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MAR 111974

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298 Dundas St., London N6B 1T8, Ontario, Canada 672-4110 MEDICAL J 0 URN A L ______v_oL_ . _«_. _No_. _3,~M_A_Rc_H...:...,_19_74 THE UNIVERSITY OF WESTERN ONTARIO

EDITOR John Van Dorp '76

ASSOCIATE EDITORS Nell McAlister '75, John Clement '76, Bill Watters '76

BUSINESS MANAGER Jonas Karalenas '76

ADVERTISING MANAGER ~erv Kril '76 ASSISTANT EDITOR

CIRCULATION MANAGER Vic Aniol '76 ASSISTANT EDITOR

Contents

58 Editorial-John Van Dorp (Editor) 59 Restoration of the Function of the Paralyzed Diaphragm-A. S. Wilson 61 Sleep and Sleep Deprivation-B. Wooley 67 The Community Health Centre: Its Implications for Medical Practice-­ Shanon Warren 70 The Jewish Attitude Toward Abortion: An Historical-Legal Study- Yehuda D. Eliezri 77 Maimonides' Prayer for the Physician 78 Pathological Photoquiz 80 Consumer Reports: Personal Observations on Free Clinics and Community Health Centres-Bill Robinson 83 A History of U.W.O. Medical School-John J. Heagerty, M.D., D.P.H. 86 Bon Mots from the Lectern-Ann Aldis 87 General Practice in Scotland: A IV Year Elective--Peter Johnston

THE UNIVERSITY OF WESTERN ONTARIO MEDICAL JOURNAL is published four times per year by the undergraduate students of the UWO Medical School. Est. in Oct. 1930. Subscription rates $6.00 per year. Notify any change of address promptly. All editorial, advertising and circulation correspondence is to be addre11ed to the editor, advertising mgr., and circulation mgr. respectively, UWO Medical Journal, Health Sciences Centre, U.W.O., London, Canada. Printers: Hunter Printing London Ltd., London, Canada.

CONTRIBUTIONS will be accepted with the understanding that they are made solely to this publication. Articles should be of practical value to students and medical practitioners. Original research work is moat welcome. Articles should not be longer than 3,000 words, and we will more readily accept those of shorter length. Introduction and summary of conclusions, should be included. Drawings and photographs will be accepted, the former to be in black Ink and drawn clearly on white cardboard.

All articles submitted must be typewritten, on one side of paper only, with double spacing and two Inch margins on each side. Canadian Press (American) spelling must be adhered to. The format for references 11 u tollowa: For bookl: author(a): title ol book, publisher, place, year. For Journals: author(a): title ol article name of Journal (abbreviated as in the World List of Scientific Periodicals), volume: page, year. '

No part of the content of this journal may be reproduced without the written authorization of the Editor. Editorial

Occasionally one comes across very charming things in print-witness more of my favourite quotes scattered like chaff through the pages of the journal. Occasionally the charm emanates from the earnestness with which an error is pursued: but sometimes that error is a dangerous one.

The editors of "Patient Care" have seen ahead of all the frauds that are perpetrated fit to pontificate in the following fashion in in the marketplace. their December 1 editorial. It is obvious that a significant number of The list of government efforts to protect Americans are incapable of deciding the consumer is seemingly endless. Every intelligently how to utilize health care day a government bureaucrat or legislator services, how to purchase prescription or comes up with a new proposal supposedly over-the-counter drugs . .. Even the most calculated to save lives, reduce costs, and casual of reviews of the reams of medical save the hapless and theoretically helpless statistics should convince the most obtuse American from satisfying his own wants and minds of that much. I'm not at all sure that desires. legislation is the answer, but I am sure that ignoring it won't make it go away. If we had In what appear to be calculated had to wait for intelligent consumer buying to responses to consumerist pressures and set trends we wou ld still have unpasteurized political motivations, those in government milk on the counters, diseased meat from the today are moving toward an Orwellian " Big butchers, completely nutritionless bread from Brother" attitude toward the health and the bakers (now it's mostly nutritionless), safety of millions of Americans. The we would still have infectious epidemic implication is that most Americans are horror stories . .. incapable of deciding for themselves how to utilize health-care services, how to Finally, and most inexcusably, state purchase prescription or over-the-counter governments (and not just Nevada) have drugs, how to relate their spending for been promoting legalized gambling in the necessities to their spending for luxuries, forms of lotteries and off-track betting as a how to protect themselves from external means of increasing tax revenues, while and internal abuses of body and mind by tightening the noose around doctors and the profit-making segment of society (most hospitals in their ability to collect of which employ the very Americans who reasonable fees for services. are supposedly thus exploited). I don't know about gambling and I'm not That sort of nonsense should be too sure what a " reasonable fee" is in medical palpably absurd to need rebuttal were it not care, but I know that as long as doctors for the quality of the journal that propounds continue to have the nation's highest taxable it. Contrary to the opinion Implied above, man income my sympathies shall lie more with does not spring from the womb as an those who are less fortunate when it comes encyclopedic authority on everything under time for another round with the chant of the the sun, complete with a price list. That sort "Rocking Horse Winner"-"we must have of philosophy was fine for the days when a more money! we must have more money! WE year's supplies consisted of a bag of sa lt, a MUST HAVE MORE MONEY!" bar of lead and a horn of powder; but it is hopelessly antedeluvian in the society it has Cyanamid of Canada Limited has a very made room for. interesting advertisement for topical steroids in the November issue of the Canadian Family To be sure most of the things on th e market Physician. It is an accepted fact that medicine today are gadgets and toys that nobody really is a male profession, by and large, but that it needs, but with advertising being what it is, should be as sexist as it obviously is, is a less it would take the resolution of a saint not to acceptable truism. I know that sexy ads sell, succumb ... and very few of us are saints. but I am not quite complacent enough to A casual stroll through downtown London accept the fact that they should sell so shopping for any average half dozen items extraordinarily well to the medical profession. will reveal price ranges of up to fifty percent. The fact that ads like this one, which more So much for the hallowed myths of the properly belongs in Playboy, and others more market-place: free competition, laissez-faire subtle, are effective enough to warrant and all the rest of the hoopla that nobody publication says something about the medical believes, but everybody uses to rationalize profession that I wish were not true: and it with. Modern life is such a p:ethora of buying also makes me thankful that I am not a that it is Impossible for anyone to keep woman having to deal with it. 58 Restoration of the Function of the Paralyzed Diaphragm A. S. Wilson

Trauma to the head and neck region has straightforward depletion). Personal become much more frequent in the past observations of normal mammalian diaphragm decade because of increased incidence of (Wilson, 1968) show that there are preterminal automobile accidents. Recently there has been expansions in the motor endings, of bizarre a further increase in neck injuries as a result shapes and sizes and the assumption was that of diving accidents probably attributable to these represent aggregates of neurotransmitter the increasing popularity of domestic substance. If we can stimulate the clinical swimming pools. situation in experimental animals and show decrease in the size of individual preterminal The cervical vertebrae are very vulnerable expansions the fatigue mechanism, in this especially when the subject dives mistakenly instance will be at least partly ex;plained. into shallow water literally head first without Clinically the fatigue problem was solved by the protection of extended arms. alternately stimulating the left and right phrenic nerve individually for periods of 8- 10 A considerable proportion of such accidents hours. result in quadriplegia and paralysis of the respiratory muscles. If the lesion is at or A second feature of the clinical story gives above the level of the phrenic nucleus further stimulation to research. It has become (Keswani, Groat and Hollinshead, 1954) the apparent in the various subjects chosen for diaphragm is paralyzed at the time of injury. ' radio-phrenic' stimulation that the position of Resuscitation is usually effective and some the lesion is very important. If the level is degree of recovery is common during assisted rostral to the 'phrenic nucleus', thus leaving respiration. It is, therefore obligatory to the whole phrenic circuit intact, the attempt maintenance of the vital functions in pacemakers will work very well. If, however, the immediate post traumatic phase so that the phrenic nucleus is damaged concomitantly the entire potential for recovery may be there is a poor response to stimulation of the realized. This usually entails the installation of phrenic nerve. The deduction here is that the a tracheostomy and the immediate use of neuronal processes of motor neurones which positive pressure artificial respiration. constitute the phrenic nerve have their cell body situated in the damaged zone and are Commonly this was the sum total of therefore likely to have been damaged. Thus treatment in the last 15-20 years but recently the axonal processes are separated from their it has been found possible to attach immediate source of metabolites and fail to pacemakers to the phrenic nerves in the neck conduct normally. and to drive the dia,phragm electronically The plight of the patient in this case is less (Judson and Glenn, 1968). Dr. Graham Vanderlinden in the Western General Hospital, hopeful unless the damaged neurones of the phrenic nerve can be supported by cell bodies Toronto, has been able to maintain a young of a nucleus other than the phrenic. If it were female patient on this artificial respiration possible to attach the central end of an intact regime for approximately 5 months with nerve to the distal stump of the defective excellent results as evidenced in the patient's phrenic it might be possible ultimately to morale. achieve sufficient regeneration to drive the As a by-product of the procedure it was diaphragmatic musculature by radio-phrenic found that the system became fatigued after stimulation. approximately 12 hours of continuous stimulation-at the rate required for Anastomis of vagus nerve to phrenic has adequate oxygenation. During the fatigue been carried out by Guth and Frank 1959 and phase the diaphragm was stimulated directly he found that, although regeneration occurred by surface electrodes and it responded there was little spontaneous function in the positively; also the phrenic nerves were still preparation. In the present case, however, the able to conduct impulses as recorded main interest lies not in the restoration of electronically. It was therefore deduced that spontaneous rhythmic function but in the factor causing fatigue was most likely providing sufficient healthy neuronal situated at the neuromuscular junction and processes to transmit the impulses of an that there was a disturbance in artificial pacemaker from the central nervous neurotransmitter substance (probably a system to the diaphragmatic musculature. 59 Which of the available nerves will be most LITERATURE CITED satisfactory for anastomosis is a matter for Guth, L. and Frank, K., (1959) Restoration of experimental study in mammals and this Diaphragmatic Function following Vagophrenic project has been commenced. It seems Anastomosis in the Rat, Exp. Neurol 1, 1. Judson, J.P., and Glenn, W.L. (1969) Radio Frequency possible that the peripheral nerve most likely Electro-phrenic Respiration, J.A.M.A. 203, 1033. to suit the phrenic functional demands will be Keswani, N.H., Groat, A.A., and Hollinshead, W.H., 1954. the recurrent laryngeal because of its Localization of the phrenic nucleus in the spinal cord of the cat. J. Anal. Soc. India 3, 82. association with laryngeal musculature and Wilson, A.S. Investigations on the Innervation of the respiratory activity. Diaphragm in Cats and Rodents. Anal. Rec., 162 : 425-432 .

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60 Sleep and Sleep Deprivation

B . Wooley

Sleep is a state in which a great part of sleep from the temporary inactivity of animals every life is passed . . . . Yet of this change, which results from an environmental so frequent, so great, so general, and so influence. The organism engaged in sleep also necessary, no searcher has yet found either has the ability to be aroused, differentiating the efficient or final cause; ... and once in sleep from states such as coma, anesthesia four-and-twenty hours, the gay and the and trance. gloomy, the witty and the dull, the clamourous and the silent, the busy and the idle, are all Sleep is not merely a state of behavioral overpowered by the gentle tyrant, and all lie inertness, it plays some sort of restitutional down in the equality of sleep . . . . role. To this date no specific physiological -samuel Johnson function has been located that shows supreme benefit from sleep, but search progresses, especially in the neurophysiology and Why do we sleep? What purpose or biochemistry of sleep. function does sleep serve? Is it a necessity? "Where are we" when we are asleep? These and many other questions arise when one PHYSIOLOGY OF SLEEP speculates on the nature of sleep, a recurring physiological process, often taken for granted. The most obvious change associated with The exact "Why?" of sleep has evaded assuming the sleeping state is that of general elucidation since man first began questioning. skeletal musculature relaxation. Along with a In the 300 years since Samuel Johnson, in low level of motor activity there is a slowing spite of considerable research, we still know of the heart rate due to a decrease in very little about the cause or effect of sleep. circulatory output; a reduction in spinal reflexes; a decrease in body temperature; "Because the waking state in adults is of a and a reduction in pulmonary ventilation, longer duration than sleep, and also because probably due to reduced gas exchange in the it constitutes the only period when overt resting tissue. Digestion does not appear to activities are carried on, the average slow down although metabolic heat production individual is likely to consider it the sole does. This last fact may account for the portion of his existence that "counts" in any reduced temperature during sleep. During way, sleep appearing as "time-out" from the sleep there is a diminuation in the activity of game of living." ' This has been a popular the ascending and descending reticular view of sleep since the days of Aristotle. But activating systems. Sleep can be said to be a would nature be so wasteful as to occupy process of passive reticular deactivation, due one third of our lives in a condition of no to the absence of all types of stimuli. value to us? W. B. Webb states: " Although we have not been able to specify the Physiological sleep in man is associated particular effects of sleep, I believe that with a slight but significant increase in sleeping is required for the fulfillment of a cerebral blood flow. There is no change or at complex of very basic needs analogous to the most a slight fall in cerebral oxygen fulfillment of nutritional needs by eating. The consumption, which distinguishes sleep from strength of sleep as a need is evidenced by other conditions where consciousness is the ravages which result from sleep starvation. impaired in association with a significant Further, sleeping places the animal in a very decrease in cerebral oxygen consumption. vulnerable condition in relation to its There appears to be a significant increase in environment. . . . consequently, the fact that arterial carbon dioxide tension in both all vertebrates studied do sleep, suggests a sleeping subjects and those about to sleep, vital role for sleep in the survival of the perhaps because respiration is a little more organism. " 2 shallow at this time.

Pieron considers sleep a suspension of Many authors argue that most of these sensory-motor activities characterized by an changes may be the result of a person almost complete absence of movement and adopting a prone and resting position and an increase in the thresholds of general that these observations shed little light on sensitivity and of reflex irritability. Pieron any functional purpose that sleep may serve. specifies that the suspension of activity is Researchers are now looking deeper than dependent upon internal necessity and not on these overt signs of sleep for clues as to the external conditions. This point distinguishes necessity of sleep. 61 ONTOGENETIC DEVELOPMENT recall when subjects were awakened from this OF SLEEP DURATION stage as opposed to other stages. Dement, conducting experiments in 1958 found that From birth onwards there is a gradual 80% of sleepers awakened during R.E.M. decrease in the total number of hours spent sleep could give detailed description of their sleeping. This corresponds to anatomical and dreams. This compares with only 7% able to physiological development. A young infant do the same thing when awakened from other spends two hours of sleep for each hour of phases of sleep. It is now definitely agreed wakefulness, while an adult spends one half upon that Stage 1-R.E.M. is associated with an hour of sleep for each of his hours of visual dreaming. wakefulness. The relative wakefulness capacity of the individual increases fourfold from birth to maturity. SLEEP STAGE PATTERNS While monitoring sleeping subjects with STAGES OF SLEEP E.E.G ., experimenters have found that there is a certain highly predictable cyclic pattern With the advent of electroencephalography exhibited by all sleepers, and that there is a in the 1930's there came a major breakthrough definite intra-subject consistency of sleep in the study of sleep. It was now possible to stage percentages during successive nights. monitor brain wave emission during sleep. R.E.M. sleep under normal conditions never Loomis, Harvey, and Hobart in 1937, defined starts out at the beginning of a sleep period, five progressive stages of sleep (A,B,C,D,E) but only after an initial stage of C or D sleep. as demonstrated by E.E.G. recordings. The R.E.M. sleep occurs in a 90 minute cycle. An sequence of events indicates the progressive average of four R.E.M. periods occur every development of slow, high voltage waves and night, lasting between ten and fifty minutes the cessation of eye movement as sleep each. They become longer toward morning. becomes deep. These E.E.G. stages are closely correlated in man with behavioral R.E.M. makes up a total of about 20- 25% and subjective signs of sleep which can be of the total sleep. Fig. 1) characterized as: A-slight drowsiness. R.E.M. SLEEP : 8-sensation of floating. THE THIRD STATE OF CONSCIOUSNESS C, D, E-definite sleep. R.E.M. sleep appears to be initiated from The existence of a further quite distinct nuclei in the pons. This has been phase of sleep was first reported in 1953, hypothesized by Jouvet, as he found in his following the observation of cyclical periods experimentations with cats that destruction of of rapid eye movement in sleeping infants. the midpontine area abolishes R.E.M. sleep E.E.G. experiments confirmed that the same without affecting slow wave sleep i.e. regular, phenomenon occurred in adults and that it was non-R.E.M. sleep. accompanied by characteristic changes in cortical activity and physiological function. The range of physiological changes This stage of sleep is often referred to as associated with R.E.M. is so wide that the R.E.M . sleep, because of the characteristic of phenomenon has sometimes been regarded as rapid eye movement, or Paradoxical sleep, a third state of consciousness distinct from because the E.E.G. tracing during this time either sleep or wakefulness. In comparing consists of irregular rapid low voltage waves R.E.M. sleep to other stages, as well as the which resemble tracing seen in awake and changes in brain wave emission, heart rate, alert animals. During this time the threshold respiratory rate and blood pressure show wide for arousal, however is elevated. fluctuations. Breathing is shallow, rapid and irregular compared to the slow deep, regular Aserinsky and Kleitman in 1955, observing breathing of non-R.E.M. sleep. Studies have the periods of rapid conjugate eye movements been done which show a blood pressure during sleep, found a high incidence of dream decrease of about 5-10 mmHg. during non-

STAGE 1 REM STAGE II STAGE III STAGE IV • • • • • • 12pm tam 2 3 4 5 6 Fig . 1. Sleep Stage Patterns 62 R.E.M. sleep and then an increase in blood PURPOSE OF R.E.M. SLEEP pressure, close to waking levels during R.E.M . sleep. Urine secretion is decreased. Extension More R.E.M. sleep is found in the young and flexor reflexes are much reduced or even than in older individuals. (Table 1). Some abolished. Some experiments have shown that feel that R.E.M . sleep's importance and cortical blood supply and brain oxygen function may lie in some type of early consumption increase. The complete abolition development. " R.E .M. mechanism serves as an of muscular tone is evidenced in the anti­ endogenous source of stimulation, furnishing gravity and neck muscles. great quantities of functional excitation to higher centres. Such stimulation would be There is a high incidence of penile erection particularly crucial during the periods in utero during R.E.M. sleep. Teeth grinding occurs in and shortly after birth, before appreciable some individuals. In contrast to highly aroused exogenous stimulation is available to the wakefulness, R.E.M. sleep shows high cortical C.N.S. It might assist in structural maturation activity with minimum thalamic excitability. and differentiation of key sensory and motor areas within the C.N.S. partially preparing them to handle the enormous rush of R.E.M . AND DREAMS stimulation provided by the post-natal mileu, Mental activity is likely continuous during as well as contributing to their further growth all stages of sleep. Dement and Kleitman after birth. The diminution of R.E.M. sleep hypothesize that during non-R.E.M. sleep this with development may signify that the mature activity is related to daily problems and brain has less need for endogenous events. In contrast, mental activity during stimulation."• Stage R.E.M. sleep in adults R.E.M. involves the fantasy and colourful may be a brain exerciser to offset reduced imagery of dreams. Grounds for this stimulation which occurs in sleep. hypothesis may be experiments in which Current theories link R.E.M. sleep with subjects are awakened from sleep, both norepinephrine and suggest that possibly it is R.E.M. and non-R.E.M., and asked to report produced or maintained by norepinephrine. what they had been thinking. Foulkes found That an adrenergic mechanism in the brain is that R.E.M. period reports showed less involved is shown by the fact that brain stem correspondence to waking life than did lesions which deplete the forebrain of reports from non-R.E.M. sleep. norepinephrine suppress R.E.M . sleep. There is A connection between dream content and also a psychological need for the dreaming physiological changes associated with R.E.M. associated with R.E.M. sleep, but a specific has been demonstrated. The limb movements function of R.E.M. has yet to be found. of dream activity have been associated with action potentials recorded in limb muscles; SLEEP DEPRIVATION dreams of laughing, talking, or choking have been associated with respiratory irregularities; The first experiments on the effects of duodenal ulcer victims show the highest rate depriving animals of sleep were performed in of gastric secretion during R.E.M.; dreams 1894 by Manaceine, who found that puppies associated with anxiety or physical effort are kept awake for four to six days died. They linked with nocturnal anginal attacks. also showed a marked hypothermia of from 4- soc at the end of the experiment. Tarozzi TABLE 1 in 1899 found localized degenerative changes in the brain of animals killed at a time when they were very sleepy. These changes EFFECT OF AGE ON TOTAL consisted of: shrinking of cells; displacement AMOUNT OF DAILY SLEEP AND of nuclei; vacuolization of cytoplasm ; the R.E.M . SLEEP IN HUMANS disappearance of Nissl granules in the prefrontal cortical region. The amount of Total Daily R.E.M. Sleep damage noted was proportional to the degree Age Sleep (hrs.) (% of total sleep) of sleepiness. These results indicated that sleep plays an important role in the 1-15 days 16 50% maintenance of life. 3-5 months 14 40% 2-3 years 13 25% In human experiments, Kleitman noted that 5-9 years 11 19% after 90 hours of sleep deprivation there was 10-15 years 9 20% a decrease in sensory activity, quickness of 19-30 years 8 22% reaction, motor speed and memorizing ability. 33-45 years 7 19% During the first night of sleeplessness, 50-70 years 6 15% subjects did not feel tired or sleepy provided they had some sort of muscular activity to from Ganong, W.F. , perform. They managed to make it through A Review of Medical Physiology, 1969, p.137 the first night quite easily except for an attack 63 of drowsiness which came between 3:00 and temperature rhythm was preserved. However 6:00 a.m. in the morning. The second day they the mean temperature level dropped over the got through without feeling that they had four days. This may give us a clue as to why missed a night's sleep. The second night it gets progressively harder to remain awake found it much harder to remain awake. Eyes after four consecutive days without sleep. tended to feel itchy and dry. Again there was However we do not know why the mean body a 2-3 hour period in the early morning when temperature goes down. the desire for sleep was almost overpowering. It was very hard to remain awake on the PSYCHOLOGICAL EFFECTS third day, especially when sitting or reading. OF SLEEP DEPRIVATION The third night was much like the second and the fourth day like the third. It was noted that Increased sensitivity to pain, hallucinations, sleep deprivation brought drowsiness which disturbances of disposition, and other changes was subject to diurnal variation, i.e. in the early in character are the outstanding and common hours of the second, third, and forth days of findings in studies on sleep deprivation. They sleep loss it was harder to remain awake than suggest fatigue of the higher levels of the at other times. cerebral cortex-levels which are responsible As well as this drowsiness cycle, there are for critical analysis of incoming impulses and other physiological phenomenon which exhibit the elaboration of adequate responses in the diurnal rhythm. There is a twenty-four hour light of one's previous experiences. hypophyseal-adrenocorticoid periodicity revealed by eosinophil counts, plasma EFFECT OF SLEEP corticosteroids concentration and keto steroid DEPRIVATION ON PERFORMANCE secretion. Perhaps more important is the diurnal temperature cycle. Body temperature In many hospitals interns are prevented tends to go down during sleep periods and from following normal sleep-wake cycles. This rise during waking periods. Kleitman often results in sleep deprivation for a day or hypothesized that for each individual there two. Friedman et al in 1971 , found that the probably exists a " drowsiness temperature ability of interns to concentrate on a task level" above which it is easy to remain awake requiring sustained attention decreased with and below which it is progressively harder to sleep loss. This may result in decreased do so. accuracy or increased time needed to complete a given task, or both. Figure 2 shows mean body temperature changes together with variation in self-rating Murray in 1965 noted that after continuous of fatigue. The two curves are almost mirror sleep deprivation there are periods in which images showing that when the body the person is incapable of responding. This temperature falls below a certain point, the then caused deteriorating performance. There subjects feel more tired. Through the sleep is not actually a decline in the ability to deprivation period the twenty-four hour perform. These periods last for a few seconds

Day 1 Day 2 Day 3 Day 4 2.5 ,,~ . 98.5 ,'· ,' I I ,, , ' ,'~ '• , . I ' I ' ' ,.... 2.0 ,,r I \ r... ,,,-' '. ,' ,, I 98.0 ' ,, ,' , ' 1.5 ,,, I ,, , ''" I I . 97.5 I ,', ,I 1.0 "' ' ,, ' 97.0 6am 6pm 6am 6pm 6am 6pm 6am 6pm 6am Fig. 2. Mean Body Temperature and Self-ratings of Fatigue in Sleep-deprived Subjects 64 and by means of E.E.G. recording they are Another old hypothesis about the cause of identified as brief sleep periods. Example: in sleep is that there is some kind of metabolite self-paced addition, sleep deprived subjects that builds up in the body during wakefulness show no decrease in accuracy, but they work and th is metabolite is responsible for causing fewer problems. In externally-paced addition sleep. During sleep it was supposed that the there appear a significant number of errors. level of th is metabolite went down as it was Subjects worked without a loss of capacity perhaps destroyed or converted, thus causing when they worked, but there were times a person to wake up. Data to support th is when they could not work. hypothesis came from experiments where the C.S.F. of sleep deprived an imals was injected The effect of sleep deprivation upon into the fourth ventrical of normal animals. performance and upon the physiological These injected animals then became sleepy. measures of arousal (E.E.G., E.M.G., They showed no ill effects after left in respiration and heart rate) depends upon the undisturbed sleep. situation in which the subject is placed. Also Wilkinson in 1961 finds that motivation must Luby in 1960 states that the energy transfer be considered in assessing the effects of systems of the body respond to sleep as a sleep deprivation upon performance. When stressor and show a marked increase in the subjects are not informed about their specific activities of ATP and AMP. ATP is performance, lack of sleep causes the usual needed to transform food energy into energy impairment. When subjects are given feed­ usable by the body. Due to the stress of sleep back on their performance they turn up with deprivation, there is increased synthesis of less impairment of their task. He also AMP and a resulting drop in uric acid suggests that a man can be capable of excretion probably resulting from the performing normally in spite of loss of sleep conservation of purines including adenine. As if the rewards for doing so are sufficiently sleep deprivation continues, th is emergency great. It seems that the effects of sleep energy mobilization begins to fa il, and this deprivation are not clearly-defined, but corresponds to the deterioration of subjects depend to a great extent on the conditions of in psychological testing. After about four days the experiment. of sleep deprivation ATP production almost ceased. Sleep will return the balance back to One might be lead to believe that muscular normal. fatigue is a contributing factor to the effects of prolonged wakefulness. Tyler in 1947 STAGE R.E.M. DEPRIVATION indicated that this muscle fatigue is not so severe as to be an important factor. The first attempt at suppressing R.E.M. sleep Exhaustion and extreme sleepiness always came in 1960. With the aid of E.E.G. tracings accompany extreme muscular weakness, but sleeping subjects were awakened each time prolonged wakefulness is not necessarily the E.E.G. showed they had entered the accompanied by great muscular fatigue. R.E.M. phase of sleep. When they were allowed to go back to sleep, it was always BIOCHEMICAL EFFECTS into the non-R.E.M. phase. To compensate, OF SLEEP DEPRIVATION the R.E.M. phase began to occur more often. Eventually the subjects had to be awakened It is in the biochemical changes associated as many as thirty times a night if the R.E.M. with sleep deprivation that many researchers phase was to be avoided. It seemed as though today are looking for clues as to the necessity the longer dreams were kept out of sleep, the of sleep, and what goes on in the body during more they tried to force their way back in. sleep. Little light has been shed on this area. If the subject was then allowed several Much research and accumulating data is nights of undisturbed sleep following R.E.M. contradictory in nature and there is such a deprivation, there was a significant increase wide range of uncontrolled variables in in the percentage of stage R.E.M. sleep. This experiments that comparisons are not increase persisted for several days (up to possible. 60% of total sleep) and was proportional to Studies where determinations have been the duration of the deprivation. Dement made on urinary total nitrogen, ammonia, concluded that there was a need for a given chloride, phosphates and acidity show no amount of R.E.M. sleep per night and that consistent alteration in urine components of this amount depended on the subject. sleep-deprived subjects from normal. Mangold eta/. in 1955 showed no difference Whether there is a need for the experience in oxygen consumption, Hb concentration, pH , of dreaming afforded by R.E.M . sleep or of or blood gases in fatigued subjects. That Kety some physiological state, represented by found an increase in cerebral blood flow R.E.M . is still unknown. Freud at the turn of during sleep disproves an old hypothesis that the century suggested that dreams were a cerebral anemia is the cause of sleep. safety valve, dissipating the accumulated 65 tension of the day, and that they represented REFERENCES the discharge of intellectual drives which 1. Kleltman N., Sleep and Wakefulness, 1963, pg. 3. were repressed in waking life. Greenburg et 2. Webb W.B., Sleep: An Experimental Approach, al, in 1972, hypothesized that dreaming aids 1968, pg. 51 . in the adaptation to anxiety-provoking stimuli. 3. Webb W.B., Sleep: An Experimental Approach, Non-medical subjects were shown a stressful 1968, pg. 164. movie of an autopsy on two consecutive days. 4. The Nature of Sleep: Ciba Foundation Symposium During the intervening night some subjects on Sleep, 1961 , pg. 1. were R.E.M. deprived, some awakened an equivalent number of times during non-R.E.M. BIBLIOGRAPHY sleep and some slept undisturbed. The results 1. Dement W., The Effect of Dream Deprivation. were that R.E.M. deprived subjects showed Science, 1960, 131 : 1705-07. significantly less habituation to the second 2. Friedman R.C., et al, The Intern and Sleep Loss. viewing, than control subjects, who showed N. Engi.J. Med., 1971 , 285 : 201-3. less anxiety. Perhaps R.E.M. sleep serves to 3. Ganong W.F., A Review of Medical Physiology, integrate memories of similar experiences with Lange Medical Publication, Los Alles, California, 1969. the current stress. 4 . Greenburg A., et al, Effect of Dream (stage R.E .M.) Deprivation on Adaptation to Stress. Psychosom. Along other lines, there is experimental Med., 1972, 34 : 257-62. indication of possible interaction of 5. Hollmann-LaRoche, publishers, Concepts of Sleep. cholinergic and serotonenergic mechanisms in Montreal, Canada. (no date) R.E.M. regulation, implicating a complex 6. Kleitman N., Sleep and Wakefulness, University of control system dependent upon the interplay Chicago Press, Chicago, 1963. of multiple factors. Many forms of emotional 7. Koella W.P., Sleep, C.C. Thomas Publisher, stress (including intra-cranial stimulation) Springfield, Illinois, U.S.A., 1967. 8. Jouvet M., Neurophysiology of the States of Sleep. have been shown to be capable of acutely Physiol. Reviews, 1967, vol. 47, no. 2. lowering endogenous norepinephrine levels 9. Luby E.D., et al, Sleep Deprivation: Effects on in a variety of animals with little effect on Behaviour, Th inking, Motor Performance and other substances. When these animals were Biological Energ y Transfer Systems. Psychosom. depleted of cerebral norepinephrine by Med., 1960, 22 : 182-92. 10. Mangold A .. et al, The Effects of Sleep and Lack electrical stimulation, a significant reduction of Sleep on the Ce re bral Circulation and in R.E.M . sleep was noted. Therefore Metabolism of Normal Young Men. J. Cl/n. norepinephrine is probably involved in the Investigation, 1955, 34 : 1092-1100. tonic phenomenon of R.E.M. sleep. 11 . Murray E.J., et al , Body Temperature and Psychological Rating During Sleep Deprivation. J. Exp. Psycho/. 1958, 56 : 271-73. " When we consider the immense human 12. Putkonen P.T.S., et al, Suppression of P.S. Following significance of sleep, the absolute necessity Hypothalamic Defense Reactions In Cats During for us to spend a considerable part of our Normal Conditions and Recovery from P.S. lives in abject mental annihilation, it is Deprivation. Brain Research, 1971, 26 : 333-37. remarkable how little we know about it, how 13. Tyler D.B., The Effect of Amphetamine Sulphate and Some Barbiturates on the Fatigue Produced little we can say to account for the necessity by Prolonged Wakefulness. Am. J. Physiology, 1947, of sleep. It is one of those extraordinary 150 : 253-62. common things which we all accept, perhaps 14 . Tyler D .. Psychological Changes During Experimental Sleep Deprivation. Disease of the not thinking that there are immense scientific Nervous System, 1955, 16 : 293-99. problems there ... . There is not as yet 15. Webb W.B., Sleep: An Experimental Approach with sufficient factual evidence to enable us to Selected Readings. The MacMillan Company, New give precise explanations of how sleep is York, 1968. brought about or why it is required and how 16. Wolstenholme G. et al, editors, The Nature of Sleep; Ciba Foundation Symposium on sleep, J. A. It brings about recovery."• Churchill, Ltd., Great Britain, 1961 . * * * In memory of Mary Maria, wife of Wm. Dodd, who died Dec. 12, 1847 aged 27 and their children, Louisa, who died Dec. 12, 1847 aged 9 months and Alfred who died Jan. 3, 1848 aged 2 years and 9 months. All victims to the neglect of sanitary regulation and specially referred to in a recent lecture on health in this town. "And the Lord said to the angel that destroyed, 'It is enough, stay now thy hand'."-From a tombstone, 81/:ston, Staffordshire. * * * From contemplation one may become wise, but knowledge comes only from study. -Edward Newton * * * To be Ignorant of one's Ignorance is the malady of the Ignorant-Amos Bronson Alcott 66 The Community Health Centre: Its Implications for Medical Practice

Sharon Warren

Today a multiplicity of professionals and becoming a member of some group.' There technologists confront any person in need of are several advantages of group practice to medical care. No one of them is likely to meet the physician, including the opportunity to all of his problems. Yet ordinarily, share operating costs and workload among communications among the various persons practice colleagues. In addition, many groups whose services he might use are so poor that organize disability insurance, retirement plans, a patient may get lost in the health care etc. for their members. Some physicians may maze. Community health centres have long even regard the constant peer review been suggested as a device for organizing the associated with group practice as an maze by gathering a variety of workers under advantage, likely to encourage all members one roof; several countries throughout the in better quality service. The opportunity for world are experimenting with, or have close consultation with practice associates adopted the technique. In recent years, a may also be welcomed by some, although few citizens' associations or industries in others may be more afraid of colleague Ontario have established prepaid group interference. insurance plans and centres to serve their insured. Studies of these centres have shown Group practice then has some clear that they reduce hospital utilization among advantages to the physician, as well as their patients and would thereby help to certain features which could be regarded as reduce the overall cost of health care to the either beneficial or a "nuisance" depending Province, since hospitalization is probably the upon the individual's personality. The most expensive aspect of patient care. This advantages of this type of organization to its apparent potential has naturally attracted the patients, in terms of comprehensive care, and government's attention and it has recently to the government, in terms of reduced costs are not so evident. ' begun to back the establishment of several such centres. Because there will always be barriers If community health centres will improve between individual professionals and technologists, comprehensive care within any patient care and reduce hospital utilization, centre may never be perfect. Even so, it what is their effect on the work of associate might be superior to the care organized by physicians likely to be? This article discusses members of a group who would have to the community health centre concept and contact other health workers on the outside some of its more important implications for or direct their patients to do so. the practice of medicine. Fewer studies have concentrated on this THE CENTRE AS AN issue than on that of comparing the two EXTENSION OF GROUP PRACTICE settings for their ability to cut the cost of health care by reducing hospital utilization There is an important distinction between among patients. Here the community health group practice and the community health centre wins, because it offers X-ray, centre. Whereas a group practice consists of laboratory and physiotherapy services and can several physicians (either family, specialty, or take some of the burden of diagnosis and a combination) cooperating within a common treatment from hospitals which might also set of offices, the community health centre have to maintain patients on a live-in basis.' places at a patient's disposal some variety For the physician associated with a of support staff: nurse practitioners, public community hea!th centre it should have the health nurses, physiotherapists, social workers same benefits, and what might be called and others. Characteristically, the centre also either benefits or drawbacks, as those offers X-ray and laboratory facilities. mentioned for an ordinary group practice. As opposed to rather slow progress in the establishment of community health centres, IMPLICATIONS OF THE CENTRE group practices are flourishing in Ontario. CONCEPT FOR MEDICAL PRACTICE Approximately 30 per cent of physicians work in such a setting, and an even greater Why then have physicians in group practice percentage are amenable to eventually not voluntarily developed their practices into 67 community health centres? There are several such projects from Ottawa) might be advised possible explanations. As part of the to consider paying physicians, in the centres transformation, any group would have to which they back, a basic salary; plus some retain at least some other types of health discriminatory increments. The primary reason professional, like the nurse practitioner. Many given was to avoid friction between physicians physicians do not feel that these workers are and the new types of professional within the potentially valuable to patient care or even centres, such as nurse practitioners, who may recognize them as doctor relief from minor be qualified to assume certain functions duties. Thus some members of any group formerly performed only by the physician.' It might be reluctant to work with such support seems unlikely that the College of Physicians personnel. Moreover, the cost of hiring such and Surgeons would be willing to support the workers is undoubtedly a constraint. widespread establishment of government centres on this basis. because of the threat to Even a group whose members uniformly independent clinical practice. Furthermore, by agreed on the advantages of certain types of applying a similar payment method to both support personnel would not be able to fulfil physicians and support personnel within the the second basic requirement of the concept, centre, the government might be precedenting i.e., provision of X-ray, laboratory and a departure from the traditional hierarchy physiotherapy facilities. The Ontario College whereby doctors have always had strict of Physicians and Surgeons regards such control over paramedics in patient facilities offered within any group practice as management. More or less important, presenting a "conflict of interest" threat. The depending upon a physician's point of view, College fears that physicians under these salaried practice could mean a reduction in conditions may be tempted to exploit their income and a loss of prestige for the patients, and the agency insuring them, by profession. ordering unnecessary tests or treatment to gain profit from such services. AVOIDING THE A few physicians have attempted to " UNPLEASANT" IMPLICATIONS circumvent any College disfavour, which might arise over the "conflict of interest" The provincial government does not appear issue, in joining centres sponsored by citizens' ready to force Ontario physicians into the associations or industries. An additional community health centre setting. On the other advantage to physicians in this instance is hand, it probably is not anxious to encourage that the centre's backers usually cover all other backers who might develop insurance operating costs, including support staff. plans separate from the government's. Nor College policy also frowns on these can it expect private physicians to establish enterprises, however, because they frequently centres which offer X-ray, laboratory and provide insurance plans separate from the physiotherapy facilities, as long as the government and therefore, must compete with College's policy on this issue remains fixed. If Medicare through advertising to attract the few experimental centres which have been clients. This advertising, claims the College, established do reduce hospital utilization unfavourably reflects on physicians associated among their patients and clearly result in with the centres.' Moreover, physicians will savings, however, the Province may eventually also be paid by the backer and, in a feel obliged to require such institutionalization restricted milieu, easily subject to interference for Ontario's physicians. should it be forthcoming. For those doctors who find the prospect of Since it is the main insurer, one might well such government action unpleasant, the most expect Ontario's government to consider itself promising way of avoiding it would be to a potential backer of such centres so that its engineer a change in the College's policy on insured will receive the benefits of those extra facilities within group practices and to under other plans and so that the Province promote the voluntary organization of will benefit from lower hospital costs. community health centres. Physician­ Government-sponsored centres would not sponsored centres would also have to at least have to use advertising in the way other types minimally involve other types of health care do and so physicians associated with them worker to complete the picture, but these could escape charge from the College. But, could still be effectively controlled by the these centres and their physician associates practices' backers. may come under fire from the College for other reasons. While financial arrangements By promoting its own institutionalization differ according to centre, the government has with such centres, the profession might essentially kept associate physicians on fee­ appear to be shaping itself up as an easier for-service under Medicare. A recent federal target for measures, such as salaried practice, commission has suggested, however, that the which the government is already Provinces (which get much of their money for contemplating. However, if community health 68 centres can alleviate hospital costs and FOOTNOTES doctors in them will not abuse the extra 1. K. Schioler, "Here Comes Group Practice", facilities, such a move is more likely to give Canadian Doctor, Vol. 39, no. 2, 1973, pp. 45-8. 2. A. Crichton, Group Practice In the System the Province an opportunity to leave Ontario (Vancouver: UBC Press, 1973). pp. 28-34. doctors alone in organizing practice and 3. Schioler, loc. cit. payment. 4. J.E.F. Hastings, " Report of the Community Health Centre Project", CMAJ, Vol. 107, 1972, pp. 369-70.

Mid wife and patient. From Eucharius Rosslin, Der Swangern frawen und hebamme (n) Roszgarte(n}, 1513. The woman in labor sits on a birth stool, supported by a friend, while the mid wife makes an examination.

69 The Jewish Attitude Toward Abortion: An Historical-Legal Study Yehuda D. Eliezri

INTRODUCTION complex and dangerous than the prevention of conception during intercourse, abortion Abortion is defined as the expulsion of a was for very long practiced more frequently fetus from the uterus by premature than contraception. Neither danger nor moral termination of pregnancy. It can occur and legal wrong in criminal abortion have spontaneously or it can be induced; it may succeeded in raising an effective barrier to be therapeutic in nature, or criminal. the operation. Tremendous interest in this subject is The moral revulsion against interfering evidenced by the flood of books, articles and with the natural course of gestation has editorials in the medical literature as well as varied widely in different ages and in the lay press. In addition, there is an civilizations. In antiquity the people of the abundance of papers and books in the legal, remote East were generally firmer in theological and social science literatures. opposing abortion than those in the West. One of the reasons for this flurry of interest Buddhism outlawed the practice for religious in abortion is the changing moral and legal reasons and punished offenders severely, attitudes toward therapeutic abortion. since the souls of the unborn children were Consequently, laws are revised to conform considered vicious and dangerous. In India with these changing sets of values. Evidence the law books condemned abortion as of this is the revision of the positions of the homicide for Hindus and Brahmas from early American Medical Association, the Canadian times. Among the Parsees, too, abortion was Medical Association and the recent decision strictly forbidden by the Avesta religion.2 of the United States Supreme Court. According to the Assyrian code, women guilty of procuring abortions were to be impaled, Rel igious attitudes concerning abortion and it was not permitted to bury their play an important role in shaping the thought, bodies.' laws and actions of va rious groups. The purpose of this study is to attempt to survey But in the West, no trace of any enactments the Biblical, Talmudic, and Rabbinic literatures, against abortions are found before 200 A.D. and, from these sources, to describe The code of Hammurabi did not rule on the Jewish attitude toward abortion. For abortion except in relation to the payment comparative purposes, the Catholic and of compensation to the husband in the case Protestant positions on abortion will be briefly of an assault on a pregnant wife resulting in outlined. the loss of the fetus.' In Greek and Roman society abortion was very widely practiced. THE PROBLEM Lecky< sums up the situation in these words: Of the estimated 1,000,000 abortions that No law in Greece, or in the Roman occur yearly in the United States, Republic, or during the greater part of the approximately two-thirds are spontaneous, Empire, condemned it . .. A long chain and at least 300,000 are induced.' of writers, both Pagan and Christian, Indications for therapeutic abortions have represent the practice as . .. almost included various threats to the life of the universal. They describe it as resulting, not mother such as psychiatric or organic disease. simp!y from licentiousness or from poverty, As a result of recently enacted laws, but even from so slight a motive as socio-economic and fetal factors are vanity, which made mothers shrink from acceptable as reasons to perform therapeutic the disfigurement of childbirth. abortions. The Platonics and Stoics held that animation began at birth and, therefore were not HISTORICAL BACKGROUND opposed to abortion at any stage of the pregnancy. But according to the Pythagorians The practice of criminal abortion is perhaps the fetus was animate, and therefore was older than any civilization. It is found on a inviolable from the time of conception.5 This surprisingly widespread scale among the attitude, some believe,5 found its way into the most primitive peoples as well as in the most Hippocratic Oath in the 4th century B.C. advanced societies.2 Although the artificial Others•, feel that this passage is of later, interruption of a pregnancy is far more perhaps Christian origin. 70 CATHOLIC DOCTRINE PROTEST ANT A TIITUDES TOWARDS ABORTION The teaching of the Pythagorian Greeks that the soul enters the body at conception The Baptists consider abortion to be prevailed in Christianity. However, the primarily 'a medical problem and that the famous Justinian Code in the 6th century theological implications can be trusted to our accepted abortions performed before forty Omniscient Heavenly Father". Similarly, the days of gestation. This ruling continued to be Methodist Church considers abortion a in force until 1588 when, in the bull scientific, medical matter on which only Effraenatum, Pope Sixtus V did away with the competent medical opinion has any value.• forty day distinction and declared abortion murder at any stage on penalty of The attitude of the Lutheran Church is very excommunication, even for those who similar to that of the Catholics in that " the counselled it. After some time, during which use of abortifacients and of medicines the penalties were somewhat diminished, designed to produce sterility is condemned". Pope Pius IX, in 1869, confirmed the doctrine The American Lutheran Conference, however, of Sixtus V. This rigorous ruling is further at its biennial meeting in 1952 pronounced affirmed in the code of Canon Law which that "abortion must be regarded as the came into force in 1918 and is now Church destruction of a living human being, and, doctrine.7 The original Pythagorian view has except as a medical measure to save the thus prevailed. mother's life, will not be used by a Christian to avoid an unwanted birth . . . ".• More important than the time of ensoulment is another Catholic dogma, The Presbyterian Church believes the life namely that the soul is in need of baptism of the mother would receive first for its salvation, which, in turn, follows from consideration. Ministers and members are the doctrine of original sin. In the 6th allowed to follow "enlightened conscience century, St. Fulgentius writes: with regard to this matter". The Episcopalians also permit individual clergymen to make the It is to be believed beyond doubt that decision.• not only men who are come to the use of The Unitarian Church states that reason, but infants whether they die in their "judgement regarding therapeutic abortions mother's womb, or after they are born, rests upon the principle of preserving and without baptism, in the name of the Father, extending human life, and this decision must Son, and Holy Ghost, are punished with be the patient's and the physician's-not the everlasting punishment in eternal fire, Church's or any other institution's".6 because though they have no actual sin of their own, yet they carry along with them As can be seen, the position of the the condemnation of original sin from their Protestant churches is not monolithic. A first conception and birth.6 definite formulation of religious law concerning abortion is often difficult to find. This attitude leads logically to the insistence To be sure, there are numerous theologians of extraction of the fetus from a deceased who express their own position; opinions mother's womb for purposes of baptism, so which are not necessarily in agreement with long as the fetus was alive, even only the official position of their church. In this temporarily. Also, a baptismal syringe was study an attempt has been made to treat only invented for the administration of baptism to the official position of religious groups or of the fetus within the w.omb. 6 All of this their recognized representatives. represents a serious concern for the immortality of the soul of the fetus. The JEWISH ATIITUDE concern is, therefore, not only for the life of TOWARD ABORTION the fetus in this world, but also in the next. It follows that in the Catholic view, abortion, The question of intentionally induced even to save the mother, is more grievous abortion is not raised directly in the Bible. a crime than murder of an already baptised Jewish law deduces the status of the fetus human being. • from various relevant passages. An unborn fetus in Jewish law is not considered a person (Hebrew: Nefesh, • "Every human being, even the infant in the mother's meaning soul) until it has been born. The womb, has the right to life immediately from. God, fetus is regarded as a part of the mother's not from the parents or from any human soc1ety . . . Therefore there is no . .. human authority . . . no body and not a separate being until it begins medical . '.. social, economic or moral Indication to leave the womb during parturition. In fact, that can show ... title tor the direct disposition concerning an innocent life . . . Thus, to save .the life until forty days following conception, the of the mother is a most noble end, but the d1rect fertilized egg is considered as "mere fluid". killing of the child as a means to this end is not llcit."-(Pope Pius XII , in Mcfadden, 8:140.) These facts form the basis for the present 71 day Jewish legal views on abortions. considered a person or Nefesh and, therefore, Biblical, Talmudic and Rabbinic support for its destruction does not incur the death these statements will now be presented. penalty. In Exodus {21 :22-23) we find the following : Turning to Talmudic* sources, The Mishnah in Tractate Oholoth'4 states the When men fight and one of them pushes following: a pregnant woman and a miscarriage results, but no other misfortune ensues, If a woman is having difficulty in giving the one responsible shall be fined as the birth {and her life is in danger), one cuts woman 's husband may exact from him, the up the fetus within the womb and extracts payment to be based on judges' it limb by limb, because her life takes reckoning. But if other misfortune ensues, precedence of that of the fetus. But if the the penalty shall be life for life ... greater part was already born, one may not touch it, for one may not set aside one Rashi, a 12th century Biblical commentator, person's life for that of another. interprets " no other misfortune" to mean no fatal injury to the woman following her Tosafot Yom Tov,'5 in his commentary on miscarriage. In that case, the attacker pays this Mishnah, explains that the fetus is not only compensation for the loss of the fetus. considered a Nefesh {person) until it has Most other Jewish commentators of this verse come out into the air of the world, and, agree with Rashi 's interpretation. {See therefore, one is permitted to destroy it to Ramban, Ibn Ezra, Malbim, Torah Temimah, save the mother's life. Similar reasoning is Hirsch, and Hertz.) Therefore, when the found in Rashi 's commentary on the Talmudic mother is unharmed following trauma to her discussion of this Mishnah'• where he states abdomen, and only the fetus is aborted, the that as long as the child did not yet come out major concern is to have the one responsible into the world, it is not called a living pay damages to the husband since the fetus person. Once the head of the child has come is legally his property. No prohibition is out, however, the child may not be harmed evident from this Scriptural passage against because it is considered as fully born, and destroying the unborn child. This act of one life may not be taken to save another. assault would be subsumed under the general prohibition to inflict any injury on any person, The Mishnah in Tractate Arachim" states here the mother: "Lest, if he should exceed, the following : and beat him ... " {Deuteronomy, 25 :3). If a pregnant woman is taken out to be Based upon this Biblical statement executed, one does not wait for her to give Maimonides in his code writes, "If .one birth; but if her pains of parturition had assaults a woman, even unintentionally, and already begun, {lit: she had already sat on her child is born prematurely, he must pay the birth stool), one waits for her until she the value of the child to her husband and the gives birth . .. compensation for injury and pain to the The commentaries on this Mishnah explain woman."'0 Maimonides continues with that the reason for not delaying the execution statements regarding how these in the former case is to avoid causing the compensations are computed. A similar anguish of suspense to the condemned declaration is found in Karo's Code of Jewish woman, even for the purpose of saving the Law." No mention is made either by life of the fetus. Maimonides or Karo regarding the status of the aborted fetus. It is part of the mother and The Talmud explains" that the embryo is belongs jointly to her and her husband and part of the mother's body and has no identity thus damages must be paid. However, the of its own since it is dependent for its life one who was responsible is not culpable of upon the body of the woman. However, as murder since the unborn fetus is not soon as it starts to move from the womb considered a person. Murder in Jewish law is based upon Exodus 21 :12 where it is written: "He that • The Talmud-which exists In two different forms, the Jerusalem Talmud and the Babylonian Talmud­ smites a man so that he dies shall be put to consists of two elements, called the Mishnah death" . The word "man" is interpreted by (Hebrew : text learnt by heart) and Gamarah (Aramaic: completion) . These are related to each the commentators to mean a man but not a other as text and commentary respectively. The 2 fetus.' The destruction of an unborn fetus former contains t~e traditional laws mostly without elaborate d1scuss1on. The latter consists of is not considered murder. discussion , examination of sources and final decision on these laws. The Talmud includes two elements: Another pertinent Scriptural passage is laws, or Halachah and Agadah, or history, allegory, meditations, philosophical and religious discussions Leviticus 24 :17 where it is stated: "And he and. moral sayings.- (Frladlander, 13 :137-8.) On the that smites any person mortally shall be put bas1s of these texts and their understanding and application In later Rabbinic literature, present-day to death." However, an unborn fetus is not Jewish law Is based. 72 (" she had already sat on the birth stool" ), it Lusitanus in the 16th century,28 and Jacob is considered an autonomous being (Nefesh) Zahaton in the 17th century.219 Apart from and thus unaffected by the mother's state. these peripheral sources, criminal abortion is This concept of the embryo being considered not treated in Jewish religious literature part of the mother recurs throughout the before the 12th century when it receives only Talmud. '~, 20 ,2', 22 The Talmudic discussion of brief mention. There is no reference to the this Mishnah continues, moreover: subject in the codes and even the responsa do not discuss it until the 17th century. The Rav Judah said in the name of Samuel : omission is all the more remarkable in view if a pregnant woman is about to be of the great deal of attenHon given to executed, one aborts the fetus so that it abortion by Christian authors and legislators may die first, to avoid her being at all times.30 disgraced.' 8 Rashi explains there that if the child escaped This silence can hardly have been due to death and was born after the mother's the ignorance of criminal abortions among execution, it would cause vaginal bleeding the Jews in the Talmudic period. It cannot and would disgrace the executed mother. have been unknown especially to those Thus we have evidence that an unborn fetus Talmudists who lived for a l.ong time under does not have the status of a living person, the sphere of the Roman Empire. The and destroying it to save the mother explanation seems to be, rather, that criminal embarrassment even after her death is abortion was virtually nonexistent in Jewish permissible if it is going to die anyway. It is society at any time. Even to the present day, 31 here important to note that the assumption as the Catholic medical historian Walsh has is clearly that the child will not survive in any testified, there are hardly any abortions case ("so that it may die first" above). • among poorer Jews, and none among the orthodox. Prior to forty days after conception, a fertilized egg is considered nothing more What are the objections to abortions in the 23 24 25 Jewish view if the unborn fetus does not than "mere fluid". , , Therefore, " one need not take into account the possibility of a have the status of a person in Jewish law? valid childbirth".26 However, after forty days If abortion is not considered murder, on what have passed, formation of the fetus is legal basis is it prohibited? considered to have occurred. Laws of ritual This question can be answered by uncleanliness must be observed for aborted establishing the time that a fetus becomes fetuses older than forty days.26 This period of equal to an adult human being before Jewish uncleanliness is similar to that prescribed Law. The Mishnah already discussed following the term birth of a child and is not above•• states that if the "greater part was the same as that for a menstruating woman. already born, one may not touch it, for one Furthermore, a woman who spontaneously may not set aside one person's life for that of aborts after the fortieth day following another". Thus the act of birth changes the conception is required to bring an offering status of the fetus from a non-person to just as if she had given birth to a live child.25 a person (Nefesh). Killing the new-born after These facts imply that the unborn fetus, this time is infanticide. Many Talmudic 26 6 24 32 although not considered a living person sources , ' , , substitute the word "head" (Nefesh), still has some intermediate status. for "greater part" in the above Mishnah. Maimonides13 and Karo" also consider the Based upon the Talmudic sources as well exit of the head to indicate birth. They both as the Scriptural passages cited earlier, one further state that by Rabbinic decree, even if may ask why do most Rabbinic authorities only one limb of the fetus was extruded and prohibit abortion, except in certain situations, then retracted, childbirth has legally taken as a serious moral offense even though it 34 place. , n is not considered murder? Distinguished Jewish physicians of ancient and recent Not only is the time of the birth important times admonished against it. Denunciations in judging whether aborting the fetus is of the practice of abortions are recorded in permissible to save the mother's life, but the the medical oaths and prayers of Asaf viability of the fetus must also be taken into Judaeus of the 7th century,27 Amatus account. The new-born child is not considered fully viable until it has survived 30 days after birth if it was born prematurely or if it • The assumption of the Talmud that the child .will not certainly is a full term baby. The Talmud survive anyway is probably based on the bel1ef that states: 35 children born before the onset of natural labor cannot survive. Few techniques were as yet Rabban Simeon ben Gamliel said: Any developed to handle premature births. Note in th is context the justification of the U.S. Supreme Court human being who lives 30 days is not decision which permits abortion on demand up to a Nefel (abortus) because it is stated the 7th month of pregnancy, since fetuses born prior to that time rarely live. (Numbers, 18:16): 'And those that are to be 73 redeemed of them from a month old shall These may be delivered at the cost of you redeem ', since prior to 30 days it is not their lives; he that pursues after his fellow certain that he will survive. man to kill him ... Further support for this view comes from The Talmud'• follows with a lengthy Maimonides'•: discussion stating that it is one's duty to disable, or even take the life of the assailant Whether one kills an adult or a day-old to protect the life of one's fellow man. child, a male or a female, he must be put to death if he kills deliberately . . . provided Maimonides comments on this Talmudic the child is born after a full term discu3sion as follows : pregnancy. But if it was born before the end of nine months, it is regarded as an . . . Consequentiy, the Sages have ruled abortion until it has survived for 30 days, that if a pregnant woman is having and if one kills it during these 30 days, one difficulty in giving birth, the child inside her is not put to death on its account. may be excised, either by drugs .or surgically because it is regaided as Therefore, although the new-born infant pursuing her in order to kill her. But, if reaches the status of a person (Nefesh} which its head has been born, it must not be it did not have prior to its birth, it still does touched for one may not set aside one not have all the legal rights of an adult human life for that of another, and this unless it is full term or it has survived for happening is the course of nature. (ie. an thirty days after birth. One is not liable for act of God, that is, the mother is pursued the death penalty if one kills such a child by Heaven, not the fetus.) 36 until it has established its viability, but it Is certainly prohibited, because "one may not Karo makes an identical statement. " set aside one person's life for that of another".•• Many Rabbinic authorities pose the following question to Maimonides. How can The permission to kill the unborn fetus to the argument of pursuit be invoked here, save the mother's life rests upon the fact that since, if indeed it were applicable, the killing such a fetus is not considered a person until of the fetus even after the head is born it is born. Maimonides'• and Karo" present should be permitted? Why do we consider a second reason for allowing abortion prior to the child to be the pursuer before his head is birth where the mother's life is endangered. born and, after, Heaven is the "pursuer"? This is the argument of "pursuit" whereby Tifereth lsraef'• states that the argument of the fetus is "pursuing" the mother. This pursuit is totally inappropriate because the argument is based upon two passages in the child endangering the mother's life is an act Bible: of God. The child does not intend to kill the mother. Furthermore, it is asked, why Is it 1. (Deuteronomy, 25 :11-12) When men necessary to invoke the argument of pursuit, strive together one with another, and since the status of the fetus, before its head the wife of one draws near to save is born, is that of a non-person? His life her husband from the hand of the should certainly be sacrificed to save that of one that smites him, and she puts her the mother even without the argument of hand and takes hold of his testicles, pursuit. then you shall cut .off her hand, your eye shall have no pity. The problem is resolved by several 2. (Leviticus, 19:16) You shall not stand Rabbis"','','2 who state that the non-person idly by the blood of your neighbor. status of the fetus prior to birth is not sufficient to warrant its destruction since this In the former case, the woman Is pursuing would still constitute a serious moral offense, the man by maiming him and she should be even if it is not a penal crime. Therefore, stopped, even at the cost of her limb. • one must invoke the argument of pursuit. The latter case is interpreted by Rashi and After the baby's head has been born, most other commentators to mean that one however, the fetus attains the status of a should not stand Idly by without attempting to person, even prior to 30 days proof of rescue one's fellow man whose life is viability and the "weak" argument of pursuit threatened by robbers, drowning or wild no longer justifies killing the child even if the beasts. Based upon these Biblical passages, mother's life is threatened. However, even 37 the Mishnah states: after the exit of the head, if both lives are threatened one may kill the fetus to save the mother. The reason for this is that the • Most Biblical commentators feel that this passage deals with a fight In which two men struggle, for mother's life is more of a certainty without example. over some object. Neither Intends or Is the fetal threat whereas the viability of the likely to kill th e other. Otherwise, this would be a case of pursuit and the woman would be required fetus is in doubt until 30 days after birth to maim the attacker. (unless the child is certainly full term). 74 We now return to the original question. If Another argument of Rabbi Unterman is the unborn child is not considered a person that a fetus, even less than 40 days after (Nefesh), why should its destruction not be conception, is considered a potential (lit: allowed under all circumstances before labor, questionable) human being, which, by nature i.e. on demand? Why is only a threat to the alone, without interference, will become an mother's life or health an acceptable reason actual human being. Therefore, this " potential for therapeutic abortion? person" has enough status to prohibit its own destruction. One answer is given by Rabbi Ya 'ir Bacharach of 17th century Germany who, A final reason for prohibiting abortion on contrary to the Mishnah,'7 states' 3 that one demand in Jewish law is suggested by the does wait for a condemned pregnant woman present Chief Rabbi of the British to give birth because a potential human Commonwealth , Immanuel Jakobovits.30 He being can arise from each drop of human points to the Mishnah" which permits seed. Interference with this pregnancy would abortion prior to birth only when the mother's constitute expulsion for naught an act strictly life is endangered. The clear implication is prohibited by Jewish law. that when the mother's life is not at stake, it would be prohibited to kill the unborn fetus. A second reason for prohibiting abortion without specific indication is that the unborn MALFORMED BABIES AND MONSTER fetus, although not a person, does have some BIRTHS IN JEWISH LAW status. This is evident from the laws regarding ritual impurity and offerings that a woman The Talmud contains the following passage : who aborts after 40 days of conception must In the case of a birth given to a adhere to. These requirements are similar creature which possesses a double back or to those prescribed following the live birth of a double spine, Rab said: If it was a a child. Thus the fetus may be considered woman (who miscarried), it is not a " partial person" ... considered as an offspring . . ... A third reason for the prohibition of That is, the laws regarding birth are not abortion on demand is that one is not observed. However, this creature, once it has permitted to wound oneself, even with been born, has the status of a person and medical safety precautions, without proper killing would be considered infanticide which cause. This might even include plastic is strictly forbidden. surgical operations that are not required for medical reasons. Therefore, a woman The 13th century Seter ChasidimSIJ undergoing vaginal abortion by manipulative describes the case of a child born with teeth means is considered as intentionally wounding and a tail. It was said by some that people herself.<5 will eat him, therefore it is better to kill him. The reply by the author was that one should A fourth reason for prohibiting abortion remove the teeth in front and the tail from without maternal danger, is that the operative below so that the infant will be like a human intervention entails danger. (See paper body and he will not come to any harm. submitted by Edward Leyton, 1972, 1st year He added that the killing of monster births is medicine, UWO, Department of Physiology, prohibited in Jewish law. and other sources). One is prohibited by Jewish law from placing oneself in danger An early Rabbinic responsum relating to a (Deuteronomy, 4:15: "Take you therefore good malformed child is that of Rabbi Elazar 5 heed unto yourselves.")<~> Fleckles in the 19th century. ' His ruling is that once a child is born of a human mother, Another reason tor prohibiting therapeutic it is a living human being in all respects and abortion in cases where no threat to the may not be destroyed. Starving it to death, mother exists is stated by the former Chief he states, is considered homicide. Rabbi of Israel, lssur Yehuda Unterman.10 He states that one may desecrate the Sabbath to The problem of malformed babies usually save the life or preserve the health of an born without one or more limbs or with unborn fetus in order that the child may seal-like limbs to mothers who took the drug observe many Sabbaths later.<7 As a result, thalidomide early in pregnancy is discussed destroying the fetus, although not legally by a recent responsum.52 Rabbi Zweig of murder, is nevertheless t.orbidden because of Belgium condemns the killing of the an "appurtenance to murder". Rabbi thalidomide deformed baby which resulted in Unterman takes to task those who permit the famous Liege, Belgium trial involving abortion prior to 40 days of pregnancy parents and a physician charged with the because the fetus, to them is considered as murder of this child. His dissertation deals, "mere fluid". He feels that even prior to moreover, mainly with abortion of such a 40 days there is an appurtenance to murder. child, which he condemns. 75 3 Rabbi Immanuel Jakobovits ' states that a mother. This is not permissible if the child physically or mentally abnormal child has the might otherwise survive or if he is certainly same claim to life as a normal child because full term. it is considered a person. Consequently, After 30 days of life or from the first day of the fear that a child may or will be deformed the life of a full term child, every human is not in itself a legitimate indication for child, whether deformed, crippled or abortion. otherwise deficient has rights equal to every other adult human being. CONCLUSION There are no Jewish authorities who would Prior to the moment of the first signs of accept a ruling that abortion is permissible parturition, the fetus is considered to be on demand and that it is a question only for an organic part of the mother (rather than an the pregnant woman and her doctor to decide. independent, living person), and aborting it There are three (persons) who drive away might not be considered murder. Moreover, the Schechinah (Divine Presence) from the some authorities consider a fertilized egg world, making it impossible for the Holy prior to 40 days of pregnancy as "mere fluid" One, blessed be He, to fix His abode in the and having a lower status than a more universe and causing prayer to be deve~oped fetus. All authorities, however, answered . . . (The third is) he who causes condemn, for various reasons, the abortion of the fetus to be destroyed in the womb, a fetus unless it can be justified for medical for he destroys the artifice of the Holy One, or, possibly, for other grave reasons. Some blessed be He, and His workmanship ... feel that such abortion is an appurtenance to For these abominations the Spirit of murder and, therefore, accept only a threat Holiness weeps . .. to the life of the mother, whether medical or (Zohar, Shemot, 3b) psychiatric.

Many authorities permit abortion not only BIBLIOGRAPHY if the life of the mother is at stake but even IN ORDER OF REFERENCE if her health may deteriorate if the pregnancy Note: should continue. A small minority of I. CLASSICAL TEXTS AND COMMENTARIES: Rabbinic opinion allows therapeutic abortion A. All refere nce from the BIBLE are from : The for reasons such as incest, rape and fear Pentateuch and Haltorahs. Edited by Dr. J. H. Hertz. Second edition, London: Sonclno Press, that a malformed child may be born. 1964. Justification for this position rests on concern B. All reference from the MISHNAH are from: for the mother, i.e. that such a birth would The Mishnah. New York: Pardes Publishing Co. , 1963. adversely affect her mental or physical health C. All reference from the TALMUD are from: The by causing her anguish, shame or Babylonian Talmud. Vllna: Romm, 1895. embarrassment. This latter viewpoint, D. Commentators to these texts occasionally quoted however, is opposed by most Rabbinic here are: RASH/ (Rabbi Solomon Yltzchaki. d.1105) authorities. TOSAFOT YOM TOV (Rabbi Yom Tov Lippmann Heller. d.1654) Once the process of labor has begun and RAMBAN (Rabbi Moses ben Nathan, Nachmanldes. d.1270) until the child's head or the major part of his Their writings are to be found included In the body has emerged, its life is still of inferior editions of the texts mentioned above. status but nevertheless vested with a certain II. CODES OF JEWISH LAW: amount of human rights to life. Here it may The two codes referred to are: be killed only to eliminate an immediate A. MAIMONIDES (Rabbi Moses ben Melman. d.1204) . threat to the mother's life. Indeed, its life MISHNAH TORAH (or YAD HACHAZAKAH.) Vilna: Rosencrantz, 1900. must be sacrificed in such cases. In Jewish B. KARO (Rabbi Joseph ben Ephraim Karo, d.1574). law it would be a criminal violation of the SHULCHAN ARUCH. Vilna: Romm, 1911 . sanctity of human life to let the mother die These will be referred to as MAIMONJDES and by refusing to kill the fetus. KARO and appropriate section.

After the head or greater part of the body 1. Taylor, H. C. Jr. "The Abortion Problem". of the infant has emerged, it assumes a status Proceedings of the conference held under the auspices of the Nail. Comm. on Maternal Health. almost equal to any living human. The Baltimore: Williams and Wiking and Co., 1952. difference is in the fact that its viability is 2. McKenzie, D. The Infancy of Medicine. London: not considered certain unless it is known 1927. 3. Neufeld, E. Ancient Hebrew Marriage Laws. without doubt that It is full term or, London: 1944. otherwise, if it has survived after birth for 30 4. Lecky, William Edward Hartpole. History of the Rise days. On the other hand the life of the and Influence of the Spirit of Rationalism In Europe. London: 1870. mother is a relative certainty. In all other 5. Edelstein, L. "The Hippocratic Oath". Supplement respects their claim to life is equally valid. to the Bulletin of the History of Medicine. 1943. Therefore, only a threat to the life of BOTH 6. Jones, W. H. S. "The Doctor's Oath". Cited by Needham, J. A History of Embryology. Cambridge: would allow sacrifice of the child to save the 1934. 76 7. Lader, Larwence. Abortion. New York: 1966. 31. Jakobovits, Immanuel, Jewish Medical Ethics, New 8. McFadden, C. J. Medical Ethics. Phila.: F. A. Davis York: Bloch, 1967. Co., 1961 . 32. TO SAFOT YOM TOV. Tractate Oho/oth. 9. Curran, F. J. " Religious Implications" . Therapeutic 33. MAIMONIDES. " Essurey Biya." Abortions, Medical, Psychiatric, Legal, Anthropological and Religious Considerations. 34. KARO. YOREH DEAH. Ed. H. Rosen. New York: Julian Press, 1954. 35. TALMUD. Tractate Shabbat. 10. MA/MONIDES. " Hilchot Chovel Umazik". (" Laws of 36. MAIMONJDES. " Hilchot Rotzeach Ushmirat Wounding and Damaging"). Hanefesh." 11 . KARO. Choshen M/shpat. 37. MISHNAH. Tractate Sanhedrin. 12. TALMUD. Tractate Sanhedrin. 38 . Lipschutz, Israel. Tlferet Israel. (Commentary on 13. Friedlander, M. The History and Philosophy of the MISHNAH) Tractate Oholoth. (d .1860.) Jewish Religion. New York: Pardes, 1946. 39 . None. 14. MISHNAH. Tractate Oholoth. 40 . Unterman, I. " Be'inyan Peekuach Nefesh Shel 15. TOSAFOT YOM TOV . on MISHNAH Tractate Ubar". (" Regarding th e danger to life of the Oholoth. Fetus" ). Noam. Vol. 6. Jerusalem, 1963. 16. RASH/. on TALMUD. Tractate Sanhedrin. 41 . Emden, Jacob. Response She'elat Yaavetz. Vol. 1. Altona, 1739. 17. MISHNAH. Tractate Arachlm. 42. Waldenberg, El iezer (Chief Justice of the Rabbinic 18. TALMUD. Tractate Arachim. Court in Jerusalem). Response Tzitz Ellezer. No. 1. 19. TALMUD. Tractate Chu/1/n. 43. Bacharach, Ya 'ir. Response Ateret Chachamlm. 20. TALMUD. Tractate Glttln. Even Haezer. Josephov, 1866. 21 . TALMUD. Tractate Nazlr. 44 . Rosen, Joseph of Rogachev. Tzolnat Paneach . 22. TALMUD. Tractate Babe Kamma. Vol. 1. Dvinsk, 1931 . 23. TALMUD. Tractate Yevamot. 45. Trani, Joseph. Response Maharlt. Lemberg, 1861 . 24. TALMUD. Tractate N/ddah. 46. Drimmer, Solomon. Response Belt Sh/omoh. Choshen Mishpat. Lemberg, 1878. 25. MISHNAH. Tractate Kerltoth. 47. RAMBAN. On TALMUD. Tractate Nlddah. 26. MISHNAH. Tractate N/ddah. 48 . Jakobovits, L. "Jewish Views on Abortion". Abortion 27. Rosner, F. and Muntner, S. "The Oath of Asaph " . and the Law. By D. J. Smith. New York: 1965. Annals of Inti. Medicine. 63 (2) : 317-20. August 1965. • 49. TALMUD. Tractate Bechorot. 50. Judah ben Shmuel the Plus. Seier Chas/d/m. 28. Friedenwald, H. "The Oath of Amatus". Jews and Buenos Aires: 1952. Medicine. Baltimore: Johns Hopkins Press, 1944. 52. Zweig, M. Y. H. "AI Hapalah Melachutlt". 29. Friendewald, H. "The Physician's Prayer of Jacob ("Regarding Induced Abortions" ). Noam. Vol. 7. Zahalon of Rome". Jews and Medicine. Baltimore: Jerusalem, 1964. Johns Hopkins Press, 1944. 51 . Fleckles, Elazar. Response Teshuvah Me 'ahavah . 30. Walsh , J. J. Religion and Health. London: 1920. Part 1.

* * * Maimonides' Prayer for the Physician

0 God, Thou hast formed the body of Endow me with strength of heart and mind, man with infinite goodness. Thou hast united so that both may be ready to serve, the in him innumerable forces, incessantly at rich and the poor, the good and the wicked, work like so many instruments, so as to friend and enemy, and that I may never preserve in its entirety this beautiful house see in the patient anything else but a fellow containing his immortal soul, and these forces creature in pain. act with all the order, concord, and If physicians more learned than I wish to harmony imaginable. counsel me, inspire me with the confidence and obedience to recognize them, for the But if weakness or violent passion disturb study of science is great: it is not given to this harmony, these forces act against -one one alone to see all that ·Others see. another and the body returns to the dust whence it came. Thou sendest to May I be moderate in everything except in man Thy messengers, the diseases, which the knowledge of this science--may announce the approach of danger and bid it be insatiable. Grant me the strength and him prepare to overcome them. opportunity to correct what I have acquired and always to extend its domain, for knowledge is boundless as is the spirit of The eternal providence has appointed me to watch over the life and health of Thy man, daily to enrich itself with new acquirement. Today he can discover the creatures. May the love of my art actuate me errors of yesterday and tomorrow he may at all times, neither avarice, nor miserliness, obtain new light in what he thinks himself nor the thirst for glory or a great reputation sure today. engage my mind; for, enemies of truth and charity, they could easily deceive me and 0 God, Thou hast appointed me to watch make me forgetful of my lofty aim of doing over the life and health of Thy creatures. good to Thy children. Here I am ready for my vocation. Amen. 77 Pathological Photoquiz

These are two photomicrographs from the kidneys of a 19 year old girl who was suffering from proteinuria and renal failure. What is your diagnosis?

History and answer are on page 86.

78 79 Consumer Reports: Personal Observations on Free Clinics and Community Health Centres

Bill Robinson ~

Last January Derryck Sm ith published in until the doctor has a sick parade at the this journal an article describing three free clinic. "Dropping Out" meant many different clinics in Ontario. I will continue this things: to some it meant a farm in the Ottawa discussion based on a slightly different Valley, until the charcoal factory moved in and perspective. This is a very personal account the escape from an oppressive system back of many of my feelings while working in two to nature proved, in part, illusory; to others free / community clinics. My approach may it was the creation of "free space" within this seem out of place in a journal but I would corporate beast, but idealists rarely suggest that this should not be the case. The compromise without becoming hardened and mode I've chosen is as much a part of my a bit cynical. Perhaps even more tragic than style of medicine as is a lab coat to a more these minor mutilations, yes even more tragic traditional medic. It may seem too honest, than the 00 or the suicide, are the ones who fairly irrational and somewhat flamboyant but chose another form of escape: the acceptance these are some of the qualities that I feel are and emulation of this travesty, only to be shot lacking in our present health care system. by National Guardsmen. But is all this reason With this article I hope to initiate a continuing enough for the many problems of these discussion of the issues presented. A clinics? Weren't these basically sound if number of you volunteer at Clinic Collective relatively untried concepts? and I hope to meet more of you when I speak " Nonspecialization, non-conformity, community at the school next month. control, flexible structuring, ready As an introduction I was trained as a dental accessibility, and free to all." What is the ass istant and paramedic at the Toronto Free secret to fitting all these together? Are the Youth Clinic. I stayed there for 16 months health needs of people being met any better until it closed and spent one month now? What's been learned from all these volunteering at the Rochdale Clinic which has experiments? Clearly, to answer all these since died. I have been on the staff of Clinic questions would require much more space Collective for about five months. I'm 24, have than a single article affords and a great deal my 3 1h year old son living with me and we more experience than I can bring to such a are landed immigrants originally from project. Let's take another look at the milieu Indiana. I give you this information so that of the previously discussed clinics. They can you may begin to see my biases and judge hold no claim to being representatives but these largely, experientially based merely the basis of our experiences. Now observations accordingly. that my youthful disappointment in the (perhaps) ill-fated (but much hoped for) I'm told that things have changed in fairly Revolution of the 60 's has vented itself, I may significant ways in the last 12 months at be allowed a more rational, though still Western. Just so, the environment within impassioned, analysis. which these clinics function is being transformed in similar ways. Probably the What hasn't changed? Certainly very little biggest difference is in the street scene. The in the political economy. The mass technology " summer of love" is long past. Even funding of the advanced industrial state still encites agencies are no longer infatuated with the the third world away from its past toward our youth / drug culture projects although with the version of the future (see the Firesign publication of John Hasting's " The Theatre). Morbidity and mortality rates are Community Health Centre in Canada" they are still too high, particularly if related to slowly beginning to give support to these expenditures. Hospital ER's are still being similar institutions. The strands of the thread forced to try to provide primary care for of history that met in Haight-Ashbury have many. The number of doctors is still being rewoven themselves or reached their end. kept artificially low thus strangling us all ; but Few need clinics to find someone able to talk funds are now more efficiently channeled them down from a bad trip; the hip capitalists, into their coffers by health insurance. legal and otherwise, can afford a private Training male (see Donelson, M. Jr. Virginia doctor which is less of a hassle than waiting Medical Monthly editorial 96:637-9 Nov. '69) 80 physician assistants (flunkies) and hospital view things just as accurately. All of our catchment clinics are offered as solutions. The energies were focused on this cabal. No one patient is still mystified and we are all still told us what to do. Being hired was a 2-3 suffering. And I'm still ranting because, if month gauntlet of volunteering. Community nothing else, these clinics have allowed me involvement, work with other agencies, to survive with my eyes open ; and these educationals, prevention-all were extraneous, things are still happening. and I've never loved anything more in my life. After the Whole Earth Catalog self-destroying The Toronto Free Youth Clinic closed last institution glow wore off and I was no longer March and the staff has scattered to places as absorbing such rarified air, I was completely distant as Nepal. Most of the paramedics and totally at sea-literally for months. I had had also lived together but that has also found something in a corrupt world to devote ended. Had you been one of the many asking myself to and built my whole existence why, you might have been told that the around it ... but it imploded and we funding had run out and no more was even rocketed through each other back out into the vaguely available, which was true. In addition, void. But is th is what you want to hear? Can most of us, including David, who as physician you even understand what I'm saying? The and elder was indispensible, were ready to corporate entity now lies locked in our move on. Moving on .. . the voluptuous curse lawyers cabinet waiting like the " dust"-stuff of and joy of our 20th century move-ment. Can bodies between souls for rebirth. a group function as a collective with fantastic turnover, not only in staff but also in The first thing one will notice about Clinic patients? The dispersed nature of the Collective after not having heard about it for population, that we aimed ourselves at, added a year is that it is no longer on Talbot St. yet another straw to our burden. In spite of No, it has not yet died; in fact it resists all the common ideal of a horizontal structure, in reasonable attempts to be beaten down. We many ways there were at least three distinct have moved to 439 Elizabeth St. in the lorne strata (MD, medical staff and others) which Ave. community, in what I hope to be was perhaps as insidiously constructive as symbolic of a significant turn for the better mercifully destructive. after a number of relatively stagnant months. The new address is a manifestation of a trend Two other concepts stand out as marking in patient population from youth to the the loci of almost all other problems. The alienated to community, inclusive. Budgeted first of these is competence. In rejecting the by what is almost certainly the last of the traditional Doctor-Nurse-Patient r.ole complex seed money (LIP) and facing virtually no with its quantifiable training process and possibility of permanent funding after May, laboratory oriented diagnostic procedures, an the cycle of money/ no money continues. But entire universe of questions were raised. we laugh. We also bitch and occasionally Foremost among these was-"if this model is even cry. Periodic poverty and budget cuts better, prove it." Cost per unit of service was also contribute to the omnipresent high certainly lower and treatment for presenting turnover rate. More than anything else, complaint was, I believe, also correlated for constant flux is the phrase that I would use to the MD and the nonprofessionals. But what typify the project. Artificial role barriers keep about competence? We considered qualities a sup,posed team splintered with streetworkers such as empathy to be primary but how do especially alienated. Advisory Board members you measure that? We found no truly valid rarely show up; the atmosphere becomes way of judging the com,petence of any oppressive; burn-out; very few patients; it primary care worker. Abhoring the multiple­ goes on and on and we're all guilty. Bu~ choice methods used on students, we here we are: nice new house; more pat1ents; accepted more or less by default the method working together more. Good change. used by professionals-peer review-and used it just as . .. how shall I say . . . judicially. Let me tell you about ourselves through a The practice of criticism/ self-criticism does rather lengthy quotation from one of our not come naturally to those raised in a briefs. competitive society. This is not to say there were no fights or firings; quite the contrary. Clinic Collective's objective is to provide a After months of this, a well-knit group resulted health care service dealing with medical, which functioned quite effectively. But in emotional, and social problems as interlocking some ways it was too tight. A unit stood areas. Service is free at point of delivery, where before there had been a crowd. whenever possible; any charges are minimal. Working together, living together, authentic, It is a place for prevention, education, creative, but socially incestuous; our second counselling, organizing, treatment, and point. Necessary to this sense of "us" was a referral. The work is done both in the Clinic, vibrant, threatening "them". We be~ame, I and in outreach programmes. We function in think, insular, inflexible, unresponsive. These co-operation with other agencies. Although are my feelings, others may disagree and there is particular emphasis on the alienated, 81 and on youth, Clinic Collective is for all Medical: Currently there is one nurse and people. one paramedic on staff. They see patients and assist doctors to the limits of their abilities, The Clinic is open Monday through Friday, co-ordinate volunteers, do outreach medicine, noon to 11 p.m. Our house is accessible both run the dental clinic, maintain supplies, and in location and hours of operation, and it has work on educational programmes. This staff is a friendly, open atmosphere. Medical workers occasionally augmented by a nurse who works and volunteer doctors provide General in our Counselling section. Practice coverage. The medical-social unit is on call at the Group and Detention Homes, Streetworkers: Acting as front-line resource Chimo House, Friendship House, Summer people and outreach counsellors, throughout Youth Hostel, St. Joseph's Hospital, and the the city, they make themselves available, and YM-YWCA. Weekly visits are made to the seek out their own clients, referring when Salvation Army Drop-In Centre. A van has necessary. They are a community liaison, and enabled us to provide mobile medical-social are directly in touch with large numbers of units throughout the city, and at the Pinery people. Provincial Park on long weekends during the summer. A venereal disease treatment centre Counsellors: Available for referrals, and on is being established in co-operation with the call to other agencies, the maintain small case M.O.H., the head of Victoria Hospital V.D. loads of intensive work (in contrast with the Clinic, and provincial V.D. control unit. Free streetworkers' extensive role}. They are also medications are provided whenever possible, available to walk-in patients with emotional through the generosity of drug companies, or and social problems. such groups as the Optimist Club. Support Staff: This includes the co­ Health Education on birth control, V.D., ordinator, financial manager, and secretary­ sexuality, nutrition, oral hygiene, etc. is done receptionist; responsibilities include through counselling, group presentations, telephoned problems, co-ordination within the public displays, free pamphlets, and a library. Clinic, Communications with other agencies, In-service training, which is open to the public, publicity, etc. covers lab procedures, homosexuality, politics In addition, one person in each section is of health , etc. New books and posters are designated service co-ordinator, and is created too. responsible for the functioning of the department, and liaison with others. Streetworkers for youth, and the Lorne Ave. neighbourhood work on the streets contacting Volunteers are an integral part of our and counselling in their clients' own services. We rely entirely on volunteer environment. Possible areas of future doctors, of whom there are sixteen for emphasis include the old, factory and office professional medical care. There are also workers, women, and immigrants. twenty-one other volunteer medical workers, ranging from nurses and medical students, to Counselling is done on an individual and a medical technologist. An additional half family basis. Some group work on specific dozen people volunteer as part of the topics is also done in the Clinic. Staff counselling and support staffs. Students from members are trained in such areas as Family, a variety of disciplines are often on placement Welfare, and Landlord and Tenant Law, with us, too. Immigration procedures, Dental Problems, etc. These figures vary from time to time, as Dental Clinic at Lorne Ave. School on volunteers change. But it is indicative of the Thursdays from 7 to 10 p.m., providing a Clinic's great dependency on volunteers that primarily preventive and educational clinic, they outnumber paid workers by nearly five in co-operation with the University and the to one. Some, of course, work only Health Department. occasionally, while others work virtually daily. Once they have proved themselves, they are All staff participate actively in general considered full members of the Association, pol icy formation, peer review, and programme and can participate completely in all evaluation. In addition, the staff work in inter­ decisions. Many go on to join the staff of the disciplinary teams, and in many cases duties Clinic, some to other established agencies. cannot be as clearly segregated in practice as in theory. We also view the education and upgrading of all staff and volunteers as an integral part Health Education: The staff counsels of the Clinic's work. individuals and groups, prepares presentations and displays, and researches and evaluates This is only the ideal but it tells you a bit technical material. Much of the work is more about us. What do we do next? Several concentrated on birth control and V.D. of us have itchy feet. We're having what we 82 call a priority workshop to discuss problems pt, RN , MD, etc. strikes me as ridiculous. In in some depth soon. We feel the medical this model the patient is allowed to present section as it now exists needs overhauling. his or her body to these health professionals That could take the form of hiring a full-time who repair it {or fail to), give it back after physician {if we could find one) or de­ doing some unknown and incomprehensible emphasizing it to the point of becoming an thing to it so that the worker thinks it is as it outreach centre doing almost exclusively should be, and sends the patient a bill, the preventive work and very little treatment. price of which is largely determined by the MD and his colleagues. The nurse {female) Now you have been given most of the works under the doctor {male) but above the pieces, how to fit them together? If we step janitors {Portugese or Italian). back and conceive of the whole health care delivery system there seems room enough, after a few alterations, for numerous models to co-exist. Well, that's as much as I can extract from my mind right now. I'm getting tired and have The part of this that I see as the most a lot to do tomorrow. I've tried to translate a valuable is continuing education within the series of mind-blowing experiences {if I may co-operative community. By this I mean, be allowed one last cliche') into print hoping health is more than the absence of disease in to see them spring to life behind your eyes. an individual, but rather a state of well-being Most of all I want your reaction to all this; in a community. Learning about everything stop in for tea sometime. Tell us what you involved in remaining healthy should be a think. If you have time, come work with us life-time process. Being forced to decide on and show us how to do it. That's what we're an immutable role after grade 13 of either all about. Shalom. A History of U.W.O. Medical School

as filched from " Four Centuries of Medical History in Canada" by John J. Heagerty, M.D., D.P.H. Canada Dept. of Health, Toronto, 1928

The London Medical School, which was in the matter of a school until the senate founded in 1881 , owes its origin to Bishop could provide proper accommodation, a five­ Hellmuth. At the instance of Bishop Hellmuth room cottage situated on the college property a meeting was held on May 24th, 1881 , at was given the faculty for the use of the junior which were present Drs. Moore, Sr.; R. M. classes and the large recreation room divided Bucke; Moore, Jr.; Levin; Fraser; Arnott; into three large lecture rooms, together with Burgess; Wishart; John A. Stevenson; and the chapel for the higher classes. The Waugh , to consider the organization of a arrangement proved satisfactory and on the Medical Faculty for Western University. So 1st of October, 1882, lectures began. Clinics acceptable was the proposal that a committee were given in the General Hospital. The was at once formed to discuss the matter with faculty was composed of Drs. Charles G. the members of the senate of the university Moore {Dean), F. R. Eccles, William Waugh, and consider the ways and means with them. J. A. Stevenson {Registrar), H. Arnott, James The committee was composed of Drs. Bucke, Niven, W. H. Moorhouse, John M. Fraser, R. Moore, Sr. , and Stevenson. A second meeting M. Bucke, G. P. Jones, A. G. Fenwick, Charles took place on the 25th of May, when the S. Moore, John Wishart, and Messrs. William committee reported that the senate agreed to Saunders {father of Dr. Saunders, the creator the creation of a medical school and offered of Marquis Wheat), and James Bowman. The to provide lecture rooms properly heated and choice of the members of the faculty caused lighted. Within a week a staff of lecturers was criticism among some of the older chosen, with Dr. Charles G. Moore as Dean practitioners in the city who believed they had and Dr. J. A. Stevenson as Registrar. prior claims to lectureship, and they opposed Unfortunately, the senate was unable to carry progress. out its part of the agreement and suitable The relationship of the medical school to quarters could not be found. The university the university was somewhat of a loose one, building accommodated the Faculty of Arts, inasmuch as the school was self-governing which was created in that year as well as and financially independent of the university Dufferin College. Finally, after much and, although the Chancellor of the university discussion and the passage of a resolution by nominally had a voice in the control of the the Medical Faculty to take no further steps school, the only actual relation the university 83 had to the school was affiliation for the " In the small cottage in the north part of purpose of granting degrees; nor did the the city, within the grounds of the old Dufferin Medical Faculty have any representation on Boys' College, which was utilized as the the senate of the university. All matters Medical School for that day, about twenty appertaining to the conduct of the school students, if I remember correctly, composed were under the sole control of the Medical the attendance the first year of the College's Faculty and the faculty had the privilege of existence. The time-honoured janitor, long, erecting a bu ilding outside the university lean, and cranky, who resided on the grounds that should belong exclusively to the premises, was an important feature of the school. The Senate agreed not to enter into institution, and his eccentricities made him the affiliation with any other medical school butt of many practical jokes at the hands of during the existence of the Medical Faculty the students." and the Medical Faculty agreed not to enter The fact that the lecturers were unpaid and into affiliation with any other university. that it was universally believed that the faculty There were fifteen students in attendance could not continue its existence, caused some during the first term and the first student, who of them to lose interest and neglect their took his final year only in the school, work. During the 1885-86 session one lecturer graduated in the year 1883. He had taken his delivered only thirteen per cent of his first three years at Trinity. This student was lectures, another only twenty-seven per cent, Dr. W. J. Roche, who afterwards became and another only thirty-one per cent. Protest Chancellor of the University and chairman of was made by the student body and a the Civil Service Commission. The following resolution passed that a lecturer who did not letter by Dr. Roche, which appeared in the give seventy-five per cent of his lectures Western University Gazette, gives a running would be asked to resign. picture of the progress of the faculty during the first year of its existence. He says: " In the At this time the Arts Faculty ceased to exist fall of 1879, having matriculated, I entered and the very existence of the medical school Trinity Medical College, and attended the was threatened. However, the courage and institution for three sessions, my room mate persistence of a few of the leading members being the present Dr. John D. Wi lson, of your of the faculty kept the school alive, and had it city. Upon the opening of the Medical not been for the continuance of the Medical Department of the Western University, taking Faculty, it is doubtful if the university would the advice of Dr. C. S. Moore, in whose office now be in existence. 1 had spent three summers as a student, and During the year 1883 Bishop Hellmuth made who was on the staff at its inception, I put in application to the Royal College of Surgeons my final session in that college. In looking of England for recognition of the degrees of back to that portion of my college life I Western Medical School, but as the school cannot say that I have ever regretted making had just been created and its standing the change from Trinity to the Western unknown, the request was not acceded to. It University. 'Tis true we did not have as good was granted, however, in 1886, and in the hospital facilities, our teachers were not as same year recognition of their entrance and experienced in the art of teaching, as the professional examinations was obtained from older institution, but the teaching was more the Royal College of Physicians and Surgeons practical and owing to the fewer number of of Edinburgh and the Faculty of Physicians students, we were afforded the privilege of and Surgeons of Glasgow. In the following making bedside examinations, and had bed­ year, 1887, the General Council of Medical side clinics, which was not feasible save to Education and Registration of the United the chosen few at Toronto. Kingdom recognized the entrance examination " I had the honour of being the only final of the London Medical School. year student at that time (1882-1883). Dr. Moore, Sr. , Dean of the Faculty, was Attendance gradually increased from 15 in Professor of Surgery; Dr. Fraser, since the first session to 19 in the second, 18 in deceased, Professor of Medicine; Dr. Fenwick, the third and 35 in the session of 1885-86, Professor of Medical Jurisprudence; Dr. Arnott, which was the fourth. Sr., Professor of Clinical Medicine; and these In the year 1886 Dr. H. A. McCallum joined gentlemen would appear every day to deliver the faculty, and to him in great measure their lectures to the one lone student of the belongs much of the success that has come year. Great changes, of course, have taken to the school. In this year the faculty suffered place in your staff. With the present the loss of Dr. C. G. Moore, Dean and personnel I am but little acquainted save by Professor of Surgery, who died, and in the their reputation, but the graduates who following year his son, Dr. C. S. Moore, are scattered over Canada, many of whom resigned. it has been my good fortune to meet, reflect credit on their Alma Mater and are making a As the number of students increased success of life. accommodation became totally inadequate, 84 and in 1887 it was decided that a new more intimate relationship with the university building was necessary. The distance from the whereby the medical school would become ' General Hospital was a great handicap and to a f~cult_y of and be administered by the overcome this a bus was provided, but it was umvers1ty. A committee appointed to consider felt that the solution of the problem was the the proposal reached an agreement in June, erection of a suitable building. With this 1913, according to which the faculty agreed object in view the faculty applied to the to grant control of the school to the Board of senate of the university for permission to Governors and to rent the property to them. construct such a building and requested The university desired to buy the property but financial assistance for the purpose. The the value, $25,871 , placed upon it was Senate, although agreeable to the proposal , prohibitive in the then state of university was unable to provide funds for the project. finances. They gave permission to move the furniture and equipment and passed a resolution to The Medical Faculty now became the effect "that as soon as the finances of the responsible for the management of the school University will permit it, in the opinion of the to the senate. An executive committee was senate $4,000 should be applied to the appointed by the Board to conduct the affairs of the school. Under the new arrangement Dr. erection of a new building for the Medical H. A. McCallum was appointed Dean and Dr. Department of the University". At this time William Waugh, Registrar, and the executive the University suffered financial reverses and committee nominated was composed of the the loss of the university property prevented Dean, the Registrar, Dr. H. Meeks, Dr. H. the carrying out of the resolution, so that the Williams, Dr. F. P. Drake, and Dr. H. W. Hill. provision of a building fell upon the shoulders The executive immediately created of the Medical Faculty. Bonds were issued departments of Anatomy, Physiology, and a syndicate formed among the professors Pathology, Medicine, Surgery, Gynecology, to finance the project. Stock was issued to and Obstetrics, and full-time paid professors the members of the syndicate, which was were appointed in a number of departments. divided among them in proportion to the number of lectures given by them since the In the following year Dr. P. S. McKibben opening of the school. The building was was appointed Assistant Dean and Dr. J. W. finally erected at the corner of Waterloo and Crane, Assistant Registrar. The standard of York Streets in the year 1887. The building entrance was raised and the course extended was completed and lectures began in 1888. from four to five years. This was again The animosity which had existed from the extended to six years in 1919. The standard beginning seemed to make new headway at maintained is high, and is constantly being this time, and there sprang up opposition to raised. the use of hospital patients for clinical purposes. This, however, gradually wore away In the year 1917 the Board of Governors, and the students were welcomed in all the realizing the inadequacy of the existing hospitals. accommodation, purchased a site at the corner of Waterloo Street and Ottawa Avenue, Dr. Moore was succeeded by Dr. H. Arnott which is situated directly opposite the Victoria and he, in turn, by Dr. Moorehouse, who Hospital and the Institute of Public Health, at became in addition Vice-Chancellor of the a cost of $21,608.80, and in 1921 a new University. He retained both positions until building was erected at a cost of $450,000. 1908 and rendered invaluable services to the The funds were supplied in part by the university. University, by the City, the Province, and the graduates. The new building was opened A valuable addition to the school was the officially on the 17th of November, 1921 by Institute of Public Health which was added in the Hon. R. H. Grant, Minister of Education 1912. The Institute provided instruction for for Ontario. The new building affords ample students in chemistry, pathology, bacteriology, and spacious quarters for lecture rooms, and public health. Modern and well-equipped laboratories, library, offices, and recreation laboratories were provided which proved a rooms and the school has entered upon boon, as the space available in the faculty another phase of progress and usefulness. building was becoming increasingly inadequate. * * The school continued the existing * relationship to the university until the year Plus ca change, plus c'est Ia meme chose: 1913, when re-organization took place and the as may be gathered from the following tally medical school became an integral part of of doctors found truant at third year clinics. the university. In October of that year negotiations were entered into between the N. T. Jaco; J. H. Walker; J. L. Sales ; 0. Medical Faculty and the university with the Clarke; L. Frelick; E. A. Reid-Smith; G. object of bringing the medical school into Hamilton; A. C. MacDonald. 85 Bon Mots from the Lectern or listening to second year med lectures

recorded by Ann Aldis

RE INTRODUCTORY REMARKS His secondary symptoms are primarily I don't think you need to copy this down. related to his primary symptoms. It's just waffle to show you I know it. (Russell) Incidentally, these patients usually die. How many times have you had TB? (Haust) Three? Well let's try and make it short. Occasionally, if it's mild, the patient can (Percy) live till, you know, they're much older. (Lewis) How is this lecture supposed to go on? And so I got under the bed with him. That's (Haines) the psychiatric approach you know. (Hobbs) A lot of our Coroner's work is tatooed. As a RE KERATIN matter of fact, at least one "born to lose" Keratin is excreted at the hairdresser's. comes to autopsy every year. (Turnbull} (Hirst) RE ADVICE RE CONGENITAL ABNORMALITIES You know one of your occupational hazards Sometimes there's a partial absence of is suicide? (Parker) something and one can go all their life Does you good to enter the hospital without knowing it. (Lewis) sometime. It's a shattering experience. (Russell) RE TUBERCULOSIS Speed is more dangerous than heroin; It's the number one killer in the world and never mind about the mafia. (Gowdy) it's also the number one killer of all the infectious diseases. (Percy) RE CLOSING COMMENTS I told you it was impossible to do RE TEST FOR BLOOD AMMONIA carbohydrate metabolism in one hour. It's no bloody good! (Binns Smith) (Binns Smith) Remember the uncinate fit if you remember RE ALKALINE PHOSPHATASE anything. (BarneN) ISOENZYME TESTING Anyway, one tries social things for people. It's a day's work of witch craft and mumbo (Deinum) jumbo. (Binns Smith} I did that awfully fast but I'm sure it's all RE THE PATIENT clear. (Barr) When you pinch them, you reach under It's not always as clear as we make out in here so the bruises don't show. (Girvin) lectures. (Hobbs) If there's no pulse and the heart's stopped It'll come to you : sometimes it never comes beating, what's probably happened? (Bolton) to some people. (Barnett)

* * * Answer to Pathological Photoquiz

These photomicrographs are from the kidneys of a 19 year old girl who developed a rapidly progressive nephrotic syndrome and renal failure, with arthalgia and recurrent congestive heart failure. She had a typical mask-like rash on her face and a positive L.E. test. Following a prolonged exposure to sun, her condition deteriorated rapidly. The first photomicrograph shows diffuse thickening of the capillary basement membrane of the glomerular tuft (wire-loop appearance). The second photomicrograph shows local fibrinoid necrosis of the peripheral portions of the tufts, with fusion of the cells forming multinucleated cell masses, some of which show ill-defined granular structures which have a lilac colour with H&E stain (Hematoxylin bodies). An intracapillary thrombus is also seen (arrow). The appearance is characteristic of disseminated lupus erythematosus. 86 General Practice 1n Scotland: A IV Year Elective Peter Johnston

What do you do in a surgery? (Hint: you lot like the people in London. Dundee, on the don't spend the night in the O.R.). If you are other hand, is a rough, tough, dirty industrial a G.P. in Scotland, you spend a couple of town, set upon the banks of the Firth of Tay. hours seeing between four and ten patients It has many tenements and broken-down per hour, depending on how big your list is. buildings, but has become more modern in What is a list? (Hint: it isn't the tilt caused its city centre. Dundee is famous for its by overloading your boat). If you are a G.P. " platties" which are buildings where all the in Scotland, your list is the number of apartments on one level share a common patients who come to you for their primary porch, which is the access to the common health care. Your list may range from 500 cold-water bathroom. The people of Dundee patients (if you have a remote Highland or tend to be more down-to-earth than those of Island practice) to 5,000 (if you are a very Aberdeen. busy city doctor). Your list is very important My clinical experience in Scotland was to you because you are paid by the National spread between the busiest city practice in Health Service on a per head basis. The list Aberdeen, a more relaxed country practice in size changes as people move into or out of little town about 12 miles south of Aberdeen, your area or the world. and an all female practice in Dundee. My What is a house call? (Hint: it isn't the non-clinical was spread between a lot of pubs mating cry of a libidinous bungalow). It is scattered throughout the countryside. something made about ten times a day by the average Scottish G.P. Home visits (as they are 1 found that Scottish G.P.'s had a great also named are made to those who are too ill advantage over their North American to visit the surgery, those who don't have the counterparts in that they knew exactly who transportation to get to the surgery, and the they are responsible for (their "list") and that elderly who are usually a combination of both. the people on their list must come t~ them The G.P.'s in Scotland complain that they first to receive medical attention. Th1s not make far too many (also that North American only unclogs their Emergency Departments, G.P.'s make far too few!) house calls, but in but also prevents people from stocking up on the same breath they will defend their use of pills from various doctors. However, ?nc_e t~e house calls on the grounds that the home primary diagnosis is made, and hosp1tallzat1on visits improve their understanding of a family is required, the G.P. must turn over control to situation. One hundred visits to the surgery the hospital consultant. Then, if he is will not yield as much information as one fortunate, he will receive a letter fro~ the glance at an apartment with three inches of consultant telling him about the pat1ent's cat-fur on the floor and a mother with three progress. This is where the North Ame~ican runny-nosed, screaming kids hanging onto her G.P. has the advantage. He can treat h1s own skirt. As a result, G.P.'s keep on making patients, deliver their babies, and is a~le to house calls. maintain contact with the consultants 1n the hospital on slightly more than a My elective in Scotland was split between correspondence basis. two cities, Aberdeen and Dundee. Aberdeen is a fishing centre of about 200,000 Comparing both styles of general practice, population on the northeast coast. of . 1 feel that the North American G.P. has more Scotland. It is known as the Gramte c1ty fun, but probably also more head~ch~s. I was because 90% of its buildings are constructed impressed in Scotland by the ded1cat10n of of grey granite from a nearby qu~rry, (s~ems the G.P.'s to their life-style (as I am logical). The buildings give the c1ty an a_1r of constantly being impressed here). I value sympathetic fallacy in that they spar~le 1n the highly the friends that I made i~ Scotla~d , and sunshine but are sombre and sober 1n the the experiences that I had. All 1n all, a fme rain. The' people are fairly conservative, a way to spend two months!

* * * A physician is a person who pours drugs of which he knows little into a body of which he knows less.-Vo/taire 87 The following is a list of fourth year Walker : Toronto, Hosp. for Sick Children. electives to date. Austin : Prince Rupert Regional Hospital. Beach : Edinburgh, Scotland, Royal Infirmary. Anderson : St. Joseph, Emergency. Bright : Zurich, Pathology. Aylett : North Bay, G.P. Campbell : Victoria & St. Joseph & St. Thomas. Beecroft : Moose Factory. Erez : Tel-Hashomer, Israel, Medicine. Bixenman : University Hospital, Medicine. Epedge : Ft. Francis, Medical Clinic. Bourne : Barbados, Ob. & Gyn. Hayley : London, England, Westminster Med. School. Cordeiro : Moose Factory. Lam : Windsor, Cancer Clinic. De Rose : Montreal, R.V.H ., Surgery. lim : Atlanta, Medicine. Frates! : S.S. Marie, Algoma Dis!. Medical Group. Mayr : Montreal Children's Hospital, Paediatrics. Gralien : Montreal General. Payne : Strathroy Medical Clinic. Graydon : London, Dermatology, Dr. W. E. Pace. Phillips : London, England, Westminster Med. School, Hunter : St. Joseph, Emergency. Surgery. McKillop : Dallas, Texas, Parkland Hospital. Sawa : Toronto, Hospital for Sick Children, Neurology. Perkin : Strathroy Gen. Hospital. Vance : U.H., Victoria, St. Joseph. Pook : Barbados, Q.E. Hospital. Wahby : C.P.R.!., Montreal R.V.H., Medicine. Simmons : London, Dermatology, Dr. W. E. Pace. Weber : Ajax-Pickering General Hospital. Tse : Etoblcoke, Ob . & Gyn. Wong : Victoria Hospital, Med. & Psy. Watters : Paris. Wooster : Thunder Bay, Cancer Clinic. Bloch : Nanalmo General Hospital. Bruchschwaiger : Richmond, B.C., General Hospital. Aldis : Montreal, R.V.H . Cumming : Hazelton, B.C., Wrlnch Mem. Hospital. Brady : New Westminster, B.C., R. Columbian Hosp. Drobac : Toronto General, Medicine. Clements : Toronto General Hospital. Fetterly : Chatham, General Hospital. Digges : Vancouver General Hospital, Med. Foxen : St. Joseph, I.C.U. Dundas : Birmingham, Eng., Paediatrics. Johnston, P. : Aberdeen, Scot., G.P. Geddes : Seaforth Medical Clinic. Kocha : L.P.H., Montreal R.V.H., Cardiology. Grace : London, Eng., Guy's Hospital. Long : Newcastle Upon Tyne, Neurology. Gulamhuseln : Nairobi, Surgery & Orthopaedics. MacDonald : Nanalmo General Hospital. Haddad : St. Joseph, U.H., Rad. & Neur. Mehta : Hamilton, Cancer Clinic. Loynes : Edmonton, Med. & Psy. Richardson : New Westminster, B.C., R. Columbian Mlechiels : Puerto Rico. Hosp. Nolewajka : Kitchener, G.P. Tiedje : St . John's Newfoundland, Medicine. Piela : New Orleans, Surgery. Vllos : L.P.H., Victoria Hospital. Schaefer : Kltchener & St. Thomas. Wal : Victoria, Psy., Toronto, Pathology & Ob. & Gyn. Tam : Kltchener-Waterloo Hospital. Walker : Moose Factory, Ob. & Gyn.

* * * Contrary to general belief, It Is not the citric acid of lime juice which Is beneficial in scurvy, citric acid having proved useless when administered alone; the antiscorbutic effects are due to the potash salts which lime-juice contains. -$ajou's Analytical Cyclopedia of Practical Medicine, 1905

* * * He Is the best doctor who knows the worthlessness of the most medicines. -8. Franklin * • • Perhaps we cannot prevent this from being a world in which children are tortured. But we can reduce the number of tortured children. And If you don't help us, who In the world wlii.-Aibert Camus, quoted In Globe and Mail article on child abuse, Dec. 29, 1973.

* * * Finally a note of cheer. Last year's Medical Journal contained an article "Beasties in the Broth" by journalism student James Fitzgerald. It was the first and only thing James had In print when he began pounding the pavement during the summer. It did not endear him to the heart of Peter C. Newman or the successors of Henry Luce, but it did carve a small niche In a suburban weekly close to Toronto. Where he goes from there only time will tell: but when he's great and famous it will be our Journal which broke the ice. 88 RALPH M. CUMMINS OPTICAL

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