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CONSERVATION OF THE OVARIES
981
considerably influenced by suggestion. Because of this I believe that only a blind controlled trial is likely to give reliable information. The trial which I have briefly mentioned had negative results, but one cannot of course prove that proguanil was ineffective. One can only say that in these 25 tests no convincing evidence of effectiveness emerged. I appreciate, of course, that proguanil is not the same as amodiaquine, which Dr. Sidi and Dr. Reinberg used; it was chosen in my series because of its freedom from side-effects. These results do not necessarily indicate that the antimalarials are never effective in chronic urticaria. One may well suppose that the symptom is the end-result of a variety of different causes or mechanisms and that an antimalarial may break a link in pathogenesis in one case and not in another. This may explain the occasional remarkable case where the effectiveness of an antimalarial seems to be undeniable although it cannot be regularly obtained in other patients. F. RAY BETTLEY. COMMUNITY MENTAL CARE? SIR,-Psychiatry is following good precedents as it evolves and develops a social conscience. It is turning from a preoccupation with those human abstractions of natural processes that are labelled " diseases " to prevention and to the promotion of mental health. Mental health is, however, too vast and too important to be delegated to any one section of medicine. Fortunately, the barriers that isolated psychiatry from the main currents of medicine (a subject discussed in your leader of Oct. 15) are being eroded from both sides. Your report that general practitioners and medical officers of health recently conferred with psychiatrists on mental health is a welcome illustration. Others among us are also concerned, and paediatricians especially so, if only because so many mental disorders have their roots in the early years of life. But mental health is too vast and too important to be delegated exclusively even to the medical profession. Allies are needed outside medicine and its traditional associates (such as psychologists and social workers). Geneticists, biochemists, sociologists, and anthropologists surely have fundamental contributions to make. So also have those non-medical agencies concerned with moral welfare, with family life and with education-of parents and of children. An enterprising pilot scheme inaugurated by Dr. S. Lebovici in a whole sector of Paris has already shown that school teachers, for example, can play a very important part in the prevention and early case-finding of mental disorders. Is the community ready for prevention ?" was asked at a recent conference on preventive psychiatry.l While that question is being pondered some of its implications will also be weighed. To prevent assumes that we know what is undesirable. To some extent we do know, but we need to know much more. In The Common Sense of Science, J. Bronowski quotes William Clifford, geometer and philospher, who wrote of scientific thought: " The truth at which it arrives is not that which we can ideally contemplate without error, but that which we may act on without fear ". I believe that in the field of mental health, psychiatry and medicine should augment their forces in order to establish a substantial basis on which to act "
subsequent carcinoma is physiologically and psychologically indefensible. Even if the ovaries are cystic an attempt should be made to conserve ovarian tissue. In the rare event of the pathological examination revealing malignancy then I admit a further laparotomy would be necessary. But I believe this course is preferable to the wholesale sacrifice of ovaries, normal and cystic, that is such a common practice. If we accept Jeffcoate’s1estimate that only 1 case of ovarian cancer can be prevented at the expense of 5000 hysterectomies and Schabort’s2 recent figure of 2 in 5000, then there is no place for routine oophorectomy. Osteoporosis and atherosclerosis are now recognised as complications of the normal and artificial menopause but the profound psychological disturbances that follow the latter have received insufficient emphasis. It is the family doctor who has to deal with these and not the surgeon since the patient never wants to see him (or her) again. A woman has an emotional attachment to her uterus and ovaries and it is unfortunate that her gonads, unlike the testicles, are not in an extracorporeal pouch secure
from unnecessary extirpation. University College Obstetric Hospital, London, W.C.1.
W. C. W. NIXON.
THE RESERVED £1 MILLION
SIR,-As members of the General Practice Reform Association, we note with approval the aim of the joint working party to raise standards of general practice, and to investigate methods of distribution of remuneration which will help to achieve this end. We believe that the most effective way of improving the quality of practice is to give every possible encouragement to the practitioner to keep up to date and to extend his knowledge of medicine, and to cooperate more closely with his colleagues in the hospital service. Accordingly, we should like to suggest that the Elmillion be used to finance the setting up of paid clinical assistantships for N.H.S. general practitioners in general hospitals. We suggest that such clinical assistantships should be made available, in rotation, to all general practitioners who desire them, and in as many clinical specialties as possible. Clinical contact between consultant and general practitioners would prove stimulating to both parties, and the hospitals would benefit in the long run through having fewer patients referred for consultant opinion. At present, general practitioners who work part-time in hospitals are remunerated from hospital sources. We can see no insuperable practical objections, however, to altering this system so as to pay for clinical assistantships out of the central pool, and we feel that the benefits of our proposal would outweigh any minor administrative difficulties. At the rate of remuneration recommended by the Royal Commission for general practitioners working in hospitals (E215 p.a. per notional half-day) the Elmillion would enable every principal in the N.H.S. to serve as clinical assistant, in one or more specialties, for one halfday per week for six months in every tliirty months. All would be enabled to share in the money, and controversial Dronosals for " merit awards " for oarticular G.P.S
withnlit fp!!r Bristol
CONSERVATION OF THE OVARIES SIR, Your annotation of Oct. 22 on conservation of the ovaries at hysterectomy is timely. The removal of normal ovaries before the menopause as prophylaxis against
Royal Hospital for Sick Children, Bristol.
1. Times Educational
JOHN APLEY.
Supplement, Sept. 30,
p.
387,
1. Jeffcoate, T. N. A. Principles of Gynæcology; p. 667, London, 1957. 2. Schabort, J. W. Trans. Coll. Phycns Surg. Gynœc. S. Afr. 1960, 4, 11.
considerably influenced by suggestion. Because of this I believe that only a blind controlled trial is likely to give reliable information. The trial which I have briefly mentioned had negative results, but one cannot of course prove that proguanil was ineffective. One can only say that in these 25 tests no convincing evidence of effectiveness emerged. I appreciate, of course, that proguanil is not the same as amodiaquine, which Dr. Sidi and Dr. Reinberg used; it was chosen in my series because of its freedom from side-effects. These results do not necessarily indicate that the antimalarials are never effective in chronic urticaria. One may well suppose that the symptom is the end-result of a variety of different causes or mechanisms and that an antimalarial may break a link in pathogenesis in one case and not in another. This may explain the occasional remarkable case where the effectiveness of an antimalarial seems to be undeniable although it cannot be regularly obtained in other patients. F. RAY BETTLEY. COMMUNITY MENTAL CARE? SIR,-Psychiatry is following good precedents as it evolves and develops a social conscience. It is turning from a preoccupation with those human abstractions of natural processes that are labelled " diseases " to prevention and to the promotion of mental health. Mental health is, however, too vast and too important to be delegated to any one section of medicine. Fortunately, the barriers that isolated psychiatry from the main currents of medicine (a subject discussed in your leader of Oct. 15) are being eroded from both sides. Your report that general practitioners and medical officers of health recently conferred with psychiatrists on mental health is a welcome illustration. Others among us are also concerned, and paediatricians especially so, if only because so many mental disorders have their roots in the early years of life. But mental health is too vast and too important to be delegated exclusively even to the medical profession. Allies are needed outside medicine and its traditional associates (such as psychologists and social workers). Geneticists, biochemists, sociologists, and anthropologists surely have fundamental contributions to make. So also have those non-medical agencies concerned with moral welfare, with family life and with education-of parents and of children. An enterprising pilot scheme inaugurated by Dr. S. Lebovici in a whole sector of Paris has already shown that school teachers, for example, can play a very important part in the prevention and early case-finding of mental disorders. Is the community ready for prevention ?" was asked at a recent conference on preventive psychiatry.l While that question is being pondered some of its implications will also be weighed. To prevent assumes that we know what is undesirable. To some extent we do know, but we need to know much more. In The Common Sense of Science, J. Bronowski quotes William Clifford, geometer and philospher, who wrote of scientific thought: " The truth at which it arrives is not that which we can ideally contemplate without error, but that which we may act on without fear ". I believe that in the field of mental health, psychiatry and medicine should augment their forces in order to establish a substantial basis on which to act "
subsequent carcinoma is physiologically and psychologically indefensible. Even if the ovaries are cystic an attempt should be made to conserve ovarian tissue. In the rare event of the pathological examination revealing malignancy then I admit a further laparotomy would be necessary. But I believe this course is preferable to the wholesale sacrifice of ovaries, normal and cystic, that is such a common practice. If we accept Jeffcoate’s1estimate that only 1 case of ovarian cancer can be prevented at the expense of 5000 hysterectomies and Schabort’s2 recent figure of 2 in 5000, then there is no place for routine oophorectomy. Osteoporosis and atherosclerosis are now recognised as complications of the normal and artificial menopause but the profound psychological disturbances that follow the latter have received insufficient emphasis. It is the family doctor who has to deal with these and not the surgeon since the patient never wants to see him (or her) again. A woman has an emotional attachment to her uterus and ovaries and it is unfortunate that her gonads, unlike the testicles, are not in an extracorporeal pouch secure
from unnecessary extirpation. University College Obstetric Hospital, London, W.C.1.
W. C. W. NIXON.
THE RESERVED £1 MILLION
SIR,-As members of the General Practice Reform Association, we note with approval the aim of the joint working party to raise standards of general practice, and to investigate methods of distribution of remuneration which will help to achieve this end. We believe that the most effective way of improving the quality of practice is to give every possible encouragement to the practitioner to keep up to date and to extend his knowledge of medicine, and to cooperate more closely with his colleagues in the hospital service. Accordingly, we should like to suggest that the Elmillion be used to finance the setting up of paid clinical assistantships for N.H.S. general practitioners in general hospitals. We suggest that such clinical assistantships should be made available, in rotation, to all general practitioners who desire them, and in as many clinical specialties as possible. Clinical contact between consultant and general practitioners would prove stimulating to both parties, and the hospitals would benefit in the long run through having fewer patients referred for consultant opinion. At present, general practitioners who work part-time in hospitals are remunerated from hospital sources. We can see no insuperable practical objections, however, to altering this system so as to pay for clinical assistantships out of the central pool, and we feel that the benefits of our proposal would outweigh any minor administrative difficulties. At the rate of remuneration recommended by the Royal Commission for general practitioners working in hospitals (E215 p.a. per notional half-day) the Elmillion would enable every principal in the N.H.S. to serve as clinical assistant, in one or more specialties, for one halfday per week for six months in every tliirty months. All would be enabled to share in the money, and controversial Dronosals for " merit awards " for oarticular G.P.S
withnlit fp!!r Bristol
CONSERVATION OF THE OVARIES SIR, Your annotation of Oct. 22 on conservation of the ovaries at hysterectomy is timely. The removal of normal ovaries before the menopause as prophylaxis against
Royal Hospital for Sick Children, Bristol.
1. Times Educational
JOHN APLEY.
Supplement, Sept. 30,
p.
387,
1. Jeffcoate, T. N. A. Principles of Gynæcology; p. 667, London, 1957. 2. Schabort, J. W. Trans. Coll. Phycns Surg. Gynœc. S. Afr. 1960, 4, 11.