nary metanephrine or renin-aldosterone studies were performed on all patients with hypertension, the cost of investigation alone would be prohibitive. For the majority of hypertensive patients, however, only a minimal laboratory work-up is needed. The cost: benefit ratio has been estimated as being 1:5. Financially, then, treating asymptomatic hypertension makes sense. The third point is the problem of inaccuracy of blood pressure measurement in a shopping centre. In our study the testing area was a quiet section closed off from the rest of the store. We took two readings 5 minutes apart, and the lowest of both the systolic and diastolic pressures were used as the final pressures. The individuals did not appear particularly tense, and the fact that our diastolic pressures averaged only 1.7 mm Hg more than those found in the physicians' offices seems to show that the tension produced in a shopping centre is no more severe than that produced in a doctor's office. Of those who had high blood pressure by our criteria, 75 % also had high blood pressure by the same criteria when they were examined by their physician; treatment was instituted in 41% of the persons who went to their physician. As screening tests go, an accuracy of 75 % does not seem unsatisfactory. The fourth point is whether health personnel should pursue "storefront" medicine at all, that is, set up to detect illness is places where people congregate. Chest radiography is done by mobile clinics, so why not blood pressure measurement? Although we agree it would be ideal to have everyone checked in his doctor's office, what is to be done for the substantial group of people who go for years without seeing a doctor, and whose blood pressures are very high? Should one wait for the occurrence of a stroke, pulmonary edema or uremic itching before starting treatment? If all allied health personnel such as pharmacists, blood bank technicians, emergency room nurses, occupational health nurses, surgeons, optometrists, dermatologists, dentists and podiatrists did blood pressure measurements on all the people they attend professionally, shopping centre screening or screening in "massage parlours or cocktail bars" would be unnecessary. Until that day comes we are forced to seek out ill people in less than ideal settings. Finally, we agree that the knowledge that they have hypertension may increase some people's anxiety about their health. One reason for anxiety, however, is ignorance and misunderstanding. How many persons with hypertension really understand what their condition means? The Harris survey
demonstrated that most hypertensive patients had a very poor understanding about their condition. Is it any wonder that they are anxious? Until people are treated as adults and given sufficient information, hypertension will continue to be an uncontrolled and misunderstood hazard in our communities. D. S. SILVERBERG, MD
University of Alberta Hospital Edmonton, Alta.
Therapeutic abortion To the editor: The letter of Dr. Wendell W. Watters (Can Med Assoc J 111: 900, 1974) commenting on the CMA policy on abortion presents cogent arguments for repeal of the present Canadian abortion law. It appears obvious that we shall never achieve consensus on which is the greater sin giving birth to an unwanted child or evacuating a uterus of an unwanted conceptus. There are, however, economic, medical and professional reasons for repealing the law. From the economic standpoint: Each year 40 000 abortions are required by law to be carried out in hospital, but the majority could be done on an outpatient basis at a saving of $300 per procedure or $12 000 000 annually for Canadian taxpayers. Is it not sensible to save health care dollars where possible? From the medical standpoint: Outpatient or office abortions under local anesthesia in the first trimester have proved safer than abortions performed in hospital. This has been documented in the United States by the Joint Program for the Study of Abortion, reporting from 66 institutions. Nosocomial infections, which are occasionally fatal, are avoided and modern office techniques under local anesthesia result in less blood loss; these factors account for the decreased morbidity and mortality as compared with the rates after abortions performed in hospital. From the professional standpoint: The uneven granting of abortion franchises in some public hospitals has not brought out the best in gynecologists carrying out this procedure. Some gynecologists have franchises in several hospitals; others have been refused a franchise to manage their patients. As a result, patients forced to seek an abortion elsewhere often encounter high surcharges payable in advance. They may also be subjected to "procedure escalation": hysterotomy, tubal ligation or hysterectomy is offered, even though these desperate women may wish to retain their fertility. It is also unfortunate that the present ritual is frequently an experience that induces anxiety and guilt and may require an
22 CMA JOURNAL/JANUARY 11, 1975/VOL. 112
Metamucil Prescribing Information INDICATIONS: For the relief of chronic, atonic, spastic and rectal constipation and for the constipation accompanying pregnancy, convalescence and advanced age. For use in special diets lacking in residue and as adjunctive therapy in the constipation of mucous and ulcerative colitis and diverticutitis. Also useful in the management of hemorrhoids and following anorectal surgery. CONTRAINDICATIONS: Presence of nausea, vomiting, abdominal pain or symptoms of an acute abdomen or fecal impaction. Metamucit Instant Mix is contraindicated in patients who must severely restrict their dietary sodium intake. PRECAUTIONS: For patients, such as those suffering from diabetes mettitus, where rigid dietary calorie control is required: Powder - 1 dose furnishes 14 calories. Instant Mix - 1 dose furnishes 3 calories. DOSAGE: Powder - one rounded teaspoonful of powder 1 to 3 times daily depending on the condition being treated, its severity and individual responsiveness. The teaspoonful of powder is stirred into an 8 oz. glass of cool water or other suitable liquid and should be taken immediately. Instant Mix - one packet 1 to 3 times daily depending on the condition being treated, its severity and individual responsiveness. The contents of the packet are poured into an 8 oz. glass to which cool water is then slowly added. The resulting effervescent mixture should be taken immediately. SUPPLIED: Powder - a refined, purified and concentrated vegetable mucittoid, prepared from the mucilaginous portion of Plantago ovata, combined with dextrose as a dispersing agent. Each rounded teaspoonful contains approximately 3.1 g of psyltium hydrophilic muciltoid per dose, a negligible amount of sodium, and furnishes 14 calories. Available in 6 and 12 oz. plastic bottles. Instant Mix - premeasured unit-dose packets. Each unit-dose packet contains 3.6 g of psyltium hydrophitic mucitloid with effervescent and flavouring excipients, 0.25 g of sodium as bicarbonate, and furnishes 3 calories. Available in boxes of 15 unit-dose packets.
NATURAL BOWEL MANAGEMENT THAT BENEFITS MANY KINDS OF PATIENTS. Complete prescribing information available on request (or in C.P.S.).
Searle Pharmaceuticals Oakvilte. Ontario
SURMONTL trim ipramine
Dosage - Oral route: ambulatory patients: 50 to 150 mg daily in 2 or 3 doses. Treatment to be initiated at lowest dosage, increased in a few days, then adjusted to lowest level required when response has been obtained. When insomnia is present, a larger portion of the dosage may be given at night. Hospitalized patients: 100 to 300 mg daily in 2 or 3 doses: occasionally up to 400 mg. Contraindications: glaucoma, prostatic hypertrophy, drug-induced ONS depression. Should not be associated with MAO inhibitors: a two-week delay is recommended before using the drug in patients having received an MAO inhibitor. Warnings: warn against engaging in activities requiring alertness until response is established. May potentiate alcohol and CNS depressants. Safety in pregnancy has not yet been established. Precautions: in elderly patients, in patients with cardiovascular problems or in those with a history of convulsive disorders: start treatment by the oral route with low doses, progressively increased - in ambulatory psychotic patients, if the drug aggravates psychotic manifestations or induces manic episodes: reduce dosage or discontinue therapy-in seriously depressed patients, because of the possibility of suicide at the beginning of treatment, close supervision should be exercised. Adverse reactions: the following have been reported: excitement, confusion, drowsiness (during initial therapy), insomnia, tremor, dystonia, epileptic seizures, dry mouth, blurred vision, urinary retention, constipation, nausea and vomiting, palpitations, orthostatic hypotension, quinidine-like reactions, changes in libido, weight gain, skin rash, obstructive jaundice. Supply: tablets: 12.5, 25, 50 and 100 mg, bottles of 50 and 500.
erroneous psychiatric labelling of the patient. Owing to opposition from those with vested interests in the status quo, the repeal of this bad Canadian law will not be easy but it will result in more economic, confidential, convenient and safer management of Canadian women. C. A. DOUGLAS RINGROSE, FRCS[C] 10830 Jasper Ave. Edmonton, Alta.
To the editor: In his letter commenting on CMA policy on abortion (Can Med Assoc J 111: 900, 1974) Dr. Wendell W. Watters uses the term "compulsory pregnancy". This term suggests that those who are opposed to abortion are motivated by a desire to punish the pregnant woman. The slogan is effective but I believe it is uncharitable and untrue. In the abortion debate the "pro-life" group are not as callous as Dr. Watters makes them out to be. Their stand is based on a real concern to preserve the unborn life, which, just as the mother, has a vital interest in the pregnancy. Even if one does not agree with their point of view one should credit them with having honourable intentions, and they in turn should credit those with views like Dr. Watters as being motivated by concern for the pregnant woman and not by a desire to destroy helpless babies to satisfy the whims of the mothers. I do not consider sound his analogy that physicians objecting to abortion can be compared to surgeons refusing to remove lung cancers as a strategy in the war against smoking. A cancer and a growing fetus are not comparable. The "pro-life" group is not composed of sadists. Although Dr. Watters presents his position as the rational one, I believe his objectivity is in doubt and that he has forfeited the right to this epithet. J. J. KRAYENHOFF, MD
References: 1. KRISTOF, F. E., et al.: Systematic studies with trimiprami ne - a new antidepressive drug. can. Psychiat. Assoc. J. 12:517-520, (Oct.) 1967. 2. DUNLEAvY, D. L. F., et al.: changes during weeks in effects of tricyclic drugs on the human sleeping brain. Brit. J. Psychiat. 120:663672, 1972. 3. MARSHALL, B.: The treatment of depression in general practice by a single-dose schedule. Practitioner, 206, 806-810, June 1971. 4. HUSSAIN, M. Z. and cHAUDHRY, Z. A.: Single versus divided daily dose of trimipramine in the treatment of depressive illness. Amer. J. Psychiat., 130, (10), 1142-44, Oct. 1973.
Full information upon request.
POuienc ,p
MEMBER
1120 Yates St. Victoria, B.C.
To the editor: As Mr. Geekie suggested in his reply to the comments of Dr. Watters on the CMA policy on abortion (Can Med Assoc J 111: 902, 1974), I have re-read his report and I cannot understand why he cannot see in his own report the specific frailties criticized by Dr. Watters. I suspect that the content of Mr. Geekie's report is a faithful description of the facts of the CMA policy, just as the spirit of the report reflects accurately the reluctance of the CMA to push vigorously for a more rational federal legislation on therapeutic abortion. This reluctance is not hard to understand since the CMA is composed of phys-
icians who hold strongly opposing opinions on the morality of therapeutic abortion. Consequently, it will be impossible to find a compromise that will satisfy all members of the association. But the matter simply cannot remain unresolved; if it does, we shall continue to dehumanize thousands of Canadian women each year, women whose only fault is that they are imperfect about as imperfect as our contraceptive technology. The most abused among these women are those who have the coincidental misfortune to live in communities with hospitals that have refused to establish abortion committees. If these women are desperate enough they may "seek the squalid and dangerous help of the back-street abortionist", particularly if they do not have the resources to seek their abortion outside Canada's boundaries. I believe that since therapeutic abortion is legal the CMA has a heavy responsibility to encourage even more strongly the establishment of at least one therapeutic abortion facility in all regions of Canada, Justice Minister Otto Lang's influence notwithstanding. But in the present circumstances this is not enough. The less unfortunate among these women are those who live near a hospital in which a therapeutic abortion committee is established and working. But even in these cases we continue to place these women on trial. A woman whose case is to be heard by the committee is in the humiliating and guilt-provoking position of having to tell her doctor what she thinks he and the committee need to hear in order to approve her request. In this distorted clinical situation we effectively deprive her of the opportunity to explore further with honesty and dignity why she could not have avoided the unwanted pregnancy in the first place. Instead, these women wish to have their abortion and run away from the doctors and hospitals where they have been tried. I suspect that many, if not most, hospitals do not have the humane and smoothly organized clinic described by Dr. Paul Mackenzie (Can Med Assoc 1 111: 667, 1974), and yet he could not follow up more than half of the patients in his series. What is wrong? What I believe is wrong is that an important, at times essential, and in some cases lifesaving, medical decision is contaminated by the stigma of the Criminal Code of Canada. Until a therapeutic abortion can be done with wisdom and good medical judgement by a competent physician, in an accredited hospital, under the supervision of the provincial governing 'body, without the stigma of the Criminal Code in the consulting room, we shall have little success
CMA JOURNAL/JANUARY 11, 1975/VOL. 112
25
demonstrated that most hypertensive patients had a very poor understanding about their condition. Is it any wonder that they are anxious? Until people are treated as adults and given sufficient information, hypertension will continue to be an uncontrolled and misunderstood hazard in our communities. D. S. SILVERBERG, MD
University of Alberta Hospital Edmonton, Alta.
Therapeutic abortion To the editor: The letter of Dr. Wendell W. Watters (Can Med Assoc J 111: 900, 1974) commenting on the CMA policy on abortion presents cogent arguments for repeal of the present Canadian abortion law. It appears obvious that we shall never achieve consensus on which is the greater sin giving birth to an unwanted child or evacuating a uterus of an unwanted conceptus. There are, however, economic, medical and professional reasons for repealing the law. From the economic standpoint: Each year 40 000 abortions are required by law to be carried out in hospital, but the majority could be done on an outpatient basis at a saving of $300 per procedure or $12 000 000 annually for Canadian taxpayers. Is it not sensible to save health care dollars where possible? From the medical standpoint: Outpatient or office abortions under local anesthesia in the first trimester have proved safer than abortions performed in hospital. This has been documented in the United States by the Joint Program for the Study of Abortion, reporting from 66 institutions. Nosocomial infections, which are occasionally fatal, are avoided and modern office techniques under local anesthesia result in less blood loss; these factors account for the decreased morbidity and mortality as compared with the rates after abortions performed in hospital. From the professional standpoint: The uneven granting of abortion franchises in some public hospitals has not brought out the best in gynecologists carrying out this procedure. Some gynecologists have franchises in several hospitals; others have been refused a franchise to manage their patients. As a result, patients forced to seek an abortion elsewhere often encounter high surcharges payable in advance. They may also be subjected to "procedure escalation": hysterotomy, tubal ligation or hysterectomy is offered, even though these desperate women may wish to retain their fertility. It is also unfortunate that the present ritual is frequently an experience that induces anxiety and guilt and may require an
22 CMA JOURNAL/JANUARY 11, 1975/VOL. 112
Metamucil Prescribing Information INDICATIONS: For the relief of chronic, atonic, spastic and rectal constipation and for the constipation accompanying pregnancy, convalescence and advanced age. For use in special diets lacking in residue and as adjunctive therapy in the constipation of mucous and ulcerative colitis and diverticutitis. Also useful in the management of hemorrhoids and following anorectal surgery. CONTRAINDICATIONS: Presence of nausea, vomiting, abdominal pain or symptoms of an acute abdomen or fecal impaction. Metamucit Instant Mix is contraindicated in patients who must severely restrict their dietary sodium intake. PRECAUTIONS: For patients, such as those suffering from diabetes mettitus, where rigid dietary calorie control is required: Powder - 1 dose furnishes 14 calories. Instant Mix - 1 dose furnishes 3 calories. DOSAGE: Powder - one rounded teaspoonful of powder 1 to 3 times daily depending on the condition being treated, its severity and individual responsiveness. The teaspoonful of powder is stirred into an 8 oz. glass of cool water or other suitable liquid and should be taken immediately. Instant Mix - one packet 1 to 3 times daily depending on the condition being treated, its severity and individual responsiveness. The contents of the packet are poured into an 8 oz. glass to which cool water is then slowly added. The resulting effervescent mixture should be taken immediately. SUPPLIED: Powder - a refined, purified and concentrated vegetable mucittoid, prepared from the mucilaginous portion of Plantago ovata, combined with dextrose as a dispersing agent. Each rounded teaspoonful contains approximately 3.1 g of psyltium hydrophilic muciltoid per dose, a negligible amount of sodium, and furnishes 14 calories. Available in 6 and 12 oz. plastic bottles. Instant Mix - premeasured unit-dose packets. Each unit-dose packet contains 3.6 g of psyltium hydrophitic mucitloid with effervescent and flavouring excipients, 0.25 g of sodium as bicarbonate, and furnishes 3 calories. Available in boxes of 15 unit-dose packets.
NATURAL BOWEL MANAGEMENT THAT BENEFITS MANY KINDS OF PATIENTS. Complete prescribing information available on request (or in C.P.S.).
Searle Pharmaceuticals Oakvilte. Ontario
SURMONTL trim ipramine
Dosage - Oral route: ambulatory patients: 50 to 150 mg daily in 2 or 3 doses. Treatment to be initiated at lowest dosage, increased in a few days, then adjusted to lowest level required when response has been obtained. When insomnia is present, a larger portion of the dosage may be given at night. Hospitalized patients: 100 to 300 mg daily in 2 or 3 doses: occasionally up to 400 mg. Contraindications: glaucoma, prostatic hypertrophy, drug-induced ONS depression. Should not be associated with MAO inhibitors: a two-week delay is recommended before using the drug in patients having received an MAO inhibitor. Warnings: warn against engaging in activities requiring alertness until response is established. May potentiate alcohol and CNS depressants. Safety in pregnancy has not yet been established. Precautions: in elderly patients, in patients with cardiovascular problems or in those with a history of convulsive disorders: start treatment by the oral route with low doses, progressively increased - in ambulatory psychotic patients, if the drug aggravates psychotic manifestations or induces manic episodes: reduce dosage or discontinue therapy-in seriously depressed patients, because of the possibility of suicide at the beginning of treatment, close supervision should be exercised. Adverse reactions: the following have been reported: excitement, confusion, drowsiness (during initial therapy), insomnia, tremor, dystonia, epileptic seizures, dry mouth, blurred vision, urinary retention, constipation, nausea and vomiting, palpitations, orthostatic hypotension, quinidine-like reactions, changes in libido, weight gain, skin rash, obstructive jaundice. Supply: tablets: 12.5, 25, 50 and 100 mg, bottles of 50 and 500.
erroneous psychiatric labelling of the patient. Owing to opposition from those with vested interests in the status quo, the repeal of this bad Canadian law will not be easy but it will result in more economic, confidential, convenient and safer management of Canadian women. C. A. DOUGLAS RINGROSE, FRCS[C] 10830 Jasper Ave. Edmonton, Alta.
To the editor: In his letter commenting on CMA policy on abortion (Can Med Assoc J 111: 900, 1974) Dr. Wendell W. Watters uses the term "compulsory pregnancy". This term suggests that those who are opposed to abortion are motivated by a desire to punish the pregnant woman. The slogan is effective but I believe it is uncharitable and untrue. In the abortion debate the "pro-life" group are not as callous as Dr. Watters makes them out to be. Their stand is based on a real concern to preserve the unborn life, which, just as the mother, has a vital interest in the pregnancy. Even if one does not agree with their point of view one should credit them with having honourable intentions, and they in turn should credit those with views like Dr. Watters as being motivated by concern for the pregnant woman and not by a desire to destroy helpless babies to satisfy the whims of the mothers. I do not consider sound his analogy that physicians objecting to abortion can be compared to surgeons refusing to remove lung cancers as a strategy in the war against smoking. A cancer and a growing fetus are not comparable. The "pro-life" group is not composed of sadists. Although Dr. Watters presents his position as the rational one, I believe his objectivity is in doubt and that he has forfeited the right to this epithet. J. J. KRAYENHOFF, MD
References: 1. KRISTOF, F. E., et al.: Systematic studies with trimiprami ne - a new antidepressive drug. can. Psychiat. Assoc. J. 12:517-520, (Oct.) 1967. 2. DUNLEAvY, D. L. F., et al.: changes during weeks in effects of tricyclic drugs on the human sleeping brain. Brit. J. Psychiat. 120:663672, 1972. 3. MARSHALL, B.: The treatment of depression in general practice by a single-dose schedule. Practitioner, 206, 806-810, June 1971. 4. HUSSAIN, M. Z. and cHAUDHRY, Z. A.: Single versus divided daily dose of trimipramine in the treatment of depressive illness. Amer. J. Psychiat., 130, (10), 1142-44, Oct. 1973.
Full information upon request.
POuienc ,p
MEMBER
1120 Yates St. Victoria, B.C.
To the editor: As Mr. Geekie suggested in his reply to the comments of Dr. Watters on the CMA policy on abortion (Can Med Assoc J 111: 902, 1974), I have re-read his report and I cannot understand why he cannot see in his own report the specific frailties criticized by Dr. Watters. I suspect that the content of Mr. Geekie's report is a faithful description of the facts of the CMA policy, just as the spirit of the report reflects accurately the reluctance of the CMA to push vigorously for a more rational federal legislation on therapeutic abortion. This reluctance is not hard to understand since the CMA is composed of phys-
icians who hold strongly opposing opinions on the morality of therapeutic abortion. Consequently, it will be impossible to find a compromise that will satisfy all members of the association. But the matter simply cannot remain unresolved; if it does, we shall continue to dehumanize thousands of Canadian women each year, women whose only fault is that they are imperfect about as imperfect as our contraceptive technology. The most abused among these women are those who have the coincidental misfortune to live in communities with hospitals that have refused to establish abortion committees. If these women are desperate enough they may "seek the squalid and dangerous help of the back-street abortionist", particularly if they do not have the resources to seek their abortion outside Canada's boundaries. I believe that since therapeutic abortion is legal the CMA has a heavy responsibility to encourage even more strongly the establishment of at least one therapeutic abortion facility in all regions of Canada, Justice Minister Otto Lang's influence notwithstanding. But in the present circumstances this is not enough. The less unfortunate among these women are those who live near a hospital in which a therapeutic abortion committee is established and working. But even in these cases we continue to place these women on trial. A woman whose case is to be heard by the committee is in the humiliating and guilt-provoking position of having to tell her doctor what she thinks he and the committee need to hear in order to approve her request. In this distorted clinical situation we effectively deprive her of the opportunity to explore further with honesty and dignity why she could not have avoided the unwanted pregnancy in the first place. Instead, these women wish to have their abortion and run away from the doctors and hospitals where they have been tried. I suspect that many, if not most, hospitals do not have the humane and smoothly organized clinic described by Dr. Paul Mackenzie (Can Med Assoc 1 111: 667, 1974), and yet he could not follow up more than half of the patients in his series. What is wrong? What I believe is wrong is that an important, at times essential, and in some cases lifesaving, medical decision is contaminated by the stigma of the Criminal Code of Canada. Until a therapeutic abortion can be done with wisdom and good medical judgement by a competent physician, in an accredited hospital, under the supervision of the provincial governing 'body, without the stigma of the Criminal Code in the consulting room, we shall have little success
CMA JOURNAL/JANUARY 11, 1975/VOL. 112
25
