لخّصلي

By adolescence cross-dressing is usually well established
but is devoid of fetishistic meaning, since feminine dress
evokes not excitement but a feeling of well-being, serenity,
and happiness. When cross-dressing is prevented for any
length of time tension, anxiety, and irritability develop.
Despite all this the individual remains capable of hetero-
sexual behaviour and usually expresses distaste for homo-
sexual practices. In one series9 30% were married and in
J. B. Randell's' -rather heterogeneous group 57% were
married. The marriages are frequently unstable and more
than half end in divorce or separation. Though often
described as a good husband, the transsexualist becomes
intensely jealous of pregnancy and motherhood in his spouse,
and persistent cross-dressing eventually makes the marital
role untenable.
Extreme revulsion for their genitalia and all signs of
masculinity often results in persistent importuning for
surgical " correction," and in some cases self-castration may
be attempted.2 3 In schizophrenia bizarre self-castration may
occur with or without delusional ideas about change of sex,
but in the transsexualist there is no other evidence of the
schizophrenic process.'1
By the time he reaches a hospital clinic the transsexualist
has usually adopted feminine garb in public; facial hair is
reduced and the testes are small and atrophic owing to self-
medication with stilboestrol, which the patient often denies.9
Many authors comment on the exceptional intelligence,
versatility, and artistic gifts of these patients.'2 13 Though
usually anxious to assert their feminine normality, many of
the patients present frank neurotic features.' On most
psychological tests they show high scores for feminine interest,
but their conviction that they have an attractive feminine
physique is sometimes in ludicrous contrast to their hirsute
muscularity.
The sincerity and conviction with which these people
describe their predicament has inclined many physicians who
have studied the disorder to regard transsexualism as an
inborn tendency, but the men patients show no chromosomal
abnormality and in every possible measure are anatomically
and physiologically male.1" However, there is an excess of
abnormal sexual behaviour among patients with Klinefelter's
syndrome and in association with certain disturbances of brain
function.
Cross-dressing and a conviction of sex change may occur
in toxic states due to amphetamine,"- psychosis," and
temporal-lobe epilepsy.' 6-18 Of particular interest are those
cases associated with clearly defined lesions of the temporal
lobe, in which normal sexuality was restored after temporal
lobectomy.1"-2 J. WAlinder" has also found a high
prevalence of- electroencephalographic abnormalities among
unselected transvestists.
Psychotherapy is at best supportive for these patients,2
behaviour therapy of unproved value,22 and the indications for
surgical operation often based on opinion rather than facts.
Many transsexual men achieve a real sense of contentment for
the first time if, despite the social and administrative prob-
lems, they can live and work as a woman. But once this
step is taken the patient rarely goes back to his former way of
life, and his demands for surgery may become more insistent.
Some authors have reported cases in which castration, with or
without other surgical procedures, has been followed by
greater emotional stability and improved social effective-
ness.'-' Some maintain that operation is the most effective
means of treatment available, yet the evidence is by no means
clear. Patients have sometimes deteriorated after operation,
or have continued to importune for further surgical changes,
while others have demanded reversal of the operation and
threatened legal action when this was shown to be impos-
sible.2 23 24 A distinct danger is the polymorphously perverse
psychopath who succeeds in obtaining a surgical operation
during a chameleon-like change. Such individuals may
indulge in exhibitionistic publicity, become prostitutes, or
engage in litigation against the surgeon. The legal status of
the converted transsexualist so far as marriage and inheritance
is concerned has yet to be tested in the courts. This
uncommon but tragic anomaly presents many problems which
are unlikely to be resolved until we have more detailed and objective accounts of the complete life history of affected persons.
Sacro-iliac Gout
Gouty arthritis has a -well-known predilection for the
metatarso-phalangeal joint of the great toe. It is the first
joint to be attacked in about 60% of cases. Then, in
descending order of frequency, come the ankles, knees, wrists,
fingers, and elbows.' Central jonts are seldom affected, so
that gout can present considerable difficulties in diagnosis on
the rare occasions when it attacks the hip, vertebral,
sternoclavicular, or mandibular joints.
One of the last places apt to be considered as a site of
gout is the sacro-iliac joint, though there are a few well-
documented reports of its occurrence here. A patient described by R. L. Lipson and C. H. Slocumb' had advanced
tophaceous gout, and among other symptoms he described
acute episodes of poorly localized pain in the lower part of
the back. Radiographs showed large cystic lesions at the
lateral margin of one sacro-iliac joint; biopsy of them
showed hyalinized fibrous tissue surrounding localized
deposits of urate. A similar radiological picture was described
by W. Bauer and E. Calkins.' S. E. Malawista and
colleagues4 suggest that this situation may not be so unusual
as is commonly supposed. These authors report three
patients, all with established tophaceous gout. One of them
had severe recurrent pain and tenderness localized to the left
sacro-iliac joint and responding promptly to colchicine. The
other two had no such history, but radiographs showed
multiple cystic lesions with sclerotic margins in the lower
two-thirds of the sacro-iliac joints, as well as characteristic
changes of gout in the peripheral joints. Abdominal radio-
graphs from 95 cases of gout were then reviewed retro-
spectively, and similar cystic lesions were found in the
sacro-iliac joints of seven of them. In a further five patients
the radiological appearance of the sacro-iliac joints was not
normal, but in the absence of subchondral cysts with sclerotic
rims it was not considered that the changes were necessarily
due to gout rather than to some other form of sacro-
iliitis.
Sacro-iliitis, with its radiological signs of erosion,
sclerosis, and fusion of the joint surfaces, is sometimes
encountered in the absence of any other abnormality; it is
sometimes associated with ankylosing spondylitis ; and it is
sometimes found in those other conditions whose relation with
one another and with ankylosing spondylitis is incompletely
understood-namely, psoriatic arthritis, Reiter's disease, and
the arthropathy accompanying ulcerative colitis5 6 and
Crohn's disease. Various forms of bacterial sacro-iliitis also
occur, though infrequently in Great Britain.
While acute gout of the sacro-iliac joint must still be
regarded as rare, it seems from the study of Malawista and
colleagues that chronic gouty sacro-iliitis is a well-defined and
more common entity. The differential diagnosis between it and
other types of sacro-iliac disease should usually be fairly easy,
because a feature common to all the patients who have been
described with chronic sacro-iliac gout is the presence of
considerable and long-standing gouty arthritis in the
peripheral joints.
Cancer Research
Reduction in the number of deaths from cancer is the result
of repeated small advances in knowledge and in methods of
treatment. Such advances come from long periods of pains-
taking effort, and the annuml report of the Imperial Cancer
Research Fund gives a good picture of the many fields in
which this sort of careful study is being made.
The relation between viruses and tumours has been the
subject of investigation for nearly 50 years, and progress,
though peraps slow, is continuing. Two years ago G.
Negronil isolated a micro-organism from human tissue-cell
cultures inoculated with bone marrow from patients with
leukaemia. The report points out that this organism has now
been identified as a mycoplasma related to Mycoplasma
pulmonis. Presumptive evidence that the mycoplasma is not
a laboratory contaminant-as has been suggested-comes from
neutralization tests carried out on sera from patients with
leukaemia and from controls. It was found that about 50%
of the sera from the patients with leukaemia neutralized the
Negroni organism, whereas the control sera showed a low
degree of neutralization in only 10% of cases.
At the East African Virus Research Institute progress isbeing made in the search for the cause of Burkitt's lymphoma.
A total of 13 viruses have been recovered from 10 cases of the
tumour. Two of these 13 appear to be herpes simplex
viruses, but the remainder are rheoviruses, mostly type 3
strains. This is exciting news, when taken together with
Stanley's recent report of lymphomas in mice infected with
rheovirus type 3 transmitted by mosquito-bite.
The report makes it clear, however, that there is increasing
emphasis on research that is more closely connected than
hitherto with the treatment of patients. Collaboration with
clinical departments in hospitals has been expanded. R. D.
Bullbrook and J. L. Hayward have already had some success2
in using measurements of urinary androgen and corticosteroid
metabolites, together with other factors, in predicting the
response to endocrine ablation of patients with advanced
cancer of the breast. A large-scale clinical trial is now under
way. The director of research, G. F. Marrian, F.R.S., points
out in his report that there is room for improvement in this
field of clinical collaboration.
Silver Salvage
The demand for silver and the price of it continue to
increase. The question arises, therefore, whether it will always
be possible to manufacture all the radiographic film which may
be required.' The matter has to be taken seriously because
there are no practicable alternatives to the standard systems
used in medical radiography. The intensifying screens convert
x rays into light of a colour well adapted to affect the
photographic material. But this system necessarily, uses
full-size film and therefore much silver. In mass radiography
the luminescent screen is photographed to a small format
(needing much less silver), but this reduces the effective
speed of the process because most of the light emitted from the
screen misses the lens of the camera. Moreover, none of
the processes which do not require silver have a speed even
approaching that provided by the silver-halide materials.
But though the problem ought to be taken seriously no
immediate shortage is likely. The price of silver is not yet
five times what it was in 1914, and many useful commodities
have risen more in price than that. A further modest increase
should not be unbearable in industry. In 1964 about 215
million ounces of silver was produced. The annual production
has not been much different from that for half a century.
About one-third of that amount is used in industry, mostly
in photographic manufacture, and a large proportion of that
in the manufacture of x-ray film. But the total usage inBy adolescence cross-dressing is usually well established
but is devoid of fetishistic meaning, since feminine dress
evokes not excitement but a feeling of well-being, serenity,
and happiness. When cross-dressing is prevented for any
length of time tension, anxiety, and irritability develop.
Despite all this the individual remains capable of hetero-
sexual behaviour and usually expresses distaste for homo-
sexual practices. In one series9 30% were married and in
J. B. Randell's' -rather heterogeneous group 57% were
married. The marriages are frequently unstable and more
than half end in divorce or separation. Though often
described as a good husband, the transsexualist becomes
intensely jealous of pregnancy and motherhood in his spouse,
and persistent cross-dressing eventually makes the marital
role untenable.
Extreme revulsion for their genitalia and all signs of
masculinity often results in persistent importuning for
surgical " correction," and in some cases self-castration may
be attempted.2 3 In schizophrenia bizarre self-castration may
occur with or without delusional ideas about change of sex,
but in the transsexualist there is no other evidence of the
schizophrenic process.'1
By the time he reaches a hospital clinic the transsexualist
has usually adopted feminine garb in public; facial hair is
reduced and the testes are small and atrophic owing to self-
medication with stilboestrol, which the patient often denies.9
Many authors comment on the exceptional intelligence,
versatility, and artistic gifts of these patients.'2 13 Though
usually anxious to assert their feminine normality, many of
the patients present frank neurotic features.' On most
psychological tests they show high scores for feminine interest,
but their conviction that they have an attractive feminine
physique is sometimes in ludicrous contrast to their hirsute
muscularity.
The sincerity and conviction with which these people
describe their predicament has inclined many physicians who
have studied the disorder to regard transsexualism as an
inborn tendency, but the men patients show no chromosomal
abnormality and in every possible measure are anatomically
and physiologically male.1" However, there is an excess of
abnormal sexual behaviour among patients with Klinefelter's
syndrome and in association with certain disturbances of brain
function.
Cross-dressing and a conviction of sex change may occur
in toxic states due to amphetamine,"- psychosis," and
temporal-lobe epilepsy.' 6-18 Of particular interest are those
cases associated with clearly defined lesions of the temporal
lobe, in which normal sexuality was restored after temporal
lobectomy.1"-2 J. WAlinder" has also found a high
prevalence of- electroencephalographic abnormalities among
unselected transvestists.
Psychotherapy is at best supportive for these patients,2
behaviour therapy of unproved value,22 and the indications for
surgical operation often based on opinion rather than facts.
Many transsexual men achieve a real sense of contentment for
the first time if, despite the social and administrative prob-
lems, they can live and work as a woman. But once this
step is taken the patient rarely goes back to his former way of
life, and his demands for surgery may become more insistent.
Some authors have reported cases in which castration, with or
without other surgical procedures, has been followed by
greater emotional stability and improved social effective-
ness.'-' Some maintain that operation is the most effective
means of treatment available, yet the evidence is by no means
clear. Patients have sometimes deteriorated after operation,
or have continued to importune for further surgical changes,
while others have demanded reversal of the operation and
threatened legal action when this was shown to be impos-
sible.2 23 24 A distinct danger is the polymorphously perverse
psychopath who succeeds in obtaining a surgical operation
during a chameleon-like change. Such individuals may
indulge in exhibitionistic publicity, become prostitutes, or
engage in litigation against the surgeon. The legal status of
the converted transsexualist so far as marriage and inheritance
is concerned has yet to be tested in the courts. This
uncommon but tragic anomaly presents many problems which
are unlikely to be resolved until we have more detailed and objective accounts of the complete life history of affected persons.
Sacro-iliac Gout
Gouty arthritis has a -well-known predilection for the
metatarso-phalangeal joint of the great toe. It is the first
joint to be attacked in about 60% of cases. Then, in
descending order of frequency, come the ankles, knees, wrists,
fingers, and elbows.' Central jonts are seldom affected, so
that gout can present considerable difficulties in diagnosis on
the rare occasions when it attacks the hip, vertebral,
sternoclavicular, or mandibular joints.
One of the last places apt to be considered as a site of
gout is the sacro-iliac joint, though there are a few well-
documented reports of its occurrence here. A patient described by R. L. Lipson and C. H. Slocumb' had advanced
tophaceous gout, and among other symptoms he described
acute episodes of poorly localized pain in the lower part of
the back. Radiographs showed large cystic lesions at the
lateral margin of one sacro-iliac joint; biopsy of them
showed hyalinized fibrous tissue surrounding localized
deposits of urate. A similar radiological picture was described
by W. Bauer and E. Calkins.' S. E. Malawista and
colleagues4 suggest that this situation may not be so unusual
as is commonly supposed. These authors report three
patients, all with established tophaceous gout. One of them
had severe recurrent pain and tenderness localized to the left
sacro-iliac joint and responding promptly to colchicine. The
other two had no such history, but radiographs showed
multiple cystic lesions with sclerotic margins in the lower
two-thirds of the sacro-iliac joints, as well as characteristic
changes of gout in the peripheral joints. Abdominal radio-
graphs from 95 cases of gout were then reviewed retro-
spectively, and similar cystic lesions were found in the
sacro-iliac joints of seven of them. In a further five patients
the radiological appearance of the sacro-iliac joints was not
normal, but in the absence of subchondral cysts with sclerotic
rims it was not considered that the changes were necessarily
due to gout rather than to some other form of sacro-
iliitis.
Sacro-iliitis, with its radiological signs of erosion,
sclerosis, and fusion of the joint surfaces, is sometimes
encountered in the absence of any other abnormality; it is
sometimes associated with ankylosing spondylitis ; and it is
sometimes found in those other conditions whose relation with
one another and with ankylosing spondylitis is incompletely
understood-namely, psoriatic arthritis, Reiter's disease, and
the arthropathy accompanying ulcerative colitis5 6 and
Crohn's disease. Various forms of bacterial sacro-iliitis also
occur, though infrequently in Great Britain.
While acute gout of the sacro-iliac joint must still be
regarded as rare, it seems from the study of Malawista and
colleagues that chronic gouty sacro-iliitis is a well-defined and
more common entity. The differential diagnosis between it and
other types of sacro-iliac disease should usually be fairly easy,
because a feature common to all the patients who have been
described with chronic sacro-iliac gout is the presence of
considerable and long-standing gouty arthritis in the
peripheral joints.
Cancer Research
Reduction in the number of deaths from cancer is the result
of repeated small advances in knowledge and in methods of
treatment. Such advances come from long periods of pains-
taking effort, and the annuml report of the Imperial Cancer
Research Fund gives a good picture of the many fields in
which this sort of careful study is being made.
The relation between viruses and tumours has been the
subject of investigation for nearly 50 years, and progress,
though peraps slow, is continuing. Two years ago G.
Negronil isolated a micro-organism from human tissue-cell
cultures inoculated with bone marrow from patients with
leukaemia. The report points out that this organism has now
been identified as a mycoplasma related to Mycoplasma
pulmonis. Presumptive evidence that the mycoplasma is not
a laboratory contaminant-as has been suggested-comes from
neutralization tests carried out on sera from patients with
leukaemia and from controls. It was found that about 50%
of the sera from the patients with leukaemia neutralized the
Negroni organism, whereas the control sera showed a low
degree of neutralization in only 10% of cases.
At the East African Virus Research Institute progress is
being made in the search for the cause of Burkitt's lymphoma.
A total of 13 viruses have been recovered from 10 cases of the
tumour. Two of these 13 appear to be herpes simplex
viruses, but the remainder are rheoviruses, mostly type 3
strains. This is exciting news, when taken together with
Stanley's recent report of lymphomas in mice infected with
rheovirus type 3 transmitted by mosquito-bite.
The report makes it clear, however, that there is increasing
emphasis on research that is more closely connected than
hitherto with the treatment of patients. Collaboration with
clinical departments in hospitals has been expanded. R. D.
Bullbrook and J. L. Hayward have already had some success2
in using measurements of urinary androgen and corticosteroid
metabolites, together with other factors, in predicting the
response to endocrine ablation of patients with advanced
cancer of the breast. A large-scale clinical trial is now under
way. The director of research, G. F. Marrian, F.R.S., points
out in his report that there is room for improvement in this
field of clinical collaboration.
Silver Salvage
The demand for silver and the price of it continue to
increase. The question arises, therefore, whether it will always
be possible to manufacture all the radiographic film which may
be required.' The matter has to be taken seriously because
there are no practicable alternatives to the standard systems
used in medical radiography. The intensifying screens convert
x rays into light of a colour well adapted to affect the
photographic material. But this system necessarily, uses
full-size film and therefore much silver. In mass radiography
the luminescent screen is photographed to a small format
(needing much less silver), but this reduces the effective
speed of the process because most of the light emitted from the
screen misses the lens of the camera. Moreover, none of
the processes which do not require silver have a speed even
approaching that provided by the silver-halide materials.
But though the problem ought to be taken seriously no
immediate shortage is likely. The price of silver is not yet
five times what it was in 1914, and many useful commodities
have risen more in price than that. A further modest increase
should not be unbearable in industry. In 1964 about 215
million ounces of silver was produced. The annual production
has not been much different from that for half a century.
About one-third of that amount is used in industry, mostly
in photographic manufacture, and a large proportion of that
in the manufacture of x-ray film. But the total usage in
1964 was 550 million ounces, 300 million of it in the United
States for coinage. This alone suggests that great reserves
are available. Silver is a precious metal which does not.
1964 was 550 million ounces, 300 million of it in the United
States for coinage. This alone suggests that great reserves
are available. Silver is a precious metal which does not.د