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ADRENALECTOMY AND HYPOPHYSECTOMY
1413 hatred from
delinquent boys when corporal punishment is indiscriminately applied? This is comparable to treating haemorrhage from, say, the inferior mesenteric artery during a laparotomy by closing the abdomen in layers-to damming a river as it flows into the sea instead of at its source, when its banks have overflowed. One must attack the root cause of the delinquency, and the only way of doing this when it becomes manifest is by a psychiatric approach-psychotherapy given by competent therapists. It is of no use " to beat the hell out of" (a colloquialism here) the delinquents, as the Cadogan report so rightly concluded, as this builds up bitter resentment when such " treatment " reinforces old patterns of rejection. The delinquents must undergo a " corrective emotional experience "-as must all neurotics and patients with character disorders (Franz Alexander). When he writes " some of us reactionaries are not very much interested in his point as to the value or otherwise of corporal punishment in constructive treatment of offenders " Dr. Webster is pessimistically admitting defeat before he even starts to attempt to repair the personality of a human being " " heading for psychological ruin-in fact, he is selfishly that in such own fellow-being reaching (his word) assisting ruin. Hospital of the University of IAN MACKAY. Pennsylvania, Philadelphia.
wants a more
specific
word than " poisoning ", to mean snakebite. I suggest " snakebite " or, if it is fatal, " fatal snakebite ". (In theory a non-poisonous snake might bite a man, but not more often, perhaps, than a man bites a dog.) London, S.W.20.
leading
"
significantly during the experiment; my control patients lost six pounds in six weeks. Secondly, the Edinburgh workers gave 4-5 g. methyl cellulose daily, compared with the 9 g. which I gave. Thirdly, the preparation used in Edinburgh was in the form of tablets, which do not swell to the same extent as the powdered methyl cellulose used by me. It is then reasonable to conclude that at least some obese patients will find it useful to take methyl cellulose, provided they take sufficient and it is in the powder form. Queen Elizabeth College, London, W.8.
JOHN YUDKIN.
THE PERSONAL DOCTOR
SNAKEBITE
SIR,-Mrs. Buckley (June 18)
TOO MANY CALORIES article on obesity SiR,ŁIn yout excellent (June 11) you refer to the contrast between the findings by Dr. Duncan and his colleagues in Edinburgh1 that methyl cellulose was ineffective in the treatment of obesity, and my finding2 that it was effective. I am writing to draw attention to some of the differences in these two sets of experiments, one or more of which may account for the different results. Firstly, there were clearly differences between the type of patient. The Edinburgh patients are rightly called refractory ", and the controls without drugs did not lose weight
JOHN PENMAN.
SIR,-Dr. Fox, in The Lancet of April 2, writes that attracting the younger practitioner to the country is a difficult matter in the United States. This is not, in my experience, completely true. While it may well be that many rural
areas
are " under-
doctored ", a large fraction of my own generation (class of 1942) have already established themselves not only in the "
ADRENALECTOMY AND HYPOPHYSECTOMY SIR,-I have read with interest the article by Mr. Atkins, Mr. Falconer, and their colleagues (May 28), together with the ensuing correspondence. It seems to me that their conclusions have to a great extent clarified the position of these various operations. On theoretical grounds one might have predicted the main conclusion since the pituitary is in a sense the traffic policeman " of the glands of internal secretion. My purpose now, however, is to draw attention to the fact that the pituitary has been shown to be accessible via the nasal sinuses since Nager, of Zurich, gave his Semon lecture in London in 1939. Possible routes to the pituitary are via the septum, through an external incision via the ethmoid, or through the maxillary sinus and ethmoid. These routes have been used in Scandinavia and in this
country, singly or in combination. A further method of approach, using the nasal bones as an osteoplastic flap, will be published elsewhere in the near future. This approach, while keeping in the midline, shortens the access and enables free use of the operating
microscope. With any of these methods of access the operation would appear to be less disturbing than either adrenalectomy or the intracranial removal of the pituitary. Furthermore the time in hospital is usually predictable and should be no longer than that needed for any patient undergoing an external ethmoidectomy-i.e., 7-10 days. If, as seems likely, the rhinological approach to the pituitary proves to give as good results as the neurological, the practical problem noted by Atkins and his colleagues-that too few neurosurgical beds are available for this work-will to some extent be solved. Radcliffe Infirmary, Oxford.
RONALD MACBETH.
suburbs but also in exurbia ". Older men and younger men, too, are moving out of the cities. As a matter of fact, one of my teachers in medical school moved his practice from Brooklyn to the remote suburbs on Long Island long after I had left the City of New York permanently. As this man was a chief of service in one of Brooklyn’s outstanding voluntary hospitals, and a specialist certified by an American specialty board, one can scarcely regard his removal as reflecting any sort of failure or maladjustment on his part. Indeed, I hear that his old hospital in Brooklyn is trying to lure him b ck. As for myself, I could not afford to bring up my five as I do now, in New York, even if I could maintain my present income in the city. The assumption that I could maintain my present income in New York, or in any other metropolis, is utterly unfounded (I am a pathologist). Further, I could not enjoy the freedom of directing my own laboratory without lay interference, as I do here. A metropolitan hospital would never give up control of the laboratory’s purse strings. This, by the way, is very much the case at the Hunterdon Medical Center, where the pathologist’s share of laboratory income goes into the group’s treasury, rather than into the hospital’s pocket. The result is that both the Hunterdon pathologist and I need not battle any sort of bureaucracy for needed funds. (I happen to know Hunterdon because we are the hospitals closest to each other in New Jersey, because the pathologist there and I have had training in the same institution, and because the pathologist and I are old friends who " cover" for each other often.) There is a great deal of interesting information in Dr. Fox’s article, much of it new to me. I think, nevertheless, that it fails to point out an important aspect of the lack of physicians in rural areas. That is the failure of the small community to meet the needs of modern practice. Once it does so, physicians will leave the " rat-race " of the big city; these physicians will be well-qualified specialists as well as generalists. The example of Hunterdon has been cited. Warren Hospital, its closest neighbour, in Phillipsburg, New Jersey, has no
children,
1. 2.
Duncan, L. J. P., Rose, K., Meiklejohn, p. 1262. Yudkin, J. ibid. 1959, ii, 1135.
A. P.
Lancet, June 11, 1960,
delinquent boys when corporal punishment is indiscriminately applied? This is comparable to treating haemorrhage from, say, the inferior mesenteric artery during a laparotomy by closing the abdomen in layers-to damming a river as it flows into the sea instead of at its source, when its banks have overflowed. One must attack the root cause of the delinquency, and the only way of doing this when it becomes manifest is by a psychiatric approach-psychotherapy given by competent therapists. It is of no use " to beat the hell out of" (a colloquialism here) the delinquents, as the Cadogan report so rightly concluded, as this builds up bitter resentment when such " treatment " reinforces old patterns of rejection. The delinquents must undergo a " corrective emotional experience "-as must all neurotics and patients with character disorders (Franz Alexander). When he writes " some of us reactionaries are not very much interested in his point as to the value or otherwise of corporal punishment in constructive treatment of offenders " Dr. Webster is pessimistically admitting defeat before he even starts to attempt to repair the personality of a human being " " heading for psychological ruin-in fact, he is selfishly that in such own fellow-being reaching (his word) assisting ruin. Hospital of the University of IAN MACKAY. Pennsylvania, Philadelphia.
wants a more
specific
word than " poisoning ", to mean snakebite. I suggest " snakebite " or, if it is fatal, " fatal snakebite ". (In theory a non-poisonous snake might bite a man, but not more often, perhaps, than a man bites a dog.) London, S.W.20.
leading
"
significantly during the experiment; my control patients lost six pounds in six weeks. Secondly, the Edinburgh workers gave 4-5 g. methyl cellulose daily, compared with the 9 g. which I gave. Thirdly, the preparation used in Edinburgh was in the form of tablets, which do not swell to the same extent as the powdered methyl cellulose used by me. It is then reasonable to conclude that at least some obese patients will find it useful to take methyl cellulose, provided they take sufficient and it is in the powder form. Queen Elizabeth College, London, W.8.
JOHN YUDKIN.
THE PERSONAL DOCTOR
SNAKEBITE
SIR,-Mrs. Buckley (June 18)
TOO MANY CALORIES article on obesity SiR,ŁIn yout excellent (June 11) you refer to the contrast between the findings by Dr. Duncan and his colleagues in Edinburgh1 that methyl cellulose was ineffective in the treatment of obesity, and my finding2 that it was effective. I am writing to draw attention to some of the differences in these two sets of experiments, one or more of which may account for the different results. Firstly, there were clearly differences between the type of patient. The Edinburgh patients are rightly called refractory ", and the controls without drugs did not lose weight
JOHN PENMAN.
SIR,-Dr. Fox, in The Lancet of April 2, writes that attracting the younger practitioner to the country is a difficult matter in the United States. This is not, in my experience, completely true. While it may well be that many rural
areas
are " under-
doctored ", a large fraction of my own generation (class of 1942) have already established themselves not only in the "
ADRENALECTOMY AND HYPOPHYSECTOMY SIR,-I have read with interest the article by Mr. Atkins, Mr. Falconer, and their colleagues (May 28), together with the ensuing correspondence. It seems to me that their conclusions have to a great extent clarified the position of these various operations. On theoretical grounds one might have predicted the main conclusion since the pituitary is in a sense the traffic policeman " of the glands of internal secretion. My purpose now, however, is to draw attention to the fact that the pituitary has been shown to be accessible via the nasal sinuses since Nager, of Zurich, gave his Semon lecture in London in 1939. Possible routes to the pituitary are via the septum, through an external incision via the ethmoid, or through the maxillary sinus and ethmoid. These routes have been used in Scandinavia and in this
country, singly or in combination. A further method of approach, using the nasal bones as an osteoplastic flap, will be published elsewhere in the near future. This approach, while keeping in the midline, shortens the access and enables free use of the operating
microscope. With any of these methods of access the operation would appear to be less disturbing than either adrenalectomy or the intracranial removal of the pituitary. Furthermore the time in hospital is usually predictable and should be no longer than that needed for any patient undergoing an external ethmoidectomy-i.e., 7-10 days. If, as seems likely, the rhinological approach to the pituitary proves to give as good results as the neurological, the practical problem noted by Atkins and his colleagues-that too few neurosurgical beds are available for this work-will to some extent be solved. Radcliffe Infirmary, Oxford.
RONALD MACBETH.
suburbs but also in exurbia ". Older men and younger men, too, are moving out of the cities. As a matter of fact, one of my teachers in medical school moved his practice from Brooklyn to the remote suburbs on Long Island long after I had left the City of New York permanently. As this man was a chief of service in one of Brooklyn’s outstanding voluntary hospitals, and a specialist certified by an American specialty board, one can scarcely regard his removal as reflecting any sort of failure or maladjustment on his part. Indeed, I hear that his old hospital in Brooklyn is trying to lure him b ck. As for myself, I could not afford to bring up my five as I do now, in New York, even if I could maintain my present income in the city. The assumption that I could maintain my present income in New York, or in any other metropolis, is utterly unfounded (I am a pathologist). Further, I could not enjoy the freedom of directing my own laboratory without lay interference, as I do here. A metropolitan hospital would never give up control of the laboratory’s purse strings. This, by the way, is very much the case at the Hunterdon Medical Center, where the pathologist’s share of laboratory income goes into the group’s treasury, rather than into the hospital’s pocket. The result is that both the Hunterdon pathologist and I need not battle any sort of bureaucracy for needed funds. (I happen to know Hunterdon because we are the hospitals closest to each other in New Jersey, because the pathologist there and I have had training in the same institution, and because the pathologist and I are old friends who " cover" for each other often.) There is a great deal of interesting information in Dr. Fox’s article, much of it new to me. I think, nevertheless, that it fails to point out an important aspect of the lack of physicians in rural areas. That is the failure of the small community to meet the needs of modern practice. Once it does so, physicians will leave the " rat-race " of the big city; these physicians will be well-qualified specialists as well as generalists. The example of Hunterdon has been cited. Warren Hospital, its closest neighbour, in Phillipsburg, New Jersey, has no
children,
1. 2.
Duncan, L. J. P., Rose, K., Meiklejohn, p. 1262. Yudkin, J. ibid. 1959, ii, 1135.
A. P.
Lancet, June 11, 1960,