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METHOHEXITONE-ASSISTED DESENSITISATION FOR PHOBIAS
217 effects of puromycin, penicillamine" and 5-fluorouridine deoxyribose 9 have not yet been tried in human porphyria, though work on animals suggests they have an action similar to that of actinomycin D. Department of Neurology, Royal Infirmary, Manchester M13 9WL.
GEORGE M. YUILL.
ALTERED ANTIGENICITY OF CULTURED MONONUCLEOSIS LYMPHOCYTES SIR.-We read the preliminary communication by Dr. Steel and Dr. Hardy 11 on altered antigenicity of cultured mononucleosis lymphocytes with great interest because we have made a similar observation in 3 patients. cultured acute-phase-monoMitomycin-C-inhibited, nucleosis lymphocytes (c.L.) in mixed cultures (M.L.R.) with fresh peripheral lymphocytes (P.L.), obtained from the same patient 3-9 months after his acute disease, caused a considerable degree of transformation (see accompanying table). STIMULATION CULTURED
OF
PERIPHERAL
AUTOCHTHONOUS LYMPHOCYTES
CONVALESCENT
ACUTE-PHASE
LYMPHOCYTES
BY MONONUCLEOSIS
cytes from the same patient. This suggests that cells acquire these surface antigens while in culture. The question remains whether a clone of mutant cells grows out or whether the antigens are uncovered, newly synthesised, or acquired from the artificial medium. This question should be answered before lymphocyte cell-lines are used for immunotherapy of tumours or drug-resistant chronic infections, as has been proposed.16 Departments of Microbiology, ULRICH JUNGE Rush-Presbyterian-St. Luke’s and JOHN HOEKSTRA University of Illinois Medical Centers, FRIEDRICH DEINHARDT. Chicago, Illinois 60612.
METHOHEXITONE-ASSISTED DESENSITISATION FOR PHOBIAS SIR,-Ishould like to reply to the points raised by Dr. Hussain 17 and Dr. Hamson 18 regarding my report of a controlled trial of methohexitone-assisted desensitisation in the treatment of phobias. 19 Dr. Hussain makes the reasonable point that an element of suggestion is likely to attach to the procedure of intravenous injection, and that this factor may have played some part in contributing to the significantly greater effectiveness of methohexitone desensitisation " (relative to " conventional " desensitisation with muscular relaxation). Unfortunately he seems not to have appreciated the aim of the study, which was to compare two treatment methods currently employed in clinical practice; the relative effectiveness of these had been in dispute, but they had not hitherto been compared directly in a controlled trial. And he has apparently misinterpreted the method of the study-during treatment with methohexitone desensitisation, the intravenous injection of a 1 % solution of methohexitone sodium was substituted for relaxation induction by progressive muscular relaxation, not added to it as Dr. Hussain’s term " double therapy " suggests. Dr. Hussain’s suggested " refinement" of injecting inert substances during the conventional desensitisation sessions would have defeated the practical aim of the work. Furthermore, the results of the experiment he envisages would represent a comparison between the effects of (1) systematic desensitisation plus progressive muscular relaxation plus an intravenous injection per se, and (2) systematic desensitisation plus methohexitone sodium plus an intravenous injection per se-i.e., his proposed design would answer neither my practical question nor his more theoretical one. If Dr. Hussain is planning an investigation, I suggest he should study the elegant design employed by Yorkston et al. 20 and apply it to a mixed phobic population less intransigent than that investigated by these workers. Dr. Hamson suggests that " hypno/auto-hypnosis might be another alternative to muscular relaxation in the desensitisation of phobic patients, stating that the technique she advocates is easy in experienced hands ". I would share her interest in the result of a further trial including this method. Meanwhile the following points should be borne in mind: (1) methohexitone desensitisation is effective even in inexperienced hands (for example, I myself had never used the technique before conducting the trial I reported); (2) certain patients are resistant to hypnosis, but it is impossible to resist the effects of an intravenous barbiturate; and (3) the one direct comparison of hypnosis and conventional systematic desensitisation in the treatment of phobic patients with which I am familiar showed the advantage to lie with the conventional method. 21 "
*
1
Granick, S., Urata, G. J. biol. Chem. 1963, 238, 821. Steel, C. M., Hardy, D. A. Lancet, 1970, i, 1322. Henle, G., Henle, W. J. Bact. 1966, 91, 1248. Spitler, L. E., Fudenberg, H. H. J. Immun. 1970, 104, 544. Junge, U. Proceedings of the Fifth Leukocyte Culture Conference
15.
(in the press). Klein, G., Clifford, P., Klein, E., Stjernsward, J. Proc. Sci. 1966, 55, 1628.
natn
Acad.
"
16. 17. 18. 19. 20. 21.
Moore, G. E. Lancet, 1969, ii, 746. Hussain, Z. ibid. 1970, i, 1291. Hamson, L. ibid. p. 1393. Mawson, A. B. ibid. p. 1084. Yorkston, N. J., Sergeant, H. G. S., Rachman, S. ibid. 1968, ii, 651. Marks, I. M., Gelder, M. G., Edwards, G. Br. J. Psychiat. 1968, 114, 1263.
218
Perhaps the hypnotic procedure used in this investigation not employ the full range of therapeutic components (" post-hypnotic suggestions ", reinforced desensitisation, " appropriate ego-strengthening ", &c.) envisaged by Dr. Hamson. But, in the absence of a controlled trial showing the superiority of hypnosis, I stand by the claim
did
"
that methohexitone-assisted desensitisation is the ment of choice for phobic symptoms. Maudsley Hospital, London S.E.5.
Obituary
"
treat-
A. B. MAWSON.
CONTAMINATION OF DISINFECTANT SOLUTIONS SIR,-Mr. Honigman’s letter (July 11, p. 98) gives a valuable reminder of the inactivation of’Savlon ’ on storage in dilute solution, or on contact with bark cork. Of course, savlon is not unique in needing certain precautions in its use: any chemical disinfectant can be made ineffective and potentially dangerous if incorrectly used. For a choice of disinfectant to be made, it is important for the user to know all the limitations to the effectiveness of the products considered. Because, in theepisode we described, the contamination of 1-in-30 savlon with a pseudomonad was not explicable in terms of prolonged storage of the disinfectant or the use of bark corks, we recorded further experimental observations on the resistance of the organism to savlon. This resistance appeared to be of the adaptive type described by Eddy,2 and, as we described, conferred on the adapted organism a resistance to freshly made 1-in-30 dilutions of savlon in distilled water, so that multiplication continued in the disinfectant. We would have recommended povidone-iodine for preoperative skin preparation in most of the cases mentioned in our paper, rather than alcoholic savlon as suggested by Mr. Honigman, because of the evidence given by Parker3 on the hazard of clostridial infection, and because povidoneiodine applied to a well-cleaned skin might exert some sporicidal action. It has lately been recognised 4 that the name Pseudomonas cepacia is synonymous with and has priority over the name that we quoted, Ps.multivorans. Cross-Infection Reference Laboratory, Central Public Health Laboratory, D. C. J. BASSETT. Colindale, London N.W.9. Croydon and Warlingham Park, Pathology Laboraties Group, J. J. STOKES Mayday Hospital, W. R. G. THOMAS. Thornton Heath, Surrey.
MEDICAL ADVICE FOR HOMOSEXUALS Mr. J. MARTIN STAFFORD, counselling secretary, Committee for Homosexual Equality, BCM/Box 859, London W.C.1, writes: " Among those who approach us with problems arising from the homosexual condition are a few who desire advice from a doctor but are reluctant to consult their own G.P.s, either because of their association with the family or because they fear that revelation of their homosexuality would meet with an unsympathetic reaction. Accordingly, we are seeking to contact G.P.S in all areas of the U.K. whose attitude towards homosexuality is tolerant and informed, and who would be willing to see people whom we referred to them. Their services would be required only very infrequently; it is primarily a matter of knowing that they are there when required. I should be most grateful if I could make known this need through the columns of your journal ". 1.
Bassett, D. C. J., Stokes, J. K., Thomas, W. R. G. Lancet, 1970, i,
2. 3. 4.
Eddy, A. A. Proc. R. Soc. B, 1953, 141, 137. Parker, M. T. Br. med. J. 1969, iii, 671. Ballard, R. W., Palleroni, N. J., Doudoroff, M., Stanier, R. Y., Mandel, M. J. gen. Microbiol. 1970, 60, 199.
1188.
HAROLD WILLIAMS FULLERTON M.A., M.D. Aberd., F.R.C.P., F.R.C.P.E., F.R.C.Path. Dr. H. W. Fullerton, regius professor of medicine in the University of Aberdeen, died on July 14, while on holiday in Jamaica. He was due to retire on Sept. 30, having attained the age of 65. An outstanding pupil at Robert Gordon’s College, Aberdeen, he entered the arts faculty at Aberdeen University in 1922. He gave up, in the junior honours year, a very promising career in mathematics and turned to medicine. He graduated M.A. in 1925, and qualified M.B. with honours in 1931. He proceeded similarly to the M.D. in 1937. After a year as housephysician in Aberdeen Royal Infirmary he became assistant to Sir Stanley Davidson, then professor of medicine at Aberdeen. Thereafter he was a Rockefeller medical fellow and research fellow in medicine at Harvard University in 1933-34 and Beit memorial research fellow in 1934-37. He returned to Aberdeen as lecturer in medicine. He was appointed to the regius chair in 1948. Last year he was president of the Association of Physicians of Great Britain at its meeting in Aberdeen. His main research interest was diseases of the blood, on which he published much work. He is survived by his wife and two daughters.
A. G. D. W. writes: " A
quiet,
reserved man, Professor Fullerton could be
readily approached by students and staff, which was much appreciated, as was his kindly consideration for their interests. A fine clinician, he had great interest and success in the teaching of students and in the training of staff. He will be greatly missed in the medical school where his tall presence had long been familiar. " A keen games player in his youth, he maintained a great interest in cricket, in which he excelled as a fast bowler. His recreations were country walks and classical music. " Our friendship extended over half a century. His absolute honesty and sincerity, his reliability and loyalty, and his ever-ready help in time of need will never be forgotten. He was one of the finest of men."
R. S. A. adds: Harold Fullerton produced notable work in haemato-
"
He was physician, teacher, and for 22 years professor and head of the department of medicine, in Aberdeen, and all of those things he did well. But his greatest achievement was to stay alive and to go on working in the face of repeated illnesses that dogged his whole professional life. In his earlier years he bled time and again, dangerously, from a duodenal ulcer, until eventually a gastrectomy was performed. In middle life an obscure fever drained his strength for years. Towards the end there was a pneumonectomy, from which he did not effectively recover. His friends will remember him for the steady determination with which he stood up to all this. Little wonder that his face could look drawn at times, but it always lit up with a ready smile and a warm sympathetic interest in other people. With a shrug he would dismiss his own troubles from the conversation, or diminish them with a dry ironic
logy.
GEORGE M. YUILL.
ALTERED ANTIGENICITY OF CULTURED MONONUCLEOSIS LYMPHOCYTES SIR.-We read the preliminary communication by Dr. Steel and Dr. Hardy 11 on altered antigenicity of cultured mononucleosis lymphocytes with great interest because we have made a similar observation in 3 patients. cultured acute-phase-monoMitomycin-C-inhibited, nucleosis lymphocytes (c.L.) in mixed cultures (M.L.R.) with fresh peripheral lymphocytes (P.L.), obtained from the same patient 3-9 months after his acute disease, caused a considerable degree of transformation (see accompanying table). STIMULATION CULTURED
OF
PERIPHERAL
AUTOCHTHONOUS LYMPHOCYTES
CONVALESCENT
ACUTE-PHASE
LYMPHOCYTES
BY MONONUCLEOSIS
cytes from the same patient. This suggests that cells acquire these surface antigens while in culture. The question remains whether a clone of mutant cells grows out or whether the antigens are uncovered, newly synthesised, or acquired from the artificial medium. This question should be answered before lymphocyte cell-lines are used for immunotherapy of tumours or drug-resistant chronic infections, as has been proposed.16 Departments of Microbiology, ULRICH JUNGE Rush-Presbyterian-St. Luke’s and JOHN HOEKSTRA University of Illinois Medical Centers, FRIEDRICH DEINHARDT. Chicago, Illinois 60612.
METHOHEXITONE-ASSISTED DESENSITISATION FOR PHOBIAS SIR,-Ishould like to reply to the points raised by Dr. Hussain 17 and Dr. Hamson 18 regarding my report of a controlled trial of methohexitone-assisted desensitisation in the treatment of phobias. 19 Dr. Hussain makes the reasonable point that an element of suggestion is likely to attach to the procedure of intravenous injection, and that this factor may have played some part in contributing to the significantly greater effectiveness of methohexitone desensitisation " (relative to " conventional " desensitisation with muscular relaxation). Unfortunately he seems not to have appreciated the aim of the study, which was to compare two treatment methods currently employed in clinical practice; the relative effectiveness of these had been in dispute, but they had not hitherto been compared directly in a controlled trial. And he has apparently misinterpreted the method of the study-during treatment with methohexitone desensitisation, the intravenous injection of a 1 % solution of methohexitone sodium was substituted for relaxation induction by progressive muscular relaxation, not added to it as Dr. Hussain’s term " double therapy " suggests. Dr. Hussain’s suggested " refinement" of injecting inert substances during the conventional desensitisation sessions would have defeated the practical aim of the work. Furthermore, the results of the experiment he envisages would represent a comparison between the effects of (1) systematic desensitisation plus progressive muscular relaxation plus an intravenous injection per se, and (2) systematic desensitisation plus methohexitone sodium plus an intravenous injection per se-i.e., his proposed design would answer neither my practical question nor his more theoretical one. If Dr. Hussain is planning an investigation, I suggest he should study the elegant design employed by Yorkston et al. 20 and apply it to a mixed phobic population less intransigent than that investigated by these workers. Dr. Hamson suggests that " hypno/auto-hypnosis might be another alternative to muscular relaxation in the desensitisation of phobic patients, stating that the technique she advocates is easy in experienced hands ". I would share her interest in the result of a further trial including this method. Meanwhile the following points should be borne in mind: (1) methohexitone desensitisation is effective even in inexperienced hands (for example, I myself had never used the technique before conducting the trial I reported); (2) certain patients are resistant to hypnosis, but it is impossible to resist the effects of an intravenous barbiturate; and (3) the one direct comparison of hypnosis and conventional systematic desensitisation in the treatment of phobic patients with which I am familiar showed the advantage to lie with the conventional method. 21 "
*
1
Granick, S., Urata, G. J. biol. Chem. 1963, 238, 821. Steel, C. M., Hardy, D. A. Lancet, 1970, i, 1322. Henle, G., Henle, W. J. Bact. 1966, 91, 1248. Spitler, L. E., Fudenberg, H. H. J. Immun. 1970, 104, 544. Junge, U. Proceedings of the Fifth Leukocyte Culture Conference
15.
(in the press). Klein, G., Clifford, P., Klein, E., Stjernsward, J. Proc. Sci. 1966, 55, 1628.
natn
Acad.
"
16. 17. 18. 19. 20. 21.
Moore, G. E. Lancet, 1969, ii, 746. Hussain, Z. ibid. 1970, i, 1291. Hamson, L. ibid. p. 1393. Mawson, A. B. ibid. p. 1084. Yorkston, N. J., Sergeant, H. G. S., Rachman, S. ibid. 1968, ii, 651. Marks, I. M., Gelder, M. G., Edwards, G. Br. J. Psychiat. 1968, 114, 1263.
218
Perhaps the hypnotic procedure used in this investigation not employ the full range of therapeutic components (" post-hypnotic suggestions ", reinforced desensitisation, " appropriate ego-strengthening ", &c.) envisaged by Dr. Hamson. But, in the absence of a controlled trial showing the superiority of hypnosis, I stand by the claim
did
"
that methohexitone-assisted desensitisation is the ment of choice for phobic symptoms. Maudsley Hospital, London S.E.5.
Obituary
"
treat-
A. B. MAWSON.
CONTAMINATION OF DISINFECTANT SOLUTIONS SIR,-Mr. Honigman’s letter (July 11, p. 98) gives a valuable reminder of the inactivation of’Savlon ’ on storage in dilute solution, or on contact with bark cork. Of course, savlon is not unique in needing certain precautions in its use: any chemical disinfectant can be made ineffective and potentially dangerous if incorrectly used. For a choice of disinfectant to be made, it is important for the user to know all the limitations to the effectiveness of the products considered. Because, in theepisode we described, the contamination of 1-in-30 savlon with a pseudomonad was not explicable in terms of prolonged storage of the disinfectant or the use of bark corks, we recorded further experimental observations on the resistance of the organism to savlon. This resistance appeared to be of the adaptive type described by Eddy,2 and, as we described, conferred on the adapted organism a resistance to freshly made 1-in-30 dilutions of savlon in distilled water, so that multiplication continued in the disinfectant. We would have recommended povidone-iodine for preoperative skin preparation in most of the cases mentioned in our paper, rather than alcoholic savlon as suggested by Mr. Honigman, because of the evidence given by Parker3 on the hazard of clostridial infection, and because povidoneiodine applied to a well-cleaned skin might exert some sporicidal action. It has lately been recognised 4 that the name Pseudomonas cepacia is synonymous with and has priority over the name that we quoted, Ps.multivorans. Cross-Infection Reference Laboratory, Central Public Health Laboratory, D. C. J. BASSETT. Colindale, London N.W.9. Croydon and Warlingham Park, Pathology Laboraties Group, J. J. STOKES Mayday Hospital, W. R. G. THOMAS. Thornton Heath, Surrey.
MEDICAL ADVICE FOR HOMOSEXUALS Mr. J. MARTIN STAFFORD, counselling secretary, Committee for Homosexual Equality, BCM/Box 859, London W.C.1, writes: " Among those who approach us with problems arising from the homosexual condition are a few who desire advice from a doctor but are reluctant to consult their own G.P.s, either because of their association with the family or because they fear that revelation of their homosexuality would meet with an unsympathetic reaction. Accordingly, we are seeking to contact G.P.S in all areas of the U.K. whose attitude towards homosexuality is tolerant and informed, and who would be willing to see people whom we referred to them. Their services would be required only very infrequently; it is primarily a matter of knowing that they are there when required. I should be most grateful if I could make known this need through the columns of your journal ". 1.
Bassett, D. C. J., Stokes, J. K., Thomas, W. R. G. Lancet, 1970, i,
2. 3. 4.
Eddy, A. A. Proc. R. Soc. B, 1953, 141, 137. Parker, M. T. Br. med. J. 1969, iii, 671. Ballard, R. W., Palleroni, N. J., Doudoroff, M., Stanier, R. Y., Mandel, M. J. gen. Microbiol. 1970, 60, 199.
1188.
HAROLD WILLIAMS FULLERTON M.A., M.D. Aberd., F.R.C.P., F.R.C.P.E., F.R.C.Path. Dr. H. W. Fullerton, regius professor of medicine in the University of Aberdeen, died on July 14, while on holiday in Jamaica. He was due to retire on Sept. 30, having attained the age of 65. An outstanding pupil at Robert Gordon’s College, Aberdeen, he entered the arts faculty at Aberdeen University in 1922. He gave up, in the junior honours year, a very promising career in mathematics and turned to medicine. He graduated M.A. in 1925, and qualified M.B. with honours in 1931. He proceeded similarly to the M.D. in 1937. After a year as housephysician in Aberdeen Royal Infirmary he became assistant to Sir Stanley Davidson, then professor of medicine at Aberdeen. Thereafter he was a Rockefeller medical fellow and research fellow in medicine at Harvard University in 1933-34 and Beit memorial research fellow in 1934-37. He returned to Aberdeen as lecturer in medicine. He was appointed to the regius chair in 1948. Last year he was president of the Association of Physicians of Great Britain at its meeting in Aberdeen. His main research interest was diseases of the blood, on which he published much work. He is survived by his wife and two daughters.
A. G. D. W. writes: " A
quiet,
reserved man, Professor Fullerton could be
readily approached by students and staff, which was much appreciated, as was his kindly consideration for their interests. A fine clinician, he had great interest and success in the teaching of students and in the training of staff. He will be greatly missed in the medical school where his tall presence had long been familiar. " A keen games player in his youth, he maintained a great interest in cricket, in which he excelled as a fast bowler. His recreations were country walks and classical music. " Our friendship extended over half a century. His absolute honesty and sincerity, his reliability and loyalty, and his ever-ready help in time of need will never be forgotten. He was one of the finest of men."
R. S. A. adds: Harold Fullerton produced notable work in haemato-
"
He was physician, teacher, and for 22 years professor and head of the department of medicine, in Aberdeen, and all of those things he did well. But his greatest achievement was to stay alive and to go on working in the face of repeated illnesses that dogged his whole professional life. In his earlier years he bled time and again, dangerously, from a duodenal ulcer, until eventually a gastrectomy was performed. In middle life an obscure fever drained his strength for years. Towards the end there was a pneumonectomy, from which he did not effectively recover. His friends will remember him for the steady determination with which he stood up to all this. Little wonder that his face could look drawn at times, but it always lit up with a ready smile and a warm sympathetic interest in other people. With a shrug he would dismiss his own troubles from the conversation, or diminish them with a dry ironic
logy.