29

excellent brief accounts are given of fundamental researchin related areas. Unfortunately there are no references tooriginal sources, and some of the work is examined some-what uncritically. The report emphasises that moreinformation is needed about the ways in which diet,exercise, smoking, and other environmental variablesexert their effects on serum-lipids, atherosclerosis, and thecomplications of atherosclerosis in subjects of varyingsusceptibility. A sizeable proportion of the report dealswith present research and care facilities for heart-disease,cancer, and stroke, and recommendations are made for theexpansion of these facilities, including detailed proposalsfor increasing ancillary services.About a third of the report is devoted to a full evaluation

of the direct costs of resources used for prevention,detection, treatment, rehabilitation, research, education,and construction of buildings. Of perhaps greater interestis the estimation of indirect costs, in terms of reduced

output. For example, the indirect cost for 1962 wascalculated to be about 38-8 billion dollars, representing9-6 million man-years lost to gainful employment. Inthis context the additional expenditure of from 357 milliondollars in the first year to 739 million dollars in the fifthdoes not seem unreasonable.

DYSPEPSIA AND COLONIC HYPERMOTILITY

THOUGH a diagnosis of X-ray-negative or non-ulcerdyspepsia rarely satisfies either the patient or his physician,little more than half of all patients with " gastric "symptoms are found to have peptic ulcer.1 There remainsa large group in whom even the most intensive investiga-tion fails to reveal ulceration. The commonest symptomsare abdominal pain and flatulence associated with dis-turbed bowel habit and sometimes aggravated by meals.Despite a variety of names-—such as spastic or irritablecolon, pylorospasm, and abdominal neurosis-visceral

pains of this type are generally believed to express anabnormal reaction of intestinal smooth muscle, for which noorganic basis is recognised and no specific treatment known.The introduction of indwelling tubes and telemetering

capsules for recording intraluminal pressures in the gutprovided a new means of investigating this numericallyimportant group of dyspeptics. A paper 2 from theCentral Middlesex Hospital describes a group of 12 patientswith periodic postprandial pain and distension of unknownaetiology who showed exceptionally high pressures in thesigmoid colon at the time when the symptoms were

present. The case-reports were largely a record of

repeated but unhelpful investigation, frequent unreward-ing consultations, and, in two patients, negative laparotomy(performed because of suspected obstruction). All the

patients, however, experienced abdominal discomfort oreven severe pain, associated with nausea, distension,flatulence, and minor disturbances of bowel habit;symptoms were generally worse after a satisfying mealthan after a less attractive one. Remissions and relapsesproceeded capriciously. Colonic motility was measuredby three fine polyethylene tubes introduced with theirtips 25 cm., 20 cm., and 15 cm. from the anus,and recordings were made before and after eating. All

patients showed gross colonic hypermotility after mealswhich provoked symptoms, and in one patient both theclinical picture and experimental findings were reproduced

1. Jones, F. A., Pollak, H. Br. med. J. 1945, i, 797.2. Connell, A. M., Jones, F. A., Rowlands, E. N. Gut, 1965, 6, 105.

by the insertion of air into the stomach. Connell and his

colleagues 2 also showed that the pressure recordingsobtained simultaneously from the three segments 5 cm.apart were often completely different. They found littleevidence that the waves were progressive from the uppersegment to the lower, and they commented that thesedissociated, independent, segmenting contractions musthave the effect of delaying rather than facilitating themovement of fasces: in their patients the effect of thegastrocolic reflex was clearly obstructive.Most of these patients showed a high level of motility

under resting conditions, and one possibility is that thepeople who react in this way have an autonomic imbalancewhich encourages parasympathetic activity. Chaudharyand Truelove 3 found that, compared with healthy subjects,these patients often gave exaggerated colonic responses toneostigmine. Psychological factors may often be important,and the common occurrence of symptoms after the

"evening meal, when the level of colonic motility is highest,probably reflects the cumulative effect of the emotionalstresses of the day as much as local factors arising fromdistension with faeces. Nevertheless the recognition ofthis now clearly defined syndrome must not preventfull investigation, since colonic hyperactivity may beinduced reflexly in association with any of a large numberof pathological lesions within the abdomen. It is essentialthat the diagnosis should be made only after carefulgeneral medical examination and investigation have shownno abnormality. The finding of sigmoid hypermotilitywithout other evident abnormality is an importantdiagnostic aid in patients who have abdominal distensionor pain after eating.

HOPE FOR THE HAIRLESS?

" THE informed physician presented with the thera-peutic suggestion to treat common baldness with testo-sterone-propionate ointment would not only be obligedto reject the proposition as contrary to biological know-ledge but would doubtlessly question the sanity of thepresenter." In these words, Papa and Kligman 4 introducethe discussion of their own very interesting findings. It iswell known that androgens are necessary for the produc-tion of common baldness in genetically predisposedsubjects. Castration arrests its advance, but it progressesagain if substitution therapy with androgens is given. It

is, therefore, all the more surprising that Papa and Kligmanshould find that testosterone applied topically should becapable of stimulating the growth of some hair folliclesin 16 out of 21 normal men with ordinary baldness.They are careful to point out that the main importanceof their findings is not that this is a useful therapeuticor cosmetic preparation but that they have demonstratedthat a substance applied to the surface of the skin canhave an effect on hair growth and that the involutingfollicle is capable of producing terminal hair again.Despite, or perhaps because of, the unfounded claims ofso many homely and proprietary remedies, both thesepossibilities have been denied by many dermatologists.The action of testosterone on the hair follicle is not clear.The dose applied is a very large one and the effect, there-fore, is presumably pharmacological rather than a replace-ment of a hypothetical deficiency of androgens. A primary

3. Chaudhary, N. A., Truelove, S. C. Gastroenterology, 1961, 40, 1.4. Papa, C. M., Kligman, A. M. J. Am. med. Ass. 1965, 191, 521.5. Hamilton, J. B. J. clin. Endocr. Metab. 1960, 20, 1309.

30

effect on the dermal tissues is suggested. The complex waysin which exogenous and endocrine influences can affect thehair cycle and hair growth have been reviewed by Rook. 6 7

Although this effect of testosterone on the scalp gives aray of hope, it can hardly yet be recommended as a

treatment. It must be remembered that, if a substance isabsorbed sufficiently to reach the hair follicles, it will

undoubtedly reach other organs as well. The initial andlargely unjustified enthusiasm for the use of topicaloestrogens abated considerably when it was found that

gynxcomastia could ensue.

PARTICLES IN INTRAVENOUS FLUIDS

THE British Pharmacopcia,8 recognising that some fluidsfor intravenous injection may contain solid particles, givesthe unequivocal directive:

" Such fluids must not be used".Garvan and Gunner 9 10 examined commercially preparedfluids available in Australia to see whether they met thisB.P. requirement. Testing many brands from Australia,Britain, Europe, the Phillipines, and the U.S.A., theyfound that all but three contained myriads of particlesranging in size from 1 to 100 microns. These were invis-ible by the simple transillumination method that mostmanufacturers use for testing their products, but theywere revealed by dark-ground illumination. Many of theparticles were unidentifiable, but Garvan and Gunnerwere able to detect whole rubber and various rubberconstituents or contaminants, such as carbon-black,whiting, zinc oxide, clay, cellulose fibres, fungi, anddiatoms. Thus, the particles were derived not from theglass bottle, as is generally supposed, but from the rubberbungs. They are released by perishing of the surface skinof the bung and by rupture of air-blisters and rubbermatrix cells during sterilisation.

Studying the possibility of harm from the particles,Garvan and Gunner found that 500 ml. of particle-con-taining fluid injected into rabbits caused about 5000 lunggranulomata, each containing fragments of cellulose fibres.Such lesions had earlier 11 12 been found in children’s

lungs after intravenous infusions. Garvan and Gunnerdiscovered them in the wall of a human cerebral aneurysmafter cerebral angiography and intravenous injection ofsaline solution. There is still no evidence that these lesions

produce clinical effects, but their avoidable creation issurely undesirable. Apart from possibly harming thepatient, they may easily baffle a pathologist examiningnecropsy material.

Garvan and Gunner admit that fluids probably cannotbe prepared absolutely free from particles and that a

purity standard must be a practical proposition for large-scale manufacture. To reduce particulate contamination,they suggest lacquering of rubber bungs or the use ofplastic bungs; indeed, the only fluids found to be satis-factory by their method of examination were in whollyplastic containers (which are difficult to sterilise) or inglass bottles with lacquered rubber bungs. Lastly, theyrecommend that manufacturers examine fluids not bysimple transillumination but by the more searchingdark-ground method. These studies were made on fluidsavailable in Australia. We are anxious to know whetherthose available in Britain are any better.

6. Rook, A. J. Br. J. Derm, 1965, 77, 115.7. Rook, A. J. Br. med. J. 1965, i, 609.8. British Pharmacopœia; p. 743. London, 1963.9. Garvan, J. M., Gunner, B. W. Med. J. Aust. 1963, ii, 140.

10. Garvan, J. M., Gunner, B. W. ibid. 1964, ii, 1.11. Bruning, E. J. Virchows Arch. path. Anat. Physiol. 1955, 327, 460.12. Sarrut, S., Nezelof, C. Presse méd. 1960, 68, 375.

COMMUNICATION WITHOUT WORDS

LANGUAGE is usually the last bit of personal develop-ment to reach full maturity. Young children must dependon

" non-verbal " communication for the expression oftheir feelings, but each child has a wealth of feeling-experience, whether gratifying or conflicted and frighten-ing, which it will delight in communicating to a trustedadult who can show that the message is understood.Nowhere is this better shown than by the intelligent deafchild who overcomes his language handicap by vivid andcomprehensible gestures. These are remarkably effectiveso long as there is an awareness of meaning, and a desireto share it with another person. By contrast, the totalmuteness of the child who has not compensated his

handicap is distressing. In time, it almost seems as ifthe lack of communication derives from an entirelyempty mind-and eventually it may cause just that.

Lowenfeld, Traill, and Rowles in two useful essaysdiscuss how comprehension develops through sharing anexperience conveyed in pictures, or by means of models.1They have elsewhere described their methods of usingtoy-sized ordinary objects in a sand-tray, whereby thechild constructs a " world" it experiences.2 Fantasyenters into all children’s play, though it may be influencedby the visual experience of watching actors or puppetson television. For example, during a short hospitaladmission, a child certainly " lived in a world of herown ", but she was quite convinced that she had becomepart of Emergency Ward 10.

In the first essay, Lowenfeld deals at greater lengthwith the philosophy behind this unspoken language offeeling-experience; the second is more concerned withhow play can be exploited in therapy. Practical advice on

equipping a playroom shows clearly that therapeuticplay is not just a catharsis, much less an experience ofdoing what you please, but an act of communicationwhich allows the therapist to become privy to the child’sdeepest emotional experiences. The child shares his bestand his worst living moments alike, in order to come toterms with what they mean to him. The role of the

therapist, only because he accepts and can interpret thecommunicated message, is to separate conflict and thusto release tension. Enormous relief comes to the childwhen he finds he is understood on his own terms. Often

language can only develop and prosper when this firststep is achieved.

In discussing the more theoretical aspects of their

subject Lowenfeld et al. draw telling analogies with somemodern paintings. For instance, they use Chagall’swork to illustrate the way in which images are super-posed, and how bodily processes experienced from withinbecome confused with events taking place in the outsideworld. Psychosomatic problems are invested with a par-ticular interest, and light can be thrown on the way theyrelate to the child’s feelings and how his behaviour givesexpression to them. When feeling of this kind is denied,the apparent hold-up in normal development may begreat.

Non-verbal communication opens a way into a worldwhich is confusing, not incomprehensible; indeed a com-pensating quality of vivid experience is sometimes lostin the more logical and cultivated utterance of the adult.1. The Non-Verbal " Thinking " of Children and its Place in Psychotherapy.

By MARGARET LOWENFELD, PHYLLIS M. TRAILL, and FRANCES H.ROWLES. Institute of Child Psychology, 6, Pembridge Villas, London,W.11. 1964. Pp. 43. 2s. 6d.

2. Lowenfeld, M. Br. J. med. Psychol. 1939, 18, 65.