graphs of Pneumoconiosis, 1971, Inindicated the characteristic opacities ternational Labour Office, Geneva, of rheumatoid pneumoconiosis.4 1972 There are also case reports of the 2. CAPLAN A: Certain unusual radiological appearance in the chest of disease in a foundry worker,5 a roofcoal-miners suffering from rheumatile maker6 and persons with asbestoid arthritis. Thorax 8: 29, 1953 tosis.7'8 3. GOUGH J, RIvERs D, SEAL RME: Pathological studies of modified pneuRheumatoid arthritis may occur moconiosis in coal-miners with rheumany years before or after the apmatoid arthritis (Caplan's syndrome). pearance of rheumatoid pneumocoThorax 10: 9, 1955 niosis, but in some persons with 4. MIALL WE, CAPLAN A, COCHRANE AL, et al: An epidemiological study rheumatoid pneumoconiosis rheumaof rheumatoid arthritis associated with toid arthritis never develops.4 In one characteristic chest X-ray appearances study 11 (55%) of 20 coal miners in coal-workers. Br Med J 2: 1231, 1953 with rheumatoid lung lesions had a A, COWEN ED, GOUGH J: 5. CAPLAN history of rheumatoid arthritis.4 The Rheumatoid pneumoconiosis in a Quebec study revealed similar findfoundry worker. Thorax 13: 181, 1958 ings in metal miners and millers with DS, POSNER E: A case of 6. HAYES silicosis. Of the 177 men with siliCaplan's syndrome in a roof tile cosis who did not have rheumatoid maker. Tubercie 41: 143, 1960 pneumoconiosis during the study pe- 7. RICHARDS AG, BARRETT GM: Rheu. matoid lung changes associated with riod 9 (5%) had rheumatoid arthriThorax 13: 185, 1958 tis. Also, the frequency of rheuma- 8. asbestosis. MORGAN WK: Rheumatoid pneumotoid arthritis was significantly higher coniosis in association with asbestosis. Thorax 19: 433, 1964 (P < 0.01) in the men with rheumatoid pneumoconiosis than in the age-matched control group. These observations indicate a strong asso- Breast-feeding ciation between rheumatoid arthritis To the editor: There is a clearly reand the development of rheumatoid newed interest in the benefits of breast-feeding, reflected in the numpneumoconiosis. Factors other than rheumatoid ber of articles and letters in this arthritis appear to be associated with journal.lA The medical profession apthe development of rheumatoid pears to be encouraging the practice pneumoconiosis.4 The observation of of breast-feeding, yet I feel it is a clear-cut pattern of concentric rings somewhat remiss to do so without of dust in sections through or near also carefully examining the effect the centres of Caplan's nodules in- of obstetric practice upon it. Technologic advances in controldicated the association between dust exposure and the development of the ling 'labour and delivery are liable disease. The Quebec study did not to make women feel that they are reveal a significant difference in not capable of giving birth unaverage duration of dust exposure assisted. The passive role instilled or in smoking habits between the in this way has been found to be men with rheumatoid pneumoco- associated with lessened maternal atniosis and the age-matched control tachment and self-esteem,5'6 both of group. However, the limited number which are vital in the delicate psyof subjects with rheumatoid pneu- chophysiologic balance of the nursmoconiosis in this study does not ing mother.7 More concretely the permit statistical evaluation of the Canadian Paediatric Society8 has roles of these two factors in the cautioned that the use of sedation or anesthesia in labour significantly development of the disease. undermines attentiveness9 and the AFAMID 0. EZENWA, M SC, PH D Occupational health and safety unit rate and intensity of sucking10'11 in McGill University the infant in the immediate post426 des Moulins Mont St. Hilaire, PQ partum period and longer. Postpartum practices that interfere with mother-baby togetherReferences ness can further complicate matters. 1. ILO U/C Classification of Radio- Rooming-in, for example, is more 1494 CMA JOURNAL/JUNE 23, 1979/VOL. 120
often the exception than the rule, and even when it exists there may be numerous restrictions to free and ongoing contact. In a project in which rooming-in was the rule rather than the exception and in which mothers were encouraged to care for their babies from the time of birth, it was found that this practice stimulated lactation in the mothers.12 Indeed, that project, developed to prevent nursery epidemics, not only achieved better acquaintance between mother and baby and stimulated lactation but also significantly increased the breast-feeding rate. Following this project all parents seemed far more confident about the care of their babies. There seems to be ample evidence that conventional obstetric practice carries with it the unfortunate side effect of potentially interfering with the early parent-child relationship. If we are to be encouraging mothers to nurse their babies, surely we should not be placing obstacles in the way of their doing this. DAVID C. MANDEL, MD, FRcP[c]
554 Spadina Ave. Toronto, Ont. References 1. VANDOR T: Advertising breast-feeding (C). Can Med Assoc J 119: 1006, 1978 2. ELLESTAD-SAYED J, CoornN FJ, DIL-
LING LA, et al: Breast-feeding protects against infection in Indian infants. Can Med Assoc J 120: 295, 1979 3. KORCOK M: Health problems of developing nations. Part I: a western solution? Ibid, p 471 4. BRIGEL P: Encouraging breast-feeding (C). Ibid, p 527 5. DEUTSCH H: The Psychology of Women: a Psychoanalytic Interpretation, Grune, New York, 1945 6. PETERSON GH, MEHL LE: Some de-
terminants of maternal attachment. Am I Psychiatry 135: 1168, 1978 7. NEWTON N: Maternal Emotions: a Study of Women's Feelings Toward Menstruation, Pregnancy, Childbirth, Breast Feeding, Infant Care, and Other Aspects of Their Femininity, Hoeber New York, 1955 8. Breast-feeding: what is left besides the poetry? A statement by the nutrition committee, Canadian Paediatric Society. Can J Public Health 69: 13, 1978 9. STECHLER G: Newborn attention as affected by medication during labor. Science 144: 315, 1964
10. BRAZELTON TB: Effect of prenatal drugs on the behavior of the neonate. Am J Psychiatry 126: 1261, 1970 11. KRON RE, STUN M, GODDARD KE:
Newborn sucking behavior affected by obstetric sedation. Pediatrics 37: 1012, 1966 12. MCBRYDE A: Compulsory rooming-in in the ward and the private newborn service at Duke Hospital. JAMA 145: 625, 1951
Legionnaires' disease To the editor: Since the summer of 1976, when Legionnaires' disease was first identified, a number of clusters and associated sporadic cases have been reported. The following is a report of one such sporadic case in Toronto. A 48-year-old assembly-line worker became ill with what appeared to be a nonspecific viral infection characterized by myalgia, weakness and fever. A pleuritic type of pain in the right lower chest subsequently developed and was followed by hemoptysis. The man was admitted to hospital with clinical findings suggesting consolidation of the right lower lung; roentgenograms confirmed the presence of pneumonia. Despite initial therapy consisting of parenteral administration of ampicillin and gentamicin, clinical deterioration associated with cyanosis and hypotension occurred. Mild leukocytosis that was predominantly polymorphonuclear was demonstrated. The sputum contained alveolar macrophages, but all cultures gave negative results. Jaundice and elevation of the hepatic enzyme values appeared. The arterial oxygen saturation was 88% and the oxygen pressure 48 mm Hg. After 3 days 20 million units of aqueous penicillin was added to the intravenous regimen because of rapid clinical deterioration. Within 24 hours there was clinical improvement, and 2 weeks later the man was discharged from hospital. He was able to return to work about 9 weeks after the onset of the illness, at which time he was asymptomatic and a chest roentgenogram was normal. The man subsequently reported that his apartment had been fumi-
ambivalence. I do not believe that most physicians in the Yukon are unduly concerned, nor do I believe that any subscribe to the belief that any one ethnic or other segment of the local population will suffer as a result of the transfer. That is, no deterioration of health care services has occurred or is expected; indeed, for some population groups the reverse may well prove to be true. Under territorial auspices, in the opinion of some physicians, the delivery of health care services may be more vulnerable to local pressures and expediencies and to local subjective or immediate value judgements. Such pressures, which may originate with opportunists or selfseekers, could conceivably militate against certain important principles, such as the maintenance of standards of excellence of care within and without hospitals, the granting of hospital privileges, the preferential handling of the so-called low-cost alternatives to the detriment of established primary- or acute-care management or both, and the increasing incursions of paramedics into fields that are essentially and traditionally those of clinical medicine and should rightfully be the province of those who are appropriately trained - physicians. These areas of concern are connected with problems of health manpower and confidentiality, to say nothing of the level of locally available managerial and legislative expertise, the lack of expedition with which proposed medical legislation may be faced in atBARRY A. TORE, MD 4430 Bathurst St., Ste. 206 tempting to come before the legisDownsview, Ont. lature, and, finally, the all-important matter of federal/provincial costHealth care services sharing arrangements. Yet another in the Yukon Territory concern is related to the position of To the editor: The proposed transfer nurses; they may, under territorial of responsibility for the delivery of auspices, find themselves limited in health care services from federal to terms of national mobility and, for Yukon territorial auspices has financial reasons, in terms of conaroused much interest both locally tinuing professional educational opand further afield. The position of portunities. If such limitations rethe medical profession in the Yukon sult, they may militate against the Territory in this matter may be of hitherto satisfactory recruitment of interest to other physicians across nurses in the Yukon. Canada. Equally potent, however, are the As with so many other topics, opinions that the transfer of delivery opinion is divided and there is much of health care services will be benegated about 24 hours before the onset of his illness, and that he had slept in the apartment against the fumigator's instructions. So far the materials used in the fumigation have not been identified, and no one else in the apartment building is known to have become ill. None of the man's coworkers became ill, and his wife, who was 7 months pregnant at the time, was free of disease. The patient was assessed in my office 7 weeks after the onset of the acute illness, and several serologic studies gave abnormal results. The immunofluorescent antibody test for toxoplasmosis was positive to a dilution of 1:256, the cytomegalovirus complement fixation test was positive to a dilution of 1:64 and the immunofluorescent antibody test for the Legionnaires' disease bacterium was positive to a dilution of 1:2048; 2 weeks later, the titre of antibody to the Legionnaires' disease bacterium had risen to 1:4096. These studies were carried out by the laboratory services branch of the Ontario Ministry of Health. Although the literature does not indicate that aqueous penicillin is the preferred antibiotic for the treatment of this disease, there seems little doubt that the clinical improvement of the patient I have described coincided with the intravenous administration of the large dose of penicillin. The precise nature of the liver disease was not totally identified.
CMA JOURNAL/JUNE 23, 1979/VOL. 120 1495
often the exception than the rule, and even when it exists there may be numerous restrictions to free and ongoing contact. In a project in which rooming-in was the rule rather than the exception and in which mothers were encouraged to care for their babies from the time of birth, it was found that this practice stimulated lactation in the mothers.12 Indeed, that project, developed to prevent nursery epidemics, not only achieved better acquaintance between mother and baby and stimulated lactation but also significantly increased the breast-feeding rate. Following this project all parents seemed far more confident about the care of their babies. There seems to be ample evidence that conventional obstetric practice carries with it the unfortunate side effect of potentially interfering with the early parent-child relationship. If we are to be encouraging mothers to nurse their babies, surely we should not be placing obstacles in the way of their doing this. DAVID C. MANDEL, MD, FRcP[c]
554 Spadina Ave. Toronto, Ont. References 1. VANDOR T: Advertising breast-feeding (C). Can Med Assoc J 119: 1006, 1978 2. ELLESTAD-SAYED J, CoornN FJ, DIL-
LING LA, et al: Breast-feeding protects against infection in Indian infants. Can Med Assoc J 120: 295, 1979 3. KORCOK M: Health problems of developing nations. Part I: a western solution? Ibid, p 471 4. BRIGEL P: Encouraging breast-feeding (C). Ibid, p 527 5. DEUTSCH H: The Psychology of Women: a Psychoanalytic Interpretation, Grune, New York, 1945 6. PETERSON GH, MEHL LE: Some de-
terminants of maternal attachment. Am I Psychiatry 135: 1168, 1978 7. NEWTON N: Maternal Emotions: a Study of Women's Feelings Toward Menstruation, Pregnancy, Childbirth, Breast Feeding, Infant Care, and Other Aspects of Their Femininity, Hoeber New York, 1955 8. Breast-feeding: what is left besides the poetry? A statement by the nutrition committee, Canadian Paediatric Society. Can J Public Health 69: 13, 1978 9. STECHLER G: Newborn attention as affected by medication during labor. Science 144: 315, 1964
10. BRAZELTON TB: Effect of prenatal drugs on the behavior of the neonate. Am J Psychiatry 126: 1261, 1970 11. KRON RE, STUN M, GODDARD KE:
Newborn sucking behavior affected by obstetric sedation. Pediatrics 37: 1012, 1966 12. MCBRYDE A: Compulsory rooming-in in the ward and the private newborn service at Duke Hospital. JAMA 145: 625, 1951
Legionnaires' disease To the editor: Since the summer of 1976, when Legionnaires' disease was first identified, a number of clusters and associated sporadic cases have been reported. The following is a report of one such sporadic case in Toronto. A 48-year-old assembly-line worker became ill with what appeared to be a nonspecific viral infection characterized by myalgia, weakness and fever. A pleuritic type of pain in the right lower chest subsequently developed and was followed by hemoptysis. The man was admitted to hospital with clinical findings suggesting consolidation of the right lower lung; roentgenograms confirmed the presence of pneumonia. Despite initial therapy consisting of parenteral administration of ampicillin and gentamicin, clinical deterioration associated with cyanosis and hypotension occurred. Mild leukocytosis that was predominantly polymorphonuclear was demonstrated. The sputum contained alveolar macrophages, but all cultures gave negative results. Jaundice and elevation of the hepatic enzyme values appeared. The arterial oxygen saturation was 88% and the oxygen pressure 48 mm Hg. After 3 days 20 million units of aqueous penicillin was added to the intravenous regimen because of rapid clinical deterioration. Within 24 hours there was clinical improvement, and 2 weeks later the man was discharged from hospital. He was able to return to work about 9 weeks after the onset of the illness, at which time he was asymptomatic and a chest roentgenogram was normal. The man subsequently reported that his apartment had been fumi-
ambivalence. I do not believe that most physicians in the Yukon are unduly concerned, nor do I believe that any subscribe to the belief that any one ethnic or other segment of the local population will suffer as a result of the transfer. That is, no deterioration of health care services has occurred or is expected; indeed, for some population groups the reverse may well prove to be true. Under territorial auspices, in the opinion of some physicians, the delivery of health care services may be more vulnerable to local pressures and expediencies and to local subjective or immediate value judgements. Such pressures, which may originate with opportunists or selfseekers, could conceivably militate against certain important principles, such as the maintenance of standards of excellence of care within and without hospitals, the granting of hospital privileges, the preferential handling of the so-called low-cost alternatives to the detriment of established primary- or acute-care management or both, and the increasing incursions of paramedics into fields that are essentially and traditionally those of clinical medicine and should rightfully be the province of those who are appropriately trained - physicians. These areas of concern are connected with problems of health manpower and confidentiality, to say nothing of the level of locally available managerial and legislative expertise, the lack of expedition with which proposed medical legislation may be faced in atBARRY A. TORE, MD 4430 Bathurst St., Ste. 206 tempting to come before the legisDownsview, Ont. lature, and, finally, the all-important matter of federal/provincial costHealth care services sharing arrangements. Yet another in the Yukon Territory concern is related to the position of To the editor: The proposed transfer nurses; they may, under territorial of responsibility for the delivery of auspices, find themselves limited in health care services from federal to terms of national mobility and, for Yukon territorial auspices has financial reasons, in terms of conaroused much interest both locally tinuing professional educational opand further afield. The position of portunities. If such limitations rethe medical profession in the Yukon sult, they may militate against the Territory in this matter may be of hitherto satisfactory recruitment of interest to other physicians across nurses in the Yukon. Canada. Equally potent, however, are the As with so many other topics, opinions that the transfer of delivery opinion is divided and there is much of health care services will be benegated about 24 hours before the onset of his illness, and that he had slept in the apartment against the fumigator's instructions. So far the materials used in the fumigation have not been identified, and no one else in the apartment building is known to have become ill. None of the man's coworkers became ill, and his wife, who was 7 months pregnant at the time, was free of disease. The patient was assessed in my office 7 weeks after the onset of the acute illness, and several serologic studies gave abnormal results. The immunofluorescent antibody test for toxoplasmosis was positive to a dilution of 1:256, the cytomegalovirus complement fixation test was positive to a dilution of 1:64 and the immunofluorescent antibody test for the Legionnaires' disease bacterium was positive to a dilution of 1:2048; 2 weeks later, the titre of antibody to the Legionnaires' disease bacterium had risen to 1:4096. These studies were carried out by the laboratory services branch of the Ontario Ministry of Health. Although the literature does not indicate that aqueous penicillin is the preferred antibiotic for the treatment of this disease, there seems little doubt that the clinical improvement of the patient I have described coincided with the intravenous administration of the large dose of penicillin. The precise nature of the liver disease was not totally identified.
CMA JOURNAL/JUNE 23, 1979/VOL. 120 1495
