- Email: [email protected]
ASSOCIATION OF CLINICAL PATHOLOGISTS
1094 of the syndrome: let anyone who thinks that he stands take heed lest he fall.... Intellect and skill may also be affected during this period of adaptation, and the displaced person may be assailed by unaccustomed doubts about his own competence. He seems slow to learn the local routine, although this is partly because he is evidently expected to know his new duties by instinct. (The home team must learn to dissociate him from his predecessor.) Yet it is not only unfamiliarity which is to blame. A heart may stay arrested because the newcomer does not know his way about the resuscitation box, but he is equally likely to have failed to move the patient on to a hard surface before starting his manoeuvres. He may be excused for his bungling performance with a strange new giving set, but -scalp-drip king that he is-he cannot get into the vein. He has been noted in the past for his clinical acumen: now, when it is important to prove himself worthy of his glowing testimonials, he misses an obvious physical sign, and has his diagnosis corrected by the medical student. All his association fibres seem to be displaced and a loss of dexterity frustrates him: things which would normally alert him, he ignores, and the prevailing sense of awkwardness can affect his professional judgment and even contribute to disaster. Spiritual depression may well overtake the spiritually minded at such a time of upheaval -ask any missionary-so that physique and psyche, soul and spirit can all suffer from the displacement syndrome.
fruste
Management largely depends
on
everyone,
including
the victim, recognising the condition, anticipating its manifestations and viewing them optimistically when they appear. It is a help to know that, like postinfluenzal depression, many people get it and most of them recover. Failure to appreciate what is amiss will cause needless worry and misunderstanding. Insight into one’s own character will suggest how the syndrome may present, and forewarn the newcomer to leave the unfavourable comparison unmade, to take a hint without also taking offence, and to be alert to the possibility of judgment being temporarily upset and to ask advice without fearing loss of face. Sweeping reforms are best left unmentioned until proved by time to be essential. For its part, the home team may feel some unconscious antagonism towards the new Dr. X because he has replaced dear Dr. Y, and accordingly seize on any display of temperament as proof that Dr. X is indeed a poor Awareness of this will help to promote substitute. understanding and avoid friction. A senior colleague’s watchful eye may avert serious mistakes and minimise small ones: a refusal to be upset by minor transgressions is a help in fostering good working relationships. The prognosis is good. Although one’s association pathways may feel completely disrupted, it is usual for normal transmission to be resumed after an interval which varies according to the degree of the displacement and the personality of the person displaced. This may be weeks or months, but rarely becomes chronic. If we expect understanding and help ourselves when going through a time of upheaval, it is only reasonable that we should be receptive and encouraging to anyone else who is in a similar position. This will include not only our colleagues, but also many of our patients in whom we probably recognise this particular syndrome less often. Yet for some of them, even a visit to the surgery is a displacement, for the language-and customs-of the place
foreign to them; a hospital admission is even worse, with its uprooting from home and stripping of privacy. Pxdiatric patients commonly voice clearly their disapproval : adults may show more subtly that they feel apprehensive and disturbed, and again symptoms are referrable to each part of the personality. Common physical signs are tachycardia and tremor, or constipation in a patient admitted for diarrhoea. Emotions are labile, and belligerence or tears easily provoked. Seeming deficit of intellect may merely reflect nervousness or embarrassment, and inability to answer a simple question without appending a family saga may be a demonstration of the thought disorder that we have known so well ourselves under other circumstances. (Because of this, a history may be more fruitful when taken for a second time, and the houseman may score over the chief because of the patient’s afterthoughts.) People who have been previously irreligious may ask to see the chaplain, the decline of the mortal body reminding them about the existence of the immortal soul. Here again we see a generalised disorder of set behaviour patterns, which admittedly probably began with the illness itself, but which becomes more pronounced in unfamiliar surroundings. Those of us who have experienced the displacement syndrome ourselves should be able to recognise it in others and to help them in ways which will demand of us only goodwill and
are
imagination. Well, there you are-to be forewarned is forearmed, and I wish you a quick adjustment and a year of tremendous Let me have your new chief’s carbon copy of this.
success.
him
a
name
and I’ll send
Yours sincerelv,
JANET GOODALL. PS.-Credit for putting a name to this condition goes of my present consultants, Dr. J. A. Black, who anticipated and kindly helped to attenuate my most recent attack.
to one
Conferences ASSOCIATION OF CLINICAL PATHOLOGISTS THE Association met in Jersey on April 21-23. Brief summaries of some of the communications follow. Alcoholism and the Laboratory Dr. JOHN CRAGG said that, in Jersey in 1965, 202 alcoholics were screened in the laboratory; the male to female ratio was 2-2 to 1. 85 of these were hospital outpatients or were admitted to the wards; the laboratory data dealt with this group. Liver tissue obtained either at necropsy or by biopsy showed fatty change in early alcoholism and the anticipated cirrhotic pattern in the later stages. In some of the early cases there were rises in the alkaline phosphatase, either independently or together with raised bilirubin,suggestive of intrahepatic cholestasis; there were also changes in the electrophoretic pattern in half the cases; in many instances the erythrocytesedimentation rate (E.S.R.) was raised and the prothrombin level lowered. In cirrhosis the serum-lipids dropped below normal and the E.s.R. fell further. Sex-chromosome Anomalies Prof. P. E. POLANI said that the frequency of chromosome anomalies was about 1 in 200 to 1 in 250 newborn infants, half the anomalies involving the sex chromosomes. Excluding the more common XXY and XXX abnormal sex complements, various different anomalies could produce ovarian dysgenesis. Among patients with this condition three main clinical categories could be distinguished: those with webbing of the neck
1095 and other major somatic anomalies and a short stature (Turner’s syndrome, about a quarter of all cases), those with short stature and minor somatic abnormalities (over half the cases), and those of normal stature but without somatic anomalies (pure gonadal dysgenesis, over a tenth of the cases). Over 80% of cases in the first clinical group were chromatin-negative and XO, whereas in the second group less than half were XO and the remainder were mostly chromatin-positive with either sex-chromosome mosaicism or structural abnormalities of the X (for instance isochromosome formation of the long arm of the X). Of patients with pure gonadal dysgenesis about a third had a normal XX complement and almost a third had an XY complement or carried an XY cell-line. About 1 in 10,000 women in the general population carried a Y chromosome. Because its presence suggests that testicular tissue might be found in their gonads, and because this appeared to carry a risk of neoplasia and of malignancy, detection of this anomaly was important. Clinical recognition was probably not difficult. In males the Y chromosome seemed to exert in some way a harmful influence when present in double dose, as recent findings in special security institutions among mentally abnormal patients liable to criminal behaviour indicated. Whereas man apparently was relatively tolerant of X-chromosome polysomy, the XO state was badly tolerated. XO persons were very often somatically malformed; and studies of early spontaneous abortions, which indicated that the frequency of XO might be of the order of 0-7% of all conceptions, suggested that in this condition there was a high risk of prenatal deathpossibly of the order of 98°0.
Blood-group Immunisation in Nigeria Dr. SHEILA WORLLEDGE had found that in Ibadan, Nigeria, in the years 1958-61, the ABO group distribution was as follows: A21%, B 23%, AB 4%,052%. ABO haemolytic disease of the newborn appeared to be commoner than in England. In 3% of births there was jaundice that was ascribed to this cause. Neonatal jaundice was found in 10% of all births. 6% of the patients were Rh negative. Anti-D was found in 9 (2-6%) out of 342 Rh-negative antenatal-clinic patients. 6 of these patients had been given Rh-positive blood, and in only 3 were the antibodies the result of the stimulation of pregnancy alone. 14 others had also received Rh-positive blood and had failed to make antibodies in a subsequent pregnancy. There did therefore seem to be a deficiency of anti-D production, at least during pregnancy. " Naturally occurring " antibodies were Anti-Lewis antibodies occurred in 10% of all common. samples. This frequency, however, was similar to that found in Britain, provided the increased incidence of potential antibody producers was allowed for. Anti-N and to a less extent anti-M and anti-S occurred in about 2% of all samples. This raised prevalence could not be explained by differences in
antigen frequency. Chromosomes in Leukaemia
In A
England
Now
Running Commentary by Peripatetic Correspondents
Six jet-hours away-Everywhere a fury of building and construction, huge new hospitals sprout in every town; 40million dollar " complexes " here, 20-million dollar " complexes " there, all completed as a rule within three years. In the United States, I am told, a hospital is old and ripe for
demolition when it has stood for twenty years. The advent of medicare, too, with its increased demand for beds lends urgency to the frenzy of building. The Albert Einstein com" plex (everything is a complex ") in the Bronx covers a huge area. As befits one of the newest and most modernly equipped medical schools in the country, it has lavish provision for research. In buildings so new and so vast that doctors, nurses, and patients constantly lose their way, secretaries at the inquiry desks on each floor don’t know who does what on which floor, nor, for that matter, the names of doctors on the staff. The hive hums. Each department is eager to show its million-dollar equipment. In the basement is an engineering shop which can turn out anything from intricate scientific tools to steel pipes. Patients’ beds can do almost everything except fly the Atlantic. Suspended over each is a television set; by means of a switch at the bedside the patient controls the choice of programme and the quality of reception. Nurses work from a central site resembling the captain’s bridge on a ship. From their desk they can talk to each patient; the patient in turn can communicate with the nurses-all in entire privacy. An arrangement of mirrors enables nurses to look along the corridors opening into the wards. Full-time specialists are increasingly common. A scheme is afoot by which the hospital pays handsome salaries and fringe benefits: in exchange it collects the fees, the whole of which it retains. The medical school, since its inception, has turned out 400 graduates, of whom 2 have elected to go into general practice; one had set out with the obstinate resolve to do just this, the other, it was explained apologetically, had begun his studies at an advanced age. Apparently there is no place for the family doctor. Medicine is too complex for one man to care for the various illnesses that may befall the family. Yet in the congeries of buildings that comprise the typical " complex " there is the familiar sight of patients, like the suppliants in Menotti’s Consul, drearily awaiting their turn to be seen. I have the impression that the ghost of the forgotten man, the patient, haunts these medical palaces. I see readily enough their advantages for the inpatient, but so-called integrated hospital centres, housing almost all medical services for the community-geriatric, obstetric, antenatal, pxdiatric, psychiatric, surgical, and medical-in what amounts to a hospital town, are another matter. Hospitals should be reserved for the services that only hospitals can provide. *
*
*
Dr. SYLVIA D. LAWLER said that examination of the chromoof the cells of the myeloid and lymphocytic series had a variety of karyotypic changes in leukaemia. Chronic granulocytic leukaemia (C.G.L.) remained the only disease with a specific abnormal marker chromosome-a deleted member of the G group, named the Philadelphia (PhI) chromosome. Some patients who had Ph-positive cells were not clinically or hxmatologically typical; but PhI-negative cases were far more heterogeneous. The PhI chromosome was probably present in precursors of all myeloid elements, but the cells of the lymphocytic series were normal. Apart from the Ph chromosome the rest of the karyotype in the chronic phase was usually, but not invariably, normal. The acute terminal stage of c.G.L. was often associated with the appearance of additional chromosome changes in the PhI-positive cells. In other types of acute leukxmia manifold chromosome changes had been described without any specific abnormalities being recognised. Nevertheless a certain pattern in these chromosome changes was now becoming apparent. The lymphocytes in chronic lymphocytic leukaemia almost always had a normal karyotype. somes
revealed
" Can you bring the chairs a little nearer, so that we can talk right up to the microphone ? " said my interviewer. She really was rather a poppet; and there we sat in a cosy little tete a tete a deux, chatting away with our heads separated by just the diameter of a 1 in. hand microphone, sitting beneath the commemorative plaque, in the middle of the vast boardroom, in which the subject of our interview had founded the British Medical Association, with an " engaged " notice firmly affixed to the outside of the door. At the second attempt (after an unintended digression by me which took the first " take " away from our planned sequence of thought), we got a clean tape which ran to exactly the required 21/2 minutes. After a few minutes of mutual congratulation a knock on the door announced the arrival of the film unit, and we were off again. Again I marred the first take, by an error of fact which I corrected as soon as it was made, but we continued from the previous question without stopping the cameras, at the director’s instruction. After a long pause, during which we discussed general topics, such as the economics of television,
fruste
Management largely depends
on
everyone,
including
the victim, recognising the condition, anticipating its manifestations and viewing them optimistically when they appear. It is a help to know that, like postinfluenzal depression, many people get it and most of them recover. Failure to appreciate what is amiss will cause needless worry and misunderstanding. Insight into one’s own character will suggest how the syndrome may present, and forewarn the newcomer to leave the unfavourable comparison unmade, to take a hint without also taking offence, and to be alert to the possibility of judgment being temporarily upset and to ask advice without fearing loss of face. Sweeping reforms are best left unmentioned until proved by time to be essential. For its part, the home team may feel some unconscious antagonism towards the new Dr. X because he has replaced dear Dr. Y, and accordingly seize on any display of temperament as proof that Dr. X is indeed a poor Awareness of this will help to promote substitute. understanding and avoid friction. A senior colleague’s watchful eye may avert serious mistakes and minimise small ones: a refusal to be upset by minor transgressions is a help in fostering good working relationships. The prognosis is good. Although one’s association pathways may feel completely disrupted, it is usual for normal transmission to be resumed after an interval which varies according to the degree of the displacement and the personality of the person displaced. This may be weeks or months, but rarely becomes chronic. If we expect understanding and help ourselves when going through a time of upheaval, it is only reasonable that we should be receptive and encouraging to anyone else who is in a similar position. This will include not only our colleagues, but also many of our patients in whom we probably recognise this particular syndrome less often. Yet for some of them, even a visit to the surgery is a displacement, for the language-and customs-of the place
foreign to them; a hospital admission is even worse, with its uprooting from home and stripping of privacy. Pxdiatric patients commonly voice clearly their disapproval : adults may show more subtly that they feel apprehensive and disturbed, and again symptoms are referrable to each part of the personality. Common physical signs are tachycardia and tremor, or constipation in a patient admitted for diarrhoea. Emotions are labile, and belligerence or tears easily provoked. Seeming deficit of intellect may merely reflect nervousness or embarrassment, and inability to answer a simple question without appending a family saga may be a demonstration of the thought disorder that we have known so well ourselves under other circumstances. (Because of this, a history may be more fruitful when taken for a second time, and the houseman may score over the chief because of the patient’s afterthoughts.) People who have been previously irreligious may ask to see the chaplain, the decline of the mortal body reminding them about the existence of the immortal soul. Here again we see a generalised disorder of set behaviour patterns, which admittedly probably began with the illness itself, but which becomes more pronounced in unfamiliar surroundings. Those of us who have experienced the displacement syndrome ourselves should be able to recognise it in others and to help them in ways which will demand of us only goodwill and
are
imagination. Well, there you are-to be forewarned is forearmed, and I wish you a quick adjustment and a year of tremendous Let me have your new chief’s carbon copy of this.
success.
him
a
name
and I’ll send
Yours sincerelv,
JANET GOODALL. PS.-Credit for putting a name to this condition goes of my present consultants, Dr. J. A. Black, who anticipated and kindly helped to attenuate my most recent attack.
to one
Conferences ASSOCIATION OF CLINICAL PATHOLOGISTS THE Association met in Jersey on April 21-23. Brief summaries of some of the communications follow. Alcoholism and the Laboratory Dr. JOHN CRAGG said that, in Jersey in 1965, 202 alcoholics were screened in the laboratory; the male to female ratio was 2-2 to 1. 85 of these were hospital outpatients or were admitted to the wards; the laboratory data dealt with this group. Liver tissue obtained either at necropsy or by biopsy showed fatty change in early alcoholism and the anticipated cirrhotic pattern in the later stages. In some of the early cases there were rises in the alkaline phosphatase, either independently or together with raised bilirubin,suggestive of intrahepatic cholestasis; there were also changes in the electrophoretic pattern in half the cases; in many instances the erythrocytesedimentation rate (E.S.R.) was raised and the prothrombin level lowered. In cirrhosis the serum-lipids dropped below normal and the E.s.R. fell further. Sex-chromosome Anomalies Prof. P. E. POLANI said that the frequency of chromosome anomalies was about 1 in 200 to 1 in 250 newborn infants, half the anomalies involving the sex chromosomes. Excluding the more common XXY and XXX abnormal sex complements, various different anomalies could produce ovarian dysgenesis. Among patients with this condition three main clinical categories could be distinguished: those with webbing of the neck
1095 and other major somatic anomalies and a short stature (Turner’s syndrome, about a quarter of all cases), those with short stature and minor somatic abnormalities (over half the cases), and those of normal stature but without somatic anomalies (pure gonadal dysgenesis, over a tenth of the cases). Over 80% of cases in the first clinical group were chromatin-negative and XO, whereas in the second group less than half were XO and the remainder were mostly chromatin-positive with either sex-chromosome mosaicism or structural abnormalities of the X (for instance isochromosome formation of the long arm of the X). Of patients with pure gonadal dysgenesis about a third had a normal XX complement and almost a third had an XY complement or carried an XY cell-line. About 1 in 10,000 women in the general population carried a Y chromosome. Because its presence suggests that testicular tissue might be found in their gonads, and because this appeared to carry a risk of neoplasia and of malignancy, detection of this anomaly was important. Clinical recognition was probably not difficult. In males the Y chromosome seemed to exert in some way a harmful influence when present in double dose, as recent findings in special security institutions among mentally abnormal patients liable to criminal behaviour indicated. Whereas man apparently was relatively tolerant of X-chromosome polysomy, the XO state was badly tolerated. XO persons were very often somatically malformed; and studies of early spontaneous abortions, which indicated that the frequency of XO might be of the order of 0-7% of all conceptions, suggested that in this condition there was a high risk of prenatal deathpossibly of the order of 98°0.
Blood-group Immunisation in Nigeria Dr. SHEILA WORLLEDGE had found that in Ibadan, Nigeria, in the years 1958-61, the ABO group distribution was as follows: A21%, B 23%, AB 4%,052%. ABO haemolytic disease of the newborn appeared to be commoner than in England. In 3% of births there was jaundice that was ascribed to this cause. Neonatal jaundice was found in 10% of all births. 6% of the patients were Rh negative. Anti-D was found in 9 (2-6%) out of 342 Rh-negative antenatal-clinic patients. 6 of these patients had been given Rh-positive blood, and in only 3 were the antibodies the result of the stimulation of pregnancy alone. 14 others had also received Rh-positive blood and had failed to make antibodies in a subsequent pregnancy. There did therefore seem to be a deficiency of anti-D production, at least during pregnancy. " Naturally occurring " antibodies were Anti-Lewis antibodies occurred in 10% of all common. samples. This frequency, however, was similar to that found in Britain, provided the increased incidence of potential antibody producers was allowed for. Anti-N and to a less extent anti-M and anti-S occurred in about 2% of all samples. This raised prevalence could not be explained by differences in
antigen frequency. Chromosomes in Leukaemia
In A
England
Now
Running Commentary by Peripatetic Correspondents
Six jet-hours away-Everywhere a fury of building and construction, huge new hospitals sprout in every town; 40million dollar " complexes " here, 20-million dollar " complexes " there, all completed as a rule within three years. In the United States, I am told, a hospital is old and ripe for
demolition when it has stood for twenty years. The advent of medicare, too, with its increased demand for beds lends urgency to the frenzy of building. The Albert Einstein com" plex (everything is a complex ") in the Bronx covers a huge area. As befits one of the newest and most modernly equipped medical schools in the country, it has lavish provision for research. In buildings so new and so vast that doctors, nurses, and patients constantly lose their way, secretaries at the inquiry desks on each floor don’t know who does what on which floor, nor, for that matter, the names of doctors on the staff. The hive hums. Each department is eager to show its million-dollar equipment. In the basement is an engineering shop which can turn out anything from intricate scientific tools to steel pipes. Patients’ beds can do almost everything except fly the Atlantic. Suspended over each is a television set; by means of a switch at the bedside the patient controls the choice of programme and the quality of reception. Nurses work from a central site resembling the captain’s bridge on a ship. From their desk they can talk to each patient; the patient in turn can communicate with the nurses-all in entire privacy. An arrangement of mirrors enables nurses to look along the corridors opening into the wards. Full-time specialists are increasingly common. A scheme is afoot by which the hospital pays handsome salaries and fringe benefits: in exchange it collects the fees, the whole of which it retains. The medical school, since its inception, has turned out 400 graduates, of whom 2 have elected to go into general practice; one had set out with the obstinate resolve to do just this, the other, it was explained apologetically, had begun his studies at an advanced age. Apparently there is no place for the family doctor. Medicine is too complex for one man to care for the various illnesses that may befall the family. Yet in the congeries of buildings that comprise the typical " complex " there is the familiar sight of patients, like the suppliants in Menotti’s Consul, drearily awaiting their turn to be seen. I have the impression that the ghost of the forgotten man, the patient, haunts these medical palaces. I see readily enough their advantages for the inpatient, but so-called integrated hospital centres, housing almost all medical services for the community-geriatric, obstetric, antenatal, pxdiatric, psychiatric, surgical, and medical-in what amounts to a hospital town, are another matter. Hospitals should be reserved for the services that only hospitals can provide. *
*
*
Dr. SYLVIA D. LAWLER said that examination of the chromoof the cells of the myeloid and lymphocytic series had a variety of karyotypic changes in leukaemia. Chronic granulocytic leukaemia (C.G.L.) remained the only disease with a specific abnormal marker chromosome-a deleted member of the G group, named the Philadelphia (PhI) chromosome. Some patients who had Ph-positive cells were not clinically or hxmatologically typical; but PhI-negative cases were far more heterogeneous. The PhI chromosome was probably present in precursors of all myeloid elements, but the cells of the lymphocytic series were normal. Apart from the Ph chromosome the rest of the karyotype in the chronic phase was usually, but not invariably, normal. The acute terminal stage of c.G.L. was often associated with the appearance of additional chromosome changes in the PhI-positive cells. In other types of acute leukxmia manifold chromosome changes had been described without any specific abnormalities being recognised. Nevertheless a certain pattern in these chromosome changes was now becoming apparent. The lymphocytes in chronic lymphocytic leukaemia almost always had a normal karyotype. somes
revealed
" Can you bring the chairs a little nearer, so that we can talk right up to the microphone ? " said my interviewer. She really was rather a poppet; and there we sat in a cosy little tete a tete a deux, chatting away with our heads separated by just the diameter of a 1 in. hand microphone, sitting beneath the commemorative plaque, in the middle of the vast boardroom, in which the subject of our interview had founded the British Medical Association, with an " engaged " notice firmly affixed to the outside of the door. At the second attempt (after an unintended digression by me which took the first " take " away from our planned sequence of thought), we got a clean tape which ran to exactly the required 21/2 minutes. After a few minutes of mutual congratulation a knock on the door announced the arrival of the film unit, and we were off again. Again I marred the first take, by an error of fact which I corrected as soon as it was made, but we continued from the previous question without stopping the cameras, at the director’s instruction. After a long pause, during which we discussed general topics, such as the economics of television,