History of Nursing in Pacific Canada

The Vancouver Medical Association Bulletin: May, 1932 Vancouver Medical Association May 31, 1932

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  m
L
CTftANOSTHEATReEBLDs:
COST TO THE
PATIENT
Recognizing the limitations of too
competitive prescription cost and
maintaining the highest potency in
pharmaceuticals, we offer to our
customers the advantages of those
savings which are currently available.
LOWEST DISPENSING PRICES
CHAS. H. ANDERS, Chemist
GORDON M. CLAY, Associate Chemist THE     VANCOUVER     MEDICAL     ASSOCIATION
BULLEfTIN
Published Monthly under the Auspices of  the Vancouver Medical  Association in  the
Interests of the Medical Profession.
Offices:
203 Medical Dental Building, Georgia Street, Vancouver, B. C.
Editorial Board:
Dr.  J.  H.  McDermot
Dr. D. E. H. Cleveland Dr. H. A. DesBrisay
All communications to be addressed to the Editor at the above address.
Vol. VIII. MAY, 1932 No. 8
OFFICERS 1932-1933
Dr. Murray Blair Dr. "W. L. Pedlow Dr. C. W. Prowd
President Vice-President Past   President
Dr. L. H. Appleby Dr. W. T. Lockhart
Hon.  Secretary Hon.  Treasurer
Additional  Members  of  Executives:—Dr.  A.  C.  Frost;   Dr.   C.  H.  Vrooman
TRUSTEES
Dr. W. D. Brydone-Jack Dr. J. A. Gillespie Dr. J. M. Pearson
Auditors: Messrs. Shaw, Salter & Plommer
SECTIONS
Clinical Section
Dr.   A.   M.   Agnew   Chairman
Dr. W. H. Hatfield Secretary
Eye, Ear, Nose and Throat
Dr. J. A. Smith Chairman
Dr. A. O. Brown Secretary
Pediatric Section
Dr.  C.  A. Eggert Chairman
Dr. S. S. Murray  Secretary
Cancer Section
Dr.  A.  Y.  McNair Chairman
Dr. A. B. Schinbein Secretary
STANDING COMMITTEES
Library Orchestra Summer School
Dr. W. H. Hatfield Dr. J. R. Davies Dr. C. E. Brown
Dr. H. A. Spohn Dr. F. N. Robertson Dr- t- l- Butters
Dr. D. M. Meekison Dr. J. A. Smith P*. C. H. Vrooman
Dr.   H.   A.   DesBbisay Dr.  J. E. Harrison Db- J- w- Arbuckle
Dr.  D.  F.  Busteed Dr- H- A- Spohn
Dr. J. E. Harrison ,, Dr- H- R- Mustard
Publications „    ... ,
Dinner Dr- J- H- MacDermot Dr. A# W. Bagnall
Dr. D. E. H. Cleveland      Dr. f. j. Buller
£R- ?* i  w"5 Dr-   H"   A>   DesBbisay Dr.  V.  C  Walsh
Dr.  A.   M.  Warner Dr   g B   Peele
Dr. A. T. Henry
Credentials V.O.N. Advisory Board
„  . t.   ^   -., i    a Dr. F. P.  Patterson Dr. H. H. Caple
Rep. to B. C. Med. Assn.     t^ath^t ^ct'
iv^j/. ►« j-jr_   ^   j_   MacLachlan      Dr.   E.  Trapp
Dr.  G. F.  Strong Dr. S. Paulin Dr. J.  W.  Shier
Sickness and Benevolent Fund — The President — The Trustees VANCOUVER HEALTH DEPARTMENT
STATISTICS, MARCH,  1932
Total Population  (Census, 1931)            246,593
Asiatic  Population   (Estimated)     -   15,000
Rate per 1,000 Population
Total Deaths	
Asiatic   Deaths     	
Deaths—Residents  only  	
Birth Registrations	
Male      154
Female 13 0
INFANTILE MORTALITY—
Deaths under one year of age 	
Death Rate—Per 1,000 births 	
Stillbirths   (not included in above)   	
CASES OF CONTAGIOUS DISEASES REPORTED
210
10.0
17
13.3
196
9.4
284
13.6
IN
February, 1932
Cases      Deaths
March, 1932
Cases    Deaths
18
63.4
7
CITY
April 1st
to 15th, 1932
Cases    Deaths
Smallpox       2 5
Scarlet   Fever     5
Diphtheria   _.  6
Chicken-pox      4 5
Measles      1059
Mumps    ;~ 62
Whooping-cough     2 5
Typhoid Fever 	
Paratyphoid    	
Tuberculosis      .	
Poliomyelitis   	
Meningitis   (Epidemic)
Erysipelas	
Encephalitis Lethargica
1
0
35
0
0
5
0
10
0
1
0
3
0
3
0
0
12
0
0
1
0
9
15
6
40
214
62
29
1
0
49
0
0
2
0
3
0
0
0
0
0
0
0
0
13
0
0
0
0
1
8
16
16
38
16
,0
0
41
>0"
0
0
0
REST HAVEN SANITARIUM
On Marine Drive, near Victoria, B. C.
Practising Physicians and Surgeons are invited to send
their chronic or convalescent patients to Resthaven. High
Blood Pressure and Diabetic Diets prepared and administered by competent Dietitian. Your instructions carefully
carried   out.     Qualified   physician   and   nursing   staff   in
attendance.
Write, Telephone or Wire
Manager,  Rest Haven,  Sidney, B.  C.
Telephone Sidney 61L or 95
— Rates are no higher than Hospital Rates —
Page Canadian Interest
in Pasteurization of Milk
It is well to remember that Toronto was one of the first
cities on this continent to achieve the pasteurization of its milk
supply, with the exception of certified milk, and there are a reasonable number of other Canadian cities with similarly protected milk
supplies.
During the past winter the question of such requirements have
been actively debated at Calgary and at Winnipeg.
The Ontario Milk and Cream Distributors' Association has long
shown a constructive interest in this matter of a safe supply, and at
their  last  annual meeting passed  the following  resolution:
"Resolved, that whereas safe milk is recognized as ttx most
nourishing food for infants and growing children, and
Whereas, it is conceded by the medical profession that increased
consumption of safe milk not only by children but also by many
adults will be highly beneficial, and
Whereas, an increased consumption if milk will give a valuable
stimulus to the dairy farmers of Ontario, and
Whereas, it is -recognized that practically alt raw milk offered
for sale is dangerous and liable to carry such germs as will cause
tuberculosis, septic sore throat, undulant fever, diphtheria, dysentery,
etc., and
Whereas, efficient pasteurization of milk is the only known
method by which milk can be made safe:
"Be it resolved, that this Association request the provincial
government to enact such legislation as will require all milk offered
for sale for human consumption in all cities, towns, and villages,
where in the opinion of the Department it is practicable, in the
province  of   Ontario,   to   be  scientifically   pasteurized."
This statement of the case will rank with the best expositions
of the reasons for the method available for the protection of city
milk supplies.
^ASSOCIATED DAIRIES
Limited
DISTRIBUTING RICH, SAFE, CLEAN MILK
Phones:
Fairmont 1000—North 122—New Westminster 1445 ■ 777
WEST GEORGIA STREET
In our new location, with the finest of
accommodation and equipment, and staffed
by seven graduate pharmacists, we feel more
than ever qualified to do justice to the confidence reposed in us by the medical profession for the past quarter of a century.
SEYMOUR 1050
All Dav
Georgia
Pharmacy
F
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All Night
Gardenal
Both products are supplied
In tubes of:
in special containers to
20 tablets 0.10 gm. (l^gr.)
30 tablets 0.05 gm. ( ^ gr.)
80 tablets 0.01 gm. (1/6 gr.)
hospitals and
institutions
Hypnotic-Sedative
Most effective in the treatment of Epilepsy.
Soneryl
LABORATORY
POULENC FRERES
In tubes of:
20 tablets 0.10 gm. (iy2 gr.)
of CANADA, LTD.
(Under    licence    Rhone-Poulenc)
Hypnotic-Analgesic
For  sample and  literature:
ROUGIER FRERES, 3 50  Le Moyne St.
MONTREAL
A decided relief for pains,
neuralgia preventing sleep.
To   be  preferred  to   morphine and its derivatives. EDITOR'S PAGE
"O World, where all things change and nought abides . . . ."
One of the saddest lines in poetry, and as we get older, we feel its
truth more and more keenly.
This issue of the Bulletin is the last to be issued under the Editorship of Dr. J. M. Pearson. It is difficult, nay impossible, to write adequately of what this means. It would be as difficult to give adequate
tribute to all that our Editor has meant, not only to the Bulletin, but to
the Vancouver Medical Association as a whole, in all its activities.
Dr. Pearson is, perhaps, more closely identified with the Vancouver
Medical Association than any man in Vancouver. He was one of its
founders—he nursed it, and kept the breath of life in it, for many years—
he has never lost nor suffered any lessening, in his keen interest in it, his
love for it, and his personal devotion to its work. To those of us who,
in a far lesser degree, have been connected with its growth and activity,
his passion, his keenness, his high ambitions for its development, have
been an inspiration and a stimulus. He has always had an unwavering
faith in the destiny of the Vancouver Medical Association, and has determined always that its standards shall be high, and kept high. And as
the old legend says of Sir Christopher Wren, "Si monumentum requiris,
circumspice . . ." For, though not one of the biggest of medical organizations (what, after all, is size?) this is a singularly complete and well-
organized one—with a Library, which is more than merely a good Library,
with its own Bulletin, with a membership which is more truly representative than is the case with most medical organizations in large cities, and
with a long record of useful work, and real achievement.
Of course ,this is not all one man's work, and Dr. Pearson, himself,
would be the first to reject as fulsome and exaggerated flattery, any
suggestion that it was. But in every organization of the kind, there are
one or two men who stand out as the leaders, as the driving force, the
vitalizing influence—and we think all our readers will agree that this is
pre-eminently true of Dr. Pearson. The old Romans had a phrase that
strikes one as singularly apt, that they used when they wished to speak
of a man who had served the state. They said that he had deserved well
of his country, not that he had served it. And Dr. Pearson has deserved
well of his professional brethren. He has done yeoman service for them,
and in doing it for his profession, he has done it for his city and his
province. For a good job well done has more than a local effect—it is a
brick well and truly laid in a larger edifice, that of society at large.
And what of the Bulletin? Only those of us who have worked with
Dr. Pearson know what he has meant to the Bulletin. As with the larger
task, so with this, his faith has never wavered, his interest has never lost
its keenness, he has given unsparingly of his time and effort—those of a
man well-equipped for the work, sane and level-headed in all his ideas and
decisions. It is not exaggerating to say, and we say it in all sincerity,
that he cannot, at present at any rate, be replaced. Those of us who
follow him feel that we can only limp and halt in the pace he has set,
on the road along which he has led us.
Page 153 We will do our best—but it will only be good if we keep in mind
the ideals he set up for the Bulletin, and hew to the line he has drawn,
straight as a swallow's flight. And, since one element at least of gratitude is "a lively sense of favours to come," it is a cause for rejoicing that
we still have Dr. Pearson to guide us in other departments of our work
as an Association. We shall still have his wise counsel, cautious and conservative, yet full of vision and courage. We, who are on the Editorial
Board of the Bulletin, will still look to him as our Editor Emeritus, and
will welcome his advice and criticism at all times—for we know that
while he has relinquished "the labouring oar," he will still keep, warm
and alive, his interest in the publication he has served so long and so well.
NEWS AND NOTES
The death occurred on March 28 th, at her home in Vancouver, of
Mrs. A. W. Bagnall. To Dr. Bagnall and his son we wish to offer our
sincere sympathy. Mrs. Bagnall's loss will be felt widely and keenly in
Vancouver, as she was an active worker in many fields of altruistic endeavour.
The Summer School Committee has secured a specially attractive list
of speakers for its 1932 session which will be held September 13th to
16th, inclusive. One of the most noted of the lecturers who will come to
Vancouver is Dr. F. R. Miller, Professor of Physiology at Western University, London, Ont. In May, Professor Miller will be formally elected to
fellowship in the Royal Society. The F.R.S. is the highest honour that can
be paid to a scientist in the British Empire. The Royal Society, which received its charter in 1662 from Charles II., is the oldest scientific organization in the world. Samuel Pepys was one of its earliest members. Its
total membership at present is about 400 in the British nations, including
10 Canadian, and 3 5 from other countries. The distinction has been
conferred upon Professor Miller in recognition of his work in advancing
the knowledge of physiology of the nervous system.
The eighth annual meeting of the Western Branch Society of the
American Urological Association will be held at Portland, Oregon, on
July 1st and 2nd. The Association has honoured our colleague Dr. A.
W. Hunter in making him president for the coming year and we hasten
to tender our warm congratulations to Dr. Hunter, on this well-merited
distinction, and also to compliment the American Urological Association
upon its perspicacity exhibited in this choice.
We note that among other entertaining features at this convention,
a "dry clinic" will be held. This would hardly seem to justify special
mention, as it is well understood that all conventions held in U.S.A. may
be dry in every sense of the word except the most literal sense. It has
Page 154 occurred to us, however, that the term may have a special significance
when applied to an urological clinic.
He was a surgeon of national reputation. In matters of life and
death he had won lasting fame by the dexterity of his hand, the precision
of his handling of the surgical instruments, the wonderful keenness of
sight that backed up his marvellous mind and fingers.
But now he was in no hospital operating room. No white costume
shrouded him. No respectful concourse surrounded him. He was clad
in knickers and sweater and other habiliments of the golfer, and he stood
on the number one tee at the country club, ready to start his Saturday
afternoon round of golf, while quite a gathering of golfers and caddies
stood waiting their turn.
The hands that could wield the surgeon's knife a hair's breadth in
either direction, swung back the driver, there was a clumsy swish—and
there was the ball, still untouched, upon its tee.
Again the club came back. Once more it swung. Buck ague had
seized the famous surgeon. He missed it three inches this time. Quickly
he swung again ,and this time the club went into the ground well back
of the ball.
And then from the crowd of caddies gathered at the sidelines came
a hoarse whisper that everyone about the tee could hear:
"Gee!    How would'ja like t' have a guy like dat woik on ye'?"
MEETINGS
The monthly General Meeting was held on the 5th of April, in the
Auditorium of the Medical Dental Building; 80 members were present.
The speakers of the evening were Drs. A. W. Hunter and J. W. Thomson.
Dr. Hunter dealt with the "Diagnosis and Treatment of Urological Emergencies" and Dr. Thomson discussed "Emergencies in Abdominal Surgery."
Dr. Thomson's paper appears in this issue. Dr. Hunter's paper will be
printed later.
At the business meeting the bylaw relating to the Sickness and Benevolent Fund was amended, giving the Executive power to waive the levy
at any time and reimpose it at their discretion. Dr. Haywood brought
up the question of radium facilities in connection with the Vancouver
General Hospital, and on motion a meeting between Dr. Haywood, the
Cancer Section officers and the Executive was arranged. The Association
went on record as approving the action of the B. C. Medical Council in
regard to the Chiropractic and Drugless Healing Bill before the
House. Dr. Vrooman announced the facilities existing at the new Preventorium for children with regard to contact cases. Drs. H. C. Graham,
O, de Muth and E. L. Reid were nominated for membership.
The Clinical meeting was held in the Auditorium of the Vancouver
General Hospital on Tuesday, April  19th, when the members had an
Page   155 opportunity of hearing Dr. R. G. Lajoie, of Paris, for many years assistant to the eminent French cardiologist, Professor Vaquez. Dr. Lajoie
spoke on "The Average Dynamic Pressure, a new Criterion of Cardiac
Efficiency." Dr. Lajoie came to Vancouver fresh from addressing the
Academies of Medicine in Montreal and Toronto and the Association was
singularly fortunate in having him at its Clinical meeting. At the
close of the meeting refreshments were served through the courtesy of
Dr. Haywood.
B. C. MEDICAL ASSOCIATION ANNUAL MEETING
As announced in the last issue of the Bulletin, the Annual Meeting
of the B. C. Medical Association will be held at Kelowna, May 26th, 27th
and 28 th. Concurrently there will be a postgraduate meeting made possible through the generosity of the Sun Life Assurance Company. Please
refer back to your Vancouver Medical Association Bulletin for April for
particulars of some of the attractions. An elaborate scientific, business
and social programme has been arranged, advantage of which should be
taken by all doctors who can make the trip.
In regard to transportation and costs. Taking Vancouver as a base
the whole trip can be done for less than fifty dollars if by rail, and much
cheaper if automobile parties can be arranged with expenses shared. Alternative routes by rail—C.P.R. via Sicamous, C.P.R. via Kettle Valley,
C.N.R. via Kamloops.
For the information of those who propose to travel by auto it may
be stated that the distance from Vancouver is approximately three hundred miles, through some of the most wonderful scenery this province
has to offer, including the famous Fraser Canyon and via Spence's Bridge,
Ashcrof t and Kamloops.
One can leave Vancouver around five o'clock in the evening, drive
leisurely as far as Hope (about four hours' journey) or continue to Alexander Lodge, a reputable hostelry about one hour's ride beyond Hope.
The Hope Tavern, at Hope, can also be recommended. Leaving either
place about six o'clock next morning one should reach Kamloops about
noon and after lunch continue to Kelowna arriving about five o'clock
that afternoon
The Kelowna Board of Trade extends to all visiting doctors a most
cordial invitation and states that the Kelowna Lawn Tennis Club will
be happy to open its Club ground for their use, and that the Kelowna
Golf Club, the only eighteen hole course in the Interior extends an invitation to the golfing members to play over the course, a special rate of
$1.00 for green fees, for the period of the Convention being offered.
Members of the Board will be at your service for drives around the
country and give an assurance that they will do everything possible to
make the Convention a success.
Speakers at the Postgraduate meeting are as under:
Dr. E. L. Pope, Edmonton.
Dr. A. Gibson of Winnipeg.
Dr. A. W. Hunter of Vancouver.
Subjects to be announced later.
Page 156 EMERGENCY ABDOMINAL OPERATIONS
By Dr. J. W. Thomson
Emergency abdominal operations produce the most frequent thrills
to the general surgeon in their histories, their diagnosis, their operations
and their results.
I remember well, Dr. R. E. McKechnie telling me of an ectopic he
saw 5 miles from Nanaimo, where he hurried back to the city, picked up
Dr. Drysdale, an emergency operating kit, and drove back to the
house, where with the patient on the kitchen table he performed the operation in 23 minutes and saved the patient's life. Last summer, Dr. Knox,
of Kelowna, told of a case they had to operate on at home, where he used
the headlights of his automobile against the kitchen windows to give
them light for the operation.
In one paper it would be impossible to discuss this whole subject and
I will confine myself to a few of the conditions necessitating an emergency abdominal operation.
Traumatic Conditions Due to External Violence
In any case of abdominal trauma the decision must be made whether
the injury involves only the abdominal wall or includes damage to the
contained viscera.   The patient's life depends on the correct diagnosis.
Wounds of the abdomen may be divided into penetrating and nonpenetrating. Penetrating wounds present external signs that direct us to
the possible location of the intra-abdominal injury. Non-penetrating
wounds may present only contusion as a guide or no visible external evidence. Injuries may involve the hollow viscera such as stomach and intestines, the solid organs such as liver, spleen and kidneys, or may involve both.
As the automobile is frequently cited in the courts today we will take
an abdominal injury resulting from an auto accident. The patient may
have been knocked down and had one of the wheels run over his abdomen,
or he may have been knocked flat on the ground—the abdomen coming
in contact with some projecting object. Almost immediately the patient
shows evidence of abdominal shock, his face becomes pallid and has an
anxious expression, the surface of the body is covered with a cold sweat,
speech is broken, respiration shallow and rapid, and the pulse feeble.
The abdomen, which may or may not present signs of injury,
is almost equally painful over its whole surface. The patient is in a condition of abdominal shock. Of the nature of the deep lesions one knows
and can know nothing definitely at this stage.
The shock must first of all be combated, and the situation will become clearer and the indications more definite in the hours which immediately follow. We all know the measures to combat shock—patient kept
flat in bed, removal of the clothing with as little disturbance as possible,
external heat and intravenous saline. The patient must be watched closely.
If the patient rallies quickly—if the character of the pulse and facial
Read  before  Vancouver  Medical  Association,   April,   1932.
Page   157 aspect become satisfactory, if there is no increase in the abdominal pain
and no distension appears, if flatus and urine are passed, no surgeon would
insist on an operation.
Now take the other picture. The pulse remains feeble and rapid,
improves after an intravenous, but speedily weakens again, the temperature remains subnormal, the extremities are cold, the patient is restless
and anxious, his respiration is laboured, the abdomen is becoming distended, is rigid and the slightest pressure on any part is painful, and it
may be that the particular area which received the impact is very tender.
Possibly there is dullness in one of the iliac fossae, some degree of resonance in the hepatic region, and neither flatus nor urine has been passed.
In my opinion resonance in the hepatic region is of doubtful value, and
should only be taken into consideration along with the other symptoms.
With such conditions present, operate at once, and do not wait for vomiting or other symptoms.
In these cases without a definite abdominal wound I consider it
absolutely essential for the surgeon to stay by the bedside and closely
observe the patient himself. After all he has to take the responsibility of
opening the abdomen. Too often in the modern hospital the busy surgeon
trusts the observations of the house surgeon who gives the intravenous
and generally takes charge. Or if he be a young surgeon in a big city,
he is almost brushed aside by the hospital attendants. It is just as necessary for the surgeon to take charge of the details of preliminary care and
observation as to whether the patient is improving or "going bad", as it
is to do the operation. By this observation he can analyze the local signs
indicative of internal haemorrhage or intestinal rupture, and can decide,
without waiting for a demonstration of the deep lesions, whether or not
to operate.
Sometimes the surgeon comes upon the scene at a stage when the
patient is already suffering from widespread peritonitis, and the question
comes up whether he should refrain from operating, and refuse to take the
responsibility of the probable death. I do not think so. The use of blood
transfusions has given us great aid. The only chance the patient has is
in operation, and sometimes a patient will recover where there seems to
be no hope. Where one has diagnosed a ruptured bowel or a continuing
internal haemorrhage, I fail to see any argument for supportive waiting
treatment.
As to the technique of laparotomy in contusions of the abdomen—
where one has no definite lead I prefer a fairly large incision, silghtly to
the right of the mid-line in the lower abdomen. After the abdomen is
opened, often the blood wells into the wound. It is necessary to swab this
away quickly and gently. Suction can often be used with great benefit.
If necessary enlarge the wound freely. If the omentum is not bleeding
raise it up and carefully inspect the intestines as they appear. Sometimes
it is of aid to cover the small intestines with a large abdominal pad, which
will more or less localize them and enable the surgeon to get some indication of the source of blood if he has not already had this. It is also
helpful in looking for mesenteric tears, as from under the pad one can in-
Page 158 spect one side of the mesentery and then the other, and also gradually
release loops for inspection.
However, I will not proceed further in detail. In preparing this
paper I asked Dr. R. E. McKechnie his procedure in similar cases. He
shrugged his shoulders, and said: "Well, when you open the abdomen proceed to do whatever is necessary." That, very tersely, is what is required.
The source of bleeding may be from a tear in the omentum, a tear
in the mesentery or meso-colon. A tear of one of the peritoneal folds,
gastro-hepatic omentum, gastro-splenic omentum, etc., a rupture of a
large vessel, a rupture of wall of intestine, stomach, uterus, bladder, etc.,
any of these may be the source. Whatever the lesion is it must be attended to. One must also inspect for multiple lesions. Sometimes the
post-mortem examination reveals the fact that we did not finish the job.
These cases require careful post-operative observation. When they
recover they are very gratifying cases.
Ileus
Ileus may be defined as an interruption to the flow of intestinal contents through the gut, together with perverted motor responses in the
intestinal musculature and associated altered metabolic reactions.
Ileus is classified into two varieties: (1) The mechanical or dynamic
variety and (2) the paralytic or adynamic variety. Dynamic ileus occurs
wherever some mechanical barrier develops to the normal flow of intestinal contents. Such obstruction of intestinal contents may occur as
the result of: (a) Pressure applied to the intestinal tract from without,
such as adhesions or tumour, (b) Encroachments upon the lumen of the
gut arising from the wall of the intestine itself, usually as the result
of tumour formation either benign or malignant. (A case was cited
by the speaker to illustrate this.) (c) The presence of foreign bodies
within the lumen of the gut such as faecoliths, large impacted gall-
stoned or other foreign bodies.:
Various arguments are put forward as to the aetiology of ileus.
Mouyihan states that obstructions after abdominal operations are almost
always, if not invariably, due to infection, especially from pelvic peritonitis originating in appendicitis, or septic conditions of the pelvic genital
organs. The limited peritonitis causes complete paralytic obstruction of
the involved segments of intestine.
Murphy and Brooks, Hartwell and Hoguet, Wilkie and others, have
presented evidence to show that the essential factor in the production of
ileus is not blockage of the lumen of the intestine, but interference with
the blood supply of the intestinal wall; only when such vascular disturbance occurs do the various phenomena characteristic of ileus develop.
Others explain it by disturbance of the autonomic nervous system
by reflex irritation. It is generally accepted that the small intestine is
Page  159 controlled by a dual and antagonistic nerve supply. The vagus nerve
fibres are essentially motor or stimulating in their action whereas the nerve
fibres from the parasympathetic system are inhibitory in their action.
The two invariable signs of ileus are constipation and vomiting.
(a) Constipation does not become absolute at the time that obstruction occurs; inasmuch as the intestinal flow below the point of obstruction may contain products of digestion, and we may succeed in getting some apparently normal stools and flatus.    This is often misleading.
(b) Vomiting is the most characteristic sign of obstruction. At
first it is accompanied by retching. Later the vomiting becomes passive,
and the vomited material may spill out of the mouth without apparent
effort on the part of the patient. The vomitus at first is dark bile, sour
smelling, later becoming brown with a faecal odor.
Pain is a variable symptom depending on the presence or absence of
peritonitis. Distension may or may not be marked. The pulse before
vomiting starts is full, bounding and rapid, but soon the blood pressure
drops and the pulse becomes more rapid, weak and thready.
The patient early shows signs of toxaemia. Beads of perspiration
occur on the forehead, the skin is moist and clammy, the lips and nail beds
are frequently cyanotic. At the beginning, he is apprehensive and alert
mentally. He is restless and tosses about in bed. Later he becomes drowsy
and semicomatose.
We have the development of physico-chemical changes.    There is:
(1) A marked dehydration, by pouring of secretions into the obstructed intestine.
(2) There  is  marked  hypochloraemia.     Various  explanations   are
given as to the development of this condition.
(3) An increase of non-protein nitrogen in the blood.
(4) Alkalosis.
Treatment
(a) Prophylactic. In reviewing some of my own cases and searching for some explanation, there seemed to be a pre-existing condition of
atony, due to toxaemia from intestinal stasis or chronic obstruction, or
due to fatigue from overwork. If this could be definitely ascertained a
blood transfusion following the operation would aid.
The second point in prophylaxis is one that we should always observe
—that is the elimination of the cause by inflicting as little trauma as
possible, gentle manipulations, using as few sponges, as possible, and these
not too hot.
In the active treatment:
Until lately our treatment has consisted of intravenous injections of
various strengths of hypertonic saline solution, the application of moist
heat, various drugs to stimulate intestinal peristalsis, and when these fail,
Page 160 the performance of a high enterostomy by the Witzel method. Usually
we have regretted waiting too long to do the enterostomy, and the mortality rate has been very high—50 to 70%.
Robertson Ward, in the California and Western Medical Journal, of
December 29th, 1931, states that in four years he has not had a single
death from peritonitis not complicated by pneumonia, septicemia or some
similar disease. He recommends (1) continuous transnasal duodenal and
gastric drainage and frequent saline lavage during the stage of dilatation
and ileus. This is to be maintained until the tone of the bowel is restored
as shown by the rapid absorption of saline solution introduced through
the tube. (2) The administration of large amounts of normal saline solution beneath the skin or intravenously. (3) Morphine as demanded for
comfort, quiet and to lessen peristaltic activity. (3) Semi-Fowler position. (5) Nourishment, if given at all during ileus, consists of glucose
per rectal drip which also means a way of getting rid of flatus.
In this paper at times I have quoted from Cutting, in the American
Journal of Surgery, for December, 1931, and Goodwin Grover, Seattle,
whose paper appears in Northwest Medicine, for April, 1931.
Dr. Appleby, during his recent visit to California, saw the above
method in operation. The sisters of St. Paul's Hospital have had the
apparatus made and have kindly loaned it to-night for demonstration. I
will ask Dr. Appleby to demonstrate the apparatus.
(Dr. L. H. Appleby demonstrated the apparatus.)
Post Operative Obstruction
We must consider three types:
(a) That which occurs months or years after an operation and is due as
a rule either to strangulation by a band, or to adhesion of part of the
intestine to a raw surface left at the time of the original operation,
to the stump of an ovarian pedicle, to a gap in the suture line after
hysterectomy, etc.
(b) That which occurs within a few days of an operative procedure,
usually directly dependent on it or due to general causes, where the
obstruction is caused by plastic exudate, by agglutination of one or
more coils of intestine to other coils of intestine or other intra abdominal viscera.
N.B.—It is possible for ileus to develop following an extra-abdominal
operation or severe trauma elsewhere in the abdomen We have one
case on record in the Vancouver General Hospital following a fractured femur.
(c) That which occurs later than this, but still within the period of convalescence usually due to residual abscess formation. To illustrate
this subdivision, I would like to cite two cases.
Case A—June 21st, 1927—Acute gangrenous appendicitis with perforation. No sponges were introduced into abdomen, but soft rubber
drains to pelvis and site of appendix were left. Convalescence normal.
Discharged July 11th.
Page  161
^UU» The patient required no more attention until March 9th, 1929, For 3
days previous he had normal colicky pains which ended more or less in the
right quadrant. When I saw him obstruction was complete, enemata giving no results, and he was vomiting. There was more or less protration.
Following an intravenous, a laparotomy was done, revealing a tight thin
band of adhesions extending from the original scar to mesentery of small
intestine. A loop of small intestine had got down back of this causing
somplete obstruction. When the band was severed gas began working its
way through the bowel. At the time of operation small-intestine distension was very marked ,and this continued and became very serious after
the operation. Saline irrigations did not give much result. Finally on
the evening of 10th, I gave an irrigation myself using at least 5 gallons,
flowing in and out. Large quantities of dark foul smelling material were
brought away, with a considerable amount of gas, and patient's condition improved. Again in 12 hours this was repeated and from then on
convalescence was more or less normal.
He was again in hospital February 15th to 25th, 1930, with an
obstruction which was relieved by enemata.
On April 1st, 1930, he developed complete obstruction with typical
symptoms. Operation was done, freeing many loops of adherent small intestine and resecting eight inches of bowel that was so damaged by adhesions that it would have been futile to leave it. For two days he was
more or less under morphine, and vomiting started with all the signs of
ileus. In spite of blood transfusion and saline transfusions on the night
of the 4th his condition was so hopeless that Drs. R. E. McKechnie, B. D.
Gillies and myself considered it would be unwise even to attempt an
enterostomy. On the morning of the 5 th a suture had given way in the
incision, some omentum and "a piece of small intestine were presenting
themselves, and under local anaesthetic an enterostomy was done. Fortunately this loop was high. His condition improved and although he
suffered much from excoriation of the skin by discharge he finally got
well. Food given by mouth would be discharged from the wound starting
five minutes after ingestion. He was given intravenous injections of glucose and saline every 6 to 8 hours and had at least three more blood transfusions. In spite of this he became very dehydrated (as R. E. M. expressed it, he dried up like a mummy). It was. the end of April before
any food passed down the intestine. Finally the fistula was closed and
the patient recovered.
In November, 1930, he was in the hospital twice, with partial obstruction.
March 31, 1931, a final operation was done to free more adhesions
and close a large abdominal hernia.
From that time to
this he has
been
in excellent hea
1th
with
occas-
ional colicky pain.
Case B—Operation
September
6th,
1927.
Chronic
appendicitis
of
retrocaecal type (done in interval).
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"All classes of Insurance" Post operative history. No vomiting. More pain than visual. Required two injections of morphine gr. 1/6 c atrophine on the 6 th and
four closes of morphine gr. 1 /6 on the 7th. On the morning of the 8th,
4 ozs. olive oil were injected per rectum and four hours later an S.S.
enema was given without any result. On the evening of the 8th, the pulse
rose to 120 but dropped on the 9th, to rise again gradually. On the 8th,
double 1.2.3. enemas with eserine gave no result, but on the morning
of the 9th, large liquid bowel movements and gas passed. Abdominal distension began to appear but good results were obtained from two enemas
on the 9th.   Moist heat was applied to abdomen.
On the morning of September 10th, four days after operation, he
turned on his right side at 2:30 a.m., felt a sudden pain and was troubled
with gas pains after this. At 4 a.m. he vomited clear greenish fluid. At
9 a.m. stomach lavage was done. Vomiting continued, the distention increased. Various enemata were tried with practically no result. On 11th,
he had a liquid stool, hiccoughs started September 11th. Gradually
vomitus became faecal in odor and practically no result was obtained
from enemas.
On the night of September 11th, enterostomy was done with drainage
of the caecum.
Patient improved and some more faecal matter passed, but on
September 12th, nausea again started. Drainage decreased. This continued and on the 13 th a second enterostomy was done. Patient died on
the night of the 13 th.
In the preparation of this paper, Dr. Arthur Proctor and I examined
100 charts at a local hospital.   We found:
Cases    Recoveries    Doubtful
Ruptured liver   9                6 —
Ruptured spleen   2 11
Ruptured rectum -  11 —
Ruptured gall-bladder   11 —
Ruptured bladder   10 —
Ruptured intestine   3                 2 —
Mesenteric thrombosis   2                 1 —
Intestinal Obstruction
Cases    Recoveries    Doubtful
Dynamic type   16 9 —
Adynamic type   10 4 2
Obstruction Recovered Without Operation
Cases
Recovered      7
Died           2
Page  163 TUMOUR METASTASIS
By Dr. G. E. Kidd
The process of metastasis cannot be explained on the basis of a few
fundamental laws. The clinician has contributed most of the meagre
knowledge which we have on the subject, since such knowledge is of
tremendous importance to him in diagnosis and treatment. He has
learned from observation what varieties of tumours are prone to give
metastasis, and to what tissues. He knows from its location, the probability of a tumour being primary or secondary; where it has probably
come from, and where it is liable to go. For example, if multiple metastases are found in the bones of the pelvis, he looks for a primary tumour
in the prostate, or if he finds the supraclavicular glands involved, he
thinks of cancer in the upper abdomen. Our knowledge of the lymphatic
drainage of parts may be of value, as in cancer of the rectum, tongue or
lower lip ,etc, but as a rule dissemination of cancer from a primary focus
cannot be followed along anatomical channels.
Experimental work—Investigators have attempted to throw light on
the formation of metastatic abscesses by the injection into the blood
stream of inorganic materials such as mercury or manganese; or of infectious material such as tubercle bacilli. They found that while some
absceses formed as a result of the blockage of end arteries by the material
introduced, yet other conditions entered in, such as the relative volume of
blood flow to each organ, the rapidity or sluggishness of the blood stream
through capillary beds, and the tissue resistance, which tends to vary
greatly. So that we have the needs and requirements of the invader on
the one hand, and various conditions, chemical, thermic, structural, immunological, etc., presented by each different tissue, on the other. It was
found, also, that in the case of the infective material introduced, a metastatic abscess could be made to form in almost any tissue by traumatizing
it. When we come to consider the question of tumour metastasis, we find
that many of these same factors enter into it.
Tendency of tumours to metastasize—The malignancy of a tumour
is usually judged by its degree of anaplasia, (the property of reverting to
a more primitive tissue), its power to infiltrate, and its power to metastasize. But a distinctly anaplastic tumour may give no metastasis, while
others with little historical evidence of anaplasia, may metastasize. For
example, the epulis, many sarcomata, and cancers of the ovary, uterus,
or mediastinum, might be expected to metastasize and do not, while other
so-called benign tumours, such as fibroma, myxoma, glioma of the retina,
and thyroid tumours, are listed by some writers as occasionally leading
to secondary growths. Other factors entering into the readiness of a
tumour to metastasize, are the richness of the blood and lymph supply,
the tendency of a tumour to invade one or other of these sets of vessels,
and the frequency with which cells are set free into the circulation. The
size of the cells must influence the readiness with which they are transported by the blood and lymph vessels, but more important is the quality
of their power to resist the destructive action of the fluids and tissues of
the body, for unless a liberated tumour cell can lodge and multiply, no
metastasis  can occur.    Many  cells  are destroyed  or  remain  quiescent,
Page 164 hindered from proliferating by the antagonism of the tissues. Such
quiescent deposits are, however, potential metastases and may after many
years of latency, commence to multiply when the conditions which restrained them are altered. A case is on record where secondary melanotic
cancer appeared in the liver 21 years after the removal of the primary
focus in the eye.
Methods of dissemination—
(1) By permeation—You are all familiar with Sampson Handley's
theory of the permeation of cancer cells by continuous extension along
lymphatics. He worked it out from actively growing cancers of the
breast. By examining strips of tissue taken from the full thickness of
the chest and abdominal walls, he found continuous chains of cancer cells
filling the lymphatic vessels which radiated from the primary tumour,
and which extended downwards to the liver and even as far as the groin.
Handley believes this to be the master process of dissemination of cancer,
and seems to have proved his case, although many authorities disagree
with him. Ewing is inclined to believe that it is not so important as
spread by embolism. He states, "It is possible that rapidly growing epidermoid and glandular cancers disseminate deeply by embolism, but that
slowly growing and recurrent tend to spread by permeation."
(2) By blood and lymph vessels—It is generally accepted that
tumour cells, either singly or in groups, may be carried by the blood or
lymph and deposited at a distance. They usually go with the current,
but Oertel has shown that by their own amoeboid motion they may make
their way against it. This is known as retrograde metastasis, and as an
example of it Adami cites a case where a cancer of the breast spread to
the head of the humerus on the same side. The circulation of the lymph
is sluggish. In the extremities it is caused by the action of the muscles,
and while a limb is at rest there is no movement of lymph. In the abdominal cavity, however, there is a continuous lymph flow caused by the
differences in pressure in the body cavities above and below the diaphragm.
On each inspiration there is a positive pressure in the abdomen and a negative pressure in the thorax.
Since the sarcomata are bathed in blood, while the carcinomata are
bathed in lymph, dissemination by the blood stream is the main method
in the case of the former, and a less common method in the case of the
latter. Entry into the blood stream may be by way of defective vessels
passing through the tumour, by invasion and rupture of an adjoining
vessel, or by way of the thoracic duct. Carcinoma may invade the vessel
by way of the perivascular lymphatics. Thrombosis usually follows such
invasion of a vessel, and the thrombus may destroy the cancer cells, or
these cells may grow on the vessel wall and later be carried to the first
zone of capillary vessels, which is usually in the lung. Here they may be
destroyed or may form a new focus, or again, without any lung metastasis,
single cells may filter through the lung capillaries and thence to the systemic circulation. Once there, they may settle anywhere. The lung
must be an efficient filter of many cells which would otherwise pass from
the pulmonary to the systemic circulation, and tumour cell emboli are
Page   165 much more frequent than tumours of the lungs. Ewing states that in
cancers of the abdominal organs, many cells go to the lungs and are encapsulated or otherwise rendered harmless.
(3) Dissemination by contact infection or apposition—This is rare
but does occur. Examples are, from breast to arm; from upper to lower
lip, or from cervix to penis.
(4) Implantation in serous cavities—as when certain ovarian
cancers rupture into the peritoneal cavity and multiple secondary foci
result from implantation.
Factors influencing tumour metastasis—
There must be many factors that influence the localization and development of neoplastic cells, and if one seeks to explain the distribution
of secondary cancer growth on mechanical and circulatory ground alone,
there is the difficulty of understanding the relatively low incidence of
metastasis to the spleen and kidney, since the mechanical arrangement of
these tissues would tend to render them particularly prone to the retention
of foreign cells. But the spleen is rarely invaded by secondary growths
and the kidney only infrequently. The spleen seems to possess a relative
immunity, and it is suggested that it is in some way connected with the
presence of lymphocytes in its tissue.
The view held by many investigators is that if but a few cells escape
from the tumour they will succeed in forming metastases only in favourable tissue soil, perhaps even at a great distance, while if large numbers of
cells are thrown into the circulation then metastic growths will occur,
not only in favourable tissues but also in any organ which mechanically
intercepts large numbers of these cells; or as Oertel expresses it,—"Two
factors determine metastasis, quantity and quality of tumour cells. When
but a few cells enter the stream, qualitative selection ensues, while if many
cells enter, a quantitative overwhelming of the body results. That is, a
large dose of cells will overcome the resistance of an otherwise unfavourable tissue."
What is a favourable tissue? It is one that does not resist or destroy
a cell as does an unfavorable one; but an unfavorable one may tend to lose
it's resistance from trauma, or as the result of poisoning by toxins thrown
off by primary growth. Cohnheim goes so far as to say that "Only when
tissues are lowered in their physiological metabolism by age, atrophy, or
inflammation, will metastasis be possible." Ewing quotes a German investigator, Freund, who claims that "Normal blood dissolves cancer cells,
while the blood of cancer patients has lost that property."
Lymph nodes lying in the proximity of a primary tumour, tend to
possess an immunity to immediate invasion. They may successfully destroy tumour cells until toxic products from the tumour reduce the gland's
resistance. For a time before actual invasion the gland may be swollen,
due to absorption of these toxins.    It later becomes atrophied or fibrous,
Page 166 which lessens its effectiveness as a filter, and the invading cells now obtain
a foothold.
It is certain that tumours tend to metasasize more rapidly to some
soils than to others, notably to tissues resembling those from which the
primary growth originated, or to those which are derived from the same
layer of the blastoderm. Thus lymphosarcoma tends to settle in lymphoid
tissues. Carcinoma of glandular organs is likely to go to other glandular
organs of the same derivation. On the other hand we mave metastasis to
bone from primary sites in the prostrate thyroid, breast, adrenal cortex
and uterus; tissues which have little in common otherwise. In connection
with metastasis to bones it may be noted that secondary growths tend to
occur in the red marrow, rather than in the yellow marrow. The former
is found in the short bones such as the vertebrae, the skull, the sternum;
also in the ribs and in the ends of the long bones. Since the marrow contains no lymphatics, it is possible that dissemination occurs as the
result of emboli being deposited in the end arteries of the marrow.
Certain individual types of tumour display a marked selectiveness, as
melanotic tumours to the liver, and primary lung tumors to the muscles.
Virchow maintained that tissues which frequently give rise to primary
tumours are seldom the site of metastasis, while those which most frequently receive such secondary growths, rarely originate primary ones.
Some writers support this theory, but Ewing is not impressed.
Cells that have escaped removal may lie dormant for years until the
resistance of the tissue lodging them is removed. It also seems true that
on occasion the removal of part of a tumour is followed by an absorption
of the remainder, by what Ewing describes as, "a mechanical disturbance
of the nutrition of the tumour, by a removal of its source of growth
stimulus."   Examples cited are ovarian carcinoma and chorioma.
Prognosis—Metastasis to internal organs, or to the bones, profoundly
influences the prognosis, and regional metastasis is much less serious than
that at a distance. Nearby lymph nodes may be enlarged with no metastasis, but as a result of toxins or infection from the primary tumour.
This is true of cancer of the tongue, of the pelvic glands in cancer of
the uterus, and of glands along the lesser curvature of the stomach in
cancer of that organ. This should be remembered when deciding on the
operability or otherwise of these organs when they are involved in malignant conditions.
In conclusion I would repeat that while we have a considerable
amount of practical knowledge on the subject of metastasis of malignant
tumours, we know little of any anatomical or pathological laws which
may govern such dissemination. The only comfort we have comes from
the general agreement of investigators, that nature has apparently given to
the tissues of the body some equipment by means of which they may
defend themselves against the invasion of tissue cells run wild. We see
nothing of the victories over these invaders, but only the results which
follow their gaining a foothold at some point where the defence has broken
down.
Page  167 MEDICAL ECONOMICS  (3)
By R. E. Coleman, M.B.
Significance of Lost Pay
Balancing the Budget is the by-word of today. Actually balancing
the budget is an acquired human trait and very much acquired at that.
It would seem that only dire necessity will force us to do it. Our natural
instinct is to try to acquire all that is apparently attainable at a minimum
of cost often regardless of present or future cost. If the present cost is
excessive we reluctantly forego our desire. If the future cost promises
to be excessive only experience and superior intelligence will check us.
There was a time on this continent, and not so very long ago, when many
business men carried on with a book-keeping system consisting of a
cheque-book only. This system was easy and pleasant, but when depression came and previous margins of profit were cut way down, most
of the businesses run in this manner failed. Those who did survive did so
by balancing their books, and balancing their books simply consisted of
adding up all their assets and all their liabilities, and comparing the two
totals. To their surprise these cheque-book business men found that there
were many items of profit and many items of loss which did not show
in the cheque-book. For example, a property bought for $1,000.00 which
depreciates 25 per cent, does not show the loss in the cheque-book. In
short these business men had devised a very accurate measuring rod in
their cheque-books, but it did not cover the entire field. They were like
the carpenter who was asked to make a measurement. When he returned
he reported that the length was twice the ruler, plus two spans of his
hand, plus the breadth of his hand, less the width of his thumb. The carpenter was probably taught his lesson by being discharged. The chequebook business men were taught their lesson by failure. The medical profession will also be taught by failure, so it behooves us to balance our
budget. The carpenter's error was due to his not using an accurate
measuring rod throughout. We must therefore select a measuring rod
that can be carried through all of the necessary manipulationst
The first and major problem is to select a unit of measurement of
the cost of the article that the physician sells. Also we must decide at
what point to commence the measurement.
What,we wish to determine is the real private cost. That is the
financial equivalent of the private enterprise represented by the average
physician. The cost of the state will be left for a later discussion. Nor
will we now discuss ultimate costs, but will content ourselves with a
point of departure. We have chosen for this point of departure that
stage in the life of a boy when private enterprise is first called upon to
initiate and finance the prospective future physician. Up to the age of
16 a boy is compelled to attend school and the parents or guardians are
compelled to finance him. After his 16th birthday private enterprise
must pay emotionally and financially to keep him at school. From now
on the business world beckons with no uncertain hand.    She says, "You
Page 168 work for me and I will give you real money. The money that I give
you is yours to do with as you like. There will be no strings to it. You
will be able to buy your own smokes. You can buy a bicycle on the instalment plan. You can buy your mother a present. You can pay your
younger brother to do all your chores for you. You can take the girls to
the movies. You will be a man, working with men in a world of men.
You will be able to see real life. You may become a millionaire. In short
you will be really living now."
Contrast this with the boy who stays at school to become a physician.
The student will have no money to spend that has not very definite strings
attached to it. Each sum that is given to him will be given to him for
I definite purpose, not to do with as the spirit moves him. His father
buys him a bicycle and it is with his father's money that the boy buys his
mother's present. IHe can only get money to take out the girls of whom
his mother approves. His daily contacts are with boys of his own age
and his contacts with adults (teachers) are in no manner on a basis of
equality. None of his associates even hints that he is a man now. His
evenings are not free. In essence he resigns his freedom, which at that
time means really living. At no time in the future will he crave freedom
as much as he does right then, for the acceptance of restrictions grows
very slowly with age and by bitter experiences. So it is true that the lost
pay at this time is a real loss.
Just here some might question the reality of this loss, citing the
example of boys and associates whose contacts are all going to school and
who deny that any of the losses mean anything to them, but such comparisons are fundamentally in error, both economically and psychologically. Financial exchanges are by their very nature based upon a competitive market. Therefore the above comparison is only possible in a
competitive market. The comparison must be made between two boy
friends whose courses differ at this point. Under such conditions observation will soon show that the loss is very acutely appreciated by the boy
who remains at school. The comparison with the boy who is unconscious
of his loss is also invalid, because the modern student of personality is only
too familiar with the fact that there may be marked symptoms of repressions, along with complete absence of consciousness of their origin
or even of their existence. There are many things in student life which
more than .indicate that as a group they are far from symptomless. To cite
common types we have the markedly shut-in students, the explosions in
pranks, and the ease with which revolutionary ideas take hold of student
bodies the world over.
That is, the prospective medical student has to a very large extent,
to forego the pleasures of living today in the form of self expression,
leisure, independence, satisfaction of the mating instincts and self respect.
What is the reward pictured to him which is to compensate for his loss?
For such losses can-not be made acceptable without future promises, (As
he reads the following list of promises the older physician will be able
Page   169
'■>»» to evaluate the degree of fulfilment realized.) He is promised the pleasure
of doing the work that he thinks he will like. In estimating the degree of
fulfilment it should not be overlooked that one prerequisite for pleasure in
one's work is the time and opportunity to do oneself justice. Nor should
it be overlooked that any work that calls for judgment requires a certain
amount of leisure for meditation and outside reading to render it satisfying. The boy is also promised financial security, and at least a good
living. He will be surrounded by grateful patients who will pay their
bills out of gratitude. There will be enough of these grateful patients so
that he will not need to bother about all of the indigent and non-pay
patients that he will have to treat. His recompense will be proportional
to the quality of his work. He will be looked up to by the community
generally. In a general way this is the nature of the promises by means
of which the medical student is induced to ignore the beckoning hand of
industry. In a sentence, he chooses the joys of really living in the future
in exchange for the joys of really living now. Do his financial returns
as a physician enable him to realize these promises?
To try to find the financial equivalent of such losses and such
promises seems at first glance to be hopeless. The paltry sum that the
boy loses seems insignificant, in comparison. There are two thoughts,
however, that help us to bridge the gap. One is that all financial exchanges are in the last analysis based upon emotions. For example,
whether or not a man buys a suit of clothes is almost entirely a balancing
of emotional values. Whether or not he has the money to buy the suit
is almost entirely the product of previous balancing of emotions. Emotions
may even lead him to undertake the purchase of a suit when he has neither
the money nor the prospect of getting the money. Actually, financial
exchanges are the sole means we have for getting numerical expressions
for human emotions. Viewed individually, as in the above example of
lost pay, they seem at first to be impossible of any scientific correlation,
but viewed statistically order begins to manifest itself, as will be found all
through our study of medical economics. The other thought that will
help us to bridge this gap between the lost pleasures and the lost pay is
the absolute differences between a small quantity and nothing. The mathematicians recognize that any measurable quantity no matter how small is
infinitely greater than zero. In physiology we have somewhat the same
idea in our term "threshold." For example we speak of the kidney threshold for sugar in the blood. We mean by that, that until the sugar in
the blood reaches a certain concentration the kidneys do not excrete it
in significant quantities. Below this minimal concentration we can demonstrate presence of sugar in the blood chemically, but we might say that
the kidneys do not demonstrate it in the urine. Statistically we know
within a comparatively narrow range what this minimal concentration is
for the human race but we can not predict it for the individual. When
we turn to the nervous system, which is more closely associated with the
emotional life of the individual with its financial equivalents, we find the
same "threshold of stimulation." Here again we can not predict the
threshold for a given individual, but we do know many ranges for the
human race; for example the intensity of electrical current to produce
a given muscular contraction.
Page 170 Returning then to our problem of the present financial equivalent of
the emotional losses accepted by the boy who has elected to study medicine, we have in his lost pay a measurable quantity which mathematically is infinitely greater than zero. Can we next satisfy ourselves that it
is physiologically above the threshold? The answer to this is given in the
statement that probably every reader of this article has personal knowledge of individual cases, in which this factor operated to eliminate potential medical students just as completely as do the various examinations.
The next question is to determine, if possible, the threshold for the main
group, in this case the Canadian population. So far I have not been able
to find any numerical expression for this quantity until we reach the
18th year. We are therefore in the position of having to commence with
the 18 th year, with the qualification that some definite but at present unknown quantity must later be added to cover the periods between 16 and
18 years. At the age of 18 a boy may begin as a postal clerk at a salary
of $1,080.00 per annum.
Why have we chosen the postal clerk's salary for our base line?
Because it does actually represent a very conservative threshold value for
Canada. How conservative will appear at some later date. In searching
for this minimal value our first thought was to use the mean yearly income of the unskilled day labourer. The inadequency of this was apparent
when it was appreciated that this group was heavily seeded with the biologically and socially unfit. Also it was apparent that it was neither
biologically possible nor socially desirable to build up an economic condition which would countenance a similiar personnel for the medical profession. It was then thought that the sequence of events through apprenticeship, to skilled artisan, to foreman and superintendent, etc., would
be suitable. Here again the comparison was found to be inadequate, in
that the type of self selection present in this group as contrasted with
the medical group was so very different. The future presented to such
a boy is almost purely financial and competitive. The financial rewards
are practically limitless. The pleasures in the work are of very secondary
considerations. On the other hand it is the apparent lack of severe financial competition in the moderate ranges that attracts some of the best
type of individuals into the medical profession. It was then realized
that the career of the postal clerk offered a very real threshold at a lower
level and that it might be possible to predict from this threshold the true
threshold for the medical profession. The postal system is a community
service, and in the main gives a high degree of satisfaction both as to
quality and cost. The pay itself is based on many years (generations) of
experience and it is probably now just adequate to draw a sufficient personnel from the industries Though it offers no great rewards, it does
offer stability; reduces competition to a minimum, especially in the
middle ranges; responsibility is minimal (in this differing markedly from
medicine); and there is much freedom as to the intensity with which the
individual applies himself. It is probably true that the workers themselves would be found to question these ideas seriously, but just as in
medicine it is the commonly accepted ideas that determine the choice
rather than the actual conditions: experienced. That is, the supply of new
workers is determined by what the entrant thinks, not by what he later
finds out for himself, and one of the objects of this study is to enable the
Page  171
^Wt»" persons who propose to finance the future supply to evaluate the various
types of returns on his financial and emotional investments.
A great deal more could and probably should be given in the way
of explanations as to why the postal clerk's pay has been chosen, but it
is hoped that the above suggestions, along with the personal experiences of
the individual physicians of Vancouver, will render our unit of measurement sufficiently acceptable to serve as a first approximation.
To sum up; medical economics the world over are in a serious position
and the members of the medical profession are being forced
at last to balance their books. It is suggested that the first
essential is the adoption of a unit of measurement which
can be carried throughout the various necessary manipulations. The second essential is to decide upon a point of departure from
which we can commence our measurements. It is proposed to use the
pay of the postal clerk as our unit of measurement. It is also proposed
that the age of 18 be our present point of departure, when the postal
clerk becomes eligible for a salary of $1,080.00 per annum. Reasons are
advanced for considering this pay one of the real and measurable quantities exchanged by the medical student for the training that he gets. It
is pointed out that the list of the losses accepted by the student in reality
represents a very high percentage of things on which the natural instincts set a high premium. In fact these losses belong to the very same
category as the future hoped-for rewards.
Bay. 4234 L
MRS. KATE PEGRAM
C.A.M.R.G.
Medical  and   Surgical  Massage
Electricity                    Remedial Exercises
1645 11th AVENUE WEST
Vancouver,  B.  C.
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Our  work  conducted   under
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n. s. Mcdonald
"Physical Culture"
804 Pender St. W.
Office Sey. 2855          Res. Doug. 4682Y
MISS BEATRICE GALLOP
C. A. m. r. g.
Graduate
McGill   University   School   of   Massage
and Remedial Exercises
419 VANCOUVER BLOCK
Vancouver, B.  C.
Telephone Sey. 3334
MRS. E. M. PARR
Chartered Society of Massage and Medical Gymnastics,  England
Canadian   Association   of   Massage   and
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906 BIRKS BUILDING
Vancouver,  B.  C.
Advertising
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329 Railway Street
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Phone Seymour 597 ^-1
"Deeds,
Not
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Periodic examination of your growing
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m*
Words"
HOW MEAD JOHNSON
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OF INFANT DIET MATERIALS* ASSIST IN
KEEPING PEDIATRIC
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NOT ALL BABIES ARE ALIKE
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All Mead Products are advertised only
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There is no ulterior motive in this effort to educate laymen on the importance of medical advice, as no reference
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Ampoules     —     Tablets
CIBA COMPANY LIMITED
MONTREAL
Messrs.   Macdonalds   Prescriptions,   Ltd.       -       Vancouver,   B.   C.
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Reference—B. C. Medical Association
For information apply to
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Seymour 4183
Westminster 288

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