,toxicity of the waste materials re- trated on the vital healer-patient problems we have only ourselves sulting from the bleaching process. There are one or two manufacturers of 100% de-inked recycled paper in the United States, but we have not yet been able to obtain information regarding the bleaching process they use and the toxicity of the waste products. All fine printing paper produced in Canada contains recycled material, the amount varying from 10% to 20% in the grades of paper regularly used in CMA publicatioxis. There are no national standards with respect to the amount of recycled material used within a particular paper grade, and there does not appear to be any paper in the grades we use that regularly contains more than 20% recycled material. Any paper containing a higher proportion would be unsuitable for printing our publications. We and a number of other
environmentally conscientious publishers continue to urge the fine-paper manufacturers to develop a relatively inexpensive, nontoxic de-inking process. In the meanwhile we will endeavour to ensure that the paper used in CMA publications contains the highest possible percentage of recycled paper currently available. Susan Stockwell Director of publications
Alternatives to medicine D r. W. Grant Thompson's editorial (Can Med Assoc J 1990; 142: 105-106) reminds us of the public's increasing tendency to consult alternative healers. We have rarely asked why. The main reason is the increasing distance between today's physician and the patient, as Norman Cousins pointed out.' Alternative healers, despite their variable training and few serious treatment options, have concen1192
CAN MED ASSOCJ 1990;142 (I )
relationship and have therefore rightly attracted a significant following.2 Historically chiropractors have been the premier alternative practitioners in Canada. Their one effective tool has been spinal manipulation. Chiropractors in effect developed from bone setters. The great surgeon James Paget3 suggested back in 1867 that doctors learn from bone setters, but he was ignored. I have used spinal manipulation in my general practice for 25 years and can attest to its value as sometimes being more effective than other measures in relieving common neck and back pain. It is difficult to prove the efficacy of spinal manipulation, as teaching hospital studies of varying quality have shown. However, patients have voted with their feet, and chiropractors have benefited from our failure to teach this simple skill in medical school. (There are, of course, very few knowledgeable teachers.) I have found that patients prefer medical doctors to give this treatment but seek out chiropractors only because we have generally failed to provide it. We have forgotten our historic roots. Hippocrates4 wrote 2400 years ago: The physician, or some person who is strong and not uninstructed, should apply the palm of the hands to the hump, and then, having laid the other hand upon the former he should make pressure, attending whether this force should be applied directly downward, or toward the head, or toward the hips.
Hippocrates here not only advocated physicians' manipulating the spine but doing so "attending"" to the anatomic planes. Few treatment procedures today have such a long history of use. If alternative healers replace us to a degree in the treatment of gastrointestinal or musculoskeletal
to blame. Michael Livingston, MA, MD 305-7031 Westminster Hwy. Richmond, BC
References 1. Woods D: A conversation with Norman Cousins. Can Jled -lssoc 1 1983; 1 28:
1110-1113 2. Livingston M: Some facets of alternative medicine. West J Jled 1985; 143: 269-270 3. Paget J: Clinical lecture on cases that bone-setters cure. Br JIed 1 1 867: 1: 1 4 4. Hippocrates. Articulations. In The (Je1lin1e 4 orks of Hippocrates, vol II (Adams F, transl), Sydenham Society. London 1869: 612
Dr. Thompson reminds us that functional (psychologic) illnesses are very common, constituting 30% to 60% of referrals in his specialty, gastroenterology. Although he emphasizes and reassures us that only physicians can make diagnoses, there are concerns about the training of family physicians in psychological medicine.'2 In fact, depression is the most frequently missed diagnosis in medicine,3 especially when it presents as chronic fatigue.4 Thompson points out that patients are overmedicated and stresses that patients can have conditions for which no technology is of any benefit. Moreover, a preoccupation with "high-tech" medicine may dull clinical acumen for organic illnesses. The "art of medicine" slowly went "the way of the vapors" after the discovery of the sulfonamides. Thompson is concerned that those with psychologic illnesses will seek alternative treatments of dubious (if not harmful) nature, but even more vulnerable are those who have formed support groups for "chronic fatigue syndrome" because they feel helpless and abandoned by the medical profession. To the ever-increasing tendency of the general public to self-diagnosis4 must be added the
ever-increasing iatrogenic factor in misdiagnosis.'24 Therefore, I am most concerned that those in such support groups may never get better, because there is ample evidence that feelings of helplessness and abandonment are associated with permanent severe apathy and depression or even death.5 When Seligman6 simulated in dogs the experience of helplessness in humans the dogs just lay down and whined rather than make any effort to avoid the conflict causing the distress! At the risk of sounding polemic I must ask, in reverence to Sydenham, Osler and Freud, Quo vadis medicinae? Ray Holland, MD, FRCPC Box 458 80 Fraser St. Port Colborne, Ont.
References 1. Heseltine GF: Toward a Blueprint for Change: a Study of Mental Health in Ontario, Queen's Printer, Toronto, 1983 2. Goldberg D, Huxley P: Mental Illness in the Community: the Pathway to Psychiatric Care, Tavistock Publ, London, 1980 3. Ayd FJ (ed): Underdiagnosis of depression. Int Drug Ther Newsl 1988; 23 (2): 11-12 4. Holland R: Chronic fatigue syndrome [C]. Can Med Assoc J 1989; 141: 375 5. Spitz RA: The First Year of Life, Intl Univs Pr, New York, 1965 6. Seligman MEP: Leamed helplessness. Annu Rev Med 1972; 23: 407-412
Dr. Thompson raises a number of important issues relating to the practice of medicine in general and to the treatment of pain complaints in particular. Although he emphasizes the importance of psychosocial factors in the causation of illness, reminds us that practitioners of alternative medicine do not adhere to the same scientific principles of diagnosis and treatment as do physicians, and points out that alternative medicine is not without its dangers, he continues to refer to the psychosocial causes of
illness as "functional", an imprecise and somewhat derogatory term. Furthermore, he defines the role of the physician as excluding physical causes when diagnosing illness, and in so doing he continues the common practice of diagnosing psychologic causes of illness by exclusion, a thoroughly nonscientific and potentially dangerous procedure. I believe that it is precisely this approach that leads patients to seek alternative treatments. Although it is appropriate to encourage a serious and sincere attitude to all of a patient's complaints, patients will usually be able to detect when a physician is unable to properly evaluate the psychologic and social factors contributing to their complaints. Disappointed that the physician cannot deliver what appears to be promised they may turn to alternative medicine for help. Although the art of medicine - that is, the intuitive part - will always be important in diagnosis, it is singularly unscientific to suggest that the psychologic processes leading to illness can be systematically evaluated by this approach. An example of a comprehensive approach to diagnosis is the clinic for the management of chronic pain. All of the 40 or so such clinics operating in Canada pay close attention to psychologic, social and physical factors in the investigation and diagnosis of chronic pain. Clinicians concerned with the management of chronic pain have for many years promoted this approach to pain management and treat psychologic, social and physical factors as a continuum, in an integrated, concurrent fashion. This approach has recently been described in a publication by the Department of National Health and Welfare entitled Guidelines for Establishing Standards for Special Services in Hospitals: Chronic-Pain Programs. Patients will continue to seek alternative therapies for this im-
portant group of illnesses as long as physicians fail to properly diagnose and treat these conditions. The guidelines for pain centres, available in both English and French from the Secretariat, Subcommittee on Institutional Program Guidelines, Health Services Directorate, Health Services and Promotion Branch, Department of National Health and Welfare, Ottawa, Ont. KIA 1B4, is one approach to this problem and could be helpful to physicians dealing with similar kinds of patients. Richard F.H. Catchlove, MB, BS Director Pain Management Centre Department of Anaesthesia Royal Victoria Hospital Montreal, PQ
[Dr. Thompson responds.] No one is totally satisfied with the word "functional", which apparently implies a physiologic rather than structural or biochemical change. However, banning the word would leave a large hole in our vocabulary. It would be necessary to invent another term. How else is one to describe ulcer-like symptoms in a patient who is found not to have a peptic ulcer or any other demonstrable structural or biochemical defect? Many international committees have struggled with this concept, and one has described a functional gastrointestinal disorder as "a variable combination of chronic or recurrent gastrointestinal symptoms not explained by structural or biochemical abnormalities. These may include symptoms attributable to the esophagus, stomach, biliary tree, small or large intestines or anus".' Further discussion of the functional-organic dichotomy can be found elsewhere.2 There is some evidence that functional disorders have a psychologic cause, but none of it is conclusive. Current views are that psychosocial phenomena may be CAN MED ASSOC J 1990; 142 (I 1)
1193
environmentally conscientious publishers continue to urge the fine-paper manufacturers to develop a relatively inexpensive, nontoxic de-inking process. In the meanwhile we will endeavour to ensure that the paper used in CMA publications contains the highest possible percentage of recycled paper currently available. Susan Stockwell Director of publications
Alternatives to medicine D r. W. Grant Thompson's editorial (Can Med Assoc J 1990; 142: 105-106) reminds us of the public's increasing tendency to consult alternative healers. We have rarely asked why. The main reason is the increasing distance between today's physician and the patient, as Norman Cousins pointed out.' Alternative healers, despite their variable training and few serious treatment options, have concen1192
CAN MED ASSOCJ 1990;142 (I )
relationship and have therefore rightly attracted a significant following.2 Historically chiropractors have been the premier alternative practitioners in Canada. Their one effective tool has been spinal manipulation. Chiropractors in effect developed from bone setters. The great surgeon James Paget3 suggested back in 1867 that doctors learn from bone setters, but he was ignored. I have used spinal manipulation in my general practice for 25 years and can attest to its value as sometimes being more effective than other measures in relieving common neck and back pain. It is difficult to prove the efficacy of spinal manipulation, as teaching hospital studies of varying quality have shown. However, patients have voted with their feet, and chiropractors have benefited from our failure to teach this simple skill in medical school. (There are, of course, very few knowledgeable teachers.) I have found that patients prefer medical doctors to give this treatment but seek out chiropractors only because we have generally failed to provide it. We have forgotten our historic roots. Hippocrates4 wrote 2400 years ago: The physician, or some person who is strong and not uninstructed, should apply the palm of the hands to the hump, and then, having laid the other hand upon the former he should make pressure, attending whether this force should be applied directly downward, or toward the head, or toward the hips.
Hippocrates here not only advocated physicians' manipulating the spine but doing so "attending"" to the anatomic planes. Few treatment procedures today have such a long history of use. If alternative healers replace us to a degree in the treatment of gastrointestinal or musculoskeletal
to blame. Michael Livingston, MA, MD 305-7031 Westminster Hwy. Richmond, BC
References 1. Woods D: A conversation with Norman Cousins. Can Jled -lssoc 1 1983; 1 28:
1110-1113 2. Livingston M: Some facets of alternative medicine. West J Jled 1985; 143: 269-270 3. Paget J: Clinical lecture on cases that bone-setters cure. Br JIed 1 1 867: 1: 1 4 4. Hippocrates. Articulations. In The (Je1lin1e 4 orks of Hippocrates, vol II (Adams F, transl), Sydenham Society. London 1869: 612
Dr. Thompson reminds us that functional (psychologic) illnesses are very common, constituting 30% to 60% of referrals in his specialty, gastroenterology. Although he emphasizes and reassures us that only physicians can make diagnoses, there are concerns about the training of family physicians in psychological medicine.'2 In fact, depression is the most frequently missed diagnosis in medicine,3 especially when it presents as chronic fatigue.4 Thompson points out that patients are overmedicated and stresses that patients can have conditions for which no technology is of any benefit. Moreover, a preoccupation with "high-tech" medicine may dull clinical acumen for organic illnesses. The "art of medicine" slowly went "the way of the vapors" after the discovery of the sulfonamides. Thompson is concerned that those with psychologic illnesses will seek alternative treatments of dubious (if not harmful) nature, but even more vulnerable are those who have formed support groups for "chronic fatigue syndrome" because they feel helpless and abandoned by the medical profession. To the ever-increasing tendency of the general public to self-diagnosis4 must be added the
ever-increasing iatrogenic factor in misdiagnosis.'24 Therefore, I am most concerned that those in such support groups may never get better, because there is ample evidence that feelings of helplessness and abandonment are associated with permanent severe apathy and depression or even death.5 When Seligman6 simulated in dogs the experience of helplessness in humans the dogs just lay down and whined rather than make any effort to avoid the conflict causing the distress! At the risk of sounding polemic I must ask, in reverence to Sydenham, Osler and Freud, Quo vadis medicinae? Ray Holland, MD, FRCPC Box 458 80 Fraser St. Port Colborne, Ont.
References 1. Heseltine GF: Toward a Blueprint for Change: a Study of Mental Health in Ontario, Queen's Printer, Toronto, 1983 2. Goldberg D, Huxley P: Mental Illness in the Community: the Pathway to Psychiatric Care, Tavistock Publ, London, 1980 3. Ayd FJ (ed): Underdiagnosis of depression. Int Drug Ther Newsl 1988; 23 (2): 11-12 4. Holland R: Chronic fatigue syndrome [C]. Can Med Assoc J 1989; 141: 375 5. Spitz RA: The First Year of Life, Intl Univs Pr, New York, 1965 6. Seligman MEP: Leamed helplessness. Annu Rev Med 1972; 23: 407-412
Dr. Thompson raises a number of important issues relating to the practice of medicine in general and to the treatment of pain complaints in particular. Although he emphasizes the importance of psychosocial factors in the causation of illness, reminds us that practitioners of alternative medicine do not adhere to the same scientific principles of diagnosis and treatment as do physicians, and points out that alternative medicine is not without its dangers, he continues to refer to the psychosocial causes of
illness as "functional", an imprecise and somewhat derogatory term. Furthermore, he defines the role of the physician as excluding physical causes when diagnosing illness, and in so doing he continues the common practice of diagnosing psychologic causes of illness by exclusion, a thoroughly nonscientific and potentially dangerous procedure. I believe that it is precisely this approach that leads patients to seek alternative treatments. Although it is appropriate to encourage a serious and sincere attitude to all of a patient's complaints, patients will usually be able to detect when a physician is unable to properly evaluate the psychologic and social factors contributing to their complaints. Disappointed that the physician cannot deliver what appears to be promised they may turn to alternative medicine for help. Although the art of medicine - that is, the intuitive part - will always be important in diagnosis, it is singularly unscientific to suggest that the psychologic processes leading to illness can be systematically evaluated by this approach. An example of a comprehensive approach to diagnosis is the clinic for the management of chronic pain. All of the 40 or so such clinics operating in Canada pay close attention to psychologic, social and physical factors in the investigation and diagnosis of chronic pain. Clinicians concerned with the management of chronic pain have for many years promoted this approach to pain management and treat psychologic, social and physical factors as a continuum, in an integrated, concurrent fashion. This approach has recently been described in a publication by the Department of National Health and Welfare entitled Guidelines for Establishing Standards for Special Services in Hospitals: Chronic-Pain Programs. Patients will continue to seek alternative therapies for this im-
portant group of illnesses as long as physicians fail to properly diagnose and treat these conditions. The guidelines for pain centres, available in both English and French from the Secretariat, Subcommittee on Institutional Program Guidelines, Health Services Directorate, Health Services and Promotion Branch, Department of National Health and Welfare, Ottawa, Ont. KIA 1B4, is one approach to this problem and could be helpful to physicians dealing with similar kinds of patients. Richard F.H. Catchlove, MB, BS Director Pain Management Centre Department of Anaesthesia Royal Victoria Hospital Montreal, PQ
[Dr. Thompson responds.] No one is totally satisfied with the word "functional", which apparently implies a physiologic rather than structural or biochemical change. However, banning the word would leave a large hole in our vocabulary. It would be necessary to invent another term. How else is one to describe ulcer-like symptoms in a patient who is found not to have a peptic ulcer or any other demonstrable structural or biochemical defect? Many international committees have struggled with this concept, and one has described a functional gastrointestinal disorder as "a variable combination of chronic or recurrent gastrointestinal symptoms not explained by structural or biochemical abnormalities. These may include symptoms attributable to the esophagus, stomach, biliary tree, small or large intestines or anus".' Further discussion of the functional-organic dichotomy can be found elsewhere.2 There is some evidence that functional disorders have a psychologic cause, but none of it is conclusive. Current views are that psychosocial phenomena may be CAN MED ASSOC J 1990; 142 (I 1)
1193
