196 MEDICAL SERVICES FOR CORONARY CARE
SIR,-We thank Dr Bradshaw’ for pointing out an apparent inconsistency between the reports of two joint working-parties of the Royal College of Physicians of London and the British Cardiac Society. The report on the Care of the Patient with Coronary Heart Disease2 stated (p.42): "A more positive approach to the problems of sudden unexpected death, and the high mortality in the first hours after the attack, is necessary. More attention must be paid to the organisation of emergency medical services including the provision of immediate coronary care ..." The report on the Prevention of Coronary Heart Disease3 stated (p.ll): "It would seem that the potential benefit from improving emergency service would be disappointingly small ... Most deaths from CHD occur far too suddenly for present forms of medical attention to be effective ..." The two statements are not really incompatible. The remit of each working-party was different. The members of the working-party on coronary care were especially concerned with the management of the patient with an acute heart-attack and anxious to draw attention to the urgent problem of sudden unexpected death and to the high death-rate after a heart attack before medical attention is summoned or becomes available. They felt that more attention should be paid to these aspects than is the case at present. The members of the working-party on prevention, on the other hand, were concerned mainly with an earlier stage in the drama of coronary heart-disease and considered that the need for prevention was emphasised by the current failure of medical attention to prevent sudden and unexpected death or reduce the early death-rate after acute heart attacks. Their comment in fact reinforces the plea for a more positive approach to the problems of sudden death and early mortality after heart-attacks made by the other working-party. Both working-parties aimed to summarise the current position and to offer practical suggestions and advice. While the parent bodies common to both working-parties (the Royal College of Physicians and the British Cardiac Society) naturally maintained the same general orientation towards the workingparties, complete freedom of expression of opinion by the experts on each working-party was encouraged. It would have been surprising, therefore, if exactly similar statements had issued from each, even though there was some overlap of mem-
without interruption. For 2 months the patient had complained of a dull ache in the right hypochondrium and had had fever and difficulty in breathing. Physical examination revealed slight jaundice, an enlarged painful liver, moderate splenomegaly, and fairly good general health. The liver became more enlarged, irregular, and hard; haemorrhagic pleurisy (on the right) and ascites appeared in the terminal period of the illness. Abnormal blood values included : E.s.R., enzymes, bilirubin, alpha-1-fetoprotem, and immunoglobulins. Isotope scan demonstrated enlargement of the liver with large irregular defect in the right lobe. Laparotomy showed the presence of a large mass in the right lobe and
jjLg)
nodules in the left lobe. Histological examination revealed the picture of hepatocellular carcinoma (malignant hepatoma). The patient died in June, 1975. Malignant hepatoma is rare under the age of 40. In an investigation among medical and surgical departments of this university in the past decade we have found 46 cases of proven malignant hepatoma, of which 26 were in females. The average age was 65 and the range was from 43 to 89 years. We would point out that the use of oral contraceptives in Italy, and especially in Sicily, is much less common than in the U.S.A. FRANCESCO TIGANO Department of Infectious Diseases, BENITO FERLAZZO of University Messina, ANGELA BARRILE 98100 - Messina, Italy
ECTOPIC PREGNANCY AND THE PILL
SIR,-We would like to draw attention, as have Bonnar,’ Hawkins,2 von Kopernik,3 and Burketo a possibly increased risk of ectopic gestation after discontinuance of oral contraceptives.
During the year 1974-75 we saw 5 cases of tubal gestation which developed immediately after discontinuing the use of the pill. The total number of cases of tubal pregnancy in that year CLINICAL DETAILS OF
5
CASES OF ECTOPIC PREGNANCY
bership. Dr Bradshaw asks if the Government and the profession are be enlightened by the Royal College of Physicians and the British Cardiac Society. Certainly; the recommendations in the first report regarding a more positive approach towards the prevention of sudden death and early mortality after heartattacks should be heeded, but because prevention is better than to
cure
emphasis
and practical second renort.
should also be
preventive
placed
measures,
on as
the need for sensible recommended in the
CYRIL CLARKE,
Royal College of Physicians,
President
London NW1
J. F. GOODWIN, Royal Postgraduate Medical School, Hammersmith Hospital, London W12
Immediate Past-President, British Cardiac Society, and
chairman, cardiological commit Royal College of Physicians
ORAL CONTRACEPTIVES AND MALIGNANT HEPATOMA
SIR,-A 22-year-old mother of three was admitted in February, 1975, with diagnosis of hepatitis. For the past two years she had been on ’Lyndiol’ (lynoestrenol 2.5 mg+mestranol 75 Bradshaw, J. S. Lancet, 1976, i, 1298. Report of a Joint Working Party of the Royal College of Physicians of London and the British Cardiac Society Jl R. Coll. Physns 1975, 10, 5. 3. ibid. 1976, 10, 213.
1. 2.
21. 3 out of the 5 women had been on sequential contraand 2 had been on the combined pill (see table). None of them had had a history of pelvic inflammatory disease or tubal or abdominal surgery. The patients had been on the pill for 12-31 months. In each case tubal pregnancy was confirmed at operation and by histological examination. We assume that a temporary hormonal imbalance after the use of oral contraceptives is responsible for this high frequency of tubal pregnancy. Some women who stop taking oral contraceptives experience a "rebound" with regard to gonadotrophins (especially luteinising hormone)5 and ovarian steroid hormones. The relatively high levels of these hormones may predispose to tubal pregnancy. Variations in cestrogen and progesterone levels affect tubal transport of the ovum by slowing its passage.6 This may be an effect on the tubal musculature or on the cilia of the epithelial lining. Support for this assumption about the cause-and-effect relationship comes from Carr’s findings5that after the use of
was
ceptives
1. 2. 3 4 5. 6.
Bonnar, J Lancet, 1974, i, 170 Hawkins, D. F. Br. med J. 1974, i, 387. von Kopernik, H., Timmel, H Zbl Gynäk 1972, 94, 1248. Burke, M , Buck, P. Br J. Hosp. Med 1976, 15, 552 Carr, D H. Proc. Can Fed biol Soc. 1968, p. 48 Blandau, R J. Comparative Aspects of Reproductive Failure, p 194. York, 1967 7 Carr, D. H. Lancet, 1967, ii, 830
New
197
oral
contraceptives (sequential
combined) the incidence of chromosomal anomalies in-
or
spontaneous abortions due creases and that this is caused by to
a
hormonal
imbalance,
as
in
the "after oill effect".
University Department of Obstetrics
DAVID B. WEISS* YESHAIA ABOULAFIA ARIEL MILEWIDSKY
and Gynæcology, Shaare Zedek Hospital, Jerusalem 91000, Israel ’Present address:
Upton Hospital, Slough, Berks SL1 2BJ.
PSYCHOTHERAPY VERSUS BEHAVIOUR THERAPY your fine editorial’ and the excel(July 3, p. 45) I would like further to examine certain important issues. Those unfamiliar with the practice of psychotherapy but entrusted with the task of making provision for psychotherapy within the N.H.S. may be unduly biased by the good results in symptomatic improvement reported in the control group in the trial you cited :2 the controls "had no formal treatment other than the initial ’in-depth’ assessment interview common to all three groups and a monthly phone-call assuring them they had not been forgotten." It has been suggested that improvements in the control group occur due to such immeasurable factors as the therapist’s personality, enthusiasm, and involvement. These may very well be contributory. In my view, the initial psychiatric interview may be of farreaching consequence if well performed, because it helps to structure psychic material in a new way for the patient, and, in a sense, to pose problems that have been obscure, in a more "scientific" manner, so that the mind may come to grips with them better. Further, the provision of expectation of cure, improvement, or growth are in themselves most material to an increase in well-being. I might even say that just this provision, without further treatment, may in itself be an enormous gain, because the patient is not then immediately brought face to face with his problem, which would have a regressive "making-more-ill" effect. This should be taken more seriously in assessing the so-called supportive or "no treatment" effect, because patients are then stimulated to relive the hopeful periods of their lives which, as often as not, have kept them going in the face of internal and external stresses. Those patients who fail in treatment and become the chronic neurotics or reactive depressives may date their failure in therapy to the actual loss of hope or expectation, which previously sustained. them or which was enhanced initially by meeting with the
SIR,-With reference
to
lent letter from Dr Weissman
therapist. I find no significant contribution in your editorial to any understanding of the psychological processes underlying improvement in either therapy. This is perhaps understandable where the issues are statistical rather than qualitative. The points made concerning the provision of psychotherapy for a national at this centre are model for specialty psychotherapy centres at a regional or area level in England. For practical as well as research reasons, the Tavistock or Cassell or Maudsley models of psychotherapy departments would be inappropriate. On the other hand the provision of single appointments of consultant psychotherapists isolated in district general hospitals or psychiatric departments, makes for a watered down effect. Such a specialty centre should contain a sufficient nucleus of trained staff of many disciplines to make an impact on a whole community by training professional nonmedical workers as well as general practitioners and so on and by coping with in-service specialty training in psychotherapy.
population
are
very
important. We
concerned with the creation of
Paddington Centre 217-221 Harrow London W2 5EH
for
a
Psychotherapy,
Road,
ISMOND ROSEN
1 Lancet, 1976, i, 1225. 2. Sloane, H. B., Staples, F. R., Cristol, A. H., Yorkston, N. Psychotherapy versus Behavior Therapy Boston, 1975.
J., Whipple, K.
CHRONIC ASTHMA AND GROWTH FAILURE IN CHILDREN
SIR,-We were surprised to learn that Lacey and Parkin,’ in their community study of children in Newcastle upon Tyne, had not encountered asthma as a cause of short stature. We had the impression that children with chronic asthma are often short, which has been the experience of others.23 Wetherefore measured the height of 183 consecutive children with asthma in an allergy practice. To see whether we could identify the cause of the stunting, when it occurred, we inquired about corticosteroid therapy, age of onset of wheezing, frequency of wheezing, appetite, milk intake, birth-weight, and frequency of respiratory infections and of fevers. Arteriolised P02 measurements were made on all who were wheezing audibly or had obvious air trapping. Po2 was also measured on all with a long history of asthma and with rhonchi heard on auscultation. Details of the methods used are given elsewhere.4 There were 90 boys and 93 girls (age range 7-20 y, mean 10 y). Their mean height was significantly below the standard mean for ages (p
SIR,-We thank Dr Bradshaw’ for pointing out an apparent inconsistency between the reports of two joint working-parties of the Royal College of Physicians of London and the British Cardiac Society. The report on the Care of the Patient with Coronary Heart Disease2 stated (p.42): "A more positive approach to the problems of sudden unexpected death, and the high mortality in the first hours after the attack, is necessary. More attention must be paid to the organisation of emergency medical services including the provision of immediate coronary care ..." The report on the Prevention of Coronary Heart Disease3 stated (p.ll): "It would seem that the potential benefit from improving emergency service would be disappointingly small ... Most deaths from CHD occur far too suddenly for present forms of medical attention to be effective ..." The two statements are not really incompatible. The remit of each working-party was different. The members of the working-party on coronary care were especially concerned with the management of the patient with an acute heart-attack and anxious to draw attention to the urgent problem of sudden unexpected death and to the high death-rate after a heart attack before medical attention is summoned or becomes available. They felt that more attention should be paid to these aspects than is the case at present. The members of the working-party on prevention, on the other hand, were concerned mainly with an earlier stage in the drama of coronary heart-disease and considered that the need for prevention was emphasised by the current failure of medical attention to prevent sudden and unexpected death or reduce the early death-rate after acute heart attacks. Their comment in fact reinforces the plea for a more positive approach to the problems of sudden death and early mortality after heart-attacks made by the other working-party. Both working-parties aimed to summarise the current position and to offer practical suggestions and advice. While the parent bodies common to both working-parties (the Royal College of Physicians and the British Cardiac Society) naturally maintained the same general orientation towards the workingparties, complete freedom of expression of opinion by the experts on each working-party was encouraged. It would have been surprising, therefore, if exactly similar statements had issued from each, even though there was some overlap of mem-
without interruption. For 2 months the patient had complained of a dull ache in the right hypochondrium and had had fever and difficulty in breathing. Physical examination revealed slight jaundice, an enlarged painful liver, moderate splenomegaly, and fairly good general health. The liver became more enlarged, irregular, and hard; haemorrhagic pleurisy (on the right) and ascites appeared in the terminal period of the illness. Abnormal blood values included : E.s.R., enzymes, bilirubin, alpha-1-fetoprotem, and immunoglobulins. Isotope scan demonstrated enlargement of the liver with large irregular defect in the right lobe. Laparotomy showed the presence of a large mass in the right lobe and
jjLg)
nodules in the left lobe. Histological examination revealed the picture of hepatocellular carcinoma (malignant hepatoma). The patient died in June, 1975. Malignant hepatoma is rare under the age of 40. In an investigation among medical and surgical departments of this university in the past decade we have found 46 cases of proven malignant hepatoma, of which 26 were in females. The average age was 65 and the range was from 43 to 89 years. We would point out that the use of oral contraceptives in Italy, and especially in Sicily, is much less common than in the U.S.A. FRANCESCO TIGANO Department of Infectious Diseases, BENITO FERLAZZO of University Messina, ANGELA BARRILE 98100 - Messina, Italy
ECTOPIC PREGNANCY AND THE PILL
SIR,-We would like to draw attention, as have Bonnar,’ Hawkins,2 von Kopernik,3 and Burketo a possibly increased risk of ectopic gestation after discontinuance of oral contraceptives.
During the year 1974-75 we saw 5 cases of tubal gestation which developed immediately after discontinuing the use of the pill. The total number of cases of tubal pregnancy in that year CLINICAL DETAILS OF
5
CASES OF ECTOPIC PREGNANCY
bership. Dr Bradshaw asks if the Government and the profession are be enlightened by the Royal College of Physicians and the British Cardiac Society. Certainly; the recommendations in the first report regarding a more positive approach towards the prevention of sudden death and early mortality after heartattacks should be heeded, but because prevention is better than to
cure
emphasis
and practical second renort.
should also be
preventive
placed
measures,
on as
the need for sensible recommended in the
CYRIL CLARKE,
Royal College of Physicians,
President
London NW1
J. F. GOODWIN, Royal Postgraduate Medical School, Hammersmith Hospital, London W12
Immediate Past-President, British Cardiac Society, and
chairman, cardiological commit Royal College of Physicians
ORAL CONTRACEPTIVES AND MALIGNANT HEPATOMA
SIR,-A 22-year-old mother of three was admitted in February, 1975, with diagnosis of hepatitis. For the past two years she had been on ’Lyndiol’ (lynoestrenol 2.5 mg+mestranol 75 Bradshaw, J. S. Lancet, 1976, i, 1298. Report of a Joint Working Party of the Royal College of Physicians of London and the British Cardiac Society Jl R. Coll. Physns 1975, 10, 5. 3. ibid. 1976, 10, 213.
1. 2.
21. 3 out of the 5 women had been on sequential contraand 2 had been on the combined pill (see table). None of them had had a history of pelvic inflammatory disease or tubal or abdominal surgery. The patients had been on the pill for 12-31 months. In each case tubal pregnancy was confirmed at operation and by histological examination. We assume that a temporary hormonal imbalance after the use of oral contraceptives is responsible for this high frequency of tubal pregnancy. Some women who stop taking oral contraceptives experience a "rebound" with regard to gonadotrophins (especially luteinising hormone)5 and ovarian steroid hormones. The relatively high levels of these hormones may predispose to tubal pregnancy. Variations in cestrogen and progesterone levels affect tubal transport of the ovum by slowing its passage.6 This may be an effect on the tubal musculature or on the cilia of the epithelial lining. Support for this assumption about the cause-and-effect relationship comes from Carr’s findings5that after the use of
was
ceptives
1. 2. 3 4 5. 6.
Bonnar, J Lancet, 1974, i, 170 Hawkins, D. F. Br. med J. 1974, i, 387. von Kopernik, H., Timmel, H Zbl Gynäk 1972, 94, 1248. Burke, M , Buck, P. Br J. Hosp. Med 1976, 15, 552 Carr, D H. Proc. Can Fed biol Soc. 1968, p. 48 Blandau, R J. Comparative Aspects of Reproductive Failure, p 194. York, 1967 7 Carr, D. H. Lancet, 1967, ii, 830
New
197
oral
contraceptives (sequential
combined) the incidence of chromosomal anomalies in-
or
spontaneous abortions due creases and that this is caused by to
a
hormonal
imbalance,
as
in
the "after oill effect".
University Department of Obstetrics
DAVID B. WEISS* YESHAIA ABOULAFIA ARIEL MILEWIDSKY
and Gynæcology, Shaare Zedek Hospital, Jerusalem 91000, Israel ’Present address:
Upton Hospital, Slough, Berks SL1 2BJ.
PSYCHOTHERAPY VERSUS BEHAVIOUR THERAPY your fine editorial’ and the excel(July 3, p. 45) I would like further to examine certain important issues. Those unfamiliar with the practice of psychotherapy but entrusted with the task of making provision for psychotherapy within the N.H.S. may be unduly biased by the good results in symptomatic improvement reported in the control group in the trial you cited :2 the controls "had no formal treatment other than the initial ’in-depth’ assessment interview common to all three groups and a monthly phone-call assuring them they had not been forgotten." It has been suggested that improvements in the control group occur due to such immeasurable factors as the therapist’s personality, enthusiasm, and involvement. These may very well be contributory. In my view, the initial psychiatric interview may be of farreaching consequence if well performed, because it helps to structure psychic material in a new way for the patient, and, in a sense, to pose problems that have been obscure, in a more "scientific" manner, so that the mind may come to grips with them better. Further, the provision of expectation of cure, improvement, or growth are in themselves most material to an increase in well-being. I might even say that just this provision, without further treatment, may in itself be an enormous gain, because the patient is not then immediately brought face to face with his problem, which would have a regressive "making-more-ill" effect. This should be taken more seriously in assessing the so-called supportive or "no treatment" effect, because patients are then stimulated to relive the hopeful periods of their lives which, as often as not, have kept them going in the face of internal and external stresses. Those patients who fail in treatment and become the chronic neurotics or reactive depressives may date their failure in therapy to the actual loss of hope or expectation, which previously sustained. them or which was enhanced initially by meeting with the
SIR,-With reference
to
lent letter from Dr Weissman
therapist. I find no significant contribution in your editorial to any understanding of the psychological processes underlying improvement in either therapy. This is perhaps understandable where the issues are statistical rather than qualitative. The points made concerning the provision of psychotherapy for a national at this centre are model for specialty psychotherapy centres at a regional or area level in England. For practical as well as research reasons, the Tavistock or Cassell or Maudsley models of psychotherapy departments would be inappropriate. On the other hand the provision of single appointments of consultant psychotherapists isolated in district general hospitals or psychiatric departments, makes for a watered down effect. Such a specialty centre should contain a sufficient nucleus of trained staff of many disciplines to make an impact on a whole community by training professional nonmedical workers as well as general practitioners and so on and by coping with in-service specialty training in psychotherapy.
population
are
very
important. We
concerned with the creation of
Paddington Centre 217-221 Harrow London W2 5EH
for
a
Psychotherapy,
Road,
ISMOND ROSEN
1 Lancet, 1976, i, 1225. 2. Sloane, H. B., Staples, F. R., Cristol, A. H., Yorkston, N. Psychotherapy versus Behavior Therapy Boston, 1975.
J., Whipple, K.
CHRONIC ASTHMA AND GROWTH FAILURE IN CHILDREN
SIR,-We were surprised to learn that Lacey and Parkin,’ in their community study of children in Newcastle upon Tyne, had not encountered asthma as a cause of short stature. We had the impression that children with chronic asthma are often short, which has been the experience of others.23 Wetherefore measured the height of 183 consecutive children with asthma in an allergy practice. To see whether we could identify the cause of the stunting, when it occurred, we inquired about corticosteroid therapy, age of onset of wheezing, frequency of wheezing, appetite, milk intake, birth-weight, and frequency of respiratory infections and of fevers. Arteriolised P02 measurements were made on all who were wheezing audibly or had obvious air trapping. Po2 was also measured on all with a long history of asthma and with rhonchi heard on auscultation. Details of the methods used are given elsewhere.4 There were 90 boys and 93 girls (age range 7-20 y, mean 10 y). Their mean height was significantly below the standard mean for ages (p
