Since the publication in this Journal of a description of the effects of placebos in rheumatoid conditions (Traut and Passerelli, 1957), there has been a growing literature on the subject of placebo responses, but little has appeared in print regarding such effects in arthritis.During a recent intra-articular injection trial in which two steroid preparations and a placebo were compared, it became apparent that responses to the latter were frequent and well marked. It was decided, therefore, to make a parallel study of the whole question of placebo responses as these occurred during the trial.The results of injection of the two steroids have already been reported; one paper dealt with the effects on rheumatoid arthritics (Chandler, Wright, and Hartfall, 1958) and the other with the effects on osteo-arthritics (Wright, Chandler, Morison, and Hartfall, 1960).The present paper is concerned chiefly with a detailed examination of the responses to the placebo injections in the same trial. It also reports the results of a subsequent dummy tablet trial on the same group of patients. Finally, some of the implications of these findings as they apply to clinical trials are discussed.Material 49 patients were included in the original trial, and of these, 10 dropped out for various reasons during the 18 months that the trial was in progress. The remaining 39 patients from whom results were complete, comprised 34 females and 5 males; 21 were osteo-arthritics, and the remaining eighteen rheumatoid arthritics, the knees being involved in every case. The age range was 29 to 76 years (mean 58 6). The two steroids used were hydrocortisone acetate, and hydrocortisone tertiary butyl acetate. The placebo consisted of the inert aqueous vehicle. Design of Injection TrialEvery patient received three courses of injections into the affected knee, each course comprising four injections with an interval of 2 weeks between injections. There was a resting period of 2 months between courses, and the order in which courses were given was arranged so that every patient eventually received a course of each steroid and a course of the placebo.Assessments for local pain and tenderness, range of joint movement, and walking time, were carried out at each visit. After careful consideration it was felt that walking-times would give the most useful single objective measurement by which clinical improvement or deterioration could be assessed. Patients were asked to walk a distance of 75 yards as quickly as possible while being timed by a stopwatch. The value taken was the mean of the four walking times which were measured fortnightly during the 2-month resting period following each complete injection course. These values were then expressed as percentages of the original walking time.Alterations of less than ±10 per cent. were classified as "unchanged", while decreases or increases of more than 10 per cent. were classified as "improvement" or "deterioration" respectively. Throughout this article the values of these walking times are referred to as "find...

No abstract

In the course of the development in this Unit of a technique for the intravenous administration of adrenocorticotrophic hormone (ACTH), it was noticed that most of the patients experienced a feeling of warmth, flushing, and even sweating during and immediately after the actual infusions. Such phenomena, indicative of peripheral vasodilatation, induced us to investigate this suggested release of tone of the smaller vessels.Following intramuscular injections of ACTH, changes in blood flow around the knee joint and an increase of skin temperature of the finger tips were reported by Janus (1950). Horwitz, Sayen, Naide, and Hollander (1951) also found an increase of skin temperature of the fingers in seven out of eleven patients after a course of intramuscular ACTH but no vasodilatation in the toes of nine out of eleven.The simplest method of ascertaining changes in the state of the peripheral circulation is by measuring skin temperatures at appropriate points. As pointed out by Abramson (1944), if environmental factors are maintained at a constant level, the surface temperature will then depend upon the temperature of the blood and the rate of flow through the skin. By imposing a thermal response test, additional information can be gathered concerning the efficiency of the thermo-regulatory mechanism of the body. This mechanism is often impaired in rheumatoid arthritis and it is much more important if an improvement can be shown here than in simple vasodilatation. MethodOur scheme was to measure first the preliminary skin temperatures and then the thermal response in exposed limbs following the immersion of one leg in hot water (440 C.) before and after intravenous infusion of ACTH.The tests were generally performed on Mondays and Thursdays at the same time, starting about 2j hours after breakfast. The infusions were started on Wednesday mornings and lasted 12-24 hours normally. They usually contained 20 mg. ACTH in 1 litre glucose-saline mixture, but doses of 10 and 5 mg. were used in some cases. The investigations were carried out in a room the temperature of which was maintained at 18-3°to 19-00 C. The form of the test has already been described by one of us (Woodmansey, 1951). The patient sat comfortably for at least 30 min. with legs exposed to the knees, feet resting on a support, and hands resting on the lap. Skin temperatures were taken periodically using an apparatus based on the Wheatstone bridge principle. One resistance arm consists of a probe containing, in a capsule, a compound with a high temperature-resistance coefficient ("thermistor"), which is placed in contact with the skin at the selected position. The current is produced by a valve oscillator, and a three-valve amplifier ensures the accurate differentiation of the null point. A variable resistanceadjusted to a minimum in the actual temperature estimation-is calibrated in degrees centigrade. The positions chosen for temperature readings were the forehead, both thumbs, and one great toe. The forehead was regarded as giving a suitable correlation ...

ABSTRACT. Touching ‐ as well as not touching ‐ conveys messages‐ It also constitutes aprimary experience with emotional and trophic effect Both functions arc important for psychotherapy. Attachment theory logically implies (and experience confirms) that patients who lacked adequate mothering in early life require ‐ like children ‐ actual physical cam‐giving. It may he necessary to communicate with some patients by touch before treatment can start, whereas others are at first afraid to be touched. However, an essential pan of psychotherapy is enabling patients to lose their fear of accepting what they need. Objections m therapeutic touching are subjective and due largely to sexual fears. Problems in this area emphasise the imperative need for all psychotherapists to have regular access to therapeutic supervision.

No abstract