Although I agree that in emotionally disturbed children environmental manipulation is more helpful than the use of drugs (although both may be necessary), it cannot be said that the families of the hyperactive children who were the subjects of our study only rarely had problems. The severity of the children's behavioural disorders alone created severe stress in many families, which frequently resulted in vicious cycles exacerbated by pre-existing family problems. I am not postulating that the families "caused" their children's hyperactive syndrome, only that some families are much better than others at helping their hyperactive children and in some families the hyperactive child's difficult behaviour resulted in his being made a scapegoat, which further worsened his behaviour. I agree that methylphenidate is a better drug than chlorpromazine for children in whom the hyperactive syndrome is diagnosed. Our study, however, demonstrated that drugs alone (even valuable drugs such as the stimulants) are not powerful enough to prevent the difficult problems these children encounter during their ado1es.. cence. Other forms of help (remedial education, modification of the structure of the high school, family counselling and behaviour modification techniques) together with medication are likely to result in more fundamental changes. Methylphenidate is an excellent drug to reduce symptomatology in about 70% of children with the hyperactive syndrome. It requires careful monitoring and, as suggested by Dr. Humeid, "drug holidays" are very important to reduce the possibility of tolerance developing and also to allow height and weight to catch up. Furthermore, "drug holidays" enable the physician to dedetermine if the child is ready to be taken off medication permanently.

to wait but the majority of these are children with nonurgent conditions whose parents are seeking immediate attention - people who should be seeing their family physicians. There is always a physician present. However, if a specific doctor is requested he may or may not be immediately available. Children are not left unattended unless mothers wander off and leave them (as some do!). Granted, Mr. Consumer, waiting is annoying and time-consuming. But while you are waiting, a child who really needs attention may be helped or even saved. Suppose that child were your child? At the risk of sounding cynical, I should like to say that during my 18 months in casualty at the Janeway I found that the parents most likely to make complaints were those who least needed to be at the hospital or those whose visit was necessitated by their own neglect. The medical and nursing staff with whom I worked were as dedicated and competent a group of people as one could find anywhere in medicine. D.S. DOHERTY, MD Box 9055, Station B St. John's, NfId.

Adverse reaction to flurazepam To the editor: I have used flurazepam on many occasions with no adverse reactions. However, recently a patient had an extraordinary reaction to the drug. This 73-year-old man took a 30-mg capsule of flurazepam about an hour before he retired for the night. It produced intense euphoria, sleeplessness, restlessness to the point of hypomania, hallucinations in which he was talking most of the night with all sorts of people who inhabited his bedroom, blurred vision, confabulation, inability to write a sensible sentence or to formulate a properly spoken sentence and, finally, hypomania to such a degree that he had to walk out in the open for miles or drive his car; he could not remember where. He reported to me that it took him several days to get over the experience. This man has no systemic disease or condition that might possibly modify the effect of the drug. There is no evidence of liver disease and the degree of atherosclerosis is moderate for his age. His only condition requiring treatment over the past 8 years has been an occasional bout of paroxysmal tachycardia of unknown etiology. THOMAS A. cUNNINGHAM, MD

Campbellford, Ont.

URINE EXTRACTS Routine urinalysis is rapid and inexpensive prophylactic care." "One or two symptoms plus a urinalysis, facilitate a diagnosis...You start on-target treatment right away. Schreiner, Professor G. Urinalysis in the 70's. 1973

GABRIELLE WEISS, MD The Montreal Children's Hospital Montr6al, Qu6.

Inconvenience to patients To the editor: The point being made in the Consumer Viewpoint "Is inconvenience to the patient really necessary?" (Can Med Assoc J 112: 227, 1975) is valid; inconvenience in health services tends to be more aggravating than inconvenience (and there is) in other services. However, criticism out of context is not fair to the hospital personnel who try to do their best to provide good patient care. At the Dr. Charles A. Janeway Child Health Centre at St. Johns, Nfld., patients requiring immediate attention are seen and dealt with promptly - at least that was my experience when I was associated with that department. Many patients have

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CMA JOURNAL/APRIL 5, 1975/VOL. 112 805