The Journal of the Philippine Medical Association

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Part of The Journal of the Philippine Medical Association

Title: The Journal of the Philippine Medical Association
Issue Date: Vol. XXX (Issue No. 2) February, 1954
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extracted text: ----75/,e ---~ O URX~ OF THE PHILIPPINE MEDICAL ASSOCIATION ------,==========:oQo ==========--VOL. XXX FEBRUARY, 19;).1 :\'o. 2 Q:able of C!iontents ORIGINAL ARTICLES: l'ng• Psychosomatic Aspects of Ophthalmology - by Gc111i11ia110 de Ocampo, M. D. 65 Diagnosis :rnd Treatment of \lyasthenia Gravis - B) Li1;0 LI. Li111, ;\f. D. a11d Noe C. Legasto, M. D. For :in lntcgr:ited Provincial Government Hospit.11. Pucriculturc C1.:nter, \lunicipal }.larcrnity and Charity Clinic Scn·icc - 74 by E11riq11c F. Ochoa, ,\!. D. '6 fCuntin:ud un p.1gr I) Publlshed Monthly by the Philippine Medical AsSCJ.:ialion Philippine General Hospital, Manila Entered as ncond class maUer al \he- .Manila Poe\ Offiat, March 1, 1 !}46 ingle Copy 1'1.20 < • > Per Ye•l' 1'12.00 .., ~~~J~l~Jku~=.iP-~~~ For under DA YTIJUE ALERTl\'ESS ANTIHISTAJUINIC the1·apy ~ ~ \ Neohetramine. ~....._ ...... (HYDROCHLORIDE) Ej fective Antihistaminic Action 1dth an exceptionally High Degree of Fr<'edom from SEDATION * ~EOIIETILUllNE TABLET:-; of 25 mg .. 50 .m.~. in bottles of 50',, !OO's * );EOHETIL\:\11?\E SYHUP in 4 oz. hottles, 6.2'.J mg. per cc. NEPERA CHEMICAL Co., Inc. Pharmaceutical 1llanufacturfrs Nepera Park, Yonkers 2, X.Y. -A: :\EOIIETILUil:\E EX!'ECTOHANT in 4 oz. bottles * ~EOHETILUII:\E CimAM in collapsible tube~ of 1 oz. UNITED DRUG Co., Inc. E:i..-clusii·c Philippine 'l?cJJ1·n;111fati·rcs P. 0. Box 0038, :Manila Free literature and samples ai·ailable on request. fttlly ttS effective ... but more pleasant to take AUREOMYCIN CALCIUM SYRUP Children, convJ.lesccnts and those experiencing dysph:i:gia, are often unwilling: or unable to 'w2~low tJ.hl~ts or c2piulcs, but will rc1dily ukc .a liquid, plc2undy flavored mcdic.ition s.uch :is Aureomycin C1lcium Srrup. This new form of aureomycin permits the administration of adequ:itc dougc lt frequent inccrnh without undul)· upsctcing che smJ.11 or debilitated p2tienc. Uniformly blended : rnd highly stable, chis ~yrup is p;artlcuLuly :i.d:ipted to the low douge therapy recommended cad1y for aurcomrci:t. ADV ANT AGES, high potency-One teaspoonful (4 cc.) contains t he equivalent of 12S mg;. of aureomycin hrdro~ chloride. pleasantly flal·ored-Can ~ taken alone or mixed with liquids or nonJcid food;. easily administered- Controlled dos.ig~ c;i., b::: .ldminimm~d as often :1s required. prompt absorption-Followed br :t bl.ind drink it is r~.tdily Jbsorbcd wi~hou~ the gutrointcstinal irritltion sometime~ c1used b~· high concentutio'1 of the dru,;. ~ck;i& LAIBORATORIJE§ DIVISION M11nila Office: .55-63 Rosario, Manila AMER:CAN e 'fananziJ COMPANY 30 Rockefeller Plaza New York 20, N. Y. F. E. ZUELLIG, INC. Exclusive Distributor• Cebu Oifice: Lapu-Lapu & Morga Sts . Jour. P .M.A. Volume XXX Numl.M:'r CONTENTS-Continutti SPECIAL ARTICLE: Address-by Paulino / . Garcia, Scaelary of Hwl!h EDITORIAL: The Philippine V ctcr>ns Memorial Hospital PRESIDENT'S PAGE MISCELLANEOUS: ABSTRACTS FROM CURRENT LITERATURE ORGANIZATION SECTION SocIETY AcT1vIT1Es NEWS ITEMS IMPORT Al'T NOTICE P•gt 100 103 105 107 108 113 Eac:h member of the ASJoei;tioo u entitled to re:::ivc a copy of tbe Journal e•ery montt,. Articles are accepted for public:atioo on condition that they arc contributed 10lely for tbit Journal. M.inu,cripts 'hould be typewritten, <iouble·spac:d, and the original, not the carboa copy. submitted. Advertising matter must be received not l;ncr tbaD the 20th of the mootll imm~di.itely prec:e,;1ng the month of issue. Our rc.idcrs arc requested to send in items of news of interest to pby,icians. We shall b• glad to know the name of the sender in :v:ry insun:::. Outside of vie~ or statements that a:-e the authoritative action of the Philippine Medical Anodation, neither the association nor the editors usume responsibility for opinions and ltatcmenu published io the Journal of the Philippine Medical Associ.ition. View1 set forth ia th• •ariu1u dtp:artments in the Journal reprcst nt tile •iews of the wri.ttrs tDt~eof. CClu Out1La11Jt119 Propediei of IRGAPYRIN Determine its Therapeutic Use as Antirheumatic Antiphlogistic, Analgesic an<! Antifebrile agent. cc. ampoules Tablets Boxes of 5 and 50 Tubes of ZG A Product of ). R. GEIGY S.A. Basie, Switzerland Represented in the Philippi11e3 by: F. E. ZUELLIG, INC. MANILA - CEBU II a refreshing, soothing collyrium FOR OCULAR IRRITATION DUE TO EYESTRAIN, DUST, SMOKE OR GLARE .Tour. P.M . .\. February, l!t:i.t Ocusol® is an isotonic, aqueous solution containing boric acid U.S.I'. 1.1%, sodium borate U.S.P. 0.5%, berberine sulfate 0.01%, distilled extract of witch hazel N. F. 2.6%, camphor U.S.P. 0.04%, methylparaben U.S.P. 0.05%, rose oil 0.01%, glycerin U.S.P. 1.3%, NaCl U.S. P. 0.38% and water 94.01%. Ocusol is harmless to the eyes; it may be used as often as required. Each package contains a sanitary, plastic eye cup. - THE NORWICH PHARMACAL COMPANY I - - - - - ~ Norwich, New York, U.S. A. t:H·hufrc Didrilmtorq in tlz~ Philipp i11.N1: Philippine-American Dru~ Company (BOTICA BOIE) C:EBG - ILOILO - LEGASPI - OAVAO Manila. P. I. Volume XXX Number 2 lll IV J our . P .M. :\ . February, 1 o:; t hi ?'!t61l~~ TerramyQ.!.!! * ••• "This newer antibiotic [Terramycin] brings about excellent results in the therapy of meningitis due to the mniingococcus~ j>Mumococcus, and H. influenzae." Bou1~. A. L. , 1Ch1rf. A1h n d i111: S h.ff. Co nla•lo H DleHn Dept._ c..11' Ce 11ntr HHpitel . (;hluao ); lllJ:O. C LI N . H O. A.lil~R., ••· H B·•· llAL. l•N. METRO DRUG CORPORATION Bu,ndia E1.1en1ioa Makui , Rizal, Philippinu Miilinc Add reu: P. 0 . Bos tSI , MHil1 Philipri •u .,CRAM FOR CRAM TERRAMYCIN IS UNEXCELLED AMONC BROAD-SPECTRUM ANt'IBIOTICS0 Vt)lume XXX Number ~ The pleasant orange flavor, and smooth, creamy tedure of St. Joseph Aspirin For Children makes these tablets a boon to the little patient whenever salicylic therapy is inditated. Besides affording unusual palatability wiffiout unpleasant after-taste, these tablets disintegrate rapidly, and are easily diS5olved for infant administration. The 11/4 grains of highest quality aspirin in each tablet eliminates the need for cutting or breaking adult siie tablets. It also permits greater flexibility and accuracy of dosage for children of all ages. These tablets are administered in Any One of Four Different Ways: {I) Dissolved on Tongue, (2) Chewed, {3} Swallowed, (4) Dissolved in a Tablespoon of Water. ST.JOSEPH ASPIRIN FOR CHILDREN v If you have not yet 1u_ ,iutd Jamples, write to MEDICAL DIRECTOR, Lev11 Hermatio•, Inc .. Mauiln, I'. I. VI HEMO IS the new vitamin and mineral fortified food drink, developed by Borden, the manufacturers of Klim and other fine food products. Hemo is quickly mixed with milk - hot or cold-to make a delicious, smoothtasting ·drink. Even persons that do not like the taste of milk find Hemo's rich flavor highly palatable. But, Hemo is not merely a delightful drink.Of even greater importance is the contribution made by Hemo to sound health and nutrition. Here are some of the important nutritional advantages of Hemo, and why doctors are giving this product preference: 1. Hemo is a vitamin-mineral food supplement that truly helps to prevent the deficiency diseases. Hemo's vitamin and mineral content compares favorably with minimum daily requirements of these food essentials (see chart at right). 2. Hemo is a food. Authorities say that vitamins and minerals taken in food are more efficiently utilized by the body. 3. Hemo is easy to digest. Enzymatic action, homogenization and heat treatment as well as the low, tolerable fat level - all contribute to Hemo's easy digestibility7Jortkns Hemo MADE BY THE MAKERS OF KLIM What is Jour. P.M.A. Fe bruary, H•!i·I HEMO? 4. Hemo is a rich source of high quality milk and cereal proteins required for tissue growth and repair. 5. Hemo supplies carbohydrates in quickly usable form for energy needs. 6. Hemo's pleasant taste appeals to one and all-normal adults, convalescents, older persons, expectant and nursing mothers, and children. ;11......_~ ~"'"':::1' ~ j!&t:/:JJ t/~,4 4000/w1:rhe. 4'100/w1:fh.. ~8, 333/nt{!,,. I ~3.. 21nf" ~D 400lirt.{I,,. 400.k.flir. 311tf 410/,,t{/,, I /(/eacu.~ !V.rfd<!A~id 10.i~ .JM,,, /Olnf- IS. 7 Inf" ~ 750lnf· 950*1. i%n/'~ 7501nf. 750lnf. fo,-a?'J"~S~,4~ ~~ ef.U.~;z;.~~-t, ..,.,..,,,.. Aeef~ ~S'i'..uu. Pocked in J lb. Tins (24 Servings) made by THE BORDEN COMPANY, NEW YORK, N. Y-, U.S.A. Volume XXX Number 2 New!!. Vll an excellent nutritive elixir with therapeutic properties . . . V~l2UIVIT()~ Squibb Multiple Glycerophosphates - Vitamins Elixir each teaspoonful (15 cc.) of this invigorating nutritive elixir contains: Calcium glyceropho•phate .. Sodium glycerophosphate ... Potassium glycerophosphate Manganese glycerophosphate Thiamine mononitrate .. . .. . Alcohol S(lUIBB \'£Ro1v110H ELIXIR 110 mg. Riboflavin .. . . ......... . 80 mg. Pyridoxine hydrocnloride . 20 mg. Niacinamide . . ......... . 10 mg. Calcium pantothenate . . . . 2 mg. Vitamin B 12 .. . ........ . ............. 17% 1 mg. 0.5 mg. 1.5 mg. 1 rug. 1.5 mcgm. Doses: adult, 1 tablespoonful t.i.d.; children, 2 teaspoonfuls in water t.i.d. VERDIVITON combines the well-known to. nic effect of multiple glycerophosphates with the appetite-stimulating and therapeutic action of B vitamins, including vitamin B,". When the patient "isn't doing so well" .. . VERDIVITON is valuable in over fatigue, loss of appetite, neurasthenia, and in rundown states, especially when B vitamin deficiency is suspected. It is particularly useful in the aged and in convalescing patients. VERDIVITON is also an excellent vehicle for other medicaments. To The MEMBERS Of the MEDICAL PROFESSION - Samples and literature 0f this Squibb Specialty are available upon request. E. R. SQUIBB & SONS PHILIPPINES CORPORATION Pasong Tamo (Buendia Extension) San Pedro Makati, Rizal, Philippines Telephone : 5-17-51 VIII .Tuur. 1,. M,A. F ebruary, 1,:,1 SALVITAE in the treatment of RHEUMATISM - GOUT - LITHAEMIA Whatever the exciting cause of the nu· merous sy.mptoms classified as Rheumatism, Gout, Lumbago, etc., may be IT JS of primary importance that the channels of elimination be kept free from all toxic and irritating obstructions. The Magnesium, Sodium, Strontium, .t,.ithium and potassium salts as combined in SALVITAE, with Sodium-Forma-Benzoate, afford the ideal eliminant and is thoroughly re liable as an alkalizing agent. Samples and lite1'ature to the medical profession on application to American Apothecaries Company 2'· 28 4ht Avenae, Lonr bland City, I. Ntw Tor k Perm it No. 960-J u ne 25, 1928 FORMULA Strontii l.acta.s , .......... .. . . ....... , .. . Lithii Carbonas .. , ... , .... . . Cactein et Quinina.e Citr:i.s , . . Sodii-FDrmo-Ben'250a.S • . . ... . .. .• , . ... , Calcii Lacw-Phosphas ..... .. . Potassii et Sodii Citro-Ta.rti-a.s Magnesii Sulphas . . ... . . .. , ... . • Sodii Sulpha.s .. .30 Gm. .16 .. .80 .. 1.60 .. . 16 .. 69.00 •• 8.00 .. 30.00 .. 100.00 Gm. Volume XXX Numbel' :! IX NOVALDIN A MOST POWERFUL FAST-ACTING, LONG-LASTING ANALGESIC NOT SUBJECT TO SPECIAL REGULATIONS. Novaldin is characterized by a wide range of usefulness, and potency with safety. Relieves pain due to COLDS, FEVER, IN· FLUENZA, RHEUMATISM, LUMBAGO and RENAL COLIC. Ampules are especially effect ive for se\·ere pain of uncerta'in or igin. AVAILABLE JN: A.mpules, 2 cc. boxes of 5 an<l 50 Tablets, Tubes of 10 and Bottles of 100. DEVELOPED AND PROD~ CED BY: ~~s~INC. NEW YOIK 18, N. Y. WINDSOt, ONT. Formula: Sodium 1-phenyl-2,3-dimethyl·4·mcthylamino-pyrazolone·N-mcthane-sulfonat.e ( Dipyronc) ~ ~ fr~~ ' / /w adequate protection costs so little / No child need be denied protection against t.lie threat of rickets and vitamin A and D deficiencies. Mead's Oleum Percomorphum is a potent, dependable source of vitamins A and D ... that can be administered at a cost of about a cent a day. Specify MEAD'S OLEUM PERCOMORPHUM ... the pioneer product with 18 years of successful clinical use. Available in 10 cc. and economical SO cc. bottles; also in bottles of SO and 250 capsules. Mead's Oleum Percomorphum MEAD JOHNSON & COMPANY • EVANSVILLE 21, IND., U.S.A. L. D. SEYMOUR & CO. (MANILA), INC. William Li Yao Bldg. 3rd Fir. Rm- 339-340 - Rizal Avenue, Manila - Tel. 3-92-64 Volume :XXX Num~r 2 XI XII Jour. I'.M . .\ . February, l~•.:..1 pRl,~gE~Y.N PRJMOLUT Corpus luteum hormone PRIMOTESTON Testicular hormone PRIA~2fQ,~! PR!l\~JIN rn rnares serum Representatives: La Estrella del Norte, Levy Hermanos Inc. Escolta - Corner Plaza Moraga · P. 0. Box 273 ·Manila THE JOURNAL OF THE Philippine Medical Association Dwoltil la lht Progrtss of M•dical Scimc• and to th• int.rests of tbt Mtdic~l profmirm in th• Philippines Manila, Philippines VOL. XXX FEBRUARY, 1954 No. 2 CoPYRtGHT, 1953, BY PHILIPPINE MEDICAL AssoctATION ··tjII <Original Artides IJrc·· PSYCHOSOMATIC ASPECTS OF OPHTHALMOLOGY* GEMINIANO DE OCAMPO, M.D. De Ocampo Eye Clinic, Manila a11d U11iversity of the Philippines There are many ocular conditions and manifestations which we can not explain fully by optics, anatomy and physiology, pathology, somatic medicine and surgery. Some of these can be understood, explored and managed by considering their psychosomatic background. Our standard textbooks and ophthalmological journals deal very meagerly with this subject. I wish to invite and stimulate thought and study on this phase of our specialty. I believe that c. DE OCi\MPO, M.D. the ideal ophthalmologist should be, not one who knows more and more of less and less, but one who is a "Jack of all trades, and master of one." The problem may be stated as follows:-ln a particular patient, is the trouble in his eyes, or is it partly or wholly in his brain; and if so, what can-we do about it? From a review of my clinical records, with a diagnosis of psychosomatic factors among other things, I have found that the following are highly suspicious of a psychosomatic patient: ( 1) Inconsistencies, obvious or subtle, in complaints, manner and behaviour, history and physical findings. For example, a very strong complaint of photophobia, but absence of it during examination. (2) Exaggeration, consciously or unconsciously, deliberate or not, of ocular complaints or reactions. For example, without signs of inflamation, an undue avoidance of light. • Read before the 7th Annual Meeting of the POOS, Nov. 24, 1952. 66 PSYCHOSOMATIC OPHTHALMOLOGY-rte Ocampo Jour. P.M.A. February, 195'1 ( 3) Multiplicity of symptoms, complaints, glasses, and doctors. (4) Non-cooperation, deliberate or otherwise, during the examination, or during history taking. (5) Psychosomatic appearance or complaints. An anxious facies, a worried look, an over-meticulous appearance, a countenance showing fear. Complaints as "cann'Jt concentrate" or "cannot absorb what one reads." (6) Changeableness of findings: In retinoscopy, muscle testing, subjective refractions, etc. (7) Vagueness of one's complaints: Blurring of vision, discomfort, pain, dizziness, all mixed up and ill-defined. In general, psychosomatic symptoms are brought about by changes in circulation, secretion, tonicity and motility. In the eye, the most frequent manifestations of psychosomatic origin are those from the intrinsic muscles, especially the muscle of accommodation. Ciliary or accommodative spasm must be suspected under the following conditions: (I) A minus glass with normal distant vision. (2) Subnormal distant and near vision in a young individual, improved by pinhole, with negative findings in the media, fundus, or visual fields. ( 3) Symptoms of momentary blurring when looking from near objects to distant objects. ( 4) Complaints of micropsia in the absence of scotoma or organic findings in the macula. ( 5) In retinoscopy, if the dynamic findings for distance with good fixation gives minus values, but normal distant vision is present, or a high positive lens is obtained, most of which cannot be tolerated subjectively. At times, one can actually notice variable position, or appearance and disappearance of the retinoscopic band of light. (Streak retinoscopy) ( 6) A variable and changing brightness of the different lines in the astigmatic chart in manifest or fogging refraction, or even in incomplete cycloplegia, is suggestive of incoordination or spasm besides astigmatism. Except in children, the presence of one or more of these manifestations calls for a breaking up of the spasm by deep cycloplegia, and in the absence of other obvious extra-ocular or systemic sources of irritation, a psychosomatic inter-relationship is worth investigating. A weak accommodation is easier to suspect and ascertain, but somatic systemic causes should first be exhausted before thinking of psychosomiasis. A slow accommodation may, in fact, be really due to ciliary spasm. Some believe that pupillary spasm (spastic mydriasis or spastic miosis) can have psychosonutic inter-relationships, and may by itself cause complaints of undue glare, or slight disturbance of vision in subdued light. The intrinsic ocular mmcles are directly under the vegetative nervous system, and can be disturbed by emotional tension. Although the extra-ocular muscles' have striated structure, they can manifest changes Volume XXX Number 2 PSYCHOSOMATIC OPHTHALMOLOGY-de Ocampo 67 of tonus and motility because of psychosomatic factors. It is well known that the degree of phorias and the prism duction values, even under standard technique of examination by the same examiner, is often variable in the same person at different times of examination; and they have to be repeated at least once, if they are to be interpreted rightly. Likewise, the degree of trophias has to be frequently repeated and rechecked, because of muscle tonus changes. I have seen a baffling case of spasm of the extra-ocular muscles parading under intermittent esotropia, with a definite psychosomatic background. It is the case of a boy (J.A.) 6 years old, first ~cen in consultation on June 28, 1950, with alternating internal squinting of both eyes. A year before, he had had two successive falls in 3 we~ks; and a few days later, he had developed the squint. It was peculiar that, for a year, the boy's eyes squinted regularly only on alternate days. The child wore glasses of plus l.00 D. on both eyes. When first seen, the degree of squint was 5 5 ° by perimeter, and equal for distance and near. The esotropia was alternating (fig. 1 & 2) . The E.0.M. was normal, and there was no definite difference in degree of squint with either eye fixing. He preferred to occlude his left glass (fig. 3), because he claimed he had some diplopia for distance which could not be elicited at near. The squint was more crmcomitant than paralytic. But when seen the next day, as the mother predicted, the eyes were perfectly straight (fig. 4) without impairment in motility. I then thought of spasm, but why did it occur regularly on alternate days. I was told by the mother that operation had been advised by two of our colleagues, while a third had advised exercises. I examined the child a third time after a week under atropine on a squinting day and found he had a hyperopia of 0.U. plus 1.50 D. The child was an Ateneo student and quite good in class. I referred him to a child psychologist. Unfortunately, he neither came back nor consulted the psychologist. Two years later, the mother came back with another patient; and when I asked her about her boy, she told me that he was perfectly normal. His eyes were straight. But in February, 1951 , he had again suffered a fall for which he was confined at the N.O.H. There the eyes became straight, until he was discharged. When his boy companion called his attention to it, his squinting came back, but upon being 1cprimanded by his mother, his eyes became straight and had remained so. I can not unravel the psychosomatic inter-relationships between the accidents and the regularly intermittent esotropia, but I believe the trouble was not in the neuro-muscular mechanism of the eye but in the child's mind. I have looked up the literature available, but I cannot find a similar case. 68 PSYCHOSOil-IATIC OPHTHALMOLOGY-de Ocampo .four. P.M . .\. February, 19:..i The so-called "innervation" to the extrinsic and intrinsic ocular muscles needs further investigation, but it seems that psychic factors definitely influence them to a great extent. It is for this reason that, in alternating hyperphoria, surgery is not advised; and one 5fould be very cautious with prisms. They have to be probed psychosomatically. I have seen several such cases. As I mentioned earlier, circulation and secretion under the influence of the vegetative nervous system are disturbed in psychosomiasis. Such new concepts of glaucoma as central thalamic regulatory mechanism of intra-ocular tension, and social service in glaucoma clinics, must take psychosomatic medicine into account. We all know that glaucoma patients are a class in themselves. An article on the personality aspects of glaucoma patients' stress this point. Even the concepts of circulatory and secretory aspects of the glaucomatous crisis may have psychosomatic factors in many cases. Let us take a case. Dr. R. C., a male dentist, 37 years old, was seen on June 15, 1950, complaining of dimness of vision and of seeing halos every morning. He had come from one of our colleagues who had advised operation for glaucoma. Pilocarpine and furmethide did not suit him. Having seen him previously, I knew he had myopia and marked exophoria. He had brou.ght three pairs of glasses when I first saw him eight months before, and he had seemed worried about something. This time he was definfrcly afraid of getting blind from glaucoma. I examined his ocular tension, fields, and fundus on three successive days at different times of the day, and could not be convinced of glaucoma. I found that he had severe ciliary spasm after pilocarpine I% t.i.d. which he had previously used for 3 months. I stopped all miotics and made provocative tests, using homatropine 2% and the water test. Still I could not elicit an abnormal rise of tension. I even checked my tonometers. Knowing his background I tried to convince him to stop all miotics and to rest assured that he had no glaucoma. I sent him to a psychiatrist, Dr. Paras. After several interviews, he reported to have uncovered some psychosomatic problems. He was a dentist who did not practice, but who was in a rice mill business. He was not in good terms with his wife, and was dissatisfied with his work. After these interviews, he came back a better man, without the ocular complaints. \'V'ith more assurance, but without miotics, he left for Jolo. After six months, his brother, a physician, happened to drop in at my clinic and informed me that the dentist was doing all right, without complaints, halos, and miotics. The physician showed a similar personality pattern as his brother. This dentist might have had rises of tension when seen by our colleague, but I think that a psychosomatic factor was involved; and this was aggravated iatrogenically. A few interviews with the psychiatrist did him much good. Volume XXX Number 2 PSYCHOSOMATIC OPHTHALMOLOGY-de Ocampo 69 I reviewed 30 cases of nervous blinking in my private files, and I found out the following: While the sex distribution was almost even, two-thirds were below 11 years. The blinking was noticed from a few weeks to many months and years in one or two cases. Pertinent findings were a few fine conjunctiva! follicles, with or without discharge, in about a third of the cases; but some psychosomatic factors were present, such as blinking in the playmate, chauffeur, or other housemate; poor showing in class; scolding by mother or father; and father's prohibition from going to shows. One had a fight with another boy, and was afraid to pass by a certain road. Some showed such nervous symptoms as sucking the lips or twitching of the face. Almost all were scolded for blinking. In fact, the majority of them stopped blinking after the parents has been told of the condition, and had been asked to ignore it and to refrain from scolding the patients. One stopped blinking only after being made to live with the grandfather instead of the mother. A few had low error of refraction; but in the majority of them, drops, surgery, or glasses were not so important as psychotherapy. Improving the lighting, general health, and ocular hygiene should go hand in hand with stopping the scolding of the child and ignoring the symptoms. It would be better if some emotional factor could be discovered. There is another very common condition: musca volitantes, which seems to have some psychosomatic aspects, not in its pathogenesis, but in its therapy. I have reviewed 5 8 such cases. After excluding under mydriasis, such organic conditions as Mittendorf dot and other congenital lens opacities, vitreous floaters, central retinopathies, or retinal detachment, reassure the patient that it is harmless and give proper ametropic correction. Colored glass is not necessary if one can overcome the fear of the patient by gaining his confidence. The less the patient tries to look for the spots, the better. I have reviewed 30 cases, noting down some psychosomatic factors, in addition to other ocular diagnosis. The most frequent complaints are headache (the so-called tension headache)' and dizziness. The most common site of the headache is the occipital and upper nuchal, and it is vague and non-characteristic. The dizziness is vague and difficult to describe, including as it does faintness with occasional transient blurring of sight. No less than ten of them have I referred to a psychiatrist. Among the psychosomatic factors I have observed are: 1. Marital unhappiness:-hatred for, and quarrels with, the husband; habitual abortion; idleness as a society matron; absence of husband; too unhappy marriages. 2. Scholastic difficulties:-School truancy, frustrated desire to study in the U.S.; dislike for the course being taken; alibi for scholastic failure to escape studying; frequent changes in courses taken and universities attended. 3. Family resentments:-headaches resulting from week-end visits to hated relatives. 4. Frustrations in business or career. 70 I'S YCHOS0.'1'111 TIC OPHTHALMOLOGY-de Ocampo Jour. P.M.A. February, 190-& 5. Nervous tension brought about by election problems, disappearing after the polls. 6. Pressure of business. 7. Fear of blindness instilled by relatives, acquaintances, or physicians. 8. Dislikes for the use of glasses. 9. Lack of emotional gratification. Let me restate the problem. Can the symptoms, at least the ocular, be satisfactorily and fully explained by ocular findings? Ocular findings may be negative or non-organic. This would depend on the examiner, his ability, his thoroughness, and his criterion for normal. In the presence of organic findings, a psychosomatic factor may still have to be sought for. It is frequently stated in the literature'"·' that psychosomiasis should not be diagnosed on negative findings. In a suspected patient (after proper and careful refraction, muscle examination, and correct lens fitting) if the complaints remain, or the ocular findings are not sufficient to explain the symtoms, one has to probe further. Is there anything wrong with the brain to account fully or partly for the unexplained symptoms? Is it necessary that such a patient be referred to a psychiatrist? This has many aspects. There are not enough psychiatrists in this country. Our society still looks down upon a person who consults a psychiatrist. Some patients complain that their psychiatrists give them only "talking therapy" or "shock therapy." I believe our group should at least know how psychosomatic probing should be done. The following may be of some help. Try to gain the patient's confidence. In addition to your personality, office set-up, reputation, and thoroughness of physical examination, set up a "private interview room" where the patient is not likely to feel embarrassed to talk openly of his emotional problems. Sometimes the nurse or the receptionists, given the right tips, may get points in the personal and family history after the first visit, or while waiting for a subsequent consultation. Little bits of information about a suspected patient may be uncovered by asking him disconnected questions while he is being given a physical examination without letting him feel that he is being investigated. It would be of some help to have a sort of questionaire to be given to the patient on his first visit for him to fill out at home. The filledout questionaire may then be attached to the chart on his second visit. This would save time, save the patient from embarrassment, and give you an inkling of what to probe when you next meet the patient-his heredity, his constitution, his bringing up, his home life, his marital and extramarital relations, the conditions under which he works, his business, his scholastic environment, etc. At least, you will be in a position to decide whether to attempt contact or to refer him to a psychiatrist. Even before reaching such a decision, you should never make the patient feel that his symptoms are imaginary but although real, do not have any serious import or organic basis. At this point you should atVolume XXX Number 2 PSYCHOSOMATIC OPHTHALMOLOGY-de Ocampo 71 tempt a clear, short and appropriate explanation of how ocular symptoms may be brought about by worry or fatigue. Some examples as "blind with rage" may help. The assurance that there is nothing organic should be backed up by a very thorough and careful somatic and laboratory check-up and followup. I am reminded at this juncture of a recent case, Mrs. D.A., 5 0 years old, female, nurse, married to a businessman, and herself in business. She consulted me on January of this year, complaining of pain, discomfort, and blurring of vision once in a while. She brought many glasses, saying that she had consulted many doctors. I saw her regularly for 6 months, tested her refraction with and without cycloplegia, her muscles and fields and fundi. I changed her glasses two or three times. She had compound hyperopia, presbyopi;1 and ciliary spasm at times. I once found right hyperphoria but often orthophoria. After ten consultations, I referred her to a psychiatrist, who interviewed her five times and who reported to me personally about her real emotional problem. This problem consisted of some resentments and conflicts connected with her only daughter, who had married against her will. She seemed to improve a little, especially after a trip to the South. Then I advised her to go abroad for relaxation. Two months later, a neuro-surgeon referred her to me after a big right temporal lobe tumor had been removed. It turned out that, after our last meeting, she had gone to a gynecologist, who could not explain all her symptoms by menopause; and that gynecologist referred her to the neuro-surgeon who made an arteriogram which was negative. It was only a few days before exploration that papilledema appeared and a positive arteriogram was obtained. This was a case of temporal lobe tumor with a psychosomatic overlay and vague ocular manifestations. Whether one could or could not uncover a psychosomatic factor in a very suspicious patient, or whether the patient has been referred to a psychiatrist, some sort of psychotherapy within an ophthalmologist's limitation is worth trying. After much reading'"·""'·"·" and some personal experience, I would suggest the following: Psychotherapy would be futile without first gaining the confidcncr: of the patient and convincing him that, although his symptoms are real, there is no urganic or serious condition in his eyes. One should never irritate a psychosomatic patient. Assurance and reassurance that his symptoms are partly or wholly caused by a tired and worried brain should be followed by making him understand and recognize how fatigue, worries, anxieties, fears, and emotional conflicts can cause his ocular and non-ocular complaints. A philosophy of life which embodies reconciliation within one's resources and resignation to one's limitations and failures should be driven home to the patient. A "change of attitude" is often better than a change of glasses. 72 PSYCHOSOMATIC OPHTHALMOLOGY-de Ocampo Jnur. P.M.A. February, 1954 Case of Regularly Intermittent Alternating Internal Squinting with Psychosomatic Background Fig. /, Right eye fixing Fig. J, Left glass covered to at'oid diploplia Fig. 2. Lt/I eye fixing Fig. 4. 011 a non-squinting day Sometimes I give my patients a copy of Dr. W. Alvarez's series of articles on "How To Live With Your Nerves." A passage in this series is inculcating in the patient, "Oh Lord, grant me the serenity to accept the things I can not change, the courage to change the things I can, and the wisdom to know the difference." Concluding Remarks I have not mentioned hysterical blindness, .or malingering, which has definite psychosomatic tie··Ups, because they ~re well covered in our textbooks. I have discussed the less obvious but more frequent psychosomatic aspects of ophthalmologic practice in this country. I think that ophthalmolog!sts should at least know how to spot a psychosomatic patient; and if he has the time, he should develop an inclination and sufficient knowledge to handle them, before referring him to a psychiatrist. Volume XXX Number 2 PSYCHOSOMATIC OPHTHALMOLOGY-de Ocampo 73 With all the interest we can develop in, and all the information we can gather about, psychosomatic medicine, we must follow up our patients if we are to gain in knowledge of this aspect of ophthalmology. REFERENCES I. Alvarez, W. C. The Neuroses, W. B. Saunders Co ... Philadelphia, 195 I. 2. Alvarez, W. C. How To Live With Your Nerves, The Register and Tribune Syndicate Copyright, 19 5 2. 3. Bob, W. Psychosomatic Problems in Ophthalmology, Am. Journal of Ophthalmology, 25: 321-329 March, 1942. 4. Cogan, D. G. Neurology of the Ocular Muscles, C. C. Thomas Springfield, 1948. 5. Fernandez, J. Psychosomatic Medicine, M. D. Journal I: 341-47 August, 19 5 2. 6. Friedman, A. P., Von Storch, T. J. C., de Sola F. N . Tension Headaches, Headache Clinic, Montifirne Hospital, N. Y. City, 1952. 7. Guiang, R. V. Psychosomatic Medicine in General Practice, J.P.M.A. 2 5: 1-9, January, 1949. 8. Harrington, D. 0. Psychosomatic Interrelationships in Ophthalmology, Am. Jour. Ophth. 31: 1241-1251, October, 1948. 9. Hibbeler, H. L. Personality Patterns of White Adults with Primary Glaucoma, Am. Jour. Ophth., iO: 181-!S6, February, 1947. I 0. Smith, G. G. Psychosomatic ll!ness in General Practice, Texas State Journal of Medicine, 47: 386-87, Aug. 195 I. I I. Weiss, E. and English 0. S. Psychosomatic Medicine, W. B. Saunders, Philadelphia 2nd Edition, 1949. DIAGNOSIS AND TREATMENT OF MYASTHENIA GRAVIS Report of a Case in a Child LINO ED. LIM, M.D.* AND NOE C. LEGASTO, M.D.''" Myasthenia gravis is a rare entity in children. In 1949 Nilsby' claimed that only 35 cases under 17 years old and only 8 cases under 8 years had been reported in the literature. During the last few years, true congenital myasthenia"'·' and neonatal myasthenia, born of myasthenic mothers'·'·'·'·'"·" may have increased the number of cases. Yet the number so far recorded is still very insignificant. One of us had the opportunity to study a case L. ED. LIM, M.D. of myasthenia gravis in a ten-year old child, with mental retardation in crisis." The purpose of this paper is to present a case of myasthenia gravis in a four-year old child, probably the first case reported in this country, and to outline the present trends in the diagnosis and treatment of this disease. Case Report L.S., 4 years old, female, Filipino, was seen at the Legasto Eye Clinic and at the Lim Children's Clinic on July 15, 1953. The mother complained that the child could not open her eyes well. Present illness had started about four weeks before, when mother noted that the child's left upper eyelid drooped. One week later, the right eyo was similarly affected. This was not accompanied by photophobia, lacrimation, discharge, swelling, or injection. Mother said that the child had not had any recent attack of chills, fever, jaundice, vomiting, convulsions or trauma. The child entered the Manila Children's Hospital a week later, on July 22, 1953, for work-up. Prior to the present illness, she had been active, but her appetite had been quite impaired. Birth History-Child was delivered spontaneously at full term at home. Birth weight: not known. Neonatal period: normal. Feeding History-Breast fed up to 1 year 1 month. Tiki-tiki was started at 6 months. Child was a poor eater. Development-Smiled at 3 months, sat up at 7 months, stood up at 1 year, walked at 1 year 3 months, and uttered words clearly at 2 years. Immunization-Had smallpox vaccination, but no DPT or BCG. Past Diseases: Child had had frequent coughing spells since she was 1 year of age. Mother was told by a physician that the child had a primary· complex. She had had measles the previous year. Denied having had varicella, mumps, diptheria, pertussis, or rubella. Family History: Two siblings living and well. Mother never had any abortion or miscarriage. Father also living and well, but separated from the mother. Denied any member of the family having muscular weakness, •Manila Children's Hospital ;and Lim Children's Clinic. •• Faculty of Medicine and Surgery, UST, University Hospital, UST and Manila Children's Hospiul. V:')lume XXX Number 2 MY ASTHENIA GRAVIS-Um et <ti respiratory, mental, or metabolic disorder. RH of parents not known. No consanguinity. PHYSICAL EXAMINATION: Poorly developed, poorly nourished, conscious, and cooperative female child, with both upper eyelids drooping. Afebrile, wt. 20-1 / 4 lbs., height 33", pulse 120/ min., respiration H/min., blood pressure-90/ 54. Eyes-0.D. Droopini: of upper eyelid. lncerpalpebral fissure: 2.5mm. at its widest diameter. Weokness on elevation of eyeball. Pupil: normal size and responding normally to light and accomodation. No appreciable weakness of orbicularis oculi muscle. Visual acuity and fundus: normal. O.S. Drooping of upper lid. lnterpalpebral fissure: 1.5mm. at its widest diameter. Exotropia 35°--40° (Hirschberg). Limited adduction of eyeball. Pupil: normal size and reacting normally to light and accommodation. Visual acuity and fundus: normal. No evidence of facial weakness. No rigidity of the neck, no headdrop, no palpable ma,,es. Lungs clear and resonant. No rales. Heart: strong and regular, no murmurs. Abdomen: soft, liver and spleen: not palpable. No other palpable masses. The extremities were soft and flabby. There were no evidences of paralysis or paresis, no deformities or ankylosis. Reflexes: Gag and swallowing reflexes were intact; abdominal reflex was present; no ankle clonus; negative Babinski; knee jerks: exaggerated; Kernig: negative, Brudzinski: negative. LABORATORY EXAMINATIONS: Blood count-RBC 4,440,000 Hemoglobin 70% WBC 14,400 Differential Seg-60%, E--4%, S.L.26% LL-103 Urine-Normal Tuberculin Test-5 T. U. + + + Stool-Ascaris ova + + +; Trichiuris + + Muscle biopsy of gastrocnemious-Some round cell interstitial infiltration. Spinal Fluid-normal X-ray: Skull-No evidence of osseous pathology, no separation of suturc:s, Sella turcica appear normal. Long Bones-No evidence of bone destruction however there is evidence of generalized demineralization with disturbance of growth lines. No evidence suggestive of rickets, scurvy, syphilis or lead lines. Chest-Supracardiac shadow appears widened presumed to be thymus. Heart and lungs are essentially normal. HOSPITAL COURSE: Child was a.dmitted on July 22, 1953. Appetite fair; afebrile; could move about like any other child, except for the ptosis of both eyelids. A test dose of prostigmine methylsulfate,t 0.3 cc. of I :2000 solution was given. With the above procedure there was improvement as shown below: Before injection (O.D. 2·5 mm (O.S. 1.5 mm f (O.D. 3.5 mm A ter injection (O.S. 4.2 mm Mobility also improved. Since the improvement was not clear-cut, it was decided to do another test on the 4th hospital day, with 0.5 cc. prostigmine methylsulfate and 1/ 500 gr of atropine. Within 20 minutes there was marked improvement; and within 30 minutes the eyes were widely open, almost simulating normal. (See figure) Prostigmine bromide 7 'I, mg. was started on 7th hospital day; but was immediately discontinued after two doses, due to abdominal pains. 75 't Prosti1min.e h:as been kindly supplied by Jose Angcles. M.0. 1oheldcr, loc., Philippine Represeotu.i.H icr I ioffm.10 LaRoche. 76 MYASTHENIA GRAVIS-Lim et al Jour. P.M.A. February, PJ;;.\ (Since this child has heavy ascaris infestation, as shown by the stool examination, we were afraid that we might produce intestinal obstruction, as there were loops of intestines that felt like cords). In the meantime the mother was given quinine sulfate (0.6 Gm) to elicit any latent myasthenia. The mother vomited the pills after one hour, and she refused to take other pills subsequently. A B Tested with 0.5 cc. prosligmi11e 111ethylS1tlphate anti 1/500 gr. atropin S1tlphate S1tbc11taneo11sly. A-Before. B-30 min. after. On the 11th hospital day, prostigmine bromide ( 5 mg) did not produce any appreciable effect on the ptosis. Eyes reexamined at this time, showed O.D. interpalpebral fissure 1.5 mm (widest diameter). Almost complete external opthalmoplegia, no exopthalmos. Pupil normal; size and normal reaction to light and accommodation. Visual acuity and fundus: normal. O.S. lnterpalpebral fissur~ 2.5 mm Exotropia 35°-40° (Hirschberg), increased on looking down. Limited adduction. Optico-kinetic nystagmus. Able to fix with left eye. Pupil normal size. The next day prostigmine was increased to 7 Y, mg tid, with little effect. At this time it was noted that the child was having an upper respiratory infection. This dose was not increased until the 17th hospital day, when the prostigmine was given every four hours at 6 a.m., 10 a.m., 2 p.m., and 6 p.m. with a half teaspoonful of syrup ephedrin for every dose of prostigmine. At this point the child responded remarkably. The next day (18th hospital day) prostigmine was again reduced to tid; but syrup ephedrin was discontinued, due to abdominal cramps, loose bowel movements, and vomiting. Child passed out five alive ascaris both by mouth and by rectum. She was sent home to continue prostigmine 7 ~l mg. tid on the 20th hospital day, well maintained at this dose. FOLLOW UP: Child was well maintained on prostigmine bromide 7 Y, mg. three times daily for 2 Y, months after disch>rge from the hospital. The child has gained weight and appeared more sociable. She was given •ntihelminthic treatment and about 70· adult ascaris were expelled. At this Volume XXX Number 2 MYASTHENIA GRAVIS-Lim et al point prostigmine was disconrinued and there was no appreciable ptosis. The patient was in remission for 3 months until last December 11, 1953 when ptosis of both eyes again re.1ppeared following an upper respiratory infection. DISCUSSION 77 The actual cause of the disease is not definitely known; but it has been postulated that the weakness of the skeletal muscle is due to the imbalance of the acetylcholine and cholinesterase, an enzyme system at the neuromuscular junction. Dale, Felberg, and Vogt" hav11 shown that acetylcholine is essential in the transmission of nerve impulses through the neuromuscular junction. It is believed that in myasthenia gravis, there is an excess of cholinesterase, preventing the normal action of acetylcholine, or the amount of acetylcholine liberated is reduced to such an extent as to effect a muscular response. It has also been thought that there is a curare-like substance at the neuromuscular junction that blocks the stimulus, or that the threshold of the muscle is increased to the effects of acetylcholine. Jones and Stadie0 showed that there is no distinct difference in the cholinesterase content of serum and muscle between myasthenic and normal individuals. \Vilson and Stoner' verified that the cholinesterase activity is not increased, and they demonstrated in the blood of myasthenic patients a substance partially soluble in alcohol which is capable of neuromascular blocking. McEachern" thought of the muscle-inhibiting properties of the thymus, but he was not able to demonstrate this relationship by thymic extracts. In 1949, Constance and associates" by using a special technique, were able to show the inhibiting properties of the thymic extract from normal and myasthenic patients, both postmortem and surgical specimens. Torda and Wolff" have shown that the serum from myasthenic pa•irnts are capable of reducing the acetylcholine synthesis in vitro. Trethcwie and Wright" have corroborated that thymic extracts from r.1yasthenics are also capable of inhibiting acetylcholine synthesis, while extracts from normal thymus increases. DIAGNOSIS-In infants, early diagnosis is not easy, especially during the neo-natal period. But if the mother is myasthenic, the possibility of neonatal myasthenia should always be borne in mind. The baby should be watched carefully. There may be masklike faces, weak cries, inability to open eyes, weakness in sucking breast or formula, and loss of activity. There may be periods of cyanosis and irregular respiration. These symptoms usually do not appear immediately after birth, but u;ually do on the second day of life. The recognition of congenital rayasthenia is even more difficult, but again the history of delayed quickening or poor foetal motility is suggestive. In older children the onset may be either slow or sudden. There may be a history of previous infection. The mother usually complains th.1L there is ptosis in one eye, then in the other eye. Some children 78 i'dY.4STHENIA GRAVIS-Lim et al Jour. P.M.A. February, 19i;4 who know how to complain may first claim to have blurring of vision or diplopia. About 50% of cases of myasthenia gravis go to the ophthalmologist on account of ptosis, or diplopia secondary to paresis of one or more of tne extra-ocular muscles." The symptoms are permanently exaggerated by fatigue, and appear later in the day. In a few cases, the eye muscles alone are involved for a long period; and it seems likely that purely "ocular" myasthenia gravis may persist indefinitely. The ocular type commencing with diplopia and ptosis is commonest." The involvement of extra ocular muscles follow no definite rule. Usually upward movements are first restricted. The ocular palsies at first are fleeting. All or any of the extra-ocular muscles may be affected. The result is paralysis of conjugate movement, which may bt. confused with the effect of supranuclear lesion. The internal musculature of the eye is usually not involved, but scattered reports of such an involvement are found in the literature. Accommodation has been reported diminished, proven by administration of prostigmine. As the disease progresses, the external ophthalmoi'kgia may become complete and permanent. Exopthalmos is occasionally observed in the absence of thyroid activity. Marcus Gunn noted retraction of the lids, so that Von Graefe's sign (~lt:vation of upper lid with defective following) was present. This suggests that the fibers innervated by the sympathetic are not involved in the process. Cases are cited wherein an apparent exophthalmos and Von Graefe's sign are present. Optico-kinetic nystagmus is present in myasthenia gravis, disappe.irs completely, and returns. after a period of rest. Aside from ptosis, 1 here are cases which show weakness of the orbicularis oculi; but this weakness may be difficult to demonstrate. It is extremely unusual that d1L orbicularis muscles are obviously excessively weak. In such instances there is a likelihood that an erroneous diagnosis of progressive bulbar palsy may have been made. Aside from the ocular symptoms, muscles of the face may be involved, as shown by masklike facies, and by the disappearance of the na'oiabial fold. In severe cases, the mouth may drool. Eating may be ea;;y at the beginning of a meal; but a little later swallowing may become difficult, so that even water may be regurgitated through the nose. Talking may be easy at the start, but after a while words are spoken very slowiy, muffled and inaudible, with a nasal twang. In the early part of the day, the child can hold his lower jaw; but after some attempts to chew, fatigue sets in. The jaw relaxes as if the child were breathing through the mouth. Due to weakness of the skeletal muscles, the child ho1s frequent falls, even when walking on level ground. The symptoms of myasthenia gravis are frequently exaggerated by infrction, but recovery comes after some rest. Because of this peculiarity, it is difficult to evaluate the efficacy of therapy. Willis, in 168 5, described the disease as follows, "Patients are able at first rising in the morning to walk, move their arms this way and that 01 lift up a weight with strength but before noon the scores of the spirit Volume XXX Number 2 MYASTHENTA GRAVIS-Lim rt al 79 which influence the muscle being spent they are scarcely able to move J..md or foot. I have now a prudent and honest woman in cure who for many years has been obnoxious to this kind of bastard palsy, not only in the limbs but likewise in the tongue. Sometimes this person speaks freeiy and readily enough but after long hasty or laborious speaking presently she becomes mute as a fish and cannot bring forth a word. Nay, and does not recover the use of her voice until after many minutes".11 The following diagnostic procedures have been used by various workers: Veits and his coworkers"·"·" recommended Jee. of prostigmine with 1/100 gr of atropin, to be given intramuscularly to an adult patient. The patient is then observed for objective and subjective improvements. Score is given every 10 minutes with an interval of one hour. In myasthenia gravis, there is almost immediate relief of symptoms, fasting for two hours or more. In other diseases no improvement of objective and subjective symptoms is to be noted. To a newborn, 1-2 mg. of neostigmine bromide in water may be given by mouth as a test Jose. However, 0.07-0.1 mg of neostigmine methyl sulfate has been tried1' intramuscularly. In our particular case, we used Yz cc. 1 ;2000 neosLigmine methyl sulfate with 1/500 gr. atropine. Terhar" tried to modify the above mentioned procedure. He gave 0. 5 mg of the neostigmine intravenously to adults. He claimed that this procedure is superior to that of Veits in that the improvement of muscular tone is immediate and clear-cut. This procedure is especially useful in mild cases which improvement is complete. We would be afraid to try this procedure on children. Bennet and Cash" suggested the use of curare only in mild and questionable cases. The dose used for adults 1 mg. per kilo body weight produces mild curarization. One tenth of this amount is injected intravenously in a minute's time. Positive sign is shown by exacerbation of symptoms. This procedure is terminated in two to three minutes by injecting atropine and prostigmine intravenously. It should never be employed unless there is some prostigmine ready, for it is potentially dangerous. Mackey·• used 0.03 mg of a tubocurarine per kilo body weight as a test dose. Eaton" attests to the great value of this test, but warned that it be not used on patients who are seriously weakened, since further weakening may result in death, in spite of artificial respiration and administration of massive doses of prostigmine. Harvey and Whitehall" described the use of quinine sulfate 0.6 Gm. 4 times daily. A positive sign is shown by exaggeration of symptoms. This test is terminated by giving prostigmine. We have tried this test to the mother but she vomited the pills. Recently another test was described by Osserman and Kaplan,'' involving the use of 10 mg. edrophonium (tensilon) chloride intravenously in adult. A positive sign is shown by increased muscular strength and absence of fasciculation. The maximum effect occurs wiLhin Yz to five minutes after the injection. 80 MY.4STHENIA GRAVIS-Lim ct al .Jour. P.M.:\. February, 19;,.1 We would also like to mention other tests. One is the quantitative measurement of the hand grip exhaustion by means of an ergograph. The Jollys reaction is brought about by stimulation of an individual muscie by Faradic current. Normally a normal muscle will remain contracted for a minimum of five minutes, but in a myasthenic muscle it is less than this. The electromyogram is also used to measure the onset of fatigue by stimulating the ulnar nerve. In normal patients no decrease of the amplitude of the action potential is noted within two minutes. If the muscles involved are confined to those innervated by the cranial nerves, testing the muscles of the extremities will not give any clue unless the muscles involved are included in the test. Retention of barium in the mouth, as observed under flouroscopy after prostigmine administration, rules out myasthenia in cases with dysphagia. Muscle biopsy, based on the findings of Buzzard," shows the presence of lymphorrage or collection of lymphocytes in between the muscle fibers. DIFFERENTIAL DIAGNOSIS-Bulbar poliomyelitis should always be considered, especially if the onset is sudden and seen during a polio season." However, lumbar puncture will give the clue. In amyotonia congenita, the involvement is in the muscles of the trunk and extremities; while in myasthenia, the muscles supplied by the bulb arl! more frequently involved. In progressive bulbar paralysis, there is atrophy of the muscles of the lips and tongue; and there is retention of barium in the mouth even after prostigmine. In myasthenia there is no barium retention after prostigmine. Bulbar tumors are usually unilateral with progressive sensory changes. There may be other changes in skull x-ray or on fundoscopic examination. There is no improvement after prostigmine in bulbar tumors. Pseudomeningitic beriberi has to be entertained; but again, in this condition, there is no response to prostigmine. Muscular dystrophy that occur in children is frequently familial as a rule with little tendency towards spontaneous remissions. Mya_ sthenia, on the other hand, is usually not familial with no atrophy of muscles, and the muscular weakness varies from time to time. Other conditions that produce muscular weakness and paralysis sl1(,uid be considered in the differential diagnosis, as in potassium intoxication and potassium deficiency. In both of these conditions, the paralysis is of the ascending type, rarely involving the muscles innervated by the cranial nerves, except in severe cases. Muscular weakness may aiso be produced in conditions like hyperthyroidism, castration, and adrenal insufficiency. TREATMENT-No specific drug has yet been found that may be used in the treatment of this disease. Many drugs have been triedephedrin, potassium, choline, guanidine, and glycol-but none of them has proved superior to neostigmine in the control of the symptoms. Margaret Walker," an English physician, thought that the symptoms produced in curare poisoning is similar to that of myasthenia gr.iv1s. Since physostigmine is an antagonist of curare, she tried to use Volume XXX Number 2 MY,1STHENIA GRAVIS-Lim et al 81 physostigmine on a myasthenic patient in 1934. To her amazement, chc. patient responded almost instantly. The next year, she used neostigmine, and again it responded with more remarkable results." Since then neostigmine has become the drug of choice for the control of the symptoms of this disease. This drug is believed to inhibit the cholinesterase from destroying the acetylcholine, and from exerting its nicotinic action. Stone and Rider' claimed that 8 5 % of the cases can be controlled by oral medication alone; but in more severe forms, parenteral and orJI medications are necessary. In crises, large doses are required and arc given hourly by intravenous routes. According to these scientists, i.hc discovery of neostigmine for myasthenia gravis can be compared to the discovery of insulin for diabetes. Odon and his coworkers" found that neostigmine causes a marked fall of cholinesterase in the serum. The fall corresponds to the period of clinical improvement, and is parallel to the dose of neostigmine. The myogram remains normal even after the serum cholinesterase has ri:;cn to preinjection levels. The disadvantage of neostigmine is that it has to be given in large dose~, and at frequent intervals day and night. In severe cases, after they have received the drug for sometime, patients seem to become irresponsive to this drug. Because of this disadvantage newer drugs have be.en tried. The insecticides used during the last war were found to possess cholinesterase-inhibiting properties. The first to receive clinical application was DFP or Diisopropylflourphosphate. Comroe and his coworkers,;o in 1946, reported seven cases treated with DFP. Two patients showed little or no improvement. Two showed considerable improvement. One showed marked improvement. And two gave obscure results, due to peculiarities of the natural cycle of the disease. DFP is capable of reducing the plasma cholinesterase to zero. Yet the muscular strength obtained in myasthenic patients is not of the same degree as that obtained with the use of neostigmine. According to Comroe and his coworkers, this difference may be due to the physioch..:mical properties of DFP, which is highly lipiod soluble, while neosiigmine is highly acqueous. This may account for DFP's predilection to nervous tissues, and for neostigmines selective action on the myonfUral junction. The human plasma cholinesterase is more susceptible to the effects of DFP than the brain or muscle cholinesterase. If neostigmine is given a few hours previous to DFP administration, it will not be able to exert its full effect. DFP, however, has a distinct advantage over neostigminc in that it has more prolonged action. From the experiences of Buchtaal and Engback," two out of the three cases could manage without prostigmine; while in the third, prostigmine could be reduced. Gaddun and Wilson" tried DFP on three cases, and all had very encouraging results. Harvey and his coworkers" studied the effects on both normal and myasthenic patients, and found 82 MYASTHENIA GRAVIS-Lim et al Jour. P.M. A. February, 19M. that normal patients develop muscle weakness and numerous spontaHc:ous fasciculations and no changes in the voltage of muscle potentials; whiie m myasthenic patients, there is an increase in muscle strength and no fasciculation. In addition, the myogram is likely to become normal. The return of strength remains detectable for 8-10 days. Due to its toxicity, like the unpleasant nervous symptoms and the gastrointestinal complications, it should be used in limited amounts, if it is to produce adequate therapeutic effects. Dejong and his coworkers" described the properties of hexaethyltei.raphosphate, HETP, as unstable but so potent that it has to be diluted I 00 times before it can be used for injection. The maximum dose given to a human is 0.86 mg per kilo. This drug is effective only if the cholinesterase is free to bound. Therefore neostigmine should not be given a few hours before HETP administration. The injection is usually repeated at intervals of three or four days. The toxic symptoms like nausea, vomiting, abdominal cramps, salivation, sweating, bradycardia, weakness, muscle twitchings and confusions are of central origin. Westerbrug and Luros'" trial on 4 cases gave very encouraging results. Tetraethylpyrophosphate, or TEPP, is a colorless liquid, miscible in water, acetone, alcohol, glycerine, or propylene glycol. Its action is twice as long as that of neostigmine, and is only 1/3 to 1/2 as potent. It i$ administered orally in 1 % solution in peanut oil or propylene glycol. When the maximum dose is reached after the appearance of toxic symptoms, the maintenance dose of 2 to 4 cc. daily is given. The toxic symptoms are easily relieved by atropine. The maximum depression of plasma cholinesterase occurs within I liuur, after administration of the compound; and the relief of symptoms is sustained for l 2 hours, gradually declining over a period of 72 hours. But the plasma cholinesterase depression ccmtinues for 16 days. If nco5tigmine is to be given in combination with HEPP, it should be given at least one hour ahead. Burgen et al" in 3 cases, Harvey" in 7 cases, and Stone and Riders' in 8 cases, all reported favorable results. Octamethylpyrophospheramide, OMPA, has a distinct advantage over the other phosphate mentioned above, in that it is less toxic and more stable. From the experiences of Rider and his coworkers" with this c;ompound, six cases in adults showed four cases in which complete replacement of neostigmine was possible. One case succumbed, and one ..:asc was a failure. These workers observed that the neostigmine requirement begins to diminish when the serum cholinesterase level approaches 60 % of normal, :ind maximum improvement in strength is achieved when the serum level reaches 10 to 20% of normal. The toxic symptoms are practically the; same as those of other organic phosphates, and can be relieved quickly Ly atropine. Thymectomy-As has been mentioned, the thymus was first implicated in this disease in 1901." Since then, more and more evidences that the thymus may play an important etiological factor have come to Volume XXX Number 2 JvJYASTHENIA GRAVIS-Lim et al 83 light. Partial thymectomy was done as early as 1912; but the procedure did not gain favorable acceptance until Blalock,'° in the United States, showed encouraging results in his first six cases. By 1944, the number thymectomized had increased to 20. Of these four died, three essentially got well, five improved considerably, five improved moderately, and three improved slightly. Blalock found that the best result was obtained in cases who had had the disease for a short period. Other authors seem to agree that thymectomy should be confined to severe cases and to those that do not respond to prostigmine.41·""' Eaton and Clagett,44 however, are of the opinion that thymectomy should be done only iri those cases where the thymic shadow can be demonstrated Ly X-ray, where the tumor has not yet invaded the surrounding structures like the great vessels, where there is no implantation in the pleura at a distance; and where the patient's age and condition are such not to make it risky for him to undergo an operation. Thymectomy by X-ray has been recommended by Aring". In the three cases he treated, the symptoms of myasthenia gravis seemed allevi;1ted. He said that in experienced hands, it is a harmless procedure and should be tried first before surgery is contemplated. The use of ACTH" in myasthenia gravis is based on sound physiologic observation. In vitro studies, ACTH increases acetylcholine synthesis; and in vivo, it reduces the size of the thymus and lymphatic tissues. Removal of the pituitary in rats induces changes in the elcctromyogram chat closely resemble the abnormality noted in patients with myasthenia gravis. In pregnancy it is associated with increased release of ACTH and is often followed by remission. Torda's and Wolff's experience with five cases showed very encour:igi!1g results. These patients were still in remission three months after therapy. Shy et al" had one case treated with cortisone, but failed. Ritter and Ebstein" also failed with ACTH therapy in a 9-year old thymectomized child. SUMMARY A four year old Filipino child with symptoms of myasthenia gravis is presented. The child responded to a test dose of prostigmine, and was maintained fairly well on oral medication. A short review of the pathogenesis, diagnosis, and ·treatment of the disease is presented. REFERENCES I. Nilsby, Ivar: Myasthenia Gravis in a Newborn Child, Acta Pediatric a. 37; 489 1949. 2. Bowman, J. R.: Myasthenia Gravis in Young Children, Pediatrics 1;472 1948. 3. Levin, P. M.: Congenital Myasthenia in Siblings, Arch. of Neur. and Psychiatrr, 62;745 1949. 4. Mackay, R. I.: Congenital Myasthenia Gravis; Arch. Dis, Childhood; 25,289 1951. !. Stnckroot, F. L.; Schaeffer, R. L.; Bergo, J.: Myasthenia Gravis Occurring in an Infant Born of Myasthenia Mother; JAMA 120; 1207 1942. 6. \\7 ilson, A.; Stoner, H. B.; Myasthenia Gravis: A Consideration of Its Causation in a Study of Fourteen Cases; Quart. Jr. Medicine, 13; I 1944. 84 MYASTHENI.-1 GRAVIS-Lim et al Jour. p·.M.A. February. 1954 7. Stone, C. T.; Rider,]. A.: Treatment of Myasthenia Gravis; JAMA, 141;107 1949. 8. LaBranche, ]. R.; Jefferson, R. N.: Congenital Myastheni_a Gravis, Pediatrics, 4;16 1949. 9. l'vlckeever, G. E.: Myasthenia Gravis in a Mother and Her Newborn Son; JAMA 147;320 1951. JO. Holt, ]. G.; Hansen, A. E.: Management of Newborn Infant with Symptoms Indicative of myasthenia Gravis; Texas St. J. Med. 47,299 1951. 11. Levinson, A.; Lim, L. Ed.: Myasthenia Gravis and Mento! Retardation; To be published. 12. Dale, H. H.; Felberg, W .; Vogt, M.: Release of Acetylcholine at Voluntary Nerve Endings; Journal of Physiology; 86;353 1936. U. Jones, M. S.; Stadie, W. C.: The Cholinesterase Content of the Muscle of Myasthenia Gravis and of the Serum of Four Other Groups of Clinical Conditions: Quart. J. Experimental Physiology; 29; 63 1939. 11. McEachern, D.: The Thymus in Relation to Myasthenia Gl'avis; Medicine; 22; I 1943. 15. Constant, G. A.; Porter, L. E.; Andronis, A., Rider, ]. A.: The Effect of Thymic Extracts on N euromuscular Response; Texas Reports Biology and Med.; 7; 350 1949. J 16. Torda, C.; Wolff, H. G.: Effect of Blood Serum from Patients with myasthenia Gravis on the Synthesis of Acetylcholine in Vitro; Journal of Clinical Investigation; 23; 469 1944. 17. Trethewie, R. E.; Wright, R. D.: Acetylcholine Synthesis and Myasthenia Gravis; Australian and New Zealand J. Surgery; 13;244 1943. 18. Guthrie, L. G.: Lancet: I; 330 1903. 19. Veits, H. R.; Schawab, R. S.; Prostigmine in the Diagnosis of Myasthenia Gnvis; New Eng. J . Med.; 213; 1280 1935. 20. Veits, H. R., Itchell, R. S.: The Proscigmine Test in Myasthenia Gravis; New Eng. J. Med. 215;1064 1936. 21. Schawab, R. S.; Veits, H. R.: Prostigmine Test in Myasthenia Gravis 3rd Report ; New Eng.]. Med. 219;266 1938. 22. Tethat, J. E.: Intravenous Neostigmine in the Diagnosis of Myasthenia Gravis, Annals of Int. Med. 29;1132 1948. 23. Bennett, A. E.; Cash, P. T.: Curare as a Diagnostic Test for Myasthenia GravisCurarization An Etiologic Clue in the Disease, Trans. Am. Neur. Asso. 68;102 1942. 24. Eaton, L. M.: A Warning Concerning the Use of Curare in Convulsive Shock T reatment of Patients With Psychiatric Disorders Who May Have Myasthenia Gravis, Proc. Staff Meeting Mayo Clinic 22;4 1947. 25. Harvey, A .. M.; Whitehill, Mr. R.: Quinine as an Adjuvant to ·Prostigmine in the Diagnosis of Myastbenia Gravi<. A Preliminary Report; Bui. Johns Hopkins Hosp. 61; 216 1937. 26. Buzzard, E, F.: The Clinical History and Post-Mortem Examination of Five Cases of Myasthenia Gravis, Brain, 28; 438 1905. 27. Walker, M. B.: Treatment of Myasthenia Gravis with Physostigmine; Lancet 1;1200 1934. 2~ . Case Showing the Effect of Prostigmine in Myasthenia Gravis; Pro. Roy. Soc. Med. 28;759 1935. 29. Odon, G.; Russel, K.; McEachern, D.: Studies of Neuromuscular Disorders: The Myogram, Blood Cholinesterase and Effect of Proscigmine in Myasthenia Gravis and Progressive Muscular Atrophy, Brain, 66;1 1943. 10. Comroe, J. H.; Todd, J . D. Gilman, A; Gammon, G. D.; Leopold, I. H.; Loelle, G. B.; Bodansky, 0: The Effect of Di-isoprophylflourophosphate (DFP) Upon Patients with Myasthenia Gravis; A. J. Med. Sc. 212;64 l 1946. 31. Buchta!, F.; Engback, L.: On the Neuromuscular Transmission in Normal and Myasthenic Subjects; Acea Psychiat. Neural. 23 ;3 1948. Volume XXX Number 2 MY ASTHENI.4. GRAVIS-Lim et al 85 32. Gaddum, J. A.; Wilson, A.: Treatment of Myasthenia Gravis with Di-isoprophylflourophosphate; Nature, London, 15 9-690 1947. H. Harvey, A. M.; Jones, B. F.; Talbot, S.; Grab, D.: The Effect of Di-isoprophylflourophosphate (DFP) On Neuromuscular Transmission in Normal Individuals and in Patients with Myasthenia Gravis: Federation Proc. 5:182 1946. 34. Dejong, R. N.; Westerberg, M. R.; Lures, ]. T.: The Clinical Use of Organic Phosphate Cholinesterase Inhibitors In The Treatment of Myasthenia Gravis: Trans. Am. Neur. Asso. 74;126 1949. 35. Westerberg, M. R.; Lures, J. T.: The Clinical use of H exaethyl Tetraphosphate in Myasthenia Gravis: Univ. Hosp. Bull. Ann. Arbor, 14;15 1948. 36. Burgen, A. S. V.; Keel, C. A.; McAlphine, D.; Tetraethylpyrophosphate in Myasthenia Gravis: Lancet 1; 519 1948 . .\7. Harvey, A. M.: Some Physiological Experiment of Nature in the Field of Neuromuscular Function: Tetra-ethyl pyrophosphate in. Treatment of Myasthenia Gravis, Potassium Deficiency, Potassium Intoxication; Proc. Inst. Med. Chicago, 17;182 1948. JS. Rider, J. A.; Schulman, S.; Richter, R. B.; Moeller, H . C.; Dubois, K. P.: Treatment of Myasthenia Gravis with Octametylpyrophosphosramide: JAMA 145 ;967 1951. 39. Weigert, Carl: Pathologisch-anacomischer Beitrag zur Erb'schen Krankheit Myasthenia Gravis); Neur. centralb. 20;597 1901. 40. Blalock, A.: Thymectomy in the Treatment of Myasthenia Gravis Journal of Thorasic Surgery; 13;H6 1944. 1 I. Harvey, A. M.: Some Preliminary Observations on the Clinical Course of Myasthenia Gravis Before and After Thymectomy Bui. N . Y. Acad. 24; 505 1948. 12. Kayes, G.: Surgery of the Thymus Gland; British ]. of Surgery 33 ;201 1946. 43. Adams, R.; Allan, F. N.: Thymectomy in the Treatment of Myasthenia Gravis, Disease of the Chest 13;436 1947. 44. Eaton, L. M.; Clagett, 0. T.: Thymectomy in the Treatment of Mysthenia Gravis; JAMA 142;963 1950. 45. Aring, C. D.: Treatment of Myasthenia Gravis with the Roentgen Ray; Ohio State Med. Journal; 39;241 1945. ·16. Torda, C.; Wolff, H. G.: Effects of Adrenocorticotrophic Hormone on Neuromuscular Function in Patients with Myasthenia Gr.vis; Trans. Am. Neuro. Asso. 74;135 1949. 47. Shy, G. M.; Brendlers, S.; Ravinnovitch, R.; McEachern, D.; Effects of Cortisone in Certain Neuromuscular Disorders, JAMA 144;1353 1950. 48. Ritter,]. A.; Epstein, N.: Myasthenia Gravis, Some Observations on the Effects of Various Therapeutic Agents, Including Thymectomy and ACTH in a Nine Year Old Child. Am. ]. Med. Science 220;66 1950. 49. Hughes, W. F.: Office Management of Ocular Diseases (Chicago: The Year Book Publisher Inc., 1913) pp. 331-333. 50. Walsh, F. B.: Clinical Neuro-Ophthalmology (Baltimore: Williams and Wilkins Company, 1947) pp. 922-930. 51. Osserman, K. E.; Kaplan, L. I.: Rapid Diagnostic Test for Myasthenia Gravis; JAMA, 140;265 1952. 52. Walker, il. P.: Congenital Myasthenia Gravis, A.j. of Dis. of Children, 86:198 195 3. FOR AN INTEGRATED PROVINCIAL GOVERNMENT HOSPITAL, PUERICULTURE CENTER, MUNICIPAL MATERNITY AND CHARITY CLINIC SERVICE ENRIQUE F. OCHOA, M.D., C.P.H., M.P.H. Chief of Division, B11retm of Hospitals The present medical relief and provincial hospital set-up in the Philippines is woefully short of equipment, buildings, and other facilities. This is mainly due to the lack of coordinated financing and of willingness on the part of some appropriating bodies to give the Bureau of Hospitals adequate financial backing with which to integrate an efficient, satisfactory government medical relief and hospital service throughout the Philippines. At present, we have 34 provincial hospitals financed "-~' - -- ---'-' under the provisions of Act 3114, as amended by r. F. OCHOA. M.D. Act 3168. The financing of provincial hospitals under this Act may have been tolerable twentyfive to thirty years ago. But the continually changing times have made the provisions of this Act, as amended, obsolete; and they have plunged our medical relief agencies and provincial hospitals into near chaos. The Manila Times in a recent editorial stated: "Next to not having a hospital, there is probably nothing worse than having one that cannot render full or satisfactory service to the community it is intended to serve. Recent reports that many hospitals throughout the Islands faced closure were very disturbing and gave the impression that we were not as gravely concerned with the people's health as we were over other aspects of the national life. To date the people have not learned to folly appreciate the boons of medical science. Many are still bound by superstition. In the rural . areas where the major portion of our people live, the hospitals are the showwindows for the modern ways of combatting disease. If these are operated shabbily for lack of either personnel or the requisite facilities, it will be difficult to convince the great mass of our people to depend less on the ministration of quacks than on those of the trained men of science. In the release of funds for provincial hospitals our concern for the people's health gets a fresh and heartening demonstration." Not only are municipal contributions to our provincial hospitals woefully inadequate; provincial participation has also lagged so far behind as to render even the semblance of a sub-standard hospital service a myth. Moreover, since some provincial capitals like Legaspi, N aga, Cagayan, Bacolod, Cabanatuan, and Dumaguete have been converted into cities, whose charters have no specific provisions for any regular aid to the provincial hospitals within their boundaries, the situation has become even worse. Finally, to be able to give a fairly adequate hospital service, in accordance with modern trends of hospital management, Volume XXX Number Z GOVERNMENT HEALTH SERVICES-Ochoa 87 the sum of P'3,000.00 per-year-per-bed for maintenance is needed; but our present provincial hospitals have to make the best of the meager sum of from PI,000.00 to Pl,200.00 per-year-per-bed, for maintenance. Another factor that has contributed to the almost chaotic financial condition of our provincial hospitals is the · fact that the sources of funds for maintenance are so varied, so vague, and so inconsistent that the chiefs of provincial hospitals and the authorities of the Bureau of Hospitals find themselves unable to pursue a definite plan or policy to be adopted from year to year. At the same time, the population of our country has increased by leaps and bounds so that, whereas in 1918, we had a population of only 14,000,000, today, we have a population of over 20,000,000; whereas, in 1918, we had a population that was indifferent ro hospital service, now-a-days, because of rapid strides in education and in health consciousness, our people have overcome that indifference and ~re now making outright demands on their government for more and better hospital facilities. This rapid increase in population, plus the increasing demand of our public for hospital service has not gone "paripassu" with the increase in appropriation for organized hospitals, because appropriations have remained practically stationary for the past fifteen or twenty years. In order to improve hospital service and hospital accommodations, the writer has endeavored to make a study of present hospital facilities, compared them with those of twenty years ago, and made efforts not only to better actual conditions but also to propose a systematic, coordinated, and centralized method of financing hospital construction and maintenance with the end in view of making facilities adequate to the needs of the general public. In this endeavor, the writer has placed emphasis on a proposed method whereby the municipal, the city, the provincial, and the national government, plus whatever aid may be obtained from charitable institutions and hospital income, may make the system more wicldy and yet flexible enough to make it consistently adaptable co ever-changing conditions. In a similar vein, one may also cite the almost confusing situation, because of inadequate financing of puericulture centers; municipal maternity and charity clinics; and dental services, both field and institutional. Municipal maternity and charity clinics are almost exclusively financed from national funds; puericulture centers are partly financed from local funds raised by local associations, plus sweepstakes aid and other forms of aid these local clubs can beg from sympathetic municipal councils ana provincial boards. Dental services get funds from swee.pstakes aids and from meager hand outs from provincial hospital budgets. Thus the sub-standard, inchoate services rendered by these field medical relief agencies of the Bureau of Hospitals are far below similar services in other countries of the world. Here, hospital and medical relief authorities spend most of their time begging for funds with which to meet their needs, thus leaving them very little time to attend to actual constructive duties. Our government can be better regarded and can brst serve the bulk of our population by integrating all funds destined 88 GOVERNMENT HEALTH SERVICES-Ochoa Jour. P .M.A. February. 1964 fo~ medical relief under a central agency administered by the Bureau of Hospitals, in budgets approved by the Department of Health, similar to die disbursement of funds by the Departments of National Defense, Public r.ducation, and Public Works. This article will deal with the method which I am advocating, to implement this central idea. TABLE I-Sho1dng Prol'incial, Municipal, National, City and S1<eep.1takes Aids to Provincial Hospitals Name of Provincial Provincial Municipal I National City Aid Phil. Charity Hospital Aid Aid Aid Sweeps. Aid I. Albay l" 11,000.00 l" 14,000.001 - l" 10,000.00 i" 3,000.00 2. Antique 7,030.00 13,000.00 - - 8,000.00 3. Bataan 4,400.00 13,000.00 - - 5,831.00 4. Batangas 14,500.00 40,000.00 - - 18,000.00 5. Bohol 16,500.00 34,000.00 - - 2,936.00 6. Bulacan 20,839.00 43,058.00 - - 3,273.00 7. Cagayan 10,000.00 22,000.00 - - 3,822.00 8. Camarincs N. 3,626.68 10,884.14 i" 16,910.00 - - 9. Camarincs Sur 16,000.00 20,000.00· - l" 19,000.00 4,740.00 JO. Capiz 12,500.00 19,000.00 - - 2,000.00 11. Ilocos Norte 6,500.00 15,000.00 - - 6,832.00 12. Ilocos Sur 7,000.00 23,000.00 - - 2,725.00 13 . Iloilo 26,185.00 37,547.00 l" 6,324.00 - - 14. Isabela 10,000.00 16,410.00 - - 8,603.00 15. Laguna 23,000.00 49,320.00 - - 10,000.00 16. La Union 8,000.00 21,000.00 - - 12,832.00 17. Leyte 26,000.00 40,000.00 i" 2,436.00 - 12,000.00 18. Marinduque 5,400.00 8,866.92 3,800.00 - - 19. Masbate 13,700.00 18,000.00 - - 5,832.00 20. Misamis Occ. 14,000.00 20,000.00 - - 4,500.00 21. Misamis Or. 16,000.00 19,000.00 770.00 l" 10,000.00 - 22. Mindoro 6,000.00 19,000.00 - - 18,832.00 23. Negros Occ. 42,500.00 5 8,000.00 - 30,500.00 2,000.00 24. Negros Or. 15 ,000.00 18,000.00 - 6,000.00 5,000.00 2 5. Nueva Ecija 21 ,000.00 27,500.00 4,000.00 7,000.00 - 26. Pampanga 22,500.00' 43,000.00 - - 3 5 ,000.00 27. Pangasinan 37,000.00 29,500.00 - 3,000.00 7,500.00 28. Rizal 43,000.00 83,000.00 - - 32,324.00 29. Samar 10,000.00 29,590.00 3,876.00 - - 30. Sorsogon 6,000.00 10,000.00 - - I 0,000.00 31. Surigao 8,000.00 20,000.00 3,939.00 - - 32. Tarlac 12,000.00 30,000.00 - - - 33. Quezon 21 ,650.00 5 8,600.00 - - - 34. Zambales 8,769.30 9,283.001 - - 50,082.30 1"525,599.98 1"942,559.06 i" 41,955.00 PIO 5 ,300.00 1"295,674.00 FINANCES: Table I shows the present financing of 34 provincial hospitals from various funds. It also shows that these provincial hospitals, with a total Volwne XXX Namber Z GOVERNMENT HEALTH SERVICES-Ochoa 89 approved capacity of 1,875 beds, are working under the following appro?riations: National aid Provincial aid Municipal aid City aid ....... . Philippine Charity Sweepstakes aid Total 41,95 5 .00 525,599.98 942,5 59.06 105 ,300.00 295,674.00 Pl,910,788.04 This total gives an annual "per-year-per-bed maintenance" of Pl,019.00, which is much below the estimated P3,000.00 per-year-per-bed standard set by the Bureau of Hospitals. Even this standard is way below that of the United States and England, where the per-bed-per-year maintenance is placed at P5 ,000.00 or Pl0,000.00. Our municipal maternity and charity clinics are maintained at an average of Pl,500,000.00 per year appropriation; and the approximately 500 puericulture centers receive a PI00,000.00 yearly national aid for their maintenance. Dental services are financed largely from sweepstakes doles from time to time as funds become available. For purposes of this study, government hospitals under the Bureau of Hospitals may be divided into the following categories: a. Provincial Hospital-A hospital established, or proposed to be established, in the capital of a province, or in a city, which used to be the capital of a province. b. Congressional or Sub-provincial Hospital-A hospital establjshed in the most centrally located municipality of a congressional district-taking into account geographical location, number of inhabitants, and accessibility by road from surrounding municipalities, as well as the capital of the province. c. Special Hospital-A hospital that has been built and was functioning heretofore. d. Reg~onal Hospital-A hospital financed heretofore from national funds almost exclusively, and dedicated as a sort of base hospital for the region in which it is located. In order to cope with adequate financing of all provincial, sub-proYincial, special, and regional hospitals, as well as other medical relief organizations under the Bureau of Hospitals, it is hereby proposed that the following sources of funds be made available to a centralized agency: (I) (2) (3) (4) Sources of Income 5 % of general funds of all municipalities .. 3 % additional to the above 5 % from general funds of municipalities in which hospitals are located 10% of general funds of all cities, except Manila 5 % of general funds of all provinces Estimated Yearly Income p 2,000,000.00 300,000.00 1,200,000.00 2,000,000.00 90 GOVERNMENT HEALTH SERVICES-Ochoa ( 5) National Government contribution (fixed amount) ( 6) National Charity Sweepstakes contribution Total available for appropriation Jour. P.M.A. February, 1964 10,000,000.00 2,500,000.00 p 18,000,000.00 With eleven million pesos available for expenditures for hospitals, municipal maternity and charity clinics, puericulture centers, and dental se1 vices, the following expanded, well-financed, and increasingly efficient medical relief activities can be effectively undertaken: ( 1) For a fixed appropriation corresponding to national & sweepstakes aid for 500 puericulture centers P 2,000,000.00 ( 2) For maintenance of about 5 00 municipal maternity and charity clinics, and dental services 3,000,000.00 ( 3 j For construction and maintenance of: 34 provincial hospitals; 12 national aid hospitals to be converted into provincial hospitals; 7 emergency hospitals to be converted into provincial hospitals; I existing city hospital; 3 existing regional hospitals; and 47 proposed congressional and provincial hospitals 13,000,000.00 TOTAL 'Pl 8,000,000.00 The f>l3,000,000.00 that could be made available for PROVINCIAL. REGIONAL AND CONGRESSIONAL HOSPITALS could be utilized in maintaining existing ones, in putting up new buildings, and in the i:u•chase of equipment for the proposed PROVINCIAL AND CONGRESSIONAL HOSPITALS. Details of this plan may be worked out !atc·r. Since the proposed PROVINCIAL AND CONGRESSIONAL I IOSPIT ALS are not functioning at present, the funds destined for their maintenance, which may average P80,000.00 yearly, could be used for construction purposes in the meantime. Later, as the hospitals are finished and fully equipped, the P 80,000.00 yearly appropriations may be used in maintaining 25- to 30-bed hospitals. With this arrangement, every province will have a STANDARD PROVINCIAL HOSPITAL; and every congressional district, a STANDARD SUB-PROVINCIAL OR CONGRESSIONAL HOSPITAL. The present REGIONAL AND SPECIAL HOSPITALS, maintained directly with national and local funds, may continue functioning as usual under this proposed setup. Table II shows the proposed distribution of PROVINCIAL, REGIONAL, CONGRESSIONAL, AND SPECIAL HOSPITALS. Thus, with a little more effort on the part of our municipalities, cities, and provinces, plus a reasonable aid that Congress may make available, hospital service will not only be rapidly expanded; its maintenance will aiso be under what may be considered a STANDARD HOSPITAL SER VICE for the Philippines. Likewise, puericulture centers and municipal maternity and charity clinics will receive direct fixed aids, Volwne XXX Number Z GOVERNMENT HEALTH SERVICES-Ochoa 91 v.·hich will enable them to render better service to the public and to make long-range plans for more comprehensive and efficient service. There is no gain-saying the fact that, through a systematic, efficient, and wellplanned medical relief service, our government may reach the most remote confines of our island republic, and thus bring the government clos>!r to the people. SUMMARY 1. A detailed study of the present set-up of our special, provincial, and national hospitals is made. 2. A study of the set-up of our municipal maternity and charity clinics, puericulture centers, and d_ental services is also made. 3. A proposed classification of government hospitals is suggested. 4. A study of proper financing is made, giving sources of funds. 5. A system of expenditures from a centralized agency is analyzed. TAl'LE II-Showing the Proposed Distribution of Proi;incial, Regional a11d Congressional Hospitals Province [ Location ----, I. Abra lBangued 2. Agusa1' iButuan City J. Albay: 1 !st Cong. Dist. ITabaco 2nd Cong. Dist. Legaspi City 3rd Cong. DisJLigao 4. Antique: 'San Jose de 5. Bataan 6. Batanes 7. Batangas: f Buenavista 'Balanga I iBasco I I !st Cong. Dist.1Nasugbu 2nd Cong. Dist. IBatangas 3rd Cong .• Dist.llipa City 8. Bohol: I !st Cong. Dist. Tagbilaran 2nd Cong. Dist. 1 Carmen Jrd Cong. DisqUbay 9. B1tkidnon Malaybaby 10. Bulacan; !st Cong. Dist. Malolos 2nd Cong. Dist.,Baliuag I Provincial__\ c~i:~,~·- jli~~ci7;f~egian~~1--:--1 :Existing as ! Emergency !Existing as I I 30 I J National I '!Existing as Provincial Existing as i Provincial !Existing as i Provincial !Existing as ! Emergency i 'Existing as Provincial Existing as Provincial !Existing as I National I - :Proposed I I IPro:cd I I iProposed I - 'Proposed I Proposed Proposed 1 Existing as i \ \ Pr~ncial Pro;sed 25 I 25 I I 35 I 25 25 25 20 25 60 25 100 25 25 25 60 25 92 GOVERNMENT HEALTH SERVICES-Ochoa Jour . P.M.A. Febt'Uary, J\}54 I Congres- Bed Ca-1 Province Location Provincial sional pa city Regional 11. Cagayan: i !st COng. Dist. Tuguegarao 'Existing as I 2nd Cong. Dist.\Ballesteros l Provincial 60 I . :--- :Proposed 25 I 12. Camarines NortciDaet iEx1stmg as I Caramines Sur: I I Provincial 20 13 . I I I !st Cong. Dist.INaga Citr :Existing as Dist.lLagonoy i Provincial I 50 2nd Cong. !Proposed 25 14. Capiz: D" I C . !Existing 1s !st Cong. 1st., ap1z I Dist.IMambusao j Emerg. 2i 2nd Cong. IE. :1 Existing .ts Disc. IKalibo j Emerg. 25 3rd Cong. I x1st1ng as lvirac 1 Provincial I 35 15. Catand11anes 1 Existing as ]Cavite I Emergency i 25 I 16. Cavile Ci tr ,Proposed 25 17. Cebtl: I I !st Cong. Dist. Bo go 1 Proposed 25 I 2nd COng. Disc. Opon I iProposed 25 3rd Cong. Dist. Carcar ;Proposed 25 4th Cong. Disc. Argao I - :Proposed 25 I 5th Cong. Dist.ISamboan I Proposed 25 6th Cong. Disc. Toledo Proposed 25 7th COng. Dist. Bantayan Proposed 25 I Ceb11 City ICebu 150 'Existing as 18. Cotabato COcabato Existing as I Nat~nal !Davao Cicy National Aid 30 19. D11vao Existing as I i National Aid: 50 I 20. llocos Norte: ! !st Cong. Dist. Laoag !Existing as i i Provincial IPro;,ed 30 2nd COng. Dist. Badoc 25 I 21. llccos S11r: !st Cong. Dist. Vigan 'Existing as ! Provincial 40 2nd Cong. Dist. Candon !Proposed 25 22. lloilo: !st Cong. Dist.IMiagao ,Proposed 25 2nd COng. Dist. Iloilo Citr Existing as I Provincial i - 60 3rd COng. Dist. Janiuay IProposod - 25 4th COng. Dist. Pototan Existing as Emerg. 25 5th COng. Dist. Passi Proposed · 25 23. Isabel a Ilagan Existing as Provincial 40 24. Lag11na: !st COng. Dist. 1 San Pablo Cic~·1 Existing :as City Hos-1 pita I 35 Volume XXX Number 2 GOVERNMENT HEALTH SERVICES-Ochoa, 93 ___ P_r_o_v_in_c_e ___ 1 __ Lo_c_a_t1_·o_n __ 1 __ P_r_o_11m_· _c_i•_l_ 1_c_';"_;ona_g_r_~s---1B;~ci~-1--R-e_g_iona __ 1_ 2nd Cong. Dist. Sta. Cruz Existing as I Provincial IO 5 I 25. La11ao Dansalan City Existing as 1· 25 1 1 1 . National Aid 26. La U11ion: !st Cong. Dist. San Fernando Existing as Provincial 4 5 i 27. 2nd Cong. Dist.,Agoo Leyte: !st Cong. Dist. Leyte 2nd Cong. Dist. Baybay 3rd Cong. Dist. Malitbog 4th Cong. Dist. Taclob•n 28. Manila: 5th Cong. DistJIBurauen 1st Cong. Dist. Tondo 2nd Cong. Dist. Sta. Cruz 3rd Cong. Dist.ISampaloc 4th Cong. Dist. Malate 29. Mttrind11q11e jBoac 30. Masbate 1 Masbate i 31. Mindoro Occ. i 'Mamburao 32. Mindoro Or. Calapan 33. Misamis Occ. loroquieta 34. Misamis Or. ',Cagayan de Oro City 3 5. Mt. Province: • I st Cong. Dist.,Bontoc 2nd Cong. Dist.,Lubuagan 3rd cong. Dist.riangan Baguio j - 36. Negros Oc.c. I st Cong. Dist. Escalante 2nd Cong. Dist. Bacolod City 3rd Cong. Dist. Kabankalan 37. Negros Or. !st Cong. Dist. Dumaguete 2nd Cong. Dist. Siquijor 38. Nuev11 Ecij11: 1st Cong. Dist. Cuyapo Existing as I Emergency 2 5 j 'Existing as Provincial · !Existing as I Pr~ncial .Existing as I Provincial Existing as Provincial 1 Proposed ! 'Existing as Provincial 'Existing as Provincial Proposed J Existing as I Provinciol Proposed I !Proposed r ro:ed ,Proposed .Proposed Existing as I Provincial Existing as I National Aid Proposed Existing as J National Aid 1Existing as I National Aid I !Existing as Provincial Existing as Provincial t roposed Proposed Existing as Emerg. Proposed 25 H 25 60 25 25 300 25 25 25 35 25 40 40 40 30 20 20 100 25 150 25 40 25 25 • Existing as I Regional 94 GOVERNMENT HEALTH SERVICES-Ochoa - -~~~~--~~~~~~~~~~~~~~~~Jour. P.M.A'. February. 19H Pr<>Vince Locati<m Crmgres- Bea Casional pacity Regirmal Provincial 2nd Cong. Dist. Cabanatuan 39. Nueva Vizcaya Bayombong 40. Palawan Pto. Princesa Special Hosp. Cu)"O 41 . Pampanga: Existing as Provincial Existing as National Aid Existing as National Aidr 1st Cong. Dist. Angeles Prop<>!ed 2nd Cong. Dist. San Fernando Existing as 42. P11ngasin11n: 43. 1st Cong. Dist. Lingayen 2nd Cong. Dist. 5an Carlos 3rd Cong. Dist. San Fabian 4th Cong. Dist. U rdaneta 5th Cong. Dist. Tayug Dagupan City Quez<m: 1st Cong. Dist. Lucena Provincial 44. 2nd Cong. Dist., 1 Lopez Special Hosp. Baler Rizal: 1st Cong. Dist. Quezon City 2nd Cong. Dist. Pasig j Proposed Existing as Provincial 45. Romblrm Romblon Existing as Provincial 46. Samar: 1st Cong. Dist. Calbayog City'I - 2nd Cong. Dist. Catbalogan Existing as j Provincial 3rd Cong. Dist. Borongan I - 47. Sorsogrm: j I 1st Cong. Dist. Bulan I 2nd Cong. Dist. 'Sorsogon Existing as I Provincial 48 . Sulu Jolo Existing as National Aid• 49. Surigao 50. Tarlac: 1st Cong. 2nd Cong. \ Surigao Existing as Provincial Dist. Camiling Dist. r arlac SI. Z11mb11/., 52. Zamboanga Norte llba I ID a pi tan 5 3. Z11mbo11nga Sur ,Pagadian I Zamboanga City Existing as Provincial Existing as Provincial Existing as National Aid Existing as Provincial Proposed Proposed Proposed Proposed 100 25 25 2 5 Special Hosp. 25 60 25 25 25 25 25 80 110 25 25 25 100 25 25 50 25 25 60 30 25 25 65 30 30 30 100 •Special Hosp. Special Hosp. Existing Regional Volume XXX Number- 2 GOVERNMENT HEALTH SERVICES-Ochoa SUMMARY Number of Existing PMvincial Hospitals Number of Existing National aid Hospitals Number of Existing Emergency Hospitals Number of Existing City Hospitals Number of Existing Regional Hospitals Number of Existing Special Hospitals Number of Proposed Provincial Hospitals Number of Proposed Congressional Hospitals Totals 34 12 7 1 3 3 3 41 104 95 Total Bed Capacity 1,875 335 150 35 350 130 75 1,025 3,975 ··tjJI ~pedal i\rtid~]J~·· ADDRESS• PAULINO ]. GARCIA, M.D. Srcretary of Health Mr. Master of Ceremonies, President Fernando, Physician Members of Congress, University Presidents, Distinguished Guests, and my dear friendsThere are times, rare though they may be, when a man believe, as I do, that he has the right to ask his comrades to hear him. Tonight, I feel [ can claim that right, if only to tell you that, more than the honor you have given me with this invitation, you have pleased me inordinately with your magnificent show of unity! That is as it should be. That is how we should always stand-single PAULINO f. GARCIA. M.D. in purpose, one and indivisible. It is not my intention to make a statement of the policy which will guide the actions of the Department of Health during my incumbency. President Magsaysay has already done that; our job is to carry out that policy to the best of our ability. I shall, however, touch on points which may not be our primary concern, but which are of vital interest to all of us nevertheless. The various professions which you represent have definite contributions to make to the three aspects of public health-preventive medicine; curative medicine, including preparative and rehabilitation measures; and health promotion. We are immediately concerned with the health of our barrio people who are the main preoccupation of the present Administration. In the rural areas, for one thing, there are no doctors, no dentists, no nurses, no midwives. For another thing, the insanitary conditions of these places are a threat to the people's health. Why is it that doctors, nurses, dentists, midwives, and other health officials do not seem to find private practice in these areas attractive? The reason, obviously, is economic. The financial returns are not so gratifying as in centers of population, and the facilities for the effective performance of their work are woefully inadequate. The steps that should be taken to remedy this deplorable situation are definite and clear. The government should encourage private practitioners to stay in these areas by offering them a reasonable subsidy, and ""Delivered at the Testimonial D inner honoring the Secrccar)'· of Health and Physician-Congressmen held Jan. 26th, 1954, at the M:mila Hotel. Volume XX% Number 2 ADDRESS-Garcia 97 by providing them, at strategic places, with the physical and other facilities which they need in their work. This means expansion of hospital services. Although we may not yet be in a position immediately to put up hospitals which meet modern standards, we could at least attempt to put up modest ones in as many strategic places as our funds would permit. In this way, emergency problem cases could be minimized. With respect to the specialists needed to man these hospitals, ou1· immediate problem is training. Towards this end, we should develop our Manila hospitals. And we should avail ourselves of the training facilities of the Philippine General Hospital, the U.S.T. Hospital, and other such institutions. This is, of course, a very ambitious program; and we do not intend to carry it out on a national scale at once. We intend to begin with pilot projects in one or two hospitals. If these projects prove successful, we shall, as fast as we can within our means, develop and train the necessary technical personnel, and extend the program to all the hospitals. In this way, we hope to raise the provincial hospitals to the category of competent medical centers, and provincial patients need not come to Manila for specialty care. The Department of Health has the cooperation of the United States Operations Mission in the Philippines, formerly FOA; WHO; and UNICEF. The assistance which we have received from these agencies have been truly remarkable and enormous. With the help of USOM, for example, we are giving special emphasis to projects tied up with economic development; and aside from improvements in environmental sanitation, we are launching a concerted attack against mass' diseases, like malaria, tuberculosis, malnutrition, yaws, schistosomiasis, and others, which are great deterrents to national economy. I cannot overemphasize the vital and important role which the people themselves should play in this health program. Every effort should be exerted to make them conscious of personal health information. It is only by teaching them hygienic ways of living that we can hope to succeed. For we shall need their support, even financial support, for many of our undertakings. It is gratifying to note the extent to which civicspirited citizens and groups in rural communities are contributing financially in carrying out both local and national health programs and services, such as the puericulture centers and the construction of artesian wells. - How do the private practitioners of the various professions fit into this ambitious program of the Department of Health? You yourselves can answer this question. All you need is initiative. You can, for example, initiate supplementary health program to support government action. You can put up private hospitals and clinics, either individually or in cooperation with one another. You may even devise a system of voluntary or pre-paid health and medical insurance, to suit people of the various income groups. And you can utilize government 98 ADDRESS-Ga,.cia Jour. P .?tt.A. February, 19S4 facilities which you can not provide yourselves, but which you need in the practice of your professions. At this juncture, I should like to mention our growing concern with regards to the increasing cost of medical care. Every one of us knows why the cost of medical care has gone up. The advances in medical techniques, and the variety of new and expensive gadgets which are used in the diagnosis and treatment of diseases-these are the main reasons. But the great majority of our people are not in a position to bear the additional expenses. They are not in a position to bear any expense. This is no exaggeration. Ask those who practise in the barrios and remote rural areas. Are we going to deprive these people of the best of medical care simply because they cannot pay for it? Most governments have accepted their responsibilities for the health of their people-responsibilities which they can fulfill only with the provision of adequate health measures. This is clearly stated in the Constitution of the World Health Organization, of which the Philippines is a member. But you would not want the government to take the full responsibility with regards to this problem. I know that the medical profession in this country is averse to even the slightest idea tending to socialized medicine. As a private practitioner, and as Secretary of Health, I am against Socialized Medicine. But the problem is with us, and something must be done to give all the people, irrespective of their ability to pay, the best and the most effective medical care. This is the essence of democracy which all of us have freely embraced, This is our pledge to serve humanity! The President has made clear in his speech to Congress that "the Spirit of Justice, not persecution, will guide us in our undertakings. The innocent, the honest, and the efficient need not fear, and that the Government will protect and defend their rights by enforcing impartiality and without political bias our civil service rules and regulations. We will not permit anyone to exact political vengeance on honest and efficient employees by dismissing them without cause. The victory' we have won is not a license for political persecution!" I should like to say one thing more before I go. Professional jealousy and intolerance, whether in one profession or among the allied professions, is never conducive to healthy professional growth. They breed suspicion and distrust. They harm the solidarity among the members of the profession and diminish the respect of the public for them. Let it be our solemn obligation to keep the people's trust and confidence in our profession. There is a very simple expedient by which this can be done. We have only to observe-to observe religiously--our professional code of ethics. I wish also to state in unmistakable terms that, as long as I ai:n the Secretary of Health, I will refrain from running for any position in our Medical Association, thus giving absolute freedom to any member of the Volume XXX Number 2 ADDRESS-Garciq. 99 Department of Health the free exercise of his suffrage in the choice of our medical leaders. I should like to reiterate once more what I said at the beginning of my remarks about the various professions which you represent making their definite and distinct contributions to the conduct of our public health. Your guest this evening, ladies and gentlemen, is bound to meet scores of difficulties and problems. During my incumbency, I shall draw heavily on your professional and technical advice. But above all, please know that your unity and cordial professional relations will be a constant source of inspiration to me in the performance of my work as Secretary of Health. THE JOURNAL OF THE Philippine Medical Association Poblisbed monthlv bv the PhiliDoin: Medic:;! AHoci:aion und::- ch: suoervision of the Coancil. Offi~e ~f Public:.ti~~. Philippine General Hospit::I. M:::'lila: Philippinu Dnottd to th: progress of M:ciic;i;I Science and to the interest~ of the Medi:2I ProieHion in ~he flhilipoinu . VOL. XXX FEBRUARY, 1954 No. 2 EDITORIAL STAFF MANUEL D. PENAS, M.D., Edi/or 1. V. \IAl.LAIU, Copy Uiltn TRINIDAD P. P:ESICAN', M.D., Bsuintu M4n•ftT MU.IA.NO M. ALIMUP.UNG, M.D. JOSE P. BANTUC, M.tl. V1cTolt1No DE D1os, M.D. ANTONIO S. FERNANDO, M.D. ASSOCIATE EDITORS CESAR FILOTEO, M.D. Ro.\IAS T. 5.ALACUI', M.D. RE:SATO MA. GUEIUl.EP.O. M.0. HU.MOCE:SES A. SANTOS, M.D W Al.Fir.JOO CE lEo:s, M.D Ac;Earco B. M. Suos, M.D. c.u.ME.LO Ri:.:~ES, M.D A:s-TOSIO G. Suos. M.D. Signed editorials express the ptrsonal views oi the writer thereof, and neither the Association nor the Journal assumes any responsibility for 1:hem. ··tjll eh it 0 rial 11~·· THE PHILIPPINE VETERANS MEMORIAL HOSPITAL The sick veterans now confined at different hospitals in the Philippines should feel happy with the knowledge that in the near future the Philippine Veterans Memorial Hospital, now under construction, will soon be completed and placed at the disposal of the Philippine Government. The Philippine veterans know that the hospitalizatiorr· benefits granted by the U.S. Government will automatically terminate on 31 December 1954. And it is the Philippine Government which will continue fulfilling this responsibility. However, our Government has recently had an exchange of notes with the Representative of the U.S. Government in the Philippines regarding the extension of Hospitalization benefits from 5 years (as embodied in the Rogers Act) to 12 years. There are at least two reasons for this. First, the Rogers Act did not take effect until 1 January 1950, pursuant to an Executive Agreement between the United States and Philippine Government. And second, very few veterans entitled to the benefit had a chance to apply for it in 1950, because they did not even know about it. VoJume XXX Number :2 EDITORIAL 101 Up to the present time, out of 6,503 Filipino veterans eligible for the hospital benefit, only 1,657 have taken advantage of it - leaving 4,846 still unhospitalized. This number will be further augmented, when the 4,289 pending claims are finally adjudicated. Besides, the U.S. Veterans Administration has been receiving an average of 350 claims a month since August 1, 1953. Whether the extension of hospitalization benefits will be granted or not will depend, of course, on the Congress of the U.S., now in session. But it is likely that America will take into consideration her position, not only in the Philippines, but also in the entire Far East; and the chances are that she will look with favor on the plight of Filipino disabled veterans, who fought for democracy side by side with her own sons. I, therefore, enjoin the officers and men in active service, the members of all veterans associations in the Philippines, the patients now confined in different contract hospitals, and their relatives to band together and put up a solid front for the common cause - to give the soldiers what is due them. Let us lend a hand to our comrades-in-arms who fought and suffered so we may enjoy our democratic way of life. - R. T. SALACUP. ··tjJI tJresihent's tlfage IJ~·· A. S. Fernando, M.D. PRIVATE PRACTITIONERS IN THE P.M.A. The Philippines Medical Directory (8th Edition, Golden Jubilee, 1953) - a publication which the PMA takes pride in presenting to the public - contains such important data on medical and health matters as lists of officers and members of the different medical organizations, particularly those affiliated with the P.M.A.; names and addresses of non-members of the P.M.A.; Philippine hospitals; Philippine medical and manufacturing houses; medical schools; and medical journals published in this country. We believe that in assessing the progress of medical and health services of a country, reliable information on the different branches of the service is essential. Likewise, before any proposal to change the existing set-up, we must analyze carefully the significance of the data available. With regard to the number of physicians engaged in private practice, and those in the employ of the government, we have compiled the following data, based on the short biographies of the members of the P.M.A. appearing in the Directory. In 1953, according to these data, there were 3,439 private practitioners and 851 physicians in the employ of the government - or 80.1 % and 19.9%, respectively, out of a total membership of 4,294. The members of the P.M.A., therefore, are predominantly private practitioners. 104 PRESIDENT'S P1\GE Jour. P.:M.A. February, l~H 'l'his is as it should be. We are absolutely against complete government control of the practice of medicine - as is in vogue in some countries, notably Russia. We want to preserve inviolate that intimate and confidential patient-physician relationship, as well as the patient's right to choose any physician he wants. At the same time, however, we are strongly for the encouragement of medical research sponsored by the government to advance our knowledge of medicine, and for giving adequate medical care of the truly indigent patients by our government physicians. Our Directory shows that these government physicians are distributed in the Department of Health, the College of Medicine, U.P.; the Medical Corps of the A.F.P.; and semi-government medical institutions. Some of these physicians are entitled to the privilege of private practice. The P.M.A. is expected, in all its decisions, to give proportionate concern to the professional interests of both the private practitioners and the government physicians, with the main objective of advancing the frontiers of medical knowledge, the raising of standard of medical practice, and the welfare of all classes of people. ··~II tlfllisrelhmenus IJ~·· ABSTRACTS FROM CURRENT LITERATURE ABSTRACTORS Honoria Acosra-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. Sarnia, M.D. DOES MENSTORIAL BLOOD CONTAIN A SPECIFIC TOXIN?-Br B. Zondek. Arn. J. Obst. & Gynec. 1953, 6>: 1065. It hos been claimed chat menstrual blood contains a toxin, an atypical euglobulin identical to nocrosin. And this toxin is supposed to be the cause of such abnormal symptoms as premenstrual tension and primary dysrnenorrhea. It is supposed also to stimulate the production of gonadotropins and adenocorticotrophins and is responsible for the endornetrial debridement. According to Smith and Smith it is this toxin in the menstrual blood which, when injected to infantile rats, causes 95% mortality. The author failed to confirm the findings of Smith & Smith. Zondek was careful co avoid baccerial contamination of the menstrual blood by making collection for one to three hour periods. With prolonged collection periods, Zondek found that animal mortality to be 60% suggesting bacterial contamination. Zondek stated chat when cultured, the menstrual blood contained in great quantities staphylococcus albus, staphylococcus aureus, an hemolytic streptococcus, streptococcus fecalis, escherichia coli, klebriella pneumoniae, and lactobacilli, with the bacterial count increasing proportionally to the increased time and contact between the blood and vagina. These organisms were recovered in the cardioc blood of animals which have appeared to die from toxic injections of menstrual blood. When the animals were given penicillin and streptomycin one hour before the injection of menstrual blood, the animals did not die. Zondek also failed to confirm the contention of Smith and Smith chat penicillin neutralizes the menstrual toxin and that penicillin and terramycin are good for creating toxernic patients. Zondek believes chat the value of these drugs lies in their antibiotic properties. They have no anti-coxernic property unless the source of the toxin is the bacteria. Commmt.-The Smiths claim to have isolated from the deciduo of women suffering from the toxemia of pregnancy a toxic substance which when injected subcutaneously is lechal to immature rats. This toxic material is said to be akin to the lethal material obt:rinable from the menstrual blood. Since Zondek failed to confirm the existence of lethal material from the menstrual blood after closely guarding it from bacterial contamination before injecting it to immature rats, I wonder if the resulc of Zondek's experiments can also apply to the postulated existence of a toxin in che decidua of women affected by the toxemia of pregnancy.-H.A.S. THE MANAGEMENT OF TOXEMIA OF PREGNANCY. By Dr. B. T. Mayer, Med. J. Australia, 1952, 2:352. In the toxemias of pregnancy we meet preeclamptic chronic hypertension, or a combination of both. Chronic hypertension, is a disease of the first 12 weeks. Pre106 ABSTRACTS FROJ'l CURRENT LITERATURE Jour. P.M.A. February, 195-t eclampsia is a disease of the last 12 weeks. It is not infrequent that chronic hypertension is complicated in the last 12 weeks of preeclampsia. One early sign of toxemia is excessive gain in weight. If this is removed by the modification of the patients' diet, the development of other signs of toxemia may not appear. When the excessive gain in weight is not corrected edema will appear which means considerable retention of water in the tissues. Edema interferes with function. Edematous liver, kidney or brain, cannot properly function and may give rise to serious consequences. Blood pressure above 120/ 80 Hg. is a sign of toxemia. But the blood pressure in pregnancy should be related to the blood pressure of the patient before the onset oi pregnancy. The presence of albumin in a cathetherized urine combined with a rise of blood pressure is a sign of toxemia. The principles of treatment arc: rest, diet, sedation, magnesium sulfate, intr1venous glucose, mercurial diuretics and delivery. Rest is a diuretic. There is perhaps better blood supply to the kidneys in the recumbent p9sition. The change in the diet is the reduction of the salt intake and to eschew the highly condimented foods. For sedatives the author gives 1/ 4 gr. phenobarbital J times daily at home. In the hospital, when stronger sedatives are necessary, he adds to the above one or two tablets of I Yz gr. pento_barbital sodium and 10 gr. chloral hydrate in the morning. In more severe cases, he gives intramuscularly J cc. of 5 0% magnesium sulfate solution and 4 cc. every 4 hours until 32 cc. have been given or the blood pressure has fallen below 140/90. The author gives also 20 cc. of glucose in 50% intravenously by syringe every 2 hours for 24 hours. This raises the blood sugar level and stimulates diuresis without the risk of introducing too much fluid. The author is against mercurial diuretics but has used mersalyl on occasion with safety. With the above treatment, most of the patients can be carried to 3 6 weeks apd a viable child. In preeclampsia when the systolic pressure is over 160 and there is much albuminutia with the patient at rest in bed, pregnancy should be terminated. Further delay is injurious to the mother and offers no advantage to the fetus. In chronic hypertension, if the patient has developed albuminuria, pregnancy should be interrupted at rhe end of 36 weeks. When there is no albuminuria, pr<gnancy may be allowed to continue until after 38 weeks. In cases of chronic nephritis, pregnancy should be terminated at the end of 36 weeks. The danger of concealed hemorrhage in the last 4 weeks is great in chis disease. In a multipara or in a primigr:ivida with "ripe" cervix, he provokes labor by rupturing the membranes. In a primigravida with a "unripe" cervix, the author strips the membranes then administers 3 hypodermic injections of 3 minims of pitocin at shore interval. If labor is not definitely established within 24 hours, he performs low cesarean section after giving prophylactic injection of penicillin and streptomycin to forestall infection. Co111111e11t. On the whoie, the above management of the toxemias of pregnancy is sound, specially the idea of rest as being diuretic and educational. There is no doubt that rest must have a sedative effect on the nervous system. We have not found necessary to use mercurial diuretics to stimulate the kidneys to excrete. Intravenous glucose was enough to do the work. We believe that mercurial diuretics are irritant to the kidney cells. We do not subscribe to the idea of gi\'ing pitocin to induce labor sp_cciaJly with the strong dose of 3 minims given 5 times. So far, we have succeeded to induce labor merely by rupturing the membranes. Pitocin mJy increase the blood pressure which is Jlready high. In one case, it gave rise to convulsions which ended in death.-H.A.S. ·tjJI ORGANIZATION SECTION rn~·· ANNOUNCEMENT FIRST POSTGRADUATE REFRESHER COURSE The First Postgraduate Refresher Course will be offered by the Philippine Medical Association free of charge to all its members in good standing. This will be held in the three big hospitals m Manila-P.G.H., U.S.T. and N.G.H., from April 15-24, 1954, or the week preceding the Annual Meeting. The course will be mainly in the form of bedside conferences to be given daily from 9:00 to 12:00 noon and 2:00 to 4:00 p.m. The number of applicants will be limited to 20-2 5 for each conference depending upon the facilities of the particular hospital concerned. Tickets will be issued to applicants. There will be five evening sessions on subjects of general interest to be held in the Science Hall of the P.G.H. If you have any particular subject to suggest, the Committee on Scientific Assembly will appreciate your sending your suggestions for consideration. Those interested in taking the course, please communicate with the Secretary-Treasurer of the P.M.A., Dr. Manuel D. Penas, at the U.S.T. Hospital, or with the Chairman of the Committee on Scientific Assembly, Dr. Jose Villanueva, at the P.G.H. First Come, First Served. * ANNOUNCEMENT Scientific exhibitors must submit the subject of their exhibits and their outlines before the end of February. All exhibitors are requested to submit mimeographed copies of the description of their exhibits to be distributed to the members during the coming Annual Meeting. * ANNOUNCEMENT Third call for tides and abstracts of papers for the Scientific Meeting of the 47th annual meeting of the Philippine Medical Associnion, April 26-30, 1954. Submit all tides and abstracts to the Chairman, Committee on Scientific Assembly, Dr. Jose Villanueva. at the Philippine General Hospital, or to the Secretary-Treasurer of the Association at the University of Santo Tomao Hospital. ··tjII SOCIETY ACTIVITIES I~·· Testimo11ial Di11ner honoring Secretary of Health, Dr. Pa11li110 J. Garcia a11d others .~h·e11 by the P.M.A. and allied medical organizations. Fro"' left to right are Dr. Juan Salcedo, Jr., former Secretary of Health; Dr. Paulino J. Garcia; Dr. Antonio S. Fernando, P.M.A. President; Senator Jose C. Locsin; Dr. Rafael Tumbokon, Undersecretary of Health; Dr. Regino G. Padua, former Undersecretary of Health, and Dr. Tomas M. Gan. Sta11di11g before the microphone is Dr. Rodolfo P. Gonzalez introducing the physiciancongressmen of the Third Congress of the Philippines, and Dr. Ma1111el D. Peiias, Sec.Treasurer of the P.M.A., and Mas/er of Ceremonies. P.M.A. GIVES TESTIMONIAL BANQUET.-The Philippine Medical Association with its component medical societies, affiliated sections, women's auxiliaries and other medical organizations gave a Testimonial Banquet in honor of the Secretary and Undersecretary of Health and the Former Secretary and Unde.rsecretary of Health and the Physician-members of Congress in the evening of January 26, 19H, at the Fiesta Pavilion, Manila Hotel. The honorees were Hon. Paulino J. Garcia, Secretary of Health; Hon. Juan Salcedo, Jr., for Secretary of H ealth; Hon. Rafael Tumbokon, Undersecretary of Health; Hon. Regino G. Padua, former Undersecretary of Health; Hon. Jose C. Locsin, Senator of the Philippines; Hon. Emilio Cortez, Representative from Pampanga; Hon. Nicolas G. Escario, Representative from Cebu; Hon. Ricardo Gacula, Representative from Ilocos Sur; Hon. Mateo S. Pecson, Congressman from Masbate; Hon. Gregorio B. Tan, Representative from Samar; Hon. Pedro G. Trono, Representative from Iloilo; and Hon. Lorenzo P. Ziga, Representative from Albay. Volume X1X Num~r 2 SOCIETY ACTIVITIES 109 The Secretary-Treasurer of the Philippine Medical Association, Dr. Manuel D. Penas, acted as the master of ceremonies. Dr. Romeo Y. Atienza, President of the Manila Medical Society, introduced the presidents, past presidents and representatives of component medical societies, affiliated specialty societies and other medical groups. Dr. Rodolfo P. Gonzalez introduced the physician-congressmen, while Dr. Ramon R. Angeles, introduced former Secretary of Health Dr. Juan Salcedo, Jr. Dr. Salcedo ga,·c brief remarks and urged cooperation with the new Secretary of Health and offered a toast to his health. Dr. Fernando, President of the P.M.A., introduced Secretary of Health Dr. Paulino J. Garcia, who responded with a coast to former Secretary Salcedo and delivered his message to the medical profession (published elsewhere in this issue). More than 600 guests were present representing almost all regions of the Philippines. A short musical interlude was rendered by Miss Juanita R. Javier who sang "Lon" is Where You Find It" and "Sa Libis ng Nayon," with Miss Julie D. Veloso on the piano. In connection with this testimonial banquet letters of congratulations were received from the Abra Medical Society, Agusan Medical Society, Zamboanga del Norr< Medical Society, Misamis Occidental Medical Society, and Camarines Sur Medical Society. Also, telegrams congratulating the honorees in the testimonial banquet were recei,·ed from Bataan Medical Society, Bohol Medical Society, Camarines Norte Medical Society. Davao Medical Society, Iloilo Medical Society, and its Women's Auxiliary, Lanao Medical Society, Leyte Medical Society, Misamis Occ. Medical Society, Negros Occ. Medical Society, Sulu Medical Society and the Zamboanga Medical Society. MANILA MEDICAL SOCIETY HOLDS SCIENTIFIC MEETJNG.-With Dr. Agerico B. M. Sison, Dean of the College of Medicine, University of the Philippines as main speaker, the scientific meeting of the Manila Medical Society was held February 16 at the Library Science Hall of the Philippine General Hospital. The meeting was called to order by Dr. Romeo Y. Atienza, President of the Society followed by a welcome address by Dr. Jose M. Barcelona, Assistant Director of the Hospital. Dr. A. B. M. Sison presented "Abdominal Manifestations of Malaria" with Dr. Francisco Diy, Lt. Col. Conrado Icasiano, and Dr. Hermogenes A. Santos as discussants. An open forum was held immediately after this. . MANILA MEDICAL SOCIETY INDUCTS OFFICERS.-The newly elected officers of the Manila Medical Society headed by Dr. Romeo Y. Atienza were inducted into office in a brief ceremony held at the Officers Club, Philippine Navy, on Dewey Blvd. on the evening of January 19, 1954. After the call to order was made the program was opened with remarks from the Society's out-going President, Dr. Heraldo de! Castillo, followed by a musical interlude rendered by Prof. Remedios Corpus Moya, Soprano. After this interlude the induction ceremony was held with the Honorable Secretary of Health, Dr. Paulino J. Garcia, administering the oath of office to the new officers. Upon assumption into office Dr. Romeo Y. Atienza delivered his inaugural address. The second portion of the program is a social interlude offered by the Council for 1954 of the Manila Medical Society. The other officers inducted into office were Dr. Antonio M. Samia, Presidentclect; Dr. Antonio 0. Gisberr, Vice-President; Dr. Ruben Apelo, Secretary-Treasurer. The Councilors are: Drs. H. del Castillo, V. Ramos, A. Ayesa, H . A. Santos, J. R. Cruz, B. Barrera, C. P. Jacinto, R. Alfonso, and S. Y. Maceda, Jr. GENERAL MEETING OF THE P.A.O.M.-The Philippine Association of Occupational Medicine held a General Meeting at the Conference Room, Sharp & Dohme, on Isaac Peral, Manila, on the evening of January 27. The program started with an opening remark by the Association's President, Dr. Enrique S. Reyes followed by the exhibition of medical film by Sharp and Dohme. New members were then inducted followed by the reading of a scientific paper on "Industrial Medical Practice in National Development Company" by Dr. Antonio de la Fuente, Medical Director, N.D.C. Discussions were led by Drs. Trajano Bernardo, Victorino de Dios, and Enrique S. Reyes. 110 SOCIETY ACTIVITIES Jour. P.M.Ao February, 19.l4 A proposal to grant a yearly award in the form of plaque to a physician for outstanding contribution in the field of industrial medicine was discussed by the members assembled. The usual business meeting was also held. CAVITE MEDICAL SOCIETY IN FORTY-SECOND MEET.-The 42nd scientific meeting of the Cavite Medical Society was held at the Seven Seas Hall in Cavite City January 31. The installation of new officers was also held. The program was opened with remarks by the out-going President, Dr. Jose N. Rosal. The new officers were then installed into office with Dr. Dominador I. Mangubat, City Mayor, administering the oath of office. After his induction the new President, Dr. Pacifico T. Arca, delivered an inaugural address. Dr. Teodorico A. Jimenez, Councilor, introduced che Society's Guest Speaker, Dr. Dominador I. Mangubat who spoke on "Medical Echics." Luncheon was offered and three prizes were donated by Mr. Jim Boo Chan, proprietor of the Pagoda Kitchen. These prizes were given away by raffles. The ocher inducted officers for 1954 were Dr. Lazaro Udasco, Vice-President; Dr. V. R. Borromeo, Sec.-Treasurer; and Councilors arc Drs. f N. Rosal, J. Alejo, C. Bellaflor, ]. Elises, J. Tranquilino, rnd S. Chan. When the officers of the PHILIPPINE FEDERATION OF PRIVATE MEDICAL PRACTITIONERS made a courtesy call and pledged their full support and cooperation lo the new Secretary of Health, Dr. Paulino]. Garcia, Jan. 8, 1954 at the Offir·e of the Department of Health. Photo shows: (left to right): Drs. Antonio M. Samia, Ro111ro H. Gusti/a, Olimpia L. Villacorta, Ramon R. Angele.<, PFPMP president, Hea//h Sccre/ary, Dr. Paulino ]. Garcia, (seated), Dr. Ramon Atiew:.a, Jr., secretary-treasz1rl'r, aud Dr. Pablo Anzures, vicc-p"sident, PFPMP. P.0.0.S. IN NINTH INAUGURAL PROGRAM.-The ninth in.1ugural progr>m of the Philippine Ophthalmological and Otolaryngological Society was held January 29 ac the Aristocrat Pavilion on Dewey Boulevard. Dr. J. Eusebio made an opening remark. The new officers were inducted into office by the President of the Philippine Medical Association, Dr. Antonio S. Fernando. Also the new Fellow of the Specialty Society was inducted by Dr. Edmundo Reyes, Chairman, Qualifying Board. After his induction Dr. Carlos Y. Yambao, President, delivered an inaugural address. Dr. Yambao stated that .specialty practice is affected by scientific, economic, political and social factors and that the area of community service has shifted from one that has been predominantly urban to another that is decidedly rural. Of the 12-point program enunciated Vol~me XXX Nu1n;.ber Z SOCIETY ACTIVITIES 111 by the Secretary of Health which is designed to implement the health program of President Magsaysay, Dr. Yambao gave especial mention co points I, 2, 8, 10 and 11 which call for reassignment of government physicians to places without physicians, to subsidize doctors .... who are willing to practice in rural areas, to encourage Community participation in health problems, to give special attention co diseases chat cake a heavy toll in lives and cause widespread ill-health and non-productivity, to safeguard the health of school children, and co carry out an intensive health education program, respectively. He urged positive collaboration between che P.0.0.S. and che Department of Healch co determine in what way EENT services might be brought not merely within the reach of, but to the very doors of rural population especially the children of pre-school and school ages. He suggested ways for study. Firstly, periodic direct and/or consultative curative services to rural areas; secondly, intensive health education of the masses in this particular field; and thridly, a revision or redirection of certain aspect of medical education so as to prepare graduates for service to rural areas. Dr. E. Reyes introduced the guest speaker, the Secretary of Health, who delivered an address. The usual business meeting was held. P.F.P.M.P. HOLDS GENERAL BUSINESS MEETING.-The Philippine Federation of Private Medical Practitioners held a general business meeting and a visit to the Arguz Pharmaceutical Products in Washington Ave., Manila, on the evening of January 23, Discussed in chis meeting were the proposed medical legislations to be presented to the Secretary of Health and. indorscd co the Fourth Congress of the Philippines, for approval. Among these are (a) Amending Republic Ace No. 546 regarding the appointments to the Boards of Examiners and ocher matters; (b) A new Medical Law co supersede the existing obsolete provisions in the Administrative Code; (c) Amendments to existing Labor Laws regar.ding cbe employment of physicians and the provisions of Medical Services in industry; (d) A law converting all Public Hospitals into indigent or charity hospitals, especially in areas where private hospitals exist. These proposals were made by Dr. Pablo Anzures, LLB., M.D. Photo taken during the 4th anniversary celebration of the Misamis Occidmtal Medical Society held at Ozamis City last Jan. 9 with the Director of Hospitals, Dr. Tra11quilino Elica11o, as Guest Speaker. May be seen above is Dr. Elica1io together with tin· officers and members of the Society. At the reception and ball given in bo11or of Dr. Elicaiio the newly elected officers of the Society W<"'e i11ducted into office. The new officers are Dr. Jesus Sanciangco, President; Dr. I. Al111011te, Vice-President; Dr. N. S. Villanueva-Bernadez, Sec-Treasurer; Dr. J. Dignum, Asst. Sec-Treasurer; Dr. G. Engracia, Librarian. Members of the Board of Directors arc Dr.. J. Lib1111ao, E. Herrera, S. Clarefe, ]'. Feliciano, F. Luaming, and H. Ramiro. 112 SOCIETY ACTIVITIES .Jour. P.M.A. February, 195.f PHILIPPINE HEART ASSOCIATION IN ANNUAL MEETING.-The Philippine Health Association held its annual meeting on Valentine's Day, February 14, at the Philippine Columbian Association Bldg., Library. This Association now under the presidency of Dr. Jose M. Barcelona, had the Secretary of Health, Dr. Paulino J. Garcia, as its guest of honor. The complete program follows: ( 1) Call to order; (2) Reading of minutes and financial report by Dr. C. Dayrit, Sec.-Treas.; (3) Announcement of the Winners of the Burke Award with Intern Benigno Aldana, Jr. for U.P., and Intern Aurora S. Padolina for U.S.T. as recipients; ( 4) Distribution of Manila Medical Society Postgraduate Seminar Certificates; (S) Announcement of new regular members; (6) Address by Dr. ]. M. Barcelona, President; (7) Introduction of the Guest of Honor by Dr. Antonio M. Samia, Vice-President; ( 8) Address by the Guest of Honor-Hon. Paulino Garcia; (9) Election of officers and the Executive Committee; (10) Induction of officers and the Executive Committee, 1954-195 5 by Dr. Antonio G. Sison, Honorary President, Philippine Heart Association. LA UNION MEDICAL SOCIETY HOLDS ELECTIONS.-Thc 1954-1955 officers of rhe La Union Medical Society were elected in a meeting held February 7 at San Fernando, La Union. The following were the new officers: Dr. Marcelino T. Viduya, President; Dr. Oscar Madamba, Vice-President; Dr. Asuncion C. Ocampo, Sec.Treasurer; and Councilors, Drs. Bruno Gaerlan, Francisco Padua, Bienvenido Nebres, and Fidel Lopez. Dr. Antonio Encarnacion is the Press Relation Officer. This is the third rime that Dr. Viduya holds the presidency of the La Union Medical Society. PANGASINAN MEDICAL SOCIETY HOLDS 49TH SCIENTIFIC MEETING AND ELECTION OF OFFICERS.-With Dr. Quintin Gomez, Chief Anesthesiologist of the Philippine General Hospital, as guest speaker, the 49th scientific meeting of the Pangasinan Medical Society was held December 20th last year. In conjunction with this scientific meeting the annual election of officers was held with the following elected to hold the helm of the Society for the year 1954 to 1955: Dr. Francisco Q. Duque, President; Dr. Alfredo Tengasantos, Vice-President; Dr. Braulio M. de Venecia, Sec.Treasurer, Dr. Lydia Urgena, Sub-Sec.-Treasurer; Dr. Pedro E. Sevidal, Auditor, Dr. Abelardo W. Tan, P.R.O.; and Drs. P. Castelo, M. P. Posadas, A. Domagas, M. Martinez, M. Bravo, and P. de Venecia, Councilors for first. to the fifth District and Dagupan City, respectively. NEW OFFICERS FOR PAMPANGA MEDICAL SOCIETY.-The annual election of officers of the Pampanga Medical Society was held in Bacolor, this province, during a whole day social affair January 2. The elected 19 5 4-19 5 5 officers arc as follows: 1).r. Mariano D. Bayani, President; Dr. Feliciano L. Pacia, Vice-President.; Dr. Pedro G. Banzali, Secretary; Dr. Rose Catap, Treasurer; Dr. Carlos Pangan, Ass't Treasurer; and Drs. B. R. Roa, P. de Guzman, M. Mercado, F. Garcia, P. Pineda, Councilors. Luncheon was served through the courtesy of Squibb and Sons. After the luncheon speeches the program was enlivened by the presentation of Moro Folk Dances, songs and others performed by the Children of the members. NEW OFFICERS FOR THE BATAAN MEDICAL SOCIETY.-In a recent lecter co the Secretary-Treasurer of the Philippine Medical Association the following officers of the Bataan Medical Society were reported elected sometime last October, 1953: Dr. Mariano Bamba, President; Dr. Melanio Banzon, Vice-President; Dr. Leoncia Wambang.co, Sec.-Treasurer; and Drs. F. Pascual, M. Su. Maria, N. Gabaya, and B. Casimiro, Councilors. Volume X:XX :Number 2 NEWS ITEMS 113 COTABATO MEDICAL SOCIETY GETS NEW OFFICERS.-ln an election held December 19, 1953, by the Cotabato Medical Society the following were duly elected: Dr. Vicente J. Capistrano, President; Dr. Leonardo C. de Guzman, Vice-President; Dr. Jose F. Serrano, Sec.-Treasurer; Drs. Samuel Rayola, Esteban Eliazo, Eulogio Ladores, Bienvenido Hizon, Kararula Balhaman, an!l.Jiergio Morales, Councilors. T ARLAC MEDICAL SOCIETY ELECTS NEW OFFICERS.-In a recent election held by the Tarloc Medical Society the following were elected for the year 1954: Dr. Trinidad Esguerra, President; Dr. Adela Espinosa, Vice-President; Dr. Juan Talon, Sec.-Treasurer; and Drs. T. Santos, S. de los Santos and M. Corpus, Councilors. THE BAGUIO MEDICAL SOCIETY held its annual ellection of officers last January 23, 1954, at the Patria Building, Session Road, Baguio. The newly-elected officers are: President, Dr. Dominador R. Narvaez; Vice-President, Dr. Hector T. Lopez; Secretary-Treasurer, Dr. Antonio H. Adorable; Councilors: Dr. Fernando D. Manalo, Dra. Jaci.nta Acena-Abando, and Dr. Lazaro P. Ricafort. The outgoing officers are: President, Dr. Fernando D. Manalo; Vice-President, Dr. Dominador R. Narvaez; Secretary-Treasurer, Dr. Floro T. Bongco; Councilors: Drs. Josefina A. Gorospe, Dr. Teodoro C. Arvisu and Dr. Efrain Montemayor. At the same time the society honored Dra. Jacinta Acena-Abando and Dr. Emilio Reyes, two of its members who had just successfully passed the recent bar examinations. THE PHI~.IPPINE OBSTETRICAL AND GYNECOLOGICAL SOCIETY HOLDS INDUCTION CEREMONIES.-Meeting at the Philippine Columbian at T>ft Avenue, the Philippine Obstetrical and Gynecological Society held an induction of officers of the year 1954, with the Hon. Paulino J. Garcia, Secretary of Health, as administering officer. The program was opened with an invocation by the Rev. Fr. Jesus Diaz, 0. P. Regent, U.S.T., followed by a short remark by Dr. Jose Villanueva, Outgoing President of the Society. New Fellows of the Society were inducted and diplomas were awarded. The recipients were Drs. Rosario Isidro-Gutierrez, Pedro M. Cajipe, Marcelo D. Cruz, and Diego C. Valenzuela. The newly elected officers were then inducted mto office with rhe Hon. Paulino J. Garcia, Secretary of Health, officiating. Dr. Alfonso Ayesa, new President of the Society delivered an inaugural address followed by an address by the Secretary of Health. The other inducted officers follows: Dr. Noe Espinola, Vice-Pre~ident; Dr. Gloria T. Aragon, Sec.-Treas.; and Dr. Julita Ramoso-Jalbuena, Asst. Sec.-Treasurer. NEWS ITEMS DR. PABLO]. NANAGAS of Lucena, Quezon, Philippines has registered for two courses in Ophthalmology at the Post-Graduate Medical School of New York University-Bellevue Medical Center. The first course which he has already completed, was a part-time course of five days' duration-consisting of differential diagnosis of diseases of the anterior segment of the eyeball and different mediums of the eye. le was given under the direction of Dr. Girolamo Bonaccolto. The second course is a nine months' course from September 28, 195 J through June 18, 19 54. It deals in the basic sciences as applied to ophthalmology and is followed by a residency in a hospital approved by the school. The course is given under the direction of Dr. A. Gerard DeVoe, professor and chairman of the Department of Ophthalmology. Dr. Naiiagas is on the staff of Quezon Memorial (Pro\'incial) Hospital in Lucena, Philippines. He is also a Fellow in the Philippine Ophthalmological and Otolaryngological Society. 114 NEWS ITEMS Jou!'. P.M.A.February, 1901 imerlci1 Greale~-:--s - LINN'S vVEEKL y s - PER. s1001 l!iiilafelic Kewspa•et , TAMP NEW YEAR. j AH~... . . s NGLE 'COPY ·6c ~oLXXVi" Ho. 39 · SIDM!Y, 0~.!_ 0. DfC!MifA 7, ltSJ \j_ WS.oh Nu""bc* 130t Medical Associatio Is Honored Philippine Islands Plaus 2 Stamps Decemlwr 16 For Group's 501.b Armiversarv It. ~t.mtY '4 ~<.f ~r:;.o !Nm Ii"> Pl>l!!Yfll'.11<$. "'.4L i.~, ... !sir ... .u. u . ... ;;1 ... r~.l<Afftl ~ .. .., .. 1<"J.cl'!lbl.c Front page of the Linn's Weekly Stamp News describing the issuance of a special commemorative stamp of the Pbilippine Medical Association commemorating its Goldeu Jubilee, Post-Graduate Medical School is p>rt of the ncwl)' developed Medical Center of New York University which proposes to serve the community and the nation through an integrated program o.f medical research, training and care. PAN-PACIFIC SURGICAL ASSOCIATION SIXTH CONGRESS, Honolulu, Hawaii, October 7-18, 1954, Doctors are cordially invited to attend the Sixth Congress of the Pan-Pacific Surgical Association to be held in Honolulu, October 7-18, 1954, and are urged to make arrangements as soon as possible if they wish to be assured of adequate facilities, An outstanding scientific program with over 100 leading surgeons, including sessions in all divisions of surgery and related fields, promises to be of interest to all members of the profession. An extensive social program is being developed for the doctors' families, The Association office has been appointed· as travel agent for those attending the Congress and it is important that all hotel and travel reservations be made through the Honolulu headquarters of the Pan-Pacific Surgical Association, For further information, please write to F. J. Pinkerton, M.D., Director General, PAN-PACIFIC SURGICAL ASSOCIATION, Suite Seven, Young Building, Honolulu, Hawaii. Volume XXX Number 2 ANTI - SHOCK II SUBTOSAN Xlll II Makes it possible to postpone or lo replace blood or plasma transfusion, soc1n~ PARISIENNE DEXPAMSIOM CHIMIQUE ..... ~~·· PARIS ____ ? ___ _ ~-----· Hemorrhages Shock Severe Burris Athrepsi• C1chexia -----> ----FORMULA 3.5 3 solution of Polivinylpyrrolidont and Mineral Salts in Physiolo9ical XIV .Juu1·. P.M.A. Februnry, 19::.4 Jn 1:11fectious and allerg1·c l'hinitis and sinusitis Biomydrin "is effective as an antibiotic in clearing the nose of pathogenic organisms and purulent secretions. In many cases, sterile cultures were obtained after a brief period of treatment." Antibiotics & Chemotherapy 3 :299 (March) 1953. Improvement in 113 of 124 Patients* Number Dlagnoeie of patients lmpro"·ed Chronic catarrhal rhinitis 11 11 Chronic allergic rhinitis 26 25 Right maxillary sinusitis 2 1 Chronic naso-pharyngeal catarrh 6 6 Chronic suppurative sinusitis 3 3 Coryza, Head cold, Catarrhal rhinitis 58 51 Influenza 2 1 Acute catarrh 4 3 Hypertrophic rhinitis 12 12 TOTAL 124 113 (91.1%) • Ey~. E"r, Nose and ThroatMonthlyU:612 (Sept.) 1963. BIOMYDRIN The Biomydrin formula THONZONIUM BROMIDE 0.05%. Synthesized in the Nepera laboratories. Exceedingly potent antibacterial. Greatly enhances the antibiotic activity of neomycin· and gramicidin. Reduces surface tension, facilitating spreading and penetrating. Mucolytic. NEOMYCIN SULFATE 0.1 % . Effective against gram-positive and gram-negative organisms. GRAMICIDIN 0.005%. Effective against gram-positive organisms. PHENYLEPHRINE HCI 0.25%. Widely preferred vasoconstrictor. THONZYLAMINE HCl 1.0%. Therapeutic concentration of this effective antihistaminic aids in controlling local allergic manifestations. • Prompt, prolonged shrinkage of nasal mucosa without secondary congestion. • pH is 6.2. Isotonic and buffered. • Does not interfere with ciliary activity. • Spray covers larger area than could be reached by drops. • Available on prescription only. llOSAGI: Adalta-2 or a 1pray1 In eacb noatrll: 4 or ' timca a da1 u needed, or aa directed by physician.. Cbllclren-1 or 2 apraya In each nostril: 4 or 6 timts • day as neNN. or H directed by physician. N epera Chemical Co., Inc. Pharmaceutical Manvfacturers, Y onkera 2, N. Y. New a11tihypertensizie agent SERPA SIL* for the treatment of essential hypertension whether benign or malignant S E R P A S I L treatment is safe and simple Packages: Tablets (0.1 mg.) - bottles of 50 Tablets (0.25 mg.) - bottles of 40 Samples and literature supplied on request. CIBA LIMITED, BASLE, SWITZERLAND Further information and samples may be obtained from our Sole Agents in the. Philippines: lleMl"S. INHELDER. INCORPORATED 143-149 Sta. Potenciana St. I Old lntramuros), Manila Telephones: 3-32-66 & 3-32-67 three ~~'~ Chloromycetiii Chloromycetin Cream Chloromycetin Ophthalmic (powder for solution) Chloromycetin Ophthalmic Ointment Extending its fields of usefulness, CHLOROMYCETIN ( Chloramphenicol, Parke-Davis) now provides topical therapy with the same outstanding advantages for which its systemic administration is so well known: UNIFORMITY • RELIABILITY BROAD SPECTRUM • WELL TOLERATED Chlorom ycetin Ophthalmic (powder for solution) Chloromycetin Ophthalmic Ointment CHLOROMYCETIN Ophthalmic preparations provide high local concentrations - without irritation - for treatment of ocular infections. LPARKE~·DAVIS & ,COMPANY Philippine Representativ~ P. L. KATIGBAK, lU.D. P. 0. BOX 1407, MANILA