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of phobic and obsessive-compulsive neuroses, are in

expansionist mood too and Eysenck’6has been moved tocall for a divorce within psychiatry so that the clinicalpsychiatrist can be left to get on treating "physical" con-ditions (i.e., the psychoses) while the behavioural psychi-atrist and psychologist manage everything else.

Clearly the issue of whether psychotherapy or behav-iour therapy actually work has acquired a particularurgency and force. Thus a comparative study of thesetwo forms of treatment, by researchers at Temple Uni-versity, Philadelphia," could hardly have been bettertimed. 94 people with moderately severe neurosis andpersonality disorders were randomly assigned to one ofthree groups. One group was treated by experienced psy-choanalytically trained psychotherapists. Another groupwas treated by behaviour therapists, while the third hadno formal treatment other than the initial "in-depth"assessment interview common to all three groups and a

monthly phone-call assuring them that they had notbeen forgotten. The three groups were evaluated at fourmonths, twelve months, and, two years. At four months,all three groups had improved significantly in "target"symptoms namely, those symptoms which the patienthimself spontaneously identified as being a specific prob-lem at the outset of the study. Both treatment groupsimproved significantly more than those on the waiting-list but there was no significant difference in the amountof symptomatic improvement, social adjustment, andwork ability between the psychotherapy and behaviour-therapy groups. The one and two year follow-ups sup-ported the view that those who had shown most im-provement at four months continued to do well.The results of this study, as one of the most

experienced American psychoanalysts, Judd Marmorpoints out,’* "offer little comfort to those adherents ofeither group who are involved in passionately proclaim-ing the inherent superiority of their particular brand oftherapy over all others". Indeed, this study strongly sug-gests that, despite their mutual antagonism, there isremarkable overlap in the approaches of both groups.Many of the differences seem matters of degree ratherthan of substance. Behaviour therapists tended to bemore directive, more concerned with symptoms, less con-cerned with childhood memories, and, despite their

reputation for coldness and lack of clinical involvement,warmer and more active therapists. Tape-recorded inter-view analysis showed that they made as many interpre-tative statements as did the psychotherapists. Thus it isnot clear whether the two groups, despite their theoreti-cally differing backgrounds, did actually use fundamen-tally different approaches to reach the same therapeuticend or whether the effectiveness of their treatments wasdue to factors common to both schools of thought. Thepatients themselves seemed in less doubt, and those whoimproved most attributed their response less to thetheoretical framework within which they were treatedthan to the personality, enthusiasm, and involvement ofthe individual therapist.

Like all good research, this study raises as many ques-tions as it tries to answer. The waiting-list group’s re-sponse to fairly basic treatment raises the question as to

16. Eysenck, H. J. The Future of Psychiatry. London, 1975.17. Sloane, H. B., Staples, F. R., Cristol, A. H., Yorkston, N. J., Whipple, K.

Psychotherapy versus Behaviour Therapy. Boston, 1975.18. Marmor, J. ibid.

how simple and regular supportive treatment, with

symptomatic relief by judicious use of drugs, would com-pare with these two more time-consuming, expensive,and complex forms of treatment. It is not easy to seehow this sort of question can be answered without theimmense investment in time, money, and research skillwhich the Philadelphia study represents. Initial attemptsto evaluate psychotherapy in the U.K. have come togrief. 19 Nevertheless, a costly expansion of psychothera-peutic manpower does need to be based on more thanpious hope and exhortation. If cheaper, quicker, yetcomparably effective methods of treatment exist, then awiser and more economic policy is to spend time nowtaking a scrupulous and unbiased look’ at what thesemight be. The Philadelphia study deserves attention notmerely from psychiatrists but also from those engaged inthe equally difficult business of apportioning slimresources to the care of the mentally ill.

REFLEX SYMPATHETIC DYSTROPHY SYNDROME

THE reflex sympathetic dystrophy syndrome (R.S.D.S.)is characterised by pain and swelling of the hand or foot,trophic skin changes in the same extremity, vasomotorinstability, and very often a precipitating factor such asmyocardial infarction, trauma, or spinal-disc disease.The affected extremity is usually the hand, and whenthere is accompanying pain and stiffness of the ipsila-teral shoulder the condition is known as shoulder-hand-

finger or shoulder-hand syndrome. Moberg21 22hasemphasised the importance of the venous pumpingmechanism at the shoulder and dorsal metacarpal regionin the normal arm. In his opinion the disturbance to thevenous and lymphatic pumping mechanisms when thearm is immobilised is sufficient to explain the genesis ofthe shoulder-hand syndrome. The arm may be immobi-lised by trauma, myocardial infarction, cervical-disc dis-ease, or stroke. However, a list of precipitating factorsin the shoulder-hand syndrome puts "idiopathic" (23%of 146 cases) at the top of the list. 23

Kozin et al.24 report clinical and histological data onthe R.S.D.s. They measured joint swelling (ring size),joint tenderness (dolorimeter score), and grip strength ineleven patients, two of whom had hip and foot involve-ment. Fine-detail radiographs and 99’ Tc-diphosphonateand 99m Tc-pertechnetate scans of the affected and con-tralateral extremities were obtained.25 These investiga-tions showed clear differences between the affected andunaffected sides, but dolorimetry revealed bilateral in-volvement. On scintigraphy, the isotope was localised tothe juxta-articular tissues, 99mTc-diphosphonate scansgiving an overall positivity of 92% on the predominantlyaffected side and 22% for the other side. In addition,synovial biopsy specimens24 from the metacarpophalan-geal or proximal interphalangeal joints of the affectedhands of four patients were histologically abnormal. The

19. Candy, J., Balfour, F. H. G., Cawley, R. H., Hildebrand, H. P., Malan, D.H., Marks, I. M., Wilson, J. Psychol. Med. 1972, 2, 345.

20. Cawley, R. H., Candy, J., Malan, D., Marks, I. Proc. R. Soc. Med. 1973,66, 943.

21. Moberg, E. Acta chir. scand. 1955, 109, 284.22. Moberg, E. Surg. Clins N. Am. 1960, 40, 367.23. Steinbrocker, O., Argyros, T. G. Med. Clins N. Am. 1958, 42, 1533.24. Kozin, F., McCarty, D. J., Sims, J., Genant, H. Am. J. Med. 1976, 60, 321.25. Kozin, F., Genant, H. K., Bekerman, C., McCarty, D. J. ibid. p. 332.

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most prominent change was in the synovial lining cells,which were thickened and disorganised, together withsubsynovial capillary proliferation and oedema. Whenthe patients took prednisone, 60-80 mg daily in divideddoses, all measurements improved, but cessation or

reduction of treatment often caused a transient flare-upof symptoms on both sides. The dose of prednisone wastapered during treatment and none of the patientsreceived corticosteroids for more than 14 weeks.Treatment of the R.S.D.S. with corticosteroids is con-

troversial,26 but in the shoulder-hand syndrome predni-sone often works when other treatments have failed?’The two papers from the U.S.A.24 25conflict with thehypothesis of Moberg and should be set against Fryk-man’s report of a low incidence of shoulder-hand syn-drome after distal radius fractures28 when immobilisationwas avoided and the patients did exercises. Prolongedimmobilisation undoubtedly leads to juxta-articular andsoft-tissue swelling, muscle atrophy, contractures, osteo-porosis ("Sudek’s atrophy"), and bony erosions. Coulda central neural mechanism be responsible? The fre-quency of bilateral involvement24 25in R.S.D.S. suggeststhat this may be so, but avoidance of immobilisation is

, obviously important in prevention.

A GOOD BREAKFAST

IT is good to start a day with an optimist like Dr Half-! dan Mahler. In the introduction to the Director-

General’s Annual Report of the World Health Organisa-tionz9he is confident that W.H.O., by joining forces witheconomists, agronomists, water engineers, and com-

munity and rural developers, can break the vicious circleof rural poverty present in many parts of the world. "Wefeel that the climate of world opinion is now ready forsuch a move." The report itself contains over 360 pagespacked with information about what W.H.O. did inalmost every sphere of medicine in 1975. The organisa-tion is to a large measure decentralised, and a briefaccount is given of the special problems of the six

regional offices, situated in Africa, the Americas, South-East Asia, Europe, the Eastern Mediterranean, and theWestern Pacific. 58 pages contain brief summaries ofsome 900 projects in the regions which receive help fromW.H.O. The centre in Geneva administers 44 expertadvisory committees and in 1975 added 23 new titles tothe Technical Report Series, bringing the total now pub-lished up to 583; it also arranged for 2127 Fellows to do

, postgraduate work in medical centres throughout theworld. The accounts of achievements, disappointments,and future plans, in simple and clear English, are a plea-sure to read; and the absence of any air of gloom givesone cheer.Nineteen seventy-five may be remembered in history

as the year that for the first time there was no new caseof smallpox in Asia. For doctors with no experience ofthis terrifying disease it may be difficult to appreciatethe magnitude of the achievement of the medical ser-vices of countries in Asia, and the credit that it is due

26. Flatt, A. E. Lancet, 1974, i, 1107.27. Mowat, A. G. Ann. rheum. Dis. 1974, 33, 120.28. Frykman, G. Acta orthop. scand. 1967, suppl. 108.29. Annual Report of the Director-General to the World Health Organisation

and the United Nations. (Off. Rec. Wld. Hlth Org. no. 229). Pp. XVI +363. Sw. fr. 18. U.S. $7·20.

to W.H.O. for providing them with leadership. Todayonly a small focus of smallpox transmission exists inremote and isolated regions of Ethiopia, and in a year ortwo the world may be rid permanently of one of thegreat pestilences of the past. Communicable diseases

rightly remain one of the major preoccupations ofW.H.O. Plans to eradicate malaria have had major set-backs for technical reasons which differ from one areato another. With the increasing number of irrigationworks, especially in Africa, schistosomiasis is spreadingand probably 600 million people in the world are

at risk of infection. Unfortunately the molluscicides andchemotherapeutic agents only partly control its spread.Similarly there is as yet no effective means of controllingblackflies, the vector of onchocerciasis, and river blind-ness remains a hazard of life for a large population inthe Volta basin. Immunisation by vaccines reduces themortality from six diseases-diphtheria, measles, per-tussis, poliomyelitis, tetanus, and tuberculosis-each ofwhich causes many deaths in various parts of the world.W.H.O. provides technical advice on the provision ofvaccines of high quality and on programmes for theiruse. The section on Family Health describes work on thecare of mothers during pregnancy and lactation and ofthe young child, and also includes nutrition, humanreproduction, and health education. Nutrition is dis-cussed under three main headings-measures againstspecific deficiency diseases, nutritional surveillance, andnational food and nutrition policies. There is an accountof the relative merits of the various methods of contra-

ception under different circumstances and the needs fornational research on their use. In all countries much ill-health arises from ignorance, and the need for healtheducation is obvious; but how to provide it effectively isstill largely an unsolved problem. These subjects, differ-ing in their technical aspects, come together in FamilyHealth. In the structure of health services and of thecurricula of schools of medicine and nursing in all coun-tries, Family Health should be a major component. It isa thoroughly practical concept.The main message of the report is that now W.H.O.’s

first priority is to help national health services to im-prove primary health care for the poor in both rural andurban areas. In many countries the urgent health prob-lems are poverty, infections, malnutrition and under-nutrition, lack of accessible potable water, and multipleenvironmental hazards. These cannot be tackled by theconventional techniques of Western medicine alone, andrequire a service centred on local communities in whichhealth and economic and social development are closelyinterlinked. The dominant factor impeding progressvaries in different areas, and may be an unjust systemof land distribution, recurring drought or crop failure,an insect-borne disease, or an economic system that en-courages women to work in industry and does not paythem adequate wages. Hence the report contains noblueprint for a scheme for a health service which is uni-versally applicable. Only if national governments bringforward schemes based on the differing needs of theirlocal communities can W.H.O. provide effective help.The immense technical skills and resources whichW.H.O. now commands have to be harnessed. If localcommunities, and through them national governmentscannot or do not accept the challenge, then the irony ofFrancis Bacon will again be clear. "Hope is a goodbreakfast, but it is a bad supper."