Musings on the consolation of philosophy ELLIOTT EMANUEL, MRCP
Ah, what a dusty answer gets the soul, when hot for certainties in this our life! George Meredith
Philosophy is not the preoccupation of ordinary people for most of their lives. In childhood the question: where does life comes from? may seem piercingly urgent for a time, less so if the biological facts are within easy reach. In adolescence the struggle to cast off a religious or moral system that has become inappropriate or oppressive may act as a shattering stimulus to doubt and criticism. In old age the acceptance of life's extinction may rekindle the fires of enquiry, or of faith. When I was 15 it seemed overwhelmingly important whether or not it was possible to prove the existence of God. The search through philosophical writings led down many dreary paths; at one time Nietzsche seemed intoxicating, as Ayn Rand now appeals to some; Freud and Marx were valued as much for their philosophical attitudes as for the other components of their work. Of course no proof is possible of this or the many other metaphysical questions men pose. The very words used to frame the questions cannot be given a clear meaning, agreed upon by all. I have heard philosophy described as rational fantasy, I came to see it as playing with words. But if nothing can be got out of these word games save what is put in, and if many of the questions discussed are literally meaningless, one is wasting one's time, and at that point I stopped. I believe my wits were sharpened by the exercise, but that is all. I wonder that anyone can take seriously the idealist position that "the universe is nothing but thoughts in the mind of God". The reality of the universe is forced on us, to reject it (seriously, and not just as a game of words) would be a symptom of disease. Our nervous systems have evolved and been conditioned to perceive and react with this reality, which in many ways is regular and orderly. Inductive reasoning, so difficult to justify by logic, is the product of brains fashioned for
survival in this world, just as they are equipped for Euclidean rather than nonEuclidean space. An animal which did not calculate on the ordinary cause and effect of everyday life would not survive, though holocaust and catastrophe strike capriciously here and there: "Like flies to wanton boys are we to the gods; they kill us for their sport." Some children and experimental animals are exposed to an environment of unpredictable caprice: they then become unfitted for the ordinary world. Unfortunately there is no absolute moral system by which to deal with ethical decisions, and philosophers have struggled as vainly to find one as to find a universal and logical system of esthetic choices. When religious belief was more homogeneous and binding, and when physicians had little influence over the course of disease, their philosophy and the basis of their ethical standards were rarely tested. Abortion was perhaps the biggest problem, condemned by the major religions and by Hippocrates, yet practised in secret. But when there were no artificial means of life support there was no problem: to ease the act of dying was an inevitable part of the physician's work. No-one had to decide whether to maintain life for a day so that a more viable kidney might be transplanted or whether or not to operate on a child with a meningomyelocele. Experiment on humans was rare and often done on the experimenter himself (as John Hunter inoculated himself with the gonococcus and inadvertently with the spirochete too). The ethics of bleeding poor Haitians to get blood and its derivatives for the American market was not a problem, nor experimentation on prisoners or children. The patient must surely have used his right to refuse treatment before the age of anesthesia, but the sharper conflicts that are now raised about his right to informed consent would not have arisen when treatment was simpler: to amputate or not, or to cut for the stone. So it came about that generations of physicians absorbed
822 CMA JOURNAL/OCTOBER 8, 1977(VOL. 117
their ethics by osmosis, by apprenticeship, and by intuition, where now the subject is systematically taught. As I have never attended one of these courses I do not know how the subject is tackled, but I wonder if more can be done than to let light into murky corners, and to bring up for discussion difficulties that will later occur under conditions of urgency and stress. I would be doubtful of any absolute rules, for medicine is practised in the context of community beliefs and actions, which vary in place and time. In the short course that changed me in 1942 from a civilian to an army doctor I was told that the army as a fighting force came before the individual, and I learned later how this affected the priority of treatment of a group of wounded men. (The moderately severe first, the very severe, time consuming and unlikely to return to fight later.) When penicillin was still scarce, its use for gonorrhea had the highest priority, as these were men who could be made fit quickly for battle. Some philosophers have talked as if a higher entity comes into existence when there is a group, as if the nation had a soul, but though it takes an army to win a battle it is the individual soldier who bleeds. The belief that a higher entity emerges and has claims with priority over human wishes has caused immense human suffering, though it harnesses enormous energies. It is valuable as the square root of minus one is valuable. Treat it as if it exists and great consequences follow, but you must refrain from asking what it means, or if anything real is designated by it. Contraception and abortion are differently regarded when we see the planet as overcrowded, from a time when King Lear could say "Let copulation thrive, for I lack soldiers." And sexual intercourse outside marriage takes on a different aspect when no longer associated with property rights or titles, and when dissociated from procreation. The term situational ethics has been given to this relativistic position by theologians trying to get a
foothold in the quicksand. It was easier when there were absolutes, but what absolutes are now accepted? The widest generalization is to do to others as we would have them do to us, found in many religions and even given a stiff and quasilogical form and "proof' by Kant. It is all we have. Psychiatry, because it deals with the soul and because it is a new science, has more than its share of philosophical difficulties, that is, difficulties that carry us back to fundamentals, though they might be resolved at a stroke by the discovery of some facts. Are there any psychiatric diseases, or are the conditions we treat merely eccentricities, differences of personality, way of life, or style? Is it even morally wrong to tie a label on a human being's existential choice? Is homosexual behaviour a sin, a sickness, or a harmless deviance like left handedness? Psychiatry is wracked by these and similar problems. The old philosophical dichotomies of idealism and materialism, of mind and body, of free will and determinism, subtly colour all our work. Should disorders of the mind be treated by psychotherapy or by drugs? Is psychotherapy to aim at breaking deterministic chains from the past, or should it mobilize the patient's creative energies to make new choices in the present or future? These questions are fought over with all the ferocious intolerance of theologians arguing whether the Son is of the same or only of similar nature to the Father. For my part I believe that I am treating diseases, some with genetic and ultimately biochemical causes, others with mainly mental and social ones, and I believe that a patient who is under medical care, perhaps taking a drug for years, has the right to the name of his condition, with the magic power that the possession of the name may have, and the knowledge that he shares his suffering with others. And I
believe that mind and body are but different aspects of living stuff, perhaps down to the lowest levels of life. In a world of ideological conflict dissent is threatening. Much is made, and with reason, of the misuse of psychiatric labelling and "treatment" of dissenters in totalitarian countries, but I have personal knowledge of one case and have heard of others, in Quebec, where the church acted "medically" to silence an awkward priest. It is possible that those concerned really believe that the dissenter is sick, but he seems to me a very different person, at least before he has been roughed up and drugged, from the schizophrenics I see. Dissent has always appeared strange and frightening to the upholders of established thought, who have not hesitated to use all their power against it, and one is astonished at the stubborn nonconformity that has so often changed history. By temperament I am a dissenter, and I am fortunate to live where I do not have to pay for this trait with mental or physical suffering, though it has certainly not helped my career. Consolatic was a special term in Greek and Roman philosophy, a kind of prescription for moral ills, and it is used in this sense by Boethius in the book whose title I have borrowed, written when he was thrown into prison from the highest office and in deep despair. But these prescriptions would hardly be acceptable now. We see on shelf beyond shelf of philosophical and theological tomes the mere shuffling of technical terms, defined and redefined, and the rules of word games, endlessly revised, and the games, endlessly replayed. To take things philosophically is to accept them stoically, on "the firm foundation of unyielding despair" (in Bertrand Russell's haunting phrase). An admirable posture, perhaps the only one for a rational man. But expect no consolation from philosophy.u
BETHUNE continued from page 793 The usually craftsmanlike director Eric Till allowed technical faults, which limited shooting time doesn't excuse. Outdoor scenes at the front in China were obviously studio creations. There were distressing sound problems, with uneven levels, background music and mechanical studio noises (camera dollies?) that obscured dialogue in love scenes; and weird variations in room ambience. What we had then was an incoherent dramatic structure, rescued from chaos by Sutherland's electrifying presence, equally compelling in comic and sombre moments. The best scenes were "set
pieces", usually in Bethune's own words: denouncing professional venality and pleading for socialized medicine in Quebec; witty student lectures and the rather graphic illustration of sexual anatomy to a startled nursing class; a touching tribute to the Chinese soldiers; the anguished fund-raising speech about Fascist bombing in Spain. And Sutherland never tried to tone down the unattractive side of Bethune - the boozing, womanizing, irascibility and cutting sarcasm. When a definitive film about Norman Bethune is finally made, its creators will approach the task with the dedication and painstaking care that only Don Sutherland displayed in this production. U
.Sanorex. (mazindol)
Action: Sanorex (mazindol) is an imidazo-iso-indole anorectic agent which shares many pharmacological properties with the amphetamines and their congeners. The effects 01 mazindol include central nervous system stimulation as well as an anorectic action. It has not been established. howener, that the action ot such drugs in treating obesity is exclusively one 01 appetite suppression. Other central nervous system actions or metabolic effects may be involved as well. As with similar drugs. rebound weight gain may occur alter discontinuation ot mazindol Tolerance to the anorectic actionhas been demonstrated with all drugs ot this class in which this phenomenon has been studied. indtcations and Citnicat Use: Sanoren may be ot value in the management ot exogenous obesity as a short-term (i.e.. a tew weeks) adjunct isa medically supervised weight-reduction regimen based on dietary restrictions. When prescribing these agents it should be borne in mind that anorectic drugs are ot limited usetulness, since patients treated with anorectic agents lost only a traction ot a pound per week more than those not taking drugs. Prolonged administration ot these agents must also be avoided since it can lead to drug dependence and abuse (see warnings). Contraindications: Sanorex is contraindicated in patients with glaucoma, severe hypertension, recent myocardial intarction, cardiac decompensation, elevated venous pressure, cerebral Ischemia, uremia, tor patients in agitated states, and in schizophrenia. Sanores should not be administered during therapy with monoamine ovidase inhibitors or within 14 days tollowing withdrawal ot these agents (to avoid hypertensive crisis). Patients who display hypersensitivity or idiosyncratic reactions to Sanores should not be given turther treatment with the drug.
Wamtngs:
Drug Dependence: Esperience with anorectic drugs with amphetamine-like properties has established that their use over prolonged periods can produce severe psychological dependence and has led to eutensive abuse Abstinence ettects and selt-administration ot mazindol have been observed in animals. While the abuse potential ot Sanvrev has not been turther detined, the possibility ot dependence should be kept in mind when evaluating the desirability ot Sanvrev as part ot a weight reduction program. Tolerance Tolerance to the anorectic effect ot mazindol may occur within a tew weeks. It this occurs, discontinuation ot the medication is indicated rather than an increase in the dose. Use in pregnancy Sanores should not be administered to women who are or.whv are likely to become pregnant unless in the opinion ot the prescribing physician the potential benetits outweigh the possible risks to mother and tetus. Reproduction studies in rats and rabbits showed an increase in perinatal mortality in animals treated with mazindol However, ISere was not a clear demonstration ot a direct teratogenic effect 01 mazindol in these studies. Use in children. Sanorex is not recommended tor use in children 12 years otage and under. Precautions: Sanorex should be used with caution in patients with hypertension, and trequent monitoring ot blood pressure is indicated. There is insufficient evidence to indicate that Sanores would not have an adverse effect in some hypertensive patients. The drug is not recommended in severe hypertension. The drug is not recommended in individuals with symptomatic cardiovascular disease including arrythmias. Insulin requirements in diabetes mellitus may be altered by Sanorev administration and the concomitant dietary regimen It is recommended that Sanorex be administered continuvusly tor a period no greater than sin weeks Sanvrev snould be prescribed in the smallest possible quantities to avoid possible overdosage. Patients should be cautioned against engaging in activities requiring rapid and precise responses, such as driving an automobile or operating machinery until their response to Sanorex has been determined. Sanorex way markedly potentiate the pressor effect ot evogenous catecholamines. It it should he necessary to administer a pressor amine to a pat:ent in shock who has recently taken Sanorex, eotreme caution is advised in administering such agents (beginning with low initial doses and caretal titration), as well as in monitoring blood pressure. Sanores may decrease the hypotensive ettect ot guanethidine and patients should be monitored accordingly Adeerse Reactions: The most trequently encountered side ettects ot Sanorex (mazindol) have been nervousness, insomnia, dry mouth, tachycardia, and constipation. Other side effects are: Central Nervous System: overstimulation, restlessness, dizziness, dysphoria, anxiety, tremor, headache. depression, drowsiness, and weakness. Cardiocascular: palpitations. tiushing. changes in blood pressure (hypertension. hypotension). Gastrointestinal: nausea. vomiting, unpleasant taste, diarrhea, and abdominal discomtorts. Integumental: rash, evcessive sweating, palor. clamminess, numbness and tingling ot hands. Endocrine: impotence, changes in libido have rarely been observed with Sanoren. Ocular: mydriasis and blurred vision. Other: dysuria.
Symptoms and Treatment ot Oeerdosage: There is no data to date concerning acute overdosage ot Sanorex (mazindol) in humans. Manitestations ot acute overdosage with amphetamines and related substances in humans include restlessness, tremor, rapid respiration, dizziness. Fatigue and depression may tollow the stimulatory phase ot overdosage. Cardiovascular effects include tachycardia, hypertension. and circulatory collapse. Gastrointestinal symptoms include nausea, vomiting, and abdominal cramps. While similar manitestations ot overdosage may be seen with Sanoren (mazindol), their evact nature have yet to be determined. The management ot acute intooication is largely symptomatic. Data is not available on the treatment ot acute intooication with Sanoreo by hemodialysis or peritoneal dialysis, but the substance is peony soluble except at very acid pH. Dosage and Administration: 2 mg. per day, taken one hour betore lunch in a single dose. Dosage Form: Each scored, peach coloured tablet contains: mazindol2mg. Available in bottles ot 30 tablets and 300tablets. Reterences available upon request Reterences: 1) Korshaber, A. Psychosomatics 14:162, 1973. 2( Murphy, JE. et at: J. 1st. Med. Rex. 3:202, 1975. Note: The diethylpropion used in this study was administered as Apisate tablets (U.K.l containing: diethyl propion 75mg; vitamin El, 5mg; B2, 4mg; BE, 2mg; nicotinamide 30mg. 3) Gogerty, J.H.: Scientilic Exhibit, Fed Am Soc Eup. Biol., Atlantic City, N.J., April 15-20, 1973
SANDOZ SANDOZ (CANADA) LIMITED, DORVAL, QUEBEC
CMA JOURNAL/OCTOBER 8, 1977/VOL. 117 823
Ah, what a dusty answer gets the soul, when hot for certainties in this our life! George Meredith
Philosophy is not the preoccupation of ordinary people for most of their lives. In childhood the question: where does life comes from? may seem piercingly urgent for a time, less so if the biological facts are within easy reach. In adolescence the struggle to cast off a religious or moral system that has become inappropriate or oppressive may act as a shattering stimulus to doubt and criticism. In old age the acceptance of life's extinction may rekindle the fires of enquiry, or of faith. When I was 15 it seemed overwhelmingly important whether or not it was possible to prove the existence of God. The search through philosophical writings led down many dreary paths; at one time Nietzsche seemed intoxicating, as Ayn Rand now appeals to some; Freud and Marx were valued as much for their philosophical attitudes as for the other components of their work. Of course no proof is possible of this or the many other metaphysical questions men pose. The very words used to frame the questions cannot be given a clear meaning, agreed upon by all. I have heard philosophy described as rational fantasy, I came to see it as playing with words. But if nothing can be got out of these word games save what is put in, and if many of the questions discussed are literally meaningless, one is wasting one's time, and at that point I stopped. I believe my wits were sharpened by the exercise, but that is all. I wonder that anyone can take seriously the idealist position that "the universe is nothing but thoughts in the mind of God". The reality of the universe is forced on us, to reject it (seriously, and not just as a game of words) would be a symptom of disease. Our nervous systems have evolved and been conditioned to perceive and react with this reality, which in many ways is regular and orderly. Inductive reasoning, so difficult to justify by logic, is the product of brains fashioned for
survival in this world, just as they are equipped for Euclidean rather than nonEuclidean space. An animal which did not calculate on the ordinary cause and effect of everyday life would not survive, though holocaust and catastrophe strike capriciously here and there: "Like flies to wanton boys are we to the gods; they kill us for their sport." Some children and experimental animals are exposed to an environment of unpredictable caprice: they then become unfitted for the ordinary world. Unfortunately there is no absolute moral system by which to deal with ethical decisions, and philosophers have struggled as vainly to find one as to find a universal and logical system of esthetic choices. When religious belief was more homogeneous and binding, and when physicians had little influence over the course of disease, their philosophy and the basis of their ethical standards were rarely tested. Abortion was perhaps the biggest problem, condemned by the major religions and by Hippocrates, yet practised in secret. But when there were no artificial means of life support there was no problem: to ease the act of dying was an inevitable part of the physician's work. No-one had to decide whether to maintain life for a day so that a more viable kidney might be transplanted or whether or not to operate on a child with a meningomyelocele. Experiment on humans was rare and often done on the experimenter himself (as John Hunter inoculated himself with the gonococcus and inadvertently with the spirochete too). The ethics of bleeding poor Haitians to get blood and its derivatives for the American market was not a problem, nor experimentation on prisoners or children. The patient must surely have used his right to refuse treatment before the age of anesthesia, but the sharper conflicts that are now raised about his right to informed consent would not have arisen when treatment was simpler: to amputate or not, or to cut for the stone. So it came about that generations of physicians absorbed
822 CMA JOURNAL/OCTOBER 8, 1977(VOL. 117
their ethics by osmosis, by apprenticeship, and by intuition, where now the subject is systematically taught. As I have never attended one of these courses I do not know how the subject is tackled, but I wonder if more can be done than to let light into murky corners, and to bring up for discussion difficulties that will later occur under conditions of urgency and stress. I would be doubtful of any absolute rules, for medicine is practised in the context of community beliefs and actions, which vary in place and time. In the short course that changed me in 1942 from a civilian to an army doctor I was told that the army as a fighting force came before the individual, and I learned later how this affected the priority of treatment of a group of wounded men. (The moderately severe first, the very severe, time consuming and unlikely to return to fight later.) When penicillin was still scarce, its use for gonorrhea had the highest priority, as these were men who could be made fit quickly for battle. Some philosophers have talked as if a higher entity comes into existence when there is a group, as if the nation had a soul, but though it takes an army to win a battle it is the individual soldier who bleeds. The belief that a higher entity emerges and has claims with priority over human wishes has caused immense human suffering, though it harnesses enormous energies. It is valuable as the square root of minus one is valuable. Treat it as if it exists and great consequences follow, but you must refrain from asking what it means, or if anything real is designated by it. Contraception and abortion are differently regarded when we see the planet as overcrowded, from a time when King Lear could say "Let copulation thrive, for I lack soldiers." And sexual intercourse outside marriage takes on a different aspect when no longer associated with property rights or titles, and when dissociated from procreation. The term situational ethics has been given to this relativistic position by theologians trying to get a
foothold in the quicksand. It was easier when there were absolutes, but what absolutes are now accepted? The widest generalization is to do to others as we would have them do to us, found in many religions and even given a stiff and quasilogical form and "proof' by Kant. It is all we have. Psychiatry, because it deals with the soul and because it is a new science, has more than its share of philosophical difficulties, that is, difficulties that carry us back to fundamentals, though they might be resolved at a stroke by the discovery of some facts. Are there any psychiatric diseases, or are the conditions we treat merely eccentricities, differences of personality, way of life, or style? Is it even morally wrong to tie a label on a human being's existential choice? Is homosexual behaviour a sin, a sickness, or a harmless deviance like left handedness? Psychiatry is wracked by these and similar problems. The old philosophical dichotomies of idealism and materialism, of mind and body, of free will and determinism, subtly colour all our work. Should disorders of the mind be treated by psychotherapy or by drugs? Is psychotherapy to aim at breaking deterministic chains from the past, or should it mobilize the patient's creative energies to make new choices in the present or future? These questions are fought over with all the ferocious intolerance of theologians arguing whether the Son is of the same or only of similar nature to the Father. For my part I believe that I am treating diseases, some with genetic and ultimately biochemical causes, others with mainly mental and social ones, and I believe that a patient who is under medical care, perhaps taking a drug for years, has the right to the name of his condition, with the magic power that the possession of the name may have, and the knowledge that he shares his suffering with others. And I
believe that mind and body are but different aspects of living stuff, perhaps down to the lowest levels of life. In a world of ideological conflict dissent is threatening. Much is made, and with reason, of the misuse of psychiatric labelling and "treatment" of dissenters in totalitarian countries, but I have personal knowledge of one case and have heard of others, in Quebec, where the church acted "medically" to silence an awkward priest. It is possible that those concerned really believe that the dissenter is sick, but he seems to me a very different person, at least before he has been roughed up and drugged, from the schizophrenics I see. Dissent has always appeared strange and frightening to the upholders of established thought, who have not hesitated to use all their power against it, and one is astonished at the stubborn nonconformity that has so often changed history. By temperament I am a dissenter, and I am fortunate to live where I do not have to pay for this trait with mental or physical suffering, though it has certainly not helped my career. Consolatic was a special term in Greek and Roman philosophy, a kind of prescription for moral ills, and it is used in this sense by Boethius in the book whose title I have borrowed, written when he was thrown into prison from the highest office and in deep despair. But these prescriptions would hardly be acceptable now. We see on shelf beyond shelf of philosophical and theological tomes the mere shuffling of technical terms, defined and redefined, and the rules of word games, endlessly revised, and the games, endlessly replayed. To take things philosophically is to accept them stoically, on "the firm foundation of unyielding despair" (in Bertrand Russell's haunting phrase). An admirable posture, perhaps the only one for a rational man. But expect no consolation from philosophy.u
BETHUNE continued from page 793 The usually craftsmanlike director Eric Till allowed technical faults, which limited shooting time doesn't excuse. Outdoor scenes at the front in China were obviously studio creations. There were distressing sound problems, with uneven levels, background music and mechanical studio noises (camera dollies?) that obscured dialogue in love scenes; and weird variations in room ambience. What we had then was an incoherent dramatic structure, rescued from chaos by Sutherland's electrifying presence, equally compelling in comic and sombre moments. The best scenes were "set
pieces", usually in Bethune's own words: denouncing professional venality and pleading for socialized medicine in Quebec; witty student lectures and the rather graphic illustration of sexual anatomy to a startled nursing class; a touching tribute to the Chinese soldiers; the anguished fund-raising speech about Fascist bombing in Spain. And Sutherland never tried to tone down the unattractive side of Bethune - the boozing, womanizing, irascibility and cutting sarcasm. When a definitive film about Norman Bethune is finally made, its creators will approach the task with the dedication and painstaking care that only Don Sutherland displayed in this production. U
.Sanorex. (mazindol)
Action: Sanorex (mazindol) is an imidazo-iso-indole anorectic agent which shares many pharmacological properties with the amphetamines and their congeners. The effects 01 mazindol include central nervous system stimulation as well as an anorectic action. It has not been established. howener, that the action ot such drugs in treating obesity is exclusively one 01 appetite suppression. Other central nervous system actions or metabolic effects may be involved as well. As with similar drugs. rebound weight gain may occur alter discontinuation ot mazindol Tolerance to the anorectic actionhas been demonstrated with all drugs ot this class in which this phenomenon has been studied. indtcations and Citnicat Use: Sanoren may be ot value in the management ot exogenous obesity as a short-term (i.e.. a tew weeks) adjunct isa medically supervised weight-reduction regimen based on dietary restrictions. When prescribing these agents it should be borne in mind that anorectic drugs are ot limited usetulness, since patients treated with anorectic agents lost only a traction ot a pound per week more than those not taking drugs. Prolonged administration ot these agents must also be avoided since it can lead to drug dependence and abuse (see warnings). Contraindications: Sanorex is contraindicated in patients with glaucoma, severe hypertension, recent myocardial intarction, cardiac decompensation, elevated venous pressure, cerebral Ischemia, uremia, tor patients in agitated states, and in schizophrenia. Sanores should not be administered during therapy with monoamine ovidase inhibitors or within 14 days tollowing withdrawal ot these agents (to avoid hypertensive crisis). Patients who display hypersensitivity or idiosyncratic reactions to Sanores should not be given turther treatment with the drug.
Wamtngs:
Drug Dependence: Esperience with anorectic drugs with amphetamine-like properties has established that their use over prolonged periods can produce severe psychological dependence and has led to eutensive abuse Abstinence ettects and selt-administration ot mazindol have been observed in animals. While the abuse potential ot Sanvrev has not been turther detined, the possibility ot dependence should be kept in mind when evaluating the desirability ot Sanvrev as part ot a weight reduction program. Tolerance Tolerance to the anorectic effect ot mazindol may occur within a tew weeks. It this occurs, discontinuation ot the medication is indicated rather than an increase in the dose. Use in pregnancy Sanores should not be administered to women who are or.whv are likely to become pregnant unless in the opinion ot the prescribing physician the potential benetits outweigh the possible risks to mother and tetus. Reproduction studies in rats and rabbits showed an increase in perinatal mortality in animals treated with mazindol However, ISere was not a clear demonstration ot a direct teratogenic effect 01 mazindol in these studies. Use in children. Sanorex is not recommended tor use in children 12 years otage and under. Precautions: Sanorex should be used with caution in patients with hypertension, and trequent monitoring ot blood pressure is indicated. There is insufficient evidence to indicate that Sanores would not have an adverse effect in some hypertensive patients. The drug is not recommended in severe hypertension. The drug is not recommended in individuals with symptomatic cardiovascular disease including arrythmias. Insulin requirements in diabetes mellitus may be altered by Sanorev administration and the concomitant dietary regimen It is recommended that Sanorex be administered continuvusly tor a period no greater than sin weeks Sanvrev snould be prescribed in the smallest possible quantities to avoid possible overdosage. Patients should be cautioned against engaging in activities requiring rapid and precise responses, such as driving an automobile or operating machinery until their response to Sanorex has been determined. Sanorex way markedly potentiate the pressor effect ot evogenous catecholamines. It it should he necessary to administer a pressor amine to a pat:ent in shock who has recently taken Sanorex, eotreme caution is advised in administering such agents (beginning with low initial doses and caretal titration), as well as in monitoring blood pressure. Sanores may decrease the hypotensive ettect ot guanethidine and patients should be monitored accordingly Adeerse Reactions: The most trequently encountered side ettects ot Sanorex (mazindol) have been nervousness, insomnia, dry mouth, tachycardia, and constipation. Other side effects are: Central Nervous System: overstimulation, restlessness, dizziness, dysphoria, anxiety, tremor, headache. depression, drowsiness, and weakness. Cardiocascular: palpitations. tiushing. changes in blood pressure (hypertension. hypotension). Gastrointestinal: nausea. vomiting, unpleasant taste, diarrhea, and abdominal discomtorts. Integumental: rash, evcessive sweating, palor. clamminess, numbness and tingling ot hands. Endocrine: impotence, changes in libido have rarely been observed with Sanoren. Ocular: mydriasis and blurred vision. Other: dysuria.
Symptoms and Treatment ot Oeerdosage: There is no data to date concerning acute overdosage ot Sanorex (mazindol) in humans. Manitestations ot acute overdosage with amphetamines and related substances in humans include restlessness, tremor, rapid respiration, dizziness. Fatigue and depression may tollow the stimulatory phase ot overdosage. Cardiovascular effects include tachycardia, hypertension. and circulatory collapse. Gastrointestinal symptoms include nausea, vomiting, and abdominal cramps. While similar manitestations ot overdosage may be seen with Sanoren (mazindol), their evact nature have yet to be determined. The management ot acute intooication is largely symptomatic. Data is not available on the treatment ot acute intooication with Sanoreo by hemodialysis or peritoneal dialysis, but the substance is peony soluble except at very acid pH. Dosage and Administration: 2 mg. per day, taken one hour betore lunch in a single dose. Dosage Form: Each scored, peach coloured tablet contains: mazindol2mg. Available in bottles ot 30 tablets and 300tablets. Reterences available upon request Reterences: 1) Korshaber, A. Psychosomatics 14:162, 1973. 2( Murphy, JE. et at: J. 1st. Med. Rex. 3:202, 1975. Note: The diethylpropion used in this study was administered as Apisate tablets (U.K.l containing: diethyl propion 75mg; vitamin El, 5mg; B2, 4mg; BE, 2mg; nicotinamide 30mg. 3) Gogerty, J.H.: Scientilic Exhibit, Fed Am Soc Eup. Biol., Atlantic City, N.J., April 15-20, 1973
SANDOZ SANDOZ (CANADA) LIMITED, DORVAL, QUEBEC
CMA JOURNAL/OCTOBER 8, 1977/VOL. 117 823
