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The Journal of the Philippine Medical Association

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The Journal of the Philippine Medical Association

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Vol. XXII (Issue No. 3) March, 1946

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THE JOURNAL OF THE Philippine Medical Association Devoted to the Progress of Me~cal S<:Wnce and to the interests of the Medical Professi.<m. in the Philippines Manila, Philippines VOL. XXII MARCH, 1946 @riginal .l\rtide.s NO. 3. OCULAR SYMPTOMS AND SIGNS ASSOCIATED WITH DEFICIENCY OF VITAMIN B COMPLEX A S. FERNANDO, M.D ., C.D. AYUYAO, M.D., AND J. N. CRUZ, M.D. College· of Medicine. University of the Philippines. This is a report of our observations on a series of 590 adult patients, who were treated in the Free Dispensary of the Philippine General Hospital from January 2, 1942 until September 30, 1943. These patients complained of dimness of vision of both eyes, and they were found to be suffering from multiple vitamin deficiencies. These ocular symptoms and signs together with th~ associated lesions, however, disap· peared upon administration of well-balanced and liberal diet, especially rich in the particular vitamins manifestedly lacking. The number of cases was small at the beginning, but it soon increased and assumed the nature of an epidemic, reaching the peak of incidence about the end of 1942; but it subsided by the end of September, 1943. Previous to this period, similar cases had come to our attention, but they were few and far between. A preliminary report on this clinical investigation was presented to the Staff Clinical Conference of the Philip· pine General Hospital on January 16, 1943, in conjunction with the presentation of a case of retrobulbar neuritis with co-existing corneal lesion associated with multiple hypovitaminoses. The patientS were divided into three groups depending upon the ocular changes, namely: (1) those with retrobulbar neuritis, 467 cases; (2) those with corneal lesion, 79 cases; and (3) those with retrobulbar neuritis and corneal lesion co-existing, 44 cases. A few of the patients were hospitalized for a detailed study and observation. The case histories of five of these are included in this report. The rest were treated in the out· pa.tient service. Inquiry into the dietary history of each of these patients revealed that, for sev· eral weeks or months prior to the onset of the defeot in sight, they had been sub· 94 DEFICIENCY OF VITAMIN B COMPLEX-Fernando et al Jour. P. M. A. March, 1?46 sisting on very deficient diet-deficient not only in quantity bu1 also in quality. This lack of adequate food was the inevitable result of the war. Wars have always been linked with hunger and disease. The majority of these patients were poor; many had lost their jobs soon after the outbreak of the war. Food had become scarse in Manila and neighbori~g· provinc~s due to lack of transporta•tion facilities, and consequently prices had soared beyond ·the reach of the common people. There was a time when many were thankful if they could eat twice a day. As a strong evidence that this epidemic was caused by dietary deficiency, the cases almost dis· appeared as soon as adequate supply of food' had . reached the masses and economic conditions had approached normalcy. The history and the physical examinations disclosed that these patients were suffering, not from any systemic disease, but from vitamin deficiencies. Those pa• tients who complained of dimness of vision but might be suspected of being af· flicted by latent syphilis, multiple sclerosis, cardio·vascular conditions, or other diseases or disorders tha1 might complicate the avitaminosis or which might render the diagnosis of vitamin deficiency not very obvious, were excluded from this series. Likewise excluded were other pathologic conditions obviously known to cause faulty absorption and utilization of foods. However, pregnant and lactating women who contracted this eye affection· were included in the series. The assistance •o( the iniemists was secured to establish the diagnosis in some cases. It is unfortunate ·that, due to lack of laboratory facilities, no tests for the estimation of the content of the principal vitamins in the blood or urine could be made. Similarly, it is to be regretted that synthetic vitamins were not available for administration to the charity patients. Tests for visual acuity and for dark adaptation, fundus examinaotion, scotometry, and other important examinations were repeatedly made, not only of hospitalized patients, but also of many of these from the free-dispensary. Besides the ocular··syndrome, a great majority of these patients presented angular stomatitis, glossitis, and symptoms of multiple peripheral neuritis-varying in degree of severity and in dura1ion and in the combinations of signs and symptoms. The diagnosis of hypovitaminosis B complex was given to these cases. RETROBULBAR NEURITIS The type of retrobulbar neuritis we observed was probably similar ta.. that described by Elliot' in his 'Tropicail Ophthalmology, where he cited many Japanese in· vestigators who had studied the ocular lesions in beriberi (~a~~e in Japanese). How· ever, there was one striking difference between the cases of retrobulbar neuritis described by Elliot and those under our study; namely, those were apparently found in frank cases of beriberi; ours were associated with vitamin B complex deficien· cy. In collaboration with Professor S. Miyashita of Osaka, Japan, Elliot wrote a brief and excellent review of the literature on retrobular neuritis of beriberi, citing Japanese investigators who blazed the trail in the study of this ocular disease in Japan. According to Elliot : In 1895, Kono published 6 cases of beriberi associated with amblyopia, central .scotoma, but presenting no fundus changes; three years later Komoto discovered that the c~use of amblyopia and other central scotoma was to be sought in a retrobulbar neurities and noted that the scotoma be· ~:::::::~~II DEFICIENCY OF VITAMIN B COMPLEX-Fernando et al 95 gan centrally and spread centrifugally; Yamamoto in 1903 first drew attention to an atrophic condition of the temporal side bf the disk; Kagoshima, in 1918, made an anatomical examination of five cases in which ~a~~e-sootoma was present, and found in all of them a distinct and limited atrophy of the fibers in the outer section of the optic nerve. Miyashita, citing Tshizu (1917) and Fugita (1918) said that the scotoma is connected with the blind spot by a narrow bridge giving it, he said, a "characteristic pestle-shaped form"; and he further stated that the color sense is disturbed in many of the cases, especially for green. Miyashita said that central vision gradually falls till it reached the low limit of 6/ 60 but that it seldom goes lower than this; that a certain degree of photophobia is observed and that some of the patients can see better in the house than out of doors; that Nakamura (1919) noted some interference with dark adaptation; that Yamaguchi found no marked contraction of the white field but that those for red and green are shrunken; while lchihara said that contractions of the visual field occur, but are transitory in nature; that Miyashita cited Captain Ishiza who found (1918) that in the earlier stages of ~a~~e there was a distinct decrease of sensibility of the cornea and conjunctiva in more than half of all the cases he examined; that Yamamoto stated .that fundus examination may reveal: (1) no evidence of any fundus lesion; (2) partial atrophy of the papilla, limited ro its temporal quadrant (stressed also by lchihara) ; or (3) the whole of the oi>tic disk may be involved in the atrophy. The eye symptoms in beriberi according to Elliot may appear early in the disease, but as a rule they do not put in an appearance until the general signs of the disease have been recognized for several months. With regard to pathology Elliot cited Wright as saying that the affected nerves show a chronic degeneration, Wallerian in appearance. Miyashita said that complete blindness need never be anticipated. Seasonal incidence : Miyashita stated that in Japan beriberi is most frequent in summer. The ocular symptoms as a rule appear after an interval of one to three months from the commencement of the trouble; hence these eye complications are mostly found in November, December and January. The ophthalmic symptoms are more common in males than in females, a marked exception being found in the latter during pregnancy and after the lying-in-period. Since the papillo-macular bundle is selected for invasion, this disease should be differentiated from tobacco-alcohol amblyopia, lead poisoning, and other intoxications, although the ocular symptoms are the same. The ~reatment consists in substituting for the dangerous forms of polished rice, some such food as a bean known as azu~i (Phaseolus radiatus) or this bean combined with barley. Food should also contain a sufficiency of nitrogenous and fatty elements and should not be too bulky. Injections of pilocarpine and strychnine are useful adjuvants. With regard to the frequency of eye symptoms of beriberi in Japan, Ichihara found that in 6,000 out-patients there were 32 cases of amblyopia (0 . 53 per cent) and that of these 32, no less than 6 were due to beriberi (18.75 per cent). We have quoted Elliot extensively to show that much of our knowledge about 96 DEFICIENCY OF VITAMIN B COMPLEX-Fernando et al Jou•. P. M. A. Marcb, 1946 this eye disease had already been acquired about 25 years ago. But we are great· ly impressed by the nearness of our observMions in this series to the findings of these Japanese investigators. Our findings corroborate theirs, except that no men· tion is made in Elliot's review of any associated corneal lesion in some instances and the concomitant clinical syndrome of angular stomatitis and glossitis. During the period covered by this report we saw at least 467 cases; 215 were males (46%) and 252 were females (54%). As to age incidence, about 60% ranged from 26 to 45 years, the oldest being 65 years, and the youngest, 17 years. The patients complained of foggy and dim vision, sometimes very marked (20/200 or even wor~), but with neither pain in, nor tenderness of, the eyeball. As to duratibn of the complaint of foggy vision when first seen in the clinic, we obtained the following history: about 1 week in duration, 8 % of the cases; over 1 week 1b 1 month, 41 % ; .over 1 month to 6 months, 38%; over 6 months to 1 year, 6.5 % ; and over 1 year, 6.5%. Regarding the amount of defect in the acuity of vision our records showed : vision less than 20/200, 17%; from 20/200 to 20/100, 46%; from 20/ 70 to 20/50, 27%; and from 20/40 to less than 20/20, 10 per cent. "SUPERFICIAL VASCULARIZING KERATJTIS" In the second group of patients we attributed the dimness of vision to the corneal lesion, which we would term "superficial vascularizing keratitis". For we believed the lesion to be similar to that peculiar type of keratitis described by Sydenstricker and his associates." • But those cases in which the visual defect was very marked and out of proportion to the corneal opacities present and which scotometry revealed central or centrocecal scotoma, were placed in the third group of patients, i.e. those with retrobulbar neuritis and corneal lesion co-existing. The usual complaints of patients with corneal lesions were: mild phatophobia, smarting sensation in the eye, dim, foggy vision, more so when the patient was in the sunlight; no history of night blindness. Oblique illumination showed that the cen· ~ral portion of the superficial layers of the cornea occupying an area about 5 mm. in diameter was steamy. Sometimes this ha1;iness was so slight as to be easily missed. Sometimes this cloudiness or nebula took the fluorescin stain, sometimes nat. Fundus examination: With the ophthalmoscope at a distance, haziness of the red reflex was observed. The fundus appeared normal except for the haziness of the details caused by the corneal opacities. Slit lamp examination revealed · this haziness to consist of fine opacities, irregularly scattered, sometimes coalescing and forming patches of denser opacities, sometimes arranged in linear formations. Op· tical section showed these opacities to be confined in the epith~lial layer of the cornea. Sensibili·ty of the cornea was usually impaired not only in the area where. the cloudiness was, but also in the whole corneal surface. When the corneal microscope was focused on the limbal area, the limbal plexus was seen to be engorged. New capillary loops were formed and from them sprang very fine capillary twigs advancing under the epithelial layer towards the center of the cornea. At the start of this investigation, we failed to focus our attention on this vascular engorgement of the limbal plexus, as the eye did not present any circumcorneal injection on mere inspection; and we therefore missed this very important lesion Volume xxu DEFICIENCY OF VITAMIN B COMPLEX-Fernan® et al 97 Number 3 in some of the cases. No associated iris or pupillary changes were observed. We are sure many cases of the mild type passed unrecognized in a busy clinic. What was this corneal lesion? What was its pathogenesis? Considering the history of dietary deficiency, the presence of angular stomatitis and glossitis in many of the pa1ients, the similarity of the corneal lesion to the ocular manifestations of ariboflavinosis described by Sydenstricker and his associates, and the prompt improve· ment following the administration of balanced and liberal diet particularly rich in ribo· flavin, we are of 1he opinion that we were dealing here with "superficial vascularizing keratitis" due mainly to riboflavin deficiency. If we did not observe in our cases marked photophobia, marked ciliary injection, extensive new corneal vascularization and opacities involving also the deeper layers of the cornea, and the involvement of the iris, it is probably because we were dealing here with a mild degree of vitamin B, deprivation. If this vitamin deficiency were allowed to progress, it is very probable that we would have met with ocular changes very similar to those described by Syden· stricker and his associates. We believe it pertinent to describe here the ocular symptoms and signs of aribo· flavinosis first reported by Sydenstricker and his associates. In June 1940 they published a report of their findings in a series of 47 patients with ocular symptoms and signs of ariboflavinosis. Photophobia and dimness of vision were the most frequent symptoms in their patients. The earliest and most common sign of ariboflavinosis, acoording to them, is circum'corneal injection. Frequently, it can be seen with a hand lens or ophthalmoscope, and it is always obvious on slit lamp inspection as marked congestion and proliferation of the limbic plexus. Actual invasion of the cornea by capillaries arising from the apices of loops of capillaries in the limbic plexus can be readily seen by retro·illumination just beneath the epithelium. Later extensive super· ficial vascularizations are produced, and these are termed "superficial vascularizing keratitis" by Sydenstricker and his associates. The superficial plexus is always more extensive and complicated than the posterior, in contrast to the predominant posterior vascularization in syphilitic interstitial kera· titis. Meanwhile superficial nebulae, !een grossly as "steaminess" of the cornea and with the slit lamp as a fine diffuse superficial opacity, usually developed. Sydenstricken and his associates were the first to report on the slit-lamp examination of the cornea and iris in human ariboflavinosis. Associated with these changes is a tendency to marked mydriasis (spastic mydriasis) and to the production of pigmented spots on 'the anterior surface of the iris. The eye lesions respond rapidly and satisfactorily to the administration of riboflavin. Superficial opacities disappear more slowly than interstitial nebulae. The order in .which these various lesions appears, evident in cases allowed to relapse, is as follows: The first sign to appear is conjunctiva! injection, followed by photophobia and impairment of visual acuity. Corneal opacities are encountered 7 to 10 days after re-instituting a deficient diet. Cheilosis and glossitis seldom recur before the end of the second week. In our consideration of the diagnosis of the corneal lesion, we ruled out "pre· xerosis comeae" described by A. Pillat• in xerophthalmia in adults. Unlike prexerosis comeae we did not observe any accompanying .Joss of lustre of the conjunctiva or cornea in our cases; no "drying·out" phenbmenon (i.e. the cornea becomes dry after exposing it from 5 to 10 seconds by retracting the lids); no "characteristic exfoliation 98 DEFICIENCY OF VITAMIN B COMPLEX-Fernando et al Jour. P. M. A. March, 1946 of corneal epithelial cells" which Pillat says are well shown by the slit lamp. Xerosis epithelialis corneae rarely occurs alone; it is often associated with one of the various types of xerosis of the bulbar conjunctiva. As a ·matter of fact, we did not observe xerosis of the conjunctiva in any of the cases in this series nor did we elicit history of night blindness. It is generally considered that "night blindness is the commonest and most easily recognizable manifestation of A avitaminosis." Another point against xerophthalmia is the engorgement of the limbal plexus and the presence of new vas· cularization. In some of the patients in this series biophotometry revealed poor dark adapta· tion. This, however, was not a constant finding in those with still a fairly good v1s1on. Because of this finding, vitamin A deficiency might be assumed. But poor dark adaptation may be produced by conditions other than lack of vitamin A in the retina. In our cases, this may be attributed to A hypovitaminosis, to the corneal opacities, to the retrobulbar neuritis, or to all the three conditions combined. Furthermore, as Gordon and Servinghaus' say, "There is the widest possible disagreement as to the reliability of the light sense in detecting this deficiency, the frequency of A avitaminosis in the population generally and the accuracy of any of the instruments now in existence for adequately measuring dark adaptation . . . The subjective ele· ments of cooperation and training are of the greatest significance in obtaining reliable results. Repeated tests on the same subject tend to produce a certain facility in per· formance which is not proportional to any true improvement in efficiency of adapta· tion. Vitamin A requirements of a single individual may deviate from the average requirements of large groups arrived at by statistical analysis. . . It may therefore be concluded that some degree of caution is necessary in the interpretation of results." Our consideration of whether this corneal epithelial lesion might be attributed to hypovitaminosis A brings us to a very pertinent question. Do we have evidence that keratomalacia in adults is found in the Philippines? We have never seen it or heard of it or read reports that it has been encountered here. Xerophthalmia in the form of xerosis conjunctivae and night-blindness in adults are accasionally found, but not a single one of the 590 patients in our series had these symptoms. The worst economic and climatic conditions in the Philippines that we have ever had have not been so unfavorable as in certain parts of North China where, Pillat reports, there are frequent outbreaks of keratomalacia in adults due to improper diet, sev~re winter, hard physical labor, and other influences. Unless the supply of vitamin A is severely cut off for a long period of time, the liver in adults-provided it is not diseased-is capable of maintaining to a minimum level the vitamin A content of the blood. For this organ is a good storage of this substance. We believe! that in the epidemic that we had it was the water-soluble factors which are known. to be readily excreted that were depleted first and to a greater degree than the fat-soluble vitamin A. In children, however, cases of avrtaminosis A occur rather frequently. During the last epidemic, these cases increased about three-fold. In adults, it was the B com• plex; and in young children, the Vitamin A that we observed to be predominantly deficient. From January 1940 to September 1941, there were 69 cases (0.8%) of xerophthalmia and 18 cases (0.22%) of keratomalacia out of a total of 8627 eye cases, as against 197 cases (2.50%) -of xerophthalmia and 49 (0.6J%) of keratomalacia out of a total of 7771 eye cases for the corresponding period from January 194 2 ' to v';!.:";:,~.~~u DEFICIENCY OF VITAMIN B COMPLEX-Fernando et al 99 September 1945. Seventy-four per cent of the cases of keratomalacia were in children under three. With regard to age incidence of those patients with corneat lesion, we found the following: 70% were from 21 to 3 5 years old; the oldest in the series being 58 years old and the youngest 14 years. As to sex incidence, 58 per cent of the patients were females and 42 per cent males. Pregnant and lactating women swelled the number of the former. REPORT OF CASES The following case reports are illustrative : (Service of Dr. Fernando) Case l: C. T., 55 years old, male, married, plumber, admit'led July 24, 1942 complaining of dimness of vision of both eyes. This had started two months before, as gradually progressive dimness of vision, accompanied by redness of the eye, slight photophobia and smarting pain in the eyes. He said he never suffered from night blindness. Complained of occasional vague pains in 1he lower extremeties. No numbness around the mouth. Angular stomatitis appeared after the dimness of vision. He had been unemployed since the outbreak of the war. He had a large family, and had no savings. The family had been subsisting on very deficient dict, consisting most of the time of gruel, small dried fish, and some vegetables. The important findings in physical examination follow: Fairly well developed and fairly nourished. Heart and lungs apparently normal. No seborrhea on the face; angular stomatitis present in both corners of the mouth; the lips slightly reddened, but not swollen. The tongue appeared glazed due to atrophic papillae, and without sensation of burning. Many carious teeth; several were missing; some exudate ap• peared on pressure of the gum (dentist's report, July 28: "advanced pyorrhea of all remaining teeth".) No tenderness of calf muscles . . Knee-jerk, normal. The eyes on inspection showed angular blepharitis, outer canthus; pupils normal; no ciliary in· jection. On oblique examination, haziness waa visible in the central portion of the anterior layer of the cornea, the rest of the cornea appearing normal; no drying-out symptom or loss of lustre in the conjunctiva or cornea. Both cornea were hyposensi• tive, the right eye more than the left. The lesion in the cornea stained slightly with flourescin. Slit lamp examination showed that 1he opacities were confined to the anterior epithelium, the central portion corresponding to the pupillary area. The optical section showed definitely 1hat the opacities were confined to the epithelium. At the limbus, many very fine new capillaries came from congested limbal loops, and crept under the epithelium towards the center of the cornea, but hardly reaching 2 mm. from the limbus. Vision: 0.D. = 10/80 and 0.S. = 10/120 and not improved with lenses. The patient could not read any of 1he Jaeger test types even with the presbyopic correction. Biophotometer test showed poor dark-adaptation (after exposure 4.64 M.C.L.) After 1en minutes-0.948 M.C.L. Perimetry, showed slightly contracted field, temporal side, for form; contracted for green. Small absolute central scotoma was present in both eyes. Fundus examination: apparently normal fundus on both eyes; Ophthalmoscope at a distance showed slight haziness of tbe red-reflex. There was small subcortical opacity of 1he lens, more dense in the right eye than in the left and situated below the central portion of the lens, so that i1 does not interfere with the vision. Blood pressure-110 systolic; 64 diastolic. . 100 DEFICIENCY OF VITAMIN B COMPLEX-Fernando et al Jour. P. M. A. March, 1946 Laboratory examinations: Blood: R . B.C. = 4,350,000. W.B.C. = 7,520 cu. mm. Differential: neutrophile 69%; lymphbcytes, 29%; monocytes, 2%. Urine: normal. Feces: Ascaris, one plus and Trichuris one plus. Basal metabolic rate - plus 12.5 (7/30/42). Conjunctiva! smear - staphylococcus aureaus and diptheroids. Blood chemistry (7 /30/42) sugar - 77.5; uric acid - creatinine - l.20. Cerebro·spinal fluid (8/ 6/42) - Normal. A dietary regimen was started Aug. !st, consisting of a balanced and liberal diet, expected to give a minimum of 5 mgm of B, daily. As the source of this vita· min would also contain plenty of vitamin A, the pa·tient was also receiving liberal supply of vitamin A (estimated to be at least 25,000 International Units.) Liver, whole eggs, camote, string beans, spinach, papaya, pork, etc. constituted most of his diet. No medicine was administered. The vision b~gan to improve on Aug. 4; it was 0 .D. = 10/80; O.S. = 20/ 60. On Aug. 11; V = 0 .D. 20/ 40; 0.S. = 20/60. On Aug. 20 V = 0.D. 20/30; 0.S . = 40 and for near = )eager No. 6 with plus 3.00 sph. On Aug. 25, V = O.D . 20/25; O .S. = 20/2 5 and near vision = Jaeger No. I with plus 3 .00 sph. Record of biophotometric readings: July 25, after exposure - 4.64 and after 10 minutes 0.948; Aug. 15, 4.98 and 0. 400; Aug 29, 0 .948 and 0.301; Sept . 16, 0.533 and 0 .210. The visual field was much improved by Aug . 4th, and on Aug. 29, normal visual field for form. Slit-lamp examination on Sept. 15, showed : Vascular changes in the cornea had almost completely regressed. The lens opacity in either eye had remained the same, but this did not interfere with the line of vision because of its location; i.e . peripheral to the free margin of the iris. Discharged on Sept. 17, 1942, recovered, near vision being Jaeger No. 8 in either eye, but with plus 3.00 sph. it was Jaeger No. I. Central scotoma completely disappeared. Ca.se 2: - Ward 4 - Bed 23. - Service of Dr. A. S. Fernando A case of Retrobulbar Neuritis with Associated Corneal Epithelial Opacities Secondary to Multiple Hypovitaminosis. E.L., 38 years old, housekeeper, admitted for the first time on Dec . 18, 1942, with the chief complaints of dimness of vision of both eyes and numbness of the lower extremities. The present illness had started 3 months before admission as numbness and occasional cramp·like pains of both lower exuemities usually occur· ring at night. Two months later she noticed a gradual diminution of vision to such an extent that close work like reading and sewing were impossible. The dimness of vision started in the left followed by the right eye weeks later. She consulted the E . E . N. T. di~pensary where a series of thiamine chloride injections was given - I mgm. daily for I 0 days. The treatment relieved her of the numbness around the mouth but no subjective improvement in ·the vision. She had history of receiving a trauma over the left eye two weeks before admission. No lachrymation or photo· phobia. Diet.-Food at breakfast consisted of a cup of coffee and some rice cakes. At ~~~:!~ ~xu DEFICIENCY OF VITAMIN B COMPLEX-Fernand-0 et al 101 lunch, meat was served about 4 times a week; first three times a week. Vegetables were usually mixed with the fish or meat, but vegetables were seldom cooked alone. Sometimes bananas or sweets. At supper same thing was served as their food was cooked once daily to economize o~ fuel. According to her, her appetite was nbt good, so that on many occasions she took very little supper or not at all. She was also nursing a child. The most important findings on admission were : a slight angular stomatitis; tongue red; knee jerk absent in the left and very weak in the right. Eyes - On the cornea corresponding to the pupillary area there were small opacities varying in size from pin point to pinhead, some clustered and some in linear formation. On oblique illumination, these opacities appeared whitish. On corneal microscopy, the epithelium presented areas of thickening which appeared whitish and glistening. With the corneal prism, these opacities were seen on the anterior surface. The opacities stained with flourescin. Th~ limbal plexus was congested. New capillaries were advancing toward the center of the cornea. Pu· pils of both eyes were practically normal in size and shape, and reacted well to light and distance. Corneal sensibility - slightly hypersensitive. She could be examined with the slit lamp for a long time . with little discomfort and no epiphora. Vision - F .V. - O .D . - c. f. at 12 ft. chart with white backgound = 3 1/ 2 ft. (black background) 0 .S. = 22 ft. - Not improved with lenses. O.S. = c. f. at 7 ft. - Not improved with lenses. N.V. - O.D. - Jo - Not improved with lenses. O.S. - Jo - Not im· proved with lenses. Fundus examination - Some black spots on an orange red reflex were seen on ophthalmoscopic examination at a distance. There was slight pallor of the tern• poral portion of the disc of both sides, otherwise normal. Perimetry showed slight contracted field for white and for colors (red and blue.) She could not recognize the green. Biophotometer test - poor dark adaptation. There was however no xerosis or dryness of the conjunctiva. Scotometry -- Centrocecal scotoma in both sides, larger in the left. Test for color blindness ( 1) using Ishihara 's book - the right could see figures on plate I only, while the left could not see the figure in any of the plates. (2) Worsted's Yarn - Could see the fundamental colors. She distinguished the red well; she recognized the blue better than the green. Laboratory examination - Blood Wassermann - negative Blood chemistry - normal Urine - normal Patient was referred to the Neurologist who gave the diagnosis of "Polyneuritis secondary to hypovjtaminosis." Discharged Jan. 13, 1943, with V = 0.D. = 20/160 O .S. counting fingers 16 ft. Corneal opacities very slight. Case 3: - (Service of Dr. Vitug) - R . A., 19 years old, female, single, from Orion, Bataan, admitted on February 14, 1943, with the following complaints: in· ability· to walk, dimness of vision in both eyes, numbness and formication of upper and lower extremities, and scabies. The dimness of vision had developed about two months before admission. A month later her legs became weak and numb, and she found it difficult to walk; she complained of numbness around the mouth, of 102 DEFICIENCY OF VITAMIN B COMPLEX-Fernando et al Jou•. P . M. A. March, 1946 chest oppression, and of angular stomatitis before admission. For the past eleven months she had been having recurrent attacks of malaria. The important physical findings were: scabies, angular stomatitis, glazed and reddened tongue, heart apparently normal, knee jerk, absent. Patient could not stand up without support. Laboratory examinations revealed nothing important, except that ·there were a few malarial parasites (schiz). Blood Wassermann test-negative. The diagnosis given was Hypovitaminosis B complex, Chronic malaria, and scabies. Vision : 0.D. = 8/200 O .S . = 8/200 Left eye with slight ciliary injection. Centrocecal scotoma 4 mm, white object at 1000 mm. Biophotometer test showed: poor dark-adaptation (After exposure - 4.98 M. C. L. and after 10 minutes - 1. 18 M. C. L.) Slit·lamp examination showed fine superficial opacities in the cen'.ral port;on of the cornea; very fine new capillaries arising from the congested limbal plexus, advancing toward the center of the cornea, and situated just under 1he epithelium. Observation on the course of the disease: Anti-beriberi diet was given. Thiamine chloride, 1 cc. by hypo dail)'. Tikitiki extract, 10 cc. t. i. d. The thiamine was changed to betaxin from March 5 to April 6 for lack of that medicine. Quinine was given for the malaria and sulphur ointment for the scabies. March 2, 1943 - the vision improved to 10/160 in either eye. March 5, 1943 - the haziness of 1he cornea had disappeared. The capilla· ries were still visible near the limbus, although they appeared smaller. April 14, 1943 - Patient could walk slowly. Calf muscles as well as those of the palm slightly atrophied. The tongue papillae were already regenerated. Vi· sion was much improved. Case 4 : - D. L., 30 years old, male, married, jobless, admitted on September 16, 1?42, for dimness of vision in both eyes which he had noticed two months before admission. Numbness around the mouth and tips of fingers and 1oes. Had slight photophobia and could see better in the shade. Because of poverty his food was very inadequate, but his appetite was good. Physical examination revealed, some carious teeth, a fairly developed, fairly nourished, stttmg patient. The neurologist gave a diagnosis of peripheral neuritis due to hypovitaminosis B. Laboratory examination : Wassermann tests- of the blood and cerebro·spinal fluid, normal. Eye examina· tion: Conjunctiva and cornea, normal Vision = O .D . 20/200, 0.S. = 20/200, and for near, Jaeger No. 11 in either eye, not improved by lenses. Centrocecat scotoma for 2 mm. white, at 1000 mm., present. Biophotometer test: September 24: After exposure 2.41 M.C .L . After 10 min· utes - 0.464 M.C.L. September 18 to October 3 - 4 teeth extracted. Medical diathermy, exposed for 15 minutes daily for 9 days. Adjuvant treat· men ts: strychnine. Discharged November 21, 1942 with Vision= 0 .D . 20/80 J . No. 2 0.S. 20/80 ]. No. 2 Volume XXll DEFICIENCY OF VITAMIN B COMPLEX-Fernando et al 103 Numbel" 3 Case 5. - Ward 6 Bed 8 - . (Service of Dr. Gutierrez)-A Case of Hypovita· minosis. - L. R., 28 years old, female, single, housekeeper, Para V, Gravida V, born in Leyte, residing in Cavite, admitted on December 1, 1942, with the chief complaint of being easily fatigued, general numbness, and dimness of vision. lllness was of 9 months duration, having started as a slight numbness of the hands and feet accompanied by occasional pricking sensations, which became worse when the patient was 7 months pregnant. Two months later, she had normal par· turition. The numbness was slow in its progress upwards until after 3 months when it rapidly involved the thighs, abdomen, and chest; and was accompanied by breath· lessness on walking short distances. She also had a sensation of thickening around the mouth and linear area of paresthesia in the back for about the same length of time. About a month previously, she had lacrymation and redness of the eyes which lasted two weeks and subsided without treatment. Since then her vision had been impaired. For one week now she was unable ·to go about on her feet. Except for the occasional vague abdominal discomfort for two months there were no other symptoms. Socio-economic history-She had come to Manila 9 years before from Lcyte Since then she had been living with a common-law husband until the previous year when he had to leave for abroad. Up to then the family had never suffered from 'Want as the husband's salary was adequate for the family of five. After her husband's departure, however, she had to depend on her in·laws, of whom only one was a wage-earner (Pl.50 per day); and he had to support a family of 10. Their diet consisted of rice, fresh or dried fish, and occasional vegetables in the form of kangkong and young sweet potatt> sprouts. She abstained from meat in the belief that it made her numbness worse. Two of her 3 living children had to be confined for deficiency diseases. She was not a chronic alcoholic but she drunk Chinese wine occasionally. Important physical findings: Fairly developed and somewhat poorly nourished, unable to walk unaided and unsteady on her feet. No angular stoma·titis. Chest symmetrical with lactating breasts. There was a slight enlargement of the heart to the right (area of dullness on percussion was 1·1/2 fingers from the right sternal border) . Heart sound rather weak-Rate 11 O/min. Moderate accentuation of the second pulmonic sound. Lungs normal. Abdomen, liver, and spleen not palpable. Linea gravida present. Extremities---negative ankle and knee jerks; no adventitious reflexes; no foot· drop; Romberg sign-positive. Impaired sensibility to pain, touch, and temperature -most marked in the hands, forearm, feet and upper abdomen and chest. Laboratory Examination: Wassermann test-negative. This case was referred to the oculist and the vision showed 20/200 in either eye, not improved by lenses. Fundus examination revealed media clear as well as fundus details. Nothing abnormal in the fundus. The visual field showed marked contraction mainly in the temporal portion. Impression given was neuritis, retro· bulbar, bilateral. Dark adaptation poor. Treatment--cod liver oil, 15 cc. after each meal three times a day with betaxin (2 mgms.) ampules injection once a day. Note on the progress:By Dec. 12, 1942, patient could walk unaided, but there was no improvement in the vision. 104 DEFICIENCY OF VITAMIN B COMPLEX-Fernando et al Jour. p, M. A. March, 1946 COMMENT We will comment first on the retrobulbar neuritis. The lesion is supposed to be in the papillo-macular bundle of the optic nerve, and our hypothesis! is that this nerve is · susceptible to attack of possibly a toxic substance in the presence of vitamin B complex deficiency. Apparently this injurious process does not operate so fre· quently in frank, uncomplicated beriberi, i. e., when the signs of B1 deficiency are prominent and unmistakable, and without concomitant ariboflavinosis. This view seems to be supported by our hospital statistics which show that rarely did our uncomplica·ted beriberi patients complain of poor vision. Our hospital figures show only 8 cases of infantile beriberi were observed in 1942, and not a single case from January to September, 1943. With regard to adult beriberi, there were 112 cases out of a total admissions of 36,891, or 0.3% from January 1940 to September 1941 as against 16 cases out of a total admissions of 20,424, or only 0.078% from January 1942 to September 1943. As to pellagra, 9 cases were recorded in the hospital during the former period, or 0.02%; and 3 cases, or 0.01% in the latter period. One striking feature noted during 1he period covered by this report is that there were relatively fewer cases of infantile beriberi, adult beriberi, and pellagra admitted to the hospital, but very frequen1 occurrence of cases of B complex deficiency in adults was noted in our out-patient service. What is the nature of this injurious attack to the optic nerve? Veasey, (citing reports of Yudkin, Carrol, Goodhart, Johnson, Laval, Buschke) says that •toxic amblyopia occurs by action of certain poisons on the optic nerve when the threshold has been lowered by avitaminosis B and can be cured by taking the latter. Veasey also mentioned Shastid as reporting in 1929 two cases of optic neuritis cured promptly by B complex and Soga (cited by Buschke) who reported an outbreak of the so called beriberi amplyopia (now known as chronic retrobulbar neuritis) in Japan. It is unfortunate that we have no access to the current Japanese medical litera·ture, owing to language difficulties. It is to be remembered tha1 the Japanese pioneered in the investigation of ocular lesions in beriberi. In connection with this unusual frequency of cases of B complex avitaminosis during the war, we should like to quote Spies and his associates: "During the past ten years, from our studies of deficiency diseases in human beings, we have a0<;umulated evidence which shows that pellagra, beriberi, and riboflavin deficiency are clearcut clinical syndromes which frequently co-exist and often are associated with other nutritional disorders. This is not surprising, since in natural foodstuffs the watersoluble vitamins are often closely associated and a diet deficient in one chemical substance is almost certain to be deficient in others." With regard to the visual defect observed in this epidemic, it is consoling t() state that we did not see a single case of blindness or atrophy of the optic nerve. This is probably due ·to the fact that the deprivations did not last long. What is the pathology of 1he nerve lesion? We cite Vedder who, in discussing the degenerative changes in the peripheral nerves, said that in most cases these degenerative changes are not to be regarded as complete. This would mean the death of the cell, from which there could be no recovery; but they do indicate a very complete exhaustion of the affected parts. Degeneration of the myelin sheath Volume xx11 DEFICIENCY OF VITAMIN B COMPLEX-Fernando et al 105 Number I is constant, according to him, but the majority of the nerve cylinders appear normal, even when ·the medullary sheath shows advanced degeneration. At this juncture, we would like to say a word or two about the diminished sensibility of the cornea and conjunctiva in many of our pa·tients. Many also com· plained of numbness around the mouth which completely disappeared when the patient recovered. Recently we saw a beriberi patient with paralysis of the left vocal cord. She complained of numbness around the mouth, but no complaint in the eyes. But when the corneal sensibility was tested, it was found much diminished. We explain these findings by changes in the terminal branches of the trigeminal nerves supplying those parts, the impairment of function being due not to complete dege· nerative change but as "complete exhaustion of the affected parts of the nerve." As we have stated elsewhere, the corneal lesion is probably due to mild B" avitami• nosis. The circumcorneal injection and the new vascularization in the cornea that came to our attention were not so extensive as those described by Sydenstricker and his associates. No iris changes were observed. Seborrhea of the nasolabial folds and face were not frequent; the burning sensation in the tongue was not frequently com· plained of. Hbwever, Sydenstricker and his associates did not mention any co·existing retrobulbar neuritis. In our cases, we suspected this whenever the dimness of vision was altogether out of proportion to the corneal opacities present. We noted that case No. 8 in their series' had a vision of only 51200, but no mention was made whether scotometry did not reveal a central scotoma. Likewise, the findings of the Japanese investigators on the cases of retrobulbar neuritis as noted by Elliot did not mention any co-existing superficial vascularizing keratitis. We do not know what the current medical literature of Japan says regarding this point. With resp~ct to nicotinic acid deficiency in B complex avitaminosis, we can say that some cases of glossitis we encountered might be attributed to the former. It is claimed that if the tongue is scarlet red and denuded and if the papillae are atro· phied, the deficiency must be in the nicotinic acid; whereas if the tongue is clean, purplish red or magenta, and frequently fissured, and if the papillae are large, flat· tened · or mushroom-shaped, and with "scalded" feeling at the tip, the deficiency must be in the riboflavin. We have described in this report an epidemic of eye diseases, the probable cause of which might be ascribed mainly to multiple vitamin deficiencies brought about by very low intake of food. We have not seen a similar epidemic before, nor has one ever been reported in the Philippines. Cases similar to these affections have appeared sporadically in our clinics, but they have been few. One of us (A. S. F.) treated a case of retrobulbar neuritis of this type a few years ago, the record of the case being as follows: Free Dispensary Case No. 379: D. E. 20 years of age, examined on January 13, 1935. Husband, a chauffeur. Complained of foggy and dim vision of 3 months duration, without either pain or redness in the eye; also of numbness of the extremities. These symptoms appeared soon after delivery. First para. Child healthy; breast•fed; was given extract of ·tikitiki as a preventive measure. The vision was counting fingers 12 feet in the right eye and I 0 feet in the left. Fundus, normal. Visual field not contracted. A definite absolute central scoto• ma in both eyes present. Corneal sensibility, normal. Knee·jerk, normal. 106 DEFICIENCY OF VITAMIN B COMPLEX-Fernando et 11! Jour. P. 111. A. March, 1946 Treatment consisted of balanced diet, but particularly rich in vitamin B1; also strychnine. Recovered. Ocular manifestations of avitaminosis have long attracted our attention, and papers on this subject have appeared from time to time. •. " But our work had always encountered a stumbling block : the determination of the specific vitamin deficiency responsible for the particular eye lesion. The same difficulty impeded our progress in this present investigation. Foremost obstacle was the lack of modern laboratory facilities for the estimation of the different vitamin content of the blood or urine, particularly of the vitamin A. Biophotometry is no longer reliable. The clinical findings should be carefully checked for the amount of the vitamin A in the blood. Etiologic diagnosis is difficult to make with a certain degree of assurance when the deficiency is of mild degree, because the clinical picture is not clearcut in many cases. When B2 deficiency is too pronounced, it has been claimed by Sydenstricker that it is possible to recognize it more easily than others on account of the specific lesions of the eye which occur early in the period of deficiency. This claim has been confirmed by us in a few cases. There are probably other factors contributing to the development of these clinical hypovitaminosis, since other members of the patient's family did not necessarily manifest the known clinical syndrome even if all the members of that family ate practically the same kind of food and in proportionately the same amount. It is possible that the others may develop sub-clinical state and that some precipitating factors may cause the sudden appearance of the recognizable characteristic manifestations of the particular disease any time. With respect to the therapy, we share the general conception that by the administra·tion of a balanced and 0liberal diet particularly rich in the vitamins in which the patient is supposed to be deficient, we take advantage of the synergestic relation between vitamins-i. e. one influencing others favorably. Patients in our service who could afford it were asked to supplement the prescribed diet with synthetic vitamins, particularly with the vitamin B complex. Extract of tikitiki was also recommended. As adjuvants, medical diathermy was tried, but we are not in a position to assert how much benefit, if at all, was derived from it. SUMMARY AND CONCLUSION We have reported here an outbreak of nutritional eye disease associated with multiple vitamin deficiencies. This seems to be the first epidemic of this nature ever reported in this country. The chief complaint was dimness of vision in both eyes, the cause of which was : (!) chronic retrobulbar neuritis or (2) superficial vascularizing keratitis or ( 3) both affections co-existing. The patients invariably gave the history of having subsisted for some time on very deficient diet-deficient both in quantity and in quality. They were on the whole healthy up to the time. of onset of their complaint. Adult males and females were attacked. In females, pregnancy and lactation were predisposing factors. In many patients associated signs and symptoms of vitamin B complex defif iciency were observed-namely, angular stomatitis, glossitis, numbness around the mouth. hyperesthesia or hyposthesia in the extremities, and other manifestations. The retrobulbar neuritis was probably brought about by several known and unknown causes but mainly by the deficiency of the B1 factor and especially of t~e Volume xxn DEFICIENCY OF VITAMIN B COMPLEX-Fernando et al 107 Number 3 vitamin B complex: Likewise, the superficial vascularizing keratitis was brought about by similar mechanism-the deficiency of the B2 factor of the same vitamin B complex playing a predominant role. The essence of the treatment was the administration of a well-balanced and liberal diet, especially rich in vitamins that were suspected to be insufficient. Prompt response was noted. In those cases in which a: let·up in the liberal dietary regime could not be helped owing to economic reasons, relapse occurred. The outbreak of the epidemic commenced soon after the war, reaching the maxi· mum height of incidence about December 1942 and practically disappeared about the end of September 1943. The cause could be traced to the sudden dislocation in the suppl}' of foods and the poor economic conditions of the masses occasioned by the na· tional emergency. Unfortunately, no laboratory tests were employed for the estima· tion of the different vitamin content of the blood or urine to check the clinical diag· nosis of hypovitaminosis. It was, therefore, found necessary to establish this diag· nosis by dietary trial. Since satisfactory results appeared promptly after dietary therapy alone, the presumption of a deficiency disease was considered verified. We conclude this report by emphasizing that there is a great necessity for con· tinuing the study of nutritional eye diseases in collaboration with the internist, the neurologist, the nutritionist, and the pathologist. There is likewise an imperative need of recommending to the public a balanced diet that is both easily available and within the reach of even the poorest in order to help forestall future outbreaks of serious epidemics of deficiency diseases in the face of sudden and unexpected national emergencies that may disrupt the adequate supply of foods for the masses. BIBLIOGRAPHY I. Elliot, Robert H., 'Tropical Opfvthalmology. Oxford Medical Publications, London, 1920. 2. Sydenstricker, V. P., Sebrell, W. H., Cleckley, H . M., Kruse, H. D., 'The Ocular Mani· festalions of Ariboflavinosis. A Progress Note. )our. A. M. A. l 14:2437·~445, (June 22) 1940. 3. Kruse, H. D., Sydenstriker, V. P., Sebrell, W. H., Cleckley, H. M.-Ocular Man ife.<ta· tions o~ Ariboflavinosis.-Pub. Health Rep. 55 : 177 (Jan. 26) 1940. 4. Pillat, A.-Keratomalacia in Adults. Arch. Ophth. 2:257 (1929) . Ibid : Does K!ratomalacia Exist in Adults.?-Arch, Ophth. 2 :256, (Sept. 1929) . S. Gordon, Edgar S., and Sevringhaus, Elmer, L.: Vitamin 'Therapy in Gerteral Practice. The Year Book Publishers, Inc. Chicago, 1940. 6. Ve•sey, C. A. (Jr.) Vitamin Bin Ophthalmology. Arch. Ophth. 25:450 (March) 1941. 7. Spies. Pdlagra. Beriberi and Riboflavin Deficiency in Human Beings. Diagnosis and 'Treatment. J. Amer. Med. A'5oc. I J 3 :931 (Sept.) 1939. 8. Vedder, E. B.;_'The Pathology of Beriberi. 'The Vitamins, A. M.A. p. 179, 1939. 9. Ubaldo, A. R. Amblyopias despues del Embarazo. Rev, Fil. Med. y Farm. Jan. 1919. 10 . Fernando, A. S. 'The Eye in Beriberi. Amer. )our. of Ophthal. 6:386·3881 1923. 11. Fernando, A. S. Observations on Fundus Lesions Among Filipinos. Amer. Jour. of Ophth. 7,203·2C'7, 1924. 12. Ayuyao, C. D . Corneal Lesions in B<riberi. )our. P . I. Med. Assoc. 13:153·161 (March) 19ll. 13 · Ocampo, G. de. and Crut, ). N., Dar~ Adaption in Adult Beriberi. Acta Medica Filipina. 2:175· 188 (Oct.) 1940. ?4 . Ocampo, G. de .. Epithelial Corneal Dystrophy Due to Hypovitaminosis. Acta Medica Fili• pina/ 3: 105·124 (July·Sept.) 1941. SIMPLE QUALITATIVE TESTS FOR ADULTERANTS IN FRESH MILK SEGUNDINO G. )AO, B.S. CHEM .• M.D., M.P.H. Medical Offic<T, Manila Health Department INTRODUCTION Milk is considered to be the best single food. Its high nutritive value is due to the fact that it contains in the right proportions the essential elements of a balanced diet. It is rich in some vitamins. The quality of the protein is especially good for body building. The fat content favors growth. And it has high calcium content in readily usable form. Milk is considered a protective food against certain deficiency dis· eases when used in combination with other foodstuffs. Furthermore, milk is very palatable and readily digestible. On the other hand, milk may cause illness and even death when contaminated with pathogenic micro·organisms or with poisonous chemical substances. Contamination of milk with harmful bacteria is rather common, as shown by reports of epide• mies of typhoid fever and other diseases traced to contaminated milk. Of all the foodstuffs, milk is perhaps the most difficult to harvest, handle, transport, and deliver in a clean, fresh, and satisfactory state. Due to the high cost and scarcity of fresh milk in the Philippines, adulteration of milk is still frequently practised by unscrupulous dealers. Adulteration is always objectionable, because it lowers the nutritive value of milk and so changes its compo· sition as it make it less easily digestible. The danger of this practice is great, because of the facility with which milk may be contaminated with pathogenic bacteria during the process of adulteration. PURPOSE AND SCOPE OF THIS PAPER This paper was written in response to the request of Dr. M. C. Icasiano, City Health Officer, to provide simple qualitative tests for adulterants in fresh milk, which can be performed easily in the field especially in the provinces where elaborate labora· tory equipments are not available. The simple tests for adulterated fresh milk are based mostly on accepted standard chemical procedures and partly on the past experiences of the author as a chemist analyst of the Food and Drug Laboratory of the government. FORMS OF ADULTERATION OF FRESH MILK The most common methods of adulteration of fresh milk as found in samples sub· mitted to the government Food and Drug Laboratory are the following: (I) watering with or without the addition of sugar, (2) watering with the addition of starch and sugar, (3) addition of diluted coconut juice to fresh milk with or without the addition of sugar. Less common forms of adulteration of fresh milk encountered in laboratory sam · 110 ADULTERANTS IN FRESH MILK-Jao Jour. P. M. A. March. 1946 pies include the following : (1) addition of soya bean milk with or without sugar, (2) use of yellow coloring matter to diluted milk, (3) remova.l of some of the fat content by skimming, ( 4) use of chemical preservatives to retard the decomposition of. the milk, and (5) use of alkalies to neutralize acidi·ty due to the souring of milk. The main object of the milk dealers in adulterating fresh milk is to increase the volume for bigger profit and to simulate as much as possible -the normal physical char· acters of fresh milk. The use of impure water, dirty bottles, and cans contaminates the milk and renders it very dangerous to public health, as the adulterated milk is usually not sterilized before it is sold to the public especially in rural communities. QUALITATIVE TESTS FOR ADULTERANTS IN MILK I . Addition Of Water Or Watering : Watering may be detected because it lowers the specific gravity of the milk. The specific gravity of milk is usually determined by a simple instrument known as the lactometer. In its fresh state, the specific gravi·ty of pure cow's milk varies from 1.027 to I . 035. The specific gravity of carabao's milk varies ftbm 1.030 to 1.035 while that of pure goat's milk is from 1.028 to 1.036. The determination of specific gravity is useful in detecting the adulteration of milk by simple dilution of the milk with water which lowers the specific gravity. Skimming of milk or removal of butterfat also lowers the specific gravity. However the addition of sugar or starch or any other substance which increases the total solids tends to raise the specific gravity. When milk is diluted or skimmed or when other substances are added to it, specific gravity test alone is not a reliable test for the addition of water. 2. Cane Sugar In Fresh Milk: Cane sugar is often used to increase the total solids in milk; and, if it is present to any marked degree, it can hardly fail detection because of the sweet taste imparted to the milk. Cane sugar in milk may be detected by boiling for a few minutes 5 to 10 cc. of the sample with about 0.1 gram of resorcin and a few drops of hydrochloric acid. If cane sugar is present, the milk becomes rose·red. 3. Starch In Fresh Milk: Heat about 5 cc. of the milk in a test tube to boiling, cool, and add a drop of iodine solution containing potassium iodide. A blue color indicates the presence of starch. 4. Coconut Juice In Fresh Milk : Evaporate to dryness about 20 cc. of the sample in a porcelain casserole on a water bath. Remove the casserole from the water bath and heat directly over a flame. A characteristic "copra" odor indicates the presence of coconut juice. 5. Soya Bean Milk In Fresh Milk : Evaporate to dryness about 20 cc. or more of the sample in a porcelain cas· serole on a water bath. While still hot, note the color. A characteristic "soya bean cake" odor denotes the presence of soya bean milk. 6. Yellow Coloring Matter (caramel or burnt sugar, annatto or achuete, anilin orange, etc.) In Milk: Place about one-half glassful of the sample in a porcelain casserole. Add a Volume XXII Number 8 ADULTERANTS IN FRESH MILK-,/ao 111 few drops of acetic acid and heat over a flame. Remove the supernatant fluid by decantation. Press the curd to remove as much water as possible and transfer the curd into a flask, add ether and allow it to soak for several hours. A brown curd indicates the presence of caramel. A bright orange curd de· notes the presence of "Anilin Orange," a coal tar dye. Evaporate the other extract on a water bath to dryness. Allow it to cool. Alkalinize it with a little sodium hydroxide solution, and pour it through small wet filter. On washing off the fat from the filter paper with water, an orange color on the paper indicates the presence of Annatto or achuette. 7. Chemical Preservatives In Milk: (a) Boric Acid : I 0 cc. of the milk: sample is thoroughly mixed with 6 drops of con· centrated hydrochloric acid, after which turmeric paper is moistened with the mixture and dried. A brownish color of the turmeric paper denotes the presence of boric acid. (b) Benzoic acid and Salicylic acid: Shake 5 cc. of hydrochloric acid with about 50 cc. of the milk in a flask. Then add one•half glass of ether, cork the flask, and shake it well. Ex· tract the curdled milk with several portions of ether, avoiding the formation of an emulsion. Transfer the ether extract to a separatory funnel and shake with diluted ammonia water to take out the benzoic acid from the fat as ammonium benzoate. Evaporate the ammonia solution in a dish over a water bath till all free ammonia has disappeared. But before getting to dryness, add a few drops of ferric chloride solution. A characteristic flesh·colored precipitate indicates benzoic acid. A violet color precipitate denotes presence of salicylic acid. ( c) Formaldehyde: Add about I 0 cc. of commercial hydrochloric acid containing a few crystals of ferric chloride to an equal volume of the milk sample in a porcelain casserole and heat slowly over the free flame nearly to boiling, giving it a rotary motion to break up the curd. The presence of formaldehyde is indicated by a violet coloration varying in depth with the amount present. Remarks: The use of chemical preservatives or alkalies in milk is not allowed by law. The best milk preserva:tives are cleanliness and refrigeration at a tem· perature below 45°F. 8. ALKALIES (Sodium carbonate and Sodium Bicarbonate). Evawrate to dryness about 25 cc. of the sample in a porcelain casse· role on a water bath. Heat the residue over a flame until reduced to ash. Allow to cool and add a few drops of hydrochloric acid. Effervescence denotes the presence of carbonates. SUMMARY 1 . The most common methods of adulteration of fresh milk in the Philippines include the following: (a) watering with or without the addition of sugar; (b) watering with the addition of starch (thickening agent) and sugar; and (c) addition of di· luted coconut milk with or without the addition of sugar. 112 ADULTERANTS IN FRESH MILK-Jao Jour. P. M. A. March, 1946 2 . Less common forms of adulteration of fresh milk are the following: (I) addition of soya bean milk with or without sugar, (2) use of yellow coloring matter in di· luted milk, (3) removal of some of the fat content by skimming, (4) use of chem· ical preservatives to retard the decomposition of milk, and ( 5) use of alkalies to neutralize acidity due to souring of the milk. 3. Simple qualitative tests for adulterants in fresh milk based on accepted stand· ard chemical procedures and on the past experiences of the author as a chemist• analyst, are compiled in this paper. 4. These tests which require no elaborate equipments can be performed easily in the field by medical officers, sanitary inspectors, and nurses. BIBLIOGRAPHY I. American public health association. Standard methods of mi~ analysis. 6th ed. N. Y. Pub. by the association. 2 . Association of offjcial agricultural chemists. Tentative methods of analysis. 3rd ed. Wash. D. C. Pub. by the association, 1930 3. Jao, Segundino G. and Jesus, P. de. Studies of adulteration of fresh cow's milk with coconut juice. JouTnal of the Philippine Isl4'tds medical association, Feb. 1936. V. 16, No. 2, p. 75·90. 4. Leach, Albert E. food inspection analysis. 4th ed. N. Y. John Wiley & sons, 19l5 ~ALL BLADDER DISEASE: AN ANALYSIS OF CASES IN THE NORTH GENERAL HOSPITAL' PABLO MORALES, M. D. AND FRANCISCO GUZMAN, M.D . Department of Surge,.y, North General Hospital Exactly what constitutes gall bladder disease is in many instances still a very debatable point. For the sake of convenience, we have included under this entity cholecystitis, gall stones, and ascaris in the biliary tract. These conditions are so in· timately associated both clinically and pathologically that a discussion of one neces• sarily involves the others. Cholecystitis may originate independendy of gall stones, or gall stones may cause cholecystitis, but we believe that ascaris in the biliary tract is almost always secondary to a preceding pathologic disturbance in the biliary system. MATERIAL The material for this work was derived chiefly from the case records of pa· ~ients in the Department of Surgery in the North General Hospital from the time of its establishment in February, 1945 to January, 1946. The charts of the surgical patients were carefully reviewed and those that seemed to come within the scope of this study were sorted out. Only those charts where the diagnosis were fully warranted by the presence of definite signs and symptoms of the disease or where the diagnosis were verified by operation were utilized. These patients were admit· ted for gall bladder disease, cholecystitis, empyema, biliary lithiasis, ascaris in the common bile duct, and in a few as cases acute abdomen. For purposes of this study, we have decided to divide our cases into: (1) Operated cases and (2) Non-operated cases. It should be mentioned and understood that when a case is admitted to Surgery, there is always the belief or at least the possibility that a surgical intervention is contemplated. Hence a patient with only a mild attack of gall bladder disease is referred to the Medical Department and only those with severe attacks are admitted to Surgery. If a patient is not operat· ed on, it signifies either that the attack has subsided and the doctor thinks that an operati~n is not necessary for the time being, or simply that the patient has stubborn· ly refused to submit to an operation in spite of the surgeon's attempts to persuade him . It has been_our observation, however, that usually the attacks in patients who refuse to submit to an operation are not so violent, for a really severe attack usually does not give the patient a chance to be stubborn. Instead he usually urges the surgeon to perform the operation. INCIDENCE During the twelve months of the hospital's existence, we have admitted 78 pa· tients with gall bladder disease to Surgery-all candidates for surgical intervention. ' Read at the Sta£! Clinical Conference of the North General Hospital, January 28, 1946. 114 GALL BLADDER DISEASE-Morales, et al Jour. P. M. A. March, 1949 Of these, 3 8 were operated on and 40 were not. (34%) were males and 25 (66%) were females. (32%) were males and 27 (68ro) were females. Of the 38 operated cases, 13 In the non-operated cases, 13 It will be noted that there have been about 2 times as many women as men in this series. Patients have ranged in age from 14 years to 71 years, although the greater number of cases have been found to be in the third decade of life. In studies on the occurrence of gall stones, one of the few facts on which almost all authors are agreed is that women are more susceptible to gall stones than men. This conclusion is one of the outstanding features encountered in any review of publications about gall stones. Fallis and McClure reviewed 320 cases of acute cholecystitis and found that the disease occurred twice as often in females as in males. Judd and Philliphs reported 508 consecutive patients which came to operation, 40 per cent of whom were men. Among patients in the Mayo clinics, women's susceptibility to the formation of gall stones when compared with that of men gave the proportion of 1.8 to 1; and, in a combined summary of reports of similar statistics from 22 writers, this proportion was found to be 2.2 to 1. We are all familiar with the phrase "fair, fat and forty" and "flatulent, fecund, female", which has been emphasized by many as being the "characteristic type" in patients with gall bladder disease. Although it is true that we have found a preponderance of these patients in females, we re• gret to report that we have not seen patients who may come under the classification of "fair". Furthermore, we have found not infrequently the occurrence of this disease in emaciated individuals. Why female patients in middle life are so prone to have gall stones has baf· fled the imagination of all investigators. The usual explanation offered for this fact has been that pregnancy favors the occurrence of gall stones (the majority of women in middle life have been pregnant). However, it is also a common observation that one may get gall stones without being fat or pregnant. The literature on the formation of gall stones is top-heavy with hypotheses, and the laiit word on the subject has not yet been said. HISTORY AND SYMPTOMS In the group of operated cases, a history of symptoms which had something to do with the biliary tract and which appeared prior to the attack under treatment was given by 35 patients. Only three definitely denied such symptoms. In the non·operated group, one half of the patients made no mention of any previous biliary sympt.oms or denied such symptoms. Many of the patients gave a history of gall bladder disease extending for many years, but the great majority could hard· ly recollect when the symptoms were first noticed. They could say "since childhood" or "even before she was married". The duration of the present attack frqm the time of its onset to the time of admission ranged from a few hours to an indefinite period of over a month. The average duration for the operated cases was 4.5 days and for the non-operated cases 2.5 days. All these cases have a common clinical character. The pain is typical and pathognomonic. It usually begins more or less suddenly in the epigastrium or right upper quadrant of the abdomen and is projected to the right back and shoulder . . At Volume XXll Number 3 .GALL BLADDER DISEASE-Mo,.ales, et al 115 the height of each seizure, the patient doubles up and writhes in agony as the pain increases in ferocity. It is at this stage usually that a patient pleadingly asks that he be operated on. A measure of relief is felt when liberal doses of morphine are given. The pain may cease as suddenly as it began after a few minutes or hours, . but the usual sequel is marked residual soreness in the region of the gall bladder for several days. In our series, we have found the pain of the biliary colic to be commonly localized at the right hypochondrium in 50% of the operated and in 670/o of the non·operated cases. A large number had localizations in the epigastrium. In 26 % of the operated cases, there was a radiation of the pain to the back and right shoulder; this was found in 10% of the non-operated cases. We have found accompanying chills and fever a rather frequent symptom, being present in 55% of the operated and in 12.5 % of the non-operated cases. Such a history was obtained by Steinke in 7 % of his group with acute cholecys• titis. Nausea and vomiting were present in many cases-in 34% of the operated and in IS% of the non-operated cases. Taylor found that 88% of his series of gall bladder disease experienced either nausea or vomiting. Nausea was noticed by Fallis and McClure in 91 % and vomiting in 83% in patients with acute cholecys· ti tis. A history of jaundice was given in 21 % of the operated and in 2.5% of the non-operated cases. A history of passing out ascaris was given by 10% of the patients in both series. The possibility of an ascaris lodging in •the biliary tract and causing the acute obstructive symptoms is entertained whenever such a history is elicited. Tenderness in the right hypochondrium has almost always been present, being elicited in 92 % of the operated and in 80% of the non-operated cases. As much as possible, Murphy's method of demonstrating tenderness of the gall bladder has been followed-hook the fingers well up under the liver and tell the patient to tak~ a deep inspiration. On inspiration, the pain becomes acute; and respiration is usual· ly interrupted. The majority of patients in the operated group had high temperature-38 . 5 to 39 C.; those in the non-operated group, 37 to 37.5 C. The white blood cell count in the operated group was high-50 o/o had I 0 to 15 thousand; in the non-operated group - 55% had 6·10 thousand. TREATMENT In our series, 44 operations were performed-IO cholecystectomies, 12 chole· cystostomies, 11 cholecystoduodenostomies, 8 lithotomies, and 3 removal of ascaris. During the early days of the hospital, most of the operations on the biliary tract were chotecystoduodenostomies. This was due to the influence of one of the consulting surgeons, Dr. Estrada, who advoca•ted the conservation of the gall blad· der in the belief that if the gall bladder is saved, it may still regain its normal function, and that the creation of a detour for the flow of bile will obviate the re· sultant bad effects should there be. a subsequent obstruction in the common bile duct. · Our present procedure is to remove the gall bladder. It is our belief that the gall bladder is the mischief-maker in the biliary tract. The troublous gall stones come from it. It is logical to remove the cause of all the trouble. We do not 116 GALL BLADDER DISEASE-Morales, et al Jour. P. M. A. March, 1946 believe in anastomosis because, first-we repeat-it does not remove the cause of trouble (the diseased gall bladder is more of a liability than an asset) ; and second, we feel that the bile will always try to follow its natural route and soon the anasto· motic opening will contract and finally close up from disuse. In fact, one of patients who came here for empyema of the gall bladder had already had his gall bladder anastomosed to the duodenum, but the opening was no longer working and he had ·developed multiple stones and cholangiectatic abscesses.' It will be noticed that we have a big number of cholecystostomies, because the condition of the majority of our patients has demanded the adoption of the safest procedure possible. We always reserve cholecystostomies for cases in which exci· sion or removal of the gall bladder would be too hazardous or in which the patient's condition warrants on1y the simplest procedures possible under the circumstances. This is, of course, not meant to be a substitute for cholecystectomy. As much as possible, we try to perform a subsequent cholecystectomy when the condition of the patient makes it permissible. To recapitulate, in treating gall bladder diseases, we first perform a cholecystecto· my. Together with this, we always do a choledochostomy-opening and draining the common bile duct-in order to explore the bile duct thoroughly. The surest way to do this is to make an incision in the anterior wall of the supraduodenal por· tion of the common bile duct and thoroughly to explore the bile ducts from within with scoops, with probes, or even with the fingers. After this, a tube is inserted to· wards the liver to provide external biliary drainage. In our operated cases we have found gall stones in 78% of the cases, non· calculous cholecystitis in 26%, and ascaris in·l8o/c. There were three (7%) cases of perforation of the gall bladder. Two (5% ) cases were doubtful; but, because of the history of recurring colics, they were labelled as biliary dyskinesia or dysyner gia. A few words should be devoted to the finding of ascaris in the biliary tract. The ascaris, like its distant cousin the schistosoma, has been known to be one of the most erratic creatures inhabiting the human host. It has been reported in places distant from its native habitat. There are reports of its being found in the com· mon bile duct. In our study of the gall bladder disease, we have found an un· usual frequency of these visitors in the common bile duct. This naturally raises the question: Does the presence of the ascaris in the common bile duct necessarily signify a pathologic condition of the biliary tract, or is the ascaris found in the common bile duct simply because it had the urge to get into a "tight hole?" We know that the gateway to the biliary tract is protect· ed by a powerful sphincter-the sphincter of Oddi. We hesitate to imagine what would happen to the poor ascaris should it ever be caught in the grips of the sphinc· ter of Oddi. Naturally, we cannot help thinking that the only time that the ascaris, with the little intelligence that nature has given him, will ever endeavor to get into the common bile duct is only when the sphincter has ceased to be a 1 On March 1, 1946, we rcoperatcd one of the lir~t patients in this series, a female p.i:!.ticni upon whom a cholecystoduodenostomy was done by Dr. Franco after removal of stones in the common bile duct. The gall bladder was distended and still joined to the duodenum. The gall bladder was opened and not even a pin•point anastomotic opening with the duodenum existed. Another stone was found in the c. b. d. Volume XXJI Number a GALL BLADDER DISEASE-Morales, et al 117 menace. Such a thing is possible when there is a pa·thologic disturbance in the biliary system; i.e. the opportune moment for the ascaris to invade the biliary sys· tern is when the ravages of an inflammatory condition has made the sphincter of Oddi powerless to prevent its intrusion. This belief has been substantiated by our finding in this series. We have found that in all the cases where an ascaris has been surprised lurking in the common bile duct, there has always been an accompanying pathologic process in the biliary tract ranging from advanced cholecystitis, multiple calculous formations, to slight inflammatory conditions of the gall bladder-where the organ has lost its normal bluish-green translucency. We have also further observed that these cases give histories of recurring biliary colics for durations beyond the usual expected life span of the ascaris. There has been a wide diversity of opinion regarding the opportune time for operation in the gall bladder disease-unlike in acute appendicitis. Many well-known surgeons advise immediate operation for acute cholecystitis. On the other hand, :here are those who advocate delayed treatment. The proponents of immediate operation regard cholecystitis in the same light as acute appendicitis-where the danger of a perforation and peritonitis is ever-present. The advocates of delayed operation contend that such complications in ·the gall bladder disease is rare, and that after an expectant treatment, the patient becomes a better risk. We feel that no hard and fast rule can be laid down. In some cases, an early operation is advisable; while in others, delay is clearly indicated. Each case should be considered as an individual problem. When a case comes with an unduly large tense gall bladder palpable, suggesting that perforation is imminent, we lose no time in ·performing an operation. In our series, we have come across three perfora· :ions and in one, we bad reason to believe that the perforation had occurred because there had been a delay of one day in the operation. Inasmuch as most of our cases come after 48 hours from onset-in other words, it is already a little late for an early operation-we feel that the proper attirude would be towards a delayed operation, in order to be able to prepare the patient and make him safe for surgery. We have, in some cases, been forced to abandon this attitude, however, because we can almost anti· cipate that such patients will refuse to submit to an operation the moment there is a relief from his symptoms. In our series of operated cases, we had three mortalities. All these cases were cholecystostomies and were very poor surgical risks from the time of admission. SUMMARY An analysis of 78 patients with gall bladder disease admirted to the surgical de· partment of the North General Hospital was made. These cases were divided into the non-operated cases (40) and the operated cases (38). There was an incidence of twice as many female as male patients: Cholecystectomy and choledochostomy was the procedure of choice in this series. Unless there were signs of imminent perforation and therefore resultant peritonitis, the patients were usually subjected to a preoperative regimen designed to build them up. A high incidence of ascaris in the common bile duct was noted. It is believed that the presence of ascaris in the common bile duct signifies a preceding pathology in the biliary system. 118 GALL BLADDER DISEASE-Morales, et al Jour. P. M. A. March, 1946 BIBLIOGRAPHY 1. Blomber, N . and Zisserman, L.: Acute .mpparative and gangrenous cholerystitis. Arn. Jour. of Surg. Oct. 1945 2., Chri•topher, F.: A t<xtbop>/t of surgery. 1942 3. DaCosta, F.: Mode,.. Surgery 4. Graham, H.: Trerttment of acute and chronic cholecystiti.o:. Surg. din. of North America . .'l.pril, 1940 5. L:ihey, F.: Acute and chronic cholt"Cy.uitis. Sur~. clin. of North American. April, 1940 TABLE 1.-Incidence of Gall Bladder Disease Operated Cases (38) Non-Operated Cases (40) Age Male (13) Female (25) Female (27) No. of Per Cent No. of Per Cent No. of Per Cent No. of Per Cent Cases Cases Cases Cases --- - - - 10-20 1 2.63 4 10 - - - - - - 21-30 3 7.90 6 15.79 5 12.5 9 22.5 - - - 31-40 5 13.60 7 18.41 5 12.5 9 22.5 - - - 41-50 1 2.63 7 18.41 1 2.5 2 5.0 --- --Above 3 50 7.90 5 13.60 2 5.0 TABLE 2.-History of Previous Attacks (Goll bladder Series N. ,G. H.) I 3 I 7.5 Occunence of Previous Attack Operated Cases Non-Operated Cases Male Female Male Female Total - Days 1 2 3 4 5 6 7 8-14 15-21 Total - - - --- --- ---None . 1 2 3 8 12 ------ - - - 'h-1 Year 2 8 10 2 6 --1-2 Years 3 2 5 3 --- ------- ---- - - 2-5 Years 1 1 2 --- ------ --- ---5-10 Years 1 3 4 1 2 --- -------- --Indefinite 6 9 15 1 3 TABLE 3.-Duration of Attack From Onset to Admission (Gall Bladder Series N. G. H.) Operated Cases (1) Non-Operated Cases Male F\emale Total Male I F\emale 1 2 3 7 8 1 1 2 1 ---1 3 4 1 10 2 8 10 2 4 4 8 3 3 4 7 1 1 2 1 2 ·----· 2 2 1 20 --8 3 --2 ---3 4 (2) Total 15 3 11 2 3 3 1 ---Over 21 1 I 1 2 2 (1) Average duration 4.5 days (2) Average duration 2.5 days Volume XXJI Number· 3 GALL BLADDER DISEASE-Morales, et al TABLE 4.-LocnlizMion of Pain (Gall Bladder Series N. G. H.) Operated Cases Non Operated Cases 119 Localization of Pain No. of Cases Per Cent No. of Cases Per Cent Right Hypochondrium Epigastrium Right Hypochondrium and Epigastrium Generalized 19 50.00 15 39.47 3 7.90 1 2.63 TABLE 5.-Signs and Symptoms (Gall Bladder Series N. G. H.) 27 67.5 11 27.5 1 2.5 1 2.5 I Operated Cases Non-Operated Cases Signs and Symptoms No. of Cases Per Cent No. of Cases 1 Per Cent Chills and Fever 21 55.26 5 Nausea and Vomitting 13 34.47 6 Jaundice 8 21.05 1 ----Ascaris 4 10.53 4 Tenderness 35 92.11 32 Radiation of Pain 26 68.42 4 Palpable Gall Bladd"'r 18 47.32 4 ·TABLE 6.-White Blood Cell Examination (Gau Bladder Series) 12.5 15.0 2.5 10.0 80.0 10.0 10.0 White Blood Cells Operated Cases Non-Operated Cases No. of Cases Per Cent No. of Cases Pier Cent 6-10 Thousand 10-15 Thousand 15-20 Thousand - Above 20 12 39.47 22 19 50.00 13 3 7.9 5 1 2.63 TABLE 7.-Temperature on Admission (Gau Bladder Series N. G. H.) 55 32.5 12.5 ----·-'11emperature Operated Cases Non-Operated Cases Male Female Total Male 37-37.5 4 7 11 7 37.5-38 4 6 10 2 38.5-39 5 12 17 1 39.5-40 - 3 TABLE 8.-0perations Performed (44) (Gall Bladder Series N . G. H.) OPERATIONS No. of Cases CHOLECYSTECTOMY 10 CHOLECYSTOSTOMY 12 LITHOTOMY 8 CHOLECYSTO-DUOJ;lENOSTOMY 11 REMOVAL OF ASCARIS 3 Female Total 13 20 6 8 3 4 5 i 8 Pier Cent 22.73 27.27 18.18 25.00 6.82 120 GALL BLADDER DISEASE-Moi·ales, et al OPERATIVE Stones Gall Bladder Common Bile Duct Combined ASCARIS TABLE 9.-0peralive Findings (Gall Bladdei· Series N; G. ii.) FINDINGS No. of Cases 10 11 ·2 7 NON-CALCULOUS CHOLECYSTITIS 10 PERFORATION 3 BILIARY DYSKINESIA 2 TABLE 10.-Coinparative Mortality (Gall Bladder Series N. G. H.) AUTHORS Cholecystostomy Cholecystectomy Blomberg and Zisserman 9.1% 20% J udd-Philiphs 48% 7% Guzman-Morales 6% 0% Jour. P. M. A. Marcb, 1946 Per Cent 26.32 28.95 6.26 18.42 26.32 7.9 5. 26 Total 29.1% 55% 6% INDEX OF, PHILIBPINE LITERATURE ON OPHTHALMOLOGY AND OTORHINOLARYNGOLOGY FROM 1892 TO 1941 (ARRANGED CHRONOLOGICALLY)' ANTONIO S. FERNANDO, M. D. Department of Ophthalmology and Otorhinolaryngology. College of Medicine, University of the Philippines 1892 GARCIA TORNELL, Mariano Establecimiento terapico·funcional Manila. Bercelona 'Tip. La Academia de Viuda e hijos de E. Ullastres y Cia. Ronda de la Universidad, 1891. 32 pages con laminas. 1905 MINER, C . J . Glaucoma among Friars. (Read by title in P. I. M. A. Annual Meeting, March 2, 1905) 1905 WOLLEY, P. G. Sarcoma of the Ciliary Body. A Case report. (Read by title at the Annual Meeting, P. I. M. A. March 4, 1905) 1906 HEISER, Victor G. The Progress of Medicine in the Philippine Islands. Jl. A. M. A. (1906) July, pp. 245·249. 1909 RUTHERFORD, H. H. (Capt. M. C., U . S. Army) Presentation of 4 cases of diseases of the internal eye. June meeting (Jun. 7) M.M.S. Case 1. Lenticular cataract of traumatic origin. Case 2. Detached retina. Cases 3 & 4. Neuritis or neuroretinitis. He gave a full history, methods of diagnosis, and indicated the line of treatment in each case. Bull. M.M.S. Vol. I, )\(o. 3, June 1909. 1910 CHAMBERLAIN, Weston P. Conjunctivitis. An Epidemic of Koch·\Veeks Bacillus Conjunctivitis among Filipinos. llull. M .M.S. May 1910, Vol. II. N.o. 5 pp. 92·95. 1910 ALBERTO, S. B. Dos Casos de Infeccion Ocular por la Linfa Vacuna. Rev. Fil.-Med. Farm. Vol. I, )\(o. 4 Oct. 1910. p. 219. (Read before Col. M·F. July 4, 1910) IN. B.-Becausc of the destruction of the libraries i1i Manila during the Battle of Liberation, the writer could not check this index and should there he some errors or omisfions, it is hoped that the readers will pardon him. As much as possible only those articles published or specifically mentioned in society transactions as read wcrd included. 122 INDEX OF PHILIPPINE LITERATURE Jour. P. M. A. 1910 NELSON, Kent (Capt., M .C., U. S . Army) Pharyngeal Syphilis Referring especially to the Diagnosis. Bull. M.M .S. Vol. II. )\(o. 7, July 1910, pp. 182-183. 1910 CHAMBERLAIN, W. P. (Major M.C., U.S. Army) Diphtheria in the Philippines. Bull. M .M .S. Vol. II. N,o. 7, July 1910, pp. 172-176 1910 BLOOMBERG, H. D. (Capt., M .C., U . S. Army) Vincem's Angina Bull. M .M.S . Vol. II. )\(o. 7, JuLy 1910, pp. 180-181 1911 SHAW, H. A . (Major, M .C ., U. S. Army) Treatment of Saddle-nose by Paraffin Injection. March, 1946 (Read before Manila Medical Society Meeting, May I, 1911.) See Bulletin M.M.S., May 1911, Vol. III, p. 91 1911 REMBE, R. Report on I 00 cases of tonsillectomy. Radical operation for cmpyema of sphenoid and frontal sinuses (prcsenta· ti on of cases) . Radical mastoid operation for extradural abscess. Two cases of parenchymatous keratitis treated successfully with "salvarsan". Some patients having xerosis conjunctivae, xerotic keratitis and xerophthalmia. Pointing out the frequency of this latter affection in the P.J., it was thought that there might be some relation between this and the high ratio of mortality amongst children due to marasmus. Meeting, Manila Medical Society, June 3, 1911. Bulletin, M.M .S . July 1911. pp. 126-127. 1911 SHAW, Henry A., (Major, M .C., U. S. Army) Visual Acuity and Rifle Shooting. Read before Annual Meeting P.I.M . A., 1911. 1911 LYSTER, Theodore C. Follicular Oonjunctivitis. A Common Disease in the Philippines easily Mistaken for Trachoma. Read before Annual Meeting, P .I.M .A., 1911. 1911 LYSTER, T. C. Presentation of Cases, Manila Med. S. meeting April 3, 1911. Case 1 : Abscess of frontal sinus ;nvolving inner canthus of left eye. " 2 : A pt. with small abscess at apex of petrous portion of left temporal bone. Both cases operated and were doing well. (See Bulletin, Manila Med. Soc. Vol. III. 1911, p. 76.) 1911 BREWER, Isaac A. Rhinal Myasis (Read by title. Annual Meeting P.I.M .A., 1911) 1912 ALBERTO, S. B. Trachoma. Su Profilaxia. Mem. y Com. 1• asamblea Regional de Me· dicos y Farmaceuticos, Feb. 7-8, 1912, p. 267. Volume XXII Nu~ber 3 INDEX OF PHILIPPINE LITERATURE 1912 UBALDO, A. R. 123 Report Preliminar sobre 200 Casos de Tonsillectomias. Memorias y Com. la Asamblea Regional de Med. y Farm. Feb. 1912. 1912 REMBE, R. Demonstration of Orbital Tumors. Meeting M.M .S. Feb. 5, 1912. (See Bull. M .M.S . Vol. IV, Feb. p. 38.) 1912 REMBE, R . Intra·orbital Tumors and their Operative Considerations. Read before Annual Meeting P.I.M.A ., Nov. 6, 1912. 1912 LYSTER, T. C . The Military Importance of Deviation of the Nasal Septum. Read before Annual Meeting, P.I.M.A., Nov. 7, 1912. 1913 UBALDO, A. R . La Operacion de Kronlein en los Tumores Intraorbitales. Rev. Fil. de Med. y Farm. Vol. IV, No. 4, April 1913. 1913 UBALDO, A. R. Algunas Lesiones Inflamatorias de la Laringe, su aspecto anatomo·pato· logico y su relacion con la tuberculosis pulmonar. Rev. Fil. de Med. y Farm. April, 1913, Vol. IV, No. 4, pp. 229·234. 1913 MONTES, Jose E. Sueros y Afecciones Oculares Rev. Fil. de Med. y Farm. Vol. IV, ]\(o. 5, May 1913, pp. 312-314. 1914 FITZBUTLER, James H . N ecesidad del Examen Bacteriologico en las Enfermedades Inflamatorias del Ojo. Rev. Fil. de Med. y Farm. Vol. V, No. 6, June 1914 pp. 310·319. 1914 SEVILLA, Victor Frecuencia de las Afecciones Inflamatorias de los scnos accesorios de la. nariz en Filipinas. 2a Assamblea Regional 1914; ActM y Memo. pp. 316·323. 1914 ALBERTO, S B. Resultado del Tratamiento Mixto del Tracoma. ActM y MemoriM 2a Asamblea Reg., 1914 pp. 312·314. 1914 UBALDO, A. R. Ambliopias despues del Embarazo (Discussed by Drs. R. Llamas and SiXto Roxas) . 2a Asamblea Regional, 1914; Actas y MemoriM p. 308. 1914 UBALDO, A. R . Infecciones Cr6nicas del Saco Lagrimal. Examen Bacteriologico de 2 S casos. Tratamiento Operatorio. ActM y MemoriM 2a Asamblea Regional, 1914 pp. 309·310. 1914 UBALDO, A . R. Abscesos Peritonsilares. 2a Asamblea Reg., Actas y Memorias, 1914, p. 309. 124 INDEX OF' PHILIPPINE LITERATURE Jour. P. M. A. 1914 ONGSIACO, R. J. Tratamiento de la Otosclerosis por la Anakinesia del Oido. Actas y Mem. 2a Asamblea Reg. (1914) pp. 326-330. (Discussed by Dr. Sevilla) . 1914 REMBE, Rheinhard Otitis Media Purulenta Cronica. Su Patologia y Tratamiento. Acta.s y Mem. 2a Asamblea Regional (1914) pp. 324·325. 1917 VELARDE, H . Foreign Bodies in Eye, Ear, Nose and Throat. Acta.s y Mem., 3a Asamblea Reg. (1917) pp. 249·261. 1917 VELARDE, H. March •. 1946 Two Cases of Conjunctivitis Vemalis in the Philippine General Hospital. Mem., y Communicaciones, 3a Asamblea Reg. de Med. y Farm., 1917. 1918 SEVILLA, Victor Neurosis refleja de la Nariz. (Submitted title Feb. 1918 at 4a. Asamblea, but not read nor published). 1918 VELARDE, H ., and PARRALES, Gregorio Report of 85 Cases of Mastoid Cases. Actas y Mem. 4a. Asamblea Reg .. Feb. 1918, p. 276. 1919 UBALDO, A. R . Ambliopias despues del Embarazo. (Further report) Rev. Fil. de Medicina y Farmacia, Vol. X, 'N,o. I, Jan. 1919. 1919 VELARDE, H. Six Cases of Glioma Retinae. Rev. Fil. de Med. y Farm., Vol. X, ]\{o. 8, Aug. 1919. 1919 BASA, Carmelo Desviaciones y Defonnidades del Tabique Nasal. Tratamiento. Read before the 4a. Asamblea, Feb. 1918. (See Rev. Fil Med. y Farm., Vol. X, 'N,o. 8, Aug. 1919) . 1919 UBALDO, A . R. Amigdalitis Agudas y Supuradas. Rev. Fil. de Med . y Farm., Vol. X, 'N,o. 10, Oct. 1919. 1919 NICOLAS, Felisa Cases of Tonsillitis in the Free Dispensary of the Philippine General Hospital. 1919. Read before the Manila Medical Society. 1920 ANGELES, Sixto de los, and VILLEGAS, Anastacia A Case of Synophthalmia. Phil. JI. of Science, Vol. 17, 'N,o. I, Jan. 1920. 1920 GOMEZ, Liborio, KAPUNAN, Amando, and GAVINO, Catalino Diphtheria in the Philipinne Islands. Phil. JI. of Science Vol. 17, ]\{o. I, July 1920, pp. 37·46. 1920 VELARDE, H. Corneal Paracentesis. Phil. JI. of Science, Vol. 17, July 1, 1920. 1920 GUERRERO, Luis E., and CONCEPCION, lsabelo Xerophthalmia in Fowls Fed on Polished Rice and Its Clinical Significance. Phil. JI. of Science, Vol. I, July 1920, pp. 99·103. Volume XXII Number 3 INDEX OF PHILIPPINE LITERATURE 1920 UBALDO, A. R . 125 Clinical Fonns of Panophthalmitis Observed in the Philippine General Hospital. Phil. JI. of Science, Vol. 17, 1920, pp. 65-69. 1920 NICOLAS, Felisa Special Features of Tonsillitis in Leukemia Cases. (Read before the Manila Medical Society). 1920 1922 NICOLAS, Felisa Bilateral Optic Atrophy Associated with Certain Meningitic Symptoms. Report of a Case. Jl. P.I.M .A., Vol. II, N,o. 2, Mar.·April, 1922. 1922 VELARDE, H. Jridectomy in the Treatment of Glaucoma, with Report of Fourteen Clinical Cases. JI. P.I.M.A ., Vol. II, N,o. 4, July·Aug. 1922. 1922 GOMEZ, L., NAVARRO, R., and KAPUNAN, A. The Schick Reaction in Filipinos. (Four plates) Phil. Jl. of Science, Vol. XX. N,o. 3, March 1922, pp. 323·327. 1922 FERNANDO, A. S. Clinical Notes on Ear, Nose and Throat Cases in the Dispensary of the Philippine General Hospital. JI. P.I.M.A., Vol. II, May·June N,o. 3, pp. 123·129, 1922. 1922 NICOLAS, Felisa A Report of Three Cases of Tuberculosis of the Conjunctiva. Arch. of Ophthalmology. Vol. 51, N,o. 4. pp. 379·383, 1922. 1922 FERNANDO, A . S., and NICOLAS, Felisa The Effect of Milk Injections in Ocular Inflammations. JI. P.I.M.A., Vol. II, N,o. 5, 1922. 1922 FERNANDO, A. S. Causes of Blindness Among Filipinos as Observed in the Philippine Gen· era! Hospital Dispensary. A Preliminary Report. Arch. of Ophthalmology, Vol. 51, N,o. 4, pp. 374-378, 1922. 1922 FERNANDEZ, Ricardo Radium Therapy in Eye, Ear, Nose and Throat Work. Jl. P.I.M .A ., Vol. II, N,o. 3, pp. 116·120 (2 ills.) 1922. 1923 NICOLAS, Felisa Notes on Vision After Cataract Extraction. t\mer. Jl. of Ophthalmology, Vol. VI, J'{o. 2, pp. 123·124, Feb. 1923. 1923 FERNANDO, A. S. The Eye in Beri·beri. Amer. /!. of Ophthalmology, May· 1923, Vol. VI, Series 3 pp. 385·388. 1923 NICOLAS, Felisa Methods of Diagnosis and Treatment of Empyema of Maxillary Sinus. JI. P.I.M .A .. Vol. III, J'{o. 3 May·June pp. 121·124, 1923. . 1923 FERNANDO, A . S. Report of a Case of Melanosarcoma of the Conjunctiva. Arch. of Ophthalmology, Vol. 52, N,o. 2, pp. 168·169, 1923. 126 INDEX OF PHILIPPINE LITERATURE Jour. P. M.. A. March, 194.6 1923 FERNANDO, A. S. A Brief Clinical Survey of Cases in the Free Dispensary of the Philippine General Hospital. Arch. of Ophthalmology, Vol. 52, )\{o. 2 pp. 170-176, 1923. 1923 FERNANDO, A. S. Ocular Manifestations in Leprosy as Observed in Culion, P. I. JI. P .I.M.A., Vol. 3, )\{o. 5, pp. 230·236, 1923. 1923 UBALDO, A . R . Intracapsular Cataract Extraction After Barraquer's Technic. Amer. JI. of Ophthalmology, Vol. 6, )\{o. 11, Nov. 1923. 1924 ALCANTARA, Vivencio C Retrobulbar Cellulitis: A Report of Three Cases. JI. P.I.M.A., Vol. IV, )\{o. I, Jan. 1924. 1924 FERNANDO, A. S . Laryngeal Symptoms in Beri·beri. Phil. JI. of Science, Vol. 24, )\{o. I, pp. 41-43, Jan. 1924. 1924 VELARDE, Herminio Fibroma of the Naso-Pharynx, with Report of Five Cases. JI. P .I.M .A. , Vol. IV, )\{o. 8, Aug 1924. 1924 UBALDO, A . R. and FERNANDO, A. S. Intracapsular Cataract Extraction with the Erisiphake, with Report of Thirty Consecutive Operations. Amer. ]our. of Ophthal., Vol. 7, )'Xu. 8, Aug. 1924. 1924 UBALDO, A . R . Biographic Sketch of Jose Rizal y Mercado. Amer. four. of Ophthalmology, Vol. 7, pp. 560-561, 1924. 1924 NICOLAS, Felisa Notes on the Nose and Throat Manifestations of Tertiary Yaws. four. P. 1. M. A., Vol. 4, pp. 140·142, 1924. 1924 FERNANDO, A. S. Observations on Fundus Lesions Among Filipinos. Amer. four. of Ophthal., pp. 203-207, 1924. 1924 ARTIGAS y CUERVA, Manuel Bibliografia Medico-Farmaceutica de Filipinas. (Con biografias de los profesionales extranjeros de nota pue han estado en el pois, y con es· pecialidad las de los Filipinos) 'Tomo 1., Imp. Manila, 737 Calero, Sta. Cruz, Manila, 1924. 1925 FERNANDO, Antonio S. and NICOLAS, Felisa Tropical Oto-laryngology with Special Reference to the Philippine Islands. four. 'Tropical Medicine and Hygiene, June 1, Vol. 28, No. 11, 1925. 1925 SOLIS, Filiberto and WADE, H. W, Bacteriological Findings in Children with Special Reference ~o Nasal Lesions. JI. P .I.M.A ., Vol. V, )\{o. 12, 1925. 1925 UBALDO, A. R. and FERNANDO, A. S. The First Case of Laryngectomy in the Philippine General Hospital. JI. P.I.M.A ., Vol. V, )\{o. II p. 323, Nov. 1925. Volume XXII Number 3 INDEX OF PHILIPPINE LITERATURE 1925 AYUYAO, Conrado, D. Tertiary Manifestations of Yaws in the Larynx. 127 JI. P .I.M.A., ]\{ov. 1925, Vol. V, p. 331. (Read before Manila M. S., Aug. 3, 1925.) (See also Tropical Diseases Bulletin 1926 Vol. 23, p. 447-448.) 1927 UBALDO, A. R. and ALCANTARA, V. C. Tuberculosis of the Larynx and Some Aspects in Its Prevention. Proceedings of the First National Congress, Manila, Dec. 13-18, 1926. Bureau of Printing, 1927. 1927 AYUYAO, C. D. Observations on Tuberculosis of the Larynx at the Public Dispensary of the Philipine General Hospital, Manila. Proceedings of the First National Congress on Tuberculosis, Manila, Dec. 13-18, 1926. Bureau of Printing, 1927. 1927 UBALDO, A. R. and ALCANTARA, V. C. A Case of Labyrinthectomy. Jl. P. I. M. A. Vol.VII, No. 3 p. 97, Mar. 1927. 1927 FERNANDO, Antonio S. Errors of Refraction among Filipinos: A Preliminary Report. JI. P. I. M. A .. Vol. 7, No. 9, Sept. 1927. 1927 ALCANTARA, Vivencio C. Perera! Endoscopy The Bulletin of San Juan de Dios Hospital of Manila 2: 209; Nov. 1927. (Read before M.M.S. July 11, 1927.) 1927 AYUYAO, Conrado D. Tertiary Manifestations of Yaws in the Nose and Throat in the P. I. JI. P .I.M.A ., 7: 411 ; Nov. 1927. 1927 FERNANDO, A. S. Our Present Problems in the Treatment of the Tuberculosis of the Larynx. Proceedings of the First National Congress on Tuberculosis held a.t Manila, Dec. 13·18, 1926. Bureau of Printing, 1927, pp. 329-334. 1928 AYUYAO, Conrado D. Microphthalmos. A Case Report. JI. P. I. M. A. 8:10 Jan. 1928. 1928 AYUYAO, Conrado D. Intraorbital Anesthesia in Enucleation of the Eyeball. "JI. P. I. M.A. 8: 173; April, 1928. 1928 AYUYAO, C. D. and DIZON, Elpidio Y. Retropharyngeal Abscess; Clinical Consideration and Treatment. JI. P .I.M.A., Vol. VIII, No. 9, p. 383, Sept. 1928. 1928 UBALDO, A. R. and AYUYAO, Conrado D. A Case of Laryngectomy. Recovery. Bull. of San Juan de Dios Hospital, Vol. 2, No. 2, 1928. (Read before the Joint session of the P. I. M. A. and the Col. M.-F. de Fil. 1927, December 15.) 128 INDEX OF PHILIPPINE LITERATURE Jour. P. ¥. A. March, 1946 1929 OROSA, Sixto Y. The First Case of Rhinosporodiosis Reported in the Philippines. JI. P. I. M. A. 9:11 ; (Jan. 1929.) 1929 UBALDO, A. R. and AYUYAO, C. D. Symphathetic Ophthalmia: Report of a Case. JI. P.I.M.A., Vol. IX, No. 14, p. 127, Apr. 1929 (Read before the Manila Med. Soc. Nov. 5, 1928.) 1929 UBALDO, A. R. and AYUYAO, C. D. Vitreous Opacities in Cataract Cases. > JI. P.I.M.A., Vol. IX, No. 7, p. 239, July 1929 (Read before the P.l. M. A. Dec. 14, 1928.) 1931 UBALDO, A . R. Notes on Cancer: Observations in Department of Eye, Ear, Nose and Throat, Philippine General Hospital during the five years. Importance of and its Early Detection. Rev. Filipina de Medicina y Farmacia Vol. XXI, No. 6, June 1931. 1930 AYUYAO, Conrado D. Acetic Acid in the Treatment of Trachoma. JI. P.I.M.A ., Vol. X, No. 3, p. 129, 1930. 1930 DIZON, Elpidio Y. Eye, Ear, Nose and Throat Manifestations in Leprosy. JI. P. I. M.A. Vol . X, No. 5, p. 211, May 1930. 1930 GAMBOA, Luis Deficiency in Vitamin A and Nyctalopia. JI. P. I. M. A. VI. X. No. 6, p. 235, June 1930. 1930 SAMSON, Jose; LARA, C. B. ; and CRUZ, M. C. Treatment of Leprous Lesions of the Nasal Mucosa. JI. P.I.M .A .. Vol. X. No. 7, p. 291, July 1930. 1931 UBALDO, A.R. and AYUYAO, C.D. Further Observations on Vitreous Opacity in Cataract. JI. P.I.M .A .. Vol. XI, No. 6, p. 231, June 1931. 1931 FERNANDO, Antonio S. Physicians in the Philippines: A General Survey During 1930-1931. JI. P.I.M.A., Vol. XI, No. 8, p. 231, Aug. 1931. 1931 FERNANDO, Antonio S. The Ear and the General Practitioner. JI. P.I.M .A., Vol. XI, No. 10, pp. 385-392, October 1931. 1931 AYUYAO, Conrado D. Refraction. JI. P.I.M.A. Vol. XI, No. 10, Oct. 1931, p. 403. (Read before the Annual Meeting P. I. M. A., Dec. 1929). 1932 ALCANTARA, V. C. and AYUYAO, C. D. Foreign Bodies in the Esophagus. JI. P.I.M .A. Vol. XII, No. 1, p. 31, Jan. 1932. (Read before the P. I. M. A. Dec. 17, 1930) . Volume XXll Number 3 INDEX OF PHILIPPINE LITERATURE 1932 UBALDO, A. R. and AYUYAO, Conrado Cataract among Filipinos. 129 ]'!. P .f.M .A . Vol. XII, No. 4, p. 160, April 1932. (Read before P. I. M. A. Annual meeting, Dec. 17, 1931.) 1932 REYES, Edmundo Blindness after Sleeping With Wet Hair. (A Case of Vaso·Constric· ti on of the Retinal Arteries). Bull. San Juan de Dios Hospital, June, 1932. 1932 TIONG, Jose 0 . Comparative Treatment of Trachoma with Acetic Acid and Chalmoogra Oil. Jl. P .I.M.A., 12: 502; 1932. 1932 PEREZ, Jose R. Treatment of Acute and Chronic Otitis Media Purulenta with Sterilized Milk. fl. P. I. M.A., 12 : 382, 1932. 1932 AYUYAO, C D. Errors of Refraction Among Filipinos. JI. P.I.M.A ., 12: 424 (Sept.) 1932. 1932 ALCANTARA, Vivencio C. Four Years of Peroral Endoscopy Work in the Philippine General Hos· pita!. (Read at the annual meeting of the P.I.M.A ., Dec. 1932). 1933 SISON, Agerico B. M. Ophthalmic Migraine of Allergic Origin. fl. P .I.M .A., 13: 250; (May) 1933. 1933 LANAHAN, Charles R . (Major, U.S. A .) Functional Measuren;ient in Ocular Muscle Surgery. fl. P . I.M .A., 13: 151; 1933. 1933 FERNANDO, A. S. and AYUYAO, C. D . Subdural Abscess of Otitic Origin : Report of an Operated Case that Recovered. fl. P .I.M .A ., 13; (73·76) (Feb.) 1933. 1933 AFRICA, Candido M . Experimentally induced Otomycosis in Monkeys. Univ. of the Phil. Natural and Applied Science Bulletin, Vol. III, No . 3, (J\(ov.) 1933. 1933 AYUYAO, Conrado D. Corneal Lesion in Beri·beri. JI. P .I.M .A ., 13: 158; 1933. 1933 ALCANTARA, V. C. Foreign Bodies in the Trachea and Bronchus. Report of Cases. (Read before the annual meeting, P .I.M.A., Dec. 14, 1933. 1934 UBALDO, A. R. and AYUYAO, Conrado V. Iniracapsular Extraction of Senile Cataract with Conjunctiva! Bridge. Jl. P.I.M.A., 14: 215·217; (June) 1934. 130 INDEX OF PHILIPPINE LITERATURE Jour. P. M. A. 1934 UBALDO, A . R and AYUYAO, C. D. Sympathetic Ophthalmia: Report of a Case that Recovered. Jl. P.I.M.A., 14; August 1934. 1934 VELARDE, H. and OCAMPO, G. de Treatment of Maxillary Sinus Suppurations. Jl. P.I.M.A., 14: 347 (Sept.) 1934. 1934 SJNGIAN, Gregorio ond GONZALES, Rodolfo P. March, 1946 Radium Therapy in the Cancer Section of the San Juan de Dios Hospital. Read before the annual meeting, P .I.M.A., Dec. 12, 1933. (Bulletin of the S. J. de Dios Hospital 8: 27·32; Feb. 1934). 1934 FERNANDO, A . S. Some Remarks on Trachoma Among Filipinos. Jl. P.I.M.A., 14: 137-141; 1934. 1934 AYUYAO, C. D. Optic Atrophy and Optic Neuritis. Jl. P.I.M.A., 14 : 482 (Dec.) 1934. 1935 FERNANDO, A . S. The Progress of Ophthalmology and Otorhinolaryngology in the Phil· ippine Islands. Report No. 1, Bulletin No. 4, Feb. 1935 of the Nation.al Research Council, pp. 303· 313. 1935 UBALDO, A. R. and AYUYAO, C. D. Modified Abscission of the Oomea (Keratectomy) Jl. P.I.M.A., 12 : 324 (June) 1935. 1935 FERNANDO, A. S. and OCAMPO, G. de Cerebellar Abscess: Report of a Case and the Necropsy Findings. Jl. P.I.M.A., July 1935, Vol. xy, pp. 381-388. 1935 REYES, Edmundo A Different Way of Performing Iridectomy for Glaucoma. Bull. San Juan de Dios Hospital, Sept. 1935. 1935 ALCANTARA, V. C. and OCAMPO, G. de Watermelon Seed in the Air Passages; Report of Cases. ]l. P .I.M .A., 15; 469 (Sept.) 1935. 1935 NICOLAS, Felisa Recurrent lntraocular Hemorrhage in a Young Adult. Jl. P.I.M.A., 15: pp. 554·558, Oct. 1935. 1935 FERNANDO, A. S. Medical Service in the Philippines. JI. P.I.M.A., 16: 223 (April) 1936. 1936 UBALDO, A. R. and AYUYAO, C . D. Blindness Among Filipinos Jl. P.I.M.A., 16: 225 (April) 1936. 1936 OCAMPO, G. de Herpes Zoster Oticus: Report of a Case with Facial Paralysis. Jl. P.I.M.A., 16: 369 (June) 1936. Volume XXII Number 3 INDEX OF PHILIPPINE LITERATURE 1936 ALCANTARA, V. C. and OCAMPO, G. de Bronchoscopic Service in the Philippine General Hospital. JI. P.I.M .A., 16: 395 (July) 1936. 1936 AYUYAO, Conrado D. Tertiary Manifestations of Yaws in the Larynx. Jl. P .I.M.A. , 16 : 769 (Dec.) 1936. 1937 FERNANDO, A. S. and OCAMPO, G. de 131 Cerebellar Abscess, with Diffused Suppurative Meningitis; Report of a Case that Recovered. Jl. P .I.M.A ., 17 : 13 (Jan.) 1937. 1937 OCAMPO, G . de Otogenic Serous Meningitis, with Report of Recovered Cases. Jl. P.I.M.A ., 17 : 101 (Feb.) 1937. 1937 ABAD, Lucio D., BRION, E . G ., and ANTONIO, J. C . Pan·Sinus Operation. JI. P.I.M.A., 17 : 235 (April) 1937. 1937 FERNANDO, A. S and OCAMPO, G. de Labyrinthi·tis: Clinical Analysis of Fifteen Cases. JI. P .I.M.A .. 17 : 271·286 (May) 1937. 1937 . AYUYAO, Conrado D. Clinical Observations on Xerophthalmia. JI. P .I.M.A. , 17: 399 (July) 1937. 1937 ALCANTARA, V. C ., and OCAMPO, G. de Bronchoscopy·minded. JI. P.I.M .A., 17: 465 (Aug.) 1937. 1937 FERNANDO, A . S., and OCAMPO, G. de Carcinoma of the Nose and Nasopharynx with Extension to the Cranial Cavity : A Case Report with Autopsy Findings. JI. P.I.M.A ., 17: 525·529 (Sept.) 1937. 1937 . UBALDO, A. R ., and A YU.YAO, C. D . On the Treatment of Chronic Hypertrophic Rhinitis. JI. P.I.M .A., 17 : 545 (Sept.) 1937. 1938 TUPAS, Alberto V ., and PECA CHE, Leon. Keratomalacia in Children. JI. P.I.M.A., 18: 147 (March) 1938. 1938 UBALDO, A . R ., and OCAMPO, G. de Post·operative Infection in Cataract Extraction. fl. P.I.M .A ., 18 : 211 (April) 1938. 1938 ABAD, Lucio D., and ANTONIO, J. C. Submucous Resection of the Nasal Septum; A Plea for its more Fre· quent Use Among Filipinos. JI. P. I. M. A. 19: 365 (June) 1938. 1938 FERNANDO, A. S., and OCAMPO, G. de Wassermann Reaction of the Cerebro·Spinal Fluid in the Diagnosis of Yaws of the Nose and Throat. JI. P. I. M. A. 18: 347 (June) 1938. 132 INDEX OF PHILIPPINE LITERATURE Jour. P. M. A. March, 1946 1938 REYES, Edmundo Un Caso de Reabsorpcion Espontanea de la Catarata Con Glaucoma Secondaria. Bull. San Juan de Dios Hospital. 1938 FERNANDO, A . S., and OCAMPO, G. de Ligating of the Jugular Vein in Lateral Sinus Thrombosis: Report of a Case. JI. P.I.M.A ., 18 : 637 (Oct.) 1938. 1939 ABAD, Lucio D., and Magbao, Manuel C. Foreign Body in Frontal Sinus (Spark·Plug of an Automobile) for Fifteen Years. JI. P. I. M. A. 19: 627 (Oct.) 1939. 1939 UBALDO, A. R., and OCAMPO, G. de Blindness in Children. JI. P. I. M. A. 19: 483 (Aug.) 1939. 1939 ALCANTARA, V. C., and OCAMPO, G. de The Larynx in Infantile Beriberi. Arch. of Otolaryngology, 30: pp. 389·399, Sept. 1939. 1939 CRUZ, Florencio Z. Incidence of Ophthalmia Neonatorum in the Philippines. JI. P. I. M. A., 19: 555 (Sept.) 1939. 1939 DELFIN, Vicente Autohemotherapy in Glaucoma Jl. P. I. M. A., 19: 683 (Nov.) 1939. 1940 AYUYAO, C. D., YAMBAO, C. V. and SIMUANGCO, P. A comparative Study of Some Treatments in the Inflammation of the Maxillary Antrum. Jl. P .I.M.A., 20 : 451·453 Aug. 1940. 1940 REYES, Edmundo Cysts of the Maxillary Sinus. Report of 4 Cases. U.S. T . Journal of Medicine 1: 7·18, Aug. 1940, No. I. 1940 OCAMPO, Gemimiano de The Role of Ophthalmology and Otolaryngology in the Solution of Some Problems of Internal Medicine. Jl. P.I.M .A. , 20 : 523·534 (Sept.) 1940. 1940 OCAMPO, G . de and CRUZ, J . N . Dark Adaptation in Adult Beriberi Acta Medica filipina 2: 175·188 (Oct.·Dec.) 1940. 1940 FERNANDO, A. S., DE LEON, W . and YAMBAO, C. V. Tertiary Lesions of Yaws in the Nose and Throat: Case Reports wi1h histologic findings. (Read before the 1940 Annual Meeting of the P.I.M.A.) \941 VELARDE, H. Immediate Objectives in the Teaching of Ophthalmology and Otorhino· laryngology. JI. P. M. A., 21: 15·18 (Jan.) 1941. Volume XXO Number 3 INDEX OF PHILIPPINE LITERATURE 1941 OCAMPO, G. de Epithelial Corneal Dystrophy Due to Hypovftaminosis. Acta Medica filipina 3: 105· 124 (July·Sept.) 1941. 1941 AYUYAO, C. D. and YAMBAO, C. V. Dacryocystorhinostomy. JI. P. M. A., 21: 391-393, (Aug.) 1941. 1941 UBALDO, A. R. and OCAMPO, G. de The Concept of Focal Infection in Ophthalmology. JI. P. M . A., 21: 443-453, Sept. 1941. 1941 FERNANDO, A. S. A Case of Temporal Lobe Abscess JI. P. M. A., 21 : 579·583 (J\(ov.) 1941. 1941 FERNANDO, A. S. Developing the Medical Specialties in the Philippines. Editorial, JI. P. M. A., 21: 463, J\(o. 9, September 1941. 133 OPHTHALMOLOGICAL AND OTOLARYNGOLOGICAL CONFERENCES By Antonio S. Fernando. M.D. and Geminiano de Ocampo, M.D. Subjects and date of publication. 1937 CHRONIC OTITIS MEDIA, SUPPURATIVE with MASTOIDITIS. Tuberculous, Left, with Osteomyelitis, Temporal Bone and Mandibular Process and Facial Paralysis. JI. P.I.M.A., 17: 183, March, 1937, J\(o. 3 1937 MASTOIDITIS, ACUTE, SUPPURATIVE, LEFT. JI. P .I.M.A., 17: 45, January, 1937, J\(o. I. 1937 SYPHILIS (?), LARYNX with Framboetic scars elsewhere. JI. P .I.M.A ., 17 : 315, May, 1937, J\(o. 5. 1937 KERATO·CONJUNCTIVITIS, LEFT, secondary to tuberculosis. JI. P.I.M .A., 17 : 431, July, 1937, J\(o. 7. 1937 RETROBULBAR NEURITIS, CHRONIC, Bil. (probably dental in origin) . JI. P.I.M .A., 17 : 493, August, 1937, J\(o. 8. 1937 UVEITIS, ACUTE, LEFT, with Vitreous Abscess (probably due to septic focus in the tonsils). JI. P .I.M.A., 17: 781, December, 1937, J\(o. 12. 1937 ERYSIPELAS, RIGHT AURICLE. JI. P .I.M .A., 17: 655, October, 1937, J\(o. 10. 1937 ALLERGIC RHINITIS JI. P.I.M.A ., 17 : 719, November, 1937, J\(o. II. 1937 NEWGROWTH, MALIGNANT (epithelioma), External Auditory Canal and Tympanum, Rt. Facial Paralysis, secondary, rt. Otitis media, suppurative, subacute, rt. JI. P .I.M .A ., 18: 595, September, 1938, No. 9. 1938 MASTOIDITIS ? ACUTE ? RT. Pulmonary Tuberculosis, left Lung. Jl.P.I.M.A., 18 : 527, September, 1938, J\(o. 9. 134 INDEX OF PHILIPPINE LITERATURE Jour. P. M. A. March, 1946 1938 PERCEPTIVE DEAFNESS, with Bell's Palsy (probably leutic.) A neuro· recurrence? Jl. P.I.M .A ., 18 : 527, August, 1938, Jl(o. 8. 1938 CHRONIC OTITIS MEDIA with MASTOIDITIS and PERILABYRINTHITIS, Jl. P.M.A ., 18: 461, July, 1938, Jl(o. 7. 1938 PERCEPTIVE DEAFNESS, Bil., Secondary to nerve involvement (probably dental in origin). JI. P.M.A .. 18: 397, June, 1938~ Jl(o. 6. 1938 Clinical Diagnosis: Mastoiditis with Temporal Lobe Abscess which rupture into the Ventricle. Anadomical Diagnosis: Tempero-sphenoidal Abs· cess. JI. P.M .A., 18: 327, May, 1938, Jl(o. 5. 1938 HYPEROPIA, SIMPLE, Bil. Rhinitis, Chronis JI. P.M.A .• 18: 173, March, 1938, Jl(o. 3. 1938 OPTIC ATROPHY, Secondary Bil. Arteriosclerosis with Hypertension JI. P.M.A., 18: 105, February, 1938, Jl(o. 2. 1938 XEROPHTHALMIA JI. P.M.A .. 18 : 657, October, 1938, Jl(o. 10. 1938 GLIOMA RETINAE JI. P.M .A., 18 : 243, April, 1938, Jl(o. 4. THE JOURNAL OF THE Philippine Medical Association Published monthly by the Philippine Medical Association under the supervision of the Council. VOL. XXII Office of Publication, 547 Herran, Manila, Philippines Devoted to the progress of Medical Science and to the interests of the Medical Profession in the Philippines. MARCH, 1946 The Council NO. l Officers of the Philippine Medical Association, 1941 extended to 1946 Presidtnt: Dr. Victorino de Dios Via .. Presidents: The Council consists of the President, the Vice·Presidents, the Secretary·Treasurer, and the followfog Councillors: Dr. R. Abriol Dr. Januario Estrada Dr. W. de Leon Dr. Honoria Acosta .. Sison Stcretary·Treasurtr: Dr. A. Villarama Dr. Jose C. Locsin Dr. M. Canizares Dr. Antonio S. Fernando ANTONIO S. fERl<ANDO, M.D., Editor I. V. MALLARI, Copy Editor PEDRO M. CHANCO, Business Manogtr Associate Editors (alphabetically listed) VICTORINO DE Dios, M. D. Jose Gumorn, M. D. Aou1co B. M. S1soN, M. D. RENATO MA. GUERRERO, MD. WALFRIDO DE LEON, M. D. ANTONIO G. SISON, M. D. CARMELO REYES, M. D. Signed editorials express the personal views of the writer thereof, and neither the Asso· ciation nor the Journal assumes any responsibility for them. Eilitnriul THE PHILIPPINE MEDICAL ASSOCIATION AND THE NEWLY ORGANIZED MEDICAL SOCIETIES The Philippine Medical Association is a pre-war Association. As a matter of fact it was founded in 1903. Before the outbreak of the war it created a special committee composed of well-known members of 'the profession with the object of studying the creation of sections on Eye, Ear, Nose and Throat; on Obstetrics and Gynecology; and on Surgery. World War No. II put a stop to the work of the committee. The proposed sections did not materialize. The committee had to be disbanded, but the spirit behind its creation lived and persisted throughout the war. And after liberation, several medi136 EDITORIAL Jour. P. M. ~ a.larch, 19'6 cal societies· on different specialties were organized or had resumed activities. Only one of these societies has affiliated itself with the Philippine Medical Association; namely, the Philippine Ophthalmological and Otolaryngological Society. The others like the Manila Roentgen Society and the Philippine College of Surgeons have not done so. The organization bf these various medical societies is a healthy movement towards the promotion of science and arts in the various field of medicine. The Philippine Medical Association would welcome their federation into one strong and solid mother organization. These different medical societies will undoubtedly hasten the rehabilitation of the medical profession. Each society, in its particular field can cater to the needs of its members. I think the main purpose of the organization of these medical societies is to elevate the standards of the medical profession and of medical practice, and to disseminate medical knowledge among a greater number of physicians. This objective can better be realized, if these newly organized medical societies would affiliate themselves with the Philippine Medical Association as sections on different specialties. The Philippine Medical Association should be looked upon as a mother association to centralize the activities of all medical societies, thus promoting cooperation and harmony among different medical societies. If and when all these medical societies become affiliated with the Philippine Medical Association - each society being a component part of the mother association, the Philippine Medical Association - the members of each society would feel at home in attending the scientific meetings of every other society. It must be remembered 'that the general practitioner, or any other group of physicians, may be interested in certain surgical, obstetrical. or other cases. Withou't one mother association to bring these newly organized medical societies together, tli.e benefits of one society may not be taken advantage of by members of other societies; and vice versa. As there are still very few physicians specializing in different lines, we cannot afford to establish societies independent of the Philippine Medical Association, without at the same time detracting from 'the importance of our national organization. To have one strong and united national organization is very desirable if we in the profession of medicine are to make ourselves heard in any government project affecting our profession, or in the formulation of policies regarding our profession and other medical matters. Therefore the Philippine Medical Association would welcome the affiliation of these newly organized societies for the benefit of all concerned.-V. de D. .tai.arellaneous ABSTRACTS FROM CURRENT LITERATURE ABSTRACTORS. lsabelo Concepcion, M. 1 D. Walfrido de Leon, M. D. Felisa Nicolas~Fernando, M . D. Carmelo Reyes, M. D. The Value of Protein and its Chemical Components (amino acids) in Stugical Repair, by Co Tui, Bulletin of the New York Academy of Medicine 21 :631 • 655 (Dec.) 1945. The author summarized the findings of the team working on this research project as follows: 1. Proteins are essential to wound hca1ing, to the maintenance of tissue integrity; and from present indications, to expeditious convalescence. Protein deficiency endangers all three. 2. /\ patient can become protein·dcficient as a result of inadequate intake and increased nitrogen output or a combination of these two factors. 3. Decreased intake may be due to the patient or neglect on the part of the attending staff. 4. Increased output may be due to increased metabolic loss and to the Joss through exudates. S. The ceiling of nitrogen intake in natural food is naturally ]ow and consequently natural food is often inadequate to repleni~h the increased protein loss in disease and injury. 6. Studies on cases of burns, of postoperative gastrectomy, cholecyslectomy and hernio .. tomy, suggest that convalescence can be shortened, strength and weight conserved by full caloric and nitrogen replacement immediately postoperatively; and that there may be a critical range of nitrogen intake for each disease category. 7. The protein hydrolysates, by raising the cei1ing level of nitrogen .. intake, are indispen• sable in many disease conditions and can be used with greater elasticity than natural food. 8. In the course of study on the value of protein hydrolysates, a new treatment of peptic ulcers has been evolved. All cases of peptic ulcers were treated with protein hydrolysates and high ca.lode diet. All were treated with !rom .5 to .6 grams nitrogen per KBW (kilogram body weight), in the form of amigen, and enough dextri•maltose to make up to 40 C per KB\\.'. The m.fatur.e:. is suspended in water, divided into eight to nine feedings, and given at two·hourly interval .... Feedings were continued two or three weeks exclusively, depending upon the clinical response and x .. ray findings. No antacids or antispasmodics were given, and wherever necessary, am· phojel in 4 cc. doses was given twice a day to control diarrhea. A full complement of vitamins was added to the feeding. The results may be summarized as folJows: Pain and distress stopped in twcnty .. four to forty .. eight hours. Vomiting stopped forty .. eight hours afted institution of the feedings; rapid roentger1ologic hea1in~: positive nitrogen balance, averaging 10 to 16 grams (first ten days); gain in weight, 1 to 8 Kilos in two to three weeks; and rapid gain in strength and morale. However, the treatment does not prevent recurrence on resumption of o1d dietary habits. 9. Protein hydrolysates for clinical use must fulfill a numbelf of criteria and clinicians using them must be quantitativety .. minded. 138 ABSTRACTS FROM CURRENT LITERATURE Jour. P. M. A.. March. 1948 10. A discussion on the assay of the nutritional course of convalescent patients has beeo attempted.-F. N . F. 'The Surgical 'Tr<atment of Essential Hypertension, by MaJj M. Peet and Emil M. lsberg, M.D., J.A.M.A. 130:467 (Feb. H) 1946. Since the first bilateral supradiaphragmatic splanchnicectomy and lower dorsal sympathetic r.anglionectomy was performed by one of the authors (M .. M. P.) in November 1933, more than 1,500 patients have received this surgical treatment for essential hypertension at the University Hospital, Michigan, as of September 1945. Surgical treatment has long been accepted here as an integral part of the therapeutic armamentarium for hypertensive disease. Its accept, ance has been tempered with the realization that its limitations are definite, that its failures are not uncommon. Rarely does surgica1 treatment result in a; cure of hypertensive disease, but it has given remarkable benefit and prolonged the life of many hypertensive patients. The authors gave the following summary of their experience: Four hundred and thirty•seven patients with essential hypertension have been followed since receiving the surgical treatment of bilateral supradiaphragmatic splanchnicectomy and lower dorsal ganglionectomy five to twelve years ago. Two hundred and fifty•on~ patients, or 57 .5 per cent of the series, are living five to eleven years after operation. At the end o.f five postoperative years 64.8 per cent of the entire series was alive. The hypertensive state in 82 per cena of the patients in this series had already progressed to serious organic disease prior to operation. Fifty-six per cent of all the males have died, while the female mortality was only 30 per cent. Ninety-five per cent of hypertensive patients who showed no preoperative evidence of cardiac, cerebrovascular or renal invo]vement are living five to eleven years after operation. Approximately one·third of all patients who manifested preoperative evidence of organic heart disease, cerebrovascular disease or impaired kidney function did not survive five to eleven years. Nineteen per cent of 112 patients with preoperative malignant hypertension are living five to eleven years later. Fifty·one patients have maintained normal blood pressure levels and 28 show no evidence whatever of hypertensive disease five to eleven years after operation. Significant redUctions in blood pressure, complete and definite symptomatic relief, im· provement of eyegrounds and improvement of abnormal electrocardiograms, cardiac' enlargement and kidney . concentration ability have been maintained fo~ five to eleven postoperative years in a remarkable percentage of patients. Sixty percent of patients who have previous cerebral accidents suffered no recurrence during the long postoperative period. Surgical treatment is a measure to be considered in the managemen~ of every case of t"ssential hypertension. but to be utili:z.ed only when indicated. Evidence of progression and activity of hypertensive disease constitutes indication for surgical treatment.-F. N. F. Penicillin 'Therapy in Abdominal Surgery: Result of Prophylactic and 'Therapeutic Use in 50 Cases. By G. P. Wollgast.-Surgery, Gynecology and Obstetrics, 81:593-710 (Dec.) 1945. Wollgast observed 5 patients who were critically ill with generali:z.ed peritonitis. Treat· ment with penicillin was started late, and all of these patients died. Later 12 additional patients with peritonitis were treate~ more adequately. Seven received local treatment and parenteral therapy; 5 received only parenteral therapy. Local administration of penicillin in 3 instances consisted in instilling 50,000 units and in 4 other cases 100,000 units of penicillin into the abdominal cavity just prior to closure. Parenteral therapy was administered intramuscularly at three-hour intervals. Dosage was varied from 10,000 units td 20,000 units every three hours, totalling 80,000 to 160,000 units every twenty·Jour hours. These patients also received all other accepted therapeutic measures. The postoperative course in 10 of these cases was un· expectedly mi1d. Twenty·five patients with infected wounds received ,Penicillin both pre· operatively and postoperatively as a prophylactic measure. Treatment consisted in parenteral , Volume XXU Number 3 ABSTRACTS FROM CURRENT LITERATURE 139 administration of 10,000 of 151 000 units every three hours intramuscularly £or an average of three or four days preoperatively. Treatment was continued postoperatively untit. the patient had been afebrile for at least three or four days. The average duration of treatment was eleven days. A man aged 31 was operated on in another hospital for perforated gangrenous appendix. On the ninth day a small incisional abscess was drained. On the eighteenth day his temperature rose to 103 P., with the onset of a septic course with daily elevations between 104 and 105 F. Improvement had not been noted ovei:; a seven·week: period prior to the use of peni· cillin, but definite improvement followed soon after initiation of this therapy. This serious postoperative complication was cured by penicillin therapy. Seven patients whose wounds became acutely infected following surgery were treated with penicillin. Six of these wounds responded remarkably to treatment.-F. N. F. Folic Acid 'Therapy. Editorial, j . A. M. A. 130:496, 1946. In 1935 Day and his associates of the University' of Arkansas reported that young rhesus monkeys given a diet consisting of casein, polished rice. whole wheat, salt mixture, cod liver oil and ascorbic acid develop 3' syndrome characterized by anemia, leukopenia, loss of weight, diarrhea and ulceration of the gums. If the daily deficiency diet is supplemented with either 10 Gm. of dried brewers' yeast or 2 Gm. of liver extract, however, normal body growth and a normal blood picture are maintained over a long period. from these experiments it seemed that yeast and liver extract contain an unknown substance essential to the nutrition of monkeys. For this unknown nutri· tion factor the Arkansas clinicians proposed the term Vitamin M. It was afterward found that this Lactobacillu~ casei factor is curative of Vitamin M deficiency in monkeys and necessary for normal growth aod hemoglobin formation in chicks. A crystalline folic acid apparently identical with this Lactobacillus casei factor was recently synthesized by Angier and his associates of the Lederle Laboratories and made available for clinical trial. The similarities of the. sprue syndrome in man to the manifestation of Vitamin M de .. ficiency in monkeys led Darby and his associates of Vanderbilt University to test the thera· peutic value of synthetic folic acid in 3 human cases, These patients were given daily intramuscular injections of 1 S mg. of synthetic folic acid as the sole therapeutic agent. By the fourth day symptoms of glossitis had di.appeared. The striking and rapid response of these patients led Darby to confirm the belief that synthetic folic acid is identical with, or closely allied to, the substance in liver extract which is effective in the treatment of sprue. Spies and his associates found that synthetic folic acid given either parenterally o~ orally is effective in producing significant hemopoietic response in persons with nutritional macrocytic anemia and with macrocytic anemia of pellagra, ·pernicious anemia, sprue or pregnancy. ·-I'. N . I'. SOCIETY ACTIVITIES Culion Medical Society:The 20th Annual Meeting of the Society was: held on January 27, 1946. The scientific program was as follows: I . Presidential Address, by Dr. J. 0 . T1ong. (He emphasized the necessity of the segregation of lepers, advocated sterilization as al measure to prevent lepers from having children, and urged against sex•sec· lusion.) 2. ls 'There Blood Calcium Deficiency in Leprosy! By Dr. E. Paras 3. Potency of Stor<d Lepromin, by Dr. Jose 0. Nolasco 4. Observations Bearing on the Incidence of Leprosy in Children of Lepers, by Dr. C. B. Lara. Manila Medical Society:The rociety held its monthly meeting on March 30, 1946 in the Sto. Tomas University gymnasium, under the auspices of the Department of Medicine of this institution. The follow· ing papers were read : 'The Operative Managemont of Hypertrophy of the Pros·iate in Patients with Coronary Disease. by Domingo_ Antonio. Jr., Major MC, P.A .C.S.; Asst. Prof., Dept. of Surgery and Urology, U.S . T.; Faculty of Medicine and Surgery. Recent Advances in the Diagnosis and Treatment of Cardiovascular Diseases. by A. Benedict Schneider, Jr., Major MC, U.S.A., Western Reserve University, Cleveland, Ohio 'Tarlac Medical Soci«y:The Tarlac Medical Society was organized on the 19th of January by 36 physicians. The following officers were elected: ·President: Dr. Gonzalo Santos Vice· Pres.: Dr. Alfonzo C. Concepcion Sec.·'Tr<as.: Dr. Jose G. Cruz Board of Censor Delegates: Dr. Marcos J. Corpus Dr. Arsenio C. Regala Dr. Marcelo S. Agana The inaugural meeting was held on March I, 1946. After the opening remarks of Dr. Jose G. Cruz, the invocation was said by Rev. Fr. Benedicto J. E. Arroyo. The officers were installed by Dr. Victorino de Dios, President, Philippine Medical Association, after which Dr. Gonzalo Santos gave the Presidential address. The guest of Honor was Dr. Jose C. Locsin, Secretary of Health and Public Welfare. A receptio" and ball climaxed the occasion. /'hilippint Uphthalmological and Utoloryngological Society:The first scientific meeting of the Philippine Ophthalmological and Otolaryngological Society was held on March 30, 1946 under the auspices of the E. E. N. T. Staff of the North General Hospital~ composed of Dr. Felisa Nicolas,fernando, Chief; Dr. Jesus Tameais, resident; Dr. Caridad Estanislao, extern; and Dr. A. S. Fernando, visiting physician. A.-SCIENTIPIC MEETING: 1 . -Relative frequency of Eye, Ear. Nose and Throat eases in the out,patieiit service of the North General Hospital. Volume XXll Number 3 NEWS ITEMS 141 2. -Presentation of cases: a.-A case of advanced glioma of the optic nerve (left) b .-A case of mastoiditis with facial paralysis (The facial paralysis re· covered after operation on tbe mastoid and tbe use of penicillin parenterally and topically and intramuscular injection of thiamine hydrochloride.) c.-A case of homonymous hemianopsia, traumatic d.-A case of cerebelJarl, abscess of otitic origin with necropsy findings e.- A case of total ophthalmoplegia, bilateral, probably syphilitic. f .-A case of a ch..i1d on which a radical mastoid operation was performed and thyrothricin was used for topical application after operation. Satisfactory results. g . -A case ofl an old woman, operated on for simple cataract extraction (extra capsular) with irrigation; the base of the iris prolapsed slightly 2 days after the operation. This1 was successfully replaced. Vision was 20'/20 and Jaeger No. 1 with the correcting glasses after several weeks. B.-BUSINESS MEETING: 7'he Philippine College of Surgeons held its scientific meeting on March 30, 1946 in the Phil· ippine General Hospital. The scientific program follows: Pus(n1t Status of Surgery in the Philippines, by Dr. Januario Estrada. Cesarean Section, by Dr. Alfredo Baens. Surgery of the Autonomic )\{ervous Sys·tem, by Dr. Gervasio·Cuyugan. The President is Dr. Nicanor Jacinto and the Secretary-Treasurer is Dr. Carmelo Reyes. NEWS ITEMS (Physicians are requested to send in news items of interest to the profession.) LOCAL: A critical shortage of medical, dental, and hospital facilities in the Philippines is leaving a large part of the population an easy victim to disease and malnutrition according to the results of a survey by Charles H. Forster, Executive Director of the Philippine War Relief, Inc. The survey revealed that approximately 11,500,000 Filipinos, representing nearly 2/3 of the total population, are without medical, dental, or hospital aid of any kind. In rural and outlying areas populated by almost 12 million Filipinos, there are barely enough medical facilities to provide emergency aid for 500,000. Philippine War Relief is at present engaged in a health and rehabilitation program designed to bdng immediate aid to these rural areas. An important part of this agency·s health program are mobile dispensaries. Brig. Gen. Howard F. Smith, Chief Public Health Adviser to the U. S. High Commissioner. •nnounced recently (Mar. 21) that the U. S. Health Service will soon organize additional malaria units to exPand its malaria control activities in the Philippines. Those interested may communicate wiih Lt.·Col. Francisco J. Dy, Customl:I Bui1ding, Port Area. The North General Hospital celebrated its first annivenary on February 28, with scientifi<: and literary•musical programs. In the scientific program, Lt. Col. Maurice H . Schnitker, Medical Consultant of AFWESPAC, was the guest speaker. He spoke on Hypertension and Hype;tensive Heart Disease. Drs. Agustin Liboro and Wenceslao Vitug led tbe discussions. Secretary Jose C. Locsin of the Department of Health and Public Welfare was the guest oi honor at the literary musical program. 142 NEWS ITEMS Jour. P. M. A. March, 19'6 Thirty•three government hospitals in Manila and the provinces have been reopened to the general public since the liberation of the Philippines last year, Dr. Jose C. Locsin, Secretary of Health and Public; Welfare, declared recently. This was made possible by the laboratory equipment and medical supplies, amounting to several million pesos donated by the United States Army to the Commonwealth Government, Locsin said. On its part, the. administration set aside Pl,779,000 for the repair and reconstruction of hospitals. It bas also opened charity clinics, maternity houses, and puericulture centers in the towns. M.ilitary hospitals havd like• wise been operating since the liberation of the country; and, in addition to caring for the sick and wounded officers and soldiers, they have also rendered medical treatment tq ciyjlians in places where there are no government hospitals. · Santo Tomas University Hospital on Calle Espana was inaugurated and blessed March 7, 1946 by Mons. Guillermo Piani, Apostolic Delegate, with Mrs. Esperanza Osmei\a as sponsor. The Hospital is located in the modern tbree·story concrete structure on the University campus. It is equipped with 60 privatet rooms, spacious general wards, two separate surgical operating rooms, and an up•to·date delivery room and nursery. Mr. C. Leoi Wilheim, Manager of the Philippine Red Cross, bas plans for extensive ex• pansion ot activities. According to a recent statement of Secretary Jose C. Locsin of the Department of Health and Public Welfare, there is a dearth of physicians in the Visayas, especially Antique~ where only two physicians are trying to serve a population of 240,000; and people depend mostly on herholarios and quacks for medical assistance. On February 19, Dr. Co Tui, Associate Professor of Experimental Surgery of New York. University, came to Manila by plane on his way to China on official mission. During his brdef stay in the city, he was feted by his Chinese and Filipino friends, among whom werel Mrs. Socorro S. Diaz, Drs. Baldomero Roxas, Jose Albert, Alfredo Baens, Vicente R. Ocampo, ?.nd Jose Santillan. Dr. Miguel Canizares, Managing Director of the Philippine Tuberculosi~ Society, stressed recently, in an appeal to the press, radio and other informatior( se:rvices, the necessity of mass education in connection with the campaign against tuberculosis. f He said that phthisis causes one out of seven deaths in the c6untry and that it is easily curable if detected early. FOREIGN : Dr. Thomas Parran, Surgeon General of the LI. S. Public Health Service, conferred with President Truman recently on plans for the establishment of. an international organization for world·wide control of communicable diseases. The body will function under the United Nations Organization. Dr. Parran will leave for Paris to assist a preparatory committee in planning for a conference in June to set up the health organization, which will :eoordinate the activities of the International Office of Public Health, the League of Nations Health Organization, and the UNRRA 'S present health activitie&. According to a United Press dispatch, Dr. A. B. M. Sison emphasized, in his address on February 8 at a meeting of the National Commission on ChiJdren in Wartime under the auspices of the Department of Labor, the urgent need of aid to Filipino children. Dr. Sison is in: the U. S. on a Rockefeller foundation grant to c:ontinue his studies in nutrition' and to obtain equipment and supplies for the rehabilitation of th( Medical Center i'n the Philippines. In the February 1946 issue of THE JOURNAL of the Kansas Medical Society, the follow· ing appeared : Volume XXIJ Number 3 NEWS ITEMS NEED FOR MEDICAL BOOKS IN MANILA 143 Some months ago the Academy·International of Medicine and Dentistry; moved its execu• tive office from St. Paul, Minnesota, to the Liberty Building, Topeka, because of its central location. According co· the executive secretary, .Mr. J, B. Young, one of tbe projects of this "rganization is to attempt to supply the destroyed medical library at the University of Manila with sufficient books to enable the school to operate. It is well known that the Japanese destroyed the University and its library until almost no piece or usable equipment remained. The Academy·lnternational of Medicine and Dentistry i~, appealing to tbe medical pro· fession all over Canada and the United States to donat<i books that may be sent 'to Manna~· Already 10,903 individual publicatfons are in transit and many more are needed. These books have come from individuals., from medical libraries, medical schoolsi and clinics. • Kansas doctors are invited to assist in this worthwhil9 undertaking through the contri· bution of books, periodicals or cash. Doctors willing to donate books should first write to the Academy•lnternational of Medicine, Liberty Building, Topeka, giving the names and authors and edition numbers of the books that are available. In an effort to send only material that is critically needed and to avoid duplication, all gifts should be cleared before they are sent. The donor will then be instructed which of these books are desired . If cash is given, the donor may be assured that all money will be used for the purchase of needed texts, that arrangements have been made with leading publishers to sell books for . this purpose at cost, and that they will be forwarded immediately to the School of Medicine, University of the Philippines. Make all checks payable to: Manila Library Fund, A•l, M. Among the important articles read at the 4 2nd Annual· Congress on Medical Education and Lcensure held February 10· 12, 1946, in Chicago were the following: The Development and Protection of High Educational Standards by the Medical Profession, by Ray ·Lyman Wilbur, M. D.; Medical Progress During the War, by Perrin H. Long, M. D.; Medical Education in Europe, by Wilburt C. Davidson, M. D.; Problems in Specialty Practice, by Paul Titus, M. D.; Research in Undergraduate Medical Education, by Oeder W . Bronk, Ph.D.; The People's Health-A National Asset, by Hon. Watson Miller Agency; Why Require Graduates or Approved Medical Schools to Pass a Basic Science Board Examination, by H. M. Platter, M. D. U. S. DOCTORS BUCK TRUMAN'S HEALTH PROGRAM -American doctors, like their British Colleagues, are refusing to be nationalized. Their arguments are very similar to those expourtded by the British Medical Association. The current issue of the Journal of the American Medical Association has denounced President Truman's health medical program as an .. attempt to enslave medicine as first among the professions, industries or trades to be so• cialized." The Journal put forth a strong plea for Congress to defeat a bill which would carry out the President's recommendations. The measure, the Journal states, would .. destroy the private practice of medicine,''I "place the medical profession under the direction of one man," "enforce the hospitalization provisions to destroy the voluntary hospital system," and " require people ·to take any doctor the surgeon general tells them to." 144 Jonr P. M . A. March, 1?46 IMPORTANT NOTICE Original articles are accepted for publication only with the understanding that they have not been and are not to be published elsewhere. The Editorial Board reserves the right to accept, reduce, or reject all manuscripts submitted for publication. Twenty-five reprints, arc given free to the author and any number of additional copies will be furnished at cost price provided that written request be made at the time the article is submitted for publication. REFERENCES TO LITERATURE CITED SHOULD INCLUDE: FOR PERIODICALS : NAME OF AUTHOR, TITLE OF ARTICLE, FULL NAME OF PERIODICAL, VOLUME NUMBER, INCLUSIVE PAGING, MONTH AND YEAR OF PUBLICATION, ALL IN THE ABOVE ORDER. EXAMPLE FOLLOWS: Pio de Roda, Alfredo : Typhus Fever in the Philippines: Weil-Felix Reaction of 500 Cases, Journal Philippine Islands Medical Association, 17:147· 156 (March) 19~6. REFERENCES TO BOOKS SHOULD INCLUDE: NAME OF AUTHOR, TITLE OF BOOK, PLACE OF PUBLICATION, NAME OF PUBLISHER, DATE OF PUBLICATION, VOLUME NUMBER, AND PAGES CITED, ALL IN THE ABOVE ORDER. EXAMPLE FOLLOWS: Peters, ]. P., and Van Slyke, D. D. : Quantitative Clinical Chemistry, Baltimore, Williams & Wilk.ins Company, 1932, vol. 2, 892-893. THESE REFERENCES SHOULD BE LISTED ON A SEPARATE PAGE AT THE END OF THE ARTICLE WITH CORRESPONDING NUMBERS IN THE TEXT. ACCURACY AND COMPLETENl!SS OF LITERATURE CITATIONS IS REQUESTED. Any other information regarding publication of figures, graphs, etc. will be furnished by the Editor upon request. ADVERTISERS are requested to send in copy and cuts. if any, for their advertisements not later than the 20th of the month immediately preceding the month of issue, othetwise, the advertisements as published in the preceding number will be issued. The Editorial Board reserves the right to accept, modify or reject all copy submitted for advertisement. MEMBERS and SUBSCRIBERS will oblige us by prompt notification of any change in their addresses, or failure to receive the Journal regularly.