The Journal of the Philippine Medical Association

Media

Part of The Journal of the Philippine Medical Association

Title: The Journal of the Philippine Medical Association
Issue Date: Vol. XXIX (Issue No. 9) September, 1953
Rights
extracted text: ----75he ---JO URXAl-4 OF THE PHILIPPINE A\EDICAL ASSOCIATION ~~-===============:::::::;oOo VOL. XXIX SEPTEMBER, 1953 No. 9 U:able of Grontenta ORIGINAL ARTICLES: Page Dihydrostreptamycin in Leprosy Cases in the AFP: A Preliminary Report - by D. M. G<1rd111io, Maj., M.D. . . . . . . . ... .. .. . .. 451 Pathology of Old Age - by Benjamin Barrera, M.D. 463 Surgical Problems in the Aged - by Luis F. Torres, f!·• M.D, . . . 46/ Almost Fatal Penicillin Anaphylactic-Like Shock Reaction. Report of a Case at V. Luna General Hospital, (Afl') - by Conrado B. Icasiano, Lt. Col., M.D. 4n (Ccmli1111eJ °" llare l) Published Monthly ~Y the Philippine Medical Assl>fiation Philippine General Hospital, Manila ~gle Copy 1'1.2~ntered ;• second elass mallor at :;. Manila Post Offico, Mar•: T. 1946Pcr Year Pl2.00 .. -~J.J.l~v- .. For Daytime ALERTNESS under ANTIHISTAMINIC therapy Prescribe NEOHETRAMINE (HYDROCHLORIDE) Effective ANTIHISTAMINIC ACTION WITH AN EXCEPTIONALLY HIGH DEGREE OF FREEDOM from SEDATION * NEOHETRAMINE TABLETS OF 25 mg., SO mg, & 100 mg., IN BOTTLES OF IOO's and IOOO's * NEOHETRAMINE SYRUP IN ONE PINT BOTTLES, 6.25 mg. per cc. * NEOHETRAMINE CREAM 2 3 IN COLLAPSIBLE TUBES OF I OZ. * NEOIIETRAMINE EXPECTORANT IN 4 OZ. BOTTLE Nepera Chemical Co., Inc. NEW YORK, U.S.A. For free literature and samples, write P.O. Box 3038, Manila SPASMO · CIBALGIN a11algesic 1wd a11tispm111odn· Pain of spastic origin J55m;J; gastro -intestinal pains ulcer pains post- operative spasms spasms in renal and biliary colic Tablets: Boules of 20. Ampoules: Boxes of 5 CIBA LIMITED, BASLE, SWITZERLAND Further information and samples may be obtained from our Sole A!rents in the Philippine.>: Messrs. ll'HELDER, INCORPORATED l-!3-149 Sta. Potenciana, intramuro5, i\laniia Telephones: 3-32-66 & :l-32-67 Jour. P.M.A .. Volume XXJX. Number !• CONTENTS-Continued Pa gt ::\1cn:uchiJ I Postoperative Acute Hypoparathyroidism :tnd Acute I-Iypothrroidism - by Pedro T. Nay, M.D. . ..... . . . . ... 477 SPECIAL ARTICLES: The Public Health Aspect of the FOA-PHILCL'SA ProgrJmme in the Philippines - by /11a11 Salcedo,/'"• M.D . .. .... ... .. . . .. 4 SO The Control of Tuberculosis - l•y Si d u A. Fra11cisco, i\l.D., F.C.C.P. 4S6 EDITORIAL: What September 1 5 Means to Us. PRESIDENT'S PAGE Our International Relations MISCELLANEOUS: ABSTRACTS FRO M CuRRF7"T LITEKAT L' RE SocIETY A cTl \ ' ITTE5 NEWS ITEMS B ooK REVIE\\' S CC.lie OutilanJl11q Properties of IRGAPYRIN Dete1·mine its Therapeutic Use as Antirlie1tmatic - Antiphlogistic, A11alges0_ and Antifebrile agent. cc. ampnulcs Tablets Boxes of 5 and 50 Tubes of 20 A Product of ). R. GEIGY S.A. Basie, Switzerland Represented in the Philippines by: F. E. ZUELLIG, INC. MANILA - CEBU 494 497 498 501 503 504 II Jour . P. M. A . Se ptember, 19.i3 The TIME-TESTED Steroid in ARTHRITIS THERAPY S cience continues to seek a cause and a cure for the arthritic syndrome. For the arthritic sufferer who can't wait but needs relief NOW, the pioneer in the field-time-tested Steroid Complex, Whittier -ERTRON'!!....is available for use now. Ertron is a potent drug, and like all potent drugs should be administered only under the direction of a physician who will determine compatible dosage levels. ~s DIVISION NUTRITION RESEARCH LABORATORIES, INC. CHICAGO 11, Ill., U.S.A. SOLE DISTRIBUTOR IN THE PHILIPPINE REPUBLIC1 LEVY HERMANOS, INC., P. 0 . BOX 273, MANILA / 111 IV Bromural «Knoll» l•t-mo " obrom1 1ovoler.,1.corbom1de) Harmless nerve sedative and soporific: 10 and '20 fableh Cardiazol - Ephedrine «Knoll» 10 I gm, Pentomc1hrlenetehoi ol +O·OI~ gm. Ephed11ne hyd rochloride .lfk ... • 1 Antiasthmatic and circulatory stimulant 10 tablets, 10 gm. liquid, 6 ampoules Calcium-Diuretin «Knoll» tlheob1omine-colcium 1oli<ylorel Diuretic, cardiac and vascular remedy 20 tableb Jour. P . ~.A . Scptt-mbcr, ]9.·,:: Volume XXJX Numbe1' 9 TO DECREASE DRAINAGE TO MINIMIZE MALODOR TO FACILITATE HEALING v Discharge and malodor of bacterial cervicitis and vagfuitis can be markedly decreased by Furacin Vaginal Suppositories. When the infection is accessible to vaginal medication, it is usually promptly eradicated by the powerful antibacterial action of Furacin, whose spcictrum includes many gram-negative and gram-positive organisms. When cauterization or conization of the cervix is indicated, use of Furacin Vaginal Suppositories pre- and postoperatively is reported to produce cleaner, faster healing with less slough and drainage. New Therapy in Cervicitis & Yaginitis Furacin Vaginal Suppositories Furacin® Vaginal Suppositories contain ·Furacin 0.2%, brand of nitrofurazone N. N. R. in a base which is self-emulsifying in vaginal fluids and which clings tenaciously to the mucosa. Each suppository is hermetically sealed in foil which is leak-proof even in hot weather. They are stable and simple to use. These suppositories are indicated for bacterial cervicitis and vaginitis, pre- and postoperatively in cervical and vaginal surgery. Literature 011 1cque$/ N 0 R W I C H, N E W Y 0 I> K· Exclu.sive Distributors in the Philippi11es: Philippine-American Drug Company (BOTICA BOIE) lrlanll•. P. l. CEBU - ILOILO - LEGASPI - DAVAO VJ -,,~J ·~;· Jour. P.M.A. September, 19;>3 Pref erred in the treatment of PERTUSSIS and other childhood infections Terram ycin is "pa.·ticularly 1'al11able in paediatric practice ... " (Wolman. B. a.nd Holzel. S.: B rit. M. J . 1:~19, 195%) Terramycin~ Safe· Effect?'.ve ·Economical· Broad-Spectrum Antibiotic. Now a·vailable in a variety of convenient dosage forms for greater flexibility. PFIZER INTERNATIONAL SERVICE CO., INC. 25 Bro(J.d Street, New York 4, N. Y., U.S. A. DJJlribulon METRO DRUG CORPOKA'flOS Bucndioa Extto5ion >.hluti, Rini, Philippinu M.iilinc Addreu: P. 0 . &ox .911, M.inil1 Philipriau WORLo's LARGEST PRODUCER OF .A.NTlilfoTlCS DtHYDROS TR E PTOMYCIN POLY MYX IN TO THE GENERAL PRACTITIONER we offer the e Argu-Gel-2 Oz. e Argumin-10 cc. e Arguzil Sirop-4 Oz. e Arguplex-4 Oz. e Arguzil Tablets- ] OO's • Arguplex Hypo-10 cc. e Arsirop-4 Oz. • Argutabs-2S's • Tas Tablets-2S's e Argutos-2 Oz. e Vermifuga-1 5 cc. - 30 cc. _/flanu/_actur.eJ bq T he House you helped build. the newly cou. <;tructed lmildin,g of th e ARGUZ PHARMACEUTICAL PRODUCTS 1427 Washington Ave., Manila T. S. ARROYO, Manager & Owner ARGUPLEX HYPO. 10 cc. v~ ~-l>THEJt INDICATIO!'liS: FORM U LA : Each cc Contains Sodium Cacodylate Strychnine Sulfate Thiamine Hcl. Riboflavin Niacinamidt Chlorobutanol Procaine Hcl. Neurasthenia, General Debility, Con,·alest'~DC'P. DOSES: 01w "" daily or as per ath·iee of the Physieian. FOR l!'liTRAMUSCULAR ONLY. 2;; Mgm. 1 !! Mgm. 2il Mgm. 1 !! Mgm. ;;o Mgm. ii Mgm. 2 •,; PEPTIC ULCER and HYPER-ACIDITY Each Tablet Contains Mag. Trisilicate ... .. Aluminum Hydroxide Gel BPlladonna Extract Powder Peppermint Flavored. P ink. DOSES: Adults : 2 - 3 T ahs. Three times daily. Chi11lrPn: I Tah. Thre,. limes 1laily. i"i grs. 3 1 2 ~'I'S. 2 Mgm. ARBUZ /-)luumaeeutiea~ /-)toJuets 1427 WASHINGTON AYE. M A N I L A • p H I L I p p I N E S i:!·S!liOS5:!1lii:!llOS!l&iil!!!liO*!!liiil!!lii:S*!liiil!-lii:!liil!Slii:SS!!lii:!liiil!+lii:S!i5iil!Slii:S!iFiil!Slii:s!iiil!slii:S!iiil!OS5:!Slii:!ll! Volume XXJX Number 9 One Step Ahead of Nature's Most Nearly Perfect Food It's not possilJlc to improve mu<'h on Mother Nalurc. Especially in her most nearly perfect foo<l-safe, pure cow's milk. But in routine fee<ling of infants there is a milk, KLIM, that actually goes the original product one better in two very important ways-dige:Slihility and uniformity. Ordinary cow's milk contains large fat particles which particu)arly in the case of infants are not always easily digested. However, through a special process the fat particles of KLIM arc reduced to a fraction of their original size-though un:iltered in composition and nulritive benefits. In similar fashion, the hard lumpy protein curd of fluid milk h changed into soft, finely divided curd. This means, very simply, that the baby l'an much more readily digest KLIM rind also get the full hcnefit5 o[ milk. The Borden System of Quality Control assures the purity and nutritive con· <istoncy of KLIM. And with KLIM the infont enjoys the flavor ~nd other benc· fits of farm·fresh milk. Finally, because it is vacuum-packed in the sanitary protected tin, KLIM is alm:iys safe, pure milk. It is not stirpfis· ing that KLIM j5 recommended everywhere wirh confidence! KLIM FIRST IN PREFERENCE THE WORLD OVER Fo.r professional informal ion taite to: THE BORDEN COMPANY, EXPORT DIVISION 350 Madison Aveaue, New York 17, N. Y., U. S. A·. VII VIII J ou1·. P.1\1.A. September, 195J SALVITAE in the treatment of RHEUMATISM - GOUT - LITHAEMIA \Vhatever the exciting cause of the numerous sy.mptoms classified as Rheumatism, Gout, Lumbago, etc., may be IT IS of primary importance that the channels of elimination be kept free from all toxic and irritating obstructions. The Magnesium, Sodium, Strontium, Lithium and potassium salts as combined in SALVITAE. with Sodium-Forma-Benzoate, afford the ideal eliminant and is thoroughly re liable a s an alkalizing agent. Samples and literature to the medical profession on application to American Apothecaries Company 29·~8 .Ust Avenue. Lone Island Cily, 1. New Tork P ermit No. 960-JuM 2;;., 1928 FORMULA ~tronlii I.act-as • •• , . , , .•.••• , , •. Lithii Carbonas . ... . ........ , ... . Caftein Et Quinina.e Citras , .. .Sodii-Fbnno-Ben21Ca.s ••......••...•... , • ... Calcii Lacto-Phosphas ........... , . Potassii et Sodii Citro-Ta.~r~ . , . Mag-nesii Sulphas ..•.••••••....••.. Soc!ii Sulphas , . . , . .30 Gm. .16 .. • 80 .. 1.60 .. .15 .. 69.00 .. 8.00 .. 30.00 .. 100.00 Gm. Volume XXIX IX Numbe1· 9 AMENOGLOBIN THEflAPY liwer•H• ... a11lo~i11.3~ Supr.urNl(Wi..le)1e" sto~Sv.b!ltlft(.C11r. Vitat.1i" &-1 .•• 1aoo1.u. R9:19ot1.,M,rrow ~.a••· Vlt.nii11C., .•. ZOOUL SplHn Su\H.tat1c."1r,~. NiaiciR a"'icle20.lff lro" . , . , , ... 28 1111i'4· M\aoir•• (lo""t~ OC£ANIC COMMER.CIAl., INC. MA ... n .. A OPVTAl.=~~ REG.TRAM MAU. ---==--~ -= - - - - - - PERNICIOUS ANEMIA • SECONDARY ANEMIAS • CONVALESCENCE • ETC. £)~ OCEAnlC commERCIAL, inc. 89 ESCOLTA, MANILA OPYTAL~~~~~§ Higher.t Quality - Hir.hest Standard x , _____ \ F~r routine infant fe¥mg. The basic DC,xtri~ Maltosc pro'duct. O~triJ~ MEAD \JOHNSON & COM.PANY Evclnsville 21, Ind., U.S.A. (} /~ //" • :_ I \j /:;; .· Jou1·. P .?at .A. September, 1953 -u:-1 I //} Especially indicated for pre· mature infants. Contains SO mg. ascorbic acid per ounce. \ To aid in counteracting \ constipation. Contains 3o/o \ ~::~;::~ ~th (~ngleness \ of purpose Designed and manufactured specifically for infant formulas, Dextri·Maltose"' has an unequaled background of successful clinical use Safety for your infant patients is assured by the dry form of this carbohydrate, meticulous laboratory control at all stages in its manufacture, and hermetically sealed, key-opening cans. Dextri·Maltose is palatable bufnot sweet; does not create a "sweet tooth" in infants. Easily measured without spilling or waste and almost instantly soluble, Dextri·Maltose is convenient for the mother. L. D. SEYMOUR & CO. (MANILA), INC. William Li Yao Bldg. 3rd Fir. Rm-339·340 - Rizal A\·enue, Manila - Tel. 3-92-64 Volume XXIX Number 9 Tailored specifically Jor refractory infections of the urinary tract: pyelonephritis pyelitis cystitis XI FURADANTIN ®brand of nitrofurontoin A new chemotherapeutic agent with definite advantages: clinical effectiveness against most of the bacteria of urinary tract infections, including many strains of Proteus, Aerobacter and Pseudomonas species low blood level-bactericidal urinary concentration effective in blood, pus and urine-independent of pH limited development of bacterial resistance Available on prescription as tablets of 50 mg. & JOO mg. rapid sterilization of the urine stable oral administration N 0 R W I C H, N E 'W Y 0 R K low incidence of nausea; no proctitis or pruritusno crystalluria or hematuria nonirritating-no cytotoxicity-no inhibition of phagocytosis - The ~ NITROFURANS tailored specifically for uro/ogic use I\ O,NO R \ 0 Literature on request Eulttsive Distributors in the Ph.il.im>i11ca: Philippine-American Drug Company (BOTICA BOIE) Manila. P. [, CEBU ·- ILOILO - LEGASPI - DAVAO A unique class of ~:~~imicrobials XII J OUl'. P.l\l A. September, 1953 In intranasal therapy ... Aramine Intranasal Decongestant i;t~~:e:i:t~ ?.0 It7;,°f.. ~J"~.::....t'IMI alomiur or drt>ppt r a~embly Foe relief of nasal congcsrion accompanying • COR YZA •SINUSITIS • NASOPHARYNGITIS •RHINITIS Effective Vasoconstrictlon without se~r rv . '~I Reactions ~ Sharp & Dahme rPHILIPPINEsJ iNc. ~,___ _ _ ISAAC PERAL, MANILA • P. 0. IQX 11IO E1Jch 100 ~.c. co11.toiru " .A.rainblt" 0.'2,; gna,,, P"~'"' '" 1/ie l1ydrot1m d·tf:!rliat' t.'.lit!\ 0.00~ per cent d.irrt.'>rosal, adckd a~ Prt6t1'1x1tic1t·. THE JOURNAL OF THE Philippine Medical Association Dtvoi.d lo the Progress of Medical Science and lo the inlcrffls of the Medical profession in the Philippines Manila, Philippines \'OL. XXIX SEPTEMBER, 19 5 3 No. 9 CorYRIGHT, 1953, BY PHILIPPINE 1vlEDICAL Assoc1ATION ··tjtl ®rigimd Artides II~·· DIHYDROSTREPTOMYCIN IN LEPROSY CASES IN THE ARMED FORCES OF THE PHILIPPINES A Preliminary Report ,,. MAJOR D. M. GARDU NO, M.C. Chief, Section Dermatology el Syphilology V. Luna General H ospital (AFP) Two decades ago, chaulmoogra oil and its derivatives were standard treatments for leprosy, just as neosalvarsan and bismuth were to syphilis. In this atomic age, penicillin is to syphilis as cortisone is to rheumatoid arthritis, chloromycetin to typhoid, and dihydrostreptomycin and sulphonc to leprosy. It is undeniable th:it, with the time-honored chaulmoogra oil, tedious years of treatment are necessary to attain amelioration and arrest of the Ma;. D. M. Gm/1.,;o ravages of leprotic infection. Now, within a relatively much shorter period, modern therapy can produce the same degree of improvement and earlier health rehabilitation. In 1951, the Jonrnal of the Philippine Medical Association publish an article -on dihydrostreptomycin in an early case of cutaneous leprosy in the AFP. A follow-up one year after the patient was discharged as an arrested case of leprosy revealed that he h:id remained clinically and bacteriologically negative. Dr. Jose 0. Nolasco, chief pathologist of the Culion Sanitaria has confirmed my diagnosis of lepromatous leprosy of the serial histological sections of the first case mentioned. Had my first case turned out to (·Read before the scientific meeting of the= i\bnil:i i\-lcdical Society on 16 June 195} lt rhe V. Lun:i Genenl Hospital, K:imias, Q .C. 452 DIHFDROSTREPTOMYCIN IN LEPROSY-Ga,.dmio Jour. P.ll .A. September, J!Jj i be a tuberculoid masquerading as a lepromatous, good results reported would have been nullified and attributed, not to the action of dihydrostreptomycin, but to a spontaneous regression often observed among tuberculoid cases. There should be no room for doubt as to the anti-leprotic action oi dihydrostreptomycin. Drs. Erikson and Johannsen of Carville Leprosarium reported in the ]01tr11al of America/I Medical Association, in 19 51, encouraging and successful results with this antibiotic in some leprosy cases. Dr. B. M. Saenz of Cuba, in an article in the Archives of Dermatology and Syphilology, in 19 5 2, reported beneficial treatment of lepra reaction with dihydrostreptomycin. Dr. Jose N. Rodriguez, in 1952, tried dihydrostreptomycin in a number of lepromatous cases at the Cebu Sanitaria, and reported very encouraging results. This is a preliminary report on 36 leprosy cases treated with dihydrostreptomycin, alone and in combinltion with promin (Dextrose sodium sulfonate) and PAS tablets. TYPE OF LEPROSY Out of the 36 cases, 19 were lepromatous, 16 vyere tuberculoid, and was neural. This classification was based on clinical manifestation, bacteriological findings, and histopathological pattern. Almost all the cases were early. The yearly physical check up in the AFP have contributed to the early detection of leprosy cases. AGE GROUP AND DURATION OF ILLNESS The youngest in the group is 19 years old, and the oldest 64 - giving an average age of 41 years. The duration of illness before treatment was started rai:igcd from as earlv as one month to as late as 7 years, giving an average duration of illness of 3.6 years. This information is tabulated as follows: T .,nu:. I - A.~1· CrCJup ··-·-- --·-- ··---------------------20 I fom:_;:40-= i Frnm 40 ,bovc 1 · Avmg~ 14 I 1 41 TABLE .'.! - Duralio11 of Ill11css - -- -- ·- -···------------------ --3-4 monchs I S-6 months t _ Below I yc:ar I 2-3 ye.us : 4-7 years I Ave. Duration to I vcu l ____ _ o_f _Jll_no_ ss_ ·--------- - ---- - -~- -- T--.--1 J.6 Y'" l..'.? months I JO --- --- . ----- ·------- ----CLINICAL MANIFESTATIONS Leprosy, like syphilis, is acquired by contact. By a strange coincidence, the pathogenesis of the two diseases bear a striking similarity. The primary lesions of syphilis - its dermal manifestations, the syphilides; the early lesions of leprosy - the depigmented areas, the pinkish reddish Volume XXIX Number 9 DIHYDROSTREPTOMYC/N IN LEPROSY-Garduno 453 macules, and the anesthetic areas - all these make their appearance after a successful systemic invasion has taken place (after a short incubation period of 10 - 90 days for the former, and 6 months to 30 years for the latter.) Again, like syphilis, the clinical manifestations of leprosy are protean in character. To illustrate a few cases: Case 9 (D S group). A sailor had a spot of anesthesia above the right knee, dotted with a mosquito-bite-like papule which was bacteriologically positive for M. leprae. Case 6 (D S and Promin group). Another ,.;(or was hospitalized for a bladder contracture, for which he was operated on. One month later, while recovering from the operation, he developed a discrete I 0¢-size nodule on the left cheek. This was soon followed by reddish infiltration of both alae nasi; and several weeks lacer, by multiple nodules on the trunk and extremities. All the while, the left great auricular presented • tender and hard enlargement the size of an ordinuy le•d pencil. The nodule on the left cheek blossomed into • 3-inch diameter lupoid-like eruption, which ulcerated on the least trauma. In a few months, the left great auricular had enlarged to the size of a thumb. Case 2 (D S and Promin group). A Philippine Military Academy cadet had verrucose and eczematous-like eruptions on the left palm and left knee, both lesions being anesthetic, fungus, and acid-fast free. The regional ulnar nerve and common pcroneal nerve were moderately enlarged. This case recovered uneventfully, with a one-year essentially negative follow-up. Case 7 .(D S group). Another soldier exhibited a ring,.•orm-like lesion on the nape of neck, which was negotive for fungus and acid-fast, but positive for sensory disturbance. Before Trea/mcnl Lej11·omalo11s Case 4 DS gro11j1 After Treatment Lejnnmatous Cn.<e 4 DS grouj1. CRS. N cgalit'e aftcr 1 yr. and ; mos. bosjiitali=alion. 454 DIHYDROSTR'EP'TOMYCIN IN' 'lEPROSY.:...Ga1·dmio Jour-. '"P·.M.A. September,. 19til · Before Trt•atment L_epro111alo11s Case 7 in DS-PAS grouji. Before Treatment Lepromato11s Case 17 DS group. After Treatment Lepromatous Case 7 in DS-PAS group. After 6 mouths hospitalization. MMRS. Still posiffre haclcriologically. After Treatment Lepromatous Case 17 DS group. CRS after 10 months hospitalization. Negatfre bacteriologically. · Vo(w:ne XXIX Nwnber· !J DJHYDROSTREPTOMYCIN JN LEPROSl'-Gard111io Case 4 (D S group) and Case 5 (D S and Promin group), T wo soldiers were hospitalized and discharged improved because of neuritis of lower extremities and slight foot .drop; one to t wo years later, a second hospitalization revealed nodular eruptions on the face and different parts of the body, in addition to aggravation of neural disturbances. In almost all the cases, one or two of th~ ·nerve trunks, usually the great auricular or the ulnar nerves, arc enlarged and tender; and the c3Ses usually start with areas of anesthesi• somewhere on the extremities, followed sometime later by a depigmented area or a pinkish macule. Case 3 (D S and Promin group) . In addition to scattered areas of . reddish infiltrations, neuritic and joint pains, this patient presented muscular atrophy of the interossei of the left hand and contracture of two digits on admission. 455 Lepra Reaction: Lepra reaction; as we know, is the reactivation of latent lepra lesions and the activation of new lesions, associated with varying degree of systemic manifestation. There were instances of lepra reaction which have hastened the resolution of leprotic lesions. On the other hand, persistent and refractory lepra fever was observed to have aggravate.cl the disease. Leprologists both here and abroad have recommended the temporary suspension of the anti-leprotic medication in the presence of lepra reaction, and the institution of supportive and symptomatic treatment. Five cases in the D S group, and one in both D Sand Promin groups and D S and PAS groups, who had moderate lepra reaction at the start recovered pari passu with the regression of the leprotic lesions. Only one case in each of the D S and PAS groups developed lepra reaction in the course of treatment, and both of them recovered uneventfully. 1 '.II -1 I __ j Lupoid-like lesion of Case 6 in DS-Promin group. V ery resistant to treatment. SIS. 456 DIHYDROSTREPTOMYCIN IN LEPROSY-Gard1tno Jour. P.l\ol.A. Se ptember, 195;1 The slight to severe neuritic and joint pains, the varying degrees of fever and chills, the anorexia, nausea and vomiting, heaflache, extreme malaise, the kerato-conjunctivities, which were observed in lepra reaction cases in this study have responded dramatically to dihydrostreptomycin even during the first month of treatment. LABORATORY FINDINGS The lepromatous cases showed positive smears for M. leprae ranging from 2 plus to 4 plus. Two tuberculoid cases gave a 1 - 2 plus positive smears. Smears were taken from the skin and nasal septum. The Wade method of skin smears was practiced. Six negative smears taken from :i clinically negative case at monthly intervals were sufficient to establish an arrested case. CBC and urinalysis were essentially normal before and after treatment. The sedimentation rate was normal in most of the cases, and slightly to moderately elevated in those cases with lepra reaction. Serology: All cases were negative for Kahn. Biopsy: Two histological sections of nerve tissues were unsatisfactory, as they showed uncharacteristic findings. Almost all the biopsies were from the skin at the border of the lesion and from the normal skin. The diagnosis of tuberculoid was based on the findings of perivascular round-cell infiltration, collection of round cells and epitheloid cells around glands and follicles, in addition to the presence of macrophages, histiocytes, etc., all in accordance with Wade's criterion of tuberculoid leprosy histo-diagnosis. A lepromatous pattern was based on the presence of giant cells and foam cells, the lepra cells of Virchow, with or without acid fast organisms, the globi· in the tissues, in addition to perivascular, periglandular, perifollicular round cell, and epitheloid infiltration. RADIOLOGIC CHEST FINDINGS Five cases presented minimal fibroid to exudative tuberculous lesions radiologically, with repeated negative sputum for acid fast. Four cases showed findings compatible with chronic bronchitis. The rest of the cases were diagnosed radiologically healthy chest. All those with chest findings cleared up after treatment, with the exception of two cases with exudative tuberculous lesions. MODE OF TREATMENT The 36 patients were divided into 3 groups - namely, the D S group of 20 patients to whom only dihydrostreptomycin was administered; the 0 D S and Promin group of 6 patients on whom a course of dihydrostreptomycin was followed by promin (dextrose sodium sulfonate) injections; and the D S and PAS group of 10 patients to whom dihydrostreptomycin was given simultaneously with PAS tablets (para amino salicylic acid). Volum• xx1x DIHYDROSTREPTOMYCIN IN LEPROSY-Garduno 457 NUmber 9 In the D S group, each patient consumed an average of 60 grams of dihydrostreptomycin, divided into 0.50 gram daily, and given in two intramascular injections. In the D S and Promin group each patient was given an average of 66 grams of dihydrostreptomycin, in the same manner as in the first group. Into each patient, an average of 103 ampule.~ of promin were shot intravenously, following the course of dihydrostreptomycin. In the D Sand PAS group an average of 71.2 grams of d1hydrostreptomycin was given in two courses - the first cou.rse lasting 120 days, and after an interval of 2 months, followed by a second course of 60 days in uniform daily dosage of 0.50 gram, in addition to a simultaneous per orem of 437.1 grams of PAS per patient. lntradermal injections of dihydrostreptomycin from 10 grams to J 5 grams (20 - 30 doses) supplemented the intramascular injections when lesions like nodules and thickened infiltrations persisted in their positivity bacteriologically. Supportive treatment like vitamins, 5 % dextrose solution, amigen in dextrose, sedatives, etc., were instituted whenever indication demanded. CUTANEOUS LESION CHANGES Representative skin lesions observed among the 36 cases and their response to treatment are described as follows: 1. Ma·cules, pale, hypo-pigmented, 2 cm. - 10 cm. diameter, mostly oval in shape, non-elevated borders, completely anesthetic, usually negative for M. leprae, located on the extensor surfaces of extremities, face, and trunk, not more than one or two in number. Slight to moderate regression. 2. Pinkish macules with fading center and raised outer zone, dotted with reddish, minute papules with gyrate borders at times, anesthetic and acid-fast free, location and number as in ( 1). Very amenable to dihydrostreptomycin alone, or in combination with promin or PAS. From marked regression to complete regression. 3. Reddish, glossy, elevated welt-like nodules, oval or circular in shape, definitely circumscribed, from 2 cm. - 5 cm. in diameter, nonpruritic, usually non-anesthetic and acid-fast negative; had to be followed with promin injections to attain complete resolution. 4. One· type of lesion seldom observed in leprosy cases and found in one case in the D S and PAS group is described as having a peculiar thickly-mt>tded elevated pinkish to reddish, moderately pruritic infiltration on the anterior and posterior chest, abdomen and neck thighs and forearms; the face and ears had a pinkish diffused infiltration; the skin smears were strongly positive for M. leprae and histologically suggestive of the lepromatous type. Marked regression, but remained positive. 5. Diffused, thickened, erythematous, edematous, glossy infiltration with subcutaneous indurations on the ears, extremities, and trunk; and when observed on the face, presented the classical leontiasis. Amenable to dihydrostreptomycin alone and in combination with PAS or promin. From moderate to marked regression to complete regression. 458 DJHYDROSTREPTOMYCIN IN LEPROSY-Garduno Jour. P.M.A. September, 1963 6. Various-sized nodules scattered on the face and trunk, rising from a surrounding infiltrated skin or from apparently normal skin, strongly acid-fast positive. Slight to moderate regression observed. 7. Lupoid-like lesion found on the cheeks. Very resistant to treatment. Slight improvement observed. 8. Verrucose and eczematous-like lesions found on the palms and extensor surface of thighs and legs. \Vhen the lesions are bacteriologically positive, they are more responsive to treatment with dihydrostreptomycin alone than when negative, in which case promin has to be followed afi:er the antibiotic to obtain clearing up of the lesions. In the cases that finally regressed in the first three months of treatment with dihydrostreptomycin, the lesions appear to have worsened, and soon start regressing on the fourth month of treatment. NEUROLOGIC CHANGES All the cases had varying areas of anesthesia; two had digital contractures; and four had slight to moderate muscular atrophies of the hands, foreanµs and legs. Eight cases with lepra reaction, which manifested neuritic pains, were alleviated and completely relieved during and after treatment. One early case of tuberculoid had complete recovery of sensory disturbance; and five had slight to moderate diminution of areas of anesthesia, especially after intradermal injections of dihydrostreptomycin. No change was observed in the digital contractures and muscular atrophies. DRUG REACTION Drug reaction due to dihydrostreptomycin - dizziness, headache, tinnitus, or eight nerve involvement - was not observed. There was freedom from acute dermal reaction, like dermatitis exfoliativa. No signs of secondary anemia or agranulocytopenia were noted during or after promin therapy. Tendency to increase in weight, improvement of appetite, and general feeling of well-being during and after treatment and observation period were very evident. GENERAL RESULT OF TREAT¥ENT In the D S group, of the 6 lepromatous cases, 5 resulted in complete regression of skin lesions, clinically and bacteriologically negative; 1 in marked regression of skin lesiop.s but still positive bacteriologically after an average of 14.1 months hospitalization; of the 13 tuberculoid cases, 11 had complete regression, CRS, also bacteriologically negative; and 2 became SIS, slightly improved skin lesions after an average of 7.8 months hospitalization: 1 neural case presented no improvement after 8 months confinement. In the D S and promin group, out of the 4 lepromatous cases, 1 became clinically and bacteriologically negative, CRS; 1 SMRS, slight to moderate regression of skin lesions, 2 SIS, slight improvement of skin ~~:::=~XIX DIHYDROSTREPTOMYCIN IN LEPROSY-Garduno 459 lesions, and these last three (3) had remained smear positive after an average confinement of 13.2 months. The 2 tuberculoid cases in this group had complete clearing up of the skin lesions, CRS, and remained bacteriologically negative after an average of 16.5 months' hospitalization. In the D S and PAS group, out of the 9 lepromatous cases, 2 had complete regression of skin lesions, CRS, as well as negative bacteriologically, after an average of eleven months of hospitalization; 3 had slight to moderate regression of skin lesions, SMRS, although remaining positive bacteriologically after an average confinement of 10.6 months; 2 had moderate to marked regression of skin lesions, MMRS, and negative bacteriologically; 1 had marked regression of skin lesions, MRS, and negative bacteriologically; and 1 had worsening of skin lesions, WS, and remained positive - these last four cases, after hospitalization of nine, six, eight months respectively. One ( 1) tuberculoid case had slight to moderate regression of skin lesions, SMRS, and remained bacteriologically positive, after eight months' confinement. Combining the results of the three groups and the average amount of drug administered to every member of each group, I prepared the following tables: No. of Cases 11 Total 20 Total' Typ< Lcpromatous. Lcproma to us Tuberculoid Tubcrculoid Neural Lcprom;itous Leprom:itous Lepromatous Tuberculoid TABLE l - DS Gro11p Ave. Amt. Drug Per I Clinical Resulu D:ictcriology Patient 60 gms Dihyj dros~rcptolmycm at O.lO ~m daily into 2 IM injec1 •ion1. \CRS Ncg:1tivc IMRS Positive I I Remained Neg. CRS 1 c3sc Pos. to Neg. I I SIS Rem.iined Neg. No ch.mgc Remained Neg. 66 gms Dihy- CRS Negative drostreptomycin plu1 SMRS Positive !OJ amps PROM IN SIS Positive Remained CRS Ncgati.ve I Average Hospitali- Percentage i zation 1-4.1 mos. 16.6 '7o 14.t mos. J.J % 7.8 mos. )6.6' o/o --1~-• mos. 6.6 % I J.J % I 8 mos. 13.2 mos. J.J % 1).2 mos. J.J % 1).2 mos. 6.6 % 16.f mos. 6.6 % 460 DIHYDROSTREPTOMYCIN IN LEPROSY-Ga•·. duno DS ontl P11i . Group 2 Lcpromatous 171.2 gms Di- CRS Negative \11 mos. --· hydrostreptoJ Lepromatous mycin plus SMRS Positive 10., mos. '437 gms PAS _ _ 2_ 1 Lcprom>tous MMRS Positive 9 mos. ---- - _ _ 1_ Leprom:atous I MRS Nc~ati\"e 6 mos. _ _ 1 __ lleprom"ous I WS Pos;t;ve 8 mos. 1 Tuberculoid SMRS Posmve I 8 mos. Total 10 Legend: MMRS-Modcucc to marked regression skin lcssions W S- Worsening skin lesions CRS-Complecc regression skin lesions MRS - Marked rcgnnion skin lesions SIS-Slight improvement skin lesions SMRS - Slight to moderate regression skin lesions Consolidating the clinical results: Jour. P .?tLA. September. 1933 I 6.6 % 10 % 6.6 o/o ),) o/o 3.3 o/o ),) % CRS - Complete regression of skin lesions, negative clinically and bacteriologically, from positive to negative, in 8 or 26.6 percent of 19 lepromatous cases. MRS - Marked regression of skin lesions, negative bacteriologically (positive to negative) - 2 cases or 6.6 percent. CRS - Complete regression of skin lesions, negative clinically and remaining bacteriologically negative, in 13 cases or 43.3 percent of 16 tuberculoid cases. SMRS - Slight to moderate regression of skin lesions, regardless of whether lepromatous or tuberculoid, and positive bacteriologically - 5 cases or 16.6 percent. SIS - Slight improvement of skin lesions, all types - 4 cases or 13.3 percent. No change - No improvement - I case or 3.3 percent. WS -Worsening of skin lesions, - 1 case or 3.3 percent. FOLLOW UP Nine cases were followed up from 6 months to I year after discharge; and they were found to have remained under control, clinically and bacteriologically negative. Eighteen cases, who had been sent to their units physically fit, were not heard from eight ( 8) months to two ( 2) years after being discharged from the hospital; and they are presumed to be well. Otherwise, they would have been re-hospitalized, with the exception of one case of tuberculoid type who was readmitted because of recurrence of skin lesion, 4 months after discharge. The remaining nine cases are still hospitalized. Volume xx1x DIHYDROSTREPTOMYCIN IN LEPROSY-Ga,rduiio :Numbel' 9 461 COMMENT The results obtained from the 36-patient group as a ·whole, namely 26.6% of complete regression of skin lesions, clinically and bacteriologically negative, among the lepromatous cases; and 43.3 % complete regression of skin lesions among the tuberculoid cases, after a relatively short period of dihydrostreptomycin and its adjunct treatment - these results, together with our observation, were encouraging and promising. They could not have been surpassed, much less equaled, by chaulmoogra oil or its derivatives. \Vhether other and more effective combinations of anti-leprotic drugs may be found, or are already found, only time and their results will tell. Would it be preferable to give dihydrostreptomycin alone or in combination with some other drugs? Table III seems to show that better results may be obtained with dihydrostreptomycin alone than with dihydrostreptomycin course of injections followed by promin, or dihydrostreptomycin simultaneously with PAS. It would be difficult to say what would be the optimum dosage of dihydrostreptomycin, PAS, promin or any sulfone when administered as an anti-leprotic. Individual weight, allergenic reaction, and intestinal absorption would have to be considered. Whether the uniform daily dosage of 0.50 gram of dihydrostreptomycin, the total dosage of 60 grams, or 90 grams, the continuous single course, or the interrupted two courses are adequate, inadequate or excessive, only the results would be the best guide. It would have been very informative and revealing had dihydrostreptomycin been combined simultaneously with chaulmoogra oil or its derivatives, and with each of the different sulfones available in the market' - namely, the diasone, diamedin, sulphetrone, etc. - or with an izoniazid; and had these different combinations been tried on groups of equal number of tuberculoids and lepromatous cases of practically the same age of infection, The reason for this latter precaution is obvious. Early cases are found to be more favorably responsive to treatment than late or advanced cases. According to some leprologists, impressive.results may be obtained with any form of anti-leprotic therapy when started on the downward trend of the parabolic curve of the course of the disease, whereas on the upward q1rve, when the disease is at its height, discouraging therapeutic failure is bound to be encountered. Clinical manifestation, sedimentation rate, and duration of illness are not adequate to forecast the downward trend, the upward trend, and the plateau line. Are there dihydrostreptomycin-resistant M. leprae just as there are dihydrostreptomycin-resistant tubercle bacilli? The difficulty of culturing M. leprae makes it impossible to answer this question. If dihydrostreptomyciO: could produce dramatic results in cases of lepra reaction, why does lepra reaction develop during dihydrostreptomycin therapy? In a similar manner, dihydrostreptomycin is used ef462 DIHYDROSTREPTOMYCIN IN= LEPROSY-Ga>'d11no Jour. P.ld.A. September, 1953 fectively against T .B. meningitis. Yet T.B. meningitis was observed to have developed during this antibiotic therapy. The action is paradoxical and defies satisfactory explanation. The number of cases in this report are so few - 36 when it should have been 100 or more if there were that number available in the army ward - to warrant conclusive observations to justify the claim, or insinuation of a claim, that dihydrostreptomycin alone, or in combination with any drug, is an effective anti-leprotic remedy. SUMMARY Thirty-six cases of leprosy - 19 lepromatous, 16 tuberculoids, and neural - were divided into three groups. Dihydrostreptomycin was administered exclusively in the DS group, in .combination with promin in the D S - Promin group, and with PAS in the D S - PAS group. The average amount of dihydrostreptomycin given to each patient was 60 grams in the DS group, 66 grams in the DS - Promin group, and 71.2 grams in the D S - PAS group. The daily dosage was 0.50 gram for an average period of 4 months to 6 months. An average of 103 ampules of ·promin and 437 grams of PAS were administered to each patient. Out of the 19 lepromatous, 8 acquired the status of CRS (complete regression of skin lesions, bacteriologically negative); two (2) MRS (marked regression skin lesions); two (2) MMRS (moderate to marked regression skin lesions) ; and one ( 1) W S (worsening of skin lesions) . Out of the 16 tuberculoids, 13 became CRS, one ( 1) SMRS (slight to moderate regression of skin lesions) ; two ( 2) SIS, (slight improvement skin lesion); and the neural case showed no change. A follow-up of some of the cases revealed that they had remained under control even 6 months to 1 year after they had been discharged from the hospital, with the exception of I tuberculoid case which showed recurrence of skin lesions. Further experimentation on the leprotic action of dihydrostreptomycin - either alone or as ari adjunct to the sulfones, PAS, or izoniazid - should be carried out. to confirm or disprove the encouraging results obtained in this study. BIBLIOGRAPHY J. Rodriguez, Jose N . - Personal communication on Dihydrostreptomycin on Lepromatous cases in Cebu Sanitaria. June 12, 1953. 2. Erikson, P. T. - Streptomycin: A useful adjunct to sulfone in certain Leproll5 Manifestations. Jour. Am. Med. Ass. pp 87 - Jan. 1951. 3. Saenz, B. M. - Lepra Reaction: Its Treatment· with Dihydrostreptomycin. Arch. Dermat. & Syph. Jan. 1952 vol. 65, pp. 59 - 68. 4. Wade, H. W. - On certain Pathological Aspects of Leprosy, Reprinted from Indian• Medical Record 1926, vol. 44, pp 258. 5. Garduno, D. M. and de Leon, David - Streptomycin in Leprosy, Early Cutaneous Type, Jour. P. M.A .. February 1951, vol. XXVII No. 2 PATHOLOGY OF OLD AGE•· BENJAMIN BARRERA, M.D. The subject assigned to me, "Pathology of Old Age," is as misleading :ts it is controversial. For this reason, I propose to change it "Structural Changes in Old Age." Broadly, the word "Pathology" gives the impression that there are changes peculiar and characteristic of old age, and that these changes are abnormal or pathological. The fact, though, is that many of these morphological changes commonly attributed to old age can be seen in various Bmjnmfo Barrer•, Mp. conditions in relatively younger individuals. For instance, towards the latter part of the Japanese Occupation, when everyone was on the verge of starvation, we saw in relatively young bodies autopsied by us changes comparable to those seen in, and described as characteristic of, old age. We have to bear in mind that, in the development of an individual, two factors are in constant play - namely, regeneration or evolution, and degeneration or involution. These changes vary only quantitatively from birth to death. It is obvious, however, that during infancy, the evolutionary changes are more preponderant th:m the degenerative; and the reverse is true in senescene and senility. The involution of the bronchial clefts in fetal life, the closure of the ductus arteriosus and hypogastric vessels in infancy, and the atrophy of the thymus in childhood are just few instances of degenerative changes in early life. When structural changes are thus seen in old people, the questions that naturally come up, and which are most difficult to answer, are: How much of these changes are directly attributable to old age, and how much are due to the usual and normal wear and tear of cells and tissues brought about by conditions other th;m aging? In other words, how much of these changes are physiological and how much are pathological? - Without wishing to tread on controversial grounds, much less to attempt to explain the mechanism or philosophy of these changes, I wish to limit myself to the presentation of the demonstrable structural changes as we commonly see them in autopsies of old persons. It may be stated at the outset that there is a great variation in the degree and speed of changes in different organs. The female gonads, for instance, are the most labile of all the organs - the ovaries presenting the most striking changes during sexual maturity and in old age. On the other hand, it is interesting to note that. the senile testicles maintain a more or less steady weight and size, although functionally impaired. ''Presented and discussed :lt the 1st. Plcn3t~' ~\;sion of the 46th Annual ~h-ccing of the P.M.A. hdd .'\pril 21, 1953, 3t the College of Medicine Building, U ST , Manila. 464 PATHOLOGY OF OLD AGE-Barrera Jour. P.~l.A. Septrmber, 19.:i3 These conspicuous anatomic and functional changes in the sex organs, which are relatively easily measured and observed (cessation of menstruation, loss of libido, etc.), have led many to think that the gonads occupy a pivotal position in the senescent changes that follow their cessation of function. It is now certain that the gonads and/ or their hormones do not in any manner affect the life span of an individual. Prolongation of youth or life itself by gonadal preparations is "a mirage, a product of wishful thinking." It is our common observation, too, that structural changes of old age are often more conspicuous among the relatively well-to-do and educated than among the poor. Could this be due to the fact that the body machine in the former class has been subjected to more stress and strain, to more insults and abuses, to more careless use and upkeep? Let me now describe briefly the most important organs that show senescent changes. (I) Heart - The heart is reduced in size and weight, although occasionally it is normal or even slightly enlarged. Most often, the heart is smaller and brown in color (brown atrophy), with a decrease in the elasticity of the valves and an increase in the thickness of the endocar.dium. Frequently, calcified atheromatous patches are seen in the valves and in the root of the aorta as well as in the coronary vessels. Many hearts show a gelatinous and edematous fluid in the epicardium, frequently called edema ex-vacuo. Histologically, the muscle fibers are seen to be atrophic and with yellowish lipochrome granules at both poles of the nucleus. Many hearts, too, show focal areas of fibrous scarring, possibly due to coronary sclerosis, although there may be no associated cardiac symptoms during the life of the individual. (2) Blood Vessels - There is a notable decrease in the elasticity of the blood vessels, especially the aorta. There are usually plenty of atheromatous patches with calcification anl also ulcerations, especially towards the end of the aorta as it bifurcates into the iliac vessels. It is difficult at times to imagine how a roughly ulcerated rigid aorta could have allowed the passage of blood through it without producing thrombosis. (3) Lungs - The lungs are frequently collapsed, with areas of atelectasis here and there. It is very seldom that we find lungs which are entirely free from bronchopneumonic changes, which at times are microscopic in size. The usual finding is a disruption of the atrophic elastic tissue framework of the lung, giving rise to senile emphysema. ( 4) Liver - This organ is invariably reduced in size, dark-brown in color, and oftentimes very finely granular. On histologic examination, the liver cords and cells are reduced in size, with an apparent or actual increase of connective tissue framework. ( 5) Spleen - The spleen in all cases is atrophic, with a wrinkled, thickened capsule. The atrophy is due to the diminution in the lymphadenoid tissue, giving the impression of increase of the connective tissue stroma. Extensive sclerosis of the arterioles is usually more marked, and appears much earlier in the spleen than other organs. The pulp of the spleen is almost acellular, The Malpighian bodies are inconspicuous. Volume XXIX Number 9 PATHOLOGY OF OLD AGE-Ba,.'i·era 465 ( 6) Pancreas - There is only a minimal decrease in the size of the pancreas. There is, microscopically, a decrease in size of the acini and islands of Langerhans, which are ·also apparently reduced in number. More striking is the great thickening of the arterial walls and infiltration of the framework of the organ with fat. (7) Kidneys - The kidneys usually show a progressive reduction in weight after the fourth decade, most often due to structural involution of the renal blood vessels. The kidneys usually show depressed areas of arterio-sclerotic infarcts. There is usually diminution in the thickness of the cortex. On histologic examination, there are still many wellpreserved glomeruli and tubules, so that there are usually no clinical evidences of renal failure. ( 8) Thymus - Usually this is very small, frequently reduced to a small fibrous mass. There is extensive atrophy, and the lymph-adenoid tissue may even disappear. The Hassal's bodies are also degenerated and calcified. There is likewise an extensive thickening of the arteries and extensive fibrosis. (9) Thyroid - The thyroid frequently shows atrophied follicles, with little or no colloid, surrounded by dense interstitial fibrosis. The arteries are almost occluded by sclerosis. ( 10) Adrenals - The adrenals are frequently reduced in size and, on section, cholesterol deposits are almost absent. Their cells are atrophied and there is increase in the delicate connective tissue framework. ( 11) Testicles - The testicles frequently maintain their normal size and weight. Under the microscope, there is seen extensive interstitial fibrosis, thickening of the , basement membrane of the tubules, and diminution of the calibre of the seminiferous tubules. Occasionally these are unduly dilated. Spermatogenesis is usually absent, the tubules at times being lined by a layer or two of the primitive cells. The interstitial cells of Leydig are fairly preserved. ( 12) Ovary - The ovaries are invariably small, atrophic, and fibrous in consistency; and on section hardly any follicles are seen. Remnants of corpus fibrosum are conspicuous. A good number of ovaries show follicular cysts of variable sizes. ( 13) Uterus - The uterus is also atrophic, with a relative increase of fibrous connective tissue. The endometrium is likewise atrophic, with only a few glands and distinctly cellular stroma remaining. The blood vessels are greatly thickened, hyalinized, and/ or calcified, with obliteration of the vascular lumen in some cases. ( 14) Prostate - The prostate is either normal in size or atrophic, with an increase in interstitial tissue. ( 15) Brain - The brain is usually smaller than normal, with deep sulci and narrow convolutions. The ganglion cells of the cerebrum are usually atrophied, with pigment and lipoid accumulation. ( 16) Skin-The skin· in old age is usually wrinkled and inelastic, due to the disappearance of the elastic fibers from the deeper layers of the dermis. Histologically, there is atrophy and disappearance of these structures. 466 PATHOLOGY OF OLD AGE-Barrera Jour. P .M.A. September, 1953 In conclusion, structural changes in the various tissues and organs of the body, as noted above, do not necessarily run paripam with functional derangement A notable example of this is the apparently normal brain in mentally deranged individuals, and extensive structural changes in the brain of apparently normal, mentally balanced individuals. This lack of relationship between structural and functional changes may be explained by the fact that most organs are endowed with tremendous reserve power and immense margin of safety. An individual, therefore, is only as old as he feels. His senescence ·and senility depends on how well he has taken care of the body-machine, and later, how well he has adjusted its performance to its capacity. As our youth has been, so is our senescence and senility! A new car may be made to run uphill on the third gear; three or four years later, rhe same car may not do the same stunt under similar conditions - it may do so on the first year. One has to admit that, as years roll by, a person's activities must be correspondingly adjusted to his age, the capability of his body. It is only when this relationship between function and capacity is disturbed that one is justified to discuss "Pathology of Old Age." SURGICAL PROBLEMS IN THE AGED * LUIS F. TORRES, JR., M.D. Section. of Urology, Dept. of Surgery, College of Medich" University of the Philippines There is a common impression that it is more risky to submit an elderly person to the knife than a younger one. To the internist, "greater risk" means arteriosclerosis, thrombosis and embolism, nutritional deficiencies, and cardio-renal status. To the surgeon it means lowered resistance to infection, !ability of renal function, decreased blood flow and blood volume, and dehydration - not to mention the reaction of an elderly person to anesthesia and his peculiar behavior after operaLuis F. Torres, fr., M.D. tion. The truth is, though, that the physiologic age of the patient does not necessarily correspond to his chronologic age. This has been proven time and time again by successful operations in patients over 80 years of age ( 8. 5 % mortality in 47 patients of 80-100 age group). Due to arteriosclerosis, the circulatory system of an elderly person is less resilient than that of a younger one. Response to hemorrhage of operative procedures is very slow. Sudden drops in the blood pressure are not compensated right away, and bleeders cannot be controlled readily by retracting the cut ends of. the arterioles. Sometimes, for example, after the prostatic ·adenoma has been enucleated, the raw surface of the prostatic capsule continues to bleed, despite all known methods of hemostasis as though the blood vessels in this region were arteriosclerotic. The brain and the myocardium are susceptible to hypoxia, which occurs in a hypertensive or arteriosclerotic patient when the blood pressure suddenly drops during the operation. In vital organs which are used to receiving their quota of blood at high pressure, the loss of elasticity of the sclerotic blood vessels prevents the compensatory mechanism that other-wise operates in such an emergency in the younger individual. Renal filtration, which is the first phase of urine formation, is also adversely affected by the lowered blood pressure in a hemorrhagic state. In the kidney of the aged, due to the concomitant nephrosclerosis, even short periods of slow blood flow may produce a renal shut-down and anuria. Advancing age apparently lowers renal reserves, to some extent, after a severe operation, even if preoperative tests of renal function show them to be normal. • Read at the Symposium on Problems of Aging during the annual meeting of the Philippine Medical Assoi:i:uion, April, UfJ. 468 SURGICAL PROBLEMS IN THE AGED-Torres Jour. P.M.A. Sepl~mber, !9.'>J The hazard of slackening blood flow through the veins of the extremities is well known to predispose to thrombosis, with the ever-present danger of embolism. Thrombosis has also been known to take place in the brain postoperatively. I recall a patient who, 24 hours after a bilateral, one-sitting pyelolithotomy, developed a cerebral thrombosis. In old age, there is usually a lack of correlation between symptoms and signs, there may be no complaints subjectively, although · the most serious pathology is progressing. Typical examples are those of perforated, gangrenous appendicitis in old people, in whom there is none of the typical right iliac pain, nausea or vomiting, fever or leucocytosis, marked abdominal rigidity and tenderness usually associated with this disease in younger individuals. This may lead the surgeon to become unduly optimistic, and so postpone the operation until it is too late. Nobody knows whether such lack of subjective symptoms or somatic reaction in the aged is due to hypofunction of the pituitary or of the adrenal cortex. Nobody knows either whether it is purely a mental reaction, one of stoicism or resignation to the vicissitudes of life, dulling the patient's sensibilities even to pain. Resistance to infection diminishes with age, presumably due to atrophy of the spleen, bone marrow, lymph tissues, and other structures concerned with immune processes. But it may be a clinical misnomer for an actual exacerbation of pre-existing latent infection not discovered before operation. This flare-up may appear to overwhelm the patient, anJ produce the impression that he has no resistance. The poor vascularity of the organs of the aged, supposedly from sclerotic changes, may also be taken as the reason for low resistance to infection. Qn the other hand, this poor vascularization delays healing, which is dependent on blood flow. In the aged, fractures are notoriously slow in healing, callus formation may not take place, and calcification of bones is very poor. The nutritional state of the patient, which is known to be poor in old age, may also have a relationship with poor resistance to infection. However, the unfavorable effect of hypoproteinemia and hypovitaminosis C on the maturation of fibroblasts should not be overlooked. The latter conditions are frequent in old age. For the individuals in this group are peculiarly subject to poor appetite, resulting from ill-fitting dentures, sedentary life, and constipation. Accuracy of diagnosis in the aged plays a great part in the adequate planning of the operative procedure. To this end, the surgeon should exhaust efforts in preparation for the operation, in order to insure smooth convalescence. Such careful preparation will enable the surgeon to meet the exigencies of the operation and to avoid exploratory procedures. It will also give the anesthetist a guide for his choice of anesthesia. Occasionally an aged patient with a suspected or proved heart disease may have to undergo a major surgical operation. The evaluation of his cardiac status from the standpoint of surgical risk is difficutt. The fundamental principles that we have followed and found practical involve the patient's exercise tolerance. Obviously, an old man who can Volume XXJX Number 9 SURGICAL PROBLEMS IN THE AGED-Torres 469 walk about three blocks and up a flight of steps to the doctor's office without manifest dyspnea or angina! pain is a good surgical risk. We have learned to rely on these two important symptoms: dyspnea and angina! pain. Dyspnea on effort indicates myocardial insufficiency. Its evaluation depends on how much effort is necessary to produce it, and whether other factors like age, weight, anemia, asthma or tuberculosis of the lungs are contributory. The actual distress manifested after effort is more significant than pulse or respiration rate. Patients with no exercise tolerance should not be operated upon except under extreme situations. Such patients usually have signs and symptoms of congestive heart failure. The factor necessary to tilt the balance one way or the other will depend on the indication for the operation. (Is removal absolutely necessary for survival?) Insignificant electro-cardiographic findings, functional murmurs and arrythmias, and other remediable cardiac disorders should not deter the surgeon from performing a necessary operation. Preoperative care is necessary part of the surgical management of an elderly patient. Most unfavorable results or fatal outcomes of surgery may be the result of a faulty preoperative preparation. Metabolic or endocrine disorders, like diabetes mellitus or hyperthyroidism, should be reduced to as near normal level as possible. Cardiac decompensation, azotemia, pulmonary disease, and foci of infection should be corrected. Even with normal blood counts and hemoglpbin levels, elderly surgical patients usually have a significant deficiency in blood volume. For this reason, hematocrit and specific gravity determinations of the blood are necessary; and preoperative transfusions may help prevent the occurrence of shock during operation. Hypoproteinemia, dehydration and electrolyte imbalance require no further discussion. Over-enthusiasm in pushing intravenous fluids must, however, be guarded against. Parenteral administration is best given intravenously, since hypodermoclysis of .electrolyte-free glucose ( 5 % dextrose in water) in a patient suffering from dehydration, salt deficiency, or shock {low physiological reserve) may produce oliguria, anuria, or circulatory collapse. The mechanism is that of withdrawal of fluid from the plasma and interstitial fluid compartments to allow absorption of the administered fluid. Hyaluronidase, when used with hypodermoclysis, is likely to intensify this possible reaction. Generally, elderly patients require less than 4 grams of salt, and about l,500 cc. of fluids intravenously; for their lower metabolic rate require much less fluid for elimination of waste. Recent knowledge of the dangers of over-administration of salt and water in such patients has decreased the frequency of pulmonary and cardiac complications (edema, hypostatic pneumonia, acut!l cardiac failure and dilatation, etc.) On the other hand, there is a tendency to rush acute emergencies to the operating room before dehydration and shock have been corrected. Old individuals are very susceptible to blood volume changes, because of their poor vasomotor compensatory mechanism and because of the inability 470 SURGICAL PROBLEMS TN THE AGED~To'rres Jour. P .M.A; September, .195\J, of their hearts to increase their rate and output. A few hours of preoperative hydration and relief of shock may mean the difference between a favorable and fatal outcome. The choice of an anesthetic agent depends considerably on the nature of the operation and on condition of the patient. Whatever anesthesia is used, it should provide for the minimum of derangement of the physiological processes in the body. Elderly patients require relatively smaller doses of premedication and anesthetic agents. All too often, routine pre-anesthetic doses have resulted in patients becoming so drowsy on the operating table that they require hardly any general anesthetic. Prolonged deep anesthesia is undesirable, and abnormally low blood pressures are detrimental. Hypertension during or after the operation is less to be feared than repeated hypotension, for the vital organs are quite sensitive to changes in oxygen tension. The operation must be performed rapidly but gently; and if possible, a stage operation should be resorted to. The philosophy of radical surgery finqs no application in the age group of eighty, at which stage life expectancy is not more than 5 .44 years. A palliative operation often suffices in cases of cancer, bearing in mind the relative benignity of malignancies in old age. The postoperative management of an aged surgical patient assumes considerable importance when we realize that it is during old age that most of complications occur. Patients in this age group usually have varying degrees of bronchitis, emphysema, or asthma. Deep postoperative analgesia for relief of pain, continuous Levine (nasal) tube suction, over-hydration, and over-administration of oxygen, with resultant shallow respiration and suppressed cough, are bound to affect a recumbent patient. They may even lead to pulmonary atelectasis, pulmonary edema, and bronchopneumonia. To relieve pain, local block anesthesia (EfocaiI,Je,<Rl procaine) or surface anesthesia (Diothane, "' Americaine"') or small doses of mild analgesics may be used. The indwelling Levine tube, while preserving the integrity of the operated organ may promote atelectasis of the lungs by discouraging deep breathing and coughing necessary to expel secretions along the tracheo-bronchial tree. Pushing fluids, particularly in the presence of anemia and hypoproteinemia may, produce hypostatic pneumonia. Early ambulation helps a great deal towards preventing a lot of complications, pulmonary, cardio-vascular, or gastro-intestinal. It also promotes appetite, intestinal peristalsis, and expulsion of gases and spontaneous voiding. SUMMARY With an intimate knowledge of the patient's cardiovascular and renal status, and of his nutritional, water and metabolic deficiencies, it is always possible to attain justifiably low mortality rates if the usual routine conservative surgical procedures are used in a rapid and expeditious manner (see Table I). In the postoperative course, early ambulation is Volwne XXIX Number 9 SURGICAL PROBLEMS IN THE AGED-Torres 471 also to be desired, and over-hydration by intravenous route must be avoided. The injection of testosterone propionate is of great help to the anabolic processes, since this hormone is a protein sparer. Twenty-five to fifty mg. of this drug, administered intramuscularly every second day, may also enhance the morale of the patient. The will to live must be awakened or maintained, both before and after the operation. TABLE I Age Bracket No. of Patients Mortality Operated on De3ths Percentage 60·69 ... .. ... . ... . . 316 ... I) 4.1 'i'o 70-79 244 14 !.7 'i'o 80-89 39 .. 2 !.! 'i'o 90-99 8 .. 2 2!.0 'i'o 100 ·o 0 % Total 608 ... .. . .. ... JI J.09 o/o The causes of death in a group of 608 cases are listed as follows: Hemorrhage :::ardiac ... Pulmonary Shock .. lowtr nephron nephrosis Uremia ..... . Others .. . Pyelonephritis . ...... . . . . TABLE ll - Comts of Death 60-69 70-79 80-89 90-100 It is clear that the higher age groups after 60 have a higher mortality rate than younger ones. All the factors explained .at the beginning of this talk are probably present. Considering all the risks involved (strangulated hernia, gangrenous appendicitis, and perforated gastric ulcer) and the type of major surgery used on elderly people, one finds that these people are just as resistant to surgical trauma as younger ones, provided the latter is tempered with gentleness and speed, and bolstered by maintaining the fluid balance of the patient. ALMOST FATAL PENICILLIN ANAPHYLACTIC-LIKE SHOCK REACTION Report of a Case at V. Luna General Hospital, (AFP) LT. COL. CONRADO B. ICASIANO, MC Penicillin is the most widely used and abused antibiotic today. This is principally because it is the most popular, the cheapest, and the easiest procured antibiotic in the market. Anybody can get from any drug store any form of penicillin preparation - inhalant powders, throat lozenges, tablets for oral use, and those given parenterally with or without doctor's prescriptions. This indiscriminate use of penicillin is not L.- _ _ __ t _ _ _ without danger. Allergic reactions to penicillin have been reported with alarming frequency. u_ col. Co>1ra<lo n. Iwww Occasionally a dangerous and even fatal anaphylactic-like shock reaction occurs when penicillin is given parenterally. A review of foreign literature reveals that such anaphylactic-likc shock reactions have been observed quite frequently. The following are some of the many published reports. Cormia, F. E. and his coworkers, in 1945, reported a case of acute anaphylactic-like shock reaction due to penicillin. Their patient suddenly collapsed after an intramuscular injection of the drug. In 1946, a similar case was reported by W. J. O'Donovan and I. Klorfojn. Their case showed positive direct skin reaction. The first death (that of an asthmatic case) due to intramuscular injection of penicillin, however, was reported by G. L. Waldbott in 1949. It occured within a few minutes after the administration of 50,000 units of aqueous crystalline penicillin. This case, however, was not autoQsied. In 1950, R. J. Burleson reported a case which developed severe prostration, dyspnea, tachycardia, hypotension and s;ollapse 15 to 20 minutes after an injection of 200,000 units of sodium penicillin G, with 0.5 cc. of 1 % procaine. Direct skin test reaction to penicillin was positive, but the reaction to procaine was negative. In 1951, R. Everett reported two cases of anaphylactic reactions following introduction of 30,000 units of sodium penicillin G, with ephedrine and gantrisin, into the paranasal sinuses. These two cases gave positive direct skin test reactions to penicillin only. In 1952, Curphey reported 2 cases of fatal anaphylaxis following injections of crystalline penicillin in two patients with bronchial asthma. One died within 5 minutes after receiving aqueous penicillin intramuscularly; and the other, within ten minutes after injection of penicillin and streptomycin. The chief pathological lesions obtained in these fatal cases of Curphey were distended lungs and marked dilatation of alveoli in the first, and extensive mucous exudate in small bronchi and alveoli in the second. In January 1953, Siegal et al reported 3 cases, with one death, of anaphylactic shock, due VoJume XXIX ~umber 9 PENICILLIN REACTION-Icasia110 473 to penicillin. The case that died was an asthmatic who had received 300,000 units of aqueous procaine penicillin because of an acute follicular tonsillitis. No autopsy was performed. At about the same time, P.S. Mayer et al reported six cases of penicillin anaphylaxis. Their patients developed anaphylactic-like shock reactions immediately after administration of aqueous procaine penicillin parenterally. One died, but five recovered. Four of the cases that recovered showed positive passive transfer skin test to penicillin, but negative to procaine. The case that died had been treated with penicillin because of persistent positive serology. Autopsy was not performed. Last May, Samuel M. Feinberg et al reported 9 cases of non-fatal and fatal penicillin anaphylactic reactions. Five cases died, and autopsy revealed insignificant findings and no other causes of sudden death. From the foregoing, it is evident that most anaphylactic-like shock reactions reported abroad happened when solutions of penicillin were given intramuscularly, and that fatalities occured mostly among asthmatic patients. Reviewing most local medical literature since the liberation, I have not been able to find a single case showing any anaphylactic-like shock reaction due to penicillin. However, through casual conversation with Vice-Dean Arturo Rotor of the College of Medicine, U.P., last April 1953, I learned that there had been about five fatal or near fatal allergic reactions to penicillin, but which had not been reported. Another case was related to me by Dr. Ramon Angeles, President, Federation of Private Medical Practitioners. A few minutes after intramuscular injection of sodium penicillin G, his patient lapsed into severe shock, but eventually recovered. This incident happened at UST Hospital but was not reported. There may have been similar other cases, though they have not been reported; or if they were reported at all, I may have missed them in my search for actual records. The present paper deals with a case of an almost fatal anaphylacticlike shock reaction to penicillin, which happened to a member of the personnel of the V. Luna General Hospital in her eagerness to treat an upper respiratory tract infection. For your information, this is the first case of anaphylactic.Jike shock reaction to penicillin that has actually occ_urred in this hospital since it started operation in 1945 - although numerous daily penicillin injections have been given both to hospitalized and dispensary patients. In spite of the apparent rarity of these cases, one cannot minimize the seriousness of such a reaction. Hence it would not be superfluous to emphasize the importance of the present case. REPORT OF CASE V.G., 42 years old, female, an army nurse assigned to the V. Luna General Hospital, was admitted for the 3rd time last Dec. 2 5, 19 5 2, cyanotic, unconscious, and in a severe degree of shock. First hospitalized last 1949, for removal of a big sebaceous cyst at her back, she was appendectomized in 1951. On both occasions, she received a series of penicillin injections without untoward reactions. Last Nov. 1952, she had urticaria following a thiamine injection. No member of her family had asthma. One sister, however, developed skin rashes after injection of a combination of streptomycin ond penicillin. 474 PENICILLIN REACTION-Ica:Mano Jour. P.M.A. September, 19M At about 8:00 P.M. on the night of 25 Dec. 1952, the patient, because of a two-week upper respiratory tract infection which had exacerbated a day before, requested a co-nurse to give her an injection of 200,000 units of sodium penicillin G. In less than five minutes, she comptained of burning taste, intense headache, chest oppression, and dimness of vision. Then she became unconscious. The events came so rapidly that, when she was seen by her companion who had given her the injection, she was cyanotic, almost pulseless, and breathless, with frothy mouth and imperceptible pulse. At the emergency room, she was observed to have puffy face and neck, swollen lips and eyelids. No blood pressure readings could be obtained. Immediate rescusitory measures were then instituted. These included injections of adrenalin, ephedrine, benadryl, nikethamide, plasma blood, dextrose, and oxygen inhalation. At 9:30 P.M.,' 01· about an hour and a half later, her blood pressure began to rise gradually but steadily, from 70/40 to 150/ 80 at 11:45 P.M. At this time, her temperature was 38.4° C, her pulse 104, and her respiration 20; but the latter was occasionally observed to be irregular and jerky. She was very restless, moaning frequently, and had to be given several injections of sodium penthotal to quieten her. She had to be catheterized to urinate. On the morning of the 26th Dec. 1952, she was observed to be in deep coma, with the following objective findings: (•)-Both pupils were miotic, not responsive to light; (b )-Eyelids puffy, fundus examination, however, was normal; (c)-No cervical rigidity; (d)-No reaction to touch, pain, or temperature; (e)-Reflexes absent - (biceps, triceps, pattelar, and babinski). Lumbar puncture was performed, and a clear fluid was obtained, with 200 mm pressure and a normal cytology •nd chemistry. CBC revealed 3.4 million RBC, 17,450 WBC, with a differential of 73 % polys, 10% small lymphocytes, and 17% eosinophiles. Blood chemistry and urinalysis were within normal limits. In view of her deep coma which was thought to be due to a greater degree to cerebral edema, concentrated human normal serum albumin (25%), in doses of 100 cc. enry 4 hours around the clock, was administered. Fortunately, 4 hours after administration of the first dose, her pupils began to react to light. From here on, she continued to improve. Soon she was able to move, she regained her consciousness, and in about a week, she was up and walking. Her recovery was uneventful until about 10 weeks later, when complaining of a severe sore throat, she went to consult one of our EENT specialists who, after a careful examination, prescribed uPondets" for her. Not knowing that Pondets are penicillin throat lozenges, she took one in her mouth; and in less than 10 minutes, she felt a burning taste, flushing of face, thick and tense sensation of her skin, heaviness of the head, dizziness, palpitation,"and metallic coughing. Her blood pressure rose to 180/90. She was given 5 O mg of Benadryl and after about two hours, all symptoms disappeared. A week after this incident, a direct intradermal skin test was performed, using the smallest amount (less than a drop) of sodium penicillin G in proportion of 200 units per cc. In less than 3 minutes, a four plus skin reaction was obtained. This was shown by the presence of a wheal and flare. The wheal, which was amoeboid in shape, was more than 5 times the size of the control. There were other accompanying symptoms like flushing of the face, thickened sensation of the skin, heaviness of the head, cough, and palpitation. These symptoms subsided 30 minutes later, but the skin reaction persisted longer. From here on, the patient continued to improve and was discharged from the hospital recovered. Volume XXIX Number 9 PENICILLIN REACTION-lcasianiJ Last June 11, 1953, as a follow. up, I again performed another direct intradermal skin test, using 40 units of sodium penicillin G per cc. A four plus skin reaction was again obtained 5 minutes after the injection. This four plus skin reaction consisted of 13 mm amoeboid shape wheal, with moderate erythema of 15 mm. The control was 5 mm wheal with hardly visible erythema. The only accompanying systemic symptom this time was the slight itching of the throat with occasional cough. COMMENT 475 This case is made of record for the first time, to emphasize to the medical profession that penicillin, though a very potent antibiotic, can cause serious and even fatal allergic reactions. Then, too, in view of the present popularity of Penicillin among both medical practitioners and laymen, there are considerable reasons for predicting that, in the course of time, there will be more persons sensitized to it. Therefore, more similar incidents are bound to be encountered. Considering the serious manifestations and the grave complications attending such an anaphylactic-like shock reaction, were this to happen in a private clinic, a dispensary, or the home of a patient where medical practitioners are handicapped by lack of emergency resuscitative equipment and medicinals, more fatalities will be expected. The prestige, professional knowledge, and ability of the physicians will likely be jeopardized if such reactions occur . What, then, is the medical profession to do to limit, if not entirely prevent, such dreadful incidents? Experiences from published reports, and the present case, have offered the following valuable suggestions: ( 1 )-A careful and complete history of every case is imperative, with special emphasis on allergic history both personal and familial, before penicillin is prescribed or administered. It must be remembered that anaphylactic-like shock reactions will occur, if ever, to any person who has never received penicillin previously, and that most fatal cases reported have occured among asthmatic patients. Likewise any history of other types of penicillin reactions, like dermatitis, purpuric spots, or urticaria must be clearly obtained, analyzed, and carefully evaluated. (2)-lmmediate direct skin test must be given every patient, especially those who are allergic or asthmatic, prior to subsequent administration of penicillin. The value of this precaution cannot be overemphasized. Experience has shown that most patients who are potential anaphylactic reactors give immediate positive skin reactions. This fact was corroborated by the cases of Cormia, Everett, Burleson, O'Donovan, Mayer, Seigal, and by the present report. If smaller doses of 100-200 units give negative results, larger doses of 3000 to 5000 units, or even higher, may be tried. ( 3 )-The intermittent use of penicillin gums, mouth, and throat lozenges, and topical applica,tions like ointments and solutions must be discouraged, if not entirely condemned; for there is no doubt that such repeated courses of penicillin therapy increase sensitization and may therefore, result in increased cases of anaphylaxis. 476 PENICJI,LIN REACTION-lcasiano Jour. P.lrl.A. September, 196·~ ( 4 )-The cautious method of giving parenteral penicillin must be adopted. This maybe done first by giving small doses, perhaps 100 to 200 units of penicillin subcutaneously, and followed 30 minutes to one hour later, by the full dose if no untoward reactions occur. ( 5 )-Safety measures in the technique of penicillin injection must be taken. This can be done by giving penicillin injections only at the outer surfaces of the arms, so that when necessary, tourniquets can be applied proximal to the site of injections. Ampules of Adrenalin solution (I: 1000), Ephedrine and Benadryl must also be readily available. In conclusion, let past experience and the present case be a reminder, and a stern warning, to those who would use penicillin indiscriminately. The importance of publishing records of similar cases in the future cannot be overlooked. For, very clearly, they would benefit others, by serving as useful criteria in formulating necessary therapeutic as well as prophylactic measures, which are consistent with local needs and conditions. SUMMARY A case of almost fatal anaphylactic-like shock reaction, due to sodium penicillin G, that happened to a member of the V. Luna General Hospital personnel (AFP) is reported. Direct intracutaneous skin test·· ing eleven weeks after the incident revealed markedly positive reaction. This is the first case reported in this hospital, in spite of the countless injections of penicillin given both to in- and out-patients. Similar cases reported abroad are reviewed. There are reasons for believing that similar cases are increasing in number and frequency. In view of similar occurrences reported abroad, and the present one, suggestions are offered to minimize, if not entirely prevent, such unpleasant, almost fatal reactions. REFERENCES I. Waldbott, George L. M.D. - Anaphylaccic Death from Penicillin J.A.M.A. - Feb. 19, 1949. Pp. 526. 2. Burleson, R. J. M.D. - Anaphylaccic Shock due co Penicillin - J.A.M.A. - Feb. 25, 1950. Pp. 562 (Alabama). 3. Cormia, F. E. et al - Reactions to Penicillin, Bull. US Army Med. Dept. Dec. 1945. p. 694. 4. Felder, S. L. and Felder L. M.D. - Unusual Reaction to Penicillin - J.A.M.A. - May 27, 1950. p. 361. 5. Everett, R. M.D. - Anaphylactic Reactions from Local Use of Penicillin - J.A. M.A. Vol. 146 p. 1314 - 1951 (New York). 6. Siegal, S. et al - Fatal and Near Fatal Penicillin Anaphylaxis Journal of Allergy - Jan. 1953 (New York). 7. Mayer, Peter, S. - Penicillin Anaphylaxis - J.A.M.A. - Jan. 31, 1953 - pp. 3 51 (Illinois) . 8. Long, Perrin, M.D. - Clinical Use of Antibiotic - Medical Clinics of North America - March 1950. pp. 307. 9. A Manual of Clinical Allergy - John M. Sheldan, M.D., Robert G. Lovell, M.D., and Kenneth P. Mathews, M.D. - Edition 1953, pp. 120-129. JO. Penicillin Allergy - by John W. Irwin et al - New England Journal of Medicine - Aug. 16, 1951. JI. Penicillin Anaphylaxis, Non-Fatal and Fatal Reactions - by Samuel M. Feinberg, M.D. et al - J.A.M._A. - May 9, 1953. MENARCHIAL POSTOPERATIVE ACUTE HYPOPARATHYROIDISM AND ACUTE HYPOTHYROIDISM Pedro T. Nery, M.D. narchial period. PEDRO T. NERY, M.D., F.P.C.S. Fac,./ty of Medicine 11nd Surgery, U.S.T. Any thyroid surgeon will not consider postoperative acute hypoparathyroidism a rare incident or accident. It occurs more often during one's early days in thyroid surgery, and rarely during his mature days with the knife. The tetany that is observed is familiar to many, and the immediate correction of it by calcium therapy is impressive. Whether this symptomatology is the result of removal or trauma to the parathyroids, directly or through it's vascular supply, is open to question. Many cases of it have been found in males and females - and, among the latter, unrelated to meThe occurrence of postoperative hypothyroidism, chronic in character with the unforgettable facies of a myxedema, is not rare. Many of the above cases have been corrected during the active course of the sequelae - with calcium, hormonal extracts, and lately, with A.T.S. - 37. And when they were corrected, especially the hyppparathyroidism, it is not unusual, in the follow up, for the signs and symptoms of the diseas~ to disappear even in the absence of medications, the belief being that the body, the gland, or both have been able to adjust themselves to the demand of the organism. The occurrence of acute postoperative hypoparathyroidism, apparendy precipitated by menstruation, does not seem to have been recorded or reported locally. Likewise the development of acute postoperative hypothyroidism is rarely mentioned in foreign literature. In fact I have found cases of it in older rather than in recent literature. The relation of these hypohormonal manifestations has not even been recorded. In the 826 thyroid operations done at the Phil. Gen. Hosp. that I ha.ve reviewed, acute postoperative hypoparathyroidism, though not common, is not rare either. Its close relationship to menstruation has never been appreciated nor mentioned. In the same series I noticed one personal case, and I have not even reported it formally, pf acute postoperative hypothyroidism not related to menstruation. This paper is on a case which I am labeling "Menarchial postoperative acute hypoparathyroidism and acute hypothyroidism." And I am presenting it in the hope that it may stimulate you to think; and that, after this paper has been discussed; I may be able to clarify the problems involved. 478 HYPOPARATHYROIDISM ... -Nery Jour. P.M.A. Septembe1·, 1953 A female, married patient was admitted to the charity ward of the U.S.T. Hospital. After a not unusual pre-operative preparation, a bilateral subtotal thyroidectomy was done. Nothing eventful was noted during the first postoperative day, except slight febrile reactions. She had her voice. On the 3rd postoperative day, she menstruated; on the 4th day, symptoms of tetany set in; and on the 5th day, the patient became apathetic and mentally confused. At the same time she developed anuria. Because the patient had been receiving, since the operation, adequate doses of sulfathiazole, the chief of the urology section and others entertained the possibility of sulfa anuria, even in the face of normal N.P.N. and the absence of sulfa crystals and RBC in the urine and leucocytes. EKG determination was done, and the findings were compatible with those of hypocalcemia, confirmed by low blood calcium level. The patient was still febrile, and blood cholesterol determination showed 400. An internist suggested giving cortone; and after it was given, the fever went down, only to go up again. I became as confused as the patient. Certainly I did not believe this to be sulfa anuria. The characteristic appearance of the patient - dull, apathetic, indifferent, somnalent, immobile, and to all appearances dead, except that there was still pulse and respiration - this was the dominant feature. Could this not be acute hypothyroidism like the case that I saw at the Philippine General Hospital? If this was acute hypothyroidism, with all the signs and symptoms of low B.M.R. as the characteristic appearance and cholesterol level insinuate, why the fever? I could not explain the fever in the light of my diagnosis; and in the absence of obvious focus of infection, I gave a therapeutic test of thyroid extract and the patient improves and recovered miraculously. I placed a question mark in my title because then, as now, there were discordant notes in my data and in the interpretation of my data. I cannot reconcile the febrile reaction, in the absence of a detectable focus of infection, with the impression of acute hypothyroidism. This patient was followed up for 6 months after discharge. One month later, with administration of thyroid and parathyroid extract, she got well, symptom free, and needing no more medications. Menstruation no longer precipitated the symptoms of acute hypoparathyroidism and acute hypothyroidism. What is the relation of the thyroid and parathyroid with other internal secretions such as gonads, adrenals and anterior pituitary? In the light of our knowledge of physiology, can we explain what has happened? What is the practical application of this observation? I am ready to be corrected by competent endocrinologists in the following belief: that the anterior pituitary secretes both gonadotropic and thyrotropic hormones, so that when gonadotropic hormones function as in menstruation, there is likewise a concomittant thyrotropic hormones stimulating the thyroid to function; but because the latter has been partially removed, or out of gear as it was in this case, the recent thyroidectomy manifestations of hypofunction and hypothyroidism supervenes. Volume XXIX Number 9 HYPOPARATHYROIDISM ... -Nery 479 Hence, the observed symptomatology and miraculous correction of it by the administration of the extract. Why then the apparent autocorrection of such maladjustment later, when the extracts are no longer given and there are no manifestations of malfunctioning? It is possible that, whatever thyroid tissue is left, and after it has recovered from trauma, it is adequate to meet the body needs. Why the apparent positive effect of ACTH on the symptomatology, or fever manifestations at least? Does adrenaline have a positive effect on thyroid function, and is it now possible that the ACTH through the adrenals whipped the remaining thyroid to work more. Anuria is no more than a picture of a low BMR. There may still be missing and loose links in the chain of this case and its interpretation - hence the question mark and the excuse for requesting your contribution. What is t!ie practical value of this paper? Is it one of those reports on a rare case or rare observation? Probably that is one. It is also a challenge to a clear endocrinological conception. As for me, thyroid operation being an elective one, I would hesitate to perform one just before or during menstruation. CONCLUSION: I. Postoperative acute hypoparathyroidism is rare. 2. Postoperative acute hypothyroidism is rarer still. 3. I have not seen, or heard of, or read about any case of Menarchial postoperative acute hypoparathyroidism and acute hypothyroidism. 4. Thyroid surgery being an elective one, would it be advisable not to perform one just before or during menstruation? ··~II ~petial Artiths IJ~ .. THE PUBLIC HEALTH ASPECT OF THE FOA-PHILCUSA PROGRAMME IN THE PHILIPPINES '' JUAN SALCEDO, JR. Secretary of Health Acting Governor Arenas, Miss Philippines, Dr. DeLien Dr. Marcos Corpus Dr. Alfonso Concepcion Reverend Father Santiago Guanlao Other officials of the Province of T arlac My friends: Jutm Salrrclo, ]r.1 i\C.D. I am profoundly grateful for the privilege of joining you today. This is an occasion which I regard highly and am very happy about, because if offers me the opportunity to share with you what I consider to be the significance of this important event, and to give you some information on the public-health movement now going on in our country. I attach great significance to the inauguration of the Maria Clara Memorial Chest Center for the following reasons: First, it opens a service necessary to protect and promote the health of the people of this province. Second, it is a sign that your provincial officials have accepted a public-health programme which their constituencies need, and that they are willing to support that programme. Third, it demonstrates the people's increasing regard for health as their business, and their willingness to actively participate and invest in it. Fourth, it is another proof that the Department of Health has been c:irrying on its programme to improve the health of our people, a programme encouraged and given full support by the Administration under His Excellency, President Elpidio Quirino. Fifth, it is a tacit recognition of the importance of high standards or levels of health to the success of our present economic development programme, for which reason FOA (formerly the MSA) and PHILCUSA are jointly giving substantial assistance to such public-health projects as the one which we are now inaugurating. • Address delivered during the inauguration ceremony of che Maria Clar:a Memorial Chest Center at Tarhc, TarJac, on August 19, l~Sl. Volume :XXJX Number 9 FOA-PHJLCUSA PROGRAMME-Salcedo 481 Finally, although this is not closely nor intimately connected with the inauguration of the Tarlac Chest Center, it is in nonetheless significant because I know you selected this date, August 19, in grateful and patriotic remembrance of an immortal Filipino who dedicated his life in the service of his people, the late President Manuel L. Quezon, whose birthday anniversary falls today; he who died from the disease this Center is now dedicated to control for the people of T arlac province. And now, my friends, I should like to talk about the public-health movement which is now going on in the country. This movement is THE PUBLIC HEALTH ASPECT OF THE FOA (formerly MSA)PHILCUSA PROGRAMME IN THE PHILIPPINES. You are all aware, I am certain, that while the main programmes of the FOA and PHILCUSA are in the fields of economic development, these agencies, nevertheless, recognize that the success of such programmes will depend greatly on the state of health of the people and of the communities. I need not elaborate on the importance of good health to the success of any economic development venture, because I know you are fully conscious of it. It must be stressed, however, that in our country the natural resources from which the economic development projects will be directed abound in health hazards which are both actual and potential. In this connection, therefore, I shall merely repeat what I have often quoted, namely: "Economic development starts with health and stops with disease." The public-health aspect of i:he FOA-PHILCUSA programme in the Philippines has several components, namely: 1. Malaria Control 2. Rural Health Units 3. Community Water Supply 4. Hospital Rehabilitation 5. Schistosomiasis or "Snail Fever" Control 6. Laboratory Rehabilitation 7. School Health 8. Public Health Education and Information 9. Public Health Training 10. Tuberculosis Control 11. Rehabilitation of the Philippine General Hospital I am going to talk only very briefly and point out the objective of each of these health aspects. Toward the end I am going to give the exact figures of the dollar and peso assistance given to these projects by FOA-PHILCUSA as of June 30, 1953. I. Malaria Control. To paraphrase an old saying, malaria is not the last but the one straw that is breaking the camel's back in the way of economic development, particularly in hinterlands or virgin areas where immense wealth is lying untapped and unexplored. Even in many parts of open areas now utilized for agriculture, malaria is still endemic. We know of several economic ventures which have failed because of malaria. Obviously, malaria has to be eradicated, or reasonably placed 482 FOA-PHILCUSA. PROGRAMME-Salcedo Jour. '.P.M.A. September, 1903 under control, if we are to obtain the maximum returns from our agriculture, and if we are to open up new resources for more wealth. For this purpose, we have activated as of today a corps of 22 malaria-control units scattered all over the country. These units have already reduced the incidence of malaria considerably and are making the opening of new lands safe for the settlers. In addition to actual field malaria-control measures, we are also constantly undertaking investigations on more practical, effective, economical, and permanent measures of control. To this project, FOA-PHILCUSA has provided, as of June 30 this year, $1,888,791.92 in commodities and P'l,934,810 for the local operating expenses. 2. Rural Health Units. In order to strengthen the health services, particularly in rural areas, we are establishing rural health units to provide preventive and curative services to the people in those areas. Each rural health unit has a complement of one doctor, one public health nurse, one midwife, one sanitary inspector, and one clerk-driver. Each unit is provided with a vehicle to allow for a greater coverage of the people in their respective areas. The target for 19 5 3 is 81 of these units. As of this day, 5 6 of these units are already out and operating in their respective areas. You have two of these units in the province of Tarlac, one already operating in the municipality of Capas and the other being readied to operate in Anao. As of June 30 this year, FOA-PHILCUSA has given assistance, to the amount of $560,000 in commodities and P'677,580 for the local operating expenses, to this project. 3. Community Water Supply. In many parts of the c©untry, particularly in remote rural areas and even in some of the poblaciones, the supply of good and potable water is inadequate. The lack of sufficient potable water is the principal cause of many of the diarrheal diseases. This project provides for the construction, in 1953, of 355 deep or artesian wells and 200 shallow or dug wells, and the development of 200 springs as sources of water supply for domestic consumption. The priority bases for the selection of the areas or· communities where the wells are to be constructed are the absence of safe and adequate water supply and high death rates. There arc now ten ( 10) sanitary engineers, recently graduated from a pre-service training from the Department of Health, who are making a survey of suitable sites for the construction of these wells. FOA-PHILCUSA has provided for this project as of June 30 this year, $1,018,500 worth in commodities, and P'l,594,010 in local counterpart. 4. Hospital Rehabilitation. The physical facilities, including equipment, in practically all of the government hospitals are below desirable standards for adequate and efficient hospital services and care. There are.new, modern, and more serviceable items of equipment which our hospitals do not have. The hospital rehabilitation project is designed to equip our government hospitals with as many pieces of this as they need and can usefully utilize or operate. Furthermore, the project aims at expanding or inVolume XXIX. Number D FOA-PHILCUSA PROGRAMME-Salcedo 483 creasing the facilities in these hospitals to desirable standards within their ability and means to support. Thirty-six (36) of our 80 government hospitals have already received assistance and the provincial hospital here in Tarlac is one of the recipients. For this project, $1,577,094.83 in commodities and $918,865 in local counterpart, have been provided by FOA-PHILCUSA as of June 30 this year. 5. Schistosomiasis or "Snail-Fever" Control. This is a disease which, like malaria, is debilitating, and is common among individuals engaged in agriculture. It is prevalent in many of the provinces of the Visayas, Mindanao, and even the southern tip of Luzon. Our farming methods and practices are conducive to contracting this disease. There are as yet no known effective measures of preventing the disease. The same can be said of the curative or remedial measures. The disease is, however, a real menace to our farmers; and it is incumbent upon us to find measures of control to safeguard the farmers against it. For this purpose, a pilot project is now being set up in Leyte. From the results of the studies and surveys already made, the work of investigation to determine the control methods is well laid out and clearly defined. They will be closely tied up with present farming practices and methods and with environmental sanitation generally. For this project, FOA-PHILCUSA has provided assistance as of June 30 this year $19,000 in commodities and 1"139,774 in local counterpart. 6. Laboratory Rehabilitation. In order to step up our production of vaccines, sera, and other biologicals which are essential for the prevention and control of many of the communicable diseases, we have taken steps to rehabilitate the Serum and Vaccine Laboratories at Alabang. FOA-PHILCUSA has assisted in this rehabilitation measure with $205,000 in commodities and 1"103,700 in local counterpart. 7. School Health. It is recognized that the children who are now in schools will furnish the bulk of the manpower for the country in the years ahead. The state of their health in the future will be greatly influenced by the measures which are taken at this stage to protect, maintain and promote it. A large percentage of the children who are now in the schools are harboring intestinal parasites which undermine their health and strength. Many of them are suffering from defects which can permapent!y be handicapping in their later years. The school health programme is designed to recognize the various diseases and defects common among the school children, to treat these diseases and to correct these defects, or otherwise to see to it that the children go through the whole period of schooling free from diseases likely to undermine their health and affect their growth and their full physical and mental development to adulthood. For this program, FOAPHILCUSA has•provided $596,030.26 in commodities as of June 30; this year. It has not, however, received any peso assistance from FOA and PHILCUSA. The peso part of the operation of the programme is 484 FOA-PHILCUSA PROGRAMME-Salcedo Jour. P.M.A. September, 1953 drawn totally from the 50-centavo voluntary contribution from each pupil. The operation of this programme was transferred to the Department of Education on July 1st this year. Let me urge all parents, however, to remit promptly the voluntary contributions of their children in schools, so as not to hinder its effective prosecution. I am making this appeal, not only because I should like to support the Department of Education, but also because it is inherently the duty of the Department of Health to protect and safeguard the health of all the people including the school children. 8. Public Health Education and Information.-The Education of the public in matters of health, including elementary knowledge about healthful living and practices, can lend itself greatly to the reduction of preventable diseases and in the improvement of the health of the individual and the community. An enlightened community in matters of health will easily accept, and may even demand, programmes and services likely to improve and promote its health. People in such communities are likely to be more ready and willing to pay for such programmes and services. Health education for the public is an integral part of any health act1v1ty. This project which is now in effect, with the help of FOA and PHILCUSA, is designed to expand and strengthen the public health education phase of the total health programme. As of June 30 this year, $68,000 in commodities and 1"116,990 for local operating expenses have been provided for this project. 9. Public Health Training. Any or all of the several public health projects or activities can succeed only if we have the personnel, particularly the technical personnel, adequately prepared and trained and are competent to do their work. All the equipment, apparatuses, and other facilities will be of little avail; public health techniques, methods, and procedures will not yield their maximum results, if the men who use them or perform the work are not technically competent. As the saying goes, "not the gun but the man behind it" wins the war. Cognizant of this fact, we have given due importance to the training of public-health personnel. Those who are being recruited for the service are first made to undergo a pre-service training. Those who are already on the job and do not have the opportunities to catch up with the latest trends and developments are made to undergo in-service training. This project is, likewise, receiving FOA and PHILCUSA assistance. As of June 30 this year, $101,000 in commodities and 1"43,795 in local counterpart have been provided for this project. 10. Tuberculosis Co;1trol. I have placed tuberculosis control next to the last of my topics for three reasons. First, it is the project of which you are now a beneficiary by virtue of the establishment of the Tarlac Chest Center which we are now inaugurating. Second, tuberculosis is still our No .. I public health problem both in terms of sickness Volume XXIX Number 9 FOA-PHILCUSA PROGRAMME-Salcedo 485 and deaths. And finally, this last of the health projects 1s not really under the Department of Health. Based on random surveys, approximately from 1,000,000 to 1,500,000 people have pulmonary tuberculosis, and about 35 ,000 people die from it annually, entailing an annual loss to the country of not less than f'807,000,000. Worse still, the great majority of those who are sick of, or who die from, the disease are in the most productive !lge period in life. FOA-PHILCUSA has provided for the tuberculosis control project, as of June 30 this year, $325,000 in commodities and 1"'218,185 for local operating expenses. 1. Rehabilitation of the Philippine General Hospital. I have included this project in this report, although it is not under the Department of Health, because it is among the health projects assisted by FOA and PHILCUSA. As of June 30 this year, it has been assisted with $5 30,000 in commodities and 1"'374,78 5 in local counterpart. The eleven ( 11) aspects of the public-health programme of the FOA-PHILCUSA in the Philippines, which I have just enumerated and briefly discussed, have received assistance, as of June 30 this year, a total of $6,888,417.01 in commodities and P'6,122,494 in counterpart funds for operation and other expenses. I should like you to view with me now these various projects in their totality. They are well-planned, well-rounded, and well-integrated. More important, they are basically sound and practical. While their immediate objectives are geared to the present programme of total economic mobilization, they are also long-term plans with adequate and necessary provisions for adjustments so that we can continue them according to our own facilities and resources when the assistance from FOA will have terminated. As I close, I should like to think that my talk has caused you to reflect on the meaning and significance of what I have told you. I believe it should mean much to all of you, for it is vitally important to our country. When any of our countrymen fall victim to diseases which can be prevented or cured, he is bound to be a liability not only to himself and to his family, but to his community and to the country as well. If we are to rise, as we ought to, from sub-standard conditions; if our country is to be prosperous, stable and secure, it is incumbent upon all of us to be fully aware that we can realize all of these only - and I mu~t underscore ONLY-if we evolve a citizenry that is physically, mentally, and emotionally strong and healthy. These are the meanings of our serious efforts to improve the health of our people. They are the fundamental reasons that the present administration is giving its full support to the public health activities of the Department of Health. It is part of the Government's concerted programme of positive action to make our people strong, productive, prosperous, happy, and secure. THE CONTROL OF TUBERCULOSIS "' SIXTO A. FRANCISCO, M.D., F.C.C.P. President, American College of Chest Physicians (Philippine Chapter) Members of the Philippine Chapter of the American College of Chest Physicians, Friends, Ladies and Gentlemen: The biggest and most pleasant surprise that I have ever experienced in my life was on May 16, 1952, when a big delegation of our fellowmembers headed by Dr. Jose B. Avellana and Dr. Fidel R. Nepomuceno came to my humble home, where I was confined for several weeks from a double fracture of the leg, just to inform me of my election as the President-Elect of the Philip- s;xto A. Frandsco, M.D. pine Chapter of the American College of Chest Physicians. My Colleagues, I, who had never even dreamt of seeking the Presidency of this organization, knowing fully well that there are other distinguished local Chest Physicians more deserving of said position, some of them much older members of our society than myself, had every reason to feel pleased and surprised. Greatly encouraged by this challenge from my colleagues, I determined to get well and within six months I was once more on my feet. Last April, after the Pan Pacific Tuberculosis Conference, I was suddenly taken ill and had to take leave outside the country upon medical advice. It was the time when elections of the Chapter were about due, so I requested the President, Dr. Carmelo P. Jacinto, to call for the election of the 1953-1954 officers, but it was agreed that the elections would take place upon my return. My Colleagues, I regret to have caused the delay of the elections, and the inauguration of the new officers. The topic of my address is "The Control of Tuberculosis." Much has been said and written about the problem of tuberculosis in the Philippines. In previous inaugural meetings of the Philippine Chapter of the American College of Chest Physicians, the Honorable Secretary of Health, Dr. Juan Salcedo, Jr., who was then the Guest Speaker, dwelt at length on the various phases and extent of the problem of tuberculosis in our country, and has particularly emphasized its socio-economic aspect. The conditions obtaining in the Philippines with regard to the tuberculosis problem are not unique. The last Pan Pacific Tuberculosis Conference has shown us how similar are the difficulties found among most "" Inaugural address delivered after the induction certmony at the Quezon Institute Confuencc Hall, August 20, 1953. Volum~ XXIX Number 9 CONTROL OF TUBERCULOSIS-Francisco 487 countries in the Pacific Area and Asia, so that a set of resolutions were formulated which were thought most suitable for implementation. The Division of Tuberculosis of the Department of Health is gratified in the knowledge that the major resolutions of said Conference were already being implemented in a fundamental balanced program as follows: I. Prevention of tuberculosis by two major weapons: (a) Health education, which is being conducted not so much by expensive printing of sparsely circulated written material, but by word of mouth, by loudspeakers, at barrio level; and (b) BCG vaccination. These two preventive services are being undertaken very extensively by field teams aided by UNICEF and WHO, and in a smaller scale in government chest centers and private institutions under government supervision. 2. Case-finding by X-rays. This is done in existing chest centers and by mobile X-ray units, of which the Division of Tuberculosis has three, one of these donated by UNICEF. With the aid of MSA/ PHILCUSA, more chest centers and mobile X-ray units will be put into operation. 3. Laboratory facilities. Each government chest center is equipped with laboratory facilities to demonstrate tubercle bacilli, and to perform other routine examinations. 4. Hospital beds. This has not been given emphasis by the government program because of the great expense that would be needed for the benefit of relatively few. For public health purposes, it was felt that a limited budget is wiser spent in preventive measures and tuberculosis dispensaries. However, there are hospital beds set up specially for such cases receiving surgical treatment and collapse therapy, and under the MSAJPHILCUSA program the creation of tuberculosis wards in general hospitals in conjunction with chest centers, rather than building expensive separate sanatoria, will be encouraged. Despite the existence of these basic services however, I have to candidly admit that the program of tuberculosis control, viewed as a whole for the country, leaves much to be desired. Not alone because insufficient funds are alloted for the TB fight, but because these funds, meager as they are, are divided among programs also divided, and among agencies, again, unfortunately divided. I have recently returned from Japan where I had an opportunity to make some:. studies and observations on Japan's tuberculosis control program, the salient points of which I believe are so worthy of consideration that I must break a self-imposed reluctance to praise an erstwhile enemy nation in order to bring home the example of what solid cooperation between government and private agencies can do in the control of tuberculosis. Before the last war, the tuberculosis problem in Japan was as serious as is here, the TB mortality death rate was about 200 to 100,000 population. It seems incredible, but true, that during the past eight years, Japan has been able to implement a balanced National Tuberculosis Program so effectively and extensively that it .is now yielding the de488 CONTROL OF TUBERCULOSIS-Francisco Jour. P.M.A. September, 19~a sired results. How did Japan do it? Is it because Japan has developed an elaborate and expensive tuberculosis program with ample TB funds available? The present economy of Japan will not premit her to adopt and develop an expensive tuberculosis prngram, and in fact the annual 19 5 3 tuberculosis budget of the Japan Antituberculosis Association is about 330,000,000 Yen or approximately $1,000,000, which is practically one-half the annual budget of the Philippine Tuberculosis Society, and twice as much as the budget of the TB Division. The present National Tuberculosis Control Program in Japan is under the leadership, control, and responsibility of the Minister of Health and \'V'elfare of the Japanese Government with the assistance and effective cooperation of several health agencies, among which are the Japan Antituberculosis Association, the National Institute of Nutrition, the Japan Medical Association whose active membership exceeds 60,000 physicians, and the Japan Chapter of the American College of Chest Physicians. The problem of tuberculosis in Japan is fundamentally considered to be educational and nutritional. Hence, this aspect of the tuberculosis problem is given top-priority. Training Centers for Health Educators on tuberculosis were established in all prefectures, and thousands of these Health Educators, are now on detail in the Ministry of Education and given assignment in public schools throughout Japan. The Japan Anti-tuberculosis Association under the direction of the Minister of Health and Welfare and with the assistance and cooperation of the Japan Chapter of the American College of Chest Physicians gives a three months course on tuberculosis, in which BCG is included, three times a year foi· physicians, public health nurses, and X-Ray technicians. Moreover, courses on tuberculosis are included in the curricula of the medical colleges in Japan. The purpose of these courses is to make available efficient tuberculosis workers among physicians, public health nurses, and X-Ray technicians, who are in the first line Of attack in the tuberculosis campaign. The National Institute of Nutrition, cooperating with the Ministry of Agriculture, assures the masses of an adequate supply of foodstuffs. Through years of research, this Institute has evolved cheap but balanced meals for the people. The next phase of the tuberculosis problem that is being given second priority is the socio-economic, in which Japan possibly excels other countries in the East. There are several pieces of social legislation such as the Daily Security Law, the National Health Insurance, and others, which look after the welfare not only of the employees but of their immediate families. Moreover, there is the so-called "family's allowance for the children" where a certain amount for each son or daughter of minor age is provided. The preventive phase of the tuberculosis problem is given the third priority. Hand in hand with the extensive and intensive health education campaign are practical demonstrations in community and rural Volume XXIX Number 9 CONTROL OF TUBERCULOSIS-Francisco 489 health centers, giving emphasis on the importance of outdoor recreation. In Tokyo along, there are no less than one hundred big parks provided with playground facilities and either botanical or zoological gardens. All these parks are generally full of people especially during week-ends, who indulge in mass gymnastics rather than merely on competitive athletics. Hiking, swimming, golf, tennis, and hunting are among those outdoor sports that are being indulged by others. As the result of this systematic physical exercise, the present generation of the Japanese people are noticeably different from those of the past; they have better physique, are taller, and present an ideal pict~re of health. An example of the present young generation of Japanese is the 19 year-old girl, Miss Kinuku Ito, whom Japan chose as her candidate for Miss Universe this year. In beauty, stature, figure and personality, Miss Ito can compete with anyone, and in fact she placed third among more than 100 contestants for Miss Un.iverse recently. Adequate rest and sleep are necessary as preventive measures against tuberculosis. In this respect, Japan is strictly observing limited amusement hours. All night clubs, cinema houses, theaters, etc., with the ex·· ception of a few patronized by foreigners, are closed at 10 o'clock in the evening. All Japanese officials and employees are expected to have at least 7 to 8 hours' sleep at night during the working days of the week. To increase or raise further the bodily resistance, mass BCG vaccination is given to all newly-born and young children and adults who are tuberculin negative reactors. The TB workers in Japan do not only mutually cooperate with each other in implementing BCG vaccination, but there is effective teamwork among them. For instance, the Japan An ti tuberculosis Association with its 46 branches all over Japan has been in-charge, for the government, of the Research and Production of BCG since 1925, when a strain of BCG was brought back to Japan by Doctor Shiga who had received it from Doctor Calmette of the Pasteur Institute in Paris. From the year 1940, BCG inoculation began to be made among army and navy men. Since 1942, the vaccination of the fluid BCG became one of the policies of the administration and was generally used for the primary school graduates before employment. The capacity of the dried BCG vaccine produced at present amounts to 67,340,000 doses, and the tuberculin solution 50,400,000 doses. In this connection, it may be of interest to mention that BCG vaccination is now made compulsory by a Japanese legislation, and that Japan has exceeded any.other country in the world in the number of people who were already vaccinated with BCG to a total of no less than 30,000,000. It see~ns significant that the dramatic drop in TB mortality in Japan took place during this period, and more significant still that the decrease in mortality occurred only within the age groups where BCG vaccination was extensively applied. The fourth priority is the medical and curative aspect of the tuberculosis problem. This is the logical sequence, because if any of the three control measures previously discussed fail,. then the tuberculous case has to be treated and/or hospitalized. At present, Japan has a total number 490 CONTROL OF TUBERCULOSIS-Francisco Jour. P.M.A: September, 19S3 of beds for tuberculous cases of 160,000 as against approximately 2,000 TB beds in the Philippines, or 80 beds to every one in the Philippines. Japan has about 4 times the population of the Philippines so that they would still have 10 beds to every one in the Philippines. In the City of Tokyo alone, there are several sanatoria of 500 to 1,500 bed-capacity each, but none of those I have visited can be compared with our beautiful Quezon Institute in style of building, equipments and facilities, of the latest types imported from the United States of America, including medical supplies, X-Ray films, absorbent cotton and gauze, silver and China wares and even kitchen utensils. The sanatoria in .Japan on the other hand, are provided with equipments such as hospital beds, surgical instruments, operating room supplies, laboratory equipments (especially microscopes) and even X-ray units of Siemen's type which are all made in their own country. Even antibiotics are manufactured in their country. I visited two antibiotic plants in the suburbs of Tokyo called "Meiji" and the other "Dauchi" which arc manufacturing Penicillin and Streptomycin, having at present a monthly production of about one ton of Penicillin and one and a half tons of Streptomycin. There is also another Pharmaceutical Manufacturing Plant that is producing isoniazid. Much research and clinical trials on isoniazid have been done in Japan and their findings coincide with those of other TB researchers, as already reported; accordingly to the Research Institute for Tuberculosis functioning under the Japan Anti tuberculosis Society, the best result so far has been obtained with the use of isoniazid in combination with streptomycin and PAS. The number of beds for TB cases has also been augmented with the establishment of TB wards or TB pavilions and operating rooms for chcsr surgery in practically all General Hospitals, government or private, throughout the country. In each of the 46 Prefectures, there are Health Community Centers, an important activity of which is the Chest Clinic and Mobile X-Ray Units. These TB Units operate with the Prefectural sanatoria which arc maintained and operated by each Prefecture with a population of 1,000,000 or more. Thus the total number of beds available for TB patients throughout the country in these 46 Prefectural sanatoria, National Government and privately owned sanatoria and in TB wards of General Hospitals, ~xceeds 160,000 in 1952 which may reach a grand total of 200,000 in 1953. Operated and maintained by the Japan Anticuberculosis Association is "The Research lnsti~ute for Tuberculosis" located in Tokyo, with 260 staff members. This Research Institute for Tuberculosis was started in April 1940, in the Hoseiyan Sanatorium of the Association and since then it has expanded so much that it had move to its present location. The role which this Research Institute has played and continue to play in the National Tuberculosis Campaign of Japan is tremendous, particularly its Special Section in the study and production of BCG (liquid and dried) that is being used throughout the country. Volume XXlX ~umb~r 9 CONTROL OF TUBERCULOSIS-Francisco Evaluation of Results ill their Antituberculosis Campaign 491 Let us evaluate the effectiveness of the control techniques employed by the Japanese in their campaign against tuberculosis within a period of six years from 1947 to 1952. J. In 1947, there was a total of 146,241 deaths from tuberculosis .1mong a population of about SO million, This was reduced to 70,499 in 1952 or more than 50S.'c. 2. The death rate from tuberculosis in 1947 was 187 .2 per 100,000 whereas in 1952 this was reduced to 82.1 per 100,000, a very significant fall to be recorded within a short period of six years. Comparing this with our statistics in the Philippines, we have in 1947 a mortality rate of 164.70 per 100,000 and in 19 5 2 we have on record 144.28 per 100,000 as our annual death rate from pulmonary tuberculosis. 3. Aside from the above statistic:il date which prove the effectiveness and success of their control measures against tuberculosis, we find among the present generation of J;1pan marked improvement in their physical condition as if they are taller, more active and healthier people than other Orientals. This yearly development of a well-balanced National Tuberculosis Program of post-war Japan at a cost of less than onehalf of the total annual budget for TB work in the Philippines is certainly phenomenal and such success may be attributed to the following: 1. Extreme economy observed in the establishment, operation :md maintenance of TB units. 2. Construction of less expensive buildings for sanatoria with more attention to simplicity and allowance to bed capacity rather than beauty and luxury. 3. Uniform and wide distribution of sanatoria throughout the country thereby providing :idequate and effective institutional isolation of TB cases. 4. Systematic and effective program training of medical and paramedical personnel which are well distributed throughout the country. 5. BCG vaccination is universal in Japan and is accepted by the whole medical profession and recognized as a contributing factor in the fall of TB mortality as supported by statistics. Mass vaccination is backed up by proper legislation. 6. Effective campaign on health education and proper nutrition. 7. Improved housing condition and environmental sanitation. 8. Integration of tuberculosis control program with other publ[c health services as seen in their health centers in every prefecture where a Chest Clinic with Mobile X-Ray Unit is a main activity. 9. As a highly industrialized country, Japan does not depend on imported equipments and supplies for . their Chest Clinics, TB Wards, and sanator,ia, hence, they can afford to establish and maintain such institutions not only in big cities but down to the remote communities all over the country. 492 CON TROL OF TUBERCULOSIS-Franci•co Jour. P .M.A. September, 1953 10. Rivalry or personal jealousies do not exist among the different agencies engaged in health work whether governmental or private. On the contrary, mutual understanding and close cooperation prevail between the Ministry of Health and Welfare with the Ministry of Education and Ministry of Agriculture. The same cordial relations also exist between these governmental agencies and the Japa,n Antituberculosis Society, the Japan Medical Association and the Japan Chapter of the American College of Chest Physicians. Concluding Remarks With no other particular disease have the health authorities and the medical profession been squarely face to face with utmost difficulty than tuberculosis. The delegates of thirty countries within the Pacific area assembled in Manila on April 18, 1953, recognized that tuberculosis is still a major medical problem in most of them and that there is a need for a periodic evaluation of the effectiveness of different methods of tuberculosis control. The 'W'HO admits that no standard plan of tuberculosis control can be formulated which will fit every country even among the underdeveloped areas but it recommends international pooling of information so that such control techniques found effective in one country may be of great interest to neighboring countries and to the rest of the world. So when a neighboring country like Japan has recently demonstrated during a comparatively short period of time and within a minimum cost possible, such effective control technique which has yielded the most desired results, there is really something there that is worth considering as a "food for thought." The Philippines has for the past 40 years made a valiant effort to combat its tuberculosis problem, but there are meager indications that the disease is losing ground so that the goal for its control appears still remote. Let us honestly ask ourselves these questions: Do the effects of the 40-year-old campaign for the control of tuberculosis run counter to the efforts exerted and to the tremendous amount of money already spent? Or is the implementation of our admittedly fine antituberculosis plan practical, economical, systematic; and does it get the adequate financial support, the necessary cooperation, and mutual understanding among all the official and non-governmental health entities or agencies that are engaged in this campaign? The correct answers to these questions will place us on a solid footing enabling us to put our National Tuberculosis Campaign on more effective strategic ground. The results, no doubt, shall be more satisfying and lasting. My friends, the Philippine Chapter of the American College of Chest Physicians has a decidedly important role to play in the solution of the problems outlined above. You have elected me to guide the affairs of this organization for this coming year, and I tremble somewhat at the great responsibility imposed upon me. Volume XXIX Nurr.ber 9 CONTROL OF TUBERCULOSIS-Francisco 493 My friends, I wish to state here and now my unequivocal policy - that of working for sincere, honest and harmonious relations among all TB workers in the Philippines. Personal differences of opinion will always exist (otherwise, this already dull world of ours would be duller still). But, as a man who has devoted the 30 best years of his life to serving people collectively, rather than individually, I maintain that one man, or a few men's whims and ideas should be submerged in the more important pool of public welfare. I alone cannot succeed. My hands are powerless without yours to lend them strength. My voice alone is feeble without yours to lend it volume, so that in the aggregate expression of our mutual desires the first round in the successful fight against tuberculosis will have been won, which may eventually lead us to final victory. ACKNOWI,EDGEMENT To Dr. Regino G. Padua, Acting Secretary of Health, for his recommendation which was approved by Malacaiian to consider my trip to Japan official; to Dr. M. Takabe, Delegate from Japan to the Pan Pacific Tuberculosis Conference in Manila last April, who furnished me with important information and statistical data on the tuberculosis problem in Japan; to Dr. Takeo Tamiya, President of the Japan Medical Society with 60,000 physicians as members, who made the necessary contacts and appointments for me with famous Japanese scientists and pharmaceutical firms; and to Dr. Hideo Kumabe, Managing Director of the Japan Antituberculosis Association with 46 branches throughout Japan, whom I have interviewed on the present activities of the Association, specially as to its relationship with the Ministry of Health and Welfare in the national campaign against tuberculosis, - to all of them, my sincere thanks and profound gratitude for having made possible the preparation of this inaugural address. THE JOURNAL Of" THE Philippine Medical Association Published monthly by the Philippine Medical Associ::.:ion und:r th: supervision of the Council. VOL. XXIX Office of Public::.tion, Philippine G:n: r:al Hospital, Manila,· Philippines Dc,·oted to th: progn:ss of McdicJl Science and to the interests of the Mcdic.ll f'rofcssion in the Philippines. SEPTEMBER, 19 <l EDITORIAL STAFF No. 9 M.u•t:EL D. Pr::NAs, M.D., Editor 1. V. MAt.LART. Copy EJit,,, Ta1NIDAD P. PEs!CAN, M.D., BusitttJf Mont1trr MAll.IAXO M. ALIMUI:.UNG, M.D. JoSE. P. DANTVC, M.D~ V1CTOTI.INO DE DIOli, M.D. AXTONJO s. FERN,\NOO, M.D. ASSOCIATE EDITORS Cu,o F1toTEo, M.D. RoMAS T. SALA.cur, M.D. RENATO MA. GuEun.o. M.0. Hu.MOGEN"ES A . SA~Tos, M.D WALFa.IDO DE LEO:S, M.D. AcE .. ICO n. M. Suos, M.D. CARMELO REYEs, M.D. A!"'To!"l10 G. SrsoN, M.D. Signed editorials express the personal views of the vrriter thereof, and neither the Association nor the Journal assumes any responsibility for ~hem. ·tjll Ehitnrial IJ~·· WHAT SEPTEMBER 15 MEANS TO US September 15, 1953 is a memorable date to the medical profession in this country. For on this date, the Philippine Medical Association celebrates two outstanding events in its life: its founding 50 years ago, and secondly, the first obser\lance of Philippine Medicine Day. In accordance with Proclamation No. 407 of His Excellency, President Elpidio Quirino, on September 2nd, every 15 of September of every year shall be known as the "Philippine Medicine Day". That is as it should be. For this date marks the birth of the Philippine Islands Medical Association, the first national medical association founded in our country. During the last 50 years, this organization has made substantial contributions to the science and practice of medicine. This is a cause for self-congratulation, not only on the part of every medical practitioner in this country, but on the part of every Filipino as well. The Proclamation of His Excellency follows: Volume XXIX Numbe1• 9 EDITORIAL "BY THE PRESIDENT OF THE PHILIPPINES Proclamation No. 407 DECLARING THE FIFTEENTH DAY OF SEPTEMBER OF EVERY YEAR AS PHILIPPINE MEDICINE DAY. WHEREAS, national progress and prosperity depend to a large extent upon a healthy citizenry ; and WHEREAS, to produce a healthy citizenry, it is necessary that the masses realize the importance of availing of the services of the medical profession, the mission of which is to safeguard, maintain and promote the health of the people; NOW, THEREFORE, I, ELPIDIO QUIRINO, President of the Philippines, by virtue of the powers vested in me by law, do hereby proclaim the fifteenth day of September of every year as Philippine Medicine Day. IN WITNESS WHEREOF, I have hereunto set my hand and caused the seal of the Republic of the Philippines to be affixed. Done in Honolulu, Hawaii (for Manila, Philippines), this 2nd day of September, in the year of 0Ul' Lord, nineteen hundred and fifty-three, and of the Independence of the Philippines, the eighth. By the President: (Sgd.) ELPIDIO QUIRINO President of the Philippines (Sgd.) .MARCIANO ROQUE Acting Executive Secretary" 495 The medical profession is deeply grateful to President Quirino fot this proclamation. For it is bound to focus the attention of our people, if only once a year, on the importance of medicine to their health and well-being - alleviating their pain and suffering and building up a strong, happy, and progressive citizenry.-A.S.F. ··~lJI tllresiitent'a tlJage jJ~·· OUR INTERNATIONAL RELATIONS With the founding of the United Nations and of one of its instrumentalities, the World Health Organization - of both of which the Philippines is a member-nation - our Association will do well to be ever-conscious of our growing responsibilities in the fulfillment of our duties to foster closer relation with international medical bodies. Because of this, we should: ( 1) have trained and capable men to participate actively in international medical conferences; ( 2) hasten as much as we can the improvement of our medical agencies, both A. S. Frrnmulo, M.D. d · • d h h government an private, m or er t at t ey may catch up with the progress of the more enlightened countries of the world in medical science and practice, in the administration of health agencies, and in the recognition of the vital importance of medical research in the progress of any country. As· a member of these international organizations we are expected to be able to offer substantial contributions to the solutions. of many complex and difficult problems pertaining to the people's health and its socio-economic implications. It will be remembered that, as early as 1908, the Philippine Medical Association initiated the founding of the Far Eastern Association of Tropical Medicine; in 1947, it became a member Association of the World Medical Association; and in 1950, it initiated the First Southeast Asia Medical Conference. With regards to the WHO, we are extremely proud that my immediate predecessor as President of the P.M.A., Dr. Juan Salcedo, Jr., was given the highest honor that that Organization can bestow - the Presidency of the WHO last year; and that Dr. Regino G. Padua, Undersecretary Qf the Department of Health, was given the first chairmanship of the first session of the Western Pacific Regional Committee Meeting of the WHO held in Geneva in May 1951, and of its second session held in Manila on September of the same year. The Pan-Pacific Tuberculosis Conference, sponsored jointly by the World Health Organization, the Department of Health of the Philippines, and the Philippine Tuberculosis Society, was held in Manila last April, 1953; and the Eighth Pacific Science Congress which will be held in Manila in November this year. It can, therefore, be seen that the Philippines is participating more and more in international activities in connection with medical science and health. It behooves us to exert greater and greater efforts, if we are to live up to the role that we must play henceforth. ~- '.• · . ~. A ' . ··tjll misrellnttenus IJ~·· ABSTRACTS FROM CURRENT LITERATURE ABSTRACTORS Honoria Acosta-Sison, M.D. Mariano M. Alimurung, M.D. Jose R. Cruz, M.D. Felisa Nicolas-Fernando, M.D. Trinidad P. Pesigan, M.D. Porfirio M. Recio, M.D. Antonio M. Samia, M.D. REVIEW OF THREE HUNDRED FIFTY THREE CASES OF PREMATURE SEPARATION OF THE PLACENTA. By G. F. Fisher. Am. J . Obst. and Gynec., 1953, 65:257. Ablatio placenta in the Charity Hospital of New Orleans during the ten year period of 1942 to 1952 secured in 353 instances giving an incidence of 1:226. It w.lS more frequent in multipara than in primipara. The maternal mortality was 1.1 j'c. In all the four mothers who died, eclampsia was associated with the ablatio placenta. The babies were stillborn in 40.3%. As ·to treatment, cesarean section, mostly of the low type, was used in 159. When vaginal delivery was contemplated, pitocin by intravenous drip was used to speed up labor and delivery. The following conditions were associated with the ablatio placenta. I. Toxemia, mostly in the form of pre-eclampsia in 37.6%·· 2. Pain was present only in 3 3.3 3 %· 3. Ligneous consistency of the uterus was found in 104 cases or in less than 301;. 4. Shock occurred in 10.4%. 5. Trauma was present only in 4.2 3 . Examples of this were cough, falls, coitus, rectal examination, attempt at external· manual rotation of ·the occiput. One else rc:rnltcd fronl a transabdomino-incrauterine tap for the relief of hydramnios, and one followed a tetmic contraction of the uterus after an injection of Y, cc. Jli.tocin. 6. Anemia and undcrnutrit1on was found ro be •n etiological factor of ablatio placenta. COMMENT. In the Philippine General Hospital from Jul)' ·1945 to December 1951, there were 107 cases of ablatio with an incidence of 1 :249. Though many cases showed toxemia in the form of hypertension and albuminuria none had eclampsia. The mortality was as high as 7 Vi percent caused mostly by severe hemorrhage. It is well to bear in mind chat manipulations such as external version and trans:lbdominal uterine upping as the author mentions may cause abbtio placenca.-H.A.S. DIET AND ATHEROSCLEROSIS. By Dr. Lester M. Morrison. Annals of Internal Medicine 37:6, Dec. 1952, p. 1172. It has been established by several observers that high fat content in the diet is an important factor in the c:lusation of atherosclerosis. The author distinguishes the terms atherosclerosis and arteriosclerosis. By atherosclerosis is meant a condition in which the intimal and medial coats of the affected artery are involved with lipid, fatty or achcromacous plaques. Jn such a condition there is narrowing of the arterial lumen Volume ·xxtx Number 9 ABSTRACTS FROll! CURRENT . LITERATURE 499 and consequent impairment of the circulation in the affected area with resultant damage in the myocardium or cerebral tissue. In the arteriosclerotic artery on the other hand, there is calcinosis in its medial coat with little or no narrowing of the arterial lumen and hence no impairment of circulation in the affected area. It is estimated that 85~{ of lesions in the cot·on:iry and cerebral vessels are due to athcrosclerotic or lipid-c01~ taining lesions. It is now the consensus that atherosclerosis is a disease of lipid and/ or lipoprotein metabolism rather than the result of old age as had been formerly taught. Morrison found that by subjecting patients with atherosclerosis (coronary thrombosis and myocardial infarction) to a low fot low cholesterol diet with a daily intake of 20-2 5 gm. plus 7 5 mg. cholesterol there was marked reduction in the mortality rate. The serum cholesterol levels fell from a mean level of 312 mg. to 220 mg. after 3 years of dietary control; and the total serum lipids fell from a level of 840 mg. to 571 mg. Morrison cites that in Norway in the war years of 1940-1945 when there was low fat consumption in the form of butter, milk, cheese and eggs there was correspondingly a reduction in deaths from coronary atherosclerosis by as much as 31 per cent. During the same .... ar years there "'as a drop in deaths from cerebr•l arteriosclerosis and renal arteriosclerosis by as much as 5 0 per cent and the reduction of the mortality from the above causes have been attributed to the severe dietary restriction of fot and cholesterol and to the coincident reduction of calories. In England there was observed a decrease of mortality from diabetes mellitus in patients of over 4 5 years br as much as 5 0 per cent. The reduced mortality attributable to the low fot intake was due rather to the decreased incidence of complicating vascular disease in the form of atherosclerosis. In other countries like England, Wales, France, the Scandinavian countries, Sweden, fin· land and Denmark there was observed a correlation between low death rate from coronary and generalized arteriosclerosis and low fat intake. In Italy, Coppo noted. high incidence of coronory otherosclerosis (thrombosis) among population who consumed high fat diet in the form of pork produces at each of the three daily meals. The author concludes that high fat and cholesterol intake is correlated with the incidence of death from coronary atherosclerosis.-H.A.S. THE DISTURBANCE OF THE NORMAL BACTERIAL ECOLOGY BY THE ADMINISTRATION OF ANTIBIOTICS WITH THE DEVELOPMENT OF NEW CLINICAL SYNDROMES. By David T. Smith, M.D., F.A.C.P. Annals of Int. Med. 37:6, Dec. 1952. The human body has a normal flor• which work for its own good. Pe11icillin >Cts specially on the gram·positiVe cocci. But proionged use of penicillin may accelerate the growth of organisms normally found in the body like Candida albicans and Pseudomonas aeruginosa which will give rise to disease. Streptomycin is more effective against gram -negative bacilli than gram positive cocci, and occasionally severe or even fatal infections with cocci occur during streptomycin therapy. Practically all bacteria are eliminated by the simulcaneous administration of both penicillin and streptomycin or :i ureomycin. Prolonged administration of a combination of penicillin and streptomycin can cause secondary myotic infection. The prolonged use of antibi.otics which includes aureomycin, chloromycetin, terr:imycin besides penicillin and streptomycin, may not only cause mycotic infections but wiH cause avitaminosis specially of the vitamin B complex and in the non formation of vit:imin K. The author makes the following conclusions: I. Prolonged therapy with penicillin suppresses or eliminates gram-posmve bacteria and stimulated directly or indirectly the multiplication of gram-negative bacilli. 2. Prolonged therapy with relatively large doses of streptomycin may suppress the gram-negative bacilli and stimulates the growth of gram-positive cocci. This effect is not so constant as the reversed one induced by penicillin therapy. 500 ABSTRACTS FROM CURRENT LITERATURE Jour. P.Ml.A . September, 1953 3. The prolonged administration of both penicillin and streptomycin simultaneously, or of aureomycin, chloramphenicol or terramycin may suppress both grampositive cocci and gram-negative bacilli to such a degree that the fungi of the yeast and mold types from the normal ecologic flora multiply and produce disease in the mouth, vagina, bronchi, lungs, and intestinal tract. · 4. Vitamin deficiencies of the B complex type including the syndrome of pellagra, may follow the prolonged administration of the newer. broad coverage antibiotics. 5. Antibiotics should not be· used in mild 2nd ill-defined infections because a drug sensitivity may develop which will prevent the subsequent use of the antibiotic in a major illness. The dangers of inducing sensitivity seem to be greatest when the antibiotics is applied locaily. 6. The newer antibiotics should not be administered for more than one week at a time unless the etiologic agent causing the infection has been identified and the indications for prolonged therapy are obvious. 7. A complete vitamin supplement, with special emphasis on the B complex group, should be given to all patients receiving prolonged therapy with the newer antibiotics. COMMENT: The use of antibiotics for any illness seems to be the fashion today. The above article is a warning that the so-called wonder drugs may do harm when given improperly causing sensitivity or when given for a long period.-H.A.S. ··~II SOCIETY ACTIVITIES II~·· HEART ASSOCIATION HOLDS SEVENTH SCIENTIFIC MEET.-The Philippine Heart Association held on Aug. 6, 1953, its seventh scientific meeting at the Conference Room of the U.S.T. Hospital. The program included five scientific papers presented and discussed before the Association's interested members and medical stu· dents. They were as follows: ( 1) A Technic on Coronary Perfusion to Differentiate Coronary Sinus and Extra-Coronary Sinus Flow in the Isolated Dog's Heart-by Dr. Agustin P. Sevalla; (2) Premature Endothelial H yperplasia of the Aorta and the Large Vessels. Report of a Case - by Drs. Emmanuel T. Gatchalian, Manuel D. Penas, Albino Ocampo, and Felix Rodriguez; (3) Electrocardiographic Patterns Simulating Myocardial Infarction-by Drs. Salvador Busuego and Raymundo Katigbak; ( 4) Apical Diastolic Murmurs in Children Simulating That of Mitra! Stenosis-by Dr. Mariano M. Alimurung; ( 5) Cardiac Effects of Indenbergia Filipensis. Preliminary Report-by Drs. Hermogenes A. Santos, Antonio M. Samia, Andres Cruz, Demetrio Nalagan, and Rene Arcilla. Shown above are new officers of the Caga)•an Medical Society ta/Ung their oath before fudge Virgiliq Y. Pobre. From left to right: Judge Virgilio Y. Pobre, Dr. Gregorio M . Reyes, Councilor; Dr. Pio La11engco, 1st Vice Pres.; Dr. Iderlhta F. Manuel,. President; Dr. Eligio Acebedo, Assistant Sec.-Treas.; Dr. Emiliano Perez, Co11ncilor; and Dr. Oscar Romero. Not in the pict11re: Dr. Esteban Alameda, 2nd Vice President a11d Dr. Tomas Nolasco, Councilor. The 7TH ANNUAL MEETING Of THE CAGAYAN MEDICAL SOCIETY was held in Tuguegarao, Cagayan, last August 14, 1913. The meeting was presided over by Dr. Gregorio M. Reyes. The program follows: (!) Brief remarks on "Do We Get Anything From Our Medical Society". by Dr. Gregorio M. Reyes; (2) Blood Transfusion In Emergency Cases For Small Town Hospital And Rural Areas by Dr. Francisco C. Cepeda; ( 3) Transverse Lie With Avulsion Of The Upper Extremities by Dr. Iderlina F. Manuel. At noon a Luncheon was given jointly by Zuellig, Inc., Doctors, Pharmaceuticals, 502 SOCIETY ACT!l'ITIES ,lQur. P.M ~\. September, l9j3 Pascual Laboratory, lnhelder Inc., E. R. Squibb and Sons, Inc., at the Patria. After the luncheon business meeting was held. The_ following officers for 19 5 4-5 5 were elected: President, Dr. lderlina F. Manuel; 1st \ 7ice Pres., 'Dr. Pio Lauengco; 2nd Vice Pres., Dr. Esteban Alameda; Sec.-Treas., Dr. Oscar Romero; Assistant Sec.-Treas., Dr. Eligio Acebedo; Councilors, Dr. Gregorio M. Reyes, Dr. Emilio Alvarado, Dr. Emiliano Perez and Dr. Tomas Nolasco. After the meeting scientific films were shown at' the U.S.I.S. thru the courtesy of F. E. Zuellig, Inc. and E. R. Squibb and Sons, Inc. Ice cream was served through the courtesy of Manuel Zamora, United Drug, Inc. and Chemidrug Company after the showing. In the evening Reception and Dance was given by Dr. 3nd Mrs. Gregorio M. Reyes in honor of the members of the Cagayan Medical Society at the Reyes Clinic. During the dance the newly elected officers were inducted by Judge Virgilio Y. Pobre, Justice of the Peace of T uguegarao, Cagayan. BULACAN MEDICAL SOCIETY HOLDS SECOND MEET. - Meeting at the New Selecta on Dewey Boulevard under the sponsorship of F. E. Zucllig, Inc., the Bulacan Medical Society held its second scientific meeting August 22, I 95 3, at 10:01) in the morning. The program commenced with an opening remarks by Dr. Jose L. Santos, V.P. of the Society, followed by a welcome address by Dr. Emilio Venturin>, a member of the B.M.S. and medical representative of F. E. Zuellig, Inc. Miss Sylvia La Torre, a popular radio singer, accompanied by Mrs. Nilda M. Redoblado of the U.S.T. Conservatory of Music, gave a musical rendition. After this Dr. A . S. Fernando,. P.M.A. president, gave a short remark on the progress of the projected P.M.A. House and other activities of the Association. Guest speaker of the occasion was Dr. Gonzalo F. Austria of the U.P. Colle'ge of Medicine who spoke on Medical tid-bits. He was introduced by Dr. Salvador C. Santiago, B.M.S. President. Films on Varidase and Aureomycin by F. E. Zuellig, Inc., was shown. Medical Samples were distributed. At 12 :00 noon luncheon was offered by the sponsor. HEART ASSOCIATION HOLDS MEET AT P.G.H.-The eight regular scientifi~ meeting of the Philippine Heart Association was held at the Philippine General Hospital on the evening of September 3. The complete program follows: ( 1) Correlation Between Pathologic and Electrocardiographic Findings in Myocardial Infarction-by Ors. A. Florentin, A. Baltazar and A. Buenaventura; (2) Thyroid Extract in the Management of Hypertension-by Dr. Edward Z. Fang; (3) The "Wolff-ParkinsonWhite Syndrome". Report of Two Cases-by Ors. Jose M. B>rcelona and S. Ador Dionisio; ( 4) Cardiovascular Actions of Phaeantharine HCl, a New Quarternary Ammonium Compound from Phaeanthus ebracteolatus (Kalimatas). Preliminary Reportby Drs. Conrado Dayrit, Gerardo V. De Leon, Horacio R. Estrada, Ernesto Valdez, Natividad Diaz and Romulo Guevara, and Gertrudes Aguihr-Santos and Alfredo C_ Santos; ( 5) Electrocardiographic Exercises-by Dr. S. Ador Dionisio. V. LUNA GENERAL HOSPITAL HOLDS SEVENTH ANNIVERSARY. - A program celebrating the .7th anniversary of the V. Luna General Hospital, AFP, was held Sept. 3. The. program started with an open house and a band concert held at 10:00 in the morning. At 12:00 noon a luncheon was offered by the V.L.G.H. Officer's Club. Other part of the program were athletics, a musical program offered by the Philippine Women's University students, distribution of prizes, and Officer's Club party. Volume XXIX Number 9 NEWS ITEM 503 JOINT MEET AT N.G.H. - The Manila Medical Society and the Director and staff of the North General Hospital held a joint scientific meeting at the Conference Room of the N.G.H. in the evening of Sept. 8, 1953. In this meeting Dr. Wenceslao Vitug and Dr. Hipolito Tanjuakio presented "Tuberculosis: A Diagnostic Problem (Report of a Case). A panel discussion on cough was also held with Dr. Miguel Canizares as moderacor. · The pmel of discussors were Dr<. ]. R. Cruz, F. A. Estrada, G. l\facaungay, F. Nepomuceno and A. B. Rotor. After the panel discussion the usual business meeting followed. JOINT SYMPOSIUM ON MENTAL HEAL TH. - The national medical and allied organizations md the Department of Health held a joint meeting on Mental Health at the Science Hall of the New Library Building of the Philippine General Hospital September 16, 1953. The organizations that participated in this meeting wer< the following: Phil. Med. Assn., Phil. Fed. of Pri\". Med. Pract., Phil. Med. Women'• Assn., Phil. Pub. Health Assn., Phil. Mental Health Assn., Phil. Dental Assn., Fed. of Dental Pract. of the Phil., Fil. Nurses Assn., Vi<iting Nurses Assn., Phil. Pharm. Assn., and Col.-Med. Far. de Filipinas. The symposium was on "Teamwork for Mental Health" with the discussions being led by Dr. Marciano Limson, Dr. Manuel V. Arguelles, Dr. Leopoldo G. Pardo, Dr. Fe de! Mundo, Dr. Alfonso Salcedo, Dean Julita Sotejo, Mr. Iluminado Cada, Dr. Mariano lcasiano, and Dr. Victorino G. Villa. Dr. Jose Fernandez acted as moderator. Guest of Honor of the occasion was the Hon. Juan Salcedo, Jr., Secretary of Health. The complete program follows: ( 1) Call to order and opening remarks - Dr. Ramon R. Angeles; (2) Welcome address - Dr. Arturo B. Rotor; (3) Introduction of the Guest Speaker - Dr. Toribio Joson; ( 4) Address by the Guest Speaker - Dr. Estefania Aldaba-Lim, Ph. D.; ( 5) Introduction of the Guest of Honor..:.._ Dr. Arsenio Regala; (6) Closing Remarks by the Guest of Honor - Hon. Juan Salcedo, Jr. Refreshments were served through tbe courtesy of Metro Drug Corp. NEWS ITEM P.I. IN INTERNATIONAL CONGRESSES IN EUROPE At the invitation of the Turkish and Italian Governments, the Philippines will be represented by Drs. Antonio Ejercito and T. P. Pesigan, both of the Department of Health, at the 5th International Congress of Tropical Medicine and Malaria which will be held in Istanbul from August 28-September 4 and at the 6th International Congress for Microbiology which will be held in Rome from September 6-12. These two delegates, who left by PAL plane on August 22, 195 3, are project directors in charge of the control of malaria and schistosomiasis in the Philippines. These two diseases which are two very important public health problems in the Philippines will be dealc with intensively in the agenda of these congresses and it is believed that with their participation and their contact with renowned workers, the successful prosecution of their respective projects will be assured. After these congresses, Dr. Ejercito will go back to the Philippines and then leave for the United States on a FOA (MSA) fellowship, while Dr. Pesigan will visit different health institutions and agencies in the capital cities of Europe such as Geneva, Stockholm, London, Paris, and Madrid where he will observe the researches being done in the variou< institutions in charge of communicable diseases control. ··tj11 BOOK REVIEWS rn~·· GIFFORD'S TEXTBOOK OF OPHTHALMOLOGY by Francis Heed Adler, 1th Edition, W B. Saunders Co., Philadelphia, 1953, cloth 488 p., 281 figures and 26 color plates. This book is quite different from the 4th edition published 6 years ago. There is much revision aimed at including and presenting materials for the undergraduate and the general practitioner of medicine. Many diagrams and photographs of the previous edition have been removed. Some of these are replaced by new ones. Some chapters, like the section on hypertensive diseases and diabetes, have been entirely rewritten in a very illuminating way and attempts are made to include new thoughts, classification and drugs to make it up-to-date. There is a confusing arrangement, however, in the inclusion of epidemic kerato~conjunctivitis under allergic conjunctivitis, on p. 207, and the omission of cortone in the section on therapeutic agents. In the chapter on Orientation on Surgical Operations, the techniques have been omitted and the emphasis is on the indications of the common operations, and what they may accomplish from the point of view of the general physician. What should be referred to the ophthalmologist is clearly pointed out throughout the next. This presupposes the availability of ophthalmologists in the different parts of the United States, which may not be so in such countries like the Philippines. This textbook of ophthalmology is to be recommended for undergraduates and general practitioners of medicine. GEMINIANO DE OCAMPO, M.D. Assoc. Prof. of Ophthalmology University of the Philippines "PRACTICAL DERMATOLOGY" by George M. Lewis, M.D., FACP, Professor of Clinical Medicine (Dermatology) Cornell University Medical Colleg~; Attending Dermatologist, The New York Hospital Secretary, The American Board of Dermatology and Syphilology, W. B. Saunders & Company, Philadelphia and London, 1952, 328 pp. The full title of this Book is "Practical Dermatology for Medical Students and General Practitioners,'; and it proves to be exactly that. It compresses in a little over 300 pages the information and advise, both diagnostic and therapeutic, that one ossociates with I 000-page textbooks on dermatology. In an unbelievably brief presentation of the subject, the author has given the general practitioner everything that he needs to know and can use. How was this unusual conciseness achieved? Firstly, by making generous and judicious use of excellent pictures and illustrations. This 263 pages of description of diseases contain 99 plates, each plate often consisting of 4 or more separate pictures. It is amazing how quickly one understands the difference between psoriasis and tinea corporis, between tuberculids and acne, by studying these pictures. Secondly, by eliminating historical notes, definitions, theoretical considerations, pathology and limiting discussions of etiology and treatment to the most essential points. Presentation of • disease begins typically with a paragraph on symptoms, a sentence or two about etiolog)", a few sentences on differential diagnosis and paragraph on treatment. Can dermatology be learned in this manner? Many professors will disagree, many general practitioners will agree. A. B. ROTOR, M.D. Dept. of Med., Coll. of Med. U.P. Volume XXIX Sumber 9 XIII HETRAZAN Dieth)ilcarbamazine Leder le HETRAZAN a product of Lederle research, has been shown by both laboratory and clinical work to be highly effective in the treatment of infestation by: ADVANTAGES: PACKAGES: Ascaris lumbricoides Loa Joa Onchocerca volvulus Wuchereria bancrofti 1. Low toxicity. 2. Specificity for the above mentioned organisms. 3. Ease of administration - avilable in Tablet and Syrup form. 4. Stability of the drug under varied conditions of climate and moisture. Tablets - Bottles of 100, 150 mg. each tablet Syrup - Bottles of 4 oz. and 16 oz., 120 mg. per 4 cc. ~ederle LABOBATOBIES DIVISION 55 Rosario; Manila .P. 0. Box 604 AMERICAN e'Janamid COMPANY 30 Rock€felller Plaza New York 20, N.Y. F. E, ZUELLIG, INC. Exclusive Dist1·ibutors Lapu-lapu & Morga Sts. Cebu City VCIV Jour . P.M.A. September, 19:i3 ~·~ Y!i'Biolac gives babies im~orfAnt Benefits! The idoal infant food, of course, is breast milk. But in the many instances where such feedings are not possible, it is indeed fortunate to have BIOLAC to prescribe. BIOLAC actually approximates breast milk closely in its over-all nutritional and digestional advantages. Modified to supply sufficient protein and reduced fat intakes, BIOLAC satisfies the infant's important needs. Growth demands are satisfied by the ample protein content, while the baby's digeslive system is not exposed to an excessi"e intake of fat found in so many other milk formulas. Both fat and protein are in easily digestible form. Lactose (natural milk sugar) has been added to furnish adequate carbohydrate. BIOLAC has been enriched with Vitamins A, Blt D and iron. Thus, in every major respect, BIOLAC is truly a complete infant food. Easy to prescribe .. . easy for the mother to prepare, BIOLAC gives babies important benefits. DOCTOR: We are confident BIOLAC will give you superior infant feeding results. Why not prove this for yourself by trying BIOLAC today? Write to us if you desire literaNte or a free clinical supply. Bio lac THE BORDEN COMPANY 3SO Madison Avenue, New York 17, N. Y., U.S. A. Volume XX!X ~1•mber ::I ' DEXEDRINE* xv tablets the antidepressant of choice, and the most effective drug for control of appetite in weight reduction Smith Kline & French, Philadelphia, U.S.A. *T. Jlf. for dexlro-amplteta111i11e sulfate, S.K.F. Sole distributors: Oceanic Commercial, Inc., P. 0. Box 243, Manila XVI Jour. P.M.A. September, l9jJ flllll ll:W IJll:?INCI IJLI: I . ..., STll:?l:IJT()M .,-c,1 N Tt1I:11:?41J.,AMBISTRYN represents an important advance in antibiotic therapy. It combines equal parts of streptomycin sulfate and dihydrostreptomycin sulfate; the patient thus gets only half as much of each drug. The risk cf vestibular damage (from streptomycin) and of hearing loss, (from dihydrostreptomycin) is reduced appreciably. Therapeutic effect is undiminished. This principle has been demonstrated in both animals and man. Cat treated with streptomycin is ataxic. Cat treated with the same amount of streptomycindihydrostreptomycin has normal equilibrium. In patients treated for 120 days with 1 Gm. per day of the combined drugs, the incidence of neurotoxicity is practically zero AMBISTRYN Squibb Stre-ptcmycin Sulfate and Dihydrostreptomycin Sulfate in equal parts 1 Gm. and 5 Gm. vials, cJ.·pressed as free base "AMBISTRYN"' is a trademark SQUIBB leader in streptomycin research and manufactu1·e E · R ·SQUIBB & SONS PHILIPPINES CORPORATION pASONG TAMO (BUENDIA EXTENSION) S'AN PEDRO MAKA.TI, RIZAL PHILIPPINES TEL. No. 5-17·51 Volu:ne XXIX Number 9 The foundation of a baby's future health is laid during the first year of life. Babies fed on Similac during this first year develop strnng, firm bodies, straight and sound teeth; and are notably resistant to ills common to infants. Exclusive Distributors: XVII The famous De Leon triplets just after birth had an average weight of 3-'h lbs. Exclusive feedings of Similac for 3 months tripled the birth weight of each child. LA ESTRELLA DEL NORTE (LEVY HERMANOS, INC.) escolta·plua moraga tel. 3-82-61 XVIII How effective is ACNOMEL 10 New evidence from a comprehensive study* Jc._ ur. P.~LA . .Seµtt>mber, rn.;·; JOO patients with acne were treated with 'Acnomel'-S.K.F.'s rapid-acting, lesion-masking acne preparation. Writing in The Journal of the American Medical Association, the author reports of • Acnomel'"Acne was either arrested or decidedly improved in all cases." Flesh-tinted 'Acnomel' "matched the average skin, enabled the patient to cover the lesions and thus prevented embarrassment" and psychological trauma. In 'Acnomel' you have, for the first time, a preparation which meets the essential therapeutic and cosmetic requirements for the successful topical treatment of acne. 'Acnomel' contains resorcinol, 2%, and sulfur, 8%, in a special grease-free vehicle. *Dexter, H. : Studies in Acne, J.A.M.A. 142:715 (March 11) 1950. m-~,;F:...-r:r~:J'.":lfL?!i~::zr~ ~I~~ 1 1 ACNOMEL ~w1c··~.:Sili1l:"'.l83c•%W>'U'li'<'Y'P.~iif'Ci.?~P..••;&;'iiflo!l:i.~~'¥\ a significant advance, clinical and cosmetic, in acne therapy SMITH KLINE & FRENCH, Philadelphia, U.S.A. Sole Distributors: Oceanic Commercial, Inc., P. 0. Box 243, Manila Volurn<? XXlX Numl>er !I • • • • • • ·• • • • DEAR DOCTOR: Please read the advertising pages. Show your interest by correspondence and patronage. Support those firms who advertise m our Journal. • • • • • • • • • .. XIX CLINITEST - (BRANO ) URINE-SUGAR DETECTION SIMPLE • SWIFT • DIRECT E,•erything needed for reliable urine. sugar testing r'.n one set! Each Clinite . .;I Reagent Tablet contained in the set contains all reagents required for copper reduction test. 1 ' '0 exren w l heat in{_!. necessary-tablets geoel'atc heat on llissolving. To perform test, simply drop one tablet into t est tnhc containin~ diluted urine. \Vait for reaction, then compare with color scale. Tablet refill available from vour Chemist. Ideal for cloctm:, patient or laboratory. Contact our represent~tive for ·---:·_ e-, -:;/~i\ literature, today! \,]!:~-:--\~~~ •J---__,\,, AMES COMPANY, INC. Elkhart; Indiana. U.S. A . EXCLUSIVE DISTRIBUTOR: ED. A. KELLER & CO., LTD . 176 Juan Luna (P . 0. Box 313) Manila, Philippine Republic xx Jour . P.M.A. September, 1953 Ideal Protection against JVhooping Cough etl.xi>L AURl(An acute infectious disease marked by recurrent attacks of cough· ing which exhaust the breath.) BROMIDE FORMULA: Gold Tribromide . 0.12 Gm. Alcolhol • . , , , ... . , . , . • .. , • ..• • , , •. , , 2.20 cc. Glycerine . ... , . , . , .......... , . . . . . . . 30.00 cc. WaUr q. s. ad. . .. ....... , . , .. , , . . . 1.20 cc. AIC'ohol content 27o by Volume OTHER INDICATIONS: Pulmonary Tuberculosis, Bronchitis, Bronchial Asthma, Cough with Fe. ver and other cases of 0 b st in ate Coughing, Painful Cough. et.~ AURl-BROMIDE t1C:TRO __ _,..II. Warning: All packages of METRO'S ELIXIR AURIBROMIDE are sealed with our Guarantee Seal as your assurance for originality. WhOOf~Covqh . J llrordllot l!lhma I r.i...oRory Couqll OllS1in"• Couqlt Available at all good drug stores. METRO DRUG CORPORATION Volume XXIX Number 9 -----Iron ---Vitamin A XXI ------Thiamine ·vitamin D----------------When the need for dietary supplement•· tion arises, the delicious food drink made by mixing Ovaltine with milk finds wide application. This dietary supplement provides generously of all nutrients considered necessary, in balanced proportion for optimal utilization. Three glassfuls daily, in conjunction with even an average diet, raises the intake of essential nucriems to opcimal levels. ity virtually assure patient acceptance, as well as consumption of the recommended three glassfuls daily. Its appealing taste and easy digesribilOvaltine finds valuable use pre- and postoperatively, following recovery from infectious disease, in pregnancy and lactation, in pediatrics in the management of food-resistant children, and to supplement restricted dietaries whether prescribed or self-imposed as a result of food aversions and idiosyncrasies. THE WANDER COMPANY, 360 N, MICHIGAN AVE., CHICAGO I , ILL. Three servings daily of Ovaltine, eaCh mode of % oz. of Ovaltine ond 8 oz. of whole milk,• provide: CALORIES • 669 VITAMIN A PROTEIN . 32.l Gm. VITAMIN 81 FAT 31.5 Gm. RIBOFLAVIN CARBOHYDRATE 64.8 Gm. NIACIN CALCIUM . . . • l.IZ Gm. VITAMIN C PHOSPHORUS • 0.94 Gm. VITAMIN 0 IRON . • • 12.0 mg. COPPER *Based on average reported values for milk. ED. A. KELLER & CO., LTD. 3000 1.U. l.16mg. 2.00 mg. 6.8mg. 30.0 me. 417 1.U. 0.50 me. 176 J. Luna, Manila Tel. 2-98-26 XXII ~our . P.M.A. Sept(,mber, 1953 For better clinical results .... Specify • ANTIBIOTICS FORTECILLIN (Injectable) 300,000 U. Cryst. Procaine Penicillin G. l 00,000 U. Buffered Cryst. Penicillin G Pot. FORTEMYCIN (Injectable) 400,000 U. Fortecillin-0.5 Grnn Dihydrostreptomycin Sulfate. . DIHYDROSTREPTOMYCIN (Injectable) I Gram Dihydrostreptomycin Sulfote. CRYSTALLINE PENICILLIN G POTASSIUM (Injectable) 200,000 Units. PENICILLIN OINTMENT (Topical), Y:! oz. and 1 oz. 1000 U./Gram. PENICILLIN OPHTHALMIC OINTl\IENT, % oz. i OUU L'./Gram. PENICILLIN TABLETS, 50,000 U. and 100,000 U. Boxes of 12 's . PENICILLIN TROCHES. 5000 U., Boxes of H's. SULFACILLIN TABLETS, 200,000 U. Penicillin G Potassium Crystalline, 0.167 Gm. Sulfadiazine, 0.167 Gm. Sulfamerazine, & 0.167 Gm. Sulfamethazinc. Boxes of 12 's. A. T. SUACO & CO., INC. J\fanufacluriu!!, Pharmacis/5 MANILA-CEBLJ Main Offices & Laboratories: 2100 Rizal A venue, Manila Branch Office: Tel. Nos. 2-94-01 : 2-76-07; and 2-94-77 105-111 ~lango Avenue Cebu City-Tel. 3- 1-2 Volume X~tA !"'iumbcr !> VITARINE superbee with FOLIC ACID XX III Recommended for the management or prevention of a deficiency of the contained factors of the Vitamin B Complex. These capsules are prepared \l"ith pure cr~·8talline vitamins of the B Complex in a base of whole dried liver powder. Bach eapsulc contains : Vitamin R , ;J mg. (Thiamine Hydrochloride ) \"itamin B .. ( G ) .) mg. ( Ribofla\·in) The VIT ARI NE \"itamin H, 0.5 mg. ( Pyridoxino Hydrochlor ide) Cuk ium Pantothenate 5 m!!. ~ i ac inami<le 20 mg. F olic Acid l).5 mJ!. Inc. ATTENTION MEMBERS! Auto Stickers are available for sale at Pl.00 a pair. Make your order frorn the Business Manager of the Journal or from the Secretary-Treasurer of the Association. XXIV Jour. P.M.A September, 19ii3 Why IT PAYS to advertise in THE JOURNAL, PHILIPPINE MEDICAL ASSOCIATION REASONS:1. It is the leading medical publication of the Republic of the Philippines, it being the official organ of the truly national medical association - The Philippine Medical Association - with a total membership of over 3,000. 2. There are at present 53 component medical societies already established in the different cities and in all the pl'ovinces throughout the Philippines, namely: 1. Abra 2. Agusan 3. Athay 4. Antique 5. Baguio 6. Bataan 7. Batangas 8. Bohol 9. Bulacan 10. Cagayan 11. Camarines Sur 12. Ca.marines Norte 13. Capiz 14. Catanduanes 15. Cavite 16. Cebu 17. Cotabato 18. Culion 19. Davao 20. Ilocos Sur 21. Ilocos Norte 22. Iloilo 23. Isabela 24. Laguna 25. Lanao 26. La Union 27. Leyte 28. Manila 29. Marinduque 30. Masbate 31. Mindoro 32. Misamis Occ. 33. Misamis Or. 34. Nueva Ecija 35. Nueva Vizcaya 36. Occ. N egros 37. Oriental N egros 38. Pampanga 39. Pangasinan 40. Quezon (Tayabas) 41. Quezon City 42. Rizal 43. Rizalian 44. Romblon 45. Samar 46. San Pablo 4 7. Sorsogon 48. Sulu 49. Surigao 50. Tarlac 51. Zambales 52. Zamboanga City 53. Zamboanga Prov. 3. Aside from this, the Association has 11 component specialty sections, namely: 1. AERO Medical Society 2. Phil. Heart Association 3. Phil. Leprosy Society 4. Phil. Obs. and Gyn. Society 5. Phil. Ophth. and Otolar. Society ti. Phil. Radiological Society 7. 8. 9. 10. 11. Phil. Soc. of Anaesthesiologists Phil. Orthopedic Association Phil. Society of Pathologists Phil. Soc. of Psychiatry & Neurology Phil. Society of Venerologists The Philippine Federation of Private Medical Practitioners is also affiliated to the Phil. Med. Assn. 4. The Journal, therefo1·e, serve~ as the most effective medium for dissemination of information on recent medical i·esearches and their application to general and specialty practice particularly the use of modern diagnostic aids and appliances and the latest preparations in modern therapeutics. 5. The circulation of the Journal has been considerably increased and otir goal is to send the Journal to each and every physician in the Philippines estimated to number now almost 7,000 6. The increasing demand for exchanges with foreign medical publications attests to the importance of the Journal in the medical world. 7. The JOURNAL is not a commercial publication, so we do not employ advertising solicitors. All Ads must pass the censorship of the Committee on Proprietary Medicine of the Philippine Medical Association with regard to its ethical standard patterned after the Journal of the American Medical Association. 8. T·he fact that advertisers have continuously patronized the Journal since 1921 is conclusive proof that it 'is the best medium for medical advertising in the Philippines. If you are interested to advertise, please communicate with the Business Manager, JOURNAL of the PHILIPPINE MEDICAL ASSOCIATION, Public Health Research Laboratories, Dept. of Health, San Lazaro Hospital Compound, Tels. 26182 (Local 41-64) and 29439 or Philippine General Hospital. Volume XXIX Number 9 GOOD NEWS FOR THE PEDIATRICIAN! NOW •.• IN TWO NEW STABLE LIQUID FORMS! • anreomye1n CALCIUM ORAL DROPS Safe, potent and economical, AUREOMYCJN is also one of the most versatile antibiotics known to science. Highly effective when given by mouth, AUREOMYCIN is the antibiotic of choice among physicians in all branches of medical practice; and in its new stable liquid form - equivalent to 100 mg. of AUREOMYCIN HYDROCHLORIDE per cc. - it gives the pediatrician greater freedom of action for it can be administered with water, milk or other nonacid foods. Pleasant tasting, too! AUREOMYCIN CALCIUM ORAL DROPS are packaged in 20 cc. vials with dropper. The dropper in the package delivers 25 mg. of aureomycin in each 5 drops. • aureomye1n CALCIUM SYRUP Aureomycin, one of the most pofont, safe and economical among the broad-spectrum antibiotics, · is now available in a new stable syrup form. Intended to overcome the natural reluctance of children toward medication in capsule and tabl~t fornw, AUREOMYCIN CALCIUM SYRUP is a palatable liquid, containing 125 mg. of aureomycin in each teaspoonful ( 4 cc.). available in bottles of 4 ounces. Look to ~c/ep,l/J for leadership LEDEBLE LAB OBA TO BIES DIVISION AMERICAN C'fanamid COMPANY 30 Rockefeller Plaza, New York £0, New York F. E. ZUELLIG, INC. MANILA CEBU CITY EXCLUSIVE DISTRIBUTORS xxv xxn TOPS FOR TOTS ILOTYCIN J our. l".~.A . ~r.~ ...-m~r. 1 ~:, : The most effective antibiotic for the common Bacterial infections of childhood ILOTYCIN (£rythro;;iyci11. Lilly) Crystalline Ethyl Carbonate, PEDIATRIC Especially hard - hitting against streptococcus, staphylococcus, and pneumococcus infection~. Cnsurpassed oral treatment for otitis media, sinusitis, tonsillitis, scarlet feyer, bronchit is, am! pneumonia. DESIGXED ESPECIALLY FOR CHILDREX - Palatable, tasfetested, and approved by the junioi· taste panel. ELI LILLY INTERNATIONAL CORPORATION l~d :a:i1pJlis 6 , Ir.diana, U_S.A. LILLY THE ORIGI.VATOR OF ERYTHRO.lIYCI.\" ',,, , \ l\ "' <~·:Kl NAO EN dfyaluronidl:zse and its clinical use for: / • hypodermoclysis / ! I • injections of irritating drugs / • excretion urography combined · with X-ray_contrast media Original packing: I ~ . ~---:- _ _ _ _ _!....lo.co and nerve block anesthesia Box containing 2 amp. each of 10 Schering unih • haematoma and local edema • rheumatic joint diseases Literature and information available upon request S C H E R I N G A. G. B E R L I N GERMANY Representative: La Estrella del Norte, Levy Hermanos Inc. Escolta - Corner Plaza Moraga • P. 0. Box 273 • Manila CRE Analgesic Cremacal provides cooling, analgesic relief from pain, burning and pruritus. Its greaseless, water-miscible base dries promptly to form a protective coating over the irritated area. Formula: Calamine ...•..................... . .. 10% Glycerine............................ 5% Benzocaine.. . . . . . . . . . . . . . . . . . . . . . . . . 1 % Phenol .............................. 0.5% Menthol ............................. 0.?5% Special water-miscible base ........... q.s. Flesh-tinted with inert coloring. Supplied in 1-oz. and 2-oz. tubes. NUMOTIZINE, Inc. 900 N. Franklin St., Chicago 10, Ill. Distributors: THE MODERN PHARMACAL PRODUCTS CO. 888 Rizal Avenue Manila,