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
developing programs of education and family planning, in spite of the best intentions and exhortations of the CMA. Until then, many troubled Canadian women will not seek the help and understanding of their physician until the remorseless progress of an unwanted pregnancy forces it upon them. Some of Mr. Geekie's confr.res may be tired and bored by the debate. They are free to sit on the sidelines. But the CMA General Council has recommended that all reference to the abortion committee be deleted from the Criminal Code of Canada. Excellent! Now is the time to regain the energy and courage necessary to convince our federal legislators of the wisdom of this recommendation. BRUCE GJBBARD, MD, FRCP[C]
Department of psychiatry McGill University Montr6al, Que.
To the editor: The history of the Nazi era reminds us of the tendency in man to abuse and enslave his brothers. The process is simple. One merely convinces oneself that one is superior and therefore entitled to dominate the lives of others. By a ruthless philosophy humans were segregated into superior and inferior groups. The inferior group was subdivided into useful and useless sections. People in the useless section were killed. The German medical profession cooperated with Hitler. Psychiatrists reversed their historical role and passed death sentences. It became a matter of routine. The whole undertaking was described by various euphemisms: help for the dying, mercy deaths, mercy killings, destruction of life devoid of value, mercy action. They all became fused into the sonorous and misleading term "euthanasia". In reality these mass killings were not mercy deaths but merciless murders. The most reliable estimate of the number of psychiatric patients killed is 275 000. The indications became wider and eventually included superfluous people, the unfit, the unproductive, and useless eaters. Finally many children and elderly people were included. Doctors took an active part and were soon willing to participate in the mass killings in the concentration camps. As a result of postwar hardships and the subsequent depression, abortion on demand or for nonmedical socioeconomic reasons had been available in Germany since the end of World War I. Since Parliament freed their hand in 1969, Canadian doctors have performed approximately 150 000 abortions. They are acting freely and voluntarily. I do not believe that their actions can be defended by moral men. It is true that
there are good men among them, men who are motivated by the highest ideals, but as a social group I view them as mass killers. In only 5 years they have learned and practised the art of mass destruction. What will the future hold for us? HEIKO BAUNEMANN, FRCSfC]
123 Whalen St. Thunder Bay, Ont.
Composition of General Council To the editor: The continuing push for abortion on demand and the 1971 decision (narrow) of CMA General Council regarding the deliberate termination of pregnancy lead me to request that the composition of General Council be set out briefly for the benefit of all CMA members. As I recall, there is a large component of General Council that represents the various affiliated organizations, special interest groups such as the Health League of Canada, the Canadian Arthritis & Rheumatism Society, etc. If this is true, disproportionate representation is being given to those members of the association who are politically active in these groups, as compared with those of us who are politically active in our provincial medical associations and their branches. J. W. MCGILLIVRAY, FRCS(C]
270 Peel St. Collingwood, Ont.
[The 1974 CMA General Council membership was composed of some 250 members of the association. Over two thirds of General Council, 170 members, were representatives of provincial divisions. Twenty-four were members of the CMA Board of Directors or chairmen of statutory CMA councils or committees. Thirty were representatives of affiliated societies, primarily medical specialty bodies such as the Canadian Association of Radiologists and the Canadian Academy of Sports Medicine. Medical-lay bodies such as those mentioned by Dr. McGillivray are classified as associated societies and are not eligible to have a voting representative at General Council. In addition there were 21 individuals who, by virtue of having held office in the CMA (past-presidents, etc.), were members of General Council. The remaining three members were the surgeon general of the Canadian Armed Forces, the director general of the treatment services branch of the Department of Veteran Affairs and the deputy minister of national health, Health and Welfare Canada. - Ed.]
Postgraduate clinical education
To the editor: In the summary to their article "Postgraduate clinical education - the Canadian experience (Can Med Assoc J 111: 813, 1974) Mueller and Ames make the statement "from the 1960 cohort 65% chose" a specialist career, and they note that, by the end of 1972, approximately 50% of the 1970 cohort had made a similar choice. They see this as a "diminishing trend toward specialty practice". Viewing percentages is often misleading, especially when the absolute figures for available positions for postgraduate training are not given. Such training positions have not increased in number at the same rate as the production of medical graduates in the 10 years referred to; Fiscal pressures, usually applied by provincial governments, have limited (and in some areas decreased) the available postgraduate training positions. Thus, the choice is not a simple matter to the postgraduate of "What do I want to do?" as much as it is "Where might I be accepted in a training position acceptable to me, in order to do what I want to do?" Despite the "continuing strong motivation for specialty practice" noted by the authors, there can be no alternative to a continuing diminishing trend, as viewed by percentages, as medical school enrolments increase and numbers of postgraduate training posts remain static or decline (which they must do as further cuts in numbers of hospital beds occur -- the present problem in Ontario). As choices become more limited in Canada, and as the Royal College gradually refuses to accept training completed in the United States and elsewhere, I believe it is safe to predict an acute shortage of specialists, probably about 10 years from now. F. W. DANBY, MD, FRCP(CJ
253 Ontario St. Kingston, Ont.
Of meetings To the editor: The Journal is fortunate that it has readers with a classical eye as sharp as Dr. Perl's (Can Med Assoc J 111: 641, 1974). Indeed it was my spelling that let me down. Desipere I meant and dissipere I wrote. The slip may have been freudian. For me, the gloom of A. D. Kelly's "Verbum sapientibus" in the same issue (page 650) was lightened by the evidence that there are still classical scholars like Dr. Perl alive and well and living in Canada. KENNETH M. LEIGHTON,
MB
3227 West 28th Ave. Vancouver, B.C.
GMA JOURNAL/JANUARY 11, 1975/VOL. 112 27
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
developing programs of education and family planning, in spite of the best intentions and exhortations of the CMA. Until then, many troubled Canadian women will not seek the help and understanding of their physician until the remorseless progress of an unwanted pregnancy forces it upon them. Some of Mr. Geekie's confr.res may be tired and bored by the debate. They are free to sit on the sidelines. But the CMA General Council has recommended that all reference to the abortion committee be deleted from the Criminal Code of Canada. Excellent! Now is the time to regain the energy and courage necessary to convince our federal legislators of the wisdom of this recommendation. BRUCE GJBBARD, MD, FRCP[C]
Department of psychiatry McGill University Montr6al, Que.
To the editor: The history of the Nazi era reminds us of the tendency in man to abuse and enslave his brothers. The process is simple. One merely convinces oneself that one is superior and therefore entitled to dominate the lives of others. By a ruthless philosophy humans were segregated into superior and inferior groups. The inferior group was subdivided into useful and useless sections. People in the useless section were killed. The German medical profession cooperated with Hitler. Psychiatrists reversed their historical role and passed death sentences. It became a matter of routine. The whole undertaking was described by various euphemisms: help for the dying, mercy deaths, mercy killings, destruction of life devoid of value, mercy action. They all became fused into the sonorous and misleading term "euthanasia". In reality these mass killings were not mercy deaths but merciless murders. The most reliable estimate of the number of psychiatric patients killed is 275 000. The indications became wider and eventually included superfluous people, the unfit, the unproductive, and useless eaters. Finally many children and elderly people were included. Doctors took an active part and were soon willing to participate in the mass killings in the concentration camps. As a result of postwar hardships and the subsequent depression, abortion on demand or for nonmedical socioeconomic reasons had been available in Germany since the end of World War I. Since Parliament freed their hand in 1969, Canadian doctors have performed approximately 150 000 abortions. They are acting freely and voluntarily. I do not believe that their actions can be defended by moral men. It is true that
there are good men among them, men who are motivated by the highest ideals, but as a social group I view them as mass killers. In only 5 years they have learned and practised the art of mass destruction. What will the future hold for us? HEIKO BAUNEMANN, FRCSfC]
123 Whalen St. Thunder Bay, Ont.
Composition of General Council To the editor: The continuing push for abortion on demand and the 1971 decision (narrow) of CMA General Council regarding the deliberate termination of pregnancy lead me to request that the composition of General Council be set out briefly for the benefit of all CMA members. As I recall, there is a large component of General Council that represents the various affiliated organizations, special interest groups such as the Health League of Canada, the Canadian Arthritis & Rheumatism Society, etc. If this is true, disproportionate representation is being given to those members of the association who are politically active in these groups, as compared with those of us who are politically active in our provincial medical associations and their branches. J. W. MCGILLIVRAY, FRCS(C]
270 Peel St. Collingwood, Ont.
[The 1974 CMA General Council membership was composed of some 250 members of the association. Over two thirds of General Council, 170 members, were representatives of provincial divisions. Twenty-four were members of the CMA Board of Directors or chairmen of statutory CMA councils or committees. Thirty were representatives of affiliated societies, primarily medical specialty bodies such as the Canadian Association of Radiologists and the Canadian Academy of Sports Medicine. Medical-lay bodies such as those mentioned by Dr. McGillivray are classified as associated societies and are not eligible to have a voting representative at General Council. In addition there were 21 individuals who, by virtue of having held office in the CMA (past-presidents, etc.), were members of General Council. The remaining three members were the surgeon general of the Canadian Armed Forces, the director general of the treatment services branch of the Department of Veteran Affairs and the deputy minister of national health, Health and Welfare Canada. - Ed.]
Postgraduate clinical education
To the editor: In the summary to their article "Postgraduate clinical education - the Canadian experience (Can Med Assoc J 111: 813, 1974) Mueller and Ames make the statement "from the 1960 cohort 65% chose" a specialist career, and they note that, by the end of 1972, approximately 50% of the 1970 cohort had made a similar choice. They see this as a "diminishing trend toward specialty practice". Viewing percentages is often misleading, especially when the absolute figures for available positions for postgraduate training are not given. Such training positions have not increased in number at the same rate as the production of medical graduates in the 10 years referred to; Fiscal pressures, usually applied by provincial governments, have limited (and in some areas decreased) the available postgraduate training positions. Thus, the choice is not a simple matter to the postgraduate of "What do I want to do?" as much as it is "Where might I be accepted in a training position acceptable to me, in order to do what I want to do?" Despite the "continuing strong motivation for specialty practice" noted by the authors, there can be no alternative to a continuing diminishing trend, as viewed by percentages, as medical school enrolments increase and numbers of postgraduate training posts remain static or decline (which they must do as further cuts in numbers of hospital beds occur -- the present problem in Ontario). As choices become more limited in Canada, and as the Royal College gradually refuses to accept training completed in the United States and elsewhere, I believe it is safe to predict an acute shortage of specialists, probably about 10 years from now. F. W. DANBY, MD, FRCP(CJ
253 Ontario St. Kingston, Ont.
Of meetings To the editor: The Journal is fortunate that it has readers with a classical eye as sharp as Dr. Perl's (Can Med Assoc J 111: 641, 1974). Indeed it was my spelling that let me down. Desipere I meant and dissipere I wrote. The slip may have been freudian. For me, the gloom of A. D. Kelly's "Verbum sapientibus" in the same issue (page 650) was lightened by the evidence that there are still classical scholars like Dr. Perl alive and well and living in Canada. KENNETH M. LEIGHTON,
MB
3227 West 28th Ave. Vancouver, B.C.
GMA JOURNAL/JANUARY 11, 1975/VOL. 112 27
