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298 Dundas St., London N8B 1 T8, Ontario, Canada 672-4110 MEDICAL J () lJ Jl ~A L______v_o_L_«~._No_ . _4~, M_A_Y~,1--974 THE UNIVERSITY OF WESTERN ONTARIO

EDITOR John Van Dorp '76

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

BUSINESS MANAGER Jonas Karalenas '76

ADVERTISING MANAGER Merv Kril '76 ASSISTANT EDITOR

CIRCULATION MANAGER Vic Aniol '76 ASSISTANT EDITOR

Contents 90 Editorial-John Van Dorp (Editor) 90 Junior lnterneships '74-'75 92 Hypertensive Disorders ("Toxemia") of Pregnancy-Leslie Bertram 99 Consumer Reports: Natural Childbirth-A Layperson's Challenge to the Medical Profession-Karen Jazey 107 The Agony and the Ecstasy of Meds '74 108 Class News 111 Parcost and Some of Our Experiences Encountered During Visits to Pharmaceutical Manufacturers-The Late J. M. Parker 114 Pathological Photoquiz 115 Dealing with the Provincial Government: How to Succeed by Really Trying -Sharon Warren 118 This is the Research That Was-A. L. Noble 122 The Tragedy of Paracelsus-Neil H. McAlister 126 Bon Mots from the Lectern-Ann Aldis 127 An Elective in the Pacific Northwest-Michael J. Austin

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I suppose that I am really a sucker for if we desist from that search: but if we statistics, but even the most incredulous souls fail to maximize the therapeutic potential of cannot fail to be moved by certain figures what we have already learned, then we presented in our Bacteriology course. Some shall be going backwards and for that no 200 million people are infested with worms, stripes could ever be too heavy. If medicine and tuberculosis still kills about five million has triumphed over the obscurity people every year. According to the Renegade surrounding the aetiology of a disease or Report on Poverty in Canada the life has devised a therapeutic regimen for its expectancy of a Canadian Indian is thirty-five cure, then surely it would be a great scandal years while that of an Eskimo is twenty. if she should yield to economics the victory In 1971 nearly 35,000 Montreal school just wrested from nature. children were examined in a survey conducted jointly by the City Health Department and Those 3,500 Montreal school children who the Catholic School Commission. More than needed hospitalization, by and large, needed half of these children turned out to be it for nothing more obscure than the physically ill and ten percent required sequelae of malnutrition: and that is the most immediate hospitalization. Furthermore as curable and preventable disease of all. will be pointed out in the Consumer Reports' That knowledge is older than Hippocrates article in this issue, while Canada's standard and yet malnutrition continues to be the of living may be among the highest in the leading cause of death in our world. We may world, her perinatal mortality rates do not have come a long way since Hippocrates rank amongst the lowest. but it is also true that, in a very real sense, we have not moved at all: like the servant There is also an article in this issue about who buried his talent ... when the the sparseness of government funding for reckoning came it was taken away from him medical research in Canada, but I would that and he was cast into damnation. were our only sin. As a nation we have been richly blest; as a people we have many talents, but there is no reason to believe that it shall be any different with us than it was with the servant, in the parable, who never used the talent which was given him. To seek new knowledge is vital; we shall stand still and lose our intellectual integrity * * * Junior Interneships '74-'75

.It Is expected that the degree of Doctor of Medicine Brady, Stephen Clarke-Royal Columbian Hospital, will be granted to all or most of these students at New Westminster, B.C. Convocation, June 7th, 1974. (Rotating lnterneshlp unless otherwise stated.) Bright, Susan Eliz.abeth-Dalhousle University Integrated Program , Halifax, Nova Scotia. Family Medicine. Brooks, Terry lynn-VIctoria Hospital london Ontario Adams, Howard Franklyn-Montreal General Hospital Family Medicine. ' ' · Montreal, Quebec. ' Bruckschwalger, Christian-University of Western Aldis, Hugh Warren-McMaster University Integrated Ontario Integrated Program london Ontario Program, Hamilton, Ontario. Straight Surgery. Family Medicine. ' ' · Anderson, Richard Raymond-University of Western Ontario Integrated Program, london, Ontario. Cairncross, John Gregory-Toronto General Hospital Straight Surgery. Toronto, Ontario. Straight Medicine. ' Campbell , John VIncent Garfield-Royal Jubilee Austin, Michael Joseph-Royal Columbian Hospital New Westminster, B.C. ' Hospital , Victoria, B.C. Aylett, Alan Archie Andrew-St. Joseph's Hospital, Clements, Nigel David-Toronto General Hospital london, Ontario. Toronto, Ontario. Straight Surgery. ' Cordei ro, Cesar Nunes-Toronto Western Hospital Beach , Anne Elizabeth- Women's College Toronto Toronto, Ontario. ' Ontario. Fam i ly Med icine. ' ' Beecroft, Wayne Arthur-St. Michael's Hospital, Cumming, Alice Mildred-University of Western Ontario lnte~rated Program, london, Ontario. Family Toronto, Ontario. Med1clne. Biggs, Michael Herbert-North York General Hospital Toronto, Ontario. ' Davidson, Barry Hilton-McMaster University Integrated Pr'?g ram , Hamilton, Ontario. Straight Medicine Blxenman , Wayne William- University of Western (M1 xe d) . Ont~rlo Integrated Program, london, Ontario. De Rose . . Gaetano (Guy)-Victorla Hospital london Stra1ght Medicine. Ontano. ' ' Bloch, Petr Gunsberger (Peter)-North York General Digges, Deborah Dean-Toronto Western Hospital Hospital, Toronto, Ontario. Toronto, Ontario. ' Bourne, Mary Elizabeth- North York General Hospital, Driedger, Harry John-st. Joseph's Hospital London Toronto, Ontario. Ontario. ' ' 90 Drobac, Milutin (M ilton)-Toronto General Hospital, Minielly, Richard Wesley-St. Joseph's Hospital, Toronto, Ontario. Straight Medicine. London, Ontario. Dundas, George Stephen-Calgary General Hospital, Mithoowani, Mohamed Hussein Ahmed--81. Joseph's Calgary, Alberta. Family Medicine. Hospital, London, Ontario. Erez, Hanna-New Mount Sinal Hospital, Toronto, Nolewajka, Andre Jozef-Unlversity of Western Ontario Ontario. Integrated Program, London, Ontario. Straight Medicine. Fetterly, Paul John Thomas-Dalhousie University Integrated Program , Halifax, Nova Scotia. Paterson, David James-Ottawa Civic Hospital, Ottawa, Ontario. Fratesi, Sante Joseph Paul-VIctoria Hospital, London, Ontario. Patrick, Lawrence Thomas-Jewish General Hospital, Montreal, Quebec. Foxen , John-University of Western Ontario Integrated Payne , John Christopher-University of Western Ontario Program, London, Ontario. Family Medicine. Integrated Program , London, Ontario. Family Galien, Raymond Alfred-Jewish General Hospital, Medicine. Montreal, Quebec. Perkin, Gary William-St. Joseph's Hospital, London, Geddes, John Alex-St. Joseph's Hospital, London, Ontario. Ontario. Family Medicine. Phillips, Thomas William-VIctoria Hospital, London, Goodge, John Douglas-University of Western Ontario Ontario. Mixed. Integrated Program, London, Ontario. Family Piela, Adele Mary-Dalhousie University Integrated Medicine. Program, Halifax, Nova Scotia. Grace, Archie Norman-University of Alberta, Pook, John Joseph-St. Joseph's Hospital, London, Edmonton, Alberta. Ontario. Graydon, John William-Victoria Hospital, London, Puodziukas, Julius George--scarborough General Ontario. Elective. Hospital, Toronto, Ontario. Greenfield, Douglas Bruce-University of Western Remington, David Brian-Grady Hospital, Atlanta, Ontario Integrated Program, London, Ontario. Georgia. Straight Medicine. Family Medicine. Richardson, Bryan Stanley-Manitoba University Growse, Michael Joseph-Manitoba University Integrated Program, Winnipeg, Manitoba. Integrated Program, Winnipeg, Manitoba. Sawa, Gordon Michael John-Toronto General Hospital, Gulamhusein, Sajadhusseln Sadikaii-St. Joseph's Toronto, Ontario. Straight Medicine. Hospital, London, Ontario. Schaefer, John Charles-McMaster University Integrated Haddad, Richard Gordon-VIctoria Hospital, London, Prog ram , Hamilton, Ontario. Family Medicine. Ontario. Schemmer, Robert Jens--sunnybrook Hospital, Toronto, Hayley, John Hargreaves-Ottowa Civic Hospital, Ontario. Straight Medicine. Ottawa, Ontario. Scholz, John Frederick-University of Western Ontario Hoggarth, Robert Bruce-North York General Hospital, Integrated Program, London, Ontario. Straight Toronto, Ontario. Psychiatry. Hunkin, John Bradley-Dalhousie University Integrated Sexton, Frederick George-Scarborough General Program, Halifax, Nova Scotia. Hospital, Toronto, Ontario. Hunter, Joseph Barry-St. Joseph's Hospital, London, Simmons, John Morris-St. Joseph's Hospital, London, Ontario. Ontario. Johnson, Leonard Stephen-Montreal General Hospital, Smith, Derryck Harold-Ottawa General Hospital, Montreal, Quebec. Mixed. Ottawa, Ontario. Johnston, Peter Sean-Dalhousie University Integrated Tam , Hon-Yin Albert-St. Joseph's Hospital, London, Program , Halifax, Nova Scotia. Family Medicine. Ontario. Kocha, Walter llarion-Royal Victoria Hospital, Thompson, Maureen Elizabeth-Dalhousie University Montreal, Quebec. Straight Medicine. Integrated Program, Halifax, Nova Scotia. Lam, Man Lung (Arthur)-St. Joseph's Hospital, Tiedje, Mary Ellen-McMaster University Integrated London, Ontario. Program, Hamilton, Ontario. Straight Medicine Law, Hugo Kwok-Cheung--8carborough General (Mixed). Hospital, Toronto, Ontario. Tse, Wing Kin-Scarborough General Hospital, Toronto, Lim, Bing-McMaster University Integrated Program, Ontario. Hamilton, Ontario. Straight Medicine. Vance, Alan Ross-University of Western Ontario Lloyd, David Jeremy-Ottawa Civic Hospital, Ottawa, Integrated Program, London, Ontario. Family Ontario. Medicine. Long, Barry Herbert-Victoria Hospital, London, Ontario. Vilos, Georgios Angelos (George)-Unlverslty of Mixed. Western Ontario Integrated Program, London, Ontario. Straight Medicine. Loynes, Richard James Shore-Royal Victoria Hospital, Montreal, Quebec. Straight Medicine. Wahby, Allen James-Victoria Hospital, London, Ontario. MacDonald, Peter John Charles-Calgary General Hospital, Calgary, Alberta. Family Medicine. Wa l, Chi-tak (Patrick)-Toronto General Hospital, Toronto, Ontario. McKillop, Barry Allen-University of Western Ontario Integrated Program, London, Ontario. Straight Walker, Dennis Martin-St. Paul 's Hospital, Vancouver, Surgery. B.C. Mackie, Carl Clarence-University of Western Ontario Walker, James Douglas-Wellesley Hospital, Toronto, Integrated Program, London, Ontario, Family Ontario. Medicine. Watters, Conrad William Lawrence-Calgary General Mayr, Patricia Jean Moyer-Victoria Hospital, London, Hospital, Calgary, Alberta. Family Medicine. Ontario. Weber, Hans-Jurgen Emil--scarborough General Mehta, Adi Erach-University of Western Ontario Hospital, Toronto, Ontario. Integrated Program, London, Ontario. Straight Wong , Godfrey Long-St. Joseph's Hospital, London, Medicine. Ontario. Michiels, Paul Joseph-Ottawa Civic Hospital, Ottawa, Wooster, Douglas Lawrence-Royal Alexandria Hospital, Ontario. Edmonton, Alberta. One of the saddest things I ever read was a description of a day in the life of a geriatric multiple sclerosis patient. This lady, whose intelligence was well above average, was almost totally incapacitated, physically. Her complaint was that to the people taking care of her, her physical condition defined her mental condition. She described how, in the middle of a spirited debate with a visiting relative, a young nurse walked by, patted her on the shoulder and said 'soothingly': "Are we being a good girl today?" -Margaret McCaffery, ed., The Canadian Family Physician, Dec. 1973 91 Hypertensive Disorders ("Toxemia") of Pregnancy Leslie Bertram

A disorder associated with hypertension, 4. It occurs after the twentieth week of proteinuria and edema has long been known gestation, although it may occur earlier in pregnant women. Speculations as to its with an hydatid mole. etiology have been made for hundreds of 5. The incidence is increased in the lower years. It was named " toxemia of pregnancy". socioeconomic strata of society. a misnomer based on the nineteenth and twentieth century search for a mythical toxin. 6. In the pure form of the disease, Recently, the term "toxemia" is being termination of pregnancy is usually replaced by the term "hypertensive disorders followed by complete disappearance of of pregnancy". the syndrome with no permanent effects. 7. It may first appear within the first The usual sequence of events is a rapid twenty-four hours following delivery. weight gain resulting from fluid retention, a rise in both systolic and diastolic pressures, " Toxemia" of pregnancy has been called and appearance of proteinuria and/or edema. the "disease of theories" by many authors. In severe cases, there may be visual A vast amount of research has gone into it disturbances or a severe headache, a but the etiology remains a mystery. frequent forerunner of a convulsion. One of the major problems that exists is the Epigastric pain, the result of a swollen liver with stretch of the capsule, is a serious sign. confusion arising due to the lack of Glomerular filtration rate and renal blood uniformity in the classification of the flow are decreased while serum uric acid hypertensive disorders. An even more basic concentration is increased. problem than classificc.tion arises in the accuracy of the results obtained. Seligman The pathologic alterations seem to be (1971) showed that blood pressure measured related to the arteriolar constriction and by the sphygmomanometric method could be spasm which occur. Postmortem studies may very inaccurate (i.e. low) when compared to show: 1. various degrees of cerebral edema the actual values measured intra-arterially. and hemorrhage; 2. a typical glomerular This is probably due to change in the quality lesion characterized by swelling of the of the Korotkoff sounds in the " toxemic" endothelial cells which are filled with a patient. As these sounds are the basis of the fibrin-like material and which almost obstruct sphygmomanometric technique, this may the capillary lumen ; 3. irregular areas of account for the occurrence of " eclampsia" in congestion and necrosis in the subcapsular apparently normotensive patients. Relating area of the liver; 4. constriction of retinal severity of disease to the value of blood arterioles; 5. pulmonary edema and 6. pressure may thus be questionable. placental infarcts. Despite, or perhaps because of, these An explanation of these hypertensive problems, a myriad of theories has been disorders of pregnancy must account for proposed to account for the hypertensive several factors: disorders of pregnancy. Some of those that I have investigated include a physiological 1. In its true form, "toxemia" is almost above-average hydration early in pregnancy, exclusively a disease of the first maternal-fetal incompatibility involving a pregnancy; in the multipara it is usually single gene locus or multiple loci and superimposed on a predisposing factor resulting in antigen production by either fetus such as renal disease or hypertensive or mother; liver involvement based on vascu lar disease. increased total serum alkaline phosphatase 2. Among the prominent predisposing levels; increased disseminated intravascular factors are diabetes mellitus, twins, coagulation; malnutrition; excess trace metals, obesity, antecedent hypertension, hydatid especially lead, causing an inhibition in mole, hydramnios, hypertensive vascular placental oxidative metabolism; placental disease and chronic renal disease. ischemia and finally, alterations in the renin-angiotensin system. This list comprises 3. The occurrence increases with the a random selection of theories based advance of the pregnancy. primarily on recent research. 92 Fig. 1: Renin-Angiotensin System

Angiotensinogen (•a plasMa proteip,of the •2~ glo ulin fraction)

+-- renin-secreted by. the juxta-gloMerular apparatus in response to l . t intra arteriolar pressure 2. Na~ reaching the ~-G apparatus 3.' sympathetic stiMulation

enzYMe, mainly in the lungs ens in ~ ~Aldostero]; secretion

! reabsorption of Na ~ and therefore of H20 by Del, collecting duct /' 7 vol~•

Rise in blood pressure

Of the above-mentioned theories, one that producing arteriolar constriction with a has a probable role is alteration of the consequent rise in systolic and diastolic blood renin-angiotensin system. I will attempt first pressure. to evaluate the renin-angiotensin system as to In normal pregnancy a change occurs In its role in the etiology of the hypertensive the renin-angiotensin system. The levels of disorders of pregnancy, and second to renin, renin substrate, and angiotensin are outline a possible hypothesis showing a appreciably increased, especially during the relationship between the renin-angiotensin latter half of pregnancy. As well, aldosterone system and several other theories. secretion is also increased, probably due to The renin-angiotensin system primarily the augmented renin-ang iotensin system. regulates blood pressure. Figure 1 outlines It has been suggested that the elevated the system. Renin, a proteolytic enzyme, secretion of aldosterone during normal is secreted into the bloodstream by the pregnancy affords protection against the juxta-glomerular apparatus of the kidney natriuretic effect of progesterone. With this nephron in response to three alterations: increased activity of the ren in-angiotensin 1) decrease in the intra-arteriolar pressure in system, one might expect a subsequent rise the region of the juxta-glomerular cells, 2) in blood pressure. However, in an extensive decrease in sodium ions reaching the survey on blood pressure in pregnancy, juxta-glomerular apparatus, or 3) increase in MacGillivray et al (1969) found that blood sympathetic stimulation. In the bloodstream, pressure in pregnancy is actually lower than renin splits a plasma protein called in non-pregnant states, and rises as angiotensinogen, releasing a decapeptide pregnancy progresses, reaching average called angiotensin I. This is converted to the non-pregnant values post-natally. octapeptide angiotensin II by converting Why then, wi th an increase in the activity enzyme as the blood passes through the of the ren in-angiotensin system does blood lungs. Angiotensin II exerts two effects, both pressu re not rise in the normal pregnancy? of which cause an increase in blood pressure. Evidence suggests that the vascular reactivity Firstly, it stimulates the secretion of to angiotensi n is com.iderably reduced in aldosterone, which causes increased pregnancy. reabsorption of sodium and water, increasing the blood volume and thus causing a rise in Something obviously has gone awry in the blood pressure. Most important, however, hypertensive disorders of pregnancy. What angiotensin II acts directly on arterioles, defects could occur in the renin-angiotensin 93 system to cause hypertension? A variety of sodium intake should be supplemented rather possibilities exist, one or more of which may than the longstanding restriction treatment. contribute to the etiology of hypertension. Four much investigated possibilities are: One problem in evaluating the hypothesis 1) an increase in a vasopressor substance of an increase in activity of the renin­ such as renin, 2) a decrease in a angiotensin system is the confusion in the vasodepressor substance, 3) a decrease in the literature regarding the level of circulating inactivation of angiotensin, and 4) an renin. Abnormal hypertriggering of the system increased vasopressor response to implies increased renin levels. However renin angiotensin II. assays are inaccurate and the results vary from high to normal to low. In fact, opinion The first hypothesis-an increase in a seems to favor low renin levels rather than vasopressor substance-is complex and has high. This appears to detract from the been studied extensively. Two possibilities hypothesis. However when R. D. Gordon exist that could cause this increase: a) a studied the renin-angiotensin system early in physiological increase in a pressor substance pregnancy, before the time of development of within the renin-angiotensin system ; or b) the hypertension, th ey found that its activity pathological increase in a pressor substance seemed to be elevated in those that later extrinsic to the renin-angiotensin system. developed hypertensive disorder. Thus the required elevation in renin could occur earlier a) By a physiological increase in a pressor in the pregnancy, predisposing the patient substance within the renin-angiotensin to the development of "toxemia". system, I am referring to a hyperactivity of a normal renin-angiotensin system. This is in b) The other possible cause of this first response to a pathology in one of the hypothesi::; {increase in a vasopressor mechanisms triggering it. For example, a substance) is the pathological increase in a chronic decrease in the intravascular volume pressor substance extrinsic to the renin­ in the region of the juxta-glomerular angiotensin system. Goretzlehner and apparatus {for which the renin-angiotensin Riethling {1968) isolated a vasopressor system could not completely compensate) substance from venous blood, urine, decidua, would lead to a continual secretion of renin. amniotic fluid, and/or placenta of six out of Subsequent formation of angiotensin II without nine cases of "toxemia" examined. No any inhibiting feedback would lead to corresponding constrictive activity was found increasing vasoconstriction and hypertension. in the normal pregnant controls. Hunter and Smith {1970) studied cardiovascular Howard {1961) isolated from the decidua of alterations in "toxemia" and found a decrease patients with hydatid mole with super­ in plasma vo lume compared with normal imposed " toxemia" a pressor substance pregnancies. This possible decrease in {which they termed hysterotonin) which was intravascular volume occurs in spite of not observed in normotensive molar apparent fluid retention {in the form of pregnancies. They felt that hypoxia was edema). If malfunctioning causes abnormal responsible for the release of hysterotonin in distribution of body fluids {increasing the the uterus in " toxemia"; and that renal interstitial fluid volume while decreasing the ischemia, a secondary effect of hysterotonin, intravascular volume) the normally led to activation of the renin-angiotensin functioning renin-angiotensin system would mechanism. In support of this theory, not get the negative feedback, and thus would placental oxygen consumption in vitro has not turn off. been found to be decreased in the placentas of " toxemic" patients when compared to A similar result would occur in chronic normal placentas. As well, the maternal depression of sodium, especially in the region placental blood flow between thirty-eight of the juxta-glomerular apparatus. A study weeks and term seems to be reduced by of cation levels in human placentas showed about two-thirds in " pre-eclampsia" and lower levels of sodium in placentas of chronic hypertension. Indeed, placental " toxemic" patients. Another article ischemia due to reduced utero-placental hypothesi zes the hyperactivation of the ci rculation is thought by many to result in renin-angiotensin system by a progesterone­ release of a pressor substance. This could induced sodium loss. Rabbits treated with cause consequent hypertensive disorders. progesterone only for twenty days showed a Hodari produced the symptoms of "toxemia" sharp ri se in mean systolic pressure. in dogs by placing snug but not constricting However those treated with progesterone plus Teflan bands around the uterine arteries saline fo r ten days showed only a very before pregnancy. In pregnancy, the bands slight increase in mean systolic pressure. prevented a normal increase in uterine flow, This pressure rose steeply in the second ten thus creating a relative uterine ischemia, and day period when water was substituted for the symptoms of "toxemia". This results in the saline. According to this hypothesis, a vicious circle: reduced utero-placental 94 circulation leads to liberation of a vasopressor same as an increase in angiotensin, i.e. substance, which in turn leads to vaso­ hypertension. constriction, resulting in further reduction in circulation, and so on. One interesting The final possibility in the alteration of the question is "which comes first", the chicken renin-angiotensin system is an increased (vasoconstriction) or the egg (ischemia)? pressor response to angiotensin. This hypothesis has been much investigated and In summary, we have seen that one possible at the present time is quite popular. The alteration of the renin-angiotensin system in hypertensive disorders of pregnancy, as the hypertensive disorders of pregnancy is an distinct from chronic hypertension, appear to increase in a vasopressor substance. This be associated with vascular hyperactivity to increased vasopressor substance could be pressor substances. Talledo, Chesley and due either to a physiologic hyperactivity of Zuspan studied the pressor response to the renin-angiotensin system because of angiotensin II and norepiphrine in thirteen pathology in the body, or it could be due to patients, all in the third trimester of pathological vasopressor production outside pregnancy. The " pre-eclamptic" patients the renin-angiotensin system. showed increased sensitivity (i.e. larger rises in mean blood pressure) to infusions of A second possible alteration in the renin­ angiotensin and norepinephrine. However, angiotensin system could be a decrease in a patients with uncomplicated hypertension vasodepressor substance. As stated earlier, reacted in the same way as did normotensive it is thought that in normal pregnancy the pregnant women. This increased sensitivity vascular reactivity to angiotensin is to angiotensin could account for normal or considerably reduced. This reduction could decreased values of circulating renin while possibly be due to a vasodepressor substance still explaining the hypertension. produced in the placenta which counteracts the effect of angiotensin. Some workers What could cause the increase in pressor succeeded in isolating from mature human response to angiotensin II? Some interesting placentas a substance that lowered blood work points in the direction of intracellular pressure and produced a marked relaxation shifts of sodium. Burks studied dog in duodenal smooth muscle. The solubility, mesenteric arteries in vitro before and after size and stability to proteases, temperature storage in various solutions. Data indicated a changes, and pH changes suggest that this relationship between artery responsiveness active substance may be a prostaglandin or and tissue levels of both sodium and related substance. From dilution studies, less potassium ions. The artery was hypotensive of this vasodepressor compound was if the tissue levels of either ion fell below demonstrated in the "toxemic" placenta than certain minimal values. If the tissue contained in the normal one. Some suggest that the both ions but with neither in excess, the placenta in "toxemia" may be damaged in artery was normoresponsive. Most significant such a way (for example, ischemia) that it is however was that if the artery contained a unable to synthesize as high quantities of minimal level of potassium and an excess of the vasodepressor substance. The renin­ sodium, the artery was hypertensive. angiotensin system, although possibly operating at normal levels, would still produce Along a similar line, Harris related arterial hypertension. reactivity to sodium levels in the extracellular compartment. He hypothesized that mucopoly­ A third change producing the same effect saccharides in the arterial wall are the site is a decreased inactivation of angiotensin. of sodium binding in the arterial extracellular This is to be distinguished from the second compartment. His evidence is that after possibility in that here the angiotensin is treating the arterial wall with hyaluronidase inactivated before it can produce vaso­ or ascorbic acid (which depolymerize the constriction. In contrast, the vasodepressor mucopolysaccharides from the wall), there substance discussed above probably acts in was a decreased arterial response to an opposite direction to angiotensin and thus constrictor agents. This parallels a decrease nullifies its effect. Talledo studied nineteen in the sodium content of the arterial segment "toxemic" patients and found that their and a consequent loss in the amount of angiotensin inactivation was decreased from rapidly exchangeable sodium ion. In contrast, values of normal pregnancies. As he also increasing the amount of rapidly exchange­ found plasma renin decreased when able sodium by raising the sodium compared to normal pregnancies, he inferred concentration of the solution in which the that endogenous levels of angiotensin may artery was soaked, resulted in an increased also be decreased. Thus a decrease in sensitivity to vasopressor agents. The same angiotensinase (an enzyme which breaks result might be expected to occur if the down angiotensin) could also occur, perhaps mucopolysaccharide component in the arterial overcompensating. The result would be the wall increased. Patients with hypertension, 95 though not specifically of pregnancy, have which the other predisposing theories work. demonstrated such an increase. If this In the process of researching this topic, one hypothesis is correct, then restricting the becomes intrigued as to how some of the dietary intake of sodium would possibly other theories might possibly tie in. If the decrease the extracellular exchangeable reader has knowledge of the research into sodium, and thus might be helpful. this etiology, he will share with me the Up to this point, evidence has been yearning to see possible interrelationships. presented to account for a change in the For example, a possible relationship renin-angiotensin system producing vaso­ involving the theory of placental ischemia has constriction. Four hypotheses have been already been discussed. With this view in presented, one or more of which may mind, I will now outline an interesting contribute to the hypertensive effect. For hypothesis of the interrelation of various example, a possible scheme interrelating two theories in the etiology of the hypertensive of the hypotheses is shown in Figure 2. A disorders of pregnancy. This hypothesis was shift in the intracellular sodium content advanced by Page and is illustrated in results in an increased pressor response of Figure 3. Incorporated into this concept, one the vascular system when the renin­ may see several of the theories described angiotensin system is activated. This leads earlier. Examples are disseminated to excessive vasoconstriction, thus decreasing intravascular coagulation, sodium retention, the utero-placental circulation. The placenta placental ischemia and renin-angiotensin becomes ischemic and releases a vasopressor alterations. substance, causing further vasoconstriction, placental ischemia, vasopressor release, and Figure 3 also shows possible consequences so on , instigating a vicious circle. superimposed on the concept of the vicious circle. The three major symptoms of In extensive reading, it becomes apparent " toxemia" are accounted for: hypertension as that more than just the renin-angiotensin a result of vasoconstriction, proteinuria as a system must be involved in the etiology of the result of a leakage due to the glomerular hypertensive disorders of pregnancy. endothelial lesions, and edema as a result of However, the renin-angiotensin system could sodium retention. As well, various other possibly be the basic mechanism through clinical symptoms discussed at the beginning

Fig. 2: A Possible Relationship Between Theories Accounting for Hypertensive Disorders of Pregnancy vasoco striction

1' p essor

!'Pressor response

utero-placental == .. - · -~ J$lacental circulation ischemia

96 Fig. 3: Consequences of the Vicious Circle in the Pathogenesis of Hypertensive Disorders of Pregnancy

Fetal hypoxia 11 or death ReducediJteroDl acental c rcUJ.at.l.on Inner vi cious circl e /of pre-eclampsia and 1 eclampsia HlPERT ..SIOH /) hyperplacentosisM

~......

Increased placental Increasedr resPOnsiveness pathology o1· D.lood --vessus to pressor substances

Reduced plasma volume

Esaape of trophoblast and thrombopl astic Jll&terial oh1tto ~tr•ooll..,.of Na~ 1· ...... )

OEDEMA "'-- a~ retention Disseminated intravas cular~ E cl amp sia agulatio\ slol fast homona.l factors)

educed Glomerular Profibrin filtrati on 0 iltrati"n rate ~.~. \

. ~Glomerul a r endo thelial f!5w lesions ~ 9! renal blood l " tubular secreti on PROTEI NURIA of uric acid

hypereuricemiaJ

-Adapted from E. W. Page "On the pathogenesis of pre-eclampsia and eclampsia." J. Obst. and Gynec. Brit. Common, 1972, Vol. 27 : 395.

97 Fig. 4: Vicious Circle Represented in Fig. 3

1. Primigr•vid uterus 2.)'uterine tonus (eg. labor) ).,~v Ascul a r demand (eg. twins) 4. Autonomic v•soconstriction ("stress") 5. DiseBsed uterine vessels (eg. diabetes) 6.1 intraabdominal pressure (eg. obesity) 7. S~' nding or supine position 8. Hypoolasia of aortA

. Riced uteroplacental circulation

Chronic hypertensive disease ~vasocenstrlction !l

placenuJ...t..- 7 Abnormal • diet Increased1 responsiveness ot blood vessels to pressor INbsunces

Escape of trophoblast '­ Large Hydatid and thromboplastic Hole material Intrace lular shifts

oodium load :+Na+l (+ steroills)

Na retention Disseminated intravascular joagul&tio'\ slj.; fYst

(+ hormonal actors)

Standing -+ Reduced Glomerular Profibrin filtration or supine filtration rate position

\ Glomerular endothelial llesions Chronic renal disease

-Adapted from E. W. Page "On the pathogenesis of pre-eclampsia and eclampsia." J . Obst. and Gynec. Brit. Common., 1972.

98 of this essay are illustrated. Most of these associated with an increase transport of involve fairly straight-forward physiological trophoblastic material to the lungs. The mechanisms. nutrition theory may have a role in increasing the placental pathology. Thus much of what At the start, it was made clear that any is known of the hypertensive disorders may concept of the etiology of the hypertensive be accounted for by this concept. disorders of pregnancy must account for certain factors. Figure 4 illustrates the outer The hypertensive disorders of pregnancy circle of predisposing factors, including represent one of the most researched fields much of the necessary criteria as well as of obstetrics. If the reader cares to take the additional possible theories advanced by time, he will find that the word "possible" various people. As far as the criteria are has been used approximately twenty-one concerned, with chronic hypertensive disease, times in the course of this discussion. This there is already a generalized vaso­ summarizes the predominant feeling still constriction. Chronic renal disease may pervading this topic: uncertainty. The render the glomeruli more susceptible to renin-angiotensin system plays a probable endothelial lesions. A reduced uterine blood role in the pathogenesis, yet this integrating flow may occur more readily in primigraviadas concept presented is no doubt still debatable because of the less extensive vascular in places. apparatus. Uterine ischemia would be favored by the vascular lesions of diabetes mellitus, • by uterine distention with twins, by increased Time and space, those cruelest masters of all intraabdominal pressure with obesity, or editors, having pushed me to extremis leave me no option but the heinous unorthodoxy of ruthlessly by increased uterine contractions as with excising a myriad of references and a prodigious approaching term. Hydatid moles are bibliography ,wh ich are available on request.-(Ed.)

Consumer Reports: Natural Childbirth A Layperson's Challenge to the Medical Profession Karen Jazey

INTRODUCTION because our statistics are more reliable but Karen Jazey, as well as being a job consider also that the slight variations in the counsellor here in London, is also a public collection of this data do not significantly relations officer for the London Childbirth alter the statistics. Statistical research by Education Association. This group which Gruenwald indicates that 40-60% of all began in September 1971 has an international perinatal deaths occur among full term infants 1 affiliation whose motto is "Freedom of Choice weighing over 5 h pounds. Some of our Through Knowledge of Alternatives". As a present practices in obstetrics, almost unique voluntary association these lay people and to the United States and Canada, undoubtedly medical professionals are dedicated to have adversely affected our standing by promoting family-centred maternity care in the thwarting the normal physiological process of firm belief that comprehensive education for childbirth and lactation. childbirth is of lasting benefit to the Doris and John Haire, co-presidents of the developing family. International Childbirth Association have considered how our country practices these WHY IS THERE A NEED FOR CHANGE eleven routines: IN MATERNITY CARE? 1. Little or no effort is made to minimize Were you aware that while Sweden and the the mother's need for analgesia and Netherlands vie for first place in the annual anesthetic through education for and comparative infant mortality rates issued by increased support during childbirth. (It is the Statistical Office of the United Nations, scientifically acknowledged that fear that Canada and the U.S. vie for 14th and and apprehension adversely affect 15th place. I've heard that this might be uterine motility and blood flow and that 99 maternal analgesia and anesthesia, poor, despite the irrefutable natural regional and general, can increase the protection against disease, infection and need for delivery by forceps and the tooth decay that breast-feeding affords need for resuscitation of the newborn.) the baby. 2. Elective induction is carried out for the 1o . The time of the first breast-feeding is sake of convenience although it is delayed 8-12-24 hours, whether or not the acknowledged that drugs used to induce mother (and infant indirectly) has or stimulate labor may increase the received medication. (There is no medical probability of fetal distress and make It evidence to support the practice of almost impossible for the mother to cope routinely delaying the time of the first with the discomfort of the intensified feeding or of giving the infant sugar contractions without the aid of analgesia water prior to being breast-fed. There is and anesthesia. ample scientific research to indicate that colostrum benefits the baby by giving 3. A family member is prohibited from being him immediate protection against disease with the mother during the stress of and infection. labor and delivery. Please note that St. Joseph's Hospital just began allowing 11 . Breast-feeding infants are restricted to a fathers in the delivery room in rigid non-physiological feeding schedule September 1973. although scientific research has shown that the average newborn varies greatly 4. The mother is not permitted to labor, in his nutritional requirements during deliver and recover in the same bed the first two weeks of life-from 3-6 without being moved from her room-an feedings the first day to 11 feedings on accepted practice in most of the world. the fifth day, gradually decreasing to 5. The mother is made to assume a 6-9 feedings daily in the second week non-physiological (l ithotomy/stirrup) of life. position for delivery-a position which inhibits the mother's ability to give birth What is considered to be the normal use of spontaneously and which increases the medication in this country is considered need for routine episiotomy. (There is no to be excessive use in countries such as scientific evidence to indicate that Sweden and the Netherlands. The adverse routine episiotomy reduces the need for effects of obstetrical medication on the fetus future vaginal repair or reduces and infant demonstrated by Brazelton, Kron, neurological impairment in the child.) Niswander, Windle and many others attest to the inherent risks of these well-intentioned 6. Placental transfusion is not allowed to medicaments. Also I was fortunate enough occur due to the early clamping of the to hear Dr. Marshall Klaus speak on his umbilical cord. (In most countries findings which demonstrated that early placental transfusion, which usually neonatal separation can Interfere with the facilitates a rapid expulsion of the common behavioural sequences present in placenta without chemical or manual women as they establish affectional ties with assistance, is considered important in their infants. Many infants survive the many reducing the incidence of postpartum diversions from physiological childbirth, hemorrhage and also the incidence of but there is still much to be considered as to future anemia in the child. how these diversions may affect the future well-being of the child and the parent-child 7. The mother and her baby are separated interactions. immediately after birth, whether or not the mother has received medication. London's Childbirth Association compiled a (There is no medical evidence to indicate short questionnaire for use in this article. that a baby who is unaffected by It was distributed for one week, February maternal medication and is kept dry and 18-22, at Victoria Hospital. Indifference and warm in his mother's arms while just plain apathy are sharply illustrated on the breast-feeding in the delivery room will part of the patient and their respective suffer an abnormal drop in body medical advisers. Twenty-nine women temperature.) received the questionnaire. For fourteen of 8. The hospital routine then sharply limits the women it was their first baby, while for the time the newborn infant spends with fifteen it was not. Nine of these women had his mother and father, the only two attended prenatal classes, while twenty had people in the world with whom he is not. Three had attended prenatal classes for bacteriologically compatible. previous pregnancies while twelve had not. Eighteen women were aware that prenatal 9. Little or no effort is made to encourage classes did exist while five were not. Six did breast-feeding, especially among the not answer. Three said they would have 100 attended if they had known of the classes resent the passive quality of their role in whi!e twelve said they would not have the process and want their husbands to share attended anyway. Eight of these women were in the experience. They regard bearing a referred to classes by their doctor while child as one of the great milestones, if not twenty-one were not. Five of these women the ultimate personal experience, in the were encouraged by their doctors to have development of a mature woman-the their husbands involved while twenty-four culmination of her biological destiny. They were not. It's hard to avoid facts which hit reject the attitude that pregnancy is some very close to home. form of disease. They see the birth of a child as a normal process, and far from wanting Our culture has created a generation of the experience blotted out by drugs, they women who, on the whole, prefer to submit want to live it and exploit it to the full. passively to being delivered of their babies, unaware that their reluctance to participate Un like some of the early converts to natural places their babies at a disadvantage. If ch ildbirth, today's advocates do not rigidly we are to effect a change for the better we oppose all medical intervention or reject must begin by helping each mother to altogether the use of forceps, analgesics and appreciate the important contribution which anesthetics. What they seek is to have these she can make to her child's long term aids placed in a different perspective-they well-being by availing herself of proper should be available, but used only when prenatal diet. Also the couple should be absolutely necessary. These modern prepared to cope with the stress and advocates of natural childbirth believe that discomfort of childbirth. Childbirth classes for the normal woman having a normal should be an inherent part of hospital pregnancy, labor and delivery, the emphasis maternity care if we are to reduce .or eliminate should be on the psychological and the mother's need for medication during emotional preparation for childbirth and labor and birth. I realize that our parenthood. conventional concept of maternity care was Whether one accepts the theory of natural adopted 50 to 60 years ago to thwart illness, childbirth or the more traditional medicated difficulty with delivery, mental incompetence delivery, it is important for women of or extreme poverty but today 90% of all childbearing age to know that the choice mothers give birth without complications. I does exist. Moreover, they should know that question the need to impose conventional they can profit from attending classes for hospital practices on the healthy maternity natural childbirth even if in the end they elect patient carrying out a normal physiological (or their doctors advise them) to follow function. While we cannot change our culture standard medical approaches. The pregnant overnight, we must begin somewhere. We woman has nothing to lose and everything to in the Childbirth Education Association feel gain from having her husband participate there is no better way than to offer directly in the events immediately preceding family-centered care to all maternity patients. birth, and she is almost bound to benefit emotionally from the atmosphere in which the Dr. Murray Enkin from St. Joseph's Hospital classes are held as well as from the in Hamilton is J.C.E.A.'s vice-president. Next instruction itself. spring Hamilton will be sponsoring the first Canadian Mid-West Regional Conference for According to the original natural-childbirth the association. This would be an excellent concept, each couple in a childbirth opportunity to share with Jay and medical education course was encouraged to form a people a "better approach to obstetrical close relationship with one of the nurses care". For any further information, please or one of the trained lay persons. This nurse, contact Ms. Jazey at 471-0406. the monatrice, or the trained lay person would act as coach for the pregnant wife and see her through labor and delivery at the * * * hospital. But the great popularity of the The following article which has been courses has made this personal attention adapted from the book, Pregnancy, Birth and impossible, and the emphasis now is on the Newborn Baby, clearly outlines many of teaching the husband to do the same job. He our group's aspirations. Perhaps It will supervises the preparatory exercises and, express to all of you who are potential where permitted, accompanies his wife into medical professionals, what we the lay people the delivery room. in this organization and many out of it, wish to share with you. There is nothing staged or artificial about his participation, and this drawing together of In recent years many women have husband and wife at a pivotal event in their questioned the purely technical approach to li ves tends to cement their dedication to each labor and delivery. They do not want to other and gives them a stronger approach " be delivered"-they want to deliver. They to parenthood. 101 As might be expected, in the classes Physical fitness is emphasized in these themselves the emphasis and the instructional courses. Peak muscle tone assists the mother details vary, but certain themes are fairly in meeting the strenuous demands of labor standard. Usually the woman and her husband as it progresses, and in the final stage join a class about two months before her enables her to bear down strongly without expected delivery date. The class meets tiring. In order to help the mother conserve weekly, and groups are kept small to enable her strength and preserve her calmness, the the enrolled couples, as well as the courses also teach techniques of general instructors and advisers, to get to know one muscle relaxation. another. A more specific element of the training is There is an element of " group therapy" the " psychoprophylactic" conditioning. The in the procedures. As the couples begin essence of this is to set up a distracting to warm to one another they share their stimulus to take the woman's mind off labor. questions and worries about the impending In the language of behavioral psychology, events. Discovering that others have the same the mother is " deconditioned" to the pain of concerns and worries and that they are uterine contractions by " conditioning" her to learning to deal with them always tends to another stimulus-in this case, a system of reinforce your self-confidence and enables breathing. you to face the future with greater equanimity. " Graduates" of the course who In the Lamaze system of natural childbirth, recently have given birth return to describe the rate of breathing is regulated according their experiences and answer questions. to the intensity and duration of the uterine Often hospital visits are arranged to acquaint contractions. In the early stage of labor the the group with some of the practices that mother's inhalations and exhalations are slow they will be encountering there. and deep. As the frequency and intensity of the contractions increase she switches to Instruction in the physiology of labor and shallow, rapid panting. In the final stage delivery is given with films, tape recordings, another rhythm of breathing helps her to video tape, charts, diagrams, still pictures either bear down or relax, thus giving her and anatomical models as well as written some measure of control over the speed of material. Much attention is paid to the nature the delivery. The husband is taught certain and rhythm of the uterine contractions In techniques of massage, or effJeurage, that the various stages of labor. The idea is to help his wife to relax during and between educate the pregnant woman to recognize contractions. the characteristics of her labor at any point so that she will have an idea of what comes The attitude toward control of pain in next and how soon. natural-childbirth courses is not heroic but realistic. It is accepted that analgesics, or In the transition stage of labor, for painkillers, in judiciously small doses, and example, just prior to the full dilatation of sometimes paracervical or other local the cervix, discomfort approaches the anesthetic may be given. Further it is maximum. This is the time when the woman assumed that general or spinal anesthetic might be expected to ask for an anesthetic. will be used if in the physician's opinion some But if she has been trained to realize that complication requires it. The mother thus only a few more contractions will carry her can proceed with a natural childbirth in out of this stage and to the beginning of the complete confidence because she knows next-the expulsion of the baby-it Is likely that the full apparatus of modern obstetrics­ she will be able to summon enough resolution anesthetic, surgery, fresh blood-is there for to go on to deliver herself. her rescue if some complication should The mother who has had the training arise. In practice, the majority of mothers in offered in these courses will know natural childbirth do not require an immediately what the physician means when anesthetic, but each is expected to do what she hears him say that the cervix is five is most comfortable and best for her. centimeters dilated and 80 per cent effaced and will be able to gauge from this Some obstetricians supplement the formal information her capacity to continue without natural-childbirth courses with review getting demoralized and giving up. Mothers sessions late in pregnancy to tie together all are taught when to accept support from the that the couples have learned and bring It into " team "-the doctor, the nurses and other focus with the actual team that will be hospital personnel-as they deal with the involved in the delivery. "Awake and aware" most intense contractions in transition. mothers and fathers can be an invaluable Fortunately, transition passes quickly, and aid to the confident management of labor and the more active pushing of the second stage, delivery. leading soon to the delivery of the baby, Until quite recently the great majority of is a welcome change. American women wanted amnesia and an 102 anesthetized delivery, with the least possible may begin on the delivery table minutes after preparation and participation. After all, it was birth. partially in response to this feeling, which represented the best thinking of the times, Whatever your thoughts about natural, or that modern obstetrics developed along the prepared, childbirth, you would do well to lines it did. But now times are different and remember that most proponents of these many physicians are showing an interest in approaches have an honest conviction that it the psychoprophylactic and other preparatory is better for the mother and father to know techniques of childbirth. what is happening and to prepare for it together; an equally honest conviction that Prepared childbirth has challenged the it is better for the newborn to have had little physician's way of thinking and acting. or no medication; and a very firm and honest Instead of " delivering" the baby, he now is conviction that the couple that achieve this asked to be available if needed, a valued kind of experience have accomplished supporting player but not the star in the something that will make them better and drama of childbirth. More physicians these more understanding persons, better mates days will be supportive of and sympathetic to and better parents. couples who want to give natural childbirth a try, and at the same time they will not The whole phenomenon can be looked push this approach upon their patients. upon as a complex social, medical and personal experience that draws upon the The trend among the doctors is in line with accumulated experiences of psychologists, a somewhat parallel trend in the hospitals. psychiatrists, obstetricians and parents An effort is being made to provide a themselves. In the newness of these comfortable atmosphere for natural deliveries approaches there is excitement and promise, and for rooming-in arrangements for the the process of giving birth assumes a mother and her new baby, as well as relaxed stature that is gratifying to participate in for arrangements for the father's visiting. Breast the parents, the physician and nurse and, in feeding tends to be fostered, is greatly aided the long run, the child, who is the focal point by livelier, nonmedicated babies and often of it all.

* * *

Book Review by J . Van Dorp

Anatomy and Physiology tor Radiographers. C.K. Warrick. Macmillan of Canada. $8.50 list. Dr. Warrick has more distinctions and degrees than a thermometer (and that is rather difficult in Scotland). In spite of it, though, he has written a readable text. If to be brief is to be virtuous then as anatomists go, Dr. Warrick is a paragon of virtue. His line diagrams are succinct and the radiographs have been remarkably well reproduced. This is not only an excellent working manual but the eat's meow for 'boning up' to essay anatomy exams. * * * Many are the platitudes about old age, but one of my favorite stories about assumptions of infirmity concerns a person whose wit never deserted him-Sir Winston Churchill. Two younger MPs passed Sir Winston as he was being assisted up a flight of stairs in the British House of Commons. " Shame about the old boy getting so senile", said one. "Yes," said the other. " I hear he has to be helped everywhere now." The 'old boy' wheeled sharply and said in piercing tones, " Yes, and they say he's deaf, too!" -Margaret McCaffery, ed., The Canadian Family Physician, Dec. 1973

* * * On one southern French campus a huge red inscription yells: "Mao--Vieux Singe". Five years ago that would have provoked a riot; nowadays there aren't enough Maoists around to scrub it out. The man chiefly responsible for the decline of campus Maoism is President Richard Nixon. You need the faith of a dervish and agility of a Sartre to cope with those photos of God entertaining the Devil in the very heart of the forbidden city. -The Globe and Mail, Feb. 27, 1974 103 MED'S 77 THE NEW CURRICULUM

MED'S 76 MED'S 75 ME D'S 74

DEFINITELY NOT DIABETIC

WATTERS BLOWS HIS OWN

TURN YOUR HEAD TO THE RIGHT ARE YOU SURE THIS IS HOW YOU AND COUGH! TEST THE GRACILIS? The Agony and the Ecstasy of Meds '74

Meds '74 came into being early in donated a giant sperm piggy bank to the September 1970, when our motley crew was Homecoming Parade. Whoever heard of first assembled, ironically enough, in the "Insemination for the Nation" ? Obviously not Dental Lounge. We were wel comed by an the judges! In Tachycardia, our flawless awesome Hippocratic Council President, a performance in " The Christmas Carol" real live Dean of Medicine and the infamous earned us second place. Second place? Even (but, as yet, unknown) Brucey Squires. Sam Fratesi 's frantic wheelbarrowing all Everyone pinched themselves to make sure over the stage couldn't put it " in the bag " it was real-some pinched others. for us. It is hard to believe that no one fainted In Pathology our class discovered a new during our first anatomy lab, though most syndrome-The True Steven Johnson were relieved to know that Mike Austin looked Syndrome-when good old Steve slept so good in green. Soon we were getting to th rough 7 out of 8 classes and th en asked 5 know each other better-everyone questions in the last lecture. The triad of recognized Timmy Lynn's guffaw-but, who symptoms found were: marcolepsy, dysarthria the hell was Rick Haddad-oh yeah, he was and multiple mounting behaviour. Multiple the skinny kid who wanted to quit and go what? Ask Steve. back to Toronto because he wasn't doing well enough! At Ch ristmas in second year we got a new classmate-Trevor Biggs (enough said). Tachycardia rolled around (and so, for the Richy Haddad earned the name of " Giant most part, did we!) Nigel (Ed Sullivan) and Cell King " which has appropriately been Walter's Ukrainian dancers put on a shortened to just "king". tremendous performance. Barry Long never looked so good in a bonnet and diapers. The highlight of the year didn't come, Mike's imitation of Dr. Gwyn earned him the however, until we had final exams safely critical acclaim of his classmates and a behind us. Who could forget Dr. Smout's "C" in anatomy. Even J. C. Payne with his yellow happy face socks at the year-end "erudite mothers" line couldn't salvage it for party. us. And, for some strange reason, we came Second year we began to see real (live) in last that year. Perhaps Peter Johnston, patients. Diagnostic clinics were always our merry-whatever, had something t.o do with interesting-we learned to expect the it (I bet he wishes he had nothing to do unexpected. Strangely, no patient ever with it!). seemed to have a classical history or The Christmas party gave us Steve physical findings. Now Brad Hunkin knows Johnson as Ronald MacDonald and Rich better than to kneel directly in front of a Minielly as Santa Claus a Ia AI Capone. hyperflexic patient when he elicits a knee Everyone had a grand time belting out jerk. Who was it who did a rectal and forgot Christmas carols and opening presents the glove? Guy De Rose now knows 12 especially Adele's kid, who got so excited different ways to examine a spleen. that he wet his pants as well as her lap. The best part of the party was that the exams Third year started off well-a party at were over. Barney's farm with its spring-fed swimming pool. We all got sucked into chopping Winter weekend brought Meds '74 its only Barney's winter wood supply-pretty clever fame-a winning ice sculpture. "Happiness is for a neurologist! dragon a piece of tail" is the motto that clinched first prize for us. Then we began our love-hate relationship with Frankie Diesel-or was it vice-versa! In The rest of first year was spent cramming therapeutics we not only learned the care and millions of assorted, but not altogether feeding of patients, but we also learned the useful, facts into our empty little heads. Queen's English. Will the real frustrated Wonder of wonders-we all made it into grammar prof please stand up? second year! Our third year Tachycardia attempt, The Aw yes-second year. A kaleidoscope of Goddoctor, saw the debut of the Chinese even greater volumes of knowledge and good mafia, starring Hugo Law and his 6 foot times. Remember the highlights? Meds '74 acupuncture needle. Impersonations were the 107 rage-Frank Deziel, Big AI, Bill Pace and in bed. (I wonder what Steve uses? Coles Charlie Drake may never forgive us! Second Notes?) And speaking of pathology, it is place was becoming habit-forming! truly amazing to contemplate the number of paired, ash-leaf shaped, erythematous lesions Clinics rolled merrily along. George Vilas that have been appearing of late on the did his first sigmoidoscopy-lucky he didn't necks of certain young ladies in our class, tell the patient he was Greek! Suddenly it especially on Monday mornings. was the 3rd Year-4th Year Party and then there was nothing to look forward to but Third year needs lectures in bedside the American Boards. The only good thing manner. One of our cohorts was examining a about them was that they were soon over! neuro case: he stepped out of the room for a minute, and when he returned the patient Fourth year at last. "Clinical jerk-help was comatose. Maybe Scope would help. ya?" runs through many a hospital hall. It In fact, perhaps we should all usc a seemed like just yesterday we were in third mouthwash: it might cut down on the number year (for some of us-it was yesterday!). of students getting thrown out of patients' rooms. Electives were far-flung-Maggsy-Beth and John Pook in Barbados catching some Despite well-known misanthropic sun-Adele in New Orleans seeing 3 gun-shot predilections, and a passionate dislike of wounds per day-Tom Phillips, John Hayley, such decadent bourgeois social farces as Greg Cairncross and George Dundas drinking parties and the like, Mr. Helliar nevertheless England into their energy crisis. Peter Bloch, managed to put in an appearance at the Peter Mac, Millie, Steve Brady and Brian annual 3rd year/4th year shindig. He was Richardson wrestling bears in B.C. when they encouraged in this regard by Messrs. wern't saving lives-Mo Thompson in Blacklock, Rowe, et at, who brought their Strathroy (where?). protesting victim bound and fettered in an old tarpaulin and ropes. Work boots and all. February 1974 brought the excitement of internships. We're spread from sea to sea­ By the way, an ominous warning was from Fets in Newfie to Campbell in Victoria issued at this same gathering. It is rumored -Look out Canada! that certain stethoscope(s) have been sabotaged by Sinister Forces, to the extent Another notable event was the infectious that sound proceeds not from the diaphragm disease that spread to eleven (count 'em) of to the hear-holes. The funny thing is, that our classmates-that psychotic condition none of the victim(s) of this prank seemed to called "engagement". They're working on a have noticed any difference! So much for cure for it right now in the Collip Lab. clinical science. Looking back at Meds School at Western, Meds '75 has long been renowned for I'm sure many of us will have fond (and not academic zeal. Dr. Vigner recently changed so fond) memories for years to come. Can the venu of the Family Medicine lectures from you imagine our first 5-year reunion. I can the Busby Room to his office, where he said hardly wait. he had two extra chairs. Group K seems to Su Bright and Peter Johnston have decided that one student constitutes a quorum for obs/gyne at St. Joes'. Of course, that is a better response than certain Class News surgeons at Westminster have been getting. FLASH! MEDS '75 Dr. Smout, our venerable honorary president, has disclosed that Tom Downs has As we trundle along the road to fourth suddenly " got relig ion". He reads the Bible year, life is not without its lighter moments. every night-in a different hotel room. It seemed appropriate in this issue to bring to light some of the mo re pecu :ia r doings of WANTED: Meds '75. Black and white photographs, with negatives, of people in our class. Copies Along clinical lines, our class is making will be made, originals and negs, returned its share of contributions. A " medical first" is to owner promptly. Please apply to yours reported by Sharon Macko, who discovered truly. spider nevi below the waist of a patient. Not to be out-done, Dr. S. Helliar has drawn A FINAL NOTICE: attention to a seldom-recognized pathological Anybody who has an eye for one of our entity-"Harrison's Sulcus"-a big charming girls had better get his application depression in the chest that is acquired by in soon. Recently engaged: Kathy McCully medical students who read that hefty tome (Dr. Galli); Cathy Whiting; Miriam Ridley 108 (Peter Brown with the dark hair-Meds '75) ; Mayr, streaked through the I.C.U. at Victoria Mary Humeniuk (Chris Bruckswager-Meds Hospital and left hearts fail ing and nurses '74). Hurry. They're going fast. wailing. (Barbie's now being sued for the cost of three defibrillators which were burnt out Hang in there, group. And keep on during the escapade, not to mention a praying , Tom. number of pacemakers.) Neil McAlister, archivist Bill (Poncho) Watt (lightbulb magnate and squash superstar) broke a world record MAD NEWS '76 ~pril ~ 1 stuffing 14 hundred-watt lightbulbs mto h1s mouth and still beating his opponent, Slack week? Never heard of itl For the the grandmaster of the farmers' squash team hardened veterans of Meds '76 school ended (to a pulp, I might add). Bill was reprimanded January 28 when 95% of these incumbent however, by the judges when they healers succumbed to the insidious discovered that he had cheated by onslaught of apathy and joined the ranks of swallowing 7 of the bulbs during the match. the mediocre. Bill is now writing a treatise on " Bulbophagia Chiropractors are launching a suit against and the light it sheds on gastric topless masseuse parlours which they claim disturbances". are putting them financially on the rack. Charles Q. Armwrecker, Quacker-in-Chief Louise Martin has been elected Marine­ expressed his disgust at the "gross ' lands Mermaid of the Month. She's been sensationalism" he feels the 'rub clubs' are holding her breath for the Olympic swim using to exploit the public. According to meet at Expo in '76 since August and Is just Chuck, the backbone of Canadian Society is beginning to turn aqua blue. Furthermore, at stake and he is not about to turn the during her elective in plastic surgery she's other cheek, until he gets to the seat of the been attempting to graft a set of gills and a problem and the masseurs have been fully propeller underneath her back fins. Good exposed for the 'rubby-dubs' that they are. luck Louise! Ms. Androgens, head of the local libbers Skai Stevenson has been peering out spoke up in behalf of the predominantly 'male from behind a monstrous homemade bread chiropractor society. She said the idea of and cheese sandwich in Path lectures males engaged in such menial tasks was not recently. Apparently he has been left a cookie without appeal for women, provided they house and a mountain of dough due to the didn 't rub you the wrong way. untimely demise of his uncle Toastmaster Speaking of appeal, the entire male Stevenson and his two children and heirs, population of Western University went on Hansel and Gretel Stevenson in a severe bout of ptomaine poisoning that hit his home­ st reak ju~t recently. Abashed onlookers hardly knew wh1ch way to turn (in the interest .of town, the Village Grimm, just last month. He propriety). Screams of panic were heard as has been trying voraciously to dispose of the boys ran through the campus pursued by his inheritance ever since. herds of curiosity seekers looking for Julian Oates, show-biz tycoon and master souvenirs to take home to the family. Joe of iniquity, is throwing a beach party this Sh~w, chief streaker for Uron College has week. In order to entice the beach boys to cla1med that streaking is rapidly becoming join the festivities he has had the entire passe and that in some areas it was 1 California coast moved into his yard, / .. of being replaced by creeping which permitted the Pacific Ocean and an oil slick to add to greater audience participation. Joe claims the atmosphere. He is staging earthquakes "It's a damn shame some of the lengths you regularly on the decade. have to go to get a little attenion around here. People don't have any respect for show Western 's own galloping gourmet, Monsieur business talent anymore. You practically Bruce le Sweek took up French cooking have to cartwheel through campus to get just this month and has had the trots ever some babes to blink an eye." Humphrey Fag, since. Le Sweetie's recipe for kosher poulet spokesman for U.W.O.'s Homophiles feels flambe is well-known among campus that streaking isn't really as decadent as epicureans not to mention the S.P.C.A. (who some people might think. "After all," says feel that topical cognac leaves much to be Hump, "it's really nothing you wouldn't see in desired in the line of anesthesia) and the any decent showerroom. People wouldn't be officials at Firehouse 7 who have been called quite so upset if they'd only slow the pace in upon occasion by seething neighbours down a little and get some of those women (no doubt burning up with jealousy) as a out of the way." backup group for Brucie's " enlightening" Not wanting to be left out of the streaking, performances. Despite his lack of success in Meds '76's feminist libertines, led by Barb his apartment with the bird under cognac, 109 Sweetie has done much better with the philosophy. Betsy admits that in a good year, French tart and peasant under grass not to out of the 50 or so boys that show up, mention the alley-cat under stress. Bruce, le she manages about a dozen fold-outs and Doux, is now working on a treat for the whole about 3 times that many fold-ups. Betsy hates neighbourhood! an H-bomb salad, and in the to see any of the boys go away disappointed event that his plans go up in smoke, so to and so she leaves them a little memento of speak, he is considering a sideline as a their encounter with the help of her pyromaniac-Keep the homefires burning branding iron. She was soliciting talent in Bruce-you're already halfway there. Europe around the turn of the 3rd quarter but with the recent step-up in campus streaking And speaking of cooking up a storm, she expects to do most of her work closer Margie Best gets the Parnelli Jones award to home. Benevolently, for fastest-cook-in-town. Besty does boiled M. McGarragJe weasel rumps in 7.02 sec. in the quarter (hindquarter) and roast aardvark nostril in MEDS '77 6.72 on nitro but does cold duck in no time at all on straight alcohol. She runs a 1500 The first year of medicine, as any other cu. in. supercharged pro-comp Westinghouse class has known it, is now over for the "flamethrower" with an 8,000 r.p.m. class of '77. In the last few days we have rotisserie apparatus powered by 2,000 struggled through the exams that officially sure-grip elastic bands and a 19" biceps. put an end to all the formal teaching of basic sciences that will ever be given us. But it is Robert Kormos has left his former only March and there are still three months residence and 73-year~old landlady on the of school left. What are we to do? Now grounds of mental cruelty and demands it's on to the applied sciences of medicine: exceeding the propriety of a landlady-tenant the pathology, the neurosciences, the relationship. He is now living with the clinical science and methods (which began in Kormorants in a broadloomed treehouse off second quarter) and the bacteriology (which the Amazon River in which he plays pinnocle began last trimester) in which our newly with a wonderboy, a sexy koala bear and acquired knowledge will be applied. a cheetah. It has been a year of adjustment and Mr. Globetrotter, J. G. Cooles, spends so change for many. The ability to maintain that much time on the B-Ball courts these days ninety average is no longer there and more that he's developed a severe case of realistic goals have been set (to maintain an hydrophobic Parkinsonism and can be average above sixty) enabling the student seen dribbling ubiquitously at anytime of the to have a fairly good time in medicine, as day. Not only does John dribble when he well as, working hard to learn and understand walks but he dribbles when he talks and the important concepts of the various rumour has it that he even dribbles in the subjects. The students themselves have been can, except when he's scoring. His passes changed from unknown numbers amongst seem to be improving according to his thousands to integral parts of a small coach M.D. , but astute observers have heard community. Now, when one says hello, it is cries of foul from the Kresge Building. He with a name (hello Richard Casey) instead has so many callouses he has to do his of just a quick "hi" because you don't know physicals with his feet. He's planning on any names. All of the changes have produced 'travelling' in the public relations field, but he a fairly tightly knit group of people. has more potential for urology. John has also been known to develop transient cases In conclusion, on behalf of the class, I of severe edema of the right foot especially would like to thank all of the faculties and when driving anything larger than a their members who contributed to what we mazaratti, but his workouts in the courts have been taught in our first twenty-four seem to be keeping him off the roads. weeks. I only hope (since it went so fast) that I remember some of it. Betsy Hall, part-time publisher of playgirl magazine and party-girl, has invited the boys Bob Brown up to her corporation lodge on Georgian P.S.: What the hell was the name of that Bay for another weekend of wine, song and muscle, I knew it last week. * * * When people's ill, they comes to me. I physics, bleeds and sweats 'em; Sometimes they live, sometimes they die, What's that to me? I let's 'em. -Dr. Lettson, 17th. c. 110 Parcost and Some of Our Experiences Encountered During Visits to Pharmaceutical Manufacturers

The Late J. M. Parker, D epartment of Pharmacology, Chairman of D rug Quality and Therapeutics Committee, (Ministry of Health)

When a lead news item in Science, were of top quality. In 1960 25% were January 25, 1974 reads "Prescription Drugs: rejected as unsuitable. In 1968, this was 10% . Health, Education and Welfare will only pay lowest Price", we should take a look at what How to examine this elusive property of has been happening in Ontario since 1968. quality? The Drug Quality and Therapeutics Committee was formed with representatives A 1968 estimate of the cost of drugs for from Ottawa, Kingston, Hamilton, London patients in Ontario paid by either the patient and Toronto. Members had varied back­ or by government amounted to $200 million grounds: Pharmacy, former pharmaceutical annually. An important sum to be concerned industry experience, internal medicine, about! The experience of the Ontario ped iatrics and pharmacology, with the Ministry of Health with direct purchase of Professor of Therapeutics from Toronto as drugs for tuberculosis and mental hospitals our first Chairman. The Ministry provided was encouraging. By using their own expertise from their laboratory and Drug laboratory services and review of company Directorate staff, in particular, Dr. Allan Dyer procedures, the Ministry was achieving -Director of Drugs and Therapeutics who has substantial savings on bids by tender. Quality had wide industrial, academic and government was assured because of their own laboratory experience. Meetings were held with the evaluations and then acceptance or rejection. Canadian Pharmaceutical Manufacturers The laboratory and purchase programme Association and the Canadian Drug began in 1960. Hospitals in many countries Manufacturers. The Federal Food and Drug had formed pharmacy and therapeutics Directorate was informed and co-operation committees and, with prior agreement from given by their inspection branch. The help of attending staff, were insisting on the use of all these bodies in the growth of our the brand of a drug which the committee programme is appreciated. had recommended for purchase. This was working without harm to patients and was We decided to produce a list of those drugs keeping down costs. which made up the most dollars involved in the Ontario drug bill. This list would then Why not just pass legislation to have the be expanded as we gained time in our review pharmacist substitute and supply the cheapest of quality. Quality was to be the criteria for drug available? Alberta tried this in 1962. inclusion in the index. How was this It has been mainly ignored and unsuccessful determined? As the committee gained in affecting drug costs. experience, the most essential components were company visits, manufacturing document The New Hampshire legislature discussed reviews, past experience and product proposing a bill to fine a physician $25.00 evaluation by the Ministry drug testing if he did not put the generic name on his laboratory. Our visits took a very simple form presc riptions. This aspect was withdrawn from -a talk with the company president about the final draft. Force is not the way to his organization and po ~icies-how they change long-standing habits! would handle a recall if an error were made, All these proposals neglected quality. Only etc. Then a plant tour-starting with the if the physician can be assured of the quality, receiving of raw materials. How these were the reliability, the consistency of quantity, quarantined until the quality was checked etc. of a drug should he use that drug. against standards. Then their system of identification of that particular shipment The experiences of the Ministry with their during its future use. Where it was kept in own purchasing programme was more than chemical stores, how it was ordered for a sufficient to alert them to the fact that not production run, who double checked the ' all drugs on the Canadian market in 1968 calculations and weighing of amounts 111 of ingredients. Then we followed products Many of the large companies have excellent through the various stages of manufacture. facilities and manufacturing policies but it is Th e frequent checks we expected Quality impossible to generalize. In contrast, a Control to do to ensure that the next step was world-wide multinationalcompany may be not undertaken if all was not right, such as operating only a small warehouse in Canada uniform mixing of ingredients. A good with drugs that have been made in manufacturer keeps scrupulous control of his Country A-quality control presumably tested labels so there can be no mixups and goods in (finished and formed in) Country B and are not released for final packaging until then shipped to Canada. This would be Quality Control is satisfied that the acceptable if the documents were in quantities are accurate, etc. We asked to see agreement but when we found all too often all these procedures. The most difficult that the lot numbers on the material for sale property to evaluate was integrity of the in Canada did not ar;ree with the documents personnel. pertaining to its manufacture in A or checked What were some of our experiences? We in B. We decided we needed our own visited some manufacturers with standards rules. One of our first was that raw materials and procedures so organized that we wished be tested before being used in production all manufacturers could visit and imitate. and that final products be checked in Canada We also visited purchasers of manufactured by a qualified laboratory responsible only to goods who searched frantically through their officials of the Canadian operation and files for certificates of quality control or who government bodies. complained that the custom manufacturers Various forms of imperialism upset us­ refused to give them any information. Some another company (foreign based) did not could not tell us even the date of know at their Canadian office that the manufacture of stocks in their warehouse. (In formulation of the drug they were selling had one case a clothes closet.) been changed by the custom manufacturers When we asked another about clinically whom they relied upon. We then began testing a product, a letter was produced from insisting that anyone who called himself the Europe saying a trial had been done. "But manufacturer keep on hand in Canada all on your material manufactured here?" we manufacturing details. We insisted and asked. Finally an admitted "No", with the persuaded the seller to have on his premises defense that the raw ingredient was purported and within his knowledge and responsibility to be the same, although there was no all the details of his product. All the information that any of that material had come ingredients! There were objections but what to Canada and certainly the trial was not can be the answer to the question? If a done with this company's capsules. question arises about active ingredients, One plant had a fine Quality Control lab fillers, incipients, dispersing agents, because but on looking through the records raw some patient has had an allergic reaction, or materials consistently failed USP or BP untoward side effect, it is the responsibility standards for such simple tests as melting of the company whose name is on the label point values. What happened? The new to have all the information on hand. materials were used anyway-the plant In one plant, which has since gone manager took little notice of "rejection" by bankrupt, we saw rows and rows of Quality Control. We were not surprised to Chlorpromazine syrup with precipitate in the learn later that here the head of Quality bottom, rejected by the Ontario Ministry of Control, a capable chemist, had quit. Health. Most companies throw out such a A brief description of the pharmaceutical problem; this group was attempting to try to industry in Canada will show the variation in add something to reduce this fault. With plants and facilities. Most of the industry such potent drugs the days of "shake well" is foreign-owned-American, Swiss, German, for a uniform dose are over. French or British, but there are many small Canadian Companies and a third group of As we walked through some plants we were custom manufacturers owned by various surprised to see how exceptionally uniform organizations. The latter manufacture tablets, the weights of capsules seemed to be as capsules or liquid preparations for other plotted on the check charts. Samples are companies. The policy of the Federal taken while the capsulating machine is Government has been that the person putting running, weighed and plotted on a graph. A his label on the preparation is called the straight line made us suspect that this " manufacturer" and this has led to some procedure was only a gesture, particularly problems in our inspections. Helpfully, some when the operator couldn't repeat it but got cu stom manufacturers were frank enough a variation f~om capsule to capsule when to tell us that if his customer was willing to we asked him to " show us how you weigh pay, he would get quality control services, but them". The importance of this is that good if not-that was his problem. manufacturing practice states a limit for 112 overweight and underweight and if this is the importance of differing amounts of exceeded, something is wrong, and the estrogens and progesterones in achieving process should be stopped and examined. an ovulatory cycle that closely resembles a Such "gestures" of compliance worried us normal one with minimal complications. Also about the overall integrity of a company. the patients' confidence in the package form, One faulty procedure which upset us very color and other details should not be much was in a company that checked the first disturbed by an unexpected change. capsules or tablets of a run for potency, etc. Naturally, these were again not for product and then signed release forms for final selection. packaging or labelling for a manufacturing However, tetracycline was a drug where we period which might go on for 2 or 3 days. found nine manufacturers were making That is the tail end of the batch was not excellent products. Our next Index showed checked at all! It is not hard to understand these as interchangeable. The legislation how this company had sold penicillin tablets allowing this was Bill 144, an amendment to which contained no penicillin in part of the Pharmacy Act. When this bill was a lot. introduced the government promised to review Everyone has heard about bioavailability­ the effects within one year. A committee there is no use even worrying about chaired by the former director of Connaught bioavailability unless a manufacturer can Medical Research Laboratories, J. K. W. process his raw materials and active Ferguson, brought in their report to the ingredients in such a way as to make a Ontario Council of Health in March 1973. uniform product free of too much or too little " .. . it was evident that a majority of any ingredient. (57%) of the prescriptions eligible for Early in our programme we realized that selection had been written by the prescriber we would improve quality. We excluded many with the intention of reducing the cost to firms from our Index. We were not sure we the purchaser and thereby expressing would affect costs. Our only force was the confidence in the list of interchangeable choice of doing business with Ontario. drugs in the CDI." We had no legal powers to deal with what we "The expenditures in 1972 for the Drugs considered tau Its. and Therapeutics Branch of the Ministry of It is worthwhile noting that none of the Health totalled $839,000.00 which included manufacturers of digoxin ordered to stop the administrative and laboratory costs selling by the Federal Health Protection involved in the operation of not only the branch recently had been approved for Parcost Programme and the Drug Quality inclusion in Parcost. This decision was and Therapeutics Committee, but also the reached in advance of the very fine Extended Care Drug Programme and the bioavailability studies done by Ottawa. We Provincial Institution Drug Purchasing realized from our visits and document reviews Program. Inasmuch as the Parcost that these companies' basic manufacturing Programme itself can reasonably claim to and control methods for digoxin were not up have contributed significantly to saving the to our standards. public of Ontario more than $5,000,000.00 Finally after nearly two years of review and in 1972, the Task Force finds that the evaluation, our first Index appeared in Drugs and Therapeutics operation and the October 1970. It did not cause much of a stir Parcost Programme have justified their cost. " among the medical profession although So we are making progress. Costs have been pharmacists began to use it. affected favourably but more important, Successive editions appeared at six month quality has imp~oved as noted by the above intervals. By 1972 we felt that we had report. The most important service rendered sufficient experience to take a further step. by the Programme has been to enable Product selection-such as many hospitals physicians and those pharmacists who have do internally. We felt confident about quality adhered to the standards of the Parcost and many companies had made improvements Programme to provide the public with as the result of our visits, checking and products of excellent quality. This is a service testing. which has become particularly necessary There are several classes of drugs where since the suppliers of many important individ:.~al variation and maintenance of a prescription drugs have become so numerous therapeutic range is critical. Digitalis in recent years that one suspects that some preparations and anticoagulants are examples are not reliable, a suspicion which has been where small overdoses can be toxic. A firm confirmed by the inspections and tests of the decision was made not to consider Ministry of Health. substitution for such classes. Other drugs What are our continuing problems? such as the oral contraceptives might broadly Foremost is to get our story to the physicians be considered as equivalent but we all know and medical students of Ontario. 113 Pathological Photoquiz

114 This 42-year-old female patient was admitted to hospital because of a palpable nodule that was situated in the right anterior side of the neck. It was estimated to be about 2 x 3 ems. In size. The patient was otherwise relatively asymptomatic and physical examination revealed no other significant positive findings. All clinical biochemical analyses were normal except for an elevated serum alkaline phosphatase. An upper Gl series, a barium enema and an intravenous pyelogram were all negative. A radioactive iodine scan of the thyroid revealed the nodule and showed it to be "cold". Subsequent surgery revealed that the nodule was situated partially within the right lobe of the thyroid gland and so it was excised along with a "cuff" of adjacent thyroid tissue. It was surgically suspected that the lesion might be malignant and so a frozen section was requested. The surgical specimen consisted of an egg-shaped nodule measuring 3.2 x 2.2 x 2.2 ems. It had a thin but clear and distinct capsule and was surrounded by a narrow rim of normal appearing thyroid tissue. The nodule showed very extensive and recent interstitial haemorrhage that was dark red in colour. No cystic degeneration was evident. The remaining tissue of the nodule appeared as a few orange-brown islets of rather soft tissue. The photomicrographs show the surgical specimen. What is your diagnosis?

The answer is on page 117.

Dealing with the Provincial Government How to Succeed by Really Trying

Sharon Warren

Health care is rapidly being "socialized" in of the profession's totem pole--are grossly Ontario and, more than it may care to, the uninformed. For example, a 1966 study of medical profession must negotiate its terms Medicare and medical students at four of work with the Province. To be successful midwestern schools found that 80% had little in negotiations the entire membership, not or no knowledge regarding the details of just its leaders, must be well informed of the the programme.' A 1968 study in Iowa which issues and their implications. Regardless of covered a wider variety of issues turned up who now bears the responsibility for keeping the same result.2 This would not be physicians informed, many fail to understand surprising, since few medical schools in current issues and the potential impact of either country stress curriculum content alternative solutions. This article suggests which aims at systematically addressing the how the profession might gain more clout in multiple social, economic and political government negotiations through effective processes and problems involved in internal communications, from the leadership organizing health care delivery. What is to its lowest ranks. included the medical students frequently reject as unimportant in comparison with THE PROFESSION LACKS KNOWLEDGE other subjects. Since October a series of three articles aimed at informing the medical students No parallel studies have apparently been of current health care delivery issues and conducted on practising physicians so that it their implications have been published in this is not known how well they are informed. journal. The articles dealt with Medicare, A review of the literature in professional regionalization and the community health journals, however, tends to indicate that centre concept. The editor solicited them, government policy and its implications are not believing that his fellow students were not frequent topics. In an informal poll, London aware of what was "going on" in Ontario. doctors will generally admit to knowing While no studies have been conducted little about such issues. Although they also in Canada to determine how much medical express an interest in knowing more, the students generally know of government policy tendency is to place any onus for informing and its probable effects on practice, them on the government rather than on American studies support the editor's themselves as individuals or on the suspicion that medical students-the base profession's leaders. 115 WHO SHOULD BE RESPONSIBLE been waged very successfully by the FOR INFORMING DOCTORS? American Medical Association, for example, The government is evidently not willing to in its attempts to forestall general assume this responsibility. And why should Medicare.' it? Presumably the government perceives its Leadership efforts on their own to win policies to be in the public's best interests public sympathy are usually defeated when (or in the best interests of being re-elected) the government can claim that this section of and is anxious to have them passed with the profession is ultraconservative and does as little real opposition as possible. An not really represent its own members. Easy uninformed medical profession benefits this to do even though the claim may be false, end. since the profession's leaders neither inform Frequently caught off guard just when members adequately nor make many efforts legislation is about to be passed, the to statistically measure their attitudes physician body has little time to consider Its towards various issues. implications and form a line of defense If desirable. As the studies of medical students THE PROFESSIONAL LEADERSHIP'S previously quoted show, a typical reaction RESPONSIBILITY in this situation is to adopt the negative Suggesting how B.C. doctors might gain opinion and argue loudly. To address any more leverage in bargaining with that policy and win points, however, a knowledge province's government, Horniman notes of the kind and magnitude of problems referendum as one of the keynotes to involved is necessary. Physicians, without success.< A referendum would essentially such knowledge, arguing their position at best involve the leadership in informing its look foolish or at worst selfish, since physician body succinctly of pending arguments against the proposal will have to legislation and probable impact on medical be based largely on experience in their " own practice. It might also recommend a backup little worlds" . Thus the professional group's method of " persuading " the government to power to bargain with the government is make changes if desirable. Following such diminished, if for no other reason than that it information, the profession would be asked can hardly find much sympathy with a to state its preferences as to how the public who has probably already been wooed details of this legislation should be shaped or by well organized and specifically appealing whether it should be opposed, including government arguments. support for the backup method. The Meanwhile where have the profession's leadership would later also provide physicians leaders been? While these people are no with feedback as to where they stand in doubt knowledgeable, their power to relation to the majority and what policy has negotiate successfully with the government is been arrived at on the basis of collected endangered by the ignorance of the opinions. This approach would undoubtedly profession's lower ranks. First, the provide the leadership with considerable government knows that the professional body clout by forcing the government to realize is not well informed on specific issues, and admit, even publicly, that it is not dealing therefore probably disorganized and possibly with isolated doctor negotiators but an apathetic because of their own confusion organized profession. and the difficulty any Individual would have Besides increasing leverage with the in straightening himself up-let alone his government itself, this approach would immediate colleagues. Consequently It probably win public sympathy. In our society, assumes that most threats of strike, strict people naturally expect any group to defend reductions of service, etc. which the group's or advance its position. With a necessary leaders might put forward can be Ignored; service like medicine, however, passive the interns and residents recent fiasco bears tactics are more readily approved. Also there partial witness to this type of situation, may be some very persuasive and "unselfish" although more than their lack of organization counterarguments which the profession's ru ined the group in its employer's eyes. leaders, backed by its members, can put Especially if precedents rather than key forward against any attempt by the issues are at stake, it may be virtually government to limit them in some impossible for the profession's leaders to professional way. Referendum informs the mobilize its members effectively. Even the body of these and allows each physician to leaders themselves know that mobilization present a favourable side of his nature to would preferably take the form of subtle whatever small public he may be able to resistance. Tactics such as mass petition influence directly. It passive tactics fall, at protests and wide publicity for rational least the professional body will be counterarguments take time, but do not organized and can move easily into a more bristle the people's backs like strikes or threatening pose in an effort to force its restrictions on service. This type of fight has wishes on the government. 116 THE REAL KEY TO SUCCESS middle-of-the-road acceptable approaches IN GOVERNMENT DEALINGS fo r the government to consider. It is likely that Doctors throughout the world have been, the government would welcome any feasible and still are, notorious for sitting back and way of avoiding a possibly messy future ignoring problems of health care delivery confrontation. The Canadian Pediatric Society until their respective governments decide to has been experimenting with this method of step in. In many cases, the profession does controll ing government measures directly not even react until a key issue is at stake related to it for some time and is proud having let small but cumulative precedents ot its accomplishments.' back them into a corner. By then it may Referendum could be adapted to help in be too late to really bargain with the formulating policy as well as gathering government at all; in essence, the battle has reaction to already proposed government been lost before physicians have begun to plans. The results may be worth the effort. fight. Not only the profession may gain, but also the It would not harm the Ontario leadership to public, from better thought out proposals try predicting some of the problems of the and counterproposals negotiated in a less future or pinpointing those already here, heated atmosphere. but not yet considered crucial by government officials. Rather than waiting for the FOOTNOTES Province to act, in a possibly unfavourable 1. Scholoton, J., et a/, "Medicare and Medical way, the profession could formulate policy of Students", JAMA, Aug. 1966, 333-8. 2. Graham, H., "Medical Students' Knowledge of its own aimed at correcting the pr.oblems. Medical Care Organization and Delivery: An An example was suggested in the most recent Exploratory Study", AJPH, Feb. 1972, 205-7. 3. Harris, R. , A Sacred Trust (New York: The New article of this series: whereby College American Library) , 1966. The author by no means restrictions on group practices being suggests that some of the more offensive AMA tactics described by Harris should be adopted In transformed more nearly into community Ontario. As a reference, the book merely points out health centre projects might be removed that certain passive tactics can be used effectively. before the government takes over their 4. Horniman , E., "Medlcollectlve Bargaining Equals sponsorship itself. Or rather than moving on Leverage" , Can. Doc., Jan. 1974, 45-9. 5. " How pediatricians deal with government" , Medical its own , the profession might suggest Post, Aug. 8, 1972, p. 11 .

Answer to Pathological Photoquiz Sections of the surgical specimen show the nodule to be an adenoma of the upper parathyroid gland. It was well enca,psulated and the narrow rim of adjacent thyroid tissue showed no definite pathological change. There was also a narrow rim of histologically normal parathyroid tissue with abundant adipose tissue· situated outside the capsule In one area and adjacent to it. As shown in the first photomicrograph, the adenoma consists of broad contiguous bands and solid Islands of chief cells. The supporting stroma is well vascularized. No real acini are being formed. These chief cells In an adenoma are larger than normal and they have very indistinct cell borders. The second photomicrograph is taken at a higher power and shows that their nuclei are enlarged and occupy about half of the cell. They also show a marked variation in size and are hyperchromatic. Mitoses however are not found and there is no invasion of the capsule. The cytoplasm of occasional cells are partially vacuolated. More ae;tive parathyroid cells of the water-clear type ("wasserhelle") are very rare and are not clearly seen in these photos. Extensive interstitial haemorrhage into the adenoma with degeneration and necrosis of the tissue is very widespread, but is not shown in the photos. It may have produced the rather large size of the encapsulated nodule that caused it to be clinically palpable. The findings are pathognomonic of a parathyroid adenoma and do not resemble the patterns found in either primary or secondary hyperplasia of the glands. Also, in spite of the rather marked cellular atypism, the lesion shows no evidence of a malignant change. It is felt that the only findings that support a diagnosis of carcinoma of the parathyroid is the presence of mitoses and invasion of the capsule or actual metastases. Regarding the clinical findings in this case, the lesion was found because it was clinically palpable. This is generally uncommon in adenomas. The serum calcium level was normal (phosphorous not estimated) but the alkaline phosphatase was elevated. There was no radiological evidence of renal lithiasis, nephrocalcinosis or localized bone lesions. The urinary calcium output was not estimated. An adenoma is by far the most common cause of primary hyperparathyroidism but the latter was not yet clinically apparent in this patient. Post-operatively the patient did well and she Is being followed clinically. F. N. Lewis, M.D., F.R.C.P.(C) REFERENCE: Kay, S. and Hume, D.M.: Carcinoma of the Parathyroid Gland. Arch. Pathol. , 96: 316-319, 1973. 117 This ts the Research That Was

R. L. Noble

Dr. Noble spent many years here working in the laboratory of the late Dr. J. ~· Collip. He returned from his present niche at the Cancer Research Centre, UBC, to deliver the following Convocation Address, October 26.

This University holds a historic spot in the adding that he would go to Toronto in a history of medical research; one might few days to look at them. There were some commence with Sir Frederick Banting, a twenty-five slides, numbered but unnamed. surgeon with an empty waiting room. In his Using that nuclear marker, Dr. Barr divided spare time, he developed the idea that it. them into two groups, male and female. On might be possible to tie off the pancreatic checking the records Dr. Linell was astounded duct and so alter the pancreas to obtain the to find the separation correct in all mysterious hormone which we now know instances. as Insulin. As you are well aware, this This was the discovery of the sex original idea led to the understanding of the chromatin, a now legally indisputable way to disease diabetes, and also all.owed Dr. Collip correctly determine the sex of an individual, to prepare active extracts of the gland and an observation which has allowed new which he was able to purify adequately so areas of research to develop, all over the that they could be administered safely to world both in patient diagnosis and patients, and provide an effective treatment treatment. To this may be added the .for this formerly fatal disease. Although contributions of Dr. Rossiter's department of the connection of the pancreas in diabetes biochemistry, and of Dr. Engel and Dr. had been previously established it was not Carroll's studies in the Collip laboratory, and until Dr. Banting's new idea opened the door others which should be included. The that real progress was made. It is of interest experience of Drs. Beer, Cutts and myself in that Dr. Collip had previously worked in the the discovery of Vinblastine was unorthodox. University of Alberta in Edmonton and had We were working and supported in Dr. developed new extraction procedures in Collip's laboratory, totally free from any connection with another hormone from the pressure to pursue the development of any parathyroid glands, and with this background fixed ideas. We were able to make original he was able to apply his methods very observations which I am sure must at times quickly to the extraction of insulin. The point have made even Dr. Collip wonder if his which I would like to stress is that these liberal ideas in the pursuit of research were scientists had the time and opportunity to not too generous. The activities of a plant think and work out original concepts. New Periwinkle (Vinca rosea) in the supposed discoveries in research are not predictable treatment of diabetes in Jamaica had been and it is of the utmost importance that the brought to our attention, and it was logical environment should be suitable for any that work should be done in the lab with the scientists who may be gifted enough and blessing of Dr. Collip who had had so much capable of doing creative thinking. to do with the development of insulin. There are many examples where the Originally we did experiments with a tea original concept has developed during work made from the leaves of this plant, which on entirely different projects. As many of you we gave to animals with diabetes, and I am know, Dr. Murray Barr, in the department sure that with the number of different brews of anatomy here, was interested in the we made from the leaves Dr. Collip must subject of fatigue in the nervous system and have thought we were in competition with was studying nerve cells under the Sir Thomas Lipton. It turned out, however, microscope after electrical stimulation. He that the extracts did nothing for diabetes but noticed a curious dark staining small body affected the white blood cells from the bone near the nucleus in certain nerve cells. In marrow of rats. This suggested a possible attempting to explain the meaning of this beneficial effect on leukemia, a form of new observation he noted that this body cancer of blood cells. When the pure occurred only in the tissues of females. substance, VLB, was eventually isolated from the plant by Dr. Beer it was sent to Even before he had done much comparative Dr. Harold Warwick, then at the Princess work on animals he asked Dr. Linell, a Margaret Hospital, Toronto, who agreed to Toronto pathologist, to set aside some human treat a few patients. Some of these eventually nervous tissue from both males and females, responded with such beneficial effect that 118 I think we were all a little surprised. I Yet, from this start it was possible to remember his long distance phone call about develop a useful drug for the treatment of his first patients as the secretary said "a cancer. Dr. Warwick from Toronto wants to speak to It seems to me likely that the Canadian you-he must be Italian because all he can sc ientist, perhaps due to his environment or say is Eureka." Treatment by Vinca alkaloids to the type of training he receives has a was eventually accepted and developed into special forte and tends to be a creator of one now used extensively in many countries original ideas. I have quoted names from this for the treatment of certain forms of cancer. university, with which I am more familiar, It is quite obvious that the outcome of our but one may go across Canada and list many research was quite unpredictable, and I am original concepts which have been developed sure that had we suggested to the National by Canadian scientists. From the West coast, Cancer Institute that they support work on a Dr. Harold Copp's recent discovery of a tea which might prove of value in the new hormone from the parathyroid gland treatment of diabetes, our application would which controls calcium in the body,-Dr. not have been received with great enthusiam. Harold Johnns' development of the cobalt

119 bomb in Saskatoon-Or. Chown's group In format has crept into science, unfortunately, Winnipeg and their new findings concerning as well as into many of our other ways of the Rh blood factor so Important to many life. This certainly does not encourage mothers and their offspring,-Drs. Parker and originality. One of the major problems today Morgan's work in Toronto on tissue culture is how to support a scientist who has formulas, which was successfully applied to original, creative ideas and is not adept, well the production of polio vaccine, and versed or even interested in the usual contributions from Dr. Charles Best and his conformities in making successful Institute and the Princess Margaret Hospital applications for research funds. in Toronto,-Dr. Charles Leblond at McGill It is possible that some of you may not developed delicate histological techniques realize just how difficult it is to obtain allowing new areas of cell function to be research funds from granting bodies which studied, and recently the work of Drs. possibly have half the amount available for Freedman and Gold at the same University the applications which they receive. who have developed a blood test for certain Applications are submitted at competitions types of cancer. At the University of Montreal where they are collected and judged by one would include studies of the vaccine a scientist's peers. The definition of a BCG which has been used for many decades scientist's peer is a colleague who was for studies .on tuberculosis, but was shown formerly a respected friend. To be a peer is by Drs. Lemonde and Frappier to have some a very unenviable job. On my first visit to beneficial effects when used to treat animals the Medical Research Council in Ottawa to with tumours. This latter observation has very act in such a capacity I was very impressed recently been developed and expanded by by the landscape which includes an eight foot clinicians to the extent that there is now a silver ball mounted outside the building. special committee of the Medical Research I did not appreciate its significance until I Council and the National Cancer Institute to joined the other peers after lunch to sit investigate the potential use of this substance gazing into this beautiful silver ball in order in the treatment .of some forms of cancer. to make our decisions regarding whose Dr. Seyle's original concepts of the cause research should be supported. To be and control of stress are also well-known. I successful an a,pplicant has to define exactly am sure that many of you in other faculties what he wants to do or discover, how he is could add to the list of names, and one immediately thinks of Dr. Herzberg, of the going to do it and with what facilities and National Research Council, who was a recent help he may have in the project. It is only recipient of the Nobel prize. with such a tabulation that it is possible to compare one application with another. This You may wonder why I have reiterated this may be ideal from the administrative point of list of Canadian discoveries which I am sure view or for selecting the most desirable are familiar to many of you. The answer is developmental types of research, but it does simple. Many scientists and I have become not give much hope for an application from increasingly concerned that the environment an individual who, if he is original, obviously for this type of research is changing does not know what he is going to discover, rapidly and is no longer suitable for original or for that matter how he is going to work and creative research. Why do I think the towards it. I would like to quote Dr. G. type of research has changed from what it Herzberg, director of the National Research was to what it is now? Why am I concerned Council Division of Pure Physics, and as I that the present environment is different mentioned previously, a recent recipient from what it was in the past? The reasons for of the Nobel prize, from his convocation this gradual change are subtle and not easy speech at York University in 1969-"The to define. However, I think that they probably thinking behind many of the discussions on arise from the simple fact that there is scientific policy, particularly when It refers insufficient research money available in to science rather than technology, completely Canada to support all research which is overlooks the way in which a creative considered to be worthy of receiving it. The scientist works. A scientific Idea originates aP,plicatlon to and eventual receipt of support on rare occasions in the mind of an individual for research from the various fund granting scientist after he has struggled with the bodies has now become highly competitive subject of his studies for many years. It for the money which Is available, and a great cannot be foreseen by a committee or a deal of gamesmanship is required to prepare scientific administrator. In order to do his best a successful application. The art of original work a creative scientist needs application writing requires such skill that freedom from specific directives and this a number of institutions actually give lectures applies irrespective of whether he works on to their applicants on how to prepare a fundamental principles or on applied research application in the most attractive problems". It would seem questionable, manner. The use of a routine stereotyped therefore, if the present method Is the best 120 way to support those who may have original If the thesis is correct that the potential concepts in research. to develop and encourage original research in this country, which has a most enviable How can one accurately select and support record , has become less than in the past then individuals in research who may have just how can this situation be corrected? original ideas? Historically, in medicine, It appears impossible for a committee to original contributions have come from all select suitable candidates from the usual type facets of interest and in many cases have not of research application. The suggested been appreciated even after they have been establishment of Putterships instead of first described, although they have led Fellowships for those who wish to simply eventually to tremendously important putter about in a lab in the hope of applications in medicine. Sir Charles Dodds, discovering something seems somewhat under whom it was my privilege to do exotic, and not too acceptable. The university postgraduate training, had the concept that environment would seem, however, to be the the hormones, or chemical messengers in the most logical locale to judge and select the body, were not highly specific types of rare candidate whose talents appear to be substances but might be duplicated by a the best suited to pursue original research. variety of synthetic chemicals. Despite much This could result in the support possibly criticism, he pursued th is idea, which of an individual and not necessarily of a ultimately led to the development of particular project. Possibly, funds might be stilbestrol and many other synthetic chemicals provided from research sources for the which mimic the action of the female sex establishment of a few persons or groups hormones. The outcome of this discovery led working in university areas in Canada. If such to the use of synthetic estrogens in the groups become a reality, it might be contraceptive pill. Drs. Minot and Murphy cautioned that one should not expect too made the rather amazing observation, from much from them. Original discoveries are the result of their deliberations, that if a made only rarely under the best person with the fatal disease pernicious circumstances. anemia were to eat a half-pound or so of raw liver a day their anemia and serious The problem is obviously not easily solved, complications disappeared. When this but 1 think it is of importance to all observation was announced it was used as a Canadians, for, unless it is solved, the humorous after-dinner medical story about research that was will not continue as the Americans who were eating pounds of raw research that is. liver to treat pernicious anemia; but their • • • observation has stood the test of time and we now know that a vitamin in the liver is Some recent statistics about biomedical effective in the treatment of this disease. research in Canada are as follows: The original observation must be accredited to the United States investigators, but other Funds allotted to the Medical Research scientists armed with this knowledge then Council of Canada increased 9.9% in 1970, proceeded to extract and Isolate the pure 5% in 1971, 2.5% in 1972. That last figure chemical vitamin which was responsible for is not even keeping pace with the most effective treatment. conservative figures on inflation and sophisticated research materials and Professor Dodds has drawn an illuminating equipment does not inflate at very analogy to emphasize the Importance of the conservative rates. The $40 million allotted is new original discovery. He likens the gradual one-quarter the per capita allotment granted accumulation of scientific knowledge to the the U.S. National Institutes of Health. Three haphazard arrangement of furniture in a years ago, 1,400 grants were funded across darkened room, presenting obstacles to the Canada, last year it was 1 ,200, even though scientist who tries to find his way about. the number of applications is increasing It is not until someone discovers and turns steadily. It is not really a question of .public on the light that everything can be arranged apathy to research either, since the bulk of in a logical order. The light switch may even the $4.5 million annually spent on Canadian be located in an area quite remote from Cancer Research comes from private the darkened room. donations. * * * My doctor has made a ·prognosis That intercourse fosters thrombosis But I'd rather expire Fulfilling desire Than abstain, and develop neurosis. Thanks to " Interface" , U. of Sask Medical Journal 121 The Tragedy of Paracelsus Neil H . McAlister

I know I am a man who does not say things that please everyone, and I am not used to giving submissive answers to arrogant questions. I know my ways, and I don't want to change them, nor could I change my nature if I wanted to. I am a rough man, born in a rough country. I was brought up in pinewoods, and may have inherited some knots. What seems to me polite and amiable may appear unpolished to another, and what is silk in my eyes may look like homespun to you .' In such an age as our .own, a time when decisive man as, in Robert Browning's everyone despises hypocrites and 'put-ons' description, " a man possessed by a fire" , by and the Coca-Cola company accordingly a demon. 3 His name has remained shrouded extols its wares as The Real Thing; when with uncertainty and legend. It was said that Jerry Rubin urges us to 'Do It'; when the he could converse with spirits at will, and supreme virtues are to 'be yourself' and to that he had a pact with the devil. Probably 'do your own thing', and when a pol ite the legendary Paracelsus was one of the gesture such as holding a door open for a prototypes for the composite character of young lady is often considered to be slightly Dr. Faustus, though the real Paracelsus might effete, people tend to find smug self­ better be described as an occult philosopher.' satisfaction even in their faults. These words, therefore, have a distinctly contemporary But a man who makes no special effort ring. They were written, however, in the to be 'am iable and polite' has few friends, sixteenth century by a man with the unlikely­ and if he, like Paracelsus, is outrageously sounding name of Philippus Theophrastus conceited besides, he tends to acquire Bombast von Hohenheim, known more numerous enemies. It is thought that conveniently as Paracelsus. He was a Theoprastus took the name 'Paracelsus' in rough-hewn character, proud of his peasant deliberate allusion to Celsus, the famous traits, unversed in the ways of the world, physician of antiquity. Although an adequate adept at the easy art of making enemies, a sense of self-importance is a necessary part philosopher, chemist, conjuror and physician, part of a scholar's equipment, the more to a genius, an incorrigible iconoclast, a good add weight to his convictions, some of and compassionate man, and in some Pa racelsus' writings come smashing down respects a despicable wretch. li ke the proverbial ton of bricks: From the middle of this age the He was also without doubt one of the most Monarchy of all the Arts has been at length paradoxical and exasperating individuals derived and conferred on me, Theophrastus who has ever walked the earth. In his life he Paracelsus, Prince of Philosophy and was utterly uncompromising. His unbending Medicine. For this purpose I have been atitude was to be the source of both his chosen by God to extinguish and blot out fame and his infamy. all the fantasies of elaborate sophistry, Paracelsus was a great man , a man whom of delusive and presumptuous work. My we can admi re, partly because of his doctrine, proceeding as it does from the absolute self-confidence: he refused to be light of nature, can never, through its intimidated by important peop:e who constancy, pass away or be changed ; but controlled the church, state, and guild of his in the fifty-eighth year after the millenium day. Indeed, his opinion of bureaucrats, and a half, it will then begin to flourish .. pundits, and academicians endears him I shall put forth leaves, while you will be especially to the modern heart: he called dry fig trees.• them " high asses ". He was never over-awed The style has helped fix the word " bombast" by the almost sacred platitudes held by his in the English language. Many people contemporaries to be immutable truths. believe that the word is derived directly from Paracelsus became, in William Osier's phrase, the family name of Paracelsus. It is scarcely the " Luther of Medicine": " the very surprising, then, that Paracelsus was the incarnation of revolt. At a period when target for considerable abuse, both during his authority was paramount, and men blindly lifetime and after his death. Thomas Fuller's followed old leaders, when to stray from the Holy and Profane State, written in 1641, beaten track in any field of knowledge was showed Paracelsus to be the archtypical damnable heresy, he stood out boldly for drunken quack: "He was never seen to pray, independent study and private judgement."' and seldom came to church. He was not " Boldly" is hardly the appropriate word: only skilled in natural magic (the utmost Paracelsus was not so much a confident and bounds whereof border on the suburbs of 122 hell) but is charged to converse constantly as far east as Constantinople, Crete and with familiars. Guilty he was of all vices but Alexandria. He covered a tremendous territory, wantonness. "• Paracelsus has periodically considering the appalling state .of roads and received a 'bad press' ever since. On the communications during the 16th century; fourth centenary of his death, one writer Paracelsus was one of the best-travelled men described him as "a rude, circuitous in the world.~ All the while he learned from obscurantist, not a harbinger of light, every source, collecting remedies, treating the knowledge and progress."' sick if he could, sometimes teaching to earn a living, and slowly developing philosophies Paracelsus certainly was rude--he was that were radically different from those that also truculent, opinionated, and downright had been taught to him in the universities . . . arrogant. Had he acquired humility, he might have been more successful in getting his In the sixteenth century, most diseases ideas across ; but then, had he been more were treated with drugs, and physicians still humble, he might never have dared to express applied Galen's materia medica, somewhat his opinions, so different they were from the fortified with Arabic drugs. Compound accepted doctrines of his day. What, then, remedies, containing more than twenty was the nature of these fearsome opinions, ingredients, were often used. Paracelsus, by so blasphemous that they aliented Paracelsus contrast, opposed this " polypharmacy": from the church, the civil authorities, and " apothecaries are my enemies because I will his professional colleagues? not empty their boxes. My recipes are simple and do not call for forty or fifty The son of a doctor, young Theophrastus ingredients. I seek n.ot to enrich the decided to adopt the same career, and apothecaries, but to cure the sick." '0 The accordingly went to Italy to study medicine. numerous elements of complicated Somewhere during the course of his concoctions, he continued, were at best schooling, however, he came to the ineffective since they often neutralized each conclusion that his studies in orthodox other. At the worst they created further medicine were irrelevant and meaningless. comp:ications, a prospect that was He became guilty of the heresy of doubt: abhorrent to Paracelsus: "When I saw that nothing resulted from their practice but killing and laming, that they The best of our popular physicians are deemed most complaints incurable, and that the ones who do the least harm .. . A they administered scarcely anything but syrup physician should be the servant of Nature, laxatives, purgatives, and oatmeal gruel, I not her enemy; he should be able to guide determined to abandon such a miserable art and direct her in her struggle for life, and to seek truth elsewhere. "• Theophrastus, and not throw, by his unreasonable just like many modern-day students, found influence, fresh obstacles in the way of the universities haunted by the stifling spirit recovery." of scholasticism. Books, not nature, were in the forefront of every discussion; authorities He believed that a physician ought to such as Avicenna and Galen were constantly administer drugs only in extreme emergencies, cited, to the complete exclusion of then giving only one effective agent for one investigation and observation. particular problem. In his stance against polypharmacy, Paracelsus was, in essence, If the universities could not teach him what the first doctor to warn against the " shotgun" he wanted to know, there were barber­ approach to treatment. Paracelsus never surgeons, craftsmen, sorcerers, miners, old missed the opportunity to visit hot springs women, clerics and laymen who could. Every and mines in the areas he visited, and his old-wives' tale or home remedy surely had growing experience in the field of chemistry some natural basis, and Theophrastus was led him to apply metals and other mineral never too proud to learn from anyone. drugs such as sulphur, antimony, mercury, How strange that this earnest young man, to copper, iron and lead. The fact that his whom professional arrogance was abhorrent, treatment was frequently at odds with Galen would later bill himself as the supreme and the predominating pathology based upon authority, the " Prince of Philosophy and the four " humors" merely convinced Medicine!" What tragic irony! Paracelsus all the more that the orthodoxies were wrong, for he was without doubt a His inquiring mind led Theophrastus on a good doctor who achieved impressive results journey of discovery that continued, with where others had failed. short interruptions, until his death. His wanderings led him throughout Italy, to After about ten years of wandering France, Spain and Portugal, to England, th roughout Europe Paracelsus had become so Scotland and Ireland, to Scandinavia and then famous that it appeared he was about to east to Lithuania and Poland. He also visited embark upon a respectable and profitable Hungary, Rumania, Croatia, and he travelled career. But through pride and tactlessness 123 the unfortunate man changed triumph into vain did Paracelsus try to explain his disaster, as the following account from the position: Biographle Universelle, published in Paris in "My accusers complain that I have not 1822, and translated by Robert Browning, entered the temple of knowledge through the shows: right door. But which one is the truly The period of his return to Germany is legitimate door-Galen and Avicenna, or unknown: it is only certain that, at about Nature? I have entered through the door of the age of thirty-three, many astonishing Nature. Her light, not the lamp of an 3 cures which he wrought on eminent apothecary's shop, has illuminated my way."' personages procured him such a celebrity, No .one was interested. that he was called in 1526 . . . to fill a chair of physic and surgery at the Paracelsus then resumed his travels, for his University .of Basil. There Paracelsus began egotism and bluntness made it practically by burning publicly in the amphitheatre impossible for him to find anywhere to settle. the works of Avicenna and Galen, assuring His constant torrent of invectives against his auditors that the lachets of his shoes the medical fraternity, made more biting by were more instructed than those two the disaster at Basil, did little to endear him physicians; that all Universities, all writers to his colleagues. Defeated and disillusioned put together, were less gifted than the with a world blind to progress, Paracelsus hairs of his beard and the crown of his withdrew into his own thoughts. In lonely head ; and that, in a word, he was to be introspection Paracelsus began to formalize regarded as the legitimate monarch of and systematize his ideas, and slowly medicine. 'You shall follow me,' cried he, something consistent emerged-an 'y.ou , Avicenna, Galen, Rhasis, Montagnana, all-embracing, unifying, mystic principle in Mesues, you , gentlemen of Paris, the light of which medicine, philosophy, Montpellier, Germany, Cologne, Vienna, chemistry, magic, theology, all the sciences and whosoever the Rhine and Danube and all the arts were one. The principle was nourish; you who inhabit the isles of the the light that had always guided him, the sea; you, likewise, Dalmations, Athenians ; appreciation and understanding of Nature. thou, Arab; thou, Greek; thou, Jew: all shall Paracelsus, though by his own assertion follow me, and the monarchy shall be "unpolished" , was not ignorant He was well mine.' acquainted with the formal philosophy of his time. But he proclaimed himself to be an But at Basil it was speedily perceived initiate to a higher philosophy, one that is that the new Pr.ofessor was no better than not merely empty words and petty games of an egregious quack. Scarecly a year had logic played according to pedantic rules. The elapsed before his lectures had fairly driven philosophy of Paracelsus is operative, a away an audience incapable of truth which once grasped allows us to comprehending their emphatic jargon." transmute nature and heal men. A system Paracelsus took care to deliver his that aspires to transform and manipulate denunciations of the old authorities in the nature is necessarily "occult", since it vernacular, instead of the conventional Latin, attempts to do what is commonly known to be which to the local doctors made his heresy " impossible" . But it is not occult in the sense seem even more heinous. His students, far of magic formulae, or jealously-guarded from eagerly embracing the new attitudes of secrets, or dusty tomes; Paracelsus' questioning and investigation, were "driven philosophy will be intuitively understood by away" from Paracelsus' lectures, alarmed at those who have achieved a sufficient degree his unconventionality which might jeopardize of spiritual preparation and attunement to the their careers. Just like their twentieth-century cosmic order. To such a mind as Paracelsus counterparts, when their own interest was at had, it becomes the "light of nature" itself, stake they proved to be a surprisingly the voice of the universe: "It is understood conservative lot. The town fathers were by the eye, it roars like the falls of the anxious to be rid of Paracelsus, who was Rhine, it is the sound of philosophy which is becoming an embarrassment to local dignity, like that of the strong wind from the sea!" and th ey simply refused to pay the new This is no dark mystery meant only for a professor any salary. No doubt they were small clique of adepts. This philosophy exists much relieved when Paracelsus left Basil in for the transformati.on of mankind, for visible bitterness. The academic minds of Europe results-a "working truth"." Although were not prepared to listen to a conceited, Paracelsus was by the very uniqueness of his self-styled Messiah who, having received most ideas an " occult" philosopher, and although of his education from quacks, charlatans, he was accused of the blackest witchcraft, barbers and worse, nevertheless presumed to he was no necromancer or sorcerer as his be the monarch of medicine and despised enemies falsely claimed. In reality Paracelsus the very foundations of decent learning. In was quite sensible: 124 People have neglected to study secret man carries within himself his own destiny, forces and invisible radiations. Nature has, or a large measure of it, and thus is within itself, forces visible and invisible, explained the third sphere, the ens naturale. bodies visible and invisible, and all are natural.'5 The one characteristic that separates man from all the other animals is his spirit, the Does this sound like the raving of a ens spirtuale. Man can remember the past, Dr. Faustus? Perhaps Paracelsus was simply contemplate the future, and hence direct his ahead of his time. We who revel in scientific destiny with more precision and guidance accuracy, in exact amounts and precise than the lower creatures. calculations, in concrete diagnosis and prescribed treatments, whose professional Paracelsus' claim that we are free on our organizations are generally suspicious of new own was a heretical thing to say during the concepts; we who indoctrinate children with sixteenth century. Any good Christian would book-learning from five years of age, would have disagreed violently, emphasizing that be well advised to ponder the prospect that God has ultimate power over our actions. all the principles which will someday guide Paracelsus nicely sidestepped any such us to new discoveries cannot necessarily criticism by including in Volumen Paramirum be found at this moment in the Library of a fifth and supreme sphere, the ens Del, or Congress. Some of nature's forces remain as God. Actually, all evidence indicates that mysterious as they were in the sixteenth Paracelsus remained a devout Christian all century. After all, what is gravity? during his life, and although he made a valiant effort to reconcile his pagan beliefs The most inspiring of Paracelsus' works with his Christian ones in Paramirum, he was a treatise on the philosophy of medicine, probably was never able to do so to his own called enigmatically the Volumen Paramirum, satisfaction. After all, the very nature of his a title coined by Paracelsus meaning occult philosophy was "diabolical" and " Beyond the Marvellous".'• The Volumen wicked according to most church authorities. Paramirum discusses five "spheres" that govern man in health and disease. Man is a This work, though an epic, was never microcosm, a replica in small scale of what published during the lifetime of Paracelsus. the world (macrocosm) is in larger version. He was a prolific writer, but it was only seldom that he could persuade anyone to The ens astrale is the first sphere. As the print one of his books, so discredited he stars move according to laws, so does man's became. The Chirurgia Magna (the Great life. Somewhat as in astrology, the Work of Surgery) was one of the few works constellations characterize a given moment, that he saw come to press, and it created and every person has his moment in regards much enthusiasm in medical circles, to good or ill health. Though superficially unexpectedly boosting Paracelsus into the foolish, this is in fact a rather clever thought, limelight for a brief period. But he since it introduces historical perspective quarrelled with other doctors, once more into the concept of illness. A person living proclaimed himself the greatest physician of now is exposed to diseases much different history, and having alienated all influential from those that afflicted people four hundred people within earshot, fell from favour and years ago. Furthermore, we should note that esteem yet again. In the final analysis, Paracelsus was no astrologer. While he Paracelsus had very little immediate impact thought that human affairs and celestial on the progress of science; his renown for affairs were arranged in a similar manner, he many years after his death was that of a emphasized: clever magician. Why is it that one of the " Stars force us to nothing, they influence greatest thinkers of the sixteenth century not, nor do they incline us ; they are free on could have so little influence upon his their own and so are we."" contemporaries? Why did his brilliant ideas fai l to produce a tremendous impact? Man, part of nature, has a physical environment from which to derive the material The story of Paracelsus is that of a to sustain life. Also from nature come tragically paradoxical person. He was a man poisons and disasters. Thus, every material laudable for his genius, yet despicable for his thing can be both good or evil-in proper arrogance; intellectually admirable, but dosages a remedy, but in excess an agent of personally revolting. Though he was clever, death. This is the second sphere, or ens his ignorance and ineptitude in human veneni. relations were truly appalling, and continuously stood in the way of much good Although all contemporaries are in more or that he might have done. Paracelsus cared less the same ens astrale, the stars for mankind in a way that few before him "influence not" to any specific degree, hence had cared-he once wrote that the basis of the differences between individuals. Each medicine was " love" . Yet he was impatient 125 and intolerant of most men, who thoroughly REFERENCES disliked him in return. On a surge of ideas 1. Paracelsus. in The Life and Soul of Paracefsus. that might have brought new light into by John Hargrave. (London : Victor Gollancz Ltd., the world Paracelsus rose to positions of fame 1951), p.41 . and influence, only to be dragged back into 2. Osier, William, The Evolution of Modern Medicine, the dark pit of disrepute by his demon, (Oxford, 1921), in A History of Medicine, by Brian Inglis, (New York: The World Publishing Company, hubris. Paracelsus possessed tools that could 1965) , p.72 . have revolutionized the world in the hands 3. q.v. Paracelsus, by Robert Browning. of a more skilful man, but he himself could 4. De Santillana, Giorgio, The Age of Adventure, not use them. (Boston: Houghton Mifflin Co., 1962), pp. 328 If. 5. Paracelsus, Selected Writings, trans. by Norbert The sin of Paracelsus was that he expected Guterman, (New York: The Bollingen Foundation, too much of people, too soon. He tried to 1958). bring his contemporaries from an age of 6. Cited In A History of Medicine, by Brian Inglis, absolutism and belief into an era of dissent op. cit., p.76 . and enquiry, and in the process he left 7. q.v. Inglis, Brian , p.77. almost everyone behind, becoming an B. Paracelsus, in A History of Medicine, p.73 . outsider, a man ahead of his time. Worse, 9. Sigerist, Henry E. , Henry E. Slgerlst on the History of Medicine, (New York: MD Publications Inc., Paracelsus did not know himself. The concept 1960), p.167. of a constantly-changing world in which 10. Paracelsus, in A History of Medicine, p.175. nothing was eternal, and in which there were 11 . Ibid., p.76. no earthly authorities was too horrible a 12. q.v. Browning, Robert, The Works of Robert concept for any sixteenth-century man--even Browning, (New York: Ams Press, Inc., 1966) , Paracelsus. Having torn down the old idols, v.1, pp. 169 ft. 13. Paracelsus. in Paracelsus: Magic Into Science, by and having destroyed the old philosophies, he H. M. Pachter, (New York: Henry Schuman Co., was left with a moral vacuum, in which he 1951) , p.49. personally had to become the new authority, 14. De Santillana, Giorgio, pp. 330 ft. the "Prince of Philosophy and Medicine". 15. Paracelsus, in The Age of Adventure, p.329. The new order had to be his doctrine, 16. q.v. Wolfram, E., The Occult Causes of Disease, Being a Compendium of the Teachings Laid Down irrefutable and changeless. Thus a great man In His " Volumen Paramlrum" by Bombastus von shrunk to the ridiculous pr.oportions of a Hohemhelm & c., (London : Rider & Co. , 1911). self-proclaimed saviour and a quack. 17. Ibid., p.331 . Bon Mots from the Lectern or listening to second year med lectures recorded by Ann Aldis I think you 've had a leslon-1 mean a THE CONNECTIONS OF THE lecture-on this previously. (Wallace) HYPOTHALAMUS: And now some GEE WHIZ facts. (Bondy) They're in every good textbook, especially I like to think that that Scandinavian blonde Dr. Barr's. (Montemurro) sneezed at me. (Hatch) SYPHILITIC GUMMA OF THE TESTIS: As we go deeper into the female genital It's as rare as rocking horse crap. tract the lectures will become more (Troster) interesting. (Ramzy) THE SECOND DIGIT: I'm going to show you a tape recording. But if we say that It's the thumb, by God (Kertesz) it is the thumb!! (Barnett) TABES DORSALIS: SUDDEN DEATH: It's been eliminated by moral reform and It's pretty abrupt. (Barnett) penicillin, and I miss it. (Barnett) A VICIOUS EVIL AFFAIR: THE AORTIC ARCH: An aneurysm. (Drake) You know, the arch of the aorta. (Lewis) A PRE-CANCEROUS LESION: A FIBROMA: The female breast. (Mills) It looks like a fibroma, feels like a fibroma I'd like to show you this table which shows and under the mike it is a fibroma. (Ramzy) a few points that were clear up until five or six years ago. (Cheevers) WHEN SOMETHING IS RARE: The only proper place for an isolated Only two at University Hospital per year. breast lump is in a bottle of formalin. (Bondy) (Wallace) 126 An Elective tn the Pacific Northwest

Michael J. Austin, '74

Following the age-old admonition of Horace pulp and paper mill. Prince Rupert also has a Greeley to "go west young man", I spent very active tourist industry, being at the two months this past summer in Prince meeting point of important north-south and Rupert, British Columbia. This interesting and east-west transportation arteries. Since a valuable learning experience was arranged third of the city's population is Haida Indian, through the University of British Columbia's the city is proud of its native heritage and Continuing Medical Education Department. boasts gift shops with native crafts, a fairly extensive museum featuring native artifacts, The programme offered at the Prince and totem poles galore in all of the city's Rupert Regional Hospital caught my eye for numerous parks. several reasons: The city has eleven doctors: one 1. It offered a learning experience in a obstetrician, three general surgeons and small town setting (by London's standards) seven general practitioners who serve an and this appealed to me since I am planning area of about 22,000 people. Since the area to practice in a smaller centre. Moreover, is obviously underserviced, the general I was contemplating practising in British surgeons often are forced to wear the hat of Columbia and thought an elective there would the general practitioner in some cases, much help me learn the political ropes of their to their chagrin. The majority of the town's medical insurance plan, etc. physicians are arranged in three clinics 2. The programme there was basically headed by the general surgeons who, unstructured but general practice oriented. because of the large turnover of general practitioners in the town over the last few 3. I enjoy the west, in general, and British years, are by and large the senior physicians Columbia in particular, very much, partly in town. from personal experience (I had spent the previous summer landing on the top of They all work out of Prince Rupert Regional mountains in the Coast Range for the federal Hospital, a beautifully modern and well­ government) and partly from my upbringing, equipped 140 bed hospital built in 1969. It since my father was born there. has a very scenic location perched atop the town's highest hill and overlooks the 4. The description of the programme hinted harbour, the mountains, three totem poles in at the chance to participate in air-sea rescue the city park directly across the street and and the like and this, plus the fact that the the most beautiful sunsets in Canada. town itself was surrounded by a vast area that is largely wilderness, appealed to my From the outset, the informality of the spirit of adventure. hospital staff impressed us and made us feel at home despite our isolation from places Thus it was that on June 16th that my familiar. The first night the programme wife and I turned our intrepid little Pinto co-ordinator took us to his home for supper westward. Eight days and three thousand in his camper truck. My wife and I lived miles of forest, prairie and mountain later we directly across from the hospital in a arrived at our destination. three-bedroom furnished apartment which the For the uninitiated, Prince Rupert is a city hospital ran as a nurses' residence. The of 17,000 persons located on the Pacific accommodation was complete with a view coast near the mouth of the Skeena River similar to that from the hospital itself and one about 400 miles northwest of Vancouver (as or two tame deer. We were provided with the Raven flies). The city is located a scant a telephone and free meals at the hospital. 30 miles from the southernmost tip of the The proximity of the room to the hospital was Alaska panhandle and on a clear night the excellent as one could just dash across the northern horizon is dominated by the low hills street for an emergency or a delivery. of the 49th state. My mornings were usually spent at the Industrially, Prince Rupert is like all of the hospital scrubbed for surgery. I was first cities of the province as it relies very heavily assistant almost invariably and was given on natural resource-related industries: a ample experience at knot tying and the like. large commercial salmon fishery and I assisted, for example, at seven Caesarean innumerable canneries, a lumber mill and a sections and did one appendix which was 127 a gratifying, yet harrowing, experience which 1 was told the first morning in no uncertain totally spoiled me for subsequent U.W.O. terms that 1 was not to crack a book while in surgery training as third assistant. The Prince Rupert-! was there to enjoy myself mornings were usually hectic, culminating in and that they would give me ample work to rounds with .one or more of the staff plus keep me busy during the day but that at various outpatient procedures in the night I was to relax. emergency department. Because of the amicability of my hosts and my ample free time I was able to sample Afternoons were usually spent in various what recreational facilities Prince Rupert had doctor's offices around town or else at the to offer. These are mostly "outdoorsy" hospital either in emergency or else pursuits since indoor recreation is indeed following up interesting patients whom the physicians informed me of. Visiting limited-two movie houses, one radio station specialists occasionally came up from St. by day and one television station which Paul 's Hospital in Vancouver and I spent a experienced periodic sustained blackouts few afternoons with a visiting ophthalmologist since the transmitter was located on a nearby mountain which was frequently obscured by and paediatrician. cloud and fog. I went salmon fishing one Evenings spent in emergency, especially afternoon in the R.C.M.P.'s annual derby and on the weekend, were particularly rewarding. caught nothing but one small cod and an Friday and Saturday nights a hodge podge of Ethanol-induced headache. We followed reserve Indians, pulp and paper workers, another physician 160 miles up a logging construction and fishermen invariably went on road to his favourite picnic spot-his camper a rampage in the entertainment sector of did admirably but our Pinto returned with " Rupert's" main drag (affectionately known two soft tires and a dented fuel tank. We locally as " Apache Pass" ). These would drove up the Skeena for Sunday afternoon arrive later with various abrasions, contusions, picnics-we ate the contents of the basket and lacerations which the medical student and the blackflies and mosquitos ate us. We is readily allowed to suture, reduce, or cast also spent several afternoons tramping around as he desires. Prince Rupert's nine hole golf course. This was constructed atop the city's sanitary Although the hospital draws from a fairly landfill site. Unfortunately the city has not small area, there is a good cross-section of produced enough litter to build the back nine pathology from the commonplace to the as yet. The fifth hole parallels the present exotic. A wide spectrum of industrial dump and besides the interesting odours accidents were commonplace In the wafting in the cool, moist air, one is treated emergency department and ranged from fish to a menagerie of creatures, both feathered hooks imbedded in various parts of the and furred, who frequent the adjacent acres­ anatomy, to traumatic tenosynovitis In fish Ravens, Bald Eagles and an occasional cleaners, to workers crushed in logging or black bear on his way for a snack (which mining operations. On the exotic side were a often prompts an untimely retreat for the true hermaphrodite delivered by C-section, sixth tee). a ruptured Echenococcal cyst, Turner's Syndrome and Polyarteritis Nodosa. In retrospect, I was very pleased with my elective experience. I was impressed with the The regional hospital was largely self­ good standard of medical care delivered sufficient, but if a case required constant despite the remoteness of the city, the monitoring or heroic and specialized patient-doctor ratio and the lack of many treatment, they were taken by ambulance diagnostic parameters considered across the ferry to Digby Island and then " necessary" in the ivory towers of medical flown by a waiting Air-Sea Rescue plane to research. And I was very impressed with the Vaucouver. These were always exciting willingness of the great majority of the city's occasions with the big Buffalo aircraft waiting physicians to take time to teach students with motors running when the ambulance the practical aspects of day-to-day practice. arrived. After delivering our patient Into the capable hands of the two Canadian Forces Most of all, perhaps, I had impressed upon medics who would accompany him to me time and again the need for more Vaucouver, the plane was off in a flash­ doctors in Prince Rupert. For those who shun hardly before the ambulance had left the the bright lights of the metropolitan centres runway. of the south, who are interested in locating in a rapidly expanding small city which Th roughout my two months in Prince retains some of its frontier character, who Rupert I was repeatedly Impressed with the enjoy the sea and the outdoors and who are friendliness of the populace in general and willing to accept the limitations and the hospital's medical staff in particular, challenges of a non-teaching environment, and with the informality of the programme. Prince Rupert would be an excellent choice. 128 070730002 RALPH M. CUMMINS OPTICAL

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