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PSYCHIATRIC CLINIC AT GUY'S
996
PSYCHIATRIC CLINIC AT
to favour the creation of
a workmen’s comas recommended commissioner pensation by the Holman Gregory committee. Among his duties would be the appointment and regulation of medical referees, the scheduling of new industrial diseases and the making of silicosis schemes. This proposal seems to raise high constitutional issues. If he worked as unobtrusively as the industrial assurance commissioner, who is also the registrar of friendly societies, all might be easy. But if his appointment fails to take workmen’s seem
GUY’S
out of politics and away from the floor of the House of Commons, there must be some responsible Minister to answer questions in Parliament. The experiences of the Unemployment Assistance Board and the controversy over the means test were discouraging symptoms. Sir ARNOLD WILSON and Prof. LEVY may be trusted to make a strong case for anything recommend. In this first instalment, thorough, scholarly and well documented, they have laid a solid foundation.
compensation
they
ANNOTATIONS PSYCHIATRIC CLINIC AT GUY’S
THE establishment of a special inpatient department for all kinds of mental illness at Guy’s Hospital,
made possible by the gift of 43,000 by Five Friends, is a new departure in British medicine. Hitherto a few beds have been provided at Guy’s, the Middlesex, and other teaching hospitals for minor forms of mental illness, especially psychoneurotic conditions, and a ward has been set apart for the same purpose at King’s College Hospital
Maudsley, but there has comprehensive inpatient accommodation exists in the psychiatric clinics of the Con-
under the direction of the
been
no
such as tinent or the United States. There are many reasons for welcoming this innovation. 1t is now generally agreed that the breach between general and psychological medicine is neither practically wise nor scientifically justified. This breach may have been produced in the past by considerations of expediency -it was thought wiser, for example, to move the " chronic lunatics " originally provided for in the will of Thomas Guy to another district and another establishment altogether-but recent advances in knowledge, including the recognition that outspoken insanity is only a fraction of the field of mental illness, has made such considerations of minor importance. The new clinic is to consist of 42 beds in addition to the 5 beds in the general wards at present allotted to psychological illness. It will be subdivided so as to enable mental illness of all kinds and degrees, including psychoneuroses, psychopathies and psychoses short of certifiability, to be accommodated. A considerable step will have been taken in this way towards breaking down the public dislike of mental illness by enabling such patients to be admitted and treated in a general hospital. The clinic comes at a time when the treatment of the severer forms of mental illness has become much more active and has taken a form for which the facilities available for physical examination and control at a general hospital are particularly appropriate. Moreover, the importance of early treatment by the newer methods makes early admission still more necessary, and the public are more likely to agree to their mentally ill relatives receiving treatment at the earliest possible moment if it is to be given in a general hospital. The advantages to medical education of such a clinic fortunately coincide with the advantages to the patient and the public. It should do much to focus the interest of the student on this branch of medicine, since he will find suitable material close at hand throughout his clinical years. The staff of the clinic should be a valuable addition to the teaching strength of the hospital, and should make it possible to extend the teaching of the psychological aspects of general
disease in the medical and surgical wards. The staff themselves will benefit from constantly rubbing shoulders with colleagues in other branches of medi. cine, so that the commonly levelled charge of the isolation of psychiatry from general medicine will lose any validity it may have. On the other hand, contact with the clinic should enable the rest of the hospital staff as well as the students to develop an intimacy with this aspect of medicine which cannot fail to be useful in their everyday practice. Further, " as iron sharpeneth iron, so a man sharpeneth the countenance of his friend," and the presence of a complete psychiatric clinic cheek by jowl with the other departments of a great teaching hospital should provide the stimulus to research that comes only from the mutual contact of diverse branches of scientific inquiry. ASPIRATION BIOPSY OF THE LIVER
THERE are few organs left in the body which are safe from the eye of a clinician looking down a " scope," or whose tissue may not be drawn up in a syringe and examined microscopically. Cysts and abscesses of the liver have been aspirated for over a hundred years, but in 1923 Bingelreported the results of exploratory puncture of the solid portion of that organ as a diagnostic aid. Since then a number of other writers have described its use, and a recent paper by Baron2 from the Mount Sinai Hospital justifies an assessment of its value. The technique seemed simple. A preliminary hypnotic is given, because the operation is painful even with local anesthesia. A 20 c.cm. Record syringe with a 9 cm. No. 13 gauge needle is employed, and after ansesthetising the skin and making a small incision the needle is inserted to the right of the epigastrium below the costal margin and directed upwards and laterally ; when the liver is reached constant suction is maintained in order to obtain a core of liver tissue, and after the needle has been withdrawn its contents are placed in fixative and sections prepared. Baron describes 35 cases of suspected hepatic metastases, cirrhosis, or catarrhal and chronic jaundice in which the operation was used to assist diagnosis. In the 16 cases of suspected carcinoma biopsy produced neoplastic tissue in 9 and normal liver tissue in 5 ; at laparotomy 3 of the latter were found to have metastases, but the other 2 were free from growth. From 1 of the 2 non-malignant cases in this group clear yellow fluid was obtained which led to a diagnosis of congenital cystic disease, and a pyelogram showed a similar change in the kidneys. In the other blood welled into the syringe used for anaesthetising the peritoneum ; a hsemangeioma was 1. 2.
Bingel, A., Verh. dtsch. Ges. inn. Med. 1923, 35, 210. Baron, E., Arch. intern. Med. February, 1939, p. 276.
PSYCHIATRIC CLINIC AT
to favour the creation of
a workmen’s comas recommended commissioner pensation by the Holman Gregory committee. Among his duties would be the appointment and regulation of medical referees, the scheduling of new industrial diseases and the making of silicosis schemes. This proposal seems to raise high constitutional issues. If he worked as unobtrusively as the industrial assurance commissioner, who is also the registrar of friendly societies, all might be easy. But if his appointment fails to take workmen’s seem
GUY’S
out of politics and away from the floor of the House of Commons, there must be some responsible Minister to answer questions in Parliament. The experiences of the Unemployment Assistance Board and the controversy over the means test were discouraging symptoms. Sir ARNOLD WILSON and Prof. LEVY may be trusted to make a strong case for anything recommend. In this first instalment, thorough, scholarly and well documented, they have laid a solid foundation.
compensation
they
ANNOTATIONS PSYCHIATRIC CLINIC AT GUY’S
THE establishment of a special inpatient department for all kinds of mental illness at Guy’s Hospital,
made possible by the gift of 43,000 by Five Friends, is a new departure in British medicine. Hitherto a few beds have been provided at Guy’s, the Middlesex, and other teaching hospitals for minor forms of mental illness, especially psychoneurotic conditions, and a ward has been set apart for the same purpose at King’s College Hospital
Maudsley, but there has comprehensive inpatient accommodation exists in the psychiatric clinics of the Con-
under the direction of the
been
no
such as tinent or the United States. There are many reasons for welcoming this innovation. 1t is now generally agreed that the breach between general and psychological medicine is neither practically wise nor scientifically justified. This breach may have been produced in the past by considerations of expediency -it was thought wiser, for example, to move the " chronic lunatics " originally provided for in the will of Thomas Guy to another district and another establishment altogether-but recent advances in knowledge, including the recognition that outspoken insanity is only a fraction of the field of mental illness, has made such considerations of minor importance. The new clinic is to consist of 42 beds in addition to the 5 beds in the general wards at present allotted to psychological illness. It will be subdivided so as to enable mental illness of all kinds and degrees, including psychoneuroses, psychopathies and psychoses short of certifiability, to be accommodated. A considerable step will have been taken in this way towards breaking down the public dislike of mental illness by enabling such patients to be admitted and treated in a general hospital. The clinic comes at a time when the treatment of the severer forms of mental illness has become much more active and has taken a form for which the facilities available for physical examination and control at a general hospital are particularly appropriate. Moreover, the importance of early treatment by the newer methods makes early admission still more necessary, and the public are more likely to agree to their mentally ill relatives receiving treatment at the earliest possible moment if it is to be given in a general hospital. The advantages to medical education of such a clinic fortunately coincide with the advantages to the patient and the public. It should do much to focus the interest of the student on this branch of medicine, since he will find suitable material close at hand throughout his clinical years. The staff of the clinic should be a valuable addition to the teaching strength of the hospital, and should make it possible to extend the teaching of the psychological aspects of general
disease in the medical and surgical wards. The staff themselves will benefit from constantly rubbing shoulders with colleagues in other branches of medi. cine, so that the commonly levelled charge of the isolation of psychiatry from general medicine will lose any validity it may have. On the other hand, contact with the clinic should enable the rest of the hospital staff as well as the students to develop an intimacy with this aspect of medicine which cannot fail to be useful in their everyday practice. Further, " as iron sharpeneth iron, so a man sharpeneth the countenance of his friend," and the presence of a complete psychiatric clinic cheek by jowl with the other departments of a great teaching hospital should provide the stimulus to research that comes only from the mutual contact of diverse branches of scientific inquiry. ASPIRATION BIOPSY OF THE LIVER
THERE are few organs left in the body which are safe from the eye of a clinician looking down a " scope," or whose tissue may not be drawn up in a syringe and examined microscopically. Cysts and abscesses of the liver have been aspirated for over a hundred years, but in 1923 Bingelreported the results of exploratory puncture of the solid portion of that organ as a diagnostic aid. Since then a number of other writers have described its use, and a recent paper by Baron2 from the Mount Sinai Hospital justifies an assessment of its value. The technique seemed simple. A preliminary hypnotic is given, because the operation is painful even with local anesthesia. A 20 c.cm. Record syringe with a 9 cm. No. 13 gauge needle is employed, and after ansesthetising the skin and making a small incision the needle is inserted to the right of the epigastrium below the costal margin and directed upwards and laterally ; when the liver is reached constant suction is maintained in order to obtain a core of liver tissue, and after the needle has been withdrawn its contents are placed in fixative and sections prepared. Baron describes 35 cases of suspected hepatic metastases, cirrhosis, or catarrhal and chronic jaundice in which the operation was used to assist diagnosis. In the 16 cases of suspected carcinoma biopsy produced neoplastic tissue in 9 and normal liver tissue in 5 ; at laparotomy 3 of the latter were found to have metastases, but the other 2 were free from growth. From 1 of the 2 non-malignant cases in this group clear yellow fluid was obtained which led to a diagnosis of congenital cystic disease, and a pyelogram showed a similar change in the kidneys. In the other blood welled into the syringe used for anaesthetising the peritoneum ; a hsemangeioma was 1. 2.
Bingel, A., Verh. dtsch. Ges. inn. Med. 1923, 35, 210. Baron, E., Arch. intern. Med. February, 1939, p. 276.