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Effectiveness of Dr. Melzack and colleagues' Fig. 5
appear to have had effective epidu-
cribe the high failure rate (33%) of
epidural anesthesia ral anesthesia. However, labour pain
epidural anesthesia in their series to
the inexperience of the anesthetists.
became more intense and more Early in their training, being unfa-
In their paper on severity of labour widely distributed because of inade- miliar with anesthetics and mindful
pain Dr. Ronald Melzack and col- quate maintenance of anesthesia. of the possible fatal outcome if ex-
leagues (Can Med Assoc J 1984; We agree that epidural anesthesia cessive medication is injected into
130: 579-584) report the distribu- was ineffective in patient C and are the epidural space, many resident
tion and intensity of pain in four surprised that she was left to labour anesthetists tend to be conservative
patients in whom epidural anesthe- for almost 4 hours with severe pain. in deciding on the dose. This some-
sia was "ineffective" and conclude Remedial action should have been times results in incomplete pain re-
that "ineffective anesthesia" caused taken. lief initially for some patients. We
unpredictable changes in pain distri- The changes in the distribution reviewed the results of epidural in-
bution. The amount of cervical dila- and intensity of pain in all four of jections performed through a cathe-
tion present when the anesthetic was these patients are totally explainable ter for obstetric patients by four
administered to these patients by the pharmacologic action of an- first-year resident anesthetists in
ranged from 2 to 5 cm. The form of esthetics injected epidurally and the their first month of training at the
epidural anesthesia, the medications progression of labour. While unilat- Wellesley Hospital, Toronto. In only
used and the site of injection were eral labour pain after administration 4 of 36 consecutive cases was there
not indicated in the article. of the anesthetic is not uncommon, no relief or inadequate relief of pain
In epidural anesthesia for relief of in most circumstances it can be initially, and in all 4 there was
labour pain the insertion of a cathe- relieved by increasing the dose of satisfactory relief after remedial ac-
ter in the epidural space to allow for the anesthetic, using a more potent tion was taken. Our experience is
subsequent injection of medication anesthetic, adjusting the epidural thus not consistent with that of Dr.
appears to be the logical choice catheter, changing the position of Melzack and colleagues.
since a single injection of the anes- the patient while an additional anes- Epidural anesthesia is a popular
thetic at 2 to 5 cm of cervical thetic is being given, or performing form of relief for labour pain. While
dilation rarely lasts for the duration another epidural injection.'`3 its potential complications must be
of labour. Patients A, B and D in Dr. Melzack and colleagues as- recognized, "unpredictable changes
180 pp. hardcover
PAGING DOCTORS Foreword by
D. Laurence Wilson, MD
Messages from a medical journalist Dean of Medicine
Queen's University
By David Woods
A collection of more than 50 articles, editorials and reviews by the Canadian Medical
Association's Director of Publications . . . and culled from CMAJ, Canadian Family Physician,
Maclean's, Quest, The Toronto Star, etcetera . . . including Medicine and the English
language, The medical profession's image, Doctors and the press, Fitter than Thou, Words to
give up . . . and interviews with William F. Buckley, Jr., Edwin Newman and Norman Cousins.
a witty, scholarly look at the
world, mostly at the world of medicine
and its practitioners" - Morris Gibson, To: Epigram Publishing, PO Box 6044, Station J,
MD, author of One Man's Medicine. Ottawa, Ontario, Canada K2A 1T1
'.1 ..Paging Doctors is a treasure of
fun, erudition, wit, good sense and Please send me copy(ies) of Paging Doctors at $20.00 each.
delicious English"' - Andrew Malleson,
MD, author of Medical Runaround. Name: (block letters)
. . .doctors don't have time to return
I Address:
to school for a course in communica-
tion. But they do have the time to read
this delightful, truthful book" - W.
Gifford-Jones, MD, syndicated colum-
nist and author of The Doctor Game.
100 CAN MED ASSOC J, VOL. 131, JULY 15, 1984
in pain distribution" is certainly not Respiratory cial endocrine pancreas. Artif Organs
one of them. 1981; 5: 784-786
poliomyelitis 3. LACY PE, DAVIE JM, FINKE EM: Pro-
CHESTER J. POTYRAK, MD
KWOK C. LEE, PH D, MD [correction] longation of islet allograft survival fol-
lowing in vitro culture (24°C) and a
Department of anesthesia single injection of ALS. Science 1979;
Wellesley Hospital 204: 312-313
Toronto, Ont. An error appeared on page 1306 of
the article by Dr. A.J.W. Alcock 4. MULLEN YS, CLARK WR, MOLNAR IG,
References and colleagues in the May 15, 1984 BROWN J: Complete reversal of experi-
mental diabetes mellitus in rats by a
issue of the Journal. The legend to single fetal pancreas. Science 1977; 195:
1. SINGH A: Unilateral epidural analgesia. Fig. 1 should have read "Numbers 68-70
Anaesthesia 1967; 22: 147-149 of new cases of poliomyelitis . . ."; 5. SUTHERLAND DER, MATAS AJ, NAJARI-
the word "respiratory" should not AN JS: Pancreatic islet cell transplanta-
2. USUBIAGA JE, Dos REIs A, USUBIAGA LE: have appeared. We apologize for
Epidural misplacement of catheters and tion. Surg Clin North Am 1978; 58:
mechanisms of unilateral block. Anesthe- this error.- Ed. 365-382
siology 1970; 32: 158-161 6. CHANG TMS: Semipermeable capsules.
Science 1964; 146: 524-525
3. BOZEMAN PM, CHANDRA P: UJnilateral
Could transplanted
analgesia following epidural and subarach-
noid block. Anesthesiology 1980; 52: 356-
7. Idem: Artificial Cells, CC Thomas,
Springfield, Ill, 1972
357 microencapsulated islets 8. LIM F, SUN AM: Microencapsulated is-
of Langerhans be the lets as bioartificial pancreas. Science
1980; 210: 908-910
"Pink urine" in morbidly cure for diabetes 9. GOOSEN MFA, O'SHEA GM, CHARAPE-
obese patients following mellitus? [correction] TIAN HM, CHOU S, SUN AM: Optimiza-
tion of microencapsulation parameters.
Biotechnol Bioeng (in press)
gastric partitioning In the June 15, 1984 issue of
CMAJ, we inadvertently "dropped" 10. SUTHERLAND DER: Pancreas and islet
[correction] the references from the medical sci- transplant registry data. World J Surg
(in press)
ence news item by Brian Berube
We apologize to l)r. Mervyn Deitel (starting on page 1531). The refer- 11. Proceedings of a workshop on preventing
and his colleagues for the typo- ence list is as follows.-Ed. the rejection of transplanted pancreas or
graphic error that appeared in their islets, January 11-14, 1982, Santa Ynez,
California. Diabetes 1982; 31 (suppl 4)
article (Can Med Assoc J 1984; References
130: 1007-1011). On page 1010 the 12. HENRICKSSON C: Transplantation of iso-
second sentence of the discussion 1. O'SHEA GM, GOOSEN MFA, SUN AM: lated pancreatic islets: current status and
Prolonged survival of transplanted islets prospects. Acta Med Scand [Suppl
should have read (with the correc- of Langerhans encapsulated in a biocom- 1983; 671: 117-119
tion in italics): "Pure uric acid crys- patible membrane. Biochim Biophys
tals are colourless, but in the urine Acta (in press)
they are almost always coloured by 2. SUN AM, LIM F, VAN RooY H, O'SHEA i.. .:....
z.
.X
adsorbed urinary pigments. ." G: Long-term studies of microencap-
-Ed. sulated islets of Langerhans: a bioartifi-
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