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FOR TRACHEOTOMY CASES
669 NEUROSIS OR PSYCHOSIS ? SIR,-Far be it from me at the present time to embark upon, or to encourage, controversy on this endless theme. As, however, you referred to my
writings and views in the leading article from which this correspondence arose, I may perhaps be allowed on the matter. The first is that if the suggestion that an anxiety neurosis and a melancholic depression have anything in common with each other in either aetiology, symptoms, course or treatment, is to be accepted or even to pass unchallenged, I for one should feel that our terminology and psychopathology were futile from beginning to end, and should withdraw in despair from any further attempt at argument or discussion. I fancy that I should do so in fairly good company. The second is that it is unfortunately possible that we may all before very long have ample opportunity to observe the greatness of the gulf that separates neurosis from psychosis. I pointed out several years ago that no better help to the differential diagnosis exists than an air-raid. No-one who has experienced an air-raid in the company of a number of both neurotics and psychotics is likely ever again to be in doubt as to whether the difference between the two is " quantitative " or "qualitative." I need not say that I share the universal hope that we shall be spared this acid test, and I trust that Dr. Symonds and Dr. Gillespie may be able to compose their differences without having to wait for it. Of course, any observant mental-hospital physician who has noted the reaction of the patients in his " convalescent " wards to a thunderstorm could say a good deal about the profound difference between neurosis and psychosis, but his evidence would, I fear, be regarded as tainted. Is it so very difficult to admit that even a psychosis must have a beginning, and that it may very often be undiagnosable or misdiagnosed at first, even by an experienced man ?‘? I cannot think that anything is gained-and the reputation of our specialty is certainly damaged-by confidently labelling an early, doubtful or undiagnosable psychosis as a neurosis, and endeavouring to have it both ways by asserting that the one may turn into the other. I am, Sir, yours faithfully,
to make two brief statements
HENRY YELLOWLEES.
it a not unreasonable deduction as to one aspect of lead intoxication. My case records perished long ago so that I cannot give precise details. When Dr. Lane has had a similar experience he will be in a better position to plead for " a more critical attitude " and to condemn " a seemingly plausible explanation " as if his middle name was Tarquin. I trust he will not mislike the comparison. I am, Sir, yours faithfully, ,
GORDON WARD. A WAR-TIME PHARMACOPŒIA ?
SIR,-In the present circumstances it is imperative to study forthwith means of preserving supplies of certain substances which, although widely prescribed, have little or no therapeutic value. Syrups, used as flavouring agents, edible oils and fats as ointment bases, alcohol in many tinctures, are instances of valuable substances which could be
solely
replaced. Belladonna pulverata, digitalis pulverata, and ergota preparata could be given in tablet form instead of the corresponding tinctures and extracts. This would mean the saving of alcohol and in addition, owing to the reduction in bulk, storage and transport problems would be simplified. Now is the time to devise a war-emergency pharmacopoeia for the whole country. A small committee of representatives of the medical and pharmaceutical professions would have little difficulty in compiling a national formulary. Such a pharmacopoeia is an urgent necessity. I am, Sir, yours faithfully, H. DAVIS, Chief Pharmacist.
University College Hospital, London, W.C.1, Sept. 7. EXPOSURE OF THE FACIAL NERVE
SiR,—Mr. Morris’s article on the surgical treatment paralysis (Lancet, 1939, Sept. 2, p. 558) prompts me to record an easy method of approach to the facial-nerve trunk. This I devised some forty years ago. I used to chisel off the tip of the mastoid of facial
process, with the insertion of the sterno-mastoid. The muscle and mastoid are turned downwards, thus exposing the nerve as it emerges from the stylomastoid foramen. It can then be followed with ease in either direction. I used this exposure first in cases of catarrhal palsy, which I now generally treat with
diathermy. "DORMANT" LEAD POISONING may be my mistake, but I seem to detect some hint of supeibity in Dr. R. E. Lane’s comments on the above subject. His experience of industrial lead poisoning is not in question; his knowledge of lead poisoning in war conditions has yet to emerge. If he will read my letter again he will see that I have not ascribed symptoms to lead " that had been absorbed many years previously." These cases to which I referred had been absorbing lead up to the time of their joining the army, perhaps two or three years before I saw them, sometimes less. This is not 1, many years." A considerable incidence of lead poisoning, diagnosed on clinical and haematological grounds, was apparent for the first time after joining up. I should be more strictly accurate if I said that a considerable incidence of acute symptoms was seen ; many of the older patients had suffered from constipation and other symptoms, possibly due to lead, for long periods. I claim to have made a clinical and haematological observation and to have drawn from
I am,
Sir,
yours
faithfully, W. KENT HUGHES.
SIR,-I hope it
FOR TRACHEOTOMY CASES
SIR,-I feel that arrangements should be made for patients who have to wear tracheotomy tubes to be given some protection against gas. Evacuation or if this is impossible their admission to a gas-proofed hospital ward would seem the most convenient way of dealing with the problem. I am, Sir, yours faithfully, W. A. MILL.
UNIVERSITY from Dr. Russell
OF
CAMBRIDGE.
-
We understand
Reynolds that he has not resigned his examinership for the diploma in medical radiology, as stated in the Cambridge University Reporter and in our issue of Sept. 2. Dr. Kesley is taking his place for the October examination only.
writings and views in the leading article from which this correspondence arose, I may perhaps be allowed on the matter. The first is that if the suggestion that an anxiety neurosis and a melancholic depression have anything in common with each other in either aetiology, symptoms, course or treatment, is to be accepted or even to pass unchallenged, I for one should feel that our terminology and psychopathology were futile from beginning to end, and should withdraw in despair from any further attempt at argument or discussion. I fancy that I should do so in fairly good company. The second is that it is unfortunately possible that we may all before very long have ample opportunity to observe the greatness of the gulf that separates neurosis from psychosis. I pointed out several years ago that no better help to the differential diagnosis exists than an air-raid. No-one who has experienced an air-raid in the company of a number of both neurotics and psychotics is likely ever again to be in doubt as to whether the difference between the two is " quantitative " or "qualitative." I need not say that I share the universal hope that we shall be spared this acid test, and I trust that Dr. Symonds and Dr. Gillespie may be able to compose their differences without having to wait for it. Of course, any observant mental-hospital physician who has noted the reaction of the patients in his " convalescent " wards to a thunderstorm could say a good deal about the profound difference between neurosis and psychosis, but his evidence would, I fear, be regarded as tainted. Is it so very difficult to admit that even a psychosis must have a beginning, and that it may very often be undiagnosable or misdiagnosed at first, even by an experienced man ?‘? I cannot think that anything is gained-and the reputation of our specialty is certainly damaged-by confidently labelling an early, doubtful or undiagnosable psychosis as a neurosis, and endeavouring to have it both ways by asserting that the one may turn into the other. I am, Sir, yours faithfully,
to make two brief statements
HENRY YELLOWLEES.
it a not unreasonable deduction as to one aspect of lead intoxication. My case records perished long ago so that I cannot give precise details. When Dr. Lane has had a similar experience he will be in a better position to plead for " a more critical attitude " and to condemn " a seemingly plausible explanation " as if his middle name was Tarquin. I trust he will not mislike the comparison. I am, Sir, yours faithfully, ,
GORDON WARD. A WAR-TIME PHARMACOPŒIA ?
SIR,-In the present circumstances it is imperative to study forthwith means of preserving supplies of certain substances which, although widely prescribed, have little or no therapeutic value. Syrups, used as flavouring agents, edible oils and fats as ointment bases, alcohol in many tinctures, are instances of valuable substances which could be
solely
replaced. Belladonna pulverata, digitalis pulverata, and ergota preparata could be given in tablet form instead of the corresponding tinctures and extracts. This would mean the saving of alcohol and in addition, owing to the reduction in bulk, storage and transport problems would be simplified. Now is the time to devise a war-emergency pharmacopoeia for the whole country. A small committee of representatives of the medical and pharmaceutical professions would have little difficulty in compiling a national formulary. Such a pharmacopoeia is an urgent necessity. I am, Sir, yours faithfully, H. DAVIS, Chief Pharmacist.
University College Hospital, London, W.C.1, Sept. 7. EXPOSURE OF THE FACIAL NERVE
SiR,—Mr. Morris’s article on the surgical treatment paralysis (Lancet, 1939, Sept. 2, p. 558) prompts me to record an easy method of approach to the facial-nerve trunk. This I devised some forty years ago. I used to chisel off the tip of the mastoid of facial
process, with the insertion of the sterno-mastoid. The muscle and mastoid are turned downwards, thus exposing the nerve as it emerges from the stylomastoid foramen. It can then be followed with ease in either direction. I used this exposure first in cases of catarrhal palsy, which I now generally treat with
diathermy. "DORMANT" LEAD POISONING may be my mistake, but I seem to detect some hint of supeibity in Dr. R. E. Lane’s comments on the above subject. His experience of industrial lead poisoning is not in question; his knowledge of lead poisoning in war conditions has yet to emerge. If he will read my letter again he will see that I have not ascribed symptoms to lead " that had been absorbed many years previously." These cases to which I referred had been absorbing lead up to the time of their joining the army, perhaps two or three years before I saw them, sometimes less. This is not 1, many years." A considerable incidence of lead poisoning, diagnosed on clinical and haematological grounds, was apparent for the first time after joining up. I should be more strictly accurate if I said that a considerable incidence of acute symptoms was seen ; many of the older patients had suffered from constipation and other symptoms, possibly due to lead, for long periods. I claim to have made a clinical and haematological observation and to have drawn from
I am,
Sir,
yours
faithfully, W. KENT HUGHES.
SIR,-I hope it
FOR TRACHEOTOMY CASES
SIR,-I feel that arrangements should be made for patients who have to wear tracheotomy tubes to be given some protection against gas. Evacuation or if this is impossible their admission to a gas-proofed hospital ward would seem the most convenient way of dealing with the problem. I am, Sir, yours faithfully, W. A. MILL.
UNIVERSITY from Dr. Russell
OF
CAMBRIDGE.
-
We understand
Reynolds that he has not resigned his examinership for the diploma in medical radiology, as stated in the Cambridge University Reporter and in our issue of Sept. 2. Dr. Kesley is taking his place for the October examination only.