appropriate to the patient's needs. While we accept the general premise that data should be interpreted with caution, we believe our groups were similar enough to justify the comparison and the conclusions drawn. MICHAEL R. HIGGINS, FRCP

Department of medicine University Hospital Edmonton, Alta

MEBWITS syndrome To the editor: The time of year is once again upon us when this syndrome reaches epidemic proportions. It is a complex and elusive clinical state seen in some healthy, retired, elderly people before they leave for their winter sojourn in Florida. The acronym stands for "medical examination before wintering in the South". The patient with MEBWITS syndrome presents with symptoms that, were they due to the disease the patient is afraid of, would result in considerable medical expense. Thus, the symptoms depend to a large extent on the patient's predilection for whatever disease might cause the most trouble and expense. Much thought goes into this process, so that the patient has a good idea which diseases are not so acute that they cannot get back to Canada to have them treated, and which will progress slowly enough that they can put up with them until they return in the spring. Colons, gallbladders and stomachs figure prominently in the list of organs potentially affected. Undoubtedly cardiologists see patients who are mainly concerned about their hearts. I suspect, however, that even the remotest prospect of a brain tumour would keep the hardiest floridian at home; thus, neurosurgeons may not see many individuals with this syndrome. Persons with MERWITS syndrome are easy to recognize. They invariably look healthy, give their histories in a slightly shifty manner, and are always willing to have any kind of investigation, even one as unpleasant as colonoscopy. This is probably what separates the people with MEBWITS syndrome from those who are truly sick. The latter will blanch a little at the prospect of colonoscopy, but

the former will welcome it with glee and even appear at any time suitable to the physician. Sigmoidoscopy is not an adequate discriminant since some clinicians perform sigmoidoscopies reasonably well and the procedure does not cause sufficient discomfort to provide a useful challenge. Once informed that he or she is well, the person with MEBWITS syndrome promptly forgets the illness and departs instantly. I wish to alert others to this seasonal and poorly recognized malady. The key question is not Where have you been?, the clue to acquired tropical illness, but rather Where are you going? The MEB WITS syndrome is almost certainly much more prevalent than the notorious Miinchausen's syndrome, and probably leads to the use of as many, if not more, medical resources. However, because this syndrome is less flamboyant it excites less attention. Now that it has been formally identified, others may be stimulated to report their experience. W.C. WATSON, MD

Director of gastroenterology Department of medicine and gastrointestinal unit Victoria Hospital London, Ont.

Continuous ambulatory peritoneal dialysis in Canada To the editor: Continuous ambulatory peritoneal dialysis (CAPD) has been a promising development in the treatment of end-stage renal disease. It was first reported by Popovich and colleagues in May 1978.1 The many advantages of CAPD were partially offset by a high frequency of peritonitis (one episode every 10 patient weeks) and a cumbersome and timeconsuming technique. Having access to peritoneal dialysate in plastic bags (Dianeal®, Baxter Laboratories, Toronto) Canadian nephrologists adopted a new technique that makes CAPD simpler and safer.2 To determine the extent that CAPD is used in Canada, I sent a questionnaire to 62 dialysis units in July 1978. Other nephrologists and the readers of the Journal might be

16 CMA JOURNAL/JANUARY 6, 1979/VOL. 120

interested in the results of my survey. The questionnaire was completed and returned by 32 centres, 19 of which were using CAPD. Instruction in CAPD was given to 165 patients (99 males and 66 females aged 7 to 74 years) or their parents or relatives. Complete data were available for 133. Of these, 117 were undergoing intermittent pentoneal dialysis and 8 were undergoing hemodialysis before CAPD was started; the remaining 8 were new patients. The average duration of CAPD was 3.7 Thonths; the total experience was 491.5 patient months. A total of 80 episodes of peritonitis occurred (31 patients had 1 episode, 14 had 2 episodes and 7 had 3 episodes), a frequency of 37% or 1 episode every 6.14 patient months. Peritonitis developed more frequently in females than in males: one episode occurred every 4.8 patient months in females and every 7.6 patient months in males. The organisms responsible for the peritonitis were Staphylococcus aureus (in 20 episodes), Staph. epidermidis (in 20), Acinetobacter (in 8), Streptococcus taecalis (in 6), Strep. viridans (in 5), diphtheroids (in 3), enterococci (in 2), Kiebsiella (in 2) and Proteus, Pseudomonas and fungi (in 1 each). For 11 episodes no positive results of culture were obtained, so they were considered to be episodes of aseptic or cryptogenic peritonitis. In 17 patients CAPD was discontinued - in 14 because of medical complications, including recurrent peritonitis, in 1 because of depression, in 1 because of weight gain and in 1 because of refusal to continue. Eight patients underwent transplantation and two others died. The remaining 106 patients were still undergoing CAPD. It appears that the frequency of peritonitis, although decreased from that reported by Popovich and colleagues,1 is still the main problem of CAPD. I think the present technique has reached its maximum efficacy, and new technologic advances are necessary. I am optimistic that the efforts of various investigators along with the interest shown by the indus-

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References

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try will soon result in a decreased infection rate.

1. POPOVICH RP, MONCRIEF JW, NOLPH KD, et al: Continuous ambulatory peritoneal dialysis. Ann Intern Med 88: 449, 1978 2. OREOPOULOS DG, RoesoN M, IZATT 5, et al: A simple and safe technique for continuous ambulatory peritoneal dialysis (CAPD). Trans Am Soc Artif

Intern Organs 24: 484, 1978

Illicit use of drugs To the editor: The Oct. 21, 1978 issue of CMAJ (page 979) and the Oct. 10, 1978 issue of The Medical Post (page 1) carry warnings about the prescribing of drugs that will be diverted to the illicit drug trade. Anyone who has been in practice for a while knows the pattern of deceit; usually transient new patients attempt to deceive us into prescribing such well known analgesics as hypnotics and cough suppressants. I find the warnings by the federal bureau of dangerous drugs and provincial licensing bodies inadequate, as they do not come to grips with the problem of how to cope with these people. The only advice appears to be to refuse to prescribe such agents. However, we know the addict will just move along to the next physician. Should these people not be considered as having either psychiatric or criminal problems? They are certainly a public health problem to the extent that they encourage the illicit use of drugs. It appears to me that this is a public health problem the authorities have done little about. I have on occasion reported a blatant case to the police drug squad. It would also be interesting to know the long-term prognosis of drug abusers. Do they spend their lives deceiving physicians? What happens to them? R.T. FRANKFORD, MD

2615 Danforth Ave., Ste. 11 Toronto, Ont. [.I.1

Spontaneous pneumothorax and pregnancy To the editor: Pneumothorax occurs so rarely during pregnancy that only 10 case reports have previously been published.'-8 Textbooks rarely mention this concurrence, and usually do so while describing the pneumomediastinum. However, one text describes this complication as being caused by anesthetic maneuvers such as intercostal block or assisted ventilation in women with normal or abnormal lungs.9 Understandably, no such case has been reported in the literature. Pneumothorax occurring spontaneously in otherwise healthy looking pregnant women has been described in only nine patients (total of 10 episodes). We report the 10th patient with this rare complication of pregnancy. We are certain that many cases have not been reported, and we know of at least two that, unfortunately, cannot be traced (P.F. Beirne: personal communication, 1977). Case report A 26-year-old woman, gravida 1, had an unremarkable past history except for asthma when she was a child. After an uneventful pregnancy she gave birth to a healthy girl following episiotomy and elective lowforceps delivery. She had been in labour for 8 hours. The second stage was normal, lasting 1 hour. Epidural anesthesia was used. While in the recovery room the patient complained of shortness of breath and pain in the right side of her chest. This was attributed to muscle strain. She spent the night in the postpartum unit, still complaining of moderate shortness of breath. Her vital signs were stable. Percussion revealed excessive resonance of the right side of the chest; auscultation detected distant asthmoid wheezing. A chest roentgenogram showed complete right-sided tension pneumothorax and displacement of the trachea to the left. A local anesthetic was administered and a pliable chest tube inserted and connected to an underwater drain. After 5 days the tube was clamped but the

CMA JOURNAL/JANUARY 6, 1979/VOL. 120 19