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History of Nursing in Pacific Canada
Vancouver Medical Association
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BULLETIN Published By The Vancouver Medical Association EDITOR: dr. j. h. MacDermot EDITORIAL BOARD DR. D. E. H. CLEVELAND DR. J. H. B. GRANT DR. H. A. DesBRISAY DR> D A STEELÂ£ Editorial and Business Office 203 Medical-Dental Building Publisher and Advertising Manager Vancouver, B. C. -'M W. E. G. MACDONALD VOL. XXVI JANUARY, 1950 NUMBER 4 OFFICERS, 1949-50 Dr. TV. J. Dorrance Dr. Henry Scott Dr. Gordon C. Johnston President Vice-President Past President Dr. Gordon Burke Dr. W. G. Gunn Hon. Treasurer Hon. Secretary Additional Members of Executive'. Dr. J. C. Grimson Dr. E. Q. McCoy TRUSTEES Dr. G. H. Clement Dr. A. C. Frost Dr. Murray Blair Auditors: Messrs. Plommer, Whiting & Co. SECTIONS Clinical Dr. M. M. MAcPHERSON_Chairman Dr. W. H. S. Stockton Secretary Eye, Ear, Nose and Throat Dr. J. F. Minnes Chairman Dr. N. J. Blair Secretary Paediatric Dr. J. R. Davies Chairman Dr. C. J. Treffry Secretary Orthopaedic and Traumatic Surgery Dr. R. H. B. Reed Chairman Dr. D. E. Starr Secretary Neurology and Psychiatry Dr. G. H. Gundry Chairman Dr. G. M. KntKPATRiCKâ_Secretary Radiology Dr. W. L. Sloan . Secretary Dr. Andrew Turnbull Chairman STANDING COMMITTEES Library: Dr. R. A. Palmer, Chairman; Dr. E. F. Word, Secretary; Dr. J. E. Walker; Dr. S. E. C. Turvey; Dr. A. F. Hardyment; Dr. J. L. Parnell. Summer School: Dr. D. S. Munroe, Chairman; Dr. A. C. Gardner Frost, Secretary; Dr. E. A. Campbell ; Dr. J. A. Ganshorn ; Dr. Gordon Large; Dr. Peter Lehmann. Medical Economics: Dr. J. A. Ganshorn, Chairman; Dr. Paul Jackson ; Dr. W. L. Sloan ; Dr. E. C. McCoy; Dr. J. W. Shier; Dr. T. R. Sarjeant; Dr. John Frost. Credentials: Dr. H. A. DesBbisay ; Dr. G. A. Davidson ; Dr. Gordon C. Johnston. Representative to B. C. Medical Association : Dr. Gordon C. Johnston. Representative to V.O.N. Advisory Board: Dr. Isabel Day. Representative to Greater Vancouver Health League: Dr. L. A. Patterson Representative to the Board of Trustees for the Medical Care of Social Assistance Cases: Dr. J. A. Ganshorn . â¢; t-ij is 1; Kll i 1 I 111? iftfiH; â i|i.l||f 1 IK illlr {W IF fit HI* ImflM i' I'B 1 J ill 1 lllllil IIIIS Hwiif Patency of the normal drainage exits of the nasal accessory sinuses is of great importance in the care of upper respiratory infections. Neo-Synephrine hydrochloride;*,'applied by any of the common methodsâdropper, spray, tampon, dasplacementlb-constricts the engorged mucosa surrounding the ostia, promoting free drainage and aeration. NEO-SYNEPHRINEÂ® Hydrochloride Brand of PHENYLEPHRINE HYDROCHLORIDE Solution 0.25% (plain or with aromatics) and 1% â 1 oz. bottles. Jelly 0.5% â % oz. tubes. NEO-SYNEPHRINE, trademark reg. U, S. & Canada. NBÂ¥ YOUK 13, N. Y. WiNDSO*, OWL ttfC. 443 SANDWICH STREET WEST, WINDSOR, ONTARIO VANCOUVER MEDICAL ASSOCIATION Founded 1898; Incorporated 1906. KINDLINESS PROGRAMME FOR THE FIFTY SECOND ANNUAL SESSION (Spring Season) JANUARY 3rdâGENERAL MEETING (Postponed). FEBRUARY 7thâGENERAL MEETING "PROBLEMS IN PUBLIC HEALTH" (Panel Presentation) Metropolitan Health Committee. (Date to be announced)âSPECIAL MEETING, SpeakerâJrofessor F. H. Bentley, Department of Surgery, University of Durham Medical School, England. MARCH 8th (WEDNESDAY) "OSLER LECTURE"âPresented by DR. GEORGE A. DAVIDSON, HOTEL VANCOUVER (Title to be announced). MARCH 28 thâSPECIAL MEETINGâ"Lecture by Dr. Cecil Watson, Professor of Medicine, University of Minnesota (Title to be announced). APRIL 4thâGENERAL MEETINGâ"The Problem of the Prostrate", Dr. L. G. Wood. MAY 2ndâANNUAL MEETING. It has been the practise in the past to hold a meeting of the Clinical Section of the Vancouver Medical Association on the third Tuesday in each month. These meetings were held at alternate hospitals and due to this fact, often two Clinical meetings were held at a hospital in one month. To overcome this situation a plan has been worked out whereby the members of the Vancouver Medical Association are invited by the various hospital Directors to attend their Clinical Staff meetings. These meetings will be held as follows: Second TuesdayâShaughnessy Hospital Third TuesdayâSt. Paul's Hospital Fourth TuesdayâVancouver General Hospital Notice and programme of these meetings will be circularized by the Executive Office of the Vancouver Medical Association. fl&ount pleasant Tflnbertafcing Co. %tb. KINGSWAY at 11th AVE Telephone FAirmont 0058 VANCOUVER, B. C. UNDERSTANDING DEPENDABILITY Page 74 INSULIN PROTAMINE ZINC INSULIN In treatment of diabetes mellitus, it is frequently necessary to supplement control of diet and exercise by the regular use of Insulin or Protamine Zinc Insulin. INSULIN-TC )RONTO â 10-cc . vials, ; 40 and 80 units per â cc. Made from Zinc-Insulin Crystals Eapid Effect â Short Duratidu â¢ftfjr PROTAMINE ZINC INSULIN - â 10- cc. vials, ;40 and 80 units per cc. Comparatively Slow Effect â Prolonged Duration CONNAUGHT MEDICAL RESEARCH LABORATORIES University of Toronto Toronto 4, Canada DEPOT FOR BRITISH COLUMBIA MACDONALD'S PRESCRIPTIONS LIMITED MEDICAL-DENTAL BUILDING, VANCOUVER, B.C. Beminal' with IRON and LIVER For the correction of IRON DEFICIENCY ANEMIAS These capsules are especially designed to disintegrate rapidly in the stomach in order to achieve higher absorption and utilization. They are well tolerated by practically all patients. Each capsule (No. 876) contains: Ferrous Sulfate, B.P. (323 mg.).... 5 grains Liver Concentrateâequivalent to 5 Gm. fresh liver Thiamin Chloride 1 mg. Riboflavin 2 mg. Niacinamide 10 mg. Pyridoxine 0.5 mg. Calcium d-Pantothenate 1.84 mg. together with other vitamin B factors as found in 150 mg. specially processed brewers' yeast. Supplied in bottles of 100 "BEMINAL" for vitamin B factors HH WITH VITAMIN C (Fortis) â¢ CONCENTRATE â¢ INJECTABLE â¢ GRANULES INJECTABLE (Fortis) . COMPOUND â¢ LIQUID â¢ TABLETS Ayerst, McKenna & Harrison Limited â¢ Biological and Pharmaceutical Chemists â¢ Montreal, Canada AMINO-BESMIN / COLCHICINE HOUDE I / DIGITALINE NATIVELLE / DYSPNE-INHAL / EUPNOGENE / Ll POTROPE N ITRINOSE XANTOPHEN FRERES STRICTLY ETHICAL SPECIALTIES 350 LEMOYNE STREET, MONTREAL 1, P.Q Some time ago the medical profession of B. C. received a letter from the Welfare Dept. which has to do with payment for drugs prescribed for Social Assistance casesâ notifying them that in future only prescriptions based on the B. C. Formulary would be paid for. Hitherto, this had not been the caseâand while, from time to time, the Depai^ment might protest about specific instances, yet the bills were paid. This has now been changed, on the score of necessary economy. The Department will not pay a druggist, if he fills prescriptions that do not conform to the new ruling, unless special permission is obtained in special circumstances. We understand that quite a few medical men have been greatly disturbed by this regulation, and have been protesting vigorously. Blame has been laid on the druggist, for not filling the prescriptionâon the Formulary, for not including many things which these men feel are necessary in their practiceâand on the Department for rigidity and autocratic behaviour. A little thought and attention to the principles of reason and fair-play may shew us that none of these charges are justifiableâ-and as a profession, we should consider whether some of us are not being unfair and unreasonable in making our protest in this way. The druggist, for instance is quite helpless in the matter- He cannot alter the regulations, and if he fills a prescription that he has no right to fill, he simply loses money out of his own pocket. As regards the B. C. Formulary. This is not by any means a perfect Formulary, as we will all admit, in that it does not contain all the drugs and preparations that we find in a well-appointed pharmacy. Each of us has his own pet prescriptions, and would like to be able to write them whenever we want. But the Formulary was prepared, and very carefully prepared, by a very faithful and hard-working Committeeâand while this Committee could not possibly please everybody, it yet did an excellent piece of work. The Formulary is subject to revision every three months, by a Permanent Reviewing Committee, and we are sure this body would gladly receive suggestions for improvement from any doctor, and would give these suggestions the fullest consideration. But it is in the nature of things that such a Formulary cannot be all inclusive. We may well reflect that in no other system of group or health insurance are free drugs provided, as is done by the Welfare Department, on account of the inability of the beneficiaries to pay for drugs. Some of the plans pay part of the cost of drugs. But our most ambitious health plan, the M.S.A., does not, and the reason is quite obvious. As the experience of New Zealand and Great Britain shews, the question of drugs is one of their most difficult problems, and bids fair to wreck the entire scheme- The Welfare Department has a limited budget, and must keep within itâand to do this, it must keep a very tight hand on costs. It is not only unfair but futile, to expect it to do anything else. We, as a profession, have made a deal with the Provincial Government to look after Social Assistance cases at a set per capita rate. We all agree, and believe we can ultimately prove to the satisfaction of the Government, that this figure is not adequateâ and there is no doubt that we shall try to have it raised. But while the contract stands, we must, of course, live up to it. It is a very good contract, compared to the condition that prevailed before it was agreed on. It is also a very good contract, as compared with conditions in the rest of Canada. We are sure that the majority of medical men in British Columbia would agree that we want to see this contract continue. If it is not satisfactory in any way there are means to remedy the situation. We have machinery of negotiation which has proved Page 75 Mil'? I If 1$ ':' "' '.' â ' '.' â if -â¢*, 7? i I "vj^"|; most efficient in the past, and can be trusted to serve us faithfully in the future. But we must not allow the plan to be wrecked from within, by the thoughtlessness or unreasonableness of our own members. And lastly, it must be remembered that if in the opinion of a physician, a certain drug or preparation which is not listed in the Formulary, is nevertheless urgently necessary, a simple note to that effect, attached to the prescription, will bring authorization within 24 hours. Or, if the matter be more urgent, a telephone message to the Welfare Department will bring quicker results. We do not see that anything can be fairer than thisâand we feel strongly that all of us should do our utmost to cooperate with the authorities, who have no easy or enviable taskâand to shew the greatest degree of generosity and fairness in dealing with this difficult problem. â¢ â¢ â¢ â¢ â¢ LIBRARY NOTES f J Library Hours: Monday, Wednesday and Friday 9:00 a.m.â9:30 p.m. Tuesday and Thursday 9:00 a.m.â5:00 p.m. Saturday 1 9:00 a.m.â1:00 p.m. Recent Accessions A Short Practice of Surgery by Bailey, H. H. and Love, R. J. M., 8th edition, 1949. A Textbook of Gynaecological Surgery by W. F. V. Bonney, 5 th edition, 1947. A Textbook of Surgery edited by F. Christopher, 5th edition, 1949. Born That Way, by E. R. Carlson, 1941 (Nicholson Collection). Chemical Anatomy, Physiology and Pathology of Extracellular Fluid, by J. L. Gamble, 5 th edition, 1949. Diseases of the ChestâDiagnosis and Treatment by A. R. Judd, 1947. Physical Diagnosis, by F. D. Adams, 13th edition, 1942. Public Health in the World Today, by J. S. Simmons, 1949. Symposium on (1) Acute Medical Emergencies and (2) Nutritional Disordersâ Medical Clinics of North America, November, 1949. The Birth of a Child, by G. D. Read, 1947. The following is a further list of journals taken in the library: Clinical Medicine Bulletin of the Johns Hopkins Hospital Clinical Science Guy's Hospital Reports Proceedings of the Staff Meetings of the Mayo Clinic Malignant Disease * Cancer Journal of the National Cancer Institute Laboratory and Experimental Medicine Journal of Biological Chemistry Journal of Clinical Investigation Journal of Laboratory and Clinical Medicine Journal of Experimental Medicine Journal of Pharmacology and Experimental Therapeutics Physiology Journal of Physiology Physiological Reviews Pathology American Journal of Pathology . Archives of Pathology Journal of Pathology and Bacteriology Pediatrics American Journal of Diseases of Children Journal of Pediatrics Archives of the Diseases of Childhood Pediatrics Page 76 w A Special Message to MEDICAL PRACTITIONERS regarding MEDICAL CERTIFICATES Â§-' OF CAUSE OF DEATH Dear Doctor: For almost thirty years the official mortality statistics for Canada have been compiled from the particulars shown on the Medical Certificate of Cause of Death completed by physicians as part of the official Registration of Death. When these statistics are being compiled, the cause or causes of death entered on the death certificate are classified according to the International List of Causes of Death. This International List has been revised about every ten years, and the Sixth Revision was unanimously adopted in April, 1948, by some twenty-nine countries, including â¢Canada and was subsequently approved by the World Health Organization and the World Health Assembly for international use. Under the Regulations No. 1 of the World Health Organization, to which Canada has subscribed, this new List is to replace the 1938 Revision in classifying and compiling Canadian mortality statistics as from January, 1950. From the standpoint of prevention of untimely deaths, it is important to cut the chain of events leading to death or to direct attention to the point at which preventive measures may best be applied or the cure instituted. For these purposes the most useful statistics is that relating to the UNDERLYING CAUSE OF DEATH, which may be defined as "(a) the disease or injury which initiated the chain of morbid events leading directly to death' or (b) the circumstances of the accident or violence which produced the fatal injury." The standard medical certificate of cause of death which was agreed upon by the International Conference was designed to bring out the information which would facilitate the selection of the UNDERLYING CAUSE OF DEATH together with those conditions which, in the opinion of the certifying physician, were a contributory factor to the death. This certificate, which will be adopted by all Provinces in Canada in 1950, is almost identical with the certificate which is now in use. It places the responsibility for indicating the train of events on the certifying physician. It is assumed and rightly so, that the certifying medical practitioner is in a better position than any other individual to decide which of the morbid conditions led directly to death, and to state the entecedent conditions, if any, which gave rise to this cause. Only in cases where the information is obscure, or where the morbid conditions or causes do not appear to be etiologically consistent or are out of their proper sequence will it be necessary to have the certificate referred back to the physician for clarification. On the following page is a facsimile of the Medical Certificate of Cause of Death, together with a typical example. As the classification of causes of death DEPENDS UPON THE ORDER in which the conditions or causes are listed on the certificate by the physician, you are strongly urged to keep the above points in mind when completing medical certificates of cause of death. By doing so you will help to improve the Provincial and National mortality statistics, whose value and importance in the field of health are universally recognized. A new edition of the Physicians* Pocket Reference is being prepared, and distribution to all practising physicians in Canada will be made within the next few months. It is hoped that this reference book will be of assistance to medical practitioners in certifying causes of death in accordance with the above principle of classification. Yours very truly Director of Vital Statistics. Dept. of Health and Welfare, Victoria, B. C. Page 77 X H < w Q Ph O Ph u Pi o w < U HH Ph iâi 1 w o r-l < o Yât Q PJ b o w if C/5 u Ph â¢-N *Â»H ^ o 5â| co rt *Â£) .-G co ^'H 4) 3 ^ .-, rt *T3 G O o G *T3 <U o 4-> G rt *T3 G rt G o <> ce G S-l rt co co O u a> G s-l V1H â Â»-> o G a> G o rt G S-i 4-> tT a> <u J3 > â M <u ||| 0 3 4_> <o g Â© J3 *"5J a> ti <a JQ' <U Â« C to to O Â« +-> bo 13 V - o 4> G -a <u -^ "V G co Ji , U âi be G a> ^ 1 <u ^ S 8 co CU 5j -G <l -Li Â«L\n?8 S-l â¢*Â» ** Six G 9 O O u HI ^_ w> .a <u g iâi â¢"Â» ^3 5-1 <U r-5 rt bÂ» W) o M JJ .â¦; O *T3 I ^ o J2 G O u CO 3 G rt o O !-l S-l O Â»Â£3 O co S-i 3 0 o <u J3 rt <U *tl <u -G â Â»-Â» 60 G co 3 rt O o !-i T3 rt c rt u G S-i -G o .a 8 o G G rt -o <u S-i 0> UÂ» G v CO 3 g o o t=! 3 âI 0 -t-> , f .. o u o 5 rt rt ? H S P CO *T3 Â« ^ Ui rt rt u ^4- Jr* u Â«3 0 ! to ON ^ Â« ^ < w Q Ph O Ph c/i U 2 8 O o CQ O u G <u 3 O^ d) CO G o o rt' S-l o o 3 H3 ,Â« a, S-i rt QJ JG o3 o u ki 0 s-i 3 ^ G fe G CO ^s rt Â«. Si ft C O co <* 5 Â° <o 8h CO G Â« CU g *-> rt <u 4-> 1âH CO U 4-1 <U 3 rt U .2*5 G ^ -5 * Â« Â§ Si Â« 3 O ? Qj Â»S> o I o ^ G <J v 3 *"Â« & %> w IS co ^S O ^ rt is V CO H* rt orj S-i O O 3 ^Â» T3 ^" CO 3 rt O o > O rt o ^G CO +-Â» i s c s ">.2 â¢ w 4-1 G o rt ^ ^ w> co^^r . G Â»-< co O Â° Â«o +J M ^ Â§ s <m ^ rt ^ t*-l CO 8 3 a *T3 â¢ 0) "w -G bo ** .9 O co +j 3 1 G 3-2 'Co ti c S Â° o o Â° n co 0 8 <u O co â¢^ SÂ» "rs -a s Â° ^ -rt â¢5- Â£> â¢Â«* a> Â«*> ui "^ G < iâi X Q H <5 i-l i H CO rt CU co O O, S-l 3 Oi o rt s-i <s <u ^G CO CO rt o s <u rt X o > O rt V ^G Â« "T3 vw O 4> CO 3 rt O bo 3 Page 78 ACT RESPECTING CORONERS Dr. Whitbread, the Coroner for Vancouver, has asked the Bulletin to publish the following: he feels that the Medical Profession should be aware of the rules governing their conduct as well as his own in the cases cited. As a profession we are bound by the provision of this Act and are liable to penalties for failure to observe its requirements. In any event as good citizens and as members of our profession we should do all in our power to cooperate with the Coroner in his performance of his duties. FDTTOR Medical Practitioners, Hospitals, and Nursing Homes, are requested to note and comply with the Coroners Act respecting deaths of persons under their care or in an institution under their supervision. Copies of the Coroners Act and amendments thereto may be obtained from Charles F. Banfield, Printer to the King's Most Excellent Majesty, Victoria, B. C. Extracts from the above Act state as follows: Every legally qualified practitioner who was last in attendance during the last illness or on the death of any person who dies from other than natural causes shall, within twenty-four hours after having notice or knowledge of the death of such person, notify in writing, the Coroner within whose jurisdiction the death occurs, that such person has died from other than natural causes. Every legally qualified medical practitioner who, in contravention of their section, neglects or fails to notify any Coroner respecting the death of any person, shall be liable, on summary conviction, to a penalty of not less than one hundred dollars and not more than two hundred and fifty dollars. (R.S., 1924, c. 49, s.8) Where a Coroner is informed that the dead body of a person is lying within his jurisdiction' and there is reasonable cause to suspect that such person has died either a violent or an unnatural death, to a penalty of not less than one hundred dollars and not more than two hundred and fifty dollars. (R.S., 1924, c. 49, s. 8.) Where a Coroner is informed that the dead body of a person is lying within his jurisdiction, and there is reasonable cause to suspect that such person has died either a violent or an unnatural death, or has died a sudden death of which the cause is unknown, or that such person has died in prison, or in such place or under such circumstances as to require an inquest in pursuance of any Act, the Coroner, whether the cause of death arose within his jurisdiction or not shall, as soon as practicable, issue his warrant to hold an inquest or injury as may be deemed necessary. Where, upon the summoning or holding of any Coroner's inquest, the Coroner finds that the deceased was attended during his last illness, or at his death, by any legally qualified medical practitioner, the Coroner may issue his order for the attendance of such practitioner as a witness at the inquest, in the form following: CORONER'S INQUEST AT , UPON THE BODY OF By virtue of this my order as Coroner for , you are hereby required to.appear before me and the jury at , on the day of , at o'clock, to give evidence touching the cause of death of (And when the witness is required to make or assist at a post-mortem examination, add "and make or assist in making a post-mortem examination of the body with (or without) an analysis (as the case may be), and report thereon at the said inquest.") gys| (Signed) C. P., Coroner. R.S., 1924, c. 49, s. 24. If the Coroner finds that the deceased was not so attended, he may issue his order for the attendance of any legally qualified medical practitioner being at the time in actual practice in or near the place where the death happened, and the Coroner may at any Page 79 Bl ;%<// At time before the termination of the inquest direct a post-mortem examination, with or without an analysis of the contents of the stomach or intestines, by the medical witness summoned to attend at such inquest; but if any person states, upon oath before the Coroner, that in his belief the death was caused, partly or entirely, by the improper or negligent treatment of a medical practitioner or other person, such medical practitioner or other person shall not be allowed to perform or assist at the post-mortem examination. (R.S., 1924, c. 49, s. 25.) Where any Coroner's order issued in pursuance of the provisions of this Act for the attendance of any medical practitioner at an inquest and the making or assisting in making a post-mortem examination, has been personally served on, if not personally served on, has been received by, the medical practitioner, or has been left at his residence or office in sufficient time for him to have obeyed the order, and he has not obeyed the same, he shall,, upon.information, laid by the Coroner who held the inquest in the order referred to, or by one of the jurors who sat on the inquest, be liable, on summary conviction, to a penalty of not less than twenty dollars and not more than one hundred dollars: Provided that if, upon hearing what is alleged by the medical practitioner, the Justice hearing the case considers that such disobedience was caused by circumstances amounting to a reasonable excuse therefor, it shall be lawful for the Justice to dismiss the information upon such terms as to costs or otherwise as may seem just. (R.S., 1924, c. 49, s. 29.) And wherever there is reasonable cause to suspect that such person or persons may have died either a violent or an unnatural death, or has died a sudden death of which the cause is unknown, it should also be reported to the Coroner immediately. It is further requested that whenever a person is admitted to an institution suffering from a serious injury that may result in their death, the Police within the Municipality in which the injury occurred should be immediately notified, so that they may obtain all particulars while the occurrence is still fresh in the minds of witnesses, and the injured person interviewed, so that statements may be obtained. Where the death takes place in a Private Hospital or Nursing Home, death must be certified by a legally qualified practitioner before such body is released for burial or sent to the City Morgue. In case the C6roner or his office cannot be contacted all reports should be made to the Detective Office of the Vancouver City Police Department, MArine 1122, or the local police department the case comes under. J. D. WHITBREAD, M.D., CM., Coroner. SILICOSIS IN B. C. Study of 12 Years' Experience C. H. VROOMAN, M.D.C.M., F.R.C.P. (C) Referee for Silicosis, Workmen's Compensation BoardâB.C. Silicosis is an ancient industrial disease long known by various names, e.g., "grinder's rot, "potter's asthma," "miner's consumption," all of which indicate its industrial origin and rather hopeless prognosis. The first recorded account of silicosis was given by Dimerbrock, in 1649, cited by King, in which shortness of breath and rigidity of the chest by granite workers in the Carpathians, who had inhaled stone dust for several years, was described. These workers in the Carpathians applied the name "widow makers" to their tools, since it was stated that women in the district had been married as often as five or six times. Even to this day the term is still used by European immigrants in the iron mines of Michigan in the same sense as in the seventeenth century. The real nature of the disease was first recognized by two English physicians, Peacock, 1860, and Greenhow, 1865âcited by King, who -showed the presence of hard Page 80 fb gritty material in pieces cut from the lung, and isolated what they called "sand" from the ashed tissue: almost an ounce (28.4 gm.) of this "sand" was obtained, which rep- presented the lifetime's inhalation of mineral dust by a knife grinder and a mason. For many years it was considered that the damage to the tissues was due to the sharp edged silica particles that were found in the lung. However, thanks to the investigations of Kettle and Gye in 1922 and Gardner in 1923, it was demonstrated that this was not the case. Gardner showed that the dust from carborundum, which is extremely hard and has just as sharp edges as silica, failed to produce the typical fibrous reaction produced by quartz. Various workers, including particularly Gardner and Kettle, showed that the changes produced by silica dust were due to some soluble substance obtained from the silica particles. The modern theory is that a toxic substance thought to be silicic acid is produced by the action of the blood plasma on the quartz particles. This substance is toxic to the duct cells which are conveying the particles from the lung alveoli to the lymphatics. This solubility theory of Silicosis was recently critically reviewed by Kin, in which various discrepancies and anomalies are pointed out. Silica dust, when inhaled into the lungs, is not inert like most dust, e.g., coal dust. The phagocytes carrying silica particles are definitely poisoned by the slow solution of the silica. The cells die and are engulfed by other cells which also die and are deposited along the lymph channels and in the small lymph nodes of the lung. There they gradually produce the typical whorl-shaped fibrosis which in time gives the specific nodulation seen in X-ray films. Silicates, with the exception of asbestos, do not produce this reaction. Other dusts mixed with the silica will inhibit this reaction, e.g., iron ore dusts or aluminum dusts. The fibrotic reaction is, therefore, modified by the purity of the silica content, also the fineness of the dust particles. Silicosis is produced by the inhalation of silica dust and the factors necessary to its production may be summarized as follows: 1. The fineness of the particles. Particles must be five microns or less in size to be dangerous. 2. The concentration of the dust in the atmosphere and the per cent content of silica. Air that contains more than 300 particles per c.c. of dust, and contains 6 per cent or more of pure silica is considered hazardous. 3. Adulterating dusts inhaled with the silica. It has been known for some time that various dusts inhaled with silica not only acted as diluents but also as directly inhibiting the development of the disease.' 4. A fourth factor is susceptibility of the workman. It is know that manifest tuberculosis increases the susceptibility of the individual to silicosis. Hence the importance of excluding workmen with known tuberculosis from exposure to silica dust. There are other unknown factors; e.g., other respiratory infections and unknown constitutional factors that increase susceptibility. It is hoped that future research will clear our knowledge on these important points. Diagnosis: The diagnosis of silicosis is based on, first, occupational history. There must be a history of exposure to hazardous silica dust for a substantial period of time. We have seen a few cases in the British Columbia mines where the exposure was less than three years, all of them acute cases, but the large majority of our cases have been exposed for five years or more. The shortness of exposure in some cases is explained by large concentrations of pure silica dust, but this is not the whole story. There seems to be, in some workmen, a greater susceptibility to silica fibrosis than in others. It has been found that even in rabbits some strains will become silicotic much more readily than others. This was a case of silicosis due to inhalation of cleansing powder with only a total 9 months exposure over a period of 8 years and death occurring 9 months after the onset of symptoms. Page 81 m **>. 'â r.u V, .'â jk3 'fl'i1 Industrial fjistory He had worked as soap cutter in soap factory for 8 years. Diiring this time he spent about one month out of the year rimming cans filled with cleansing powder. This work was very dusty and he had not been exposed a total of more than 9 months. Onset of symptoms January, 1937. Symptomsâshortness of breath, dry irritative cough. He gradually got worse, strength poor. Had to quit work 3 months after onset of symptoms. When seen by me was obviously extremely illâvery dyspnoeic. Examination of chest shows signs of consolidation over upper half of both lungs. X-ray showed dense shadows, mottled, over most of both lungs. Completely dense in upper half. He was diagnosed as having probably acute pneumonic phthisis. He died four days later. Post mortem showed gross silicotic fibrosis of both lungs with some terminal pneumonia. No evidence of TB. We had another case of definite silicosis in a man who gave a history of only 10 months work as a sandblaster, who died of advanced silicosis. Post Mortem showed Silicosis but no Tuberculosis. The character of the dust and the silica content make a tremendous difference in the hazard of the exposure. Some mines in B. C. are particularly bad and have produced a large number of Silicotics. In these mines the field rock is almost pure quartzite. Other mines produce comparatively few Silicotics as the silica content is comparatively low and diluted with inert dusts. The second standard of diagnosis is the typical nodular fibrosis seen in the X-ray film. Without this typical nodulation one cannot make a diagnosis of silicosis. It is true that the lungs may be "effectively occupied" by silica dust and the man be removed from contact with the dust for a period of years before the typical nodulation. shows. Two soldiers who were miners prior to the war, both in the same mine, enlisted in 1941. Their enlistment films showed normal chests; yet in 1944 they both showed very marked silicosis, although during the period of three years they were in the Canadian Army Overseas they were not exposed to any dust. The typical case may go on for a number of years and the annual X-ray examination show no change. Gradually, however, there develops a generalized increase of the linear lung markings and some enlargement of the hilar shadows. The linear markings gradually extend to' the periphery, showing a fine reticulation. There may be no change in this appearance for a number of years. Irvine of South Africa has likened the appearance at this time to the branches of a leafless treeâthen rather suddenly, often in the space of six months or a year, the tree suddenly starts to leaf outâthe leaves in this case being the discrete nodules, from 2 mm. to 6 mm. in diameter, widely spread over both lungs. At this time, there are usually few or no symptoms, except possible, slight dyspnoea on exertion. The disease may remain stationary at this stage for a number of years and the man can carry on at his work quite efficiently. Other cases may progress fairly rapidly, the discrete shadows becoming conglomerate, and showing evidence of silicosis with infection. The man becomes dyspnoeic, develops chronic cough with occasional blood spitting, and is only able to carry on at light work. If he develops manifest tuberculosis with a positive sputum, he rapidly becomes totally disabled and his life expectancy is reduced to a few years. As to whether a given case will progress rapidly cannot be predicted; and as to why some do and others do not is one of our unsolved problems. Infection with tuberculosis certainly speeds up the progress of the disease, but a number of definitely acute cases of silicosis proceed rapidly to death without any evidence of tuberculosis. In most cases the progress is slow. There is progressive increase of the fibrosis with compensatory emphysema; dyspnoea becomes quite severe on very little exertion. The man develops an irritative cough, some times with considerable wheeziness. His general remains good but he cannot earn a living because of shortness of breath. Without serious intercurrent infections these men may live out their life expectancy, especially if they are economically provided for by some form of compensation. Page 82 J>n^t;jSll^Â£^^^ !* Differential Diagnosis: It must be laid down as a dictum until further research proves the contrary that, unless a patient has the typical X-ray appearance of nodulation, silicosis cannot be diagnosed as a cause of disability. All the symptoms of silicosis may be present, with also sufficient history of hazardous exposure to dust. Emphysema, chronic heart disease with congestive failure, and asthmatic bronchitis all may produce similar clinical symptoms, and at times the X-ray appearance may be misleading. These cases are the ones that are often most difficult to decide in regard to compensation. There are a number of conditions which show a nodular X-ray appearance that are not due to silicosis. The following is a list of the most common conditions showing X-ray appearance similar to Silicosis: Miliary Tuberculosis. Pulmonary congestion due to nutral stenosis or other heart conditions. Miliary calcification caused by histoplasmosis Sarcoidosis. Carcinomatosis. ActinomycosisâMoniliaâor other fungi infections Massive fibrosis of lungs following non-tuberculosus infection. SILICOSIS IN B. C. On November 20th, 1936, Silicosis was made a compensatable disease for workmen in the metalliferous mines of B. C. Prior to that time the workman becoming disabled from Silicosis was simply turned adrift to fend for himself as best he could. As far as prevention of the disease was concerned, there had been very little done. There was no adequate inspection of the dust and ventilating conditions in the mines. There was a law forbidding dry drilling and some regulations to keep down the dust by the use of water but generally speaking the conditions in most of the metalliferous mines were very hazardous. In 1935 a survey was made of five of the leading mines of the Province and 1,339 miners were examined. Out of 703 of these who had been five years or more underground, 105 or 14.9% were Silicotics. Following this survey, Silicosis was made a compensatable disease. An amendment was also passed to the Metalliferous Mines of B. C. were compelled to have an annual medical examination of their employees with an X-ray film of their chests. These examinations are made by the mine physician at the expense of the employers, and a yearly certificate was issued to each miner by the examining doctor. The results of these examinations are forwarded to the Compensation Board and reviewed by the Silicosis Referee. The referee's position is that of advisor and consultant to the examining doctors. He has, though, the power to cancel or reinstate any miner's certificate if he thought so advisable. In the course of the past 12 years, 25,359 miners have had an initial examination and the results are shown in Table 1. In the matter of rejections for conditions not showing in the X-ray film the decision is largely up to the examining physician. With a large number of doctors doing the examinations and constant changing of doctors at the Mines it has been very difficult to establish any definite physical standards. As fare as the X-ray of the chest is concerned, the main things looked for are, of course, Tuberculosis and Silicosis. It will be noted that 215 mines or .8% were rejected because of Pulmonary Tuberculosis. These cases were mostly Minimal Pulmonary Tuberculosis in which there was a definite lesion in the lung that might even be fairly well healed but was not definitely calcified. Men are not rejected because of a few calcified nodules in the parenchyma of the lung or because of well calcified hilar glands. In the case of Silicosis, and Tuberculosis these are, of course, all rejected and advised to apply for pension. In the case of simple Silicosis of the early type which is non progressive and who show little disablement, most of these are issued certificates and allowed to remain at work. If they are young men and the disease seemed to be the progressive type, they Page 83 ^Sir- Total TABLE I. Examination of Men in the Metalliferous Mining Industry in B. C. 1937-1938. Total Initial Exams Total Rejected CAUSE OF REJECTION Year Simple T.B. T.B. & Silicosis Silicosis Acquired Outside B.C. Chronic Bronchitis Heart Condition Other Conditions 1937 5,486 86 69 1 1 3 7 5 1938 2,284 21 12 6 3 1939 1,568 24 12 3 1 _ 3 5 1940 1,189 45 23 11 2 3. 6 1941 1,831 26 13 ?Â§1N 1 2 2 5 1942 1,988 36 15 5 1 2 13 1943 1,232 57 17 3 2 5 7 23 1944 581 26 8 _ 1 .,. 3 15 1945 501 20 3 P 1 4 4 8 1946 1,672 17 7 _ 2 3 5 1947 2,193 43 17 gpfj 3 1 2 20 1948 4,834 10 1 _ 3 2 1 3 25,359 411 197 20 37 111 ar I* hi'''' are advised to leave the mines and apply for pension. Many of these are early non-progressive cases in older men (over 40) and who had worked most of their lives in the mine and we felt that they should not be deprived of their means of livelihood. This is the policy that has been generally adopted in Canada and the United States. Our experience agrees with that of others who observe that the disease does not as a rule progress faster because these men are left at their mining occupations. The dust conditions in the mines are immensely better than they were 10 years ago. These cases are checked each year and if progrssion is noted they are advised. We feel that to deprive men of their means of livelihood will in many cases work a great hardship. At the present time we have 37 silicotics working in mines. They have worked an average of 5l/z years since the diagnosis in their disease. We have records of 130 silicotics who have not been pensioned as yet, 96 of whom we have had no records for two years or more. Many of these have apparently left the industry and some of them have moved out of the Province. Any silicotic who leaves the mine permanently can apply for pension. If he shows no disability due to Silicosis he will not be eligible for pension. His claim is placed in suspense and when and if he at any time develops disability due to Silicosis, his pension can be paid without further investigation. In 1940 Pneumonoconiosis was made a compensable disease "in a workman who had been exposed to dust conditions that are deemed to have contributed to the development of the disease." Since that time 13 men have been pensioned for Pneumonoconiosis. These men were stone cutters, foundry workers, sand blasters and so forth. No annual examinations are made in any of these occupations. Since 1936 when Silicosis was made a compensatable disease, 468 employees of the mining industry have been pensioned for Silicosis. Of these 217 have died. TABLE II. Number of Miners Pensioned for Silicosis since 1937. 1937 I â â I 23 1938 j 33 1939 59 |||j 1940 33 1941 j 54 1942 j 42 1943 | 1 42 1944 | 64 1945 | 1 | 36 Page 84 Â¥P â 1946 36 1947 I 24 1948 23 Total i '. 468 Total number of deaths 217 Total number remaining on pensions 251 Total number of silicotics who have not applied for pension 130 Number of Silicotics working in mines in 1947 37 TABLE HI. Causes of Death in Pensioners for Silicosis as Certified by Death Certificate. Total number 217 Silicosis with Tuberculosis j 121 55.8% Silicosis . 14 | Silicosis and Pneumonia I 20 f 32.2% Silicosis and Heart ' 36J Other Causes ! 26 12% 217 Causes of Death in Pensioners where Post Mortems were made, or TB was proven by positive sputum. Total number 133 Silicosis and Tuberculosis proved by positive sputum or Post Mortem 98 73.9% Silicosis and Pneumonia 5 Silicosis and Heart 11 16 12% Silicosis present but not cause of death Cancer of lung 3 Cancer of other organs . 4 Other causes , 10 17 12.6% Coronary Diseaseâno silicosis i 1 Chronic Bronchiectasis : 1 2 1.5% Average age at deathâ53 133 Average years of exposureâ14.88. An analysis of the cause of death in these Silicotics is shown in Table III. PROPHYLAXIS The most important treatment of Silicosis is its prevention and there has been very considerable and highly important and effective work done in prevention of Silicosis in this Province. Soon after Silicosis had been made a compensatable disease, a competent dust inspector and engineer was appointed, by the Compensation Board. An assistant has been appointed more recently to the staff. They have done very important work in improving the dust conditions in the mines of this Province. They make regular inspection visits to the mines and make dust counts and recommendations. They are able to point out to the mine owners the hazardous areas and advise as to remedy. Following their suggestions hundreds of thousands of dollars have been spent by the mine owners in improving the dust conditions in the mines of B. C. They report that in most mines the conditions are now reasonably good and do not exceed a maximum count of 300 particles per c.c. of air. In some parts of the mines, as in the raises, where drilling is being done, conditions are still hazardous, counts sometimes running as high as 2,000 particles per c.c. Conditions are continuously improving and the mines are immensely less hazardous than 10 years ago. USE OF ALUMINUM DUST PROPHYLAXIS AND TREATMENT OF SILICOSIS In 1937, Denny, Robson and Irvine reported that in dusting experiments with quartz dust they could produce nodular fibrosis in rabbits, but if the quartz dust was mixed with a freshly ground aluminum powder in particles the size of less than 5 microns, with a proportion of aluminum dust of 1 per cent it would prevent the occurrence of nodular fibrosis. In 1939, they showed this inhibiting action of aluminum is produced largely by covering the quartz particles with an insoluble and impermeable coating which is gela- Page 85 Sir'- tinous hydrated aluminum, and which stains red with aurine. Further experiments by Belt and King showed the particles so treated were treated by the body cells as more or less inert bodies. Further work by several observers have shown that aluminum dust did not cause lung damage nor did it favour the development of tuberculosis or any other lung condition. Following the publication of these beneficial effects of aluminum dust in rabbits, under the supervision of the Mclntyre Research Ltd., prophylactic treatment has been installed in a large number of mines in Canada and other places. During the past two years most of the mines in British Columbia have installed this treatment. In the change room, or dry room, there has been installed a blower which blows from small canisters of aluminum powder, giving a concentration of 1 gram of aluminum dust per 1,000 cubic feet of room volume. This is inhaled by the men for a period of 10 minutes before going underground. The treatment is voluntary on the part of the men but has been enthusiastically adopted and no bad effects have been noted. In fact, in some of the mines it has become quite popular as a cure for various respiratory complaints, and I have been told that some of the women are taking it for a variety of conditions. As to its effect in prevention of silicosis, there is no evidence as yet, nor is it likely that definite evidence can be provided for five to ten years. In no sense does the use of aluminum supplant the other important measures of dust control. In the last 3 years there has been a definite fall in the incidence of new cases of silicosis. Â§iM Any statistics on this at this time would be unsatisfactory as there are such factors as lessened employment in the metalliferous mines during the war and at present time the number employed in mines has not reached the pre-war level. There was also a prolonged strike in 1946. However, the indications are definite that there is being considerable less Silicosis produced now in the mines of B.C. than 10 years ago. We think that this is largely due to the dust prevention measures that have been installed. Whether aluminum is a factor it is entirely too early to come to any conclusion. TREATMENT OF KNOWN SILICOTICS WITH ALUMINUM DUST In 1944, it was decided by the Workmen's Compensation Board of British Columbia to offer certain pensioners from silicosis the opportunity of taking aluminum dust as a therapeutic measure for their disease. Under supervision of the Mclntyre Research, an air-tight chamber, 560 cubic feet capacity, was constructed. Into this chamber was blown aluminum dust from small canisters, to give a concentration of 0.5 mgms. of aluminum powder per litre of air. The patients stood outside the chamber and inhaled through the mouth this aluminum dust for a period of 10 minutes daily for one hundred treatments. The men selected were all definite cases of silicosis, who had developed no evidence of pulmonary Tuberculosis. They were all pensioned from 50 to 100 per cent for disability due to Silicosis. They were all assured that any improvement in their condition would not result in reduction of pension. They were all medically examined and X-rayed, both before and after treatment. -* Since then 41 have started treatment. 34 have taken 24 or more treatments. About 50% stated they had improved symptomatically. In two cases there were X-ray changes for the better. In one the improvement has been remarkable. It is impossible to come to any conclusions from such limited numbers. The statement of improvement was entirely symptomatic, and similar results might be obtained by giving any harmless treatment with a large dose of hope and faith. However, generally speaking, the psychologic effect was good on at least 50%. We did not think there was any harm done even in those who stated they were unimproved or worse. The whole subject of aluminum and its use in the prevention and treatment â of Silicosis is reviewed in a recent article by Brown & Winkle for the Council of Pharmacy and Hygiene, of the American Medical Association, and the concensus of opinion is that as yet the value of aluminum for Silicosis has not as yet been entirely proven and that it may be a considerable time before its value can in any way be accurately assessed. There is no evidence to show that its use is in any way harmful. Page 86 r CONCLUSION Silicosis is a definite industrial hazard to the hard rock miners of British Columbia. This hazard is considerably less than 12 years ago, mainly due to dust control measures being enforced. The use of aluminum dust may prove to be of considerable help in eliminating this disease. It is too early to assess its value as yet. The use of aluminum in the treatment of known Silicotics has proved of some pschological value but no consistent objective signs of improvement have been found. We have not found that the use of aluminum dust either for prophylaxis or treatment was in any way harmful. A review of the deaths of silicotics shows that about 5 % of pensioners for Silicosis die of Silicosis and Tuberculosis. SUMMARY 1. The present status of our knowledge of the etiology-pathology, and diagnosis of Silicosis is briefly outlined. Conditions effecting the progress of the disease are briefly discussed with some illustrative cases. 2. The conditions prior to Silicosis being made a compensatable disease in B.C. are outlined. Statistical tables are given of initial examinations of miners, also of number of miners pensioned since 1937, number of miners compensated, and cause of death in Silicotic pensioners. 3. Preventive measures are discussed, especially in reference to dust prevention and also the use of aluminum dust as a prophylactic measure. 4. A brief account is given of the treatment of 34 silicotic pensioners by aluminum dust. Jj 1 BIBLIOGRAPHY 1. Dhnerock cited by King. Solubility theory of Silicosis:âOcc. Med. July, 1947. P.P.P. 426-429. 2. Kettle and Gye. Silicosis and Miners' Phthisis, ibid. 3:241, 1922. 5. Gardner. Studies on the Relation of Mineral Dusts to Tuberculosis: III., Am. Rev. Tuberc 7:344, 1923. 4. Vrooman, C. H. Silicosis and its incidence in British Columbia. Journal of Can. Med. Ass.â25-293-297â1936. 5. Denny-Robson-Irwin. The prevention of Silicosis by Metallic Aluminium. II. Journal Can. Med. Ass. 40-213-1939. 6. Brown & Winkle. Jour. Am. Med. Ass. 140-1024âJuly 23, 1949. y â hi iftfl m . Page 87 THE PRACTITIONER AND THE ANTIBIOTIC AGE OF VENEREAL JOHN H. STOKES, M.D.2 The succession of breath-taking eye-goggling leaps with which the intelligence of, man, his unguided demoniac, or his unwittingly unintelligent intelligence, has covered space andv time compressed into a chronologic instant of a decade or two is as much a reality in the field of medicine as in the physical sciences. We are in somewhat the position of the man in H. G. Wells' series of stories under the title of The Time Machine who discovered himself the possessor of an omnipotent wishing power and who, after a few preliminary passes, such as turning lighted lamps upside down, ordered the sun to stop. Bringing up on the lee side of a not yet uprooted rock, as all of civilization hurtled past him into dust with the cessation of rotation of the earth, he just managed in time to gasp a wish that everything be as it was before, and saved himself from Heaven knows what. We can afford to give thought to his situation, as paralleled to no small extent by our own, and to utter a prayer for deliverance from goodness knows what as events hurtle past us in the atomic and antibiotic age. For, as physicians, we stand at the edge of transformations which are as precipitous and even cataclysmic as the end of diagnostic medicine, the coming age of the pressure ampoule and the self-treatment of disease, the twilight of the medical practitioner; unless indeed he can catch the ledge of psychosomatics or break his fall in the branches of the pediatric tree; or catch the gnarled roots of obstetrics or surgery as he plummets to oblivion. Figure 1.âWhat the antibiotics hare done for venereal disease control 1. Provided almost, ideally safe, reactionless, and increasingly inexpensive treatment for syphilis, gonorrhea, chancroid, and granuloma inguinale, with lymphogranuloma venereum next on the list. 2. Provided treatment so rapid that its duration is a matter of hours and (at most) days,'instead of weeks, months, and years. This has abolished patient*education in course, hampered contact tracing, weakened follow-up. 3. Provided treatment so rapid and simple as to make almost immediate reinfection a commonplace, and put free treatment in the position of subsidizing venery. 4. Relegated heavy metal and arsenic for practical purposes to the domain of the dodo and the moa. 5. Put fever and the "hot box" into cold storage if not the scrap heap. 6. Provided safe and painless protection of the syphilitic mother and fetusâ practically 100 per cent effective for the fetus. 7. Robbed congenital syphilis of its terrors. 8. Fallen just short of abolishing the reservoir of infectious syphilis lind gonorrhea. 9. Put oral prophylaxis and the single-shot cure for what-have-you on the horizon âthe tablet in the glass of whiskey, the pressure-ampoule dose in the thigh. 10. Returned the management of venereal disease to the practitioner if not to the patient himself. Effective self-treatment is just over the horizon. 11. "Put the skids" under fear. Where do the weak spots lie? In (2), (3), answer is immunization. (8), (9), and (11). The only real 1 Read before the Vancouver Medical Society on May 10, 1949. 2 Professor of Dermatology-Syphilology, Graduate School of Medicine, University of Pennsylvania; Director, Institute for the Study of Venereal Disease, University of Pennsylvania; Consultant to the Secretary of the Army. Page 88 My business is with but a single sector of this field of possibilities, in which the antibiotics have done things to us, DDT'd us into a disturbed, unstable biologic equilibrium, full of glow and promise, but with some ugly flickers and shadows here and there. Figure 1 summarizes the situation. Now let us turn in figure 2 to the objectives of epidemiologic control and attempt a simple and realistic statement. Figure 2.âObjectives of epidemiologic control of venereal disease 1. To identify or uncover every infection, particularly in its transmissible stage; not only the infection itself but the "from whom, to whom" of it; recalling that every day's or hour's delay may mean a new infection. 2. To block infection transmission by methods of treatment which shall be quick (8 hours); lasting (as near no relapse and 100 percent cure as possible); reactionless; not too costly; not leave humanity in a worse state, than before their application. 3. To use methods applicable by the practicing physicians directly to the patient, with a minimum of assistance from without. Assistance means intermediation, loss of time, loss of privacy, increased cost. 4. To eliminate uncontrollable methodsâself-treatment, across-the-counter prescribing, nostrums, quacks. 5. To educate for early recognition of disease before transmission, entrenchment, and treatment resistance occur. Where are the weak spots? (1) "From whom, to whom," (2) The "worse state," (5) Education for "early recognition." Let us now turn the problem around on itself and consider the obstacles to epidemiologic control of the venereal diseases. Figure 3 presents another topical summary (my students used to call my dermatological textbook "the telephone directory"). You will easily see how formidable and far reaching are the odds arrayed against us; how questionable indeed is even the immense power and antibiotic-implemented treatment to control and overcome these obstacles; how difficult are many of the crucial interpretations, snch as those involving cure and relapse statistics and failure rates; and how strong is the temptation to heterodoxy, such as treatment on suspicion and treatment of the contact without diagnosis. Figure 3.âObstacles to the epidemiologic control of the venereal diseases Obstacle 1.âThe tie-in with sex: a vital drive, undercover practice, money backing promiscuity and alcohol, the perennial fountainheads of venery. Obstacle 2.âThe stigma of venereal disease. Venereal disease is clandestine, will fight uncovering to the last ditch. It smears whatever it touches. Obstacle 3.âPublic and personal ignorance and lethargy. Try teaching people something they want to know for 25 years and see how slowly they leari. Then try teaching them something they don't want to know. Set the threshold of inertia and resistiveness at a minimal 65 percent. Obstacle 4.âMedical unfamiliarity with venereal disease in all its aspects is now being made more serious by medical underestimation of the future problem. ("Penicillin has it in the bag." Now a common attitude.) Obstacle 5.âMedical non co-operation. The doctor has too much to learn, too much to do, to master intricacies, elusiveness and paper work. Page 89 Figure 3âContinued Obstacle 6.âThe subthreshold, asymptomatic onset of venereal disease and its initial period of unrecognized infectivity. If every patient upon infection ran a high fever with convulsions and a blazing rash, there would soon be an end to venereal disease. Obstacle 7.âThe carrier state. Conspicuous in gonorrhea, still a riddle in human, though recognized in animal experimental syphilis. Defeats recognition, maintains potential infectivity. Obstacle 8.âRelapse and noncure. At a guess; for gonorrhea, 0 to 4 percent; for syphilis, 4 to 30 percent; for granuloma inguinale, 30 to ? percent; for lymphopathia venereum, ? percent. Maintains, with (6), (7), and (9), the reservoir of infection. Obstacle 9.âReinfection. Clinically unprovable, yet known to be frequent; an inevitable product* of quick cure and no developed immunity; reinfection tangles all treatment-result and cure statistics, ping-pongs infections back and forth, sets the epidemiologic brain in a whirl. Obstacle 10.âThe mobile site and source of exposure. Contributions of gasoline and rubber, the automobile and facile transportation, have enormously complicated the control of the infected person. Obstacle 11.âThe approaching day of effective self-treatment. We must face the fact that the adequate treatment of venereal disease is getting less complicated than insulin; may soon join the aspirin category. Obstacle 12.âThe approaching day of treatment on suspicion, without diagnosis and without follow-up of results. To our generation, this is a hauling down of the flag of medical idealism and scholarship. Obstacle 13.âThe nonvenereal use of antibiotics. What will it do to the prevalence of venereal disease and the status of the suspected infectee? Current indications place the toughest problems under (5), (6), (8), and (9). The amplification of these three resumes, topic by topic, would be material for a course rather than a single talk. I shall, therefore, confine myself to a discussion of ways and means by which the doctor can identify the infections that come his Way; and some perhaps rather radical conceptions of what he might do when a venereal infection, a transmissible infection; is identified, or suspected. Identification of the Infection, i.e., Case Uncovering There are three golden moments in the public health control of the venereal infections: the moment when the patient comes before you with a suspicious complaint; the foment when a contact is named or described in identifiable terms; and the moment, when fortuitously, voluntarily, or under mandate of law, a blood test can be taken. The place of smears, cultures, special tests like the Frei, search for Donovan bodies in biopsies, spinal fluid examinationâthese may be silver, but they are not gold. On 4he morning of the day I wrote these lines, I asked a class of eight public health nurses training as experts in the venereal disease nursing field what they considered the weakest spot in venereal disease control in their 3 months' observation of the problem in, university clinics and in public health clinics in a large and, so far as venereal disease is concerned, a highly organized city. "Doctors don't take time to get the history and to make an examination of the patient," they said, and I listened respectfully, for they were contact- tracing and case-uncovering and follow-up experts. I could not help recalling the comment of one of our greatest internists, a Middle Westerner, who said, "The doctor does not examine," and of one of our sagest medical figures in the East, who said, "The doctor does not read." Page 90 to Two weeks and two days before the incident! have described, 18 men stood around a stretcher on which lay an unclothed patient covered with a blanket. Many of these men had already met diplomate qualifications, and all expected to be dermatologists and syphilolo- gists. They were invited to inspect the patient preparatory to a discussion of diagnosis and treatment. The staphylodermic eczematoid lesions of legs, arms, and trunk were inspected. A third of the men had already started back to their seats, when I exclaimed, "Now I have you!" The diagnostic day was saved by three men who plucked at the blanket before I spoke, and exposed the penis, on which was a coronary primary lesion made visible by three sutures for experimental biopsy. Five days before I heard the verdict of the nurses, another man lay stripped upon a stretcher. On his penis too was a biopsied papule. A diagnosis of granuloma inguinale had been made. He was known to have had a chancre and secondaries, treated 4 months before with 1,200,000 units of procaine penicillin once a week for 4 weeks Â»(an experimental system). His lesions had cleared, so the story went, and then the induration had appeared on the penis and had been biopsied. The darkfield examination was said to be negative. His titered serologic test for syphilis had taken a sudden leap upward after an initial fall, but this too was overlooked. Rut what was overlooked most of all was a cluster of ringed lesions about his chin and nares and a half dozen classical secondary recurrent papules on the dorsum of his tongue, with several mucosal mucous patches. If this man had been seen by your grandfathers and mineâwith a keen appraising look, a finger to the pulse, and a "Stick your tongue out, my lad!" he would have been diagnosed on sight. No biopsies for granuloma inguinale for him. Yet this patient had been seen by experts in training; he had been seen but not observed, as my chief used to say. I owe a lifetime's professional debt to the country doctor who diagnosed the first case of acute labyrinthitis in syphilis that I saw. How did he do it? The man lay retching on a bed, the room turning about him.. My senior picked up a limp arm and pushed the sleeve to the shoulder; then out of the corner of his mouth said, "Look!" and I saw the first, grouped follicular syphilid, without the slightest idea of what it was, of my career. Rut my senior, the country doctor, knew what it was. Failure to examine, inability to spot and integrate evidence, a low index of suspicion, are the obstacles on which the epidemiologic control not only of syphilis but of all venereal diseases stubs its toe. Of course, I came to the defense of the profession when the nurses assailed us, and pointed out to them the many reasons why the doctor -does not do stripped examinationâ the space requirements, the time requirements, the waiting room full of patients, the telephone, the paper work. Then I had to admit that it takes only a 2-by-2 foot space and less than 7 minutes of time (that's a lot, I know) to do a reasonably thorough examination of a male for a venereal disease. Figure 4 outlines what can reasonably be expected of a physician examining a patient for venereal disease. Contact tracing and the history This new-fangled business of chasing down the spreaders of venereal disease is the essence of modern epidemiologic control. It ranks with the principle of sterilization of infectiousness by treatment. It is the "from whom, to whom" question. It is a costly but an indispensable necessity. It requires office work and a field force, exploration of the patient's mind, and exploration and detailed detective knowledge of his world. A trained questioner is not enough. Good contact tracing requires a personality, a photographic and cataloging mind, knowledge of the lingo and the locus, an uncanny ability to put things together, a sort of crossword or jigsaw-puzzle mindâand footwork, everlasting footwork. Contact tracers who have broken records in numbers of contacts brought in have turned up out of anywhere, in any walk of life; been picked out of the waiting queues in clinics and from the touts and barflies along the waterfront. A good one, well grounded in public Page 91 - Figure 4.âLet's be realistic! What can the practicing doctor do? iti' yFi&ljf/.-'i. We Can Expect: 1. The doctor to ask questions. What's the matter? How long have you had it? What have you done about it? Where do you think you got it? J JO Wh8 have you been with? 2. A suspiciously alert and intent inspection of the scalp and skin, anus and genitalia, palms and soles, mouth and teeth, lymph nodes. 3. A darkfield examination once in a hundred to a thousand times. 4. A smear on every male urethral discharge, as a check. 5. Cultures for gonococcus, but only at clinical centers, houses of detention, etc. 6. Use of serologic tests for syphilis, safeguarded by State approval of laboratories 7. A serologic test for syphilis on every genital lesion and every exposed- person. 8. A serologic test for syphilis pre- maritally and pre-natally every time. 9. A serologic test for syphilis before transfusion, operation, and in general medical examination. 10. A simplified form of reporting. 11. Knowledge and use of public health resources (diagnostic). 12. A growing demand for free antibiotics. We Cannot Expect: 1. Much personal effort at contact tracing, or any great inclination to call State help on it. 2. As good an examination of women as of men. 3. Routine darkfield examination on primary or secondary lesions, direct or by mail. 4. Adequate examination of women once in a hundred times. 5. Smear or culture reports before instituting treatment. The doctor must do something now. 6. Trustworthy serology from uncontrolled laboratories. 7. An adequate diagnosis of seronegative primary syphilis. 8. Routine blood tests on all patients by any considerable body of physicians. 9. Adequate interpretation of the nonspecific or "biologic false" positive. 10. Complicated paper work and and epidemiologic questionnaires..m| 11. Much turning over of venereal disease to public facilities. 12. Much interest in technically exacting pretreatment diagnosis. ST health, in the maplike liaison knowledge of his terrain, in sympathy, tolerance and magnetism, possessed of the come-hither eye and voice, is a priceless asset. Such people are born rather than made. Can the everyday doctor be a contact-tracing asset? Such qualities are rare, even in chiefs of clinics, we must admit. Rut the doctor can do more than he thinks he can, even if he never moves outside the five questions in figure 4. In the answer to the question, "What's the matter?" one places and estimates the patient. "How long?" and "What did you do?" give you a base-line estimate of your public authoritiesâtheir success Page 92 in education, for one thing. It took the first World War to increase by one-half of one percent the proportion of early syphilis that came in before the second week of the chancre. "Where do you think you got it?" and "Who have you been with?" the doctor ought to ask âbut the phone rings or his tongue sticks, and he doesn't. There is a world of human interest and sense of accomplishment open to the doctor who will take the trouble. Especially should he meet the responsibility in the protection of the marital partner, the juvenile and bobby-soxer, the unraveling of the school epidemic, the supplying of the health authority with information on prostitute foci, and the identification of flagrantly promiscuous patients. Rut realistically, we don't do it, and we are more than slow in calling a nurse or worker into the inquiry. The worst ailment of contact-tracing effort is common to all attack methods in venereal disease. It is delay. One of my best nurses told me that she would wait for a positive diagnosis of the principal or source before proceeding to seek and bring in contacts. It took a salvo of argument to make her see the delay involved. Not only does one seem to lose one's time sense, but one tends to become chair-borne in the contact-tracer's headquarters. A letter takes the place of a hand on the shoulder. "He says he got it from the girl who jerks soda two blocks down at L 's Drug. Would you go after her?" "Why, u-h-h-hâ?" The belief that once a venereal germ enters the human system, sexual relations come to a stop instead of being stimulated, and our forgetfulness of the ticking of the clock, block effective venereal disease control. Add the fact that venereal disease in women is undetected if not undetectable in its infectious stages, and we have a triumvirate of realities against which the gods themselves may fight in vain. "Rut hold on a minute, Doctor," you say, "you're getting too realistic! We'll tighten up our examinations, but you say, *What's the use?' We'll ask the hateful questionsâyes, we'll allow sitting space in our offices for venereal disease, since a nurse can get the patient out in 'ampule time' and everyone is getting penicillin now for everything anyway, and we won't even have to see him after the first round. We'll even hunt for our pad of. blanks and fill out that epidemiologic quiz on your report card and then hunt for the envelope and perhaps the stamp to send it off. And then you tell us it's no use! There's no means of making a darkfield examination in this town, so we'll send him to the next town with delay (if he arrives at all) and with the possibility of renewed exposure (notwithstanding our warning him not to). The long-distance darkfield by mail, may we say parenthetically, just isn't used. What's left to us, at your service? Why the blood test, of course! And now you're going to tell us that crutch is of no use, either." i ilftt1 III Some limitations of the smear and blood test approach The smear involves delay, undependability (especially in women), difficulty in obtaining (especially in women). Culture is feasible, but again there is delay, and the laboratory plant and transmission stymies are serious and expensive. Waiting for these reports in the present status of gonorrhea in the antibiotic age is hard to justify. Smears and cultures become matters for confirmation and record and are hotly disputed as to their meaning for cure. There are fewer and fewer smears, less and less culture likely, except in medicolegal work. Now as to the blood test for syphilis. You are all aware that it involves delay. A Friday blood arrival at the laboratory may get you no answer before Wednesday. It if is returned negative, shall you go ahead and treat the genital lesion as a seronegative primary or not? The "golden opportunity," as Pusey called it, is the seronegative primary stageâif you know it's a primary. *In fact, the work of Eagle in experimental syphilis indicates that the amount of penicillin necessary to cure syphilis in the incubation period is only one-fourth the amount necessary when the primary lesion appears. And the seronegative, primary stage human infection is cured by penicillin with only a 1.7 to 4 percent failure rate as compared with 7 to 10 percent for the seropositive and 15 to 30 percent for the full-blown secondary stage. Page 93 What excuse is there, then, for the serodiagnosis of early syphilis except as a confirmation of a suspicion that it might have been more realistic public health, if not idealistic medical scholarship, to accept the probability as a fact and treat accordingly? "Now, Doctor, you are back in the salvarsan days, those polemics between Taege and Riecke, which you used to translate so laboriously from German into English. Shall chancroid be treated as primary syphilis?" Let us further consider the serologic test. Its performance is open to all comers, more's the pity. Rut central or pilot laboratory control has gradually become a reality. In Pennsylvania, when in the process of revising the venereal disease control basic law, we made the premarital and prenatal tests compulsory, we made them the basis for a laboratory approval system by insisting that a test which is made compulsory by the State cannot be performed except in a laboratory whose methods, as evidenced by results, conform to a standard, and are periodically checked for conformity to that standard. Rut the serologist is still too often a prima donna singing his pet stanza in a vacuum. Only recently have some of the larger laboratories accepted conformity. Refore we could undertake in serious fashion the study of the biologic false or nonspecific positive reaction in a large blood donor center, it was necessary to tune, as for an orchestra performance, the technics of three participating private laboratories before the clinical and final laboratory group evaluations could begin. The conformity of State with national standards in the United States has had its uphill struggle too, but is now established. Well before one gets to the problem of the nonspecific positive, then, one has to realize that uncontrolled serology is seriously untrustworthy and capable of wrecking lives, hopes, and happiness. One has to realize that a valuable antigenic discovery like the cardiolipins may lose its specificity in this or that man's private system. One must realize that quantitation (the return of results in units of reagin that fit into accurate curves of therapeutic response)x is a modern necessity in testing the blood in early syphilis, in testing the spinal fluid in neurosyphilis, and in testing the blood of the infant of" a syphilitic mother. To report in pluses now marks reporter and user as "back numbers." Perhaps you would like to see the laboratory report of a patient with neurosyphilis, turned out by a tuned and smoothly running serologic machine (see page 25, figure 5), with the jolt thrown into it by a single day of antigen trouble under a technical transition in laboratory control. And while you view the smooth part of this chart, let me say that the examination of the spinal fluid is so full of crotchets and possibilities of error that hardly one laboratory in five can have its results used interchangeably with those of a standard or top-notch performer. For several years, the nonspecific positive test has given medical practice much concern. The concern has not yet caught up with mass blood testing and the "Wasserman barbecue." State, regional, racial and national, industrial, city school, and lodge checks take no account of the inescapable fact (based on several studies, including the results of separations-tests in the armed forces) that as high as 40 percent of positives in a common run, especially of a single precipitation test, may be nonsyphilitic positives. As case uncovering by blood testing has stepped up its pace in the past half decade, the consultant's office has been jammed with shocked and bewildered people who, walking in supposed security, found themselves I confronted by a positive blood tesf; report. The question, "What does this mean and what to do?" heard at the start from the perplexed and sometimes angry doctor, has changed, and the change is significant of the antibiotic age in syphilis epidemiology. The question now reads, "This woman had a positive, was given 6 million units of penicillin, her baby has had 3.6 million units, both are blood negative, what to do next?" The only answer to that is too often, "t~Joodness knows!" Again, treatment on suspicion is overtaking diagnosis. Perhaps it may-be bringing coals to Vancouver-Newcastle, but it would round out this part of the text to summarize from one of my previous papers the elementary controls the doctor can place upon the biologic false or nonsyphilitic factor, in his diagnosis by blood test. Note the titered or quantitative test is essential to such differentiations. Page 94 i a a. d. e. f. A non specific positive is to be suspected under the following circumstances: If there is complete disagreement between the results of complement fixation and precipitation tests, and especially if it is the precipitation test that is positive. If the reactions in quantitative tests are fluctuant and of low titer on repetition. If there exists, or there is a history of an acute infection within thirty days of the time the test is taken. If repeated quantitative tests (in the absence, of course, of supportive evidence of syphilis) show over a period varying from ten to one hundred and twenty days a decline to, or close to, negative. In using a precipitation test alone, no matter which one, without a complement fixation check. In winter, as distinguished from summer, testing (respiratory infection season). "7. j. The drawing of blood for a seralogic test should be accompanied by questions: (1) Have you had or been treated for syphilis or gonorrhea? Ask again and again. (2) Have you had malaria? (3) Have you had within a month a fever, cold, grippe, pneumonia, or severe sore throat? (4) Have you had any preventive inoculations within three months (tetanus, typhoid, smallpox vaccination)? (5) Have you had blood tests before? Results? "k. At least a once-over physical inspection. (1) Pupils. (2) Rashes (semistripped or stripped). (3) Oral mucosa if possible of indicated. (4) Genitalia if possible or indicated. (5) Tibiae. (6) Signs of intercurrent infection. "1. Temperature, pulse, respiration. Auscultation of heart and lungs if above normal "Such basic information and often much more must be regarded as essential to the diagnosis of syphilis by the positive serologic test."* What is being done to meet the nonspecific positive problem in the blood-test diagnosis of syphilis. It must be admitted, as the old square-rigger sailors used to say, we are hanging in stays. Verification tests have not worked out. The Neurath euglobulin inhibition test is still under investigation and will have a margin of error, I should guess, of not less than 20 percent. It is too complex for mass application, though its extension as a special aid is justified. The best available plan seems to be a clinical or consultant, evaluation center that can combine multiple tests from different laboratories (producing the so-called serologic pattern of the case) with an adequate clinical judgment of examination findings. This is a ponderous and expensive mechanism of which the doctor and his patient are understandably slow to take advantage even when it is accessible. What actually seems to be happening is again this transition from pretreatment diagnosis to prediagnostic treatment or treatment on suspicion. Doctor or patient rightly or wrongly seem to feel that 10 million units of penicillin is as prompt, cheap, and dependable an answer in the doubtful case as the equivocations of a consultant who ends, after expensive deliberations, with inevitable hedging and a recommendation of the same 10 million units of penicillin "just in case" someone should be wrong. â¢Reproduced from "The Recent Advances in Sypbilologic Diagnosis and Treatment.' The Pennsylvania Medical Journal, April 1947, pp. 719-20. Page 95 ift I m, Figure 5.âAn Example of Unresponsive Blood, C.S.F. Resistance and Clinical Progression, in spite of Penicillin No. 45, A. K., W. M. (age?) 2/7/44. Taboparesis. Previous treatment: 30 arsphenamine, 50 bismuth. Routine STS positive 1942. Positive CSF 1/3/44. Anisicoria, coarse tremor of tongue. Mental: station, gait, and reflexes O.K. Date Days post pen. Kline Cells Wass. Prot. Mastic. Clinical 1/3/44 Pre- Pen. 1 0122 2+ 1233310000 (1) 1,200,000 units penicillin (every 3 hours) 2/7/ to 2/11/44 2/ 7/44 2/23/44 3/29/44 5/ 3/44 10/3/44 1/30/44 1 18 45 80 233 352 8 1Â±0 32 2 21Â±0 16 Tremor of tongue and anisicoria; otherwise negative. Slight ataxia; impression: no change(?). â¢ 5 3 RBC 4 0 4444 0122 0124 0012 0112 20 20 20 20 20 2444111000 1221000000 2443210000 2221100000 2221100000 (2) 2,400,000 (every 3 hours) 5/4/ to 5/11/45 3/ 5/45 5/ 8/45 6/12/45 11/5/45 2/27/46 447 451 486 636 750 21Â±0 3 3 3 3 Somewhat unstable; has roaring in head. Continues to have roaring in head. Romberg si. positive. Has had some hallucinations. Impres" sion: paresis worse. 0012 0000 0000 0000 20 10 20 20 2221100000 0000000000 1110000000 1110000000 32 Neg. 21Â±0 (3) 6,400,000 (every 3 hours) 3/29/ to 4/8/46 1 3/29/46 4/ 3/46 1/22/47 9/ 3/47 2/25/48 12/15/48 781 786 1085 1304 i 1479 1772 32 Some pain in right calf; still has roaring in head. No change (?). No clinical change. *False positive day in laboratory traced to defective complement. 4 3 4 2 0 0000 0112 1244 0000 Pos. 4+* 20 20 20 20 20 1110000000 1222100000 2344210000 0000000000 1110000000 Neg. 4 Neg. 2 Page 96 .' The latest meeting, held in Washington on April 7 and 8, rated cardiolipin-lecithin antigens (there are two), which Arnold and Mahoney say must be standardized for treated and non- tieated cases, for climate, for other diseases, and for the detection of nonspecific positives, as the best existing answer. Kline, in discussing their paper, went so far as to say that biologic false-positives are all technical and due to poor antigen. Rut the Great White Hope of serologic testing is now asserted to he in a wholly different direction: the detection of Nelson's treponeme- immobilizing antibody in syphilitic serum, whose specificity eliminates biologic false positiveness entirely, and whose general application to the serologic identification of syphilis on a large scale awaits only the stymie (which it must be admitted is serious) of the cultivation of virulent Treponema pallidum, whose only available source at present is syphilitic rabbit testicular emulsion. This series of rather critical, not to say sour, comments on the blood test uncovering mechanism cannot be allowed to pass without a final general endorsement of the STS, the serologic test for syphilis. Nothing at the present time remotely suggests a justification for failure to use it anywhere and everywhere that it can be used, with and without symptomatic provocation. Tragedy lurks behind every omission, a tragedy so much more serious than the occasional puzzles of false or nonspecific returns, that there is no comparison. A single instance, almost up to the minute, comes from an area in which the law, the practice, and the physician cooperation are all at a high level. Ingraham, Rose and Reerman, surveying a series of cases collected between 1946 and 1948, found 75 pregnant women whose syphilis had been neither recognized nor treated before or during the pregnancy, with a wholesale infant mortality and morbidity (70 percent) that could have been avoided if prenatal cure and prenatal blood testing had been carried out. Moore has welLemphasized how often the doctor's own family can be involved in an unrecognized syphilis, under the delusion that the professions is sacrosanct and safe. Is Treatment on Suspicion the Answer? Refore we face this question even more directly than we have up to this point, let us examine a few more straws for wind direction. Certain advances made possible by the antibiotics are essential parts of the problem. The oldest in point of time is the recognition of the importance of what would be adequate treatment for gonorrhea but indubitably insufficient treatment for a masked onset of syphilis. The 600,000-unit level is below the lowest recognized total dose for the treatment of seronegative primary syphilis recommended to our Armed Forces by the National Research Council's Subcommittee on Venereal Diseases. It is a little difficult to picture as practicable for gonorrhea a 6 million unit dose of penicillin, even at a daily single-injection level of 1.2 million units for 5 days. It must be recalled too that prolongation of effect by sustained blood levels is essential to cure the syphilis in animals. Here the absorption retarders come to our aid. Wright, Nicholson, Arnold and Mahoney have just reported that a sustained significant level for 72 hours from a single injection in man is as effective when procaine penicillin in oil with aluminum monostearate is used as was a 7-day round-the-clock course of water-soluble penicillin with the earlier preparations. Combining their views with those of Thomas, Rein and Kitchen, calling into the estimation Eagle's statement that the sterilizing dose for syphilis in the incubation period is one-fourth the curative dose required when the primary lesion develops, we are practically at the point where a single dose cure of around 1.5 million units is at hand for syphilis in the incubation period, and for gonorrhea, and, by implication, for effective treatment prophylaxis. It will not surprise you to know that oral penicillin too is under study now as a prophylactic against gonorrhea and that a 300,000-unit tablet will be or actually is available, which will almost certainly be tried in syphilis, notwithstanding that we know next to nothing of its effectiveness except that oral administration with the booster-dose system can maintain adequate blood levels in most patients but that unaccountably some patients fail to show significant blood levels at all. For a number of reasons, the Journal of the American Medical Association recently Warned editorially against the trial of oral penicillin as a venereal prophylactic under civilian conditions. Page 97 m m if Ml rtffi! From the attempt to treat syphilis effectively when combined with gonorrhea, and to develop a single-dose cure for both diseases, it is but a step to an attempted single-dose protection from infection of the exposed individual. Historically, treatment prophylaxis has been attempted with the arsenicals and with bismuth, but the practice has been confined to the positively exposed single individual. How Alexander, Schloch and Mantooth, amid protesting Oh-h-h's have again taken the bull of ping-pong reinfection and contact protection boldly by the horns and reported a 1-day treatment for contacts, consisting of a single 900,000-unit dose of penicillin in oil and wax, a single injection of 60 mg. of mapharsen, and a single injection of bismuth camphocarboxylate. They estimated the level of infection incidence in untreated contacts as 62 percent, of their treated contacts at 11 percent. This is a maximum figure which they believe is practically negated by the probability that all the failures were leinfections. Last month they reported further studies omitting the mapharsen injection and using the "system," which they speak of as abortive treatment, in the treatment of symptomatic early syphilis. The results thus far, they believe, compare favorably with generally accepted present-day treatment standards. At the Washington meeting, Plotke and his co-workers reported from the Chicago Rapid Treatment Center, using only 600,000 units as the protective dose, that six times as many infections (25.4 percent) developed among untreated contact controls as among the treated contacts (4-percent) of persons with infectious syphilitic lesions. I believe we may say that there is developing, then, a rational, practical simultaneous treatment of gonorrhea and syphilis in the incubation period, which can also be applied both to manifest infections and to contacts on suspicion. It is true that such a statement must be qualified, as must all penicillin statistics, by the fact that not enough time has elapsed yet for final judgment of penicillin cure. It is even a temptation to imagine the administration simultaneously with procaine penicillin and aluminum monostearate of dihydrostreptomycin, aureomycin (which, as you know, is a rather slow orally administered antisyphilitic), and Chloromycetin (which with aureomycin is active against granuloma inguinale) to all earlg-; symptomatic venereal disease and to all persons suspected of exposure, as a massive control effort with possibilities. Standing on this threshold, then, let us review the field and roughly draft exploratory rules for treatment on suspicion (without positive diagnosis, or on a history'of exposure, or on preponderance rather than conclusiveness of evidence). it* 4$ m â¢ Figure 6.âAn exploration of principles for treatment on suspicion in venereal disease 1. The fields involved: (a) Purulent urethritis, vaginitis, and Rartholinitis before smear of culture report is received. (b) All suspicious genital lesions, suspicion to include all sexual exposure I whatsoever. (c) All accessible sexual contacts of a person with infectious lesions, who on explanation can be induced to accept a single-dose or multiple-dose abortive treatment. (d) Persons in whom the clinical and serologic evidence for infection is strong but not conclusive. (e) Pregnant women with positive blood serologic tests who have not had adequate penicillin therapy for syphilis previously, regardless of the stage or age of their infections. (f) Women of promiscuous habits, who may be assumed to have been exposed to gonorrhea, activity not demonstrable because of the difficulty of positive diagnosis. Â§||| Page 98 Figure 6âContinued 2. The institution of treatment shall be accepted as tantamount to a positive diagnosis, and treatment shall be conducted as if a diagnosis had been made. 3. All possible steps to establish a diagnosis of record shall be taken before' treatment, e.g., smears, darkfield examination, blood test. 4. The treatment shall be the maximum currently accepted for the conditions suspected. Suggestions: (a) For early gonorrhea (first week), 1.2 million units procaine penicillin with aluminum monostearate, 600,000 units on first and fourth days. (b) For gonorrhea of 2 weeks' standing, 2.4 million units at 600,000 units on first, third, fifth, and seventh days. (c) For a suspicious genital (or extragenital) early syphilitic lesion (even though darkfield negative and seronegative), 6 million units procaine penicillin with aluminum monostearate, 600,000 units daily or every other day, or 6 days a week. (d) For venereal contacts, including suspected incubation stage syphilis, 1.2 million units procaine penicillin with aluminum monostearate; 600,000 units in each buttock or 600,000 units a.m. and p.m., same day. (e) For pregnant syphilitic women, early or late infections, and pregnant women exposed to syphilis, 4.8 million units at 600,000 units daily of procaine penicillin with aluminum monostearate or penicillin in beeswax oil. (f) For probably biologic false positives (nonspecific positive reactors), especially pregnant women, 4.8 to 6 million units. 5. A separate category in reporting shall be provided by the health authority for treatment on suspicion. 6. The follow-up and cure criteria shall be adhered to as rigidly for the suspected as for the demonstrated infection (this to include a quarterly check for 2 years on all suspected incubation or clinical early syphilis, and a year on gonorrhea). These are suggestions for your consideration, not rules for your observance. For one who came to this occasion resolved only to present perspective, not to advocate decision, you will see that, like the turtle, I have rather stuck my neck out as I walked. Those of you who are concerned with medicine as an intellectual discipline, and differential -diagnosis as one of its choicest expressions, will shudder at the ultimates suggested by such an approach to the epidemiology of venereal infections. That this radical and heterodox procedure is capable of extinguishing venereal disease, even with the advances which one can already envisage for the near future, seems to me improbable. Rut far more improbable âin fact, quite impossibleâappears to me the extinguishing of pretreatment-diagnosed venereal disease. Short of the hoped for but still remote achievement of immunization, prerecognition and on-suspicion therapy, even with its chances of relapse, its margin of untraced contacts, its battledore and shuttle-cock reinfections, seems, in the new age, definitely the better bet. The problem of promiscuity I have deferred to a closing paragraph a mere mention of a critical topic, which I have presented more fully elsewhere. Cold analysis of the accomplishments of chemotheraputic age in the control of venereal disease, aided by all the contributory efforts that a generous Page 99 m government has put at the disposal of venereal disease control workers, has- not been too encouraging. Ground gained at one point has been lost at another. The reinfection problem in syphilis, the weekly gonorrhea, the spread of venereal disease downward into teen-age and childhood, the reappearance of sinister trends like wide-open prostitution and sex commercialization, prophylaxis without regard for social and moral implications, the imperiled status of the family, are only a few of the salients at which critical battles are being fought on a front that embraces all of human life. Mere treatment of venereal disease is certainly not the answer. And were it the answer, and were venereal diseases wiped out, it is now clear that the accomplishment would have heavy costs in the social, moral, and material life of man. A world of accepted, universalized, safeguarded promiscuity is something to look at searchingly before it is accepted. Venereal disease is now seen as flag-bearer for a social ailment, a maladjustment, shall we say, an unbiologic trend in the behavior of man. If promiscuity is not to be accepted, and I say for myself, unhesitatingly, it should not be, a .whole new arsenal of weapons must be brought to bear upon the sex and venereal disease problem. It is a reasonable question, whether by eliminating disease, without commensurate attention to the development of human idealism, self-control, and responsibility in the sexual life, we are not bringing mankind to its fall instead of its fulfillment. When, as he sometimes does, the physician takes the stand that his business is the extinction of disease by any and every method, regardless of its moral repercussions, and lets the chaplain look after the rest, he is on dangerous ground. First of all, he is a leader of men, and secondly, a servant of bodily health. If he debases the spirit of man by the methods he employs to save his body, he is indeed the Devil's servant. If he is to measure up to his humanistic tradition he must concern himself constructively with the conservation of family living, and with education for it. A Symposium on Current Progress in the Study of Venereal Diseases Held in Washington, D.C., on April 7 and 8, under the auspices of The Syphilis Study Section, Division- of Research Grants and Fellowships, National Institutes of Health, United States Public Health Service, in conjunction with Hie Eleventh Annual Session of the American Venereal Disease Association. Government Printing Office, Washington, D.C., 1949. "The Role of Cardiolipin Antigens in the Serology of Syphilis," by R. C. Arnold and J. F. Mahoney. Discussed by R. S. Kline. "Immobilization of Virulent Treponema pallida by Antibody in Serum and Cerebrospinal Fluid of Syphilitic Patients," by Robert A. Nelson, Jr., Judith A. Diesendruck and Harold E. Zheutlin. "Treatment of the Syphilitic Pregnant Woman with Penicillin in Absorption-Delaying Vehicles," by Norman R. Ingraham, Jr., Elizabeth Kirk Rose, and Herman Reerman. "The Treatment of Early Syphilis with Three Injections of Penicillin and with One Injection of Penicillin," by R. D. Wright, F. P. Nicholson, J. F. Mahoney, and R. C. Arnold. "Experiences with Single and Multiple Treatment Schedules of Early Syphilis with Procaine Penicillin in Oil and Aluminum Monostearate," by Evan W. Thomas, Charles R. Rein, and Delmas K. Kitchen. "The Dynamics of Penicillin Action in Relation to its Use in the Treatment of Syphilis. A Recapitulation of Experimental Data," by Harry Eagle. "Abortive Treatment of Syphilis. Results Obtained in the Incubation Primary and Secondary Stages of Syphilis," by Lee J .Alexander, Arthur G. Schoch, and Walter M. Montooth. "Penicillin in the Prophylactic Treatment of Syphilis/' by Frederick Plotfe, Henry Eisenberg, Amelia H. Raker, and M. E. Laughlin. Page 100 References 1. Arnold, R. C; Mahoney, J. F.: Role of cardiolipin antigens in the serology of syphilis. Symposium on Current Progress in the Study of Venereal Diseases. Pp. 207-209. Government Printing Office, Washington, D.C., 1949. Discussion by R. S. Kline, ibid, Pp. 209-211. 2. Nelson, R. A., Jr.; Diesendruck, J. A.; Zheutlin, H. E.: Immobilization of virulent Treponema pallida by antibody in serum and cerbrospinal fluid of syphilitic patients. Ibid. Pp. 15-18. 3. Ingraham, N. R., Jr.; Rose, A. K.; Reerman, H;: Treatment of the syphilitic pregnant woman with penicillin in absorption-delaying vehicles. Ibid. Pp. 34-39. 4. Moore, J. E.: The Diagnosis of Syphilis by the General Practitioner. Supp. No. 5 to Ven. Dis. Inform. Government Printing Office, Washington, D.C., 1940. 5. Wright, R. D.; Nicholson, F. P.; Mahoney, J. F.; Arnold, R. C: Treatment of early syphilis with three injections of penicillin and with one injection of penicillin. Symposium III? on Current Progress in the Study of Venereal Diseases. Pp. 28-34. Government Printing Office, Washington, D.C., 1949. 6. Thomas, E. W.; Rein, C. R.; Kitchen, D. K.: Experiences with single and multiple Treatment schedules of early syphilis with procaine penicillin in oil and aluminum monostearate. Ibid. Pp. 283-286. 7. Eagle, H.: Dynamics of penicillin action in relation to its use in the treatment of syphilis. Recapitulation of the experimental data. Ibid. Pp. 272-276. 8. Alexander, L. J.; Schoch, A. G; Mantooth, W. R.: Abortive treatment of syphilis. Results obtained in the incubation, primary, and secondary stages of syphilis. Ibid. Pp. 267-271. 9. Plotke, F.; Eisenherg, H; Raker, A. H.; Laughlin, M. E.: Penicillin in the abortive treatment of syphilis. Ibid. Pp. 260-267. 1 3 Reproduced from pp. 719-20, "Recent Advances in Syphilologic Diagnosis and Treatment The Nonspecific Positive Serologic Test and the Use of Penicillin," by John H. Stokes, M.D. The Pennsylvania Medical Journal, April 1947. 2559 Cambie Street, Vancouver, B.C. Page 101 &M9&&&&1; JOHN WYETH & BROTHER (CANADA) LIMITED WALKERVILLE {W& ONTARIO iNUmd Trod. Moi* r!,ti, ' â '- - Supplements the sun... removes the shadow of RICKETS Rickets may be found in apparently healthy and well nourished infants due to an insufficient intake of vitamin D plus inadequate exposure to ultraviolet rays. It is now generally accepted that a vitamin D supplement should be given regularly not only to infants but to older children and adolescents. Mead's Oleum Percomorphum With Other Fish Liver Oils and Viosterol is useful for this purpose. ifjHi ; V-; \nI Mead's Oleum Percomorphum 1. Is a highly potentf source of natural vitamins A and D. 2. May be given in drop doses that are easily administered and well tolerated, and is supplied in capsule form also. 3. Has a background of sixteen years of successful clinical use. tPotency: 60,000 U.S.P. units of vitamin A and 8500 U.S.P. units of vitamin D per gram. Each drop sup- Plies 1250 units of vitamin A and 180 units of vitamin D; each capsule, 5000 units of vitamin A and 700 units of vitamin D. Supplied in 10 cc. and 50 cc. bottles; and in bottles of 50 and 250 capsules. LOCAL REPRESENTATIVE: D. M. TURNER, The Branches Caledonia Avenue, Deep Cove, B.C., Canada â Deep Coveâ2261 eMooM. THE TREATMENT OF PINWORM INFESTATION w M ft "VERMILET" Tablets Enteric coated tablets of Gentian Violet "(Sowf Infestation with pinworms is common in children and not unknown in adults. The high incidence of infestation revealed in recent surveys makes this condition a major public health problem. Symptoms may be entirely absent. Diagnosis is best established by using The National Institute of Health technique of stroking the skin-anal margin with a cellophane swab in the morning before bathing, and examining the swab for ova of the parasite. The demonstration of pinworms in one member of a family should render the entire family suspect, and all infested individuals should be treated simultaneously. Fortunately, 90% of cases can be cured within a short time with little inconvenience. Clinical records show that the most effective treatment is the administration of gentian violet, in the form of tablets. "Vermilet" Tablets are specially made to pass undissolved through the stomach and to dissolve in the lower part of the ileum. NOTE:âGentian violet is contra-indicated in heart disease, hepatic and renal disease, gastro-enteritis, pregnancy, and in the presence of febrile or debilitating diseases. DOSAGE INFANTS:âUnder three years of age, 3/20 gr. (9.6 mg.) for each apparent year of age. For children unable to swallow a tablet, it is suggested that the tablet be concealed in a teaspoonful of oatmeal; the child will swallow the tablet with a bolus of the cereal. CHILDREN:âOver 3 years of age, 3/20 gr. (9.6 mg.) for each apparent year of age, divided in three parts and taken before meals. F'rom 10 to 16 years of age, one tablet of J4 8rÂ« (32 mg.) three times daily before meals. ADULTSMTwo tablets of H &â¢ (32 mg.) three times daily before meals. Repeat dose daily for 8 days, rest for one week, then repeat dose for additional 8 days. No patient should be discharged as cured unless 3 or 4 swabs, examined at intervals of a week apart, show absence of ova "VERMILET" Tablets E.C.T. No. 409 "imaf 3/20 gr. (9.6 mg.) E.C.T. No. 410 "gJoMf y2 gr. (32 mg.) Bottles of 200 and 500 tablets. A package of twabf and literature dot" cribing technique for demonttrating the ova will be sent free upon requetti Chante* g.S5ioaat&(?o. MONTREAL CANADA she deserves breakfast Control nausea and of pregnancy with NIDOXITAL NIDOXITAL Nidoxital logically combines benzocaine, pentobarbital sodium, nicotinamide, dl-methionine, and pyridoxine hydrochloride thus providing a prompt quieting effect on the specific organs involved in the vomiting syndrome. Nidoxital further tends to maintain hepatic function, protein and fatty acid metabolism, and normal nerve function. The usual dosage of Nidoxital Capsules is one capsule taken three times daily 45 minutes before each meal. In the interests of economy, original prescriptions should specify 12 to 24 capsules only. QrthO PHARMACEUTICAL CORPORATION (CANADA) LIMITED â¢ TORONTO, ONT. iff!!" Â»j mt-t I STOVAGMflL antiparasitic and antiseptic restorative of the biological media IN THE TREATMENT OF LEUCORRHEA trichomonas vaginitis vulvovaginitis of pregnancy senile leucorrhea infantile non-gonoccocal vulvovaginitis HOW SUPPLIED Tablets of 0.25 Gm. of STOVARSOL'Toulenc" bottles of 100, 500 and 1000 Powder containing 0.25 Gm. of STOVARSOL per Gm. bottles of 30 and 200 Gm. information and samples upon request pouLcnc LimiTCD mODTRâ¬BL the forms of Fe+ + Iron Therapy Ferrous Sulphate Ferrous Gluconate Iron Pyrop hosp hate ANGLO-CANADIAN DRUG COMPANY LTD. OSHAWA CANADA THE SUFFIX ANCA WILL IDENTIFY ANY OF OUR PRODUCTS ON A PRESCRIF OSTEOTABS WITH IRON AND VITAMIN C III; Each enteric coated tablet contains: Purified Selected Bone Meal 5 grains Ferrous Sulphate U.S.P. Crystal 5 grains Vitamin C (Ascorbic Acid) 25 mgms. Vitamin A 500 Int. Units Vitamin D 500 Int. Units Vitamin Bi (Thiamin HCI.) 0.75 mgm. Vitamin Bo (Riboflavin) 0.75 mgm. FERROSULPH NERVINE TABLETS Each sugar coated tablet contains: Ferrous sulphate U.S.P. Crystal 5 grains Vitamin Bi (Thiamin HCI.) 1.0 mgm. Vitamin B2 (Riboflavin) 0.5 mgm. Phenobarbital Sodium 1/4 grain Ext. Nux Vomica 1/4 grain Phosphorus . 1/100 grain FERRANCA TABLETS Each sugar coated tablet contains: Ferrous Gluconate N.F 5 grains Vitamin Bi (Thiamin HCI.) r 1 mgm. Vitamin B2 (Riboflavin) 0.75 mgm. Niacinamide 3.5 mgms. Liver Extract equivalent to 20 grains of fresh liver IRO-PLEX SYRUP Each ounce contains: Iron Pyrophosphate 24 grains Vitamin Bi (Thiamin HCI.) . 3.0 mgms. Vitamin B2 (Riboflavin) 4.0 mgm. Vitamin Be (Pyridoxine) 1.5 mgm. Pantothenic Acid 7.5 mgm. Niacinamide 15.0 mgm. wÂ£J^hJe0e?L wed Treat nent of the non-hospitalized patient in need of penicillin rapy may be effected in practically all cases with the use of a "Cillenta" preparation. These products of illin G (crystalline) are entirely prepared in the Ayerst laboratories. Their range of form and potency ensures the physician of a suitable product whatever the patient's penicillin requirements may be. the P ei licii // Tablets Ointment Throat Lozenges Ophthalmic Ointment Tablets tor Pediatric Use Soluble Tablets Compound Tablets CtaeM* Ayerst, McKenna & Harrison Limited â¢ Biological and Pharmaceutical Chemists â¢ Montreal, Canada ffe Introducing Cafergone (E.C. 110) Oral Migraine Therapy I * > I CAFERGONE is the first highly effective oral preparation providing rapid and sure relief to the migraine sufferer. Each tablet contains: 1 mg. ergotamine tartrate 100 mg. caffeine (Free Base). . . . "Practically all of the patients in this series had previously used ergotamine tartrate to abort or relieve headache and they uniformly stated that E.C. 110 was more effective than ergotamine used alone" . . . (Horton, Ryan & Reynolds, Proc. Staff Meet., Mayo Clin., 23:105,1948). . . . "Although E.C. 110 (CAFERGONE) was developed primarily for the relief of the migraine attack, it is uniformly effective and has a much wider range of usefulness in the relief of headache of all other types, especially typical and atypical histaminic cephalgia" . . . (Hansel, Ann. Allergy, 6: 155 â 161, 1949). . . . "CAFERGONE . . . definitely seems to be an excellent preparation to use to abort headaches, especially those of the migraine and histaminic cephalgia types" . . . {Ryan, Postgrad. Med., 5: 330,1949). Literature and samples available on request. SANDOZ PHARMACEUTICALS LTD. SANDOZ *Â« 391 ST- JAMES STREET WEST MONTREAL, P.Q ..till W* pi Six physicians' helpers, qualified â every one! ID R Y C O . . . an easily digested, vitamin fortified infant food, which hastens recovery of birth weight, and supplies optimum nutrition during the early months of most rapid growth. Because of its high protein, low fat and moderate carbohydrate content, Dryco enables you to prescribe a formula with a wide range of adjustment for the special as well as the normal feeding case. 2C.M.P. PROTEIN MILK ... a high- protein, lowered fat and low carbohydrate acidified milk. It has been used with great success for infant feeding in cases of diarrhoea in the bottle fed infant, dyspepsia, malnutrition due to gastro-intestinal disturbances, coeliac disease, and as a feeding for the premature infant when breast milk is not available. 3 CM.P. LACTIC ACID MILK ... is spray-dried pasteurized milk inoculated with a culture of lactic acid bacilli and incubated to a definite acidity. C.M.P. Lactic Acid Milk has all the excellent qualities of the freshly prepared product, and in addition is uniform and stable. It is easily and quickly reliquefied for instant use. A MULL-SOY ... an emulsified soy ^* bean food used as a replacement for milk in cases of milk allergy in infants, children and adults. It is palatable, well-tolerated and easy to digest. Mull-Soy diluted with equal volume of water contains all the essential nutritional properties of average cow's milk. C BORDEN'S EVAPORATED MILK *^ . . . a pure, fresh whole milk evaporated to double concentration, and homogenized for extra smoothness and ease of digestion in infant feeding formulas. Vitamin D increased. 6KLIM . . . spray-dried, powdered milk containing all the valuable nutritive qualities of fresh whole milk. A simple effective means of providing extra milk solids without increasing the total bulk of the diet. The spray drying process results in soft flocculent easily digested curd particularly desirable in infant feeding formulas. Formula Foods Professional Literature on request. Mailed, postage paid, to any physician in Canada. THE BORDEN COMPANY, LIMITED. soJ^'^o^oTon^ The Aerohalor's WIDE OPENING floats the penicillin powder on through the mouth You prescribe simple and effective penicillin powder inhalation when you specify the Aerohalor. Simple because it is as easy to use as smoking a pipe. Effective because its wide mouthpiece provides optimum conditions for an open airway through the mouth, and because only a small amount of powder is inhaled with each inspiration. The Aerohalor comes assembled with detachable mouthpiece and ready for oral inhalation. Easily-interchangeable nosepiece included in package. Prescribed separately, in quantity needed, are disposable Aerohalor* Cartridges. Each contains 100,000 units of finely divided crystalline penicillin G potassium. Aerohalor's effectiveness proved by clinical investigation.1 Write for professional literature. Abbott Laboratories, Limited, Montreal. 1. Krasno, L., Karp, Mâ and Rhoads, P.S. (1948), The Inhalation of Penicillin Dust, J. Amer. Med. Assn., 138:344, October 2. *Trade Mark for Abbott Sifter Cartridge. Aerohalor and Aerohalor Cartridge patented in U. S. and foreign countries. AEROHALOR TRADE MARK REG D. (^^^f^^UYi^r^^^^' EXCLUSIVE AMMILIICE LIMITED FAir. 0080 NW. 60 OXYGEN THERAPY SUPPLIED ON YOUR ORDER. 24 HR. SERVICE J. H. CRELLIN W. L. BERTRAND &*b When prescribing Ergoapiol (Smith) for your gynecologic patients, you have Ihe assurance that it can be obtained only on a written prescription, since this is the only manner in which this ethical preparation can be legally dispensed by the pharmacist. The dispensing of this uterine tonic, time-tested ERGOAPIOL (Smith) âonly on your prescription â serves the best interests of physician and patient. INDICATIONS: Amenorrhea, Dysmenorrhea, Menorrhagia, Metrorrhagia, and to aid involution of the postpartum uterus. GENERAL DOSAGE: One to two capsules, three to four times dailyâas indications warrant. In ethical packages of 20 capsules each, bearing no directions Literature Available to Physicians Only. ERGOAPIOL (smith) Ethical protective mark, M.H.S., visible only when capsule Is cut in hall at seam. MARTIN H. SMITH COMPANY 150 LAFAYETTE STREEI KEW YORK 13. Hits
Periodicals
W1 .VA625
English
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Vancouver, B.C. : McBeath Spedding Limited
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Medicine--Periodicals
The Vancouver Medical Association Bulletin: January, 1950
Text