargaining group since it 
includes in its membership both the 
employer and employee groups. 

This is a debatable point. All mem- 
bers of the ANPQ are equal as mem- 
bers of the Association — the question 
of employee-employer relationships 
does not exist. Also, under the French 
system of 'cadres," separate levels can 
belong to the same union, but not in 
the same unit. 


The Labor Relations Committee is 
presently carrying out an intensive 
study of the entire subject. Many pro- 
fessional organizations today are seri- 
ously questioning whether they should 
directly conduct collective bargaining. 
Several are inclined to believe that they 
should set up parallel corporations. 
The main strength in the profession 
taking this responsibility directly, 
would be the preservation of standards. 
Dr. John Crispo's statement: "As long 
as professional groups remain in con- 
trol of their own collective bargaining, 
the ends and means will be subject to 

their control,"* merits thoughtful con- 
sideration. The presently existing nur- 
ses' unions have experts in labor rela- 
tions. They have well-developed struc- 
tures and are operating quite effective- 
ly. We believe that the merits, or 
otherwise, of leaving bargaining to 
these organizations should be evalu- 
ated. However, the very important 
question of standards must be safe- 
guarded. The setting of standards is 
the responsibility of the professional 
association. The union's main concern 
is regulating working conditions and 
employer-employee relations. 

As we proceed to find the right 
solution, the following positive facts 
command serious thought: 

1. The system of hospital insurance in 
operation throughout Canada has tended to 
equalize salaries and to maintain equal 

2. On January I, 1965, the Quebec Hos- 
pital Insurance Service accepted, in the 
budgets of those hospitals whose nurses 
were not in contract and who requested it, 
the basic salary recommended by the ANPQ 
for 1965. 

3. The latest contract signed by the Al- 
liance des Infirmieres, including the fringe 
benefits, reached and in some aspects sur- 
passed ANPQ recommendations. 

4. Increased state control of services is 
evoking many changes. 

We are prompted, then, to ask: is 
collective bargaining going to continue 
to be necessary for the profession? The 
future will have to reveal the answer. 

Some challenges that face the pro- 
fession incude: adoption of classifica- 
tions in all employment situations; a 
clear definition of functions; credit for 
special preparation; and the main- 
tenance of standards to justify the eco- 
nomic demands of the profession. 
Though nurses have a legitimate in- 
terest in and right to economic and so- 
cial security, they must not allow them- 
selves to overlook professional respon- 

The past year has seen us devote 
many, many hours to these complex 
problems. We feel confident that with 
concerted effort and goodwill, we shall 
find the solution that will best meet 
the needs of the nurses and the people 
of our province. 


1. Canada. Dept. of Labor. Women's Bu- 
reau. Collective Action by Nurses to Im- 
prove Their Salaries and Working Condi- 
tions. (Cat. No. L38-2064.) 

2. Ibid. 

3. Act respecting the Association of Nur- 
ses of the Province of Quebec. 10 George 
VI, chapter 88. 1946. 

4. Crispo. John H. G. Collective Bar- 
gaining and the Professional. The Canadian 
Nurse, 59:943, Oct. 1963. 


APRIL 1965 


The need to adopt systematic pro- 
cedures in the selection of students 
for admission to schools of nursing 
is of vital concern to nurse educators. 
This is true for all types of nursing 
programs, and not only because of 
the necessity to obtain the best pos- 
sible students. Admission procedures 
are also important for the design and 
performance of the whole curriculum. 
A prominent Canadian nursing educa- 
tor, commenting on the importance of 
admission policies in nursing school 
programs, states : 

Selection may be conceived as one step 
in the student's whole nursing school 
program. In setting up the program for 
the nursing school, the needs and capacities 
of the student must be considered. Informa- 
tion concerning students' educational and 
social backgrounds and their various stages 
of mental, emotional and physical develop- 
ment is essential, if the curriculum is to 
be built on these foundations, and articulate 
as closely as possible with what has gone 
on before. Careful selection of students 
can supply much of this information.! 

The penalties for poor selection of 
students is too great to be ignored. 
The most important consideration, the 
quality of nursing care administered 
to patients, many suffer significantly. 
Poor academic grades may result in 
failure and lead to withdrawals. Such 
failures are costly, both to the student 
and the school. In addition to the 
obvious costs to the students, there 
are costs of less than optium utilization 
of facilities and faculties. More im- 
portant, the missed opportunities for 
students who would have completed 
the program satisfactorily, but who 
were not accepted, represent important 
penalties for poor admission policies. 
This is an important consideration in 
light of research evidence showing that 
two out of every three students who 
enroll in a school of nursing will 
eventually graduate. - 

Nurse educators, therefore, cannot 
afford to ignore admissions policies and 

Mrs. Wood is a lecturer at the School 
of Nursing. The University of Western 
Ontario. She holds a Bachelor of Nursing 
Science degree from that University and a 
Master of Education degree from Boston 






Vivian Wood 

A discussion of pre-admission nursing tests and their 
utilization in a school oj nursing program. 

APRIL 1965 


procedures. Nevertheless, many schools 
appear to need serious study and 
improvement in this area. Dr. Helen 
Mussallem's study of Canadian schools 
of nursing found that "almost half of 
the schools had not formulated admis- 
sion or selection policies." 

Only 24 per cent of the schools 
surveyed had selection policies for 
admission of students that were based 
on the objectives of the school ; and 
only one-half experienced an attrition 
rate over a three-year period that 
compared favorably with the national 
average for schools of nursing in 

Today, the pressure is high to turn 
out the best possible graduates from 
hospital schools of nursing.'' The 
expanding need for medical services, 
combined with the increased com- 
plexity of modem day medical and 
nursing techniques, demand and in- 
creasing flow of competent nursing 
graduates into the profession."' Improv- 
ed selection procedures should aid 
significantly in this effort. However, 
improvement in these procedures is 
not easily accomplished : sources of 
reliable information are limited and 
difficult to utilize; few formal measures 
of some of the most important at- 
tributes for success in nursing have 
been available. Thus, the creation of 
an effective admissions procedure is 
a challenging and difficult task for 
nursing school faculties. 

This paper will briefly review the 
various tools that may be used by 
nursing personnel in the selection of 
student nurses. The main emphasis 
will be on psychometric pre-admission 
nursing tests and their utilization in 
a school of nursing program. 

The usual criteria used in assessing 
applicants to a school of nursing are 
related to general ability, academic 
achievement, physical and emotional 
health and personality qualities." Figure 
1 illustrates the tools used to obtain 
information for the application of 
these criteria. 

Let us consider some of the 
strengths and weaknesses of each of 
the above sources. Generally speaking, 
each has some usefulness — but also 
some serious limitation. Consider first, 
letters of recommendation. 

Thomdike and Hagen state : 

The letter of recommendation is such 
an unstructured document that it is hard 
to study by sound research techniques . . . 
However, several investigators have attempt- 
ed to make analyses of the content of the 
letters and to scale them with respect to 
the enthusiasm of the endorsement they 
provided. A moderate degree of agreement 
has been found between different letters 
written about the same person . . . The 
between-letters reliability would be repre- 
sented by a correlation of -+-.40.'^ 

Thus, effective use of letters of 
recommendation implies application of 
sound judgment that can only be 
obtained through experience. 

The interview, a favorite tool for 
studying people, is wisely used by col- 
leges, professional schools and schools 
of nursing. For admission purposes, 
the strength of the interview lies in 
its flexibility and adaptibility. Thom- 
dike and Hagen have commented : 

Evidences for the validity of the impres- 
sions or conclusions derived from interviews 
is spotty and contradictory. Interview 
procedures are basically subjective, variable 
and heavily dependent on the skill of the 
interviewer. It has been repeatedly demons- 


Review of High 
School Records 

Reports of Physical 


Letters of 


Fig. I 

trated that different interviewers interview- 
ing the same person, came up with quite 
varied impressions of him.8.» 

TGrades are normally considered the 
best predictors of academic success 
in nursing schools. They are far from 
perfect predictors, however, and usual- 
ly do not provide any measure of the 
equally important emotional or per- 
sonality factors. Another tool used 
is the student's health record. However, 
policies toward students' health as a 
factor in nursing success vary, depend- 
ing on the school. In one study, it 
was noted that : "over 73 per cent of 
the schools replying considered good 
general health and a good health 
history of primary importance, while 
44 per cent stated that candidates 
should not have any lung diseases." "' 
Past practice, therefore, indicates that 
the health record is useful and im- 
portant in admissions. 

The above four tools for evaluating 
prospective students are widely used 
by many schools of nursing. Two of 
them, secondary school grades and 
health records, provide data that has 
some uniformity and relative dependa- 
bility. The other two, interviews and 
letters of recommendation, are not 
neariy as reliable, but deal with im- 
portant factors about which grades 
and health records provide almost 
no information. As a means of sup- 
plementing interviews and letters of 
recommendation with a more stand- 
ardized measuring device, a growing 
minority of nursing schools are using 
psychometric tests for admissions pur- 
poses. These tests are sometimes 
referred to as "aptitude" or "pre- 
admission nursing tests." 


In Canada, the use of psychometric 
tests as part of the admission program 
has been increasing. In 1949, only 13 
schools had established a selection 
testing program." By 1952, 24 schools, 
or 21.6 per cent of Canadian schools, 
stated that they gave a battery of 
tests.*- A more recent study completed 
in 1961, revealed that approximately 
23 out of 55. or 41.8 per cent, of 
schools of nursing in Ontario were 
either thinking of or using some form 
of psychometric tests. This rising use 
of psychometric tests requires that 
school of nursing admissions officers 
be familiar with their purposes, con- 
struction, uses and limitations. 


A test has been defined as "an 
instmment designed to measure any 
ability, quality, skill or knowledge"" 
(of an individual). The test may be 
regarded as a means of sampling those 
attributes that are considered impor- 


APRIL 1965 



May not be 

infallible as 



Do not measure 






May depend on 
knowledge acquired 
and be more favorable 
for some 

Candidate may 
not have test 

Physical factors may 
influence candidates' 
performance, for example, 
anxiety, illness, fatigue 

Fig. 2 

tant to the area in question, in this 
case, nursing. The basic function of 
the test is to predict success or be- 
havior of one sort or another ; and 
the test of its worth is how well those 
predictions are made. Various ways 
of assessing test predictability will be 
discussed later. 

When properly applied, nursing 
pre-admission tests have been found 
to be valuable in predicting success 
in nursing school programs. For ins- 
tance, Jack R. Martin, in his study 
"The Correlation Between Pre-admis- 
sion Tests and Graduation from 
Nursing School," found that a signi- 
ficant correlation existed between the 
scores of nursing applicants and the 
scores of graduates on the pre- 
admission tests." Therefore, in situa- 
tions where the applicants' back- 
grounds are appropriate, ^'' such tests 
provide information that is helpful in 
identifying those who have a good 
chance of becoming licensed nurses. 

In addition to student selection, 
admission tests also serve in designing 
individual student curricula. Consider, 
for example, an arithmetic test such 
as that found in the George Washing- 
ton University Nursing Aptitudes Se- 
ries.*" (This battery of pre-admission 
nursing tests was one of the first 
available.) If a student scores very low 
in such a test, while doing well on 
other tests, she way be assigned extra 
work in arithmetic. This can be ac- 
complished through the use of a tutor, 
a programed mathematics book, or a 
refresher course. Also, the instructor 
in the school of nursing responsible 
for the teaching of pharmacology 
(where arithmetic is needed) may give 
guidance and individual attention to 
those students who needed the extra 

A third function of the pre-admis- 
sion test is in providing guidance to 
the student who has been admitted to 
a nursing school. >• The test results 
may be used to provide direction, both 


in classwork or in other activities. 
When counseling, a member of the 
nursing school faculty will be able to 
utilize test information in understand- 
ing and defining a student's problems 
and in helping her to work through 
them. In summary, admission tests 
may be used to evaluate candidates, 
to design their curricula, and to help 
in guiding and counseling students 
after admission. 


Admissions tests are not infallible 
as predictors. No standardized test is. 
For example, in the National League 
for Nursing Pre-entrance Guidance 
Test, the following results were 
achieved : "24 out of 80 students in 
the 30th percentile or above failed to 
receive licensure — and 7 students 
who scored below the 30th percentile 
became licensed nurses/' '"* For the 
test to be a perfect selection device, 
every student who scored above the 
minimum acceptable score would have 
to be successful on the licensing 
examination and every one below that 
score would have to be unsuccessful. 

A second limitation of any stan- 
dardized test is that it does not 
measure motivation. To date, there is 
no known method for measuring this. 
These selection tests are designed only 
to measure ability. They do not give 
any indication of how the candidate 
will apply herself. The alert, indus- 
trious student who receives a lower 
score than a lethargic, uninterested 
student, may be more devoted to the 
nursing of patients than the latter. 
Then, there is the "margin of error" 
factor with any selection test. Physical 
factors, such as fatigue, illness, anxiety, 
may affect the applicant's performance. 
Another influencing factor that may 
work against the candidate is her lack 
of experience in taking objective tests. 
The more experienced candidate may 
be test-wise and the results may not 
be indicative of her true ability. Less 

informed candidates are thus at a 
disadvantage. Some of the tests depend 
to a certain extent on the knowledge 
acquired ; thus some questions may be 
more favorable for some candidates 
than others. Figure 2 illustrates the 
shortcomings of admissions tests. 


Selection requires care for several 
reasons, some of which arise out of 
the nature of the tests themselves. First, 
it is impossible, in most cases, to 
measure directly a sjjecific factor. One 
cannot measure whether or not a recent 
high school graduate will graduate 
from a nursing program, for example. 
To be sure, a prediction can be made, 
in many cases, with good accuracy. 
Nevertheless, no direct measure for 
success in a nursing program exists. 

In a test designed to provide a 
forecast for such success, only indirect 
measures are possible. The test de- 
signer works with those attributes that 
can be measured. He attempts to select 
for measurement those attributes that 
seem fundamental to success. For a 
program involving much mathematics, 
the test would probably contain some 
mathematical problems to solve. A 
well-designed test concentrates on 
factors critical to successful perfor- 
mance in the activity or behavior in 
question and measures those factors 
accurately. Thus, the admissions of- 
ficer responsible for selecting a test 
must first satisfy herself that the test 
is relevant for the intended use ; that 
it does, in fact, consistently measure 
that which it is supposed to measure ; 
that it is appropriate for the group to 
which it will be administered ; and 
that it can be administered with reas- 
onable effort and cost. Those four 
characteristics of a good test are 
commonly referred to as validity, re- 
liability, norms, and practicability.'" 
They are illustrated in Figure 3. 


Validity is concerned with the 
degree to which the test in question 
measures that which it is supposed to 












Fig. 3 

APRIL 1965 


measure.-" Are the test results (when 
administered singly or in combination) 
actually significant in predicting suc- 
cess in the program ? 

In the selection of students for 
schools of nursing, one measure of a 
test's validity is the degree to which 
it predicts whether or not these ap- 
plicants will be successful in complet- 
ing the program of the school and in 
passing licensing examinations. The 
most vital question — "how successful 
will the applicants be in their future 
careers ?" cannot be answered with the 
data currently available. The faculty 
may wish to know "how does the test 
perform in our situation ?" One cannot 
answer this until the test has been used 
many times. One can, however, cal- 
culate the correlation of scores at 
admission with marks obtained in the 
examinations in the first year of the 
program. Sometimes this information 
is available from the organization that 
produces the test. Sometimes the 
designer of the test must be ask for 
the relevant data. In many case, it is 
usually good practice for the school 
using the test to measure validity by 
correlating test scores with the sub- 
sequent performance. Generally, grades 
on examinations or over-all averages 
are the most convenient measures of 
performance to use. 


Reliability is defined as "the degree 
to which a pupil would obtain the 
same scores, if a similar test were re- 
administered to her."-i If the subse- 
quent scores are close to the original, 
the reliability is deemed to be high. 
"Does the test really work ?" is a 
question raised. As used in psychome- 
trics, the term reliability thus refers 
to the test's stability or consistency. A 
test's reliability may be usually obtain- 
ed from the manual. If the publishers 
have not included this information in 
the manual, the prospective user should 
write to them asking for it. 


Norms are "measures based on test 
scores which describe the performance 
of a specified group. "^^ Norms are 
used to test the applicabilitv of the 
test for the groups that the school will 
be testing. The predictability of the 
test is usually ascertained by adminis- 
tering it to a test group and comparing 
their subsequent performance to the 
test scores (a procedure we have 
recommended for users). The validity 
and reliability measures are calculated 
from the scores of these test groups. 
The test group usuallv has certain 
characteristics with certain distributions 
of ages, of ethnic backgrounds, of 
income groups, of intelligence, etc. Test 

norms describe some of these charac- 
teristics of the group. If the norms 
of the test group differ widely from 
your applicants, then the test may not 
be a good prediction. Information 
about the norms of the test group is 
usually available in the test manual. 


This is the last consideration in 
assessing an admissions test. Is the 
cost of the test reasonable ? Are the 
tests easy to administer ? Is it required 
that the tests be administered by 
qualified people ? Does the agency 
send in the results to the school and 
assist with prediction estimations? Does 
the agency, as part of its services, 
provide the school with achievement 
test during the three-year program ? 
All these are vital considerations that 
the admissions people must take into 


The need for an increasing number 
of competent nurses rises every year. 
At the same time, changing concepts 
of nursing care and medical technology 
demand that the calibre and training 
of nursing graduates also rise. The 
implications for careful selection of 
students applying to schools of nursing 
are manifest. 

The traditional tools for assessing 
candidates with high school grades, 
interviews, letters of recommendation, 
and health examinations do not provide 
any systematic means for assessing 
important aptitude and personality 

The use of psychometric pre-admis- 
sion tests is increasing every year. 
Nurse educators who are using or 
considering such tests should take care 
to assess, choose and use them care- 

Several such test are available to 
nursing school admissions personnel : 
but they should not be selected 
or administered haphazardly. Instead, 
prospective users of such tests should 
find the answers to several questions 
before choosing one. Does the group 
used in the initial test and design of 
the test closely represent the group 
your school used to obtain students 
(are the norms representative) ? Do the 
tests predict success in the areas ap- 
propriate to your program ? Has the 
test high validity ? Does the test suit 
your program ? 

The answers to the above questions 
will never be clearly positive. Pros- 
pective users must carefully weigh the 
strengths and weaknesses of the par- 
ticular test being considered before 
deciding to select one. Subsequent 
use of the chosen test should take 
into account its inadequacies. Users of 

such tests should periodically compare 
the actual performances of students 
against test scores achieved prior to 

Finally, admission tests do not 
replace existing selection tools. Pro- 
perly used, they augment the traditional 
tools and can improve the calibre of 
the admissions job. 


1. Aikin, R. Catherine. Admission Re- 
quirements and Selection Procedures 
Effective in Schools of Nursing. 
Paper submitted to the Faculty of 
Nursing Education in candidacy for 
the degree of Masters of Arts in the 
Division of Social Sciences. Chicago, 
ininois, 1952, p. 2. 

2. Dorrfeld, Mildred E.. Thomas. Ray 
and Baumberger, Theodore. A Study 
of Selection Criteria for Nursing 
School Applicants. Nursing Research 
7:67-70, 1958. 

3. Mussallem. Helen K. Spotlight on 
Nursing Education. Ottawa. Canadian 
Nurses' Association. 1960. p. 49. 

4. Spurgeon, David. Wanted, a Neu 
System for Training Nurses. Toronto. 
The Globe and Mail, May 23, 1963. 

5. Blishen. Bernard R. : The Nurse and 
the Changing Social Order. Paper 
presented at the First Nettie Douglas 
Fidler Lecture, University of Toronto. 
October 25. 1963, p. 3. 

6. N.L.N. Evaluation Staff. Let's Examine 
How to Choose Pre-admission Tests. 
Nursing Outlook, August 196!. 

7. Thomike. R. L. and Hagen E. 
Measurement and Evaluation. 2nd ed 
John Wiley & Sons, 1961. p. 352. 

8. I hid., p. 318. 

9. The reader will find an interesting 
second chapter on the "Interview" in 
a book by Philip E. Vernon. Persona- 
lity Tests and Assessments. London. 
Metheun and Co.. Ltd., 1953. pp. 20-31. 

10. Aikin, Admission Requirements, p. 39. 

11. Erskine, Helen. Psychometric Testing 
Techniques. The Canadian Nurse 47: 
652, September 1951. 

12. Aikin, Admission Requirements, p. 652. 

13. Baron. Denis and Bernard. Harold. 
Evaluation Techniques For Classroom 
Instructors. Toronto, McGraw - Hill 
Book Co.. Inc., 1958. p. 286. 

14. Martin. Jack R. TTie Correlation 
Between Pre-admission Tests and 
Graduation From Nursing School. The 
Journal of Nursing Education. Decem- 
ber 1962. p. 3. 

15. To be discussed in Part II — Under- 
standing Psychometric Tests. 

16. George Washington University Series. 
Nursing Aptitude Tests. Washington. 

1 7. National League for Nursing. The 
N.L.N. Pre-nursing and Guidance 
Examination, 3rd. ed. New York, 
National League for Nursing. 1961. 
p. 32. 

18. Ihid.. p. 24. 

19. Ross. C. C. and Stanley, Julian. 
Measurement in To-day's Schools, 3rd 
ed. Prentice-Hall, Inc.. 1954. p. 106, 

20. Lyman Howard B. Test Scores and 
What Thev Mean. Prentice-Hall. Inc.. 
1963. pp. 25-31. 

21. A Glossary of Measurement Terms. 
California Test Bureau, p. 12. 

22. Baron and Bernard. Evaluation Tech- 
niques, p. 282. 

23. Ross and Stanley. Measurement, pp. 


APRIL 1965 



In hospital, the first line supervisor is the head nurse. Her understanding and 

application of good interpersonal relations determine her 

success in this role. 

Annabel C. Sells 

The development of the study of 
human relations is due to the efforts 
of research workers in the social 
science fields. As a science, it is re- 
latively new. Industry has prompted 
and sponsored much research in this 
area and has adapted some of the 
results into personnel management, 
not only to increase production and 
profits, but also to help employees find 
personal satisfaction in their work and 
in their relationships with co-workers. 
The result has been stabilization of 
staff and increased production and 

Close Contact with Staff 

Personnel management is not solely 
the responsibility of the personnel di- 
rector. It begins with the "first line" 
supervisor who works constantly with 
employees.' In most hospitals, it is the 
nursing administrator — not the per- 
sonnel director — to whom nurses 
look for clarification and application 
of personnel policies. Obviously, a 
nursing supervisor must possess know- 
ledge of personnel management respon- 
sibilities; she must understand and be 
able to explain the terms of the poli- 
cies and the reasons for their existence. 

Miss Sells is a head nurse at the War 
Memorial Children's Hospital. London, On- 
tario. She prepared this paper while attend- 
ing the University of Western Ontario. 

and know when exceptions are possi- 
ble.- This knowledge provides the su- 
pervisor with a guide for decisions she 
may be called upon to make. More- 
over, it may prevent her from making 
a decision that would reverse a previ- 
ous one, thereby causing dissatisfac- 
tion among the staff. 

In the hospital, this first line super- 
visor is the head nurse. Of all those in 
administrative positions it is she who 
has the closest contact with the staff 
and patients on her ward. She directs 
the planning, the teaching, the coor- 
dination of patient care, and supervises 
the execution of the latter. From her, 
stems the general atmosphere of the 
ward regarding the standards of nurs- 
ing care, and the degree of harmony 
and cooperation among the staff and 
with other departments. Obviously, she 
must possess, along with other leader- 
ship skills, the ability to work with 

Human relations has been defined 
as "the application of all the social 
science disciplines to personnel man- 
agement."'' The head nurse must have 
some knowledge of the social sciences; 
but before she can apply this knowl- 
edge to her relationships with others, 
she must first understand herself. 

Stevens'* lists three ways to achieve 
better understanding of self: 

1. Recognize that self-understanding is 
necessary and basic to understanding others. 

We must be able to recognize our own 
fears, prejudices, and faults. We must un- 
derstand why we have them before we can 
take steps to eradicate or at least repress 
them so that our behavior toward others 
does not produce a negative or antagonistic 
response. This will help us to be more un- 
derstanding and tolerant of the faults and 
prejudices in others. 

2. Realize that knowledge about one's 
motivations is essential to achieve psycho- 
logical and social harmony. 

3. Realize that goals must be defined, un- 
derstood and accepted — then assure that 
they can be reached. We should know what 
we wish to do, what we hope to become, 
and how we wish to accomplish this. We 
must then take the positive attitude that it 
can be done. Often, we need the help and 
counsel of a person more able and experi- 
enced to help us overcome a problem. We 
should not depend on ourselves completely^ 
since each of us is bounds by habits and 
prejudices of which we may be unaware. 
Care should be taken in defining and set- 
ting goals. Those set too far beyond our 
reach lead to frustration and a defeated at- 
titude; on the other hand, goals set just 
beyond our grasp tend to spur us to greater 

The head nurse who has learned to 
understand herself, is better adjusted 
to face reality and to help others do 
so. She will realize that neither she nor 
anyone else can reach an "unrealistic 
mark of perfection."' 


APRIL 1965 


Five Basic Requirements 

According to industrial manage- 
ment, first line supervisors should 
meet five basic requirements." Since a 
hospital is considered an industry, 
these same requirements can be ap- 
plied to head nurses. 

1 . She must have a thorough knowledge 
of her work. For example, the head nurse 
of a chest surgery unit should have had ex- 
perience and preparation in this field, and 
know the specialized kind of care these pa- 
tients require. She must be familiar with the 
equipment in use and be prepared to cope 
with emergencies in a calm and efficient 
manner. She must be abreast of new devel- 
opments and methods in her field of nursing. 

2. She must have a knowledge of her re- 
opments and methods in her chosen field 
of nursing. 

sponsibility is, of course, to the patients. 
She must be sensitive to all their needs — 
physical, spiritual, mental, social, and eco- 
nomic — and contrive, in various ways, to 
meet them so that the best possible nursing 
care is given. This responsibility for patient 
care has been delegated to the head nurse 
by the director of nursing who expects her 
to uphold the standards and philosophy of 
nursing service and the hospital.* 

The head nurse has a responsibility to 
the doctor to create a "therapeutic environ- 
ment"9 for his patient. With him, she plans 
patient care and to him she reports her own 
observations and those of her staff. She also 
owes him the courtesy of maintaing the pa- 
tient's confidence in him. 

The head nurse has a responsibility to 
her staff to give them good leadership in 
nursing care and in personal relations; to 
help them grow professionally, and to attain 
job satisfaction. 

To herself she has the responsibility of 
seeing that the above are accomplished to the 
best of her ability. 

3. She must have skill in instructing. 
Teaching both patients and staff is an im- 
portant aspect of the head nurse's role. 

4. She must have skill in improving meth- 
ods. Inflexibility does not leave room for 
progress, nor does it assure that one method 
is best in all situations. Initiative and crea- 
tiveness are great assets to any leader as 
well as a willingness to use any feasible 
plan proposed by another staff member. 
Her prestige will not suffer: rather it will 
be raised, by admitting that others have 
contributions to 

5. She must have skill in working with 
people. This requirement is one of utmost 
importance; without it, the first four are 
ineffectual. People want to be recognized as 
individuals; to have their efforts, and work 
identified and appreciated. Their response to 
the leader who realizes this, will make any 
effort on her part more than worthwhile. 

Uses Various Methods 

"Every individual brings to his job 
a complex pattern of behavior, attitu- 

des and concepts which are a result of 
his total previous experience."'^ It is 
a wise leader who realizes this and 
adopts a method of leadership best 
suited to achieve the desired results. 
The head nurse has three basic meth- 
ods of leadership at her disposal. 
These are: autocratic, democratic and 

Continuous use of the autocratic 
method is the way of the dictator — it 
stifles any ingenuity and initiative on 
the part of the staff and leads to dis- 
satisfaction and unrest. Situations do 
arise, however, when it is necessary 
for the head nurse to be autocratic. 
On the other hand, continuous use of 
laissez-faire methods can lead to utter 
confusion and the staff becomes a 
rudderless ship. At times, and in cer- 
tain situations, this method can be ef- 
fective and satisfying since it allows 
others the satisfaction of testing and 
applying their own proposals. The 
democratic method allows for the par- 
ticipation of all in the planning for pa- 
tient care, and in organization. It pro- 
motes professional growth and har- 
mony. A mixture of all three is best 
and it is one of the skills of a good 
leader to know when to use which 
method. ^- 

A cause of many misunderstandings 
is the lack of good communication. 
The head nurse must remember that 
communication is a two-way street; 
she must acquire the ability to listen 
as well as to tell. Also, unspoken com- 
munication can be just as important as 
oral or written means — expression 
and gestures often relay what words 
do not. The head nurse must make 
her communication clear to her staff, 
plan for their responses, or feed-back, 
and be receptive to it. Her staff will 
not hesitate to come to her if they can 
be certain she will listen attentively 
and appraise their proposals objec- 
tively. A receptive attitude and an hon- 
est attempt to consider a suggestion 
will often help to offset a negative de- 

Developing Leaders 

An effective head nurse helps her 
staff grow professionally. One method 
is by delegating responsibility and 
helping the staff member to accept it. 
Often, in the bustle of ward activity, 
the head nurse becomes so bogged 
down and harried by her responsibili- 
ties that the position of a leader may 
appear very unattractive to the young 
staff nurse. Each nurse who holds a 
leadership position should encourage 
and help other nurses to prepare to be- 
come better leaders than she is her- 

Five "i's" are suggested to help at- 
tract potential leaders:'-^' 

1. Identify the leadership characteristics; 

2. interpret the role of the leader; 

3. inspire the ambition to become ,n leader; 

4. instruct for leadership; 

5. initiate the climate for leadership. 


The staff naturally looks to the head 
nurse for guidance, support, and praise. 
The head nurse who is able to estab- 
lish and maintain good personal rela- 
tions will very likely have a group of 
enthusiastic'" and conscientious work- 
ers who will strive to help her gain 
her goal of improved patient care. 

Sister M. Gerald has divided admin- 
istrators into three classes:" 

1 . The few who make things happen; 

2. the many who watch things happen; 

3. the majority who do not know what has 

All of us who are, or aspire to be. 
head nurses hope we will belong to the 
first group. We must remember that 
these skills are not an end in them- 
selves — ■ they are only tools — and the 
strongest tool a head nurse has is "the 
power of example."'* 


1. Christopher. W. I. Hospital Personnel 
Management. Hospital Progress. 43;52. 
June 1962. 

2. Ibid., p. 54. 

3. Knowles. W. H. Personnel Manage- 
ment, A Human Relations Approach. 
New York. American Book Co.. 1955. 
p. 102. 

4. Stevens, L. F. Understanding Ourselves. 
American Journal of Nursing. 57:1022- 
23, August 1957. 

5. Ibid., p. 1023. 

6. Brill, N. The Importance of Under- 
standing Yourself. AJN, 57:1325-26. 
Oct. 1957. 

7. Whitehill. A. M. Personnel Relations. 
The Human Aspect of Administration. 
New York. McGraw-Hill Book Co.. 
1955, pp. 135-36. 

8. Barrett, J. The Head Nurse. New York. 
Appleton-Century-Crofts, 1962. p. 11. 

9. Barrett, op. cit., p. 15. 
10. Knowles. op. cit., p. 164. 
1 I. Whitehill. op. cit., p. 6. 

12. Koontz, H,. O'Donnel, C, Uris. A. 
Readings in Management. New York, 
McGraw-Hill Book Co., 1959, p. 227. 

13. Hodnett, E. The Art of Working with 
People. New York, Harper and Harper 
Brothers, 1959, p. 71. 

14. Newton. M. E. Developing Leadership 
Potential. Nursing Outlook. July 1957. 
p. 403. 

15. Ibid., p. 403. 

16. Barrett, op. cit., p. 10. 

17. Gerald, Sister M. Progressive Adminis- 
tration. Hospital Progress. May 1962. 
p. 142. 

18. Newton, op. cit., p. 401. 


APRIL 1965 


Lung Cancer and Smoking 

The province of Saskatchewan has experienced a striking increase in the incidence 
of lung cancer which is comparable to the situation revealed by national studies. 

A.J Bailey, m.b., ch.b., m.r.c.p. 

By virtue of its cancer program, it 
is estimated that cancer clinics have 
access to at least 95 per cent of all 
cases of cancer occuring in Saskat- 
chewan. Since these patients are ade- 
quately documented and followed, we 
have a unique opportunity to study the 
pattern of lung cancer, and indeed all 
forms of malignant disease. 

I would like to describe briefly our 
experience with lung cancer during 
1945-57 inclusive. For this purpose 
I have divided the cases under discus- 
sion into two parts, 1945-51 and 1952- 
57. These two periods were chosen 
deliberately since the maximum bene- 
fits of modem management were not 
fully available until around 1950. Since 
that time the facilities available in 
this province for the treatment of lung 
cancer compare very favorably with 
any other centre on the North Ameri- 
can continent, from the surgical, 
radiotherapeutic and chemotherapeu- 
tic standpoints. It would seem likely, 
therefore, that our results in treatment 
of lung cancer should be at least 
equivalent to the average results in 
other parts of the worl. 

During the years 1945-51, 332 
patients were seen in whom a firm 
diagnosis of bronchogenic carcinoma 
had been made. Of this number 76 
per cent were deemed inoperable — 
in other words, three out of every four 
cases seen during this period had no 
chance of survival from the outset. Of 
the remaining 23.1 per cent subjected 
to surgery, 1 1 .6 per cent were found 
to have non-resectable disease, giving 
a total of 88.5 per cent who had no 

Dr. Bailey is Senior Clinic Associate, 
Allan Blair Memorial Clinic, Regina, Sas- 

hope of cure. In the remaining 11.5 
per cent, some appropriate form of 
resection was feasible. At least these 
patients had a chance of surviving but 
this leaves only one patient in 10 with 
any hope of cure. 

It might be reasonably assumed 
that during the next period, 1952-57, 
as a result of advances in surgical and 
anesthetic techniques, increasing ex- 
perience of the surgeons, broader 
spectrum antibiotics, increased kn