399 should be obtained from different places. However, on the basis of the paper of Allwright et al. and my own as yet
unpublished observations, I believe that the " water story will probably prove to be a work of fiction. 201 Wickham
"
Terrace,
Brisbane 4000, Australia.
DEREK MEYERS.
VAGOTOMY SIR,-Iwas pleased to see that you once again (Jan. 18, p. 149) enumerated the advantages of proximal gastric vagotomy (P.G.v.) over other forms of vagotomy for duodenal ulcer. In fact there seems little justification for continuing with truncal vagotomy so long after the Leeds/ York trial1 showed it to be inferior to other procedures. However, after having stated the advantages of no drainage, you then assert that " the surgeon need have few qualms about doing such a procedure ". The obstruction to outflow from the stomach may be due to active ulceration with acute inflammation and cedema as well as scarring. It is well known that even after medical treatment alone, gastric emptying can improve, and Johnston et al.have already shown that over 90% of patients with radiologically proved pyloric stenosis have nearly normal gastric emptying one year after P.G.v. and no drainage. In my own experience of a similar number of cases I can confirm this observation. Similar improvement may occur after vagotomy for fibrous peptic stricture of the oesophagus.3 I would hope, therefore, that all surgeons would have considerable qualms before performing such an irreversible operation. It is surely better to add a pyloroplasty later if no improvement occurs than to perform an unnecessary procedure on maybe 90% of the patients. You should have given more emphasis to the need to achieve a complete vagotomy before considering the rarer cause of recurrence, G-cell hyperplasia. No-one is certain what role circulating gastrin plays in recurrence after vagotomy and, after all, adding a vagotomy to an antrectomy increases the level of circulating gastrin whilst decreasing the risk of recurrence. As Cox4 "and others have often stated, recurrence after vagotomy is almost always due to incomplete vagotomy". If the surgeon cannot achieve a complete vagotomy, and the results suggest that most do not, then he should use an intraoperative test before he thinks about routine gastrin assays. While the treatment of gastric ulcer by P.G.v. is more controversial, you should not lose sight of the fact that the aim of the operation is to prevent recurrence, not to remove an ulcer. Since the natural history of gastric ulcer is one of healing and recurrence, operating when the ulcer is healing does not mean that it is setiologically different from a large active ulcer. " Finally, is an acute bleed an unsuitable situation " for P.G.v. if it proves to be the best operation for duodenal ulcer as suggested by the evidence published so far ? You suggest that " the need is for a quick operation ". I would suggest that time can be saved by not delaying the decision to operate in those requiring operation. Then the surgeon, as the first manoeuvre, should underrun the bleeding vessel, preferably via a duodenotomy. Once this is accomplished there is ample time to perform the proper operation. Charing Cross Hospital (Fulham), .
Fulham Palace Road, London W6 8RF.
A. H. AMERY.
1.
Goligher, J. C., Pulvercraft, C. N., de Dombal, F. T., Conyers, J. H., Duthie, H. L., Feather, D. B., Latchmore, A. J. C., Harrop Shoesmith, J., Smiddy, F. G., Willson-Pepper, J. Br. med. J. 1968, ii,
2.
Johnston, D., Lyndon, P. J., Smith, R. B., Humphrey, C. S. Br. J. Surg. 1973, 60, 790. Burge, H., Amery, A. H. Ann. R. Coll. Surg. 1974, 53, 189. Cox, A. G. in Vagotomy on Trial (edited by A. G. Cox and J. Alexander-Williams); p. 69. London, 1973.
781.
3. 4.
SiR,—Ifound your leading article (Jan. 18, p. 149) very interesting. I am a Greek surgeon with a special interest in gastric surgery. I came to England 8 months ago and have been privileged to work with Mr Harold Burge at Charing Cross Hospital. During this time highly selective vagotomy without drainage has been used for all cases of duodenal and gastric ulcers, with the electrical stimulation test. I have carried out long-term follow-up studies of his patients. This operation is technically simple and quick and easily learnt by the junior surgeon. The use of the Burge test is essential and very simple. Even Mr Burge fails not infrequently to achieve complete section. Sometimes two and three attempts must be made before the test proves complete nerve section. In the hands of less experienced surgeons the incidence of incomplete vagotomy is high. There is strong evidence that ulceration does not recur if nerve section is complete. To report recurrence-rates is unsatisfactory unless the test has proved complete nerve section. In my opinion, however, the use of highly selective vagotomy without drainage both for duodenal and gastric ulcer with the Burge test is probably the greatest recent advance in gastric surgery. Charing Cross Hospital (Fulham), Fulham Palace Road, London W6 8RF.
NICOLAS MAKRIS.
PROSTAGLANDINS AND ASTHMA SIR,-Work in our laboratory 1,2 has shown that the
contracting guineapig trachea, in vitro, releases a mixture of P.G.F2,, and p.G.B2. The release is probably a result of the mechanical event of contraction. Release can also be elicited by gentle stimulation of the tracheal mucosa but not of the adventitia. Pretreatment of the guineapig trachea with indomethacin and other prostaglandin-synthesis-inhibiting drugs reduces the spontaneous tone of the trachea, decreases the response to low doses of contractile agonists, and increases the response to high doses of these agonists. We have concluded from these results that, in the guineapig trachea, contraction results in prostaglandin release and that the released prostaglandins modulate the response to contractile agonists. We have not been able to demonstrate an effect of indomethacin on airway responses to histamine in guineapigs in vivo.3 The methods available for in-vivo animal studies (recordings of dynamic compliance and pulmonary resistance 4) are probably not sensitive enough to detect any in-vivo counterpart of the changes in slope of dose-response curves to agonists which we observed in vitro. Dr Smith and Dr Dunlop (Jan. 4, p. 39) conclude from their results that indomethacin does not affect antigeninduced or exercise-induced asthma in man. However, they used the F.E.V.1.0to assess the airway constrictor responses, and this is a relatively insensitive method.5 Until experiments along these lines are performed with sensitive methods suchas recording of partial expiratory flowvolume curves6 one cannot exclude that prostaglandin release in airway tissue may modulate airway constrictor responses in man. Our ability to detect subtle changes in airway responses induced by drugs is probably better in man than in animals. Several sensitive function tests which 1. 2. 3.
4.
5. 6.
Orehek, J., Douglas, J. S., Lewis, A. J., Bouhuys, A. Nature New Biology, 1973, 245, 84. Orehek, J., Douglas, J. S., Bouhuys, A. Unpublished. Bouhuys, A., Brink, C., Douglas, J. S., Finch, P. J. P. Fedn Proc. 1975 (in the press). Dennis, M. W., Douglas, J. S., Casby, J. U., Stolwijk, J. A. J., Bouhuys, A. J. appl. Physiol. 1969, 26, 248. Bouhuys, A., Mitchell, C. A., Schilling, R. S. F., Zuskin, E. Trans. N.Y. Acad. Sci. 1973, 35, 537. Bouhuys, A. Breathing—Physiology, Environment and Lung Disease; p. 174. New York, 1974.
400
require voluntary breathing
manoeuvres can
only be
used
in man. Yale University, Lung Research Center, 333 Cedar Street, New Haven, Connecticut 06510, U.S.A.
AREND BOUHUYS.
ORAL BACTERIAL VACCINE AND COLDS SIR,-Ishould like to support Dr Tyrrell’s suggestion (Jan. 11, p. 108) that the potential protective effect of vaccines administered intranasally for the prevention of respiratory-tract infections is worth consideration. There is a growing volume of evidence that antigens applied to the respiratory mucosa stimulate an immune response to the secretions (as I have observed in influenzaand whoopingcough 2). Protection against influenza using a " live " intranasal vaccine appears to be imminent, but it is unlikely that the research effort that has been applied to that problem will be given to producing similar " live " intranasal vaccines for the less serious respiratory infections. Injectable polyvaccines are known to be effective, so that the simultaneous administration of multiple antigens does not appear to interfere significantly with the stimulation of a humoral response to the individual components. A similar responsivity in the respiratory mucosa may be postulated for intranasally administered antigens. This raises the possibility of an intranasal polyvalent vaccine made up of the commoner viral and bacterial agents which cause (or complicate) upper-respiratory-tract infections. Their number, which can cause the common-cold syndrome, for example, is legion, and quantity production of most of them would present formidable difficulties. However, epidemiological studies would help to solve the first of these problems, and the demonstration of protective efficacy would be a powerful stimulus to solve the second. 5 Topferstrasse, 6004 Lucerne, Switzerland.
GERALD THOMAS.
CLINICAL TRIALS WITH VITAMIN C
SiR,—The data of Dr Briggs (Nov. 16, p. 1211) do not really clarify the issue of the optimum dose (if any) for the assumed anti-" cold " effect of vitamin C. In fact, owing to the small number of subjects involved (61 altogether), the observed difference (11%) between the percentage of subjects cold-free in the 1 g. per day group (43%) and in the 50 mg. per day group (54%) estimates a true difference that may be anything, at the 95% confidence level, from 36% in favour of the 50 mg. schedule to a 14% in the opposite direction-i.e., in favour of the 1 g. schedule. It should be obvious that the smaller the trial the more likely is a verdict of no difference or " equivalence " of two doses. Some approximate sample-size arithmetic3 shows that in a trial like the one reported (with. say, 30 subjects per group, a response-rate of 50%, an average number of days of cold per person of 1-7 with an assumed standard deviation of 1 -5) one has a fairly good chance of detecting as statistically significant only large differences, such as an increase in the percentage of subjects cold-free from 50% to 80% or more or a reduction by 60% or more in the number of days of cold per person. This is well beyond the size of the possible effect of vitamin C so far reported in most studies. 4-7 G. IV International Symposium of Aerobiology, 1973. G. J. Hyg., Camb. (in the press). 3. Mace, A. E. Sample Size Determination. New York, 1964. 4. Anderson, T. W., Reid, D. B. W., Beaton, G. H. Can. med. Ass. J. 1. 2.
Thomas, Thomas,
1972, 107, 503. 5. Wilson, C. W. M., Loh, H. S. Lancet, 1973, i, 638. 6. Coulehan, J. L., Reisinger, K. S., Rogers, K. D., Bradley, D. W. New Engl. J. Med. 1974, 290, 6. 7. Saracci, R., Bardelli, D., Mariani, F. Unpublished.
In the light of the available knowledge, small-scale trials seem wholly inadequate to provide evidence of the effect of vitamin C on the symptoms and signs of colds and to the dose range.
more
refined task of identifying an optimum
Section of Clinical Epidemiology and Biostatistics, C.N.R. Laboratory for Clinical Physiology, University of Pisa,
Italy.
R. SARACCI D. BARDELLI F. MARIANI.
PIMOZIDE IN MONOSYMPTOMATIC PSYCHOSIS
SIR,-We wish to report our recent experience of pimozide (’Orap’, Janssen) as an apparently specific treatment of monosymptomatic psychosis. This type of disorder presents many diagnostic problems and can often be regarded as lying somewhere along the paranoia/paraphrenia/paranoid-schizophrenia axis. In the past two years we have seen 5 patients who each had a single hypochondriacal complaint of delusional intensity. Such cases, whatever their aetiology, often have In our patients the xtiologies have a bad prognosis. probably been diverse although the end-state has been fairly characteristic. The patient is in clear consciousness; he has a single hypochondriacal delusion; and his personality appears otherwise quite intact, although his way of life has usually been profoundly affected by the delusion. In our small series the ages have varied widely (4 men aged 20, 20, 42, and 57, and a woman aged 80). The aetiologies were also varied: the 2 youngest patients may be schizophrenic, the 42-year-old has a previous history of heavy alcohol consumption, and the 57-year-old is on steroids for a protein-losing enteropathy. The elderly lady had peripheral arteriosclerosis though no clinical evidence of dementia. The presenting symptoms ranged from the complaint that an offensive bowel odour was causing ostracisation, through complaints of oddness of appearance, to 2 cases in which the patients complained of parasitic infestation. In no instance was there objective evidence of physical disorder. One of the 20-year-old men had already had a rhinoplasty and had then begun to complain that his neck was overlong. In every case the exhibition of normal doses of pimozide (ranging from 2 to 6 mg. daily in one morning dose) produced rapid remission of the complaint. Even where the delusion did not totally disappear, social adjustment improved markedly, and each patient was able to return within days
or
weeks to
a
much
more
normal life.
One
patient (the man aged 42) has since had two depressive episodes which have been successfully treated, but his delusion has never returned apart from a short period when he had spontaneously stopped taking pimozide. A 6th patient, a youth of 18 with a persistent complaint that his nose was overlong, received no benefit from pimozide and complained of severe tension symptoms while taking it. He differed from the other cases in that we regarded his diagnosis as one of personality disorder with dysmorphophobia, and he has subsequently done quite well with plastic surgery and simple supportive psychotherapy. We therefore suggest that pimozide may be an effective treatment for monosymptomatic psychoses, a group of disorders traditionally difficult to treat, and the response appears to be fairly independent of the primary cause of the psychosis. In addition, pimozide may differentiate rapidly between cases of monosymptomatic psychosis with dysmorphic delusions and superficially similar cases of dysmorphophobia due to neurotically determined factors. We intend to pursue this line of investigation further. Like Sim,l we suspect that these cases are commoner than 1.
Sim, M.
A Guide to
Psychiatry; p. 593. Edinburgh, 1974.
unpublished observations, I believe that the " water story will probably prove to be a work of fiction. 201 Wickham
"
Terrace,
Brisbane 4000, Australia.
DEREK MEYERS.
VAGOTOMY SIR,-Iwas pleased to see that you once again (Jan. 18, p. 149) enumerated the advantages of proximal gastric vagotomy (P.G.v.) over other forms of vagotomy for duodenal ulcer. In fact there seems little justification for continuing with truncal vagotomy so long after the Leeds/ York trial1 showed it to be inferior to other procedures. However, after having stated the advantages of no drainage, you then assert that " the surgeon need have few qualms about doing such a procedure ". The obstruction to outflow from the stomach may be due to active ulceration with acute inflammation and cedema as well as scarring. It is well known that even after medical treatment alone, gastric emptying can improve, and Johnston et al.have already shown that over 90% of patients with radiologically proved pyloric stenosis have nearly normal gastric emptying one year after P.G.v. and no drainage. In my own experience of a similar number of cases I can confirm this observation. Similar improvement may occur after vagotomy for fibrous peptic stricture of the oesophagus.3 I would hope, therefore, that all surgeons would have considerable qualms before performing such an irreversible operation. It is surely better to add a pyloroplasty later if no improvement occurs than to perform an unnecessary procedure on maybe 90% of the patients. You should have given more emphasis to the need to achieve a complete vagotomy before considering the rarer cause of recurrence, G-cell hyperplasia. No-one is certain what role circulating gastrin plays in recurrence after vagotomy and, after all, adding a vagotomy to an antrectomy increases the level of circulating gastrin whilst decreasing the risk of recurrence. As Cox4 "and others have often stated, recurrence after vagotomy is almost always due to incomplete vagotomy". If the surgeon cannot achieve a complete vagotomy, and the results suggest that most do not, then he should use an intraoperative test before he thinks about routine gastrin assays. While the treatment of gastric ulcer by P.G.v. is more controversial, you should not lose sight of the fact that the aim of the operation is to prevent recurrence, not to remove an ulcer. Since the natural history of gastric ulcer is one of healing and recurrence, operating when the ulcer is healing does not mean that it is setiologically different from a large active ulcer. " Finally, is an acute bleed an unsuitable situation " for P.G.v. if it proves to be the best operation for duodenal ulcer as suggested by the evidence published so far ? You suggest that " the need is for a quick operation ". I would suggest that time can be saved by not delaying the decision to operate in those requiring operation. Then the surgeon, as the first manoeuvre, should underrun the bleeding vessel, preferably via a duodenotomy. Once this is accomplished there is ample time to perform the proper operation. Charing Cross Hospital (Fulham), .
Fulham Palace Road, London W6 8RF.
A. H. AMERY.
1.
Goligher, J. C., Pulvercraft, C. N., de Dombal, F. T., Conyers, J. H., Duthie, H. L., Feather, D. B., Latchmore, A. J. C., Harrop Shoesmith, J., Smiddy, F. G., Willson-Pepper, J. Br. med. J. 1968, ii,
2.
Johnston, D., Lyndon, P. J., Smith, R. B., Humphrey, C. S. Br. J. Surg. 1973, 60, 790. Burge, H., Amery, A. H. Ann. R. Coll. Surg. 1974, 53, 189. Cox, A. G. in Vagotomy on Trial (edited by A. G. Cox and J. Alexander-Williams); p. 69. London, 1973.
781.
3. 4.
SiR,—Ifound your leading article (Jan. 18, p. 149) very interesting. I am a Greek surgeon with a special interest in gastric surgery. I came to England 8 months ago and have been privileged to work with Mr Harold Burge at Charing Cross Hospital. During this time highly selective vagotomy without drainage has been used for all cases of duodenal and gastric ulcers, with the electrical stimulation test. I have carried out long-term follow-up studies of his patients. This operation is technically simple and quick and easily learnt by the junior surgeon. The use of the Burge test is essential and very simple. Even Mr Burge fails not infrequently to achieve complete section. Sometimes two and three attempts must be made before the test proves complete nerve section. In the hands of less experienced surgeons the incidence of incomplete vagotomy is high. There is strong evidence that ulceration does not recur if nerve section is complete. To report recurrence-rates is unsatisfactory unless the test has proved complete nerve section. In my opinion, however, the use of highly selective vagotomy without drainage both for duodenal and gastric ulcer with the Burge test is probably the greatest recent advance in gastric surgery. Charing Cross Hospital (Fulham), Fulham Palace Road, London W6 8RF.
NICOLAS MAKRIS.
PROSTAGLANDINS AND ASTHMA SIR,-Work in our laboratory 1,2 has shown that the
contracting guineapig trachea, in vitro, releases a mixture of P.G.F2,, and p.G.B2. The release is probably a result of the mechanical event of contraction. Release can also be elicited by gentle stimulation of the tracheal mucosa but not of the adventitia. Pretreatment of the guineapig trachea with indomethacin and other prostaglandin-synthesis-inhibiting drugs reduces the spontaneous tone of the trachea, decreases the response to low doses of contractile agonists, and increases the response to high doses of these agonists. We have concluded from these results that, in the guineapig trachea, contraction results in prostaglandin release and that the released prostaglandins modulate the response to contractile agonists. We have not been able to demonstrate an effect of indomethacin on airway responses to histamine in guineapigs in vivo.3 The methods available for in-vivo animal studies (recordings of dynamic compliance and pulmonary resistance 4) are probably not sensitive enough to detect any in-vivo counterpart of the changes in slope of dose-response curves to agonists which we observed in vitro. Dr Smith and Dr Dunlop (Jan. 4, p. 39) conclude from their results that indomethacin does not affect antigeninduced or exercise-induced asthma in man. However, they used the F.E.V.1.0to assess the airway constrictor responses, and this is a relatively insensitive method.5 Until experiments along these lines are performed with sensitive methods suchas recording of partial expiratory flowvolume curves6 one cannot exclude that prostaglandin release in airway tissue may modulate airway constrictor responses in man. Our ability to detect subtle changes in airway responses induced by drugs is probably better in man than in animals. Several sensitive function tests which 1. 2. 3.
4.
5. 6.
Orehek, J., Douglas, J. S., Lewis, A. J., Bouhuys, A. Nature New Biology, 1973, 245, 84. Orehek, J., Douglas, J. S., Bouhuys, A. Unpublished. Bouhuys, A., Brink, C., Douglas, J. S., Finch, P. J. P. Fedn Proc. 1975 (in the press). Dennis, M. W., Douglas, J. S., Casby, J. U., Stolwijk, J. A. J., Bouhuys, A. J. appl. Physiol. 1969, 26, 248. Bouhuys, A., Mitchell, C. A., Schilling, R. S. F., Zuskin, E. Trans. N.Y. Acad. Sci. 1973, 35, 537. Bouhuys, A. Breathing—Physiology, Environment and Lung Disease; p. 174. New York, 1974.
400
require voluntary breathing
manoeuvres can
only be
used
in man. Yale University, Lung Research Center, 333 Cedar Street, New Haven, Connecticut 06510, U.S.A.
AREND BOUHUYS.
ORAL BACTERIAL VACCINE AND COLDS SIR,-Ishould like to support Dr Tyrrell’s suggestion (Jan. 11, p. 108) that the potential protective effect of vaccines administered intranasally for the prevention of respiratory-tract infections is worth consideration. There is a growing volume of evidence that antigens applied to the respiratory mucosa stimulate an immune response to the secretions (as I have observed in influenzaand whoopingcough 2). Protection against influenza using a " live " intranasal vaccine appears to be imminent, but it is unlikely that the research effort that has been applied to that problem will be given to producing similar " live " intranasal vaccines for the less serious respiratory infections. Injectable polyvaccines are known to be effective, so that the simultaneous administration of multiple antigens does not appear to interfere significantly with the stimulation of a humoral response to the individual components. A similar responsivity in the respiratory mucosa may be postulated for intranasally administered antigens. This raises the possibility of an intranasal polyvalent vaccine made up of the commoner viral and bacterial agents which cause (or complicate) upper-respiratory-tract infections. Their number, which can cause the common-cold syndrome, for example, is legion, and quantity production of most of them would present formidable difficulties. However, epidemiological studies would help to solve the first of these problems, and the demonstration of protective efficacy would be a powerful stimulus to solve the second. 5 Topferstrasse, 6004 Lucerne, Switzerland.
GERALD THOMAS.
CLINICAL TRIALS WITH VITAMIN C
SiR,—The data of Dr Briggs (Nov. 16, p. 1211) do not really clarify the issue of the optimum dose (if any) for the assumed anti-" cold " effect of vitamin C. In fact, owing to the small number of subjects involved (61 altogether), the observed difference (11%) between the percentage of subjects cold-free in the 1 g. per day group (43%) and in the 50 mg. per day group (54%) estimates a true difference that may be anything, at the 95% confidence level, from 36% in favour of the 50 mg. schedule to a 14% in the opposite direction-i.e., in favour of the 1 g. schedule. It should be obvious that the smaller the trial the more likely is a verdict of no difference or " equivalence " of two doses. Some approximate sample-size arithmetic3 shows that in a trial like the one reported (with. say, 30 subjects per group, a response-rate of 50%, an average number of days of cold per person of 1-7 with an assumed standard deviation of 1 -5) one has a fairly good chance of detecting as statistically significant only large differences, such as an increase in the percentage of subjects cold-free from 50% to 80% or more or a reduction by 60% or more in the number of days of cold per person. This is well beyond the size of the possible effect of vitamin C so far reported in most studies. 4-7 G. IV International Symposium of Aerobiology, 1973. G. J. Hyg., Camb. (in the press). 3. Mace, A. E. Sample Size Determination. New York, 1964. 4. Anderson, T. W., Reid, D. B. W., Beaton, G. H. Can. med. Ass. J. 1. 2.
Thomas, Thomas,
1972, 107, 503. 5. Wilson, C. W. M., Loh, H. S. Lancet, 1973, i, 638. 6. Coulehan, J. L., Reisinger, K. S., Rogers, K. D., Bradley, D. W. New Engl. J. Med. 1974, 290, 6. 7. Saracci, R., Bardelli, D., Mariani, F. Unpublished.
In the light of the available knowledge, small-scale trials seem wholly inadequate to provide evidence of the effect of vitamin C on the symptoms and signs of colds and to the dose range.
more
refined task of identifying an optimum
Section of Clinical Epidemiology and Biostatistics, C.N.R. Laboratory for Clinical Physiology, University of Pisa,
Italy.
R. SARACCI D. BARDELLI F. MARIANI.
PIMOZIDE IN MONOSYMPTOMATIC PSYCHOSIS
SIR,-We wish to report our recent experience of pimozide (’Orap’, Janssen) as an apparently specific treatment of monosymptomatic psychosis. This type of disorder presents many diagnostic problems and can often be regarded as lying somewhere along the paranoia/paraphrenia/paranoid-schizophrenia axis. In the past two years we have seen 5 patients who each had a single hypochondriacal complaint of delusional intensity. Such cases, whatever their aetiology, often have In our patients the xtiologies have a bad prognosis. probably been diverse although the end-state has been fairly characteristic. The patient is in clear consciousness; he has a single hypochondriacal delusion; and his personality appears otherwise quite intact, although his way of life has usually been profoundly affected by the delusion. In our small series the ages have varied widely (4 men aged 20, 20, 42, and 57, and a woman aged 80). The aetiologies were also varied: the 2 youngest patients may be schizophrenic, the 42-year-old has a previous history of heavy alcohol consumption, and the 57-year-old is on steroids for a protein-losing enteropathy. The elderly lady had peripheral arteriosclerosis though no clinical evidence of dementia. The presenting symptoms ranged from the complaint that an offensive bowel odour was causing ostracisation, through complaints of oddness of appearance, to 2 cases in which the patients complained of parasitic infestation. In no instance was there objective evidence of physical disorder. One of the 20-year-old men had already had a rhinoplasty and had then begun to complain that his neck was overlong. In every case the exhibition of normal doses of pimozide (ranging from 2 to 6 mg. daily in one morning dose) produced rapid remission of the complaint. Even where the delusion did not totally disappear, social adjustment improved markedly, and each patient was able to return within days
or
weeks to
a
much
more
normal life.
One
patient (the man aged 42) has since had two depressive episodes which have been successfully treated, but his delusion has never returned apart from a short period when he had spontaneously stopped taking pimozide. A 6th patient, a youth of 18 with a persistent complaint that his nose was overlong, received no benefit from pimozide and complained of severe tension symptoms while taking it. He differed from the other cases in that we regarded his diagnosis as one of personality disorder with dysmorphophobia, and he has subsequently done quite well with plastic surgery and simple supportive psychotherapy. We therefore suggest that pimozide may be an effective treatment for monosymptomatic psychoses, a group of disorders traditionally difficult to treat, and the response appears to be fairly independent of the primary cause of the psychosis. In addition, pimozide may differentiate rapidly between cases of monosymptomatic psychosis with dysmorphic delusions and superficially similar cases of dysmorphophobia due to neurotically determined factors. We intend to pursue this line of investigation further. Like Sim,l we suspect that these cases are commoner than 1.
Sim, M.
A Guide to
Psychiatry; p. 593. Edinburgh, 1974.
