Showing papers in "Journal of the Royal Society of Medicine in 1979"

Individual Psychotherapy and the Science of Psychodynamics

Abstract: Medical psychotherapists usually enrage their clinical and academic colleagues by their bland and sometimes seemingly defensive refusal to conduct conventional 'outcome' research. Dr Malan is an exception. Morevoer, though a psychoanalist at heart, he has retained the capacity to relate the uniqueness of individual experience to the generalities of social life. Measurements in the latter sphere can genuinely reflect the former and changes in the former. Probably as a consequence he is able to think more clearly, and in a demystifying way, about the practical issues of psychotherapy. Does it work and under what circumstances does it work and what light can its impact throw on our further understanding of human experience? The present book is a tribute to him. It is simply and clearly written. Medical and nonmedical readers, givers and receivers of psychotherapy can all benefit from reading it. Successive sections of the book deal with such matters, all illustrated by attractively presented case material, as the nature of some psychological mechanisms; their relevance to human relationships, especially with would-be therapists; gender identity; the potentially healing experience of depression and the nature of the task of assessment for treatment. This is not a book primarily concerned with research method. Clinicians however are likely to find themselves time and time again identifying with the many truths within it. It is a profoundly clinical book and one of the best of its kind.

Endometrial histology and biochemistry in climacteric women during oestrogen and oestrogen/progestogen therapy.

Abstract: PIP: 177 patients were recruited between 1973 and 1977 to participate in a study to determine the endometrial response to exogenous estrogens and the modifying effect of progestogens on this response; hence, the endometrial proliferation during cyclical estrogen therapy and sequential estrogen/progestogen therapy was studied longitudinally. The patients were peri-or postmenopausal. Cyclical thereapy ranged from 2-47 months (mean, 15.1 months). With high-dose estrogen, cystic glandular hyperplasia was diagnosed in 16 (23%) patients, and atypical hyperplasia in 6 (9%); with low-dose regimens, cystic glandular hyperplasia was diagnosed in 4 (12%) and atypical hyperplasia in 2 (6%) patients. Sequentia therapy ranged from 2-50 months (mean, 16.2 months). With high dose regimens, 1 (2%) was found to have cystic glandular hyperplasia and 1 atient (2%) atypical hyperplasia; with low doses atypical hyperplasi was diagnosed in 1 patient (3%). these data therefore suggested that progestogens protected the endometrium against estrogen-induced stimulation, although complete protection was not afforded. Progestogens also depressed cytoplasmic progesterone receptor levels and induced the formation of estradiol 17-beta-dehydrogenase, as shown by the following findings: in all samples from Weeks 2 and 3, no activity of the enzyme was detectable. During norethisterone administration (Week 4), however, the activity rose to the premenopausal secretory range and was significantly higher than that in Weeks 2 and 3 (P .001 and P .001, respectively). Measurement of cytoplasmic progesterone receptor confirmed that the estrogenic stimulus being applied to the endometrium was potent.

Single-layer mass closure of major laparotomies by continuous suturing.

Abstract: Surgeons who close major laparotomy incisions in a single layer (excluding skin) usually put interrupted sutures of non-absorbable monofilament material. In 305 consecutive patients we have, instead, used continuous deep-bite mass sutures with satisfactory results. The suture material, chosen at random, was either monofilament nylon, monofilament stainless steel wire or polyglycolic acid (PGA). The length of material used was measured, and this figure divided by the number of bites to give the mean distance from the cut edges at which the needle had been inserted. The ratio of length of suture material to number of bites ranged from 3-10 em (mean 5.90, s.d.I.46). There were no burst abdomens, but 26 incisonal hernias were detected within six months of operation; these were significantly associated with male sex, old age, long incisions, long operations, postoperative coughing and distension, blood transfusion and wound sepsis. Steel sutures were removed from 5 patients because of pain or sinuses, and nylon sutures from one. We conclude that laparotomy closure by a single continuous layer of sutures is satisfactory, and that there is little to choose among nylon, PGA and steel. The incidence of incisional hernias would be reduced by the elimination of wound sepsis.

Incidence of ENT problems in general practice.

Abstract: Introduction Medical students are occasionally told that a particular specialty occupies a quarter or even a third of the work of the general practitioner. I remember this being said more than once of ENT conditions. However, such figures do not seem to be substantiated by any references in the literature. The data would have to be collected by someone with experience of ENT surgery working in general practice; my own background has provided me with such an opportunity. Since qualifying 22 years ago, I have worked continuously in specialist ENT work, latterly in a part-time capacity, whilst for the past 18 years I have been a principal in general practice.

Fatal tricyclic antidepressant poisoning.

Abstract: Introduction In 1975 there were 234 deaths in the United Kingdom attributed to tricyclic antidepressants and a further 111 cases where these drugs had been taken along with others. Thus, these drugs were involved in 11.6% of the total 2984 deaths from solid and liquid poisons (OPCS 1977). There have been numerous case reports describing the clinical features of poisoning but only a few of these have included large numbers of fatal cases (Frejaville et al. 1965, 1966). Because fatal poisoning appears to be a growing problem, we decided to conduct a survey of all deaths from these drugs, in a single year, to ascertain the epidemiological and clinical features and to see in which particular areas management proved most difficult.

Management of malignant dysphagia by intubation at endoscopy.

Abstract: A method of relieving dysphagia in inoperable oesophagogastric neoplasms by per oral intubation using the Nottingham tube introducer was attempted in 63 patients with 3 failures. Twelve patients di...

Tooth eruption and function in an early Anglo-Saxon population.

Abstract: Chronic inflammatory periodontal disease has become the most prevalent human malady due mainly to the effects of soft diet texture allowing the accumulation of bacteria in relation to the gingival margin (Newman 1974). So widespread is this disease, that is is difficult to find a human population exhibiting physiologic dental and periodontal function. It is usually necessary, as in the present study, to have recourse to the jaw remains of ancient or primitive groups. which had masticated food of natural texture. Generally these show minimal pathologic changes typical of 'civilized' populations consuming soft diet. Other mammals also show increasing severity of chronic inflammatory periodontal disease when subjected to diets differing in texture, but not chemical content, from those ofequivalent groups consuming such foods in their natural form (Egelberg 1965, Hatt et al. 1968).

Timing of tourniquet removal after knee replacement.

Abstract: This paper describes a prospective trial which was set up in order to decide whether after knee replacement it is better to remove the tourniquet (pneumatic cuff) before closure of the wound or to leave it on until compressive dressings have been applied. In 80 operations studied, there was less blood loss when the tourniquet was removed after closure and bandaging, but there was no difference in wound complications. The only statistically significant difference was attributed to the timing of tourniquet removal in those patients (about half) who were receiving low-dose heparin.

Inhalation sedation - an adjunct to improved dental care: preliminary communication.

Abstract: Introduction There are a number of children who find great difficulty in accepting dental treatment, and some form of sedation is frequently recommended for successful treatment of such patients. Many sedatives have been tried but recently attention has again focused on nitrous oxide (Lindsay & Roberts 1977, Hill & O'Muliane 1976, O'Muliane et al. 1978). One of the objectives of this study was to determine whether or not inhalation of nitrous oxide in oxygen has a useful sedative effect in the dental treatment of anxious children. The preliminary findings are now reported.

Blood Groups and Diseases.

Abstract: From the combination of knowledge and actions, someone can improve their skill and ability. It will lead them to live and work much better. This is why, the students, workers, or even employers should have reading habit for books. Any book will give certain knowledge to take all benefits. This is what this blood groups and diseases tells you. It will add more knowledge of you to life and work better. Try it and prove it.

Antimitochondrial drugs in cancer chemotherapy: preliminary communication.

Abstract: In initial studies with yeast cells it was found that the primary target of the antidepressant chlorimipramine (Anafranil, CIBA-Geigy) and the anti-leprosy drug clofazimine (Lamprene, CIBA-Geigy) was the mitochondrion (Hughes & Wilkie 1970, Rhodes & Wilkie 1973). Both drugs inhibited the respiratory chain, although by different mechanisms. The oxygen uptake of isolated rat liver mitochondria was affected in a similar way to that of the intact yeast mitochondria. When these studies were extended to human skin fibroblast cultures (Wilkie & Delhanty 1970, Delhanty et al. 1974, Mittwoch & Wilkie 1971), both drugs again had a direct effect on oxygen uptake in the human cells similar to that in yeast cells. The significant finding in this series of experiments was that SV-40 transformed cells (cancer type) were much more susceptible to the inhibitory effects of the drugs than the non-transformed fibroblasts. Results with chlorimipramine on transformed cells are included in the above references, while clofazimine results showed that about 2 jsg/ml in the culture medium was a lethal dose for transformed fibroblasts but about 8 jig/ml was required to kill non-transformed cultures (unpublished results). It was noted that the respiratory rate of transformed cells was significantly less than their normal counterparts in oxygen electrode studies (Wilkie & Delhanty 1970). These results indicated that depression of mitochondrial activity (already low), in the cancer type cells, by treatment with antimitochondrial agents kills these cells, while normal cells can recover from this treatment.

Safety of cimetidine in obstetric patients.

Abstract: Cimetidine has been suggested as a new approach to the prevention of the acid pulmonary aspiration syndrome in obstetric anaesthesia. In 20 patients in labour cimetidine 200 mg intravenously did not prolong labour or alter the pattern or strength of uterine contractions. The fetal heart rate did not show any alteration in rate or pattern and it was confirmed that cimetidine crosses the placenta. These findings suggest that further studies of cimetidine in obstetric patients would be safe.

Prosthetic replacement of shoulder joint: preliminary communication.

Abstract: Although Jules Emile Pean is recorded as having performed the first total prosthetic replacement of the shoulder as long ago as 1891 (Pean 1894), the modern era of shoulder replacement is no more than ten years old and has been pioneered by Neer in New York, and Lettin in London (Neer 1973, 1974,Lettin & Scales 1973). A prosthetic replacement which is basically an imitation of the normal anatomy of the glenohumeral joint was devised and a vast array of similar prostheses have since been tried.

Relapse of Henoch-Schönlein disease associated with lung carcinoma.

Abstract: A relationship between carcinoma and immune complex glomerulonephritis is well established. Membranous glomerulonephritis in particular has been described as a complication of carcinoma of the lung, the colon and other sites (Row et al. 1975). Henoch-Schonlein disease is associated with a proliferative glomerulonephritis which is well documented as having an immune complex aetiology (Evans et al. 1973). We report a patient with Henoch-Sch6nlein disease which occurred initially at the age of 8 years and which relapsed with a proliferative glomerulonephritis 49 years later, when he developed a bronchial carcinoma.

Osteoarthrosis and sport.

Abstract: SUMMARY The many possible predisposing factors in sport and personal memory of a disabled ex-athlete ensure the thought of a firm connection between sport and osteoarthrosis. A superficial review of the available literature appears to support this view. The capacity of a ‘normal’ joint to withstand large stresses is extremely great and there is no definite evidence that wear and tear or trauma alone, without an alteration in joint mechanics, causes the development of osteoarthrosis. The early correction of any, even the most minor, biomechanical fault is particularly important in sport as the hard use to which an athlete puts his joints makes the development of osteoarthrosis most likely. Prevention of osteoarthrosis must be considered in the sports context where adequate treatment, discouragement of an athlete continuing to play whilst injured, advice on change to a less demanding sport or total exclusion must be considered. The simple requirement of complete rehabilitation with more exacting criteria of recovery should be stressed. The one case of severe osteoarthrosis reported in the personal series was associated with gross ligamentous laxity in both knees. He sustained a torn meniscus and anterior cruciate ligament, spent six weeks in plaster and played a competitive match one week later. There is no way in which that footballer could have been ready to play. The reported series on osteoarthrosis in sportsmen and review of the literature on various bone changes suggest that it is doubtful if the diagnosis of osteoarthrosis should be made on the basis of minor variations from normal which may be an adaptation to the demands placed upon the tissues rather than be a degenerative process. I would suggest that osteoarthrosis is not common in sportsmen and that the commonly used criteria for the diagnosis of early osteoarthrosis be applied with caution to subjects in whom there is a history of prolonged strenuous sporting activity.

Dermatomyositis without apparent myositis, complicated by fibrosing alveolitis.

Abstract: Polymyositis is characterized clinically by muscular weakness and pathologically by Inflammatory and degenerative changes in muscles (Pearson & Currie 1974). When the typical sk~n lesions (Pearson 1963) coexist with the myositis the term dermatomyositis (OM) is used. It IS not generally recognized that the cutaneous features may precede the muscle involvement by many years (Krain 1975). We report a case of OM without obvious myopathy, complicated by fibrosing alveolitis.

Treatment of Colles' fractures.

Abstract: Hearing conservation in premature infants From Dr Ann Stewart and Mr Solomon Abramovich Departments ofObstetrics and Paediatrics, and Royal Ear Hospital, University College Hospital and Medical School, London WCI Sir, We have read with interest the letter from Professor Harris and others (November 1978 Journal, p 852) and agree that exposure to increased levels of noise is as undesirable for the newborn premature infant as it is for any other individual. We, however, like Stennert et al. (1977), are unable to accept the proposal made by Douek et al. (1976) that ambient noise in incubators is the cause of sensorineural hearing loss among low birth weight survivors. Such infants are very liable to suffer hypoxia and hyperbilirubinaemia, both of which are thought to cause sensorineural hearing loss. They also are liable to bleeding into the subependymal matrix of the brain and into the ventricles. Extension of haemorrhages from these areas into the inner ear has been reported in infants who died after receiving ventilatory support for respiratory distress (Spector et al. 1978). All these factors, therefore, must be considered when attempting to evaluate the influence of ambient noise on the hearing oflow birth weight infants nursed in incubators. We have examined the hearing ofa group of III infants who weighed ::;::; 1500g at birth. These infants represented 86% of the surviving infants of this birth weight who were cared for in the Neonatal Unit of University College Hospital, London in the years 1966-1972. All these infants were nursed in commercially-available incubators for periods ranging from 2-80 days (mean 37 days). None received continuous positive airway pressure from a head box. Sound pressure levels at all octave frequencies in our incubators were similar to those shown in Figure 1 of Professor Harris' letter. Ten (9%) of these infants had sensorineural hearing loss (mean 51 dB) when tested at a mean age of 6.5 years. None of the audiograms of these 10children showed notches at 4000 Hz, which are considered to be characteristic of damage to the cochlea due to long-term noise exposure. They all had either a gradual fall of threshold towards the high frequencies, or an abrupt loss at 8000 Hz only. The mean duration of incubator stay did not differ between the infants with sensorineural hearing loss and those without. In contrast, perinatal illnesses, particularly those known or likely to have caused hypoxia in the newborn period including apnoea, were significantly associated with sensorineural hearing loss. Jaundice appeared to have an additive effect (Abramovich et al. 1979). We conclude that sensorineural hearing loss in very low birth weight infants is probably caused by hypoxia in the newborn period and is not due to the ambient noise in' commercially-available incubators in current use. Nevertheless, we agree that careful attention must be paid to ambient noise levels in newborn nurseries, particularly as monitoring devices employing noise signals are being used with increasing frequency, in addition to motor-driven incubators. Yours sincerely

Pathogenesis of hypertensive retinopathy: a review.

Abstract: Clinical picture The earliest clinical features of accelerated hypertension are small linear haemorrhages accompanied by cotton-wool spots close to the optic disc and posterior pole. Exudates are inconspicuous at first but common a few weeks later: they are often found in the macular region where they tend to be arranged in a star-figure but may also occur in other parts of the posterior retina. Increasing haziness of the posterior retina commonly presages oedema of the disc, which becomes congested and swollen. Direct changes in the retinal vessels include diffuse arteriolar narrowing, widened and enhanced light reflexes due to increased thickness of the vessel wall, and arteriovenous crossing changes. Nipping of the veins is commonly an illusion related to the effect of arteriolar mural sclerosis in concealing blood flow through the vein as it passes behind the arteriole. However, none of these vascular changes is peculiar to malignant hypertension, identical appearances developing in the benign phase and in a proportion of ageing normotensive people. Conversely, some hypertensive individuals may have insignificant arteriolar changes as gauged by ophthalmoscopy.

Cimetidine: Does neurotoxicity occur? Report of three cases

Abstract: There have been several reports of neurotoxicity attributed to cimetidine. These include confusion (Grimson 1977, Delaney & Raven 1977, McMillen et al. 1978, Wood et al. 1978) and twitching (Grave et al. 1977). In none have plasma cimetidine estimations been performed. Here we report three cases of neurotoxicity in which the plasma cimetidine concentration was estimated. Cimetidine was present in the CSF of two of the cases. The causative role of cimetidine is discussed.

Isolated ACTH deficiency and TSH deficiency in the adult.

Abstract: Introduction Isolated deficiency of a single anterior pituitary hormone without ascertainable disease of the pituitary gland or hypothalamus is known to clinical endocrinologists, even if uncommon. The pathogenesis is obscure. Probably the commonest defect is isolated gonadotrophin deficiency, usually causing failure to enter puberty (Odell 1966); when associated with anosmia, and familial (Kallman et al. 1944,Santen & Paulsen 1973), it is often attributed to a 'mid-line defect of brain development' or other hereditary cause as also in the Lawrence-Moon Biedl syndrome, or in Friedreich's ataxia. Isolated growth hormone deficiency without apparent cause also usually becomes evident in childhood, as growth failure, and so may be a developmental or inherited defect. However, isolated adrenal corticotropic hormone (ACTH) or thyroid-stimulating hormone (TSH) deficiency is usually discovered in subjects over 40 years of age (Odell 1966). In such patients it is hard to imagine that the defect is a developmental one, and there is little published data indicating whether the cause is primarily in the pituitary or in hypothalamic releasing hormone mechanisms. Autoimmune pituitary failure seems possible. Reported here are 2 cases which have been fully investigated, including autoimmunity studies and the use of extrasensitive cytochemical assays capable of measuring changes in the subnormal levels of ACTH or TSH present. The results, together with those of previous cases, are compatible with an acquired defect in the pituitary itself, but this is not clearly defined.

Metabolic functions of skeletal muscles of man, mammals, birds and fishes: a review.

Abstract: Concept of the storage function of muscle The skeletal muscles are always thought of as relatively small individual units and we forget that, taken together, these units, which are composed of an almost identical tissue, constitute a huge organ, which represents a large proportion of the body mass. While the obvious function of the skeletal muscles, the production of movement both for locomotion and for the maintenance of posture, has been studied in great detail, little attention has been paid to another function of this great mass of homogeneous tissue. The second function is the provision of a large reservoir of protein, which enables the muscles, working in concert with the liver, to regulate the levels of glucose and of amino acids in the circulating blood in the various conditions which lead to alterations in these levels. In a normal 70 kg man it is customary to think of the liver, weighing some 1.5 kg, as the largest organ in the body; but the skeletal muscles, weighing about 32 kg and making up roughly 45% of the total body mass, are some 20 times the weight of the liver. The major constituent of both liver and muscles, apart from water, is protein and much of this protein is labile: it is continually being broken down and resynthesized. The rate of breakdown and resynthesis differs considerably in the various tissues of the body. For instance, Millward (1970) has shown that the daily turnover rate of liver protein is of the order of 48% whilst the turnover rate of the protein of skeletal muscle is 12%. However, when one takes into account the relative sizes of these two masses of tissue, the actual amount of protein that is broken down and resynthesized in the muscles is twice as large as that in the liver. It is the labile nature of muscle protein which enables the skeletal muscles to act asa storage organ and thus to 'play an important part in maintaining the levels of glucose and of amino acids in the circulation. The advantages of a rapid protein turnover in muscle and liver, as a means of adapting to a changing environment, have been emphasized by Swick & Song (1974).

Learning as a process of selection and amplification.

Abstract: These are only a few examples of how learning occurs during development by a process of sculpturing, selecting among the possible variations, combinations and sequences of actions. This is how we b...

Steroid endocrinology after the menopause: a review.

Abstract: The menopause is defined as the last menstrual period in a woman's life. It is the inevitable consequence of the natural rate of atresia of ovarian follicles. Because in premenopausal women 95% of circulating oestradiol-171B is secreted by these follicles, the menopause is associated with a reduction of oestrogen secretion. Measurement of oestrogens by biological techniques showed, many years ago, that blood levels in postmenopausal and castrate women were lower than in preimenopausal women. However, even 40 years ago it was realized that oestrogens were not always undetectable in postmenopausal women (Fluhmann 1936). The development of biochemical methods of measurement made it possible to investigate extraovarian sources of steroids after the menopause. Direct secretion of oestrogens by the adrenal gland had been inferred by Brown et al. (1959) after noting premenopausal levels of urinary oestrogens in an ovariectomized woman who had been treated with corticotrophin (ACTH). Direct ovarian and adrenal secretion of steroids after the menopause has since been studied by determining hormone concentrations in the blood draining these glands. Although this method of collection of blood samples itself may disturb glandular secretion, the studies reported have suggested that neither the adrenal cortex nor the ovarian stroma makes a significant direct contribution to circulating oestrogens after the menopause (Baird, Uno & Melby 1969, Judd et al. 1974). Extraglandular production of oestrogens through aromatization of androgens was first recognized in humans by West et al. (1956), who identified oestrone and oestradiol in the urine of 2 adrenalectomized, ovariectomized women after injections of testosterone propionate. The subsequent development ofisotopic techniques has allowed this aspect ofsteroid endocrinology to be studied in greater detail. The peripheral pathways of conversion and interconversion of androgen and oestrogens suggested by the isotopic studies of Baird, Horton et al. (1969) are as follows: Androstenedione Oestrone

Evolution of the vertebrate immune system.

Abstract: Introduction The importance of the immune system to the antimicrobial defence mechanisms of man is obvious when one considers, for example, the low resistance to pyogenic infections in patients with Bruton type agammaglobulinaemia, or the susceptibility to certain viral diseases associated with thymic hypoplasia in Di George's syndrome. The vertebrate immune system is superimposed upon more ancient defence mechanisms which rely mainly on phagocytosis and on a variety of antimicrobial humoral substances, but it by no means replaces such mechanisms. On the contrary, it becomes increasingly linked to them with interrelationships at all stages from processing of the antigen by macrophages to its final elimination by phagocytosis or by complement-mediated lysis. In this interrelationship, the recognition molecules of the immune system come to impose a fineness of discrimination upon older defence mechanisms such as phagocytosis which themselves have intrinsically low specificity.

Integration or disintegration in the mental health services.

Abstract: The organization and management of services for the mentally ill involve the use of conceptual models which underlie patterns of care and service delivery. These models are usually fairly simplistic in character, but they may make the difference between the encouragement or the destruction of good psychiatric practice. In breaking down the old asylum system in Britain and nobody wanted to preserve it in its nineteenth century form, for its failings were massive and obvious we have abolished one framework and we have not yet agreed on a satisfactory one to take its place. Figure 1 is a simple diagrammatic representation of the asylum system. The large area represents the community, typically a town. The arrow out of it represents the act of sending a patient to the mental hospital. The hospital is well clear of the town'in an airy and healthy situation' as the 1808 County Asylums Act put it (Jones 1972). Perhaps this was partly due to a solicitude for the patients' health at a time when towns were breeding grounds for disease, but it was also due to a straightforward rejection mechanism: the patient had been found incapable of living in normal society, he was a nuisance or a danger, nobody wanted him, so society threw him out, and the asylum was the receptacle. The second arrow is concerned with the patient's chances of getting back into society again, and the question-mark suggests that they are rated as problematic. At a time when