The death of Albert Prince Consort: the case against typhoid fever.

The case against typhoid fever as the cause of the Prince's death rests partly on some uncharacteristic clinical features during the terminal 22 days of his illness, and partly on other aspects of his temperament and emotionally threatening life events, which tend to favour ulcerative colitis or Crohn's disease. That he had been intermittently unwell with abdominal symptoms for several months before the terminal stage of his illness, only 9 days after this sensitive and vulnerable man was confronted by an intensely personal insult, lends further support to a diagnosis of inflammatory bowel disease. His many admirable qualities unfortunately did not include those needed to surmount deeply injured feelings at his son's behaviour, notably flexibility, sufficient sense of humour and tolerance of human frailty. Had he been able to swear or laugh at his son's foolishness, it might have saved him, and so might adequate psychological management. Some patients with fulminating inflammatory bowel disease, if that is what the Prince had, decline such help, preferring to brood rather than speak, and take their bottled-up feelings of resentment to the grave.

Specificity revisited and updated.

Typicality is probably a better representation of Alexander, Dunbar and others' conclusions than specificity, which was always too absolute a term. As such it became a valid cause of objection by opponents. No genuine attempts to repeat the original studies have been made and most of the original opposition to the concept is now acknowledged as invalid. Typicality (specificity) in psychosomatic disorders appears to be conferred by coping mechanisms acquired through interaction with mother and early surrogates in infancy and childhood as a means of reducing tensions and restoration of homeostatic emotional equilibrium. Psychosomatic medicine patients share one such mechanism, notably superstability/alexythymia, but contained within it are coping mechanisms typical for differing disorders. Examples are listed, and also mention of typicality of recurrently provocative life events/situations. Until typicality is appreciated, taught, learned and practised, success in management of psychosomatic disorders will be limited. The current bio-psycho-social approach is too imprecise.

Hyperventilation.

Physicians' and specialists' continued failure to recognise, diagnose and treat adequately the majority of hyperventilators is a disgrace. Hyperventilation Syndrome (H.V.S.), incorrectly labelled myalgic encephalomyelitis (M.E.), is the latest example of the profession's incompetence. Reasons for failure to teach doctors about H.V. are discussed followed by its incidence, and the tendency for patients to gravitate to Specialist Departments where general history and a complete physical examination have become more perfunctory as sophisticated tests have multiplied. Signs which should alert a clinician's suspicion are listed, which if present should lead to a series of suggested facilitating questions. Controversial aspects of tests to confirm diagnosis are discussed, and also recent work on the relationship of panic attacks to hyperventilation and vice versa. The need for understanding and how to elicit the typical psychopathogenesis is stressed. Lastly, a form of management is described which requires combined competent physiotherapy and competent psychological management. The latter involves uncovering the underlying psychopathology and then helping the patient resolve early loss or alienation which when reawakened by further losses or anticipated loss or surrogates, precipitate symptomatic H.V.

Giant cell (temporal) arteritis-polymyalgia rheumatica: a critical review.

Giant cell (temporal) arteritis G.C.(T) A. is common disorder and affects medium sized and large arteries in people over the age of fifty. Many series show that up to 50% of people with the clinical syndrome of polymyalgia rheumatica (PMR) go on to develop manifestations of G.C.(T) A. within a year; others may do so later. A critical review is offered of aspects of the subject which despite much study and research remain controversial or neglected. This includes epidemiology: statistics from routine autopsy suggests that the disease affects more people than are diagnosed clinically. The need to resolve uncertainty whether intracerebral vessels are involved or not, is now urgent, particularly in view of the wide spread use of short courses of Dexamethasone in the treatment of stroke. All clinicians should recognise the implications of the fact that they are dealing with a disease which may be active and yet symptomatically silent.

Pathological mourning: a key factor in the psychopathogenesis of autoimmune disorders. A special contribution.

Prolonged mourning has been recorded as a precipitant life event in RA and other autoimmune disorders, but other events such as retirement, redundancy and injury have also been identified. The author's submission is that pathological mourning is present in all patients with AI disease, and that other events such as those mentioned are only precipitant because they uncover mourning until then kept in check by occupation and use of work as a drug. When time for reflection and loneliness allows long suppressed ambivalent feelings, guilt and bitterness to surface, remorse over 'unfinished business' increasingly dominates the patient's thoughts. Children and young people rarely have the opportunity to mourn, thus early loss is often paramount and is awakened from the unconscious years later when further losses of key figures or surrogates, including pets, occur or are anticipated. Psychotherapy involves helping patients resolve their pathological mourning.