366

Education is essential, both to make individualsaware of the hazards of alcohol, and to create a climateof opinion favourable to the suggested action. This

report will be but a small step in that direction, for itwill not be easy to remove the popular image of the"friendly drunk", nor to change the accepted Britishpractice of lubricating most social occasions with alco-hol. Indeed, prohibition and temperance are not thereport’s aim. It seeks to reduce social drinking to a non-harmful level, suggesting as a guideline a maximum in-take of four pints of beer, four doubles of spirits, or abottle of wine in a day (and that is too much if takenregularly). Businesses are urged to examine jobs whichseem to necessitate drinking, and we are all urged to ex-amine our own practices as hosts in our own homes. Dowe regard our dispensing of drinks with sufficient re-sponsibility ? Does embarrassment, or our misguidedbelief that it is polite, cause us to pour stiffer drinks foracquaintances known to be inclined towards over-

indulgence ? .

This is a well-balanced document which can hardlyfail to impress on the reader the size and seriousness ofthe alcohol problem, and of its disastrous potential overthe next few years. Doctors are in a strong position totake a lead in the necessary education campaign, as theyhave done over smoking.

PEPTIC ULCER AFTER RENAL TRANSPLANTATION

PATIENTS with renal transplants are susceptible to adepressingly large number of gastrointestinal complica-tions, including fungal oœsophagitis, pancreatitis, small-bowel obstruction or infarction, ischæmic colitis, andcolonic perforation.I-4 Probably the commonest of all is

’

peptic ulceration, with a frequency as high as 18%.5 Itis a serious disease in transplanted patients, often com-plicated by perforation or haemorrhage, and carries anoverall mortality of 43%.5 The ulcers may have devel-oped before transplantation, for peptic ulceration is notuncommon in renal failure.6 In 377 patients trans-

planted in Minnesota, evidence of previous peptic ulcer-ation was found in 30.7 Serum-gastrin can be high inrenal failure, probably owing to failure of the kidneys todegrade gastrin.8 Basal acid output by the stomach andthe peak response to pentagastrin can also be raised,9 es-pecially in patients who have been on haemodialysis forsome months.6 After renal transplantation serum-gastrinfalls rapidly8 11 but, paradoxically, basal and peakacid secretion can increase further.l2 The role ofsteroids in causing ulcers has been questioned,13 butthere now seems little doubt that large doses increase the

1. Hadjiyannakis, E. J., Evans, D. B., Smellie, W. A. B., et al. Lancet, 1971,ii, 781.

2. Julien, P. J., Goldberg, H. I., Margulis, A. R., et al. Radiology, 1975,117,37.

3. Penn, I., Groth, C. G., Brettschneider, L., et al. Ann. Surg. 1968, 168, 865.4. Aldrete, J. S., Sterling, W. A., Hathaway, B. M., et al. Am. J. Surg. 1975,

129, 115.5. Owens, M. L., Passaro, E., Wilson, S. E., et al. Ann. Surg. 1977, 186, 17.6. Ventkateswaran, P. S., Jeffers, A., Hocken, A. G. Br. med. J. 1972, iv, 22.7. Spanos, P. K., Simmons, R. L., Rattazzi, L. C., et al. Archs Surg. 1974, 109,

193.8. Korman, M. G., Laver, M. C., Hansky, J. Br. med. J. 1972, i, 209.9. Gordon, E. M., Johnson, A. G., Williams, G. Lancet, 1972, i, 226.

10. McConnell, J. B., Stewart, W. K., Thjodleifsson, B., et al. Lancet, 1975, ii,1121.

11. King, R., Hansky, J. ibid. 1974, i, 169.12. Chisholm, G. D., Mee, A. D., Williams, G., et al. Br. med. J. 1977, i, 1630.13. Conn, H. O., Blitzer, B. L. N. Engl. J. Med. 1976, 294, 473.

risk of peptic ulceration. Conn and Blitzer13 reviewed 42controlled investigations involving over 5000 patients towhom steroids had been prescribed for various condi-tions. There was a significant increase in peptic ulcer-ation in patients who received a cumulative total dose ofmore than 1 g of prednisone.13 Kidney transplant pa-tients frequently receive doses of this order-in fact, itis common practice to administer 1 g of methylpredniso-lone on the day of transplantation. Nonetheless, the as-sociation between the dose of steroids received and ulcer-ation is not completely clear, and in one study steroiddosage was no larger in a group of transplanted patientswith ulcers than it was in a group who remained ulcer-free.14 Azathioprine is believed not to cause peptic ulcer-ation.15 In two controlled studies involving 110 patientson steroids for ulcerative colitis, the addition of azathio-prine to the treatment of one group was not followed bya greater incidence of peptic ulceration in that

group. 16 17 Another possible factor in the xtiology isvirus infection, since cytomegalovirus (C.M.V.) is oftendetectable after transplantation. 18 In patients with otherdiseases c.M.v. has been discovered in the mucosa of thestomach and duodenum, often in association withulcers,19 and the virus has been blamed for causing ulcer-ation of the cæcum.20 This evidence is not very strong,and there is so far only one report of c.M.v. being foundin association with a peptic ulcer in a patient with atransplant. 4

Immunosuppression does not seem to prevent pepticulcers from responding to medical treatment and for un-complicated ulcers this approach has been recom-

mended. 14 Unfortunately haemorrhage or perforationis often the presenting feature and under these cir-

cumstances urgent operation is required. Cimetidine hasbeen used successfully in cases of haemorrhage but halfthe patients have relapsed within a short period,14 andalthough further haemorrhage can follow operation, 1

surgery still seems the safest treatment. Some workersrecommend prophylactic ulcer surgery before transplan-tation in all patients with a history of peptic ulceration,since the frequency of complications may be reduced inthis way. 5 This will not, however, greatly reduce theoverall incidence of complications, since most ulcersarise in transplanted patients who have had no previoussymptoms. In fact, Chisholm et al. 12 were quite unableto identify those patients at risk even after examiningpre and post transplant measurements of gastric-acidsecretion. Enteric-coated steroid tablets and regular ant-acids do not seem to have much prophylactic value.Some encouraging news has come from King’s CollegeHospital,21 where 30 transplanted patients were treatedwith cimetidine in doses up to 1 g a day from the dayof transplantation. There were no episodes of hoemor-rhage, whereas in a previous series of 33 patients treatedwith antacids alone there were six such episodes. If these

14. Archibald, S. D., Jirsch, D. N., Bear, R. A. Can. med. Ass. J. 1978, 119,1291.

15. Weinberg, A. L. in Progress in Immunology II: vol. v, Clinical Aspects II(edited by L. Brent and J. Holborow), p. 253 Amsterdam, 1974.

16. Rosenberg, J. L., Wall, A. J., Levin, B., et al. Gastroenterology, 1975, 69,96.

17. Jewell, D. P., Truelove, S. C. Br. med. J. 1974, iv, 627.18. Summons, R. L., Lopez, C., Balfour, H., et al. Ann. Surg. 1974, 180, 62319. Wolfe, B. M., Cherry, J. D. Ann. Surg. 1973, 77, 490.20. Henson, D. Archs. Path. 1972, 93, 477.21. Jones, R. H., Rudge, C. J., Bewick, M., et al. Br. med. J. 1978, i, 398.

367

results can be confirmed in a proper controlled trial,prophylactic cimetidine should reduce the hazards oftransplantation.

HOSTILITY TO PSYCHOSURGERY)

A REVIEW of the practice of psychosurgery, or "func-tional neurosurgery" as the Society of British Neuro-logical Surgeons somewhat fastidiously calls it, suggeststhat adverse publicity may well have caused a reductionin the number of such operations done annually.’ 1Whereas an estimated 158 operations were carried outin Britain in 1974, the equivalent figure for 1975 was154 and for 1976 was 119. A similar trend has been

reported in the United States.2Opposition to psychosurgery, like opposition to other

controversial psychiatric therapies such as electrocon-vulsive treatment and psychoanalysis, makes much ofthe fact that to date there is no conclusive proof that thetreatment actually works. The multiplicity of existingpsychosurgical techniques, together with emphaticclaims for their efficacy over almost the entire range ofpsychiatric conditions, make the precise worth of psy-

chosurgery difficult to establish. Such problems, how-ever, did not deter a research committee of the RoyalCollege of Psychiatrists from proposing a multicentre,prospective, controlled trial in which patients, referredfor consideration of psychosurgery, were to be assessedand randomised to surgical and non-surgical treat-

ments.3 For reasons which remain shadowy but whichhave been related to active political lobbying by the cri-tics of psychosurgery (there were 11 separate questionson the subject in the House of Commons during 1976alone) and to professional doubts that such a trial wouldactually clarify anything, the trial has never materia-lised. It seems unlikely to do so.Not that there is a lack of a scientific reports on the

subject. The problem is that much of it is utterly worth-less. Valenstein’s review2 of over 150 articles publishedbetween 1971 and 1976 makes dismal reading in thisregard. Most of the articles lacked any objectivemeasurement and relied almost entirely on clinicalacumen and subjective impressions. Using a well-triedand accepted system of rating publications for scientificmerit,4 Valenstein found that over 90% of the psycho-surgery reports got an extremely low overall score. Inthe great majority, important variables’ were confoundedin such a way as to make it difficult if not impossible todetermine whether any postoperative changes should beattributed to the surgery or to the intensification of psy-chotherapy, drug treatment, behavioural management,or social rehabilitative methods undertaken by the

therapeutic team and the patient’s relatives.Despite the adverse publicity and the poor quality of

much of the research, many surgeons and psychiatristsseem bemused and even irritated by public alarm and

1 Barraclough, B. M., Mitchell-Heggs, N. A. Br. med. J. 1978, ii, 1591.2 Valenstein, E. S. in Psychosurgery, U.S. National Commission for the Pro-

tection of Human Subjects of Biomedical and Behavioural Research;appendix 1-1-1-143. U.S. DHEW Publ. no. (05) 77-0002. Washington,D C., 1977.

i Research Committee, Royal College of Psychiatrists in Neurosurgical Treat-ment in Psychiatry, Pain and Epilepsy (edited by W. H. Sweet, S. Obra-dor, and J. G. Martin-Rodriguez); p. 175. Baltimore, 1977.

4 May P R. A., Van Putten, T. Compreh. Psychiat. 1974, 15, 267.

disquiet concerning the ethical aspects of psychosurgery.Speakers at the Fourth World Congress of PsychiatricSurgery (1975), to judge by the published report,s wereunanimous in concluding that psychosurgery is no dif-ferent in logical consequences from any other therapy.The speakers were almost all surgeons and psychiatristscommitted to this form of treatment (the exception beinga lecturer in music); and it is noteworthy that a multi-professional group, reporting to the U.S. National Com-mission for the Protection of Human Subjects of Biome-dical and Behavioral Research, came to a more cautiousconclusion. The Commission’s report, however, was farfrom hostile to psychosurgery. Indeed, after a most thor-ough review of the published work and evaluation ofseveral studies specially undertaken for it, the Commis-sion found in favour of the use of psychosurgical proced-ures under properly supervised conditions. Among itssuggestions was the setting up of special review boards,approved by the U.S. Department of Health, Educationand Welfare, which would establish that a surgeon is

competent to perform the procedure in question, thatthere are good indications for the procedure, that ade-quate preoperative and postoperative assessments aredone, and that a patient has given adequate consent. Ithas been argued6 that if psychosurgery was restricted toa few specialised centres where the procedures can becarefully monitored, where research can be undertaken,and where experience can be accumulated, specialreview boards and restrictions would be unnecessary.However, it is clear from Barraclough and Mitchell-Heggs’ figures’ that this position has not yet beenreached in Britain. While four major neurosurgical unitsaccounted for two-thirds of the operations, a furthertwenty-seven units were performing up to five such oper-ations each per year.

The thorny issue of psychosurgical treatment for in-voluntarily committed patients or for prisoners with in-tractable psychiatric ill-health or severe behavioural dis-orders has produced varying recommendations. TheU.S. National Commission agreed that such procedurescould be used, under certain medical and legal safe-guards, whereas the New South Wales Committee of In-quiry,’ which in many other respects adopted the sameapproach as the American one, ruled against permittingpsychosurgical procedures in cases where informed andunfettered consent was doubtful. At present the use of .

psychosurgery in Britain is regulated by the usual re-strictions on any medical treatment included in theMental Health Act of 1959. Many of the ethical ques-tions relating to psychosurgery, such as the issue of in-formed consent, the conflict between research goals andpatient safety, and the adequacy of review procedures,are questions of .general medical ethics too. In the areaof psychosurgery, however, the dispute has been particu-larly acrimonious.8 Critics tend to portray surgery asmutilation and to insist that it blunts, or as one voci-ferous critic puts it, "partially kills" the individual. 9

Some proponents of the procedure hardly help by assert-

5. Sweet, W. H., Obrador, S., Martin-Rodriguez, J. G. (editors). NeurosurgicalTreatment in Psychiatry, Pain and Epilepsy. Baltimore, 1977.

6. Bridges, P. K., Bartlett, J. R. Br.J. Psychiat. 1977, 131, 249.7. Kiloh, L. G. Med. J. Aust. 1977, ii, 296.8. Clare, A. Psychiatry in Dissent; p. 268. London, 1976.9. Breggin, P. R. U.S. Congressional Record, 1972, 118 (26), Feb. 24, 5567.