interest rates paid on policies with profits; and look at the enormous buildings financed with money from the insurance companies - our money. We are supposed to be among the most intelligent members of the nation, but we allow ourselves to be taken for the biggest rides by many sorts of tricksters. Surely it is time for us to put our house in order. Does anyone really believe in the myth of the "busy physician"? We all know that there should be no such person as a physician who is too busy to look after his interests and those of his colleagues. We all know there is only the disorganized doctor; he who spends too much time in the hospital coffee room when he should be in his office or thinking about his own management. It was all very well when the profession was at the top of the tree; we all know that the figures for our incomes quoted by government and unions are false. They do not take into account the proper estimate of current expenses and are always at least 2 years out of date. At least our medical associations are trying to do something about this, but it seems to be. rather late. I would like to hear from all members of the medical and allied professions who agree with me and will join me in starting our own insurance company. I am sure that there will be many impediments put in our way and presented as reasons for it being impossible to have our own insurance scheme. However, there is no law preventing us from having our own insurance and trust company; only our lack of interest prevents it. I believe it is most important to us all to stop wasting our money. IvoR H. DuNLoP, MB, B5, LMCC 506 Chinook Professional Building Calgary, Alta.

Increased cyanide values in a Laetrile user To the editor: Considerable interest has been generated recently by the supposed benefits and hazards of Laetrile as an anticancer agent. Morse, Harrington and Heath1 have warned us of the possibility of cyanide poisoning due to the ingestion* of Laetrile - a warning lent credence by the recent death of a child in Buffalo of apparent cyanide poisoning following an overdose of

Laetrile. I report a case of nearsyncope associated with elevated cyanide values in a Laetrile user. A 69-year-old man had had a sarcoma of the left humerous diagnosed several years before I saw him. After removal of the left shoulder girdle, followed by lobectomy for pulmonary metastasis, a secondary lesion developed in the right lung. Apparently he was told that no further treatment was available, so he started taking Laetrile, obtained in Mexico. He had been taking this agent for a year when I first saw him, at which time his clinical condition appeared to be stable. The patient presented in the emergency room on two occasions because of episodes of weakness, light-headedness, palpitations and headaches of 5 to 10 minutes' duration. On each occasion he had taken twice his usual oral dose of Laetrile approximately 1 hour before his episode of weakness "to see what effect it would have". On both occasions, by the time he was brought from his rural home to the emergency room (approximately half an hour), he was asymptomatic and no abnormalities were seen on physical examination. Complete blood count and concentrations of serum electrolytes, lactate dehydrogenase and hydroxybutyrate dehydrogenase, and of blood glucose were normal and no abnormalities were seen on an electrocardiogram on the first visit. The cyanide value in a blood sample drawn on the second visit, approximately 2 hours after ingestion of the double dose of Laetrile, and processed by a forensic laboratory with extensive experience in this determination was 0.6 mg/dL. The patient was lost to follow-up about 6 months after the second episode. Normal values of cyanide in blood have been reported as being 0.01 to 0.02 mg/dL.' Values ranging from 0.02 to 0.75 mg/dL have been reported in cases of acute intoxication in patients with coma who have subsequently recovered,34 but the values in patients who have died have ranged from 0.26 to 3.1 mg/dL."6 No reference could be found to the kinetics of clearance of cyanide from the blood, and this patient's cyanide value when he was symptomatic can only be conjectured. Similarly, the relation between the patient's symptoms and his elevated cyanide values is strictly presumptive. However, it is noteworthy that his symptoms occurred only in association with the increased dose of Laetrile. The symptoms were reproduced with the patient's self-administered second dose,

18 CMA JOURNAL/JULY 8, 1978/VOL 119

at approximately the same time after ingestion, and they did not occur at any time before or after these two episodes. Although further investigation of this patient was not possible, I believe this report raises a number of questions worthy of consideration. DAvU M. MAXWELL, MI)

Emergency department McMaster University Medical Centre Hamilton, Ont.

References 1. MORSE DL, HARRINGTON JM, Hn.m CW: Laetrile, apricot pits, and cyanide poisoning (C). N Engi J Med 295: 1264, 1976 2. WALLACE JE, L..nD SL: Determination of drugs in biologic specimens. md Med Surg 39: 412, 1970 3. NAUGHTON M: Acute cyanide poisoning. Anaesth Intensive Care 2: 351, 1974 4. CURRY AS: Poison Detection in the Human Organs, 2nd ed, CC Thomas. Springfield, III, 1969 5. GETI'LER AG, BAINE JO: The toxicology of cyanide. Am J Med Sci 195: 182, 1938 6. HALS'rR0M F, M0LLER KG: The content of cyanide in human organs from cases of poisoning with cyanide taken by mouth, with a contribution to the toxicology of cyanides. Acta Pharmacol Toxicol (Kbh) 1: 18, 1945

Prevention or cure? To the editor: I find it sad that Elliott Emanuel feels so insecure and threatened by the movement to humanize medicine and is so out of touch with the realities of our modem industrialized society (Can Med Assoc 1 118: 111, 1978). His equating of patients with worshippers in his reference to "demystifying" medicine and religion leaves no doubt as to the role he sees himself in. Dr. Emanuel is, of course, par-

tially correct in stating that "the preventable causes of much current ill health are known to everyone". However, he is entirely wrong when he continues: "It is beyond the power of a physician to remove these causes. They reflect our society and will only be altered by changes in society that even governments seem powerless to bring about." The pre-

ventable causes of ill health are certainly not known to much of society, and the physician and the other members of the health care team

have a duty to bring this knowledge to the attention of society. If gov-

eminent cannot or will not act to stop or control the myriad antihealth activities that affect our lifestyle and our environment, then society must act alone and persuade governments to act on its behalf; the concerned physician must increasingly see his role as that of a catalyst and a guide in motivating society to understand the problems and demand action. Of course curative physicians will always be needed - though, to paraphrase Dr. Emanuel, the cure of one illness leaves us alive to incur another. It would be so much better if a lot more energy were focused on prevention, though I realize this might mean a little less work for a physician like Dr. Emanuel. I work in a community health centre and can assure Dr. Emanuel that I have not had to give half my time to lectures, or work without secretarial help, or hand out pamphlets from door to door; however, I would not consider it beneath my dignity to carry out some or all of these activities if I believed it would improve the health of my patients. As for Dr. Emanuel's absurd comments regarding using sick people as a means of revolutionary action, I can only assume that he still sees "Reds under every bed". A recent international study on health care stated: "There are no health problems without social values" and "Seen from the point of view of the physician, his unique concern for the problems of the individual patient before him should be but part of his concern for the needs and problems of entire populations, and the professional recognition that medicine has both individual and collective responsibilities."1 To attempt to improve society and thus reduce sickness may appear revolutionary to a few people such as Dr. Emanuel, but to many it is plain common sense. T. HANCOCK, MB, BS

Health service Lakeshore Area Multi-services Project Inc. Toronto, Ont.

Reference 1. Koin. R, WHITE KL (eds): Health Care: An International Study, Oxford U Pr, Fair Lawn, NJ, 1976, pp 3, 74 To the editor: I do not wish to enter a competition to decide who is the more humane or the more up to date. My editorial was written in the con-

text of Quebec, where a few years This was made obvious in the deago a cabinet minister was murdered scription of the use of a long-acting by revolutionaries and his body relaxant in the letter by Dr. N. Jackstuffed into the trunk of a car, and son (Can Med Assoc 1 118: 483, where a segment of the ruling party 1978). has open revolutionary aims. In EastIn these days of mechanical pumps ern Europe the work of poets, musi- it may be well to reflect that emercians, artists, and of course physi- gency situations can occur anywhere, cians has to serve the revolution. To and magnificent machinery and sutell people they are sick because of perlative specialists may not be availthe dirty rotten system under which able. Therefore, a good rule in anesthey live is to exploit them for revo- thesia is to administer no more of a lutionary aims. Physicians in Quebec drug than is absolutely necessary. have refused, almost unanimously, to Many surgeons are satisfied with the relaxation obtained by an amount of go along with this. relaxant that permits adequate, ELLIOTT EMANUEL, MD almost adequate, respiration. This or is 325 Dorval Ave., Ste. 201 Dorval, PQ what assisted respiration is all about. Management of the patient subjected to less than total paralysis may be The wondering, wandering more demanding. A sensitive hand patient on the rebreathing bag is more appropriate in the realm of assisted To the editor: Some people, through respiration than a mechanical pump. no fault or intent of their own, have Dr. Jackson reported an unusual no idea of their medical condition, and unexpected complication of enthe medication they are taking or dotracheal intubation. It is always even the name of their physician or difficult to discuss an accident behospital. Usually, somewhere, there cause there is an unavoidable eleis a well documented record of the ment of misgiving and concern. patient's medical history that includes Whether at a meeting, by way of a review of previous illnesses, sur- spoken reminiscence or in a written gery performed, complications, test report, a description of an accident results, roentgenographic findings, during surgery always provokes critiand recommendations for future pos- cism from the supermen who never sible developments. Such informa- have problems. tion, even if it includes only a physiRODNEY HOWKINS, MRCP, DA cian's telephone number or the name Bishop's House of a clinic, can save money and time Cuffley, Hertfordshire spent in repeated investigations. England I suggest that a simple booklet be provided to patients that includes their medical history. Some physi- Misuse of statistical terminology cians may claim that this would cause (correction) more paperwork, but the prospective Dr. R.C. Nair has pointed out that savings are enormous. Perhaps pa- the degrees and university position tients could be charged a fee for this appearing with his name at the end booklet. Such a solution would be of of his letter to the editor (Can Med great benefit to physicians confronted 1 118: 1206, 1978) are inwith a crisis when the necessary in- Assoc correct. We obtained this informaformation is somewhere other than tion, which unfortunately he did not in their office. supply with his letter, from one of A. HuRTIG, BA, MD, FRCS the institutions with which he is af150 Metcalfe St. filiated. His degrees are MStat, PhD, Ottawa, Ont. and he is an assistant professor with the department of epidemiology and community medicine at the UniverAssisted respiration sity of Ottawa. We urge our correspondents to To the editor: Assisted respiration has a place in the most up-to-date add routinely their degrees to their and orthodox anesthetic procedures, names (with judicious selection if the but it is not necessary to abolish list is long), for we prefer to publish spontaneous respiration to obtain ad- pertinent degrees in all bylines and vantage from long-acting relaxants. signatures.-Ed. CMA JOURNAL/JULY 8, 1978/VOL. 119 1.