References Diabetes supplement was published? 1. University Group Diabetes Program: A study And how about the Medical Letter? of the effects of hypoglycemic agents on In 1972 and again in 1974 they envascular complications in patients with adultonset diabetes. II. Mortality results. Diabetes dorsed the UGDP conclusions and 19 (suppi 2): 789, 1970 2. University Group Diabetes Program: Effects warned physicians about oral hypoglyof hypoglycemic agents on vascular comcemics; between these two warnings 2 plications in patients with adult-onset diabetes. IV. A preliminary report on phenyears elapsed - ample time to read formin results. JAMA 217: 777, 1971 the Diabetes supplement in its entirety. Were pages 793 and 794 missing from [The author, of course, wrote this letter their copy? Had some plumbers stolen tongue-in-cheek and without malicious these two pages on a dark night in intent; he does not believe insulin is New Rochelle? dangerous.-Ed.i While pondering the possible reasons for the coverup of the lethal potential Carbohydrates and brain metabolism of insulin, I perused the UGDP report on phenformin2 and found another To the editor: When theories about the startling observation that had been role of carbohydrates in nutrition are carefully uncommented upon and un- under discussion, as in Dr. Muliner's publicized. The remarkable discovery letter "Carbohydrates, brain metabolthat no longer must remain hidden is ism and contraceptive-induced depresthat hyperglycemia control is respon- sion" (Can Med Assoc J 112: 1046, sible for the increased rate of cardio- 1975), it is always worth pondering vascular deaths. During the 4th year the diet of the Eskimo people. of the study (at exactly 4¾ years) the In the centuries when the Eskimos placebo group had a cumulative death lived undisturbed by the lifestyles of rate of 0% and the "mean fasting other races, there were some tribes who blood glucose value.., was 1 % higher ate very little carbohydrate; how much, than baseline", whereas the insulin- indeed, can anyone get from caribou, variable group had a cumulative rate seal and fish? If Dr. Mullner's theory of death due to cardiovascular disease is correct, then surely depression and of 4.6%, associated with a fasting affective disorders must have been rife blood glucose value "22% lower than among these tribes, whose diet conbaseline". The better the glycemia con- sisted almost entirely of protein and trol, the higher the risk of death. fat. This fact has always been a stumbThe reasoning of the UGDP people ling block for those who hold that carand their followers seems to be: as long bohydrates are essential. as there is a significant association beJ.D.H. ILas, MD, B CH tween the death rate in a group of dia7750 Bayview Ave. Thornhill, Ont. betics and the treatment to which they had been assigned, the treatment is automatically responsible for these To the editor: Until recently, medicine deaths (irrespective of the innumerable had not been practised much among instances of bias and flaws in design and the Eskimos and no one has recorded execution). The same reasoning should the incidence of affective disorders therefore be applied to insulin. Insulin among those who continued living in leads to more deaths due to cardio- the style of their ancestors. What is vascular disease after 4 years of treat- known, however, is that Eskimos had, ment, and does it by decreasing the and probably still have, the shortest average lifespan among humans. It is blood sugar concentration. also known that the native populations But no leaks occurred. No warnings of North America (Eskimos and Incame through the scientific or lay press. dians) have developed metabolic proAnd ever since this 1971 article was cesses substantially different from the published, diabetics have been peril- rest of us in respect of some specific ously exposed to glycemia control with enzymes. insulin. Washington Post: the Sugargate It is often overlooked that herbivora coverup is all yours now. Save the and omnivora, including caribou and diabetics from insulin. Open the secret seal, used as a source of protein for files of the UGDP and bring the Bio- humans have much glycogen in their metrics Society with you - they can muscles. but help reinforce the UGDP concluI suggest that there are valid reasons sions. And ask the FDA to impose the for nature supplying us with carbohylabelling of each bottle of insulin with drates in amounts that far exceed the the caution: "May increase risk of death due to cardiovascular disease amounts of proteins. Most, if not all, of our protein is derived from herbiafter 4 years of use." vora. In general, if man could, like bacteria, utilize any of the 79% nitroPiam BIRON, MD Professor of pharmacology gen in the atmosphere, he would not University of Montreal need to consume meat. However, he Montreal, Que.

would still need carbohydrates as a source of energy for synthesis and also as a part of the protein molecule. Just what happens when protein and fat metabolism proceeds in the absence of adequate and available carbohydrate reserves is clearly demonstrated in uncontrolled diabetes. J.W. MULLNER, MD, PH D

2824K Cedarwood Dr. Ottawa, Ont.

The Morgentaler case To the editor: I am gratified by the decision of the Canadian Medical Association General Council at its annual meeting in Calgary in June to reaffirm its position on Section 251 of the Criminal Code, requesting that the therapeutic abortion committee be abolished. However, I believe that the statement authorized by the Board of Directors after the meeting of General Council regarding our colleague Dr. Henry Morgentaler shows professional bias and unclear thinking tempered with extreme conservatism. While most segments of society seem able to separate the issues easily in this case, the Board of Directors has chosen to sidestep the injustice faced by Dr. Morgentaler and refuses to comment on the essence of the matter because it "does not have the expertise". The issue is not abortion, nor is it the mistreatment of a prisoner in jail. What disturbs any civil libertarian is the threat to our judicial system implicit in the Morgentaler case. The fact that anyone, for whatever charge, can be acquitted twice by a jury and still be in jail is hard to comprehend. The fact that the appeal courts overturned the jury's verdict and passed sentence without ordering a new trial is a threat to everyone's liberty. The fact that the section of the Criminal Code, a loophole invoked by the justices of the Supreme Court, has never before been invoked in Canadian legal history until the Morgentaler case smacks of persecution. And the fact that the CMA Board of Directors has refused to lend its support to our colleague who, all other issues aside, now finds himself facing yet another appeal by the Crown after a jury acquittal, is an example of total social and professional irresponsibility. Pama N. COLES, MD 266 Brunswick Ave. Toronto, Ont.

Teaching of ambulatory care To the editor: "Ambulatory archipelago" is a collection of material on the use of ambulatory care settings for the training of medical students and res-

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idents. This collection includes a review of the literature and a discussion of the proceedings and recommendations of a workshop organized to look at the development of ambulatory care teaching in pediatrics at the University of British Columbia. The workshop, held in April 1975, included family physicians, nurses and pediatricians who are involved in the training of health care workers and have experience in ambulatory care settings. Topics discussed included training in primary health care, use of community settings, specialty and subspecialty training and residency programs. Copies of the report are available from the undersigned. R. TONKIN, MD, CM, FRCP[C]

Department of pediatrics University of British Columbia 1144 Commercial Dr. Vancouver, BC V5L 3X2

Health guide for travellers

To the editor: In response to numerous requests from the medical profession and the public, the division of tropical medicine and international health of the Canadian Public Health Association has produced a booklet entitled "Health Guide for Travellers to Warm Climates". Although this booklet has been written primarily for the public, it has been found useful by physicians and public health workers who are called upon to give advice to the travelling public. It is now on sale in some pocketbook outlets or may be obtained for $1.95 from the undersigned. S.K.K. SEAN, MD Queen Mary Veterans Hospital 4565 Queen Mary Rd. Montreal, Que. H3W 1W5

Taplow: Ia fin d'une epoque

Monsieur le r.dacteur: En lisant la convocation pour le diner d'adieu du professeur E.G.L. Bywaters, directeur du Medical Research Council Rheumatism Unit, lors d'une visite r.cente au Canadian Red Cross Memorial Hospital de Taplow, Angleterre, nous ne pouvions nous emp.cher de penser que son d& part marque la fin d'une 6poque pour Taplow et qu'avant de passer . la suivante, on se doit d'en - commenter le m.rite et la grandeur. En juin 1947 le Canadian Red Cross Memorial Hospital ouvrait ses portes. Les locaux et l'6quipement de l'h6pital militaire canadien &aient donn.es . Ia nation anglaise par notre pays pour &re utilis.s "comme un centre national de recherche contre 1'arthrite chez les enfants". Durant 10 ans ce centre fonctionna comme un h6pital r6gional et une unite

de recherche en rhumatisme. C'est depuis 1958 qu'on l'a vu croitre Ct devefir grace . ses facilit.s cliniques et de laboratoire, et . la reconnaissance du MRC, une unit6 de reputation internationale dans l'6tude et le traitement du rhumatisme juvenile plus particuli.rement. Plus de 500 publications diff.rentes y ont . r.dig6es en 20 ans, r.fl6tant l'intensit. de l'effort de recherche accompli. L'enseignement dispens6 a vite d6pass6 le niveau national et ce centre a accuejili de tr&s nombreux "fellows" venus de tous les coins du monde travailler en clinique ou dans ses laboratoires. Plusieurs de nos coll.gues, boursiers de la Soci6t. Canadienne Contre l'Arthrite et le Rhumatisme, ont d'ailleurs eu ce privil.ge et ont rapport. au pays une qualit6 de formation qui a enrichi la rhumatologie canadienne. Depuis 1962 le docteur Barbara Ansell s'est jointe . l'.quipe m.dicale de Taplow et l'ampleur du travail qu'elle a accompli aupr.s des enfants rhumatisants n'a fait qu'accroitre la qualit. et la reputation de ce centre. On y est frapp6, non seulement par le haut niveau du savoir, mais encore par l'excellence des soins aux malades incluant m.me l'aspect psychosocial et scolaire puisque Taplow offre une 6cole . plein temps . ses enfants malades. L'effort scientifique medical et humain d.ploy6 . Taplow est d'un niveau remarquable qui a enrichi la recherche, J'enseignement et le soin aux malades dans le domaine des maladies rhumatismales. Les contingences administratives entraineront sans doute des changegements importants apr.s la retraite du professeur Bywaters mais nous savons que l'.quipe de Taplow n'a pas fini d'oeuvrer et que l'esprit de ce centre va continuer . vivre en Angleterre et, gr&ce . son rayonnement, dans plusieurs autres coins du monde. MONIQUE CAMERLAIN, MD, FRCP[C]

Universit. de Sherbrooke Unite des maladies rhumatismales Sherbrooke, Quo.

Medical licensing

To the editor: The writer of the report "Council on Medical Education learns English-language FMGs not always tops" (Can Med Assoc J 112: 1118, 1975) does not draw any unjustified conclusions from the figures quoted on the success rates of different groups in the LMCC examinations. He simply states the facts. However, I fear some readers may draw unjustified conclusions; indeed, I have seen unjustified comparisons published elsewhere. Anyone with a minimum knowledge of research methodology knows that a valid comparison between the performances

182 CMA JOURNAL/AUGUST 9, 1975/VOL. 113

of different groups cannot be made unless the populations are matched. Information on this requirement is not provided. The average Canadian student sitting for this examination does so at the end of his medical school training. This is the most appropriate and, from the candidate's point of view, probably the optimum point in his career to sit the examination. At this point he has been described as an "undifferentiated physician". In contrast, the foreign medical graduate is not necessarily at this point in his career and some are far removed from it. We are also not provided with information on this point. I am registered in two or three provinces in Canada without benefit of the LMCC. I qualified about 20 years ago. I have spent the last 10 years practising psychiatry and obtained the certification of the Royal College of Physicians and Surgeons of Canada in this specialty a few years ago. I am engaged in a busy practice and have limited time for continuing study. I am certain that if I had to sit the LMCC examinations next month my performance would be dismal. In fact, I am sure it would be much inferior to that of a young Canadian graduate who is finishing medical school this year. On the other hand, I would be surprised if it were much below that of any other Canadian psychiatrist who obtained his LMCC 20 years ago, has spent the last 10 years practising psychiatry, and is in general engaged in a busy practice. The main difficulty in making this comparison is that Canadian physicians in similar circumstances are not usually asked to resit the LMCC examinations and therefore no comparative figures exist. I do not believe that it would add much to the efficiency of my psychiatric practice for me to try to obtain the LMCC at this stage. If it is seriously held that this would be the case, I can only suggest that possibly those of my colleagues who are also certificated psychiatrists but hold Canadian medical degrees should also be urged to resit their LMCC examinations so that they too may be given the opportunity to brush up on such topics as obstetrics and gynecology and general surgery and thus achieve a higher standard of psychiatric practice throughout Canada. I am sure that in the future we shall see an increasing number of provincial licensing bodies requiring the LMCC as a prerequisite to licensing. I understand that the College of Physicians and Surgeons of Alberta is studying the feasibility of making this examination a prerequisite of any residency training in that province. I suspect that in many cases this will be used to serve political