perform an abortion, then this oath allows the physician to perform the abortion. In fact, given the whole tenor and thrust of the oath, it could even be argued that in such a case the oath enjoins the physician to perform an abortion as a matter of conscientious and professional medical practice. It should therefore be clear that the policy of the CMA does not contradict the Hippocratic Oath. It is entirely in keeping with the oath. The CMA's policy insists that the decision to perform an abortion be made as a medical decision, following the best professional judgement of the physician, and that it be made in accordance with the standards of good medical practice. That is exactly what the Hippocratic Oath enjoins those who take it to do. It should also be clear that there is no contradiction between saying that the CMA's Code of Ethics retains the principles in the oath and saying that the CMA's policy on abortion is in keeping with its Code of Ethics. Therefore, I cannot agree with Brown's conclusion that "any physician that actively participates in an abortion could [therefore] be liable of unethical medical conduct". Eike-Henner Kluge, PhD Director of ethics and legal affairs Canadian Medical Association
Reference 1. Edelstein L: The Hippocratic Oath. Bull Hist Med 1943 (suppl 1): 1-64
Having read the latest edition of our association's Code of Ethics I was surprised and perhaps disappointed with the closing statement: "The complete physician is not a man apart and cannot content himself with the practice of medicine alone, but should make his contribution, as does any other good citizen, towards the well-being and betterment of the community in which he lives."
Surely in 1990 and in an official publication regarding the ethics of our profession it should be possible to word such a statement in a way that includes those who are women. Peter E. Hoogewerf, MD 4-2151 McCallum Rd. Abbotsford, BC
[The statement to which Dr. Hoogewerf refers is an epilogue extracted from a section of the code adopted by General Council at the 88th annual meeting of the CMA and printed in the 1956 edition of the code; this section is no longer part of the code. Obviously General Council then believed as some of us still do - that the use of the masculine encompasses both sexes. We trust that Hoogewerffound no gender problems in the 49 articles of the code. - Ed.]
Third World aid D
r. W. Harding le Riche is right when he points out the short-term nature of most aid programs for the Third
World (Can Med Assoc J 1990; 142: 707-708). Who carries on after the urgent intervention to save lives? It is certainly too much to ask any one agency to provide aid from the womb to the tomb. What, then, is the alternative? I suggest that every aid program have a predetermined time frame for phasing itself out and have within it the means for launching the recipient country on the road to self-reliant development. For instance, a population control program should have as an integral part of its operation a transfer to the recipient country of the technology to produce its own contraceptive devices and the means of popular education. Similarly, a much-needed vaccination program should provide a transfer of technology so that the recipient country or regional centre would
be able to provide its own supply of vaccines. Otherwise, the good intentions, the miracles in the making, might well lead to disaster, even the disaster of perpetual dependence on First-World charity. It is really an application of the wisdom of the Chinese proverb about giving a hungry man a fish or teaching him how to fish. Even then we must ensure that he has access to a river with fish. Le Riche is emphatic that "Africa needs active birth control now, not in a generation or two, when all the elephants and rhinoceri have been killed, and all the trees have been cut down." His credibility would have been enhanced if instead of concentrating on the fate of the elephants, rhinoceri and trees he had shown concern for the disastrous effects on the African people and the deterioration in the quality of their lives. Such preoccupation betrays a tunnel vision that is not uncommon in the environmental movement. Concern for the welfare of the indigenous people on all the continents pales beside emotional investment in flora and fauna. Joseph M. DuW, MD 3986 Hammond Bay Rd. Nanaimo, BC
Metronidazole and fungating tumours D
~r. Patrick J. Taylor, in "A medical potpourri" (Can Med Assoc J 1990; 142: 866-867), comments on the use of metronidazole gel to reduce odour from fungating neoplastic lesions. When I worked in palliative care in Britain, in 1986-87, I applied metronidazole topically for the same purpose but with a method passed on to me by a colleague in the same field. We (as usual, "we" means the nurses!) crushed 400-mg tablets of the CAN MED ASSOC J 1990; 143 (2)
89
the LFCN. On the other hand, meralgia following anesthesia, with the patient in the lithotomy or another position, is well recognized. So why do a few people get meralgia but most don't? The answer lies in landmark studies by Dr. William Ghent, of Kingston, Ont., who found that there are several variations in the anatomic passage of the LFCN in relation to the inguinal ligament.2 Such abnormalities predispose the nerve Mervyn M. Dean, MB, ChB, MRCGP to compression, including during PO Box 10 hip flexion, such as in the lithotoHampden, Nfld. my position, and also when the patient is lying recumbent for an operation. Bilateral meralgia Cause and effect are often difficult to prove in patients with paresthetica and PID focal peripheral neuropathies; for years Sigmund Freud ascribed his D r. Arthur S. Rotenberg own meralgia paresthetica to psyhas reported a case of chosomatic factors.3 bilateral meralgia paresthetica (sensory symptoms and D. Stewart, MB, BS, FRCPC signs in the distribution of the John Montreal Neurological Institute lateral femoral cutaneous nerve and Hospital [LFCN]) and attributes the disor- Montreal, PQ der to involvement of the nerve by pelvic inflammatory disease References (PID) (Can Med Assoc J 1990; PL (eds): Gray's 142: 42). This view is challenged 1. Warwick R, Williams Longman, EdinAnatomy, 35th ed, by Dr. Brian Knight, who suggests burgh, 1973: 559, 1052 that the nerve damage was due to 2. Ghent WR: Meralgia paraesthetica. Can Med Assoc J 1959; 81: 631-633 kinking and stretching while the Stevens H: Meralgia paresthetica. Arch patient was in the lithotomy posi- 3. Neurol Psychiatry 1957; 77: 557-574 tion (ibid: 708-709), a suggestion that makes little impression on Rotenberg (ibid: 709). [Dr. Rotenberg responds.] It is anatomically implausible for PID and pelvic peritonitis to As I previously indicated, the incause LFCN damage. The fallopi- flammatory effects of this paan tubes lie well within the true tient's infection were not confined pelvis, whereas the LFCN lies far to the true pelvis. They were suffilaterally in the false pelvis, deep cient to cause several days of ileus to both the peritoneum and the and abdominal distension. The laparoscopy report stated that: iliacus fascia. I I have discussed this case "very distended bowel loops were with two gynecologists who noted. Pneumoperitoneum was worked for many years in coun- less than ideal due to the great tries where PID was common and distension within the abdomen. A severe. Neither has ever seen such large amount of effusion was presa case of meralgia, and both think ent." Acute abdominal distension that on the basis of anatomic factors and surgical findings it is may compress the LFCN at the highly unlikely for PID to damage inguinal ligament and precipitate drug and incorporated the powder into various inert carriers. An alternative that we tried was silver sulfadiazine. Unfortunately, I did not keep a record of the results, but my recollection is that the 50% rate quoted is about right for both drugs. I am sure that most workers in palliative care are familiar with these techniques. If the metronidazole gel does become available it will save the nurses' arms!
90
CAN MED ASSOC J 1990; 143 (2)
meralgia paresthetica. Such compression of the nerve at its point of angulation is consistent with the current mechanical theory of the cause of meralgia paresthetica. Dr. Stewart emphasizes that individual variability is important in the cause of meralgia paresthetica. The patient that I described was examined in the lithotomy position five times during the year that this condition persisted. At no time did lithotomy positioning aggravate the symptoms. Bed rest, by comparison, is thought to precipitate meralgia paresthetica and consistently aggravates it.',2 Stewart has not provided references to cases in which meralgia paresthetica followed lithotomy positioning. Arthur S. Rotenberg, MD, CCFP Department of Family Medicine North York General Hospital Willowdale, Ont.
References 1. Stewart JD: Focal Peripheral Neuropathies, Elsevier, New York, 1987: 333336
2. Keegan JJ, Holyhoke EA: Meralgia paresthetica - an anatomical and surgical study. J Neurosurg 1962; 19: 341-345
Diagnosis and treatment among relatives A lthough I agree with some of Dr. Lloyd Bartlett's
constructive remarks, as quoted by Patrick Sullivan in his article "Pay more attention to your own health, physicians warned" (Can Med Assoc J 1990; 142: 1309-13 10), I take issue with the statement that doctors "should never diagnose or treat themselves or their families". In my immediate family and one cousin, doctors have missed several serious conditions, namely scoliosis, duodenal ulcer, ventricular septal defect, iatrogenic gout and a brain tumour. I readily
Reference 1. Edelstein L: The Hippocratic Oath. Bull Hist Med 1943 (suppl 1): 1-64
Having read the latest edition of our association's Code of Ethics I was surprised and perhaps disappointed with the closing statement: "The complete physician is not a man apart and cannot content himself with the practice of medicine alone, but should make his contribution, as does any other good citizen, towards the well-being and betterment of the community in which he lives."
Surely in 1990 and in an official publication regarding the ethics of our profession it should be possible to word such a statement in a way that includes those who are women. Peter E. Hoogewerf, MD 4-2151 McCallum Rd. Abbotsford, BC
[The statement to which Dr. Hoogewerf refers is an epilogue extracted from a section of the code adopted by General Council at the 88th annual meeting of the CMA and printed in the 1956 edition of the code; this section is no longer part of the code. Obviously General Council then believed as some of us still do - that the use of the masculine encompasses both sexes. We trust that Hoogewerffound no gender problems in the 49 articles of the code. - Ed.]
Third World aid D
r. W. Harding le Riche is right when he points out the short-term nature of most aid programs for the Third
World (Can Med Assoc J 1990; 142: 707-708). Who carries on after the urgent intervention to save lives? It is certainly too much to ask any one agency to provide aid from the womb to the tomb. What, then, is the alternative? I suggest that every aid program have a predetermined time frame for phasing itself out and have within it the means for launching the recipient country on the road to self-reliant development. For instance, a population control program should have as an integral part of its operation a transfer to the recipient country of the technology to produce its own contraceptive devices and the means of popular education. Similarly, a much-needed vaccination program should provide a transfer of technology so that the recipient country or regional centre would
be able to provide its own supply of vaccines. Otherwise, the good intentions, the miracles in the making, might well lead to disaster, even the disaster of perpetual dependence on First-World charity. It is really an application of the wisdom of the Chinese proverb about giving a hungry man a fish or teaching him how to fish. Even then we must ensure that he has access to a river with fish. Le Riche is emphatic that "Africa needs active birth control now, not in a generation or two, when all the elephants and rhinoceri have been killed, and all the trees have been cut down." His credibility would have been enhanced if instead of concentrating on the fate of the elephants, rhinoceri and trees he had shown concern for the disastrous effects on the African people and the deterioration in the quality of their lives. Such preoccupation betrays a tunnel vision that is not uncommon in the environmental movement. Concern for the welfare of the indigenous people on all the continents pales beside emotional investment in flora and fauna. Joseph M. DuW, MD 3986 Hammond Bay Rd. Nanaimo, BC
Metronidazole and fungating tumours D
~r. Patrick J. Taylor, in "A medical potpourri" (Can Med Assoc J 1990; 142: 866-867), comments on the use of metronidazole gel to reduce odour from fungating neoplastic lesions. When I worked in palliative care in Britain, in 1986-87, I applied metronidazole topically for the same purpose but with a method passed on to me by a colleague in the same field. We (as usual, "we" means the nurses!) crushed 400-mg tablets of the CAN MED ASSOC J 1990; 143 (2)
89
the LFCN. On the other hand, meralgia following anesthesia, with the patient in the lithotomy or another position, is well recognized. So why do a few people get meralgia but most don't? The answer lies in landmark studies by Dr. William Ghent, of Kingston, Ont., who found that there are several variations in the anatomic passage of the LFCN in relation to the inguinal ligament.2 Such abnormalities predispose the nerve Mervyn M. Dean, MB, ChB, MRCGP to compression, including during PO Box 10 hip flexion, such as in the lithotoHampden, Nfld. my position, and also when the patient is lying recumbent for an operation. Bilateral meralgia Cause and effect are often difficult to prove in patients with paresthetica and PID focal peripheral neuropathies; for years Sigmund Freud ascribed his D r. Arthur S. Rotenberg own meralgia paresthetica to psyhas reported a case of chosomatic factors.3 bilateral meralgia paresthetica (sensory symptoms and D. Stewart, MB, BS, FRCPC signs in the distribution of the John Montreal Neurological Institute lateral femoral cutaneous nerve and Hospital [LFCN]) and attributes the disor- Montreal, PQ der to involvement of the nerve by pelvic inflammatory disease References (PID) (Can Med Assoc J 1990; PL (eds): Gray's 142: 42). This view is challenged 1. Warwick R, Williams Longman, EdinAnatomy, 35th ed, by Dr. Brian Knight, who suggests burgh, 1973: 559, 1052 that the nerve damage was due to 2. Ghent WR: Meralgia paraesthetica. Can Med Assoc J 1959; 81: 631-633 kinking and stretching while the Stevens H: Meralgia paresthetica. Arch patient was in the lithotomy posi- 3. Neurol Psychiatry 1957; 77: 557-574 tion (ibid: 708-709), a suggestion that makes little impression on Rotenberg (ibid: 709). [Dr. Rotenberg responds.] It is anatomically implausible for PID and pelvic peritonitis to As I previously indicated, the incause LFCN damage. The fallopi- flammatory effects of this paan tubes lie well within the true tient's infection were not confined pelvis, whereas the LFCN lies far to the true pelvis. They were suffilaterally in the false pelvis, deep cient to cause several days of ileus to both the peritoneum and the and abdominal distension. The laparoscopy report stated that: iliacus fascia. I I have discussed this case "very distended bowel loops were with two gynecologists who noted. Pneumoperitoneum was worked for many years in coun- less than ideal due to the great tries where PID was common and distension within the abdomen. A severe. Neither has ever seen such large amount of effusion was presa case of meralgia, and both think ent." Acute abdominal distension that on the basis of anatomic factors and surgical findings it is may compress the LFCN at the highly unlikely for PID to damage inguinal ligament and precipitate drug and incorporated the powder into various inert carriers. An alternative that we tried was silver sulfadiazine. Unfortunately, I did not keep a record of the results, but my recollection is that the 50% rate quoted is about right for both drugs. I am sure that most workers in palliative care are familiar with these techniques. If the metronidazole gel does become available it will save the nurses' arms!
90
CAN MED ASSOC J 1990; 143 (2)
meralgia paresthetica. Such compression of the nerve at its point of angulation is consistent with the current mechanical theory of the cause of meralgia paresthetica. Dr. Stewart emphasizes that individual variability is important in the cause of meralgia paresthetica. The patient that I described was examined in the lithotomy position five times during the year that this condition persisted. At no time did lithotomy positioning aggravate the symptoms. Bed rest, by comparison, is thought to precipitate meralgia paresthetica and consistently aggravates it.',2 Stewart has not provided references to cases in which meralgia paresthetica followed lithotomy positioning. Arthur S. Rotenberg, MD, CCFP Department of Family Medicine North York General Hospital Willowdale, Ont.
References 1. Stewart JD: Focal Peripheral Neuropathies, Elsevier, New York, 1987: 333336
2. Keegan JJ, Holyhoke EA: Meralgia paresthetica - an anatomical and surgical study. J Neurosurg 1962; 19: 341-345
Diagnosis and treatment among relatives A lthough I agree with some of Dr. Lloyd Bartlett's
constructive remarks, as quoted by Patrick Sullivan in his article "Pay more attention to your own health, physicians warned" (Can Med Assoc J 1990; 142: 1309-13 10), I take issue with the statement that doctors "should never diagnose or treat themselves or their families". In my immediate family and one cousin, doctors have missed several serious conditions, namely scoliosis, duodenal ulcer, ventricular septal defect, iatrogenic gout and a brain tumour. I readily
