- Email: [email protected]
THE LIFE FOR ME
535
values obtained by the simultaneous use of antipyrin and nearly similar would indicate that these factors not of such magnitude as to interfere with the are estimation. urea were
Nutrition Research Laboratories. Coonoor, S. India
S. G. SRIKANTIA C. GOPALAN.
THE LIFE FOR ME
SIR,-Dr. Scott (Feb. 15) rightly criticises me for not plugging preventive psychiatry (though in all fairness It isn’t easy to cover I did give it a passing mention). one’s whole specialty in two and a half brisk columns. It is good news that he and some psychiatrists are cooperating in preventive work, and I look forward indeed to hearing more about it. He mentions clinics, though I have an awful feeling that he is only referring to childguidance work; these weren’t the ones I was referring to in the Widdicombe File: I was harking back to the infant-welfare and toddlers and all that; whereas the good G.P. is well-enough qualified to take these over, I rather doubt if many would be happy as child psychiatrists, let alone set aside a corner of their surgeries for the usual clinic accretion of sand, water, and shattered toys. But if Dr. Scott thinks child-guidance clinics are preventive I must disagree: the ones I worked in were dealing only with disturbed children; to say that they are preventive because treatment early means less delinquency and neurosis is much the same to me as saying that major surgery is preventive because you hope to prevent the patient’s death. The only approach to real preventive psychiatry that I have yet heard of appears in what I believe are the terms of reference of the Ingleby Committee-namely, to consider whether local authorities should have new powers to prevent or forestall the sufferings, mental and physical, of children in their own homes. I must say I hope they get them. Far from being antipathetic towards child guidance, may I assure Dr. Scott that I wouldn’t mind going in for it myself. Perhaps I may interject, though, that these S.H.M.O. vacancies don’t interest me much: it will be consultancy or nothing; and I’m afraid the same goes for my
as
reassurance; and it is
Dr. Ryle writes of the need for scientific detachment. This is easier for the hospital doctor to achieve, as so many hospital patients learn to their cost. Perhaps the main difference between hospital and general practice is this very matter of detachment, the too-objective approach in hospital and the too-subjective approach in general practice. The validity of Dr. Clyne’s article of Feb. 1 cannot be in doubt. The masterly way in which Dr. Clyne gave verbal expression to his attitude towards his patient made me feel that here at last was an attempt to describe the very stuff of general practice. H. STEPHEN PASMORE. London, W.8. A PLASTIC APPROACH TO SURGERY
SIR,-If a scientific communication is to be understood universally it is essential that terms should be used with accuracy and precision. When Mr. Heanley uses the term Langer’s lines he can scarcely object if a reader assumes that he means the lines described by Langer. From the definition which he now gives (Feb. 22) it appears that this is not so. Unfortunately his definition is not of a Langer’s line but rather of what he might have called with more accuracy a " line of election for surgical incision ". As I pointed out (Jan. 25) the two terms are not synonymous.
On the question of priority of description Wood Jones1 makes some interesting observations which are also at variance with Mr. Heanley’s statements. IAN A. MCGREGOR. Glasgow Royal Infirmary.
pals.
Widdicombe-in-the-Moor.
RICHARD COBBLEIGH.
THE DOCTOR’S ATTITUDE TO HIS PATIENT
SIR,-As I read Dr. Ryle’s letter last week, I surmised Ryle must be a competent well-qualified young man with several hospital jobs to his credit, but with less than ten years’ experience of general practice. My surmise was confirmed by reference to The Medical Directory. Even Dr. Ryle, who feels he can write more easily than others about scientific detachment, is writing within a circumscribed pattern that can be discerned by his less scientific colleagues. that Dr.
Dr. Ryle feels that the personality of the doctor is receiving much attention in the description and investigation of disease, and that " facts, based on observation and experience, can guide our actions irrespective of our personalities ..." The trouble is that if we practitioners do not take our personalities into account, we pick up the wrong facts and come to the wrong conclusions, and we ignore the reality of functional or stress disorders which form such a large part of our work. too
When, for example,
we investigate a case of dyspepsia by scientific inquiry related to the function of the stomach, and find no abnormality, we make a diagnosis of functional disorder and reassure the patient there is nothing really wrong as no organic disease can be found. We get a little rufflcd when the patient turns up a few weeks later asking for more
a
his symptoms have continued unabated in spite of only when we can make a personality change, by realising that we have been reassuring ourselves and not the patient, that we can take further steps to help the patient. What a small, and yet what a vast, change takes place when we stop asking our patients detailed questions about their functional disorders and attempt to listen to the expression of their real feelings and fears! In such cases we lay aside the tools of scientific inquiry that are used for the investigation of organic disease, and pick up the tools that help us to interpret the language of functional disorder-a language that has still to be learnt by the medical profession.
X-rays
our
RADIOSTRONTIUM IN BONES
SIR,-The following observations
are
based
on
reading
your informative annotations and articles during the past year, and some of the publications which you have
reviewed. Some indication of the possible world-wide increase in the distribution of strontium 90 is given by the following figures quoted from an A.E.R.E. report 2: Concentration on ground on Jan. 1, 1956 4-5 mc. per sq. km. Maximum concentration on ground due to bombs exploded by that date (this will be 14 mc. per sq. km. reached in about 1969) Equilibrium value (reached in about 100 years’ time) if the present rate of weapon firing continues indefinitely.... 200 mc. per sq. km. Bryant et al. show clearly the routes by which strontium 90 is already entering the human body (e.g., rain, soil, grass and other crops, cow’s milk) and they say: ..
......
" The highest 9°Sr activity in human bone found in our series to the end of 1956 is 1-55 s.u. which is 1/60 of the maxi1. Wood Jones, F. The Principles of Anatomy as Seen in the Hand; p. 102 et seq. London, 1944. 2. Stewart, N. G., Crooks, R. N., Fisher, E.M.R. The Radiological Dose to Persons in the U.K. due to Debris from Nuclear Test Explosions prior to January, 1956. A. E. R. E. HP/R 2017. H.M. Stationery Office. 3. Bryant, F. J., Chamberlain, A. C., Morgan, A., Spicer, G. S. Radiostrontium in Soil, Grass, Milk, and Bone in the United Kingdom. A.E.R.E. HP/R 2353. H.M. Stationery Office. See Lancet, 1957, ii, 942.
values obtained by the simultaneous use of antipyrin and nearly similar would indicate that these factors not of such magnitude as to interfere with the are estimation. urea were
Nutrition Research Laboratories. Coonoor, S. India
S. G. SRIKANTIA C. GOPALAN.
THE LIFE FOR ME
SIR,-Dr. Scott (Feb. 15) rightly criticises me for not plugging preventive psychiatry (though in all fairness It isn’t easy to cover I did give it a passing mention). one’s whole specialty in two and a half brisk columns. It is good news that he and some psychiatrists are cooperating in preventive work, and I look forward indeed to hearing more about it. He mentions clinics, though I have an awful feeling that he is only referring to childguidance work; these weren’t the ones I was referring to in the Widdicombe File: I was harking back to the infant-welfare and toddlers and all that; whereas the good G.P. is well-enough qualified to take these over, I rather doubt if many would be happy as child psychiatrists, let alone set aside a corner of their surgeries for the usual clinic accretion of sand, water, and shattered toys. But if Dr. Scott thinks child-guidance clinics are preventive I must disagree: the ones I worked in were dealing only with disturbed children; to say that they are preventive because treatment early means less delinquency and neurosis is much the same to me as saying that major surgery is preventive because you hope to prevent the patient’s death. The only approach to real preventive psychiatry that I have yet heard of appears in what I believe are the terms of reference of the Ingleby Committee-namely, to consider whether local authorities should have new powers to prevent or forestall the sufferings, mental and physical, of children in their own homes. I must say I hope they get them. Far from being antipathetic towards child guidance, may I assure Dr. Scott that I wouldn’t mind going in for it myself. Perhaps I may interject, though, that these S.H.M.O. vacancies don’t interest me much: it will be consultancy or nothing; and I’m afraid the same goes for my
as
reassurance; and it is
Dr. Ryle writes of the need for scientific detachment. This is easier for the hospital doctor to achieve, as so many hospital patients learn to their cost. Perhaps the main difference between hospital and general practice is this very matter of detachment, the too-objective approach in hospital and the too-subjective approach in general practice. The validity of Dr. Clyne’s article of Feb. 1 cannot be in doubt. The masterly way in which Dr. Clyne gave verbal expression to his attitude towards his patient made me feel that here at last was an attempt to describe the very stuff of general practice. H. STEPHEN PASMORE. London, W.8. A PLASTIC APPROACH TO SURGERY
SIR,-If a scientific communication is to be understood universally it is essential that terms should be used with accuracy and precision. When Mr. Heanley uses the term Langer’s lines he can scarcely object if a reader assumes that he means the lines described by Langer. From the definition which he now gives (Feb. 22) it appears that this is not so. Unfortunately his definition is not of a Langer’s line but rather of what he might have called with more accuracy a " line of election for surgical incision ". As I pointed out (Jan. 25) the two terms are not synonymous.
On the question of priority of description Wood Jones1 makes some interesting observations which are also at variance with Mr. Heanley’s statements. IAN A. MCGREGOR. Glasgow Royal Infirmary.
pals.
Widdicombe-in-the-Moor.
RICHARD COBBLEIGH.
THE DOCTOR’S ATTITUDE TO HIS PATIENT
SIR,-As I read Dr. Ryle’s letter last week, I surmised Ryle must be a competent well-qualified young man with several hospital jobs to his credit, but with less than ten years’ experience of general practice. My surmise was confirmed by reference to The Medical Directory. Even Dr. Ryle, who feels he can write more easily than others about scientific detachment, is writing within a circumscribed pattern that can be discerned by his less scientific colleagues. that Dr.
Dr. Ryle feels that the personality of the doctor is receiving much attention in the description and investigation of disease, and that " facts, based on observation and experience, can guide our actions irrespective of our personalities ..." The trouble is that if we practitioners do not take our personalities into account, we pick up the wrong facts and come to the wrong conclusions, and we ignore the reality of functional or stress disorders which form such a large part of our work. too
When, for example,
we investigate a case of dyspepsia by scientific inquiry related to the function of the stomach, and find no abnormality, we make a diagnosis of functional disorder and reassure the patient there is nothing really wrong as no organic disease can be found. We get a little rufflcd when the patient turns up a few weeks later asking for more
a
his symptoms have continued unabated in spite of only when we can make a personality change, by realising that we have been reassuring ourselves and not the patient, that we can take further steps to help the patient. What a small, and yet what a vast, change takes place when we stop asking our patients detailed questions about their functional disorders and attempt to listen to the expression of their real feelings and fears! In such cases we lay aside the tools of scientific inquiry that are used for the investigation of organic disease, and pick up the tools that help us to interpret the language of functional disorder-a language that has still to be learnt by the medical profession.
X-rays
our
RADIOSTRONTIUM IN BONES
SIR,-The following observations
are
based
on
reading
your informative annotations and articles during the past year, and some of the publications which you have
reviewed. Some indication of the possible world-wide increase in the distribution of strontium 90 is given by the following figures quoted from an A.E.R.E. report 2: Concentration on ground on Jan. 1, 1956 4-5 mc. per sq. km. Maximum concentration on ground due to bombs exploded by that date (this will be 14 mc. per sq. km. reached in about 1969) Equilibrium value (reached in about 100 years’ time) if the present rate of weapon firing continues indefinitely.... 200 mc. per sq. km. Bryant et al. show clearly the routes by which strontium 90 is already entering the human body (e.g., rain, soil, grass and other crops, cow’s milk) and they say: ..
......
" The highest 9°Sr activity in human bone found in our series to the end of 1956 is 1-55 s.u. which is 1/60 of the maxi1. Wood Jones, F. The Principles of Anatomy as Seen in the Hand; p. 102 et seq. London, 1944. 2. Stewart, N. G., Crooks, R. N., Fisher, E.M.R. The Radiological Dose to Persons in the U.K. due to Debris from Nuclear Test Explosions prior to January, 1956. A. E. R. E. HP/R 2017. H.M. Stationery Office. 3. Bryant, F. J., Chamberlain, A. C., Morgan, A., Spicer, G. S. Radiostrontium in Soil, Grass, Milk, and Bone in the United Kingdom. A.E.R.E. HP/R 2353. H.M. Stationery Office. See Lancet, 1957, ii, 942.