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PHILOSOPHY OF CLINICAL MEDICINE
929 No system is perfect, and the criticism that a parttime professor of surgery might be out of touch with the laboratory is just as valid as that the whole-time man might be out of touch with the general practitioner. In both cases the opportunity is there. As yet it is much too early to decide whether whole-time clinical chairs produce a higher standard of work-after all it is only about ten years since the ins itution of such chairs in any university. The president of the Royal College of Surgeons has a great responsibility, and his opinion rightly carries great weight. It is therefore most disappointing that he should be so damning towards an experiment which has only just begun. Department
of
Surgery,
JOHN GRIEVE.
Medical School, Dundee.
SALICYLATE AS AN ANTICOAGULANT 9 prompts me to refer to the articlein which he recommended a combination of aspirin with ascorbic acid and tragacanth as an anticoagulant in coronary thrombosis and angina of effort. There are some rheumatic patients whose treatment is complicated by attacks of phlebitis, with or without obvious thrombosis. In these cases Dr. Gibson’s formula is most valuable, as it not only prevents thrombosis but also relieves the rheumatism. As Dr. Gibson points out, when the mixture is given with food there is no gastric disturbance. H. WARREN CROWE. London, W.1.
SIR,—Dr. Gibson’s letter of Dec.
PHILOSOPHY OF CLINICAL MEDICINE
SIR,—in his lecture
on
the
psychosomatic approach
to clinical
medicine, Dr. Ranyard West2 raises important questions and suggests an answer. Most people will agree that when the same patient can be treated with kaolin on Thursday and by a psychological probe on Monday, clinical medicine has reached a state of theoretic confusion and of therapeutic chaos. In this note I suggest that the cause of this state of affairs is that clinicians are over-simplifying the clinical situation and therefore failing to make necessary distinctions in clinical diagnosis and treatment. The practical usefulness of the psychosomatic approach is not questioned ; but we must ask whether that approach does not break down in practice, at the same point at which physical and psychological medicine break down-namely, when " the clinical case " transforms itself into a " living person." A person is not a hyphenated body-mind, of which fact Dr. West is aware when he writes : " it is often the patients rather than their doctors who succeed in adapting themselves to two conflicting philosophies of medicine." How does it happen that patients can reconcile, without instruction, incompatible opposites that defy the best minds in our
profession ? Sherrington has shown where the integration of these opposites is achieved ; even if he has not stated clearly how that integration is achieved. It takes place " in experience," in the process of living. Life psychically experienced and life physically experienced become " one life and one experience " in the awareness of the self that he is in fact an enduring entity, an " I." It has been objected that few people are aware of their continuing self-identity ; but, as Sherrington says elsewhere, this is due to the nature of conscious mind which has been evolved to meet practical situations and not in the interests of self-awareness. The mind is able to attend " to only one main task at a time." It seems then that, as clinicians, we may be taking the "self as a unity for granted, and studying only the " self in its manifoldness "—i.e., its organs, functions, cells, and complexes. Hence we have failed to aras7p "
1. Gibson, P. C. Lancet, 1949, ii, 1172. 2. West. R. Ibid, 1950, i, 1025.
the clinical significance of those diagnostic factors and those therapies whose value depends upon their origin in, or their effect upon, the unity of the personality. A. N. Whitehead has said that the problem before philosophy is to provide a satisfactory doctrine of personality and of the facts of the continuing selfidentity of the organism. Doctors face this problem as a need for a coherent theory and practice of personality diagnosis and therapy. W. D’Arcy Thompson and his school make the same point. Having demonstrated the significance of the form of the living organism in all biological theory, they have shown that the form (i.e., the self-identity) of the organism largely determines the particular shape that the organism will assume, at each stage of its life-cycle. C. G. Jung makes the same point-as is well brought out by J. Jacobi in her study of Jung’s work. By insisting upon the significance of the " formal" causes of mental behaviour as well as upon the efficient and final " causes of it, Jung makes an important practical distinction. Some students of Freud hold that the doctrine of the super-ego, if followed to its logical direction. The increasing conclusions, leads in a similar " attached to purposes, life-aim and lifeimportance styles " by other psychologists reveals a similar trend. are realising that the " disMany general practitioners " are of great practical importance orders of personality in clinical medicine in general, and in the preventive diagnosis of illness in particular. It seems reasonable to suggest, therefore, that a concerted attempt should be made to separate the " formal " or " personality disorders" (together with their clinical antecedents and consequents) from the many syndromes, &c., that have been distinguished hitherto solely by paying attention to disorders of the " manifold "—i.e., the psychosoma, or the body, or the mind (when this has been viewed as an organisation of instincts "). Following this line of thought, some of the more obvious disorders of personality-sometimes called disorders of attitude " can be indicated : ,.
"
"
1. There is
’
"
a
large
clinical group of
patients
who manifest
syndromes of despair." The basic psychology of this group In practice was discussed by Kirkegaard many years ago. three clinical varieties of this syndrome can be distinguished : (a) the " despair of ever becoming an individual," which is the commonest personality disorder of the young ; (b) the despair of ever becoming a self (i.e., an integrated personality), which is the commonest personality disorder of those under, say, 35-40 years of age ; and (c) the despair before death (also called the eternal despair) to which Dr. West seems to refer when discussing the death-acceptance instinct "
"
and which, as Jung insists, is the psychological disorder par excellence of middle and later life. All of these despairs are unconscious. Whenever they are made fully conscious, they are in a fair way to being cured, as a rule. 2. The major syndromes produced either by an arrest or by a repression of normal personality evolution are also well recognised. They are accompanied by recognisable effects and by certain peculiar disturbances of the normal awareness of self-identity," and of the normal awareness of reality. Examples of the personality " regressions " are to be found in every mental hospital. 3. Again certain critical ages in the normal evolution of the personality are recognised. These are age-periods during which arrest or repression are most liable to occur, and they mark periods of transition from one stage to another in the evolution of the integrated personality from its early antecedents in the innate character of the infant. Childhood, adolescence, maturity (about 35), and middle-age are the dangerous ages in the evolution of the personality. If we agree to call the " innate form of the infant " by the name character," then the integrated mature personality may be said to be the " form of the mature adult," and so on. In this sense character is innate, while personality is in part determined by innate qualities, and in part by experience. All attempts hitherto made to isolate a group of "
"
basic instincts,
complexes,
or
sentiments, capable of
930
serving as a sound personality, seem
theoretic basis for the diagnosis to have proved unsuccessful. The same is true in the field of social psychology where the hopes raised by Pareto’s original analysis seem to me to have faded. Similar failures attended the efforts of the old faculty-psychologists and of the system-physiologists (as J. S. Haldane insisted). I suggest, then, that all of these failures have arisen from the same causenamely that attention has been concentrated exclusively upon the manifoldness and not upon the unity of the self, upon the psychosoma and not on the personality. On the practical side, this new approach to medicine offers the clinician the help of a number of " therapies of personality " (as the Americans term them). At one extreme those include suggestion, prestige-therapy, and the morale therapies. They include also a wide variety of therapies by occupation, by arts, crafts, and play, also some new group and social therapies that are of
being actively studied ; and, of course, education, persuasion, and other methods of personality healing. Finally there is a group of therapies of which more may be heard in the future-namely, various specifically religious therapies all of which call for careful study by clinicians. The importance of revising medical theory and practice in the direction here proposed can hardly be overemphasised. The new approach will be found to complete, rather than compete with, established clinical methods. If I am right;it will clear up the prevalent intellectual muddle, enable the general practitioner and the specialist to work together towards a single end, open up new avenues in therapeutics, and bring medicine into line with recent advances in biology and philosophy. now
Worcester.
HOWARD E. COLLIER. CEREBRAL PALSY
am sure that no articles which you have have contributed more to the understanding of each disease as a problem affecting all aspects of the patient’s life-physical, psychological, social, and financial-than have those in your excellent Disabilities series. Of these, none has made a deeper impression on me than that on cerebral palsy (Dec. 16). Here isa disability which is seldom treated by parents or friends with understanding ; and no wonder, since even the neurologist may find difficulty over the details of diagnosis. It is perhaps because of this uncertainty as to the problem to be tackled that orthodox medicine has in the’past paid so little attention to the final and, in the end, the most important question : What can be done ?’? It is appalling that an adult woman should be able to report that only " within the last two years ... I have benefited from specialised cerebral-palsy treatment." Previously, she had helped herself laboriously through inarticulacy to speech, and through uncontrolled movement to the achievement of functionally adequate, though slow and awkward, performance. Surely the fact that she has benefited from her recent specialised treatment suggests that an understanding of the nature of the disability may, with our present knowledge, form a useful basis of treatment. This article can leave no doubt in the mind of any reader as to the possibility that a patient with cerebral palsy may yet be highly intelligent. It is a sobering thought that others, with less inspired parents, with only a little less intelligence or determination, or with a slightly more severe disability, fail in the struggle for lack of skilled help, to pass their days excluded from all society in a back room or incarcerated in a home for mental defectives. Much is already being done, and local authorities are now obliged to provide for the education of every child capable of benefiting. But without highly skilled guid-
SIR,—I
published
can do little to make these children and so will be largely wasted. Our aim should be to undertake treatment of these children from the first moment in infancy when abnormality can be detected, when their adaptability is greatest, so that as many as possible may, by school age, be fit to go to normal schools without the disadvantages described by your contributor, and so that no intelligent child need exhibit unintelligibility, drooling, or others of the grotesque handicaps which often militate against ance
such education
socially acceptable,
social acceptance or employment. So far only one hospital has undertaken, through a research unit and an advice clinic for parents, the difficult task involved. The value of its work, only now becoming appreciated, gives us a pointer to the future. London,
W.I.
WILLIAM DUNHAM.
GERMAN MEASLES IN GIRLS’ SCHOOLS
SIR,—Mr. Robinson (Dec. 16, p. 827) appears to have overlooked the possibility of one of his daughter’s schoolfriends having a pregnant mother. J. W. NICHOLAS. Silver End, Essex. STUDY OF DELINQUENCY SIR,—One sometimes doubts whether it takes two to make a quarrel, and I have no wish to offer myself as a protagonist, particularly as I some time ago published
views which " The reliable
agree with Dr. Stott’s. Thus : based on painstaking, sometimes even tedious, collection of data.... There is no short cut. We have no crystal ball."1 And : " Where the psychiatrist has insufficient time to study his cases and to interview the parents, the magistrate will be justified in considering that as good a guess may be made in the court room as elsewhere." 2 In the same paper psychiatrists are urged to follow up the results of their recommendations and to be prepared to modify the treatment after placement away from home. These and other points, such as the use of psychiatric jargon and loose terms, and many more not mentioned by Dr. Stott, have been dealt with in lectures for some years. I find having made a lot of mistakes a good basis for teaching. I would, however, like to take up the point made by Dr. Stott (Nov. 25) about treatment being too " clinic centred." With this I agree, but he also says in this connection : A refusal to treat, or a picking or choosing of our patients, will only damage our reputation among the magistrates...." In my experience with both juvenile and adult court work, precisely the opposite obtains. The magistrates, and any other experienced workers in the field, know full well that in the present state of our knowledge only a proportion of seriously delinquent cases are amenable to clinic treatment. I believe magistrates simply want to know if a particular case will respond at home with help, or whether some other course must be taken. They will therefore appreciate a frank statement upon the matter ; they do not these days expect the clinics to perform wonders with impossible material. Dr. Stott reports two hearsay cases in which clinicians refused to see cases which were "too bad " and " unco6perative " respectively. This, as he reports it, sounds very shocking. But if the two clinicians had in fact declined to treat the cases in their clinics because they appeared unsuitable for such treatment, and if they indicated what other course should be adopted, then these ignorant clinicians might after allbe quite sensible people. We are asked to " imagine what would be said of a family doctor who refused to treat a patient because he did not respond to his one and only prescription." But this is unduly difficult to imagine, because the training of family doctors (like that of psychiatrists) provides
largely
report is
1. Probation, 1949, 5, 286. 2. Proc. R. Soc. Med. 1948,
41, 201.
of
Surgery,
JOHN GRIEVE.
Medical School, Dundee.
SALICYLATE AS AN ANTICOAGULANT 9 prompts me to refer to the articlein which he recommended a combination of aspirin with ascorbic acid and tragacanth as an anticoagulant in coronary thrombosis and angina of effort. There are some rheumatic patients whose treatment is complicated by attacks of phlebitis, with or without obvious thrombosis. In these cases Dr. Gibson’s formula is most valuable, as it not only prevents thrombosis but also relieves the rheumatism. As Dr. Gibson points out, when the mixture is given with food there is no gastric disturbance. H. WARREN CROWE. London, W.1.
SIR,—Dr. Gibson’s letter of Dec.
PHILOSOPHY OF CLINICAL MEDICINE
SIR,—in his lecture
on
the
psychosomatic approach
to clinical
medicine, Dr. Ranyard West2 raises important questions and suggests an answer. Most people will agree that when the same patient can be treated with kaolin on Thursday and by a psychological probe on Monday, clinical medicine has reached a state of theoretic confusion and of therapeutic chaos. In this note I suggest that the cause of this state of affairs is that clinicians are over-simplifying the clinical situation and therefore failing to make necessary distinctions in clinical diagnosis and treatment. The practical usefulness of the psychosomatic approach is not questioned ; but we must ask whether that approach does not break down in practice, at the same point at which physical and psychological medicine break down-namely, when " the clinical case " transforms itself into a " living person." A person is not a hyphenated body-mind, of which fact Dr. West is aware when he writes : " it is often the patients rather than their doctors who succeed in adapting themselves to two conflicting philosophies of medicine." How does it happen that patients can reconcile, without instruction, incompatible opposites that defy the best minds in our
profession ? Sherrington has shown where the integration of these opposites is achieved ; even if he has not stated clearly how that integration is achieved. It takes place " in experience," in the process of living. Life psychically experienced and life physically experienced become " one life and one experience " in the awareness of the self that he is in fact an enduring entity, an " I." It has been objected that few people are aware of their continuing self-identity ; but, as Sherrington says elsewhere, this is due to the nature of conscious mind which has been evolved to meet practical situations and not in the interests of self-awareness. The mind is able to attend " to only one main task at a time." It seems then that, as clinicians, we may be taking the "self as a unity for granted, and studying only the " self in its manifoldness "—i.e., its organs, functions, cells, and complexes. Hence we have failed to aras7p "
1. Gibson, P. C. Lancet, 1949, ii, 1172. 2. West. R. Ibid, 1950, i, 1025.
the clinical significance of those diagnostic factors and those therapies whose value depends upon their origin in, or their effect upon, the unity of the personality. A. N. Whitehead has said that the problem before philosophy is to provide a satisfactory doctrine of personality and of the facts of the continuing selfidentity of the organism. Doctors face this problem as a need for a coherent theory and practice of personality diagnosis and therapy. W. D’Arcy Thompson and his school make the same point. Having demonstrated the significance of the form of the living organism in all biological theory, they have shown that the form (i.e., the self-identity) of the organism largely determines the particular shape that the organism will assume, at each stage of its life-cycle. C. G. Jung makes the same point-as is well brought out by J. Jacobi in her study of Jung’s work. By insisting upon the significance of the " formal" causes of mental behaviour as well as upon the efficient and final " causes of it, Jung makes an important practical distinction. Some students of Freud hold that the doctrine of the super-ego, if followed to its logical direction. The increasing conclusions, leads in a similar " attached to purposes, life-aim and lifeimportance styles " by other psychologists reveals a similar trend. are realising that the " disMany general practitioners " are of great practical importance orders of personality in clinical medicine in general, and in the preventive diagnosis of illness in particular. It seems reasonable to suggest, therefore, that a concerted attempt should be made to separate the " formal " or " personality disorders" (together with their clinical antecedents and consequents) from the many syndromes, &c., that have been distinguished hitherto solely by paying attention to disorders of the " manifold "—i.e., the psychosoma, or the body, or the mind (when this has been viewed as an organisation of instincts "). Following this line of thought, some of the more obvious disorders of personality-sometimes called disorders of attitude " can be indicated : ,.
"
"
1. There is
’
"
a
large
clinical group of
patients
who manifest
syndromes of despair." The basic psychology of this group In practice was discussed by Kirkegaard many years ago. three clinical varieties of this syndrome can be distinguished : (a) the " despair of ever becoming an individual," which is the commonest personality disorder of the young ; (b) the despair of ever becoming a self (i.e., an integrated personality), which is the commonest personality disorder of those under, say, 35-40 years of age ; and (c) the despair before death (also called the eternal despair) to which Dr. West seems to refer when discussing the death-acceptance instinct "
"
and which, as Jung insists, is the psychological disorder par excellence of middle and later life. All of these despairs are unconscious. Whenever they are made fully conscious, they are in a fair way to being cured, as a rule. 2. The major syndromes produced either by an arrest or by a repression of normal personality evolution are also well recognised. They are accompanied by recognisable effects and by certain peculiar disturbances of the normal awareness of self-identity," and of the normal awareness of reality. Examples of the personality " regressions " are to be found in every mental hospital. 3. Again certain critical ages in the normal evolution of the personality are recognised. These are age-periods during which arrest or repression are most liable to occur, and they mark periods of transition from one stage to another in the evolution of the integrated personality from its early antecedents in the innate character of the infant. Childhood, adolescence, maturity (about 35), and middle-age are the dangerous ages in the evolution of the personality. If we agree to call the " innate form of the infant " by the name character," then the integrated mature personality may be said to be the " form of the mature adult," and so on. In this sense character is innate, while personality is in part determined by innate qualities, and in part by experience. All attempts hitherto made to isolate a group of "
"
basic instincts,
complexes,
or
sentiments, capable of
930
serving as a sound personality, seem
theoretic basis for the diagnosis to have proved unsuccessful. The same is true in the field of social psychology where the hopes raised by Pareto’s original analysis seem to me to have faded. Similar failures attended the efforts of the old faculty-psychologists and of the system-physiologists (as J. S. Haldane insisted). I suggest, then, that all of these failures have arisen from the same causenamely that attention has been concentrated exclusively upon the manifoldness and not upon the unity of the self, upon the psychosoma and not on the personality. On the practical side, this new approach to medicine offers the clinician the help of a number of " therapies of personality " (as the Americans term them). At one extreme those include suggestion, prestige-therapy, and the morale therapies. They include also a wide variety of therapies by occupation, by arts, crafts, and play, also some new group and social therapies that are of
being actively studied ; and, of course, education, persuasion, and other methods of personality healing. Finally there is a group of therapies of which more may be heard in the future-namely, various specifically religious therapies all of which call for careful study by clinicians. The importance of revising medical theory and practice in the direction here proposed can hardly be overemphasised. The new approach will be found to complete, rather than compete with, established clinical methods. If I am right;it will clear up the prevalent intellectual muddle, enable the general practitioner and the specialist to work together towards a single end, open up new avenues in therapeutics, and bring medicine into line with recent advances in biology and philosophy. now
Worcester.
HOWARD E. COLLIER. CEREBRAL PALSY
am sure that no articles which you have have contributed more to the understanding of each disease as a problem affecting all aspects of the patient’s life-physical, psychological, social, and financial-than have those in your excellent Disabilities series. Of these, none has made a deeper impression on me than that on cerebral palsy (Dec. 16). Here isa disability which is seldom treated by parents or friends with understanding ; and no wonder, since even the neurologist may find difficulty over the details of diagnosis. It is perhaps because of this uncertainty as to the problem to be tackled that orthodox medicine has in the’past paid so little attention to the final and, in the end, the most important question : What can be done ?’? It is appalling that an adult woman should be able to report that only " within the last two years ... I have benefited from specialised cerebral-palsy treatment." Previously, she had helped herself laboriously through inarticulacy to speech, and through uncontrolled movement to the achievement of functionally adequate, though slow and awkward, performance. Surely the fact that she has benefited from her recent specialised treatment suggests that an understanding of the nature of the disability may, with our present knowledge, form a useful basis of treatment. This article can leave no doubt in the mind of any reader as to the possibility that a patient with cerebral palsy may yet be highly intelligent. It is a sobering thought that others, with less inspired parents, with only a little less intelligence or determination, or with a slightly more severe disability, fail in the struggle for lack of skilled help, to pass their days excluded from all society in a back room or incarcerated in a home for mental defectives. Much is already being done, and local authorities are now obliged to provide for the education of every child capable of benefiting. But without highly skilled guid-
SIR,—I
published
can do little to make these children and so will be largely wasted. Our aim should be to undertake treatment of these children from the first moment in infancy when abnormality can be detected, when their adaptability is greatest, so that as many as possible may, by school age, be fit to go to normal schools without the disadvantages described by your contributor, and so that no intelligent child need exhibit unintelligibility, drooling, or others of the grotesque handicaps which often militate against ance
such education
socially acceptable,
social acceptance or employment. So far only one hospital has undertaken, through a research unit and an advice clinic for parents, the difficult task involved. The value of its work, only now becoming appreciated, gives us a pointer to the future. London,
W.I.
WILLIAM DUNHAM.
GERMAN MEASLES IN GIRLS’ SCHOOLS
SIR,—Mr. Robinson (Dec. 16, p. 827) appears to have overlooked the possibility of one of his daughter’s schoolfriends having a pregnant mother. J. W. NICHOLAS. Silver End, Essex. STUDY OF DELINQUENCY SIR,—One sometimes doubts whether it takes two to make a quarrel, and I have no wish to offer myself as a protagonist, particularly as I some time ago published
views which " The reliable
agree with Dr. Stott’s. Thus : based on painstaking, sometimes even tedious, collection of data.... There is no short cut. We have no crystal ball."1 And : " Where the psychiatrist has insufficient time to study his cases and to interview the parents, the magistrate will be justified in considering that as good a guess may be made in the court room as elsewhere." 2 In the same paper psychiatrists are urged to follow up the results of their recommendations and to be prepared to modify the treatment after placement away from home. These and other points, such as the use of psychiatric jargon and loose terms, and many more not mentioned by Dr. Stott, have been dealt with in lectures for some years. I find having made a lot of mistakes a good basis for teaching. I would, however, like to take up the point made by Dr. Stott (Nov. 25) about treatment being too " clinic centred." With this I agree, but he also says in this connection : A refusal to treat, or a picking or choosing of our patients, will only damage our reputation among the magistrates...." In my experience with both juvenile and adult court work, precisely the opposite obtains. The magistrates, and any other experienced workers in the field, know full well that in the present state of our knowledge only a proportion of seriously delinquent cases are amenable to clinic treatment. I believe magistrates simply want to know if a particular case will respond at home with help, or whether some other course must be taken. They will therefore appreciate a frank statement upon the matter ; they do not these days expect the clinics to perform wonders with impossible material. Dr. Stott reports two hearsay cases in which clinicians refused to see cases which were "too bad " and " unco6perative " respectively. This, as he reports it, sounds very shocking. But if the two clinicians had in fact declined to treat the cases in their clinics because they appeared unsuitable for such treatment, and if they indicated what other course should be adopted, then these ignorant clinicians might after allbe quite sensible people. We are asked to " imagine what would be said of a family doctor who refused to treat a patient because he did not respond to his one and only prescription." But this is unduly difficult to imagine, because the training of family doctors (like that of psychiatrists) provides
largely
report is
1. Probation, 1949, 5, 286. 2. Proc. R. Soc. Med. 1948,
41, 201.