478
episodes with amenorrhoea, hot flushes, high F.S.H. levels, and low urinary oestrogens were followed by menstrual cycles in which the F.s.H. levels were low and there was an ovulatory pattern of oestrogen excretion. On several occasions they observed an unusual association of high urinary oestrogens with high gonadotrophin levels. Clearly pituitary and ovarian function can vary considerably (and not always in phase) in a woman approaching the menopause. and
failed to provide her with a yes/no answer. Perhaps her disappointment will encourage further studies of ovarian function in perimenopausal women.
pregnanediol
important that the patient is given the coradvice. On the one hand, if her fertility is underestimated, she may have to cope with an unexpected addition to her family, at an age when the risks associated with pregnancy are increased. Ori the other hand, the risks of oral contraception also increase with age,18 and other contraceptive methods are not without their complications. 19 Admittedly, for the increasing number of couples who have undergone vasectomy or tubal ligation, the question is of minor importance. A further consideration for the doctor is whether the patient’s secondary amenorrhoea is due to the menopause or there is some other explanation such as pregnancy, It is
rect
post-pill amenorrhoea, 20 or hyperprolactinæmia21 or other endocrine disorders. The knowledge that the average age of the menopause in most European communities is about 5 07,22 and that persistent anovulation is uncommon under the age of 453 assists in selection of patients for further investigation. The following guidelines are suggested. Regular menstruation implies regular ovulation irrespective of the patient’s age. However, conception is rare after the age of 50 and extremely rare after the age of 52. Women under the age of 50 who have amenorrhoea of more than a year’s duration (some would say 2 years) are very unlikely to ovulate subsequently. If hormonal evidence of ovulation is required, a pregnanediol estimation on a random sample of urine on day 21 of the cycle provides useful confirmation. Alternative diagnoses should be considered in women under the age of 45 presenting with secondary amenorrhoea. Persistently raised plasma-F.s.H. values suggest primary ovarian failure (at least at the time of sampling) and indicate that other investigations are likely to be unproductive. If the plasma-F.s.H. is not raised, then other explanations should be sought and measurement of plasma-prolactin should be considered. Our
patient
is
disappointed because
we
have
among Medical Patients
Psychiatric Illness
LiPOWSKi’ estimated that 30-60% of medical inpatients and 50-80% of medical outpatients have psychiatric illness severe enough to demand special attention. Until lately investigators have used widely differing criteria for what constitutes a psychiatric case, but with the arrival of psychiatric screening tests and standardised diagnostic research interviews comparisons become possible. GLASSand his colleagues2 applied the Hopkins Symptom Checklist and a psychiatric research interview to 82 medical outpatients attending the University of Chicago Hospitals, and used the FEIGHNER criteria3to diagnose psychiatric illness. The symptom checklist was not very helpful in separating psychiatrically ill from well patients, but the investigators made psychiatric diagnoses in no fewer than 83% of the patients. These workers
that the mean checklist scores were similar to those found by GOLDBERG 4,1 for patients attending general practitioners in Philadelphia, yet in that survey the prevalence of psychiatric illness was only 25%. In Philadelphia the illnesses were diagnosed with the Clinical Interview Schedule6 designed at the Institute of Psychiatry, London. Since in both surveys most of the diagnoses were of minor affective disorder, the British criteria are presumably narrower that those of FEIGHNER. The rather lower prevalence figures found by British investigators among medical outpatients would be consistent with this: CULPAN and DAVIES7 detected psychiatric illness in 31% of newly referred patients to Dulwich Hospital, and GOLDBERG8 in 34% of patients with diseases of the small intestine attending a follow-up clinic at St. Thomas’. These rates are close to those in patients attending a general practitioner5,9 and are substantially higher than those in note
the community at large.
10,11 investigators have used standardised case-finding techniques on medical inpatients, Several
Lipowski, Z. J. Psychosom. Med. 1967, 29, 201. Glass, R., Allan, A., Uhlenhuth, E., Kimball, C., Borinstein, D. Archs gen. Psychiat. 1978, 35, 1189. 3. Feighner, J. P., Robins, E., Guze, S. B. ibid. 1972, 26, 57. 4. Goldberg, D. Detection of Psychiatric Illness by Questionnaire. London. 1. 2.
1974. 5.
of General Practitioners Oral Contraception Study. Lancet, 1977, ii, 727. 19. Vessey, M., Doll, R., Peto, R., Johnson, B., Wiggins, P. J biosoc. Sci. 1976, 8, 373. 20. Shearman, R. Lancet, 1971, ii, 64. 21. Thorner, M. O., McNeilly, A. S., Hagan, C., Besser, G. M. Br. med. J. 1974, ii, 419. 22. Burch, P. R. J., Gunz, F W. N.Z. med J. 1967, 66, 6 18.
Royal College
Goldberg, D., Rickels, K., Downing, R., Hesbacher, P. Br J. Psychiat. 1976, 129, 61. 6. Goldberg, D., Cooper, B., Eastwood, M. R., Kedward, H. B., Shepherd, M Brit. J. prev. soc. Med. 1970, 24, 18.
Culpan, R , Davies, B Comprehens. Psychiat 1960, 1, 228. Goldberg, D. Gut, 1970, 11, 459. Goldberg, D., Blackwell, B. Br. med J. 1970, ii, 439. 10. Goldberg, D., Kay, C., Thompson, L Psychol Med 1976, 6, 565. 11. Culpan, R., Davies, B. M., Oppenheim, A. N. Br med. J. 1960, i, 855. 7. 8 9.
479
MAGUIRE and his colleaguesl2 at Oxford used the General Health Questionnaires as a screening test and found that 23% were psychiatrically ill at subsequent interview, while other workers record a prevalence of depression between 20% and 24%.13-15 The most disturbing finding is that the medical staff are usually unaware of the illnesses. MOFFic and PAYKEL14 detected 43 depressed patients among 150 medical inpatients. Of these only 6 had any mention of depression in the notes; 4 were on antidepressants, 2 had been referred to a
psychiatrist. Patients who complain excessively, refuse to cooperate in treatment, or are very noisy are likely to be referred,12 while the quiet and cooperative will probably go on suffering in silence. One survey revealed that middle-class patients were four times more likely than working-class patients to have their depressive illness recognised by their physician.15 FOLSTEIN and his colleagues at Johns Hopkins Hospital have used the General Health Questionnaire to show that there is substantial undetected psychiatric morbidity on the medical wards," the neurological ward,17 and the cancer
ward.18
So, we now have. ample evidence of the high prevalence of undetected and untreated psychiatric disorder. Does it matter? Probably it does. QUERIDO 19 showed that the psychosocial adjustment of medical inpatients is a powerful determinant of the outcome of their illness; and minor affective disorders often respond to social, psychological, and
pharmacological
treatments.
Most of these dis-
orders would be detected by routine use of a psychiatric screening questionnaire, followed -by discussion of reported symptoms with the clinician. In patients whose depressive illness has presented with somatic symptoms, and in others whose physical illness is complicated by depression, much needless suffering might be prevented. Even when depression is an "understandable" consequence of physical disease, symptoms may be alleviated in many patients.14,20 HINTON2o reviewed his own psychiatric consultations with 50 dying patients, and was able to report definite psychological improvement in 17 of them. However, few would disagree with his view that "if the emotional reaction is understandable and proportionate, if medication is sufficient and if the patient has little strength or desire to discuss his problems, then a psychiatrist can appear de trop". 12
Maguire,
G. P.,
_
Julier, D. L , Hawton, K. E., Bancroft, J. H. ibid. 1974,
i,
268. 13 14
Stewart, M, Drake, F., Winokur, G.Dis.Nerv.Syst 1965, 26, 479. Moffic, H, Paykel, E. S. Br. J.Psychiat 1975, 126, 346. 15 Schwab, J, Bialow, M., Brown, J., Holzer, C.Ann intern. Med. 1967, 67, 695 16 Knights, E. B., Folstein, MF.ibid. 1977, 87, 723. 17 Depaulo, J.R., Folstein, M. F Ann Neurol.1978, 4, 225. 18 Lobo, A, Folstein, M.F., Abeloff, M.Unpublished.
19 Querido, A. Br Jprev. soc. Med.1959, 13, 33. 20
Hinton J. Proc R Soc Med 1972, 65, 1035.
LIFE WITH A SPLIT BRAIN WHEN surgery is done on the corpus callosum the effect is to interrupt communication between one side of the brain and the other.’-’ In split-brain animals the two halves of the brain can show a functional separation one from the other. Each side is capable of performing many tasks on its own and each hemisphere can independently perceive, remember, and learn. For example, each hand of the split-brain monkey can be trained to discriminate between different wooden shapes but the animal is unable to transfer what it has learned from one hand to the other. In human beings, the effects are similar. After Bogen and Vogel, in Los Angeles, had done full split-brain surgery on a small number of patients for relief of severe and intractable epilepsy, Sperry and Gazzaniga reported the major symptoms that followed. A new series of patients operated on by Wilson are now under study on the East Coast of the U.S.A. and these patients offer an opportunity to extend and confirm much of the earlier work.6 Broadly speaking,’ such patients present a picture of two separate individuals inhabiting the same body: not only has the brain been divided but so too has the mind. The mechanisms of perception are duplicated within the two cerebral hemispheres. The patients have little difficulty in analysing the information coming from the world to either the right or the left hemisphere. The difficulty they have is in relating the information of one hemisphere to that of the other. Each seems to form a separate realm of experience for the most part unknown to the other. The patient can report everything which falls in the right field of his vision and stimulates the left, speaking, hemisphere but he cannot speak about the things he sees with his right hemisphere. Thus we have the "major" hemisphere of the brain that can talk and write and the "minor" hemisphere that cannot express itself through these means. The mentality, intelligence, and comprehension of the right hemisphere reveal themselves, however, in special tests using the left hand. Sperry suggested that these people no longer have one inner visual world, like the rest of us, but rather two separate and independent inner visual worlds. The left hemisphere can eloquently describe its feelings in speech-a facility denied to the right hemisphere. The right hemisphere, however, has its own specialisations, particularly that for Gestalt perception and spatial functions. In line with these different specialisms and the fact that each side of the brain can possess particular knowledge and construct its own inner realm of experience the suggestion is that different and separate spheres of consciousness operate at each side of the brain. Many patients are able to spell out answers to questions by means of cardboard letters manipulated by the left hand. The examiner poses the question by asking "who" whilst projecting the words "are you" to only the right hemisphere and the left hand spells out the letters PAUL.8 The right hemisphere’s favourite person was Henrv Winkler or "The Fonz". The favoured career of 1. Sperry, R. W. Harvey Lect. 1968, 62, 293. 2. Gazzaniga, M. S. TheBisected Brain. New York, 1970. 3. Dimond, S. J. TheDoubleBrain. Churchill Livingstone London, 1972. 4. Sperry, R W. Scient. Am 1964, 210, 42. 5. Bogen, J. E., Vogel, P. J. in Les syndromes de disconnexion calleuse chez l’homme(editedbyF Michel and B Schott) Lyon, 1975. 6. Gazzaniga, M. S. Ann. N Y Acad Sci 1977, 299. 7 Dimond, S. J. IntroducingNeuropsychology Springfield,Illinois, 1978. 8. LeDoux, J. E , Gazzaniga, M. S.Scient. Am (inthepress).
episodes with amenorrhoea, hot flushes, high F.S.H. levels, and low urinary oestrogens were followed by menstrual cycles in which the F.s.H. levels were low and there was an ovulatory pattern of oestrogen excretion. On several occasions they observed an unusual association of high urinary oestrogens with high gonadotrophin levels. Clearly pituitary and ovarian function can vary considerably (and not always in phase) in a woman approaching the menopause. and
failed to provide her with a yes/no answer. Perhaps her disappointment will encourage further studies of ovarian function in perimenopausal women.
pregnanediol
important that the patient is given the coradvice. On the one hand, if her fertility is underestimated, she may have to cope with an unexpected addition to her family, at an age when the risks associated with pregnancy are increased. Ori the other hand, the risks of oral contraception also increase with age,18 and other contraceptive methods are not without their complications. 19 Admittedly, for the increasing number of couples who have undergone vasectomy or tubal ligation, the question is of minor importance. A further consideration for the doctor is whether the patient’s secondary amenorrhoea is due to the menopause or there is some other explanation such as pregnancy, It is
rect
post-pill amenorrhoea, 20 or hyperprolactinæmia21 or other endocrine disorders. The knowledge that the average age of the menopause in most European communities is about 5 07,22 and that persistent anovulation is uncommon under the age of 453 assists in selection of patients for further investigation. The following guidelines are suggested. Regular menstruation implies regular ovulation irrespective of the patient’s age. However, conception is rare after the age of 50 and extremely rare after the age of 52. Women under the age of 50 who have amenorrhoea of more than a year’s duration (some would say 2 years) are very unlikely to ovulate subsequently. If hormonal evidence of ovulation is required, a pregnanediol estimation on a random sample of urine on day 21 of the cycle provides useful confirmation. Alternative diagnoses should be considered in women under the age of 45 presenting with secondary amenorrhoea. Persistently raised plasma-F.s.H. values suggest primary ovarian failure (at least at the time of sampling) and indicate that other investigations are likely to be unproductive. If the plasma-F.s.H. is not raised, then other explanations should be sought and measurement of plasma-prolactin should be considered. Our
patient
is
disappointed because
we
have
among Medical Patients
Psychiatric Illness
LiPOWSKi’ estimated that 30-60% of medical inpatients and 50-80% of medical outpatients have psychiatric illness severe enough to demand special attention. Until lately investigators have used widely differing criteria for what constitutes a psychiatric case, but with the arrival of psychiatric screening tests and standardised diagnostic research interviews comparisons become possible. GLASSand his colleagues2 applied the Hopkins Symptom Checklist and a psychiatric research interview to 82 medical outpatients attending the University of Chicago Hospitals, and used the FEIGHNER criteria3to diagnose psychiatric illness. The symptom checklist was not very helpful in separating psychiatrically ill from well patients, but the investigators made psychiatric diagnoses in no fewer than 83% of the patients. These workers
that the mean checklist scores were similar to those found by GOLDBERG 4,1 for patients attending general practitioners in Philadelphia, yet in that survey the prevalence of psychiatric illness was only 25%. In Philadelphia the illnesses were diagnosed with the Clinical Interview Schedule6 designed at the Institute of Psychiatry, London. Since in both surveys most of the diagnoses were of minor affective disorder, the British criteria are presumably narrower that those of FEIGHNER. The rather lower prevalence figures found by British investigators among medical outpatients would be consistent with this: CULPAN and DAVIES7 detected psychiatric illness in 31% of newly referred patients to Dulwich Hospital, and GOLDBERG8 in 34% of patients with diseases of the small intestine attending a follow-up clinic at St. Thomas’. These rates are close to those in patients attending a general practitioner5,9 and are substantially higher than those in note
the community at large.
10,11 investigators have used standardised case-finding techniques on medical inpatients, Several
Lipowski, Z. J. Psychosom. Med. 1967, 29, 201. Glass, R., Allan, A., Uhlenhuth, E., Kimball, C., Borinstein, D. Archs gen. Psychiat. 1978, 35, 1189. 3. Feighner, J. P., Robins, E., Guze, S. B. ibid. 1972, 26, 57. 4. Goldberg, D. Detection of Psychiatric Illness by Questionnaire. London. 1. 2.
1974. 5.
of General Practitioners Oral Contraception Study. Lancet, 1977, ii, 727. 19. Vessey, M., Doll, R., Peto, R., Johnson, B., Wiggins, P. J biosoc. Sci. 1976, 8, 373. 20. Shearman, R. Lancet, 1971, ii, 64. 21. Thorner, M. O., McNeilly, A. S., Hagan, C., Besser, G. M. Br. med. J. 1974, ii, 419. 22. Burch, P. R. J., Gunz, F W. N.Z. med J. 1967, 66, 6 18.
Royal College
Goldberg, D., Rickels, K., Downing, R., Hesbacher, P. Br J. Psychiat. 1976, 129, 61. 6. Goldberg, D., Cooper, B., Eastwood, M. R., Kedward, H. B., Shepherd, M Brit. J. prev. soc. Med. 1970, 24, 18.
Culpan, R , Davies, B Comprehens. Psychiat 1960, 1, 228. Goldberg, D. Gut, 1970, 11, 459. Goldberg, D., Blackwell, B. Br. med J. 1970, ii, 439. 10. Goldberg, D., Kay, C., Thompson, L Psychol Med 1976, 6, 565. 11. Culpan, R., Davies, B. M., Oppenheim, A. N. Br med. J. 1960, i, 855. 7. 8 9.
479
MAGUIRE and his colleaguesl2 at Oxford used the General Health Questionnaires as a screening test and found that 23% were psychiatrically ill at subsequent interview, while other workers record a prevalence of depression between 20% and 24%.13-15 The most disturbing finding is that the medical staff are usually unaware of the illnesses. MOFFic and PAYKEL14 detected 43 depressed patients among 150 medical inpatients. Of these only 6 had any mention of depression in the notes; 4 were on antidepressants, 2 had been referred to a
psychiatrist. Patients who complain excessively, refuse to cooperate in treatment, or are very noisy are likely to be referred,12 while the quiet and cooperative will probably go on suffering in silence. One survey revealed that middle-class patients were four times more likely than working-class patients to have their depressive illness recognised by their physician.15 FOLSTEIN and his colleagues at Johns Hopkins Hospital have used the General Health Questionnaire to show that there is substantial undetected psychiatric morbidity on the medical wards," the neurological ward,17 and the cancer
ward.18
So, we now have. ample evidence of the high prevalence of undetected and untreated psychiatric disorder. Does it matter? Probably it does. QUERIDO 19 showed that the psychosocial adjustment of medical inpatients is a powerful determinant of the outcome of their illness; and minor affective disorders often respond to social, psychological, and
pharmacological
treatments.
Most of these dis-
orders would be detected by routine use of a psychiatric screening questionnaire, followed -by discussion of reported symptoms with the clinician. In patients whose depressive illness has presented with somatic symptoms, and in others whose physical illness is complicated by depression, much needless suffering might be prevented. Even when depression is an "understandable" consequence of physical disease, symptoms may be alleviated in many patients.14,20 HINTON2o reviewed his own psychiatric consultations with 50 dying patients, and was able to report definite psychological improvement in 17 of them. However, few would disagree with his view that "if the emotional reaction is understandable and proportionate, if medication is sufficient and if the patient has little strength or desire to discuss his problems, then a psychiatrist can appear de trop". 12
Maguire,
G. P.,
_
Julier, D. L , Hawton, K. E., Bancroft, J. H. ibid. 1974,
i,
268. 13 14
Stewart, M, Drake, F., Winokur, G.Dis.Nerv.Syst 1965, 26, 479. Moffic, H, Paykel, E. S. Br. J.Psychiat 1975, 126, 346. 15 Schwab, J, Bialow, M., Brown, J., Holzer, C.Ann intern. Med. 1967, 67, 695 16 Knights, E. B., Folstein, MF.ibid. 1977, 87, 723. 17 Depaulo, J.R., Folstein, M. F Ann Neurol.1978, 4, 225. 18 Lobo, A, Folstein, M.F., Abeloff, M.Unpublished.
19 Querido, A. Br Jprev. soc. Med.1959, 13, 33. 20
Hinton J. Proc R Soc Med 1972, 65, 1035.
LIFE WITH A SPLIT BRAIN WHEN surgery is done on the corpus callosum the effect is to interrupt communication between one side of the brain and the other.’-’ In split-brain animals the two halves of the brain can show a functional separation one from the other. Each side is capable of performing many tasks on its own and each hemisphere can independently perceive, remember, and learn. For example, each hand of the split-brain monkey can be trained to discriminate between different wooden shapes but the animal is unable to transfer what it has learned from one hand to the other. In human beings, the effects are similar. After Bogen and Vogel, in Los Angeles, had done full split-brain surgery on a small number of patients for relief of severe and intractable epilepsy, Sperry and Gazzaniga reported the major symptoms that followed. A new series of patients operated on by Wilson are now under study on the East Coast of the U.S.A. and these patients offer an opportunity to extend and confirm much of the earlier work.6 Broadly speaking,’ such patients present a picture of two separate individuals inhabiting the same body: not only has the brain been divided but so too has the mind. The mechanisms of perception are duplicated within the two cerebral hemispheres. The patients have little difficulty in analysing the information coming from the world to either the right or the left hemisphere. The difficulty they have is in relating the information of one hemisphere to that of the other. Each seems to form a separate realm of experience for the most part unknown to the other. The patient can report everything which falls in the right field of his vision and stimulates the left, speaking, hemisphere but he cannot speak about the things he sees with his right hemisphere. Thus we have the "major" hemisphere of the brain that can talk and write and the "minor" hemisphere that cannot express itself through these means. The mentality, intelligence, and comprehension of the right hemisphere reveal themselves, however, in special tests using the left hand. Sperry suggested that these people no longer have one inner visual world, like the rest of us, but rather two separate and independent inner visual worlds. The left hemisphere can eloquently describe its feelings in speech-a facility denied to the right hemisphere. The right hemisphere, however, has its own specialisations, particularly that for Gestalt perception and spatial functions. In line with these different specialisms and the fact that each side of the brain can possess particular knowledge and construct its own inner realm of experience the suggestion is that different and separate spheres of consciousness operate at each side of the brain. Many patients are able to spell out answers to questions by means of cardboard letters manipulated by the left hand. The examiner poses the question by asking "who" whilst projecting the words "are you" to only the right hemisphere and the left hand spells out the letters PAUL.8 The right hemisphere’s favourite person was Henrv Winkler or "The Fonz". The favoured career of 1. Sperry, R. W. Harvey Lect. 1968, 62, 293. 2. Gazzaniga, M. S. TheBisected Brain. New York, 1970. 3. Dimond, S. J. TheDoubleBrain. Churchill Livingstone London, 1972. 4. Sperry, R W. Scient. Am 1964, 210, 42. 5. Bogen, J. E., Vogel, P. J. in Les syndromes de disconnexion calleuse chez l’homme(editedbyF Michel and B Schott) Lyon, 1975. 6. Gazzaniga, M. S. Ann. N Y Acad Sci 1977, 299. 7 Dimond, S. J. IntroducingNeuropsychology Springfield,Illinois, 1978. 8. LeDoux, J. E , Gazzaniga, M. S.Scient. Am (inthepress).
