RECURRING ULCERS OF THE MOUTH
1
44 he is on doubtful ground in what he says about love. Only erotic love finds its expression in coitus, uniquely so among chaste women, much less among men, but the institution of marriage does not depend upon erotic love; affection, charity, and reasonable sexual adjustment are quite enough to ensure its success, and in such cases con- tinence within marriage may be, and ideally should be, sufficient to keep the family within manageable size. A good Catholic will, of course, submit himself and his private opinions unconditionally to the official ruling of the Church, whatever that may be, and meanwhile it is I am sure important for Christians of every denomination to avoid the humanist notion of perfectibility in this world, which is and will remain to its consummation a " vale of tears ". Darlington. JOSEPH V. WALKER. RECURRING ULCERS OF THE MOUTH P. D. H. CHAPMAN. SIR,-I have had an interesting experience of this condition. A woman had suffered from these ulcers occasionally through- out her adult life. She had been a moderate cigarette smoker since the age of 20. She had a duodenal ulcer in middle life. Five years ago, at the age of 58, she gave up smoking. The ulcers then became severe and almost continuous. Treatment was an utter failure. Six months ago she started to smoke again. Within a week, the ulcers healed and have not recurred up to the present. My patient, since she restarted smoking, has eaten fewer sweets, and these are chiefly liquorice all-sorts. I refrain from sneculation and merelv record the facts. Bridlington. MORE ACID/BASE DISTURBANCES G. J. ADDIS W. S. T. THOMSON. Southern General Hospital, Glasgow. SIR,-We wonder whether your leader of Nov. 23 will help anyone who may be struggling to come to terms with this rather difficult subject. It exaggerates the differences which exist between the various workers in this field in order to call attention to the need for terminological agreement. We feel that these differences are more apparent than real, and we are certain that in any given situation any experienced group will take precisely the same action for precisely the same reasons though the language used may vary slightly from one side of the Atlantic to the other. No one would deny the benefits which could accrue from the adoption of a universal nomenclature, but for the present there is no need for acid/base studies to stagnate in a morass of conflicting terminology, since the advent of modern instruments and methods allows the acid/base status of the blood to be characterised in terms of three simple indices. These indices are: (1) an unambiguous and preferably quantitative measure of the non-respiratory component; (2) an unambiguous and quantitative measure of the respiratory component; and (3) a precise measure of the resulting hydrogen-ion concentration. The names and units in which these are expressed are a matter for personal choice and will in no way alter the significance of the results. These indices are self-explanatory, and, when used intelligently in conjunction with clinical appraisal of the patient, the magnitude and complexity of any disorder of hydrogen-ion regulation is at once apparent, and the indicated treatment becomes obvious. There is no need to invoke the aid of descriptive terms such as acidosis and aci-deemia. These undoubtedly cause confusion in some minds and, most important, are of absolutely no help in either diagnosis or treatment. There seems little point in reviving the argument whether blood values faithfully reflect intracellular levels. At present this is a sterile and nihilistic approach that would logically deny us even the value of ordinary blood- electrolyte estimations. The empirical fact remains that the intelligent use of acid/base measurements as of electrolyte levels in the blood helps to make patients better. In the last analysis this remains the object of the exercise. COMBINING THE ANTIDEPRESSANT DRUGS SIR,-Dr. Sargant (Nov. 16) criticises us for relying on " quotations from the literature ". This too is Dr. Sar- gant’s practice, but, whereas we quoted from various recognised authorities, his are entirely from a single source. Further, he suggests that the reasons for quoting thus are: (a) " lack of sufficient personal treatment experi- ence "; and (b) fear " to voice opinions opposite to the accepted ones ". In answer to the first criticism we per- sonally have worked in departments in Essex, South West England, and now Shropshire, in which well over 10,000 patients are seen annually (this might be nearer 20,000!). This implies that neither London, Cambridge, nor New- castle has the monopoly of psychiatric patients. In reply to (b) we have shown quite clearly that we have opposing views, for nothing could be more public than the corre- spondence columns of The Lancet. It appears that Dr. Sargant encourages us to give our own personal views and chides us for not doing so; under these circumstances we therefore summarise the methods we use. We recognise the dichotomy between endogenous and neurotic depression, which we accept as a useful, practical clinical distinction. We have strict criteria for diagnosing both-e.g., (1) the endogenous type having such essential features as central depressive mood, diurnal variation in this depression, early morning waking, verbal retardation, possible psycho- motor retardation, preoccupation with feelings of guilt and hopelessless, and agitation; (2) the neurotic (reactive) depres- sion occurring in a neurotic personality with a previous history of neurotic traits with depression usually superimposed upon this, with strong environmental factors. Though there is no general agreement, differences between those two groups have been observed by workers in the biochemical field. 1 2 The treatment of choice of the endogenous group of moderate degree would be drugs such as imipramine (’ Tofranil ’) or ’ Pertofran’, and next amitriptyline (’Tryptizol’). If the endogenous depression is of a severe degree or there is a threat to life, then modified electroplexy would be undertaken. In neurotic depression drugs are of more doubtful value, but can be tried as an adjunct to psychotherapy. The drug chosen would depend greatly on the individual therapist. It is better to have extensive experience of a few drugs rather than slight experience of many. Initially we try phenelzine (’Nardil’) because we have found it as effective as any of the monoamine- oxidase inhibitors and less toxic than most. Alternatively we would use nialamide (’Niamid’). One of us has extensive experience with iproniazid (’ Marsalid ’) and realises that there is a group of patients (often resistant to other antidepressants) who respond to this drug, which should be used as long as regular liver-function tests are undertaken and there is no previous history of liver-disease. This is an outline of our plan showing that our primary aim is to diagnose the syndrome as accurately as possible and then to select the appropriate treatment. In our experience this is effective in about 90% of patients and there is no need to revert to a combination of anti- devressants. There remains, however, a comparativelv 1 Anderson, W. McC.. Dawson, J. J. ment. Sci. 1962, 108, 80. 2. Anderson, W. McC., Dawson, J. ibid. 1962, 109, 225.
Transcript of RECURRING ULCERS OF THE MOUTH
44
he is on doubtful ground in what he says about love. Onlyerotic love finds its expression in coitus, uniquely so
among chaste women, much less among men, but theinstitution of marriage does not depend upon erotic love;affection, charity, and reasonable sexual adjustment arequite enough to ensure its success, and in such cases con-tinence within marriage may be, and ideally should be,sufficient to keep the family within manageable size.A good Catholic will, of course, submit himself and his
private opinions unconditionally to the official ruling ofthe Church, whatever that may be, and meanwhile it isI am sure important for Christians of every denominationto avoid the humanist notion of perfectibility in this world,which is and will remain to its consummation a " vale oftears ".
Darlington. JOSEPH V. WALKER.
RECURRING ULCERS OF THE MOUTH
P. D. H. CHAPMAN.
SIR,-I have had an interesting experience of thiscondition.A woman had suffered from these ulcers occasionally through-
out her adult life. She had been a moderate cigarette smokersince the age of 20. She had a duodenal ulcer in middle life.Five years ago, at the age of 58, she gave up smoking. Theulcers then became severe and almost continuous. Treatmentwas an utter failure. Six months ago she started to smoke
again. Within a week, the ulcers healed and have not recurredup to the present. My patient, since she restarted smoking,has eaten fewer sweets, and these are chiefly liquorice all-sorts.
I refrain from sneculation and merelv record the facts.
Bridlington.
MORE ACID/BASE DISTURBANCES
G. J. ADDISW. S. T. THOMSON.
Southern General Hospital,Glasgow.
SIR,-We wonder whether your leader of Nov. 23 willhelp anyone who may be struggling to come to terms withthis rather difficult subject. It exaggerates the differenceswhich exist between the various workers in this field inorder to call attention to the need for terminologicalagreement.We feel that these differences are more apparent than
real, and we are certain that in any given situation anyexperienced group will take precisely the same action forprecisely the same reasons though the language used mayvary slightly from one side of the Atlantic to the other.No one would deny the benefits which could accrue fromthe adoption of a universal nomenclature, but for thepresent there is no need for acid/base studies to stagnate ina morass of conflicting terminology, since the advent ofmodern instruments and methods allows the acid/basestatus of the blood to be characterised in terms of three
simple indices.These indices are: (1) an unambiguous and preferably
quantitative measure of the non-respiratory component;(2) an unambiguous and quantitative measure of the
respiratory component; and (3) a precise measure of theresulting hydrogen-ion concentration. The names andunits in which these are expressed are a matter for personalchoice and will in no way alter the significance of theresults. These indices are self-explanatory, and, when usedintelligently in conjunction with clinical appraisal of thepatient, the magnitude and complexity of any disorder ofhydrogen-ion regulation is at once apparent, and theindicated treatment becomes obvious. There is no need toinvoke the aid of descriptive terms such as acidosisand aci-deemia. These undoubtedly cause confusion insome minds and, most important, are of absolutely no helpin either diagnosis or treatment.
There seems little point in reviving the argumentwhether blood values faithfully reflect intracellular levels.At present this is a sterile and nihilistic approach thatwould logically deny us even the value of ordinary blood-electrolyte estimations. The empirical fact remains thatthe intelligent use of acid/base measurements as of
electrolyte levels in the blood helps to make patients better.In the last analysis this remains the object of the exercise.
COMBINING THE ANTIDEPRESSANT DRUGS
SIR,-Dr. Sargant (Nov. 16) criticises us for relying on"
quotations from the literature ". This too is Dr. Sar-
gant’s practice, but, whereas we quoted from variousrecognised authorities, his are entirely from a single source.
Further, he suggests that the reasons for quoting thusare: (a) " lack of sufficient personal treatment experi-ence "; and (b) fear " to voice opinions opposite to theaccepted ones ". In answer to the first criticism we per-sonally have worked in departments in Essex, South WestEngland, and now Shropshire, in which well over 10,000patients are seen annually (this might be nearer 20,000!).This implies that neither London, Cambridge, nor New-castle has the monopoly of psychiatric patients. In replyto (b) we have shown quite clearly that we have opposingviews, for nothing could be more public than the corre-spondence columns of The Lancet.
It appears that Dr. Sargant encourages us to give our ownpersonal views and chides us for not doing so; under thesecircumstances we therefore summarise the methods we use.We recognise the dichotomy between endogenous and neuroticdepression, which we accept as a useful, practical clinicaldistinction. We have strict criteria for diagnosing both-e.g.,(1) the endogenous type having such essential features as
central depressive mood, diurnal variation in this depression,early morning waking, verbal retardation, possible psycho-motor retardation, preoccupation with feelings of guilt andhopelessless, and agitation; (2) the neurotic (reactive) depres-sion occurring in a neurotic personality with a previous historyof neurotic traits with depression usually superimposed uponthis, with strong environmental factors. Though there is nogeneral agreement, differences between those two groups havebeen observed by workers in the biochemical field. 1 2The treatment of choice of the endogenous group of moderate
degree would be drugs such as imipramine (’ Tofranil ’) or’ Pertofran’, and next amitriptyline (’Tryptizol’). If the
endogenous depression is of a severe degree or there is a threatto life, then modified electroplexy would be undertaken. Inneurotic depression drugs are of more doubtful value, but canbe tried as an adjunct to psychotherapy. The drug chosenwould depend greatly on the individual therapist. It is betterto have extensive experience of a few drugs rather than slightexperience of many. Initially we try phenelzine (’Nardil’)because we have found it as effective as any of the monoamine-oxidase inhibitors and less toxic than most. Alternatively wewould use nialamide (’Niamid’). One of us has extensiveexperience with iproniazid (’ Marsalid ’) and realises that thereis a group of patients (often resistant to other antidepressants)who respond to this drug, which should be used as long asregular liver-function tests are undertaken and there is no
previous history of liver-disease.This is an outline of our plan showing that our primary
aim is to diagnose the syndrome as accurately as possibleand then to select the appropriate treatment. In our
experience this is effective in about 90% of patients andthere is no need to revert to a combination of anti-devressants. There remains, however, a comparativelv
1 Anderson, W. McC.. Dawson, J. J. ment. Sci. 1962, 108, 80.2. Anderson, W. McC., Dawson, J. ibid. 1962, 109, 225.
