History of Nursing in Pacific Canada

The Vancouver Medical Association Bulletin: February, 1943 Vancouver Medical Association Feb 28, 1943

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 The BUL
of the
VANCOUVER
MEDICAL ASSOCIATION
Vol. XIX
FEBRUARY, 1943
With Which Is Incorporated
Transactions of the
Victoria Medical Society
tbt
Vancouver General Hospital
and
StiPaul's Hospital
In This Issue:
NEWS AND NOTES
COLLEGE OF PHYSICIANS AND SURGEONS-
ELECTION OF MEMBERS OF COUNCl3{§|
NOTES ON THE B. C. FORMULARYJ|^.-_||g||
SYMPOSIUM ON "NEUROSES^!-	
No. 5
Page
124
129
Spo
133
SUMMER SCHOOL
The Annual Summer School of the Vancouver Medical
Association will be held at the
HOTEL VANCOUVER, JUNE 22nd to 26th, Inclusive
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WALKERVILLE. ONT.
■ THE     VANCOUVER    MEDICAL     ASSOCIATION
ULLETI
Published Monthly under the Auspices of the Vancouver Medical Association
in the interests of the Medical Profession.
Offices: 203 Medical- Dental Building, Georgia Street, Vancouver, B. C.
EDITORIAL BOARD:
Db. J. H. MacDermot
Dr. G. A. Davidson Dr. D. E. H. Cleveland
All communications to be addressed to the Editor at the above address.
Vol. XIX.
FEBRUARY, 1943
No. 5
OFFICERS, 1942-1943
Dr. J. R. Neilson Dr. H. H. Pitts Dr. 0. McDiarmid
President Yice-President Past President
Dr. Gordon Burke Dr. A. E. Tbites
Hon. Treasurer Hon. Secretary
Additional Members of Executive: Dr. Wilfrid Graham, Dr. J. A. McLean
TRUSTEES
Dr. F. Brodie Dr. J. A. Gillespie Dr. W. T. Lockhabt
Auditors: Messrs. Plommeb, Whiting & Co.
SECTIONS
Clinical Section
Dr. D. A. Steele _ Chairman Dr. J. W. Millar Secretary
Eye, Ear, Nose and Throat
Dr. A. R. Anthony. Chairman Dr. C. E. Davies Secretary
Pediatric Section
Dr. J. H. B. Grant Chairman Dr. John Piters Secretary
STANDING COMMITTEES
Library:
Dr. F. J. Buller, Dr. D. E. H. Cleveland, Dr. J. R. Davies,
Dr. A. Bagnall, Dr. A. B. Man son, Dr. B. J. Harrison
Publications:
Dr. J. H. MacDermot, Dr. D. E. H. Cleveland, Dr. G. A. Davidson.
Summer School:
Dr. J. E. Harrison, Dr. G. A. Davidson, Dr. R. A. Gilchrist
Dr. Howard Spohn, Dr. W. L. Graham, Dr. J. C. Thomas
Credentials:
Dr. A. W. Hunter, Dr. W. L. Pedlow, Dr. A. T. Henry
V. 0. N. Advisory Board:
Dr. L. W. McNutt, Dr. G. E. Seldon, Dr. Isabel Day.
Metropolitan Health Board Advisory Committee:
Dr. W. D. Patton, Dr. W. D. Kennedy, Dr. G. A. Lamont.
Greater Vancouver Health League Representatives:
Dr. R. A. Wilson, Dr. Wallace Coburn.
Representative to B. C. Medical Association: Dr. C. McDiarmid.
Sickness and Benevolent Fund: The President—The Trustees.
ve
***** For Nutritionally Under-Par Patients
NAVITOL MALT COMPOUND
Two tablespoonfuls Navitol Malt
Compound contain the equivalent of:
s     .
Vitamin A
Vitamin D
Vitamin C
5000 U.S.P. units
800 U.S.P. units
30 milligrams
Thiamine hydrochloride
1 milligram
Riboflavin
Niacin amide *
Calcium
2 milligrams
10 milligrams
750 milligrams
(2 gm. tricalcium
phosphate)
Iron 106 milligrams
(10 gr. iron and ammonium
citrates,    10    mg.    average
assimilable iron)
*Suggested  by National  Research
Council—not official.
ic NAVITOL MALT COMPOUND
provides a palatable, convenient
and effective means of preventing
or correcting many common vitamin
and mineral deficiencies in the diet.
The recommended dose for adults
—two tablespoonfuls (one fluid
ounce or 40 grams)—supplies the
full minimum daily adult requirement, or more, in vitamins, calcium
and assimilable iron. Suggested
dosage for children is one table-
spoonful.
INDICATIONS
There are numerous instances where
the diet is insufficient to meet the
vitamin and mineral requirements
of the patient and nutritional supplementation is advisable. There are
other instances, where the diet is
seemingly adequate in which malnutrition may occur as the result of
interference with food intake, increased metabolism, malabsorption,
malutilization, hastened destruction
and excretion.
Navitol Malt Compound is acceptable to patients old or young. The
syrup mixes readily with milk and
other aqueous fluids. It is available
in 1-lb. and 2-lb. jars.
For literature address 36 Caledonia Rd.,
Toronto.
ERlSQJJIBB &.SONS
of Canada, Ltd.
MANUFACTURING CHEMISTS TO THE
MEDICAL PROFESSION SINCE  1858 VANCOUVER HEALTH DEPARTMENT
STATISTICS—DECEMBER, 1942
Total population—estimated    271,597
Japanese  population           ...Evacuated
Chinese population—estimated   8,767
Hindu population—estimated   j [  367
Rate per 1,000
Number       Population
Total deaths     327
Japanese deaths     2
Chinese deaths  i_i  17
Deaths—residents only   294
14.2
Population evacuated
22.8
12.7
BIRTH REGISTRATIONS:
Male,  305;  Female,  269  574
INFANTILE MORTALITY: Dec, 1942
Deaths under one year of age      13
Death  rate—per 1,000 births 4-/    22.6
Stillbirths   (not included in above)       11
24.9
CASES OF COMMUNICABLE DISEASES REPORTED IN THE CITY.
November, 1942    December, 1942    Jan. 1-15, 1943
Cases Deaths      Cases Deaths      Cases Deaths
Scarlet Fever     60           0             47           0             28 0
Diphtheria         0           0               0           0               2 2
Oiphtheria Carrier  j      0           0              0           0               0 0
Chicken Pox  I    42           0             4r>           0             23 0
Measles      7           0             12           0             10 0
Rubella         5 0 0 0 10
Mumps     190           0           173           0           141 0
Whooping Cough     21           1               6           0             12 0
Typhoid Fever       0           0               0           0               0 0
Undulant  Fever        10               0           0               0 0
Poliomyelitis      3           0               0           0               0 0
Tuberculosis      47 15 36 17 19
Erysipelas       0           0               7           0               0 0
Meningococcus Meningitis       2           1               5           0               2 0
V D   CASES REPORTED TO PROVINCIAL BOARD OF HEALTH
DIVISION OF VENEREAL DISEASE CONTROL
West North       Vane.    Hospitals &
Burnaby    Vane.   Richmond   Vane.      Clinic   Private Drs. Totals
Syphilis   (Nov., Dec.)—   0               1               4               1               43               32 81
Gonorrhoea   (Nov., Dec.)    1               0               0               2             100               6o 168
Phone MArine 5411
Res.: MArine 2988
*Sealuce QcUlQfi
CANADIAN PHYSIOTHERAPY ASSOCIATION
GRADUATE McGILL UNIVERSITY SCHOOL
OF MASSAGE AND REMEDIAL GYMNASTICS
Electricity, including Short Wave
House Visits
417 Vancouver Block
Vancouver, B. C.
Page 121 PITUITARY EXTRACT (posterior lobe)
FOR USE IN OBSTETRICS, IN SURGERY AND
IN THE TREATMENT OF DIABETES INSIPIDUS
A sterile aqueous extract is prepared from the posterior lobe
of the pituitary gland, and is supplied as a solution containing
ten (10) International Units per cc.
POTENCY
Each lot is biologically
assayed in terms of the
International  standard
PURITY
The extract is prepared as a
clear, colourless, sterile liquid with
a    low    content    of    total    solids.
STABILITY
Samples of each lot are tested at
definite intervals to ensure that ail
extract distributed  is fully potent.
PITUITARY EXTRACT (POSTERIOR LOBE) is supplied by
the Connaught Laboratories in packages of five 1-cc.
rubber-stoppered vials.
CONNAUGHT   LABORATORIES
UNIVERSITY  OF   TORONTO
Toronto, Canada
DEPOT FOR BRITISH COLUMBIA
MACDONALD'S PRESCRIPTIONS LIMITED
MEDICAL-DENTAL BUILDING, VANCOUVER, B.C. VANCOUVER MEDICAL ASSOCIATION
FOUNDED  1898     ::    INCORPORATED  1906
Programme of the Forty-fifth Annual Session     (Spring Session)
GENERAL MEETINGS will be held on the first Tuesday of the month at 8:00 p.m.
CLINICAL MEETINGS will be held on the third Tuesday of the month at 8:00 p.m.
These meetings are  to be amalgamated with  the  clinical staff meetings  of  the
various hospitals for the coming year. Place of meeting will appear on the agenda
General meetings will conform to the following order:
8:00 p.m.—Business as per Agenda.
9:00.p.m.—Paper of the evening.
1943
January    5—GENERAL MEETING. Round Table Discussion of Functional Diseases.
Chairman, Dr. George A. Davidson, who, will be assisted by six other
speakers.
January 19—COMBINED CLINICAL MEETING AND CLINICAL STAFF MEETING at VANCOUVER GENERAL HOSPITAL.
February    2—GENERAL MEETING.
Dr. B. J. Harrison: "Whence and Whither?"
February 16—COMBINED CLINICAL MEETING at ST. PAUL'S HOSPITAL.
March    2—OSLER LECTURE—Dr. D. E. H. Cleveland.
March 16—COMBINED  CLINICAL MEETING  AT THE VANCOUVER GENERAL HOSPITAL.
April    6—GENERAL MEETING.
Dr. C. W. Prowd: To Be Announced.
April 13—COMBINED CLINICAL MEETING at ST. PAUL'S HOSPITAL.
MArine 6735
805, 718 Granville Street
C.S.M.M.G. C.P.A.
Mm Ada £. McmJzAcmi
wishes to inform the Medical Profession that she has resumed her
Physio-Therapy practice at 805 Birks Building.
Short Wave Remedial Exercises
Massage
HIGH   BLOOD   PRESSURE
BETTER RESULTS OBTAINED WITH
BIOGLAN
Another Product of the Bioglan Laboratories, Hertford, England
Phone MA. 4027
Stanley N. Bayne, Representative
1432 MEDICAL-DENTAL BUILDING
Descriptive Literature on Request
THE SCIENTIFIC HORMONE TREATMENT
Vancouver, B. C.
Page 122 RADIOSTOLEUM
(Vitamins A and D)
TRADE MARK
The provision of an extra-dietary source of Vitamins A and D
should be continued at least throughout the winter months and
until adequate amounts of salads and green vegetables are available and until sunlight is sufficiently intense and prolonged to
produce appreciable amounts of Vitamin D in the body.
No more convenient and economical means of effecting this is
available than by the use of Radiostoleum, the original solution of
standardised Vitamins A and D.
Radiostoleum is issued as a solution in oil and in capsules. For
administration to infants and in the larger doses for adults, solution
in oil is generally preferable and most convenient. The prophylactic and smaller therapeutic doses for adults are best given in capsules'.
Radiostoleum liquid provides 15,000 international units of Vitamin
A and 3000 international units of Vitamin D in each gramme
(about 30 drops) and 6000 international units of Vitamin A and
1200 international units of Vitamin D in each capsule.
For those physicians who prefer to prescribe a preparation containing a higher proportion of Vitamin D, Radiostoleum-D (formerly
Radiostoleum 250-D) is available, each gramme of which contains
15,000 international units of Vitamin A and 10,000 international
units of Vitamin D.
Stocks of Radiostoleum are held by leading druggists throughout the Dominion,
and full particulars are obtainable from
THE BRITISH DRUG HOUSES (CANADA) LTD.
Toronto Canada
Rstm/Can/432 The hospital situation in British Columbia, and more especially in Vancouver, gives
promise of becoming one of our major problems. It has seemed to us for some time
that as a community, we are adopting altogether too casual an attitude towards this
matter: as, in our democratic way, we so often do, when confronted by a condition of
affairs which grows steadily, but slowly, worse; till some day it assumes the proportions
of a crisis.
We feel that the crisis as regards our hospital affairs is very near, if it is not already
upon us. Of course, there is a war on, and we must expect to have some difficulties
and problems to face and solve, but perhaps something might be done, if we put our
minds to it. For years now, the ratio of hospital beds to population has shrunk steadily
and continuously, till we are very definitely and seriously short of hospital accommodation. More and more we have been educating our patients to go to hospital for care
and treatment—and this is as it should be; more and more we are using forms of
treatment, and specialised therapies, that can only be put in effect in a hospital. The
ratio of nurses to the number of patients has been increasing steadily: but the quota of
nurses available has also been shrinking, till now we are faced with a very critical
shortage.
The latest development is a sharp increase in hospital rates. It is not for us to
criticise this: we accept the statement of hospital authorities that it is unavoidable.
The rise of prices (though this is not very great, owing to price-fixing), the forced
increase in wages, the eight-hour day for nurses, and so on, we are told, has made an
increase in rates absolutely necessary.
Well, even so, this adds heavily to the burdens we already had to bear. As medical
men, it affects us rather definitely. As citizens, it affects us too. We can hardly fee
optimistic enough to expect that after the war rates will come down again: that would
fly directly in the face of economics, as history records economic change.
There is such a thing as the Law of Diminishing Returns: we have sometimes
thought that next to the Law of Gravitation, it is the most fundamental law there is.
It will undoubtedly operate in this crisis at some time in the not too distant future.
Meantime, is there anything we can do about it? or about the whole matter of hospital
care?
Various things come into our mind. First, the establishment of cheaper, yet still
efficient, hospitals. Second, the inauguration of an adequate system of Home Nursing,
so that, thirdly, we could get our patients home sooner. It is not necessary, surely, for
maternity patients to stay in so long, when all is normal—for so many ambulatory
patients, with casts on their arms, or splints on their fingers, to occupy hospital beds.
Shortage of beds is largely due to our own individual lack of care, and indifference.
But it is not enough to talk about it. The province, the municipalities, should join
with the medical profession, in a study of this problem, and should between them work
out remedies and devise expedients for relief. Otherwise, a serious state of affairs will
be the result.
We are glad to receive a short article from Dr. C. E. Dolman for publication in this
issue, on the Laboratory Diagnosis of Venereal Disease. This embodies recent work, and
will be not only of interest, but also useful practically, to medical men in general.
Page 123 NEWS    AND    NOTES
Some news from Overseas has reached us and we are glad to report as follows:
Colonel J. F. Haszard, formerly of Kimberley, is now Officer Commanding No. 16
General Hospital, which is more or less known as a British Columbia unit.
Lieut.-Col. S. G. Baldwin, formerly of Vernon and latterly doing Obstetrics and
Gynaecology in Vancouver, who left here as O.C. of No. 12 Field Ambulance, is now
Officer Commanding No. 2 Canadian Casualty Clearing Station.
Wing Commander D. M. Meekison, the well-known Orthopaedist from Vancouver,
now serving with the R.A.F., is listed on the programme of the British Post-Graduate
Medical School, University of London, held January 18th-22nd.
Major Roy Huggard has received a surgical appointment with No. 16 General Hospital.   We have not heard that he has been promoted to the rank of Lieut.-Colonel.
•1m A **m *£
*C *¥ *? *&*
We are glad to learn that Capt. R. R. Laird, prisoner of war, is up and about and
showing some improvement following his extensive wounds during the Dieppe raid.
* # * S5-
During the visit of Brigadier G. B. Chisholm, D..M.S., Ottawa, and Colonel G. A.
Winfield, in charge of Medical Administrative Services, a luncheon was held at the Hotel
Georgia, one hundred and thirty-three being present. Lieut.-Col. Gordon Fahrni of
Winnipeg, Surgical Consultant in the Western area, was also present.
* *      *      *
Lieut.-Col. J. D. Adamson, late of Winnipeg, Medical Consultant in the West,
accompanied by Colonel Fahrni, visited all areas in the Pacific Command.
sj. sj- sE- sj-
Captains D. H. Williams and J. A. Leroux, formerly of the Division of Venereal
Disease Control, have both completed their basic training at Borden.
Captains W. J. Endicott and F. L. Wilson, formerly of Trail, and Capt. G. McL.
Wilson, latterly of Revelstoke, and Capt. S. L. Williams of Nanaimo have completed
their training.
* I       s-       *
Flight-Lieut. N. A. Stewart has been promoted to Squadron Leader, we are glad
to note.
* *       *       *
Capt. A. M. Evans has received the rank of Major. Major Evans was formerly at
the British Columbia Cancer Institute.    He is now serving in Great Britain.
Great sadness was cast over the profession by the loss of Capt. J. M. McDiarmid,
formerly of New Westminster, Vancouver and Abbotsford.
Capt. G. L. Stoker of the R.C.A.M.C. is apparently attached to the R.A.M.C. as
Medical Officer with a Field Ambulance in Tunisia.
Medical Officers at the Victoria Military Hospital are listed as: Lieut.-Col. W. S.
Baird, formerly of Vancouver, Officer Commanding; on the Medical side are—Major
Stuart G. Kenning, formerly of Victoria, Capt. D. W. Moffatt, formerly of Vancouver,
and Capt. J. M. MacKinnon, formerly of Victoria, also giving Anaesthetics; Major R. H.
L. O'Callaghan in Surgery; Capt. J. A. McCaffrey—Genito-Urinary; Capt. I. C.
Tchaperoff—Radiology.
Page 124 Capt. C. G. G. Maclean has been moved from Little Mountain Standing Medical
Board, and is now serving with the Victoria Medical Hospital, on the Medical side, and
will be doing some Dermatology.
Capt. N. B. Hall, formerly of Campbell River, has been stationed at Gordon Head
Camp, and has now moved to Prince Rupert.
*c-        s>        *        *
Major Kenneth L. Craig and Capt. E. Stewart James are now at the Gordon Head
Hospital.    Major Craig is Officer Commanding.
sfr ;;- jj. jj.
Capt. W. J. Endicott, formerly of Trail, is now stationed with the Artillery in
Victoria. *       |       ,:.       |
The Army reception centre, which has been developed at Little Mountain, Vancouver, has new Medical Board arrangements in charge of Major Paul H. King. Associated with him will be: Capt. Kingsley Terry in Medicine; Capt. A. B. Manson in
Surgery; Capt. J. Ross Davidson in Orthopaedics, Capt. G. H. Francis doing Eye, Ear,
Nose and Throat; Capt. Taylor—X-ray examination. Capt. Hamilton is also associated
with this group, as is Dr. J. Freundlich in Cardiology. This group will be responsible
for the acceptance or refusal for admission to the Army.
Capt. Manson has been at Vernon Military Hospital and Capt. Ross Davidson has
been at Victoria Military Hospital just prior to coming to the Little Mountain Centre.
*•       *       «•       #
Capt. W. M. Toone, formerly of Kimberley and Nelson, has left for Kingston to
join a hospital unit.
Major F. E. Coy is Commanding Officer of Prince Rupert Military Hospital.
Major A. L. Cornish, who has been Officer Commanding, Prince Rupert, will assume
command of Nanaimo Military Hospital.
Recent promotions are those of: Lieut.-Col. W. A. Clarke, Assistant Command
Medical Officer, Major K. L. Craig and Major D. E. Alcorn.
Drs. George Hall, F. M. Bryant, D. M. Baillie and G. A. McCurdy of Victoria
travelled to Vancouver as examiners at the Dominion Council examinations in January.
Prior to the departure of Dr. Thomas McPherson and Dr. H. M. Robertson to attend
the meeting of General Council of the C.M.A. in Ottawa, a special meeting of the Victoria Medical Society was held to discuuss the question of Health Insurance. There was
a large attendance and many Medical Officers in the area were present.
*!- s5- sS* sC*
Congratulations are extended to Dr. and Mrs. L. W. Cromwell on the birth of a
son, and to Dr. and Mrs. J. D. Stenstrom on the birth of a daughter.
Dr. J. D. Stenstrom has now entered the R.C.A.M.C.
mf* *r *r .   *?
Dr. Leonard Panton of Kelowna spent three weeks in Los Angeles doing post-graduate study.    Dr. Panton serves a large part of the Okanagan as Eye, Ear, Nose and
Throat specialist.
#       *       *       *
Dr. Donald M. Black of Kelowna will remain at the Coast for a month. During his
absence Dr. H. D. Sparkes, recently an interne at St. Paul's Hospital, will act as locum
tenens.   Dr. Sparkes is awaiting appointment as Medical Officer with the Air Force.
Page 125 Dr. H. F. P. Grafton, who is associated with Dr. R. W. Irving at Kamloops, was in
Vancouver applying for appointment as Medical Officer with the R.C.A.M.C.
$      Dr. G. E. Bayfield, who is on Moresby Island with the Morgan Logging operations,
called at the office on a recent visit to Vancouver.
A A A A
Dr. C. C. Brdwne of Nanaimo travelled to Vancouver to attend the luncheon given
to Brigadier Crrisholm and Colonel Winfield. Dr. Browne enjoyed a visit with his classmate, Colonel Winfield.
*      *       *      *
We are glad to report that Dr. A. P. Miller of Port Alberni has recovered and
returned to practice following his recent operation.
The situation in the Cariboo, of which we have heard much, is no longer the cause
for so much comment and criticism. Dr. F. Sedziak is replacing Dr. Black at Wells;
Drs. Gerald Baker and J. C. Kovach are maintaining the service at Quesnel; Dr. K. K.
Pump has taken up practice at Williams Lake; and Dr. F. A. Olacks is still at Ashcroft,
although the latter would be glad to be relieved for the duration so that he may enter
War Service.
*^ A A A
Recent entries to the R.C.A.M.C. include: J. H. Black of Wells, Paul Phillips of
Princeton, S. L. McWilliams of Nanaimo, R. E. McKechnie II and W. W. Simpson of
Vancouver, A. Herstein, R. C. Newby and J. D. Stenstrom of Victoria, H. K. Atwood
and G. I. Theal, formerly internes at the Vancouver General Hospital.
S»- it Sf- rt
Recent entries to the R.C.A.F. include: E. B. Trowbridge and J. W. Whitelaw of
Vancouver.
CORRESPONDENCE
DEPARTMENT OF NATIONAL DEFENCE
|§' army §
H. Q. Pacific Command,
Vancouver, B. C,
Editor, 5th February, 1943.
Vancouver Medical Association Bulletin,
C/o Vancouver Medical Association,
925 W. Georgia Street,
Vancouver, B. C.
Dear Doctor MacDermot:
The medical staffs of military hospitals frequently have to submit indents to medical
stores for various instruments and I am receiving frequent requests from these hospitals
for surgical instrument catalogues. It is now impossible to obtain these catalogues from
the surgical supply houses.
In order to facilitate this matter I wonder if you would put a note in the Bulletin
asking any medical men who have such catalogues and are not using them to consider
letting me have them for my hospitals.
I would be grateful if such were the case and they were forwarded to Officer-in-
Charge Medical Command Stores, Vancouver Barracks. If necessary available catalogues in the Vancouver area would be called for.
WALLACE WILSON, Colonel, R.C.A.M.C,
Command Medical Officer, Pacific Command.
[In printing the above, we gladly urge medical men to do all they can to help Colonel Wilson in the
matter to which he refers. "We suggest that anyone having catalogues notify our Librarian, Mrs. Craig,
and she will hold these and notify Colonel Wilson.    DO IT NOW.—Ed.]
Page 126 j. m. McDiarmid, m.d. (capt., r.c.a.m.c.)  j
Our readers will have noticed a reference in "News and Notes" to the death
of Capt. J. M. McDiarmid, R.C.A.M.C, which occurred while he was on duty
at Prince Rupert. Capt. McDiarmid's car went over a bluff, and he was killed
in the fall.
A great many men in British Columbia, who knew Dr. McDiarmid so well,
will grieve sincerely over his tragic death. A relatively young man, he leaves
a mark in the life of the Lower Mainland where he practised. He served his
interne term in the Vancouver General Hospital, then went to Abbotsford,
where he did excellent work for many years. He tried to practise in Vancouver,
and would have done well there—but his old patients in the Valley wanted him
so often and so badly that he spent most of his time there: so he decided to
make New Westminster his headquarters. He was rapidly becoming one of
the leading men in that city, when the war broke out. He joined the R.C.A.M.C.
and was detailed later to Prince Rupert. He leaves a family, to whom we
extend our deepest sympathy. Quiet, courteous, and friendly, he was greatly
liked by all who knew him—and we mourn his untimely end.
I pHERBERT McGREGOR, M.D.
Dr. Herbert McGregor of Penticton died on Sunday, February 21st. Doctor
McGregor was in his sixty-second year and had practised Medicine in Penticton
since 1908. He was a graduate of the University of Manitoba, 1907. His
son, Flight-Lieut. H. B. McGregor, was associated in the practice prior to
entering the R.C.A.F.
Doctor McGregor was President of the Okanagan District Medical Association; was a Vice-President of the British Columbia Medical Association; and
a member of Council of the Canadian Medical Association; was highly respected by his colleagues, and enjoyed a deserved reputation as a skilful physician and surgeon.
The sympathy of the profession is extended to Mrs. McGregor and a daughter at home,' and his son, Flight-Lieut. McGregor.
Dr. R. B. White of Penticton represented the British Columbia Medical
Association at the service.
LIBRARY NOTES
RECENT ACCESSIONS TO THE LIBRARY:
The Modern Attack on Tuberculosis, 1942, by Henry D. Chadwick and Alton S.
Pope.
Surgical Clinics of North America, Symposium on New Trends in Surgery, Philadelphia Number, December, 1942.
Renewals for the Nelson Loose-Leaf System.   Some of the interesting articles received are:
Further Advances in the Treatment of Pneumococcus Pneumonia, by Edward S.
Rogers.
Pertussis, by William St. Lawrence.
The Thymus, by John Caffey.
Cranial Trauma, by Sidney W. Gross.
Epilepsy, by William G. Lennox.
Renewals for the Oxford Loose-Leaf Medicine, including the following:—
Chemistry of Carbohydrates in Relation to Disease, by William T. Salter.
Lipid Pneumonia, by Louis Hamman.
Peritoneoscopy, by Edward B. Benedict.
Toxoplasmosis, by Henry Pinkerton.
.  Page 127 MISSING FROM LIBRARY
The following journals are missing from the Library shelves:
Journal of the American Medical Association, November 21st, 1942.
Journal of the Royal Army Medical Corps, June, 1942.
Mayo Clinic Staff Proceedings, March 25th, 1942.
New England Journal of Medicine, December 3rd, 1942.
Practitioner, June, 1942.
These numbers are urgently needed to complete the files for 1942, for
binding purposes. Members are asked to check any journals they have out and
return them to the Library at the earliest opportunity.
Volume 43 of the American Journal of Obstetrics and Gynaecology is also
missing and it would be greatly appreciated if the borrower would return it
immediately.
MICROFILM SERVICE
"Medicofilm" is the term used by the Army Medical Library to describe its service
of microfilms on medical subjects.
The Vancouver Medical Association Library has subscribed to this Service for over
a year and we are happy to report a growing interest among the members.
It has proved to be particularly valuable in obtaining copies of articles appearing in
publications to which this Library does not subscribe, and when one realizes that it
affords access to practically everything on file in the Army Medical Library at Washington, one realizes its tremendous possibilities.
To further facilitate the use of "MedicofHm," a very satisfactory desk projector has
been purchased by the Library Committee. The reader is kept on a special table which
may be moved to any part of the Library that happens to be free at the moment for
darkening.
The cost to the Doctor of obtaining films is negligible. The minimum charge for
any article up to 25 pages is 25 cents. An additional 10 cents is charged for each 10
pages in excess. All the details of remittance and Customs clearance are handled by the
Library.
It is the hope of the Library Committee that microfilm strips will be left in the
Library after being read,.so that an adequate file may be accumulated in time.
It is hoped also that full use will be made of this Service, and it is suggested that
those who are not familiar with its details visit the Library to obtain further information and have the reader demonstrated.
CANADIAN MEDICAL ASSOCIATION
| HOW TO BECOME A MEMBER!      §
THE FEE IS $8.00 NOW |§
The office of the College of Physicians and Surgeons accepts the $8.00
fee for transmission to the Canadian Medical Association office.
THE CANADIAN MEDICAL ASSOCIATION NEEDS YOU.
YOU NEED THE CANADIAN MEDICAL ASSOCIATION.
The C.M.A. must speak for Canadian Medicine and represent it -with
95 to 100% membership.
Page 12S College of Physicians and Surgeons
President < Dr. W. A. Clarke, New Westminster
Vice-President 1 ; Dr. F. M. Bryant, Victoria
Treasurer Dr. H. H. Milburn, Vancouver
Members of Council—Dr. F. M. Auld, Nelson  (District No.  5); Dr. F. M. Bryant, Victoria
(District No.  1); Dr. W. A. Clarke, New Westminster   (District No.  2);  Dr. Thomas
McPherson, Victoria (District No.  1); Dr. H. H. Milburn, Vancouver  (District No. 3);
Dr. Osborne Morris, Vernon  (District No. 4); Dr. Wallace Wilson. Vancouver  (District
No. 3).
Registrar J Dr. A. J. McLachlan, Vancouver
Executive Secretary Dr. M. W. Thomas, Vancouver
ELECTION OF MEMBERS OF COUNCIL
District No. 1, which extends from Victoria to Atlin—one member to be elected.
Dr. Thomas McPherson was elected two years ago for a term of four years. Dr. F.
M. Bryant was elected for a term of two years. It is necessary to elect one member who
will carry on for a term of four years.
The following candidates, one of whom will be voted for, are standing for election:
Dr. F. M. Bryant, who has served for two years, is standing for re-election; Dr. J. H.
Moore of Victoria and Dr. D. M. Baillie of Victoria are both candidates in this election.
District No. 2, centred on New Westminster.
Lieut.-Col. W. A. Clarke, who was elected two years ago for two years, is a candidate for re-election. The new candidate in the field is Dr. G. S. Purvis of New Westminster.
District No. 3, which includes Vancouver, the North Shore, and close outlying points
on the Lower Coastal Mainland.
One member will be elected for a term of four years. Colonel Wallace Wilson was
elected two years ago for a four-year term.
Dr. H. H. Milburn, who was elected for a two-year term, is a candidate for reelection.   Dr. Frank A. Turnbull is the other candidate in District No. 3.
All members elected at this time will serve for four years.
In Districts No. 4 and 5 both members of Council have two years to serve, they
having been elected two years ago for a four-year term. Dr. F. M. Auld of Nelson is
the member from No. 5, and Dr. Osborne Morris of Vernon is the member for No. 4
District.
Changes in the Medical Act provide that all councillors will in future be elected
for a term of four years with certain members retiring every two years. This will provide for a certain continuity of service among members of Council, and will assure no
complete disruption of the personnel.
Ballot forms will be distributed in March, and will be returned properly marked
before 10:00 a.m. on the first Monday in April, which this year falls on April 5th.
Scrutineers properly appointed will meet at that hour and count the votes. New councillors will take their seats on the first Monday in May, the date of the Annual Meeting
of Council.
Please note: 1943 dues must be paid before the member is eligible to vote. Disappointment by voters will thus be avoided.
Page 129 Vancouver Medical   Association
NOTES ON THE B. C. FORMULARY
No. 1.    ANALGESICS
The term "Analgesic" is used here to refer to the central analgesics only, including
those possessing antipyretic properties.
Section 4, Part 2, of the B. C. Formulary includes six prescriptions in this class,
numbered for convenience F 1, 2, 3, 15, 16, and 17.
You will notice that all these preparations contain acetylsalicylic acid as their basic
ingredient; which drug has proved, by clinical experience, alone or in combination with
other potentizing drugs, to be the safest and most reliable analgesic for functional pain.
For severe traumatic pain, or the pain of malignant disease, morphine is usually the
drug of choice.
Of the drugs used with acetylsalicylic acid for their synergistic action, codeine phosphate is considered the most generally useful, a dose of from l/% to % grain in combination being sufficient for most cases. Prescriptions containing these strengths are exhibited
in the B. C. Formulary as Tablet No. F 17, and Capsule No. F 1.
Increasing the quantity of codeine in combination above % grain should seldom be
necessary, as the result it is possibly more an additive than a synergistic action; and as
the value of codeine lies more in its efficiency as a depressant of the cough reflex than as
an analgesic, better pain-relieving action should be obtained by more frequent administration of one of the weaker preparations, or an adequqate dose of a stronger narcotic*
Capsule No. F 2, containing Dovers powder, is designed for those cases where an
additional diaphoretic action is required.
A prescription which can be ordered with confidence in a great many instances where
an analgesic is required, is that containing phenobarbitone Yz grain with acetylsalicylic
acid 5 grains, especially valuable where moderately severe pain interferes with the
patient's sleep. The addition of phenobarbitol, like codeine, results in a potentiation1
of the properties of acetylsalicylic acid. It also possesses a marked analgesic action in,
itself, differing from most of the other barbiturates in having a prolonged sedative
action on the motor, and to a lesser extent on the sensory cortex2.
This prescription, Capsule No. F 3, B.C.F., being non-narcotic, can be telephoned
to the pharmacist if necessary; unlike any preparation containing codeine.
The use of a non-narcotic preparation where possible is especially important at this
time to conserve the basic drugs used to manufacture morphine, so greatly needed on
the fighting fronts.
In prescribing from the B. C. Formulary, please order the preparation by name,
including the number if you wish as a double check; and avoid the habit of ordering by
number only.
The consistent use of British Pharmacopoeia drugs in their simple forms, and by their
official names, and the use of the prescriptions of the B. C. Formulary, will result in a
marked reduction of average drug costs to the patient.
1.
REFERENCES:
'The Technic of Medication," Bernard Fantus, published by the American Medical Association.
2.    "Sedatives and Analgesics," Walter J. Dilling, "The Practitioner," Feb., 1940.
Page 130 DIVISION OF LABORATORIES, PROVINCIAL BOARD
OF HEALTH
EARLY PROCEDURES AND METHODS OF REPORTING IN
LABORATORY DIAGNOSIS OF VENEREAL DISEASE.
SERO-DIAGNOSTIC TESTS FOR SYPHILIS.
C. E. Dolman,
Director, Division of Laboratories.
Aa a meeting of Provincial Laboratory Directors and representatives of the Armed
Forces held under the auspices of the National Research Council at Ottawa some months
go, it was decided to standardize the serological procedures used throughout Canada in
testing for evidence of Syphilis in blood specimens from Army, Navy and Air Force
personnel. At the same meeting, decisions were made respecting a uniform method of
reporting the laboratory findings, while the Laboratory of Hygiene at Ottawa agreed
to further the securing of consistency among the various laboratories by supplying the
requisite standardized antigens.
Procedure.—To employ a different set of tests and reporting methods for the Armed
Services from those in use for the civilian population would obviously be unsatisfactory.
The Division of Laboratories has therefore decided to adopt the following system, which
will be applied to all blood specimens submitted for serological tests for syphilis. The
presumptive ^JUahn test, which is in general somewhat more sensitive but less specific
than the standard Kahn test, will first be carried out. When the presumptive Kahn
findings are negative, the results will be reported KAHN NEGATIVE, and no further
tests will be done on the specimen. On the other hand, all specimens giving a doubtful
or positive presumptive Kahn result, will be submitted to a standard Kahn test and a
Kolmer-Wasserman (complement-fixation) test; and the results of the latter two tests
will then be reported as NEGATIVE, DOUBTFUL or POSITIVE.
Discrepant Reports.—If the serological findings do not accord with the clinical or
epidemiological evidence relating to a given patient, or if the serological reports themselves are discrepant, additional blood specimens should be sent in. When discrepancies
do occur in the laboratory reports, these should not be regarded as due to errors of
technique or of reporting on the part of the Laboratories, but rather as inevitable consequences of inherent differences of sensitivity and specificity in the tests performed.
For instance, the Kolmer-Wasserman test tends to be somewhat more sensitive than the
standard Kahn, and the former may give more doubtful or positive results in early
syphilis, or in cases under specific treatment, when the standard Kahn reaction is negative. But sometimes the reverse occurs. One of the main reasons for reaching the
decision made at the Ottawa Conference on Sero-diagnostic Procedures for Syphilis was
that in the experience of some of the larger laboratories in Eastern Canada, the Kolmer-
Wasserman test proved less liable than the Kahn to give false positive reactions in young
adults (e.g., Army personnel) hospitalized with mumps, upper respiratory tract infec-
j tions, and other non-syphilitic conditions. There are some reasons to doubt whether
this preliminary experience will be substantiated; but meanwhile physicians can greatly
aid the Laboratories in the solution of these problems by supplying all the information
sought on the requisition forms accompanying specimens. Any physician who particularly wishes to have a complement-fixation test done on a patient whose blood may have
previously given a negative presumptive Kahn reaction, should give his reasons upon the
requisition form. The Laboratories cannot otherwise undertake to perform the time-
consuming and intricate complement-fixation test. To have made this test available at
all under present difficult circumstances, has entailed a very special effort. Finally, it
cannot be too often emphasized that the diagnosis of syphilis should not be made upon
a basis of serological results alone. The Laboratory findings must always be considered
in conjunction with the relevant clinical and epidemiological data.
Page 1^1 Reports on Smear Examinations for Gonococcus
In view of accumulating evidence suggesting that an infection indistinguishable
from gonorrhoea may be transmitted by a micro-organism which is not necessarily found
intracellularly on direct microscopic examination of smears, and which may not conform in all particulars to the characteristic morphology ascribed to the gonococcus, the
Laboratory is now reporting its findings in the following terms:—
1. Typical intracellular diplococci.
2. Typical extracellular diplococci.
3. Atypical diplococci.
4. Negative.
It must be emphasized that the reporting of atypical diplococci is by no means to
be deemed evidence of gonococcal infection. Further, the decision as to what shall be
reported as atpyical diplococci, and what shall be termed negative, must necessarily
remain somewhat arbitrary. Physicians can help in clarifying the significance of such
atypical diplococci by stating on the requisition form any relevant epidemiological information, the patient's clinical condition, the type and duration of treatment, and the
results of previous laboratory examinations.
OSLER DINNER
The Osier Dinner will be held in the Mayfair Room of the Vancouver
Hotel, on Tuesday evening, March 2nd, at 7:00 o'clock.
Dr. D. E. H. Cleveland, the Osier Lecturer, will speak on "The Fear of
Skin."
Another feature of the evening will be the awarding of the P. G. F. Degree
for 1943.
Tickets may be obtained from the Library or at the Vancouver General,
St. Paul's or Shaughnessy Hospitals.
PATON FUND
Acknowledgment of subscriptions to the Fund in support of Surg. Lieut. Commander W. M. Paton's proposed library at a West Coast Naval Base, is made herewith:
Blair, E. M.
Buller, F. J.
Caple, H. H.
Gillespie, J. A.
Gillies, B. D.
Gillies, G. E.
Hallowes, B. J.
Harrison, J..E.
Henry, A. T.
Hodgins, G. L.
Hunter, A  W.
Lawrence, Grant
Lee, G. H.
Lennie, T. H.
MacDermot, J. H.
McDiarmid, Colin
MacLachlan, A. T.
McLean, J. A.
Murray, D. F.
Neilson, J. R.
Pedlow, W. L.
Riggs, H. W.
Schinbein, A. B.
Seldon, G. E.
Smith, Lee
Story, Boyd
Strong, G. F.
Sutherland, J. A.
Thomson, J. W.
Trites, A. E.
Turnbull, Frank
Turvey, S. E. C.
Page 132 VANCOUVER MEDICAL ASSOCIATION
SYMPOSIUM ON "NEUROSES"
Held at the January meeting of the Vancouver Medical Association.
THE BACKGROUND AND PERSONALITY OF
THE NEUROTIC
Gordon H. Hutton, M.D.
This topic leads to a consideration of the etiology of neurotic disorders, and causation of psychiafcnc conditions probably is the most important question in psychiatry
today. The chief hope of the future lies in the preventive measures that may be deduced
from its study.
Any discussion of the roles of heredity and environment opens up the age-old argument of the relative importance of these factors. A generation ago, herdity held the
stage; a half a generation ago, environment and the behavioristic school of thought
dominated the scene; and now we are getting back to a more rational point of view.
Both are important.
I believe that it is the opinion of most people in psychiatric work that a predisposition to mental diseases is clearly indicated by the histories of unstable personality adjustments in the antecedents, such as the constitutional inadequacies, anxieties without
reasonable cause, alcoholism, epilepsies, fears, compulsions, obsessions, etcetera.
If all such predisposition led to frank disease, probably most of us would be so
affected: and, in our culture, with no practical eugenics, the outlook would be black
indeed.
It is clear, however, that predisposition to mental illness may remain latent. By no
means every offspring of neurotic parents develops a neurosis. It is also true that neuropathic children of essentially normal parents are to be found.
But the quantitative estimate is important, and, for example, if neuropathic persons
marry, or if there is a heavy seeding of neuropathic traits in other antecedents, the children are more markedly tainted; and more likely to develop a neurotic disability. One
must not forget, however, that the child may have imitated, rather than inherited,
these traits. The history of nervous disorders in other siblings is also information of
great practical importance. The same soil that without water is a desert, may, under
irrigation, produce luxuriant vegetation. On the other hand, no matter how much we
may water a rock, we will still be unable to produce a single blossom. So it is with
human beings. The original materials vary, and the conditions under which these
materials develop into character and personality vary also.
Mental development occurs in response to the needs of adaptation—the mind grows
in complexity as the necessary adaptations multiply. Adaptation implies, originally,
conflict. With protoplasm, there is no change in the essential reactions, or adaptations,
if the environmental relations are constant. And it is not different with the multicellular creature, man.
In early life, all activities are immediately concerned with an increase in pleasurable,
and a reduction of painful, stimuli—the pleasure principle. Later, the increasing demands of reality make necessary a postponement of pleasurable attainment, until certain
intermediary conditions have been fulfilled—the reality principle.
The child usually remains in closest association with the mother, and then others
may take over the dominant tutoral role, and the manner in which these early relationships are handled gives a tremendous bias or bent to the developing personality. Broken
homes are unquestionably important factors in many mental disorders, whether by the
death of one or both parents in the early life of the child, or by divorce, legal separation,
or the wrangling of dysharmonious parents who may continue to live under the same
roof.   The feelings of insecurity which these may provoke is frequently great.
Imitation is a training method that is used early by the child. Parents are like the
delegates of Society, interpreting and demonstrating to the child what is appropriate and
acceptable. If the pattern that is demonstrated is well integrated, reasonably controlled,
and effectively directed, the induced reactions of the child are favorable.    If, on the
Page 133 other hand, the parents display unreasonable, unpredictable, uncontrolled behaviour, the
child's response is often decidedly unfavourable.
Failure of adaptation at any point in development implies dissatisfaction, and in
quest of relief from distressing feelings, the individual may revert to a lower level, even
to the infantile stage of helplessness.
We must study the degree of these morbid trends, how fixed they are, whether simple
or involved—relatively benign, or malignant.
Henderson and Gillespie quote Ross on the Common Neuroses—1924, with reference to the psychiatric importance of Pavlov's conditioned reflex data. An emotional
reaction, first aroused by certain mental events, tends afterwards to be aroused by any
other mental event which has become associated with the first one. This secondary
mental event may be totally without primary emotional significance in itself, but, by
virtue of its association, it becomes capable of arousing the emotional reaction.
The signs of emotional disturbance, physical or mental, aroused in this way, without
adequate conscious reason, are reflected on by the subject, and mistaken for signs of
various specific diseases, as of heart, thyroid, gastro-intestinal tract, etc.; or the primary
stimulus may be a simple physiological one, artificially given an emotional aura. An
example of this was observed several days ago. A 24-year-old patient gave a history
that ten years previously he had become quite chilled while playing out-of-doors in
wintry weather. Having been trained by an over-solicitous mother, he hurried home
in dire distress. He shivered considerably, and the mother, in great apprehension,
bundled him off to bed, surrounded him with hot-water bottles, and summoned the
doctor. With too much emphasis, cod-liver oil capsules were prescribed, and the patient
and mother told that he must continue to take these if he would forestall a return of
the ominous condition. Ten years later, the patient is still religiously taking his capsules, says that he would surely die if he were prevented from taking them, but in spite
of this, does not avoid a marked fear of cold, so that he often absents himself from
work for a week or ten days, "to catch a chill in time." He has added headaches,
fainting attacks, g-i symptoms, and even more widespread inadequacy, and dependence
on his mother, to his train of symptoms.
Our study of the background, and considerable of the personality of the patient,
is made from historical data, obtained from the patient himself and from others who
know him most. Often very helpful, even essential, diagnostic and therapeutic leads
are thereby uncovered. The items that may be significant are as wide and numerous as
human experiences. Antenatal, birth, infancy, childhood, adolescent, adult developments—habit formations—educational, social—including marital—occupational and
recreational adjustments, hopes, fears, aspirations, failures, conflicting loyalties, etc.,
must all be canvassed.
The medical history, with particplar emphasis on how the child was treated emotionally by parents and others, especially for any protracted illness, should be learned, for
unquestionably, many neurotic symptoms have their origin in that setting.
A physical defect or deformity may be of specific significance, and certain examples
fulfil, Adler's theory to the letter—i.e., that a psychical compensation for an inferiority,
physical or social, accounts for the development of a neurosis.
Self-assertive and self-abasing trends must be evaluated, and the integrative process
must be assessed.
If we remember that the neurotic, like all of us, is a part of all that he has met, we
shall have a useful understanding of him.
CLASSIFICATION OF THE NEUROSES
Dr. E. A. Campbell
The group of mental conditions termed Neuroses or Psychoneuroses has been classified differently by many authors.   The most acceptable clinical grouping is:—
1. Neurasthenia.
2. Anxiety States, including Anxiety Neuroses and Anxiety Hysteria.
Page 134 3. Hysteria.
4. The Obsessive-Compulsive Psychoneuroses or Psychasthenia.
1. Neurasthenia or Nervous Exhaustion. This term has often been used in a very
wide sense. It makes for accuracy of definition if its use is confined to those cases in
which fatigue, mental or physical, is the prominent symptom. Along with complaints
of fatiguability, weakness and exhaustion, are head pressures, poor sleep, irritability, a
feeling of tension, inappetence, various aches and pains, subjectively poor memory, and
difficulty with concentration. There are exaggerated reflexes and various visceral disturbances such as gastric and intestinal motility and secretory variations, often mistaken
for peptic ulcer or appendicitis, and cardio-vascular irregularities, urinary ugencies and
frequencies, menstrual irregularities, neurogenous skin reactions and variations in special
sensibilities, are common. This frequently leads the patient to couch his complaint in
terms of "sexual" difficulties, "spinal trouble" (backache), "heart disease,',, and
"stomach ulcers."
These reactions usually result from the person experiencing a disappointment, from
inconsistently evaluating and not constructively utilizing his needs, drives, aims, capacity
to perform, .etc., in terms of available opportunities and from faulty and poor regulation of his habits.
This type of reaction not infrequently is brought to the surface in a fairly adequate
personality when the individual is afflicted with some physical disability, such as a more
or less chronic infection, or the partial loss of some function or part of his body.
(2) Anxiety States are the commonest of all the Psychoneuroses, and fortunately
are the most responsive to treatment. Anxiety states or syndromes always occur in an
individual who is tense and uneasy, whatever the cause may be, and are characterized by
rather suddenly occurring, transient attacks lasting from a few seconds to as long as an
hour, during which the patient subjectively experiences:—
Difficulty in breathing: often described by the patient as a "choking," "a lump in
the throat," "like a weight upon the chest," or "can't breathe in."
Palpitation: subjectively portrayed as a "pounding," "skipping," "fluttering,"
"racing," or a momentary stoppage of the heart, or merely as a "heart attack."
Precordial discomfort, frequently expressed as "a pain," "a pressure," "an awful
feeling," "a squeezing of the heart," with radiations to the neck, arms or abdomen.
Perspiration or "cold sweats," not infrequently associated with a "shivering feeling
of the skin" or "goose pimples."
Vertigo of a subjective type which the patient recounts as "giddiness," "feeling I'll
faint," "swimming in the head."
Various complaints referable to the gastro-intestinal tract, most common of which
are "gas in the stomach," "heaviness, like gas was pushing up," "sick at the stomach,"
and very often epigastric cramping, periodic slight looseness of the stools (diarrhoea)
and flatulence.
Feeling of weakness depicted as "my knees feel like they'll give way, my energy-
leaves all at once," or "I feel faint—can't do anything for a few minutes."
With these attacks, there is invariably existent an underlying and accompanying
emotional factor which is best described by the term anxiety. (Anxiety is a fear of
danger from within, viz.,. a fear of impending physical illness, or a feeling of uneasiness and an unpleasant expectancy of something about to happen without a certainty of
its coming to pass.)
If the complete complaint is elicited, it will usually be learned that the patient has
difficulty in sleeping, has some anorexia, tires easily, has a "tight" pain in the head, feels
slowed up or confused in his thinking, is irritable, restless, has lost weight, has not been
up to par for some time, "feels worried" without knowing what about or why, and
practically always feels cold and "cannot get warm enough."
Direct examination usually reveals a tense, restless, uneasy, apprehensive person who
often keeps the clothing loosened around the neck and who has a dry mouth, cold,
moist hands and feet. There is variable pulse and blood pressure, and a palpable, tender
colon.    This syndrome occurs most frequently between the ages of 21-25 and 36-40.
Page 135 It is 2 l/z times more frequent in women than men and occurs 3 times more often in
the married than the single.
These states usually arise as the culmination of a period of tension resulting from
some emotional disturbance or frustration, and is a sort of alarm signal indicating failure
on the part of the personality to handle some conflict.
Patients with such disorders constitute a large number of those cases treated in general practice as indigestion, peptic ulcer, functional cardiacs, suspected tuberculosis,
suspected undulant fever, and thyroid dyscrasias.
(3 ) The Hysterial Reactions are simulators of structurally determined diseases. They
are reactions which are essentially functional phenomena in that the function, or set of
functions, is more or less disturbed and disabled in action. These are classically exemplified in hysterical muscle contractions, types of pseudo-paralysis, disturbances in gait,
fantasies, dreamlike states and fugues, loss of voice and vision, areas of anaesthesia, loss
of memory, and so on. These reactions are likely to occur in individuals in need of
sympathy and appreciation, who early in j life have shown a constitutional instability,
and previously have revealed tendencies to evade or shut out particular situations or
experiences in life, who are complaining and manifest some types of illnesses. Psycho-
pathologically it occurs on the basis of an unsatisfactory attempt on the part of the
personality to solve problems arising out of life experiences.
(4) The last group is that of the obsessive-compulsive-ruminative-tension states,
alluded to by the terms Psychasthenia (Janet) and Compulsion Neuroses (Freud). To
briefly mention the component terms, we have obsession, which is an imperative and
recurring idea which appears to the individual to be beyond his control and out of keeping with his personality, and which he therefore recognizes as being illogical. These
are superstitions, fear of germs, diseases, sharp instruments, of losing the mind, fear of
committing some anti-social act, and so on. Compulsion is a similar phenomena. It is
the imperative urge to do some act which is unnatural and beyond the control of the
individual.^ Common manifestations are—counting of land-marks, repeating of digits,
an urge to call people names, to take so many steps, to carry out ritualistic toiletries,
such as washing the hands, dressing, touching or not touching things.
Rumination refers to the tendency for certain past experiences and actions to be gone
over and over in the person's thinking. Accompanying the above tendencies there are
usually evidences of tension, exemplified by irritability, restlessness, agitation, broken
sleep, tantrums, and so on.
One has mentioned briefly the various types of Psychoneuroses which are met in
every-day practice, and treatment of these will be discussed later this evening.
NEUROSES IN WAR TIME
J. C. Thomas, M.D.
The term "shell shock" appeared during the War 1914-1918. Oppenheim, Mott
and others attributed the early cases to physical causes. In cases with negative pathological findings, molecular changes in the nervous system were postulated; but the
occurrence of severe concussion without nervous symptoms and rapid recovery under
psychotherapy strongly countered this view.
So much confusion arose that a committee of enquiry was appointed in 1920 to consider the different types of hysteria and traumatic neurosis, commonly called "shell
shock."
They concluded that this term had been a gross and costly misnomer and should be
eliminated from the nomenclature. The war produced no new nervous disorders, and
those which occurred had previously been recognized in civil medical practice.
Page 136 The cases divide themselves into three main classes:
(1) Genuine concussion without visible wound, as a result of shell explosion. The
cases in this group were less than 10% of all cases of "shell shock."
(2) Emotional shock, either acute in men with a neuropathic predisposition or
developing slowly as a result of prolonged strain and terrifying experience, the final
breakdown being brought about by some trivial cause.   These formed 80% of all cases.
(3) Nervous and mental exhaustion, the result of prolonged strain and hardship.
It is therefore but a summary of the above to say that "shell shock" was less than
10% "commotional" and 80% "emotional."
Incidence.—The incidence of neurosis in the last war is difficult to estimate accurately.
B.E.F. 6,000 cases of shell shock were admitted annually during the war to British
hospitals. One-seventh of all discharges from the Army in 1917 were for nervous and
mental disease. An analysis of 1,043,653 British casualties revealed that 34 per 1,000
casualties were neuroses.
In 1918, out of 160,000 pensioners, 32,000 were securing pensions for functional
nervous disorders, while in 1921 this figure had risen to 65,000 and stood at 29,000
in 1939.
C.E.F.—Of 180,496 casualties, 24 per 1,000 were nervous and mental disorders.
Farrar states that 58% of these were neuroses.
A.E.F.—Profiting by the allied experience, the U.S.A. attempted to eliminate neurotics from the A.E.F. In the first year of the war 12% of all rejections on mobilization were for nervous and mental disorders, and inspection in camps led to the rejection
of a further 9% of the first million recruits. Of these rejections 15% were for neuroses. Their casualties from functional nervous disease were 9.5 per 1,000 total casualties
Among prisoners of war psychoneuroses are rare. Morheim found only 5 in 40,000
prisoners.
Gillespie states that there was no evidence to show any increase in neurosis among
the civilian population in the last war.
Neuroses in war time embrace the following groups:
(1) Pre-war neuroses which are continued unchanged.
(2) Pre-war neuroses aggravated in war-time.
(3) Character disorders developing manifest neurotic symptoms.
(4) Neuroses occurring in apparently well-adjusted individuals.
The same background and personality described by a previous speaker are found in
the neuroses in war time. The fear of showing fear is common to both soldier and
civilian, in modern warfare. In addition there are new sources of fear. Besides fear of
attack or injury there is fear of economic distress, threat of family separation, shortage
of food, deprivation of luxuries and pleasures.
In war, individualism declines and is succeeded by mass reactions. The feeling of
sharing comimon dangers leads to a strengthening of community ties. This leads to
surrender of privileges, self-sacrifice and a disregard of minor physical ailments.
The same types of reaction are seen in war time as in peace time. Unfortunately,
certain diagnostic labels such as "soldier's heart," "Army dyspepsia,' have crept into the
vocabularies around Army hospitals. These types are sufficiently numerous to become
the subjects of specialist investigation and there are many reports in the literature of
these studies. One wonders whether they do eventually get into the neuro-psychiatric
clinics to be included in statistical studies.
The following reports are abstracted to show the character of the problem in the
present war.
Page 13? In the British army, Sutherland reports an analysis of 100 cases of neuroses. Eighty
had previous traits, indicating emotional instability. In 36, it was merely an aggravation
of a previous psychoneurosis. In a study of 326 cases, Hadfield found a predisposition
in 82%.   Numerous others report similar finding.
Hyland and Richardson, C.M.A./., November, 1942:
1171  cases of mental disease at No.  1  Neurological Hospital—September,  1941, to April,  1942.
(649)  55% were psychoneuroses.    Of these  (488)  75% were classed as anxiety states.
150 CASES ANALYSED:
Family history, 56%.
Nervous disorders prior to enlistment, 80%.
Precipitating factors:
(1) Difficulty  in   adaptation     68 cases
(2) Domestic worries ; '. 50 cases
(3) Fears related to enemy action ! 33  cases
(4) Physical  disease or infirmity 23  cases
(5) Trauma 14 cases
(6) Complicated   love   affairs 4 cases
Baillie: American Journal of Psychiatry, January, 1941:
In the 12 months' period, October, 1939, to September, 1940, 303 patients were referred.to the
neurological clinic at Christie Street Hospital, Toronto. The proportion of admissions to enlistments is 1 per 100. Two hundred were summarized and classified. Of these 70 were constitutionally inferior, while 8 were suffering from psychoneuroses.
In his opinion 68, or 34% of these cases, should have been obviously unsuitable on enlistment,
while another 60, or 30%, should have been obvious during a comparatively brief preliminary
training period.
The figures presented show that there is a history of previous nervous disorder or
predisposition in 80% of the neuroses of this war. Surely this is the strongest indictment of the selection of recruits in the early years of war. The following quotation is
from a circular letter from the Surgeon-General of the U. S. Army which is pertinent:
"The army is in no sense a social service or curative agency. It is to be considered
neither a haven of rest for the wanderer or shiftless, nor a corrective school for the
misfits, the ne'er-do-wells, the feeble-minded, or the chronic offender. Furthermore,
it is neither a gymnasium for the training and development of the undernourished, or
undeveloped, nor is it a psychiatric clinic, for the proper adjustment to adulthood,
emotional development. Therefore, there is no place within the army for the physical
or mental weakling, the potential or prepsychotic, or the behaviour problem. If an individual is a behaviour problemi in the civilian community, he will certainly become a
more intensified problem in the service."
Thus the chief function of the medical boards and the medical officers would appear
to be the prevention of inclusion into the service of those individuals and to provide for
their exclusion as rapidly as their undesirability shall make itself evident. The latter
may not be possible until some training has been given.
It was found that training and esprit-de-corps were two important factors in combatting neurosis. The famous Guards Regiments did not have many such cases, because
of these factors. At Dunkerque, they marched to the beach and halted to await their
turn to be taken off. They were among those who retained most of their kit during the
retreat.
The unit M.O. should be the first to recognize precipitating factors in his men. He
knows their problems and background and should be better able to recognize the early
symptoms. He may be best qualified to recommend transfer to other more suitable
duties.
"With so much training and standing by, the value of recreation for men in the services is greatly increased. Here the various auxiliary services play an important part in
maintaining morale and mental health.
What of the future? Gillespie has pointed out that the change from war to peace
may be more devastating than from peace to war. Peace may present problems more
complicated and, to some natures, more distasteful than those of war.    It is not an
Page 138 uncommon story in the history of "shell-shock" cases to learn that they were well
during the war and that it was only after the war, in some cases many years, that they
developed their trouble which they attributed to service. Loss of business, financial and
domestic worries, may produce a state of emotional tension and fearful expectation.
With peace individualism return, self-sacrifice diminishes and the way of the constitutionally inferior becomes harder again, after the strains of war.
COMPENSATION NEUROSIS
Frank Turnbull, M.D.
"Compensation neurosis" is an unfortunate term. It suggests, erroneously, that the
sole cause of such a neurosis is desire for compensation, or the accident per se, depending on one's point of view. Thus we have the spectacle of the hard-boiled medical man
to whom such a neurosis only means a desire for wages without work or an insurance
settlement, in a sense that is close to malingering. On the other hand we find lawyers
who argue that if neurosis follows an accident and disables a man, the accident must be
entirely responsible.    Both of these views are obviously distorted and extreme.
The. symptoms of a neurosis that follows injury are the same as the symptoms of a
neurosis that occurs without any relation to injury. Post-traumatic neuroses may be
roughly grouped into the common types—hysteria, anxiety neurosis, neurasthenia and
mild depression. In hysteria the patient subconsciously converts his mental conflicts
into dramatic symptoms such as paralysis, anaesthesia or aphonia. Anxiety neurosis,
neurathenia and mild depression present various combinations of weakness, anxiety,
emotionalism, irritability, loss of interest, inability to concentrate, palpitation, tremor,
sweating, dizziness and headache.
The state of the patient's mind prior to the accident is of great importance in the
production of a neurosis. He may have an hereditary lack of emotional control, or a
poor weak mind that is incapable of withstanding any stress. He may have serious
domestic, social, or economic conflicts that have kept him very close to the breaking
point. He may be poorly nourished or have some systemic disease that lowers his
stamina and morale.
The accident itself often only tips the scales. It may cause considerable mental and
physical shock, days of discomfort and pain, and nights of insomnia. These are circumstances that will test the stability of the strongest nervous system. It is not surprising
that many patients develop a functional nervous disorder.
Then why is there such a difference in the degree and permanence of disability from
neurosis, between the non-compensation and the compensation case—e.g.,^between the
man who injures himself by running his own car into a telephone pole, and the man
who suffers the same injury while driving a company car and thus is eligible for compensation? The difference is a matter of exaggeration of symptoms in the second case.
Pure malingering is very rare in our experience with workmen. Usually the exaggeration of neurotic symptoms is partly subconscious and partly wilful. The term "wilful"
is used here in the sense of weak-minded acquiescence to, and abetting of, a situation
that they know is not entirely to their credit.
To understand compensation neurosis one must appreciate the importance of this
element of exaggeration. Our neuropsychiatric confreres emphasize the antecedents of
accident as the structure on which every neurosis is built. But their explanation does
not tell us why the symptoms that do develop are exaggerated a hundredfold or a
thousandfold in the compensation case.
The causes of exaggeration of neurotic symptoms are various. There is commonly
a sense of resentment. The injured workman feels that someone should pay for the
misery and disablement that he has suffered. Even when the accident has resulted from
his own negligence or carelessness he is able to project the blame on someone else. Frequently he feels, and often rightly so, that his future ability as a workman has been
Page 139 impaired by the accident. He fears that he may have permanently lost the job that he
has held for years, or that if he takes on a new job and does not make good he will be
blackballed forever in the labour markets. This is particularly true with an older workman who was beginning to worry about the competition of younger and more robust
mien long before he was hurt. Family and friends will invariably console the old man
in his belief that he has never been the same since his accident. How often the old
workman remarks that he has paid into compensation for years and has never received
any benefit. He feels that he is not asking much of the Compensation Board, just a
small pension for the rest of his life.
Suggestion by others always adds fuel to the fire. The patient's wife is worried
and harrassed by the reduction in his income, and her concern is seldom well concealed.
The man's friends remind him of other injured workmen, and endless discussions about
compensation are overheard in the hospital wards. Often an uncautious remark from
his doctor, or injudicious display to the patient of his X-ray plates, may engender fear
that fans the flame of his neurosis. It is always unfortunate if the doctor does not have
a precise answer to the patient's questions about length of disability. If the doctor has
doubts about this, who can blame the patient if he develops fears that he may never
recover?
In conclusion, the following suggestions for the prevention and handling of compensation neurosis are offered:
1. Every compensation case is a potential neurotic. Functionanl symptoms should
be recognized early and the total situation organized in a manner that will prevent the
exaggeration of these symptoms. This is practical psychotherapy, and it is entirely in
the hands of the general practitioner. Unless circumstances are exceptional the medical
attendant should inform the patient of the prognosis at the earliest possible moment.
It is in the best interests of the patient for the doctor to form his prognosis as though
the case were not affected by compensation. For the foreigner, whose command of our
language is slight, the use of a good interpreter in the early stages of convalescence is
important. His English may suffice for basic needs, but it is sadly inadequate when he
tries to relate fears and queer feelings to his doctor.
2. Psychotherapy in the sense of reviewing a man's background and pointing out
his bad habit of thinking, is almost useless while he is still receiving compensation.
Before such treatment can attain any success it is necessary for the workman to receive
a final settlement of his claim in a lump sum payment. In a case under the Workmen'*
Compensation Board of British Columbia, the practical difficulties of this form of settlement are numerous. It is a procedure that is seldom attempted. Thus psychotherapy
as a cure for the fully developed compensation neurosis is no solution of the problem.
3. To enable workmen to return to a self-supporting state in a more reasonable
period, more light jobs and part-time jobs must be made available, with an assurance
of adequate wages, and a return to their old job when they are fit.
4. For workmen who have no regular employer the gap between compensation and
gainful employment should be spanned by adequate unemployment insurance.    The
Unemployment Insurance Commission will then have the responsibility of finding the
man another job, a responsibility that the Workmen's Compensation Board does not, at
present, assume.
*       *       *       *
EARLY PSYCHOTIC MANIFESTATIONS
RESEMBLING NEUROSES
Dr. W. A. Dobson
In most of the psychoses before the disease expresses itself frankly, there is found,
early, a picture lasting from months to very much longer in which the manifestations
are not unlike those exhibited in a well developed neurosis, but while the complaints may
be similar, the background,  the personality of the patient,  and his reactions to his
Page 140 environment are vastly different.    The latter elements are important ones that must be
brought out to avoid confusion and error in arriving at a correct diagnosis.
It is of importance to the patient that his case be understood early, as the approach
to and management of a neurosis is very different from the treatment of a psychosis.
In the latter, the psychoses, much of the success in using the later methods depends on
an early attack on the illness.
Irritability, anxiety, introspection, impaired concentration, worry, insomnia, weakness, undue fatigability, loss of appetite, impaired interest, headaches, ringing in the
ears and many other complaints without organic foundation are not confined to the
neurotic but are frequently prodromes of a psychosis that will declare itself more frankly
later on.
If a diagnosis of a neurosis has been made and later a psychosis develops, the original
diagnosis has almost invariably been wrong.
Strecker in his Clinical Psychiatry states: "It is only the occasional patient whose
neurosis becomes so severe and so complicated that he is judged mentally abnormal
according to strict clinical standards. Those who break under the strain of life tend
to develop a neurosis or a psychosis and only infrequently do they merge from one into
the other."
Frequently a psychotic syndrome may be preceded by long periods of neurotic-like
symptoms and it is to stress that point that I wish to present some typical cases that
came to my notice in recent years.
Mrs. K. N.—Nothing unusual was noticed until, as a girl of 16, she "dressed up"
one evening and announced that she was going to a party with one of her girl friends.
She did not return until about breakfast time the following morning. She was tired,
irritable, and refused to give any information regardingn the previous night.
She lived with her father, who was separated from his wife. Temper, tantrums,
defiance and "hysterical" episodes continued for some days and she was then taken to
the family doctor, who felt that the home environment was responsible for the apparent
neurosis.   He advised a girl's school in another city.
Some months later she arrived home unexpectedly and explained that the teachers
were unfair to her and that she had had trouble with some of the other pupils. She
asked for a business course but took little interest in it and gave it up after a few
months.
Two years later she married a man whom she had known only a short time. Thev
were not suited to each other and she was poorly provided for and neglected a good deal.
Moodiness, temper tantrums and periods of extreme excitement recurred every few
months. It was again thought that her unfavorable environment was the cause of
neurotic episodes.
After two years she obtained a divorce and eventually married an understanding,
sympathetic man who provided her with a good home and they soon had a circle of nice
congenial friends. It was felt by her friends that she would have no recurrences, but
before the end of a year the old symptoms began to be exhibited at intervals but not
severe enough, in the opinion of her husband, to necessitate any special examination.
However, the attacks became more severe and eventually more frequent and alarming. About the close of the next 12 months expansive delusions and hallucinations
became manifest, she thought she had a great mission to perform, talked intimately
about important people who were really known to her by name only.
A psychiatric examination was then made, ten years after her first upset, and the
diagnosis of schizophrenia was made. The patient is now in a mental hospital and with
a very poor prognosis.
Miss JR.., teacher, 5 8 years of age.
Taught school for over 30 years in Ontario and was considered successful.
Never much for social life but history did not indicate a "shut in" personality.
At the close of her last term at teaching she felt tired, had a poor appetite, mild
headaches, and could not get interested in anything as usual.
Page 141 Her doctor Considered she needed a long rest and advised giving up her work for at
least a year. "Neurasthenia" was given as the diagnosis and with rest and tonic treatments she improved and decided to come to the Coast. Here she continued to improve
and it was thought that she would soon recover from the "neurosis." She had a setback after about two months and was put in a rest home for observation.
She was difficult to approach and it was felt that she was worrying unduly about
some episode in the past. Eventually she discussed a rather innocent happening of many
years before. After that frank talk she rapidly improved, she lost her tenseness, began
to eat and sleep well and was discharged in the care of a sister a few weeks after
admission.
A month later she rapidly became depressed and suicidal and was certified as a case
of involutional melancholia.
THE SIGNIFICANCE OF SYMPTOMS IN THE NEUROSES
S. E. C. Turvey, M.D.
I have been asked to discuss the significance of the actual complaint of the patient,
and how these specific symptoms should be evaluated by the physician. Your chairman
suggested that I discuss headaches and backaches in the allotted ten minutes, but fortunately he has an excellent sense of humour.
Just as in any disease, we must never forget that the patient comes to us because of
a-specific complaint or complaints with which we must deal in order to give him relief
or to cure him, but in no branch of medicine does the actual complaint mean as little
as in the so-called functional disorders. I say "so-called" advisedly, because I am surprised that we still tolerate this ivision between the non-organic and the organic disease.
A disease is "organic" when there is a recognizable structural defect. When the search
for this defect fails, or when, for clinical reasons, the presence of such a defect seems
unlikely, it is regarded as a "functional" defect. To quote Kinnear Wilson: "This
antithesis between organic and functional disease still lingers at the bedside and in medical literature, though it is transparently false and has been abandoned long since by all
contemplative minds." For one reason, all patients who have a so-called functional
condition have symptoms which to them are unpleasant and should be classified etymo-
logically as "pain." And pain can never be in the imagination of the patient. One
either has a pain or one does not, but the fact that one pain has an organic basis and
another is a somatic misinterpretation, cannot alter the irrefutable fact that both are
pains. The reality of the pain of the psychoneurotic is no less than that of the man
with a crushed limb. I frequently hear excellent j&iysicians tell their patients there is
nothing wrong with them, "Just forget it and don't worry," or, even worse, "This is
all in your head, you are just imagining it." A leading medical institution (clinic) to
the south of us treats functional disorders by doing every imaginable test for organic
function, then almost literally patting the patient on the back, assures him they have
ruled out every serious disease and that he must not worry any more about his complaints. We must not forget that the patient consulted the physician for a sensation
that was not pleasurable but painful. To eliminate organic disease is of little interest to
the sufferer.
As Kinnear Wilson so aptly writes: "In the first place, symptoms are physiological
reactions to stimuli, of which only three classes exist—pure excitants, pure depressants,
and those which first excite and then depress. Symptoms therefore stand for either
excitation or arrest of function, or exhibit a sequence in which the latter follows the
first. Without exception, all are 'functional' whether classifiable as motor, sensory,
vegetative, or physical; they consist in either increase (or 'escape') of function, or of
decrease—together, in change of function—and there is nothing else. Further, none
can be specific unless we imagine reactions themselves to be so—an impossibility when
the heterogeneousness of stimuli is borne in mind.
Page 142 T
"In the second, being the expression of a dynamic process a symptom is likely to
fluctuate from time to time, and this is true of all; innumerable symptoms taken to be
the mirror of structural disease do so vary—witness the 'fluidity* of tremors in paralysis
agitans, mobile pareses of myasthenia gravis, fleeting paresthesias of polysclerosis, and
so on. Only when structural change is permanent, when tissue reaction has come to
an end, does a given symptom become stabilized or static. Symptoms per se exemplify
dynamic alteration in function and may or may not coincide with evident structural
change. Further, those due to dynamic and to static 'lesions' cannot in general be distinguished; an extensor response present for five minutes after a major seizure is identical
with one, based on lateral sclerosis, that endures; the transient hemiplegia of angiospasm
has the same features as that of permanent occlusion. Differences obtain, however,
between certain psychoneurotic symptoms and those of the same orders induced by
structural lesions."
In the past fifty years of medicine, all of you can recall many instances of disorders
which had been classified as "functional," for which advancing medical science has
since found an organic base, so now the symptom is treated with respect. As one of my
colleagues in this symposium will tell you later, there is a great deal of evidence now
arising, and from anatomists—of all people—that would suggest there may be an
"organic basis" for many psychoneuroses. At the present time, we are justified in using
the term "neurosis" or "psychoneurosis' to indicate a disease of which we do not yet
know the exact mechanism, but it should be kept, always in the back of our minds that
there can be no radical distinction between the neurosis and any other syndrome of
organic disease of the nervous system. As our chemical and pathological techniques
and our therapies improve in the future, the functional states of today may acquire a
dignified organic background.
When I say that the complaint or symptom in the functional state is not important,
I infer that it is relatively unimportant. If a man has angina of effort> that is obviously
a significant complaint which should be analyzed thoroughly and treated adequately.
But people with a neurosis have not only one complaint as a rule, but may have a dozen
or more. To attempt to treat each one would be an endless task. Undoubtedly, we
should take an adequate history and do a thorough examination, but when we can find
no organic basis for the condition, then the individual symptoms must be fitted into the /
broader background of the patient's heredity, personality and development. At the risk
of repeating what has been said by others this evening, I would emphasize the futility
of attempting to explain to the patient the significance of each symptom. We should
rather make a rational analysis of the individual as a unit and, of course, explain to the
patient the purpose of this therapeusis. The history of the patient's present illness can
be only a few lines, but the family history and developmental history must be long
paragraphs.
Another thing I would like to emphasize is the significance of terminology, which
I will illustrate by three examples. A patient will complain of dizziness. To accept
his definition of the word "dizzy" can be an error, because there are at least four types
of dizziness, and all have a different significance. In the first of these, there is an objective sense of movement of external objects in the patient's environmnt. This to the
physician is vertigo. In the second, there is a subjective sense of movement in which
the patient feels as if he Mmself is spinning or swaying or failing, or as if he has been
hit by some invisible force. In the third, there is actual movement of the patient insofar
as he sways, staggers or even falls. Lastly, there is a postural instability in which the
dizziness occurs only when the patient is in certain positions. The site of origin of
these types of dizziness may vary from the cerebellopontine angle, to the brain stem, to
the cerebellum, to the cerebrum, to the labyrinth, to the Eustachian tube, to the spinal
cord or to a psychoneurosis.
Another instance would be the use of the word "unconscious." Probably there are
no two physicians who have the same conception of this word. To some, it means a
state of coma or stupor in which the patient cannot be roused; to others, it means that
the patient is not aware of his environment.   The football player who is dazed and runs
Page 143 with the ball in the wrong direction is certainly not aware of his environment and
properly should be called "unconscious" but not many of us use the term in this way.
I have workmen tell me that they have been unconscious for three weeks after a head
injury, but on analysis of what they mean by "unconscious," it is evident that they
have been in coma two to three minutes but they have not been aware of their environment for two to three weeks, and have only been suffering from post-traumatic amnesia.
The third example concerns the confusion of the laity and the medical profession
concerning the word "headache." It varies from several varieties of pain, to a pressure-
sensation, to a 'funny feeling," to pins and needles in the scalp, to a "crawling sensation in my head," etc. The patient's complaint should never be accepted unless his
meaning of the term is analyzed.
In conclusion, the symptoms in the neuroses are of great significance to the patient
and must be evaluated patiently by the physician, but they are probably the smallest part
of the broad problem.
TREATMENT    $
Dr. Geo. A. Davidson
The Psychobiological Concept: Earlier speakers have emphasized the background and
personality of the psychoneurotic individual. It was pointed out that treatment is
started with the understanding of the individual and that it is necessary to be familiar
with the patterns of behaviour and characteristics of the individual to be treated. This
will only come from a carefully taken biographical sketch, for we find a certain pattern
of behaviour running through the life story and not simply peculiar behaviour suddenly
stated. In medicine we are too apt to be content with a cross section view of the
individual. We too often ask what has happened to this individual at this time, rather
than seek the longitudinal view which familiarizes us with the kind of individual with
whom we are dealing and the environmental and familial influences that have influenced
his behaviour and reaction to sickness and other problems. This longitudinal picture
has been called the Psychobiological concept and is stressed in dealing with personality
disorders in modern medicine.
The Insecure Diagnosis: One should beware of making diagnoses that are vague and
indefinite. Too often the pain is thought to be due to a "little neurotis," "arthritis" or
"colitis" when there is nothing whatever to support such a diagnosis. Worse still are
labels such as nervous debility, nervous depletion, and chronic nervous exhaustion—
meaningless labels that convince the patient that he has a disorder that baffles the medical profession and everyone else. Once such a diagnosis has been made the patient is
reluctant to relinquish it. "Nobody has understood my trouble as well as Dr. X and
he told me I had chronic nervous exhaustion and that it would take months or years
vto get over it."
One "don't" in the treatment of the patient with functional disease is: "don't encourage him in the belief of the organic nature of his complaints. Often, because of
inadequate explanation and the simple command to "try this," the patient is encouraged
to believe that the medical man is convinced that his symptoms are organic. If not,
why does he treat the complaints? In other words, the giving of drugs is the tacit
agreement with the patient of the physician's belief of the organic nature of his symptoms. Don't encourage the overwork theory or untold harm may be done. If the
patient is having difficulty in standing up to his problems and his medical adviser suggests overwork (and many, many more patients seem to be more afraid of overwork
than actually do overwork) he is given a legitimate excuse to evade his work and
responsibilities and has the encouragement of his medical adviser. In future, when the
problems become difficult he is likely to again rely on this form of behaviour and leave
his poor wife to stoke the furnace and do the other unpleasant tasks. At this stage a
medical man may be able to nip a flagrant neurosis in the bud or he may encourage the
Page 144 development of a condition which may last for years or for life and cause great suffering
to the patient, family and friends.
If sedatives are given, tell the patient why they are given, e.g., you have symptoms
that are the result of your anxiety. You have had difficulty in keeping your emotions
under control because of your inability to find a solution for your problems. These at
present seem too much for you. This medicine is to help you to relax, to help you to
sleep and to help you to regain better control of yourself so that we may go into your
problems more fully and work out a solution for them. I shall be glad to help you with
your problems. The medicine is not meant to cure you and will not cure you, but
will simply help you over this difficult period. In this way the patient is made to realize
that he is not going to be allowed to simply sit back and let his medical adviser arrange
his whole future. At once he is made to realize that this is his problem and that he
must prepare himself to solve it.
However, the patient must be allowed to keep his self-respect. He has been told
to snap out of it, pull himself together, to stop worrying and thinking about himself
so often that he feels that he is to blame. Point out his assets. Usually he is an individual with average or high intelligence; he is often over-scrupulous and he has usually
been making sincere efforts to adjust. His failure to do so has added to his emotional
problems and has increased his difficulties. Building him up a little (but still omitting
the overwork theory) is worthwhile and may start him on the road back.
The Physiological Concept: Dixon1 of Portland has stressed the physiological approach to the treatment of the neuroses. In most of the neuroses we find physical
complaints such as weakness, headaches, pressure sensations, choking sensations, cardiac
disturbances, stomach and bowel disturbances, and. vasomotor disturbances such as
blanching, flushing, sweating, etc. When the complaint is of the compulsion-obsession
type with the fears of sleeplessness, suicide, homicide, etc., there are usually physical
symptoms as well if one enquires for them, but frequently they are not mentioned as
they are overshadowed by the fears.
Dixon1 starts out by explaining to the patient that there are two -nervous systems:
(a) the voluntary, (b) the autonomic, and he briefly describes the functions of each.
He impresses the patient with the fact that we all suffer from such symptoms in emergencies and points out that the difference is that in the patient's case the symptoms are
more prolonged. In this way he gives the patient a tangible basis for his complaint and
lets.him see that his symptoms are understandable. He believes that it is necessary to
repeat these views over and over to the patient as in his bewildered state the patient is
unable to grasp much at one sitting. He repeats over and over again the story of worry
being a function of the frontal lobes, of it being relayed to the more primitive hypothalamus which is the centre for the autonomic nervous system and of the impulses
travelling through the formatio reticularis to the reticulo-spinal tract to the antonomic
system, the endocrines, the adrenals, etc., producing the symptoms that we all know and
feel at intervals for short periods.
With this simple explanation and encouragement the patient is likely to settle down
sufficiently to discuss his problems satisfactorily and to be less concerned about his
symptoms. Then the relationship of his anxiety to such things as his feelings of childhood insecurity can be stressed so that he can better understand his symptoms and himself, and as a result will be less afraid of them and more able to deal with them. It is
the thing that is not understood that is most likely to produce symptoms.
It is not thought wise to try to "eliminate" thoughts and the advice frequently
given to "forget it—there is nothing wrong with you" is more likely to do harm than
good. Certainly, the symptoms are very definite, very real and very distressing in the
true condition.
Actually, physiological disturbances play a large part in medical practice. Witkower,
Rodger and Wilson2 stated that nine out of ten patients admitted to cardiac hospitals
during the last war were suffering from functional diseases. These were the men diagnosed as D.A.H. with the rapid heart, pain over the cardiac area, breathlessness and
anxiety.    The group as a whole had an unusually keen sense of duty, were usually the
Page 145 sons of hard working fathers, teetotallers and strict disciplinarians. The patients themselves were more often than not over-scrupulous and over-conscientious. Not infrequently the onset of the trouble was following acute febrile symptoms, but there is no
support for the belief that the condition was a toxic one. The vague condition often
called "Colitis" (unqualified) is often the bowel's reaction to anxiety.
One should be on the lookout for physiological manifestations of anxiety following
organic disease and especially following head injury. Again it may be emphasized that
the more stable the individual the less likelihood of such symptoms developing. There
again the medical man plays a very important part in his ability to dispel anxiety early
in both patients and relatives. One is justified in doing so according to Ritchie Russell3.
He states: "In most cases of closed injury in young subjects a good recovery can be
confidently predicted if the patient survives the first 24 hours. It is noteworthy, therefore, that within a short period of admission to hospital the atmosphere around the
patient should change from one of anxious care to that of cheerful optimism. The
second stage should be reached, if possible, before recovery of full consciousness. The
patients mental reaction to recovery of consciousness in bed, surrounded by dim lights
and shadowy figures, with a splitting headache, confused thoughts and complete amnesia
for the reason of it all, may be almost catastrophic, and frequently sows the seeds of a
future anxiety neurosis. Medical and nursing personnel often aggravate this reaction by
talking to him of severe concussion, fracture of the base, probably long incapacity and
possible after-effects.    These sadistic activities must be rigorously suppressed."
It will be seen that in discussing treatment the tendency is to a large extent to discuss prophylaxis.
When one sees a patient in an acute anxiety state, unable to sit still, weeping, wringing his hands, and unable to intelligently discuss his condition or to listen to what is
said, the best procedure is a few days in bed in hospital with sedation, the elimination
of relatives and overanxious friends and a firm but kindly nurse in charge. This hospitalization should not continue long but may be an opportunity of getting acquainted
with the patient and getting him started properly on the subsequent treatment. In
practice one is much more frequently called upon to deal with a fairly well established
condition.
Summary.
Discussion is given of the treatment of the psychoneuroses.
The psychobiological concept is discussed.
Insecure diagnoses such as "neuritis" are not advisable.
The patient should be permitted to keep his self-respect.
The physiological concept in treatment is discM&sed. ♦
BIBLIOGRAPHPY
1. Dixon, Henry, Portland Oregon: Personal Communication.
2. Witkower, Rodger and Wilson: Lancet, 1941, Vol. I, p. 531.
3. Russell, Ritchie: B.M.J., 1942, Vol. II, p. 521.
CANADIAN MEDICAL ASSOCIATION
HOW TO BECOME A MEMBER!
THE FEE IS $8.00 NOW
The office of the College of Physicians and Surgeons accepts the $8.00
fee for transmission to the Canadian Medical Association office.
THE CANADIAN MEDICAL ASSOCIATION NEEDS YOU.
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The C.M.A. must speak for Canadian Medicine and represent it "with
95 to 100% membership.
Page 146 THE RELATION OF THE PHARMACISTS OF CANADA
TO PUBLIC HEALTH AND HEALTH INSURANCE
By H. H. Wolfenden, F.A.C.
(Continued from the January Issue)
(rPresent-day Deficiencies" in Public Health and Medical Services
The fact that Dr. Heagerty's letter makes specific mention of his instructions to
discuss "present day deficiencies in the field of public health and medical services" holds
particular interest for all who have given close attention to the methods by which an
improved state of healthiness might be attained throughout the whole population of a
country such as Canada. In any field of human activity nothing is more simple than
to point out deficiencies, defects, some measure of laxness on occasion, sometimes culpability, often areas where improvements could be made. This possibility, of course, has
already been seized in Canada—in various articles, for instance, in the press, and
especially in some which have given indefensible quotations of complex statistics from
reports like that of the "Study and Distribution of Medical Care and Public Health
Services in Canada" by the National Committee for Mental Hygiene. On the basis of
uncertain, and in many cases wholly dissimilar, statistics from that report, which should
never be compared at all, writers have agitated the public with statements that "the
health of Canadians is a national disgrace," and that it is in a "deplorable condition,"
leading even to the suggestion that "most of the population is without adequate medical
care." Another "Study" for the Royal Commission on Dominion-Provincial Relations,
by A. E. Grauer, has also adopted that easily critical viewpoint which alleges that there
are, in our present public health arrangements, "many instances of poor organization,
lack of co-operation, lack of knowledge, lack of adequate funds at any time, lack of
adequqate funds at the right time—and consequent waste." In an imperfect world
more seriously imperfect, we are now learning, than was previously understood before
the outbreak of this war—lack of uniformity is of course inevitable. Lack of uniformity, however, is not a crime—nor of itself is it undesirable. Men are not.all born
"free and equal"; their mental and physical equipments are startlingly lacking in any
kind of similarity; their ambitions are far from being identical; and their powers of
concentration vary widely. These inequalities in human capacities are so utterly
unchangeable, and in many respects so resistant and unresponsive to any kind of control, that the first grave question to be settled in formulating any approach to policies
respecting public health ought to be some clearer notions of the degree of success that
is likely to attend the imposition from above of rules and regulations which, by their
very nature, must attempt to reduce all the complicated ramifications of human endeavour to a simple and invariable formula. The promulgation of a "plan" of some sort,
mainly because it satisfies the planner's craving for uniformity in an uncertain world,
generally produces little more than another set of problems, over which the planner
then proceeds to rule with a powerful and often arbitrary hand. This is not to say that
all "planning" is defective; it does imply, however, that we should nont be deluded into
reposing faith in the mere fact that a "plan" has been produced, which then is to be
pressed actively on an unprepared and unthinking population. It will be most desirable, therefore, for everyone to seek the motives of the plan, to understand the groups
from which its advocacy comes, to examine its provisions carefully, and to withhold
agreement until it shall be found to satisfy the legitimate requirements of all those who
must be ruled by it. Such explorations of any scheme which aims to impose static
regulations on a dynamic world reflect one of the first rights of every citizen in a
democracy.
The Importance of the Preventive Services.
Because it is thus much too easy, and in the main destructive, simply to point out
imperfections in the present organization of the public health services, careful thought
should be given, at the commencement of any discussion of the whole problem, to the
steps which would be most" advisable and statesmanlike for the amelioration of those
defects.    Certainly it is a truism to observe that prevention is better than cure—but it
Page 147 is a platitude which in this field contains much more truth than has ever been conceded
by the advocates of "health insurance." On several previous occasions—particularly in
an address on "The Financial Implications of Compulsory Health Insurance" before the
Sixth Canadian Conference on Social Work in 1938 (reprinted in the Report of the
National Committee for Mental Hygiene already mentioned, and also in the booklet
entitled "The Canadian Medical Association and the Problems of Medical Economics,"
containing a reprint of my articles in the Canadian Medical Association Journal—I have
emphasized that "the co-ordination and enlargement of the preventive services, for all
the people, could do much more to eliminate illness, to prevent its spread, and to control
its ill effects than we have yet realized. Those preventive services might include not
only the wider dissemination of public health literature, sanitary engineering, more
effective control of epidemic diseases, and more intensive scientific research in medicine
and public health—as advocated by the Commissioners themselves in their final views as
stated in the Report of the Royal Commission on Dominion-Provincial Relations—but
also they might embrace, after some preliminary period of education, such evidently
sound precautions as the certification of fitness for marriage, sterilization, the designation of pregnancy as a notifiable condition, periodical health examinations, and wider
sickness registration, as well as improved nutrition, better control and ultimate elimination of slum conditions, wider facilities for physical and mental recreation, and similar
measures with the object of producing a better race of people.
Many parts of such a programme, of course, would encounter varying degrees of
opposition, and because they do not tempt the electorate with nebulous promises of a
medical Utopia they find little support except amongst a few. Those who have re-
emphasized the importance of preventive measures as the first step to be considered in
any "plan" are, however, in good company. In Great Britain, for example, some most
pertinent thoughts on this subject were expressed in a notable Reservation to the
Majority Report of the Royal Commission on National Health Insurance, in the following language:
"On a review of the evidence we cannot but feel that there is considerable confusion
in certain quarters with regard to the relation which exists between the care of the
individual's health and the wider question of the promotion of the health of the community. Obviously the medical profession can give curative treatment to individuals
alone; obviously, also, a community in which every individual is healthy will be a healthy
community. It seems in consequence to be frequently assumed that by merely attending to the health of individuals, a healthy populations will finally emerge. We believe
this to be a profound error, and we are glad to be able to cite the evidence of the British
Medical Association that the organization of a National Health Insurance Scheme
(which primarily relies on giving medical benefit to individuals) is not even probably
the best means of utilizing unlimited resources for the promotion of national health.
We are also glad to be able to quote their view that 'the alleviation or cure of morbid
conditions when once they have arisen' is relatively to other matters, a minor part in
the campaign for public health. . . . Ill-health will remain if the causes of ill-health
remain, and the fundamental problem here is not, strictly speaking, a medical one.
Ultimate victory may come from the sanitary side of medical science."
In Canada, moreover, after a very extensive examination of the whole problem from
coast to coast, the Commissioners of the Dominion-Provincial Relations enquiry refrained from recommending "health insurance"; they were content only to point out
that "Provincial responsibilities in health matters should be considered basic and residuel,"
and that "Dominion activities . . . should be considered exceptions to the general rule
of Provincial responsibility"—whence they concluded that "it must not, of course, be
assumed that the Commission is in any way recommending the adoption of health insurance by the provinces; this is clearly a matter of Provincial policy in which the province
should have full discretion."
From these carefully expressed opinions by detached observers it is clear that the
first approach to the whole public health problem ought to be through the enlargement
and improvement of the preventive services.    While this would naturally and properly
Page 148 entail some increase of government activities, especially by the Dominion and Provincial Public Health Departments, it would require the active co-operation of the medical,
dental, pharmaceutical, and allied professions; in fact, it might involve so great an
increase in "the sanitary side of medical science" that the doctors, dentists, pharmacists,
and others associated with them would find their work so much enlarged, and in its
preventive aspects so largely compensated from the public funds, that many of the
present economic pressures that are partially responsible for the current discussions of
"health insurance" might largely disappear. Such an emphasis on the preventive services, moreover, ought to be possible without the development of unwelcome regimentations by government officials, so long as the whole question could be approached in a
spirit of mutual assistance and co-operation. Until that stage is reached, however, all
these discussions will continue to degenerate, sooner or later, into manoeuvres for position
by pressure groups within the nation, with the inevitable consequence that any measures
ultimately adopted are then likely to be in reality designed mainly for the economic
benefit of certain particular classes and workers at the taxpayers' expense.
The importance of thus examining the possibility of extending the preventive services becomes evident if, as I have suggested elsewhere (see "The Canadian Medical
Association and the Problems of Medical Economics," pp. 5 and 99, and in previous
papers), we take time to relize that at present "we permit uncontrolled birth, provide
only partial health supervision during school years, then allow the adult to impair his
health in any way he chooses—through misfortune, ignorance, carelessness, or abuse;
and then, when people of all classes thus eventually fall ill, the 'health insurance5 plan
suggests that only a special class of them shall be assisted, in respect of certain particular
types of illness, and for an arbitrary length of time." It would seem to be not only
logical but wise "to concentrate a little more attention on the earlier portions of this
sequence of events," and for all the people*—not merely for a special group for a limited
time, as in fact is done under the usual stereotyped plans of governmental "health
insurance.
(To be Continued Next Month)
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Page 149 MS3BP5BSWSP
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Vitamin D 400 Int. Units
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DIGESTIVE DIFFERENCES
FOUND IN VARIOUS
"BULK"-FORMING MATERIALS
7 0Z.
I CiBBtOi
<>«
Diets included
known equalized
amounts of fibre from
various common food
sources. Subjects reported that of all the
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other gave as satisfactory laxative action as KELLOGGS
ALL-BRAN.
_W5S&* "*ES  U 01-
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'oz.
urnicr
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STUDIES recently undertaken at
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sources of "bulk" in the diet.
While heretofore nutritionists generally proceeded on the theory that
"fibre" from one food is no more or
less digestible than the fibre from
another, results of this research
indicate that there are wide differences in the human digestion of fibre
from different sources.
Obviously, the more fibre is
digested, the less remains to aid
proper elimination. Therefore, when
diets do not appear to supply
adequate "bulk", it may be desirable
to consider other sources of "bulk"
rather than merely adding more
"bulk" from the same sources.
Subjects of this experiment also
reported that of all the foods tested
the most desirable laxative action was
produced by KELLOGG'S ALL-
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KELLOGG COMPANY OF CANADA, LTD.
London, Canada
Kindly send me free reprint of full
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Doctor	
Address	 m
11I1IIIIIII1IIIIII1IIIIIITIITIITTITTI IITlIIIllIIIlIIttllllllllflllllllllllllllltlllllllllllllllllllllllllllltllltllllllllllllllllllllllllltllElIIlIIIIlIIlltllfllllllllllllllllilllltllllllllillllllllltllllllllllllllll
66
That muscle's
from eating
1     milf
In urging upon parents the im-.
portance of a milk-rich diet for
growing children, physicians are
performing a communal service
of utmost value.
All normal children—even
those with a limited tolerance for
milk consumed as a beverage —
will readily "eat" more milk, if it
is offered to them in an appetizing form.
Irradiated Carnation Milk is
especially useful in accomplishing
this result. Its creamy smoothness
due to homogenization, improves
the taste and texture of the food.
And it may often be used undiluted (double rich), or only
partially diluted, to increase
significantly the milk solids in
every serving.... Carnation Co,
Limited, Abbott Street, Vancouver.
IRRADIATED
Carnation
b**?^
^^7
"FROM CONTENTED COWS"
Milk
A Canadian Product For a third of a century we have maintained
a top-flight pharmaceutical service—and have
been rewarded by the confidence of the medical profession.
Phone
MArine 4161
jChAl &JhuAu»*\
GEORGIA PHARMACY
f-M .1.7   t:  t
•■•*•**
(fritter Sc lattttafGfii
ESTABLISHED 1893
VANCOUVER, B. C.
North Vancouver, B. C.
Powell River, B. C.
r s^
#
$
H& ^itttf
Gta Ktautefc
/
^
s
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New Westminster, B. C.
For the treatment of
NEUROPSYCHIATRY
DISORDERS
Reference—B. C. Medical Association
. For information apply to
Medical Superintendent, New Westminster, B. C.
or 721 Medical-Dental Building, Vancouver, B. C.
PAcific 7823
Westminster 288
27

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