from the use of doxycycline oc- 3. WELLING PG. KocH PA, LAU CC, et al: Bioavailability of tetracycline and curred in their patients, the duradoxycycline in fasted and nonfasted tion of their study was only 3 subjects. Antimicrob Agents Chernweeks. Thus, long-term prophylaxis other 11: 462, 1977 with this agent should not be undertaken at present. Liaison psychiatry If physicians elect to use doxyis cycline for prophylaxis of diarrhea To the editor: Liaison psychiatry psychiatrist a work the consulting in selected persons who will be travelling for brief periods, they should does in a general hospital. Articles psyknow that the dosage used in the have been written about liaison work about psychiatric study by Sack and colleagues was chiatry and care units two 100-mg capsules taken with a in dialysis units, intensive that is It evident meal on the day of travel and one and elsewhere.1 their 1 00-mg capsule taken with a meal psychiatrists are rediscovering do daily thereafter. Data from their roots in medicine; after all, we or study suggested that protection from not read of liaison neurology is diarrhea may extend for at least 1 dermatology, whose usefulness week after treatment is stopped. self-evident. There is hesitancy on both sides. However, until further data are have often available, daily administration of Physicians and surgeons to the the drug should probably be con- been turned off by exposure psychiof tinued while the patient is at risk. esoteric "dynamic" systems exponents their that and believe atry It is important that doxycycline to the be taken with, or immediately after, have little to offer, especially may bethe ingestion of food to minimize seriously ill. Psychiatrists trained to the occurrence of nausea. When the lieve they have not been of presdrug is taken with food its absorp- be useful in the situations thrust on tion is not impaired.2'3 As with tetra- sure into which they are ward. Howcycline, some hypersensitive persons a medical or surgical we as should, that we feel, if ever, may experience photosensitivity of any person to hospital admission while taking doxycycline; the conof every a review to lead should current use of an effective sunscreen then a or her health, his of aspect compound is recommended when must history the of personal review such persons are exposed to sunchest as as important at least be light. The usual contraindications cervical cytology to the use of tetracycline in children roentgenography, Many physitests. blood or routine and in women during pregnancy in fact, have do, and surgeons cians and lactation should be observed of their paknowledge an intimate when the use of doxycycline is conrarely enter they though lives, tients' sidered. even a few significant facts into the JOHN B. ARMSTRONG, MD, PH D record. Others embark on exhausMedical director Pfizer Company Ltd. tive investigations without discovKirkland, PQ ering what sort of people their paReferences tients are and what sort of life they 1. SACK DA, KAMINSKY DC, SACK RB, are leading. When a young woman et al: Prophylactic doxycycline for travelers' diarrhea. Results of a prospective double-blind study of peace corps volunteers in Kenya. N Engi J Med 298: 758, 1978 2. ROSENBLATr JE, BARRETr JE, BRODIE
JL, et al: Comparison of in vitro activity and clinical pharmacology of doxycycline with other tetracyclines, in Proceedings of the Sixth Interscience Conference on Antimicrobial Agents and Chemotherapy, Philadelphia, PA, 26-28th October, 1966, HOBBY GL (ed), Am Soc Microbiol, Ann Arbor, Mich, 1967, pp 134-41
complains of dizziness, by which
she usually means a transient feeling of loss of control, disorientation or fear, electroencephalography, roentgenography of the skull, computerized tomography, and an ear, nose and throat examination will be costly and unhelpful, whereas a half hour's skilful conversation may determine the cause and point towards
the cure. Admittedly it is easier to scribble the orders for investigation
than it is to find a private place to talk, but the latter is always possible. By contrast, when a patient becomes confused and agitated 1 or 2 days after an operation the panic button is pressed and the psychiatrist is begged to drop everything and take over. But this situation seems among the least of the challenges I meet, for every physician should know how to use diazepam and chlorpromazine. It is widely accepted that a psychiatrist or an interested physician should interview every patient who takes an overdose of a drug or otherwise self-inflicts an injury. Although the impulse is usually spent in the act, and, surprisingly, the changes in entourage that the patients seek are often achieved, this is a situation in which skilled outside help is needed; the interview may catalyse constructive change or initiate treatment outside the hospital. Gynecologists have, in my experience, been alert to the help psychiatrists can give their patients; their work, after all, is closely associated with the emotions of their patients. Abortion, tubal ligation sought by young women and depression following gynecologic procedures obviously require psychiatric consultation. Would that we could do more for persons suffering from frigidity or loneliness. A common situation is for the psychiatrist to be consulted at the end of a long, arduous and fruitless investigation of a difficult case. However, this is not always the correct course of action. For example, consider the case of a 54-year-old woman who is vomiting and losing weight, and has even been seen by nurses to put her fingers down her throat to induce vomiting. The psychiatrist is asked to consider a diagnosis of anorexia nervosa. But, apart from her age, she does not give the impression of being a hysterical, depressed or manipulative woman. She has pain in the right iliac fossa, which is the clue to intermittent obstruction by a knuckle of bowel caught in adhesions. Not every obscure illness is psychogenic, and, conversely, much
CMA JOURNAL/APRIL 7, 1979/VOL. 120 795
physical disease is exacerbated by emotions. Time, energy and money are saved if the psychiatrist is consulted early. Low back pain should be a frequent cause for consultation between psychiatrist and surgeon, unless the surgeon can handle the psychologic aspects alone. Once a myelogram and surgical exploration have been done a functional problem has become an organic one. It is often striking to see how little of the disability is due to the undoubted physical disease, and how much is due to the desperate life situation, which is rarely mentioned in the discharge summary. Let us consider the case of a 48-year-old man who has angina and angiographic proof of partial obstruction of two coronary arteries. However, his biggest problems are that he has only a grade 5 education, has mismanaged his business as a painter and has left his wife because of her violent temper and her debts of $10 000. If someone is happy he or she can live with a disability that would become unbearable if home or job were miserable. Operations are dangerous to a depressed patient who has lost the will to live. Patients who are known to be psychotic, neurotic or depressed can acquire a physical disease and turn up in a general hospital. They usually make wonderful patients. Neurosis especially seems to go into abeyance during a serious physical illness (perhaps it becomes unnecessary or the patient does not have enough energy to maintain it), but it returns in full force during convalescence. A factor often overlooked is the loneliness of many hospital patients, whether they are in a single-bed room or are sharing a room with someone who is much older or younger, or very sick, or speaking another language. A few hours a day spent with other patients can stave off confusion. I have little doubt that the consultant services of psychiatrists are underused in general hospitals, and to a very significant degree, mainly because of an overemphasis on diagnosing and treating physical disease.
For psychiatrists, general hospital work consumes more time and is less easy to organize than work in the office, but it brings them in contact with ordinary people who have courage and humour in the face of misfortune; this gives them a more balanced picture of life. Many cases cannot be given a clear diagnosic label, a source of regret only to those who take psychiatric diagnosis too seriously. The patients can be described by the problems they face and the way in which they face them. Our job is not to label, but to add another dimension to our colleagues' perception of the sick. As a result, our reports often read like scripts for soap operas unless they are disguised in pseudotechnical jargon. However, these scripts are taken from life, and, with help, our patients can sometimes change them. ELLIOTT EMANUEL, MD, MRCP, DCH, DPM
352 Dorval Ave., Ste. 201 Dorval, PQ
Reference
93, 1979), I suspect that the name of the reporter, Glennis Zilm, has been misspelt. Surely the name is Zaim preceded by Vander, as in that of the individual who introduced the draft legislation. If this is not the case, surely some of the widespread and severe criticisms of the proposed act would have been included in the report. Residents of British Columbia appreciate the irony that in the International Year of the Child legislation could come into effect that would be less effective in helping children and their families than the 1901 Protection of Children Act it replaces. DONA COATES BC director Canadian Association for Young Children Vancouver, BC
[Our reporter, Glennis Zilm, is a freelance writer of impeccable integrity and is unrelated to William Vander Zalm, the minister of human resources in British Columbia. Ed.]
1. MOORE GL: Adult psychiatrist in medical environment. Am J Psychiatr 135: 413, 1978
MEBWITS syndrome To the editor: I was glad to see from Dr. W.C. Watson's letter that other physicians are aware of the MEBWITS (medical examination before wintering in the South) syndrome (Can Med Assoc 1 120: 16, 1979). I would like to add another symptom that characterizes this common fall-and-winter syndrome - the demand for 3 to 6 months' free supply of drugs (paid for by taxpayers who are not fortunate enough to winter in the South). This symptom is one that should be eliminated by the politicians who claim they are concerned with the cost of health care. D.A. Eciuia, MD 496 Main St. Exeter, Ont.
Family and Child Services Act To the editor: In the report about the Family and Child Services Act proposed by the British Columbia government (Can Med Assoc 1 120:
796 CMA JOURNAL/APRIL 7, 1979/VOL. 120
FOAMTADS? TABLETS
COMPOSITION Each GAVISCON tablet contains alginic acid, 200 mg; aluminum hydroxide, 80mg; magnesium trisilicate, 20mg. INDICATIONS For symptomatic treatment of heartburn and .sophagitis associated with gastric acid reflux of hiatus hernia and other causes. DOSAGE Adults: 2 to 4 tablets 1 to 4 times daily, after meals and on retiring. ACTIONS GAVISCON tablets, when chewed, produce a viscous, demulcent, antacid foam which floats on thestomach contents. The alkaline foam readily flows into the casophagus during reflux. GAVISCON is also effective in reducing the frequency of the reflux episodes. ADMINISTRATION GAVISCON tablets must be chewed thoroughly. They may be followed by a drink of water or milk if desired. CONTRAINDICATIONSThereare nospecificcontraindications forGAVISCON FOAMTABS. See "Precautions" below. PRECAUTIONS Each GAVISCON tablet contains approximately 22 mg of Na+ which should be noted for patients on severely restricted sodium diets. The divalent cations of magnesium and aluminum interfere with the absorption of tetracycline, iron and phosphate. In addition, oral magnesium may accumulate in the serum of patients with impaired renal function. Each GAVISCON tablet contains 1.2 g of sucrose which is equivalent to 4.7 calories. ADVERSEEFFECTSNausea,vomiting,eructation,flatulence. OVERDOSAGE Should overdosage occur, gastric distention may result and is best treated conservatively. PRESENTATION GAVISCON FOAMTABS are white tablets with the name GAVISCON" imprinted on one side and the letterWimprinted on theoppositesideSupplied in plastic bottles of 100 tablets. STORAGE PRECAUTIONS Tablets should be stored in a cool, dry place. WINThROP LABORATORIES Division of Sterling Drug Ltd., Aurora, Ontario L4G 3H6 'Reg. Trade Mark of Femng Pharmaceuticals Limited. tTRADE MARK Full prescribing information available on request.
JL, et al: Comparison of in vitro activity and clinical pharmacology of doxycycline with other tetracyclines, in Proceedings of the Sixth Interscience Conference on Antimicrobial Agents and Chemotherapy, Philadelphia, PA, 26-28th October, 1966, HOBBY GL (ed), Am Soc Microbiol, Ann Arbor, Mich, 1967, pp 134-41
complains of dizziness, by which
she usually means a transient feeling of loss of control, disorientation or fear, electroencephalography, roentgenography of the skull, computerized tomography, and an ear, nose and throat examination will be costly and unhelpful, whereas a half hour's skilful conversation may determine the cause and point towards
the cure. Admittedly it is easier to scribble the orders for investigation
than it is to find a private place to talk, but the latter is always possible. By contrast, when a patient becomes confused and agitated 1 or 2 days after an operation the panic button is pressed and the psychiatrist is begged to drop everything and take over. But this situation seems among the least of the challenges I meet, for every physician should know how to use diazepam and chlorpromazine. It is widely accepted that a psychiatrist or an interested physician should interview every patient who takes an overdose of a drug or otherwise self-inflicts an injury. Although the impulse is usually spent in the act, and, surprisingly, the changes in entourage that the patients seek are often achieved, this is a situation in which skilled outside help is needed; the interview may catalyse constructive change or initiate treatment outside the hospital. Gynecologists have, in my experience, been alert to the help psychiatrists can give their patients; their work, after all, is closely associated with the emotions of their patients. Abortion, tubal ligation sought by young women and depression following gynecologic procedures obviously require psychiatric consultation. Would that we could do more for persons suffering from frigidity or loneliness. A common situation is for the psychiatrist to be consulted at the end of a long, arduous and fruitless investigation of a difficult case. However, this is not always the correct course of action. For example, consider the case of a 54-year-old woman who is vomiting and losing weight, and has even been seen by nurses to put her fingers down her throat to induce vomiting. The psychiatrist is asked to consider a diagnosis of anorexia nervosa. But, apart from her age, she does not give the impression of being a hysterical, depressed or manipulative woman. She has pain in the right iliac fossa, which is the clue to intermittent obstruction by a knuckle of bowel caught in adhesions. Not every obscure illness is psychogenic, and, conversely, much
CMA JOURNAL/APRIL 7, 1979/VOL. 120 795
physical disease is exacerbated by emotions. Time, energy and money are saved if the psychiatrist is consulted early. Low back pain should be a frequent cause for consultation between psychiatrist and surgeon, unless the surgeon can handle the psychologic aspects alone. Once a myelogram and surgical exploration have been done a functional problem has become an organic one. It is often striking to see how little of the disability is due to the undoubted physical disease, and how much is due to the desperate life situation, which is rarely mentioned in the discharge summary. Let us consider the case of a 48-year-old man who has angina and angiographic proof of partial obstruction of two coronary arteries. However, his biggest problems are that he has only a grade 5 education, has mismanaged his business as a painter and has left his wife because of her violent temper and her debts of $10 000. If someone is happy he or she can live with a disability that would become unbearable if home or job were miserable. Operations are dangerous to a depressed patient who has lost the will to live. Patients who are known to be psychotic, neurotic or depressed can acquire a physical disease and turn up in a general hospital. They usually make wonderful patients. Neurosis especially seems to go into abeyance during a serious physical illness (perhaps it becomes unnecessary or the patient does not have enough energy to maintain it), but it returns in full force during convalescence. A factor often overlooked is the loneliness of many hospital patients, whether they are in a single-bed room or are sharing a room with someone who is much older or younger, or very sick, or speaking another language. A few hours a day spent with other patients can stave off confusion. I have little doubt that the consultant services of psychiatrists are underused in general hospitals, and to a very significant degree, mainly because of an overemphasis on diagnosing and treating physical disease.
For psychiatrists, general hospital work consumes more time and is less easy to organize than work in the office, but it brings them in contact with ordinary people who have courage and humour in the face of misfortune; this gives them a more balanced picture of life. Many cases cannot be given a clear diagnosic label, a source of regret only to those who take psychiatric diagnosis too seriously. The patients can be described by the problems they face and the way in which they face them. Our job is not to label, but to add another dimension to our colleagues' perception of the sick. As a result, our reports often read like scripts for soap operas unless they are disguised in pseudotechnical jargon. However, these scripts are taken from life, and, with help, our patients can sometimes change them. ELLIOTT EMANUEL, MD, MRCP, DCH, DPM
352 Dorval Ave., Ste. 201 Dorval, PQ
Reference
93, 1979), I suspect that the name of the reporter, Glennis Zilm, has been misspelt. Surely the name is Zaim preceded by Vander, as in that of the individual who introduced the draft legislation. If this is not the case, surely some of the widespread and severe criticisms of the proposed act would have been included in the report. Residents of British Columbia appreciate the irony that in the International Year of the Child legislation could come into effect that would be less effective in helping children and their families than the 1901 Protection of Children Act it replaces. DONA COATES BC director Canadian Association for Young Children Vancouver, BC
[Our reporter, Glennis Zilm, is a freelance writer of impeccable integrity and is unrelated to William Vander Zalm, the minister of human resources in British Columbia. Ed.]
1. MOORE GL: Adult psychiatrist in medical environment. Am J Psychiatr 135: 413, 1978
MEBWITS syndrome To the editor: I was glad to see from Dr. W.C. Watson's letter that other physicians are aware of the MEBWITS (medical examination before wintering in the South) syndrome (Can Med Assoc 1 120: 16, 1979). I would like to add another symptom that characterizes this common fall-and-winter syndrome - the demand for 3 to 6 months' free supply of drugs (paid for by taxpayers who are not fortunate enough to winter in the South). This symptom is one that should be eliminated by the politicians who claim they are concerned with the cost of health care. D.A. Eciuia, MD 496 Main St. Exeter, Ont.
Family and Child Services Act To the editor: In the report about the Family and Child Services Act proposed by the British Columbia government (Can Med Assoc 1 120:
796 CMA JOURNAL/APRIL 7, 1979/VOL. 120
FOAMTADS? TABLETS
COMPOSITION Each GAVISCON tablet contains alginic acid, 200 mg; aluminum hydroxide, 80mg; magnesium trisilicate, 20mg. INDICATIONS For symptomatic treatment of heartburn and .sophagitis associated with gastric acid reflux of hiatus hernia and other causes. DOSAGE Adults: 2 to 4 tablets 1 to 4 times daily, after meals and on retiring. ACTIONS GAVISCON tablets, when chewed, produce a viscous, demulcent, antacid foam which floats on thestomach contents. The alkaline foam readily flows into the casophagus during reflux. GAVISCON is also effective in reducing the frequency of the reflux episodes. ADMINISTRATION GAVISCON tablets must be chewed thoroughly. They may be followed by a drink of water or milk if desired. CONTRAINDICATIONSThereare nospecificcontraindications forGAVISCON FOAMTABS. See "Precautions" below. PRECAUTIONS Each GAVISCON tablet contains approximately 22 mg of Na+ which should be noted for patients on severely restricted sodium diets. The divalent cations of magnesium and aluminum interfere with the absorption of tetracycline, iron and phosphate. In addition, oral magnesium may accumulate in the serum of patients with impaired renal function. Each GAVISCON tablet contains 1.2 g of sucrose which is equivalent to 4.7 calories. ADVERSEEFFECTSNausea,vomiting,eructation,flatulence. OVERDOSAGE Should overdosage occur, gastric distention may result and is best treated conservatively. PRESENTATION GAVISCON FOAMTABS are white tablets with the name GAVISCON" imprinted on one side and the letterWimprinted on theoppositesideSupplied in plastic bottles of 100 tablets. STORAGE PRECAUTIONS Tablets should be stored in a cool, dry place. WINThROP LABORATORIES Division of Sterling Drug Ltd., Aurora, Ontario L4G 3H6 'Reg. Trade Mark of Femng Pharmaceuticals Limited. tTRADE MARK Full prescribing information available on request.
