History of Nursing in Pacific Canada

The Vancouver Medical Association Bulletin: February, 1952 Vancouver Medical Association Feb 29, 1952

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 BULLETIN
OF
The Vancouver Medical Association
EDITOR:
dr. j. h. MacDermot
EDITORIAL BOARD
DR. D. E. H. CLEVELAND DR. | H. B. GRANT
DR. H. A. DesBRISAY DR.- j. L. McMILLAN
Publisher and Advertising Manager
W. E. G. MACDONALD
VOLUME XXVIII
FEBRUARY, 1952
NUMBER 5
Db. J. C. Gbimson
President
OFFICERS 1951-52
Dr. E. C. McCoy
Vice-President
Db. Henby Scott
Past President
Db. Gordon Bubke
Hon. Treasurer
Db. D. S. Munboe
Hon. Secretary
Additional Members of Executive:
Db. J. H. Black Db. Geobqe Langley
TRUSTEES
Db. G. H. Clement Db. A. C. Fbost Db. Murray Blair
Auditors: Messrs. Plommeb, Whiting & Co.
SECTIONS
Eye, Ear, Nose and Throat
De. B. W. Tanton Chairman Db. John A. Ievjng Secretary
Paediatric
Db. Peteb Spohn Chairman Db. John W. WmTELAW-Secretary
Orthopaedic and Traumatic Surgery
Db. A. S. McConkey Chairman Dr. W. H. Fahrni Secretary
Neurology and Psychiatry
Db. R. Whitman Chairman Db. B. Bbyson Secretary
Radiology
Db. R. G. Moffat Chairman Dr. H. Brooke Secretary
STANDING COMMITTEES
Library:
Dr. A. F. Habdyment, Chairman; Db. J. L. Pabnell, Secretary;
Db. F. S. Hobbs, Db. J. E. Walkeb, Db. E. Fbance Wobd, Db. D. W. Moffatt
Co-ordination of Medical Meetings Committee:
Db. J. W. Fbost Chairman Db. W. M. G. Wilson Secretary
Summer School:
Db. J. H. Black, Chairman; Dr. J. A. Irving, Secretary; Dr. B. T. H.
Marteinsson; Dr. Peter Spohn; Dr. S. L. Williams; Dr. J. A. Elliott.
Medical Economics:
Db. F. L. Skinneb, Chairman; Db. W. E. Sloan, Db. G. H. Clement,
Db. E. A. Jones, Db. Robebt Stanley, Dr. F. B. Thomson, Dr. R. Langston
Credentials:
Dr. Gordon C. Johnston, Dr. W. J. Dorrance, Dr. Henby Scott
V.O.N. Advisory Committee
Dr. Isabel Day, Db. D. M. Whitelaw, Db. R. Whitman
Representative to the B.C. Medical Association: Db. Henry Scott
Representative to the Vancouver Board of Trade: Db.. E. C. McCoy
Representative to Greater Vancouver Health League: Dr. J. A. Ganshorn
Published  monthly   at  Vancouver,  Canada.     Authorized  as  second  class  mail,  Post  Office Department,
Ottawa, Ont.
Page 95 Accepted
by the A.M.A's Council on Pharmacy and Chemistry
Cafergot, n.n.r.
(E.C. 110)
Oral Migraine   Therapy
►
CAFERGOT is the first highly effective oral preparation providing rapid and sure relief to the migraine
sufferer. Each tablet contains:
1 mg. ergotamine tartrate
100 mg. caffeine (Free Base).
►
ii'i
♦
I
'Practically all of the patients in this series had
previously used ergotamine tartrate to abort or relieve
headache and they uniformly stated that E.C. 110 was
more effective than ergotamine used alone" . . .
{Morton, Ryan & Reynolds, Proc. Staff Meet., Mayo Clin. 23: 105, 1948).
. . . "Although E.C. 110 (CAFERGOT) was developed
primarily for the relief of the migraine attack, it is
uniformly effective and has a much wider range of usefulness in die relief of headache of all other types, especially
typical and atypical histaminic cephalgia" . . .
(Hansel, Ann. Allergy, 6: 155—161,1949).
. . . "CAFERGOT . . . definitely seems to be an excellent
preparation to use to abort headaches, especially those of
the migraine and histaminic cephalgia types" . . •
(Ryan, Postgrad. Med., 5: 330, 1949).
SANDOZ
Literature and samples available on request.
SANDOZ PHARMACEUTICALS LTD.
286 ST. PAUL ST. W.
MONTREAL, P:Q.
Page 96 VANCOUVER MEDICAL ASSOCIATION
PROGRAMME FOR THE FIFTY-THIRD ANNUAL SESSION
Founded 1898; Incorporated 1906
REGULAR MONTHLY MEDICAL  MEETINGS
First Tuesday—General Meeting—Vancouver Medical Association—T.B. Auditorium.
Clinical Meetings, which members of the Vancouver Medical Association are invited
to attend, will he held each month as follows:
Second Tuesday—Shaughnessy Hospital Staff Meeting.
Third Tuesday—St. Paul's Hospital Staff Meeting.
Fourth Tuesday—Vancouver General Hospital Staff Meeting.
Fifth Tuesday—(when one occurs)—Children's Hospital Staff Meeting.
Programme of General meetings will be circularized monthly by the Executive
Office of the Vancouver Medical Association Programme of Clinical meetings will be
displayed weekly on bulletin boards prepared for that purpose and placed in the Vancouver General, St. Paul's and Shaughnessy Hospitals.
VANCOUVER GENERAL HOSPITAL
Regular Weekly Fixtures in the Lecture Hall
Monday, 8:00 a.m.—Orthopaedic Clinic.
Monday, 12:15 p.m.—Surgical Clinic.
Tuesday—9:00 a.m.—Obstetrics and Gynaecology Conference.
Wednesday, 9:00 a.m.—Clinicopathological Conference.
Thursday, 9:00 a.m.—Medical Clinic.
12:00 noon—Clinicopathological Conference on Newborns.
Friday, 9:00 a.m.—Paediatric Clinic.
Saturday, 9:00  a.m.—Neurosurgery Clinic.
ST. PAUL'S HOSPITAL
Regular Weekly Fixtures
2nd Monday of each month—2 p.m _||- Tumour Clinic
Tuesday—9-10 a.m | Paediatric Conference
Wednesday—9-10  a.m Medical Clinic
Wednesday—11-12 a.m § Obstetrics and Gynaecology Clinic
Alternate Wednesdays—12 noon Orthopaedic Clinic
Alernate Thursdays—11 a.m Pathological Conference (Specimens and Discussion)
Friday—8  a.m. .- Clinico-Pathological Conference
(Alternating with Surgery)
Alternate Fridays—8 a.m Surgical Conference
Friday—9 a.m Dr. Appleby's Surgery Clinic
Friday—11  a.m Interesting Films Shown in X-ray Department
Page 97 is a
Vitamin
Fraud
D
ayalets
(Abbott's Multiple Vitamins)
NO FISH-OIL.
_jFASTE OR BURP
mil
*•**-* *~M E«h DAYALET
Tablet Contains:
_>. Vitamin A 10,000 Int. units
(synthetic vitamin A palmitate)
Vitamin D 1000 Int. units
(Viosterol)
^^B   Thiamine Mononitrate..   5 mg.
K.S&&     - 5^3    Riboflavin Sp:M&..   5 mg.
Niacinamide .| 25 mg.
Pyridoxine
Hydrochloride 1.5 mg.
->■ Vitamin B12 IP- - ■ 1 rocg.
(as vitamin B12 concentrate)
Pantothenic Acid     5 mg.
(as calcium pantothenate)
Ascorbic Acid 100 mg.
JtIers is a case of between-mealitis which
spoils her appetite for more balanced fare.
For Maude and other subclinical deficients,
the road back to vitamin balance often
combines dietary reform with Dayalets—
the Ashless, burpless multivitamin tablet
containing nine important vitamins.
There's no fish oil in Dayalets because
the vitamin A is synthetic. No fish-oil
taste, burp or odor, no allergies due to fish
oils. Dayalets can't leak, won't stick
together in the bottle. One daily
as a supplement, two or more for
therapeutic use. In bottles     — -^
of 50,100 and 1000 tablets.    fijL&UOtf]
Abbott Laboratories Limited • Montreal
Page 98 SHAUGHNESSY HOSPITAL
Regular Weekly Fixtures
Tuesday, 8:30 a.m.—Dermatology.
Wednesday, 10:45 a.m.—General Medicine.
Wednesday, 12:30 p.m.—Pathology.
Thursday, 10:30 a.m.—Psychiatry.
Friday, 8:30 a.m.—Chest Conference.
Friday, 1:15 p.m.—Surgery.
BRITISH COLUMBIA CANCER INSTITUTE
685 West Eleventh Avenue,
Vancouver 9, B.C.
SCHEDULE OF WEEKLY CLINICAL MEETINGS
Monday—9 a.m. - 10 a.m Ear, Nose and Throat Clinic
Tuesday—9 a.m. - 10 a.m Weekly Clinical Meeting of Attending Medical Staff
Tuesday—10:30 a.m. - 11:30 a.m -—Lymphoma Clinic
Daily—11:45 a.m. - 12:15 p.m Therapy Conference
B.C. SURGICAL SOCIETY
Spring meeting—April 25th, 26th, 1952.
EXCLUSIVE AMBULANCE
LIMITED
FAir. 0080
NW. 60
OXYGEN THERAPY SUPPLIED ON YOUR ORDER
'M 24 HR. SERVICE
J. H. CRELLIN
W. L. BERTRAND
Page 99 &f
Otorhinolaryngologists frequently express preference for
Neo-Synephrine hydrochloride to alleviate turgescence and
nasal congestion in colds, sinusitis and various forms of rhinitis.
"When considerable nasal obstruction exists, relief may be
obtained by the instillation of some shrinking agent into the
nose... as for example Neo-Synephrine hydrochloride ( ^4 % ) "*
A "desirable preparation of this type has been perfected
in Neo-Synephrine hydrochloride. It may be used for local
application in the nose in-^4 to 1 % solution."2
Neo-Synephrine's "desired effect occurs within from two
to fifteen minutes..."3
"Its action is sustained for two hours or more."3
Neo-Synephrine hydrochloride is notable for freedom from
sting and for effectiveness on repeated application. There are
few complaints of after effects such as burning and nasal congestion ... and little tendency to develop local sensitivity.1
OF    CANADA    LTD.
WINDSOR,  D N T.
1. Tatt, l.i Clinical Allergy. Philadelphia. W. B. Saunders Co., 1947. pp. 335-336.
2. Hansel, f. K.: Allergy of Ihe Nora and Paranasal Sinuses. Si. louis. C V. Mosby Co., 1936, p. 769.
3. Kellef, S. f.s Choice of Sympathomimetic Amines. Cornell Conferences on Therapy, II, 1947, p. 156.
Neo-Synephrine, trademark raa. U. S. « Canoda, brand of phenylephrine
^^n
443 SANDWICH STREET WEST, WINDSOR, ONTARIO
Page 1#0 VANCOUVER HEALTH DEPARTMENT
STATISTICS—JANUARY, 1952
Total population—estimated   „  b; g     397,140
Chinese  population—estimated    li             6,282
Other—estimated    _ ■__  _  „ \ _  640
December, 1951
Rate per
Number 1000 pop.
Total deaths   (by occurrence)       .       33 8 10.2
Chinese deaths  .„ a  6 11.5
Deaths, residents only    sl|S|   317 9.6
Birth   Registrations—Residents   and  Non-Residents
(includes late registrations,)
Male   ..
Female
December, 1951
Number
383
334
717
21.7
Infant Mortality—residents only
Deaths under 1 year of age •	
Death rate per 1000 live births 	
Stillbirths (not included in above item)
December, 1951
10
19.9
4
CASES OF COMMUNICABLE DISEASE REPORTED IN THE CITY
December, 1951 December, 1950
Cases Deaths Cases Deaths
Scarlet  Fever     ...  135 — 71 —
Diphtheria    H     — — — —
Diphtheria Carriers  1    — — — —
Chicken  Pox   .  142 — 47 —
Measles    ^ _._  390 ||p — 9 —
Rubella          15 — 13 —
Mumps    . -l||:-          54 — 55 —
Whooping Cough    .—     11 — 11 —
Typhoid Fever    i     — — — - —
Typhoid Fever Carriers       — — — —
Undulant Fever  s       — — — —j
Poliomyelitis        — 1 — —
Tuberculosis      29 8 44 10
Erysipelas          3 — 1 •—
Meningitis      — — 1 —
Infectious Jaundice      — — — —
Salmonellosis  ^       2 — — —
Salmonellosis Carriers      — — — —
Dysentery        6 — 7 —
Dysentery  Carriers        — — -— —
Tetanus        — — — —
Syphilis        19 — 6 1
Gonorrhoea   159 — 130 —
Cancer   (Reportable  Resident)        97 52 78 44
Page 101 {CONNAUGHT>
ANTI-MEASLES  SERUM
Concentrated and Irradiated Human Serum
FOR MODIFICATION OR PREVENTION OF MEASLES
Human serum prepared from the blood of healthy adults so as to involve
a pooling from a large number of persons provides an economical and effective
agent for the modification or prevention of measles.
Modification is often preferable since it reduces to a
minimum the illness and hazards associated with measles,
but does not interfere with the acquiring of the active and
lasting immunity which is conferred by an attack of the
disease. On the other hand, complete prevention of an attack
of measles is frequently desirable, and can be accomplished
provided that an ample quantity of serum is administered
within five days of exposure to the disease.
Serum supplied by the Connaught Medical Research
Laboratories is concentrated to one-third the volume of normal
adult serum and is irradiated so as to minimize the occurrence
of homologous serum jaundice.
HOW SUPPLIED
Irradiated Anti-Measles Serum, pooled and
concentrated, is distributed by the Laboratories   in   5-cc.   rubber-stoppered   vials.
CONNAUGHT   MEDICAL   RESEARCH   LABORATORIES
University of Toronto Toronto, Canada
Established  in  1914 for Public Service through Medical  Research  and the development
of Products for Prevention or Treatment of Disease.
DEPOT FOR BRITISH COLUMBIA
MACDONALD'S    PRESCRIPTIONS    LIMITED
MEDICAL-DENTAL BUILDING, VANCOUVER, B.C.
Page 102 Library Hours:
Monday, Wednesday and Friday 1 - 9:00 a.m. - 9:30 p.m.
Tuesday and Thursday | 9:00 a.m. - 5:00 p.m.
Saturday  B fc 9:00 a.m. - 1:00 p.m.
Recent Accessions:
Association of American Physicians, Transactions of 64th Session, Volume 64,  1951
(gift). .8 | ' ■ H
Cook, F. A., Return from the Pole, 1951  (Nicholson Collection).
Feiling, A.  (editor), Modern Trends in Neurology, 1951.
Glaister, J., Medical Jurisprudence and Toxicology, ?th edition, 1950.
Harrison, T. R. (editor), Principles of Internal Medicine, 1951.
Hutchison, R. and Hunter, D., Guide to the Practical Study of Medicine, 12th edition,
1950.
Major, R. H., Physical Diagnosis, 4th edition, 1951.
Mitchell-Heggs, G. B.  (editor), Modern Practice in Dermatology.
Surgical Clinics of North America—Symposium on Abdominal Surgery, Philadelphia
Number, December, 1951.
Thorn, G. W., The Diagnosis and Treatment of Adrenal Insufficiency, 2nd edition, 1951.
U.S. National Research Council, Sub-committee on Burns of the Committee on Surgery
-^Symposium on Burns, 1951. |p
J
BOOKS—IN MEMORIAM
In future, on the death of a member of the Association, no flowers will be sent to
the funeral, but an appropriate book, duly inscribed, will be placed in the-Library to
his honour.
U.S. PUBLIC HEALTH REPORTS
As from January, 1952, the U.S. Public Health Reports will be published monthly
instead of weekly, and two other publications of the U.S. Public Health Service, the
CDC Bulletin and the Journal of Venereal Disease Information will be incorporated
with it.
We publish below the letter of thanks and appreciation sent to Dr. I. Steiman by
the Library Committee for his recent valuable gift to the Library, and we publish at
the same time, the title page of the first volume of this great work, which we are sure
will be of interest to members.
Page 105 November 20 th, 1951.
Dr. I. Steiman,
751 Granville Street,
Vancouver 2, B.C.
Dear Doctor Steiman:
Your extremely valuable and most generous gift to our Library of the two volumes
of the works of Hippocrates in Greek and Latin, published in Geneva in 1657, have
been most gratefully accepted by the Library Committee and may I, on their behalf,
thank you most sincerely for them.
This tremendous work, whose pages are excellently preserved, will find a place in
our Historical Collection and the Committee hopes that your gesture will spur other
members on to present such works so that we can be as proud of our Historical Collection as we are of our new Library, and the building in which it is housed.
Once again assuring you of our very sincere appreciation and our indebtedness to
you in presenting a copy of this famous work. . 3*p|
Yours sincerely,
*
JOHN L. PARNELL, M.D.,
Secretary, Library Committee.
A Gut Showing a picture of Dr. Steinman's Gift is being made, and will be included in the next issue of THE BULLETIN.
February 18, 1952.
The Editor,
Bulletin of the Vancouver Medical Association
203 Medical-Dental Building
Georgia Street, Vancouver, British Columbia
Dear Doctor: Wm
We are writing to extend a cordial invitation to your readers to attend a three-day
Sectional Meeting of the American College of Surgeons to be held at The Vancouver
Hotel in Vancouver, British Columbia, on March 31, April 1 and 2; 1952.
The program will include two days of scientific sessions at The Vancouver Hotel,
March 31 and April 1, and a day of teaching clinics and demonstrations in Vancouver
hospitals on April 2. Distinguished speakers will present papers, panels and symposia
on current surgical problems, and new surgical motion pictures will be shown, including
several which were prepared especially for the Cine Clinics at the 1951 Clinical Congress,
and also a stereoscopic colored film on Radical Resection for Carcinoma of the Stomach,
which is attracting a great deal of attention wherever it is shown.
J. Russell Neilson and his Committee on Arrangements have made extensive preparations to assure a good meeting and a warm welcome to Vancouver for all visiting
surgeons. Hotel accommodations may be obtained by writing to Mr. M. H. Burns,
Manager, The Vancouver Hotel, Vancouver, British Columbia.
Sincerely yours,
H, P. SAUNDERS, M.D., F.A.C.S.
Associate Director.
Page 106 FORGOTTEN FUNDAMENTALS
FRANK HEBB, M.D.
Our readers who enjoyed Dr. Hebb's article entitled (tThe Care of the Dying"
published in April, 1951, will appreciate his thoughtful paper which follows. It is well
worth our while to consider these aspects of Medical Science as well as the purely
scientific- ones.
The Editor.
One of the most influential teachers of Medicine in our time, Dr. A. H. Gordon,
is the author of the following: "In the progress of our art the case of illness may, by
almost imperceptible stages, pass from being a person through the stage of being a
problem and end in being regarded as so much material."
There seems to be little doubt that the rediscovery of the patient as a person constitutes an important challenge to Medicine today. Many physicians tend to regard the
patient in terms of his physical and chemical functioning and in the light of his
previous illnesses and his heredity. They tend to be more concerned with illnesses per se
than the kinds of persons who suffer from them. They see their patients as instances
of hyperthyroidism, gastric ulcer or hypertension and not as persons suffering from
emotional disorders with somatic manifestations. This attitude may be quite satisfactory
if the suffering derives from acute infections or is traumatic in origin, but for at least
one-third of all patients who consult physicians this professional approach is unsatisfactory. The physician may have developed remarkable technical skill and yet be handicapped in his professional service because of his inability to understand the needs of his
patients as human beings. Sick people are often frightened and helpless and dependent,
like children. Doctors who are familiar with this psychological aspect of illness are apt
to have a more tolerant attitude towards their patients. It therefore is as important to
know what kind of patient has the disease as to know what kind of disease has the
patient.
Every patient requires a different method of approach according to his psychological makeup, whether for the purpose of eliciting a reliable history, making a clinical
examination or obtaining a sample from a vein. This, the frequently ridiculed "bedside
manner" which secures the confidence of the patient, is of fundamental importance
in Medicine. It is an art which is more often inborn than acquired and which develops
with experience.
The depth and extent of fear among patients is not sufficiently realized. It is seen,
for example, in the reaction of the public to heart affections which they persist in
regarding as peculiarly dangerous to life. In the Lancet, September 15 th, 1951, Sir
John Parkinson states: "The truth is there are only a few varieties of heart disease
which carry the risk of sudden death. Not only the risk but the resultant disability
is exaggerated. After a coronary thrombosis a man will inquire about his chances of
further attack; or if he does not ask he and his relatives will constantly think about it
and they should be told that it is unlikely to happen though not impossible. Many
patients a few months after such an attack are able and wise enough to forget about it.
Then the unjustified idea is still held that in cardiac cases exertion must be restricted
because it entails danger. Modern medical opinion allows children with congenital malformations of the heart to participate in any and every form of activity which they
can undertake without distress. It does them good, not harm and these children will
not hurt themselves. Many adults might, with advantage, follow the same rule in
regard to their handicaps. You will have heard of the pathologist in the post-mortem
room who said that he was not surprised at what people died of, but he was surprised
at what they could live with." (William Boyd).
Sometimes we say too much to the patient. Here we often burden him with a
load of anxiety which adds to the illness we are trying to relieve. Patients feel well
until they are told they have high-blood pressure or a murmur.   Then they become
Page 107 afflicted with many grievous symptoms which could be gathered from hearsay or from
patent medicine advertisements. When we say too little it causes the fear of the unknown and the gaps may be filled in by the patient with alarming inventions and superstitions, e.g., a patient with shingles has nearly always been told by his grandmother
that "if they meet in the middle you die." People with mild arthritis are usually terrified
of becoming "crippled with rheumatism" and so on. In these cases re-assurance is more
important than medicine.
Often we forget the patient. I refer to that kind of discussion where the patient
is treated as if he were unconscious or stone-deaf or as if he were already on the postmortem slab. Sotto-voce murmurings about polysyllabic diseases awaken needless terror
in their hearts. Again it is the unknown they fear most. They resent the omission of
any clear statement of what is the matter and what should be done about it. A French
cynic once remarked "Women and doctors alone know how necessary and beneficent
to Mankind is the lie." Truth has often to be softened. Truth can be a terrible thing—
it should be tempered but never falsified to those whom we serve. If a patient unfeign-
edly insists on truth it is his human right and he must be told. Put yourself in the
patient's place. Someday you may have to. As for prognosis most patients who are
ill want an answer to three questions. Shall I get quite well? How soon will this happen?
If I cannot recover completely/ what will be the limits of my activity in the future?
To frame answers is to reach the goal of much scientific thought and method; for in
prognosis we see the combination of scientific knowledge and human understanding.
It must be reduced to what the patient wants to know in terms he can understand.
Whenever a definite and encouraging prognosis can be given the patient should have
the benefit of it. To give a bad prognosis to the patient almost always does more harm
than good. We should be encouraging but in doing so avoid unbridled optimism.
Sometimes prognosis is too vague to justify an emphatic pronouncement; and it is better
to be non-committal than to box the compass of probabilities and possibilities. The
patients we forget are those who have a good prognosis but carry unnecessary burdens
of anxiety about their health which limit their happiness and activity and they bear
these burdens for lack of re-assurance which could have been given without delay.
Sometimes we are guilty of physical cruelty, e.g., a man has secondary cancer and
the primary focus may eventually be discovered at post-mortem. Often his last days
are made uncomfortable by playing at "hunt the Primary" as one might "hunt the
slipper." Then there are minor cruelties which can easily be avoided, e.g., by withholding a fractional test meal on a patient suffering from pernicious anaemia when he
is admitted with a haemoglobin reading in the twenties. Administer liver first; his
achlorhydria will keep! The Parkinsonian need not be pushed to see how far he totters
forward nor should the patient with myxoedema be subjected to the indignity of hair-
pullfng by the clinician.  There are enough other signs to make a diagnosis.
Turning now to problems in diagnosis with patients as persons: We know that
in the fields of human physiology and pathology the scientific approach may establish
a biological fact with exactitude; for example such simple determinations as a red-cell
.count or a figure in blood-chemistry. But experience soon shows that the isolated fact
can be widely interpreted by reason of the many variables, the infinite permutations arising from the complexity of factors, and the integration of the systems which make up
the human organism, not to mention the fallibility of the observer. Charles Nicolle
wrote: "Error is all around us and creeps in at least opportunity. Every method is
imperfect." Commonsense, which includes art and instinct, helps the observer to make
the probable true interpretation. But there can be no substitute for a carefully taken
and weighed history with examination and observation of the patient by competent
clinicians. Without this information intelligent use of the laboratory as a diagnostic
aid is not possible. Tests, /to matter how well done, will not do the thinking for the
clinician and such tests are not always demanded and employed with judgment. A
diagnostic approach neglecting or misinterpreting history and physical findings reveals
Page 108 a lack of understanding by the physician and may be conducive to mischief, loss of
valuable time, and unneccessary cost.
Today we do not tend to produce physicians as shrewd and as skilled in diagnosis
as those individualists of the nineteenth and early twentieth centuries. As modern
doctors with so many scientific checks at our command we would do well to imitate
our forbears more closely by carefully orientating our cases before demanding wholesale laboratory work. What has been called "clinical instinct" is too often scoffed at and
cynically described as "blind man's bluff". True science teaches us above all to doubt,
to be careful and to be humble: I think we can accept Thomas Huxley s view that
Science is nothing but trained and organized commonsense. Commonsense appreciation
of Medical Science must admit and recognize that though men are all of a pattern, the
pattern is never the same.
Have science and its advances tended to make medical diagnosis appear easy and
automatic? May I quote a Parisian surgeon (Burnand) who said: "We live under the
rule of Pharmacy. The equation Disease A equals Drug A not only tyrannizes the
minds of the public, it haunts the practitioner whose professional capacity is rated
according to the skill with which he applies the formula. There is something still
worse; Mass Medicine, socialized and mechanized to excess tends to substitute an even
more deceitful equation: Symptom B equals Drug B. Faced with a difficult case, too
many physicians think it advisable to try a series of drugs in the hope that a happy accident will point out the one good effective drug after a series of failures. The doctors
are positively forgetting that the human organism possesses in itself defences and a
potential for cure which they should utilize more often with more faith and who in
our day thinks of the resources of another age . . . Morale, the will to health, the will
to recover."
Medicine today is indeed tending to sacrifice Art for Science.   If the scientific
method becomes the end rather than the means then the future is gloomy, when patients
are to be treated not as human beings but as a series of laboratory exercises and I feel
that many will agree that today the Medicine of our forefathers is regarded too often
as something quaint and curious, often absurd, and at times amusing, but useless and
obsolete when viewed in  the  light  of  modern  knowledge.   This  narrow  view  is  as
unfortunate as it is fallacious.   The enormous accumulation of facts and the multiplication of discoveries have increased rather than diminished the necessity for a backward
view.   Some of our leading thinkers have dared to suggest that the pace has been too
rapid and a little slackening of the speed might enable us to make a' fuller use of
the   information   at   our   disposal.    Medicine   which   so   deeply   concerns   mankind   is
both scientific and humanistic.  We might do well to cultivate broader interests and to
study theory besides practice—otherwise in gaining the whole world Medicine may be
in grave risk of losing its own soul.   Yesterday's contribution cannot be neglected.
' Finally may I say that Medicine with one per cent humanism and ninety-nine per
cent technique would be almost as futile as Medicine which is mnety-mne per cent
humanism and one per cent technique. Granted the team of humanism and technical
excellence Medicine has a great future. To enter into our inheritance each and all of
us must contribute according to his means and no contribution can be too small.
BIBLIOGRAPHY
Parkinson   Sir John, The Patient and the Physician.   The Lancet 2:457-459, September 15, 1951
Gr^t Whither'Medicine?   (Letter to fe Editor). ffigMlg 2:83 0-8:Jl   D,cemb et  22,  1945.
Whitbv   Sir Lionel, The Science and Art of Medicine.   The Lancet 2:131-133, July 28, 1951.
Whitby, Mr ^neV' c      d   M   A   j   31:191-193, August, 1934.
B^er^o'rl,^"de'of the Physician.   | A. M. A. 145:1122-1125, April 14, 1951.
Burnand, R., Fear of Life and Magnificent Folly.   Concours Medical 73:1563-1565, April 28, 1951
A.W   R    Seven Sins of Medicine.   The Lancet 2:358-360, August 27, 1949.
feRD.&Thne trch J a Philosophy of Medicine.   The ^ncet 1:405-409   M.ch 23 rd   1946
Neal,  M.   Pinson,  Diagnostic  Drifts,  Deceptions   and   Common  Misses.    J.   A.   M.   A.   146.537-541,
1.
2.
3.
4.
5.
6.
7.
8.
9.
10. Cok, Les^e!Prognosis and the Patient.   The Lancet 1:1-3, January 5, 1946.
Page 109 CANADIAN MEDICAL ASSOCIATION-B. C. DIVISION
October,   1951  — September,  1952
OFFICERS
President Dr. H. A^ L. Mooney, Courtenay, B.C.
President-Elect 1 Dr. J. A. Ganshorn, Vancouver, B.C.
Vice-President-.:: I Dr. R. G. Large, Prince Rupert, B.C.
Honorary Secretary-Treasurer Dr. W. R. Brewster, New Westminster, B.C.
Chairman, General Assembly  Dr.  F. A. Turnbull, Vancouver, B.C.
STANDING COMMITTEES CHAIRMEN
Constitution and By-Laws Dr. R. A. Stanley, Vancouver, B.C.
Finance I -Dr. W. R. Brewster, New Westminster, B.C.
Legislation   .. , Dr.  J.  C.  Thomas, Vancouver, B.C.
Medical Economics I Dr. R. A. Palmer, Vancouver, B.C.
Medical Education : Dr. G.  O. Matthews, Vancouver, B.C..
Nominations r..^ Dr. H. A. L. Mooney, Courtenay, B.C.
Programme and Arrangements Dr. R. C.. Newby, Victoria, B.C.
Public Health Dr. G. F. Kincade, Vancouver, B.C.
SPECIAL COMMITTEES CHAIRMEN
Arthritis and Rheumatism - : Dr. A. W. Bagnall, Vancouver, B.C.
Cancer Dr. A. M. Evans, Vancouver, B.C.
Civil Defence Dr. L. H. A. R. Huggard, Vancouver, B.C.
Emergent Epidemics \ Dr. G. F. Amyot, Victoria, B.C.
Hospital Service Dr. J.  C. Moscovich, Vancouver, B.C.
Industrial Medicine ~—Dr. E. W. Boak, Victoria, B.C.
Maternal Welfare Dr. A. M. Agnew, Vancouver, B.C.
Membership Dr. L. H. Leeson, Vancouver, B.C.
Pharmacy i_. Dr. D. M. Whitelaw, Vancouver, B.C.
EDITORIAL
The organization and financing of the B.C. Division are now well under way.
Its committees have been chosen from our elected representatives and these are now
actively attacking their numerous problems. A well trained executive secretary has
been engaged and will soon be in our midst. The profession can well be proud of its
accomplishments thus far and can look forward to the future with considerable
confidence.
There still remains one matter which demands our immediate attention and that
is 'Public Relations.' So far the doctors have been indifferent to and traditionally loath
to embark upon such a programme. Furthermore, until recently, there has been no body
with authority to speak for the profession. Now there can be no excuse for further
delays. Industry, business, governments and various successful organizations and
associations have, for years, been actively aware of its value. We should enter this
field at the earliest possible moment. If the public regard us with favour there will be
little danger of bureaucratic interference but if the reverse is true we shall be very
vulnerable.
Undoubtedly .the relationship between the individual doctor and his patient is
essential to good feeling between the profession and the public as a whole, but this is not
enough in modern practice. The oft repeated reference to the much loved, self
sacrificing family doctor with his little black bag and! horse and buggy is very touching
Page 110 but it is an anachronism in the streamlined twentieth century with its scientific knowledge and costly techniques.
One can only condemn the noisy blatant publicity that has sometime been used
because it does more harm than good. On the other hand a continuous flow of unimpeachable information regarding the problems, activities and achievements of the
medical profession would be well and sympathetically received by an interested public
and would do much to dispel the misunderstanding and antagonism built up by our
self imposed isolation.
Furthermore, deliberate attacks of a political nature which may distort the facts,
should be met and exposed immediately, honestly and publicly by some one with
authority to speak for the profession.
-I   G. J.
DR. H. A. L. MOONEY ||
President
C.M.A., B.C. Division
Some of the problems facing the B.C.M.A. should be remembered by all members
of the Profession. They are easy of solution if each one practising in the Province
will bear his share of the responsibility.
The first of these is Finance. We are starting from scratch. There is no large
Reserve of Funds to draw upon. It is for this reason that the Board of Directors, after
setting the annual fee of the Division at $30.00, approved of a Founders Fee. It is
not too late to subscribe to the Special Fund. In any event please send in your Regular
Membership Dues as promptly as you can.
The second is Membership. This of course is inseparable from our Financial
Problem. The greater the membership, the lower the cost will be to each; the greater
the interest that will be taken in the solution of the difficulties that are ahead of us;
and in general the better will be the spririt of cooperation of all concerned. Join
the Association now; remind your friends; become a Medical Missionary for your
Association.
The third is Sectionalism. As individual members we should strive to see what is
good for the Profession as a whole. We are practising during a period of general
economic unrest, and if ever we needed Unity in Medicine we do today. One cannot
help remember the words of Benjamin Franklin who on July 4, 1776 said, "We must
all hang together, or assuredly we shall all hang separately." Let us all try to see the
viewpoint of the other fellow; and with tolerance and good will reach a settlement
of any differences that arise.
Finally, and I quote from the Editor of the V.M.A. Bulletin, "We must be
patient, and give the Division adequate time to do its work." A vigorous start has
been made in the Economic Problems that are presently before us. A target date of
April 15, 1952, has been set for a Revised Tariff for the whole Profession. All
Committees are accepting their responsibilities and discharging their duties faithfully
and as rapidly as may be. It is probably inevitable that some mistakes will be made.
We hope that this will not be so, but again we appeal for tolerance and your continued
support and interest.
Let us all look forward to a year of vigorous accomplishment in the spirit of
Unity and Cooperation.
PUBLIC RELATIONS FOR THE MEDICAL PROFESSION
By W. J. FOWLER
Public relations problems of an association are different from those of an ordinary
business organization.    True, the association is made up of hundreds of individuals.
Page 111 But in many ways it is an entity in itself.    And while it is controlled by its members,
it is an organization capable of its own activities. Up
The public relations program must be for the mutual benefit of all members. It
cannot be for the advantage of some! The problem of the association is a two-way
problem. It must serve and protect its own members to maintain its own standing with
them. And it must act as an agent in interpreting the policies established by the
members to the general public.
To interpret these policies in acceptable fashion; to promote and maintain the
goodwill of the public towards the medical association is the work of the public
relations counsel.
The Public Relations counsel will need to plan a long-range public relations
program. While the occasional article or photo feature is of interest to the public,
a sustained, repetitive program is required to tell the message of the medical profession
to the public, and keep on telling it, until the majority of citizens understand what the
medical profession has done for the public throughout history; what it is doing now
and what it hopes to do in the future. A constant repetition embodied in various
articles, human interest stories, reports of speeches and meetings would go far to improve
relations between the doctor and the public.
The immediate need from publicity, is to establish the medical association in the
minds of the public, the members, and the government.   The first goal is prestige!
There will be occasions when a brief, intensified campaign can be used for specific
purposes. On such occasions it may be necessary to embark on an advertising campaign,
to quickly explain a specific problem. This type of professional advertising is used by
the legal profession, successfully. However, if a sufficiently sound and effective public
relations policy has been maintained over a period of time, advertising should be
necessary only on rare occasions.
If a government ruling had implications for the medical profession, the public
relations counsel would seek to make the public understand the position of the medical
profession. In such an event it is obviously essential that every member of the
profession understand the issue at stake—and the association's stand.
When the association's activities make news, it will be the duty of the public relations officer to present these stories in a style, and language, that the average citizen will
understand and accept. To expect everyone to read, or listen to, ideas expressed in
words that are hard to understand is sheer optimism. Our message must be told
in simple words, eye-catching photographs and colorful stories.
Normal meetings and operations of the medical association should be reported,
interpreting the profession's service to the public.
The convention of the association must be exploited, publicity-wise, as fully as
possible.    It represents an event and its expressions of opinion are timely, newsworthy.
From time to time there will be interesting, unusual and sometimes colorful events
connected with the work of the profession that, retold to the public, will enhance
the prestige of the entire group. It is important in this type of "news" not to single
out any one member of the association but to benefit the whole group.
Speeches by members of the association which would enhance the prestige of the
profession in general, should be properly reported to press and radio.
Replying to criticism and misinformation appearing in print or in speeches is
another task of the publicity officer.
An imminent crisis, such as the one on S.A.M.S., could be handled by an intensified
short-term publicity campaign, in addition to the longe-range program.
Anticipation of news events may provide good results. If action is planned,
detrimental to the association, the association can arm news writers, columnists, radio
commentators and free-lance writers in advance, so they will be prepared to* handle
the question intelligently when it actually becomes "new". (A recent example of this
is the conservationists' approach to the Buttle Lake controversy.)
Page 112 Do You Recognize the Rump?
Page 113 An association as important as that of the medical profession requires a counsel
whose knowledge of public relations techniques is wide, an experiencel counsel with
keen judgment of what makes people like and dislike, who can predict the public
reaction to a given policy or event. The counsel is called on for advice; is respected
for opinions of public response, as much as a lawyer is respected for knowledge of
jurisprudence.
The public relations counsel must be a sensitive pulsefeeler; be able to spot a
trend; able to make publicity plans in accordance with the policy of the publicity
committee of the medical association. An efficient "PR" counsel is an expert writer,
able to get a story in newspapers, magazines, movies and over the radio. Working
in an entirely different field—a public relations counsel is equivalent to the doctor who
advises, diagnoses, prescribes and operates!
WHAT TYPE OF PUBLIC RELATIONS?
By DR. J. H. MacDERMOT
There can be no question of the vital importance of good public relations between
the professions and the public that they have to serve. Nor is there much doubt that,
speaking for the medical profession at least, both we and the public suffer from a flood
of misinformation, misunderstanding and misrepresentation, that stems from a grave
lack of good public relations between the two parties concerned. So that we must
give this subject immediate and thorough consideration.
I have been reading with great interest an article by Dr. W. J. Fowler, "Public
Relations for the Medical Profession"—in fact, I have read it two or three times.
A great deal of what he says seems to me to be true and timely. But, in my humble
opinion, he has left untouched a full half of the problem—the public's side of the
argument—and I personally at least do not agree with his choice of agents who shall
help us to solve the problem.
To be more specific. We should, I think, define clearly what we mean by good
public relations. Since there are two parties concerned, it must be, as Dr. Fowler
states, a two-way problem. It must be more than this. It must be a fifty-fifty
proposition. It involves a deal, a trade, a bargain—between two contracting parties.
Therefore both parties must receive equal benefits. In thinking of public relations we
must think, not only of what we shall gain from it—but, and just as important, what
we shall have to give.  We have duties and responsibilities as well as rights and privileges.
I may be all wrong and perhaps unjust in my understanding of what Dr. Fowler
means, but it seems to me that he is rather more concerned with the latter of these
than he is with the former. "The first goal is prestige," he says. To my mind, that
is rather putting the cart before the horse. The net result will or will not be a gain
in prestige, according to the way in which we make and carry out our bargain.
The poor public relations from which both parties to the case suffer are at least
partly, and I think to a large degree, our own fault.
First, and here I heartiily agree with Dr. Fowler, we have not given the public
the facts and information and knowledge regarding our work, the rules under which
we work, and so on, to which it is entitled—knowledge which will enable them to
understand and appreciate our position. This is notably true in matters like* the
working of the Medical Act, the Health Insurance debacle, and similar matters. As Dr.
Fowler says, this must be one of our prime concerns.
Secondly, and the public is quite aware of this, we are not sufficiently uniform and
agreed among ourselves, as regards our own behaviour, our own policies—we suffer
from a lack of discipline within our own body. One has only to ask any Committee
on Economics to be told this most emphatically.
Thirdly, as a profession we ourselves need education and training in public
relations, as well as in our relations with each other.    Many, if not most of us, lack
Page 114 the knowledge of facts, of what constitutes good public relations, of our own
responsibilities and duties, that we should have. And It will, I feel, be one of the
primary duties of whatever body takes charge of Public Relations, to educate our
membership in these matters. It is not going to be easy—it is going to be very hard—
but till our own skirts are clean, till we can guarantee fair dealing and honest trading,
not only by the majority, but by all our members, we shall never have the full
confidence of the public. Fine words and aisplays, and records of the undoubtedly
great achievements of the medical profession, will not avail us much if there is any
ground of question of our complete integrity. The individual patient trusts his
individual doctor, because he has found in him a man of integrity, on whom he can
rely to play fair—but one rotten apple in a barrel will soon destroy the confidence of
those who shop for apples. We must find some way by which we can quickly detect
and remove the offending apple—and even better, not let it get into the barrel.
These things may all seem to be truisms, but after a good many years of practice,
and after much thinking on this matter, I have come to the conclusions that these
truisms. are too often ignored, and are vital to the problem. Till these considerations
are faced and settled we may have the most highly-touted and highly-paid publicity
counsel, but he will do no good, or very little, the ground will be unsafe under his feet.
And that brings me to my last point. I do not agree that we should be led in
this matter by any public relations counsel, or by any layman. He cannot know our
side of the case—he cannot influence our thinking and acting—he cannot tell us the
truth and press it home. This is our problem, and we must solve it. Our leaders must
choose or appoint a medical man of knowledge and understanding and experience of
practice, respected by his fellows in the profession, and willing and able to talk
straight; a man whom we can follow and uphold, who can gain the confidence of the
press and public, because of his knowledge and ability to present facts, and speak with
authority.    Such a man will not be easy to find.
The best public relations we have had so far was when a medical man, our former
Executive Secretary, assumed to some extent this duty. He was approachable, friendly,
and on the job at all times and had very good relations with the press.
And our present Executive Secretary, over-loaded as he has been with his own
work, and with little or no time at his disposal, has done a remarkably good job in
this regard. But it is a full-time job, and justice cannot be done to it except by a
full-time worker.
We have had more than one layman to help us—as far as I could see, none of
then was ever able to do anything—and it was not necessarily their fault. The idea
of publicity for publicity's sake, of protest against fancied or real injustice, of an attempt
to present our side of the case, was, I think, only a small part of the problem we had
to solve.
In deciding on a scheme of public relations, all these things must be taken into
consideration. I hope I have not seemed too critical of Dr. Fowler's article. I agree
entirely with his suggestions as to what should be done—merely I do not think he goes
far enough, and as I have said, I do not think we should go outside our profession for
a Public Relations leader.
MEDICAL PUBLIC RELATIONS
By F, L. SKINNER
Public relations for the medical profession is the unwanted necessity to which we
are being forced by the modern trend if life. In the past, the doctors were held in high
esteem as hard working men doing their best for all members of the community. With
the increase of socialism has come resentment of any group making an income above
the average. We are now attacked on many sides with an occasional regretable incident
greatly  embellished,   and  other  stories   twisted  or   completely  manufactured,   to   use
Page 115 as ammunition against us. There are very few people who do not consider their own
doctor, a fine upstanding citizen, but unfortunately, it seems there are equally few
who do not think the medical profession in general is a strong, tight union out to
exploit them. The time has come when we must counteract these reports. In our
present society, truth needs help to stand against propaganda, and we must supply this
public relations, or else we and our patients will suffer.
Public relations has three facets; first and very important, is that done by each
doctor in his daily contact with his patients. Second is the necessary but neglected
aspect of relations among ourselves. Lastly is the dissemination of truthful information
to the public, to correct the erroneous impressions being spread by others.
Our programme must take into count all three of these aspects. The first point
is up to each individual doctor, to continue acting honestly in the best interest of his
patients. There are those who feel public relations are unnecessary, but they are refusing
to look at the present day picture and trends. Others feel we should hire professionals to
conduct the crusade. This introduction of outsiders might cause certain resentments
which would interfere with the cordiality and effectiveness of our internal co-operation.
We would lose considerable control over a programme conducted by laymen who
could not possibly appreciate our standards and ethics, and we might easily find that
their advertising enthusiasm led them far beyond any points we wish to go. It is an
extremely dangerous procedure to allow this power out of our own hands and our
advisors would find their efforts hamstrung if they had to be continually referring
back for authority.    Cost is a factor, and this would undoubtedly be expensive.
The Vancouver Medical Association had a committee of Public Relations for a
year, consisting of three doctors with little help. Much was accomplished. While not
perfect, it does give an indication how best to carry out our needs. After much
study, these doctors made recommendations which were drawn up as tentative rules
and regulations of a committee on Public Relations of the British Columbia Medical
Association. Briefly, the committee was to consist of a chairman, plus representatives
from Vancouver and Victoria medical societies, at least one rural representative, wtih
the Editor of the Bulletin and the chairman of the economics committee as ex-officio
members. Provision for liaison with all districts is included in the recommendations
and it is felt that all dealings with the press or other publicity media should be
conducted through this committee. They should lay down general policies, help out any
local district with the desired publicity on some local problem, and should be contacted
before any doctor made statements of his own, that the overall programme of the
committee may not be jeopardized. Dr. Gordon Ferguson, the new executive
secretary of the British Columbia Medical Association would work with this group
and be in charge of the ordinary day to day factors. A stenographer could give part
time to collecting and filing miscellaneous information which could be available when
necessary. This committee should command the respect and co-operation of all doctors.
There should be little expense handling our public relations in this most efficient manner.
WANTED
Association with Medical group or clinic. 28 years old. Married.
Experience mainly in Internal Medicine, Pediatrics and Obstetrics.
Correspondence invited.   Available July 1st.
DR. GERD P. WEIH
8809- 112th Street, Edmonton, Alta.
Page 116 PUBLIC HEALTH AND MENTAL HEALTH NEWS
G. F. AMYOT, M.D., D.P.H.,
Deputy Minister of Health, Province of British Columbia
A. M. GEE, M.D.,
Director, Mental Health Services, Province of British Columbia
Active Treatment Services Geriatric Division Preventive Services
Crease Clinic of    Prov. Mental Hospital Homes for Aged      Child Guidance Clinics
Psychological       (a) Essondale (a) Port Coquitlam (a)   Vancouver
Medicine, Essondale (b) Colquitz (b) Vernon (b)  Victoria
(c) New Westminster   (c) Terrace (c)  Travelling
(The Woodlands School)
Rehabilitation  Services
(a) Women's Division
(b) Men's Division
(d)  Delinquency Unit
Research  Division
Research Colony
University of
British Columbia
The chart set forth above shows the major divisions under which the various units
of the Mental Health Services are organized.
The Active Treatment Division is the largest and the one with which the
practitioner is probably most familiar. The newer developments of the Mental
Health Services are closely related to the Active Treatment Division and comprise the
Rehabilitation Services, the Research Division and the Crease Clinic.
M REHABILITATION SERVICES
The Rehabilitation Services operate the Vista, a rehabilitation centre for 'women
patients. The Vista is a comfortable, modern home in a good residential area in
Vancouver. Every effort has been made to avoid any suggestion of institutional
atmosphere and the home is run with no more in the way of regulation or restriction
than one might expect to find in a normal family. Residents are expected to be on
time for meals, observe reasonable hours of retiring and rising and to advise the
housekeeper when detained on visits to prospective employers. Before a patient is
transferred to the Vista the attending physician, Assistant Clinical Director and Social
Service Department evolve a definite plan to meet the needs of the patient.
The social worker assigned to the case then works through the details of the njan
with the patient and by means of her knowledge of community resources assists her
in securing suitable employment. The progress of the patients in the Vista is supervised
by the Assistant Clinical Director, who makes weekly visits for this purpose.
For the men there is a Rehabilitation Officer, who, in conjunction with the medical
staff and the social service department, assists in evolving a plan of rehabilitation and
then with the cooperation of the National Employment Service and similar organizations
aids the discharged patient to obtain suitable employment. It has been found with the
men that it is not necessary to operate a home such as the Vista, but for those men who
do require temporary housing until fully self-supporting, an arrangement has been made
with the Y.M.C.A. and the Salvation Army Hostel whereby rooms are available.
RESEARCH DIVISION
The Research Division is housed on the campus of the University of British
Columbia and is closely associated with the Faculty of Medicine. Dr. W. G. Gibson
holds the appointment of Director of Research, while Dr. Margaret Kennard and Dr.
John Harvey are appointed Senior Researchers. In addition to their research duties
each has an appointment in the Faculty of Medicine with definite teaching assignments.
Page 117 The basis laboratory equipment for this division is now on hand and research projects
in the field of neurophysiology are now in progress.
CREASE CLINIC
The Crease Clinic of Psychological Medicine was opened to receive patients
January 1st, 1951. This Clinic was established to provide facilities for the active treatment of the mentally ill while the illness is in its early stages. Patients are admitted
for a maximum period of four months, this limitation being placed by the Clinics of
Psychological Medicine Act. Patients may be admitted as "Voluntary patients" employing Forms A and F or as "Certified patients" requiring Form A completed by a
relative and two Forms B completed by physicians.    No legal form is required.
The Crease Clinic is well supplied with diagnostic and therapeutic equipment so
that all types of investigation and therapy in nervous and mental diseases may be
undertaken.
Since the Clinic is for the purpose of providing active treatment the profession
is requested to select for certification patients of favaurable prognosis who can complete
a course of treatment in four months. Patients who will require a longer treatment
period must be committed to the Provincial Mental Hospital, Essondale, under the
provisions of the Mental Hospitals Act.
IMPORTANT INCOME TAX INFORMATION
The following information has been received from the. Canadian Medical Association concerning Income Tax.
Many physicians who practise in partnership, have been affected by rulings of the
Income Tax Appeal Board, which had the effect of requiring them to claim deductions
for the legitimate expenses of practice from the partnership income rather than in
their personal income tax returns. The application of this ruling to the taxation
years 1949 and 1950 has resulted in the disallowance of practice expenses claimed in
personal returns for those years and in assessment for additional tax.
'*A recent directive from the Department of National Revenue to District Income
Tax Offices cancels this ruling and taxpayers who are partners may continue to claim
as deductions in their personal returns the allowable expenses of earning their income.
The situation therefore reverts to that which applied before the ruling of the Appeal
Board in the case of 'Mr. I.'
"Doctors who have paid additional tax for 1949 and 1950 as a consequence of the
disallowance of expenses charged in their personal income tax returns, SHOULD MAKE
WRITTEN APPLICATION FOR REFUND WITHOUT DELAY.
"Section 52 (i) of the Income Tax Act, quoted hereunder, applies;
'The Minister may, upon mailing the notice of assessment, refund, without
application therefor, any overpayment made on account of the tax and he shall make
such a refund after mailing the notice of assessment if application in writing is made
therefor by the taxpayer within 12 months from the day the overpayment was made
or the day on which notice of assessment was sent."
"If you have made overpayment under these circumstances and have not made
an appeal or have not already made application for adjustment, you are strongly advised
to apply in writing to your District Income Tax Office for a refund before the expiry
of twelve months from the overpayment."
You will observe that partners may continue to claim as deductions in their
personal income tax returns, their share of the total allowable expenses of the partnership. This constitutes a re-establishment of the conditions which applied prior to the
recent controversial rulings of the Income Tax Appeal Board.
It is particularly important that taxpayers who have been assessed additional tax
for 1949 or 1950 in respect of disallowed practice expenses, claim a refund of any
overpayment prior to the lapse of twelve months.
Page 118 Ayerst, McKenna & Harrison Limited
Biological and Pharmaceutical Chemist*
Montreal, Canada
111
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to be specific for macrocytic
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In adults "MATUREX" - No. 340
Each capsule contains:
Vitamin B12     10 mcgm.
Desiccated Stomach Tissue. 250 mg.
Folic Acid 0.67 mg.
Ferrous Sulfate B.P... (5 gr.) 323 mg.
Ascorbic Acid     50 mg.
Liver Extract, equivalent to     1 Gm.
fresh liver
"MATUREX" Non-Ferrous - No. 341
The same formula as No. 340 but
without ferrous sulfate.
|en "MATUREX" Pediatric - No.338
III        Each capsule contains:
Vitamin Bi2       5 mcgm.
Desiccated Stomach Tissue.    80 mg.
Folic Acid 0.67 mg.
Ferrous Sulfate B.P. (13^ gr.) 100 mg.
Ascorbic Acid    25 nig.
Liver Extract, equivalent to 0.5 Gm.
fresh liver
■ ATUREX" Pediatric Non-Ferrous No. 339
The same formula as No, 338 hut
without ferrous sulfate.
Available in bailies of 24,
100 and 500. Urecholine prevents or relieves the distressing symptoms of postoperative abdominal distention or gastric retention
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GLYCURRANT
For the Relief of
Persistent Coughs
A combination of effective sedatives and expectorants in a delicious preparation
of Black-currant juice.
GLYCURRANT overcomes the difficulty of allaying persistent cough
without resorting to respiratory depressants in large doses. It combines
stimulating expectorants and respiratory sedatives of established
efficiency, skilfully combined to relieve the chest, in a vehicle specially
designed to exert its soothing local action on the irritated structures of
the throat.
EACH FLUID OUNCE CONTAINS
Codeine Phosphate       gr. %        Menthol  gr. 1/20
Syrup "Wild Cherry min.   40        Tincture Squill  mm.   40
Glycerin    min.   80        Tolu min.   40
Black Currant Juice min. 165        Alcohol 5 percent
Dosage: Adults 1 to 3 teaspoonfuls undiluted should be sipped slowly every 3
or 4 hours. The size of the dose and the frequency of administration are varied
at the physician's discretion.
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CZu&utt DIFFERENTIAL DIAGNOSIS OF CONVULSIONS
IN CHILDREN |
By HARRY BAKER, M.D.
"Do you mean that you think you can find the answer to it?" said the March hare.
"Exactly so," said Alice.
"Then you should say what you mean," the March hare went on.
"I do," replied Alice hastily.
"At least I mean what I say.    That's the same thing you know."
"Not the same thing a bit!" said the Hatter.
That's how I feel about discussing this differential diagnosis.
A dictionary definition of epilepsy is "a spasmodic disease in which the sufferer
suddenly falls down without sensation or consciousness and commonly recurring at
intervals." We cannot restrict ourselves to this picture or there would be no room for
any discussion.
From the doctor's point of view any recurring paroxysmal disorderly uncontrolled
manifestation of any neural process might be regarded as a fit regardless of whether
there is or is not a loss of consciousness. There may or may not be involvement of
skeletal muscles. Only this broad concept allows us enough scope to take in all the
clinical pictures which we want to mention tonight.
Through the centuries observing clinicians have enlarged the understanding of
the "falling sickness" so that today there is a broad pattern into which we fit this large
problem.   Three large factors have contributed toward this:
1. Careful study of cases, bedside, in the O.R. and in the laboratory, with careful
correlation of findings.
2. A growing armamentarium or drugs for therapy.
3. E.E.G.
When a child is brought to a doctor with the story that the child is having some
type of *lspell," a large problem is presented to that doctor. He has two large groups
of condition to consider.
1. That diversified pattern of condition which is made up of epilepsy and its
many clinical variants.
2. Other causes of spells.
How shall one go about to differentiate at least into which group this particular
patient fits? First we must have a careful history and physical examination. There
are times when one need go no further (at least for the time being). There is in many
cases good justification to start the indicated therapy and observe progress based in
history and physical examination alone. If the progress is satisfactory one may do
further investigation for confirmatory evidence. These may be of value for prognosis;
where the case is less obvious more investigation must be done. In a large percentage
of cases this will include E.E.G.
From the paediatrician's point of view I must say this: The unity of the organism
must be kept foremost in mind in dealing with any problem relating to childhood. The
brain and the body act as one within the environment. Change in any one of these
is reflected in the other. The balance is dynamic. It is being proven more and more
that in different conditions of childhood there are associated dysrhythmic E.E.G. waves.
For example mere overbreathing or the giving of a few grams of glucose will change
the character of the E.E.G. It is more and more difficult at times to draw a straight
line between the two groups, previously outlined.
The "other causes of spells" includes these reasonably well recognized clinical
pictures.
1. Breath-holding spells.
2. Temper tantrums.
3. Syncope.
Page 119 4. Spells associated with fevers.
5. Staring spells.
6. The role of hypoglycemia.
7. Tetany of the new born.
8. Tetany of the older infant associated with rickets.    Here we may include all
other forms of tetany.
9. Tetanus.
10. Recurrent abdominal pain.
11. Recurrent headaches with vomiting spells  (Migraine).
12. ^Tic habit spasms.
13. Chorea.
14. Behaviour problems.
15. Convulsions associated with poisons and toxemia.
16. Convulsions due to space-filling lesions.
17. Hysteria
18. Degenerative brain conditions.
19. Allergy.
20. Convulsions associated with brain injury, e.g. cerebral palsy.
1. Breath-Holding Spells—most common under two years of age—but may occur
later. The child starts to cry in anger or fear. Finally the paroxysm of crying becomes
so severe that the child does not appear to take in a breath. He becomes cyanosed.
The cyanosis grows deeper. He holds his breath till he grows black in the face. When
he finally takes a breath he is quite pale. The child may be so tired as to have a good
sleep.    Some of these are probably epileptic spells.
2. Temper tantrums—-These are similar I think to number one but in older
children, i.e. beyond the two year old level.
3. Syncope—said to be associated with a defective reflex regulation of the vascular
system producing a temporary anaemia of the brain. Mild injuries or shocks bring it
on. There is often a mild convulsive seizure with it as the child comes to. This
condition is common and should have been mentioned earlier. It seems to me that
this like convulsion with fever should be investigated for possible trouble.
4. Spells with fevers—There is not much room for a "wait and see" attitude for
this type of case. There are many excellent surveys which tell us that a goodly number
of these children go on to having recurring convulsions without fevers.
Any child who has more than one convulsion, even if associated with fever, should
be thoroughly investigated including an E.E.G. Then, of course, there is the other
side of the problem. Children often have a convulsion with meningitis or encephalitis.
If there is any doubt in a child with fevers and convulsions a spinal tap should be done.
For good results we must diagnose acute meningitis early and treat it vigorously.
5. Staring spells—are usually due to day dreams or boredom. We must think
also of petit mal or early personality changes associated with psychosis.
6. Hypoglycaemia—certainly in recurring convulsions one should think of hypoglycaemia. As a cause of convulsions in non-diabetic children it is very rare (6 cases
under 14 years on record). Time and time again the mother will tell you that child's
spells are more prone to come early in the A.M. One may discuss at great length
why the susceptible child is more prone to have spells in the A.M. Glucose we know
influences the E.E.G. Ketogenic diet will control spells. How far should one go
into investigating a child who is suspected of having hypoglycaemic convulsions?
Let us look into the causes of hypoglycaemia:
1. Functional Hypoglycaemia—due to instability of the vegetative nervous system.
Here the glucose level never drops low enough to cause spells in unsusceptible children.
It is rare in children.
Page 120 2. Organic Hypoglycaemia—
(a) Due to hypertrophy of islet tissue or islet tumour is rare in children. It is a
progressive condition.
(b) Due to liver condition—not common in children.
(c) Due to Glycogen Storage disease—The first step in the diagnosis of this
condition is to think of it.
For this group of cases in addition to all other work, the laboratory work should
include—The level of fasting blood sugar and the rapidity with which hypoglycaemia
may be induced by fasting. The type of glucose tolerance curve. In addition one
might do these tests.
1. Epinephrine test.
2. Response to injection of insulin.
It is important also to consider the time of occurence of attacks and their relation
to meals. A spell of hypoglycaemia should respond to an injection of glucose value.
There are rare cases of hypoglycaemia associated with the pituitary and adrenals.
Hypoglycaemia of the new-born with resultant convulsions, should be looked for, when
the parturient mother is diabetic.
7. Tetany of the new born—not common.    The treatment is calcium.
8. Tetany of the older infant with rickets—The treatment is calcium and Vitamin
D. The diagnosis may be difficult to prove. It is not common now. There are other
causes of tetany, e.g. associated with celiac disease, tetany of alkalosis—This in turn
may be due to several causes (overbreathing, excessive ingestion of alkali, excessive
loss of chloride.)
9. Tetanus—The convulsive feature here when once seen cannot be readily forgotten. The causative wound may not be very obvious. The patient is conscious and
is literally stimulated into spasms by various mild stimuli. There is of course the
clenched jaw .with lips drawn back.
10. Recurrent Paroxysmal attacks of abdominal pain—have been associated with
dysrhythmic E.E.G. patterns.    They respond to the same drugs as do epilepsy.
11. There is the child who has recurrent headaches with or without vomiting spells.
12. Tic habit spasms—on the whole tic habit spasms are not confused with spells
of an epileptic type. Rather they are confused with chorea. There is a rather convincing report in the New England Journal Medicine of a small series of tic habit spasms
which were associated with dysrthythmic waves. The response to drug therapy was good.
13. Chorea—may be so violent as to be termed chorea insaniens. The movements
are so marked as to appear to be a fit. The movements are continuous. The child is
awake.   It is not a common condition.
14. Behaviour Problems—In a recent report of 160 cases of behaviour problems,
35% had abnormal E.E.G. In a control group of "normal" children only 10% had
abnormal waves.    The authors gave no conclusions.    It is a large unexplained problem.
15. Convulsions may be associated with many types of toxaemia, e.g. uraemia, insulin
overdose, strychnine, camphorated oil.
16. Convulsions due to space filling lesions can be a real puzzle if there are no
other signs and symptoms.
17. Dysfunction of the emotions may produce paroxysms of movements. In
children hysteria usually takes on rather signs of weakness or paresis.
18. Degenerative conditions of the C.N.S. in the child are not common. They
are not commonly associated with spells.
19. Convulsions due to allergy are rare in children with normal E.E.G. waves.
However in a child with a strong allergic background associated with spells one would
be justified in trying vigorously to uncover an allergic factor.
Page 121 20. Cerebral Palsy—When one has a goodly number of brain injured children to
watch over a period of time it is surprising how many of them are found to have
convulsions.
I don't think my attempt to separate the epileptic syndrome from the non epileptic
group has been very successful. The line drawn is not straight. It is impossible to
say what you mean and mean what you say.
REFERENCES
1 Ligingstone et al: Febrile Convulsions:-u.c. clinical study "with special reference to heredity and prognosis.   J. of Pediatrics: Nov. 30, 1947.
2 Peterman, M. G.: Convulsions in childhood; Am. J. Dis. Child. Oct., 1946. Volume 72.
3 The Diagnosis and Treatment of Endocrine disorders in Childhood and Adolescence. Lawson Wilkins.
4 The significance of "tics" as possible manifestations of epilepsy. N. Eng. J. Med. Vol. 23 8 Feb. 26,
.    1948.
5 Miller and Lennox,  E.  E.  G.  in behaviour  problems  in  children.  J.  of  Pediatrics.  Dec.   1948.
6 Abdominal Epilepsy. Ed. J. Am. M. Ass. July 17, 1948.
'     Less   commonly  recognized  allergic  conditions   in  infants   and   children.   Round   Table  Discussion   in
"Pediatrics." Sept. 1951.
EPILEPSY
By DR. W. J. FOWLER
Dr. Baker has given you a short summary of the differential diagnoses of convulsions
in children and we will now proceed with the discussion of epilepsy per se.
Epilepsy, a symptom, is a specific reaction form of different portions of the brain
to irritative foci. It depends also for its development, upon the existence of certain
inherited and acquired susceptibilities of the patient as well as the occurrence of other
physiologic changes which precipitate the epileptic seizures.
The fit, which is the characteristic, the only essential feature of epilepsy, varies
so widely in character that a definition of it except in general terms, is not easy to give.
It may be said, however, that it is the expression of a sudden and transient disturbance
of cerebral function. If the disturbance be widespread, there will be loss of alteration
in consciousness. If the disturbance be localized, consciousness may be unimpaired. In
either case, sudden and transient symptoms, motor, sensory, or purely mental, may be
present and they commonly take the form of positive symptoms; that is motor spasm,
abdominal sensations, or special sense phenomena. The negative symptom of transient
weakness of a limb may also occur.
AETIOLOGY
Although more than sixty causes of epilepsy have been recorded, patients with
epilepsy may for our purpose, be placed in two general groups.
1. Symptomatic
(a) Cases of epilepsy beginning early in life which are associated with congenital
mental defect or congenital diplegia, that is those cases in which there is evidence of
congenital defect in the development of the nervous system.
(b) Cases of epilepsy beginning at any time of life which are associated with evidence
of an acquired lesion of the brain, that is injury, tumour, or disease.
2. Idiopathic
(a) Cases of epilepsy beginning at any age which are at first, associated with normal
mental condition and in which no clinical evidence of organic disease of the brain can
be found, that is so-called idiopathic or as Dr. W. Lennox prefers to call it, physiological
or biological epilepsy. This type of epilepsy, he feels should be classified as a metabolic
disease, the primary disorder being a disturbed physiochemical reaction of the discharging or communicating  cells  of  the  central  nervous  system.     Thus  epilepsy is
Page 122 comparable to diabetes, but its manifestations instead of  being continuous and progressive, are abruptly intermittent.
It has always been regarded as a hereditable condition, but it obeys no known
laws of inheritance and it is probable that what is inherited, if anything is, is in instability
of function in the cells of the cerebral cortex. Given contributary circumstances in
the life of the individual thus affected, the instability may so increase as to overflow
in a fit. Certainly the hereditable qualities of epilepsy have been greatly exaggerated
in the past, and in consequence severe restrictions upon the liberty of conduct of the
epileptic have been imposed in the guise of medical advice; as for example, in the matter
of marriage and reproduction. There is no general agreement on the question of
whether epileptics should or should not have children. Dr. W. Lennox has found out
that the incidence of epilepsy in the relatives of epileptics, is about five times as frequent
as in the general population, but he does not think that the parents of an epileptic
child should necessarily be warned against having further children.
PATHOLOGY
There are no consistent pathological findings in the so-called idiopathic epileptic.
In the symptomatic epileptic of course, one finds definite pathology somewhere in the
brain. This may be due to failure of development of the brain, such as in congenital
spastic diplegics who have a 25% incidence of epilepsy, and in the acquired infantile
hemiplegics, where there is a 33% incidence of epilepsy. Dr. Penfield believes that the
mechanism producing epileptic seizures where there is a scar present, is that the glial
contraction pulls on the meninges and blood vessels starting a vaso-motor reaction
which causes anoxia of the cortex in that region with subsequent epileptic seizure.
INCIDENCE H§
The incidence of epilepsy is about five per thousand in the United States of
America.
ONSET ^1'
About 10% of all seizures start in the first three years of life, about 50% occur
before the age of ten, and about 70% before the age of 20.
TYPES
There are three recognized types:
1. Grand mal.
2. Petit mal.
3. Psychomotor.
The type of epilepsy does not necessarily depend on the cause.
' Sometimes, all three types will be recognisable in the same patient.
Grand Mal
In the gjrand mal variety of fit, there is a relatively constant sequence of events.
About 50% have an aura before consciousness is lost. This is commonly an indefinable
sensation in the epigastrium, but it may consist of some special sense aura, that is
flashes of light, ill-formed image, an unpleasant sense of smell or taste. It may be
more complex and consist in the idea that the patient is somewhere familiar and is
looking at a scene he has seen before. This is most commonly a symptom in the so-called
uncinate fit, where the epileptic focus is in the temporal lobe. On the other hand,
motor phenomena may immediately precede the onset, such as spasm of an arm or turning
of the head and eyes to one side. After these momentary preliminaries, consciousness is
suddenly lost, the patient sometimes uttering a typical cry as this happens. He falls to
the ground, the entire skeletal musculature enters into strong tonic spasm which arrests
the respiratory movements. As a result, the patient becomes cyanosed. If the strength
of spasm is not equally distributed through the musculature, the patient may turn over
on his face, or only the head and eyes may be deviated or one side of the face contorted.
Page 123 In a few seconds, this tonic spasm intermits and a series of clonic jerking movements
take possession of the muscles. This may go on for some indefinite time, becoming
slower in rate and the patient lapses into a flaccid coma. During this clonic phase,
the breathing is forcibly expressed at each spasm. Froth may be expelled from the
mouth and, the tongue may be bitten if it be protruding between the teeth when the
jaws go into spasm. When this happens, the froth may be blood-stained. During this
phase, there may be incontinence of urine or less often of faeces, some subjects almost
invariably wet themselves and bite the tongue, while others convulsed with equal
violence, may.not do so.    The pulse may be rapid and forceful.
As the stage of flaccid coma arrives, examination of the patient becomes practicable. Pupils are found dilated and the corneal reflexes absent. The tendon jerks
also may be absent and the plantar responses of the extensor type.
Gradually the reflexes return to normal and consciousness begins to return, to be
fully restored in a further minute or two. During the stage of returning consciousness,
the patient may be confused and disorientated, vomiting, or more commonly headaches
may then ensue and in many cases, the patient passes into a deep sleep.
Status Epilepticus
The Jacksonian or focal fit is usually described under the heading of grand mal.
The essential feature of this is that the underlying cerebral disturbance begins in a cir-
cumbscribed cortical region. It may remain confined to this, or it may spread to
adjacent regions, in some instances becoming generalized, so that consciousness is lost
and a picture of grand mal is produced. From the fact that the onset of change in the
brain is local, the initial manifestations of the fit correspond in character to the function
subserved by the discharging focus. Thus is may be motor, sensory, gustatory, auditory
or visual. The most familiar variety of Jacksonian fit is that which starts in the
motor cortex. It begins with a localized clonic spasm, the usual region of initial
involvement being the angle of the mouth, thumb and index fingers, or the big toe.
The convulsion may then spread in an ordered progress from the point of onset; thus,
it may spread from the angle of the mouth to the remaining facial muscles and then
to those of the neck and eyes, so that the head and eyes deviate. Starting in the hand,
it may spread up the arm to the shoulder, trunk, thigh and leg muscles. Should the
convulsion spread to the muscles of the opposite side, consciousness is commonly lost
and the convulsion then becomes generalized.
Petit Mal
This consists of a momentary disturbance of consciousness, ranging from a change
so slight as to be scarcely perceptible to complete loss, in which the psatient falls to
the ground. The infant sitting in his nursery chair may suddenly let his head fall
forward onto his mug or plate or the little shelf of the chair and as quickly, lift his
head again. The older patient may drop what he is holding, stop for an instant in the
flow of his speech and then resume where he has left off. The observer looking at the
patient, will note perhaps, a sudden lapse of fixation in his gaze, often described as "a
vacant look." The eyes may turn up or to one side, the lids may flicker, a further
convulsive movement of the face or hand may be seen, a flushing or sudden pallor.
When consciousness is totally lost for two or more seconds, the subject may not
be able to take up his train of thought or action immediately and may have to be
reminded of this. An essential feature of these phenomena is their transience. They
have passed within a moment, but this is not to say that the patient is as quickly
restored to normal consciousness. After petit mal attacks, there is—in some subjects
only-^-^an intervening period of abnormal or incomplete consciousness before the normal
state of mind is restored. In this period, which may last for a few minutes or for
as long as an hour or more, the subject appears fully conscious, but he is not normally
in touch with his environment or in full possession of his facilities. In this circumstance,
he may ,be seen to perform. ^ number of simple or uncomplicated acts, which are
inappropriate and may on occasions, prove very embarrassing or even bring the subject
Page 124 within the arms of the law. The conduct so displayed, is spoken of as "post-epileptic
automatism" and is a phenomena with which the doctor should be familiar. The
automatism of a given epileptic is often stereotyped. He may take off his collar and
tie and put them in his pocket. He may proceed to undress himself more completely,
he may empty his bladder deliberately, he may pick up and purloin any loose objects
within his reach, he may make a series of what appear to be irrevelant remarks, or
may become pugnacious or may walk from the room. Post-epileptic automatism is
fortunately not a common sequel of petit mal and in many subjects it never occurs.
Petit mal seizures are seen mostly in children and they tend to grow out of them.
Psychomotor
The so-called psychomotor epilepsy, or as some prefer to call it, psychic phenomena,
is of all the three types, the most difficult to diagnose with accuracy. There is even
great disagreement as to its actual claim to a separate entity amongst various authors.
These seizures are hard to describe because the appearance and actions of the
patient may be even more diverse than in the case of grand mal. The patient does not
completely lose consciousness or control of himself. The patient is in a state in which
he acts as though he were conscious but afterwards has usually no memory of what took
place. In the attack he may stumble incoherently, make chewing motions, get up and
walk about or perform acts like buttoning or unbuttoning his clothes. He may attempt
response to questions or walk about the streets. Usually the attacks last only a few
minutes but they may go on for hours and even days. In the latter event, the patient
on regaining consciousness may find himself in a different city. Though acting like an
intoxicated person, he is never hilarious, but rather is morose and irritable and may
become ugly or violent if forcibly restrained. Occasionally he may commit a crime in
an attack. Convulsive movements may be present but they take the form of a tonic
rather than a clonic spasm. In a tonic or "contortion" spasm, the patient becomes
unconscious, his arms and legs may stiffen, or, if sitting, his body may twist; he may
clamp his jaws; perhaps drool a little and may become dusky in the faceM-He may not
fall even if standing, and there is never the violent rhythmic jerking movements of
the grand mal.
CLINICAL ANALYSIS
History
In taking the history of the patient with epilepsy, there are several points of prime
importance. Does the patient have a history of head injury, difficult or prolonged
birth, old brain abscess, meningitis, or cerebral venous thrombosis, which may have
been responsible for the development of a focal contracting cerebral lesion. ;|| Is the
development of the child within normal limits Do the seizures have a focal onset
indicating a focal cerebral lesion?
Description of the seizures should be obtained from all possible observers. Inquiry
as to the aura or onset of the attack should be specified and any post-ictal paralysis
should be recorded.
Physical Examination
Examination of the patient may provide evidence of an old head injury or
asymmetry of the skull or bodily asymmetry may indicate a destructive lesion in the
post-central region.
Neurological examination is of primary importance as ^t may provide a clue as to
the location of a focal lesion when no other is present. On the other, hand, the
neurological examination may reveal no abnormalities, even in the presence of a large
epileptogenic focus. Post-ictal paralysis may furnish localizing evidence when other
evidence is lacking. lllll
It is in the nature of things that diagnosis must very commonly be made upon an
account of fits given by observers who, fromunfamiliarity with epilepsy and from the
stress of emotion which seeing the fit evokes in them, are not the most reliable of
Page 125 witness, and unless one has a fairly accurate description of an attack that can be
consistent with an epileptic seizure, the patient is better admitted to hospital for
investigation, where their epileptic seizures may be witnessed and descriptions recorded
by trained personnel.
While in hospital, X-rays of the skull should be done. An E.E.G. is a valuable,
but not an infallable guide in epilepsy in children. Dr. Kennard will later discuss the
electroencephalogram for you.
A pneumoencephalogram should always be done so that one may arrive at a definite
conclusion as to whether this is a symptomatic or idiopathic epilepsy, and if symptomatic, whether any surgical intervention should be undertaken.
The diagnosis of epilepsy may be easy if a good description of the fit is obtained,
but in other cases it is difficult and a large number of possible causes must be ruled out
before it can be made. (Baker.) It may be impossible in some cases to determine
whether infantile convulsions are significant of beginning of epilepsy or not. As a rule,
seizures occurring in relation to definite illness, have no great significance. On the
other hand, those which occur repeatedly, which are very severe or prolonged and those
which occur without any discoverable cause, are more ominous. Focal convulsions
are more significant than generalized convulsions. Seizures occurring during the
course ©f an acute infectious disease, may be insignificant or may mark the development
of cerebral damage as a result of which epilepsy may develop.
During the latter part of childhood and in adolescence, the development of seizures
is presumptive evidence of epilepsy. Fever, infectious and metabolic disturbances
rarely cause convulsions after the age of five.
No child should be labelled an epileptic until complete investigation justifies this
diagnosis. One must remember, that if the diagnosis of epilepsy is made, the patient
must embark on a long course of treatment, the discussion of which I will now leave
to Dr. Ackland.
THE TREATMENT OF EPILEPSY IN CHILDREN
By N. L. ACKLAND, B.A., M.D.
VANCOUVER,   B.C.
Mr. Chairman, Ladies and Gentlemen:
I am more than pleased to have been given the opportunity to speak to you on
the treatment of epilepsy in children. My only regret is that our time is so limited
as I feel discussion of this aspect of epilepsy is well worth a whole evening itself.
I cannot hope to cover all phases of treatment in detail, but I would like to point
out how pressing the problem is, and in general, to outline how I feel it should be
attacked.
Few people, even doctors, have any idea how great a public health problem epilepsy
is. How many of you are aware that it was second only to mental disease as a cause
for rejection from the U.S. Army in the last two wars—or that its coincidence is equal
to that of diabetes or active tuberculosis,—or that it occurs in about one in every
200-300 of the general population?1
One wonders why these facts are so little known. It probably boils down to the
stigma which has come to be attached to the disease. To many people, epilepsy is
synonymous with mental deterioration, or with insanity. This misconception is
frequently aided and abetted by the still popular belief among many physicians that
for epilepsy there is no effective therapy. No wonder patients and relatives so often
succumb to an attitude of pessimism and despair! No wonder they struggle to conceal
the affliction when supposedly enlightened people evidence so much misunderstanding
and prejudice!
Page 126 In Massachusetts, the state that prides itself for having more facilities for the
investigation and care of epileptics than anywhere else, and that boasts of housing the
headquarters of the International Epilepsy League, as late as 1948, a physician was not
allowed to give contraceptive advice to an epileptic patient who desired to marry but did
not wish to have children.2 26% of the Colleges and Universities of New England
have blanket rules against admission of scholastically qualified, but epileptic students,
in spite of the fact that in a series of 300 private epileptic patients, Collins and Lennox3
found a better than average intellectual level. Fourteen States in the U.S. forbid an
epileptic to marry, yet the hereditary or genetic factor is not the major factor in the
build of epileptics. An epileptic is not allowed to waive his right to accident compensation—a further discrimination against him by an unheeding and uninformed society.
Faced with these almost insurmountable obstacles to normal living, as well as handicapped
by seizures themselves, is it any wonder that personality aberrations are frequent?
I mention these facts to emphasize one point and that is, that the treatment of
epilepsy is not merely the dispensing of pills, but involves the intelligent and sympathetic
handling of the child and his parents; aid in home, school, economic and community
problems and last but not least, public education.
It is obvious that such a therapeutic programme covering so many aspects of the
child's life, will be time consuming for the physician. If I might borrow from Dr.
Bridges, I quote 'The cost of neglect needs to be carefully weighed against the cost of
prevention.' In my experience this cost is so high to the community, as well as to the
patient, that no physician should contract to treat such a patient unless he is willing
to devote a few solid hours to the problem. In this regard, I might add, that the largest
measure of success in proportion to effort expended is likely to come from work with
children and adolescents rather than adults who already have established fixed patterns
of behaviour.
Our aim should be, not only to stop all seizures, but to insure as far as possible,
that the patient grow up to be emotionally mature, socially well adjusted and economically independent. To achieve this goal frequently we must «utilize all the resources
the community has to offer. To date in most localities, these are woefully inadequate
but I hope that with increasing pressure from professional and lay groups, this will
be corrected.
More specific reference to therapy might come under the following headings—
1. General.
2. Surgical.
3. Medical. |§|
4. Social.
1. General:
General rules for maintenance of good health are required. Adequate rest
and adequate diet are necessary. Alcohol, over fatigue and constipation are to be
avoided. In this, one must not overlook the benefit of mental and physical
activity. . It is common knowledge that patients who are happy and active both
physically and intellectually have fewere seizures than if the reverse is true.
Numerous studies have demonstrated that acidosis tends to inhibit petit mal seizures
and its electrical counterpart, the spike and wave complex. It is reasonable to
suppose that physical and mental activity favour a shift toward acidity, accounting
for their favourable effect. In addition, ample evidence is accumulating to show
that states of inactivity, such as sleep, tend to favour the appearance of seizures.
Therefore, the old fad of stressing rest for children with epilepsy is probably to be
condemned and in its place we should emphasize the importance of normal activity
if we are to avoid the development of a neurotic pattern.
Regarding the Ketogenic diet, I can only say that I have given it up because
of the practical difficulty in keeping young children on it for any time, the
emotional problems so restrictive a regimen may precipitate and because we now
Page 127 have drugs which are simple to use and much more effective.
2. Neurosurgery:
Neurosurgery is necessary for only a very small group of patients who cannot
be controlled medically and in whom we can clearly demonstrate a removable
epileptogenic focus. We must always remember that removal of one scar must
leave another, but we hope a better one. One large clinic in the U.S. recently
reported that with the newer approach to therapy they have not had to refer
any patient to surgery for the past ten years.4
3. Medical:
Many of the anti-convulsant drugs have appeared in recent years and more,
even better ones, are on the horizon. However, I shall mention only the common
ones.    But first let me stress a few general principles any physician should know.
1. He must know enough about the patient's seizures to be able to select the
most suitable drug for him.
2. This infers a detailed knowledge of the drug to be used. For example,
phenobarbital or dilantin as a rule, are of little or no value in classical petit
* mal (the 3 sec. spike and wave complex) whereas tridione or paradione are
almost specific. On the other hand, tridione may accentuate grand mal
seizures.
3. Treatment must be strictly individualized regarding type of drug, dosage,
rapidity of increase, etc.
4. The dosage must be adequate and properly spaced. It is the general consensus
of those with most experience in treatment of epilepsy, that the dosage of any
drug should be gradually increased, until either one obtains maximal control
of seizures or disturbing side reactions appear. Too many physicians are
afraid to use adequate amounts of medication and their unfortunate patients
continue to have seizures and become hopelessly warped in their attitudes.
I recall vividly the case of a 2 9 -year-old man whom I saw last year. His seizures
began at about age 5 and were all nocturnal. In spite of this he was rejected by his
parents who showed marked favouritism for ah older brother and a younger sister. He
developed many neurotic traits and finally had to quit school because of a nervous
breakdown. Neither the patient nor his family got any support from their physician.
From 1929 to 1948 he was tried on various medications. He finally gave up all
medication after being placed on one capsule of dilantin a day which was ineffective.
His seizures have been completely controlled with Al/z grs. of dilantin and 2 grs, of
phenobarbital per day. In the meantime, however, he had developed such a great
sense of inferiority mixed with feelings of hostility and resentment that all efforts at
rehabilitation have failed.
5. Persistent treatment is essential and varying dosages and combinations of drugs
should be used until all are exhausted before one concludes all seizures cannot
be controlled. *jgM
6. The patient and his parents must be given some explanation of the various
drugs and the reasons they are used if one is to expect co-operation and wishes
to avoid giving the patient the idea the doctor is "experimenting" or just
"muddling along."
7. The patient must be given explicit instructions as to how and when to take
his medicine. There is a definite psychological value in having a specific
regimen of treatment outlined. Far too often do we hear from patients that
they have just been told "to take an extra tablet if you feel an attack coming
on." Patients frequently have no warning, and this type of advice only
reveals lack of interest plus ignorance on the doctor's part and seriously
threatens the patient's confidence in him.
Page 128 8. The patient must be instructed to report at regular intervals until all attacks
are controlled and then at yearly intervals.
9. If drugs are used which have a toxic side effect, the patient should be
forewarned and instructed to report to his physician should any appear.
However, care must be taken to avoid alarming the patient.
10. The patient must not be allowed to juggle his own medication. Many
therapeutic failures are due to this which in turn only reflects the physician's
disinterest.
11. Never discontinue medication abruptly, as not only isolated seizures, but
status epilepticus may supervene. Patients must therefore be instructed to
avoid running short on holidays, etc. The only -exception to this general
rule is with the 'diones. These can be withdrawn abruptly without untoward
results.
12. Last but by no means least, keep the patient on medication long enough.
Tell him in the beginning that he might require some medication all his
life but that his best chance for "cure" lies in suppressing all attacks for
several years. As a rough rule of thumb I tell patients that I shall probably
want them to .take iwhateyer dosage or combination is necessary to stop all
attacks, for 2-3 years and then (depending on the EEG findings to some
extent) it may gradually be reduced over the next 2-3 years.
Specific Drugs: ||||
1. Bromides—were the first drugs found to be effective, and were the mainstay
of treatment for about 60 years. They are of little value today as they
are too toxic for prolonged use and their anticonvulsant value is small
compared to the newer medications.
2. Phenobarbital—came   into   use   about   1912.     It   is   still   one   of   the   most
valuable and least expensive. It is relatively safe, and requires little
supervision once correct dosage is attained. It may be useful in all types
of seizures except the classical petit mal group. Other medications can
can be added. Its most serious drawback is its hypnotic effect. This can
be overcome with stimulants such as caffeine, dexedrine, or methedrine.
We must remember that in children particularly, it may excite bad behaviour. It may produce a rash. Extreme toxicity results in confusion,
ataxia, nystagmus, and coma. The sodium salt is of great value when
used parenterally for status epilepticus.
3. Mebaral—may be substituted for luminal.    Its anticonvulsant action is less
but so is the sedative action gram for gram, (i.e. gr. 3 of mebaral are
equivalent to gr. 1^4 of luminal.)
4. Dilantin—introduced in 1939.    It is of value in grand mal and psychomotor
attacks. It is not a hypnotic. It requires careful supervision as there
often is not much margin between the dose giving full therapeutic
(effect and that producing toxic signs. These are usually swollen gums,
(not serious), hirsutism in adolescent girls, nystagmus, diplopia, tremor,
unsteady gait and dizziness. Gastric distress can be relieved with antacids.
About 5% or less are allergic to it and in 1-2 weeks a measles-like rash
appear. Two patients have died following haemorrhagic cutaneous
eruption.    It may accentuate petit mal "absences."
5. Mesantoin—Chemically  related   to   dilantin  and  can   be  added   to   dilantin
therapy.    It does not cause ataxia or hypertrophy of the gums.    It may
increase "psychomotor" attacks but in general, is beneficial.   It must be
built up  slowly,  to avoid  toxic  symptoms   (drowsiness,  rash,  fatigue,
lJL  aplastic anaemia, exfoliative dermatitis.)
Page 129 6. Thiantoin Sodium—chemically similar t© dilantin but is tolerated in much
larger doses.   Is, no better anti-convulsant.   It can produce the same side
III reaction and also may depress bone marrow.
7. Tridione—This is the drug of choice for the petit mal triad, but it may act as
a convulsant initiating or increasing the frequency of grand mal seizures^
After age 5 children can tolerate- adult dosage. It may produce a
measles-like rash in which case it may be discontinued and later resumed,
"glare" affects some older children and adults. Jt may also cause gastric
discomfort, somnolence, irritability or hiccough. Its major toxic effect
may be as a bone marrow depressant.
8. Paradione—chemically similar to  tridione.    The indications  for its use  are
the same. It is somewhat less toxic and glare is less troublesome. These
two do not provoke seizures if suddenly withdrawn. Hoenig has
observed that the eosinophilia we see so frequently in children on the
'diones, is related to helrninthia infection.5
9. Phenurone—a new drug soon to be available in Canada.    The literature to
date   indicates   it   is   of   particular   value   in   control   of   psychymotor
|11| attacks.6-7   The most frequent side effects have been personality changes
(16-17% usually appearing within the frst 4-6 weeks of therapy.)
Before its toxic effects were fully realized, 4 deaths occurred jfrom
hepatitis, but with adequate supervision this complication can be avoided.
10.   Methylphenylsuccinimide, P.M. 334, has recently been reported to be equal or
more effective than tridione and to be relatively non-toxic.8
Studies have been made on many other drugs too numerous to mention as
well as such substances as hormones (ACTH)9 10 and antibiotics (aureomycin) n
to which I must refer you to the literature.
4. Social:
I am convinced that emotional disturbances in epileptic patients precipitate
true seizures which may be difficult or impossible to control with attention only to
medication. I have a young man who has an atrophic lesion of his left temporal
lobe (confirmed by pneumoencephalography) associated with an active "spike"
focus. "He has typical "psychomotor' seizures of brief duration associated with
automatic behavious. He is quite unstable and paranoidal. He was most unhappy
at his last job and in spite of intensive medication could not be controlled. He
has since changed jobs and is happier and more contented. Coinicident with
this, his seizures stopped and have remained controlled for about a year although
his medication has been appreciably reduced. I have a young woman who developed
seizures at puberty. She was initially well controlled but after about two years,
seizures returned. Her physician did not seem interested and made no serious
"attempt to deal with the problem. Eventually the discouraged parents took her to
a chiropractor who stopped all medication. For two years she was partially confined
to bed with seizures. Eventually, she had a carotid-jugular anastomosis with"
no improvement. In the meantime, she became very resentful of her parents'
over-anxious yet critical attitude and at the same time had gross feelings of
inferiority and insecurity. When seen over a year ago she could not talk to me
at all in the presence of her mother. With a moderate dosage of medication her,
attacks were reduced from 1-3 per week to less than one per month. The latter
occurred when she was upset. Following several sessions in which she was allowed
to ventilate her hostility and with help in changing the parental attitude, etc., she
has had no further seizures for the past 8 months with no alteration in medication.
She is now keeping house for a group of University girls and is well on the way
to being rehabilitated.
These cases are mentioned to show that a well rounded programme includes
much more than directions for use of anti-convuisants.   The general health of the
Page 130 ,,>-: child, his habits of living, interests, attitudes and fears, as well as conditions in
the home and community all require attention. It is important to realize that
the attitude of the physician toward the disease, and the manner in which he handles
the child and family, are all part of treatment. He must enable both the patient
and the family to understand the problems they face. While the goal of therapy
is to stop all seizures, if complete relief is not possible, then the patient must be
helped to reach the most satisfactory adjustment to the situation as it exists.
Treatment begins with the first interview. The care and thoroughness with
which the physician proceeds will not only increase the accuracy of his conclusions
but will also influence the attitude with which the parents accept the facts and
make plans for the future. Therefore take your time. Try to understand the
parent's attitude. The onset of seizures has been a harrowing experience for them
and they have weird notions about epilepsy. They often have an exaggerated
idea of the importance of heredity and feel guilty of passing some taint on to their
child. This may make it difficult for them to accept the diagnosis of epilepsy,
leading them to shop about until they find someone who will say it was due to
worms, etc. It may also lead to over-anxiety regarding the physical status of the
child with much fussing over diet, rest and bowel movements—all of which tend to
create anxiety and neurotic manifestations in the child. They areusually anxious
for the child to do well and so push him beyond his capabilities, and so add to
his anxiety and resentment.
Explain your diagnosis. Perhaps it might be well to avoid the word epilepsy.
Point out that the real problem is not to give the condition a name, but to learn
everything possible about it. Epilepsy is simply a convenient term to describe
a person who has spells, and since the child does have spells, the important task
is to try to uncover their cause and correctly treat them.
Nothing is to be gained and much may be lost by emphasizing the medical
ignorance of the disease.    Give a simple description of the brain and localization
of function.    To know that seizures are related to changes in circulation and
oxygen supply to nerve cells helps remove the mystery and superstition that often
surround epilepsy, and make it appear more tangible and understandable.    The
multiple causations can be  enumerated, but  avoid unnecessary emphasis on the
hereditary aspect as it readily becomes a source of guilt.    Do not say there will
be  immediate   relief. ' Stress   the  long  range  view  so   parents  will  not  be   too
disturbed if other seizures occur.    Mention can be made of surgery and where it
may fit in the particular case.    Parents often have exaggerated ideas of the effect
of constipation and diet on epilepsy.    Aside from ensuring adequate raw food and
roughage in diet, encourage an attitude of healthy neglect..  Generous amounts
of physical activity are necessary.    The parents should encourage the child to live
a life as normal as possible and to conform as others do to normal discipline.
However,  too  much  restriction  produces   resentment  and  rebellion  which may
result in the child not taking the medication.    Each child should be taken into
the confidence of the doctor and given an explanation commensurate with his
abHity to understand.   He should them be made to feel that he is important in the
plan and not just a pawn if one wishes to secure his confidence and co-operation.
Parents should be reassured regarding isolated attacks and instructed as to how to
handle them.    They must be given specific instructions as to medication and the
reason for it.   It should be explained why it may be necessary to continue medication
for some years after the last seizure.    The consequences of stopping abruptly or
too soon should be stressed.
In subsequent interviews, the parent and child should be seen separately.   The
child is usually seen first so he will feel more free to talk.    As one gets to know
them better, emotional, family and community problems will arise and have to be
dealt with.    One cannot bully or brow beat parents or patients and expect co-
Page 131 operation!^: Often they must learn by experience in spite of the physician's advice.
If the doctor is able to avoid ill feeling at such times, and to remain in position as a
sympathetic advisor, he will eventually gain in stature and have greater control of
his patients. This type of interest may have to be carried into the community
and school in order to obtain satisfactory results. Fortunately in Vancouver we
can utilize the Child Guidance Clinic, the Metropolitan Health Department as
well as several other agencies. I have found these groups not only willing to help,
but all too- frequently begging for the physician's interest and help.
I am sorry I have not time to develop this theme more fully for, as you may
have guessed, I consider it as important, if not more so, than the other aspects of
therapy.
I hope that in this short time I have been able to emphasize some of the more
important points in treatment and to have left you with a few practical suggestions
as to how best carry it out. ||i|
BIBLIOGRAPHY:
1 Epilepsy with Convulsive Disorders in Children.    E. M. Bridge, M.D., McGraw-Hill Book Co. Inc.,
1949.
2 Lennox, William G., McBride, M. & Patter, G., "Who cares for the Epileptic?" New England Jr. of
§ Medicine, 238:215-218,  1948.
3 Collins, L. & Lennox, W. G.—"The Intelligence of 300 Private Epileptic Patients."    Prac. of Assoc.
for Research in Nervous and Mental Disease.    Chapter XLIII, Vol. XXVI,   1946.;®
4 Yannet,   H.—"The   Treatment   and   Prognosis   of   Convulsive   Disorders   in   Children."     Bulletin   of
New York Academy of Medicine, 27:466-474, July, 1951.
5 Hoenig,   J.   "Fifty   cases   of   Epilepsy   Treated   with   Tridione."   Journal   of   Mental   Svience,   Vol.
XCVII:362-375, April, 1951.
6 Davidson, D. T. Jr. & Lennox, W. G.—"Phenaoetylurea—Phenurone in Epilepsy." Disease of Nervous
' System, Vol. II, No. 6, June, 1950.
7 Tyler, M. W., King, E. A. — "Phenacemide in  Treatment  of Epilepsy."    J.  A.  M.  A.   147:17-21,
September. 1, 1951. mM
8 Zimmerman—"Use of Methylphenylsuccinimide in Treatment of Petit Mal Epilepsy." Arch. Neur. &
Psych. 66:156-162, August, 1951.
9 Klein   &  Livingstone  —  The  effect  of  A.C.T.H.   in   Epilepsy."   Journal   of  Pediatrics   37:73 3-742,
November, 1950.
10 Daifinon et al—Status Epilepticus Coincident with use of Petuitary Adrenaocorticotrophic Hormone,
J.A.M.A. 146:25-27, May 5, 1951.
11 Stamps, Gibbs & Haase — "Epileptic Patients treated with Aureomycin," Disease of Nervous System,
12:227-330, August,  1951.
THE USE OF THE ELECTROENCEPHALOGRAPH IN THE
DIAGNOSIS AND TREATMENT OF EPILEPSY
By MARGARET A. KENNARD, M.D.
(Department of Neurological Research, University of
British Columbia Medical School)
The electroencephalogram (EEG) can be a useful and practical aid in the
diagnosis and treatment of epilepsy. But, since interpretation of EEG patterns is
still empirical and since new data are still providing new interpretations, a diagnosis,
even when made by an experienced electroencephalographer, can never be more than
confirmatory and should be used only as such by the clinician. The value of the EEG
at present may be compared with that of the X-ray at an earlier date, when ventriculography and angiography were less well developed and standardized than they are
today.
1. The EGG in known epileptics
There can be no doubt that the presence of a paroxysmal EEG pattern in the
record of an individual who has some type of clinical seizure is confirmatory of epilepsy.
But only when a paroxysmal attack appears in the record coincident with a clinical
seizure can the EEG be said to make the diagnosis without possibility of doubt.    The
Page 132 presence of such a paroxysmal discharge during an attack suspected of being hysterical
must rule out hysteria since a paroxysmal cortical discharge is, by definition, an
"epileptic" discharge. Absence of any paroxysmal change in EEG during a "seizure"
will, on the other hand, rule out epilepsy. In no other instance, however, can the
EEG be more than confirmatory, since about ten per cent of EEGs taken from known
epileptics are normal—i.e. recorded at a time when the individual's cortex is relatively
non-excitable—and since about five per cent of normal adults have abnormal EEGs.
In the case of the relatives of epileptics Lennox has shown3 that thirty per cent may
have abnormal records although such individuals may never develop clinical seizures.
There are a number of other situations in which the EEG may supplement clinical
information with regard to epileptic seizures:
The type-of EEG pattern should assist in the diagnosis of the type of seizure, for
the patterns of grand mal, petit mal and psychomotor seizures have distinctive differences. Aid may thus be offered by the EEG with respect to medication, particularly
when mixed clinical patterns have appeared which must be sorted out according to
the present prevailing type. ,
The relative excitability of the cortex may also be detected by the EEG. A record
which reveals large amounts of paroxysmal activity denotes a cortex which is very
probably nearer to discharges having clinical manifestations than is a cortex which shows
relatively little paroxysmal activity. But, although this is in general true, it is not exact,
for there are cortices which, under medication, may show signs of extreme excitability
for long periods of *time although the activity remains sub-clinical. Whereas, if the
drug is removed, seizures may ensue without demonstrable changes in the EEG record.
Although the relative excitability as shown in such cases has undoubted physiological
meaning, it is often true in individual cases that practical explanations are not forthcoming. Finally, in epileptics, the EEG may define a focus of abnormal activity sharply
localized within the forebrain which has been hitherto unsuspected. It may suggest
the size of the focus and the extent of involvement of the surrounding tissue. It may
also indicate whether this focus is due to a space-occupying lesion, to trauma, to
developmental or to destructive distortions.
2. The EEG in "borderland" epileptics
There are two groups within the "borderland of epilepsy" which may have paroxysmal EEGs indistinguishable from those of epileptics with more conventional types
of seizures.
The first of these is composed of patients who have some type of paroxysmal
seizure associated with changes in, or loss of, consciousness but which does not develop
into any of the clinical manifestations commonly known as epileptic. Fainting spells,
blackouts and various types of transient behavioural disturbances are the most common
of these. While some may result from circulatory or other changes not primarily
related to the cerebrum, there are others which must be directly attributed to cerebral
changes. Kersliman and Hunter2 recently reviewed a large number of adults in this
latter group in which a four-year follow-up after the first EEG recording revealed
that certain EEG patterns related to these borderland fits were apt to be associated
with the latter development of true seizures. Whereas there were other clinical groups,
with abnormal records, of a different type in which there was, statistically, less
possibility of the development of paroxysmal behavior. Their conclusions were that
individuals with episodic types of clinical behaviour, if associated with certain types of
EEG abnormality, should be treated as potential epileptics both by choice of medication
and in selection of their jobs and life situations.
The second borderland group contains those subjects with paroxysmal records,
showing abnormal foci in the temporal lobes, who, clinically, exhibit psychomotor
epileptic behavior. These have come under much consideration lately since it has been
shown that the ablation of such a temporal focus will, in some cases, abolish the
paroxysmal pathological behaviour1.   In addition, Hill
and his associates4 have described
Page 133 paroxysmal, aggressive behaviour patterns associated with bilateral, slow wave formations at 4-6/sec. in the temporal and temporo-parietal regions.
3. The EEG and behavior disorders
Finally, there is another type of abnormal EEG which appears in children and young
adults and which, because it is often paroxysmal, may be confused with the EEG
patterns of the epileptic. This last type appears in disorders of behaviour which may not
be paroxysmal. There are between 50 and 70 per cent of abnormal records of this
type in groups of young schizophrenics, neurotics and delinquents of various kinds as
reported by many observers. The meaning of these EEG abnormalities is not yet
clear but there are several facts which appear from a study of this group of cases:
Those children or young adults with behaviour disorders who have also an abnormal
EEG have apparently a more severe disorder with less favorable prognosis than do those
with normal EEGs.
There is an hereditary factor in the EEG abnormality. As in true epilepsy, the
presence of an abnormal EEG in the subject is related to similar abnormal EEG patterns
in his parents and siblings, although these relatives have neither epilepsy nor behavioural
pathology.
Because of the paroxysmal nature of the EEG in some instances it has been thought
that, although the behavioural patterns are not paroxysmal, they may relate to epilepsy.
Therefore anticonvulsant drugs have been tried on many cases and there are many
reports on the subject. Almost all agree that anticonvulsant medication has no eiiect
on the behavioural patterns.'
In conclusion, among the disorders of behaviour, the borderland and the true
epileptics, the outstanding characteristic of the EEG records is a relative instability
of pattern which, when extreme, produces paroxysmal bursts of activity. Unstable
personality, therefore, seems to be related always to unstable electrocortical activity.
But there is no indication, as yet, that all behavioural disturbances are epileptic in nature.
For this reason, unless more definite information appears as the result of continued
research into the basic meaning of the EEG, its findings will continue to be utilized
as an index of cortical activity, but never as more than a confirmatory diagnostic aid.
REFERENCES
1 Gibbs, F. A.  and Gibbs, E.  L., Psychiatric implications of discharging temporal lobe lesions,  Trans.
Am. Netfcol. Ass., 1948, 73, 133-137.
2 Kershman, John and Hunter, R. C. A., Encephalosyncope or larval epilepsy;  a follow-up, EEG Clin.
Neurophysiol., 1950, 2, 169-176.
3 Lennox, W. G., The heredity of epilepsy as told by relatives and twins, fount, of Med. Assn., 1951,
146, 529-536.
4 Pond, D. A., Rey, J. H. and Hill, D., Biological correlates of constitutional EEG abnormalities of the
temporal lobes, EEG. Clin. Neurophysiol, 1950, 2, 111-112.
THE INSTITUTIONAL CARE OF THE EPILEPTIC CHILD
By N. L. RICHARDSON, M.D.C.M.
Crease Clinic of Psychological Medicine
ESSONDALE, B.C.
At the outset it should be emphasized that the need for institutional care of the
epileptic child is restricted to a very limited few of those so afflictedJ% Further, in the
course of time with improved care for this group of children, the need for such action
will diminish. However, there will always be a need for institutions where a type of
care can be provided other than that available at the community level. Many of
these children have suffered such extensive brain damage as to preclude their living
in the home. Public provision for their care is, therefore, necessary. In addition group
care of the less severe cases is at times imperative. Those epileptic children requiring
some form of institutional management might be listed as follows:
Page 134 (1) The grossly retarded child—Here the epilepsy is just another symptom of a
much greater affliction. These children include the congenital defective and can be
found under all the diagnostic classifications of intellectually retarded individuals.
(2) The child who is showing mental deterioration as a result of uncontrollable .
seizures.    This group should be very small and will continue to decrease with better
and more effective seizure control.
(3) The group of children of normal intelligence but who are showing personality deviations of sufficient degree to interfere with their satisfactory adjustment
at the community level. This of course is the most hopeful and therapeutically rewarding in the institutional setting.
Institutional care for the first group, that of the retarded epileptic, is provided
best by the hospitals for defective children. These hospitals are designed to care for
the physically and intellectually handicapped child. The Woodlands School in New
Westminster is such a hospital. The children of this group, in addition to suffering
from seizures, are often grossly handicapped. Many are unable to care for themselves. Some are physically crippled, others have severe cerebral palsy, agenesis or
marked cerebral destruction. The program of care for these children is chiefly one
of providing the following: Adequate physical care, medical management of seizures,
simple habit training for the most defective, school opportunities for those equipped
intellectually to make use of them, planned recreational activities within the scope
of each child, and occupational programs designed on an individual basis.
The two institutions concerned in the care of the second group of epileptic
children, that is those showing deterioration, are hospitals for the retarded child and
the mental hospital. This is a disappointing and rather unhappy group from a treatment standpoint. However, any improvement that is achieved is largely the result
of adequate control of the seizures along with planned social stimulation. The deterioration seen in this group is often more apparent than real. With stimulation through
organized recreational and occupational activities some of these patients will show
improvement in behaviour. These activities arouse new interests and often not only
reduce the number and severity of the seizures, but holds in abeyance or sometimes
clears up what at first seemed mental deterioration. There will remain, however, some
in whom custodial care alone is of value. The institutional life in itself is of benefit
to these children and it aids them to adjust in an environment in which less stress
and strain is encountered and one in which they are permitted to perform simple
duties.
The third group of children who require a type of institutional care, comprise
a rather important group. These are the epileptic children of normal intelligence
but showing unmanageable behaviour patterns. The size of this group m particular
will vary with the degree and extent of the community facilities. Where these facilities are designed to meet the needs of the epileptic child, the necessity for care outside the home is diminished. This includes extension and availability of modern medical care; an education program in all areas of community life which will help to bring
receptivity in homes and schools; and the services of a Child Guidance Clinic. Few
medical conditions are more conducive to the development of undesirable personality
traits than epilepsy. This may in small part be due actually to the cerebral dysrhythmia itself. Much more important, however, are the unfortunate psychological insults
to which the epileptic child is exposed as a result of an uninformed or indifferent
social environment. Many of the abnormal behaviour patterns can be traced to obvious parental mishandling and the rejection suffered at the hands of the community.
Although a program of preventive work with the application of sound mental hygiene
principles at the home, school and general public level will in time reduce the number
of epileptic children with personality disturbances, some communities have found it
advantageous to use the ^epileptic colony" in the treatment of these children.
Page 135 The epileptic colony is designed for the care of the epileptic child of average
intelligence but with serious personality or behaviour difficulties. Ther are several
such institutions in the United States and Great Britain but as yet there are none in
Canada. Epileptic colonies in the United States are perhaps the best known. As of
1946 the Ministry of Education of England lists seven such residential treatment
centres for epileptic children. "Lingfield Colony" in Surrey, England is amongst the
better known and will serve to describe this type of care. This colony looks after 255
children between the ages of 5 and 16. Only educable children are admitted and an
intelligence quotient of 60 is taken as the lower limit of educability. There are four
homes or cottages housing 155 boys and three homes for 100 girls; classification in
the homes being by age. Each home has a cottage mother or father in charge. Unfortunately these cottages at Lingfield are somewhat large. Ideally they should house
15 to 20 children to best maintain the family atmosphere as opposed to the institution.
However, economic and administrative factors make the larger cottages necessary.
The rest of the physical facilities at the colony consist of a school under the charge
of a headmaster and ten assistant teachers, a recreational hall and a small hospital.
The paramount advantage to an epileptic child of admission to a residential
schoolVs a psychological one. Here the epileptic child -at once becomes a normal
member of the community in which he lives. In the outside world he has all too
often been regarded as someone special; often it is true as someone meriting special
sympathy, but just as often as someone to be rather afraid of or openly disliked. In
the residential school all this is changed. Any sense of inferiority disappears. Restrictions of activity such as swimming apply equally to all among whom he lives. In
addition to the above mentioned advantages the residential school provides opportunities for adequate schooling and vocational training commensurate with each child's
capabilities. These opportunities are all too often denied by the outside school and
social community. The major drawback to this type of care is the one inherent
in any institutional program—loss of family life and limitation of social contracts.
However, where the family is either rejecting or inadequate in their relations with
the child, removal to a more accepting environment where medical care, education,
normal play activities and the development of special interests are encouraged would
seem justified. The duration of residential care will vary with each case; in some
instances the period of three to six months will suffice to establish treatment and
modify the child's attitude towards his disease and former environment. The time
can be shortened if a satisfactory re-educational program is simultaneously being
carried on in the child's home. More often, however, a period of several years is
required to give the child full benefit of such care.
The colony plan in Lingfield is more fortunate than some of the American
colonies. Lingfield has been able to restrict their admissions to the educable group,
whereas, colonies such as Craig Colony in New York State have had to serve a more
custodial role as they have had to admit increasing numbers of primary defectives
with epilepsy. This, of course, interferes with the educational and therapeutic programs
for which such institutions were originally designed.
Finally in some communities selected cases related to this third group of epileptic
children are admitted to residential treatment centres for disturbed children. These
institutions are designed essentially for the primary behaviour disorders of childhood.
However, as many epileptic children in addition to their epilepsy show severe emotional disturbances they can be benefited by treatment in this setting. One such
type of children's psychiatric hospital which treats epileptic children with personality
disturbances is the private hospital, The Emma Pendleton Bradley Home, in East
Providence, Rhode Island. This hospital provides medical care of seizures, psychotherapy for secondary personality problems and parental guidance, i
REFERENCES
1 J. Taylor Fox—"Residential Schools for Epileptic Children in England."    The Nervous Child.    VoL
6. No. 1. Jan. 1947. pp. 36-92.
Page 136 g Herman Yannet—"The care of the Epileptic Child in Residential Schools in America."    The Nervous
Child.    Vol. 6. No. 1. Jan.  1947. pp 93-98.
■* Eugene   Davidoff—"The   treatment   of   institutionalized   Epileptic   Children."     The   Nervous   Child.
Vol. 6. No. 1. Jan. 1947. pp. 57-75.
4 Edward M. Bridge—Epilepsy and Convulsive Dirorders in Children,  pp.  510-523.
5 Hoch & Knight—"Epilepsy." pp.  58-68.
Dr. F. O. K. Garner of the Victoria T.B. Unit has been appointed superintendent
of the Tranquille Sanatorium. Dr. K. S. Alstad is now the director of Victoria Unit
Division of T.B. Control.
Drs. E. H. W. Elkington and H. G. Grieve of Victoria attended the Pan-American Opthalmological Congress in New Mexico.
Dr. J. C. Moscovich, Director of S.A.M.S., spoke at the monthly meeting of the
Victoria Medical Society on the handling or Social Assistance cases.
Dr. J. K. Flint has begun a general practice in South Burnaby.
Dr. Arthur Walshe oi Vancouver is now taking post-graduate studies in California.
Dr. Don Moffatt of Vancouver is the new member of the Vancouver Board of
Trade representing medicine.
Dr. E. C. McCoy of Vancouver has been elected president of the Board of Directors of the M.S.A.   This is the first time a medical man has occupied the position.
Dr. Harry Baker of Vancouver has been elected vice-president of the B.C. Division of the Canadian Federation of Artists.
Dr. A. C. McCurrach, president of the Vancouver Point Grey Community Association, is attempting to get lurid movies eliminated from Saturday children's
matinees.
Dr. Gordon Ferguson of Saskatchewan has been appointed executive secretary
of the C.M.A., B.C. Division in place of Dr. Lynn Gunn who is now Registrar of
the College.
Dr. John H. Harland of Ireland is now practicing with the Irving Clinic in
Kamloops.
Dr. P. G. Margetts of Vancouver is now company physician at Kitimat for the
Alcan project.
Dr. H. S. Stalker of Tranquille will be supervisor of the new tuberculosis hospital in Vancouver to be opened this spring.
§ BIRTHS
Dr. and Mrs. G. L. Nanson of Vancouver—a son.
Dr. and Mrs. A. H. Phelps of Vancouver—a daughter.
Dr. and Mrs. R. S. Purkis of Victoria—a daughter.
Dr. and Mrs. W. S. Wilson of New Westminster—a son.
Dr. and Mrs. W. N. Perry of Vancouver—a son.
Dr. and Mrs. H. L. Chambers of Vancouver—a daughter.
Dr. and Mrs. J. E. Ross of Vancouver—a daughter.
Dr. and Mrs. G. Kirkpatrick of Vancouver—a daughter.
MARRIAGES
Dr, John Schinbein of Vancouver and Dorothea Clayton, R.N.
Dr. Nelson Keilly of Victoria to Mrs. Frances McKinnon of Fredericton, N.B.
Dr. Polina Zdanowicz to Mr. Paul Pariseau of Victoria.
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Page 138
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