didates who have applied several times are given credit for their perseverance and for their well established strong motivation to study medicine. This year Queen's University offered positions to several applicants who had been rejected in previous years. The admissions committee of the faculty of medicine at Queen's University has included a representative from the lay public as well as two student representatives for the last several years. Choosing a medical class from a very large pool of highly desirable applicants is indeed a difficult task. However, I assure Mr. Meadows that, although the selection procedure is far from perfect, the committee does not operate like "a coldly ratiorrar computer". PAUL C.S. HOAKEN, MD Chairman Faculty of medicine admissions committee, 1975-76 Queen's University Kingston, Ont.
To the editor: Mr. Meadows repeats many erroneous charges that are often levelled at medical school admissions committees. While several of these charges may (and probably did at one time) have a factual basis, there have been radical changes in recent years. I doubt whether nowadays one could adduce any credible evidence that admissions committees in Canadian medical schools are driven by any motive other than that of conscientiously endeavouring to choose students with the potential for ultimately providing the best possible quality of medical care to the citizens of Canada. True, they don't always succeed in this endeavour, but Canada can and should be proud of what they have been able to achieve. University transcripts are not accepted at face value by most (perhaps all) admissions committees. While practices vary, most employ a type of weighing-on-value system with respect to both the courses that have been taken and to the institution at which they were taken. To equate an 80% average achieved in an introductory course where few students fail with an 80% average achieved in an advanced course where the achievement of honours standing is a rarity would reflect the kind of idiocy that I have never encountered in an admissions committee. The offspring of physicians do not enjoy any priority status in selection for medical school, though it is true that they are more likely to apply for entry to medical school and thus be over-represented in the applicant pool. If Mr. Meadows believes that judgements of admissions committees have never been questioned seriously, he has been living in a different milieu than most of us. The nickus a few years
ago over the admission of Chinese students to the University of Toronto was given national coverage and thus led to a great deal of public scrutiny of that university's admission practices. The public interest in the medical school admission process is well served through the presence on most admissions committees of lay members and, in many cases, of student members. Mr. Meadows' final paragraph seems to reflect his belief that computers have a major role in the admission process. This also is not so. Computers may be used at some of the larger schools for the handling of complex data but in most cases they are not used in admission procedures. Even where they are used for this purpose, admission decisions remain human decisions, made by serious, sympathetic and dedicated people. The central problem in medical school admissions at present is that there are many more capable and dedicated young people wanting to enter medicine than can be accommodated. All applicants are aware of this and the wiser ones plan their university careers in such a way as to provide rewarding alternative career pathways against the possibility that they may not be admitted to medical school. A surprising number, however, fail to do this or do it so late in their academic careers that alternatives are hard to find. Whether this problem could be alleviated by more vigorous and effective premedical counselling is clearly a subject that deserves serious consideration in our universities. DOUGLAS WAUGH, MD Executive director Association of Canadian Medical Colleges Ottawa, Ont.
Tardive dyskinesia treated with manganese To the editor: Dr. I. Ray (Can Med Assoc J 117: 129, 1977) reported a case of tardive dyskinesia treated successfully with deanol acetamidobenzoate. This, he suggested, reinforced the hypothesis that this condition is caused by dopaminergic overactivity. A recent report by Kunin1 throws light on another aspect of this serious side effect of long-term treatment with tranquillizers. Reasoning from published observations that phenothiazines are potent chelators of manganese and that manganese is present in high concentration in the extrapyramidal system, Kunin treated with chelated manganese 15 patients that had withdrawal symptoms and tardive dyskinesia. Ten were also treated with niacin or niacinamide. Four patients returned to normal in a few days, there was definite improvement in nine patients in 2 to 5
days, and one patient, although unresponsive to manganese, responded dramatically to niacin. Only one patient showed no response. Kunin suggested that manganese may be useful in the prevention as well as the treatment of tardive dyskinesia. I have seen similar responses in a smaller number of cases. A. HOFFER, MD, PH D 3A-2727 Quadra St. Victoria, BC
References 1. KUNIN RA: Manganese and niacin in tite treatment of drug-indUced dyskinesia. J Orthomol Psychiatry 5: 4, 1976
Is gynecology good for obstetrics? To the t.ditor: Although I thoroughly agree with the general message of Dr. H.B. Atlee's commentary on this subject (Can Med Assoc J 117: 287, 1977), I believe two points warrant some comment. I am disturbed by Dr. Atlee's question "Have we advised her about breastfeeding, or do we leave that to the neonatologist, who imagines he can make as good a milk as God and that there is no difference to a baby between a rubber nipple and its mother's breast?" Every neonatologist I have known, including those who have written recently on the subject, has been well aware of the superiority of breast milk and breastfeeding. I think this question perhaps reveals that Dr. Atlee has had an unhappy experience or is expressing a bias against the pediatricians who have a close interest in the welfare of the newborn. That Dr. Atlee has a tendency to overdraw his remarks is evidenced by his phrase "the callousness of professionalism". I do not accept that callousness is a characteristic of professionalism. Finally, I wish Dr. Atlee had not used the word "physiologize"; I criticize the editors of the Journal for permitting the publication of this unacceptable corruption. AF. HARDYMENT, MD, FRCP[C]
1217-75 W Broadway Vancouver, BC
Management of cardiac arrest To the editor: We cannot be reminded too often of the essential primary steps to be taken in cases of cardiac arrest to maintain life in the first few minutes, otherwise the chance for survival may be lost before the services of experts with sophisticated equipment are available. As indicated by Dr. Alam S. Khan (Can Med Assoc J 117: 162, 1977), the diagnosis can be established quick-
CMA JOURNAL/OCTOBER 22, 1977/VOL. 117 859
ly. The indications for treatment should include cardiac arrest due to any illness, such as an overwhelming infection, or any accident no matter where it occurs. I take issue with Dr. Khan's advice to reserve the "cardiac thump" for patients in whom the arrest has been witnessed or monitored electrocardiographically. If this procedure can initiate cardiac activity and save a life (many authorities have advocated it as the initial step) why delay its use until it may be too late? We recognize our responsibility to teach mouth-to-mouth resuscitation when equipment may not be available to the chance rescuer who is the first person to arrive at the scene of the emergency. Dr. Khan advises his medical readers to apply a clean handkerchief or gauze sponge over the mouth of the victim "if available and desirable". Such advice for physicians, and medical and first-aid personnel, who may anticipate the need to respond to such emergencies, is superfluous. When would such basic items be neither available nor desirable? As long ago as 1962, Elam1 stated: The professional rescuer faces a problem. Unlike the chance rescuer, he is repeatedly called upon as part of his duty to respond to emergencies involving resuscitation. Repeated oral contact with dead and dirty strangers is distasteful to the most dedicated person and constitutes an occupational hazard. For him an accessory which minimizes such exposure is desirable. In contrast to the occasional lay rescuer, the professional will remember to carry his own adjunct. All professional rescuers should be trained in the safe use of equipment of their preference and should be taught how to distinguish the situation where they can do harm from the one where intervention is helpful. For the trained rescuer, equipment should be portable and simple and easily applied. One advantage in the use of an adjunct is that it may include a non-rebreathing valve to divert expired air of the victim from contact with the rescuer's mouthpiece. Such a valve reduces the degree of cross-contamination from the victim to the rescuer. This description, even in 1977, fits only one device - an oral rather than an oropharyngeal airway with a nonreturn valve; namely, the Brook airway. At the annual meeting of the Canadian Medical Association in Quebec this year, the General Council passed a resolution recommending to appropriate federal and provincial departments the list of items to be included in the medical kit carried on medical emergency flights. The Brook airway was mentioned specifically as an essential piece of equipment. Why then, should it not be found wherever its use might be anticipated - for example,
on all hospital wards and in emergency departments, in physicians' and dentists' offices, in physicians' bags and first-aid kits, in the equipment carried by rescue teams, in fire and police vehicles, at pools and beaches, and on boats? In 1963, Dr. B.B. Milstein2 stated: "It is probable that the courts would hold that a doctor who failed to treat cardiac arrest because he was ignorant of the necessary techniques or had not ensured that the essential apparatus was available, was guilty of negligence." Apart from the use of a clean handkerchief or gauze sponge, "if available and desirable", should it not be mandatory for medical and first-aid personnel to be prepared, especially when on duty, by equipping themselves with useful, reliable, simple and safe devices to offset reluctance for esthetic reasons, to minimize the chance of cross-infection, to enhance the efficacy of the procedure and to increase the chances of a successful outcome?3 JOSEPH BROOK, MD 505 Canada Building Saskatoon, Sask.
References 1. ELAM JO: Theory and applications, in Artificial Respiration, WHITTENBERGER JL (ed), New York, Har-Row, 1962 2. STEVENSON HE JR: Cardiac Arrest and Resuscitation, 2nd ed, St. Louis, Mosby, 1963 3. WYLIE WD, CHURCHILL-DAVIDSON HC (eds):
A Practice of Anaesthesia, 3rd ed, Chicago, Year Bk Med. 1962
Prophylaxis for exposure to rabies in humans To the editor: I commend the Journal on the publication of the timely editorial by Drs. Ferguson and CallcottStevens (Can Med Assoc J 117: 12, 1977). While I agree with most aspects of the article I take exception to the comment "an initial [fluorescent antibody) negative laboratory report is no indication for discontinuing therapy." While it may be true that animals that initially have been reported as having negative results of a fluorescent antibody test have subsequently been proven to have rabies virus by inoculations into laboratory animals, there is no evidence that such animals have rabies virus in the saliva. To the best of my knowledge there has never been a case reported of transmission of rabies from an animal with a negative result of a fluorescent antibody test. The United States Public Health Service advisory committee on immunization practices,1 in their most recent statement on rabies, states "if the brain is negative by fluorescent antibody examination for rabies, one can assume that the saliva contains no virus, and the bitten person need not be treated", a position that is concurred with by the
860 CMA JOURNAL/OCTOBER 22, 1977/VOL. 117
The smallest dose of estrogen in any oral contraceptive in Canada.
1/20
each white tablet contains mg norethindrone acetate and 20 mcg ethinyl estradiol
INDICATION - MinEstrin 1/20 is indicated for the control of conception. CONTRAINDICATIONS - Thrombophlebitis, thromboembolic disorders, cerebral apoplexy, or a past history of these conditions; markedly impaired liver function; known or suspected carcinoma of the breast or genital tract; known or suspected estrogen dependent neoplasia; undiagnosed abnormal genital bleeding; during the period a mother is breast feeding an infant; any ocular lesion such as partial or complete loss of vision, defect in visual fields or diplopia arising from ophthalmic vascular disease; when epiphysial closure is not complete; when pregnancy is suspected; classical migraine; history of cholestatic jaundice; coronary thrombosis. WARNINGS-If any thrombotic disorder occurs or is suspected, the drug should be discontinued immediately. Pretreatment and periodic physical examination should include special reference to breast and pelvic organs. Preexisting uterine fibromyomata may increase in size. Conditions influenced by fluid retention, such as epilepsy, asthma, cardiac or renal dysfunction, require careful observation. PRECAUTIONS-Among the precautions associated with oral contraceptive usage are the following: Endocrine, possibly liver function tests and thyroid function tests may be affected. Altered bleeding patterns may be induced. Diabetic patients or those with a familial history of diabetes should be carefully observed while receiving oral contraceptives. Oral contraceptives may mask the onset of the climacteric. Susceptible women may experience an increase in blood pressure. Patients with a history of jaundice should be given oral contraceptives with great care. ADVERSE REACTIONS - Possible adverse reactions include thrombophlebitis, pulmonary embolism, cerebral thrombosis, nausea, altered bleeding patterns, edema, breast soreness, changes in weight, headache, acne, depression, premenstrual tension, hirsutism, and neuro-ocular lesion. DOSAGE FORMS-MinEstrin® 1/20 is available in Simpak® dispensers of 21 tablets (white) and Simpak dispensers of 28 tablets (21 white tablets and 7 lilac inert tablets). Each white tablet contains 1 mg of norethindrone acetate and 20 mcg of ethinyl estradiol. Full product information available on request.
PARKE-DAVIS EE.
Parke, Davis & Company, Ltd. Scarborough, Ontario MiK 5C5
To the editor: Mr. Meadows repeats many erroneous charges that are often levelled at medical school admissions committees. While several of these charges may (and probably did at one time) have a factual basis, there have been radical changes in recent years. I doubt whether nowadays one could adduce any credible evidence that admissions committees in Canadian medical schools are driven by any motive other than that of conscientiously endeavouring to choose students with the potential for ultimately providing the best possible quality of medical care to the citizens of Canada. True, they don't always succeed in this endeavour, but Canada can and should be proud of what they have been able to achieve. University transcripts are not accepted at face value by most (perhaps all) admissions committees. While practices vary, most employ a type of weighing-on-value system with respect to both the courses that have been taken and to the institution at which they were taken. To equate an 80% average achieved in an introductory course where few students fail with an 80% average achieved in an advanced course where the achievement of honours standing is a rarity would reflect the kind of idiocy that I have never encountered in an admissions committee. The offspring of physicians do not enjoy any priority status in selection for medical school, though it is true that they are more likely to apply for entry to medical school and thus be over-represented in the applicant pool. If Mr. Meadows believes that judgements of admissions committees have never been questioned seriously, he has been living in a different milieu than most of us. The nickus a few years
ago over the admission of Chinese students to the University of Toronto was given national coverage and thus led to a great deal of public scrutiny of that university's admission practices. The public interest in the medical school admission process is well served through the presence on most admissions committees of lay members and, in many cases, of student members. Mr. Meadows' final paragraph seems to reflect his belief that computers have a major role in the admission process. This also is not so. Computers may be used at some of the larger schools for the handling of complex data but in most cases they are not used in admission procedures. Even where they are used for this purpose, admission decisions remain human decisions, made by serious, sympathetic and dedicated people. The central problem in medical school admissions at present is that there are many more capable and dedicated young people wanting to enter medicine than can be accommodated. All applicants are aware of this and the wiser ones plan their university careers in such a way as to provide rewarding alternative career pathways against the possibility that they may not be admitted to medical school. A surprising number, however, fail to do this or do it so late in their academic careers that alternatives are hard to find. Whether this problem could be alleviated by more vigorous and effective premedical counselling is clearly a subject that deserves serious consideration in our universities. DOUGLAS WAUGH, MD Executive director Association of Canadian Medical Colleges Ottawa, Ont.
Tardive dyskinesia treated with manganese To the editor: Dr. I. Ray (Can Med Assoc J 117: 129, 1977) reported a case of tardive dyskinesia treated successfully with deanol acetamidobenzoate. This, he suggested, reinforced the hypothesis that this condition is caused by dopaminergic overactivity. A recent report by Kunin1 throws light on another aspect of this serious side effect of long-term treatment with tranquillizers. Reasoning from published observations that phenothiazines are potent chelators of manganese and that manganese is present in high concentration in the extrapyramidal system, Kunin treated with chelated manganese 15 patients that had withdrawal symptoms and tardive dyskinesia. Ten were also treated with niacin or niacinamide. Four patients returned to normal in a few days, there was definite improvement in nine patients in 2 to 5
days, and one patient, although unresponsive to manganese, responded dramatically to niacin. Only one patient showed no response. Kunin suggested that manganese may be useful in the prevention as well as the treatment of tardive dyskinesia. I have seen similar responses in a smaller number of cases. A. HOFFER, MD, PH D 3A-2727 Quadra St. Victoria, BC
References 1. KUNIN RA: Manganese and niacin in tite treatment of drug-indUced dyskinesia. J Orthomol Psychiatry 5: 4, 1976
Is gynecology good for obstetrics? To the t.ditor: Although I thoroughly agree with the general message of Dr. H.B. Atlee's commentary on this subject (Can Med Assoc J 117: 287, 1977), I believe two points warrant some comment. I am disturbed by Dr. Atlee's question "Have we advised her about breastfeeding, or do we leave that to the neonatologist, who imagines he can make as good a milk as God and that there is no difference to a baby between a rubber nipple and its mother's breast?" Every neonatologist I have known, including those who have written recently on the subject, has been well aware of the superiority of breast milk and breastfeeding. I think this question perhaps reveals that Dr. Atlee has had an unhappy experience or is expressing a bias against the pediatricians who have a close interest in the welfare of the newborn. That Dr. Atlee has a tendency to overdraw his remarks is evidenced by his phrase "the callousness of professionalism". I do not accept that callousness is a characteristic of professionalism. Finally, I wish Dr. Atlee had not used the word "physiologize"; I criticize the editors of the Journal for permitting the publication of this unacceptable corruption. AF. HARDYMENT, MD, FRCP[C]
1217-75 W Broadway Vancouver, BC
Management of cardiac arrest To the editor: We cannot be reminded too often of the essential primary steps to be taken in cases of cardiac arrest to maintain life in the first few minutes, otherwise the chance for survival may be lost before the services of experts with sophisticated equipment are available. As indicated by Dr. Alam S. Khan (Can Med Assoc J 117: 162, 1977), the diagnosis can be established quick-
CMA JOURNAL/OCTOBER 22, 1977/VOL. 117 859
ly. The indications for treatment should include cardiac arrest due to any illness, such as an overwhelming infection, or any accident no matter where it occurs. I take issue with Dr. Khan's advice to reserve the "cardiac thump" for patients in whom the arrest has been witnessed or monitored electrocardiographically. If this procedure can initiate cardiac activity and save a life (many authorities have advocated it as the initial step) why delay its use until it may be too late? We recognize our responsibility to teach mouth-to-mouth resuscitation when equipment may not be available to the chance rescuer who is the first person to arrive at the scene of the emergency. Dr. Khan advises his medical readers to apply a clean handkerchief or gauze sponge over the mouth of the victim "if available and desirable". Such advice for physicians, and medical and first-aid personnel, who may anticipate the need to respond to such emergencies, is superfluous. When would such basic items be neither available nor desirable? As long ago as 1962, Elam1 stated: The professional rescuer faces a problem. Unlike the chance rescuer, he is repeatedly called upon as part of his duty to respond to emergencies involving resuscitation. Repeated oral contact with dead and dirty strangers is distasteful to the most dedicated person and constitutes an occupational hazard. For him an accessory which minimizes such exposure is desirable. In contrast to the occasional lay rescuer, the professional will remember to carry his own adjunct. All professional rescuers should be trained in the safe use of equipment of their preference and should be taught how to distinguish the situation where they can do harm from the one where intervention is helpful. For the trained rescuer, equipment should be portable and simple and easily applied. One advantage in the use of an adjunct is that it may include a non-rebreathing valve to divert expired air of the victim from contact with the rescuer's mouthpiece. Such a valve reduces the degree of cross-contamination from the victim to the rescuer. This description, even in 1977, fits only one device - an oral rather than an oropharyngeal airway with a nonreturn valve; namely, the Brook airway. At the annual meeting of the Canadian Medical Association in Quebec this year, the General Council passed a resolution recommending to appropriate federal and provincial departments the list of items to be included in the medical kit carried on medical emergency flights. The Brook airway was mentioned specifically as an essential piece of equipment. Why then, should it not be found wherever its use might be anticipated - for example,
on all hospital wards and in emergency departments, in physicians' and dentists' offices, in physicians' bags and first-aid kits, in the equipment carried by rescue teams, in fire and police vehicles, at pools and beaches, and on boats? In 1963, Dr. B.B. Milstein2 stated: "It is probable that the courts would hold that a doctor who failed to treat cardiac arrest because he was ignorant of the necessary techniques or had not ensured that the essential apparatus was available, was guilty of negligence." Apart from the use of a clean handkerchief or gauze sponge, "if available and desirable", should it not be mandatory for medical and first-aid personnel to be prepared, especially when on duty, by equipping themselves with useful, reliable, simple and safe devices to offset reluctance for esthetic reasons, to minimize the chance of cross-infection, to enhance the efficacy of the procedure and to increase the chances of a successful outcome?3 JOSEPH BROOK, MD 505 Canada Building Saskatoon, Sask.
References 1. ELAM JO: Theory and applications, in Artificial Respiration, WHITTENBERGER JL (ed), New York, Har-Row, 1962 2. STEVENSON HE JR: Cardiac Arrest and Resuscitation, 2nd ed, St. Louis, Mosby, 1963 3. WYLIE WD, CHURCHILL-DAVIDSON HC (eds):
A Practice of Anaesthesia, 3rd ed, Chicago, Year Bk Med. 1962
Prophylaxis for exposure to rabies in humans To the editor: I commend the Journal on the publication of the timely editorial by Drs. Ferguson and CallcottStevens (Can Med Assoc J 117: 12, 1977). While I agree with most aspects of the article I take exception to the comment "an initial [fluorescent antibody) negative laboratory report is no indication for discontinuing therapy." While it may be true that animals that initially have been reported as having negative results of a fluorescent antibody test have subsequently been proven to have rabies virus by inoculations into laboratory animals, there is no evidence that such animals have rabies virus in the saliva. To the best of my knowledge there has never been a case reported of transmission of rabies from an animal with a negative result of a fluorescent antibody test. The United States Public Health Service advisory committee on immunization practices,1 in their most recent statement on rabies, states "if the brain is negative by fluorescent antibody examination for rabies, one can assume that the saliva contains no virus, and the bitten person need not be treated", a position that is concurred with by the
860 CMA JOURNAL/OCTOBER 22, 1977/VOL. 117
The smallest dose of estrogen in any oral contraceptive in Canada.
1/20
each white tablet contains mg norethindrone acetate and 20 mcg ethinyl estradiol
INDICATION - MinEstrin 1/20 is indicated for the control of conception. CONTRAINDICATIONS - Thrombophlebitis, thromboembolic disorders, cerebral apoplexy, or a past history of these conditions; markedly impaired liver function; known or suspected carcinoma of the breast or genital tract; known or suspected estrogen dependent neoplasia; undiagnosed abnormal genital bleeding; during the period a mother is breast feeding an infant; any ocular lesion such as partial or complete loss of vision, defect in visual fields or diplopia arising from ophthalmic vascular disease; when epiphysial closure is not complete; when pregnancy is suspected; classical migraine; history of cholestatic jaundice; coronary thrombosis. WARNINGS-If any thrombotic disorder occurs or is suspected, the drug should be discontinued immediately. Pretreatment and periodic physical examination should include special reference to breast and pelvic organs. Preexisting uterine fibromyomata may increase in size. Conditions influenced by fluid retention, such as epilepsy, asthma, cardiac or renal dysfunction, require careful observation. PRECAUTIONS-Among the precautions associated with oral contraceptive usage are the following: Endocrine, possibly liver function tests and thyroid function tests may be affected. Altered bleeding patterns may be induced. Diabetic patients or those with a familial history of diabetes should be carefully observed while receiving oral contraceptives. Oral contraceptives may mask the onset of the climacteric. Susceptible women may experience an increase in blood pressure. Patients with a history of jaundice should be given oral contraceptives with great care. ADVERSE REACTIONS - Possible adverse reactions include thrombophlebitis, pulmonary embolism, cerebral thrombosis, nausea, altered bleeding patterns, edema, breast soreness, changes in weight, headache, acne, depression, premenstrual tension, hirsutism, and neuro-ocular lesion. DOSAGE FORMS-MinEstrin® 1/20 is available in Simpak® dispensers of 21 tablets (white) and Simpak dispensers of 28 tablets (21 white tablets and 7 lilac inert tablets). Each white tablet contains 1 mg of norethindrone acetate and 20 mcg of ethinyl estradiol. Full product information available on request.
PARKE-DAVIS EE.
Parke, Davis & Company, Ltd. Scarborough, Ontario MiK 5C5
