ation system. The National Committee on Physician Manpower3 has stated that we should be certifying 105 additional specialists in anesthesia each year for the next 10 years in order to meet projected requirements. In the 1976-77 examination year only 49 candidates obtained certification in anesthesia from the Royal College of Physicians and Surgeons of Canada; since 1973-74 the nLlmbers certificated have steadily declined. At the present rate, we shall never meet the manpower requirements in anesthesia. The board of inquiry rightly suggested ways of actively recruiting well qualified anesthetists. It favoured a reappraisal of the value of the anesthetist as a medical specialist. Owing to circumstances beyond their control many anesthetists have to work an excessive number of hours. The average duration of an anesthetic in Canadian hospitals ranges between 61 and 78 minutes.3 Ideally, on a basis of 1200 cases per year, an anesthetist should not be reqLlired to spend more than 1560 hours per year administering anesthetics. This would allow additional time for carrying out other important duties such as the training of medical and paramedical personnel, the preoperative assessment of patients, the provision of consultation services for medical and surgical conditions that require the specialized knowledge and training of an anesthetist, the evaluation and treatment of pain problems and the management of patients in intensive care units. The best way to encourage qualified medical graduates to specialize in anesthesia is to improve financial prospects and working conditions. Accordingly, provincial fee schedules must be adjLlsted so that, when performing the ideal yearly workload, the individual anesthetist will be able to earn an income equal to that of other medical specialists with similar training and responsibilities.

The board of inquiry strongly recommended the introduction of anesthetic technical assistants (ATAs) with limited duties to assist anesthetists in the adminisration of anesthetics. However, the effectiveness of such personnel has not been established. The Canadian Anaesthetists' Society, realizing that this concept required further assessment and evaluation, included the following statement in its official guidelines for the minimal standards of practice in anesthesia: Qualified medical and paramedical personnel or anaesthetic technicians may with the approval of the governing body of the hospital, render certain ancillary assistance in providing anaesthetic, resuscitation and intensive care service. These personnel must be properly trained, must have received accreditation by an appropriate Provincial authority where applicable and the tasks which they are to perform must be clearly defined. An Anaesthetist should only delegate or assign to those personnel, those tasks for which they are accredited.4 The board of inquiry has stated that one anesthetist may, in certain circumstances, be able to anesthetize two patients simultaneously with the aid of ATAs. In the province of Quebec, however, where technicians recruited from respiratory technologists have been used to assist anesthetists, the association of anesthetists has recently recommended that these technicians should only be employed on a one-to-one basis with an anesthetist. The board of inquiry gave much thought to the factors involved in the promotion and maintenance of standards. The policy that every patient once anesthetized must be under direct continuous competent supervision was substantiated. The board also pointed out that the time-tested method of providing progressive graded responsibility to anesthetic residents in university training programs was compatible with their

idea of direct continuous competent supervision. The board stressed the need for more specific criteria for assessing the quality of care in anesthesia and recommended that there should be more research into morbidity in anesthesia as well as development of regional peer review and medical audit programs. These excellent suggestions should be instituted in every province. In respect of the medical education of anesthetists the board's recommendations were timely and well conceived. Possibly more detailed suggestions concerning the funding of university departments could have been formulated. However, it is now up to the various departments of anesthesia throughout Canada to discuss and negotiate improved and more satisfactory financial arrangements with the appropriate provincial health authorities who, after reading the complete report, will understand better the unique problems facing the specialty of anesthesia. To maintain the present high standards of anesthesia in Canada there is no substitute for well trained, experienced and conscientious anesthetists who practise under the direction of a competent and dedicated department head, who in turn has the full support and cooperation of the hospital board. JOHN H. FEINDEL, MD, CM, FRCP[C] Past president, Canadian Anaesthetists' Society Department of anesthesia Halifax Infirmary Halifax, NS

References I. ANDERSON DT (chmn): Board of Inquiry into Anaesthetic Practices in Saskatchewan. Report December, 1976, Regina, Queen's Printer, 1977 2. SHEPHARD DAE: Anesthesia in Saskatchewan: the Anderson report. Can Med Assoc / 116: 806, 1977 3. VANDEWATER SL (chmn): Report of ihe Working Party in Anaesthesia, to the Requirements Committee on Physician Manpower, 1974-7S, Kingston, published by the authority of the minister of National Health

and Welfare 4. Guidelines for the Minimal Standards of Practice in Anaesthesia, approved by the council of the Canadian Anaesthetists' Society, Feb 1, 1975, Toronto, Canadian Ansesthetists' Society, 1975

History, science and the community* Every historian who takes up a new appointment uses the opportunity to tell his new colleagues what history means to him - and what it can mean to them - and it is also an exercise to help the historians discover what they think. There are two principal schools of thought on the writing of history of *Based on an address given at the inauguration of the Jason A. Hannah chair for the history of medical & related sciences, University of Toronto, Toronto, Ont., Jan. 13, 1977

science and of medicine, and almost all the work that is published follows one of these two schools. For one group, history is a disentangling of the ideas of the past, the tracing of the ancestry of our thinking. For the other group, the social history of the sciences the formation of professions, the growth of institutions - is the prime concern. For the first group, the historians of ideas, ideas have an existence independent of men. For the second group, the social school, an institutional history could be the history of any

institute at all; the scientific work produced there is almost irrelevant - in fact, it is mostly not read at all by the historian. Historians of these two schools are the products of two different types of training: internalists, who often spend part of their life practising the science whose history they are concerned with, and externalists, who are usually trained primarily in history or sociology. As Professor 0. Temkin has said1 and he has been in the field since 1920 - internalism parallels the feeling of

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the scientist himself, that he is a free agent, moving towards a steadily improving understanding of the truth; it is this feeling for the logical development of ideas, the solution of problems within the available technology, that corresponds to his own experience of working inside a science, as a scientist or a physician, and it is difficult to argue against such a concept. Even the sociologist Karl Mannheim, who saw most human ideas simply as conscious or unconscious justifications of the thinker's own social position, made an exception for the intelligentsia.2 One of the most interesting analyses of scientific thinking was produced during the 1940s and 1950s by Michael Polanyi, a Hungarian emigr6 who was a physical chemist working in Manchester, England. Polanyi's main contribution was to suggest that scientific knowledge was of two kinds - explicit knowledge and tacit knowledge. Explicit knowledge, which could be formulated as laws and stated in textbooks, was knowledge on which the mind could focus directly. Tacit knowledge was the inexplicit understanding of personal experience - a kind of scientific existentialism, except that for Polanyi this tacit knowledge was shared by other members of the scientific community and formed the basis of their

Prescribing information Ventolin® indications: To relieve bronchospasm in: Bronchial asthma of all typas. Chronic bronchitis, other chronic bronchopulmonary disordars in which bronchospasm is a complicating factor. Suggested dosage: Vantolin Inhaler: One or two inhalations rapaated evary four hours, if raquired. More than eight inhalations per day is not recommended. Vantolin Tablets: To be taken three or four times daily. Adults: 2 mg - 4 me. The optimum single dose for moat adult patients is 4 me. With elderly patients or with patients who are unusually sensitive to bets-adrenergic stimulants, it is advisable to initiate treatment with 2 ma. Children: 6 to 12 years: 2 me Over 12 years: adult dosage Presentation: Ventolin Inhaler: A metered aerosol, delivering 100 mcg of salbutamol per inhalation. Each 15 ml canister provides at least 200 inhalations. Ventolin Tablets 4 me: Each tablet contains salbutamol sulphate 4.8 me, equivalent to salbutamol 4.11 me. Bottles of 1110. Ventolin Tablets: 2 me: Each tablet contains salbutamol sulphate 2.4 me, equivalent to salbutanol 2.0 me. Bdttles of tee. Contreindication Hypersensitivity to any of the ingredients and tachyarrhythmias. Warnings: The safety of salbutamol in pregnancy has not been established. Care should be taken with patients suffering from myocardial insufficiency, arrhythmia, hypertension, diabetes mellitus, or thyrotosicosis. Preceutions: Use with caution in patients sensitive to sympathomimetic amines. Other beta-adregenic drugs, e.g. isoprenaline, should not be given concomitantly. Adverse reactions: Headache, dizziness, nausea, tremor and palpitation, nervousness and leg cramps may occur. The only reported side effect of significance with Ventolin Tablets is a fine tremor of skeletal muscle in some patients, usually affecting the hands. The degree of tremor is dose related and caused by a direct action on skeletal muscle, not by CNS stimulation. This effect is common to all beta-adrenergic stimulants and usually stops with reduction of dosage. Symptoms end treatment of overdosege: Overdosage may cause peripheral vasodilation and increased irritability of skeletal muscle, tachycardia, arrhythmia and hypertension. In case of overdose, gastric lavage should be performed. In order to antagonize the effect of salbutamol, the use of a beta-adrenergic blocking agent, such as propranolol, may be considered.

belief in the propositions of official, explicit, scientific knowledge. It was shared faith in this tacit knowledge that determined the self-regulating growth of science and the initial criticism by members of the scientific community. It was this shared but unspoken understanding of the nature of things that made the dialogue between scientists possible, and this faith that supported the novice who had not yet learned to be a scientist, but trusted his teachers to make him one. Polanyi pointed out the stylistic similarity often found between the work of teacher and student, often for more than one generation. In 1958 Polanyi wrote: We must recognize belief as the source of all knowledge. Tacit as.nt... the sharing of an intellectual idiom and of a cultural heritage, affiliation to a like minded community: such are the impulses which shape our vision of the nature of things... No intelligence can operate outside such a fiduciary framework.3 Polanyi's sociologic theory of scientific thought might well provide the historian with a useful methodology. Reading the materials of past science, one would ask not whether all this was true - that is, how close it was to our ideas about nature - but how it fitted into the scientific community from

Beclovent® INDICATIONS Treatment of steroid-responsive bronchial asthma: (1) In patients who in the past have not been on steroids but the severity of their condition warrants such treatment. 12) In steroid-dependent patients to replace or reduce oral medication through gradual withdrawal of systemic steroids. CONTRAINDICATIONS Active or quiescent untreated pulmonary tuberculosis, or untreated fungal, bacterial and viral infections, and in children under six. Status asthmaticus, end in patients with moderate to severe bronchiectasis. WARNINGS In patients previously on high doses of systemic steroids. trsnsfer to BECLOVENT Inhaler may cause withdrawal symptoms such as tiredness, aches and pains, and depression. In severe cases, acute adrenal insufficiency may occur necessitating the temporary resumption of systemic steroids. The development of pharyngeal and laryngeal candldiasis Is csuse of concern because the extent of its penetration of the respiratory tract is unknown. If candidlasis dave lops the treatment should be discontinued and appropriate antifungal therapy initiated. The incidence of candidiasis can generally be held to a minimum by having patients rinse their mouth with water after each Inhalation. PRECAUTIONS 1. It is essential that patients be informed that BECLOVENT Inhaler is a preventive agent, must be taken at regular intervals, and Is not to be used during an asthmatic attack. 2. The replacement of a systemic steroid with BECLOVENT Inhaler has to be gradual and carefully supervised by the physician, the guidelines under Dossge and Administration should be followed in each case. 3. Unnecessary administration of drugs during the first trimester of pregnancy is undesirable. Corticosterolds may mask some signs of infection and new infections may appear. A decreased resistance to localized infection has been observed during corticosteroid therapy. During long. term therapy, pituitary-adrenal function and hematological status should be periodically assessed. 4. Fluorocarbon propellants may be hazardous if they are deliberately abused. Inhalation of high concentrations of aerosol sprays has brought about cardiovascular toxic effects and even death, especially under conditions of hypoxia. However, evidence attests to the relative safety of aerosols when used properly and with adequate ventilation. 5 There is an enhanced effect of corticosterolds on patients with hypothyroidism and in those with cirrhosis. S. Acetylsalicylic acid should be used cautiously in conjunction with corticosteroids in hypoprothrombinemia. 7. Patients should be advised to inform subsequent physicians of the prior uxe of corticosteroids. ADVERSE REACTIONS No major side-effects attributable to the use of recommended doses of BECLOVENT Inhaler have been reported. No systemic effects have been observed when the daily dose was below 1 mg Itwenty puffs). Above this dose, reduction of plasma cortisol, indicating adrenocortical suppression, may occur. Therapeutic doses may cause the appearance of Candida albicans In the mouth and throat. The replacement of systemic steroids with BECLOVENT Inhaler may unmask symptoms of allergies which were previously suppressed by the systemic drug. Conditions such as allergic rhinitis and eczema may thts become apparent during BECLOVENT therapy after the withdrawal of systemic corticosteroids.

which it came. We can avoid the vulgar historical error of thinking the scientists of the past naive and credulous, and wrong, and ask instead what was the system of beliefs and tacitly accepted understanding that their explicit statements expressed. The idea is a fertile and useful heuristic one; and historians may well be able to understand things about the scientific thinkers of the past that they themselves were unaware of. On the things of which they could not speak, historians today need not remain silent. In doing this for past science, they become aware of the tacit dimension in their own thinking, and aware of it as a source of explicit scientific ideas. Their own self-consciousness widens to include those sources of thinking that have been found to be important in past science. But for me, Polanyi's theory has something missing. His scientific thinkers are quite separate from the rest of the community. For him, academic freedom in science means that scientists must keep themselves free from all outside influences. As he put it in 1962,. "The soil of academic science must be extraterritorial in order to secure its rule by scientific opinion... But scientists do not exist in a selfcontained world, a sort of embassy on foreign soil, and this is particularly SYMPTOMS AND TREATMENT OF OVERDOSAGE Overdosage may cause systemic steroid effects such as adrenal suppression and hypercorticism. Decreasing the dose mill abolish these side-effects. DOSAGE AND ADMINISTRATION The optimal dosage of BECLOVENT may vary widely and must he individually determined, but the total daily dose should not esceed me of beclomethasone dipropionate (20 puffs). Adults: The usual dose is two inhalations (100 mcg) three to four times daily. If this dose is not sufficient, it can be doubled initially. As a maintenance dose, many patients do well on two inhalations daily. Children: insufficient information is available to warrant the safe use in children under six years of age. The average daily dose for children over six years of age is S mcg/kg of body weight. IMPORTANT: As a steroid aerosol, Beclovent Inhaler is for maintenance therapy, it is not intended to give immediate relief, and effectiveness depends both on regular use and proper technique of inhalation. Patients must be instructed to take the inhala. tions at regular intervals and not, as with bronchodilator aerosols. when they feel a need for relief of symptoms. They should also be instructed in the correct method of use, which is to exhale complefely, then place the lips tightly around the mouthpiece. The aerosol should be actuated as the patient breathes in deeply and slowly. This ensures maximum penetration into the lungs, and the breath should be held as long as possible following each inhalation. The patient's attention should be drawn to the Instruction Sheet, enclosed in each Beciovent pack. In the presence of excessive mucus secretion, the drug may fail to reach the bronchioles. Therefore, if an obvious response is not obtained after ten days. attempts should be made to remove the mucus with espectorants and/or with a short course of systemic corticosteroid treatment. Careful attention must be given to patients previously treated for prolonged periods with systemic corticosteroids, when transferred to BECLOVENT. initially BECLOVENT and the systemic steroid must be given concomitantly while the dose of the latter is gradually decreased. The usual rate of withdrawal of the systemic corticoid is the equivalent of 2.5 mg of prednisone every four days if the patient is under close observation. If continuous supervision is not feasible, the withdrawal of the systemic steroid should be slower, approximately 2.5 mg of prednisone for equivalent) every ten days. If withdrawal symptoms appear, the previous dose of the systemic drug should be resumed for a week before further decrease is attempted. There are some patients who cannot completely discontinue the oral corticosteroid. In these cases, a minimum maintenance dose should be given in addition to BECLOVENT inhaler. SUPPLIED BECLOVENT Inhaler is a metered-dose aerosol delivering 50 micrograms of beclomethasone dipropionate with each depression of the valve. There are two hundred doses in a container. Official product monograph on request.

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obvious in sciences such as medicine, genetics or social biology that deal with social questions. For such sciences outside influence cannot be called lay interference. Their practitioners work not only as scientists but also as members of the larger community. Their thinking and their practice are an expression as much of the society from which they are drawn as of a secluded scientific community. It is interesting that Polanyi's theory was itself a reaction to such "external" pressures. He began to develop it in the early 1940s, at a time when an active movement for the central planning of science had appeared in Britain, led by individuals of the political left. In 1938 the British Association for the Advancement of Science started a new division for the social and international relations of science. Bernal's famous book "The Social Functions of Science"5 and Lancelot Hogben's "Science for the Citizen"6 provided the ideas, and the Association of Scientific Workers, the scientific labour union, provided the drive and the organization. Their manifesto was published, and their position enthusiastically supported, by the journal Nature.7 Polanyi's theory of tacit knowledge developed in response to this movement. In defending his personal freedom against state interference, he produced a theory that justified his position: where the source of science is in its tacit dimension, it is impossible to plan it from outside. Only what is already explicit knowledge is available to the outside community: only what is already known can therefore be planned. In 1939 the Oxford zoologist J.R. Baker attended one of the public meetings of the planning group,' and he, too, was moved to protest. He sent a circular letter to 39 practising scientists' inviting them to join a society for the protection of science against central planning, and of individual scientists against the necessity of working as part of a team. Polanyi, who had already published his earliest protest, "The rights and duties of science"'0 in 1939, joined Baker's group, which was called the Society for Freedom in Science, and he became its chief philosopher. His papers were published in pamphlet form by the society, and his thought developed under this stimulus into a complete philosophy or psychology of science, drawing ideas from his personal experience as a physical chemist and his reading of gestalt psychology and existentialism to form a complete defence against the arguments, and the political power, of the left. Polanyi's philosophy, which claims that science is, and must be, independent of all social pressures, is itself a

product of social pressure. It arose as an ideologic weapon in a struggle for power between the political left and the profession. The most important message of the dispute for the historian is that he cannot confine himself to the relations of scientific thought and practice as they appear from within the profession. The scientist is a member not only of the scientific community but also of a wider one or of several intersecting ones made up of interlocking interest groups. Much of his education and his upbringing has taken place before he has thought of becoming a member of a profession, and even when he has joined one he is still a member of a family, a race, a sex, a class, an economic group and a nation, each with its own cultural peculiarity. Like the profession, all these groups within the community are different for every time and place. It is the historian's job to make his hearers aware not only of the ideas of the past but also of the social nexuses within which science was produced and, by implication, within which we live. The idea of a university education, as somebody once said, is to make you aware of your position within the universe. The wider self-consciousness must include not only ideas and relations inside the profession as they have changed over time - and medicine has probably the longest history of any science - but also the way in which professional theory and practice affected, and were conditioned by, the wider community. The historian must reject the unnatural distinction between internal and external history; it is at the point of contact between the two that you get the best sparks. PAULINE M.H. MAZUMDAR, MB, B5, M TECH (IMMUNOL), PH 13 Jason A. Hannah professor of the history of medical & related sciences University of Toronto Toronto, Ont.

References 1. TEMKIN 0: Scientific medicine and historical research. Perspect Biol Med 3: 70, 1959 2. MANNHEIM K: Ideology and Utopia: an Introduction to the Sociology of Knowledge, London, Routledge & Kegan, 1936, pp 136-46 3. POLANYI M: Personal Knowledge: Toward a Post-critical Philosophy, Chicago, U of Chicago Pr, 1958, p 266 4. Idem: The republic of science: its political and economic theory. Minerva 1: 54, 1962 5. BERNAL JD: The Social Function of Science, London, Routledge & Kegan, 1939 6. HoosEN L: Science for the Citizen, London, Allen & Unwin, 1938 7. GREGORY R: The commonwealth of science: the new charter of scientific fellowship presented by Sir Richard Gregory, Bart., F.R.S., President of the British Association, at the end of the Conference on Science and World Order, London, Sept. 26-28 1941. Nature 148: 393, 1941 8. BAKER JR: Counterbiast to Bernalism. New Statesman and Nation 174: July 29, 1939

Apresol i ne

(hydralazine hydrochloride)

anti hypertensive INDICATIONS: Various forms of hypertension or as an adjunct in: fixed essential hypertension,alone whether of benign or malignant character; hypertensive toxemias of pregnancy, pre-eclampsia and eclampsia.

CONTRAINDICATIONS: Hypersensitivity to hydralazine; coronary artery disease and mitral valvular rheumatic heart disease. ADVERSE REACTIONS: Side effects are usually transitory and reversible with reduction of the dosage. Tachycardia, headache, palpitation, weakness, nausea, vomiting and postural dizziness, sion. Less freqently, numbness and tinglinghypotenof the extremities, flushing, depression, nasal congestion, lachrymation, conjunctivitis, edema, tremors, dyspnea, anginal symptoms, skin rash, drug fever, muscle cramps, giant urticaria and a lupus-like syndrome (arthralgia) in some cases following administration for long periods. Peripheral neuritis, evidenced by paresthesias, numbness and tingling has been observed. Published evidence suggests an antipyridoxine effect and addition of pyridoxine to the regimen should be implemented if symptoms develop. Blood dyscrasias, consisting of reduction in hemoglobin red cell count ,leukopenia, ag ranulocytosis andand purpura have been rarely reported. If such abnormalities develop, discontinue therapy. PRECAUTIONS: Myocardial stimulation produced by APRESOLINE can cause anginal attacks and ECG changes of myocardial ischemia. The drug has been implicated in the production of myocardial infarction. It must, therefore, be used with caution in patients with suspected coronary artery disease. Also, use cautiously in the presence of advanced renal damage and recent coronary or cerebral ischemia. Use in Pregnancy: APRESOLINE should be used in pregnancy only when, in the opinion of the physician, its use is deemed essential to the welfare of the patient (toxemia of pregnancy). DOSAGE Hypertension: Orally: In general, after initiating therapy increase dosage, adjusting according to gradually individual response. As a single agent, initially 10mg four times daily, increasing slowly to a maximum practical dosage of 200 mg daily. In combination with other hypotensive agents, lower dosages of APRESOLINE will be appropriate. When there is urgent need, therapy in the hospitalized patient may be initiated intravenously or intramuscularly. Usual dose is 20-40 mg, repeated necessary. Certain patients, especially those with as marked renal damage, may require a lower dose. Pressure may begin to fall within a few minutes after injection, with an average maximal decrease occurring in 10 to 80 minutes. Most patients can be transferred to oral APRESOLINE within 24 to 48 hours. Toxemia of Pregnancy a) Early toxemia and hypertension of pregnancy; one 10mg tablet orally, four times daily, slowly increasing the dosage upto 400 mg per day, or until a therapeutic result is obtained. b) Late toxemia and pre-eclampsia: 20 to 40 mg intramuscularly or by slow, direct intravenous injection or infusion. Repeat as necessary.

SUPPLIED All forms contain hydralazine hydrochloride. Tablets of 10 mg (yellow scored) Tablets of 25 mg (blue coated) Tablets of 50mg (pink coated) Ampoules of 1 ml aqueous solution containing 20 mg Bottles of 100 and 500. Ampoule package size of 10. Full information available on request.

9. BAKER JR, TANsLEY AG: The course of the

controversy on freedom in science. Nature 158: 574, 1946 10. POLANY! M: The rights and duties of science. Manchester School of Economics and Social Studies 10: 175, 1939

CIBA Dorval, Que. H9S iBi

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