History of Nursing in Pacific Canada

The Vancouver Medical Association Bulletin: April, 1940 Vancouver Medical Association Apr 30, 1940

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Vol. XVI.
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In This Issue:
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|fl|ENDS IN ANJESTHESimrDr^^p. ^^z^'^^^^^^^^^^^^9^
SPECIAL CORRESPONDENCE-_i^^^^^^^^^^^^^^^^^^p5.
j||fcSE OF SUBDURAL H^MATOMA-^t^
gifE HANDS AND INFECTION OF CLEAN WOUNDS—J, P. Henry, I^i^p98
CASE OF POLYCYSTIC KIDNEYA^ITH^^pMPLICATlONS«
SIGMUND FREUD AND PSYCHOANALYSIS—Dr. D. E» Alcorni^^^^fc04
VANCOUVER ^AEDICAI^SSOC^ATION
SUMMEI#CHCK>LJiuN:i^i^ TO 28th INCLM940 if THE    VANCOUVER    MEDICAL   ASSOCIATION
BULLETIN
Published Monthly under the Auspices of the Vancouver Medical Association
in the interests of the Medical Profession.
Offices: 203 Medical-Dental Building, Georgia Street, Vancouver, B. C.
EDITORIAL BOARD:
Dr. J. H. MacDebmot
Db. G. A. Davidson Db. D. B. H. Cleveland
All communications to be addressed to the Editor at the above address.
Vol. XVI.
APRIL, 1940
No. 7
OFFICERS,  1939-1940
Db. A. M. Agnew                  Db. D. F* Busteed Db. Lavell H. Leeson
President                            Vice-President Past President
Dr. W. T. Lockhabt Db. W. M. Paton
Hon. Treasurer Bon. Secretary
Additional Members of Executive: Db. M. McC. Baibd, Db. H. A. DesBbisat.
TRUSTEES
Db. F. Bbodie Db. J. A. Gillespie Db. F. W. Lees
Historian: Db. W. L. Pedlow .
Auditors: Messbs. Plommeb, Whiting & Co.
SECTIONS
Clinical Section
Db. F. Tubnbull Chairman Db. Kabl Haig Secretary
Eye, Ear, Nose and Throat
Db. W. M. Paton —.Chairman Db. G. C. Labge Secretary
Pediatric Section
Db. J. R. Davies Chairman Db. E. S. James Secretary
| STANDING COMMITTEES
Library:
Db. F. J. Bulleb, Db! D. E. H. Cleveland, Db. J. R. Davies,
Db. W. A. Bagnall, Db. T. H. Lennie, Db. J. E. Walker.
Publications:
Db. J. H. MacDebmot, Db. D. E. H. Cleveland, Db. G. A. Davidson.
Summer School:
Db. T. H. Lennie, Db. A. Lowbie, Db. H. H. Caple, Db. Fbank Tubnbull,
Dr. W. W. Simpson, Db. Kabl Haig.
Credentials:
Db. A. B. Schinbein, Db. D. M. Meekison, Db. F. J. Bulleb.
V. O. N. Advisory Board:
Db. I. Day, Dr. G. A. Lamont, Db. S. Hobbs.
Metropolitan Health Board Advisory Committee:
To be appointed by the Executive Committee.
Greater Vancouver Health League Representatives:
Dr. W. W. Simpson, Db. W. M. Paton
Representative to B. C. Medical Association: Dr. L. H. Leeson.
Sickness and Benevolent Fund: The Pbeshjent—The Trustees. in the form you  prefer
/       THIAMIN  CHLORIDE               Or for the Clinicians who feel
uun                                  it is better therapy to use the
Tablets                   §             B-COMPLEX
1  mgm.                 333 I.U.                  B-Complex Syrup
5  mgm.                  1665  I.U.              Derived from natural sources
—containing all  the  recog-
jjl                                            nized factors in the Complex.
Supplied in
Vials                                        3, 6 and 12-oz. bottles.
5 cc.            10 mgm. per cc.
5cc.            25 mgm. per cc.    j§                B-G Capsules
-
5 cc.            50 mgm. per cc.              contain not less than 150 In-
,..                  . .                                      ter. units of Bx and 150 gam-
10 cc.            10 mgm. per cc.              mas Riboflavin.
Yeast Tablets
Ampoules                                         N.N.R.
6 x 1 cc.   p         10 mgm.                jn bottles of 100, 250 and
lOOx 1 cc.               10 mgm.                                 1000.
As we have no trade names for these products
please specify SQUIBB on your prescription.
For Literature write
ERSqjjibb &.Sons of Canada.Ltd.
MANUFACTURING   CHEMISTS   TO   THE    MEDICAL    PROFESSION    SINCE    1858
36 CALEDONIA ROAD, TORONTO. VANCOUVER HEALTH DEPARTMENT
STATISTICS, FEBRUARY, 1940
Total population—estimated  269,454
Japanese population—estimated      9,094
Chinese population—estimated       8,467
Hindu population—estimated \ _           339
Rate per 1,000
Number Population
Total deaths  244 11.4
Japanese deaths —  6 8.3
Chinese deaths jj  10 14.9
Deaths—residents only  206 9.6
BIRTH REGISTRATIONS:
Male, 185; Female, 171.-.
.   356
Feb., 1940
INFANTILE MORTALITY:
Deaths under one year of age  7
Death rate—per 1,000 births  19.7
Stillbirths (not included in above)  8
16.7
Feb., 1939
9
26.5
5
CASES OF COMMUNICABLE DISEASES REPORTED IN THE CITY
March 1st
January, 1940     February, 1940       to 15th, 1940
Cases   Deaths     Cases   Deaths     Cases   Deaths
Scarlet Fever r ,  10
Diphtheria    ,  0
Chicken Pox 125
Measles    67
Rubella  1
Mumps i  16
Whooping Cough  23
Typhoid Fever  0
Undulant Fever  0
Poliomyelitis ■  0
Tuberculosis  36
Erysipelas ■    7
Ep. Cerebrospinal Meningitis   0
Paratyphoid Fever Carrier  0
V. D. CASES REPORTED TO PROVINCIAL BOARD OF HEALTH.
DIVISION OF VENEREAL DISEASE CONTROL.
West North       Vancr.    Hospitals,
Burnaby    Vancr.    Richmond   Vancr.       Clinic   Private Drs.    Totnls
Syphilis     0 0 0 0 27 28 55
Gonorrhoea      0 0 0 1 70 35 106
0
6
0
11
0
0
0
0
0
0
0
122
0
77
0
0
82
0
6
0
0
9
0
5
0
0
3
0
0
0
0
12
0
13
0
0
0
0
0
0
0
1
0
0
0
0
0
0
0
0
14
42
18
4
0
1
0
2
0
0
0
0
0
0
0
1
0
0
0
BIOGLAN
THE SCIENTIFIC HORMONE TREATMENT
Descriptive Literature on Request.
A Product of the Bioglan Laboratories, Hertford, England.
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Phone: SEy. 4239
1432 Medical-Dental Bldg.
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MEDICAL-DENTAL BUILDING VANCOUVER, B. C. Each tablet contains:
Theobromine -   -   - -     5 grams
*Neurobarb E.B.S.   - - Yt gram
Sodium Bicarbonate -     5 grams
Being antispasmodic and sedative in action, the ingredients of
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SPECIFY E.   B.   S.      ON  YOUR  PRESCRIPTIONS
j There is an old Latin tag, "De mortuis nil nisi bonum." For the benefit of any stray
reader who may not have remembered all he learnt at school, this means "Nothing but good
concerning the dead." Too often we act as if it read: "Nil bonum nisi de mortuis." "Nothing good except about the dead."
"We tend to take people for granted, and to abstain from gracious acts and words of
appreciation and affection, all too often. It is the "flegme Britannique," no doubt—but
we sometimes wonder whether a kind word now wouldn't be worth a great deal more than
the finest, most Periclean of orations, when we are no longer there to hear it: or when,
even if we do hear it, we cannot say "Thank you."
All of which longwindedness leads up to a forthcoming celebration of an anniversary
by one of our oldest and dearest members, Dr. Robt. E. McKechnie, Senior, who has now
passed the fiftieth milestone in his medical career. No man better deserves our affection
and esteem: no man, we say without slightest fear of question, has a greater measure
of it: and this esteem, this affection, are given him not only by his colleagues and professional brothers, but by men and women in every walk of life, from the highest to the lowest.
Dr. McKechnie (R.E. to everyone who knows him) is much more than a prominent
Vancouver citizen, or an eminent Vancouver surgeon. He is an international figure in
many ways. He has served his profession in almost every possible capacity—alike in federal, provincial and local activities, he has been ever a leader, and thus a devoted servant,
of his fellows.
He has done his share in politics, has been a member of the Legislature of this province.
In federal medical activities he has been an active member of the Dominion Medical
Council.
He has been an outstanding figure in educational circles: and his present position as
Chancellor of one of the leading Canadian Universities is his as long as he cares to fill it.
His advice and counsel have been freely sought in every walk of life: and in fact from the
day he started his medical career, fifty years ago, he has been two things, which any man
would be proud to be, a good doctor and a good citizen.
He has been honoured in many ways, as the long string of letters after his name shows:
by his King, by other universities, by leading educational institutions. The City of Vancouver gave him its "Good Citizen" medal in appreciation of his long and fathful service.
And with it all, he has preserved a modesty of demeanour, a kindliness and a true friendliness which have never varied or failed—and which have made him not only a respected
and valued member of our community, but a dearly loved friend. Every one of us will
join in the heartiest congratulations to him on his long and successful career: every one of
us will from our hearts wish him "Many, many happy returns" of this anniversary of his.
Long may he live and be with us, for our sakes fully as much as for his own.
It is with very hearty congratulations and good wishes that we record the recent
marriage of our Librarian (and Chief Editor of this journal, if the truth be told, as she does
75% of the work connected with it), Miss Jessie M. Choate. There is a slight feeling of
regret tempering this congratulatory feeling of ours—a purely selfish regret, we fear, since
we shall miss her badly—but the congratulations are very sincere: since we wish her all the
happiness in the world, and this is, for her, a step towards that end. We wish her all prosperity and a happy, peaceful life, and we know that every one of us will say the same.
Miss Choate has been a very devoted member of our staff for some years. She was
engaged as a Librarian, and from the beginning the Library has been her chief activity.
Many a man owes very much to her skill and patience in this regard.
She has been a tower of strength to the Bulletin: both in the mechanical gathering
and collating of material, and its proofreading, and also through her willing co-operation
Page 185 with editor and publisher alike. What on earth we shall do without her we do not know,
but we cannot do anything about it, except make the best of it, and carry on. In the
meantime, we retain the pleasantest and most grateful memories of our association with her.
DINNER TO DR. AMYOT
Each member of the profession will have received a letter regarding the forthcoming
complimentary Dinner being given to Dr. G. F. Amyot, our new Provincial Health Officer,
by the B. C. Medical Association, on April 4th.
We hope sincerely that every medical man that can possibly do so will make it his business to be at this dinner.  There are many reasons for this.
First, Dr. Amyot himself. He is, we believe, the best possible choice for this position,
and British Columbia is indeed fortunate in this appointment. Dr. Amyot has had a wide
experience in matters of public health; not only in Vancouver, or in Canada—but in the
U. S. A. as well, where he has for the past two years been lecturing and studying public
health matters.
He has it in his blood. His distinguished father, Dr. J. A. Amyot, so well known to all
Canadian medical men, has here a worthy successor to wear the mantle he has himself now
put aside. Dr. Gregory Amyot, our guest and colleague, has vision and ideas, and those
who have heard him speak on these matter, on recent occasions, have testified to the breadth
and statesmanship of his vision.
Dr. Amyot has always considered the whole of the medical profession, and not merely
one branch of it.* Just before he left Vancouver he had been working on a scheme to
include the practitioner of medicine in the preventive and health forces of the community:
to utilise the services of the theraputic side to reinforce the preventive side. This, we
understand, is still his hope and plan—and we should help him with this, and show our
willingness to do so. There is, and should be, only one medical profession. It has two main
duties: the first, to prevent and forestall disease: the second, to treat and heal it when it
comes. There should be no sharp division between the two branches: they should work
together and in the utmost harmony and understanding. This is another reason why, when
we have an opportunity, as we shall here, to bring the two branches together, and maintain and fortify friendly relations, we should do so.
The dinner should be a very large one, and should be an outstanding event. So we urge
everyone to come on Wednesday, April 4th, and give Dr. Amyot a real and hearty welcome.
NEWS    AND    NOTES
DINNER
Guest of Honour:
DR. G. F. AMYOT
Provincial Health Officer.
The President and Board of Directors of the British Columbia Medical
Association request that you attend this Dinner in compliment to Dr.
Amyot on his appointment to this important position in
British Columbia Medicine.
Place HOTEL VANCOUVER, BANQUET ROOM (1st floor)
Date THURSDAY, APRIL 4th.
Hour RECEPTION AT 7:30—DINNER AT .8:00.
Dress Optional, FORMAL PREFERRED.
Charge $2.00.  Please secure tickets beforehand.
Page 186 We offer our congratulations to Dr. and Mrs. Douglas Telford on the birth of a son on
March 9, 1940.
Dr. G. A. Davidson has left for the East, where he will attend the meeting of the
American College of Physicians in Cleveland. He will visit New York and Toronto before
returning about the end of April.
Dr. and Mrs. J. A. MacLean are receiving congratulations upon the birth of a son on
March 1, 1940.
The marriage took place on March 23rd of Miss Margaret E. Milburn, eldest daughter
of Dr. H. H. Milburn, to Dr. Frederick O. R. Garner. Dr. and Mrs. Garner will make their
home in Kamloops. We offer them our heartiest congratulations and best wishes for their
future.
Dr. Gerald Baker of Quesnel visited on the Lower Mainland and on Vancouver Island
and enjoyed a well-earned vacation. He had his fishing-rod—took a steelhead out of the
Vedder River—and spent several days at Fisherman's Lodge, Oyster River, on Vancouver
Island, luring lusty trout.
Dr. G. D. Oliver, who was associated with Dr. Baker at Quesnel, is still in Great Britain.
Dr. Baker reports that Dr. Oliver secured the F.R.C.S. (Edin.) in the recent examinations.
Congratulations to Dr. Oliver.
Dr. D. W. Davis of Kimberley has been visiting in Vancouver.
Dr. H. H. Mackenzie of Nelson was in Vancouver for a few days.
Dr. N. J. Paul of Squamish called at the office.
Dr. Andrew Turnbull of Victoria was in Vancouver on March 11th, and attended the
meeting of the Committee on Cancer of the British Columbia Medical Association.
Col. A. L. Jones, D.M.O., M.D. No. 11, spent several days in Vancouver. On March
11th Colonel Jones went to Prince Rupert.
Major W. Allan Fraser of Victoria is doing special work under Military Headquarters
in setting up arrangements for the care of venereal disease.
Captain and Mrs. G. C. Large of Vancouver made the round trip to Stewart during
his leave.
Dr. W. T. Kergin, formerly of Prince Rupert, now residing in Vancouver, visited the
Skeena riding during the election campaign in support of Mr. Olaf Hansen, the Liberal
candidate.
Dr. and Mrs. C. A. Armstrong of Port Simpson are receiving congratulations on the
birth of a son on March 5th in Prince Rupert General Hospital.
Dr. W. H. (Bill) White of Penticton has sufficiently recovered from his recent operation to be holidaying in Spokane.
Dr. J. Vernon Murray of Creston was in Vancouver recently and called at the office.
Page 187 Dr. H. F. P. Grafton was called to Belleville, Ont.  The profession extends sympathy
to Dr. Grafton in the loss of his mother.
The profession regrets the passing of Mrs. R. F. Greer and extends sympathy to Dr.
Greer in his bereavement.
Dr. and Mrs. J. L. Murray Anderson of Victoria are receiving congratulations on the
birth of a son.
Dr. G. F. Amyot, Provincial Health Officer, has been elected to membership in the
Victoria Medical Society.
LIBRARY NOTES
Journals in the Library.
The attention of the members is drawn to the complete list of Journals which are
received in the Library, which has now been prepared and may be found on the Reading
Room table for reference. As will be seen from the list, many of those received are sent
free of charge, or as exchange copies for the Vancouver Medical Association Bulletin.
In order to accommodate the increased number of journals in the Reading Room, the
Library Committee has authorized the construction of a new magazine stand, which will
match the one already in use. When this is installed there will probably be some rearrangement of the order in which the journals are to be found on the shelves, and a plan will be
put up which will make the location of any journal a simple matter.
Items from the Journals.
Diagnosis of Polycythemia—Annals of Internal Medicine, February, 1940, p. 1136.
Studies in Peripheral Vascular Disease.  No. 1: Intravenous calcium in occlusive vascular
disease.—Annals of Internal Medicine, January, 1940, p. 1150.
Infectious mononucleosis—Medicine, February, 1940, p. 85.
Symposium on Traumatic Surgery—Amer. Jour, of Surgery, February, 1940.
Symposium on Peripheral Vascular Diseases—Arch, of Surgery, February, 1940.
Symposium on Intervertebral Disks—Arch, of Surgery, March, 1940.
Symposium on Surgery of the Aged—Surg. Clin, of North America, February, 1940:
Surgery of the Aged: Indications and Contraindications, by Dr. George de Tarnowsky.
Treatment of Intestinal Obstruction, by Dr. Albert H. Montgomery.
Treatment of Carcinoma of Rectum and Colon, by Dr. Guy V. Pontius.
Surgery of Thyroid Gland in Aged, by Drs. Bernard Poris and Harold A. Roth.
Surgery of Liver, Gallbladder and Bile Ducts in Aged, by Dr. Warren H. Cole.
Urologic Surgery in Aged, by Dr. Herman L. Kretschmer.
Management of Fractures of Neck of Femur by Operative Fixation, by Dr. Kellogg
Speed.
Osteochondritis of Knee in Aged Patients, by Dr. Elven J. Berkheiser.
Appendicitis in Aged, by Dr. Edwin M. Miller.
Senile Changes of Vulva, by Dr. Ralph A. Reis.
Diagnosis and Management of Cancerous and Precancerous Lesions in Aged, by Dr.
Cleveland J. White.
(There are 13 other Clinics in this number in addition to the Symposium.)
The 69th Annual Meeting of the American Public Health Association will be held in
Detroit, Michigan, October 8-11, with the Book-Cadillac Hotel as headquarters.
The Michigan Public Health Association, the American School Health Association, the
International Society of Medical Health Officers, the Association of Women in Public
Health, and a number of other allied and related organizations will meet in conjunction
with the Association.
The Michigan Committee on Arrangements is headed by Mr. Abner Larned of Detroit.
■Dr. Henry F. Vaughan, Health Commissioner of Detroit, is Executive Secretary.
Page 188 The Annual Meeting of the American Public Health Association is the largest and
most important health convention held on this continent. It will bring 3500 health officials to Detroit for a series of scientific meetings covering all phases of health protection
and promotion. A Health Exhibit will be held in connection with the meeting and an
Institute on Health Education is scheduled prior to the official opening.
Dr. Reginald M. Atwater is Executive Secretary of the American Public Health Association, with offices at 50 West 50 th Street, New York City.
The following were recently elected to membership in the Vancouver Medical Association: Dr. Thomas Dalrymple, Dr. R. S. Manson and Dr. R. A. Wilson. Dr. D. J. Bell
was elected a Life Member of the Association.
The next general meeting will be held in the Auditorium of the Medical-Dental Building on April 2nd, when Dr. H. H. Boucher will give the paper of the evening, on "Low
Back Pain."
ANNUAL MEETING
The Annual Meeting of the Vancouver Medical Association will be held on April 23 rd,
1940. The meeting will follow a dinner, details of which will be announced later.
Members are reminded that nominations for officers of the Association must be posted,
before the meeting, in the Library.
VANCOUVER MEDICAL ASSOCIATION
SUMMER SCHOOL CLINICS
Dates—June 25th to 28th, incL, 1940.
Place—Hotel Vancouver, Vancouver, B. C.
Plans are almost completed for the Annual Summer School, to be held in the Hotel
Vancouver in June from the 25 th to the 28 th, inclusive.
The Committee feels that it will have a most varied and interesting programme, and
has kept in mind the interests of the General Practitioner and the Specialist.  While as yet
the final decision has not been made as to all topics, the list of speakers who have definitely
promised to be here is as follows:
Dr. A. W. Farmer, Department of Surgery, University of Toronto Medical School,
Toronto. Dr. Farmer will speak on Children's Surgery.
Dr. P. C. Jeans, Professor of Paediatrics, University of Iowa, Iowa City, who will discuss
children's diseases.
Dr. William Magner, of the Department of Pathology, St. Michael's Hospital, Toronto.
Dr. Magner will speak on Jaundice and Anaemia, from both pathological and clinical
standpoints.
Dr. Wm. S. Middleton, Professor and Dean of the University of Wisconsin Medical
School, Madison, Wis.   Dr. Middleton's lectures will be on some phases of Internal
Medicine.
CANADIAN MEDICAL PROTECTIVE ASSOCIATION
The protection afforded by the Canadian Medical Protective Association has proven
satisfactory to a large number of our members.
Some members of the practising profession in British Columbia have not secured membership and this protection.
Be advised.
Page 189 TRENDS IN ANESTHESIA
Dr. D. D. Freeze.
Given before Vancouver Medical Association, March 5, 1940.
What I have to say tonight is not in any sense a scientific dissertation on the subject of
anaesthesia, nor am I going to trouble you with statistical data. My paper will be devoted
to what might be termed a meditative consideration of the drastic changes which have
occurred within recent years. It is pretty definite that the practice of medicine in general
is subject to what might be termed "vogues." What is heterodox today may be orthodox
tomorrow. We have all seen new ideas eagerly taken up, popularised for a time, and then
slowly forgotten. This is natural, it is dynamic, it is characteristic of growth and life.
Just to mention an instance, it is a far cry from the time when inhalations of ether for the
treatment of respiratory diseases was orthodox practice, to our present feeling toward it
in this regard. If I am not mistaken it would seem that we are about to see the replacement
of catgut by the non-absorbable suture for many uses in surgical practice: this, after
untold labour and expense in producing an absorbable suture to replace the then orthodox
non-absorbable one. And so in the field of anaesthesia during the past two decades there
have been modifications and additions, which, while on the whole improving the scope of
anaesthesia, have also complicated an otherwise pretty clear picture. In reality there have
actually been no new methods introduced. Intravenous and rectal anaesthesia are described
as far back as 1910, but in both instances ether was the drug used and its intravenous use
never passed the experimental stage. Rectal ether, both in vapour form and mixed with oil,
has had a certain popularity to within recent times. In fact, at one time the rectal administration of ether was the only non-inhalation method available in general anaesthesia. The
rectal use of ether and oil even yet has its advocates for certain conditions.
Forms of local anaesthesia, including splanchnic block and sacral and parasacral block,
were quite popular a few years ago. Spinal anaesthesia has been used since before the turn of
the century, but not ony of these methods threatened the position of inhalation anaesthesia.
These, briefly, summarize practically all the methods for invoking anaesthesia in use today,
so that the great changes and developments in its practice have been along the lines of new
materials and improved technique, these having revived old methods previously unsatisfactory. In practically every instance the revival of an old method has been through the
discovery of a new drug.
Intravenous
Let us consider the intravenous method. This type of anaesthesia had not been used up
to the discovery of sodium amytal, a barbituric acid derivative. With the finding that this
drug would create complete loss of consciousness when introduced into the blood stream,
without any initial restlessness or unpleasant sensations, and would permit operative procedures with comparative safety, the barbiturates were launched on a wave of anaesthetic
popularity that for a time threatened all other methods. So rapidly did the gospel of its
efficacy disseminate that it assumed the proportions of a crusade. Many of you may recall
an article appearing in one of our papers, vivid and idealistic, describing an operation in a
home for the extraction of teeth under amytal. It read like a page from the Arabian Nights.
A number of apparently satisfactory major surgical procedures were accomplished with
amytal only, but after its initial enthusiasm had dwindled it was apparent that large doses
necessary for surgical procedures were not exactly safe, and likewise the stormy post-operative period requiring free use of narcotics and sometimes actual restraint led to its use in
smaller doses for hypnotic effect only. In reality this drug was never routinely satisfactory
for surgical anaesthesia. Product, however, followed product, until today there are two
drugs, pentothal sodium (Abbott) and evipal (Winthrop), which are being used more or
less routinely for surgical procedures of moderate duration. Just now it would appear that
pentothal has outstripped its competitor in popularity, chiefly from its control of reflexes,
although it is not considered quite as safe a drug as evipal. Pentothal has been vised by a
number of surgeons for intra-abdominal surgery, including long operations, but in nearly
every instance where a series of cases has been reported there appears a warning against its
routine use for major surgical procedures.
My personal experience with both these drugs has been, generally speaking, satisfac-
Page 190 tory, but they have only been used in minor cases or where inhalation or spinal anaesthesia
could not be made available. The longest instance I can personally report was a recent case
of an hour's duration. This was an operation on the face involving laceration of both nose
and mouth, thus precluding an inhalation anaesthetic. The use of pentothal here proved a
happy choice. The patient was placid throughout and made an uneventful recovery. On
the other hand, I would like to' submit the report of a case of a young boy with an oral
growth. The operation was for the insertion of radium needles. Pentothal was chosen,
and. even after the administration of a full gram the patient reacted so strongly to any
operative procedure that it was necessary to use a supplemental inhalation anaesthesia. As it
turned out, this was not a good procedure, and for a time the patient developed rather
alarming symptoms.
Rectal
In rectal methods for general anaesthesia, not taking into consideration the use of paraldehyde, the use of ether in oil has been pretty well abandoned, though one sees the method
occasionally mentioned in recent writings.  Replacing it is avertin, a bromine derivative,
which, while an excellent hypnotic and much favoured for pre-operative administration,
is of little value per se for even minor operations.   It enjoys a well-earned reputation in
many quarters, but opinion regarding its safety is strongly divided, more so, I would say,
over this drug than over any of the other modern ones. This is particularly true both among
surgeons and obstetricians. Where used, it has borne the brunt of criticism for nearly every
form of post-operative complication.   It is considered by some in obstetrics to increase
respiratory depression in the newborn* with delayed resuscitation, but, on the other hand,
has not delayed resuscitation occurred after every type of delivery, when where anaesthesia
has only been used to the degree of analgesia? And so, obstetrically speaking, there are the
Boffkins and the Slearys—"and year by year, in pious patience, vengeful Mrs. Boffkin sits
waiting for the Sleary babies to develop Sleary fits." For caesarian sections, I am a Sleary.
In my opinion, avertin in an excellent and most satisfactory drug for pre-operative
medication. It is difficult for one to place one's finger on a single instance of pre-operative
or post-operative complication that could be directly attributed to Avertin, or that could
not or has not occurred in anaesthesia without its use. One is naturally suspicious of its use
in hepatic disease, but case after case has been reported of its use in the presence of jaundice
without complication.   An interesting instance of its non-toxic effect occurred a few
months ago, when through an error in transcribing the weight of a child the avertin dosage
of 100 mgm. per kilogram was based on a weight of 71 lbs. instead of 41 lbs. This worked
out at the unheard-of dosage of 175 mgm. per kilogram. The anaesthetist, not knowing of
the error, reported the operation, an encephalogram, as the "slickest" avertin he had seen.
The patient's condition was good throughout; there were no untoward symptoms; the child
awoke 4 hours after the administration of the drug, and 24 hours later his condition had
continued good and his kidneys were functioning well. The average dose as used today lies
somewhere between 80 and 100 mgm. per kilogram.   Here it would appear that ample
margin of safety exists.
Evipal has also been prepared for rectal use, but it has never been extensively used by
this method.
Spinals.
Another method of anaesthesia which has become extremely popular in recent years is
spinal block. Here again it has been pretty much a matter of new drugs, and there is still
room for improvement. I mean by that that those drugs which can be used satisfactorily
for short operations tend to produce discomfort, restlessness, pallor, nausea and shock,
while on the other hand those which have not shock-producing proclivities do not lend
themselves to short anaesthetics. Specifically, novocain crystals—most satisfactory from
an anaesthetic point of view for operations up to an hour, but tending to produce severe
depression with the symtoms just previously mentioned. Pontocain, an essentially long-
acting drug, while leaving the patient with a better sense of well-being and much more
placid, does not act with any certainty in diminishing doses- Its freedom from the unsatisfactory immediate complications as seen with Novocain is a curious phenomenon. Would
I be going too far in suggesting that the sympathetic system would appear to be less affected
with pontocain than with novocain?  Generally speaking, drugs for spinal anaesthesia may
Page 191 be grouped under those in a solution lighter than spinal fluid, those in solution heavier than
spinal fluid, and those essentially isotonic. Each group has its advocates, but among those
who have adopted spinal anaesthesia more recently the isotonic form is best liked. In this
group the height of anaesthesia is obtained through barbitage, that is, the drug is forced the
required distance up the canal by means of re-injected spinal fluid. Spinal anaesthesia is
best suited for operations below the diaphragm, and intra-abdominally is more successful
in lower abdominal operations than in the upper abdomen.
In perusing reports of clinics where spinal anaesthesia was the anaesthetic of choice it is
to be noted that in upper abdominal operations supplemental anaesthesia is frequently resorted to either for the control of pain or for improved relaxation. As an anaesthetic of
choice, while kindly disposed towards it, I do feel that it is essentially an anaesthetic for
the physically fit. On the other hand, it does lend itself satisfactorily to extra-abdominal
operations in elderly people. Laparotomies in infants for pyloric stenosis are reported under
spinal with success. Opinion is divided regarding pre-operative medication, and varies from
a desire for complete basal narcosis to a modest dose of morphia. There does not appear to
be any contra-ihdication one way or the other, though halfway measures, where the patient
is drowsy but restless and uncooperative, are most unsatisfactory. Here it is difficult
sometimes to tell whether the patient's behaviour is the result of pain from the site of
the operation or merely the drunken effect of his pre-medication. To know definitely that
the spinal anaesthetic is efficient is a great help in deciding on the necessity or otherwise
of some supplemental anaesthesia, so that it seems to me that the anaesthetic first and medication following is the more rational procedure.
I would like to mention a point in regard to the use of the high-tension unit under
spinal anaesthesia. Is the flow of electrical potential through tissues capable of exciting reflex
action? It is interesting to note that two cases of coronary attack, clinically, occurred
under spinal with the high-tension unit. It would seem safer to keep the cardiac area away
from the electric flow; that is, the metal pad under the hips for operations below the
diaphragm, and between the shoulders for operations above the chest.
Gas.
Now let us consider the remaining group of anaesthetics, within which are harboured
nearly all anaesthetic villains, namely, the inhalation group: what has been done in this
group, and should their use be continued except where necessary. Without a doubt the
greatest advances of recent years have been in the field of gaseous anaesthetics. Here gases
of relatively increasing power for producing satisfactory anaesthesia have been added, but
with increasing toxic dangers and explosive hazards. One must, I suppose, believe in an
Aladdin's lamp to imagine a completely innocuous substance capable at the same time of
producing profound unconsciousness with muscular paralysis. It really doesn't seem
reasonable. Do you recall some fifteen years ago when ethylene appeared, more powerful,
used with a higher oxygen content—both advantages over nitrous oxide—but highly
explosive, nevertheless in the final analysis requiring some ether for the production of complete muscular paralysis?
May I digress here a moment to give my view in regard to muscular relaxation? When,
to a substance inherently incapable of producing muscular relaxation, is added one capable
of so doing, and relaxation is obtained, it would seem that it must have come from the
latter. It is all very well, for instance, to talk of supplementing nitrous oxide with a little
ether for relaxation. If ether is to produce relaxation it is going to do so in a certain blood
concentration, and whether that blood concentration has been reached through nitrous
oxide as a vehicle, or air, the amount of ether in the blood stream is the same. There are possibly those among us tonight who have in the past worked with nitrous oxide when it was so
popular for general surgery, and they must recall the diverse methods in use for introducing
sufficient ether for relaxation. The best gas anaesthetist unquestionably was the one with
the most tricks up his sleeve. Did not a patient lose her life at Montreal during a meeting
there of the American College of Surgeons in 1920 directly due to this effort to introduce
sufficient ether with nitrous oxide for relaxation—and this in the hands of an exceptionally
experienced anaesthetist? It could have happened to anyone in those days. Literally dozens
of ridiculously risky anaesthetics were administered in those seemingly far-off days with
Page 192 nitrous oxide, in the name of safety, and it is to be hoped that the pendulum of time in its
inexorable swing will never again pass within the orbit of a period as fraught with discomfort, dissatisfaction and danger. What a friend ethylene must have been to those who were
using nitrous oxide almost exclusively; with its greater potency and higher oxygen content.
Yet ether was still necessary for good relaxation, and that necessity, added to its inflammable character, militated against its adoption in many places, including Vancouver. As
you are aware, it has never been used here, and now that it has been supplanted by
another gaseous substance, cyclopropane, I think one can honestly say that it really has
never been missed.
With the introduction of cyclopropane for surgical use in 1932, together with the
carbon dioxide adsorption technique for the administration of gases, a real advance in
gaseous anaesthetics occurred. Here is a substance with real potency, capable of producing
moderate relaxation in low strength, thus permitting the use of oxygen to an almost unlimited degree. Exhilaration and secretion are negligible; recovery is rapid; nausea, while
occurring, particularly after the deeper anaesthesias, is usually of short duration. Is there
any blemish on the escutcheon of so ideal a material? Generally speaking, it may be said
that the element of safety diminishes directly as the increase in potency. Here is a gas
which is comparable to chloroform, in that it has real coma-producing qualities with
intense action on medullary centres, and, clinically at least, acting directly on heart muscle
to the end that variations in pulse rate may occur quickly, and a persistent tachycardia be
a real cause of anxiety. It, too, is inflammable within anaesthetic ranges. However, its
virtues far outweigh its faults, and it is being used increasingly, and in some places to the
exclusion of all other inhalants.
Let it be noted, however, that the recorded successes of the gases in major surgery are
intimately bound up with the free exhibition of narcotics or hypnotics prior to operation,
and I mean free. At that, relaxation can never reach the profundity of that obtainable with
ether or spinal block.
Another comparatively new comer among the inhalants, and concerning which I am
but vaguely familiar, is vinthene or vinyl ether, a derivative of the ethylene series. Its
chief recommendations are: a rapidity of action, relaxation under analgesia, and rapid
recovery.  Its faults, salivation and rapid deterioration.
Happily, as I see it, the old guard of inhalants are still with us, and should be given a
little more than the "passing tribute of a sigh."
There are those who in their enthusiasm for modern trends would give to ether and its
associates that relation which old Dobbin once bore to the enthusiastic motorist in other
days—a nuisance on the highway, but "a refuge and a strength; a very present help in
trouble!" ^
Ether is probably yet the most widely used single drug in anaesthesia, and is likely to
continue so for some time. What a tradition it possesses! The first in the field, and still
the big brother to all the newer ones after the lapse of nearly a century. It is stable; like
one of its close cousins it actually improves with age, and it is the most versatile of them
all, in that it can lend itself to all situations. It is, in reality, the centre of the anaesthetic
solar system, about which its satellites revolve. True, it possesses faults aplenty, but most of
these are surmountable, and a well-conducted ether anaesthetic gives a pretty satisfying
picture. Its being a fat solvent is one of its greatest faults, permitting the useless storing
of ether in the tissues, which must be later eliminated, leading to a long-drawn-out,
nauseated recovery period. It is pungent and irritating to the larynx, but if coughing in
the initial stages bears any relation to subsequent respiratory conditions, why shouldn't
those tearing, heart-rending spasms, frequently heard in the hospital corridors, due to the
inhalation of a laryngeal irritant, be conducive of more acute respiratory trouble?
Admitted that it appears to disadvantage in upper abdominal operations, yet I was
impressed with a recent statement made to the effect that respiratory complications in
upper abdominal operations under spinal are no greater than with ether. Why are there
hot more acute respiratory conditions following tonsillectomy under ether, where the
tract is so much more subjected to abuse, and aspiration is shown to be inevitable? Lung
abscess? Admitted! but never the acute respiratory flare-up of the laparotomy.  The sen-
Page 193 sitive and susceptible respiratory tract of the infant has been subjected to the vapor of
ether without respiratory complication times without number. It will give complete
relaxation, placid, effortless respiration, with little or no circulatory disturbance, over long
periods of time, which, after all, are accomplishments not to be overlooked in any anaesthetic.
Besides its tendency to respiratory complications there exists one really formidable
complication which is causing growing concern and for which a satisfactory explanation
has not been found. I refer to the appearance of convulsions or clonic movements under
ether anaesthesia, fortunately seen only occasionally. They seem to be associated only with
ether and the background is much as follows: young person in the teens or early twenties,
in good physical condition, with an acute illness—often appendicitis—associated with
pyrexia and leucocytosis.
There does not appear to be any warning of their advent, appearing in an anaesthetic
well under way, and well organized—anoxemia does not appear to be a factor; they commence as circum oral or orbital twitchings, spreading rapidly downwards over the chest
and extremities, interfering with respiration and presenting a truly alarming picture. Fatal
terminations have occurred, and one wonders whether the cardia is sometimes involved
in a similar way. A good deal has been published in recent years on the subject, and diverse
explanations offered, but the last word has certainly not yet been written.
Kemp—our Kemp—published a paper on the subject, attributing the probable cause
to an alkalosis—and recommended carbon dioxide inhalation as a remedy. In some cases,
but only in some, will carbon dioxide help; in others it intensifies the condition. This would
suggest a more complicated origin. Deeper anaesthesia makes matters worse.
Two of the more recent suggested causes are: (1) The presence of a neurotropic
organism, and (2) a physiological or biochemical disturbance.
Suggested treatment involves withdrawal of drug, maintenance of oxygenation, and
sedation.  The barbiturate evipal has been successfully used in some cases.
Down through the years I have seen convulsions cease sometimes with the withdrawal
of ether, sometimes with the use of drop chloroform, and sometimes with carbon dioxide
inhalations, and treatment was instituted in that order. Today an intravenous injection of
evipal or pentothal sodium would be indicated early.
Of the other inhalants I will only make mention. Opinion continues sharply divided
on the use of both ethyl chloride and chloroform for general anaesthesia, but they continue
to maintain the noiseless tenor of their way; doing good work for those who still maintain
an abiding faith in their virtues.
To summarize, these newer methods for creating anaesthesia have certainly broadened
the field and offered quite a wonderful range of choice. At the same time certain complicating factors have been introduced, as in some cases combinations of the various methods
have been necessary to complete an operation; a spinal anaesthetic possibly passing through
the stages of gas and ether, or if near the finish, the intravenous type. Just what ?oes
on under these circumstances is far from clear, but I admit a profound respect for an
intravenous barbiturate followed by ether; both pulse and respiration can be disorganized
and one's confidence decidedly undermined. In attempting to estimate the anaesthetic
values of these hypnotic drugs, more of which will undoubtedly appear, some datum, or
assumed base, on which to appraise their qualities is necessary. While the method I am about
to mention will probably not stand the searching light of truth, it is a help both in teaching
and in selecting an anaesthetic.
Briefly it is this: Unconsciousness is represented as a baseline, the extremities of which
represent natural sleep and coma. The anaesthetics of the intoxicating type, such as ether,
chloroform and cyclopropane, are essentially coma-producers, and the coma-producers are
the real paralyzing anaesthetics. One, therefore, can place somewhere on this baseline the
relative value of a certain drug in proportion as its effect is merely an artificial sleep, or a
coma. A recent article from the Lahey Clinic, where spinal is used routinely for upper
abdominal operations, distinguishes between the barbiturates and ether for supplemental
anaesthesia as to whether relief from discomfort is required or actual relaxation. This points
to the likelihood of the modern hypnotics in use as not producing true relaxation.
Page 194 An interesting point in this regard occurs with vinethene, where, under what would
appear to be very light anaesthesia, the lid and eye reflexes being active, there may occur
complete relaxation of the extremities. This must not be confused with the true muscle
paralysis necessary for laparotomies. It would seem, then, for the time being, that the real
field of major anaesthesia must be distributed—other than local methods—between spinal
and inhalation methods. With the gaseous forms of inhalation out-popularizing ether
where feasible. |^i
What does the future hold? Who can say? Certainly loss of consciousness as a mode
of controlling pain will always be in demand, irrespective as to how unconsciousness may
be induced. Up to the present the intoxicating group of drugs still holds the high water
mark for profound anaesthesia, and it would seem that where such is required it will not be
one for the mere sleep producers, but for the coma producers capable of doing a man's job.
I would just like to say a word on the more recent trends of post-operative pulmonary
ventilation. Here is a clear example of what I term a "vogue" in the early part of the
paper. The use of carbon dioxide, and oxygen, post-operatively, was hailed as the greatest
innovation for the prevention of respiratory complications. Now, after several years of
its successful application, such a mixture has been shown not only to be of no help but a
possible source of trouble. The reason behind this is simple. The natural pulmonary ventilation is done with an atmosphere of which approximately 80% is an inert non-absorbable
gas. When such is replaced artificially by a completely absorbable atmosphere pulmonary
collapse may ensue. It is therefore now considered that ordinary air with a small amount
of carbon dioxide added is more advantageous than oxygen and CO2.
CORRESPONDENCE
The Editor,
The Vancouver Medical Association Bulletin,
Vancouver, B. C.
Sin-
In the editorial column of the March, 1940, issue you have made certain comments
about the excellent review of sixty-eight cases of brain tumour, which was compiled from
records of the Vancouver General Hospital, covering the years 1934-1938, by Drs. D. P.
Robertson and C. E. Gould. As all but one or two of the forty-two cases which were
operated upon were mine, I may be excused for recording a few thoughts which were
stimulated by your editorial.
You state: "It is doubtful if more than two or three men in Vancouver realize that
there had been sixty-eight cases of brain tumour in this city in these five years." May I
suggest, sir, that you should have gone further, and deplored the fact that there are so few
cases in this series from the largest hospital in the Province.
I am informed by the records department at St. Paul's Hospital in this citv that during
this same period of 1934-38 nineteen cases of brain tumour were admitted to that institution, of which six were verified by operation or post-mortem. Outside of the Vancouver
General Hospital and St. Paul's Hospital, there are no specialized neurosurgical services in
this province, and I doubt whether during this period more than five or ten cases were
treated surgically at other hospitals. In other words, approximately ninety-seven cases of
brain tumour in B. C. during the period 1934-38 received presumably adequate neurosurgical care. The number of patients who die from brain tumour can be conservatively
estimated as 1.34 per cent of the total mortality. (Garland, H., and Armitage, G.: Jour.
Path. & Bad., 1933, 37:461.)   In B. C, that works out to an average of eighty-four cases
Page 195 per year, or four hundred and ten cases during 1934-38. The discrepancy between ninety
seven treated cases and three hundred and thirteen untreated cases is too great.
I am, Sir, yours faithfully,
Frank Turnbull, b.a., m.d.
913 Medical-Dental Building,
Vancouver, B. C.
March 7, 1940.
[Dr. Turnbull's letter is an important comment, not only for the facts it contains, but as showing
the immense value of specially directed, competent, attention to diagnosis. We confess to being quite
surprised by what he says about the number of undiagnosed and untreated cases of brain tumour that
must exist at all times. Perhaps on some future occasion Dr. Turnbull and his colleagues would go
further into this matter, and give to the profession of B. C. at large a lead in the recognition and
adequate care of these unfortunates. Many must be curable, and all should be given a better chance
than they apparently now have. The criteria of diagnosis: the signs and symptoms that should
arouse our suspicion, all these should be better known, and this rather twilit area of our medical
knowledge should have more light let in on it. We are very grateful to Dr. Turnbull for this
note of his.—Ed.]
British  Columbia  Medical  Association
(Canadian Medical Association, British Columbia Division)
President. Dr. F. M. Auld, Nelson
First Vice-President Dr. E. Murray Blair, Vancouver
Second Vice-President^—. Dr. C. H. Hankinson, Prince Rupert
Honorary Secretary-Treasurer X)r. A. H. Spohn, Vancouver
Immediate Past President Dr. D. E. H. Cleveland, Vancouver
Executive Secretary Dr. M. W. Thomas, Vancouver
CHAIRMEN OF STANDING COMMITTEES
Constitution and Bylaws: Dr. H. H. Mil-
burn.
Programme and Finance: Dr. G. F. Strong.
Legislation: Dr. G. C. Kenning.
Medical Education: Dr. D. M. Meekison.
Archives: Dr. M. McC. Baird.
Maternal Welfare: Dr. C. T. Hilton.
Public Health: Dr. A. H. Spohn.
Ethics and Credentials Dr. S. A. Wallace.
Economics: Dr. W. A. Clarke.
Pharmacy: Dr. C. H. Vrooman.
Hospital Service: Dr. W. S. Turnbull.
Cancer: Dr. Roy Huggard.
Editorial Board: Dr. J. H. MacDermot.
The Committee on the Study of Cancer held a meeting on March 11th, which was
attended by sixteen members. Dr. Amyot flew over from Victoria to be present and discuss with the Committee the whole question of the development of a Biopsy Service which
would make it possible for the practising profession to have this aid to diagnosis made more
easily available.
Page 196 ancouver
leneral
Hospital
CASE OF SUBDURAL HEMATOMA
Dr. T. F. H. Armitage
A white male, aged 64, was admitted to the service of Dr. F. N. Robertson (Vancouver
General Hospital) on August 19, 1939. Two days previously he had complained of a pain
in his head, and said he did not feel well. The next day his right arm and right leg gradually
became weak, and then he became unconscious. No further history was obtainable.
Physical Examination: Temperature 98.2, pulse 66, respirations 20.
The patient was restless, drowsy and unable to speak.
Cranial Nerves: Both fundi showed moderate arteriosclerosis but no papillcedema. The
pupils were equal in size and reacted to light. The corneal reflexes were present and equal.
Right lower facial weakness was present. The tongue protruded to the right side.
Motor System: There was a flaccid right hemiplegia and slight weakness and slight
spasticity of the left arm and leg.
Sensory: Though sensation to pin prick seemed normal throughout, the patient's cooperation was too poor for adequate sensory examination.
Reflexes: These were increased on the left side -|—\-, and there was normal activity on
the right side. There was a bilateral extensor plantar response.
The blood pressure was 150/90.
A diagnosis of thrombosis in the left internal capsule was made at this time.
Progress: For the week following admission his condition remained the same. At times
he was very difficult to arouse and he had difficulty in swallowing. At other times he was
able to co-operate to a slight extent. His temperature ranged from 98.2° F. to 102.6° F.
At the end of the first week we obtained from his wife a history of head injury ten
weeks previously, with subsequent headaches. The.patient was seen-by Dr. F. Turnbull of
the subdepartment of neurosurgery, who reported aS "follows: "Cerebral thrombosis is the
most likely diagnosis in this case, but in view of the history of recent head injury, he should
have an exploratory trephine of his skull." >*TSH'-
X-ray of the skull showed no evidence of fracture.
The report of the operation by Dr. F. Turnbull, which was done on the morning of
August 31, is as follows:
"Under local anaesthesia, burr holes were-made over the upper anterior parietal region
on both sides. On the right side this was negative, but on the left side a typical subdural
haematoma was encountered.
"The burr holes were enlarged to about 1%' in diameter and the outer capsule of the
haematoma, which was about Ys in thickness, was incised in cruciate fashion. The brain
was about Yz depressed from the dura, and by inserting a soft catheter it was found that
the haematoma extended forward over the frontal pole and laterally over the temporal pole
—posteriorly about l" from the site of trephine. The contents seemed to be entirely liquefied, and were washed out with saline. The brain seemed to expand very little, even though
the patient coughed a great deal.
"Tight closure was made in the usual manner, leaving a Penrose drain leading out
through stab wounds in adjacent skin margins from the subdural space."
In the afternoon of the day of operation the patient was talking, but was confused at
times. He continued to improve and gradually regained the use of his right arm and leg.
On the tenth post-operative day the patient began to complain of dizziness and headache
and his right arm and leg again became weak. He was taken to the operating room and
the report of the second operation performed by Dr. F. Turnbull is as follows:
Page 197 "Under local anaesthesia, a burr hole was made about 1J4" anterior to the site of
previous drainage on the left side. The subdural haematoma was opened into and the brain
was found to have not completely expanded, being about Ya" to Y2"- away from the dura
still. A number of adhesions of semi-solid old blood clot were scooped out from the lateral
margins of the haematoma cavity, and the cavity thoroughly washed out.
Following this procedure the brain had practically expanded to the dura. A drain was
inserted and closure made in the usual manner."
From this time onward the patient improved steadily and was discharged from hospital thirty-seven days after admission. At this time his speech was normal and there was
only slight weakness of his right arm and leg.
The history obtained from the patient himself after recovery, which was not fully
available from his relatives, was that, while doing carpentering on June 25, he fell about
twelve feet to the ground, striking his head. He was unconscious about ten minutes, and
then complained of headache, dizziness and weakness, but went on and finished his day's
work three hours later. He stayed home four days but was up and around, with complaints of dizziness and headache. He went back to work for five days and finished bis
job. He stayed around home and did light work for eight weeks, although he did not feel
well. On August 18, the day before admission, the patient states he "thought he was going
off his head." The patient did not recall anything that happened from this time until September 4, seventeen days later. This was three days after his first operation.
The patient was seen two months after discharge from hospital; he was feeling well,
was back to work and had regained complete use of his right arm and leg.
This case represents the essential value of a complete history; also the value of an
exploratory trephine of the skull, which can be done under local anaesthesia with very little
disturbance to the patient, in cases where there is any history of head injury suggesting the
possibility of subdural hxmatoma.
THE HANDS AND INFECTION OF CLEAN WOUNDS
By J. P. Henry, M.B.
Clean wounds can derive infection from several sources4 112. Only the role of the
hands will be considered in this brief review. The recent contributions of Devenish ,
Price15 16lT and Gillespie8 have clarified many issues. What follows is for the most part
based on their conclusions.
In 1861, Semmelweis21 first demonstrated that the shocking mortality prevailing in
lying-in hospitals was due to septic materials on the hands. During the ensuing years great
strides were made in the development of an antiseptic, then of the aseptic technique. So
great have been the advances of the past forty yars that it is a temptation to assume our
present methods to be not only correct in principle but also adequately effective in practice.
Thus Meleney states that a hospital conference considered an estimate of 2% to be high
for the incidence of clean operative wound infections12. It was with a shock that they
realized the true figure to be nearly 15%.
All authorities agree that it is impossible to sterilize the hands3 9 10, and that even a
few minutes after scrubbing fresh hordes of organisms pour up onto the surface of the
sKin
s
The misconception that these are harmless and that only hands that have come into
contact with infected wounds are liable to infect the operative field19 has been disproved3 .
Just as in infectious diseases, the healthy carrier is a more important disseminator of infection than the patient himself, so the hands may frequently be infested with dangerous
organisms which do not originate from septic cases, and since only "transient" organisms
not indigenous to the skin can with certainty be eradicated, the inherent dangers of the
situation may readily be appreciated.
Source of Transient Organisms
The transient population of the hands consists of harmless mould spores and non-pathogenic saprophytes20, but a varying number of dangerous organisms such as Streptococcus
haemolyticus are also found. The latter usually derive from breeding grounds in the nose
Page 198 and throat8 2, The percentage of a hospital staff carrying Streptococcus haemolyticus in
the throat varies from 5% to 30%2. This figure increases during periods of epidemic
infection. It is estimated that nobody can escape being a carrier of these organisms at
some time or other.
Removal of Transients
Ridding the hands of transients is a comparatively simple matter. The healthy skin,
when washed and freed from grease, will entirely rid itself of subsequently inoculated
organisms such as Streptococcus haemolyticus or B. coli, etc., within a few hours20 3. The
mechanism by which this is accomplished is unknown. The power resides in the stratum
corneum and vanishes when the latter is injured14. This adds force to the arguments of
those who maintain that the greatest care should be taken to avoid chafing the skin during
its preparation5 '. In carriers it is, however, necessary to remove transient organisms more
rapidly, for the hands are being constantly re-infected from the reservoirs in the nose and
throat3.
Fortunately plain soap solution in standard concentrations will kill Streptococcus
haemolyticus, etc., in less than three minutes when applied to previously cleansed but not
specially prepared hands3. If, after washing and drying, a dram of Dettol 30% cream is
massaged into the hands until it evaporates, they will be entirely freed from transients and
will resist infestation for a further period of several hours3. 70% alcohol may be substituted for Dettol, although it is not so effective. It should be rubbed in with a gauze sponge
for at least two minutes to allow time for action1'. The rubbing is important, as it increases
contact with the more deeply lying bacteria17. If mercury perchloride is used, it should,
according to Price15, be used after the alcohol and not before, since it relies for its effect on
the precipitation of a sterile coating of complex mercurial albuminoids, which inhibit the
action of the alcohol by preventing access to the bacteria beneath. To sum up—soap and
water for three minutes, applied to previously cleansed hands, followed either by Dettol or
70% alcohol with mercuric chloride to follow, will reduce transient infestation to a point
where it would be safe to operate even without rubber gloves, were they the only organisms
to be feared9 10 19.
Sources of Resident Organisms
Freeing the hands from indigenous residents presents a very different problem. The
commonest organisms to be found are Staphylococcus albus and aureus, but Micrococcus
tetragenes, B. proteus, B. coli, B. subtilis, and Diphtheroids, are all frequently recovered20.
All of these have been proved responsible for wound infection of varying severity12 \
which, in areas of low resistance, have even terminated fatally1. The majority of infections of clean wounds have been proved to be due to Staphylococci12, and it has been shown
recently that pathogenic strains (i.e., producing coagulase and Alpha haemolysin8 22 n)
can be found on the hands of 15 % of a hospital staff8. On one-third of these carriers the
organisms are true residents and cannot be eradicated by the usual pre-operative scrub
routine (soap solution followed by alcohol). Their source appears to be the nasal vestibule,
for in most skin carriers a heavy nasal infestation by the same serological strain was demonstrable11 8. Chronic nasal catarrh and sinus infection increase the liability to a carrier state.
It was estimated that a high percentage of the staff of an operating theatre become, at
some time in their career, temporarily infested with these pathogenss. Such skin carriers
will, whenever they perspire, excrete organisms into their gloves . It has been found that
after an operation 15 % of the new gloves used by skilful operators have in them minute
perforations through which bacteria-laden perspiration can be expressed in quantities
sufficient to initiate an infection4.
Removal of Resident Organisms
The results of the usual preparatory routine are interesting. After scrubbing for six
minutes, the resident organisms are reduced by one-half only, and this halving, with every
six minutes of scrubbing, continues until patience is exhausted and an irreducible minimum
attained16. The remaining organisms will double themselves every forty minutes under
rubber gloves16. The average number of permanent residents is eight million. They cannot
be reduced below about two hundred thousand16. In unhealthy rough hands, a higher
percentage of these organisms are pathogens, showing that scrubbing is not only disap-
Page 199 pointing in its results, but can be dangerous if carried to the point of chafing the hands.
Most authorities advise a soft brush and practically confine its use to the nail sulci and the
palms of the hands5 7 3 19 13.
Ethyl alcohol is effective only when used in a dilution of exactly 70% by weight in
water . Slight deviations greatly diminish its powers for a reason which is not understood.
Rubbing with an alcohol sponge reduces the residents by 50% for each minute it is
employed. Alcohol is particularly effective against staphylococci17. The 70% solution
is not a fat solvent and its value in the preparation of the skin probably rests on its germicidal action alone17.
Dettol Cream 30% is a valuable agent but it cannot destroy staphylococci with the
same rapidity and certainty that it can streptococci3. Mercuric chloride 1-1000 requires
a full twenty minutes to kill staphylococci at room temperature in vitro. It is thought that
the secret of its undoubted efficacy, even as a rinse for the skin, may be that a complex mercury protein derivative is instantly precipitated, which acts as though it were a tough
sterile coating, through which the underlying bacteria cannot escape15. It requires twenty
minutes of scrubbing to wear away this film15. There is danger, however, because underneath this shield the bacteria breed at an increased rate, due in part to the stimulating
effect of the mercury20 -18, and if the barrier should break down during the operation
numbers of virulent organisms could be liberated. The film also inhibits the autolytic
power of the skin. Pathogenic transients imprisoned under it may thus succeed in forming
colonies and become residents. This theory of the mode of action of mercurials is derived
from circumstantial evidence and further enquiry is necessary to substantiate it. It is not
known exactly how impermeable the barrier is, but even if it should prove fully effective,
the use of mercurials will continue to be limited by their injurious effect on some skins.
However carefully a deep staphylococcal skin carrier prepares his hands, by the current
routine of scrubbing and alcohol, they remain a potential danger3. Comparison by Devenish
of the post-operative figures of two surgeons of equal skill, one a deep carrier and the other
free from pathogens, shows how high these dangers may become8.
Suggested Improvements
Plentiful powdering of the hands and avoidance of hot water and vigorous scrubbing,
by diminishing the subsequent accumulation of fluid perspiration within the gloves19 10,
decreases the number of organisms which can escape from a perforation. Finally, the
chances of perforation are greatly decreased by handling needles and tissues with instruments only, wherever possible4.
Surgery has extended into regions of the body which have little or no ability to combat
organisms, even those hitherto regarded as non-pathogenic1. This must be remembered,
as well as the percentage among us who are unwitting carriers of ineradicable though
highly virulent organisms. A review of the scrub technique in representative hospitals
showed a count reduction of some 10 to 50% only16. Some improvement could be effected
by shortening the time spent with the scrubbing brush and devoting it to rubbing the
hands with an alcohol sponge16. When the transient population has been removed, soap
solution is of little value, as it is not lethal to staphylococci3. This leaves only the gradual
detergent action of the brush16. 70% alcohol with its affinity for staphylococci3 will
achieve in two minutes as much bacterial reduction as twelve minutes of assiduous scrubbing17. Dettol is of great value in obstetrics, which is most concerned with streptococcal
infections3. Mercurials find a place in surgery for the temporary immobilization of the
organisms which always remain. It remains to be seen whether it is wise to use them
repeatedly; the consensus of opinion appears to reserve them for the occasional and for the
bare-handed operator, and finally for rough, heavily contaminated hands5 19 15.
Summary
1. Frequency of transient streptococcal and persistent staphylococcal infestation of the
hands.
2. The easy removal of transients and the difficulty of eradicating residents.
3. Suggested modifications in technique.
Page 200 REFERENCES:
Cairns: Lancet, 1:1193, May, 1939.
Colebrook: B.M.J., 2:723, Oct. 21, 1933.
Colebrook: Jour. Obstet.  & Gyntec. B. E.,
40:966, 1933.
Devenish & Miles: Lancet, 1:1993, May 13,
1939.
Doderlein: Oper. Gyntec, Leipzig, 1924.
Ernst: Problem des Haiti. Inf., Copenhagen,
1937.
Garrod & Keynes: B.M.J., 2:1233, 1937.
Gillespie: Lancet, 2:890, Oct. 21, 1939.
Kocher: Oper. Surg., 1903.
McDonald: S. G. & O., 21:82, 1915.
McFarlane: B.M.J., 2:939, Nov. 5, 1939.
20.
Meleney: S. G. & O., 60:264, 1935.
Moynihan: Brti. J. Surg., 8:27, 1920.
Pijoan: Arch. Surg., 34:590, 1937.
Price: S. G. # O., 69:595, 1939.
Price: J.A.M.A., 111:1993, Nov. 26, 1938.
Price: Arch. Surg., 38:528, 1937.
Proc. Roy. Soc. of Brit., 120:147, 1936.
Theobald: Jour. Obstet. & Gyntec. of the B.
E., 31:54, 1924.
Topley & Wilson: Principles Bacteria and Immunology, 1936.
Semmelweis: Pest. Wein., 1861.
Bigger: B.M.J., 2:836, Oct. 23, 1937.
CASE OF POLYCYSTIC KIDNEYS WITH COMPLICATIONS
Earle R. Hall, M.D.
(Presented at Clinical Meeting of Vancouver Medical Association, April, 1939.)
This case for presentation is interesting because of several factors involved. Diagnosis
is usually of prime consideration in any medical problem, and in this instance plays an
extremely important part. Treatment, the aim of which is generally to produce complete
recovery or the greatest possible degree of improvement and restoration to normal, required
deliberation and some degree of precision. In this respect the role of conservatism had to
be ever foremost. Prognosis and surveillance of future treatment are worthy of considerable thought and speculation.
The following is a case history and summary of progress reports and findings: J. T.,
male, age 38 years, married, first came under supervision on July 8, 1936, with the following history:
Previous Illnesses: Negative.
Previous Venereal: Denied.
Previous Kahn: Negative report, few months previously.
Family History: Father died age 36—cause unknown to him, but stated that he had
had "kidney trouble," and had had two operations on one of the kidneys. Mother died
result of carcinoma of uterus. Otherwise negative.
Complaints Presented: (1) Pain in the left lumbar area; (2) fever.
Onset and Course: About six months previously, following a chill, he felt out of sorts
for a few days, and then noticed that the urine appeared to have blood—well mixed. He
developed a fever, temperature ranging from 101 to 103. He received medical attention,
and urine examinations were reported positive for hematuria and pyuria. He remained
in bed for about a month with gradual improvement, temperature returning to normal.
At this time he had no dysuria and apparently very little frequency. He stated that micturition was a little slower in starting. Following this illness he was in good health until
a few days later, when he developed a pain in the left lumbar area, this coming on for no
apparent reason. The pain was described as a dull aching type, did not radiate. He had no
urinary distress. A flat X-ray of the renal tract was taken with negative report. The pain
became more severe and radiated anteriorly downward to the left lower quadrant. His temperature rose to 102 degrees and he was admitted to St. Paul's Hospital, July 8, 1936.
Examination at Hospital: Patient did not appear acutely ill, temperature 102, pulse 98.
Abdomen showed some tenderness at the left renal area and the lower pole of the left
Page 201 kidney was palpable, tenderness extending downward toward the left anterior quadrant.
Otherwise negative.
Urine:   S.G. 1022, acid, albumen -j—j-, sugar 0;
Microscopic: pus -j-, bacteria -)—|—|—|-.
N.P.N.: 36 mgs.  Haemo.: 87%. R.B.C. 4,750,000; W.B.C. 8,500.
Blood Pressure: 140/80.
Cystoscopy and Pyelography—July 9, 1936—S.P.H. = Urine obtained from bladder
was clear; bladder was negative; both ureteral orifices were negative. Catheters passed up
both ureters without obstruction. Urine from the right kidney was clear; urine from the
left kidney was thick and showed many flakes of pus. Pyelograms were made; the urine
sent for examination. A large ureteral catheter was inserted within the left ureter to the
renal pelvis as a retention catheter for drainage.
X-Ray Report of Pyelograms: "Bi-lateral enlargement of kidneys, with large pelves and
calices—probably congenital."
Report of Urines: The urine from the left kidney showed 39,425 w.b.c. per c.mm. The
right ureter showed 12.5 cells per c.mm. Direct urine smears were negative for tbc. Urine
was sent for animal inoculation.
Culture of Urine showed Haemo. Staph, from both kidneys.
The ureteral catheter was removed from the left kidney after 72 hours. At this time
it was draining freely, and his temperature, which had dropped to 100 degrees after its
insertion, had been ranging from 99 to 100. Twenty-four hours after removal of catheter,
temperature was 99, and he was feeling much improved and refused to stay in hospital any
longer. He was discharged July 14, 1936.
Following his discharge from hospital he was well for one week, when he had return of
fever—his temperature being normal in the morning but rising to 101 to 102 at night.
I was called to see him at his residence on the evening of July 25th, at which time his temperature was 103, and he appeared to be slightly irrational. He was admitted to Vancouver
General Hospital the same night, and diagnosis of left pyonephrosis was made.
Operative Treatment—July 26, 1936, V.G.H., under general anaesthesia—Left
Nephrostomy: The left kidney was exposed through the usual left lateral lumbar incision,
and it was found to be about four times normal size, and its surface was studded with
multiple cysts, these varying from the size of a pea to larger than a hen's egg—this was
a typical polycystic kidney. With considerable difficulty the kidney was freed as fast as
possible, numerous adhesions being removed near the hilus in order to reach suitable area
for nephrotomy. In the region of the hilus near the pelvis, the kidney was incised and a
free flow of pus obtained, and a drain tube inserted. This was inserted down to the renal
pelvis and brought out through the lower angle of the wound. Many of the larger cysts
were punctured, and thin sero-purulent fluid obtained. Swabs were sent to the Laboratory
for culture.
He sustained this operation well and his post-operative course was uneventful. Cultures of pus from kidney and cysts after ninety hours showed no growth.
Urine Report: Urine smears showed colon bacilli, negative for tbc. Urine specimen
voided after operation showed pyuria varying from -j- 2 to -(-4.
N.P.N, two days ofter operation was 40 mg.
N.P.N, one week after operation was 3 0 mg.
N.P.N, two weeks after operation was 3 0 mg.
August 16th patient was discharged from hospital, wound well healed.
August 24th, report of animal inoculation (urine obtained at first cystoscopy, July
9th) : Right kidney, negative.  Left kidney, positive for tbc.
August 24th, admitted to V.G.H. for cystoscopy and obtaining of urine for further
study.
September 26th, report of animal inoculation was negative for tbc. Urine was sent to
the Laboratory which first reported presence of tbc. from left kidney. This report was
received on November 16th and animal inoculation was now reported negative.
During the next three months the patient made steady improvement, and urine examinations varied from a few w.b.c. to pyuria -f-1 and at times -\-2.   Urine examination
Page 202 showed presence of B. coli and he received various mandelic acid preparations which would
clear the urine for limited periods. Rectal examination showed a prostate that was somewhat enlarged and the prostatic strippings showed presence of pus. Stained smear showed
presence of B. coli and staphylococci. The diagnosis of chronic prostatitis—non-specific
was added and he was placed on treatment directed to the eradication of the infection in
the prostate.
The patient was not seen for a period of about six months, but during this time he
made steady improvement, put on weight, and micturition was normal. Urine examination showed pyuria -j-2. A recheck of his pyelograms was advised.
December 19, 1938—V.G.H.—Cystoscopy and Pyelography. Urines were also sent
for animal inoculation.
  Report of Pyelogramss "The general outline of both kidneys appears greatly enlarged
without any localized deformity of the excretory system—possibly a polycystic condition
of both kidneys."
February 7, 1939—report of guinea pig inoculation: Guinea pigs inoculated separately
with urine from right kidney, left kidney and bladder urine were all negative for any
evidence of tbc.
The patient continued treatment for prostatitis during 1939 and showed gradual
improvement in his general health. Last examination of the patient was in March, 1940,
at which time he was feeling well, although the urine still showed a few pus cells. Micturition was apparently normal. Nocturia about once each night. Examination of the prostate still showed presence of pus in the strippings, and he was advised to continue therapy
for this.
Final Diagnosis: 1. Bilateral Polycystic Kidneys. 2. Acute Left Pyelonephritis—Pyonephrosis.   3. Chronic Prostatitis, Non-specific.  4. Sub-acute Pyelonephritis.
Summary: At the first contact with this case it was not difficult to make a tentative
diagnosis of renal infection with possible presence of a calculus. This being based upon
the fever, pyuria and associated pain, together with previous history of haematuria. Following cystoscopy and pyelography the possibility of a stone was ruled out, and the X-rays
showed typical pyelograms as produced by polycystic kidneys. The presence of pus and
extremely high cell count in the urine from the left kidney indicated a severe infection of
this organ. This condition was undoubtedly a pyelonephritis, which on account of inadequate drainage went on to a pyonephrosis requiring nephrostomy for relief. This operation
verified the existence of a polycystic kidney.
The first report of animal inoculation being positive for tbc. in the left kidney produced a problem. It is extremely rare to find tuberculosis involving polycystic kidneys
which are usually bi-lateral and congenital in origin. It was felt that the report of
tbc. was an error and that more urines should be studied. Subsequently there were three
occasions when animal inoculation was carried out and these reports were all definite in
their negative findings. These examinations were at different laboratories, and the one first
reporting positive tbc. later reported a completely negative guinea pig autopsy.
A definite pyogenic prostatitis of non-specific origin was found to be present and I
consider that this was probably the source of the renal infection, the latter being the result
of an ascending infection. The same organisms, i.e., colon bacillus and staphylococcus,
were present in the prostatic strippings and in direct urine smears.
Page 20} Victoria  Medical   Society
Officers, 1938-39.
President : Dr. W. A. Fraser
Vice-President Dr. A. B. Nash
Hon. Secretary Dr. E. H. W. Elkington
Hon. Treasurer  Dr. C. A. Watson
SIGMUND FREUD AND PSYCHOANALYSIS
D. E. Alcorn, M.D.
Victoria, B. C.
The death, last year in London, of Sigmund Freud removed one who, perhaps more than
any other physician, has left the impress of his genius upon the thought of our times. For
we find his influence extended beyond the field of psychiatry and psychology into that of
art, ethics, and even religion. Modern art, especially of the surrealist variety, is filled with
dream symbolism; ethics has begun to consider seriously psychological factors; and even
religion has studied them.
It has, therefore, been a source of considerable difficulty to many to know why physicians in general, and psychiatrists in particular, have been so slow in accepting psychoanalysis. Myerson1, in a recent survey, found only 25 out of 179 psychiatrists, 5 out of
75 neurologists, and 2 out of physologists and other workers in allied fields, who accepted
psychoanalysis more or less wholeheartedly, although there were many others who accepted
some of his teaching, with more or less reservation. Some have felt that this was simply
medical conservatism, and that the doctors would come around in time. But nearly half a
century has elapsed since Freud began his first teaching: half a century which has been
characterized by such advances as the introduction of diphtheria antitoxin and insulin,
which are now fully accepted by the medical profession.
Even more puzzling is this situation to those who use the term "psychoanalysis" as
synonymous with "psychiatry" and psychotherapy." The term "psychoanalysis" should
be reserved for the technique and theory originated by Sigmund Freud, and should not be
applied even to the closely allied systems of Jung and Adler.
Technique and Theory.
(a) Technique. Freud, early in his investigations, elaborated a technique, the essentials
of which have not been greatly modified since. Briefly, it is as follows: One hour a day is
reserved in advance for the patient, for six days a week; the treatment extending from several months to several years2. This should be paid for in advance. Treatment unpaid has
not been generally satisfactory, as the patient tends to stop at convenient points in the
analysis and thus defeat the purpose of the treatment. For the poor, a very different kind
of therapy is required; namely, financial assistance. Incidentally, the role which finances
play in the neuroses is not so well recognized by many of his followers*
During the treatment, the patient usually reclines on a couch. Freud's own instructions
are as follows: "Before I can say anything to you, please tell me what you know about
yourself. One thing more before you begin: your talk with me must differ in one respect
from an ordinary conversation. Whereas, usually, you rightly keep the threads of your
story together and exclude all intruding associations and side issues, so as not to wander too
far from the point, here you must proceed differently. You will notice that, as you relate,
1. Myerson, A.:  The attitude of neurologists,  psychiatrists  and  psychologists towards  psychoanalysis.
Am. J. Psycb., 96:623, 1939.
2. Freud, S.: Further recommendations in the technique of psychoanalysis.  Collected Papers, 11:31, 1913. various ideas will occur to you, which you feel inclined to put aside with certain criticisms
and objections. You will be tempted to say to your 'this or that has no connection here,'
or 'it is quite unimportant' or 'it is nonsensical' so that 'it cannot be necessary to mention
it.' Never give in to these objections, but mention it even if you feel a disinclination against
it, or indeed just because of this. Later on, you will perceive and learn to understand the
reason for this injunction, which is really the only one you have to follow. So say whatever
goes through your mind. Act as if you were sitting at the window of a railway train, and
describe to someone behind the changing views you see outside. Finally, never forget you
have promised absolute honesty, and never leave anything unsaid because, for any reason,
it is unpleasant to say it." This is the free association method by which unconscious
material is brought to light3.
Regarding the physician, according to Freud4, "he must bend his own unconscious,
like a receptive organ, toward the emerging unconscious of the patient. The physician's
unconscious mind must be able to reconstruct the patient's unconscious, which has directed
his associations from communications derived from it." One of the rules by which this is
accomplished is: "One has simply to listen and not try to remember anything in particular."
(b) Unconscious. Freud uses a large number of technical terms in describing his
theories. First, there is his system of consciousness, etc.
(1) The conscious, including the perceptual consciousness;
(2) The unconscious (formerly vailed the subconscious), which applied to "any mental process the existence of which we are obliged to assume, because we infer it
from its effects"—such as dreams, hallucinations, slips of the tongue, recall by
association, etc.—"but of which we are not directly aware." From this he differentiated the preconscious, to be applied to that "which is transformed into conscious material easily," reserving the unconscious for the rest.
One might add to this scheme of things, although I do not know that Freud ever did so,
a third concerned with physiological processes outside of consciousness altogether.
(c) Conflict. The mental apparatus of the individual Freud divided into three regions:
(1) The ego, which "in popular language" "stands for reason and circumspection";
(2) The id, which "stands for untamed passions"7;
(3 )  The super-ego, which is roughly equivalent to the conscience8.
The ego and super-ego might be either conscious or unconscious; the id is unconscious.
The ego also contains the perceptual consciousness and the preconscious9.
Freud at first divided the instincts into two groups:
(1) The ego-instincts, under which he'placed "everything that had to do with the
preservation, maintenance and advancement of the individual";
(2) The sexual instincts, to which he "ascribed the rich content implied in infantile
and perverse sexual life"10.
Freud's "investigation of the neuroses led him to regard the ego as the restricting and
repressing force, and the sexual impulses as the restricted and repressed ones." Thus
we have here the element of conflict which is central to the Freudian conception. However,
as time went on, he found it increasingly difficult to separate the two, and he was finally
faced, as Jung had been before him, with the alternative of "either dropping the term
libido (sexual energy) altogether, or using it as meaning the same as psychic energy in
general." He did not keep to this long, however, and presented another pair
(1)   "The sexual instincts in the widest sense of the word" and
3. Freud, S.: Ibid.
4. Freud, S.: Recommendations for physicians on the psychoanalytical method of treatment.   Collected
Papers, 11:29, 1912.
5. Freud, S.: New Introductory Lectures on Psychoanalysis (1937), trans, w". H. Sprott.  Hogarth Press,
p. 94.
6. Freud, S.: Ibid, p.   95.
7. Freud, S.: Ibid, p.  102.
8. Freud, S.: Ibid, p. 87.
9. Freud, S.: Ibid, p.  105.
10.     Freud, S.: Ibid, p.  125.
Page 205 (2)   "The aggressive instincts, whose aim is destruction."11
To these two, the terms life and death instincts are sometimes applied. Freud's explanation
of the origin of this "death" instinct is interesting: "If it is true that once, in an inconceivably remote past, and in some unimaginable way, life arose out of inanimate matter, then,
in accordance with our hypothesis, an instinct must at that time have come into being
whose aim it was to abolish life once more, and to re-establish the inorganic state of things."
"He goes on to say "the question whether all instincts without exception do not possess a
conservative character, whether the erotic instincts do not seek a reinstatement of an
earlier state of things, when they strive towards the synthesis of living substance into larger
wholes . . . must be left unanswered."12
(d)   Neuroses.  Freud13 at first divided neuroses into four groups:
(1) Pure neurasthenia which he believed to be due to excessive masturbation, numerous spontaneous emissions, etc.
(2) Anxiety states, characterized by irritability, worry, tachycardia, dyspnoea, tremor,
paraesthesias, apprehensiveness, etc., and which he attributed to failure to secure
adequate sexual gratification in the presence of stimulation. These he regarded as
physiological in origin.
(3) Hysteria due to sexual traumata during early childhood, of a passive character.
Infantile sexuality plays, an important role, and consists in seeking stimulation
and thereby satisfaction of various portions of the body; namely, in order, (a)
the oral, (b) the anal (which is associated with sadistic trends), (c) the phallic
(penis.and clitoris), and (d) the genital, which he regarded as being established
abter puberty14. It is at this time (the infantile sexual period) that there occurs
that love of mother, fear of father and castration by him, and finally the internalization of the father's threats to form the super-ego, that make up the Oedipus
Complex.
(4) Obsessional Neuroses are also due to infantile sexual traumata, but in this case
active or at least pleasurable, so that there is the added feeling of guilt, which
manifests itself in the ceremonials, etc., of the patient.
His doctrine of infantile sexuality brought Freud into violent conflict with his confreres, and most psychiatrists have continued to this day skeptical of these traumata. In
connection wtih this, the following experience of Freud is of interest: "At the time when
my main interest was directed on to the discovery of infantile sexual traumas, almost all
my female patients told me that they had been seduced by their fathers. Eventually I was
forced to the conclusion that these stories were false, and thus I came to understand that
hysterical symptoms spring from phantasies and not from real events."10 Freud's views of
the neuroses have undergone many changes since, too complex to enter into here.
Prepsychoanalytic Technique and Theory.
It is perhaps of interest to enquire as to how much of this elaborate system actually
originated with Freud, in an attempt to differentiate psychoanalysis from other forms of
psychotherapy. This can be answered best by reference to the ideas current before the
appearance of Freud's first article on psychiatry in 1892.
(a) Therapy. Regarding therapy, the most important agency then used was hypnosis,
which had been known for nearly a century, and its relationship to hysteria known for
about half a century. One of the most commonly accepted explanations of hypnosis was
that it was due to hysteria, a view which was supported by Charcot's discovery that he
could produce hysterical symptoms by hypnosis. In 1881 Breuer told Freud of a case which
he had cured by recalling apparently forgotten unpleasant memories by means of hypnosis.
In 1886 we find Freud with Charcot, and again in 1889 with Bernheim, who developed
suggestion as a therapeutic technique, as well as teaching hypnosis.
Ibid, p.  133-134.
Ibid, p.   138, 140.
Heredity and the Aetiology of the Neuroses.   Collected Papers, 1:8, 1896.
New Introductory Lectures of Psychoanalysis, p. 128.
Ibid, p.  159.
Page 206
11.
Freud,
S.:
12.
Freud,
S.:
13.
Freud,
S.:
14.
Freud,
S.:
15.
Freud,
S.: (b) Unconscious. Among the many theories presented to explain hypnosis, one of the
most widely accepted (Myers16, Beaunis1' , Carpenter18, etc.) was that there were other
forms of consciousness, besides that of the normal waking self. Jung traced the doctrine
of the unconscious back to the early 1880's19 to Carus.
Dr. Paul Carus's system20 is of particular interest.  He refers to the following levels.
(1) Conscious central neural activity;
(2) Subconscious peripheral neural activity indirectly connected with central consciousness, "so that we have a dim idea of its proceedings." This he connected not
only with hypnosis but also with dreams. "The ego of the dream possesses a chain
of memories of its own, which perhaps has never been connected with the memory
chain of the conscious ego in the waking state," and goes on to suggest that the
content of the dream might be recalled by an accidental association.
(3) Unconscious neural activity, such as reflexes, etc.
As Carus was an oriental scholar, I feel almost certain that he was influenced by ancient
Hindu concepts.  The Mandukyophanishat21 mentions four states of the self (Jivatma):
(a)  The waking self (Jagrat) ;
(2) The dreaming self (Svapna) ;
(3) The well-sleeping (dreamless sleep) self (Sushuptih) ;
(4) In which the self is united with Brahma;
the elaboration and explanation of which, here and elsewhere in the Hindu scriptures,
reminds me very much of Carus.
Of course there were many other similar concepts in the West. Spinoza refers to unconscious instinctive motivation22. The old Egyptian concept of the ka, or double, is suggestive.
(c) Conflict. The conflict between "untamed passions" and "conscience" for the
"self"—between the "flesh" (sarx) and the "spirit" {pneumo) for the "soul" (psyche)2*
—between the Hindu "mind" (manas), dominated by "desire" (kama), and the "enlightenment" (buddhi) for the "ego" (ahamkara)—has formed the subject of innumerable
sermons since the beginning of ethical religion.
The importance of sex in relationship to human behaviour was not neglected in the
1880's, and was regarded as the principal manifestation of the activity of the "flesh." Carus
remarks that "human soul-life may be compared to an elipse. It is determined and regulated from two centres: one of which is in consciousness, the other the sexual instinct."
Freud mentions three instances in which the importance of sex was stressed to him by his
teachers, one of which (Chrobak's suggestion that a neurosis in a particular case might be
due to sexual abstinence) is significant. Masturbation was regarded as the cause of a vast
number of things, of which depression, anxiety, lethargy, neurasthenia, are the most frequently mentioned.
(d) Neuroses. Whyt, in 1765, differentiated between neurasthenia, hysteria and
hypochondriasis. Obsessions and phobias (by which were known what we now call anxiety
states, at least in many instances) were also well known.
But, if Freud did not originate these ideas, at least he clarified them, gave them names
free from religious or philosophical connotations, and supported them with a vast mass of
clinical observations.
T>
24.
.25.
Myers, F. W. H.: The Subliminal Consciousness.   Proc. Soc. Psychical Research, 8: p. 298.
Beaunis, H: Le somnambilisme provoque.   Paris, 1887.
Carpenter, W. B.: Principles of Mental Physiology.   London, 1881.
Jung, C. G.: Modern Man in Search of a Soul.  New York, 1933, p. 1.
Carus, P.: The Soul of Man.   Open Court Pub. Co., Chicago, 1891.
Mandukya Upanishad, v. 3-12, trans, by R. E. Hume: The Thirteen Principal Upanishads.   Ovford
Univ. Press, 1921, p. 391.
Spinoza, B.: Ethica, pt. Ill, Prop, ix, schol.   Modern Student's Lib.   Scribner, p. 217.
Alcorn, D. E.: New Testament Psychology.  Brit. J. Med. Psychology, v. 16, p. 270, 1937.
Freud, S.: Historv of the Psychoanalytic Movement, The Basic Writings of Sigmund Freud.   Modern
Library, New York, 193 8, p. 93 8.
Spitzka, E C: Insanity.   Cycloptedia of the Diseases of Children.   J. M. Keating, Lippincott, Philadelphia, 1891, p. 1047.
Henderson, D. K., and Gillespie, R. D.: A Text Book of Psychiatry, p. 404.
201 Present Non-Psychoanalytical Technique and Theory.
Still I feel that most of the important advances in psychiatry since the 1890's have
been made by workers outside the field of psychoanalysis. Kraepelin's differentiation
between the manic depressive and dementia praecox disorders; Pavlov's experimentation
with conditioned reflexes; Havelock Ellis's monumental work on the Psychology of Sex
(although Freud influenced him in his last volume); the establishment of the definite
relationship between lues and general paresis—to mention four—are such advances, most
of which came out before Freud was widely known. And since then, the use of malaria
and insulin has changed the prognosis of two of the most serious mental disorders known.
But, confining ourselves to the neuroses, what is the situation today?
(a) Technique. Today we have other means, less expensive, less lengthy, and, most of
us feel, more effective than psychoanalysis. Psychoanalysis is not only limited by the conditions which it can treat (hysteria, obsessions, phobias) 21, but also by the financial status,
intelligence, age, and co-operation of the patient2S. One of the most widely used forms of
psychotherapy ("exploration" or "analysis" as opposed to "psychoanalysis") begins with
the systematic study of the individual, his background, environment, and physical condition, and then treating his personality problems by treating him by endeavouring to
correct what is unhealthy—be it foci of infection, financial uncertainty, his sex life, or
inhibitions. Thus, besides advice, instruction, re-education and suggestion, the social service worker, the surgeon, the club or church may be called in; things that are not done by
either the psychoanalyst or the hypnotist. It may not be possible to deal with all the factors, but often enough can be attended to, to enable the individual to adjust himself, which
is, after all, the object of therapy. One other thing I would like to stress is that, while past
events are important in conditioning the individual, his neurosis occurs in response to a
present situation, and will continue until this situation can be dealt with satisfactorily, and
will recur when a new situation demands it, whether he has been psychoanalysed or treated
by any other form of psychotherapy or not. This method was elaborated by Adolph Meyer,
Havelock Ellis, and many others.
(b) ..Unconscious. In the so-called unconscious, we see today not only the mass of
unverbalized experiences, unperceived sensations, unremembered memories, and unrealized
desires, but also many forces outside the individual, such as the form of our social customs.
In this respect we tend to be closer to Carus's conception than to Freud's.
(c) Conflict. We have given up almost entirely the long-established concept of
instinct, and see it now more as a tendency to establish an equilibrium between a vast mass
of forces, no longer divided into two definite opposing camps. These forces are made up
of stimuli from the environment, the machinery needed to react to these stimuli, the conditioning reflex arcs or rather complexes, etc. Indeed, instinct is more closely related to the
physical capacity to react to a given stimulus than to anything else.
(d) Neuroses. These are no longer regarded as clear-cut entities. Our ideas regarding
their aetiology have tended, if anything, to drift away from the sexual. Masturbation, for
instance, is now regarded more as a symptom than a cause.
In short, we are drifting steadily further and further away from the idea of a mind
split up into separate entities or faculties, and have come to look upon them more as patterns or systems, alterable according to the circumstances. In this process the Gestalt
school has made valuable contributions.
Conclusion.
Freud's greatest contribution lies not so much in what he said as in how he said it. His
very extremism, his force of language, the stirring way in which he presented his material,
has gained popular attention, and some measure of popular support. By proclaiming the
importance of sex, he has made it possible for us to discuss sex freely. By proclaiming the
function of the unconscious, he has made it possible for us to point out unrecognized motivation. But, even greater than these, he has, by proclaiming the unconscious hypocrisy of
those who think pleasure sin, advanced immeasurably man's right to enjoy pleasure—
pleasure, not only in sex, but in life itself, and the right of all men and women to it.
27. Freud, S.: New Introductory Lectures, p. 199.
28. Freud, S.: Psychotherapy.   Collected Papers, 1:12, 1904.
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