- Email: [email protected]
SMOKING OBSCURED
952 competent cell donor.
capable
of
reflecting
the immune status of its
This work was supported by grants from the United States Public Health Service (HDO0542), New York City Health Research Council (U-1030), and the American Heart Association. K. H. is a career scientist of the New York City Health Research Council (1416), and C. S. R. is a special fellow of the United States Public Health Service.
Departments of Pathology, Dermatology, and Medicine, New York University School of Medicine, New York, New York 10016.
CAROLYN S. RIPPS M. J. FELLNER K. HIRSCHHORN.
HOMOGRAFT INTERACTION MacLaurin’s article and the accompanying leading SIR,-Dr. article (Oct. 23) both raise interesting possibilities which deserve further comment. Dr. MacLaurin is to be congratulated on his success in showing that, even after eleven days in a mixed cell culture, it is possible to induce further blastoid cell transformation by the addition of phytohasmagglutinin (P.H.A.). However, there are several aspects of this work and the accompanying review which I think require further consideration. Firstly, the assumption, for which the author has produced published evidence, that these transformed cells produce antibodies. The communications cited 1refer to experiments on one patient only; these findings have not been confirmed further by the authors, and many workers in this field have failed to produce supporting evidence. Secondly, the use of the mixed lymphocyte test as an in-vitro test of histocompatibility is not yet fully established, although there is evidence that it reflects the degree of relationship between individuals. Bain and Lowenstein3 have demonstrated a reduced interaction between siblings compared with unrelated individuals. We have confirmed this and found in a small series of experiments that the degree of significance was greater than p=0.001.4 Ceppelini5 has produced data suggesting that this test can discriminate between siblings, parent/child combinations, and unrelated individuals, thus confirming the hypothesis of Newth.s The usefulness of the mixed lymphocyte culture depends entirely on the accuracy with which the transformation is measured. To increase the sensitivity, Bain and Ceppelini have used specific thymidine incorporation. We have retained the morphological approach, but have abandoned the recording of results in terms of percentage, which we believe to be meaningless. The degree of response in the cultures can only be of value if related to the number of immunologically competent cells-i.e., lymphocytes-present at the beginning of the experiment. We maintain that it is necessary to determine absolute numbers of cells at each stage of the experiment. We would question the interpretation that Dr. MacLaurin places on his results, in view of the information supplied. It is unusual, in our experience, to achieve a transformationrate greater than 20% in a mixed’lymphocyte culture, when an accurate differential count is performed on the prepared material. There is uneven distribution of nucleated cells in a smeared sample, and a count of a few hundred cells concentrated near the tail of the smear will inevitably increase the percentage of positives obtained. Without information as to the absolute number of cells present, one cannot assume that the addition of P.H.A. to a mixed culture on the eighth day enhances the activity and survival of the previously activated cells. Only some (i.e., less than 20%) of cells in a mixed culture transform, whereas the majority of cells in a P.H.A.-stimulated culture transform. Possibly the increase in blast-cell percentages encountered by Dr. MacLaurin in his mixed cultures subsequently stimulated with P.H.A. is due to the transformation 1.
Elves, M. W., Roath, S., Taylor, G., Israels, M. C. G. Lancet, 1963, i,
2. 3.
Forbes, I. J. ibid. 1965, i, 198. Bain, B., Lowenstein, L., MacLean, L. D. Histocompatibility Testing; p. 121. Washington, 1964. Chalmers, D. G., Coulson, A. S., Evans, C., Yealland, M. F. T. Unpublished. Ceppelini, R. Histocompatibility. Copenhagen, 1965. Newth, D. R. Transplantn Bull. 1961, 27, 452.
1292.
4. 5. 6.
of previously unaffected lymphocytes. His suggestion, also, that the death of the transformed cells in the mixed cell culture is due to a histocompatibility reaction must be viewed with caution. All the Celllqlfesent in the culture come from two individuals. It would be surprising if, after production of immunologically active cells, capable of taking part in a graft reaction, such cells were only capable of destroying each other, and not the unstimulated lymphocytes contained in the culture from which the blastoid cells were derived. Finally, the views expressed in the final paragraph of your leader must be challenged. In a complicated subject such as histocompatibility all approaches must be explored. To suggest, as you do, that this technique lacks the specificity of classical serological methods, and is therefore inferior, is misleading. The use of serological methods in the detection of antigens in histocompatibility is fraught with difficulty; leucocyte antigens are the most widely used system at present. The preparation of monospecific sera is tedious, and only a few examples are at present available; and the monospecificity may only be apparent when one particular type of test is used. Secondly, much of the graft versus host reaction takes place at the cellular level, and as yet there is no proof that all the histocompatibility antigens can be recognised by classical antigen/antibody techniques. Addenbrooke’s Hospital, D. G. CHALMERS. Cambridge. A HISTORY OF MEDICINE SiR,ņIcan understand your otherwise amiable reviewer’s irritation at my use " of’virus’ as a synonym for micro" " " organism "; but is it fair to call it misuse " ? Virus has a long and respectable history, clinical as well as colloquial, in its meaning " disease agent " or, broader, " agent of evil ". But it was ordinarily used about undiscovered agents; so when germs were found, I take it, the term became clinically confined to those disease agents which remained undiscovered. And, when they were discovered, they assumed the title of viruses, to distinguish them from the germs. If this is what happened, it is an understandable process; but I really do not see why we laymen should be deprived of a valid term simply to suit clinical laziness. Patients, after all, do not distinguish between viruses and germs (though to have a virus disorder is for some curious reason more fashionable). So why can not we keep the term in its old sense ? Come to think of it, if there is any question of misuse, the medical profession is more blameworthy. Viruses are continually being described in respectable medical journals as the cause, rather than as the agent, of disease. So far as I am aware, the evidence suggests they are more symptoms than causes.
Still worse is the deplorable and growing habit of doctors falling back on a diagnosis of a virus disorder " when what they actually mean is, We don’t really know what is the "
"
with him ". The useful term " functional " fell into disrepute in this way; so that even to this day many doctors shy away from it. A pity. BRIAN INGLIS. London, W.2.
matter
SMOKING OBSCURED SiR,ņIn your annotation (Oct. 16) on Professor Eysenck’s book, Smoking, Health and Personality, you note that " the book, we are told, is intended for the intelligent layman ". The report of the Royal College of Physicians’ committee on smoking, too, was professedly written for the layman to understand. You accuse Eysenck of arguing " the importance of air pollution as a cause of lung cancer, without acknowledging the fact that this was given careful attention in the R.C.P. report." Where ? The report devoted just over a page to brushing aside some of the arguments against air pollution, and concluded that " The interaction of air pollution and smoking requires further investigation." But on p. 2 of the report we find: " The importance of atmospheric pollution will be the subject of a separate report. Although the effects of thi;
953 hazard and of tobacco smoking may be inter-related, at least in the case of lung cancer and bronchitis, the preventive measures required in respect of air pollution are of a character so entirely different from those required in respect of smoking that the two hazards are best considered separately." The intelligent " layman might ask, If there is an interrelation, isn’t that a very good reason for considering them together ? " But the report was approved for publication four years ago, and there is still no sign of the promised separate report. You go on to say: " He [Eysenck] insists not only that air pollution is important, but that it is a more important cause of lung cancer than cigarette smoking; but he has omitted much of the available evidence which tends in the opposite direction to which he would lead his readers." Eysenck is by no means alone in this opinion. It is shared by several eminent men, notably by Professor Pybus, who has shown that the coal smoke over Britain in a year contains about 375 tons of carcinogenic benzpyrene, against eight pounds from all the tobacco smoked in the same time. As a layman the chief difficulty I found in the way of conviction by the R.C.P. report was precisely that omission of available evidence of which your reviewer accuses Eysenck. It reads as if the committee had decided that smoking was the chief cause of lung cancer and then set out to prove it, lightly brushing aside any evidence inconvenient to their decision. The United States Surgeon General’s report admittedly introduced no new evidence, but only reviewed in detail what was already known. May I just add that I am a very modest smoker, with a negligible cigarette consumption, and that I dislike other people’s smoke ? I am trying to arrive at the truth behind a great deal of propaganda, in the belief that there is danger in accepting too readily that the major cause of lung cancer has been found and that all we need to do is to give up smoking. I wish I could believe it was as simple as that. But for every argument advanced in the reports I keep on finding equally cogent ones pointing the opposite way. Professor Eysenck, before developing his personality thesis, seemed to me to paint both sides of the picture pretty fairly. C. HARCOURT KITCHIN. London, N.2. CARCINOMA OF BRONCHUS SIR,-Dr. Fletcher drew attention last week to some of the difficulties of comparing the lung-cancer mortality among women in 1963 with that among men in 1922, as attempted by Dr. Myddleton (Oct. 16). Dr. Myddleton’s data on smoking are fallacious, and, if more appropriate data are used, the conclusions are quite different from those he reached. His figures for the amounts of cigarette tobacco consumed appear to have been derived by adding together the average amount smoked per adult male or female for successive years as shown in the report which he cites.1 In this report (table ill) the cigarette consumption per adult male is given for each year from 1891 and the subsequent increase could be accounted for largely by the entry of new cohorts to the ranks of cigarette smokers, while men of earlier cohorts continued to smoke pipes. The sum of the mean annual consumptions per adult male from 1891 to 1922 cannot therefore be expected to give a useful estimate of the cumulative consumption of cigarettes by the middle-aged or elderly men who died from lung cancer in 1922. To obtain his figure of 66 lb. of cigarette tobacco smoked by the average woman up to 1961, Dr. Myddleton has presumably added up the entries for the mean annual consumption of cigarettes as given in table iv of the report1 for each year from 1922 to 1961. There is evidence within the same report (table xm) that in 1961 the smoking habits of women varied considerably with age, and again it cannot be expected that Dr. Myddleton’s procedure would give a satisfactory estimate of the cumulative consumption of cigarettes by the middle-aged or elderly women who died from lung cancer in 1963. In table xvii of the report1 there are proper estimates of the cumulative 1. Todd, G. F. Tobacco Manufacturers’ Standing Committee; research paper no. 1.
London,
1962.
consumption of cigarettes by men and women of specified ages for periods of 10 and 20 years, and tables are now available for 30-year periods.2 It is not yet possible to assess the cumulative consumption of cigarettes throughout adult life for people of all ages, but the latest tables show that on average men aged 47 in 1964 had smoked 131,000 cigarettes since the age of 16, and women aged 47 had smoked 45,000 in the same age-period. This 3:1 ratio in the number of cigarettes smoked by men and women up to age 47 is quite close to the 4:1 ratio in lung-cancer death-rates of men and women in the age range 45-49,3 and these data would not be as difficult reconcile with the cigarette-smoking hypothesis as those presented by Dr. Myddleton. M.R.C. Air Pollution Research Unit, St. Bartholomew’s Hospital Medical College, R. E. WALLER. London, E.C.1. to
COT DEATHS SIR,-Your leading article last week made no reference to postmortem temperature recordings. I have only seen three cases of sudden unexplained death in infants, but in each the rectal temperature was above 101°F. The possible relation of the condition to infection would be better understood if body temperature was recorded in all cases. Silsden, Keighley,
near
D. G. WILLITS.
Yorkshire.
THE LISTER CENTENARY SIR,-Sir Francis Walshe pointed out (Sept. 25) that the Lister commemorative tablet had not been replaced on Lister’s old home at 12, Park Crescent when it was rebuilt, and Dr. Godlee replied (Oct. 23) that he had happily been able to rescue the " original bronze memorial." The present occupiers, the Spastics Society (not the University Grants Committee, who are our neighbours in no. 14), will be very happy to see the original memorial tablet restored to its rightful place. If the tablet is in a satisfactory condition it is to be restored to an external site; if not it will be replaced by a modern plaque, and we shall be very proud to place the older one in our entrance hall. Director, Spastics Society, C. P. STEVENS. 12, Park Crescent, London, W.1.
PSYCHOANALYSIS IN PSYCHOTHERAPY SIR,-An advertisement for a consultant psychotherapist in your columns includes the statement: "A training in analytic methods is not a requirement and the candidates should have an interest in the development of a wide range of psychological techniques as part of an integrated treatment programme." Many medical colleagues may think this advertisement unexceptionable, and since the appointment of a consultant psychotherapist is still fairly rare they can be forgiven for doing so. Those of us who have acquired this status after arduous training and lengthy experience are likely to be less sanguine. It must therefore be emphasised that " a training in analytic methods " almost certainly means a training in psychoanalysis which, in this country, is not simply concerned with techniques but includes the only systematic instruction at present available in the principles of mental functioning. A comparable advertisement for the appointment of a consultant ear, nose, and throat surgeon would read something like this: " A training in surgical principles and technique is not required, but candidates should have an interest in the development of a wide range of oto-rhino-laryngological methods of treatment." It is not difficult to imagine the outcry this would provoke. If, however, analogies are suspect then the advertisement may be paraphrased: A theoretical and practical knowledge of medical psychology as it has developed since 1895 is "
not 2. 3.
required." Todd, G. F. Personal communication. Registrar General’s Statistical Review of England and Wales, 1963: part I, tables, medical. H.M. Stationery Office, 1965.
capable
of
reflecting
the immune status of its
This work was supported by grants from the United States Public Health Service (HDO0542), New York City Health Research Council (U-1030), and the American Heart Association. K. H. is a career scientist of the New York City Health Research Council (1416), and C. S. R. is a special fellow of the United States Public Health Service.
Departments of Pathology, Dermatology, and Medicine, New York University School of Medicine, New York, New York 10016.
CAROLYN S. RIPPS M. J. FELLNER K. HIRSCHHORN.
HOMOGRAFT INTERACTION MacLaurin’s article and the accompanying leading SIR,-Dr. article (Oct. 23) both raise interesting possibilities which deserve further comment. Dr. MacLaurin is to be congratulated on his success in showing that, even after eleven days in a mixed cell culture, it is possible to induce further blastoid cell transformation by the addition of phytohasmagglutinin (P.H.A.). However, there are several aspects of this work and the accompanying review which I think require further consideration. Firstly, the assumption, for which the author has produced published evidence, that these transformed cells produce antibodies. The communications cited 1refer to experiments on one patient only; these findings have not been confirmed further by the authors, and many workers in this field have failed to produce supporting evidence. Secondly, the use of the mixed lymphocyte test as an in-vitro test of histocompatibility is not yet fully established, although there is evidence that it reflects the degree of relationship between individuals. Bain and Lowenstein3 have demonstrated a reduced interaction between siblings compared with unrelated individuals. We have confirmed this and found in a small series of experiments that the degree of significance was greater than p=0.001.4 Ceppelini5 has produced data suggesting that this test can discriminate between siblings, parent/child combinations, and unrelated individuals, thus confirming the hypothesis of Newth.s The usefulness of the mixed lymphocyte culture depends entirely on the accuracy with which the transformation is measured. To increase the sensitivity, Bain and Ceppelini have used specific thymidine incorporation. We have retained the morphological approach, but have abandoned the recording of results in terms of percentage, which we believe to be meaningless. The degree of response in the cultures can only be of value if related to the number of immunologically competent cells-i.e., lymphocytes-present at the beginning of the experiment. We maintain that it is necessary to determine absolute numbers of cells at each stage of the experiment. We would question the interpretation that Dr. MacLaurin places on his results, in view of the information supplied. It is unusual, in our experience, to achieve a transformationrate greater than 20% in a mixed’lymphocyte culture, when an accurate differential count is performed on the prepared material. There is uneven distribution of nucleated cells in a smeared sample, and a count of a few hundred cells concentrated near the tail of the smear will inevitably increase the percentage of positives obtained. Without information as to the absolute number of cells present, one cannot assume that the addition of P.H.A. to a mixed culture on the eighth day enhances the activity and survival of the previously activated cells. Only some (i.e., less than 20%) of cells in a mixed culture transform, whereas the majority of cells in a P.H.A.-stimulated culture transform. Possibly the increase in blast-cell percentages encountered by Dr. MacLaurin in his mixed cultures subsequently stimulated with P.H.A. is due to the transformation 1.
Elves, M. W., Roath, S., Taylor, G., Israels, M. C. G. Lancet, 1963, i,
2. 3.
Forbes, I. J. ibid. 1965, i, 198. Bain, B., Lowenstein, L., MacLean, L. D. Histocompatibility Testing; p. 121. Washington, 1964. Chalmers, D. G., Coulson, A. S., Evans, C., Yealland, M. F. T. Unpublished. Ceppelini, R. Histocompatibility. Copenhagen, 1965. Newth, D. R. Transplantn Bull. 1961, 27, 452.
1292.
4. 5. 6.
of previously unaffected lymphocytes. His suggestion, also, that the death of the transformed cells in the mixed cell culture is due to a histocompatibility reaction must be viewed with caution. All the Celllqlfesent in the culture come from two individuals. It would be surprising if, after production of immunologically active cells, capable of taking part in a graft reaction, such cells were only capable of destroying each other, and not the unstimulated lymphocytes contained in the culture from which the blastoid cells were derived. Finally, the views expressed in the final paragraph of your leader must be challenged. In a complicated subject such as histocompatibility all approaches must be explored. To suggest, as you do, that this technique lacks the specificity of classical serological methods, and is therefore inferior, is misleading. The use of serological methods in the detection of antigens in histocompatibility is fraught with difficulty; leucocyte antigens are the most widely used system at present. The preparation of monospecific sera is tedious, and only a few examples are at present available; and the monospecificity may only be apparent when one particular type of test is used. Secondly, much of the graft versus host reaction takes place at the cellular level, and as yet there is no proof that all the histocompatibility antigens can be recognised by classical antigen/antibody techniques. Addenbrooke’s Hospital, D. G. CHALMERS. Cambridge. A HISTORY OF MEDICINE SiR,ņIcan understand your otherwise amiable reviewer’s irritation at my use " of’virus’ as a synonym for micro" " " organism "; but is it fair to call it misuse " ? Virus has a long and respectable history, clinical as well as colloquial, in its meaning " disease agent " or, broader, " agent of evil ". But it was ordinarily used about undiscovered agents; so when germs were found, I take it, the term became clinically confined to those disease agents which remained undiscovered. And, when they were discovered, they assumed the title of viruses, to distinguish them from the germs. If this is what happened, it is an understandable process; but I really do not see why we laymen should be deprived of a valid term simply to suit clinical laziness. Patients, after all, do not distinguish between viruses and germs (though to have a virus disorder is for some curious reason more fashionable). So why can not we keep the term in its old sense ? Come to think of it, if there is any question of misuse, the medical profession is more blameworthy. Viruses are continually being described in respectable medical journals as the cause, rather than as the agent, of disease. So far as I am aware, the evidence suggests they are more symptoms than causes.
Still worse is the deplorable and growing habit of doctors falling back on a diagnosis of a virus disorder " when what they actually mean is, We don’t really know what is the "
"
with him ". The useful term " functional " fell into disrepute in this way; so that even to this day many doctors shy away from it. A pity. BRIAN INGLIS. London, W.2.
matter
SMOKING OBSCURED SiR,ņIn your annotation (Oct. 16) on Professor Eysenck’s book, Smoking, Health and Personality, you note that " the book, we are told, is intended for the intelligent layman ". The report of the Royal College of Physicians’ committee on smoking, too, was professedly written for the layman to understand. You accuse Eysenck of arguing " the importance of air pollution as a cause of lung cancer, without acknowledging the fact that this was given careful attention in the R.C.P. report." Where ? The report devoted just over a page to brushing aside some of the arguments against air pollution, and concluded that " The interaction of air pollution and smoking requires further investigation." But on p. 2 of the report we find: " The importance of atmospheric pollution will be the subject of a separate report. Although the effects of thi;
953 hazard and of tobacco smoking may be inter-related, at least in the case of lung cancer and bronchitis, the preventive measures required in respect of air pollution are of a character so entirely different from those required in respect of smoking that the two hazards are best considered separately." The intelligent " layman might ask, If there is an interrelation, isn’t that a very good reason for considering them together ? " But the report was approved for publication four years ago, and there is still no sign of the promised separate report. You go on to say: " He [Eysenck] insists not only that air pollution is important, but that it is a more important cause of lung cancer than cigarette smoking; but he has omitted much of the available evidence which tends in the opposite direction to which he would lead his readers." Eysenck is by no means alone in this opinion. It is shared by several eminent men, notably by Professor Pybus, who has shown that the coal smoke over Britain in a year contains about 375 tons of carcinogenic benzpyrene, against eight pounds from all the tobacco smoked in the same time. As a layman the chief difficulty I found in the way of conviction by the R.C.P. report was precisely that omission of available evidence of which your reviewer accuses Eysenck. It reads as if the committee had decided that smoking was the chief cause of lung cancer and then set out to prove it, lightly brushing aside any evidence inconvenient to their decision. The United States Surgeon General’s report admittedly introduced no new evidence, but only reviewed in detail what was already known. May I just add that I am a very modest smoker, with a negligible cigarette consumption, and that I dislike other people’s smoke ? I am trying to arrive at the truth behind a great deal of propaganda, in the belief that there is danger in accepting too readily that the major cause of lung cancer has been found and that all we need to do is to give up smoking. I wish I could believe it was as simple as that. But for every argument advanced in the reports I keep on finding equally cogent ones pointing the opposite way. Professor Eysenck, before developing his personality thesis, seemed to me to paint both sides of the picture pretty fairly. C. HARCOURT KITCHIN. London, N.2. CARCINOMA OF BRONCHUS SIR,-Dr. Fletcher drew attention last week to some of the difficulties of comparing the lung-cancer mortality among women in 1963 with that among men in 1922, as attempted by Dr. Myddleton (Oct. 16). Dr. Myddleton’s data on smoking are fallacious, and, if more appropriate data are used, the conclusions are quite different from those he reached. His figures for the amounts of cigarette tobacco consumed appear to have been derived by adding together the average amount smoked per adult male or female for successive years as shown in the report which he cites.1 In this report (table ill) the cigarette consumption per adult male is given for each year from 1891 and the subsequent increase could be accounted for largely by the entry of new cohorts to the ranks of cigarette smokers, while men of earlier cohorts continued to smoke pipes. The sum of the mean annual consumptions per adult male from 1891 to 1922 cannot therefore be expected to give a useful estimate of the cumulative consumption of cigarettes by the middle-aged or elderly men who died from lung cancer in 1922. To obtain his figure of 66 lb. of cigarette tobacco smoked by the average woman up to 1961, Dr. Myddleton has presumably added up the entries for the mean annual consumption of cigarettes as given in table iv of the report1 for each year from 1922 to 1961. There is evidence within the same report (table xm) that in 1961 the smoking habits of women varied considerably with age, and again it cannot be expected that Dr. Myddleton’s procedure would give a satisfactory estimate of the cumulative consumption of cigarettes by the middle-aged or elderly women who died from lung cancer in 1963. In table xvii of the report1 there are proper estimates of the cumulative 1. Todd, G. F. Tobacco Manufacturers’ Standing Committee; research paper no. 1.
London,
1962.
consumption of cigarettes by men and women of specified ages for periods of 10 and 20 years, and tables are now available for 30-year periods.2 It is not yet possible to assess the cumulative consumption of cigarettes throughout adult life for people of all ages, but the latest tables show that on average men aged 47 in 1964 had smoked 131,000 cigarettes since the age of 16, and women aged 47 had smoked 45,000 in the same age-period. This 3:1 ratio in the number of cigarettes smoked by men and women up to age 47 is quite close to the 4:1 ratio in lung-cancer death-rates of men and women in the age range 45-49,3 and these data would not be as difficult reconcile with the cigarette-smoking hypothesis as those presented by Dr. Myddleton. M.R.C. Air Pollution Research Unit, St. Bartholomew’s Hospital Medical College, R. E. WALLER. London, E.C.1. to
COT DEATHS SIR,-Your leading article last week made no reference to postmortem temperature recordings. I have only seen three cases of sudden unexplained death in infants, but in each the rectal temperature was above 101°F. The possible relation of the condition to infection would be better understood if body temperature was recorded in all cases. Silsden, Keighley,
near
D. G. WILLITS.
Yorkshire.
THE LISTER CENTENARY SIR,-Sir Francis Walshe pointed out (Sept. 25) that the Lister commemorative tablet had not been replaced on Lister’s old home at 12, Park Crescent when it was rebuilt, and Dr. Godlee replied (Oct. 23) that he had happily been able to rescue the " original bronze memorial." The present occupiers, the Spastics Society (not the University Grants Committee, who are our neighbours in no. 14), will be very happy to see the original memorial tablet restored to its rightful place. If the tablet is in a satisfactory condition it is to be restored to an external site; if not it will be replaced by a modern plaque, and we shall be very proud to place the older one in our entrance hall. Director, Spastics Society, C. P. STEVENS. 12, Park Crescent, London, W.1.
PSYCHOANALYSIS IN PSYCHOTHERAPY SIR,-An advertisement for a consultant psychotherapist in your columns includes the statement: "A training in analytic methods is not a requirement and the candidates should have an interest in the development of a wide range of psychological techniques as part of an integrated treatment programme." Many medical colleagues may think this advertisement unexceptionable, and since the appointment of a consultant psychotherapist is still fairly rare they can be forgiven for doing so. Those of us who have acquired this status after arduous training and lengthy experience are likely to be less sanguine. It must therefore be emphasised that " a training in analytic methods " almost certainly means a training in psychoanalysis which, in this country, is not simply concerned with techniques but includes the only systematic instruction at present available in the principles of mental functioning. A comparable advertisement for the appointment of a consultant ear, nose, and throat surgeon would read something like this: " A training in surgical principles and technique is not required, but candidates should have an interest in the development of a wide range of oto-rhino-laryngological methods of treatment." It is not difficult to imagine the outcry this would provoke. If, however, analogies are suspect then the advertisement may be paraphrased: A theoretical and practical knowledge of medical psychology as it has developed since 1895 is "
not 2. 3.
required." Todd, G. F. Personal communication. Registrar General’s Statistical Review of England and Wales, 1963: part I, tables, medical. H.M. Stationery Office, 1965.