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" THESE DYING DISEASES "
1073 such visitors. After all, our visiting medically trained either. But the advantages of visiting have already been demonstrated in practice as well as in theory. I know of a Scottish mental hospital, for example, where the physician-superint - endent has arranged with various local Church guilds to " adopt " the more lonely of his patients, and to give them friendship, and even an interest in life. Here, once every month, a busload of guildswomen arrive at the hospital; there is chatter and laughter in the corridors, there are picnics, days at the seaside, and even days spent in the comfort of their visitor’s own home.
taken into the
chaplains
hospitals by
are not
All the mentally ill are, at bottom, starving for the want of love, and for outside interest in themselves. Since there are people willing to do what they can to help these patients, surely every mental hospital ought to be
encouraging-indeed seeking-such help ?z Edzell, Angus.
H. G. WOODLEY.
RETICULOHISTIOCYTOSIS in 1955,1 under the heading A Rare Disease with Features Resembling both Rheumatoid Arthritis and a Lipoid Accumulation, I referred to the case of a man which I first described with Dr. W. Freudenthalunder the heading Nodular Non-diabetic Cutaneous Xanthomatosis with Hypercholesterolasmia and Atypical Histological Features. Dr. George Graham gave me frequent opportunities of observing the case of a man under his care with analogous symptoms. This man ultimately died and an elaborate account of his case was publishedunder the heading A Case of Hitherto Undescribed Lipoidosis simulating Rheumatoid Arthritis. I now believe that Graham’s case was of exactly the same nature as that of Parkes Weber and Freudenthal, but complicated by the supervention of a sarcomatous growth and a microbic infection, which caused the patient’s The case of Weber and Freudenthal apparently death. subsequently recovered with considerable permanent changes in bones and joints.-l I think that " congenital development diseases " are not so very rarely terminated by the supervention of malignant growth, which complicates the diagnosis. F. PARKES WEBER. London, VG’.1.
SIR,-In The Lancet
" THESE DYING DISEASES "
SIR,-Dr. Vickers (March 19) advocates abolition of the venereal-diseases clinic and dispersion of its patients to other hospital departments. This, from a dermatologist, is very strange: syphilis is still the great imitator, and rashes appear to be the least common sign in early or late syphilis. In the Services, venereal diseases and skin diseases were formerly combined, but early in the late war it was found necessary to separate them-particularly on the insistence of the dermatologists. Under Dr. Vickers’ scheme the following questions would arise: (1) Would a patient be able (as at present in v.D. clinics) to attend without an appointment and without a doctor’s letter ? (2) Who would see the transient patient-e.g. the longdistance driver, or seaman, who carries a small travelling book (v.15 and v.44 respectively) in which all treatment given and all pathological reports are recorded. Could the patients be seen immediately and by whom ? (3) Who would undertake the care of the pregnant syphilitic woman, and which department would investigate false positive 1. Lancer, 1955, ii, 395. 2. Brit. J. Derm. 1937, 30, 522. 3. Graham, G., Stansfield, A. G. J. Path. Bact. 1946, 58, 545. 4. Parkes Weber, F. in MacKenna’s Modern Trends in Dermatology;
p. 309. London, 1948.
Wassermann reaction ? Who would be responsible for telling a patient, without confirmation, that she has syphilis-knowirig the likely effect on the patient and the family, and the risk of legal action against the doctor ? (4) Who would see the cases of Reiter’s syndrome-the ophthalmologist, the genitourinary surgeon, or the general
physician ? (5) Which department would deal with neurosyphilitics with cardiac complications ?
Investigation of the patient’s social background, tracing contacts, and dealing with " case holding " until adequate treatment has been given is not the work of the several departments mentioned by Dr. Vickers. Moreover the v.D patient prefers the confidential approach and constant sympathetic staff found in v.D. clinics. The success of the anti-v.D. scheme in Great Britain has depended largely on the coordination which the venereologist has created from the chaos which existed when so many treated venereal diseases. And, whereas the returns to the Ministry as at present compiled by the venereologist are at least a good indication of the epidemiological situation of venereal diseases, under Dr. Vickers’ regime no return would ever be completed. A. I. MORRISON. The Royal Hospital, Sheffield, 1. SIR,-Although
CEREBRAL PALSY I hardly dare to quarrel with the
definition of cerebral palsy proposed by such an eminent " interested people " in their letter of May 3, group of I do feel that the second explanatory footnote (which reads, " This excludes such quantitative disorders of movement as might be met with in mental defectives ") is both misleading and unjust. If we are to have strict definitions about cerebral palsy let us also be clear about mental deficiency. Other " interested people ", like myself, whose work lies with patients suffering from " damage of the brain from intrinsically or extrinsically caused development disorder (occurring in fcetal life or after birth) or perinatal, paranatal or postnatal in origin " (footnote 4), do not call their patients mental defectives or think of them as such. Mental deficiency is a legal term, not a diagnosis. It is
great disappointment to us that pxdiatricians and neurologists continue to perpetuate, along with nearly all the rest of the medical profession, such misunderstanding. They regard all brain damage severe enough to preclude educability as mental deficiency " and an invidious distinction has grown up between cerebral palsy and mental defectiveness, whereas we know that it is quite possible for a child with cerebral palsy to be deemed, quite correctly, ineducable and, therefore, mentally defective. This child is not suffering from some other disorder superimposed on his cerebral palsy, His " non-progressive brain damage " is merely more severe. In exactly the same way the child showing quantitative disorders of movement, which excludes him, by the definition, from the " cerebral palsy " group, is suffering from either brain damage which may also fit quite well into footnote 4 of the definition or from some other physical disorder-e.g., metabolic. He is not, however, suffering from mental deficiency a
"
"
earnestly hope for the closer integration of mental deficiency " (sic) with general medicine, and this will not come about as fast as it might so long as the severely damaged child suffering from an obvious, clear-cut physical disorder is suddenly labelled " mentally defective " by the general hospital physician and instant dispatch to an institution " advised. Botleys Park Hospital, J. M. CRAWFORD. Chertsey, Surrey. I
"
taken into the
chaplains
hospitals by
are not
All the mentally ill are, at bottom, starving for the want of love, and for outside interest in themselves. Since there are people willing to do what they can to help these patients, surely every mental hospital ought to be
encouraging-indeed seeking-such help ?z Edzell, Angus.
H. G. WOODLEY.
RETICULOHISTIOCYTOSIS in 1955,1 under the heading A Rare Disease with Features Resembling both Rheumatoid Arthritis and a Lipoid Accumulation, I referred to the case of a man which I first described with Dr. W. Freudenthalunder the heading Nodular Non-diabetic Cutaneous Xanthomatosis with Hypercholesterolasmia and Atypical Histological Features. Dr. George Graham gave me frequent opportunities of observing the case of a man under his care with analogous symptoms. This man ultimately died and an elaborate account of his case was publishedunder the heading A Case of Hitherto Undescribed Lipoidosis simulating Rheumatoid Arthritis. I now believe that Graham’s case was of exactly the same nature as that of Parkes Weber and Freudenthal, but complicated by the supervention of a sarcomatous growth and a microbic infection, which caused the patient’s The case of Weber and Freudenthal apparently death. subsequently recovered with considerable permanent changes in bones and joints.-l I think that " congenital development diseases " are not so very rarely terminated by the supervention of malignant growth, which complicates the diagnosis. F. PARKES WEBER. London, VG’.1.
SIR,-In The Lancet
" THESE DYING DISEASES "
SIR,-Dr. Vickers (March 19) advocates abolition of the venereal-diseases clinic and dispersion of its patients to other hospital departments. This, from a dermatologist, is very strange: syphilis is still the great imitator, and rashes appear to be the least common sign in early or late syphilis. In the Services, venereal diseases and skin diseases were formerly combined, but early in the late war it was found necessary to separate them-particularly on the insistence of the dermatologists. Under Dr. Vickers’ scheme the following questions would arise: (1) Would a patient be able (as at present in v.D. clinics) to attend without an appointment and without a doctor’s letter ? (2) Who would see the transient patient-e.g. the longdistance driver, or seaman, who carries a small travelling book (v.15 and v.44 respectively) in which all treatment given and all pathological reports are recorded. Could the patients be seen immediately and by whom ? (3) Who would undertake the care of the pregnant syphilitic woman, and which department would investigate false positive 1. Lancer, 1955, ii, 395. 2. Brit. J. Derm. 1937, 30, 522. 3. Graham, G., Stansfield, A. G. J. Path. Bact. 1946, 58, 545. 4. Parkes Weber, F. in MacKenna’s Modern Trends in Dermatology;
p. 309. London, 1948.
Wassermann reaction ? Who would be responsible for telling a patient, without confirmation, that she has syphilis-knowirig the likely effect on the patient and the family, and the risk of legal action against the doctor ? (4) Who would see the cases of Reiter’s syndrome-the ophthalmologist, the genitourinary surgeon, or the general
physician ? (5) Which department would deal with neurosyphilitics with cardiac complications ?
Investigation of the patient’s social background, tracing contacts, and dealing with " case holding " until adequate treatment has been given is not the work of the several departments mentioned by Dr. Vickers. Moreover the v.D patient prefers the confidential approach and constant sympathetic staff found in v.D. clinics. The success of the anti-v.D. scheme in Great Britain has depended largely on the coordination which the venereologist has created from the chaos which existed when so many treated venereal diseases. And, whereas the returns to the Ministry as at present compiled by the venereologist are at least a good indication of the epidemiological situation of venereal diseases, under Dr. Vickers’ regime no return would ever be completed. A. I. MORRISON. The Royal Hospital, Sheffield, 1. SIR,-Although
CEREBRAL PALSY I hardly dare to quarrel with the
definition of cerebral palsy proposed by such an eminent " interested people " in their letter of May 3, group of I do feel that the second explanatory footnote (which reads, " This excludes such quantitative disorders of movement as might be met with in mental defectives ") is both misleading and unjust. If we are to have strict definitions about cerebral palsy let us also be clear about mental deficiency. Other " interested people ", like myself, whose work lies with patients suffering from " damage of the brain from intrinsically or extrinsically caused development disorder (occurring in fcetal life or after birth) or perinatal, paranatal or postnatal in origin " (footnote 4), do not call their patients mental defectives or think of them as such. Mental deficiency is a legal term, not a diagnosis. It is
great disappointment to us that pxdiatricians and neurologists continue to perpetuate, along with nearly all the rest of the medical profession, such misunderstanding. They regard all brain damage severe enough to preclude educability as mental deficiency " and an invidious distinction has grown up between cerebral palsy and mental defectiveness, whereas we know that it is quite possible for a child with cerebral palsy to be deemed, quite correctly, ineducable and, therefore, mentally defective. This child is not suffering from some other disorder superimposed on his cerebral palsy, His " non-progressive brain damage " is merely more severe. In exactly the same way the child showing quantitative disorders of movement, which excludes him, by the definition, from the " cerebral palsy " group, is suffering from either brain damage which may also fit quite well into footnote 4 of the definition or from some other physical disorder-e.g., metabolic. He is not, however, suffering from mental deficiency a
"
"
earnestly hope for the closer integration of mental deficiency " (sic) with general medicine, and this will not come about as fast as it might so long as the severely damaged child suffering from an obvious, clear-cut physical disorder is suddenly labelled " mentally defective " by the general hospital physician and instant dispatch to an institution " advised. Botleys Park Hospital, J. M. CRAWFORD. Chertsey, Surrey. I
"