366
Education is essential, both to make individuals of the hazards of alcohol, and to create a climate of opinion favourable to the suggested action. This report will be but a small step in that direction, for it will not be easy to remove the popular image of the "friendly drunk", nor to change the accepted British practice of lubricating most social occasions with alcohol. Indeed, prohibition and temperance are not the report’s aim. It seeks to reduce social drinking to a nonharmful level, suggesting as a guideline a maximum intake of four pints of beer, four doubles of spirits, or a bottle of wine in a day (and that is too much if taken regularly). Businesses are urged to examine jobs which seem to necessitate drinking, and we are all urged to examine our own practices as hosts in our own homes. Do we regard our dispensing of drinks with sufficient reaware
sponsibility ?
Does
embarrassment,
belief that it is
polite,
acquaintances indulgence ?
known
or
our
misguided
pour stiffer drinks for be inclined towards over-
cause us to
to
.
This is a well-balanced document which can hardly fail to impress on the reader the size and seriousness of the alcohol problem, and of its disastrous potential over the next few years. Doctors are in a strong position to take a lead in the necessary education campaign, as they have done over smoking. PEPTIC ULCER AFTER RENAL TRANSPLANTATION
’
PATIENTS with renal transplants are susceptible to a depressingly large number of gastrointestinal complications, including fungal oœsophagitis, pancreatitis, smallbowel obstruction or infarction, ischæmic colitis, and colonic perforation.I-4 Probably the commonest of all is peptic ulceration, with a frequency as high as 18%.5 It is a serious disease in transplanted patients, often complicated by perforation or haemorrhage, and carries an overall mortality of 43%.5 The ulcers may have developed before transplantation, for peptic ulceration is not uncommon in renal failure.6 In 377 patients transplanted in Minnesota, evidence of previous peptic ulceration was found in 30.7 Serum-gastrin can be high in renal failure, probably owing to failure of the kidneys to degrade gastrin.8 Basal acid output by the stomach and the peak response to pentagastrin can also be raised,9 especially in patients who have been on haemodialysis for some months.6 After renal transplantation serum-gastrin falls rapidly8 11 but, paradoxically, basal and peak acid secretion can increase further.l2 The role of steroids in causing ulcers has been questioned,13 but there now seems little doubt that large doses increase the E. J., Evans, D. B., Smellie, W. A. B., et al. Lancet, 1971, ii, 781. 2. Julien, P. J., Goldberg, H. I., Margulis, A. R., et al. Radiology, 1975, 117,37. 3. Penn, I., Groth, C. G., Brettschneider, L., et al. Ann. Surg. 1968, 168, 865. 4. Aldrete, J. S., Sterling, W. A., Hathaway, B. M., et al. Am. J. Surg. 1975, 129, 115. 5. Owens, M. L., Passaro, E., Wilson, S. E., et al. Ann. Surg. 1977, 186, 17. 6. Ventkateswaran, P. S., Jeffers, A., Hocken, A. G. Br. med. J. 1972, iv, 22. 7. Spanos, P. K., Simmons, R. L., Rattazzi, L. C., et al. Archs Surg. 1974, 109, 1.
Hadjiyannakis,
193. 8. 9. 10.
Korman, M. G., Laver, M. C., Hansky, J. Br. med. J. 1972, i, 209. Gordon, E. M., Johnson, A. G., Williams, G. Lancet, 1972, i, 226. McConnell, J. B., Stewart, W. K., Thjodleifsson, B., et al. Lancet, 1975, ii,
11. 12. 13.
King, R., Hansky, J. ibid. 1974, i, 169. Chisholm, G. D., Mee, A. D., Williams, G., et al. Br. med. J. 1977, i, Conn, H. O., Blitzer, B. L. N. Engl. J. Med. 1976, 294, 473.
1121.
1630.
risk of peptic ulceration. Conn and Blitzer13 reviewed 42 controlled investigations involving over 5000 patients to whom steroids had been prescribed for various conditions. There was a significant increase in peptic ulceration in patients who received a cumulative total dose of more than 1 g of prednisone.13 Kidney transplant patients frequently receive doses of this order-in fact, it is common practice to administer 1 g of methylprednisolone on the day of transplantation. Nonetheless, the association between the dose of steroids received and ulceration is not completely clear, and in one study steroid dosage was no larger in a group of transplanted patients with ulcers than it was in a group who remained ulcerfree.14 Azathioprine is believed not to cause peptic ulceration.15 In two controlled studies involving 110 patients on steroids for ulcerative colitis, the addition of azathioprine to the treatment of one group was not followed by a greater incidence of peptic ulceration in that group. 16 17 Another possible factor in the xtiology is virus infection, since cytomegalovirus (C.M.V.) is often detectable after transplantation. 18 In patients with other diseases c.M.v. has been discovered in the mucosa of the stomach and duodenum, often in association with ulcers,19 and the virus has been blamed for causing ulceration of the cæcum.20 This evidence is not very strong, and there is so far only one report of c.M.v. being found in association with a peptic ulcer in a patient with a
transplant.4 Immunosuppression does not seem to prevent peptic responding to medical treatment and for uncomplicated ulcers this approach has been recommended. 14 Unfortunately haemorrhage or perforation is often the presenting feature and under these circumstances urgent operation is required. Cimetidine has been used successfully in cases of haemorrhage but half the patients have relapsed within a short period,14 and although further haemorrhage can follow operation,1 ulcers from
seems the safest treatment. Some workers recommend prophylactic ulcer surgery before transplantation in all patients with a history of peptic ulceration, since the frequency of complications may be reduced in this way. 5This will not, however, greatly reduce the overall incidence of complications, since most ulcers arise in transplanted patients who have had no previous symptoms. In fact, Chisholm et al. 12 were quite unable to identify those patients at risk even after examining pre and post transplant measurements of gastric-acid secretion. Enteric-coated steroid tablets and regular antacids do not seem to have much prophylactic value. Some encouraging news has come from King’s College Hospital,21 where 30 transplanted patients were treated with cimetidine in doses up to 1 g a day from the day of transplantation. There were no episodes of hoemorrhage, whereas in a previous series of 33 patients treated with antacids alone there were six such episodes. If these
surgery still
14.
Archibald, S. D., Jirsch,
D.
N., Bear, R. A. Can. med. Ass. J. 1978, 119,
1291.
15. Weinberg, A. L. in Progress in Immunology II: vol. v, Clinical Aspects II (edited by L. Brent and J. Holborow), p. 253 Amsterdam, 1974. 16. Rosenberg, J. L., Wall, A. J., Levin, B., et al. Gastroenterology, 1975, 69, 96.
Jewell, D. P., Truelove, S. C. Br. med. J. 1974, iv, 627. Summons, R. L., Lopez, C., Balfour, H., et al. Ann. Surg. 1974, 180, 623 Wolfe, B. M., Cherry, J. D. Ann. Surg. 1973, 77, 490. Henson, D. Archs. Path. 1972, 93, 477. 21. Jones, R. H., Rudge, C. J., Bewick, M., et al. Br. med. J. 1978, i, 398. 17. 18. 19. 20.
367
results
can
prophylactic
a proper controlled trial, cimetidine should reduce the hazards of
be confirmed in
transplantation.
HOSTILITY TO PSYCHOSURGERY)
of the practice of psychosurgery, or "funcneurosurgery" as the Society of British Neurological Surgeons somewhat fastidiously calls it, suggests that adverse publicity may well have caused a reduction in the number of such operations done annually.’1 Whereas an estimated 158operations were carried out in Britain in 1974, the equivalent figure for 1975 was A
REVIEW
tional
154 and for 1976 was 119. A similar trend has been reported in the United States.2 Opposition to psychosurgery, like opposition to other controversial psychiatric therapies such as electroconvulsive treatment and psychoanalysis, makes much of the fact that to date there is no conclusive proof that the treatment actually works. The multiplicity of existing psychosurgical techniques, together with emphatic claims for their efficacy over almost the entire range of psychiatric conditions, make the precise worth of psychosurgery difficult to establish. Such problems, however, did not deter a research committee of the Royal
College of Psychiatrists from proposing a multicentre, prospective, controlled trial in which patients, referred for consideration of psychosurgery, were to be assessed and randomised to surgicaland non-surgical treatments.3 For reasons which remain shadowy but which have been related to active political lobbying by the critics of psychosurgery (there were 11 separate questions on the subject in the House of Commons during 1976 alone) and to professional doubts that such a trial would actually clarify anything, the trial has never materialised. It seems unlikely to do so. Not that there is
a
lack of
a
scientific reports
on
the
subject. The problem is that much of it is utterly worthless. Valenstein’s review2 of over 150 articles published between 1971 and 1976 makes dismal reading in this regard. Most of the articles lacked any objective measurement and relied almost entirely on clinical acumen and subjective impressions. Using a well-tried and accepted system of rating publications for scientific merit,4 Valenstein found that over 90% of the psychosurgery reports got an extremely low overall score. In the great majority, important variables’ were confounded in such a way as to make it difficult if not impossible to determine whether any postoperative changes should be attributed to the surgery or to the intensification of psychotherapy, drug treatment, behavioural management, or social rehabilitative methods undertaken by the therapeutic team and the patient’s relatives. Despite the adverse publicity and the poor quality of much of the research, many surgeons and psychiatrists seem bemused and even irritated by public alarm and 1 Barraclough, B. M., Mitchell-Heggs, N. A. Br. med. J. 1978, ii, 1591. 2 Valenstein, E. S. in Psychosurgery, U.S. National Commission for the Protection of Human Subjects of Biomedical and Behavioural Research; appendix 1-1-1-143. U.S. DHEW Publ. no. (05) 77-0002. Washington, D C., 1977. i Research Committee, Royal College of Psychiatrists
in Neurosurgical TreatPsychiatry, Pain and Epilepsy (edited by W. H. Sweet, S. Obrador, and J. G. Martin-Rodriguez); p. 175. Baltimore, 1977. 4 May P R. A., Van Putten, T. Compreh. Psychiat. 1974, 15, 267. ment in
disquiet concerning the ethical aspects of psychosurgery. Speakers at the Fourth World Congress of Psychiatric Surgery (1975), to judge by the published report,s were unanimous in concluding that psychosurgery is no different in logical consequences from any other therapy. The speakers were almost all surgeons and psychiatrists committed to this form of treatment (the exception being a lecturer in music); and it is noteworthy that a multiprofessional group, reporting to the U.S. National Commission for the Protection of Human Subjects of Biomedical and Behavioral Research, came to a more cautious conclusion. The Commission’s report, however, was far from hostile to psychosurgery. Indeed, after a most thorough review of the published work and evaluation of several studies specially undertaken for it, the Commission found in favour of the use of psychosurgical procedures under properly supervised conditions. Among its suggestions was the setting up of special review boards, approved by the U.S. Department of Health, Education and Welfare, which would establish that a surgeon is competent to perform the procedure in question, that there are good indications for the procedure, that adequate preoperative and postoperative assessments are done, and that a patient has given adequate consent. It has been argued6that if psychosurgery was restricted to a few specialised centres where the procedures can be carefully monitored, where research can be undertaken, and where experience can be accumulated, special review boards and restrictions would be unnecessary. However, it is clear from Barraclough and MitchellHeggs’ figures’ that this position has not yet been reached in Britain. While four major neurosurgical units accounted for two-thirds of the operations, a further twenty-seven units were performing up to five such operations each per year. The thorny issue of psychosurgical treatment for involuntarily committed patients or for prisoners with intractable psychiatric ill-health or severe behavioural disorders has produced varying recommendations. The U.S. National Commission agreed that such procedures could be used, under certain medical and legal safeguards, whereas the New South Wales Committee of Inquiry,’ which in many other respects adopted the same approach as the American one, ruled against permitting psychosurgical procedures in cases where informed and unfettered consent was doubtful. At present the use of . psychosurgery in Britain is regulated by the usual restrictions on any medical treatment included in the Mental Health Act of 1959. Many of the ethical questions relating to psychosurgery, such as the issue of informed consent, the conflict between research goals and patient safety, and the adequacy of review procedures, are questions of .general medical ethics too. In the area of psychosurgery, however, the dispute has been particularly acrimonious.8 Critics tend to portray surgery as mutilation and to insist that it blunts, or as one vociferous critic puts it, "partially kills" the individual.9 Some proponents of the procedure hardly help by assert-
5. Sweet, W. H., Obrador, S., Martin-Rodriguez, J. G. (editors). Neurosurgical Treatment in Psychiatry, Pain and Epilepsy. Baltimore, 1977. 6. Bridges, P. K., Bartlett, J. R. Br.J. Psychiat. 1977, 131, 249. 7. Kiloh, L. G. Med. J. Aust. 1977, ii, 296. 8. Clare, A. Psychiatry in Dissent; p. 268. London, 1976. 9. Breggin, P. R. U.S. Congressional Record, 1972, 118 (26), Feb. 24, 5567.
Education is essential, both to make individuals of the hazards of alcohol, and to create a climate of opinion favourable to the suggested action. This report will be but a small step in that direction, for it will not be easy to remove the popular image of the "friendly drunk", nor to change the accepted British practice of lubricating most social occasions with alcohol. Indeed, prohibition and temperance are not the report’s aim. It seeks to reduce social drinking to a nonharmful level, suggesting as a guideline a maximum intake of four pints of beer, four doubles of spirits, or a bottle of wine in a day (and that is too much if taken regularly). Businesses are urged to examine jobs which seem to necessitate drinking, and we are all urged to examine our own practices as hosts in our own homes. Do we regard our dispensing of drinks with sufficient reaware
sponsibility ?
Does
embarrassment,
belief that it is
polite,
acquaintances indulgence ?
known
or
our
misguided
pour stiffer drinks for be inclined towards over-
cause us to
to
.
This is a well-balanced document which can hardly fail to impress on the reader the size and seriousness of the alcohol problem, and of its disastrous potential over the next few years. Doctors are in a strong position to take a lead in the necessary education campaign, as they have done over smoking. PEPTIC ULCER AFTER RENAL TRANSPLANTATION
’
PATIENTS with renal transplants are susceptible to a depressingly large number of gastrointestinal complications, including fungal oœsophagitis, pancreatitis, smallbowel obstruction or infarction, ischæmic colitis, and colonic perforation.I-4 Probably the commonest of all is peptic ulceration, with a frequency as high as 18%.5 It is a serious disease in transplanted patients, often complicated by perforation or haemorrhage, and carries an overall mortality of 43%.5 The ulcers may have developed before transplantation, for peptic ulceration is not uncommon in renal failure.6 In 377 patients transplanted in Minnesota, evidence of previous peptic ulceration was found in 30.7 Serum-gastrin can be high in renal failure, probably owing to failure of the kidneys to degrade gastrin.8 Basal acid output by the stomach and the peak response to pentagastrin can also be raised,9 especially in patients who have been on haemodialysis for some months.6 After renal transplantation serum-gastrin falls rapidly8 11 but, paradoxically, basal and peak acid secretion can increase further.l2 The role of steroids in causing ulcers has been questioned,13 but there now seems little doubt that large doses increase the E. J., Evans, D. B., Smellie, W. A. B., et al. Lancet, 1971, ii, 781. 2. Julien, P. J., Goldberg, H. I., Margulis, A. R., et al. Radiology, 1975, 117,37. 3. Penn, I., Groth, C. G., Brettschneider, L., et al. Ann. Surg. 1968, 168, 865. 4. Aldrete, J. S., Sterling, W. A., Hathaway, B. M., et al. Am. J. Surg. 1975, 129, 115. 5. Owens, M. L., Passaro, E., Wilson, S. E., et al. Ann. Surg. 1977, 186, 17. 6. Ventkateswaran, P. S., Jeffers, A., Hocken, A. G. Br. med. J. 1972, iv, 22. 7. Spanos, P. K., Simmons, R. L., Rattazzi, L. C., et al. Archs Surg. 1974, 109, 1.
Hadjiyannakis,
193. 8. 9. 10.
Korman, M. G., Laver, M. C., Hansky, J. Br. med. J. 1972, i, 209. Gordon, E. M., Johnson, A. G., Williams, G. Lancet, 1972, i, 226. McConnell, J. B., Stewart, W. K., Thjodleifsson, B., et al. Lancet, 1975, ii,
11. 12. 13.
King, R., Hansky, J. ibid. 1974, i, 169. Chisholm, G. D., Mee, A. D., Williams, G., et al. Br. med. J. 1977, i, Conn, H. O., Blitzer, B. L. N. Engl. J. Med. 1976, 294, 473.
1121.
1630.
risk of peptic ulceration. Conn and Blitzer13 reviewed 42 controlled investigations involving over 5000 patients to whom steroids had been prescribed for various conditions. There was a significant increase in peptic ulceration in patients who received a cumulative total dose of more than 1 g of prednisone.13 Kidney transplant patients frequently receive doses of this order-in fact, it is common practice to administer 1 g of methylprednisolone on the day of transplantation. Nonetheless, the association between the dose of steroids received and ulceration is not completely clear, and in one study steroid dosage was no larger in a group of transplanted patients with ulcers than it was in a group who remained ulcerfree.14 Azathioprine is believed not to cause peptic ulceration.15 In two controlled studies involving 110 patients on steroids for ulcerative colitis, the addition of azathioprine to the treatment of one group was not followed by a greater incidence of peptic ulceration in that group. 16 17 Another possible factor in the xtiology is virus infection, since cytomegalovirus (C.M.V.) is often detectable after transplantation. 18 In patients with other diseases c.M.v. has been discovered in the mucosa of the stomach and duodenum, often in association with ulcers,19 and the virus has been blamed for causing ulceration of the cæcum.20 This evidence is not very strong, and there is so far only one report of c.M.v. being found in association with a peptic ulcer in a patient with a
transplant.4 Immunosuppression does not seem to prevent peptic responding to medical treatment and for uncomplicated ulcers this approach has been recommended. 14 Unfortunately haemorrhage or perforation is often the presenting feature and under these circumstances urgent operation is required. Cimetidine has been used successfully in cases of haemorrhage but half the patients have relapsed within a short period,14 and although further haemorrhage can follow operation,1 ulcers from
seems the safest treatment. Some workers recommend prophylactic ulcer surgery before transplantation in all patients with a history of peptic ulceration, since the frequency of complications may be reduced in this way. 5This will not, however, greatly reduce the overall incidence of complications, since most ulcers arise in transplanted patients who have had no previous symptoms. In fact, Chisholm et al. 12 were quite unable to identify those patients at risk even after examining pre and post transplant measurements of gastric-acid secretion. Enteric-coated steroid tablets and regular antacids do not seem to have much prophylactic value. Some encouraging news has come from King’s College Hospital,21 where 30 transplanted patients were treated with cimetidine in doses up to 1 g a day from the day of transplantation. There were no episodes of hoemorrhage, whereas in a previous series of 33 patients treated with antacids alone there were six such episodes. If these
surgery still
14.
Archibald, S. D., Jirsch,
D.
N., Bear, R. A. Can. med. Ass. J. 1978, 119,
1291.
15. Weinberg, A. L. in Progress in Immunology II: vol. v, Clinical Aspects II (edited by L. Brent and J. Holborow), p. 253 Amsterdam, 1974. 16. Rosenberg, J. L., Wall, A. J., Levin, B., et al. Gastroenterology, 1975, 69, 96.
Jewell, D. P., Truelove, S. C. Br. med. J. 1974, iv, 627. Summons, R. L., Lopez, C., Balfour, H., et al. Ann. Surg. 1974, 180, 623 Wolfe, B. M., Cherry, J. D. Ann. Surg. 1973, 77, 490. Henson, D. Archs. Path. 1972, 93, 477. 21. Jones, R. H., Rudge, C. J., Bewick, M., et al. Br. med. J. 1978, i, 398. 17. 18. 19. 20.
367
results
can
prophylactic
a proper controlled trial, cimetidine should reduce the hazards of
be confirmed in
transplantation.
HOSTILITY TO PSYCHOSURGERY)
of the practice of psychosurgery, or "funcneurosurgery" as the Society of British Neurological Surgeons somewhat fastidiously calls it, suggests that adverse publicity may well have caused a reduction in the number of such operations done annually.’1 Whereas an estimated 158operations were carried out in Britain in 1974, the equivalent figure for 1975 was A
REVIEW
tional
154 and for 1976 was 119. A similar trend has been reported in the United States.2 Opposition to psychosurgery, like opposition to other controversial psychiatric therapies such as electroconvulsive treatment and psychoanalysis, makes much of the fact that to date there is no conclusive proof that the treatment actually works. The multiplicity of existing psychosurgical techniques, together with emphatic claims for their efficacy over almost the entire range of psychiatric conditions, make the precise worth of psychosurgery difficult to establish. Such problems, however, did not deter a research committee of the Royal
College of Psychiatrists from proposing a multicentre, prospective, controlled trial in which patients, referred for consideration of psychosurgery, were to be assessed and randomised to surgicaland non-surgical treatments.3 For reasons which remain shadowy but which have been related to active political lobbying by the critics of psychosurgery (there were 11 separate questions on the subject in the House of Commons during 1976 alone) and to professional doubts that such a trial would actually clarify anything, the trial has never materialised. It seems unlikely to do so. Not that there is
a
lack of
a
scientific reports
on
the
subject. The problem is that much of it is utterly worthless. Valenstein’s review2 of over 150 articles published between 1971 and 1976 makes dismal reading in this regard. Most of the articles lacked any objective measurement and relied almost entirely on clinical acumen and subjective impressions. Using a well-tried and accepted system of rating publications for scientific merit,4 Valenstein found that over 90% of the psychosurgery reports got an extremely low overall score. In the great majority, important variables’ were confounded in such a way as to make it difficult if not impossible to determine whether any postoperative changes should be attributed to the surgery or to the intensification of psychotherapy, drug treatment, behavioural management, or social rehabilitative methods undertaken by the therapeutic team and the patient’s relatives. Despite the adverse publicity and the poor quality of much of the research, many surgeons and psychiatrists seem bemused and even irritated by public alarm and 1 Barraclough, B. M., Mitchell-Heggs, N. A. Br. med. J. 1978, ii, 1591. 2 Valenstein, E. S. in Psychosurgery, U.S. National Commission for the Protection of Human Subjects of Biomedical and Behavioural Research; appendix 1-1-1-143. U.S. DHEW Publ. no. (05) 77-0002. Washington, D C., 1977. i Research Committee, Royal College of Psychiatrists
in Neurosurgical TreatPsychiatry, Pain and Epilepsy (edited by W. H. Sweet, S. Obrador, and J. G. Martin-Rodriguez); p. 175. Baltimore, 1977. 4 May P R. A., Van Putten, T. Compreh. Psychiat. 1974, 15, 267. ment in
disquiet concerning the ethical aspects of psychosurgery. Speakers at the Fourth World Congress of Psychiatric Surgery (1975), to judge by the published report,s were unanimous in concluding that psychosurgery is no different in logical consequences from any other therapy. The speakers were almost all surgeons and psychiatrists committed to this form of treatment (the exception being a lecturer in music); and it is noteworthy that a multiprofessional group, reporting to the U.S. National Commission for the Protection of Human Subjects of Biomedical and Behavioral Research, came to a more cautious conclusion. The Commission’s report, however, was far from hostile to psychosurgery. Indeed, after a most thorough review of the published work and evaluation of several studies specially undertaken for it, the Commission found in favour of the use of psychosurgical procedures under properly supervised conditions. Among its suggestions was the setting up of special review boards, approved by the U.S. Department of Health, Education and Welfare, which would establish that a surgeon is competent to perform the procedure in question, that there are good indications for the procedure, that adequate preoperative and postoperative assessments are done, and that a patient has given adequate consent. It has been argued6that if psychosurgery was restricted to a few specialised centres where the procedures can be carefully monitored, where research can be undertaken, and where experience can be accumulated, special review boards and restrictions would be unnecessary. However, it is clear from Barraclough and MitchellHeggs’ figures’ that this position has not yet been reached in Britain. While four major neurosurgical units accounted for two-thirds of the operations, a further twenty-seven units were performing up to five such operations each per year. The thorny issue of psychosurgical treatment for involuntarily committed patients or for prisoners with intractable psychiatric ill-health or severe behavioural disorders has produced varying recommendations. The U.S. National Commission agreed that such procedures could be used, under certain medical and legal safeguards, whereas the New South Wales Committee of Inquiry,’ which in many other respects adopted the same approach as the American one, ruled against permitting psychosurgical procedures in cases where informed and unfettered consent was doubtful. At present the use of . psychosurgery in Britain is regulated by the usual restrictions on any medical treatment included in the Mental Health Act of 1959. Many of the ethical questions relating to psychosurgery, such as the issue of informed consent, the conflict between research goals and patient safety, and the adequacy of review procedures, are questions of .general medical ethics too. In the area of psychosurgery, however, the dispute has been particularly acrimonious.8 Critics tend to portray surgery as mutilation and to insist that it blunts, or as one vociferous critic puts it, "partially kills" the individual.9 Some proponents of the procedure hardly help by assert-
5. Sweet, W. H., Obrador, S., Martin-Rodriguez, J. G. (editors). Neurosurgical Treatment in Psychiatry, Pain and Epilepsy. Baltimore, 1977. 6. Bridges, P. K., Bartlett, J. R. Br.J. Psychiat. 1977, 131, 249. 7. Kiloh, L. G. Med. J. Aust. 1977, ii, 296. 8. Clare, A. Psychiatry in Dissent; p. 268. London, 1976. 9. Breggin, P. R. U.S. Congressional Record, 1972, 118 (26), Feb. 24, 5567.
