1
271 10. Rodriguez, A., Rodriguez, M., Eisenberg, L. Amer. J. Psychiat. 1959, 116, 540. 11. Warren, W. Cited by L. Hersov (footnote 3). 12. Med. Offr, 1959, 102, 292. 13. Lyons, H. A., Calvy, G. L., Sammons, B. P. Ann. intern. Med. 1959, 51, 897. 14. Daniels, A. C. Dis. Chest, 1949, 16, 360. 15. Aikens, R. L. Canad. med. Ass. J. 1959, 81, 891. 16. Lichtenstein, R. S., Marshal, C., Walker, A. E. A.M.A. Arch. Neurol. 1959, 1, 288. required inpatient treatment; but on the whole the outlook is good, especially for children below 11 years old of whom 8900 attending one clinic were going to school regularly 10; over that age the figure dropped to 36%. The " hard core " cases were found to come from the most seriously disturbed families: in such cases the school refusal may well be a clinic refusal, and, later on, a work refusal." Clearly, the sooner treatment is started the better; and this requires efficient and rapid communication between parents, school, and the many other agencies that may become involved.12 MEDIASTINAL MASSES THE situation and radiographic appearance of medias- tinal neoplasms, cysts, vascular abnormalities, and glan- dular enlargements sometimes give a clue to their nature, but short of thoracotomy an exact diagnosis is usually impossible. Lyons et al.,13 reviewing a series of 782 mediastinal masses, urge that preliminary investigations additional to chest radiography should nevertheless not be neglected. They found that barium swallow and angio- cardiography not infrequently helped to establish the diagnosis or to assess operability, and scalene-node biopsy 14 above all proved to be a most valuable ancillary procedure. Scalene-node biopsy established the diagnosis in 92% of lymphomas and in 72% of granulomatous lesions with otherwise negative findings, and was also the most fruitful line of investigation in metastatic mediastinal lesions. Lyons et al. emphasise that for full exploitation of the method technical experience is neces- sary : a point also made by Aikens,15 who reports useful results with this procedure in various respiratory condi- tions-especially sarcoidosis and, to a lesser degree, bronchial carcinoma. In obscure mediastinal and pul- monary conditions it seems, therefore, that scalene-node biopsy may sometimes avert the necessity for thoracotomy. EXPLORING SUBCORTICAL FUNCTION WHEN medically intractable epilepsy is to be treated by local cerebral surgery, definition of the precise site where the epileptic discharge originates is important. Originally such operations were planned in relation to macroscopic abnormality of the cortex; but when the electrical sub- strate of epilepsy was recognised its location was assumed to indicate also the site of origin of the clinical seizure. On this basis brain tissue showing such activity, even if macroscopically normal, was sometimes removed. There is now increasing evidence that, although some relation- ship between the site of origin of electrical abnormality and epilepsy exists, the correlation is far from complete. The search for a spike focus, and the excision of regions where it arises, are therefore now less keenly pursued- though the results are often beneficial. Earl Walker and his colleagues,16 who have already contributed much to this subject, have reviewed the results of subcortical recording in temporal-lobe epilepsy. They note that the absence of surface activity, including that from sphenoidal leads, does not exclude a subcortical temporal focus. They also find that, as with surface 1. Wilson, T. S., Carter, H. S. Med. Offr, 1959, 102, 249. activity, spontaneous subcortical spike discharges are often unaccompanied by any overt clinical attack: and they suggest that these non-ictal discharges seem not to affect the normal functioning of the area, so far as simple tests of mentation can show. Stimulation of deep temporal-lobe structures and basal ganglia suggested that the threshold for excitation of amygdala and hippocampus is relatively low, and that spread of discharge from these areas is wide. Confusion and alteration of thought were common, as were visceral, vasomotor, and emotional changes. An interesting finding was that stimulation of amygdala, thalamus, and globus pallidus elicited pain in one half of the body. The general picture is of visceral and affective responses from a number of sites, including medial temporal, inferior frontal, and thalamic. But relatively few stimulations, even of those producing electrical after-discharge, gave rise to clinical features of any sort. INFECTION AT THE HAIRDRESSER’S MOST men choose their hairdresser for reasons of nearness, cheapness, or cleanliness. (Women add other criteria less easily summarised.) The " cleanliness " is judged, we would guess, by standards that are basically unconnected with health. People dislike the shop which is stuffy or which has a smell to which they are not accustomed. They do not care for a floor littered with shorn locks, or sheets which have not been laundered recently. With shame they may admit that they avoid the shop whose customers come from another income group (whereas they would share a seat on the omnibus without a thought). They seem to feel that they may " catch something ". Yet the evidence that the hair- dresser’s shop plays any important part in the spread of disease is negligible. " Barber’s rash " is primarily an eczema, often complicated by staphylococcal infection; and though it can be spread by the use of a common razor or towel, the bacteria more often come from the patient’s own nose. Moreover, public shaving is a dying custom and many of those who have this disease have never been shaved. Microsporon audouini was certainly disseminated by the hairdresser, but ringworm due to this fungus is now rare compared with that derived from animals. (That it was commoner in boys than girls may have been due to the fact that small girls tended to have their hair cut at home and the close crop of the small boy allowed the fungus easier access to the skin.) Any ill- ventilated enclosure encourages the spread of respiratory infections, but the barber’s shop cannot be more dangerous than the four-ale bar. An attempt to give some objective value to the assess- ment of cleanliness in hairdressers’ shops has been made in Glasgow.l Fifty establishments were subjected to thorough inspection and judged by much the same standards as those used for eating-houses, with particular attention to such things as the disinfection of instruments. As might be expected, there was wide variation between the shops: indeed, almost the only thing they had in common was poor sanitary facilities for the staff. Shops patronised entirely by women were on the whole cleaner than those reserved for men, but this is not surprising: in every walk of life men wear dirtier clothes and have dirtier habits. Many bacteriological examinations of premises and equipment were made; but the difficulty

EXPLORING SUBCORTICAL FUNCTION

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271

10. Rodriguez, A., Rodriguez, M., Eisenberg, L. Amer. J. Psychiat. 1959,116, 540.

11. Warren, W. Cited by L. Hersov (footnote 3).12. Med. Offr, 1959, 102, 292.13. Lyons, H. A., Calvy, G. L., Sammons, B. P. Ann. intern. Med. 1959,

51, 897.14. Daniels, A. C. Dis. Chest, 1949, 16, 360.15. Aikens, R. L. Canad. med. Ass. J. 1959, 81, 891.16. Lichtenstein, R. S., Marshal, C., Walker, A. E. A.M.A. Arch. Neurol.

1959, 1, 288.

required inpatient treatment; but on the whole the outlookis good, especially for children below 11 years old of whom8900 attending one clinic were going to school regularly 10;over that age the figure dropped to 36%. The " hardcore " cases were found to come from the most seriouslydisturbed families: in such cases the school refusal maywell be a clinic refusal, and, later on, a work refusal."Clearly, the sooner treatment is started the better; andthis requires efficient and rapid communication betweenparents, school, and the many other agencies that maybecome involved.12

MEDIASTINAL MASSES

THE situation and radiographic appearance of medias-tinal neoplasms, cysts, vascular abnormalities, and glan-dular enlargements sometimes give a clue to their nature,but short of thoracotomy an exact diagnosis is usuallyimpossible. Lyons et al.,13 reviewing a series of 782mediastinal masses, urge that preliminary investigationsadditional to chest radiography should nevertheless notbe neglected. They found that barium swallow and angio-cardiography not infrequently helped to establish the

diagnosis or to assess operability, and scalene-node

biopsy 14 above all proved to be a most valuable ancillaryprocedure. Scalene-node biopsy established the diagnosisin 92% of lymphomas and in 72% of granulomatouslesions with otherwise negative findings, and was alsothe most fruitful line of investigation in metastaticmediastinal lesions. Lyons et al. emphasise that for fullexploitation of the method technical experience is neces-sary : a point also made by Aikens,15 who reports usefulresults with this procedure in various respiratory condi-tions-especially sarcoidosis and, to a lesser degree,bronchial carcinoma. In obscure mediastinal and pul-monary conditions it seems, therefore, that scalene-nodebiopsy may sometimes avert the necessity for thoracotomy.

EXPLORING SUBCORTICAL FUNCTION

WHEN medically intractable epilepsy is to be treated bylocal cerebral surgery, definition of the precise site wherethe epileptic discharge originates is important. Originallysuch operations were planned in relation to macroscopicabnormality of the cortex; but when the electrical sub-strate of epilepsy was recognised its location was assumedto indicate also the site of origin of the clinical seizure.On this basis brain tissue showing such activity, even ifmacroscopically normal, was sometimes removed. Thereis now increasing evidence that, although some relation-ship between the site of origin of electrical abnormalityand epilepsy exists, the correlation is far from complete.The search for a spike focus, and the excision of regionswhere it arises, are therefore now less keenly pursued-though the results are often beneficial.

Earl Walker and his colleagues,16 who have alreadycontributed much to this subject, have reviewed theresults of subcortical recording in temporal-lobe epilepsy.They note that the absence of surface activity, includingthat from sphenoidal leads, does not exclude a subcorticaltemporal focus. They also find that, as with surface

1. Wilson, T. S., Carter, H. S. Med. Offr, 1959, 102, 249.

activity, spontaneous subcortical spike discharges are

often unaccompanied by any overt clinical attack: and

they suggest that these non-ictal discharges seem not toaffect the normal functioning of the area, so far as simpletests of mentation can show.

Stimulation of deep temporal-lobe structures andbasal ganglia suggested that the threshold for excitationof amygdala and hippocampus is relatively low, and thatspread of discharge from these areas is wide. Confusionand alteration of thought were common, as were visceral,vasomotor, and emotional changes. An interestingfinding was that stimulation of amygdala, thalamus, andglobus pallidus elicited pain in one half of the body. Thegeneral picture is of visceral and affective responses froma number of sites, including medial temporal, inferiorfrontal, and thalamic. But relatively few stimulations,even of those producing electrical after-discharge, gaverise to clinical features of any sort.

INFECTION AT THE HAIRDRESSER’S

MOST men choose their hairdresser for reasons of

nearness, cheapness, or cleanliness. (Women add othercriteria less easily summarised.) The " cleanliness " is

judged, we would guess, by standards that are basicallyunconnected with health. People dislike the shop whichis stuffy or which has a smell to which they are notaccustomed. They do not care for a floor littered withshorn locks, or sheets which have not been launderedrecently. With shame they may admit that they avoidthe shop whose customers come from another incomegroup (whereas they would share a seat on the omnibuswithout a thought). They seem to feel that they may" catch something ". Yet the evidence that the hair-dresser’s shop plays any important part in the spread ofdisease is negligible. " Barber’s rash " is primarily aneczema, often complicated by staphylococcal infection;and though it can be spread by the use of a commonrazor or towel, the bacteria more often come from thepatient’s own nose. Moreover, public shaving is a dyingcustom and many of those who have this disease havenever been shaved. Microsporon audouini was certainlydisseminated by the hairdresser, but ringworm due tothis fungus is now rare compared with that derived fromanimals. (That it was commoner in boys than girls mayhave been due to the fact that small girls tended to havetheir hair cut at home and the close crop of the small boyallowed the fungus easier access to the skin.) Any ill-ventilated enclosure encourages the spread of respiratoryinfections, but the barber’s shop cannot be more

dangerous than the four-ale bar.An attempt to give some objective value to the assess-

ment of cleanliness in hairdressers’ shops has been madein Glasgow.l Fifty establishments were subjected to

thorough inspection and judged by much the same

standards as those used for eating-houses, with particularattention to such things as the disinfection of instruments.As might be expected, there was wide variation betweenthe shops: indeed, almost the only thing they had incommon was poor sanitary facilities for the staff. Shopspatronised entirely by women were on the whole cleanerthan those reserved for men, but this is not surprising:in every walk of life men wear dirtier clothes and havedirtier habits. Many bacteriological examinations of

premises and equipment were made; but the difficulty