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THE POSITION OF NEUROLOGY
38 needed to help sort out the variables, but it is essential agree about what we are talking. Professor Duguid is more ambitious than I when he seeks to know the full and precise sequence of events in the tissues in every At present, I am merely asking about interrelacase. tionships and factors in the mode of life that influence the outcome. Laboratory of Physiological Hygiene, ANCEL KEYS. are
PANCREATITIS
we
SiR,-In your account of his Moynihan lecture1 Dr.
reported as describing a case of pancreatitis following embolisation of the cceliac artery. Dr. MacKenzie stated that in some cases of pancreatitis evidence of intravascular fat could be found, and he suggested that this fat might derive from the
Walter C. MacKenzie is acute
liver. As pathologist to the Royal Alexandra Hospital at in 1952-53,I performed the necropsy examinaEdmonton THE POSITION OF NEUROLOGY tionon the patient mentioned by Dr. MacKenzie (a SIR,-Sir Russell Brain in his letter on this subject woman, aged 59 ; A102/53) and also on the other patient (June 19) has raised other issues of importance to the treated for acute hsemorrhagic pancreatitis in that hospital service. He suggests hospital during my stay there (a man, aged 35 ; A74/53). proper development of the that what is needed is a " comprehensive and representaThen, as now, I regarded the occurrence of acute tive medical committee " at regional board level. It is hsemorrhagic pancreatitis as a result of embolism as unlikely that he means that such a committee’ should something which might happen occasionally but not as supersede the medical staff committees at hospital level ; sufficient cause for theoretical speculation. On the other but that is what I fear would happen on anything but hand, in these two cases I was deeply impressed by the minor issues, such is the insidious influence of power. pathological picture of severe damage to the renal Members of such a body would advise on matters affecttubules ; and finding a similar severe acute nephrosis in ing hospitals in which they had not worked, and of two subsequent cases here in Sudbury I was led to further whose problems they would have dangerously little investigations. - In search of confirmation of my knowledge. One can imagine the irritation in the teaching findings I asked for samples of fixed material from my hospitals if a similar scheme were ever applied to them two cases in Edmonton, but this was unfortunately not by the University Grants Committee or the Ministry forthcoming. However, the findings, in my two cases of Health. Regional hospital boards for reasons of here appear to be conclusive enough in themselves. geography, quite apart from pressure of work, are not In these two cases frozen sections stained with Sudan IV sufficiently in touch with local conditions to bring showed widespread and heavy fat embolisation in balance or wisdom to many of the schemes they institute. kidneys, lungs, and heart, and particularly heavy intraOverworked officials at a distance, dealing with dozens vascular fat pools in and about the pancreas. My studies of hospitals but with allegiance to none, are poor substi(to be reported at length elsewhere) further showed direct tutes for local men who have to live with the fruits of of this fat into the vasculature from the disrupted entry their labours. interlobular and peripancreatic fat. This, Sir, appears The present dichotomy of control between hospital to be a far more likely course of events than the derivation management committees and regional hospital boards of fat emboli from liver fat as postulated by Dr. often results in confusion and frustration which is not MacKenzie. Further the experimental demonstration the fault of either, but of the system which denies the that pancreatitis may be produced by intra-arterial right of elementary housekeeping to the one and of injection of fat emulsions after ligation of the pancreatic complete executive power to the other. A block grant duct proves nothing more than that pancreatitis may be system for management committees and a breaking produced by any form of embolism. down of the rigid barriers between maintenance and Sudbury, Ontario, MATTHEW NIATTREW J. G. Gr. LyNei-i. LYNCH. capital expenditure would go a long way towards restorCanada. ing the sense of responsibility which existed in the best MENTAL CARE voluntary hospitals before 1948. In such an event big decisions on policy would again be taken locally, and SIR,-The recent articles and letters suggest that medical staff committees would function more usefully psychiatric preventive care and reablement can best be than they do now. The role of regional boards in my carried out in the home and the workshop. They stress opinion should be limited to the essential one of liaison the role of the psychiatric staff, leaving out the contriand coordination and to the organisation of appointment of other patients and, more important, of the bution release committees. Such a scheme would many of the as a whole. To be effective a mental health community at and able officers with laymen present struggling very like a child guidance, must be carried out with service, distance and paper at regional level to strengthen the cooperation not only of the patient’s family, but also management committees and local hospitals from which’ the of social agencies in the community. so many of them came in 1948. That this is possible has been shown during the last The very important matter of the development of 7 years, during which 1500 patients, aged three weeks to I and which services, support neurological strongly ninety years, have been seen at our clinic. We have have urged locally, is a good example of a problem four psychiatrists doing (part-time) a total of 13 sessions that cannot be considered in a vacuum. The needs of per week. We see over 200 new patients annually, as other specialties are very great. How inadequate are well as domiciliary and general-hospital referrals. Our the existing services ? Can the department of radiology patients receive an average of 10 psychotherapeutic accommodate the extra work of neuroradiology ? Are interviews and are followed up indefinitely. We use there the beds and the nurses ?‘ Is there theatre and in the for our two beds and otherwise general hospital, ward space for the neurosurgeon who must surely be to at care have thank Dr. Park, Roffey inpatient Ling the bushesThese and many other questions lurking in ’Dr. Maxwell Jones at Sutton, Dr. Cook at Bexley, and must be asked and answered by clinicians with local depending on the severity knowledge in the medical staff committees of the hos- other medical superintendents, of case. the (and geography!) pitals concerned, and not, I hope, at regional board A case-load of this size has necessitated social therapy. level. Only if there were disagreement between the major hospitals of an area after full discussion on the most On a limited scale we have organised groups for adults and children ; our play-reading group has been in efficient and economical siting of a neurological unit of the function the might coordinating regional board existence for 4 years. Outpatient reablement has also been carried out by mixing with physically ill patients play a useful part. J. W. PAULLEY. Ipswich. 1. Lancet, 1954, i, 1126. Minnesota. University of Minnesota.
‘
PANCREATITIS
we
SiR,-In your account of his Moynihan lecture1 Dr.
reported as describing a case of pancreatitis following embolisation of the cceliac artery. Dr. MacKenzie stated that in some cases of pancreatitis evidence of intravascular fat could be found, and he suggested that this fat might derive from the
Walter C. MacKenzie is acute
liver. As pathologist to the Royal Alexandra Hospital at in 1952-53,I performed the necropsy examinaEdmonton THE POSITION OF NEUROLOGY tionon the patient mentioned by Dr. MacKenzie (a SIR,-Sir Russell Brain in his letter on this subject woman, aged 59 ; A102/53) and also on the other patient (June 19) has raised other issues of importance to the treated for acute hsemorrhagic pancreatitis in that hospital service. He suggests hospital during my stay there (a man, aged 35 ; A74/53). proper development of the that what is needed is a " comprehensive and representaThen, as now, I regarded the occurrence of acute tive medical committee " at regional board level. It is hsemorrhagic pancreatitis as a result of embolism as unlikely that he means that such a committee’ should something which might happen occasionally but not as supersede the medical staff committees at hospital level ; sufficient cause for theoretical speculation. On the other but that is what I fear would happen on anything but hand, in these two cases I was deeply impressed by the minor issues, such is the insidious influence of power. pathological picture of severe damage to the renal Members of such a body would advise on matters affecttubules ; and finding a similar severe acute nephrosis in ing hospitals in which they had not worked, and of two subsequent cases here in Sudbury I was led to further whose problems they would have dangerously little investigations. - In search of confirmation of my knowledge. One can imagine the irritation in the teaching findings I asked for samples of fixed material from my hospitals if a similar scheme were ever applied to them two cases in Edmonton, but this was unfortunately not by the University Grants Committee or the Ministry forthcoming. However, the findings, in my two cases of Health. Regional hospital boards for reasons of here appear to be conclusive enough in themselves. geography, quite apart from pressure of work, are not In these two cases frozen sections stained with Sudan IV sufficiently in touch with local conditions to bring showed widespread and heavy fat embolisation in balance or wisdom to many of the schemes they institute. kidneys, lungs, and heart, and particularly heavy intraOverworked officials at a distance, dealing with dozens vascular fat pools in and about the pancreas. My studies of hospitals but with allegiance to none, are poor substi(to be reported at length elsewhere) further showed direct tutes for local men who have to live with the fruits of of this fat into the vasculature from the disrupted entry their labours. interlobular and peripancreatic fat. This, Sir, appears The present dichotomy of control between hospital to be a far more likely course of events than the derivation management committees and regional hospital boards of fat emboli from liver fat as postulated by Dr. often results in confusion and frustration which is not MacKenzie. Further the experimental demonstration the fault of either, but of the system which denies the that pancreatitis may be produced by intra-arterial right of elementary housekeeping to the one and of injection of fat emulsions after ligation of the pancreatic complete executive power to the other. A block grant duct proves nothing more than that pancreatitis may be system for management committees and a breaking produced by any form of embolism. down of the rigid barriers between maintenance and Sudbury, Ontario, MATTHEW NIATTREW J. G. Gr. LyNei-i. LYNCH. capital expenditure would go a long way towards restorCanada. ing the sense of responsibility which existed in the best MENTAL CARE voluntary hospitals before 1948. In such an event big decisions on policy would again be taken locally, and SIR,-The recent articles and letters suggest that medical staff committees would function more usefully psychiatric preventive care and reablement can best be than they do now. The role of regional boards in my carried out in the home and the workshop. They stress opinion should be limited to the essential one of liaison the role of the psychiatric staff, leaving out the contriand coordination and to the organisation of appointment of other patients and, more important, of the bution release committees. Such a scheme would many of the as a whole. To be effective a mental health community at and able officers with laymen present struggling very like a child guidance, must be carried out with service, distance and paper at regional level to strengthen the cooperation not only of the patient’s family, but also management committees and local hospitals from which’ the of social agencies in the community. so many of them came in 1948. That this is possible has been shown during the last The very important matter of the development of 7 years, during which 1500 patients, aged three weeks to I and which services, support neurological strongly ninety years, have been seen at our clinic. We have have urged locally, is a good example of a problem four psychiatrists doing (part-time) a total of 13 sessions that cannot be considered in a vacuum. The needs of per week. We see over 200 new patients annually, as other specialties are very great. How inadequate are well as domiciliary and general-hospital referrals. Our the existing services ? Can the department of radiology patients receive an average of 10 psychotherapeutic accommodate the extra work of neuroradiology ? Are interviews and are followed up indefinitely. We use there the beds and the nurses ?‘ Is there theatre and in the for our two beds and otherwise general hospital, ward space for the neurosurgeon who must surely be to at care have thank Dr. Park, Roffey inpatient Ling the bushesThese and many other questions lurking in ’Dr. Maxwell Jones at Sutton, Dr. Cook at Bexley, and must be asked and answered by clinicians with local depending on the severity knowledge in the medical staff committees of the hos- other medical superintendents, of case. the (and geography!) pitals concerned, and not, I hope, at regional board A case-load of this size has necessitated social therapy. level. Only if there were disagreement between the major hospitals of an area after full discussion on the most On a limited scale we have organised groups for adults and children ; our play-reading group has been in efficient and economical siting of a neurological unit of the function the might coordinating regional board existence for 4 years. Outpatient reablement has also been carried out by mixing with physically ill patients play a useful part. J. W. PAULLEY. Ipswich. 1. Lancet, 1954, i, 1126. Minnesota. University of Minnesota.
‘