consequences of the provision of a government monopoly health plan are potentially disastrous. The medical profession in Canada is becoming subservient to government bureaucracy, and one way to escape from the trap is to deal directly with patients. In many medical offices it is impracticable to invoice individual patients for services rendered. With the increasing use of credit cards I see no reason why a group of physicians who are determined to deal directly with their patients should not take advantage of Chargex, Master Card, American Express, etc. I should be interested to hear from physicians who support the concept of the medical charge card, or who favour entering some form of association with established credit card organizations in Canada.
well as the patient's own tumour cells. The patient responded rapidly to antitumour therapy with prednisone, vincristine and cyclophosphamide, and is doing well after 8 months of therapy. To our knowledge, this is the first reported case of reticulum cell sarcoma associated with antinucleolar antibodies. J.H. JONCAS, MD, PH D P. ROBITAILLE, MD
P. BENOIT, MD Department of pediatrics Sainte-Justine Hospital Montreal, Que.
References I. RITCHIE RF: Antinucleolar antibodies: their frequency and diagnostic association. N Engi J Med 282: 1174, 1970 2. TAN EM, NORTHWAY JD, PINNAs JL: Clinical significance of antinuclear antibodies.
Postgrad Med 54: 143, 1973
3. PINNAS JL, NORTHWAY JD, TAN EM: Antinucleolar antibodies in human sera. J finmunol 111: 996, 1973 4. BECK JS, ANDER5ON JR, MCELHINNEY AJ,
A. GEOFFREY DAWRANT, MD, B CR Box 7692, Station A Edmonton, Alta.
et al: Antinucleolar antibodies. Lancet 2: 575, 1962 5. Bowa JM, ANGERMAN 3, McBama CM, et al: Antinucleolar antibodies in sera of patients with melanoma (abstr no 338). Cancer Res 12: 85, 1971
Antinucleolar antibodies in reticulum cell sarcoma
Therapeutic abortion
To the editor: Antinucleolar antibodies are one type of antinuclear antibody rarely found in human serum.1'2 They have been reported in patients with scleroderma and Sj6gren's syndrome,3'4 melanoma,5 and undiagnosed illnesses or syndromes manifesting Raynaud's phenomenon.3 We have recently studied a patient with reticulum cell sarcoma whose serum had a titre of 1/128 for antinucleolar antibodies. A 6-year-old boy was admitted to hospital with fever and an inguinal mass that had enlarged over a month. While the child was in hospital the mass invaded the overlying skin, which became purplered, and generalized adenopathy developed. After 2 weeks another subcutaneous mass formed over a rib in the right midposterior thorax, and a minimal right pleural effusion developed. The only notable laboratory finding was a serum 1gM value of 1120 mg/dl. Infectious and other causes for the lesions were excluded. Two successive biopsies of the inguinal nodes and invaded skin disclosed reticulum cell proliferation with numerous atypical mitotic figures, compatible with the features of reticulum cell sarcoma. A diagnosis of Hodgkin's disease could not be made in the absence of Reed-Steinberg cells, among other criteria. Epstein-Barr virus (EBV) antibody studies showed absent viral capsid (VCA), early (EA) and nuclear (NA) antibodies but revealed antinucleolar antibodies on Molt 4 cells used as controls in the EB-NA tests. The same antinucleolar pattern was demonstrated in a variety of cells, including lymphoblastoid cells of Raji and HRlK types; lymphoblastoid cells in culture from patients with infectious mononucleosis and healthy individuals; human embryo fibroblasts; primary monkey and rat kidney cells; as
To the editor: In the abortion issue I believe that our only concern as physicians is in regard to how we define "therapeutic abortion". By this term surely we mean abortion carried out to prevent or treat a condition associated with pregnancy, or as a direct result of pregnancy, that threatens the woman's life or health. As a psychiatrist I have examined many patients who were referred for emotional or psychological assessment and, where appropriate, I have recommended that the pregnancy be terminated. Such a recommendation has also been made when the presenting disorder was in the category of a psychosocial condition; this allows a variety of conditions to be included within an ethical medical framework. While I am prepared to agree that in this area there may be dispute, nevertheless it is quite different from the so-called "abortion on demand", which has no ethical medical basis. Therapeutic abortion is adequately covered by current legislation, if not by health service facilities (and there are indeed great differences and gaps between medical and health services). However, I do not believe that the solution lies in changing the law. Rather, it seems that those who wish abortion on demand would like the law to be altered so that physicians would in fact be altering the ethical medical basis on which they practise; the procedure could then no longer be considered a therapeutic abortion. If society wishes to sanction abortion on demand, then the law could
276 CMA JOURNAL/AUGUST 23, 1975/VOL. 113
'Demulen® ethynodiol diacetate ethinyl estradiol Indication - Oral Contraception Contraindications - Malignant tumors ot the breast or genital tract, estrogen dependent neoplasia, signiticant liver dystunction, history ot cholestatic jaundice, during breast teeding, undiagnosed vaginal bleeding, history ot CVA, coronary thrombosis, classical migraine, thrombophlebitis or thromboembolic disease, ocular lesions such as partial or complete loss ot vision: detect in visual tields, diplopia: suspect pregnancy. Warnings - Discontinue medication at the earliest manitestation ot: thromboembolic disorders such as thrombophlebitis, cerebrovascular disease, pulmonary embolism, myocardial ischemia, retinal thrombosis: visual defects, proptosis, diplopia, undiagnosed severe headache, classical migraine, papilledema, ophthalmic vascular lesions, psychiatric disturbances. Rule out pregnancy alter two consecutive periods are missed or alter the first missed period it the prescribed regimen has not been followed. Demulen may cause metabolic imbalance: observe carefully in epilepsy, asthma, cardiac and renal dysfunction. Precautions - Before use, a thorough history should be taken and a thorough physical examination performed, including the breasts and pelvic organs and a Papanicolaou smear. Follow up examination should be within six months and at least yearly thereafter. Liver, thyroid and other endocrine function teats should not be considered accurate unless therapy has been discontinued. Withdrawal of medication for 2 to 4 months is necessary before alteration in thyroxine binding reverts to normal. Similar precautions apply to liver function studies and other tests of protein binding (e.g. plasma cortisol). Follow diabetic patients or those with a family history of diabetes closely for decrease in glucose tolerance. Persistent irregular vaginal bleeding requires investigation. In metabolic or endocrine disease and when metabolism of calcium and phosphorus is involved, careful clinical evaluation should precede medication. Possible influence of prolonged therapy on pituitary, ovarian, adrenal, thyroid, hepatic or uterine function awaits further study. Risks of complications due to adrenocortical insufficiency appear to be minimal, but may occur. Treatment may mask the onset of the climacteric. Advise the pathologist of therapy with Demulen with relevant specimens. Uterine fibroids are subject to the same complications as may occur in pregnancy. Sudden enlargement, pain or tenderness require discontinuance of medication. Patients with a history of emotional disturbance, especially the depressive type, are prone to recurrence. If this occurs, discontinue medication. Discontinue medication in patients who develop transient aphasia, paralysis, or loss of consciousness. Give Demulen to patients with signs of essential hypertension only under close supervision. Elevation of blood pressure may occur at any time and even if asymptomatic necessitates cessation of medication. Give with great care and under close supervision to patients with a history of jaundice. Do not prescribe to those with a history of cholestatic jaundice, especially associated with pregnancy. In those patients who develop severe generalized pruritus or icterus, consider hepatic dysfunction and withdraw medication. If the jaundice is of the cholestatic type, do not resume medication. Considering the. oversuppression syndrome patients may be advised to discontinue medication after approximately two years and resume only after normal ovulatory cycles have been re-established. Avoid prescribing to patients with a history of prolonged episodes of amenorrhea or infertility. Assess adolescent patients for adequate skeletal development prior to medication. Oral contraceptives may accelerate epiphyseal closure. After discontinuing Demulen, the patient should await the resumption of normal ovulating cycles before attempting to become pregnant. Use special judgment in prescribing to women with recurrent fibrocystic disease of the breast. Estrogen-progestogen combinations may increase plasma lipoproteins. Use with caution in women with pre-existent hyperlipoproteinemia. Adverse Effects - The following have been noted with varying incidence: nausea, vomiting, other GI symptoms, breakthrough bleeding, spotting, change in menstrual flow, amenorrhea, edema, suppression of lactation, migraine, cholestatic jaundice, rash (allergic), rise in blood pressure and mental depression. Disturbances in bleeding patterns are usually most pronounced during the first cycle and usually disappear after several cycles. The following have been reported, although no cause and effect relationship has been established: anovulation posttreatment, premenstrual-like syndrome, changes in libido and appetite, cystitis-like syndrome, headache, nervousness, hemorrhagic eruption, and itching. Thrombophlebitis, pulmonary embolism and neuro-ocular lesions have been observed, although a cause and effect relationship has neither been established nor disproved. Various laboratory results may be altered particularly BSP. coagulation factors, tests of thyroid function, metapyrone. pregnanediol and corticosteriod determinations. Dosage - Demulen 21 - One tablet daily. Cyclic administration 3 weeks on tablets and one week off. Demulen 28 One tablet daily. Continuous administration 21 active tablets followed by 7 inert tablets. Availability - Each white, round tablet with Searle' on one side and 71 on the other contain ethynodiol diacetate 1.D mg.. and ethinyl estradiol 0.05 mg. Available in 21 and 28 day Compack dispensers (on green foil).
Searle Pharmaceuticals OakviIIe, Ontario L6H 1M5
THE BRITISH COLUMBIA HEART FOUNDATION announces a
CLINICAL FELLOWSHIP in
CARDIOVASCULAR DISEASE COMMENCING JULY 1, 1976 GENERAL Open to individuals who wish to take a year of training in a British Columbia centre, with a programme acceptable to the Foundation. Applicants must have completed at least three years of training, after graduation from an approved Medical School. Prior to application, an applicant must have secured a position in a teaching centre in B.C. which would be made available should the Fellowship be granted. The Fellowship will involve clinical hospital work and it will be necessary for the applicant to fulfill the requirements of the B.C. College of Physicians and Surgeons, appropriate to the appointment at the Institution concerned. TENURE The award will commence July 1, and the awardee will devote 12 consecutive months to the objects of the award. STIPEND $14,876 per year. Arrangements for travel expense to British Columbia will be made on an individual basis. APPLICATIONS To be submitted by October 31, 1975. Application forms and regulations may be obtained from your University Registrar, Department Head. or ROBERT K. DAVIES, Executive Director The B.C. Heart Foundation, 1881 West B.oadway, Vancouver, B.C., Canada. V6J 1Y5
be changed so that this procedure could be carried out, although not by physicians, who at present are the only trained, experienced people who may, with legal sanction, terminate a pregnancy. The solution would be to train and legalize abortionists, who would not be physicians, to perform abortion on demand, a procedure that has nothing to do with the ethical practice of medicine. As physicians, we should make this clear to governments and to the public so that we can disentangle ourselves from the kind of debate that has been raging, to which some of our professional colleagues have unfortunately contributed by their confusing statements or unethical practices. ROBERT HALLWAY, MB, DPM
123 East 13th St. North Vancouver, BC
Error in drug dosage To the editor: We request use of your columns to warn of a dangerous error in drug dosage in the article on infective endocarditis in the new (14th) edition of our "Textbook of Medicine", published by W.B. Saunders Company. The error is in the sixth paragraph, first column, page 315, where the recommended dose of gentamicin is given as 50 to 100 mg per kilogram body weight. The correct figure should be 1.0 to 1.5 mg per kilogram of body weight intramuscularly or intravenously every 8 hours. In the same paragraph the dosage of kanamycin should be corrected to 5 mg per kilogram of body weight intramuscularly or intravenously every 8 hours. The error was discovered after several thousand copies of the book had been distributed in May and June of this year. All copies released by the publishers in July and afterward will contain a correction. The publishers are sending notices about this to all
Applications received after the closing date cannot be considered. 278 CMA JOURNAL/AUGUST 23, 1975/VOL. 113
hospitals, booksellers and purchaserr whose names are known, but there is no way to locate everyone who possesses an early copy of the book. We hope that readers of this notice who know anyone who has a copy released during the first 2 months will call the error to that person's attention. PAUL B. BEESON, MD WALSH MCDERMOTr, MD Veterans Administration Hospital Seattle, WA
Fallopian tube stump perforation To the editor: Problems with stumps of hollow viscera such as the appendix and the gallbladder are rare. Recently I had a patient with perforation of an inflamed fallopian tubal stump, a condition I had not previously been aware of. A 30-year-old black woman, para 3, gravida III, was admitted to hospital because of moderately severe, steady right lower quadrant abdominal pain radiating to her groin and back for 4 days and vaginal discharge for 1 day. Her last menstrual period had begun 12 days before and had been normal, and she had previously been healthy. Tubal ligation via laparotomy had been performed 18 months previously. Three months before this admission she had been treated for trichomonal vaginitis. The right lower quadrant of the abdomen was tender and a right adnexal mass (diameter, 5 cm) exquisitely tender. A moderate amount of white cervical discharge was noted; culture yielded coliforrn bacilli, Streptococcus viridans and Staphylococcus albus. The complete blood count was normal and the erythrocyte sedimentation rate was 90 mm/h. Examination under anesthesia did not aid in diagnosis. Laparoscopic examination revealed bilateral Irving tubal ligations and about 30 ml of blood in the pelvis. The swollen right tubal stump (length, 5 cm; width, 1.5 cm), with a small clot attached to the perforation on the anteroinferior aspect, was excised. Microscopic examination revealed
FOR HOUSE DUST Sensitivity! Since 1935 our products have been sold only on physician recommendation. We cover the major causes of household dust with a complete line of durable, washable encasings for mattresses, box springs, and pillows. Write for our instructional series, 'Avoidance of House Dust and Feathers', a patient education aid designed to assist you in the explanation of causes and effects of household allergies and dust sensitivity. It is available to you without charge. --S.
well as the patient's own tumour cells. The patient responded rapidly to antitumour therapy with prednisone, vincristine and cyclophosphamide, and is doing well after 8 months of therapy. To our knowledge, this is the first reported case of reticulum cell sarcoma associated with antinucleolar antibodies. J.H. JONCAS, MD, PH D P. ROBITAILLE, MD
P. BENOIT, MD Department of pediatrics Sainte-Justine Hospital Montreal, Que.
References I. RITCHIE RF: Antinucleolar antibodies: their frequency and diagnostic association. N Engi J Med 282: 1174, 1970 2. TAN EM, NORTHWAY JD, PINNAs JL: Clinical significance of antinuclear antibodies.
Postgrad Med 54: 143, 1973
3. PINNAS JL, NORTHWAY JD, TAN EM: Antinucleolar antibodies in human sera. J finmunol 111: 996, 1973 4. BECK JS, ANDER5ON JR, MCELHINNEY AJ,
A. GEOFFREY DAWRANT, MD, B CR Box 7692, Station A Edmonton, Alta.
et al: Antinucleolar antibodies. Lancet 2: 575, 1962 5. Bowa JM, ANGERMAN 3, McBama CM, et al: Antinucleolar antibodies in sera of patients with melanoma (abstr no 338). Cancer Res 12: 85, 1971
Antinucleolar antibodies in reticulum cell sarcoma
Therapeutic abortion
To the editor: Antinucleolar antibodies are one type of antinuclear antibody rarely found in human serum.1'2 They have been reported in patients with scleroderma and Sj6gren's syndrome,3'4 melanoma,5 and undiagnosed illnesses or syndromes manifesting Raynaud's phenomenon.3 We have recently studied a patient with reticulum cell sarcoma whose serum had a titre of 1/128 for antinucleolar antibodies. A 6-year-old boy was admitted to hospital with fever and an inguinal mass that had enlarged over a month. While the child was in hospital the mass invaded the overlying skin, which became purplered, and generalized adenopathy developed. After 2 weeks another subcutaneous mass formed over a rib in the right midposterior thorax, and a minimal right pleural effusion developed. The only notable laboratory finding was a serum 1gM value of 1120 mg/dl. Infectious and other causes for the lesions were excluded. Two successive biopsies of the inguinal nodes and invaded skin disclosed reticulum cell proliferation with numerous atypical mitotic figures, compatible with the features of reticulum cell sarcoma. A diagnosis of Hodgkin's disease could not be made in the absence of Reed-Steinberg cells, among other criteria. Epstein-Barr virus (EBV) antibody studies showed absent viral capsid (VCA), early (EA) and nuclear (NA) antibodies but revealed antinucleolar antibodies on Molt 4 cells used as controls in the EB-NA tests. The same antinucleolar pattern was demonstrated in a variety of cells, including lymphoblastoid cells of Raji and HRlK types; lymphoblastoid cells in culture from patients with infectious mononucleosis and healthy individuals; human embryo fibroblasts; primary monkey and rat kidney cells; as
To the editor: In the abortion issue I believe that our only concern as physicians is in regard to how we define "therapeutic abortion". By this term surely we mean abortion carried out to prevent or treat a condition associated with pregnancy, or as a direct result of pregnancy, that threatens the woman's life or health. As a psychiatrist I have examined many patients who were referred for emotional or psychological assessment and, where appropriate, I have recommended that the pregnancy be terminated. Such a recommendation has also been made when the presenting disorder was in the category of a psychosocial condition; this allows a variety of conditions to be included within an ethical medical framework. While I am prepared to agree that in this area there may be dispute, nevertheless it is quite different from the so-called "abortion on demand", which has no ethical medical basis. Therapeutic abortion is adequately covered by current legislation, if not by health service facilities (and there are indeed great differences and gaps between medical and health services). However, I do not believe that the solution lies in changing the law. Rather, it seems that those who wish abortion on demand would like the law to be altered so that physicians would in fact be altering the ethical medical basis on which they practise; the procedure could then no longer be considered a therapeutic abortion. If society wishes to sanction abortion on demand, then the law could
276 CMA JOURNAL/AUGUST 23, 1975/VOL. 113
'Demulen® ethynodiol diacetate ethinyl estradiol Indication - Oral Contraception Contraindications - Malignant tumors ot the breast or genital tract, estrogen dependent neoplasia, signiticant liver dystunction, history ot cholestatic jaundice, during breast teeding, undiagnosed vaginal bleeding, history ot CVA, coronary thrombosis, classical migraine, thrombophlebitis or thromboembolic disease, ocular lesions such as partial or complete loss ot vision: detect in visual tields, diplopia: suspect pregnancy. Warnings - Discontinue medication at the earliest manitestation ot: thromboembolic disorders such as thrombophlebitis, cerebrovascular disease, pulmonary embolism, myocardial ischemia, retinal thrombosis: visual defects, proptosis, diplopia, undiagnosed severe headache, classical migraine, papilledema, ophthalmic vascular lesions, psychiatric disturbances. Rule out pregnancy alter two consecutive periods are missed or alter the first missed period it the prescribed regimen has not been followed. Demulen may cause metabolic imbalance: observe carefully in epilepsy, asthma, cardiac and renal dysfunction. Precautions - Before use, a thorough history should be taken and a thorough physical examination performed, including the breasts and pelvic organs and a Papanicolaou smear. Follow up examination should be within six months and at least yearly thereafter. Liver, thyroid and other endocrine function teats should not be considered accurate unless therapy has been discontinued. Withdrawal of medication for 2 to 4 months is necessary before alteration in thyroxine binding reverts to normal. Similar precautions apply to liver function studies and other tests of protein binding (e.g. plasma cortisol). Follow diabetic patients or those with a family history of diabetes closely for decrease in glucose tolerance. Persistent irregular vaginal bleeding requires investigation. In metabolic or endocrine disease and when metabolism of calcium and phosphorus is involved, careful clinical evaluation should precede medication. Possible influence of prolonged therapy on pituitary, ovarian, adrenal, thyroid, hepatic or uterine function awaits further study. Risks of complications due to adrenocortical insufficiency appear to be minimal, but may occur. Treatment may mask the onset of the climacteric. Advise the pathologist of therapy with Demulen with relevant specimens. Uterine fibroids are subject to the same complications as may occur in pregnancy. Sudden enlargement, pain or tenderness require discontinuance of medication. Patients with a history of emotional disturbance, especially the depressive type, are prone to recurrence. If this occurs, discontinue medication. Discontinue medication in patients who develop transient aphasia, paralysis, or loss of consciousness. Give Demulen to patients with signs of essential hypertension only under close supervision. Elevation of blood pressure may occur at any time and even if asymptomatic necessitates cessation of medication. Give with great care and under close supervision to patients with a history of jaundice. Do not prescribe to those with a history of cholestatic jaundice, especially associated with pregnancy. In those patients who develop severe generalized pruritus or icterus, consider hepatic dysfunction and withdraw medication. If the jaundice is of the cholestatic type, do not resume medication. Considering the. oversuppression syndrome patients may be advised to discontinue medication after approximately two years and resume only after normal ovulatory cycles have been re-established. Avoid prescribing to patients with a history of prolonged episodes of amenorrhea or infertility. Assess adolescent patients for adequate skeletal development prior to medication. Oral contraceptives may accelerate epiphyseal closure. After discontinuing Demulen, the patient should await the resumption of normal ovulating cycles before attempting to become pregnant. Use special judgment in prescribing to women with recurrent fibrocystic disease of the breast. Estrogen-progestogen combinations may increase plasma lipoproteins. Use with caution in women with pre-existent hyperlipoproteinemia. Adverse Effects - The following have been noted with varying incidence: nausea, vomiting, other GI symptoms, breakthrough bleeding, spotting, change in menstrual flow, amenorrhea, edema, suppression of lactation, migraine, cholestatic jaundice, rash (allergic), rise in blood pressure and mental depression. Disturbances in bleeding patterns are usually most pronounced during the first cycle and usually disappear after several cycles. The following have been reported, although no cause and effect relationship has been established: anovulation posttreatment, premenstrual-like syndrome, changes in libido and appetite, cystitis-like syndrome, headache, nervousness, hemorrhagic eruption, and itching. Thrombophlebitis, pulmonary embolism and neuro-ocular lesions have been observed, although a cause and effect relationship has neither been established nor disproved. Various laboratory results may be altered particularly BSP. coagulation factors, tests of thyroid function, metapyrone. pregnanediol and corticosteriod determinations. Dosage - Demulen 21 - One tablet daily. Cyclic administration 3 weeks on tablets and one week off. Demulen 28 One tablet daily. Continuous administration 21 active tablets followed by 7 inert tablets. Availability - Each white, round tablet with Searle' on one side and 71 on the other contain ethynodiol diacetate 1.D mg.. and ethinyl estradiol 0.05 mg. Available in 21 and 28 day Compack dispensers (on green foil).
Searle Pharmaceuticals OakviIIe, Ontario L6H 1M5
THE BRITISH COLUMBIA HEART FOUNDATION announces a
CLINICAL FELLOWSHIP in
CARDIOVASCULAR DISEASE COMMENCING JULY 1, 1976 GENERAL Open to individuals who wish to take a year of training in a British Columbia centre, with a programme acceptable to the Foundation. Applicants must have completed at least three years of training, after graduation from an approved Medical School. Prior to application, an applicant must have secured a position in a teaching centre in B.C. which would be made available should the Fellowship be granted. The Fellowship will involve clinical hospital work and it will be necessary for the applicant to fulfill the requirements of the B.C. College of Physicians and Surgeons, appropriate to the appointment at the Institution concerned. TENURE The award will commence July 1, and the awardee will devote 12 consecutive months to the objects of the award. STIPEND $14,876 per year. Arrangements for travel expense to British Columbia will be made on an individual basis. APPLICATIONS To be submitted by October 31, 1975. Application forms and regulations may be obtained from your University Registrar, Department Head. or ROBERT K. DAVIES, Executive Director The B.C. Heart Foundation, 1881 West B.oadway, Vancouver, B.C., Canada. V6J 1Y5
be changed so that this procedure could be carried out, although not by physicians, who at present are the only trained, experienced people who may, with legal sanction, terminate a pregnancy. The solution would be to train and legalize abortionists, who would not be physicians, to perform abortion on demand, a procedure that has nothing to do with the ethical practice of medicine. As physicians, we should make this clear to governments and to the public so that we can disentangle ourselves from the kind of debate that has been raging, to which some of our professional colleagues have unfortunately contributed by their confusing statements or unethical practices. ROBERT HALLWAY, MB, DPM
123 East 13th St. North Vancouver, BC
Error in drug dosage To the editor: We request use of your columns to warn of a dangerous error in drug dosage in the article on infective endocarditis in the new (14th) edition of our "Textbook of Medicine", published by W.B. Saunders Company. The error is in the sixth paragraph, first column, page 315, where the recommended dose of gentamicin is given as 50 to 100 mg per kilogram body weight. The correct figure should be 1.0 to 1.5 mg per kilogram of body weight intramuscularly or intravenously every 8 hours. In the same paragraph the dosage of kanamycin should be corrected to 5 mg per kilogram of body weight intramuscularly or intravenously every 8 hours. The error was discovered after several thousand copies of the book had been distributed in May and June of this year. All copies released by the publishers in July and afterward will contain a correction. The publishers are sending notices about this to all
Applications received after the closing date cannot be considered. 278 CMA JOURNAL/AUGUST 23, 1975/VOL. 113
hospitals, booksellers and purchaserr whose names are known, but there is no way to locate everyone who possesses an early copy of the book. We hope that readers of this notice who know anyone who has a copy released during the first 2 months will call the error to that person's attention. PAUL B. BEESON, MD WALSH MCDERMOTr, MD Veterans Administration Hospital Seattle, WA
Fallopian tube stump perforation To the editor: Problems with stumps of hollow viscera such as the appendix and the gallbladder are rare. Recently I had a patient with perforation of an inflamed fallopian tubal stump, a condition I had not previously been aware of. A 30-year-old black woman, para 3, gravida III, was admitted to hospital because of moderately severe, steady right lower quadrant abdominal pain radiating to her groin and back for 4 days and vaginal discharge for 1 day. Her last menstrual period had begun 12 days before and had been normal, and she had previously been healthy. Tubal ligation via laparotomy had been performed 18 months previously. Three months before this admission she had been treated for trichomonal vaginitis. The right lower quadrant of the abdomen was tender and a right adnexal mass (diameter, 5 cm) exquisitely tender. A moderate amount of white cervical discharge was noted; culture yielded coliforrn bacilli, Streptococcus viridans and Staphylococcus albus. The complete blood count was normal and the erythrocyte sedimentation rate was 90 mm/h. Examination under anesthesia did not aid in diagnosis. Laparoscopic examination revealed bilateral Irving tubal ligations and about 30 ml of blood in the pelvis. The swollen right tubal stump (length, 5 cm; width, 1.5 cm), with a small clot attached to the perforation on the anteroinferior aspect, was excised. Microscopic examination revealed
FOR HOUSE DUST Sensitivity! Since 1935 our products have been sold only on physician recommendation. We cover the major causes of household dust with a complete line of durable, washable encasings for mattresses, box springs, and pillows. Write for our instructional series, 'Avoidance of House Dust and Feathers', a patient education aid designed to assist you in the explanation of causes and effects of household allergies and dust sensitivity. It is available to you without charge. --S.
