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we physicians feared rebuff, we have failed to offer our services to the school systems. And, we have missed opportunities (as did the IMA House of Delegates) to inform and influence our legislators, possibly under the misapprehension that it might be politically inopportune. Yet, this did not deter our California colleagues. It is also probable that we, as individual physicians, have reneged on our responsibilities in this one area of preventive medicine, either because we felt unqualified by lack of learning, or because we were not comfortable in dealing with this sensitive subject. That excuse is no longer valid. Excellent courses are now everywhere available so that any of us can acquire a good working knowledge in human sexuality. And with knowledge we attain confidence and comfort. Late word from Washington, DC, indicates that the Senate Human Resources Committee is marking up S2910, the "Adolescent Health Services and Pregnancy Prevention and Care Act." The stated purpose of S2910 is "to reduce unwanted initial and repeat pregnancies among teenage girls." What a pity we have to run to Washington for help when we can do a better job here at home. No one expects us to effect a total cure of all teenage sex-related problems, but there is every indication that parents, churches, legislators, even educators, are looking to the medical profession to pick up our share of the responsibility. We hear loud cries for "health prevention" and "cost containment" from the politicians. Where can we make a better start than with the teenagers of America? E. R. W. FOX, MD Special Editor for Idaho Coeur d'Alene, Idaho

Psychiatry and Psychotherapy TO THE EDITOR: Contrary to Friedmann's argument (West J Med 129:156-159, Aug 1978) that psychiatry might leave the psychotherapeutic treatment of the severely disturbed in the hands of nonmedically trained psychotherapists, it seems more likely that nonmedical psychotherapists will have little or no role in the care of these patients as practical therapeutic applications are developed from recent advances in neurobiology. Psychiatry today is at the threshold of a scientific revolution similar to medicine's experience in the late 19th century when the foundations for scientific medicine based upon bacteriology, bio-

logical chemistry and the systematic examination of diseased tissues were being discovered. Like psychiatry today, medicine then was divided along ideological lines; the various camps saw themselves as the respositories of the eternal verities of the healing process. With the spreading acceptance of an empirical approach to diagnosis and treatment, these ideological schools withered; the result is the medicine practiced today. The significant finding of this early period in the emergence of scientific psychiatry is that the causes of the major mental disturbances are more complex than the total psychological explanations offered by the ideological schools. Neurobiology suggests significant genetic and biochemical implications. The understanding of these disturbances is further complicated by the tendency of the manifestations of these illnesses to be profoundly susceptible to coloring by the characteristics of the surrounding culture, and perhaps to the effects of current psychotherapeutic modalities and the welfare schemes designated to assist these sufferers. The shift towards scientific psychiatry has changed the conception of what constitutes ideal treatment for the severely disturbed. Until about 20 years ago, the ideal was psychoanalysis in which patients were seen in individual treatment several times weekly. Medication was rarely used, symptomatic relief by medication being perceived as inimical to the healing process theorized to occur by insight. This system gave way to the present conception which combines psychotherapy with medication. Neither of these approaches has consistently led to fundamental cures in most patients with severe mental illness. The advantage of the newer combined method is a reduction for many patients in social pathology such that many can lead relatively independent lives free of the burdens of long-term hospital stays. The current system appears to be a compromise while awaiting definitive treatments. Because the monetary costs of these labor- and capital-intensive current treatments are extremely high, their. future usefulness may depend more upon the national economic health than upon clinical outcomes. Within the context of the emergence of scientific psychiatry, the fate of nonmedically trained psychotherapists might be the same as the physician ideologues of the late 19th century who were rendered obsolete by the march of medical progTHE WESTERN JOURNAL OF MEDICINE

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ress. At the present primitive state of psychiatric knowledge, nonmedical psychotherapists might appear the relative equals of psychiatric physicians in the practice of psychotherapy. The same comparison could have been made between the first scientifically trained physicians and their ideological counterparts in the early days of modern medicine. Neither had much to offer patients aside from ineffective nostrums and bedside psychotherapy. The arrival of pathophysiological diagnosis and effective pharmacology caused the obsolesence of the physician ideologues and their schools. With no knowledge of scientific medicine, nor even the tools to learn it, they had little to offer but psychotherapy. However, a scientific physician was able to use psychotherapy in its most effective form, as a vehicle to gain his patient's cooperation to accept definitive treatment for hitherto untreatable diseases. Similarly, nonmedical psychotherapists are likely to go the way of physician ideologues of the last century as the promise of definitive medical treatments for the severe mental disturbances is met. MARK I. KLEIN, MD Berkeley, California

Charter Tour Difficulties TO THE EDITOR: The Medical Society of Santa Barbara County, California, is having difficulty recouping travel deposits from an Ontario, Canada, consumer protection fund, and we would like to let other physicians realize our dilemma. We have been trying for more than 18 months to recover almost $88,000 lost when an Ottawa firm, Professional Seminar Consultants, Ltd. (Psc, Ltd.) defaulted on a charter tour of the Soviet Union. Our medical society and three other professional groups have sued the Ontario Travel Industry Compensation Fund which rejected 96 American claims totaling $187,750 but approved claims of Canadian consumers against PSC, Ltd. for $150,000. The matter is now pending before the Ontario Commercial Registration Appeals Tribunal, with a decision expected by winter. The Canadian licensing and investigatory authorities have refused to comment on the reasons for the thrice delayed denial of United States consumers' claims. We have attempted to apply pressure at the ambassadorial level with little success. At the request of Senator Alan Cranston, the Consulate General of the United States discussed the claims with the Registrar of the Travel

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Industry Act. The Registrar said that the Travel Industry Compensation Fund and its Board of Trustees' decisions are completely independent of the Government of Ontario and out of its control. Meanwhile, there are 150 Californians, almost half from the tour sponsored by our Society, who are still out their monies. Our Society and its tour participants were assured that services were insured by the Travel Industry Compensation Fund. We find need for litigation appalling. LEONARD A. PRICE, MD President Medical Society of Santa Barbara County Santa Barbara, California

'Speed' and Hematuria TO THE EDITOR: Emergency room patients with microscopic hematuria and flank pain but no demonstrable renal stone are often suspected of seeking narcotics. An interesting, and potentially lethal, variation was seen at Kaiser Hospital, Hayward, California, recently. A 21-year-old man came to the emergency room complaining of 24 to 48 hours of dull right flank pain. Analysis of urine showed no leukocytes or bacteria, but the specimen was "loaded" with red blood cells. Findings on intravenous pyelogram (IvP) were normal. Physical examination showed no abnormalities. Subsequent laboratory data showed a prothrombin time of 49 seconds (control 12.3); partial thromboplastin time, 48 seconds (control 34.9); platelets, 319, 000 per cu mm; hematocrit, 42 percent; creatinine, 1 mg per dl; serum glutamic oxaloacetic transaminase (SGOT), 30 units. There was no family or personal history of bleeding problems; the patient had had a tonsillectomy and hernia correction without incident. There was no history of renal or hepatic disease. The patient did have a new job, worked the graveyard shift and was using "speed," bought on the street, to stay awake. His girlfriend brought in the "speed," then identified as 10 mg Panwarfin® (warfarin sodium) (white tab with Abbott insignia). Sold Panwarfin as an "upper," he had been ingesting 30 mg a day for the previous three to four days. Treatment with vitamin K1 corrected the laboratory abnormalities. In view of this experience, perhaps prothrombin time should be checked to rule out unsuspected anticoagulant ingestion in all patients in whom findings on an IVP are normal, hematuria is present and use of street drugs is suspected. BRUCE FRANKLIN, MD Hayward, California

Psychiatry and psychotherapy.

CORRESPONDENCE we physicians feared rebuff, we have failed to offer our services to the school systems. And, we have missed opportunities (as did the...
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