the piece on my chiropractic adventure. It is obvious from their various comments that I need to clarify a number of points. First, I must emphasize that my account was nothing more than an anecdote, a (to me) rather amusing account of a minor adventure. As such it has no general validity and was not intended to have. I am not so naive as to believe that a statistic of one means anything. In calling it an exercise in faith healing I was referring only to that particular experience, not to chiropractic medicine in general. Second, Dr. Bednar must have misread me, since at no point did I say or imply that my chiropractic visit did me any good. My pain was already decreasing at the time of the visit and continued to do so; my frame is now fully restored to its normal, rather elderly state of decrepitude. Drs. Murphy, Sommer, Lawrence and Livingston all raise an important point - the generally low level of knowledge in the medical profession concerning spinal problems. I became acutely aware of this when I went directly from medical graduation into the army. There I discovered that those infantrymen on my sick parades who were not suffering from respiratory infections were nearly all complaining of either back pain or sore feet. In both of these areas my medical education had left me in a state of almost tbtal ignorance. As scientific advances enable us to deal more effectively with life-threatening human illnesses it is hoped that we will be better able to educate our students in those that are merely inconvenient. Dr. Bourdeau should be reassured to know that one of the three family physicians who saw me did indeed have a special interest and training in spinal problems. It was he and my physiotherapist who suggested that the JUNE 15, 1992
most likely diagnosis was spinal stenosis. He referred me for a CT scan and to an orthopedic surgeon. Both the radiologist and the surgeon agreed with this diagnosis. Faced with the unwelcome prospect of a laminectomy and still in considerable discomfort after many weeks, I decided to explore the possible benefits of chiropractic in the hope of finding relief and avoiding, or at least postponing, surgery. I have no wish to cross swords with Dr. Reardon in the matter of hip versus buttock. He is referring to the diagnostic distinguishing features; I, as an average uninformed patient, was indicating where I thought the pain was. I defer to his special knowledge. If Dr. McWhirter were one of my regular readers he would know that when I make critical comments I make no exclusions on the basis of race, creed, colour, occupation or social status. There's something wrong with all of us, and I think it is important to remind ourselves of this. I am all in favour of dedicated, hardworking professionals - I only wish we had more of them. Douglas Waugh, MD Ottawa, Ont.
per Olean Herald), which offers a cash incentive for patients to see a physician about a hair-growth product. I think it is important for Canadian physicians to address this kind of problem and introduce measures to prevent physicians from jumping into bed with such companies. We need to constantly remind ourselves of the distinctness of Canadian medicine. Significant efforts will be needed to maintain this distinctness in the face of the economic pressures to merge and identify with the ethics and standards of practice of the US pharmaceutical-medical structure. Manjit S. Walia, MD, FRCPC Department of Paediatrics University of Western Ontario London, Ont.
Reducing the cesarean section rate in a rural community hospital I found this article (Can Med Assoc J 1991; 145: 14591464), by Drs. Stuart Iglesias, Robert Burn and L. Duncan Saunders, very stimulating; it provides some ideas and leadership for those of us studying our quality of
obstetric service. Statistics, of course, can conPatients and found most of us some of the pharmaceutical time. In the article I note the companies statement that among the nulliparous women the rate of cesarean I have followed with interest section decreased but that the difthe recent articles and letters ference was not significant. The in CMAJ on the relationship article also states that "this debetween physicians and pharma- crease was due to a drop in the ceutical companies. Equally im- number of dystocia-related cesareportant is the relationship be- an sections." tween pharmaceutical companies I am at a loss to understand and our patients. these two comments. If the differI was particularly appalled ence was insignificant how can during a recent visit to the United one possibly comment on its sigStates by an advertisement in Pa- nificance? rade (the magazine of the newspaI also note that there were CAN MED ASSOC J 1992; 146 (12)
2137
two cases of scar dehiscence. Comparative incidence rates are not provided, but this seems a high number of cases among only 1 161 patients. Referring to the same cases there is a statemnent that "neither mother needed blood transfusions." All too often transfusions as markers of morbidity are not indexed by authors, and it would be interesting to know how many women who delivered vaginally received transfusions. The morbidity associated with cesarean section is often described with reference to fever, but rarely do we see comparable figures for transfusion, which is clearly a morbid event (with or without the concerns about human immunodeficiency virus that have arisen since 1985). My only other comment is about the availability of epidural analgesia in a small community
hospital. The. authors report an increased incidence of epidural analgesia, from 35% to 57%, between 1985 and 1989. Unfortunately, they fail to mention whether. this refers to continuous or terminal epidural analgesia. Presumably a large number of these instances were terminal analgesia, since the demands on any anesthesia department for continuous epidural analgesia is a major problem in community hospitals. There, is no doubt that greater availability of continuous epidural service will have a substantial effect on the rate of cesarean section. I commend the authors for what appears to be a very successful program in their obstetric service and an apparent reduction in the cesarean section rate. Richard U. Johnston, MD, FRCSC Orillia, Ont.
[The authors respond.] We appreciate Dr. Johnston's careful reading of our article and thank him for his encouraging comments. The finding that the decreased cesarean section rate among nulliparous women was not statistically significant (p = 0.069) is not irreconcilable with the statement that "this decrease was due to a drop in the number of dystocia-related cesarean sections." A p value of 0.069 means that in about 7% of similar studies one might expect results as extreme (as those we observed) to occur by chance. We observed a decrease in the rate of cesarean section from 23% to 12% in the nulliparous women. The dystociarelated rate decreased by 7% (from 16% to 9%) and therefore accounted for most (64%) of the total decrease of 11%. The scar dehiscence rate of 2
urns.'*~~
g patients of all ages out of itchy situations is Benadryl's claim to fame... From newborns to adults! Benadryl capsules and now Benadryl Children's Liquid quickly quell the urge 2138
CAN MED ASSOC J 1992; 146 (12)
to scratch annoying pruritic conditions. And when you compare Benadryl to the non-sedating antihistamines in terms of speed of action and efficacy, they're just not up to scratch.1 Benadryl LE 15 JUIN 1992
most likely diagnosis was spinal stenosis. He referred me for a CT scan and to an orthopedic surgeon. Both the radiologist and the surgeon agreed with this diagnosis. Faced with the unwelcome prospect of a laminectomy and still in considerable discomfort after many weeks, I decided to explore the possible benefits of chiropractic in the hope of finding relief and avoiding, or at least postponing, surgery. I have no wish to cross swords with Dr. Reardon in the matter of hip versus buttock. He is referring to the diagnostic distinguishing features; I, as an average uninformed patient, was indicating where I thought the pain was. I defer to his special knowledge. If Dr. McWhirter were one of my regular readers he would know that when I make critical comments I make no exclusions on the basis of race, creed, colour, occupation or social status. There's something wrong with all of us, and I think it is important to remind ourselves of this. I am all in favour of dedicated, hardworking professionals - I only wish we had more of them. Douglas Waugh, MD Ottawa, Ont.
per Olean Herald), which offers a cash incentive for patients to see a physician about a hair-growth product. I think it is important for Canadian physicians to address this kind of problem and introduce measures to prevent physicians from jumping into bed with such companies. We need to constantly remind ourselves of the distinctness of Canadian medicine. Significant efforts will be needed to maintain this distinctness in the face of the economic pressures to merge and identify with the ethics and standards of practice of the US pharmaceutical-medical structure. Manjit S. Walia, MD, FRCPC Department of Paediatrics University of Western Ontario London, Ont.
Reducing the cesarean section rate in a rural community hospital I found this article (Can Med Assoc J 1991; 145: 14591464), by Drs. Stuart Iglesias, Robert Burn and L. Duncan Saunders, very stimulating; it provides some ideas and leadership for those of us studying our quality of
obstetric service. Statistics, of course, can conPatients and found most of us some of the pharmaceutical time. In the article I note the companies statement that among the nulliparous women the rate of cesarean I have followed with interest section decreased but that the difthe recent articles and letters ference was not significant. The in CMAJ on the relationship article also states that "this debetween physicians and pharma- crease was due to a drop in the ceutical companies. Equally im- number of dystocia-related cesareportant is the relationship be- an sections." tween pharmaceutical companies I am at a loss to understand and our patients. these two comments. If the differI was particularly appalled ence was insignificant how can during a recent visit to the United one possibly comment on its sigStates by an advertisement in Pa- nificance? rade (the magazine of the newspaI also note that there were CAN MED ASSOC J 1992; 146 (12)
2137
two cases of scar dehiscence. Comparative incidence rates are not provided, but this seems a high number of cases among only 1 161 patients. Referring to the same cases there is a statemnent that "neither mother needed blood transfusions." All too often transfusions as markers of morbidity are not indexed by authors, and it would be interesting to know how many women who delivered vaginally received transfusions. The morbidity associated with cesarean section is often described with reference to fever, but rarely do we see comparable figures for transfusion, which is clearly a morbid event (with or without the concerns about human immunodeficiency virus that have arisen since 1985). My only other comment is about the availability of epidural analgesia in a small community
hospital. The. authors report an increased incidence of epidural analgesia, from 35% to 57%, between 1985 and 1989. Unfortunately, they fail to mention whether. this refers to continuous or terminal epidural analgesia. Presumably a large number of these instances were terminal analgesia, since the demands on any anesthesia department for continuous epidural analgesia is a major problem in community hospitals. There, is no doubt that greater availability of continuous epidural service will have a substantial effect on the rate of cesarean section. I commend the authors for what appears to be a very successful program in their obstetric service and an apparent reduction in the cesarean section rate. Richard U. Johnston, MD, FRCSC Orillia, Ont.
[The authors respond.] We appreciate Dr. Johnston's careful reading of our article and thank him for his encouraging comments. The finding that the decreased cesarean section rate among nulliparous women was not statistically significant (p = 0.069) is not irreconcilable with the statement that "this decrease was due to a drop in the number of dystocia-related cesarean sections." A p value of 0.069 means that in about 7% of similar studies one might expect results as extreme (as those we observed) to occur by chance. We observed a decrease in the rate of cesarean section from 23% to 12% in the nulliparous women. The dystociarelated rate decreased by 7% (from 16% to 9%) and therefore accounted for most (64%) of the total decrease of 11%. The scar dehiscence rate of 2
urns.'*~~
g patients of all ages out of itchy situations is Benadryl's claim to fame... From newborns to adults! Benadryl capsules and now Benadryl Children's Liquid quickly quell the urge 2138
CAN MED ASSOC J 1992; 146 (12)
to scratch annoying pruritic conditions. And when you compare Benadryl to the non-sedating antihistamines in terms of speed of action and efficacy, they're just not up to scratch.1 Benadryl LE 15 JUIN 1992
