experiences do not exist. In the same tion depend primarily upon an excespatients we can see that the general sive or inappropriate response to inadaptation syndrome (GAS) may not direct pathogens" but what will happen necessarily have Selye's three phases: if there is no response at all? Man dies a schizophrenic may have a deep bed- more often from fear and panic when sore without showing any "alarm re- he has a myocardial infarction (MI) action"; his "adaptation" will consist than from myocardial necrosis.5 If we of not reacting to the stressor. "Ex- could prevent ventricular fibrillation haustion" will, in fact, become the only a few would die of MI. Does this defence of the physically and mentally mean that a schizophrenic who does deteriorated organism. He will survive not react to an acute MI has the apin conditions in which a normal indivi- propriate reaction? Certainly not. What dual will die of septicemia. The non- does Selye mean by "We are not yet availability of iron ions or certain perfect"? Are ants perfect because they amino acids will make bacterial growth are in excellent shape after having impossible, according to Massawe, existed perhaps 10 times longer than Muindi and Swai.3 man? Are mosquitoes now perfect beNonspecificity v. specificity: Selye cause of their acquired resistance to states "These terms may be applied to chiorophenothane (DDT)? both the eliciting agent and the reThe statement by Selye that "glucosponse." Should this be valid only "if corticoids... suppress many of the the demand... is. intense"? If the de- usually helpful, defensive, inflammatory mand is not intense will the reaction be or immunologic reactions" shows clearlocalized or will stress not occur at ly how tricky and dangerous the classiall? Does the local adaptation syndrome fication into syntoxic and catatoxic exist without GAS under normal condi- agents can be. Glucocorticoids, if given tions? in excessive doses or for an excessive I do not think that the words "eu- period, produce side effects in the same stress" and "distress" are appropriate. way as digitalis or barbiturates. They are used incorrectly when Selye The danger in applying concepts with states that eustress is "agreeable or seemingly general and definite validity healthy" but distress is "disagreeable or is that problems may be oversimplified pathogenic". Electroshock therapy may and appear to be solved by being be distressing but it often improves labelled with a word. Lectures about health. Everybody will agree with the stress induce "eustress", which is cer"conditioning of stress" but does this tainly "agreeable" but may not necesmean that a stressor will not produce sarily be "healthy". stress at any time, as Selye states? S. HONTELA, MD At the meeting of the Canadian SoPsychogeriatric service Douglas Hospital ciety on Gerontology held in Toronto Montreal, PQ Oct. 22 to 24, 1975 I gave a paper "Senile psychosis and stress", in which I discussed the localized reaction to the References pathogen in patients with organic brain 1. DARWIN CH: The Descent of Man and Selecsyndrome.4 tion in Relation to Sex, London, John MurWe may see very frequently that nevertheless the patient's reaction to the pathogen was inappropriate - in terms of "non psychogeriatric" medicine - the healing process is normal and those patients may show a very high biological resistance. The stress may involve a localized area of the damaged tissue or of the affected organ and humoral changes can perhaps more effectively take place precisely because of the diminished neocortical inhibition. As a clinician I can hardly agree with the differentiation between "direct" and "indirect" pathogens. There is no doubt that the decisive factor in getting sick is the presence of a sensitive receptor. The worst cholera or smallpox epidemics have had their survivors. Therefore it is difficult to accept Selye's statement that "mechanical trauma, intense heat and strong acids or alkalis will cause tissue damage irrespective of the body's response Selye states that "diseases of adapta-
ray, 1871 2. CANNON WB: Bodily Changes in Pain, Fear, Hunger and Rage, 2nd ed, repr of 1929 ed, Washington, McGrath, 1970 3. MAsst.wa AU, MuINDI JM, SwAl GBR: Iron and resistance to infection. Lancet 2: 314, 1974 4. HONTELA 5: Senile psychosis and stress, in Proceedings of the 2nd General Biennial Meeting of the Canadian Society of Gerontology, Toronto, Oct. 22.24, 1975, p 4 5. ANDRUs EC: Emotional factors and cardiac function. Biol Psychiatry 10: 581, 1975
To the editor: 1 am glad to have the opportunity of seeing Dr. Hontela's letter. However, there is no point in discussing his innumerable questions in a letter, as every detail is dealt with at length in the 2nd edition of my book "The Stress of Life". Interested readers of the Journal will find readily accessible, although brief, discussions of the same subjects in the March and June 1975 issues of the Journal of Human Stress - one article by myself, and the other by John W. Mason of Walter Reed Medical Center, Washington. HANS SELYE, CC, MD, PH D, D SC University of Montreal Montreal, PQ
718 CMA JOURNAL/OCTOBER 23, 1976/VOL. 115
Premature labour To the editor: Dr. K.S. Koh reviewed the role of uterine relaxant drugs in the control of premature labour (Can Med Assoc J 114: 700, 1976) but failed to mention that nylidrin hydrochloride is the most effective ft-sympathomimetic drug according to a controlled, doubleblind comparison of placebo, ethanol, isoxsuprine and nylidrin in the treatment of 194 pregnant women in Helsinki's University Hospital.1 The relative successes of the four treatments are summarized in Fig. 1. Nylidrin was p1005 -. N S -. -NI-----,
.
RAIE%
R.
PLAcEDO
EThAWL
B.JPRINE
NYLIORIN
FIG. 1-Success rates of four agents used to treat premature labour. the only form of treatment significantly superior to placebo. Otherwise Koh's article was excellent. PIERRE BIRON, MD Department of pharmacology University of Montreal Montreal, PQ
Reference 1. CASTR.N 0, GUMMERUS M, SAAiuKosKI 5: Treatment of imminent premature labour.
Acta Obstet Gynecol Scand 54: 95, 1975
To the editor: I thank Dr. Biron for pointing out the omission of nylidrin as a uterine relaxant drug in my review article on premature labour and for drawing my .attention to this valuable drug. However, new knowledge is accumulating with such speed that any review of a subject must be read with a retrospective glance to the time it was written, rather than when it was published. The time interval between the submission and publication of my paper was slightly more than 1 year. K.S. KOH, MD Health Sciences Centre
700 William Ave. Winnipeg, MB
Designing doctor shows restraint To the editor: For my own safety I have designed and constructed a practical automotive passive restraint. Like many people I forget to fasten my seat belt and the seat belt buzzer conked out long ago. While the seat belt requires active fastening, my passive restraint is always there. I wanted something that would be simple, effective and inexpensive. It has
U
XIL (amoxicillin)
The new generation broad-spectrum penicillin INDICATIONS AND DOSAGE Infections of the ear, nose and throat due to streptococci, pneumococci, and penicillinsensitive staphylococci; infections of the upper respiratory tract due to H. influenzae; infections of the genitourinary tract due to E. coli, P. mirabilis, and S. faecalis; infections of the skin and soft tissues due to streptococci, penicillin-sensitive staphylococci and E. coli: USUAL DOSE: ADULTS 250 mg every 8 hours CHILDREN 25 mg/kg/day in divided doses every 8 hours In severe infections or infection associated with organisms where sensitivity determinations indicate higher blood levels may be advisable: 500 mg every 8 hours for adults, and 50 mg/kg/day in divided doses every 8 hours for children may be needed- This dosage should not exceed the recommended adult dosage. Infections of the lower respiratory tract due to streptococci, pneumococci, penicillinsensitive staphylococci and H. influenzae: USUAL DOSE: ADULTS 500 mg every 8 hours CHILDREN 50mg/kg/day in divided doses every 8 hours This dosage should not exceed the recommended adult dosage. Urthrltis due to N. gonorrhoeae: 3 g as a single oral dose. CONTRAINDICATION In patients with a history of allergy to the penicillins and cephalosporins. Product Monograph available on request. SUPPLIED AMOXIL-250 Capsules-each contains 250 mg amoxicillin (as the trihydrate) AMOXIL-500 Capsules-each contains 500 mg amoxicillin (as the trihydrate) AMOXIL-125 Suspension-125 mg amoxicillin per 5 ml, in 75 ml & 100 ml bottles AMOXIL-250 Suspension-250 mg amoxicillin per 5 ml, in 75 ml & 100 ml bottles AMOXIL Pediatric Drops-is ml (50 mg/mI) in dropper bottle
AYERST LABORATORIES Division of Ayerst, McKenna & Harrison Limited Montreal, Canada Made in Canada by arrangement with BEECHAM, INC. .Regd
St...1,.g
*..t ..d g.1..g
. d..Ii...,d
/
vii
LI .I I1 FIG. 1-Design of passive restraint.
been my experience that electrical devices frequently go wrong; accordingly, I avoided them. My device consists of several parts (Figs. 1 and 2): Floor mount: two 5"-square sections of steel girder, each 10" long, one mounted on top of the other and secured together by six ½" nuts and bolts; another six 12" bolts pass through the floor and are held beneath by washers and a strengthening plate. Floor mount slide: a 10" length of U-shaped aluminum, the same width as the floor mount, open side uppermost. Stem: a 4 x 40" U-shaped steel section with the open side down. Clamp: a 14" length of flat steel, bent over the floor mount and stem, fitting like a saddle. Hitch pin: an ordinary hitch pin transfixing the clamp and the upper steel portion of the floor mount. Lap bar: attached to the stem, near the driver's right hip, from the hinged left armrest. It angles up from 'the floor mount to clear the seat and then across to form an armrest for the driver.s right elbow. Middle pad: a 12 x 12" square of steel tubing attached to the lap bar, sitting vertically in front of the driver like the breastplate of a suit of armour. Left armrest: a 4" length of hinged
U-shaped aluminum. The hinge is a 5"square section of steel girder. Foam rubber, secured with medical adhesive tape, is applied liberally to all edges and ends. The entire contrivance is covered in black, mottled material that looks like leather but isn't. Unfortunately the quality is inferior to that of the car upholstery. I use the car every day and find this device very practical. To get in I simply lift the left armrest and slide behind the lap bar and middle pad. The original central armrest is still free to move up and down. Three people can still be accommodated in the front seat.
4
FIG. 2-The finished product.
CMA JOURNAL/OCTOBER 23, 1976/VOL. 115 723
Prescribe
Bendectin Helps prevent morning sickness before it starts
DESCRIPTION Each delayed-release tablet contains: Dicyclomine hydrochloride (Bentylol)-antispasmodic.10 mg. Doxylamine succinate (Decapryn)-antihistamine.10 mg. Pyridoxine hydrochloride.10 mg. ACTIONS Bendectin provides the action of three unre; lated compounds, each having a different type of effect: the antispasmodic quiets g.i. spasm associated with nausea; the antihistamine is related chemically to other drugs used to control nausea and motion sickness; the pyridoxine hydrochloride corrects vitamin B6 deficiency that may occur during pregnancy. The antiemetic action of Bendectin is delayed by a special coating that permits the nighttime dose to be effective in the morning hours-when the patient needs it most INDICATION AND CLINICAL USE Nausea and vomiting of pregnancy. CONTRAINDICATIONS Bendectin is contraindicated in patients with frank urinary retention, stenosing peptic ulcer, pyloric or duodenal obstruction, prostatic hypertrophy, or cardiospasm. PRECAUTIONS Because of potential drowsiness, Bendectin should be prescribed with caution for patients who must drive automobiles or operate machinery. Bendectin also should be used cautiously with alcohol or other drugs that depress the central nervous system or in patients with epilepsy. ADVERSE REACTIONS The adverse reactions that may occur are those of the individual ingredients. In particularly sensitive patients, dicyclomine hydrochloride may cause atropine-like effects such as dry mouth, blurring of vision, thirst, or dizziness. On rare occasions fatigue, sedation, rash, constipation, anorexia, nausea and vomiting, headache, and dysuria have occurred. Doxylamine succinate may cause drowsiness, vertigo, nervousness, epigastric pain, headache, palpitation, diarrhoea, disorientation, irritability, convulsions, urinary retention, or insomnia. Pyridoxine hydrochloride is a vitamin that is generally recognized as having no adverse effects. DOSAGE AND ADMINISTRATION Adults: 2 Bendectin tablets at bedtime. In severe cases or when nausea occurs during the day: 1 additional Bendectin tablet in the morning and another in midafternoon. DOSAGE FORM Tablets in bottles of 100 and 500.
Merrell
ThE WM. 8. MERRELL COMPANY DMslon of Richardson.MerrU (Canada) Ltd., Weston, Ontario. M91 1R9 MEMBER
If the car should come to rest following an accident in such a way as to obstruct the left door, the device can be removed by pulling out the hitch pin. This device could be used to protect passengers as well as drivers if appropriately fitted. NOEL JACKSON, MB, B5, DRCOG Box 850 Biggar, SK
Anencephaly associated with megavitamin therapy To the editor: I read with interest the letter by P. Averback in the June 5, 1976 issue of CMAJ (page 995) reporting a case of anencephaly apparently associated with megavitamin therapy. It would have been helpful if Dr. Averback had provided more information on this case - that is, for what condition was the patient receiving megavitamins, was therapy helpful, what doses of the various vitamins was she receiving, and were there any other well documented factors that might have been contributory? Dr. Averback might also care to comment on the frequency of fetal abnormalities when the mother has received long-term therapy with phenothiazines. E.T. PATERSON, MB, CH B P0 Box 2010 Creston, BC
To the editor: The purpose of my letter was to record a single case of anencephaly in the offspring of a woman receiving vitamin therapy during pregnancy. This patient was taking tablets of vitamins B1 (100 mg), B6 (100 mg) and C (200 mg), niacin (200 mg) and brewer's yeast, all in variable quantity, but at a minimum of four tablets of each per day. Her physician had started this therapy 6 months prior to conception and it had been continued (by the patient) during psychotherapy for chronic anxiety. According to her psychiatrist she is presently well and is taking no medications. No well documented other contributory factors were found.
undertaking this much needed task in such a praiseworthy manner. Not everybody will agree with all aspects of the report and certainly the recommendations of the frequency of obtaining cervical smears in various "risk" segments of our population will create certain problems (especially if paying agencies attempt to enforce rigidly these recommendations by the implementation of fee constraints), but these problems should be resolved on a realistic practical basis. I wish to draw attention to the portion of the report relating to quality control. I agree with most of what is stated but it is perhaps unfortunate that reference is made to New York State programs without pointing out that the proficiency testing program was designed to evaluate performance of cytotechnologists under test conditions. It is questionable whether the program evaluated the day-to-day performance of the technologists because they are generally not called upon to make final independent evaluations as they were asked to do in the testing program. It is agreed that no quality control program is complete without an external proficiency testing mechanism. This should evaluate the system as it is practised and as it affects patient care. The College of American Pathologists has tested a model that uses cytology smears from patients' files. External proficiency testing in both histopathology and cytology will shortly be part of their survey program. Similar programs are currently being considered for use in Canada. D.W. PENNER, MD Director, department of pathology Health Sciences Centre 700 william Ave. Winnipeg, MB
To the editor: I was pleased to read Dr. Penner's favourable comments on our task force report, though he is expressing his views personally and not as the voice of the Canadian Association of Pathologists. I am sure that the task force members all share his view that some of the problems presented by the recommendations will be resolved on a realistic and practical basis. Penner states that the reference to P. AvERBACK, MD Department of pathology the New York State program on proMcGill University ficiency testing was "unfortunate" but Montreal, PQ goes on to agree with our stated need for "external" proficiency testing proCervical cancer screening grams, stating that "similar programs programs are currently being considered for use To the editor: The CMA Journal is to in Canada." Quoting from our report: be congratulated on the June 5, 1976 issue. All members of the task force Many laboratories processing cytology on cervical cancer screening programs specimens in Canada have developed over under the chairmanship of Dr. R.J. the years their own "internal" qualityWalton deserve our warmest thanks for control programs, based upon standards CMA JOURNAL/OCTOBER 23, 1976/VOL. 115 725
ray, 1871 2. CANNON WB: Bodily Changes in Pain, Fear, Hunger and Rage, 2nd ed, repr of 1929 ed, Washington, McGrath, 1970 3. MAsst.wa AU, MuINDI JM, SwAl GBR: Iron and resistance to infection. Lancet 2: 314, 1974 4. HONTELA 5: Senile psychosis and stress, in Proceedings of the 2nd General Biennial Meeting of the Canadian Society of Gerontology, Toronto, Oct. 22.24, 1975, p 4 5. ANDRUs EC: Emotional factors and cardiac function. Biol Psychiatry 10: 581, 1975
To the editor: 1 am glad to have the opportunity of seeing Dr. Hontela's letter. However, there is no point in discussing his innumerable questions in a letter, as every detail is dealt with at length in the 2nd edition of my book "The Stress of Life". Interested readers of the Journal will find readily accessible, although brief, discussions of the same subjects in the March and June 1975 issues of the Journal of Human Stress - one article by myself, and the other by John W. Mason of Walter Reed Medical Center, Washington. HANS SELYE, CC, MD, PH D, D SC University of Montreal Montreal, PQ
718 CMA JOURNAL/OCTOBER 23, 1976/VOL. 115
Premature labour To the editor: Dr. K.S. Koh reviewed the role of uterine relaxant drugs in the control of premature labour (Can Med Assoc J 114: 700, 1976) but failed to mention that nylidrin hydrochloride is the most effective ft-sympathomimetic drug according to a controlled, doubleblind comparison of placebo, ethanol, isoxsuprine and nylidrin in the treatment of 194 pregnant women in Helsinki's University Hospital.1 The relative successes of the four treatments are summarized in Fig. 1. Nylidrin was p1005 -. N S -. -NI-----,
.
RAIE%
R.
PLAcEDO
EThAWL
B.JPRINE
NYLIORIN
FIG. 1-Success rates of four agents used to treat premature labour. the only form of treatment significantly superior to placebo. Otherwise Koh's article was excellent. PIERRE BIRON, MD Department of pharmacology University of Montreal Montreal, PQ
Reference 1. CASTR.N 0, GUMMERUS M, SAAiuKosKI 5: Treatment of imminent premature labour.
Acta Obstet Gynecol Scand 54: 95, 1975
To the editor: I thank Dr. Biron for pointing out the omission of nylidrin as a uterine relaxant drug in my review article on premature labour and for drawing my .attention to this valuable drug. However, new knowledge is accumulating with such speed that any review of a subject must be read with a retrospective glance to the time it was written, rather than when it was published. The time interval between the submission and publication of my paper was slightly more than 1 year. K.S. KOH, MD Health Sciences Centre
700 William Ave. Winnipeg, MB
Designing doctor shows restraint To the editor: For my own safety I have designed and constructed a practical automotive passive restraint. Like many people I forget to fasten my seat belt and the seat belt buzzer conked out long ago. While the seat belt requires active fastening, my passive restraint is always there. I wanted something that would be simple, effective and inexpensive. It has
U
XIL (amoxicillin)
The new generation broad-spectrum penicillin INDICATIONS AND DOSAGE Infections of the ear, nose and throat due to streptococci, pneumococci, and penicillinsensitive staphylococci; infections of the upper respiratory tract due to H. influenzae; infections of the genitourinary tract due to E. coli, P. mirabilis, and S. faecalis; infections of the skin and soft tissues due to streptococci, penicillin-sensitive staphylococci and E. coli: USUAL DOSE: ADULTS 250 mg every 8 hours CHILDREN 25 mg/kg/day in divided doses every 8 hours In severe infections or infection associated with organisms where sensitivity determinations indicate higher blood levels may be advisable: 500 mg every 8 hours for adults, and 50 mg/kg/day in divided doses every 8 hours for children may be needed- This dosage should not exceed the recommended adult dosage. Infections of the lower respiratory tract due to streptococci, pneumococci, penicillinsensitive staphylococci and H. influenzae: USUAL DOSE: ADULTS 500 mg every 8 hours CHILDREN 50mg/kg/day in divided doses every 8 hours This dosage should not exceed the recommended adult dosage. Urthrltis due to N. gonorrhoeae: 3 g as a single oral dose. CONTRAINDICATION In patients with a history of allergy to the penicillins and cephalosporins. Product Monograph available on request. SUPPLIED AMOXIL-250 Capsules-each contains 250 mg amoxicillin (as the trihydrate) AMOXIL-500 Capsules-each contains 500 mg amoxicillin (as the trihydrate) AMOXIL-125 Suspension-125 mg amoxicillin per 5 ml, in 75 ml & 100 ml bottles AMOXIL-250 Suspension-250 mg amoxicillin per 5 ml, in 75 ml & 100 ml bottles AMOXIL Pediatric Drops-is ml (50 mg/mI) in dropper bottle
AYERST LABORATORIES Division of Ayerst, McKenna & Harrison Limited Montreal, Canada Made in Canada by arrangement with BEECHAM, INC. .Regd
St...1,.g
*..t ..d g.1..g
. d..Ii...,d
/
vii
LI .I I1 FIG. 1-Design of passive restraint.
been my experience that electrical devices frequently go wrong; accordingly, I avoided them. My device consists of several parts (Figs. 1 and 2): Floor mount: two 5"-square sections of steel girder, each 10" long, one mounted on top of the other and secured together by six ½" nuts and bolts; another six 12" bolts pass through the floor and are held beneath by washers and a strengthening plate. Floor mount slide: a 10" length of U-shaped aluminum, the same width as the floor mount, open side uppermost. Stem: a 4 x 40" U-shaped steel section with the open side down. Clamp: a 14" length of flat steel, bent over the floor mount and stem, fitting like a saddle. Hitch pin: an ordinary hitch pin transfixing the clamp and the upper steel portion of the floor mount. Lap bar: attached to the stem, near the driver's right hip, from the hinged left armrest. It angles up from 'the floor mount to clear the seat and then across to form an armrest for the driver.s right elbow. Middle pad: a 12 x 12" square of steel tubing attached to the lap bar, sitting vertically in front of the driver like the breastplate of a suit of armour. Left armrest: a 4" length of hinged
U-shaped aluminum. The hinge is a 5"square section of steel girder. Foam rubber, secured with medical adhesive tape, is applied liberally to all edges and ends. The entire contrivance is covered in black, mottled material that looks like leather but isn't. Unfortunately the quality is inferior to that of the car upholstery. I use the car every day and find this device very practical. To get in I simply lift the left armrest and slide behind the lap bar and middle pad. The original central armrest is still free to move up and down. Three people can still be accommodated in the front seat.
4
FIG. 2-The finished product.
CMA JOURNAL/OCTOBER 23, 1976/VOL. 115 723
Prescribe
Bendectin Helps prevent morning sickness before it starts
DESCRIPTION Each delayed-release tablet contains: Dicyclomine hydrochloride (Bentylol)-antispasmodic.10 mg. Doxylamine succinate (Decapryn)-antihistamine.10 mg. Pyridoxine hydrochloride.10 mg. ACTIONS Bendectin provides the action of three unre; lated compounds, each having a different type of effect: the antispasmodic quiets g.i. spasm associated with nausea; the antihistamine is related chemically to other drugs used to control nausea and motion sickness; the pyridoxine hydrochloride corrects vitamin B6 deficiency that may occur during pregnancy. The antiemetic action of Bendectin is delayed by a special coating that permits the nighttime dose to be effective in the morning hours-when the patient needs it most INDICATION AND CLINICAL USE Nausea and vomiting of pregnancy. CONTRAINDICATIONS Bendectin is contraindicated in patients with frank urinary retention, stenosing peptic ulcer, pyloric or duodenal obstruction, prostatic hypertrophy, or cardiospasm. PRECAUTIONS Because of potential drowsiness, Bendectin should be prescribed with caution for patients who must drive automobiles or operate machinery. Bendectin also should be used cautiously with alcohol or other drugs that depress the central nervous system or in patients with epilepsy. ADVERSE REACTIONS The adverse reactions that may occur are those of the individual ingredients. In particularly sensitive patients, dicyclomine hydrochloride may cause atropine-like effects such as dry mouth, blurring of vision, thirst, or dizziness. On rare occasions fatigue, sedation, rash, constipation, anorexia, nausea and vomiting, headache, and dysuria have occurred. Doxylamine succinate may cause drowsiness, vertigo, nervousness, epigastric pain, headache, palpitation, diarrhoea, disorientation, irritability, convulsions, urinary retention, or insomnia. Pyridoxine hydrochloride is a vitamin that is generally recognized as having no adverse effects. DOSAGE AND ADMINISTRATION Adults: 2 Bendectin tablets at bedtime. In severe cases or when nausea occurs during the day: 1 additional Bendectin tablet in the morning and another in midafternoon. DOSAGE FORM Tablets in bottles of 100 and 500.
Merrell
ThE WM. 8. MERRELL COMPANY DMslon of Richardson.MerrU (Canada) Ltd., Weston, Ontario. M91 1R9 MEMBER
If the car should come to rest following an accident in such a way as to obstruct the left door, the device can be removed by pulling out the hitch pin. This device could be used to protect passengers as well as drivers if appropriately fitted. NOEL JACKSON, MB, B5, DRCOG Box 850 Biggar, SK
Anencephaly associated with megavitamin therapy To the editor: I read with interest the letter by P. Averback in the June 5, 1976 issue of CMAJ (page 995) reporting a case of anencephaly apparently associated with megavitamin therapy. It would have been helpful if Dr. Averback had provided more information on this case - that is, for what condition was the patient receiving megavitamins, was therapy helpful, what doses of the various vitamins was she receiving, and were there any other well documented factors that might have been contributory? Dr. Averback might also care to comment on the frequency of fetal abnormalities when the mother has received long-term therapy with phenothiazines. E.T. PATERSON, MB, CH B P0 Box 2010 Creston, BC
To the editor: The purpose of my letter was to record a single case of anencephaly in the offspring of a woman receiving vitamin therapy during pregnancy. This patient was taking tablets of vitamins B1 (100 mg), B6 (100 mg) and C (200 mg), niacin (200 mg) and brewer's yeast, all in variable quantity, but at a minimum of four tablets of each per day. Her physician had started this therapy 6 months prior to conception and it had been continued (by the patient) during psychotherapy for chronic anxiety. According to her psychiatrist she is presently well and is taking no medications. No well documented other contributory factors were found.
undertaking this much needed task in such a praiseworthy manner. Not everybody will agree with all aspects of the report and certainly the recommendations of the frequency of obtaining cervical smears in various "risk" segments of our population will create certain problems (especially if paying agencies attempt to enforce rigidly these recommendations by the implementation of fee constraints), but these problems should be resolved on a realistic practical basis. I wish to draw attention to the portion of the report relating to quality control. I agree with most of what is stated but it is perhaps unfortunate that reference is made to New York State programs without pointing out that the proficiency testing program was designed to evaluate performance of cytotechnologists under test conditions. It is questionable whether the program evaluated the day-to-day performance of the technologists because they are generally not called upon to make final independent evaluations as they were asked to do in the testing program. It is agreed that no quality control program is complete without an external proficiency testing mechanism. This should evaluate the system as it is practised and as it affects patient care. The College of American Pathologists has tested a model that uses cytology smears from patients' files. External proficiency testing in both histopathology and cytology will shortly be part of their survey program. Similar programs are currently being considered for use in Canada. D.W. PENNER, MD Director, department of pathology Health Sciences Centre 700 william Ave. Winnipeg, MB
To the editor: I was pleased to read Dr. Penner's favourable comments on our task force report, though he is expressing his views personally and not as the voice of the Canadian Association of Pathologists. I am sure that the task force members all share his view that some of the problems presented by the recommendations will be resolved on a realistic and practical basis. Penner states that the reference to P. AvERBACK, MD Department of pathology the New York State program on proMcGill University ficiency testing was "unfortunate" but Montreal, PQ goes on to agree with our stated need for "external" proficiency testing proCervical cancer screening grams, stating that "similar programs programs are currently being considered for use To the editor: The CMA Journal is to in Canada." Quoting from our report: be congratulated on the June 5, 1976 issue. All members of the task force Many laboratories processing cytology on cervical cancer screening programs specimens in Canada have developed over under the chairmanship of Dr. R.J. the years their own "internal" qualityWalton deserve our warmest thanks for control programs, based upon standards CMA JOURNAL/OCTOBER 23, 1976/VOL. 115 725
