for cardiopulmonary resuscitation into Canadian medicine, it must be stated that they conflict with those generally recognized. K.G. FERGUSON, MD, FRCPIIC] Chief, department of emergency medicine Victoria Hospital London, Ont.
Report of the coronary artery surgery task force To the editor: The members of the task force deserve thanks for presenting an objective factual summary of the published data on aortocoronary bypass surgery (Can Med Assoc J 117: 451, 1977). They allude to the need for further study on the effect of this operation on mortality from ischemic heart disease, and suggest that some answers will be forthcoming from national randomized studies.1 Unfortunately none of the studies that are quoted are from Canadian centres, nor do they address themselves to the situation of the patient who is at risk from ischemic heart disease and is not "lucky" enough to suffer angina before his or her fatal myocardial infarction. He or she belongs to a much larger group than that under discussion in the published review. The need for a clinical indicator of ischemic heart disease is obvious angina is one that is easily recognized - so that patients may be assigned to a subset and subjected to randomized trials. In our concern for the obvious, we have been timid in approaching the less obvious, but larger, population of patients who die suddenly without premonitory symptoms. It is extremely unusual for a patient who is not having cardiac pain to undergo surgery. An internationally known and respected cardiac surgeon was recently criticized for operating on a group of patients with critical coronary artery stenosis in the absence of cardiac symptoms (40% had had an unheralded myocardial infarction). This criticism is unjustified if one asks the question Should one wait for the development of angina or the patient's acute myocardial event before recommending surgery? and Could aortocoronary bypass delay or forestall this event? Unfortunately, in this review randomization was not carried out into control and treatment groups so these questions are not answered. Canada is in an excellent position to consider this large subset. The communication that exists between our medical schools and their cardiovascular disciplines and, in turn, their affiliation with the Canadian Cardiovascular Society and the Canadian Heart Foundation put an onus on our
spokesmen in these organizations to initiate cooperative trials in Canada. DAVID A. MURPHY, MD Maritime Heart Centre Halifax, NS
Reference I. RUSSELL RO, MORASKI RE, KoucHouKos N, et al: Unstable angina pectoris: national cooperative study group to compare medical and surgical therapy. I. Report of protocol and patient population. Am I Cardiol 37: 896, 1976
Is gynecology good for obstetrics? To the editor: I agree wholeheartedly with Dr. H.B. Atlee's comments on this subject (Can Med Assoc J 117: 287, 1977). The medical profession has made pregnancy and delivery much safer for both mother and baby than they were 50 years ago, but has intervened, sterilized and monitored to the point of dehumanization. In the search for high-risk pregnancies we often lose sight of the fact that most pregnancies are "normal". In how many normal pregnancies are the risks increased by such common forms of intervention as elective induction, artificial rupture of the membranes, prescription of diuretics or sedatives, and the use of epidural anesthesia and the consequent necessity of forceps delivery? The average mother-to-be begins labour unprepared to meet its stresses. How many of us answer her questions and deal with her worries with a hearty back-slap and a "Don't worry about a thing my dear. We'll look after everything for you"? She arrives at hospital in the grip of tremendous physical and emotional forces. Instead of being supported and encouraged she is immediately stripped of husband, clothes, dignity and pubic hair. If she becomes upset she is sedated or given epidural anesthesia. In reaction to this dehumanizing process (or is it in self-defence?) more and more parents-to-be are turning to groups such as the International Childbirth Education Association to become informed about the normal processes of pregnancy, labour and delivery, the dangers of unnecessary intervention, and how they as a team can help themselves maintain control of their labour and delivery. An increased number of couples are even demanding home confinement to preserve the beauty and dignity of their childbirth. Marshall Klaus's well publicized work on maternal-infant bonding is causing many couples to question our hospital postpartum practice of almost immediate separation of child from mother and only brief, scheduled contacts thereafter. We doctors who practise obstetrics
1128 CMA JOURNAL/NOVEMBER 19, 1977/VOL. 117
must watch for risk factors, complications and problems (including psychologic). In a normal pregnancy we must assume a lifeguard role - we cannot swim for our mothers-to-be but must be ready to save them if they need us. Normal pregnancy is not a disease demanding a cure from us; it is a tremendously powerful creative force requiring our support. As Dr. Atlee suggests, we must emphasize its physiology, not its pathology. PHILIP E. SHEA, MD 833D Upper James St. Hamilton, Ont.
Is there any lasting effect of foreign medical development? To the editor: From 1964 to 1968 a group of Canadian physicians and nurses were involved in a service and hospital development program in Kluang, Ja hore, Malaysia. The Kluang District Hospital is situated 129 km north of Singapore and serves a population of 50000. This project was supported by private Canadian donors and administered through CAREMEDICO. Many of the volunteers were influenced by the work and books of Dr. Tom Dooley. After his death Dooley's medical service organization in Vietnam and Laos was taken over by CARE and the program was expanded rapidly to include hospital development and teaching as well as direct patient care. Over the 4-year period of service by the Canadian group many changes were made in the hospital in Kluang. A central sterile supply room to service the operating facilities was designed and built and the local staff was instructed in its use. A modern sterilizer was added. An intensive care unit was provided that introduced a new concept to the staff. The laboratory, which hitherto had been able to carry out only simple tests, was upgraded to include within its scope a wide range of biochemistry, bacteriology and hematology. A blood bank was established. These changes were instituted only after the spending of much time in consultation with the Malaysian physicians in attendance at the hospital. During the time in which the new developments were taking place, Malaysian and MEDICO physicians provided medical services in the wards and outpatient department. Canadian nurses and laboratory technicians worked with their Malaysian counterparts. The MEDICO team believes that any development project should operate a complete preplanned course that includes a deliberate phase-out period in order that MEDICO may serve to in-
Report of the coronary artery surgery task force To the editor: The members of the task force deserve thanks for presenting an objective factual summary of the published data on aortocoronary bypass surgery (Can Med Assoc J 117: 451, 1977). They allude to the need for further study on the effect of this operation on mortality from ischemic heart disease, and suggest that some answers will be forthcoming from national randomized studies.1 Unfortunately none of the studies that are quoted are from Canadian centres, nor do they address themselves to the situation of the patient who is at risk from ischemic heart disease and is not "lucky" enough to suffer angina before his or her fatal myocardial infarction. He or she belongs to a much larger group than that under discussion in the published review. The need for a clinical indicator of ischemic heart disease is obvious angina is one that is easily recognized - so that patients may be assigned to a subset and subjected to randomized trials. In our concern for the obvious, we have been timid in approaching the less obvious, but larger, population of patients who die suddenly without premonitory symptoms. It is extremely unusual for a patient who is not having cardiac pain to undergo surgery. An internationally known and respected cardiac surgeon was recently criticized for operating on a group of patients with critical coronary artery stenosis in the absence of cardiac symptoms (40% had had an unheralded myocardial infarction). This criticism is unjustified if one asks the question Should one wait for the development of angina or the patient's acute myocardial event before recommending surgery? and Could aortocoronary bypass delay or forestall this event? Unfortunately, in this review randomization was not carried out into control and treatment groups so these questions are not answered. Canada is in an excellent position to consider this large subset. The communication that exists between our medical schools and their cardiovascular disciplines and, in turn, their affiliation with the Canadian Cardiovascular Society and the Canadian Heart Foundation put an onus on our
spokesmen in these organizations to initiate cooperative trials in Canada. DAVID A. MURPHY, MD Maritime Heart Centre Halifax, NS
Reference I. RUSSELL RO, MORASKI RE, KoucHouKos N, et al: Unstable angina pectoris: national cooperative study group to compare medical and surgical therapy. I. Report of protocol and patient population. Am I Cardiol 37: 896, 1976
Is gynecology good for obstetrics? To the editor: I agree wholeheartedly with Dr. H.B. Atlee's comments on this subject (Can Med Assoc J 117: 287, 1977). The medical profession has made pregnancy and delivery much safer for both mother and baby than they were 50 years ago, but has intervened, sterilized and monitored to the point of dehumanization. In the search for high-risk pregnancies we often lose sight of the fact that most pregnancies are "normal". In how many normal pregnancies are the risks increased by such common forms of intervention as elective induction, artificial rupture of the membranes, prescription of diuretics or sedatives, and the use of epidural anesthesia and the consequent necessity of forceps delivery? The average mother-to-be begins labour unprepared to meet its stresses. How many of us answer her questions and deal with her worries with a hearty back-slap and a "Don't worry about a thing my dear. We'll look after everything for you"? She arrives at hospital in the grip of tremendous physical and emotional forces. Instead of being supported and encouraged she is immediately stripped of husband, clothes, dignity and pubic hair. If she becomes upset she is sedated or given epidural anesthesia. In reaction to this dehumanizing process (or is it in self-defence?) more and more parents-to-be are turning to groups such as the International Childbirth Education Association to become informed about the normal processes of pregnancy, labour and delivery, the dangers of unnecessary intervention, and how they as a team can help themselves maintain control of their labour and delivery. An increased number of couples are even demanding home confinement to preserve the beauty and dignity of their childbirth. Marshall Klaus's well publicized work on maternal-infant bonding is causing many couples to question our hospital postpartum practice of almost immediate separation of child from mother and only brief, scheduled contacts thereafter. We doctors who practise obstetrics
1128 CMA JOURNAL/NOVEMBER 19, 1977/VOL. 117
must watch for risk factors, complications and problems (including psychologic). In a normal pregnancy we must assume a lifeguard role - we cannot swim for our mothers-to-be but must be ready to save them if they need us. Normal pregnancy is not a disease demanding a cure from us; it is a tremendously powerful creative force requiring our support. As Dr. Atlee suggests, we must emphasize its physiology, not its pathology. PHILIP E. SHEA, MD 833D Upper James St. Hamilton, Ont.
Is there any lasting effect of foreign medical development? To the editor: From 1964 to 1968 a group of Canadian physicians and nurses were involved in a service and hospital development program in Kluang, Ja hore, Malaysia. The Kluang District Hospital is situated 129 km north of Singapore and serves a population of 50000. This project was supported by private Canadian donors and administered through CAREMEDICO. Many of the volunteers were influenced by the work and books of Dr. Tom Dooley. After his death Dooley's medical service organization in Vietnam and Laos was taken over by CARE and the program was expanded rapidly to include hospital development and teaching as well as direct patient care. Over the 4-year period of service by the Canadian group many changes were made in the hospital in Kluang. A central sterile supply room to service the operating facilities was designed and built and the local staff was instructed in its use. A modern sterilizer was added. An intensive care unit was provided that introduced a new concept to the staff. The laboratory, which hitherto had been able to carry out only simple tests, was upgraded to include within its scope a wide range of biochemistry, bacteriology and hematology. A blood bank was established. These changes were instituted only after the spending of much time in consultation with the Malaysian physicians in attendance at the hospital. During the time in which the new developments were taking place, Malaysian and MEDICO physicians provided medical services in the wards and outpatient department. Canadian nurses and laboratory technicians worked with their Malaysian counterparts. The MEDICO team believes that any development project should operate a complete preplanned course that includes a deliberate phase-out period in order that MEDICO may serve to in-
