be placed? Penicillin C remains the preferred agent for the treatment of streptococcal pharyngitis, and the preferred alternative is erythromycin. However, cefaclor is a reasonable alternative. Otitis media is a disease of much clinical importance because of its long-term sequelae. Amoxicillin and ampicillin are still excellent agents in geographic areas where Hemophilus is not resistant to ampicillin and children are not allergic to penicillins. Further clinical experience is needed to establish the precise place of cefaclor in relation to erythromycm plus sulfisoxazole and to the combination agent trimethoprim-sulfamethoxazole in the treatment of otitis media. Cefaclor has been established as a satisfactory agent. In recent years it has been shown that Hemophilus may cause sinusitis, but it is not yet established which of amoxicillin, thrimethoprim-sulfamethoxazole, tetracycline and cefaclor is the best therapeutic agent. Data presented at the symposium suggested

that cefaclor is effective in this clin- ing N. gonorrhoeae its short half-life ical situation. and the necessity for several days of In the treatment of acute exacerba- oral therapy make it less useful than tions of bronchitis we do not know other agents. whether cefaclor is better than amoxiThe use of cefaclor to treat shigelcillin, ampicillin, trimethoprim-sulfa- losis is extremely controversial. Most methoxazole or tetracycline. Com- of the workers in England and many parative studies now under way will in the United States (including Dr. evaluate many factors, such as the Neu) believe that adults with shigelnumber of hours fever persists, the losis rarely need to be treated. The degree of cough, sputum production cure rates for children treated with and the degree of purulence of the cefaclor do not seem to be significantsputum. ly better than those that would be achieved with fluid therapy. Further clinical experience is needed to deUrinary tract infections termine whether cefaclor has a role Urinary tract infections generally in the treatment of this infection. respond to most agents if the infectIn the final area, that of skin ing organisms are susceptible. Data and soft-tissue infection, therapy is presented at the symposium indicated again controversial. Dr. Neu bethat elderly patients infected with lieves that bullous impetigo due to ampicillin-resistant E. ccli respond S. aureus, usually f3-lactamase-prowell to cefaclor therapy without gas- ducing strains, may be an indication trointestinal side effects. However, it for cefaclor therapy. In other forms has not yet been established that this of impetigo due to S. pyogenes penidrug is superior to older and less cillin is the preferred therapeutic expensive agents. agent; when the patient is allergic to Although cefaclor has cured infec- penicillin, erythromycin or cefaclor tions caused by penicillinase-produc- could be used as an alternative U

The Royal College of Physicians of London: a short history In 1421 the English Parliament sent a petition to King Henry V, asking that all except university graduates should be excluded from the practice of medicine and that others who wished to practise should be required to undergo examination. These recommendations were accepted, but never carried out. In 1511 Parliament passed an act limiting medical practice to those who had undergone strict examination. In London and for 11 km around, the bishop of London or the dean of St. Paul's Cathedral was to conduct the examination with the assistance of four physicians or surgeons. For the rest of England, the bishop of each diocese was to conduct the examination in a similar manner. (The Church was involved because the clergy were literate and the organization of the Church throughout the country constituted an efficient civil service.) The act allowed Oxford and Cambridge to re-

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S

S The present building of the Royal College, opened in 1964

college as: "to withstand in good time the attempts of the wicked, and to curb the audacity of those wicked men who shall profess medicine more for the sake of their avarice than from the assurance of any good conscience, whereby very many inconveniences may ensue to the rude and credulous populace." The president had power to fine and imprison those who practised without adequate qualifications. Five years later an act of Parliament confirmed the foundation. It included the words: "that no person be suffered to exercise and practise physic, but only those persons that be profound, sad [serious], and discreet, groundedly learned, and deeply studied in physic." The act also extended the college's zone of influence and its licensing powers from London to the whole of England. The early days of the college were largely devoted to the suppression of unqualified practice, notably by apothecaries. The college did not object to practice by surgeons, provided they did not prescribe drugs or attempt to treat internal diseases. Indeed, the college aided the surgeons by providing their anatomical teaching. These efforts at the control of malapraxis, as it was called, met with variable success. It became increasingly difficult for the college to obtain convictions, specially in areas remote from London, because some of the irregular practitioners were protected by important and influential patients. In 1617 the foundation of the Society of Apothecaries greatly improved the status of the apothecaries. It laid down standards for the education and examination of entrants. (The society still exists as a craft guild of the City of London and its licence is still a legal qualification.) The apothecaries finally emerged as real doctors with the Apothecaries Act of 1815. They were forerunners of the general practitioner. Among the contributions to medicine made by the college was the institution in 1541 of an elaborate system of examinations, with prescribed texts and numerous oral tests. This was 250 years before the

older universities replaced their medieval and merely formal disputations by the modern type of examination. Working for improvement

In 1587 the collge founded its own herb garden and in 1618 published the first London Pharmacopoeia. As the college was for many years the only body of organized medical and scientific experts in the country it was often consulted by governments. In the 17th century it became the licensing body for medical books. In the 18th century it supervised mental hospitals in London and Middlesex. In the 19th century the college gradually began to reform itself. In 1835 the fellowship was opened to medical graduates of universities other than Oxford and Cambridge. Despite the work of the college, the general state of medical practice in the British Isles in the early 19th century was far from satisfactory. Census returns show that of those practising medicine, about one third were properly qualified, one third held only a half qualification (that is, were qualified either in medicine or in surgery) and one third had no qualification at all. There were also some peculiar territorial anomalies, for example, that a graduate of Edinburgh could not practise in Glasgow and vice versa; more strangely still, a graduate of London University could not legally practise in London without the college licence. Since 1830 reformers had striven to abolish these and other anomalies and had made many unsuccessful attempts to introduce legislation to control the profession. At last, in 1858, the first Medical Act became law. For the first time the whole profession was brought under some degree of government control. The object of the act was not to suppress unqualified practice, but merely to enable those seeking medical advice to distinguish between qualified and unqualified practitioners. For this purpose the General Medical Council was established. Its chief duties were to keep a medical register, to allow entry to the register only to those properly qualified and to remove from it prac-

488 CMA JOURNAL/FEBRUARY 17, 1979/VOL. 120

titioners found guilty of serious professional misconduct. The act gave some privileges to those registered and imposed some disabilities on the unregistered but made no general prohibition of unqualified practice. The territorial restrictions were removed, and a doctor whose name was on the register could practise anywhere in the British Isles or overseas dominions. The act did not meet all the aims of the reformers, one of which was to establish a single portal of entry to the profession. Today there are still 23 bodies that give a primary qualification (and three medical schools at new universities will shortly add to this number). Amalgamation In 1885 the college combined with the College of Surgeons to give a new kind of licence, a joint primary qualification - Member of the Royal College of Surgeons and Licentiate of the Royal College of Physicians, usually abbreviated to MRCS, LRCP. Today there are thus three grades in the college - licentiates (who must also be MRCS), members (who have taken a severe examination in medicine) and fellows (who are selected from the members without examination). The College of Surgeons has only two grades members (who correspond to the licentiates of the sister college) and fellows (who have taken a severe examination in surgery and correspond to the members of the sister college). The College of Physicians is governed by its fellows, the College of Surgeons by an elected council of its fellows. There are similar Royal Colleges of Physicians in Edinburgh and Glasgow. In recent years all three have combined their membership examinations, so that the holders of this diploma are now styled MRCP (United Kingdom, or UK). Although the title of the college includes the words "of London", it now extends its influence all over the country. of The the Royal collegeCollege publishes of Physicians the Journal of

London for general circulation, and continued on page 503

Ludiomil® ..de 1936; family practice; MCFP; associate staff, Moose Jaw Union and Providence hospitals; senior member, Canadian Medical Association. Died Dec. 24, aged 76; survived by wife Harriet, daughter Margaret, son Robert. Taylor, Cecil Harry, Winnipeg; University of Manitoba, 1928; general practice; semiretired. Died Dec. 4, aged 77; survived by wife Thelma, daughter Marilyn, sons Robert, Kent. Therrien, Emile E., Vancouver; University of Manitoba, 1935; obstetrics, gynecology and general surgery; CRCS[C]; retired; honorary staff, Lion's Gate Hospital; senior member, Canadian Medical Association. Died Dec. 13, aged 71; survived by wife Bernice, daughters Sandra, Corneil, Dennis, son Peter. Tsakiris, Anastasios G., Sherbrooke; PQ; University of Zurich, 1955; chief of cardiology service, Centre Hospitalier Universitaire de Sherbrooke; professor, cardiovascular research, University of Sherbrooke. Died Oct. 25, aged 47. ROYAL COLLEGE continued from page 488 the College Commentary on college affairs for internal circulation. It has for centuries had a strong interest in social questions and preventive medicine and has issued many reports in these fields. Early examples were on the health hazards of industry in 1627 and on the evils of gin drinking in 1725. In modern times there have been important reports on housing, abortion, drug addiction, smoking and atmospheric pollution. The college has occupied five homes of increasing size. The present building, designed by Denys Lasdun, was opened in 1964; although it is in the modern idiom, it embodies the panelled Censors' Room of 1674 brought from a previous building. For over 400 years the college has never ceased to strive to carry out the ideals of its founders: to maintain and improve the standards of medical practice. FO.G.

Brief prescrIbIng information, IndIcations Endogen. ous depressive illness, including the depressed phase of manic-depressive illness (bipolar depression) and involutional melancholia. Selected patients suffering severe depressive neurosis. Contraindications Ludiomil (maprotiline) should not be used concomitantly with monoamine oxidase inhibitors; at least fourteen days should elapse between discontinuing one of the interacting drugs and replacing it with the other. Ludiomil is contraindicated in patients with existing severe hepatic or renal damage, a history of severe blood dyscrasias, narrow angle glaucoma, convulsive disorders and during the acute recovery phase following myocardial infarction. Not recommended for use in children. Use In Pregnancy Safe use of Ludiomil during pregnancy and lactation has not been established, therefore, it should not be administered to women of childbearing potential or nursing mothers unless the benefits outweigh the possible hazards. Warnings Extreme caution should be used when Ludiomil (maprotiline) is given to patients with known cardiovascular disease including a history of myocardial infarction, arrhythmias and/or ischemic heart disease. Use with caution in hyperthyroid patients or those on thyroid medication, and in patients with a history of urinary retention, particularly in the presence of prostatic hypertrophy. Close supervision and careful adjustment of dosage is required when administering Ludiomil with anticholinergic or sympathomimetic drugs. Patients requiring concomitant treatment for hypertension should not be given antihypertensives of the adrenergic-neurone inhibitor type, such as guanethidine. Activation of psychosis in schizophrenic patients, hypomanic or manic episodes in patients with cyclic disorders have occurred with tricyclic antidepressants. The use of an antipsychotic drug in these latter two conditions is recommended should they occur in the course of Ludiomil administration. PrecautIons Seriously depressed patients must be carefully supervised due to the possibility of suicide. Patients should be warned that their responses to alcoholic beverages or other CNS depressants may be exaggerated. Patients should also be cautioned against performing potentially dangerous teaks that require mental alertness and good physical coordination. Periodic blood cell counts and liver function tests are recommended with prolonged therapy. Prior to elective surgery, Ludiomil should be discontinued for as long a period as clinically feasible. Adverse reactions The following adverse reactions have been reported either with Ludiomil or the tricyclic antidepressant drugs: Neurological: numbness, tinghng, peresthesias of extremities, incoordinatlon, stasis, tremors, peripheral neuropathy, extrapyramidal symptoms, seizures, alteration in EEG patterns, tinnitus. Behavioral: confusional states (especially in the elderly) with hallucinations, disorientation, delusions; anxiety, restlessness, agitation, insomnia and nightmares, hypomania, mania, exacerbation of psychosis, decrease in memory, feelings of unreality, weakness and fatigue, drowsiness, dizziness, urinary frequency. Autonomic: dry mouth and, rarely, associated sublingual adenitis; blurred vision, disturbances of accommodation, mydriasis; constipation; paralytic ileus; urinary retention, delayed micturition, dilation of the urinary tract, perspiration, flushing. Cardiovascular: hypotension, hypertension, congestive heart failure, tachycardia, palpitation, myocardial infarction, arrhythmias, heart block, stroke and syncope. Hematologic: bone marrow depression including agranulocytosis, eoslnophilia, purpura and thrombocytopenia may occur as an idiosyncratic response. Leukocyte and differential counts should be performed in any patient who develops fever and sore throat during the therapy; the drug should be discontinued if there is evidence of pathological neutrophil depression. Gastrointestinal: nausea or vomiting, anorexia, epigastric distress, diarrhea, bitter taste, stomatitis, abdominal cramps, black tongue, dysphagia, increased salivation, altered liver function. Endocrine: gynecomastia in the male, breast enlargement and galactorrhea in the female, increased or decreased libido, impotence, testicular swelling, elevation or depression of blood sugar levels, weight gain or loss. Allergic or toxic: skin rash, petechiae, urticaria, itching, photosensitization (avoid excessive exposure to sunlight); edema (peneral or of face and tongue); drug fever, obstructive jaundice, nasal congestion. Dosage Adults Outpatients: initially 25 mg t.i.d., may be increased in increments of 25-50 mq to a maximum of 50 mg q.i.d. Hospital patients: initially 50 mg b.i.d. or t.i.d., may be increased in increments of 25-50 mg to a maximum of 300 mg daily. Elderly patients: generally 25 mg t.i.d. or q.i.d. Maintenance: dosage may be gradually reduced to 75 mg daily or less. A single daily dose of 75 mg to 150 mg at bedtime can be given by virtue of the long half-life of Ludiomil. This would ensure better patient compliance and may obviate the need for hypnotics. Sup p lied Tablets containing maprotiline hydrochloride, film coated, slightly biconvex: 25 mg, light orange marked CIBA one side and DP on other; 50 mg, orange marked CIBA on one side and ERonother75 mg, coral, scored, marked CIBA on one side and on other. Bottles of 50 and 500 tablets. Product Monograph supplied on request. References 1. Trick, K.L.K.: Double-Blind Comparison of Maprotiline (Ludiomil*) with Amitriptyline in the Treatment of Depressive Illness. J. Int. Med. Research, Vol. 3, Suppl. 2, 1975. Edited by JE. Murphy, Cambridge Medical Publications Ltd., England. pp. 67-70 2. Mathur, G.N.: A Double-Blind Comparative Clinical Trial of Maprotiline (Ludiomil) and Amitriptyline. J. mt. Med. Research, Vol. 3, Suppl. 2, 1975. Edited by JE. Murphy, Cambrid9e Medical Publications Ltd., England. pp. 71-743. Singh, A.N., Saxena, B.: Maprotiline (Ludiomil,@ CIBA 34,276-BA) and Imipramine in Depressed Outpatients: A Double-Blind Clinical Study. Current Therapeutic Research, Vol. 19, No. 4, April, 1976.4. Product Monograph-Ludiomil5

DORVAL OU.BEC. H951B1

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see page 487

Dorval, Que. H9S iBi

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C-7117

For the Optimum Management of Iron Deficiency

Sbi-FE

(ferrous sulfate) hematinic INDICATIONS: The management of iron deficiency states and anemia. CONTRAINDICATIONS: Iron therapy is contraindicated in the presence of hemochromatosis, hemosiderosis and hemolytic anemia.

WARNING: Keep out of reach of children. ADVERSE REACTIONS: Gastro-intestinal side effects such as nausea and gastro-intesti nal irritation are rare. Other side effects which have been rarely reported are: vomiting, constipation, diarrhea, abdominal pain and skin rash. PRECAUTIONS: Slow-Fe, like all oral iron preparations, may aggravate existing peptic ulcer, regional enteritis and ulcerative colitis. Iron when given with tetracyclines, binds in equimolecular ratio thus lowering the absorption of tetracyclines. DOSAGE: Prophylaxis: One tablet daily is sufficient to maintain an adequate iron intake during pregnancy and in patients with simple iron deficiency. Iron Deficiency: Depending on the severity, one or two tablets of Slow-Fe daily, usually in one dose. In mild anemias, one tablet daily will usually suffice. For moderate or severe anemias, two tablets daily should be given until hemoglobin levels return to normal.* In severe cases, up to a maximum of 4 tablets daily may be given. In the case of children, one tablet of Slow-Fe daily is a suitable dose for children able to swallow a small tablet. *This physiological process may require a period of up to eight weeks. Once the desired hemoglobin level is attained, the dose can then be reduced to one tablet daily for maintenance to build up the iron reserves over a further 12 to 16 weeks. Supplied: Eac hoff-white, film-coated Slow-Fe tablet contains 160 mg of dried ferrous sulfate (=50 mg elemental iron) in a specially formulated matrix. Packaged in push-through packs containing 30 tablets per sheet and are available in units of 30, 120 and 4,800. References: 1. Product Monograph. Full information available on request.

CIBA c-9053

The Royal College of Physicians of London: a short history.

be placed? Penicillin C remains the preferred agent for the treatment of streptococcal pharyngitis, and the preferred alternative is erythromycin. How...
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