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LEUCOTOMY
149
of Transport, in his wisdom, consider an of such safety devices and a means of attractive to the motoring public ? Birmingham Accident Hospital, Birmingham.
approved list
making
them
WILLIAM GISSANE.
SEQUENCE HYPOTHESIS SIR,-Despite my junior position in the medical profession I trust you will accept my congratulations for your leading article of July 14 on this subject. Biochemical research has always held a fascination for me; but pressure of medical work has prevented my following this up, and a lapse of even a year or two renders large areas of such a fast-moving subject incomprehensible. The relevance of such erudite biochemistry to current medicine may seem obscure to some: but I, for one, was delighted by the breadth of your editorial wisdom and the lucidity of your exposition. For there are few fields of human inquiry that may be ignored with impunity when considering advances in medical thought. ROBERT A. JOHNSON. Epping, Essex. THE
LEUCOTOMY SIR,-Dr. Russell Barton (July 7) has done the patient a service by his powerful arguments against mass leuco" tomy to promote the return to work of many patients still in psychiatric hospitals ", and I am confident that the majority of my colleagues will agree with his views. After several years’ experience in a number of mental hospitals, I am not impressed by the results of modified leucotomies which seem to exert little or no influence upon the behaviour of chronic schizophrenics. If leucotomy is ever to be contemplated for them a standard operation seems to be the treatment of choice in the first instance. The dangers that may attend the performance of two leucotomy operations on the same subject are well known, and in my view, are sufficient to contraindicate standard leucotomy in persons who have already undergone a modified procedure. It is doubtful whether prefrontal leucotomy is ever " indicated for the so-called " chronic schizophrenics who form the bulk of our long-stay mental hospital population. The majority of these patients have been shown to suffer from " institutional neurosis ". This is primarily an iatrogenic condition and is therefore no justification for leucotomy on scientific grounds, or indeed for any other reason. These patients are probably best helped at present by careful reappraisal of the diagnosis
exclude underlying organic conditions, by phenothiazines, and occasionally by E.C.T., particularly when there to
is excessive social withdrawal. Social reorganisation of the mental hospital along the lines suggested by Mandelbrote,l aims at opening up channels of communication for the institutionalised patient and is complementary to existing clinical methods of treatment. Such environmental manipulations include the widespread use of group discussion, integration of the sexes within the mental hospital, industrial therapy, and an active organised rehabilitation programme for all longstay patients. These measures frequently enable patients, where the prognosis was hitherto hopeless, to be returned to the community, including perhaps some of those who were leucotomised by our predecessors and have vegetated in the back wards ever since!
HYPERBARIC OXYGENATION OF SUBMERGED MAMMALS letter of June 23 Dr. Goodlin ascribed his SIR,-In of newborn and foetal mice and of survival prolonged human foetuses in a hyperbarically oxygenated salt solution to cutaneous respiration. It would seem more likely, however, that in newborn mice the gas exchange occurred primarily in the lungs. This would also explain why the foetuses required an intact placental circulation to survive under these conditions, apparently because the circulation through the lungs is not yet adequate to meet the respiratory demands. It is a well-known fact that foetuses and newborn mammals tolerate prolonged periods of asphyxia.l2 Dr. Goodlin reports that his newborn mice survived submerged up to nine hours, or six times as long as controls. In similar experiments 3-5 it had been found that adult mice may continue breathing fluid up to 18 hours-that is approximately 1000 times as long as controls. These animals were submerged in a balanced salt solution to which tris(hydroxymethyl)aminomethane (T.H.A.M.) had been added to minimise hypercapnic acidosis due to deficient elimination of carbon dioxide. It seems likely that addition of T.H.A.M. to the liquid medium would improve the possible usefulness respiratory of a " foetal incubator ". Applied Physiology Division, Department of Physiology, University of Leiden.
LOGIC AND HYPERTENSION SIR,-Nowadays odium scholasticum is usually discreetly veiled, but your readers and those of your contemporary are being treated to a splendid display. Although I am the focus of this passion, I find its manifestations of great interest, particularly the imperative need of my critics to invent attitudes and views that are foreign to me, and their satisfaction in striking their creature down. The need for such fabrication is, I suspect, the most eloquent testimony to the weakness of their case. McMichael has now done it again. He writes (July 14): " Many of us have tried, in private, on the rostrum, and in print, to convince Sir George Pickering that the search for definable influences and separable clinical groupings in hypertension is a continuing challenge." Why, Sir, should John McMichael try to convince me, since I was engaged in this exercise long before he became concerned in it and have continued to be so. I suspect that McMichael thinks I am a renegade because, after some 25 years devoted almost exclusively to this kind of pursuit, I begin to doubt, as the late Sir James Spence did, whether " phenomenology was a sufficient occupation for an experienced mind. It seemed not unimportant to investigate the larger issues that have been classically studied in terms of inheritance and environment. With regard to the central dispute, McMichael writes: " The onus is clearly on Sir George to bring more evidence and not on his challengers to prove that such a vague and semi-philosophical notion as a physiological abnormality is wrong ". Would McMichael please provide your readers and me with the reference in my writings to the " concept of a physiological abnormality ". A difference between us is that McMichael seems to write and think in "
1. 2.
Herrison
Hospital, Dorchester,
J. C. BARKER.
Dorset. 1.
Mandelbrote,
B. Ment.
Hyg., N.Y. 1958, 42,
3.
J. A. KYLSTRA.
3. 4. 5.
Edwards, W. F. De l’influence des agens physiques sur la vie. Paris, 1824. Fazekas, J. F., Alexander, F. A. D., Himwich, H. E. Amer. J. Physiol. 1941, 134, 281. Kylstra, J. A. Experientia, Basel, 1962, 18, 68. Kylstra, J. A. Acta physiol. pharmacol. Neerl. 1962, 10, 327. Kylstra, J. A., Tissing, M. O., van der Maën, A. Trans. Amer. Soc. artif. intern. Org. (in the press).
of Transport, in his wisdom, consider an of such safety devices and a means of attractive to the motoring public ? Birmingham Accident Hospital, Birmingham.
approved list
making
them
WILLIAM GISSANE.
SEQUENCE HYPOTHESIS SIR,-Despite my junior position in the medical profession I trust you will accept my congratulations for your leading article of July 14 on this subject. Biochemical research has always held a fascination for me; but pressure of medical work has prevented my following this up, and a lapse of even a year or two renders large areas of such a fast-moving subject incomprehensible. The relevance of such erudite biochemistry to current medicine may seem obscure to some: but I, for one, was delighted by the breadth of your editorial wisdom and the lucidity of your exposition. For there are few fields of human inquiry that may be ignored with impunity when considering advances in medical thought. ROBERT A. JOHNSON. Epping, Essex. THE
LEUCOTOMY SIR,-Dr. Russell Barton (July 7) has done the patient a service by his powerful arguments against mass leuco" tomy to promote the return to work of many patients still in psychiatric hospitals ", and I am confident that the majority of my colleagues will agree with his views. After several years’ experience in a number of mental hospitals, I am not impressed by the results of modified leucotomies which seem to exert little or no influence upon the behaviour of chronic schizophrenics. If leucotomy is ever to be contemplated for them a standard operation seems to be the treatment of choice in the first instance. The dangers that may attend the performance of two leucotomy operations on the same subject are well known, and in my view, are sufficient to contraindicate standard leucotomy in persons who have already undergone a modified procedure. It is doubtful whether prefrontal leucotomy is ever " indicated for the so-called " chronic schizophrenics who form the bulk of our long-stay mental hospital population. The majority of these patients have been shown to suffer from " institutional neurosis ". This is primarily an iatrogenic condition and is therefore no justification for leucotomy on scientific grounds, or indeed for any other reason. These patients are probably best helped at present by careful reappraisal of the diagnosis
exclude underlying organic conditions, by phenothiazines, and occasionally by E.C.T., particularly when there to
is excessive social withdrawal. Social reorganisation of the mental hospital along the lines suggested by Mandelbrote,l aims at opening up channels of communication for the institutionalised patient and is complementary to existing clinical methods of treatment. Such environmental manipulations include the widespread use of group discussion, integration of the sexes within the mental hospital, industrial therapy, and an active organised rehabilitation programme for all longstay patients. These measures frequently enable patients, where the prognosis was hitherto hopeless, to be returned to the community, including perhaps some of those who were leucotomised by our predecessors and have vegetated in the back wards ever since!
HYPERBARIC OXYGENATION OF SUBMERGED MAMMALS letter of June 23 Dr. Goodlin ascribed his SIR,-In of newborn and foetal mice and of survival prolonged human foetuses in a hyperbarically oxygenated salt solution to cutaneous respiration. It would seem more likely, however, that in newborn mice the gas exchange occurred primarily in the lungs. This would also explain why the foetuses required an intact placental circulation to survive under these conditions, apparently because the circulation through the lungs is not yet adequate to meet the respiratory demands. It is a well-known fact that foetuses and newborn mammals tolerate prolonged periods of asphyxia.l2 Dr. Goodlin reports that his newborn mice survived submerged up to nine hours, or six times as long as controls. In similar experiments 3-5 it had been found that adult mice may continue breathing fluid up to 18 hours-that is approximately 1000 times as long as controls. These animals were submerged in a balanced salt solution to which tris(hydroxymethyl)aminomethane (T.H.A.M.) had been added to minimise hypercapnic acidosis due to deficient elimination of carbon dioxide. It seems likely that addition of T.H.A.M. to the liquid medium would improve the possible usefulness respiratory of a " foetal incubator ". Applied Physiology Division, Department of Physiology, University of Leiden.
LOGIC AND HYPERTENSION SIR,-Nowadays odium scholasticum is usually discreetly veiled, but your readers and those of your contemporary are being treated to a splendid display. Although I am the focus of this passion, I find its manifestations of great interest, particularly the imperative need of my critics to invent attitudes and views that are foreign to me, and their satisfaction in striking their creature down. The need for such fabrication is, I suspect, the most eloquent testimony to the weakness of their case. McMichael has now done it again. He writes (July 14): " Many of us have tried, in private, on the rostrum, and in print, to convince Sir George Pickering that the search for definable influences and separable clinical groupings in hypertension is a continuing challenge." Why, Sir, should John McMichael try to convince me, since I was engaged in this exercise long before he became concerned in it and have continued to be so. I suspect that McMichael thinks I am a renegade because, after some 25 years devoted almost exclusively to this kind of pursuit, I begin to doubt, as the late Sir James Spence did, whether " phenomenology was a sufficient occupation for an experienced mind. It seemed not unimportant to investigate the larger issues that have been classically studied in terms of inheritance and environment. With regard to the central dispute, McMichael writes: " The onus is clearly on Sir George to bring more evidence and not on his challengers to prove that such a vague and semi-philosophical notion as a physiological abnormality is wrong ". Would McMichael please provide your readers and me with the reference in my writings to the " concept of a physiological abnormality ". A difference between us is that McMichael seems to write and think in "
1. 2.
Herrison
Hospital, Dorchester,
J. C. BARKER.
Dorset. 1.
Mandelbrote,
B. Ment.
Hyg., N.Y. 1958, 42,
3.
J. A. KYLSTRA.
3. 4. 5.
Edwards, W. F. De l’influence des agens physiques sur la vie. Paris, 1824. Fazekas, J. F., Alexander, F. A. D., Himwich, H. E. Amer. J. Physiol. 1941, 134, 281. Kylstra, J. A. Experientia, Basel, 1962, 18, 68. Kylstra, J. A. Acta physiol. pharmacol. Neerl. 1962, 10, 327. Kylstra, J. A., Tissing, M. O., van der Maën, A. Trans. Amer. Soc. artif. intern. Org. (in the press).