34

LETTER1S

TO THE

JOLTRNAL

Canad. Med. Ass. J.

July 2, 1966, vol. 95

Letters are welcomed and will be published as space permits. Like other material submitted
for publication, they should be typewritten, double-spaced, should be of reasonable length,
and will be subject to the usual editing. The accuracy of statements of fact contained in
these letters is the responsibility of the correspondent.
Views expressed in Letters to the Journal are those of the writers concerned and are NOT
to be interpreted as the opinions of The Canadian Medical Association or of the editors.

THE IMPACT OF CHANGING PATTERNS

OF MEDICAL CARE
To the Editor:
I write to congratulate Dr. L. J. Genesove on his
succinct and clearly focused article, "The Impact of
Changing Patterns of Medical Care" (Canad. Med.
Ass. J., 94: 117.8, 1966). He describes two related
difficulties into which the practice of medicine has
been drifting, difficulties which result from rapid
change: increasingly unsatisfactory retrieval of clinical information and an increasingly fuzzy concept of

professional secrecy. He discusses the eroding influence

of both processes on standards of medical care, and
their potential for social, economic and political abuse
of clinical information.
In the matter of "medicare", the public; understandably, seems to be more concerned with the payment of bills than with the physician-patient relationship, a concept the nature and importance of which
are difficult to condense into slogans. The profession
is in this way at some disadvantage, and enlists little
more than lip-service from politicians in support of
its views. The issues raised by Dr. Genesove, on the
other hand, are concrete, easily grasped, and obviously
close to the interest and welfare of everyone. Moreover, it is on such specific issues that the public and
the profession can most easily be seen to have an
identical point of view, and the hazards of third-party
intervention can be shown up most sharply.
On their own merits alone, these specific problems
require urgent attention and action. In addition, however, if good solutions to them are found, this cannot
fail to improve the whole climate of "medicare" discussions, perhaps decisively.
JANIES H. BROWN, Ch.B., M.R.C.P.(E), D.P.M.
5770 South Street,
Halifax, N.S.
LIVE MEASLES VIRUS VACCINE
To the Editor:
I am prompted to write concerning the letter by
Dr. Pestri entitled "Encephalitis After Live Measles
Virus Vaccine" in the May 21 issue (Canad. Med. Ass.
J., 94: 1133, 1966).
Dr. Pestri and Dr. Napke are of course right that
instances of this sort are of great importance and
should be reported to a central compiling agency.
However, the association in time between vaccine and
one incident of this kind has no statistical validity and
to publish this case report under the title that was
used, while technically accurate, is at the same time
misleading. When hundreds of thousands of children
are being vaccinated, it is inevitable that occasional

cases of severe disease will occur shortly after

vaccination.
The question of severe reactions to the measles
vaccine was considered by the W.H.O. Scientific Group
on this subject (W.H.O. Technical Report Series No.
263, 1963). Data on a large number of vaccinations
were considered in that study. Only one case of
encephalitis, and that unlike measles in pathology, was
found in 160,000 controlled vaccinations.
FRANCIS L. BLACK, Ph.D.,
Associate Professor of Epidemiology.
Yale University,
New Haven, Conn., U.S.A.

MATERNAL MORTALITY STUDIES:

CEPHALOPELVIC DISPROPORTION
To the Editor:
I would like to comment on a recent Maternal
Mortality Study, "Cephalopelvic Disproportion"
(Canad. Med. Ass. J., 94: 1126, 1966).
Would the article have been more helpful if the
Maternal Mortality Committee had reported how much
blood and clot were found in the abdominal cavity at
autopsy?
Even with immediate laparotomy and transfusion
with blood, do not some of these patients die? If the
answer to this last question is "yes", would it not be
more accurate to point this out in the review?
J. M. BOYD GARLAND, M.D.
P.O. Box 631,
Brantford, Ont.
To the Editor:
In the case to which Dr. Garland refers, we were
unable to be more specific concerning the amount of
blood found in the peritoneum than was recorded at
the autopsy, namely, "The abdominal cavity contained
several litres of blood and blood clot."
In our opinion, under "ideal circumstances" (with
immediate laparotomy and immediate massive blood
transfusion), no maternity patients with dehiscence of
a previous classical Cesarean section scar should die.
With anything less than this-because of the rapid and
excessive intraperitoneal hemorrhage which is associated with this type of catastrophe deaths will occur.
The lessons inherent in this case are: (1) A classical
Cesarean section should not be performed at any time.
(2) When a woman 20 or more weeks pregnant who
had a previous classical Cesarean section develops
acute abdominal pain, she should be considered to
have dehiscence of the previous uterine scar until
proved otherwise. (3) The dehiscence of such uterine
scars in subsequent pregnancies occurs most often
before the onset of labour. (4) When such a catastro-