the general hospital..7 As proposed by Flannery and demonstrated by Spaulding,8 general internists with appropriate psychiatric and psychosomatic training function more effectively in this role. How would they best receive this training? While Hollenberg and Langley suggest "that the trainee in general internal medicine might spend an elective period in psychiatry, particularly in ambulatory care and consultation", an alternative is for the liaison psychiatrist to teach medical residents on the medical service to which he is also assigned. Several studies have shown the high prevalence of psychopathologic disorders and emotional distress among medical patients and the low referral rate for psychiatric consultation.9'10 Integrated teaching in the medical setting therefore provides access to a wider range of mixed medicalpsychiatric disorders than is generally seen in a department of psychiatry, and the psychosocial dimensions of illness are also better observed. Along these.lines innovative training programs for primary care physicians have been developed at the Boston City Hospital.11 Hamerman12 recently outlined an integrated clinical and educational program for medical house staff and attendings at the Montefiore Hospital. In Japan comprehensive psychosomatic training for internists exists at the university level.13 It is essential that Canadian universities and the Royal College of Physicians and Surgeons of Canada develop similar integrated programs for training general internists if they are to practise holistic medicine as consultants and providers of primary or continuing care or both.
5. ABRAM HS: Primary care and consultation-liaison psychiatry (E). J Nerv Ment Dis 164: 301, 1977 6. FLANNERY JG: Psychosomatic medicine in a general hospital: some dilemmas. Can Med Assoc J 114: 665, 1976 7. TAYLOR GJ: The mind-body dichotomy. Psychosomatics (in press) 8. SPAULDING WB: The psychosomatic approach in the practice of medicine. mt J Psychiatry Med 6:169, 1975 9. Lipowsiu ZJ: Psychiatry of somatic diseases: epidemiology, pathogenesis, classification. Compr Psychiatry 16: 105, 1975 10. MAGUIRE GP, JULIER DL, HAWTON JH, et al: Psychiatric morbidity and referral on two general medical wards. Br Med 1 1: 268, 1974 11. LAZERSON AM: The psychiatrist in primary medical care training: a solution to the mind-body dichotomy? Am J Psychiatry 133: 964, 1976 12. HAMERMAN D: Psychological care of the medically ill: a primer in liaison psychiatry (C). Psychosom Med 39: 370, 1977 13. IKEMI Y, Aoxi H: Comprehensive psychosomatic training for internists. Dynamic Psychiatry 9: 287, 1976
chiatrist's evolving role in medicine. 2. ENGEL GL: The need for a new medical model: a challenge for biomedicine. Science 196: 129, 1977
3. EISENBERG L: Disease and illness. Culture Med Psychiatry 1: 9, 1977 4. ILLICH I: Medical Nemesis; the Expropriation of Health, Penguin, London, 1976
1. ROBINSON DR, Si4um H, MCGUIRE MB, et al: Prostaglandin synthesis by rheumatoid synovium and its stimulation by coichicine. Prostaglandins 10: 67, 1975
2. HORROBIN DF, KARiW.i RA, M.Nxcu MS, et al: Systemic lupus erythematosus: a disease of thromboxane A2 synthesis and action. IRCS J Med Sci 5: 547, 1977
Insurance and the medical profession
To the editor: There are approximately 29 000 medical practitioners in Canada with disability, life, office overhead, accident, car and home insurance. Many are also paying annual premiums for their dependants' coverage to a company that does not have their true interests at heart. We all know that insurance companies are obliged to abide by the rules set for them, but the very fact that they need these rules is an indication that the companies had to be controlled at some time because Coichicine therapy of their unreasonable profits. Of To the editor: I was interested in the course the primary endeavour of all
recent report of the use of coichicine in the treatment of familial Mediterranean fever by Skrinkas and colleagues (Can Med Assoc J 117: 1416, 1977). My group has recently demonstrated that, although moderate doses of colchicine stimulate prostaglandin synthesis,1 low doses of the drug seem to stimulate thromboxane A2 production selectively and to inhibit production of other prostaglandins.1 Thromboxane A2 is a product of the arachidonic acid pathway of prostaglandin metabolism and we have proposed that it is the key substance exerting feedback inhibition over the pathway.2 If thromboxane production fails, prostaglandins A2 GRAEME J. TAYLOR, MB, CII B, MRC PSYCH, produced in massive excess; we are FRcP[c] Head, consultation-liaison service suggest this is what is happening in Mount Sinai Hospital systemic lupus erythematosus. SevToronto, Ont. eral of the features of familial Mediterranean fever, including fever, abReferences dominal pain and polyserositis, could 1. LEIGH H, RFISER ME: Major trends be attributed to an excess of prosin psychosomatic medicine. The psyAnn Intern Med 87: 233, 1977
References
taglandin. If such an excess were due
to a failure of normal synthesis of thromboxane A2, then colchicine might increase the synthesis of thromboxane A2 and so inhibit overproduction of other prostaglandins. D.F. HORROBIN, MA, D PHIL, BM, B CH
Clinical Research Institute of Montreal Montreal, PQ
16 OMA JOURNAL/JULY 8, 1978/VOL 119
insurance companies is to make
money for their shareholders. There is nothing wrong with this, especially
if one is a shareholder, but most of the members of the medical profession are not shareholders.
I suggest that it is time we took our insurance into our own hands and that we begin with a Canadian Medical and Allied Insurance Company. There are enough funds for us to do this: for example, 29 000 medical practitioners each pay at least $2000 a year in premiums, which totals $58 million. Where is the money going? Into the coffers of insurance companies, with a small return to the payers of premiums. If one calculates the profit generated by the funds supplied to insurance companies by members of our profession alone over a number of years the sum is astronomic. For too long we have believed those who told us that we are too busy to do it ourselves and that we should therefore just hand over our money. We deserve the results but we do not need to permit this to happen any longer. Look at how they have treated us; look at the assets of any insurance company; look at
how we have been sold a bill of goods about full-life versus term insurance; look at the incredibly low
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-
5. ABRAM HS: Primary care and consultation-liaison psychiatry (E). J Nerv Ment Dis 164: 301, 1977 6. FLANNERY JG: Psychosomatic medicine in a general hospital: some dilemmas. Can Med Assoc J 114: 665, 1976 7. TAYLOR GJ: The mind-body dichotomy. Psychosomatics (in press) 8. SPAULDING WB: The psychosomatic approach in the practice of medicine. mt J Psychiatry Med 6:169, 1975 9. Lipowsiu ZJ: Psychiatry of somatic diseases: epidemiology, pathogenesis, classification. Compr Psychiatry 16: 105, 1975 10. MAGUIRE GP, JULIER DL, HAWTON JH, et al: Psychiatric morbidity and referral on two general medical wards. Br Med 1 1: 268, 1974 11. LAZERSON AM: The psychiatrist in primary medical care training: a solution to the mind-body dichotomy? Am J Psychiatry 133: 964, 1976 12. HAMERMAN D: Psychological care of the medically ill: a primer in liaison psychiatry (C). Psychosom Med 39: 370, 1977 13. IKEMI Y, Aoxi H: Comprehensive psychosomatic training for internists. Dynamic Psychiatry 9: 287, 1976
chiatrist's evolving role in medicine. 2. ENGEL GL: The need for a new medical model: a challenge for biomedicine. Science 196: 129, 1977
3. EISENBERG L: Disease and illness. Culture Med Psychiatry 1: 9, 1977 4. ILLICH I: Medical Nemesis; the Expropriation of Health, Penguin, London, 1976
1. ROBINSON DR, Si4um H, MCGUIRE MB, et al: Prostaglandin synthesis by rheumatoid synovium and its stimulation by coichicine. Prostaglandins 10: 67, 1975
2. HORROBIN DF, KARiW.i RA, M.Nxcu MS, et al: Systemic lupus erythematosus: a disease of thromboxane A2 synthesis and action. IRCS J Med Sci 5: 547, 1977
Insurance and the medical profession
To the editor: There are approximately 29 000 medical practitioners in Canada with disability, life, office overhead, accident, car and home insurance. Many are also paying annual premiums for their dependants' coverage to a company that does not have their true interests at heart. We all know that insurance companies are obliged to abide by the rules set for them, but the very fact that they need these rules is an indication that the companies had to be controlled at some time because Coichicine therapy of their unreasonable profits. Of To the editor: I was interested in the course the primary endeavour of all
recent report of the use of coichicine in the treatment of familial Mediterranean fever by Skrinkas and colleagues (Can Med Assoc J 117: 1416, 1977). My group has recently demonstrated that, although moderate doses of colchicine stimulate prostaglandin synthesis,1 low doses of the drug seem to stimulate thromboxane A2 production selectively and to inhibit production of other prostaglandins.1 Thromboxane A2 is a product of the arachidonic acid pathway of prostaglandin metabolism and we have proposed that it is the key substance exerting feedback inhibition over the pathway.2 If thromboxane production fails, prostaglandins A2 GRAEME J. TAYLOR, MB, CII B, MRC PSYCH, produced in massive excess; we are FRcP[c] Head, consultation-liaison service suggest this is what is happening in Mount Sinai Hospital systemic lupus erythematosus. SevToronto, Ont. eral of the features of familial Mediterranean fever, including fever, abReferences dominal pain and polyserositis, could 1. LEIGH H, RFISER ME: Major trends be attributed to an excess of prosin psychosomatic medicine. The psyAnn Intern Med 87: 233, 1977
References
taglandin. If such an excess were due
to a failure of normal synthesis of thromboxane A2, then colchicine might increase the synthesis of thromboxane A2 and so inhibit overproduction of other prostaglandins. D.F. HORROBIN, MA, D PHIL, BM, B CH
Clinical Research Institute of Montreal Montreal, PQ
16 OMA JOURNAL/JULY 8, 1978/VOL 119
insurance companies is to make
money for their shareholders. There is nothing wrong with this, especially
if one is a shareholder, but most of the members of the medical profession are not shareholders.
I suggest that it is time we took our insurance into our own hands and that we begin with a Canadian Medical and Allied Insurance Company. There are enough funds for us to do this: for example, 29 000 medical practitioners each pay at least $2000 a year in premiums, which totals $58 million. Where is the money going? Into the coffers of insurance companies, with a small return to the payers of premiums. If one calculates the profit generated by the funds supplied to insurance companies by members of our profession alone over a number of years the sum is astronomic. For too long we have believed those who told us that we are too busy to do it ourselves and that we should therefore just hand over our money. We deserve the results but we do not need to permit this to happen any longer. Look at how they have treated us; look at the assets of any insurance company; look at
how we have been sold a bill of goods about full-life versus term insurance; look at the incredibly low
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-
