History of Nursing in Pacific Canada

The Vancouver Medical Association Bulletin: June, 1932 Vancouver Medical Association Jun 30, 1932

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The Bulletin
Vancouver Medical Association
Recent Surgical Advances
Medical Economics (iv)
September 13 th to  16 th
Vol.   VIII.
JUNE,   1932.
No.   9
Published -monthly at Vancouver, B. C, by
McBeath-Campbell Ltd.,  326 Pender Street West
Subscription,  $1.50 per year. STOAMBSrHEAraeKBLDe.
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.
CHAS. H. ANDERS, Chemist
Published Monthly under the Auspices of the Vancouver Medical Association in the
Interests of the Medical Profession.
203 Medical Dental Building, Georgia Street, Vancouver, B. C.
Editorial Board:
Dr.  J. H.  McDermot
Dr. EK E. H. Cleveland Dr. H. A. DesBrisay
All communications to be addressed to the Editor at the above address.
Vol. VIII. JUNE, 1932 No. 9
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
Dr. W. D. Brydone-Jack Dr. J. A. Gillespie Dr. J. M. Pearson
Auditors: Messrs.  Shaw, Salter & Plommer
Clinical Section
Dr.   A.   M.   Agnew Chairman
Dr. W. H. Hatfield 'j Secretary
Eye, Ear, Nose and Throat
Dr. J. A. Smith j j Chairman
Dr. A. O. Brown Secretary
Paediatric Section
Dr. C.  A. Eggert , Chairman
Dr. S. S. Murray Secretary
Cancer Section
Dr. A. Y.  McNair Chairman
Dr. A. B. Schinbein i Secretary
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 j
Dr. D. M. Meekison Dr. J. A. Smith Dr- c- h- Vrooman
Dr.   H.   A.   DesBbisay Dr.  J.  E. Harrison Dr- J- W- Arbuckle
Dr.  D.  F.  Busteed Dr- h- A. Spohn
Dr. J. E. Harrison Dr- h- r- Mustard
Publications rr   ,., ,
Dinner Dr- J- H- MacDermot Dr, a. W. Bagnall I
n»   h   w   p^-t-c Dr< D> E* H* Cleveland Dr. F. J. Buller
Dr. H. H. Pitts Dr.   H.   A.   DesBbisay Dr   w   c   wat<:„
Dr.  A.  M.  Warner if- CW'  C'  Walsh
Dr. A. T. Henry Dr- S" B" Peele
Credentials V.O.N. Advisory Board
Rep. to B. C. Med. Assn.     ^  F:  P: ^/terson Dr. H. H. Caple
Dr.   A.  J.   MacLachlan      Dr.  E.  Trapp
Dr. G. F. Strong Dr. S. Paulin Dr. J, W. Shier
Sickness and Benevolent Fund — The President — The Trustees j VANCOUVER HEALTH DEPARTMENT
Total Population   (Census  1931)     246,593
Asiatic   Population   (Estimated)  15,000
Rate per 1,000 Population
Total Deaths 1	
Asiatic  Deaths    	
Deaths—Residents only   	
Birth Registrations 	
Male       155
Female 143
Deaths under one year of age 	
Death  Rate—Per   1,000   births 	
Stillbirths   (not  included  in  above)     —   8
March, 1932
Cases     Deaths
Smallpox    -'_        9
Scarlet   Fever           15
Diphtheria     6
Chicken-pox           40
Measles        214
Mumps          62
Whooping-cough          29
Typhoid Fever 	
Meningitis   (Epidemic)   	
Encephalitis Lethargica	
May 1st
to 15th, 1932
Cases    Deaths
3 3
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
Write,  Telephone or Wire
Manager, Rest Haven,  Sidney,  B.  C.
Telephone  Sidney 61L or 95
— Rates are no higher than  Hospital  Rates  •—
Page l; MilkrBorne Typhoid
Outbreak at Yale
The Milk Inspector's Letter of March, 1932, from the
Michigan Department of Agriculture, Bureau of Dairying,
contains the following interesting item:
"A milk-borne typhoid outbreak result
ing in
twelve cases
and one death occurred recently at Yale, Michigan.
The first case developed on February 1st, 1932, and the
last on February 15 th. All but one of the cases were-
known to have used the milk of one raw milk dealer,
and the other may have used it.
The milk supply of the city, which had been entirely
raw, was ordered pasteurized. The dealer supplying the
suspected milk sold- 'milk produced on his own farm and
milk purchased from another farm.
A wo-man who was staying at the farm from which milk
was bought' was found to be a typhoid carrier. The search
for a carrier was unsuccessful at first because the carrier
had left the farm, but she happened to come back while
the investigation was still in progress.
The case which proved fatal ivas a lady of 49, the mother
of twelve children.
This outbreak is another argument against raw milk, particularly milk produced on a farm- having no sterilizing
or other proper equipment for milk handling and transported to another place for bottling raw."
There are about fifty such arguments each year and
still the use of raw milk continues in many cities, and
occasionally is sharply defended by some of the older
members of the medical profession.
Fairmont 1000—North 122—New Westminster 1445 A SECOND INVITATION
Just in case you were not able to take advantage of the first.
Naturally proud of the new Georgia Pharmacy,
we want to be sure that every friend and every
member of the medical profession pays a personal
visit to our new store.
All Day
All Night
Pharmaceutical Chemist
Some fortnight ago, an account appeared in the daily press of a
somewhat acrimonious exchange of opinions between certain members
of the City Council and the Hospital Board. The differences seemed to
be based mainly on points of dignity and correct procedure, and do not
concern us greatly; but in the course of discussion, certain statements
were made that are worthy of comment.
One of the aldermen referred feelingly to the deficit incurred in
the operations of the Vancouver General Hospital, and the burden this
imposed on the taxpayer. That there is a deficit is unfortunately true—
it would seem to be a malady common to all hospital administrations—
ours no more than any other, perhaps. As taxpayers, we all regret its
existence, and apparent inevitableness. The point we would make here,
is that medical men are taxpayers, no less, and probably somewhat more
(we refer to the highway robbery known as a "professional tax") than
any other income-earner—and so bear their full share of the burden
imposed by the hospital deficit.
But there is another deficit, larger and more burdensome, to which
the worthy alderman did not refer. Dr. B. D. Gillies, however, referred
to it, and we doubt whether his full remarks were reported, when he
said that the medical men were carrying a large deficit of their own,
which was not shared in by any other taxpayers.
Consider the situation—the Vancouver General Hospital is bound
under its charter to furnish medical services to all indigent persons—and
this means, of course, that these persons pay nothing for these medical
services.    It is the state really that furnishes this service.
We are told that there were 30,000 patients seen in the outdoor
clinics of the Vancouver General Hospital during the past year. It is
probably a minimum estimate, when we suggest that on the average
each of these people received ten dollars worth of treatment from a
medical man, apart from laboratory and other hospital service. This
would mean that the doctors who gave this service gave some $300,000
worth of their time.
Again, consider the indoor staff work. There are constantly some
three to four hundred patients on the indigent list. "Would it be too
much to allow two dollars a day for medical service to these people?
This would mean another two hundred and fifty thousand dollars or so
a year, supplied free by medical men. That is, over half a .million dollars
of deficit carried by less than a hundred medical men—and what the
burden of outside charity work is, nobody can tell.
And this burden is not really the medical man's burden. It has
been placed on his shoulders to carry, while the state trudges carefree
alongside, glad to have found a willing horse (or is it another member
of the equine species we are?) to bear the heaviest part of the load. And,
if the state carries a burden due to sickness, it carries no more than do we,
who bear our full share as taxpayers.
Page   174 The situation, if we stop to give it due thought, is serious, and
is becoming intolerable. We commend it to the B. C. Medical Council,
which will shortly assume new duties and new powers, as the first problem they should consider, and attempt to solve. For this load is not only
unfair—it is crushing, and medical men are not only staggering, but
actually falling, under the weight of the burden which should not be
carried by them alone.
Dr. G. F. Strong leaves for the United Kingdom on June 6th, where
he will attend the British Medical Association meeting. He will stop
over at Toronto en route, where he will read a paper before the Canadian
Medical Association.
Dr. A. S. Monro will be one of the official delegates to the British
Medical Association meeting in London in July, from the Canadian
Medical Association. The other official delegates will be Drs. Primrose,
Bazin and Routley.
We regret to learn of the loss which our Treasurer, Dr. W. T.
Lockhart, has sustained in the death of his brother, Mr. Andrew O. Lock-
hart, which occurred on May 17th, in Vancouver.
Dr. H. A. Rawlings left on May 22nd for England. He expects
to spend four months abroad, for the greater part of the time in the
British Isles.
The 14th annual venue of the International Golf Team match be-
tweent physicians of British Columbia and Seattle was played at Oak Bay
Golf Course, Victoria, on May 7th. Unlike the thirteen matches of the
past, this one was a single thirty-six hole match as contrasted with the
seventy-two hole home and home affair. These games are played for the
Dr. Richard W. Perry trophy. Last year it was won by Seattle; this year
Dr. Dan Houston, the official herder of Seattle players, gathered only
twenty doctors, a counter attraction in Tacoma preventing a larger number from coming. Victoria, under the careful selection of Dr. M. J.
Keys, mustered fifteen men and Dr. J. P. Bilodeau, captain of the Vancouver contingent, brought over thirty-three, including four from New
Westminster. When the smoke of battle cleared away, the game was all
Unlike the other years the evening was given over to contract bridge
and a delightful time was spent. Next year, if the Doukhobours are released and the taxes are reduced and if the out-door department is not
Page 175 over out-doored, and the war debts cancelled, etc., etc., etc., etc., we expect to continue as in previous years—a home and home match.
—J-P. B.
The session of the 1932 Summer School will be held on September
13 th to 16th inclusive, in the Oak Room of the Hotel Vancouver. The
following speakers have consented to take part in the programme:
Dr. L. E. Clerf—Professor of Bronchoscopy and Oesophagoscopy, Jefferson Medical College, Philadelphia.
Dr. W. E. Galxie—Professor of Surgery, University of Toronto.
Dr. G. C. Hale—Professor of Medicine, Western University, London,
Dr. H. F. Helmholtz—Professor of Paediatrics, the Mayo Clinic.
Dr. W. B. Hendry—Professor of Obstetrics and Gynaecology, University
of Toronto.
Dr. Karl F. Meyer—Professor of Bacteriology, University of California
Medical School.
Dr. F. R. Miller—Fellow of the Royal Society, Professor of Physiology,
University of Western Ontario.
It is expected the name of one further speaker will be added to this
list, but our negotiations with him are not yet completed.
It will be seen that a widely diversified range of subjects will be
dealt with by the lecturers. Titles and complete programme will be published in future issues of the Bulletin. It is probable that the fee of
$10.00 usually charged may this year be reduced but particulars as to
this will be announced later.
It will be remembered that last year there was no Summer School
owing to the meeting of the Canadian Medical Association and we hope,
therefore, that the attendance at the meeting in September will be well
above the average.
Lyon H. Appleby, M.D., F.R.C.S., F.R.C.S. (Can.), Vancouver, B.C.
1.    Bowel decompression by the method of continuous gastric suction
To those who have followed the development of abdominal surgery
since the opening of the present century, the attainment of an extremely
low operative mortality in both operations of election and acute abdominal cases, has been a source of great satisfaction. The interval appendix
is practically devoid of risk. A mortality rate of 3 % would cover almost
the whole field of abdominal surgery with one important exception. The
exception has been intestinal obstruction    In spite of the great advance
Read before the Fraser Valley Medical  Society, May,  1932.
Page   176
•» in surgery within the abdomen in other departments, obstruction carries
today, as it did thirty years ago, an average mortality rate of 47%. In
other words, every second case dies. Obstruction has resisted the attempts
of corps of surgeons and research workers to discover some means of
bringing this condition more into line with other conditions within the
abdomen. Enterostomy in some of its many forms, has been the greatest
single life-saving measure.
It is, perhaps, not as fully realized as it might be, that in general
peritonitis there is an associated intestinal obstruction which must be relieved as much as the intraperitoneal infection. Only a part of the
toxaemia of peritonitis is peritoneal—a large part is intestinal. The best
results in peritonitis have been obtained by those surgeons who have
performed enterostomy the soonest—appreciating the dual load of toxins
—and thereby relieving both. We have seen in recent years the use of
hypertonic saline solutions, bacillus Welchii antitoxin, the rectal exhibitions of bile and many other adjuncts to the standard surgical treatment of obstruction.
The recently introduced method of continuous gastric suction drainage in peritonitis and in certain types of obstruction to which it is applicable, gives promise of being the first real step forward for many years.
There are two primary types of intestinal obstruction—strangulated and
non-strangulated—as represented by strangulated hernia on the one
hand, and adynamic ileus or carcinoma of the sigmoid on the other. It
is obvious that no temporizing can be allowed in cases of the strangulated
type. But whereas it may be used even here as an adjunct, it may avoid
the necessity of operation altogether in cases of ileus, etc.
To take a typical case:—An annular carcinoma of the sigmoid with
slowly increasing distension and late onset of vomiting. The first step
here is a flat X-ray plate of the abdomen to determine just one thing—
whether or not the ileo-caecal valve is competent. With an incompetent
valve the coils of the small intestine appear greatly dilated, while if competent, the dilatation is largely colonic. Now if an ileo-caecal valve is
incompetent, the fluid faeces back up into the small bowel and the whole
intestinal tract becomes dilated. The method of continuous gastric suction drainage is most applicable here. I have seen five gallons of fluid
removed from such an abdomen in twelve hours, along with an unmeasured amount of gas The greatly distended abdomen, with its dangerous operative risk, in 24 hours was flat, soft and flaccid and the operative
risk was restored to normal. Unfortunately, this does not work in this
particular type of case in the absence of an incompetent ileo-caecal valve.
Hence the necessity for a flat X-ray plate. When it does work, however,
it permits an entrance to the abdomen through which no previous colostomy has been performed and aids materially in keeping the operative
field clean. In cases, likewise, of post-operative ileus—usually following
a ruptured appendix—the type of case which hitherto had to be reopened
and an enterostomy performed at once if life was to be saved—continuous gastric suction drainage has almost eliminated the necessity for
these operations In the Californian hospitals where I recently saw this
machine in action, the mortality rate in intestinal obstruction since last
October was reduced to 4%, and thirty-six successive cases of generalized
Page 177 peritonitis were so treated in conjunction with peritoneal drainage without
the loss of a single case Probably no bowel can actually contain five
gallons of fluid, but the pressure of obstruction once relieved, permits of
a great outpouring of secretion into the bowel, which goes to make up
the total of removed fluid
This brings out two very important factors; the removal of such
great quantities of fluid necessarily results in great dehydration and a
degree of alkalosis. The mechanism of the development of alkalosis is
not absolutely clear, but undoubtedly the loss of great quantities of
chlorides from the gastric juice so withdrawn is a factor. Consequently,
in association with the gastric suction drainage, there is kept up a continuous intravenous injection of saline and glucose, which sustains the
patient, overcomes the dehydration and corrects the alkalosis by the replacement of depleted chlorides. A close check on the degree of alkalosis
may be readily kept by frequent determinations of the COa combining
power co-efficient.
We have all seen cases of obstruction relieved by operation—the
patient for a few hours progressing to our satisfaction, but suddenly dying
as though overwhelmed by some severe poison against which no resistance
whatever could be offered. The bowel proximal to the obstruction,
loaded with pent up, highly toxic liquid faeces, does not permit of rapid
absorption due to its impaired circulatory condition incident to its obstruction. But the obstruction once relieved, we permit the passage of
these highly toxic products into fresh, undamaged bowel below the obstruction from which absorption is easy, rapid and overwhelming. It
is the removal of this toxic fluid, together with the mechanical relief of
the obstruction, which has so reduced the mortality by means of continuous gastric suction drainage.
This is an important thing. Knowing our mortality rates in peritonitis and intestinal obstruction cases to be so high, we have long awaited
relief in some form. If such a simple procedure will reduce a mortality
rate in intestinal obstruction to even 10%, its value is beyond computation. If it only does one half what those who sponsor it claim, it is
still is the only really valuable contribution of the present century to the
surgery of intestinal obstruction.
2.    Bacteriophage in the treatment of chronic suppurating wounds.
It seems remarkable that an important discovery may to some extent,
remain dormant from a practical standpoint, when that discovery is
made by someone working in the field of pure as opposed to applied
Science. It is eleven years since D'Herelle published his initial work on
the bacteriophage and yet it is only in recent months that the rationale of
certain, almost heretical forms of treatment, are to be explained as a
result of it.
D'Herelle, while working with agar plate cultures of organism of
the intestinal flora, noted on the surface of his plates, which had been
evenly covered with growths, small clear islets developing, from which
the bacterial culture seemed to have entriely disappeared. Making a
bouillon culture of the organisms, he transferred a small speck of this
Page   178 clear area on the agar to such a bouillon culture, and to his astonishment,
found that in a few hours the organisms had completely disappeared.
They were not simply dead and sedimentized as a chemical reagent might
cause them to be, but were completely lysed or dissolved by some "lytic
agent." This lytic agent was found to pass through the finest filters and
to be specific for various organisms. This substance, ultramicroscopic
parasite as he believed it to be, he named a bacteriophage. This bacteriophage would seem to have invaded the field of surgical therapy through
the development of certain methods of treating common forms of chronic
suppuration, and though these treatments are, or were, wholly empirical,
they may now be explained on the basis of the development of a specific
phage, and once again the pure has become the applied science
The history of infected wounds and chronic suppuration goes back
far into the dark ages; incantations, voodooism, horrible concoctions, were
superseded by actual cautery, chemical cautery, antisepsis, Carrel Dakin-
ism, intravital dye staining, up to the modern surgical care and cleanliness
of wounds as we now know it. Little wonder that in these modern days
Orr's treatment of chronic suppuration should have resulted in such a
revulsion of feeling, and seem so repulsive to modern surgeons. What does
Orr do and recommend?
Let us take for example, a case of chronic osteomyelitis. He does a
straightforward operation of debridement, but this is not followed by
the usual careful aseptic surgical daily dressings. He fills the wound full
of sterile yellow vaseline, covers this with fold after fold of gauze soaked
in the same vaseline, bandages the whole tightly, applies a plaster cast
and does not look at it or dress it for eight or ten weeks. The wound
literally stews in its own secretions. Imagine the state of affairs when
the cast is removed; a stinking, fetid, pus-soaked wound. Everything
apparently directly inimical to good surgical progress as we know it.
But when the wound is washed out, cleansed, it is clean; granulations
are pink and healthy. The wound is filled again with vaseline and the
whole closed up for another eight weeks. At the end of the second or
third seance, the wound is usually healed, very frequently after years of
surgical cleanliness have failed to effect a cure. The same principal has
been in use for years in England in the treatment of chronic ulcers.
They are bound tightly under elastic adhesive and allowed to swelter
for weeks in their own secretions. I saw, just last months in a Los
Angeles Hospital, a cast removed from a femur. The odour, when the
cast was removed, reminded me of an exhumation, but the granulations
were fresh, clean and healthy. My initial feeling of repugnance on
witnessing several other such cases, began to grow into a feeling of
respect and wonder. Empirical as the treatment of Orr undoubtedly
has been, Albee has recently explained it on the basis of the spontaneous
development of a specific bacteriophage which has been given time to
develop and work in the enclosed wound. Orr's method of treatment
has spread widely through America, where it is on trial. Albee has
given it a rationale on the basis of the work of d'FIerelle and his bacteriophage.
The work being done and the cases I saw under that type of treatment, have reminded me of an incident which occurred in my student
Page 179 *
days. My old Professor of Surgery, Professor William Anglin, had opened
an axillary abscess and next day on my rounds he asked me if I had
dressed it. I said "Yes, I had washed it out clean, etc, etc." He put
his hand on my shoulder and said, "It is all right son, but let's you and
I not wash out our abscesses in future, you know if an abscess has free
drainage, it is best not tinkered with; there is something about an acute
abscess cavity which is best left alone." Succeeding years have taught
me the wisdom of his words, but I know that his knowledge of the
bacteriophage at that time was about equal to my present knowledge of
the interplanetary movements in space.
I wonder if we really are too surgically clean and careful with our
chronic suppurative cases?
Cultures of specific bacteriophages are now on sale through reputable pharmaceutical houses.
3.    Maggots.
A somewhat similar method of treatment of chronic suppurative
lesions, particularly of bone, has, of recent years, developed at first sight
to surprising proportions. The infestation of wounds, particularly in
War time, with the larvae of the blow fly, commonly known as maggots,
is a matter of ancient and common knowledge. Many of the writers in
the early part of the last century and particularly those in the time of
the American Civil War, noted the presence of maggots in wounds and
all agreed that they did no harm, and several commented upon the fact
that they seemed to do some good. Zaccharias, an American surgeon
during the Civil War, is apparently the first surgeon ever to deliberately
use maggots in the treatment of chronic suppurations.
However, the late Dr. W. S. Baer, of John Hopkins Hospital, Baltimore, is the pioneer of modern maggot therapy and the treatment has
come to bear his name. His observations of the splendid condition of
two serious gunshot wounds after lying on the battle fields seven days,
impressed him, and on his return to civil life, he conducted a series of
experiments on animal and subsequently on hospital patients, with strikingly successful results. The comparative innocuousness of maggots has
long been known; the comparative freedom of such wounds from other
pathogenic bacteria and the rapid removal of debris were soon noted.
The type of case to which maggot therapy has, up to the present,
been applied, are chiefly those of chronic suppurative processes of bone.
These cases are treated as follows: A preliminary operation opens the
wound up and removes grossly as much debris as possible. The wounds
are then packed with plain sterile gauze, no antiseptics whatever having
been vised in the course of the operation. After 24 hours, the wound
is completely filled with maggots 36 hours old, the edges of the wound
covered for an inch or more beyond their margins with adhesive and a
wire cage or screen placed over all and the part set out in direct sunlight. This tends to promote an even temperature. The maggots are like
dogs and seek the shade, and penetrate into the deeper recesses of the
wound. The wound is left undressed and untouched for five days, with
the exception of occasional aspiration of secretion to prevent the maggots
Page   180
^* from drowning. After five days they are washed out and a twenty-four
hour rest allowed and the wound re-filled with fresh maggots. The life
cycle of the maggot is seven days, when pupation occurs, and fresh
maggots are required. Patients are unable to feel maggots working in
the wound, the adhesive on the edges is to rest the cage upon and to prevent the maggots tickling the skin, which is sometimes trying.
The action of maggots is not so simple as it at first might seem.
Their first action is, undoubtedly, that of simple scavengers, eating their
way around the sequestra and loosening them, permitting their extrusion;
the ingestion in like manner of bacteria, detritus of all sorts, etc. They
have no power whatever to attack living tissue, and on the fifth day
when they are washed out, the wound is already covered with pink granulations. A second change which takes place is the definite and decided
alkalinity of the tissues, which develops at once. All infected wounds
are of an acid reaction, whereas these wounds are definitely alkaline.
There is in addition, a definite biological reaction an din recent months
biological extracts of sterile maggots are being used in chronic mastoid
and sinus disease with encouraging results.
The greatest original problem in connection with maggots, was the
difficulty of freeing them from bacteria and anaerobic spores with which
they are infested, Recently, however, it has been found possible to sterilize the eggs and raise the maggots in sterile culture. However, in California, where I recently saw so much of this work, they still use anti-
tetanic serum as prophylaxis, though no case of tetanus has ever developed or other untoward symptoms displayed by patients undergoing
this type of treatment in California, so far as I am aware. In one of Baer's
early cases death occurred from tetanus so introduced.
4.    Primary closure of the bladder in prostatectomy.
Prostatectomy has always been an operation, the indications for
which required careful adjudicating before recommending its performance. Usually required, in the afternoon or twilight of life, its subjects
were not good risks. It involves long hospitalization, frequent dressing,
careful lavage, the presence of an unpleasant odour about the place, and
is withal, highly successful. In early days perineal prostatectomy was the
fashion, to be supplanted by suprapubic prostatectomy, through the
advocacy of men like Fryer. The latter operation is today the standard
operation of most clinics; although in the hands of Lowsley, the perineal
route has been developed to a high degree of efficiency and popularity.
Enucleation with the finger, assisted by a finger in the rectum, was
for many years a standard operation and the prostrate was "shelled" out
blindly, and by the sense of feel alone. Gradually came the development
of illuminated bladder retraction and the dissection of the prostrate from
its fossa under direct vision with instrumental, rather than digital removal. In this way haemorrhage came to be much more efficiently controlled by grasping bleeding points in the fossa, and ligature. Various
inflatable bags shaped to fit a prostatic cavity served a useful purpose.
But whatever method was used, the after treatment always included a
large suprapubic  drain and  a urinary fistula,  which,   under good con-
Pa^ 181 m
dition in the average case, closed in approximately twenty-eight days,
and in less favourable cases, lasted twice that before closing and occasionally much longer.
A recent advance has ,in the past year, proved its worth, though
it has been in use in various centres longer than that. An attempt
is now made to close over the raw surface occasioned by removal of the
prostrate, by suturing the bladded mucosa to the transected urethra,
effectually controlling bleeding, hastening healing and reducing intravesical oozing to a minimum. A large double-eyed catheter is sutured
into place to drain the bladder through the urethra and the abdominal
wound and bladder are closed by primary complete suture. A high percentage of successes is recorded.
It is a most difficult thing to suture the bladder mucous membrane
to the urethra and so cover in all raw areas, unless one is equipped with
the special instruments required. Illuminated bladder retractors are an
essential. Although the actual suturing may be done by hand with small
fully curved needle, a new boomerang needle has been introduced which
is "fired" by a spring and passes through five-eighths of a small circle,
it's withdrawal carrying with it the suture; much as the old fashioned
Barker skin needle used to do by having a small recess notched in its
side for reception of the suture. This boomerang needle greatly facilitates this part of the operation.
The advantages of this modern operation are obvious—open instrumental dissection in a relaxed field, under spinal anaesthesia, is a more
essentially surgical operation than blind digital dissection, with frequently
serious haemorrhages. A suction apparatus keeps the field clear for a
direct vision operation. The primary closure of the bladder has reduced
the hospitalization by at least fifty per cent., and in some cases, to as
low as eight days. The multiple daily dressings and odour are done
away with and very often by the end of a week, a patient can void
normally at frequent intervals. In one case which recently came under
my observation the removal of the sutures on the ninth day revealed a
suprapubic wound soundly healed by primary union, with a patient
voiding normally per urethram.
This particular type of surgery—like neurological surgery—requires
an armamentarium peculiarly its own.
5.    Carcinoma of the Cervix.
About three years ago I gave up operating upon cases of carcinoma
of the cervix and have relied solely upon the use of radium in these cases.
My results in cases of cervical cancer were so bad, and the mortality so
out of proportion to the rest of my work, that I felt that in my hands at
least, this condition was no longer one to be treated by surgical measures.
I have since met many surgeons who have likewise either discontinued
radical hysterectomy for cancer of the cervix, or operate on the very
earliest cases only. My routine performance used to be radical hysterectomy, followed by radium or deep X-ray therapy. There was a sizeable operative mortaility and the extension of life, in my hands, was never
Page   182
*m much more than a year or a year and a half, which I considered most
unsatisfactory. Radium would do as much and eliminate the initial
operative mortality.
The work, however, of Dr. Frank Lynch, of the University of
California Hospital, has recently changed my ideas. One of the outstanding features of his series, is that out of over three hundred cases,
he has lost track of only two, and knows the fate, whereabouts, and conditions of all his cases. This has necessitated a most careful and commendable system of "follow up" records.
To be very brief: He divides his cases into four groups, group 1
being the very earliest and Group 4 the far advanced cases. Of the
last three groups we have nothing to say; he relies upon radium and does
not operate at all. He defines Group 1 cases as those very early cases
of carcinoma, confiend strictly to the cervix or cervical canal, with no
extension laterally and no extensive destruction of tissue, no vaginal involvement. In other words, the earliest recognizable cases of cancer of
the cervix. Dr. Lynch explains that much of his previous poor results
were due to operative mortality; peritonitis developing from contamination with infected mucosa and cervix, etc. His procedure is now, and
for some years has been, simply this: He first has the cervix treated extensively by radium, which clears up the cervix and acts as a lymphatic
seal to the peri-cervical tissues. Approximately three weeks later he
goes in and does a pan-hysterectomy by the abdominal route, going well
beyond the uterus, cervix and adnexa. There has been a small primary
operative mortality, much less than before, but all his cases of Grade 1
have survived, and many have lived over ten years with no signs of recurrence. In fact, if my memory serves me correctly, he has not lost a
case of Grade 1 carcinoma of the cervix since following this routine,
except the initial small operative mortality I saw in one morning, in his
"follow up" clinic, eleven cases of ten year cures of Grade 1 cancer.
The important features, I believe, are that nothing but Grade 1
cases are subjected to surgery, the primary lymphatic sealing by preliminary radium treatment three weeks prior to operation and the wide
subsequent hysterectomy. The remainder are treated by radium alone. The
results have been exceedingly striking, and if they are borne out by other
operators, it is going to further emphasize the need of a little less haste
in cancer surgery. I share, I think, the anxiety of most surgeons to get
cancer cases to the operating theatre quickly to prevent any further
advance of the disease by delay. I wonder perhaps, if this very haste has
not, in the past, been our undoing. I have, in recent years, had a small
series of cases of cancer of the breast in which I have done a preliminary
lymphatic occlusion by X-ray therapy and have removed the breast two
weeks later. Although I have not had enough of these cases over a sufficient period of time to compare the results with cases treated in the usual
way by primary operation and secondary X-ray therapy, I believe the
idea is sound and that a little less surgical haste and a little more preliminary radiation may be the means of improving our cancer statistics,
in the cervix as well as elsewhere.
Page 183 M
6.    Surgery of Hirschsprung's Disease.
The work of Royle and Hunter on plastic tone and the relief of
spastic diplegias provoked very considerable excitement some years ago
and gave promise of bringing relief to a vast throng of Nature's unfortunates. Their primary premise of dual innervation and plastic tone
seems to have fallen into disrepute, and its use in the conditions for which
it was originally introduced, most certainly has lost favour and it is now
almost never performed. Certain secondary phenomena, however, occurring in these cases upon whom sympathectomy had been performed, at
first unappreciated, have come to develop a real importance, and their
work is proving of service, though in a far different field to what they
originally intended.
The value of sympathetic release in certain vascular diseases, such
as Raynaud's disease, is to well established and too well known to require
further comment. It's use in Buerger's disease, though of more limited
value, is likewise well known, as are the alcohol injections of sympathetic
trunks in angina pectoris.
The phase of sympathetic surgery in which I am most interested tonight is in that hitheto intractable type of case: Hirschsprung's disease
or congenital megacolon. It is only within the past year or two that
its value has met with widespread acceptance, and its failure of earlier
appreciation is probably a result of primary disappointment in sympathetic
surgery in the spastic paraplegias.
The essential pathological changes in the bowel in a case of Hirschsprung's disease, are hypertrophy of all coats, especially the muscularis, and
a huge dilataion of the affected bowel or segment of bowel amounting to
gigantism of the colon. There is in addition, a total absence of demonstrable obstructive phenomena in the congenital type of case. There is
in these cases, an undemonstrable segment neurogenic dysfunction
against which the peristaltic waves of even the greatly hypertrophic
colonic musculature is impotent.
The operation most commonly performed, is bilateral resection of
the second, third and fourth lumbar sympathetic ganglia through an extraperitoneal incision in the loin, similar to, but longer than a kidney
incision. The peritoneum is pushed inwards, the ureter adheres to the
peritoneum, the surface of each psoas muscle is exposed and the ganglia
very easily found and resected. They are quite large and easily demonstrated. The extra-peritoneal operation I prefer. It is associated with
very little surgical schock. Much less, I feel, than that associated with
the transperitoneal approach.
of tl
le exact mechanism ot the operation is still somewhat in dispute.
The probability is that the sympathetic over a segmental distribution is
hypertonic, failing to "let go" or relax the bowel in advance of an oncoming wave of peristalsis under parasympathetic or vagal control. Resection of the sympathetic, affords this sympathetic release and permits
the peristaltic wave to pass the area of previous neurogenic obstruction
or achalazia as Hurst has termed it    The obstruction being relieved  (for
Page   184
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**» obstruction it is, even if not organic) the bowel emptying itself
gradually, over the course of a year becomes reduced to something more
nearly approaching normal. I have had three cases, two of them over
three years ago, one of them two years ago, and all have shown thoroughly
satisfactory clinical cures, and the X-ray evidence I show in these slides
is indicative of the degree of restoration occuring in the colon over a
period of 18 months between the first and second slides. These cases,
hitherto intractable, have become exceedingly satisfactory cases.
7.    New Work on Cancer.
Each succeeding week sees a new cure for cancer foisted upon the
medical profession, and each in turn has slipped into the limbo of the
past. So much so is this true, that one hesitates to call attention to anything new lest this year's sensation may be the memory of tomorrow.
Yet, recent work of Dr. Wily Meyer is at least of more than passing
interest. Meyer developed the thesis that cancer could only grow in an
alkaline medium, and that the production of an acidosis was inimical to
its growth, and if faithfully continued, somtimes resulted in clinical cure.
Frequent examinations of the pH. of the blood, he states, shows the
presence of an alkalosis, or at least, a diminished acid content ,and that
this condition is, if not the cause of cancer, at least the favourable soil
wherein it is permitted to grow and develop. Willy Meyer is quite dogmatic about it and states his theory boldly and fearlessly; further he supports it with case records of some half dozen cases of apparent clinical
cures by means of sustained acidosis treatment.
His mehod is simple: he gives these patients 35 drops of pure, concentrated hydrochloric acid in plenty of water three times a day, gradually working up to this level from smaller doses. In addition to this
they breathe from a bag, 4)^% Co2 in pure oxygen for from two to
four, hours each day. He combines this treatment with intensive deep
X-ray therapy of the primary tumour and its metastases, for fifteen minutes three times each week. This treatment necessarily requires hosp-
pitalization and is continued for several months.
One particularly interesting case record is cited: a gastric carcinoma
operated upon by Dr. C. H. Mayo and pronounced inoperable with
mestastases; some time later shown by X-rays to be slowly diminishing,
and subsequently showing complete disappearance with apparent clinical
cure; he patient having faithfully followed the acidosis treatment at
Professor Fischer-Wasel's Clinic at Frankfurt, Germany.
Meyer attributes the so-called spontaneous tures or "miraculous
cures" of cancer to the development of an acidosis as a result of severe
inflammations, fevers, Coleys fluid, starvation, etc. The method must
be carefully checked and re-checked by frequent and repeated examinations of the pH of the blood, C02 combining power, etc., and the
patient kept well on the acid side of the reaction. Furthermore, he hints
that in the event of a clinical cure, the determination of the pH' may
indicate a developing recurrence, and be indicative that further or renewed treatment is necessary.
Page 185 m
I recently had the pleasure of inspecting and seeing demonstrated the
new huge million volt deep X-ray machine housed in the California Institute of Technology, in Los Angeles. A million volts. Instruments of
such terrific power must be housed underground in specially constructed
vaults and their power is beyond computation. If such stupendous doses
prove practically to be of value, it will of course, eliminate radium entirely. My first reaction to this machine was simply that I did not think
I would care to subject a patient of mine, or more particularly myself,
to the ravages of such a monster as a million-volt deep therapy outfit,
with so little known as to its effects and the dangerous potentialities
which it must hold. However, so many things in recent years, that at
first sight seemed dangerous, have subsequently been shown to be quite
the reverse, that I am growing to approach these things, if not more
credulously, at least in a spirit of more sympathetic tolerance and withal
less critically. The increasing use of radiation in recent years, both in
the form of deep X-ray therapy and radium, the passing over to the
radiologist of one thing after another that used to be considered wholly
surgical, particularly in the field of malignancy, is probably one of the
outstanding trends in modern day surgery. Whether it is due to earned
results or good advertising on the part of the radiologist, I am not prepared to say.
A further recent development in radiography has been the development of instantaneous X-ray photography. By this method you will see
in several of the slides I show, soft tissues outlined in a way hitherto
impossible. The instantaneous photography completely eliminates motion;
the crying, struggling child can be taken with the same ease as an intelligent adult. I show here a slide showing the loops of dilated intestine
in a bowel obstruction and here I show a carcinoma of the larynx beautifully outlined, showing the rings of the trachea, the uvula and the soft
tissues of the pharynx standing out as in an etching. These slides are on
view in the radiographic department of St. Paul's Hospital where they
wee taken. This case of carcinoma of the larynx is here visualized in
a way hitherto impossible.
Just what help all this is going to be to those of us who are daily
having to treat cancer in all of its stages, it is impossible as yet to say.
Whether this work of Meyer's will or will not develop into anything of
importance, it is not for us to even surmise. However, it is comparatively
new, intensely interesting and the flight of time will prove or disprove its
8.    Singultus.
In an otherwise normally progressing post-operative surgical case,
I do not know of any condition so distressing, so apparently wholly unnecessary, and withal so demoralizing to patient, nurses, and surgeon alike,
as the development of a persistent hiccough. The unheralded complication of simple surgical procedure is always debilitating and frequently
fatal. Nearly everything has been tried from sorcery down, or up as the
case may be; iodine, benzol benzoate, gastric lavage, digital compression
of the phrenics, sodium amytal, deep anaesthesia, all have been tried, all
Page   186 have been successful at times and as often not, and it is the case or cases
where these simple measures do not suffice that a new method of treatment has been developed. It is strange that every so often the entire
nation follows the case of a persistent hiccough in the daily press and
this sharp inspiratory spasm of diaphragm and glottis has frequently
invoked the sympathy of the entire world.
Injection of the phrenic nerve has been tried many times before. I
have twice use it with success. The important thing however, in recent
findings attributed to Weeks, is that the diaphragmatic spasm is always
unilateral and that it can be readily demonstrated by fluoroscopy, upon
which folium of the diaphragm the condition depends. This is new. I
have upon other occasions failed with phrenic injection of novocaine—
probably I attacked the wrong side. Also, strangely enough, radiography
or rather fluoroscopy, has shown that in a gall bladder case, it is by no
means always or even in the majority of cases, the right leaf of the diaphragm which is at fault. Nor in splenectomy is it necessarily always
the left leaf.    Hence the necessity for preliminary fluoroscopy.
However, simple phrenic injection is by no means all-sufficient. In
many cases the relief is very transitory. It has been found necessary in
most instances to cut down under local anaesthesia, expose the nerve
which is readily discovered on the anterior scalene muscle and tie it
tightly with a strand of catgut, performing a nerve section in situ with
your ligature and interrupting completely, for some time, the flow of
nerve impulses to the affected leaf of the diaphragm. The catgut being
absorbed, leaves a nerve in situ, neuroglia and myelin sheath preserved in
apposition and permits a rapid regeneration of the nerve and subsequent
recovery. It is to be remembered however, that the phrenic is not the
only nerve of supply to the diaphragm, the lower six intercostals supplying its outer folia, and although division of the phrenic is usually sufficient, it may in intractable cases, be necessary to supplement it with paravertebral anaesthesia on the affected side. The fact that hiccoueh is
usually unilateral is so simple, that it would appear to verge almost on
the ridiculous that it should not have been appreciated before, and has
pointed the way to permanent relief of one of the most distressing and
erstwhile dangerous post-operative conditions with which we are faced.
9.    Persistent Exophthalmos.
I had a patient some years ago suffering from a medical complaint,
whom I transferred to the care of a physician. One day my colleague
was called up by this patient in a state of great excitement, and upon
arriving at the home, discovered that a prominent unilateral exophthalmic
eye had become dislocated onto the cheek. It was easily reduced. Such
accidents are more uncommon than rare and a high degree of persistent
exophthalmos, sufficient in many instances to provoke corneal changes of
of a pathological nature, is not usual following severe toxic goitres in
whom metabolism may be normal, and in whom a clinical cure is often
otherwise wholly satisfactory. Besides being a potential source of panophthalmitis, these eyes are frequently a matter of grave concern to
patients, particularly women.
Page 187 May I pause for a moment or two to state that the cause of exophthalmos in other than tumours or cavernous sinus lesions is unknown. I
was taught that exophthalmos was due to a contraction of Muellers
muscle. This muscle is vestigial, can scarcely ever be demonstrated in
man, and where demonstrated, could never by the widest stretch of the
imagination, be powerful enough to exercise any effect whatever The
idea of sympathetic irritation has not been borne out clinically or experimentally It is not due to retro-ocular fat deposition or anyone of the
numerous theories advanced. The fact is that we do not know what
causes this simple condition.
Professor Naffziger, of San Francisco, and Brian King, of Seattle,
working independently, conceived the idea that it was due to the retention of a retro-ocular solid form of oedema, a myxoid form of oedema
one might almost call it. Very interesting pathological findings have
come to light as a result of their work. For instance, the strip muscles
of the eye are literally strips under normal conditions, yet in these cases
they are enlarged many times their normal diameters and appear as quite
powerful structures. I was shown by Dr. Naffziger cross sections of an
external rectus muscle hypertrophied to approximately ten times its
normal size, removed from such a case, as well as many microscopic slides
of bits of muscle removed during operation, all showing gross hypertrophy.
Now physiologically, there is only one known cause for muscle
hypertrophy and that is increased work, whether it be in the brawny
biceps of a mechanic, the thumb muscles of a fowl plucker, the musculature of an obstructed bladder or of an overburdened heart. Obviously these muscles are overworking and may be considered to be enlarged or hyperplastic in an attempt to prevent ocular extrusion altogether.
The theory is that this retro-bulbar, solid oedema has gradually forced
the eye forward and the strip muscles have become hyperplastic as a
compensatory measure. Dr. Naffziger has devised an operation by means
of which this oedema may be relieved, and through the course of time,
permit the eye to recede. He makes a transverse incision across the head,
just behind the hair line, turns down a flap and then a large bone flap is
turned down exposing the dura, which is easily lifted off the roof of the
orbit in the anterior cerebral fossa. The bulb of the eye is then thoroughly
decompressed by removing the roof of the orbit and the roof
of the optic canal Not a difficult operation, because the bone here is as
thin as parchment and decompression is easy The original idea was to
drain this solid oedema by means of strands of mercurialized silk into the
sub-dural space, following the principle of Sampson Handley in draining
the oedematous arm of the too radical breast amputation However, as
the oedema is more of a myxomatous type, this system does not work well
and in fact is not necessary, as the decompression is sufficient. The flaps
are accurately replaced and no scar is visible anywhere
I show in this slide the area of bone removed from the anterior
cerebral fossa. You see it involves a part of the wing of the sphenoid
over the optic canal.
Page   188 I was permitted to see one such case in hospital, post-operatively,
although I regret to say I did not see the operation itself. The eyes recede
very slowly, but over a period of a year usually become approximately
normal. The case I saw was seven weeks post-operation and already there
was appreciable recession as measured by the exophthalmometer and
the millimetric lid slit measurements. The operation is not difficult, the
condition distressing, the results appear to justify it. At any rate, the
first patient, a nurse who had a unilateral operation performed, returned
in six months to have it done to the other side. Very interesting and
something to think about, gentlemen ....
10.    Basal Synergic Anaesthesia.
This subject is now over three years old and perhaps this would
not be an unsuitable place to take stock of what the present position is.
Sodium Amytal, the original preparation, was really introduced under
misopprehension. It was supposed to be a new anaesthetic. It did not
take long to realize that it was not. It was followed by avertin, nembutal, pentabarbital and a host of others. All these preparations are
basal synergies to anaesthesia and nothing more. How have they stood
the test of time?
I have now records of over a thousand operations performed in the
past three and a half years using one or another of these preparations as
a preliminary to ordinary anaesthesia. I really believe they represent one
of the greatest advances in surgery in the present century. They are not
anaesthetics, never have been and should not be used as such. Wherein
then is their value? I feel their greatest contribution has been the development of a consciousness in the mind of the surgeon of the psychical
reactions of a patient about to undergo a surgical operation. I believe
I have come to appreciate this very fully. Some months ago I saw a case
die on the table following simple ether induction, where the patient had
come upstairs in mortal terror. The anaesthetist had had one previous
death under similar circumstances and has since resolutely refused to give
an anaesthetic to a frightened patient. Only upon the very rarest
occasions in the past three years have I permitted a conscious patient to
come to an operating room for his or her anaesthetic. I think we have
become too accustomed to surgery ourselves, and too thoughtless, very
often, of what is a major event in a patient's life. Conscious" of all this,
I give every patient an induction dose of Sodium Amytal downstairs in
her room, with all solutions prepared before entering. They drop asleep
in their room and never know they have left it and never know what
the inside of an operating room looks like. To people of a strongly phlegmatic temperament, this is not important, but they are heavily in the
I am sure that this little extra kindness and appreciation of a patient's
feeling is not lost or them. I know from experience of a thousand cases
how much they appreciate it. Add to this the quiet post-operative sleep.
They are conscious in four or five hours with a few hours more amnesia.
There is almost a complete absence of post-operative nausea and vomiting,
actually only 4% of my cases have vomited at all post-operatively. There
Page 189 is a total absence of sweating under the usual either anaesthesia. The great
contribution of basal synergic anaesthesia has been the development of
a finer appreciation in the minds of the surgeons of a patient's pre-oper-
ative mental state and post-operative distress, and a resultant endeavour
on his part to alleviate or eliminate these unpleasant features in every
way possible
We never are injured by gaining a reputation for kindness.
11.    The demonstration of standard surgical operaticns to medical students by motion picture in colour with voice.
I recently saw two motion pictures of operations in colour with voice,
presented before the Pacific Coast Surgical Association in Santa Barbara,
featuring operations by Drs. Maurice Kahn and Rae Smity of Los Angeles.
These pictures were produced by one of the large motion picture
companies of Hollywood, photographed by experts, and developed with
al lthe facilities of their laboratories. The operations were standard ones,
the colour was as nealy technically perfect an dnatural as could be imagined the voice reproduction clear and distinct. The idea behind the development of these pictures, far superior to any previous attempts would appear
to be the formation of a circuit involving all the American medical
schools where pictures of standard operations would be circulated much
as ordinary pictures are now circulated in the R.K.O. Circuit. The
pictures produced in quantity, and so much more cheaply, to be leased
to the Medical Schools for the education of students. These primary
films, experimental in nature, though technically almost perfect, were
prohibitive, in that they cost about six thousand dollars each, required
a full sized theatre projection machine, qualified projectionist and expensive sound reproducing machinery. However, it was hoped that
quantity production could bring them down to a commercially practicable level.
The medical student of the future, sitting comfortably in his seat
watching the details of operations brought into a focus of a few feet,
seems a far cry from the days most of us can remember, craning necks
from a precarious stool or gallery for an occasional glimpse of a blood
stained swab. Though the development is probably one of the future,
the practicability of the idea has been demonstrated from photographic
and sound reproducing standpoints. Whether the whole thing will become
economically possible remains to be seen.
A paper such as this must of necessity be sketchy, brief and overlook
many equally interesting developments of recent years, for lack of time
and space. I would have liked to include in this tonight, the recently
standardized indications for surgical intervention in cranio-cerebral injuries, the work of Hartman on Cortin, the work of Hunter, Turnbull
and Walton on hyperparathyroidism in connection with Von Reckling-
hausens disease of bone, blood sedimentation tests, the intriguing new developments in thoracic and neurological surgery and a host of others.
However, I have tried to present a paper tonight which I hope may be so
diversified as to find some point of interest for all of you. If any of the
suggestions herein set down may have interested you or be at all helpful
to you in your work, then I am well rewarded.
R. E. Coleman, M.B.
It was decided in the last paper to adopt the pay of the Canadian
postal clerk as a unit of measurement for calculating the capital investment represented by a physician practising in Vancouver. Attention
was drawn to the fact that the loss of the pay is associated with
emotional sacrifices of considerable magnitude. The question was raised
as to whether the emotional and financial reward realized by the average
physician warranted the average emotional and financial prices paid. In
the present paper certain phases of the origin of the financial capital which
makes possible the acceptance by the medical student of these financial
and emotional losses will be considered.
When the professional economist studies the ultimate origin of
capital he reduces his problem to "human factors" which he accepts as
denoting the boundaries of his science much as the chemist accepts
chemical elements as denoting the boundaries of chemistry. Though the
chemist takes advantage of the physicist's extended knowledge of the
chemical elements and the economist takes advantage of the extended
knowledge of the psychologist concerning the "human factors," yet
the two boundaries are more or less definitely accepted. In medical economics, however, the analysis of the "human factors" is the major problem
so that, in the following discussion, the bearing of the economist's human
factors on capital will be reviewed.
The total capital of a community at any one time has in the main
two types of origin. This capital is in part the result of savings and in
part the result of tapping new sources of wealth. A man may save a
portion of his income or he may originate a new source of wealth. In
either case the total capital of the community is increased. There are
certain mental and emotional characters associated with the capacity to
accomplish eiher of these results which, though more or less familar,
particularly to physicians, do not commonly lead to the correlations that
they seem to warrant. The act of saving may be instinctive or emotional
on the one hand, or it may be the result of conscious thought. The storage of units by a squirrel for example is purely instinctive; but when we
say that a certain man is a miser we mean that he is activated by emotions
that are, in our opinion, not justified by the actual conditions. That is,
his act of saving is emotional, not reasonable. On the other hand, when
a man saves money for his old age we recognize that the act necessitates
the suppression of powerful instincts and emotions. We also have a definite feeling that this last example indicates a superior mental level. Are
we right? The answer partly depends upon what type of thinking we
consider the more desirable and partly on our reasons, for setting whatever standard we do set. The great difficulty in answering a question of
this nature is its highly personal significance; personal bias being the
strongest and at the same time the most subtle enemy of all scientific
reasoning. The result is that under such conditions we feel more secure
in our deductions when we can bring to bear independent data which has
been sufficiently established in other fields of science to be considered
Page 191 m
reasonably free from bias. For this reason biological analogies will be
drawn which will be found to confirm certain common ideas, and refute
certain others concerning the capacity to save, the capacity to tap new
sources of wealth and levels of thinking.
In a general way survival is highly desirable to the individual, but
it is essential to the group. Therefore that type of mental response would
be the best which best maintains the human race, at the same time with
duce consideration for the future. Without going into definitions we
can correlate thinking, emotions and instincts as follows. A new and
strange situation calls for conscious appreciation and conscious motivation. If the experience is repeated sufficiently often everyone knows
that a habit is formed. That is, motivation ceases to enter consciousness. With the passage of time, habits imperceptibly merge into emotions
as they accumulate dynamic value, as evidenced by the familiar illustration of the real emotional pleasure with which one goes back to old habits,
even though the acquiring of the habit was highly irksome at the time
of its formation. Every experienced general practitioner is only too
familiar with the reality of this sequence, even to the point of the breaking up of homes. Conversely every physician is also familiar with the
serious physiological results which may follow alterations in what seem to
be minor habits in older persons. When a stereotyped response is carried on
through many generations its dynamic value assumes the magnitude of an
instinct. In general then, the longer the history of a stereotyped response
the greater will be the dynamic force behind it and consequently the
greater will be the force necessary to alter or suppress it.
Next let us correlate the effect of time on the intensity of stereotypy,
with certain accepted sequences to be found in the independent field of
evolution. What would a professional biologist predict concerning the
bearing of man's evolutionary history on the habit of saving as evidenced
today? Speaking in evolutionary periods, saving, in the sense that we
are using the word, is of such recent origin that one might almost call
it the present. Until agricultural methods had developed to the point that
harvests could be stored and held over long enough to offset a crop failure,
nature set a premium on those individuals who could act most efficiently
in the present. How recent this is, for the progressive and dominant
Western nations is indicated by the history of English farming. Even as
late as the fifteenth century practically all of rural England was commonly on the verge of starvation. The general nature of the crops was
such that even during ordinary winters only the strongest cattle were
kept over, the rest having to be slaughtered, and even these selected
animals were but skin and bones by the spring. Therefore the accepted
sequence of biological evolution would lead us to predict a selective process resulting in a high numerical predominance today in the human race
of those individuals whose stereotypy would attain maximum efficiency in
dealing with the present, as contrasted with those individuals whose present
actions would be largely controlled by possible future results. This would
lead us to anticipate that the present generation would tend to react most
efficiently in the present. Also since, as we have already noted, instincts
during evolutionary time accumulate dynamic force, the inclination to
consider only the present would tend to have the dynamic value of an
instinct.    Therefore any alteration  calling for the  suppression of  this
Page   192 primary impulse for the present satisfaction in favour of future possible
benefit would demand at least an equivalent amount of emotional energy
from an opposing source. That is, the inclination to save would be opposed
by an instinct to consider only the present.
When we look for emotional forces which could control or suppress
these habits, emotions and instincts arising from the unconscious and
which call for stereotyped responses based upon innumerable past experiences, chiefly calling for consideration of the present, we must seek for
them in the conscious rather than the unconscious phases of the mind. It
is obvious that to meet such a situation the individual must be able to
appraise consciously the present and future, with sufficient emotional
force to offset the dynamic effect of the unconscious or automatic tendencies to ignore the future. Speaking generally we can divide individuals
into two groups. The one group tends to act impulsively in a stereotyped
manner to all stimuli, the nature of the response varying little with
variations in the setting. The other group tends to react as a result of
conscious thought, their primary stereotypy being kept in check. Since
the type of response is determined by the play of unconscious and conscious forces we would anticipate that those individuals who consciously
visualized the widest intellectual terrain would be most effective in controlling the primary stereotyped responses. That is, there would be a
marked tendency for mental superiors (using the term in its obvious
sense) through their broader mental vision to outstrip the inferiors in
any field that required control or suppression of instincts or emotions in
favour of new situations because the larger number of conscious opposing
stimuli would be more likely to assume the magnitude necessary to suppress the instinct.
Thus we find that a consideration of the mechanism by which
habits, emotions and instincts are developed, along with certain accepted
facts from the independent field of biology leads us to anticipate that the
mental reaction which leads to saving a part of present assets for possible
future needs would tend to be found chiefly in individuals with superior
mental capacity. That is, one of the economist's "human factors" responsible for setting up that portion of the community's capital which owes
its origin to savings is the intelelctual level of the community. Further
since the saving effected by the mental inferiors is purely imitative, in the
last analysis practically all of the savings of the community would tend
to owe their ultimate origin to the mental superiors. In a general way
these ideas are common knowledge, but the above analysis seems to warrant a much wider application than the casual observer feels free to admit.
No let us consider the ultimate origin of that portion of the community's capital which owes its origin to tapping new sources of wealth.
Such increases are of the general nature of discoveries, inventions, etc.
The man who discovers a coal mine in a sense increases the community's capital, but on second thought it is apparent that the increase
of the community's wealth is more directly dependent upon the many inventions that make it possible to mine, transport and utilize the coal,
than on the coal in the mine. Communities without any coal are able to
secure it as a result of such inventions. This brings up the whole question of the biological drift of the capacity to invent or make discoveries.
Page 193 Throughout the entire animal and vegetable world there are two tendencies that are continually at war. On the one hand there is a tendency
to stereotyped repetitions and on the other hand there is a tendency to
alterations. The science of heredity itself is chiefly a mathematical study
of the balance between these forces. When we reach the mental level of
the mammals we find that the young tend to experiment more than do the
adults. There are two different processes which combine to effect this
change in the individual. They are both familiar, especially to the
physician. One is the decrease of surplus energy with increasing age, and
the other is the suppression of curiosity, incident to experience. The
practicing physician is only too familiar with the loss of interest and
curiosity coincident with loss of physical strength in disease, but the bearing of this factor on inventions will be left to a future paper. For the
present we will deal only with the bearing that biological selection and
the particular experiences of the individual have on the faculty of curiosity. The survival of a biological group is in part the sum of the play
between stereotyped repetitions and of individual experiments resulting
from curiosity. One of the chief causes of man's dominance has been
his curiosity, so that we would anticipate that selection would have
maintained a high value for this faculty in the human group, more especially in the advanced races which owe much of their domination to
the curiosity, a direct contrast with the biological development of the
tendency to save. On the other hand every one is familiar with the fact
that most curiosity is non-productive. Indeed it is actually so dangerous
that the excessively curious child is notoriously a great worry to its
mother. The technic by means of which mothers curb this faculty in
the nursery is the bogie, which principle is carried over into adult life
under the general caption of taboo. The principle of bogies and taboos
is that they act on the mind of the individual in the absence of supervision by others. The actual dangers of experiments, to the individual and the
group, are such that some mechanism was almost essential to prevent the
death of the individual on the one hand and to prevent the extermination
of the group on the other hand. One of the consequences of the taboo
is to create in the mind of the individual an actual fear of the curiosity
impulse itself. The very temptation to experiment uncovers its own antagonistic fear, so that the individual either completely curbs the impulse
to expremiment or manifests the usual symptoms of an emotional conflict, such as nervous tension. One of the most potent examples of taboo
is the English expression, "It is not done." Also, no doubt many good
experimenters were completely suppressed in England by the oft repeated
remark of a father, "What was good enough for your father and your
grandfather will be good enough for you." The history of the resistance
to improvements in English farming is replete with illustrations of the
efficiency of this as a taboo.
Many of the familiar results of this conflict between the native
curiosity instinct and its acquired antagonistic fear could be anticipated.
For example the individual with few impulses would seldom come in conflict with the taboo and so would experience relatively little difficulty in
accepting the restraint. Also the individual whose impulses carried
minimal dynamic values, even though the impulses themselves were frequent, would similarly experience relatively little difficulty in accepting
Page   194 the' restraint. On the other hand those individuals whose curiosity impulses carried maximum dynamic values would have to develop maximum
fear to effect suppression. If such individuals were unfortunate enough
to have frequent or continuous impulses they would be subject to frequent
or continuous fears. The psychiatrist also knows that for the most part
the individual would simply experience the fear without any conscious
appreciation of its cause. The manifestations of this fear would be a
feeling of inferiority, insecurity, irritability, pugnacity, etc.; the usual
signs of emotional conflict. It would be further anticipated .that in some
individuals the fear of the taboo would be insufficient to completely
supress the dynamic force of the curiosity impulse so that the individual
might either reduce the fear by experimenting in secret or might set out
to fight the origin of the fear which is the social structure about him; i.e.,
the individual becomes antisocial. Whether or not then a given individual
would succeed in completely suppressing the curiosity impulse would depend upon the strength and frequency of the impulses and upon whether
or not the impulse was rewarded. This gives us the answer to our question as the ultimate origin of that portion of the community's capital that
is the product of discoveries and inventions. It is apparent that new
ideas will present themselves most often to those individuals whom we
recognize as having superior intelligence. It is also apparent that the
broader the mental horizon the more frequently the new idea will be
found to fit in with the actual facts and so receive reward. There seems
therefore little reason to doubt that the tapping of new wealth by the
community owes its ultimate origin in the main to the mental superiors.
It is also clear, unfortunately, that in many individuals the price of their
discoveries will be excessive to the point of making them more or less
anti-social, an altogether too common occurrence.
Though it is commonly appreciated that individuals with mental
capacities above the average tend to save more than do those of lesser
mental capacity and similarly those with superior mentality tend to make
more profitable discoveries, the bearing that this has on the total capital
controlled by the community is not commonly appreciated among the
members of the medical profession. Well established facts of common
scientific knowledge are presented which indicate that for practical purposes the capital of the community owes its origin to the mental superiors.
In a later paper it is proposed to show the bearing that the origin of the
capital represented by the medical graduate has on medical economics.
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Westminster 288


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